This guest blog post was contributed by Dr. Drew Harris, DPM, MPH. Drew Harris is a public health researcher, consultant and advocate and is the founding chairman of the New Jersey Public Health Institute.
In 1874, this anecdote appeared in the Report of the Health Commission of State of New Jersey:
When the cholera broke out in South Amboy in 1866, the very bed on which the patient died was sold at auction. When a physician had sought in vain for power to obtain it and to use disinfectants, he only saved the town from a fearful risk by seizing the articles and burning them by active and illegal force.
I have used this story in lectures and presentations to make the case for why law and the lawmaking process is essential to public health. I always conclude with two simple questions: If you were this doctor, what would you do and why did he have no other options?
The question of whether you’re willing to break the law to protect the community’s health is about the courage of your convictions. It’s easy to be brave in the abstract but how many professionals are willing to put their job and freedom on the line for what they believe is important. Let’s also not forget the courage it must have taken in 1866 to enter the house of a highly contagious patient with nothing but a black bag and a crude understanding of how cholera spreads—no gloves, no mask, nothing.
It’s really the second question about why “active and illegal force” was even necessary that is most important. Why did this nameless doctor lack the legal power to protect the community? At that time, the ability of local officials to regulate people or property to protect public health was quite limited. The sale of adulterated foods and medicine was rampant. There were no building construction codes, no regulation of living conditions. Privies and cesspools could be co-located with drinking water wells. Manufacturers dumped their waste directly into streams and rivers with impunity.
Dr. Ezra Mundy Hunt, a public health pioneer, used this story about the desperate South Amboy, NJ physician to make his case for an empowered public health system. He led a group of 19th century public health advocates to lobby for a New Jersey state department of health with the authority to use the force of law to improve the state’s health conditions. Ultimately, he was successful in creating a strong state health agency and requiring every community to establish its own local health department. Only by marrying an evolving understanding of how disease spreads through a community with the coercive force of government were these public health champions able to improve health outcomes.
Dr. Hunt, et al accomplished their goal by wielding political power and employing what we would now call a “grassroots” and “grasstops” campaign. They had tried unsuccessfully to use scientific arguments to persuade the legislature that more needed to be done to protect public health. After several failed attempts at appealing directly to the New Jersey Legislature, they fanned out across the state to meet with key opinion leaders (local physicians, lawyers, judges and clergy) to describe the benefits of a state-level health department. They promoted the benefits of collective action to address the conditions that led to ongoing and recurrent disease outbreaks. Most importantly, they encouraged these community leaders to engage the local population to contact their representatives in the state capital. It was the weight of this public pressure that eventually forced New Jersey’s political leadership to create the state’s first Board of Health in 1877.
The essence of Public Health is political. Without the means to effect change by implementing and mandating best practices, it is just another exercise in pure research. Scientific research develops vaccines against infectious diseases, proves that pasteurization makes milk safe and discovers the link between squalid living conditions and disease outbreaks. But, it’s public policy that turns those findings into action. And, policymaking—the power to enact laws—is inherently political.
Like Hunt and his colleagues, public health practitioners must embrace the political realm and use the powers of persuasion and an engaged electorate to move the levers of power. If we are to achieve our goal of “healthy people in health communities” then we must get our hands dirty. We shouldn’t be afraid to exercise our constitutional right to speak out on issues important to our communities, states and country. As experts, it is our professional and moral obligation to lend our voices to the public debate. If we confront institutional barriers that prevent us from speaking out then we must work directly to overcome them or indirectly through organizations and people who can. We must become community leaders by educating our colleagues, neighbors, patients and clients about local health challenges and opportunities and rally them to the cause of good public health.
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