See attachment
Unit VIII Article Review
Weight: 10% of course grade
Instructions
For this assignment, choose a peer-reviewed article to review. Use the databases in the CSU Online Library or another source that contains
peer-reviewed articles
, and find an article about a concept tied to the unit outcomes in this unit. Write a
three- to five-page
review (not counting the cover page and references page) of the article that includes the following information:
· Briefly introduce and summarize the article.
· Identify the author’s main points.
· Who is the author’s intended audience?
· How does the article apply to this course? Does it support the information in your textbook?
· How could the author expand on the main points?
The article must be no more than three years old. Use APA style when writing your review.
CHE 6303, Strategies of Health Promotion 1
Course Learning Outcomes for Unit VIII
Upon completion of this unit, students should be able to:
1. Apply health-related information to educate the public with the intent to reduce the risk of disease and
enhance quality of life.
1.1 Describe the current focus on health disparities and its relationship to diverse populations.
1.2 Describe the range of factors (within an ecological model) that contribute to health disparities.
6. Discuss ethical issues that may arise in the promotion of health awareness.
Required Unit Resources
Chapter 15: Culture, Diversity, and Health Disparities: Are Current Theories Relevant?
Chapter 16: Career Choices and Social/Behavior Theory in Public Health: A Brief Introduction
Unit Lesson
There are disparities that exist for certain populations in our society with respect to their health status or
quality of life indicators. There are many specific factors that contribute to this aspect of inequality still
occurring within the United States. Public health professionals are continuously striving to improve the
situation or to have a more equal society. Before reducing these disparities, we really need to understand
what these factors are, and then we can develop the appropriate strategies to tackle these serious issues.
The common categories that are often linked to health disparities include social, economic, and environmental
considerations. There is strong evidence that suggests that access to care, for example, is one of those
factors. Evidence and data suggest that individuals from certain ethnic minority groups (e.g., African
Americans, Hispanics, and Native Americans) do not have the same level of health insurance coverage rates
as other Americans. This creates a health disparity because specific minority groups do not have the primary
care services required to sustain a minimum quality of life. Thus, there has to be a coordinated effort on the
local, state, and federal levels, so the situation is improved. Other factors indicate that these minority groups
have the highest rates of heart disease and associated risk factors such as heart attacks and strokes. These
factors contribute to lower quality of life indicators and increased levels of mortality.
Another factor includes individuals from minority groups living in undesirable conditions such as insufficient
housing and being in poor economic condition. All of these have a direct impact on the individuals’ health
conditions. This continues to illustrate the need for continued efforts from various government agencies at all
levels to work on improving a person’s income levels and housing conditions. Therefore, investments in better
housing and transportation as well as more job creation should be ongoing.
Other contributing factors may include low or insufficient levels of education, poor mental health or behavior-
related issues, and higher rates of alcohol, tobacco, and substance use. Again, as we have learned, there
needs to be effective and successful health promotion strategies and interventions in place that would be able
to decrease the occurrence of health-inhibiting behaviors.
Let’s go back to the issue of mental status for a moment. There are still perceived and real indications of
racism and bigotry in the United States—even today. This discrimination can lead to anxiety, stress, and
depression. As we have learned so far, stress and depression can have very serious health impacts on
individuals. Thus, there is a need to continue working on tackling the issue of racial discrimination and health
UNIT VIII STUDY GUIDE
Culture, Diversity, and Health Disparities
CHE 6303, Strategies of Health Promotion 2
UNIT x STUDY GUIDE
Title
disparities among minority groups. The medical care has to be comprehensive in that it should offer services
related to improving mental health and any behavior-related issues.
We have discussed all of these factors at some point in this class. Now, I hope you can see how all of those
are really affecting many individuals from minority groups and how important it is to have a coordinated and
robust effort at the local, state, and federal levels that interacts with the health promotion of minority groups.
Public health agencies’ practitioners, researchers, healthcare industry professionals, and local leaders are
trying to promote health and improve the lives of the individuals from those minority groups by consolidating
their efforts. These leaders are also directing their attention (in order to improve individuals’ medical care and
personal behavior, lifestyles, and conditions) to the following:
1. policies/programs/interventions to promote youth development and education;
2. policies/programs/interventions to promote economic development and reduce rates of poverty;
3. policies/programs/interventions to promote healthier homes, schools, neighborhoods, and
workplaces; and
4. policies/programs/interventions to improve living and working conditions (Cawley et al., 2015).
Culturally-Competent Care
Another important issue has to do with the way or ways a healthcare organization, such as a hospital, deals
with individuals from minority groups in terms of providing effective, timely, high-quality, and culturally
competent medical care.
Cultural competency: Healthcare professionals need to be aware and understand individuals’ cultural
differences, values, and norms in order to be successful in delivering medical care. Healthcare professionals
also need to have certain core competencies. When we talk about physicians, for example, we typically talk
about the competencies that fall into these six main categories:
1. patient care,
2. medical knowledge,
3. professionalism,
4. systems-based practice,
5. practice-based learning, and
6. interpersonal and communication skills.
Please consider all of the information discussed throughout the past eight units as you continue your studies
and professional careers. Public health education and awareness is at the forefront in the promotion of
improved health outcomes.
Reference
Cawley, J., Sweeney, M. J., Sobal, J., Just, D. R., Kaiser, H. M., Schulze, W. D., Wethington, E., & Wansink,
B. (2015). The impact of a supermarket nutrition rating system on purchases of nutritious and less
nutritious foods. Public Health Nutrition, 18(1), 8–14.
