Public health solutions depend on proximity to practice and people in communities
IN BRIEF: The effective practice of public health requires academics to leave the comfort of universities, collaborate with people in communities and learn the lessons they teach us. Bryan Stevenson, author of Just Mercy, referred to that closeness as proximity. When we allow ourselves the physical closeness and vulnerability that come from authentic interactions, we can use the shared knowledge that results to develop scalable solutions that improve health and lives. It is part of a cycle that often starts with practice and leads to research that improves practice. In this post, I recount examples of public health impact that came from getting close to the people in communities and learning from and with them. Those examples are some of the most powerful lessons I have learned in my career.
In public health, in contrast to what clinicians do, we focus not only on individuals but also on other levels of organization, such as worksites, clinics and communities. Our scale is much larger than individuals, but we should never forget that communities are made up of people. While there used to be a strong distinction between medicine focusing on individual patients and public health directed at larger social units, the movement towards population health and value-based care has blurred the lines.
Ultimately, the goal of practice for the Gillings School of Global Public Health is to improve the health of people in North Carolina and beyond. Public health practice helps us understand the needs and issues of populations so we can work with them collaboratively to solve problems they have helped identify and develop solutions that improve lives and health. In the process, we develop practice-based evidence that gets translated into evidence-based practice, as Lawrence Green, DrPH, has argued persuasively (e.g., in American Journal of Public Health, Dec. 2001).
As part of a public university, we have a strong commitment to improve the health of North Carolinians, and that’s been a fundamental focus of the school from its earliest days. I am committed to that, and our Practice Advisory Committee is made up of members from across the state, including representatives of governmental public health and other organizations; some are funders or are in fields related to health but not health per se. We are working together to improve the health of people across North Carolina.
Practice and research are interdependent
Some ask how practice and research are interrelated. They are highly interdependent. The most useful research often comes from practice insights and lessons and should generate knowledge that influences practice. Such research should come, in part or fully, from communities and from working with communities and community practitioners. As numerous authors have noted, public health research and public health practice have much in common, e.g., surveillance, evaluation, systematic methods, and statistical analysis, but they are not the same (see Otto, Holodniy, and DeFraites, 2014). As these authors said, “The purpose of research is to generate or contribute to generalizable knowledge,” while “the purpose of public health practice is to prevent disease or injury and to improve the health of communities through such activities as disease surveillance, program evaluation, and outbreak investigation.”
Solutions to public health problems and challenges should be among the outcomes of the collaborative research I mentioned above. Solutions include discoveries about the root causes of health and other inequities and strategies to overcome them. The results of discoveries should lead to effective interventions and evidence-based practice. Public health interventions are of many kinds, e.g., methods to increase access to prevention and health services, programs to enhance knowledge and behaviors, policies, laws, regulations, and macro-strategies, such as provision of food, funds, transportation and education, including early childhood education.
Making a difference in communities
An example of the cycle from research to practice comes from work by Gillings School and other environmental scientists in partnership with a community in Apex, N.C. Leaders in a largely Black, low-income community approached a Gillings faculty member to express long-held frustration that the community still had not been connected to city water, although newer communities had been built and connected. Community leaders invited our faculty and students to partner with them to collect water samples, interview residents and determine whether residents were, as they thought, suffering ill health from their dependence on wells that often became contaminated. Indeed, the data supported the beliefs of community members.
Ultimately, using a variety of data, including from hospital emergency room visits, community leaders made the case to city council members that the community was being affected adversely by denial of access to city water. The result was a commitment from city council to connect the community to city water. I attended a meeting in a local Apex pizza parlor in which community members, faculty and students came together to debrief. This great example of community-based participatory research demonstrates how public health data, collected collaboratively by academics and community members, can affect regulations and provision of equitable water and sanitation. That’s public health practice at its best and is a result of the practice-to-research-to-practice cycle.
Getting close to community members enabled researchers and others to understand the toll that contaminated well water took on people in the community—those who ended up in emergency rooms due to enteric infections, those who had to wash dishes in a gas station sink; there were constant reminders that this community was being denied basic services that others received without ever having to ask. The kind of inequity to which the community was subjected day after day takes a devastating toll. I am grateful that our people made a difference, but they could not have done it alone.
Understanding leads to solutions
Public health practice helps us understand the needs and issues of populations—to get as close as possible to walking in their shoes—so we can work with them to develop and apply scalable solutions that improve lives. When I say communities, I mean that broadly, whether defined by geography, as in the example above, or other characteristics. To understand communities’ needs, we also must learn from the experiences and perspectives of public health and other practitioners (see Green again, this time in American Journal of Health Promotion, Oct.19, 2020).
I think back to practice work and the research-to-practice cycle early in my career that continues to influence me, such as sitting day after day in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics, in Pennsylvania, talking with clients about why they smoked so we could design effective cessation programs for new mothers; going to senior centers in Philadelphia and trying to learn from the clients why they didn’t get screened for cancer, and interviewing cancer patients at the end of their lives about why they entered clinical trials. These were practical, applied research projects that were done with various communities to improve practice, and the resulting interventions became part of routine practice.
Clients and community members often give us the answers to address their problems, but we must engage with them to find those answers. We are humbled when they share the stories of their lives. I remember working with Jo Anne Earp and Geni Eng in Bertie County, N.C., and meeting with women and agency staff in their communities to discuss breast cancer and mammography. With trust built over years, the team collaborated with women and organizations in communities. That close engagement was critical to developing interventions that increased use of mammography and reduced breast cancer rates based on women helping other women in their communities.
The human side of public health
I don’t want the importance of practice to get lost or for it to be seen as a stepchild of research. Practice is a necessary part of the circle from discovery to implementation. The data we collect are more than numbers in tables; they represent unique individuals, each with stories to teach us. When I look back on my own career, I realize it is those moments of vulnerability and closeness that led to the most effective interventions and strongest personal lessons. Those are the experiences that changed me and enabled me to be part of a process that improved health.
I will never forget meeting with people in a barn in eastern N.C., and the stories they told us about how industrial farming was destroying their health, well-being and lives. We sat together and talked over the wonderful, homemade food they had brought to share. Research conducted by Steve Wing, PhD, now deceased, in collaboration with community members, not only identified the very real harms of hog farm proximity but ultimately led to both a successful lawsuit against industrial hog owners and better regulations, with the potential to improve health and lives. Wing’s research also led to a cadre of knowledgeable advocates who spoke on behalf of their communities. At a memorial service after his passing, one of the community members spoke movingly about the impact Wing had had. That impact never would have occurred if Wing had not sat at kitchen tables and listened to people, a key element of effective practice.
And I think the same is true in the justice sector, that we cannot make progress in creating a more just society, healthier communities, if we allow ourselves to be disconnected from the people who are most vulnerable — from the poor, the neglected, the incarcerated, the condemned. If you’re trying to make policies in the criminal justice space but have never met someone who’s in a jail or prison, you haven’t been to a jail or prison, you’re going to fail.
I think sometimes, when you’re trying to do justice work, when you’re trying to make a difference, when you’re trying to change the world, the thing you need to do is get close enough to people who are falling down, get close enough to people who are suffering, close enough to people who are in pain, who’ve been discarded and disfavored — to get close enough to wrap your arms around them and affirm their humanity and their dignity. And that’s why, whether you graduate from Harvard Law School or you graduate from college, whether you’re a social worker or a teacher, you should not underestimate the power you have to affirm the humanity and dignity of the people who are around you. And when you do that, they will teach you something about what you need to learn about human dignity, but also what you can do to be a change agent.