Grand Rounds: Public Health as a Public Good

Grand Rounds: Public Health as a Public Good


well good afternoon I am very excited to
be here I’m very excited that you’re all here and I’m very excited about what
we’re going to do this afternoon with all of your input and help so to set the
stage last spring as the department chairs of scoid center directors and
deans we’re meeting probably for the five gazillion time in in terms of
leadership thinking for the coming year it became very clear to all of us that
we wanted to shape Grand Rounds for this year as a vehicle for school-wide coming
together around several different things one of course is to help us see both
what the big issues of our present and future are and to help us recognize new
ways to think about them that could actually transform our thinking about
public health science and about public health itself and to to see if we could
look at issues that we take for granted that we know or ones we need to figure
out and actually rotate the lens a little bit into unexpected directions so
that we think we a to use land Freight Friedman’s
phrase and I seal in here so that we see the problem differently think about the
problem differently and perhaps that will enable us to solve it differently
and better the other part of this frame was that in that kind of disruptive
approach to things we have in our bailiwick and feel responsible for could
we see how thinking differently could in Abell interdisciplinary collaborations
on critical areas where in fact only interdisciplinary solutions may be able
to solve some aspects of that and as the school commits more and more and more to
recognizing the major interdisciplinary problems and to figuring out how we
potentiate the ability of faculty and students to understand them and solve
them and work together in those solutions our Grand Rounds would is a
critical vehicle we agreed to enabling that so Grand Rounds of course happens
just once a month not every day it is the one coming together of our faculty
and students when they join and we’re thrilled that the students are here to
really take on the intellectual issues that span all disciplines of public
health and to take them on together and to think in interdisciplinary and
transdisciplinary ways about them so that small agenda is what we’re about
and we are starting today with a very non-trivial question I believe in fact a
an over question which we would like to try and lay out some dimensions of from
myself and my three fabulous colleagues who are here and I’ll introduce them in
a second and then engage everybody here in thinking together about them because
the question affects all of us the question for today is I have to figure
out how to advance the slides oh here it is not working let’s say it’s Kim here I
need your help what do they do or what should they have done oh thank you
I hadn’t upside down good it’s a bad sign so the question we’re going to pose
to ourselves and to all of you is is public health a public good now it’s a
question that I think intuitively and implicitly we all understand that the
we’ll probably all think the answer is yes – or we probably wouldn’t be on this
mission which we are so passionately on but we would like to raise the question
– a very explicit level because we believe it’s a critical moment right now
in our history to be able to make sure that we can demonstrate the public good
value of public health in ever more compelling ways and so with that
background I’m thrilled today to be to be joined in this discussion by Ivan
Sampa from health policy and management on the Left Maryanne the–who’s last
name starts I always lose in pronunciation would you say it so I can
do it better thank you thank you and who I know a lot better than I can pronounce
her name and David Rosner from associate medical sciences I’m going to start this
off with some introductory thoughts about public health and public goods and
then we will hear about five minutes from each of my co-presenters and then
we will have a discussion among us and with you and their microphones here and
probably extra ones wandering around Kim is that right yeah so we hope that we
will have very engaged discussion so let’s start
with the question on the screen is public health of public good and ground
our thinking of course in the definition of public health from the National
Academy of Medicine the public health is what we do together as a society to
ensure the conditions in which everyone can be healthy a definition everyone in
this room can probably recite by heart and and it’s important I think for us to
be reminded about how much we do together and how much of a profound
difference we do make because that’s the starting argument about public good and
so I just want to share with you what was going on in the u.s. in the 1880s
when science came to medicine and to the beginnings of public health and American
medicine and American public health were founded remember this was only Ford let
30 to 40 years since the idea of the germ theory was introduced and yet at
the first meeting first couple meetings of the Association of American
physicians which is was the association that in a lot of ways was the
springboard for American medicine and public health before they started to
separate here are the programs from 1887 I selected things from the programs of
1887 88 90 just to think about how where we’ve come from in a mere hundred and
thirty years in 1888 we’re talking about the geographic distribution of typhoid
fever and in 1887 wondering if antibiotic treatment essentially aspirin
would be useful as therapy we I put in italics the presentation was the first
science that was a particular public health focus
so in 1890 the influence of soils in the causation of disease in 1891 what can