The Decline and Disorganization of
Public Health in the United States
Social Implications
William W. Darrow
Abstract
Public health in the United States has lost its edge. It made a significant impact on human
well-being, capacities, and potential in the late nineteenth and early twentieth centuries.
Now it takes a backseat to biomedical research and therapeutic medicine. Population health
with its traditional emphasis on preventing harm has been displaced by an exorbitantly
expensive and continually expanding medical care system devoted almost exclusively to
restoring or rehabilitating the health of patients – no matter the cost. The failure to control
the spread of human immunodeficiency virus (HIV) in the United States can be attributed
to adherence to an inadequate biomedical model that ignores the social. Social quality
theory, designed to further social justice, solidarity, equal value, and human dignity, can
contribute to identifying and correcting deficiencies in biomedical approaches to HIV
prevention and other public health problems that continue to plague the people of the
United States.
Keywords: biomedical model, disease prevention, health promotion, human well-being,
social quality, structural interventions, treatment as prevention
Almost 100 years ago, C.-E.A. Winslow (1920: 188) characterized public health as,
“The science and the art of preventing disease, prolonging life, and promoting physical
health and efficiency through organized community efforts and informed decision
making.” Much more recently, the Centers for Disease Control and Prevention (CDC)
Foundation (2015) defined public health as “the science of protecting and improving
the health of families and communities through promotion of healthy lifestyles,
research for disease and injury prevention, and detection and control of infectious
diseases.” In the same year, the Association of Schools and Programs of Public Health
(2015) left out both the science and the art in its action-oriented definition: “Public
health protects and improves the health of individuals, families, communities, and
populations, locally and globally.” These three different definitions reflect different
emphases by members of different organizations in different eras. The concerns and
strategies of the public health profession have changed as societies and the people who
live in them have confronted new challenges affecting their population’s health.
In contrast to private physicians and other clinical providers in the United States,
public health professionals try to prevent health problems from happening or recurring
International Journal of Social Quality 5(2), Winter 2015: 29–45
ISSN: 1757-0344 (Print) • ISSN: 1757-0352 (Online) © Berghahn Books 2015
doi:10.3167/IJSQ.2015.050203
William W. Darrow
30 • International Journal of Social Quality • Volume 5 Number 2 • Winter 2015
by designing, developing, and implementing educational interventions; formulating,
enacting, and monitoring public policies, delivering specific services, and conducting
epidemiologic and other kinds of applied research (CDC Foundation 2015). Since
public health is concerned with the health of entire populations and not any one
patient, it seeks to eliminate health disparities by promoting health-care equity,
quality, and accessibility. Private medicine, on the other hand, focuses primarily on
treating individuals after they become sick or injured. It involves the delivery of
medical services to a diseased or disabled patient in exchange for monetary fees. These
fees are to be paid by the patient, the patient’s family, or a private insurance company
and may be supported wholly or in part by contributions from local, state, or national
governments. Private medicine is a privilege, not a right of all citizens, and should be
contrasted with universally available “socialized medicine.” In the United States,
vested interests have successfully opposed having the federal government significantly
involved in the control and delivery of medical care (Pescosolido et al. 2001).
Both professions – public health and private medicine – are devoted to fostering
human well-being. Well-being has been defined as “a state of being with others, where
human needs are met, where one can act meaningfully to pursue one’s goals, and
where one enjoys a satisfactory quality of life” (Wellbeing in Developing Countries
2007). It is a multidimensional concept that combines a desirable end-state with
process and has both objective and subjective dimensions. Efforts to assess well-being
and understand the processes that affect it typically recognize various aspects, such as
the material, the relational, and the affective and cognitive (Gough and McGregor
2007). Since it involves how people think and feel about their lives, thoughts about
human well-being might include perceived needs, life goals, and subjective experiences
(McGillivray 2007). In an international Gallup survey, five elements were discovered
to be essential: (1) social, (2) financial, (3) physical, (4) career, and (5) community
well-being (Rath and Harter 2010).
The aims of this article are to compare and contrast the public health and private
medical professions in the United States, examine biomedical and alternative
conceptual models for the prevention and control of HIV/AIDS, and explore social
quality theory as a means of assessing current approaches to HIV control and achieving
human well-being. Since 1985, the federal government of the United States has
invested heavily in biomedical research to develop better diagnostic tests, safe and
effective antiretroviral therapies, a safe and effective vaccine, and a cure for HIV/
AIDS. To an ever increasing extent, it must support medical care for growing numbers
of men and women who become infected with HIV each year and must receive
expensive medical care for the rest of their lives. Little money is devoted to
implementing, evaluating, and improving structural interventions that address the
underlying causes of HIV transmission or to effective health education and prevention
programs that serve to interrupt continuing viral spread in states, municipalities, and
vulnerable communities of the United States. Social quality theory might provide a
way of correcting deficiencies in the prevailing “Treatment as Prevention” strategy
adopted by the Obama administration to prevent and control HIV infections in the
United States (White House Office of National AIDS Policy 2010).
