Connecting the Dots of a Public Health Career

The Congressional record of Senator Frank Lautenberg illustrates a career dedicated to issues aligned with public health and inspires some thinking about one’s own public health career. His steadfast pursuit of principles that mark his legislative record over many years should make each of you proud to be associated with a School of Public Health that makes an award in his name. More onerous is the burden for anyone who receives the award and dares compare his or her own career with the Senator’s. A humbling moment of comparing my own attempts at influencing change with his led me to reflect on three things I would urge you to consider as you embark on your postdegree career from this School of Public Health. I call them connecting the dots of a public health career.

The first is to ask, not what do you want to do, but what do you want to accomplish. Embrace the longevity and continuity of your career as an opportunity to make a cumulative contribution, building on each accomplishment, as a foundation for the next, not as an end in itself. Each leg of your journey presents you with a new fork in the road, with two or more options of where to proceed next. Anticipate those forks as you near the completion of each endeavor and consider which branch will enable you to serve the public’s health most effectively. And remember—remind yourself as your boss or your colleagues press you to take up the next challenge of that organization—your loyalty or your commitment is not to an institution, but to a cause, a value; a value that led you to a career commitment to public health.

The second is to question what John Kenneth Galbraith (1958) called the “conventional wisdom,” what the dogma or the fad or the path of least resistance of your time has caused many of your colleagues and contemporaries to accept as normal and necessary. There is always a degree of wisdom of the crowd, the homeostasis of getting by without rocking the boat. To challenge such homeostasis in the name of social justice for some who are not benefitting equally from it is to make trouble at some level, if only in your own equanimity, your comfort level. This too demands an anchor in values that you need to clarify and solidify early and often. If there is one anchor I hope you will seize on now as you come to your commencement, it is that your public health degree is not primarily a commodity. Its primary purpose is not your own private or personal bargaining chip but an investment of public resources in you for the public good.

The third lesson I draw from Senator Lautenberg’s career in relation to our situation in public health is to get clear about and use your values to guide your career decisions and stick with your ethics. In an era of questionable Congressional values, it is refreshing to see the continuity and consistency of values inherent in the legislation and causes Senator Lautenberg has sponsored or championed. You have been, or soon will be, similarly challenged to find the touchstones and guideposts that give direction, continuity, and gravity to the professional and career decisions that you must make repeatedly and endlessly, even beyond retirement, for you will continue to be called on to contribute your wisdom, wealth, and time to the causes you will have championed.

Let me try to put these three touchstones or guideposts into more concrete, contemporary career questions or decisions you will face.

Today, in a time of work ethics being questioned on many sides by an electorate concerned with government spending, by financially devastated investors concerned with insider trading and other Wall Street ethical practices, by retirees concerned with the banks’ reckless investment of their pension funds, and by everyone concerned that professionals are on the take rather than serving our collective needs, you must reconnect continuously with your core values and your public health commitment.

One example of challenging conventional wisdom: We are rightly proud of our public health science traditions in epidemiology, environmental sciences, biostatistics, management and policy sciences, and increasingly in social and behavioral sciences. But the latter have begun to challenge some of the science-to-practice assumptions of the former—particularly when those assumptions come in the form of canons of evidence-based medicine translated to public health. The health problems of the first half of the 20th century were spectacularly reduced by the application of public health sciences to the control of communicable diseases.

But with the rising curve of chronic diseases crossing the declining curve of communicable diseases about mid-century, we turned increasingly to social and behavioral sciences to cope with the chronic disease risk factors, most of which are behavioral, and risk conditions, most of which are social (see especially Golden & Earp, 2012, p. 370). We also rode the wave of systematic reviews of evidence from highly controlled trials dictating evidence-based practice and policy (Green & Ottoson, 2004). Some bent on making government support of social programs more accountable have sought to apply evidence-based medicine rules and criteria to community-level social programs that could never prove their effectiveness by randomized controlled trials, nor generalize their results beyond (Rothwell, 2005).

Some of our great public health success stories of the last third of the 20th century, such as tobacco control and automobile injury control, required comprehensive, mutually reinforcing interventions, including mass media, and policies to which individuals in communities could not be randomly assigned (Ahmad, Boutron, Dechartres, Durieux, & Ravaud, 2010; Mercer, DeVinney, Fine, Green, & Dougherty, 2005).

What the social and behavioral sciences have added is a growing sensitivity of public health to context. This has made suspect the simple exportation of interventions tested in scientifically controlled settings to other settings and populations (Green, 2001). If I may make one more appeal to your connecting the dots of a public health career, it is to treat every public health program or policy you oversee or promote in your communities as a natural experiment, to evaluate what you do, to test the applicability or external validity of the evidence-based practices to your population or community. My challenge to the National Institutes of Health and the policy makers who would demand that everything we do should be evidence-based is that much of the evidence is produced under such artificial circumstances that it bears little relevance to many contexts of public health practice. Indeed, many of the most important public health interventions cannot be tested with randomized, controlled trials (Mercer et al., 2007). They can be tested and developed with other evaluation designs adaptable to free-living community settings and circumstances of public health practice (Livingood et al., 2011). If we want more evidence-based practice, we need more practice-based evidence. You can help produce that evidence.

A final observation: It is not just good public relations that make the Centers for Disease Control and Prevention the most respected and trusted of the federal agencies. It is not just a few dramatic movies such as “Contagion” that have made public health one of the fastest growing undergraduate majors, when we had few such universities offering that major only a decade ago. It is not for padding the endowment income of universities that they have doubled and then tripled the number of schools of public health in recent years. It is not to reduce the competition for federal grants that the Council on Education for Public Health has accredited a proliferating number of those schools of public health. These are signs that the American public and the Canadian and European publics—all adding schools of public health—have begun to recognize the alternatives public health offers to medical care, hospitals, and drugs as paths to a more equitable, cost-effective, cost-beneficial, and value-integrated way to the health of populations. The values and methods of public health converge more harmoniously with other population movements and benefits such as conservation and protection of the environment, literacy and education (especially of women in developing countries—the most effective intervention for many developmental goals in poor societies), reduction of disparities, giving children a better head start with equal opportunity to fulfill their potential, and giving the growing aging population better prospects of fulfilling their increased longevity with QALYs rather than disabilities.

For this last benefit, I will be additionally thankful to you in my late career and postretirement years (or pseudoretirement, as they seem to have become). Senator Lautenberg will also have reason to be grateful for having lent his name and his long years of effective political influence to our cause.