and should be done to limit the prevalence of TB and man and there was a
presentation by an expert in sanitary administration for cholera and Glasgow
1866 there were talks the first talks of those first science and the relationship
of drinking water to disease the bacteriological study of drinking water
etc etc so just to ground us and how much has been accomplished in 137
something years let’s then recognizing those roots Susser and stein laid out
this wonderful framework of the progression of science for health since
the 19th century since those presentations really taking us through
the sanitary statistics era which was that period and including the time I
just showed you cellular series infectious disease era
product is easier molecular biology era we are all still we are still in all of
these but we have been adding eras in a sequential and layering way including
eco epidemiology which has its foundations right here and the
personalized medicine my hope will add personalized precision public health era
in there and many others that many of you are working on and the progression
of these ears of science for health has had dramatic impact and I think
sometimes when we are slogging uphill with whatever Sisyphus and stone were
pushing it’s easier to easy to forget how much of a difference Public Health
has profoundly made think for example about causes the top three causes of
death in the United States which would which in 1900 were infectious disease
and by 1950 or chronic supposedly non-community
diseases and during that time there were dramatic declines in TB and typhoid
fever by 1949 smallpox was no longer present in the u.s. in the 1950s to 60s
the new vaccine led to the eradication of polio in the US and since that time
just focusing on infectious diseases due to vaccines since 1924 a hundred and
three million cases of smallpox polio measles mumps hepatitis A and diphtheria
have been prevented including 24 million in whistle s decade and then we can go
on from there and each of you can cite statistics of impact and your own in
many other fields but I’ll just pick out three first of all by 1950 more than
half the drugs in common medical use had been unknown ten years before so just
the explosion of antibiotics and other pharmacological therapies is really
pretty recent by 2000 public health science led interventions had led to a
decline in cardiovascular disease mortality rates in the u.s. to one third
of the 1960s rates with 50 percent due to primary and secondary prevention and
50% to treatment and because of all of this and so much more which we don’t
have time to go through today u.s. life expectancy rose from 47 in 1900 to 68 by
1950 and to 79 by 2000 and it’s still rising and we have created longer lives
really as the first time in human history when people are getting to live
this length of life so the impact of the work we have done as a field is
profoundly important and from these immense successes we have learned that
first of all science and evidence actually lays a basis
effectively improving health which was exactly the goal of the bringing science
into medicine public health in the 1880s in the u.s. we have learned the
societies that are ill or less productive leading many countries to
make a right to health a basic right of citizenship along with the values and
the principles that underlie that right to health and of course from our mission
point of view it’s very clear to us that investing in health of all her residing
in a society establishes our values and principles as a society and from all of
that we now have a lot of economic data about what the return on investment is
over and above well-being so for example Jameson at all published in 2013 that
achieving the MDGs was estimated to yield economic benefits of nine to
twenty fold in the coming 20 years and that globally every one dollar that was
invested for example of water and sanitation had a 4.3 dollar return
through lower healthcare costs for family planning had saved more than four
dollars on complications of pregnancies and the more you invested the return on
investment escalated in terms of childhood immunization that for every
dollar invested in seven vaccinations had a forty three billion dollar net
savings etc etc on a u.s. level the ROI analyses I think are quite compelling
for example the net benefits after taking costs into account of the Clean
Air Act Amendments a little bit contentious at the moment is that the
net benefits over 20-year period were twelve trillion dollars with a benefit
to cost ratio of thirty to one that’s probably about as good as it ever gets and that reducing childhood exposure to
another environmental toxin mercury through mercury and air toxic standards
led to savings of more than 37 billion dollars per year in health benefits over
a period of 10 years and I anti-smoking campaigns are highly cost effective and
their drug treatment programs for example for every dollar spent result in
seven dollars saved and benefits so the economic valuation of these health
benefits for society are also now present to a meaningful degree if not on
every issue we would like to have the month and there’s compelling evidence
for across this aggregate ways of thinking about it in terms of the value
of societal investments for health and the value of societal investments in
science for health and yet what’s going on in the US public health all share of
US health spending is dropping it reached a high in 2002 of 3.1 8% of
total health expenditures decline from 2002 to 2014 to 2.7 percent and is
projected to declined in by 2023 to 2.4 percent of US health expenditures even
while we blithely say that for example public health is responsible for 70% of
a populations health and since 2008 the per capita public health spending has
fallen by 9% now Aristotle said if we go back a little ways what is common to the