The Decline and Disorganization of Public Health in the United States
International Journal of Social Quality • Volume 5 Number 2 • Winter 2015 • 31
The Evolution of Public Health and Expansion of Private Medicine
“Public health in the United States did not begin as a systematic, rational, centrally
directed activity following a coherent plan,” write Fee and Brown (2002: 32) in their
historical overview, “but rather as a fitful, episodic, and necessity-driven response to
immediate local threats.” The American Civil War (from 1861 to 1865) marked a
major turning point. Reform efforts led to the “sanitary science” movement and
creation of the American Public Health Association in 1873. Initially, physicians
provided strong support and leadership for the “practical application of public
hygiene.” Waves of immigration generated an interest in “progressive” ideas that
“combined the new sciences of bacteriology, chemistry, sanitary engineering, and
industrial toxicology with political, economic, and humanitarian principles” (Fee and
Brown 2002: 36). Progressives “sought a middle ground between the cutthroat
principles of entrepreneurial capitalism and the revolutionary ideas of contemporary
socialists.” They saw a need for governmental authority that emphasized “public need
over private greed.”
“By the early twentieth century, public health was seen as cost-effective as well as
useful,” notes Nancy Kass (2001: 1776), “and more money was directed to public
health programs.” After the armistice of the Great War (from 1914 to 1918) was
signed, however, the American Medical Association disproportionately increased its
influence (Fee and Brown 2002). Conservative private physicians opposed federal
programs as examples of “creeping socialism.” Public health in the United States was
“relegated to a secondary status,” observed Paul Starr (1982: 197), “less prestigious
than clinical medicine, less amply financed, and blocked from assuming the higher-
level functions of coordination and direction.” The surge of interest in public health
that crested in the Progressive Era crashed with the global economy in 1929 (Fee and
Brown 2002). The Democratic administration of president Franklin D. Roosevelt
tried to pick up the pieces with its “New Deal” in the 1930s, but World War II, the
Cold War with the Soviet Union, and McCarthyism diminished all attempts to
establish a national health service in the United States.
Post–World War II public health branched along two major paths: evidence-based
medicine and epidemiologic research into the deleterious effects of lifestyle (Berridge
2011). Generous amounts of federal funds were allocated to hospitals and a specialist
system of tertiary care (Brandt and Gardner 2000). Traditional public health (and its
focus on prevention) lost out in terms of power, prestige, and financing to technology-
based medicine (and its focus on treatment). Instead of reforming the practice of
medicine, evidence-based medicine sought to improve biomedical outcomes through
cohort studies, the randomized clinical trial, and other empirical methods. Changing
patterns of disease led to studies of chronic diseases with quantitative statistical
techniques to identify distal “risk factors” instead of immediate causes. Programs to
modify behavior through the persuasive use of mass media drew attention to
“individual responsibility” for health. Support for community health initiatives
virtually disappeared in the 1980s as neo-liberal critics in the United Kingdom as well
as the United States opposed “social engineering” and objected to “the nanny state”
dictating the proper way to live one’s life (Berridge 2011).
William W. Darrow
32 • International Journal of Social Quality • Volume 5 Number 2 • Winter 2015
The distancing of medicine from public health in the twentieth century was not
merely due to self-interest (Brandt and Gardner 2000). The profession of medicine
gradually coalesced around a rigorous scientific perspective and the fundamental
worldview of logical positivism, an abiding commitment to personal care and
treatment, and an ideological conviction about the sanctity of the biomedical
paradigm. Physicians had come to rely on an understanding of disease and its cure
that made public health’s broad social and environmental agenda superfluous. Many
doctors believed that public health could best be served by the medical care and
treatment offered by practicing physicians to individual patients. The reductionist
biomedical model minimized the role of societal, behavioral, and environmental
factors in the therapeutic physician–patient relationship. “Issues of socioeconomic
status, ethnicity, race and culture, personal psychology, and gender were no longer
considered significant factors in disease causation as individuals became patients in an
expanding tertiary health care system. Indeed, the very nature of the biomedical
paradigm was to uncouple disease from its societal roots and to focus research and
education on specific diseases” (Brandt and Gardner 2000: 711).
A New Perspective, New Public Health, and Health Promotion
Against the view of many disease entities partitioned into separate silos, there were
mounting concerns about escalating costs and limited societal benefits, especially in
countries that had established national health services (Berridge 2011). Canadian
minister of national health and welfare Mark Lalonde (1974) noted that the underlying
factors that influence susceptibility to disease lie in the social environment, physical
environment, genetic endowment, and the biological and behavioral responses of
individuals to potentially harmful agents. This “new perspective” divided the
determinants of health into four fields: lifestyles, environment, human biology, and
health-care organization. “A significant proportion of health care is ineffective,
inefficient, inexplicable, or simply unevaluated,” argued Evans and Stoddard (1994:
39), “We are reaching the limits of medicine.” They systematically developed a more
comprehensive model for making wide-ranging policy decision about health. “Well-
being, the sense of life satisfaction of the individual … should be the ultimate objective
of health policy,” they argued (p. 47), “the ultimate test … is whether or not it adds
to the well-being of the population served.”
Growing interest in evidence-based medicine and the effects of lifestyle in the
United States and elsewhere also led to conceptualizations of a “new public health”
and “health promotion” (Kickbusch 2003). Since the mid-1970s, the term “new
public health” had been recognized and defined in various ways by health professionals
working in different parts of the world. Tulchinsky and Varavikova (2010: 26),
working in Israel and the former Soviet Union as well as the United States, defined it
as follows:
The New Public Health [NPH] is an integrative approach to protecting and promoting the
health status of both the individual and the society. The dimensions of the NPH include
conceptual, methodological, scientific, political and moral factors recognizing the
The Decline and Disorganization of Public Health in the United States
International Journal of Social Quality • Volume 5 Number 2 • Winter 2015 • 33
interdependency and interrelationship of the health of people, communities, and nations.
As outlined at the Alma-Ata conference of 1978, the NPH encompasses a wide range of
essential preventive, curative, and rehabilitative factors crucial to the health and well-being
of a society.
