Public Health Has a Power Problem: Being Right Isn’t Enough

Power isn’t a word that we use very often in public health. Even for someone steeped in public health policy, we much more frequently discuss equity, interventions, community engagement, and of course the conditions that shape the public’s health.

But power? Not so much.

What brought it to mind was a training this morning on “power mapping” offered by the Johns Hopkins Lerner Center for Public Health Advocacy. The session was designed to help public health professionals think more strategically about the political landscape.

I’m not going to describe the mechanics of what I learned here—the Lerner Center can do that much better than I can—but spending a morning working through these ideas left me thinking about something bigger: public health has a power problem.

It first struck me last week while watching an epidemiologist win a Democratic primary for a U.S. Senate seat in Michigan. It was so unusual to see someone run for office with a background in public health that it helped me see the scale of the power vacuum.

The training added another level. It reminded me that having facts on your side doesn’t mean you’ll win a policy fight, especially absent power. Whether it is the dangers of flavored tobacco, the benefits of vaccination, or the urgency of addressing climate change–public health has an impressive body of evidence.

The wins…less so.

Being right isn’t nearly enough

Public health professionals spend an enormous amount of time solving problems. We identify health risks, collect data, conduct studies, estimate odds, evaluate programs, model outcomes, and synthesize evidence. When the evidence isn’t clear, we work harder to produce better evidence.

Eventually, though, we need somebody to do something with it. And that’s where things get complicated. You can have a stack of peer-reviewed studies showing that a policy will likely improve health, and you can explain the evidence clearly. But when it comes to changing policy–you can still lose.

The obvious reason is that people with power don’t make decisions solely with evidence. Elected officials, CEOs, directors and school boards (all common power holders) face constituents, clients, and consumers. They balance budgets, donors, and investors, and juggle public opinion and relationships. There are nearly always competing priorities.

Evidence matters a lot. But evidence isn’t power.

Afterschool soda and competing interests

I’ve encountered it at my children’s elementary school, where a few years ago I figured out how to stop the “student store” from selling soda and huge tankards of sugary iced tea. I knew from my work in this area that the district had a rule against this, but it took me a while to get something done about it.

I recruited my 5th grade son to help solve this, thinking it might be a good experience. He was not only a constituent and consumer, but he served on the school’s student leadership body. Putting aside his own strong preferences for sugar, he raised questions, and quickly found he was up against “competing interests.”

When that didn’t work, we recruited a few other families who then shared the concern with others. But it wasn’t until I found myself having a conversation at school with a parent who knew the principal that the power map became clear.

The principal walked up to say hello, and we explained that we were just discussing who to talk with about the sodas. The public health evidence was easy to express, and it helped that the sale of soda was likely breaking district rules. But the relationship was key; the principal knew and trusted this other parent. By the afternoon, sodas were gone.

That’s power.

I think that is why this morning’s advocacy training resonated with me. Some of the ideas were familiar because we encounter them in common spaces. I’ve often thought about who I need to talk with to solve a problem and how to build support for a solution. What I hadn’t done was think of that knowledge as a formal public health skill set. I now realize that maybe we should.

Teaching public health to understand power

Most public health students take some form of health policy class. After the Lerner Center training this morning, I’m less certain that we teach them how to navigate power. There is a wide gap between knowing what should change and actually making the change. Power may need to become a more explicit part of public health education.

There is an obvious complication here. A large share of the public health workforce is employed by government, universities, and nonprofits where the boundaries around lobbying and political activity can be complicated. Public health also has good reasons to value scientific independence, especially with trust in its institutions at a low-point.

The answer isn’t to turn every epidemiologist into a political operative. But does the pressure to remain credible makes us too discomfited by power itself? To change the conditions that help communities stay healthy, eventually somebody has to change a budget, regulation, ordinance, or law. And somebody has to motivate that person to do it.

Maybe that means teaching the tools of advocacy–including understanding power–to more students. Public health already excels at generating good evidence. We may need to become more comfortable and capable with the skills to turn that evidence into action.

Author information

Gregory Stevens

Professor at California State University, Los Angeles

Gregory D. Stevens, PhD, MHS is a health policy researcher, writer, teacher and advocate. He is Chair of the Department of Public Health at California State University, Los Angeles. He serves on the editorial board of the journal Medical Care, and is co-editor of The Medical Care Blog. He is also a co-author of the book Vulnerable Populations in the United States.

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