greatest number has the least care bestowed on it is that what’s going on
and if so what do we do about it another rather famous person reflected on that
when Adam Smith when in 1802 he said he recognized the existence
certain Goods and I quote which though they may be in the highest degree
advantageous to a great society are however of such a nature that the
profits could never repay the expense to an individual or a small number of
individuals and which it therefore cannot be expected that any individual
or small number of individuals should erect now another way to say that I
suppose is that public goods without strong special interest support are
likely to be under provided their number of political scientists in the audience
and so when we get to discussion period I hope you’ll weigh in here but based on
those recognitions of course there is a strong theory of government for
centuries that society needs government to overcome the failures of the market
and in that investment in allocation and distribute distribution of these kinds
of public goods that special interests are not going to adequately invest in
and that government is the provider of public goods to supply those collective
needs that society has and that government interferes either financially
or by direct provision on those select items aspects even though it is we all
assume that private goods and services will always constitute the bulk of
people’s purchases and finally that people centred societies call for a wide
range of publicly supplied goods when people cite public goods in the main
they’re not talking about public health they’re talking about parks they’re
talking about social security they’re talking about police they’re talking
about transport they may even be talking about student aid but in most of the
discourse public health doesn’t show up there are some recent exceptions to that
and so what I’d like to pose to us today is where is public health and where
should it be in those in that theory and the practice now there are principles
for for the standard economic definition of public goods that once provided no
one can be excluded from receiving them so non-excludable and one person’s
consumption doesn’t prevent anyone else from consuming it so non so if I get it
you still can get it too so we’re not in competition we’re non-rival hrus and
finally that there’s no commercial incentive to produce these Goods because
enjoyment can’t be made conditional on payment so I’m sure I would imagine that
in this quite expert in a studio audience all you’re sitting here and
saying yeah there clearly are clear public health examples of that are they
all aspects of public health maybe we can think about that one place to start
from the evidence I showed you in thinking about whether public health is
a public good is that I think we’re all in agreement that it’s needed by
everybody that most effectively it’s delivered at a population level much of
it and at scale and that that kind of approach for certain problems that need
to be solved is highly effective and cost-effective and I showed you often
has a high return on investment and many aspects of what public health delivers
are both nonexcludable and nonrival risks in that economic definition and we
all know that we are gonna need public health science public health policy
public health practice even more in coming years given the complexity and
seriousness of the problems that were confronted with both nationally and
globally and their pace basic public good needs that if they are retracted if
they’re invested in the problems very rapidly
reemerged like when grease in the face of austerity cut back on spraying
mosquitoes and basic Public Health functions and suddenly Greece started
seeing malaria where it hadn’t seen it before in years 40 years now the the
case that’s always offered is the most obvious one in terms of public health as
a public good is the prevention and containment of infectious or
communicable diseases both in terms of preparing for the next pandemic and how
to respond to it as well as in terms of disease eradication less obvious are
many other issues and under discussed are most other issues but certainly at a
global level we have lots of threats that one could think these same cat
these same criteria could be extended to from antimicrobial resistance to
emerging infections global climate change and health impacts environmental
degradation and health impacts global food systems issues of how patenting
patenting makes discoveries excludable and or exclude excludes people from
access and probably a host of other issues spats said now 18 years ago a
globalizing world requires a theory of global public goods and that many of
today’s international crises have their roots in a series under supply of global
public goods I I would say that it would be very valuable for us as a faculty to
interrogate that and also to interrogate the value of what we do every single day
in terms of science but and to make the compelling case and figure out how to do
it as to how you particularly for us in a national and parochial way u.s. health
science investment is a public good for our country as well as for an
interdependent world statement was that it helped people
everywhere benefit from the accumulated stock of global knowledge but at this
time I think it’s very important for us to grapple with how to articulate the
value of science for health I think we have assumed as a society that public
health science and practice are public goods but given the decreasing support
well governmental public support for public health and as I showed you in
some of the data before we have to ask are there rationales that are not
grasped that we need to offer for the high value of this investment and for
the public good does a case need to be made that the public’s health is a