Tulchinsky and Varavikova go on to say that the New Public Health is new in that it
links “health promotion” with health-care access; it is an integration of transdisciplinary
and multi-organizational efforts. The mission of the New Public Health is to maximize
human health and well-being and to help redress societal and global inequities. “Above
all,” declare Tulchinsky and Varavikova (2010: 28), “the New Public Health is
concerned with action.”
Health education in the United States, especially in the 1950s and 1960s, had
been used to motivate “at-risk” individuals by encouraging personal responsibility for
behavior change (Minkler 1989). A broader approach to stimulating action
accompanied visions of a new public health. The World Health Organization
conceived of health promotion as “a process of enabling people to increase control
over and to improve their health.” The process of empowerment represented “a
mediating strategy between people and their environments, synthesizing personal
choice and social responsibility in health.” The concept of health promotion was based
on the moral principles of an open society concerning the rights and dignity of all
human beings, respect for diversity and dissent, and with increasing social justice and
self-determination.
This new idea of health promotion, with its focus on empowerment and health as
a resource for living, challenged the prevailing biomedical model of doctor knows best
(Breslow 1999). Attempts were made to subvert the new discipline of health promotion
with its far-reaching consequences for social change (Berridge 2011). Funding was a
major issue and hospitals, doctors, and drug companies demanded the lion’s share of
it for research and medical care. Multidisciplinary research would be encouraged,
especially if it complemented evidence-based medicine and the biomedical model, but
always under the condition that the health-care industry controlled the purse strings.
Revolutionary ideas about “a new public health,” “health promotion” rather than
“disease prevention,” and “healthy cities” projects scattered around the globe were
unable to survive for very long in the United States due to the unfavorable political
climate of “privatization,” “deregulation,” and “downsizing government” that arrived
with the presidential election of Ronald W. Reagan in 1980.
Modern and Postmodern Public Health
The New Public Health with health promotion at its core held promise for replacing
the “incomplete, obsolete, and misleading framework” of biomedicine with a more
expansive biopsychosocial view of the underlying determinants of health (Evans and
Stoddard 1994: 59). Hopes were dashed when community intervention trials and
Healthy Cities Projects were transformed into “politically innocuous, inexpensive,
highly visible, and relatively ineffective” campaigns for individual behavior change
(p. 44). Van der Maesen and Nijhuis (2000) reacted against the trend to co-opt the
William W. Darrow
34 • International Journal of Social Quality • Volume 5 Number 2 • Winter 2015
new public health movement by making distinctions among “traditional,” “new,” and
“modern” public health.
Traditional epidemiologic methods, based on simplistic notions of causality, “are
too blunt to dissect the complexities of today’s health problems,” argued van der
Maesen and Nijhuis (2000: 134). They cannot help us understand the societal
dynamics of health and disease or lead us to interventions to bring about meaningful
change in population health. Contemporary public health, “with epidemiology as its
scientific core and rooted in Paretonian thought, is not logically orientated towards
understanding societal conditions that improve or undermine health and prevent ill
health” (p. 140).
In their original conceptualization, van der Maesen and Nijhuis (2000) used the
adjective “social” in a non-theoretical way. Since then, social quality scholars theorized
anew the noun “social” and also its adjective. It is a result of the dialectic between
processes of self-realization of human beings and the formation of collective identities.
The outcomes refer to the consequences of the current production and reproduction
relationships of people. They will appear as “societal outcomes.” In the context of this
theory the traditional non-theorized use of the adjective “social” refers in this theory
to societal phenomena. Also the adjective “public” in “public health” refers in this
theory to a “societal phenomena” and not to an equation of common aspects of
individual people. In the reference to van der Maesen and Nijhuis that follows, the
adjective “social” should be read as “societal.”
“Mainstream epidemiology increasingly serves as a tool of molecular biology,” van
der Maesen and Nijhuis continued (2000: 134); therefore, it cannot serve as “the
scientific cornerstone of modern public health.” “Most of the collectivist elements …
in the Ottawa Charter vision, with its emphasis on promoting health through state
policy intervention, action [g]roups (rather than individuals), involvement of lay
persons (rather than professionals) and the creation of environments that make
healthy choices easy choices, was lost in favo[u]r of strategies aiming at individual
behavior change” (p. 135). A new socio-ecological model is needed “to generate
knowledge concerning the [a]etiology of patterns of population health, disease, and
well-being” (p. 134).
In the conceptualization of a “modern public health” proposed by van der Maesen
and Nijhuis (2000: 135), “public is synonymous with larger social configurations
(communities) of subjects that interact. The reciprocity between social structures and
individuals is crucial. The social, political, economic and cultural conditions for
interaction are in a sense given, but the result of the interactions in turn also changes
the conditions.” The challenge for a modern concept of public health is to connect a
behavioral approach to individuals with a systems approach to societal-based
structures. In this vision of modern public health, societal aggregates should be the
unit of analysis and they should be assessed in terms of “social quality.”
Van der Maesen and Nijhuis (2000) point out that medical policy is not public
health policy. “Modern public health needs a new orientation, distinct from the old
public health (biological hygiene) and from the recent or new public health approaches
(individualistic health promotion). Modern public health means considering modern
problems of socio-political, socio-cultural and socio-economic relationships, new
The Decline and Disorganization of Public Health in the United States
International Journal of Social Quality • Volume 5 Number 2 • Winter 2015 • 35
forms of inequalities, exclusion and the marginalization of many groups of urban
inhabitants” (p. 139). Modern public health offers three strategies: (1) improving
societal conditions that stimulate health, (2) preventing societal conditions that
threaten health, and (3) neutralizing existing societal conditions that cause ill health.
