Who speaks for health?

On the role of community voices in the work of public health.

Public health is concerned, correctly, with putting the community front and center in all we do. This reflects our intent to listen to community priorities and to center the needs of the communities we serve. We cannot fully address these needs if we do not engage with communities, making sure that we bring into the conversation those who are affected by the work of public health. One would be hard pressed to find much disagreement with this statement in public health today. And yet, the practice of engagement with communities can be substantially more complicated than this statement might suggest. Balancing the values, data, and often-evolving science that informs the work of public health can at times lead to uncomfortable conflict between the various considerations that inform the work of public health. Starting from a place of appreciation for, and elevation of, the community engagement that is central to our work, I wanted today to ask some perhaps difficult questions about what we mean by “community” and the extent to which our engagement with communities is sometimes complicated and requires careful thinking about what we do, and why we do it.

I will start with an example on a subject that is core to community health: care during childbirth. There has been a remarkable global decrease in neonatal and maternal mortality over the past several decades. This improvement is attributable, in no small part, to broader access to quality care during childbirth and in the first days of life. Providing such care means ensuring that childbirth takes place in facilities that have the capacity, staff, and equipment to maintain the safest possible environment for patients. Having such facilities also depends on having trained staff who can appropriately address unexpected emergencies; health care providers who are able to carry out technical procedures, like, for example, emergency surgeries, bring about better health outcomes. This suggests that our goal should be to ensure that all childbirth happens in facilities that are suitably equipped and have adequately trained staff.

At some level this statement is straightforward and does not seem overly challenging. Yet, getting to this goal in the context of childbirth is more complicated than it seems. A long overdue and decades long push to de-medicalize childbirth has led to a worldwide effort to create more opportunities for childbirth to happen in community settings. This has been an important movement, one that has seen a return to regarding birth as a process with the dignity of the mother and child at its center. However, the notion of childbirth happening in community settings is, in some contexts, at odds with the need to ensure these settings all have the trained providers who can provide optimal care, particularly in emergencies, and particularly in low-resource contexts. After all, as the Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goal Era noted, it is desirable that “… health systems be judged primarily on their impacts, including better health and its equitable distribution.” And when it comes to childbirth, it is not at all clear that this can be achieved in all contexts with community-based childbirth that is not accompanied by closely available specialized care. Rather, this suggests that all childbirth should take place in facilities that can deliver caring, supportive childbirth, with the capacity to handle urgencies to save neonatal and maternal lives. I am very much in favor of—and recognize that there is enormous support for—the idea of delivering babies at a clinic embedded within the community where the families live, and, as such, I understand it can feel “anti-community” to even suggest that not all community-based facilities can effectively deliver the safest possible care. But that is indeed sometimes the case. Recognizing that the safest care requires certain levels of service means having the courage to insist on such care, even if this means moving away from some community-centric work when it cannot meet the high standards of care that mothers and children deserve.

This has at times been met with community disagreement, and voices that argue for maintaining community clinics, even if this may challenge the achievement of optimal health indicators, in this case the wellbeing of mother and child. Implicit in the debate is the prioritization of some factors (such as proximity to delivery) over others (possible risk to the lives of babies and mothers due to substandard care). This raises an uncomfortable question: is the community right? The answer is messy. To say “no” is to risk tipping into the paternalism of which public health is sometimes guilty. Too often we have found ourselves imposing our approach on populations, replying to any objections with “Trust us, this is for your own good. You may think you know what is best for your community, but we know better.” This can lead to public health becoming arrogant or worse. The history of public health is the history of much progress towards shaping healthy populations. But we have also made mistakes, sometimes horrible ones, when we have ignored community voices and behaved with more regard for what we think is best than for the wellbeing of the populations we serve.

There seems little question that communities, then, are best served when they have a seat at the table of public health decision-making. These decisions are best made when they reflect a process of sharing—a sharing of values, of inputs and concerns, of our collective stake in the wellbeing of the community. However, this raises a complication—how do we deal with it when there are different community values about what matters for health, about what approaches should be elevated in our pursuit of health? Who speaks for communities, particularly when communities are not all speaking with one voice? These questions are not easy to answer, but they are unavoidable if we are to ensure we live up to the aspirations of public health.

Examples of challenges between expressed community preferences and better health outcomes are in no way new. When Edward Jenner developed a smallpox vaccine in 1796, for example, efforts to introduce inoculation to the population were met with resistance on the grounds of religion, politics, and simple fear, in an upswelling of opposition which prefigured present-day vaccine resistance. Had early 19th century scientific authorities chosen to defer to the community voices opposing vaccination, vaccines might never have had a chance to save the countless lives it would ultimately preserve. It is heartbreaking to think about a world in which we do not have vaccines, or in which we do not take steps we know will help save the lives of mothers and children. Even if the voices opposing public health in these cases are compelling, their reasons understandable, the weight on the other scale—the health of populations—means we should not lightly abandon public health approaches when our data and values strongly suggest to us they are right.

Returning to the example of childbirth, I think it is clear that the safety of mothers (and all child-bearing persons) and children should be our paramount concern and that other considerations should not distract us from this focus. We should listen, we should engage, always. But we should do so with the understanding that we have a responsibility to safeguard health. This is particularly so if this puts us at odds with legitimate perspectives that argue against steps we feel we need to take. In our pursuit of the mission of public health we should look to understand why it is that our aspirations may be misaligned with community aspirations, and how to best recalibrate towards ensuring we are balancing data, values, tradeoffs, and community concerns. Much of the push for community engagement in the context of childbirth has emerged from years of over-medicalization of childbirth. Our job is to understand that and to create environments of supportive, community-centered childbirth world-wide which are also supported by facilities that ensure the best health outcomes for mothers and children.

Where does this leave us? How do we make sure we always engage community in our conversations and actions on health, balancing at times different perspectives? It seems to me that the answers lie in much of what I have been writing about here—in the importance of public health thinking being humble and self-reflective, in establishing clear priorities in our engagement with tradeoffs and our efforts to balance values and data, and in respecting the autonomy of persons. The key to doing so is to aspire to a balance in our efforts, with community voices and public health data playing complementary roles. It is also important to remember that, in many ways, the distinction between public health and the communities we serve is a false one, creating a sense of “us” and “them” where one need not exist. All of us in public health come from communities and through our own experience we understand to varying degrees how these networks shape our values and priorities. This understanding should inform all we do. We should keep in mind, always, how perceived differences between groups are so often illusory, and we should work to build bridges that support the shared pursuit of health based on empathy, respect, and mutual understanding.

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Also this week.

I recently expanded communication to include Threads. Read latest posts here.