public good in ways we’ve never made it before and how do we make that
compelling and how do we articulate the value of health itself and what public
health brings to health and how do we articulate a more compelling explication
of why science for health not only matters but is critical for our
collective future and of course in a time of scaling back of governmental
commitments and a time of really complex health problems that are ahead of us do
we need to also draw in other sectors like the corporate sector to be
responsible for the public good with government in new ways one of the people
who wrestled with that question was Elinor Ostrom who run won the Nobel
Prize a decade and a half ago for her work on governing the Commons and she
focused on the issue of the tragedy of Commons the degradation of the
environment which is to be expected whenever many individuals use a scarce
resource in common like our planet and she offered that neither the state nor
the market is uniformly successful in the in this context and enabling
individuals to sustain turn productive use of natural resource
systems and that we needed to look at novel combinations and approaches that
work could be more optimally successful in securing the public goods so I’ll end
by saying that a series of prepositions that if science for health and health
itself are understood to be public goods than it is to our collective benefit to
secure these and that pure public goods that are inseparable that are
inseparable and inclusive and have been relied upon to be provided by public
leaders but the public means are declining and how do we confront that
Adam Smith again said in 1802 increasingly we will need to be explicit
about explicit about how governments and markets should work together to provide
the range of goods fundamental to people’s well-being and I believe that
we need as a faculty to think about whether we need to develop articulation
of how to include health and science for health expectations in investments in
the public good expectation so thank you I’m gonna stop there I hope that this
framing was useful and I am eager to hear from my colleagues and we’ll start
with having some pot great hi hi everybody Thank You Dean
freed for the further great setup so we were asked to summarize our thoughts
briefly so we can get on to the to the more useful Q&A and I’ll try my best to
just make a few high-level points here so the punchline here is that I’m
actually a little bit I’m an economist by training I should say and I’m a
little bit nervous about the public health as public good framing at least
from an economic perspective and originally I thought that this would
make me an exceptionally poor candidate for this panel but I was told it’s okay
even encouraged to be disruptive so that’s that’s a little bit what I’m
gonna do but hopefully kind of pre creative at the same time I will also
apologize I’m going to be a bit pedantic about the economic meaning of a public
good and while normally I’d be reluctant to do so I think that a lot of the kind
I think is appropriate to do so since a lot of the move to cast public health as
a public good is quite explicitly trying to invoke things like non-rival tea and
non-rivalry and non excludability and some of the some of the economic
concepts and I kind of want to talk very quickly about where that takes us so as
linda pointed out a public good is a polar case of an externality it’s a non
rival in the sense that the cost of extending the service to an additional
person is zero it’s not excludable in the sense that it’s difficult or
expensive to prevent non-payers from from using it and things like national
defense and lighthouse and firework firework shows are sort of classic cases
of public goods now I’ll start by saying I very much understand the appeal of
this frame especially in the here-and-now
so public goods are the types of things that everyone from Adam Smith to the
Heritage Foundation to Paul Ryan kind of agree that you know are a useful thing
for the government to be to be doing given market failures and whatnot and
indeed as Linda pointed out not only some of Public Health’s but some of
humanity’s greatest achievements have involved Public Health generating public
goods from you know smallpox to control pollution
and climate change or the efforts to control it and and things like that and
I think even going forward a number of our Grand Challenges to use that
terminology antibiotic control climate change again an old classic that’s made
a comeback nuclear proliferation involve kind of public good kind of issues so I
and I do think there for a number of issues we can get some analytic traction
from this concept a particular case where I think it’s quite useful is is in
there is this idea of global public goods because it highlights this idea
that there you know the unit of analysis there is the state and the complicating
factor is that there is no world to government right so the public good
frame focuses our attention on how to design global institutions to support
these kinds of things where there are likely to be freed up free-rider
problems right and I think that’s that’s a key thing about public goods
you know the reason we don’t have them is because they’re free-rider problems
I’m waiting for you to provide it you’re waiting for me to provide it technically
speaking that’s that’s that’s a global public good and so or a public good and
you know there’s work by Scott Barrett who’s at SEPA are calling it CPA he’s
done some work on global public goods and what what you really get from that
is the rich and variegated set of things that fall under this umbrella of global
public goods and you see the power of the concept because it helps you think
about how something like asteroid you know preventing an asteroid from hitting