“Growing individualization is a consequence of modern economic relations,”
according to van der Maesen and Nijhuis (2000: 140), “not a result of so called
postmodern philosophy as a deliberately chosen cultural shift.”
As the twentieth century was coming to a close, Inglehart (1997) described a
“postmodern shift” in advanced industrial societies away from religious and secular
authority to individual autonomy in the pursuit of subjective well-being. In contrast
to concerns about “inequalities, exclusion, and marginalization” expressed by van der
Maesen and Nijhuis, Inglehart drew attention to the high levels of economic security
and welfare attained within the past few decades by some nation-states. In these
countries, support for democratic principles was rising along with distrust of political
authority and big government. People living in these countries were more likely to
turn to self-help remedies and less likely to believe that governmental actions could
solve problems. Modernization was marked by a rational and legal worldview, faith in
scientific expertise, subordination of the individual in bureaucratic organizations, and
an “apparently inexorable growth of the economic, political, and social role of
government.” Post-modernization, according to Inglehart (1997), means a declining
respect for authority and governmental interventions, less faith in scientific advances
to help humanity, and doubts that technology will make our lives better. As some
societies move further into this postmodern phase of development, what are the
implications for biomedicine and “modern public health?”
Human Well-being and the Quest for Social Quality
Public health and private medicine have coexisted in the United States because both
professions were able to make their case for improving the quality of human life, one
by looking out for the well-being of the entire community and the other by looking
out for the well-being of the individual patient. Their professional interests diverged
when it came to competing for scarce resources to accomplish their respective missions.
Public health sought support to maintain health and prevent disease and injuries as
private medicine required more and more resources to restore health and treat disease
and injury. The rivalry intensified as medicine disproportionately increased its share
of revenue while funds to support public-health services continued to dissipate.
Toward the end of the twentieth century, public health realized that it had been
overtaken by the medical profession, declared the field to be in “disarray” (Institute of
Medicine 1988), and pleaded for finances to support essential public-health services.
Table 1. The Essential Public Health Services in the United States (1994)
1. Monitor health status to identify and solve community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve health problems.
William W. Darrow
36 • International Journal of Social Quality • Volume 5 Number 2 • Winter 2015
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care
when otherwise unavailable.
8. Assure competent public and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health
services.
10. Research for new insights and innovative solutions to health problems
The Essential Public Health Services describe the public health activities that should be
undertaken in all communities (Centers for Disease Control and Prevention 2014). They
provide a working definition of public health and a guiding framework for the responsibilities
of local public health systems in the United States.
In an article published in the first issue of the International Journal of Social
Quality, David Phillips compared quality of life, social quality, and human
development approaches to the individual and the social as understood in the social
quality theory (Phillips 2011). “Quality of life” has collective as well as individual
attributes. At the individual level, the concept includes subjective as well as objective
elements (Phillips 2006: 242). Basic needs must be met and material resources must
be sufficient to fulfill societal requirements. In addition, autonomy must be guaranteed
to make informed choices to enjoy, flourish, and participate in the full range of societal
activities. Collectively, quality of life requires socio-economic, socio-political, and
socio-cultural as well as environmental sustainability, civic integration, integrity,
synergy, extensive network ties, integrative norms and values relating to trust,
reciprocity, other-regarding behavior, fairness, equity, social justice, and egalitarianism.
Phillips (2011: 79) acknowledges that he has drawn from the work of Sen (1993,
2004), Nussbaum (2011), and others. An alternative approach is provided in social
quality theory that “was developed from the mid-1990s onward as an antidote to the
predominance of economic measures of quality of life.”
Social quality theory rests on the premise that people are essentially social beings
(Phillips 2011). The “social” is defined by the productive and reproductive relationships
manifested in structures, practices, and conventions (Lin et al. 2009). The theory
recognizes a constitutive interdependency: the dialectic between the self-realization of
individuals as social beings and the processes leading to the formation and re-
formation of collective identities (Phillips 2011). Tensions between societal-level
development and the development of individual human beings and between the
formal world of systems, institutions, and organizations and the informal life-worlds
of families, groups, and communities guide its examination and understanding of
societal transformation and the quality of daily circumstances (Beck et al. 2012).
Social quality has recently been redefined as “the extent to which people are able
to participate in social relationships under conditions which enhance their individual
well-being, capacities, and potential” (Berting 2012: 93). It enables reciprocity
between the operations of institutions or organizations (representing societal based
structures) and the interaction of people (representing human agency) (van der
Maesen and Nijhuis 2000). Social quality theory maintains that citizens must: (1)
have access to a minimum level of economic security, (2) experience a basic level of
The Decline and Disorganization of Public Health in the United States
International Journal of Social Quality • Volume 5 Number 2 • Winter 2015 • 37
social inclusion, (3) live in a community that exhibits social cohesion, and (4) be
empowered to develop their competencies. It also includes four core values (social
justice, solidarity, equal value of all humans, and human dignity) that align with the
four essential conditions (Ward 2006; Ward et al. 2011). The long-term aim “is to
enhance the social quality of people’s lives (especially vulnerable groups)” (Ward et al.
2006: 11). Social quality theory has relevance for public health, because the concept
of “social quality” serves to link the collective “public” with the personal “health” (van
der Maesen and Nijhuis 2000).
