Cultural Determinants of Health: The Epidemic of Ignorance

In my last article here (“It Does Take a Village”), I described the “toxic culture” of our country as “one full of myths that blind us to how the society really works and for whom.” I argued that to promote population health, we must explain “ how power and privilege are distributed and used to drive agendas that oppose health and well-being for all.” It is worth asking what it is in our political culture that makes the nation so inhospitable to the public health ethic. If we hope to improve the public’s health, we must reveal the toxic values in the myths that poison the thinking of so much of our population.


The unique handicap of public health in America is being burdened with political baggage, sometimes referred to as “American Exceptionalism,” that goes back to our earliest years as a nation, but some of its key principles were famously articulated by Calvin Coolidge in the 1920s. Those principles promote maximization of profit and glorify private ownership at the expense of social welfare.


             “The chief business of the American people is business.”

             “Civilization and profit go hand in hand.”

“Ultimately property rights and personal rights are the same thing.”

 -- Calvin Coolidge


These principles promote liberty over charity, libertarian irresponsibility over communitarian solidarity. Our history reflects the debate between them, but neither of them has ever so dominated the process of government as the business ethic does now. The problem for public health arises from its being dependent on the good governance that employs a judicious balance of the principles. The influence of commercial interests on public health has been felt most powerfully through their success in redefining the very role of government from serving public interests to serving transnational corporate interests.


President Eisenhower in his Farewell Address (1961) warned us against the “unwarranted influence… by the military-industrial complex” in the councils of government. That influence has transformed war and the threat of war into opportunities to maximize profit making, and the influence has spread over all the operations of government, and even over the role the sciences play in the nation. Thus we see real dangers like climate change obscurely through the lens of neoliberal ideology, not clearly through that of science.


Corporate interests have the constitutional right to use their wealth to further their goals, but they have no right to control public health’s mission and agenda. That agenda must be controlled by those public health professionals who have the vision and the commitment to serve the best interests of social justice by advancing the right to healthcare and health equity for all. Public health is vested in getting everyone to see health as more public than private. If we cannot promote health as a socially determined endowment to which all are equally entitled, we will witness its becoming a commodity with a price set in the marketplace, only to be enjoyed by the privileged.


Public health can find little support in a nation where the market distribution of income is seen as moral, and its unequal distribution is seen as representing social justice. A nation where poverty has been criminalized.   


By valuing health as a human right, as necessary for social justice, we are engaged in a class war. The Sixties’ War on Poverty acknowledged that by seeing community empowerment as the road to health improvement. But societal health disparities are denominated in perceptions as much as in incomes, so how wellness is framed, seen, and valued is part of what the war is about.


Essential Public Health Services:

3.  Inform, educate, and empower people about health issues.


I think we must ask ourselves whether we have been working under a politically correct blindness in our failure to identify political power as the primary determinant of health. Academic objectivity has led us to hypocrisy. Radical voices are necessary to identify the forces that would maintain public blindness and apathy. We must name all the agents our epidemiology reveals to us as endangering the public’s health, and that is a political process. Our integrity and ethics as professionals requires us to use our knowledge of what is opposed to good health to better inform our public’s participation in the political process. And then we ought to be participating in that process too. The success of Vermont’s Healthcare Is a Human Right Campaign furnishes an example of what needs to be done.  


Promotion of the public health ethic is essential to fulfilling our mission in society. The public must understand how what we work for is grounded and inspired scientifically and morally, and dedicated to better lives for all. Ultimately, it must better understand what society ought to do, and how only government can do it.


By John Steen