the earth is a very very different public good provision problem than
climate change which is very very different still than disease eradication
I’m in the first case it’s kind of the best effort across nation states that
matter in the second case it’s the aggregate effort and in the third case
it’s the weakest link so that’s kind of how the concept can be useful it helps
us think about the kind of institutions we need to Pro to provide the kinds of
things that would benefit us all as linda indicated the frames also useful
in thinking about political economy so i realized at times arrival good so i’ll
try to go quickly over this you know some of
you may have seen the signs upstairs you know there’s a rally for medical
research in Washington DC today and there you’ll see not only advocacy for
science as a public good but also for cancer research of science so cancer
research is a public good Alzheimer’s research as a public good
and they’re the frame does help us think about why public health doesn’t do all
that well because the beneficiaries of public health research are kind of very
diffuse may not even be born yet may not even know that they’re likely to benefit
from these kinds of activities and organizing around that is it is very
very difficult so there too the concept I just I think does provide some
analytical leverage that’s that’s quite useful to us so so that’s really good
and in my last minute or so this is where I’ll be a bit disrupted I think
it’s a mistake to frame public health as a public good in general at least if
we’re trying to bring all the economic baggage of public goods with it and
that’s because of what that framework leaves out so many useful public health
activities don’t fit neatly in this faint framework without a lot of
semantic gymnastics clearly infectious disease control pollution reduction
things like that do but others the NCD problem guarantee and human rights
access to medicines insurance healthcare those things you can kind of strangle
the concept to kind of get it to fit there but it you know it doesn’t it
doesn’t fit naturally and this is this is a point that you know people from you
know libertarians like Richard Epstein to our former chair of hpm Sherrod lead
have kind of made that you know if you want to use the public goods apparatus
that’s gonna exclude a lot of things that are traditionally thought about as
public health activities so to be clear you know in conclusion I’m here neither
to defend the economic concept of a public good nor to bury it rather the
point is that it’s useful for thinking about some collective action problems
but when taken literally it leaves a lot out and when not taken literally it
loses much of its of its analytic force since the goal is to be not just
disruptive here but also Interdisciplinary I’ll end by saying
that for things like national health insurance prevention Human Rights access
to medicines even you know many economists including I think all the
economists on our faculty believe that the government should be involved but
it’s not because their public goods but it’s it’s for ethical reasons because
they’re the right thing to do but unfortunately since Smith and Hume you
know while they did today we economists don’t have very good language for
articulating kind of the right thing to do and I think an interdisciplinary
conversation around economic and other definitions of the public good perhaps
bringing in some political scientists on useful policy frames would be it would
be an interesting one indeed so I’ll stop there and look forward to the Q&A hello everybody thank you for coming
very much so I’m going to shift gear a little bit and I’m going to focus more
on environmental health as a public good just because it seems that it’s
especially under attack recently and I think at least in this room we can all
agree that a clean environment is a collective benefit that no one should be
excluded from efforts to minimize environmental pollution should be
considered public good even if we adopt a more social definition of perceived
public needs and once we know there is clear evidence that environmental
pollution causes ill health and when it’s removed health improves no one is
excluded from this benefit and everybody gains and I’ll be using air pollution as
an example because one that’s what I do but too easily it can be easily extended
these concepts that all say can be easily extended to other environmental
exposures think of lad think of pesticides other heavy metals and so on
sir pollution is a well-established environmental threat globally not the
first but probably the most notorious air pollution episode most of you here
have heard of is called was called London Fog during
one week in December 1952 in London air pollution concentrations skyrocketed and
in January of 1953 next month three papers appeared at the land set of me
showing that following that episode the number of deaths and the number of
cardiovascular respiratory admissions with emergency admissions were 2.5 to 3
times higher than expected forty years later the New England Journal of
Medicine published the Harvard six cities studies which is the
quintessential against air pollution and health study showing a link between air
pollution and mortality this monday preparing for this they did a very quick
PubMed search for air pollution and mortality and that yielded around 4,000
papers just mortality no other outcomes in June the New England Journal of
Medicine again published the most to take the most comprehensive air
pollution study of more than 60 million Medicare and release across the entire
United States confirming all previous findings and also showing that even at
air pollution levels below well below the current national standards this
length of their pollution and mortality still holds it’s not just mortality fine
