I recently attended the annual meeting of the American Public Health Association, a super-size conference in which over 10,000 public health professionals congregate (this year in San Diego) for five days of presentations, discussion and networking, fuelled by bad coffee and a desire to collect as many badge ribbons as possible. As well as reminding me of the best American qualities (friendliness, enthusiasm, Mexican food), the conference offered insights into what’s current (and what’s not) on the US public health agenda.
Gun violence received a lot of attention, including compelling presentations from two young gun control advocates, Eden Hebron and Tatiana Washington, and a strong assertion from the US Surgeon General (Jerome Adams) that gun violence should be treated as a public health issue (refuting a recent tweet from the NRA, Dr Adams contended that gun control is ‘totally in my lane’). The broader social determinants of gun-related violence were highlighted by a number of speakers including Deborah Prothrow-Stith – who argues for an eco-social understanding of the underlying causes, highlighting how the unequal impact of gun violence (which disproportionately affects African American communities) reflects the historical basis of many contemporary drivers.
There was a similar focus on the US’s current opioid epidemic and its broader social causes. Echoing Prothrow-Stith’s analysis, Dr Jay Butler from the Alaska Department of Health and Social Services noted how the opioid crisis highlights pre-existing social inequities in terms of race, socioeconomic position, incarceration and homelessness, encouraging us to view this as a community problem rather than an individual problem. As with gun violence, speakers talked of the need to treat these problems as public health issues rather than simply enforcement issues.
The link between public policy and health inequalities was strongly emphasised by my old professor Dr David Williams, who drew on US experience in the latter part of the 20th century to illustrate how changes in policy that improve living conditions for vulnerable populations lead to narrowing of health inequities; just as the biggest threats to population health and health equity come from funding cuts outside the health sector. Williams (citing Kaplan et al 2008) described how the period immediately following the introduction of the Civil Rights Act saw improvements in the living conditions of African Americans and a reduction in racial disparities in health; while the reverse applied following the Regan administration’s cuts in health and social services, which led to a widening of both social and health inequities (as described by Mary Mundinger in 1985). Williams used these historical cases to highlight the risks to health equity arising from contemporary public policy, noting in particular how recent tax cuts for higher earners places pressure on federal budgets which in turn is used as a rationale for reductions in public spending on social security and Medicaid.
While Williams was particularly direct in his criticism of the current administration, he certainly wasn’t the only conference speaker to voice concern over the direction of US federal policy or to warn against its adverse consequences for population health. The issue of migrant health was also highlighted in this context, referencing not only current policy but also historical relations between the US and its southern neighbours. Again, there was an emphasis on the underlying economic and political factors that drive individuals and families to seek a better life in the USA, despite the hardship and discrimination they face on arrival.
One issue that received less attention than I expected was the commercial determinants of health. I was pleased to find two (thinly-attended) sessions on trade and health – at which I came across one of our former MSc students, the fabulous Courtney McNamara (now working at the Norwegian University of Science and Technology) – but overall the role of the commercial sector in health appears to be something of a blind spot in US public health discussions. The panel in which I presented (on conflicts of interest from corporate involvement in public health) appeared (somewhat oddly) under the ‘ethics’ section of the programme. Even more oddly, in contrast with the crowds queuing to speak to various rock-star presenters there appeared to be only two of us at a book-signing session with the wonderful Marion Nestle – who would surely have been inundated in a UK public health conference.
Of course there were many other sessions that I didn’t have time to cover, and I confess I did not avail myself of either the APHA Steps Challenge or a stress-relieving peach. But I came away from the conference with a renewed sense of optimism for public health in America and the potential for the expertise, insights and commitment of this community to have positive impacts on health and social participation more broadly. It’s encouraging to be reminded about the breadth of talent and the depth of critical engagement that exists in US public health. Muchas gracias, San Diego!