“Health related social quality refers to the conditions, circumstances, and societal
based systems (institutions, organizations) that improve or undermine health” (van
der Maesen and Nijhuis 2000: 136). With reference to medical policies, quality
primarily refers to the efficacy and the ethical aspects of medical interventions for
patients. With reference to modern public health, attention should be given to the
social quality of living conditions, circumstances, and systems. Social quality aspects
of health-care systems include a socially equitable distribution of services and their
availability, accessibility, and capacity for empowerment. “The challenge of our
modern enterprise of public health is to improve social conditions related to health.
In doing so, we are in fact meeting our values and norms, in other words, the ethical
questions of public health. In our opinion,” conclude van der Maesen and Nijhuis
(2000: 141), “modern public health, based on a theory of which we have attempted
to outline some principles, has to play an important part in this moral endeavor.”
The Decline, Disorganization, and Displacement of Public Health:
The Case of AIDS
Acquired immune deficiency syndrome (AIDS) was first recognized in the United
States by the CDC in summer 1981 (Valdiserri 2013). Epidemiological research into
the source of the outbreak suggested that it might be a sexually transmissible pathogen,
a previously unknown retrovirus was found to be the infectious agent, and an enzyme-
linked immunosorbent assay was developed and patented in 1985 to test people for
human immunodeficiency virus (HIV), “the virus that causes AIDS” (Darrow 1991).
Following these discoveries, the United States Public Health Service began to
formulate a response to AIDS that would rely primarily on biomedical research to
explicate pathogenesis, improve diagnostic tests and clinical care, develop safe and
effective therapies, deliver a safe and effective vaccine, and find a cure (Darrow 2013a).
In spite of failures to develop a safe and effective vaccine, find a cure, and reduce
the average number of new HIV infections in the United States to less than 40,000 per
annum, the United States Public Health Service remains resolute in its adherence to
the biomedical model. With evidence from randomized control trials that virally
suppressed patients rarely infect others, a “treatment as prevention” program has been
launched to find, test, treat, and retain in care at least 90 percent of all persons infected
with HIV in the United States (Bärnighausen et al. 2014). Increasing amounts of
federal funds are being spent on maximizing outcomes in President Obama’s “HIV
Care Continuum Initiative” as monies for social, structural, and behavioral interventions
William W. Darrow
38 • International Journal of Social Quality • Volume 5 Number 2 • Winter 2015
in the United States evaporate (Kippax and Holt 2009). Public-health programs
designed to mobilize communities, establish “safer” norms, and interrupt HIV
transmission have been displaced by biomedical programs designed to screen everyone
between the ages of fifteen and sixty-five years, immediately treat everyone who is
found to be infected and continue to do so for the rest of their lives, and prophylactically
treat everyone who is uninfected but at risk of HIV infection (Darrow 2013b).
Very little if anything contained in President Obama’s National HIV/AIDS
Strategy (White House Office of National AIDS Policy 2010) fits into the architecture
of Social Quality Theory. None of the four constitutional factors – personal security,
social recognition, social responsiveness, and human capacity – is addressed. None of
the four conditional factors – socioeconomic security, social cohesion, social inclusion,
and social empowerment – is addressed. None of the four normative factors – social
justice, solidarity, equal value, and human dignity – is addressed. Suggestions to adopt
a systems approach to HIV prevention and address the structural determinants of
HIV transmission were overlooked in the original strategy created by the president’s
advisers (Livingood et al. 2011). The 2015 update serves to reinforce the idea that the
sturdy walls of the HIV/AIDS silo erected by biomedical scientists and their political
allies shall remain intact (White House 2015).
Less than one year before his tragic death in the crash of Swiss Air flight 111,
Jonathan Mann (1998: 118) presented a paper to the Institute of Medicine in which
he described “a crisis of identity about the nature, roles, and responsibilities of public
health” and called for “a creative renewal, a renaissance of modern public health.” He
identified “social context” as the major determinant of health status, “Yet, paradoxically,
public health has avoided addressing directly the societal conditions which largely
determine the burden of preventable disease, disability, and death.” Public health must
work for “societal transformation,” and Mann believed that human rights provided
“public health with a more useful framework, vocabulary, and guidance for analysis
and direct response to the societal determinants of health than any framework
inherited from the past biomedical or public health tradition” (p. 120). President
Obama’s national strategy is all about “widespread HIV testing,” “linkage to care,”
“full access to pre-exposure prophylactic (PrEP) services,” “medication adherence,”
“remaining engaged in comprehensive care,” and “universal viral suppression.” It has
little to say about – and less to do with – the violations of human rights that racism,
prejudice, and discrimination continue to cause those communities in the United
States that are particularly vulnerable to HIV infection and related conditions.
The updated National HIV/AIDS Strategy based on “treatment as prevention” and
other biomedical interventions is difficult to justify in terms of the “Principles of the
Ethical Practice of Public Health in the United States” (table 2) or the “Ethical
Framework for Public Health” proposed by Nancy Kass. Kass (2001: 1776) proclaimed,
“Public health is the societal [not biomedical] approach to protecting and promoting
health. Generally, through social, rather than individual, actions, public health seeks to
improve the well-being of communities.” She proposed a six-step framework for
analyzing the ethical implications of proposed policies and programs, such as President
Obama’s “National Action Plan”: (1) What are the goals? – a major goal must be to
improve the health status of a population; (2) How effective is the program in reaching
The Decline and Disorganization of Public Health in the United States
International Journal of Social Quality • Volume 5 Number 2 • Winter 2015 • 39
its stated goals? (3) What are the known and potential burdens? (4) Can the burdens
be minimized or are there alternatives? (5) Is the program implemented fairly? (6) How
can the benefits and burdens of a program be fairly balanced?