particles and diesel exhaust have been classified as known carcinogens to human
other outcomes include cardio respiratory endpoint neurodevelopment
neurodegeneration adverse pregnancy outcomes and many many more and there
has been progress we are doing progress in the United States and Europe air
pollution levels have been steadily slowly but steadily decreasing but we do
still hear about these cheating scandals implying that maybe not all of us are on
the same page yet and globally on average air pollution levels have
actually been increasing in 2015 the most recent gbd ranked exposure to
ambient fine particles as the fifth factor for mortality risk factor
and six factor for dollies globally so air pollution is bad
clean air pollution is a public need once clean air is provided no one can be
excluded so it’s not excludable and if I breathe in clean air if I consume it
that doesn’t prevent anyone else from also breathing in clean air so it’s
non-rival risk so it also meets the strict definition of public debts as
well in this case and the knowledge the information that air pollution is bad
should also be public goods and once this knowledge is disseminated then we
can all it will enable all of us to demand action to understand the issue
and demand action so in my last few minutes I’ll just like to finish with
some questions that I have personally been struggling with especially since
November so I said information and knowledge
should be public goods but are they actually public goods these days or are
they just access goods now and the scientists we are doing our jobs we’re
doing our research we are publishing our papers but we are also educators with a
capital e and with that hat on are we doing our job adequately adequately
sorry are we disseminating the knowledge are we adequately adequately difficult
work for me apart you communicating the risk and should whom should we
communicate these risks to our students our peers that we are doing hopefully
okay but also the general public the regulatory agencies the industry to
maybe change their practices or chemists and engineers or engineering schools to
promote development of new technologies that would help address these issues
because efforts to minimize environmental pollution should be a
partnership between the public sector the private sector and academia and as
public health leaders in one of the best universities in the world what is our
job in this equation what is responsibilities in in doing our job in
disseminating this knowledge to whomever we should and does this responsibilities
depend on and should it be reactive to government actions and regulations or
rolling back of regulations the achievement of clean air of clean
environment and the positive impact on health should be considered public good
what are some responsibilities in promoting and ensuring this recognition
and thank you let’s see if I can get this technology going first of all I
think Mary Anza raised a very important question let’s see if this works
ok ok I’m going to talk about a very practical issue which for historian is
usually unusual more than likely we’re expected to talk about totally
irrelevant things about some distant moment to the past but what I want to do
is talk about one of the themes that this series is built around disruptive
thinking and how we can really in some sense encourage it
maranatha began by saying who should be educating who should be talking to who
should we be trying to influence how should our knowledge or our specialized
knowledge be disseminated what I want to talk about is a website that we’re
developing with at the website the center which hopefully will be a public
website that will create disruptive thinking and that will educate
populations that previously had no access to the information they
desperately need the website is a brilliant invention of really Merlin
Chuck kuan-yin who has taken about six million corporate documents that I and
Jerry Markowitz have accumulated over the years and figured out a way of
trying to make them useful to communities and to different populations
that are involved in protesting and discussing and debating about what is
disease what is occupational disease what is
environmental disease who should be responsible for the damage done by a
century of industrialism who should be holding bearing the responsibility for
cleaning up the mess we’ve gotten into and in some sense how do we assess
responsibility for harm what happens essentially when a public good comes up
against private Bad’s that’s what the website’s really built around it’s built
around making millions and millions of documents available I just put these
pictures up because what I want to transmit to all of us is that there’s a
huge public debate going on outside the walls of this institution going on
outside the walls of academia going outside the walls of the NIH and the
government itself the debate is happening in newspapers the debate is
happening in community discussions about why their ground waters polluted it’s
happening in every community from Flint down to Houston today and it’s a debate
about the role of the role of corporations and having created a toxic
mess and who should be accountable to it in that debate
our lawyers communities workers that have been affected by damage done to
them I raise this only because sometimes we think of public health is essentially
our own private preserve something that we control and we define but in fact the
debates over what even diseases is occurring in a public sphere that we
have to be responding to so effectively what I’m trying to point out is that
this website is really an attempt to attempt to bring to the public what we
believe is important information but also to communicate with the public what