Table 2. Principles of the Ethical Practice of Public Health in the United States (Public
Health Leadership Society 2002)
1. Public health should address principally the fundamental causes of disease and
requirements for health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the rights of
individuals in the community.
3. Public health policies, programs, and priorities should be developed and evaluated
through processes that ensure an opportunity for input from community members.
4. Public health should advocate and work for the empowerment of disenfranchised
community members, aiming to ensure that the basic resources and conditions necessary
for health are accessible to all.
5. Public health should seek the information needed to implement effective policies and
programs that protect and promote health.
6. Public health institutions should provide communities with the information they have
that is needed for decisions on policies or programs and should obtain the community’s
consent for their implementation.
7. Public health institutions should act in a timely manner on the information they have
within the resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of approaches that
anticipate and respect diverse values, beliefs, and cultures in the community.
9. Public health programs and policies should be implemented in a manner that most
enhances the physical and social environment.
10. Public health institutions should protect the confidentiality of information that can
bring harm to an individual or community if made public. Exceptions must be justified
on the basis of the high likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional competence of their employees.
12. Public health institutions and their employees should engage in collaborations and
affiliations in ways that build the public’s trust and the institution’s effectiveness.
Kass (2001: 1779) believes that:
Health education is the ideal public health intervention since it is completely voluntary and
seeks to empower people to make their own decisions regarding their health once they are
equipped with accurate information. From an ethics perspective, education clearly is
preferable to other preventive strategies, to the extent that they are equally effective, because
it poses few, if any, burdens.
President Obama’s national strategy is not molded around effective health education
for HIV prevention. His “National Action Plan” may benefit the National Institutes
of Health, CDC, and other federal agencies, the American health-care and
pharmaceutical industries, academic researchers and the universities that receive
reimbursement for indirect costs, state and local health departments, for-profit and
not-for-profit AIDS service organizations, and, perhaps a few others, but there is very
little chance that it will “improve the well-being of communities” suffering the most
William W. Darrow
40 • International Journal of Social Quality • Volume 5 Number 2 • Winter 2015
from the burdens of HIV/AIDS. Importantly, the incidence of HIV infection in the
United States is not decreasing. In Florida, the number of reported HIV cases
increased by 23 percent during the first six months of 2015 (3,555 persons newly
infected with HIV) compared with the first six months of 2014 (Sweeney 2015).
Further Considerations
The influence of the public-health profession on national health policy has declined
precipitously in the United States as the powerful interests of high-technology
biomedicine and its political supporters have risen (Fee and Brown 2002). The Reagan
administration set out to dismantle regulatory agencies and social programs in the
1980s and, subsequently, cut the budget for Health and Human Services by 25
percent, thus undermining early attempts to mount an effective preventive program
against AIDS. “Health is about political choices,” acknowledges Ilona Kickbusch
(2014: 83). The dynamics of health policy in the twenty-first century “will require
facing a matrix of power, interests, institutions which reinforce unsustainable
production and consumption patterns, unsustainable lifestyles and inequalities.”
Unfortunately, the focus of health policy remains on expenditures to treat those who
are sick rather than on investments to improve conditions for maximizing social,
mental, and physical health outcomes of all who live in the United States. The world
we want will not be the world we get without a new political and social movement
that addresses the social, commercial, and political determinants of health.
According to former CDC director Bill Foege (2010), a major problem with the
“dysfunctional” health-care system in the United States is that the marketplace that
controls health care is concerned primarily with profit, not with quality of care.
Treating disease is reimbursable, but preventing it is not. The US health system should
be reformed to provide incentives to assure conditions for people to be healthy and to
help people make healthy choices (Foege 2010). Jonathan Mann (1998: 119) agreed,
“Public health must work for societal transformation,” and offered a few further
recommendations. A shift away from biomedical traditions and toward modern
human rights is required to identify, promote, and protect the societal pre-conditions
for human well-being. Through its focus on societal determinants of well-being,
human rights provides public health with a more useful framework, vocabulary, and
guidance for analysis and direct response to the societal determinants of health than
any framework inherited from the past biomedical or public-health tradition. Human
rights have the capacity to change lives and the course of history.
The first public-health revolution dealt with the prevention and control of
communicable diseases, the second with non-communicable chronic diseases, and the
third with maximizing health as “a resource for living” (Breslow 1999). The concept
of “health promotion” was introduced to advance considerations of health beyond
disease prevention. “Health promotion has come to be understood … as a commitment
to social reform and equity” (Kickbusch 2003: 384). Health professionals “should
adopt a new mind set and ethos to enable, advocate, and mediate for supportive
environments, community action, and reorienting health services away from costly
The Decline and Disorganization of Public Health in the United States
International Journal of Social Quality • Volume 5 Number 2 • Winter 2015 • 41
treatments and towards cost-saving prevention.” The orientation should be holistic
and ecological rather than reductionist and pathophysiological, the emphasis should
be on health education (not on political propaganda and persuasive advertising), and
the focus should be on the determinants of health in populations.
“Biomedical approaches, by themselves, may be inadequate to reduce HIV
incidence,” admits Ronald Valdiserri (2014: 326). “HIV is a profoundly social disease,
its causes and consequences deeply embedded in the social, cultural and political
processes that shape national development, social institutions and civil society,
interpersonal relations and everyday lives,” write Kippax and Holt (2009: 3). In
contrast to the narrowly defined biomedical approach of universal testing, treatment,
and retention of infected individuals in care adopted by the Obama administration,
Jones and colleagues (2014) recently recommended an alternative “art in public
health” approach. Their public-health approach recognizes and seeks to address the
structural barriers of marginalization, stigmatization, and criminalization of key
populations, provide people at high risk for HIV with access to consumer-friendly
information and intensive community-based interventions, advance health equity,
promote human rights, and prevent new HIV infections. “To effectively reach key
populations and control HIV, far more engagement of communities and civil society
is essential” (Jones et al. 2014: 275).
Conceptualizations of health and its determinants are strategically important
because they determine the kinds of interventions that might be considered and chosen
(Fielding et al. 2010). Biomedical interventions narrowly address specific risk factors
or pathophysiologic causes of injury and disease. Comprehensive public health
interventions, on the other hand, more widely attempt to assess and modify policies,
institutional practices, community capacities, interpersonal interactions, and harmful
behaviors as well as biologic factors. The medical model cannot create healthy
communities, yet as much as ninety-seven cents out of every health dollar in the United
States continues to be spent on biomedical research and health care. State and local
governmental agencies must perform the ten essential services of public health with
very little support. Many of the 2,794 local health departments in the United States are
sparsely staffed and under-resourced; their ability to carry out necessary functions is
severely hampered. Marketing forces and commercial interests have stoked individual
desires at the cost of the common good. A major paradigm shift away from the medical
model is needed to design and support interventions and policies that provide the
greatest return across the full spectrum of health (Fielding et al. 2010).
Complex systems abound in public health (Luke and Stamatakis 2012). These
systems are characterized by nonlinearity, threshold events, and chaotic behavior. They
consist of many heterogeneous elements that interact with one another. The
interactions produce an emergent effect that is different from the effects of the
individual elements. This effect persists over time and adapts to changing circumstances.
To capture emergent effects, it is necessary to study the system as a whole, rather than
to decompose it and study its various parts. Traditional study designs and analytic
tools are inappropriate for studying complex public-health systems. Systems science
study designs, such as computer simulation models and network observation studies,
have the ability to assess the influence of context on health behaviors.
William W. Darrow
42 • International Journal of Social Quality • Volume 5 Number 2 • Winter 2015
Poverty-trap models that require a breadth of scientific methods and draw upon
the ecology of complex systems are an example of this kind of thinking (Ngonghala
et al. 2014). Biophysical and biosocial processes often play fundamentally important
roles in the structure of extreme poverty, but these processes are complex and include
nonlinear feedbacks. Developing poverty-trap models can provide a general framework
for exploring the effects of poverty on quality of life and can inform potentially
promising interventions with social as well as public-health implications.
Conclusion
Social quality theory was formulated in the mid- to late 1990s to provide a vision of
a united Europe pulling together disparate strands of public policy based on principles
of social justice and democratic decision making (Beck et al. 2001). The social quality
initiative rejected “turbo capitalism” and the traditional approach that subordinated
all areas of public policy, including public health, to economic policies and imposed
a top-down form of governance. It required governments to provide minimum levels
of socio-economic security, social inclusion, social cohesion, and social empowerment
to participate in community decision making. It advanced a new interpretation of “the
social” as an outcome of the dialectic of processes of individual self-realization and of
the formation of collective identities. It rejected the traditional duality between “the
social” and “the economic,” the “individual” and “social structures.” Modern public
health as a concept was based on the nature and consequences of this dialectic.
Instead of a focus on short-term profits, “dog-eat-dog” competitiveness, and
“winner-take-all” market mechanisms, the social quality approach brought people
together by enabling a large number of people and interest groups to be involved in
deliberations, decision making, consensus building, program implementation, and the
monitoring and modification of public policies. A social quality approach to public
health might provide an excellent opportunity for Americans to examine shortcomings
in the current HIV “treatment as prevention” strategy promulgated by biomedical
elites, consider more viable (and less costly) approaches to health promotion for HIV
prevention, and achieve better quality of life circumstances, especially in vulnerable
communities of the United States that continue to suffer the most. This will happen
by taking onboard the dialectic between people’s self-realization and the collective
identities they are part of. The reduction to the mainstream “individualism” as a neo-
liberal proposition rejects the adage that people are in essence “social beings,” a final
outcome of this dialectic. The adjective “public” in traditional “public health”
suppositions misses a theoretically founded meaning and is at the end of the day an
individualistic-oriented health approach. Such is the case with the current biomedically
driven “Test and Treat” approach to HIV prevention.
William W. Darrow began his career in public health with the New York City
Department of Health in 1961, conducted social, behavioral, and epidemiologic
research on HIV/AIDS and other sexually transmitted diseases with the Centers for
Disease Control and Prevention in Atlanta until 1994, and currently serves as a
The Decline and Disorganization of Public Health in the United States
International Journal of Social Quality • Volume 5 Number 2 • Winter 2015 • 43
professor of public health in the Robert Stempel College of Public Health and Social
Work at Florida International University in Miami. He teaches graduate-level courses
on ethical issues in public health, health promotion program planning and evaluation,
and the history and foundations of public health.
Acknowledgment
The author gratefully acknowledges the assistance of Professor Laurent J. G. van der
Maesen in providing helpful updates on recent developments in social quality theory.
No financial or other support for this work was sought or obtained from the Centers
for Disease Control and Prevention, National Institutes of Health, Bill & Melinda
Gates Foundation, Gilead Sciences, or any other for-profit corporation, public agency,
or private foundation. The author has no conflicts of interest to report.
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