they can use in their own battles and their own discussions about what is
disease and who should be held accountable I got involved I’m going to
go through a brief little history of my own little experience because I’ve been
deeply involved in lawsuit around environmental damage in which
judges and juries and judges and juries and expert witnesses are all coming in
and out of court discussing very sophisticated issues than that we have
to really be aware of these occurred because of a series of books that I and
Jerry markets have written and a lot of information that we’ve accumulated over
the years through these lawsuits for those of you don’t know it there’s an
extraordinary body of information about what science knows what corporations
knew what people were testing how they were testing and how they were shaping
our perceptions of what our responsibilities are over the decades in
the corporate coffers that have been coughed up literally by of these
lawsuits since Mary Alfa began with lead with air
pollution I just wanted to start out with this one slide because this is
really the issue that got me involved in in all these environmental suits and
that was a lawsuit a series of debates that occurred in the 1920s about the
introduction of tetraethyl lead into the gasoline cars were then beginning to
burn at the beginning of the 20th century I just want to point out that we
were at the center of that we seen public alarm about what could be the
long-term effects of the introduction of what was known as a deadly industrial
toxin led into a widely dispersed environmental toxin gasoline when it was
burned this was the first real linking of what was understood as occupational
disease with what was become very soon understood as environmental disease and
under our environmental damage it’s kind of the beginning when the government
actually for the first time began to identify an environmental toxin
something that had previously been kept within the walls Jerry and I wrote this
article cost a little bit of problems we then in fact got very involved in a
whole series of lead paint suits I’m not going to go too much in but basically we
went through records that we were revealed
through discovery of lead industry corporate documents which revealed a
long history of knowledge about how the public good was being undermined by
private greed essentially and these documents led to really the uncovering
of a huge number of materials that ended up in court cases around the country
these were the kinds of documents juries saw from the 1930s to the 1950s about
how lead was understood as a toxin killing children literally virtually
every day by the lead industry these documents ended up causing lawsuits and
creating lawsuits not about past damage not about what’s been done to people but
lawsuits which were aimed creatively at trying to create a new body of law that
would actually prevent future damage these lawsuits were built bought in
order to gain money for public health departments around the country for us to
basically remove lead from the walls of the nation the corporate discussions
that occurred within the walls of these corporations ended up leading to the
kind of reaction on the part of the public that said they knew they made the
mess they are responsible for it 19 2005 we were involved in major lawsuits which
revealed to the journal to thee in to the juries these kinds of internal
documents that talked about lead poisoning among children and also
pointed out how they were marketing led to children in their various kinds of
ads these were very effective they were effective not because they proved
epidemiologically the statistical relationship between exposure and harm
but they proved it to juries that had a common sense understanding that
something wrong had been done that this was a moral choice that the society had
made to allow corporations to continue to do that in the absence of concrete
statistical evidence these are just some images from a little booklet that
I love these that made a big impression on juries because they really talked
directly to how directly they were trying to influence children to buy
products and use products that were made with lead at a time when they were
internally discussing the dangerous to these very same children this led us
into some problems needless to say pain lawyers work to
describe it historians they say headlines that historians rarely see
about themselves the newspapers made was quite proud during this court case when
I was on the stand for six and a half days pain lawyers were that discredits
historian lead paint historian testifies for third day lawyer historian spar over
LED paint the reason I’m pointing this out is because we were talking not to
ourselves and not to other professionals but we were talking for audiences of
people who understood what was at stake and had a very direct interest in it
this was with the result of what of the lawsuit this is a headline from the New
York Times on in April after the lawsuit ended which the jury came back with a
decision to order to order the lead industry to pay four billion dollars
would be billion dollars for the state of Rhode Island to remove the light from
the walls of primarily Providence that was later overturned by the Supreme
Court but it was a groundbreaking decision in which for the first time the
industry was held accountable from a massive industrial pollution this is
what happened to us just very quickly this is not just an academic debate
that’s going on about what is the public good and who should be held accountable
for past harm this was a response of the industry in which we were told this was
a law article that said we could safely leave the fate of Rosner and Markowitz
as historical scholarship to their community of acted emissions and
historians baffle one discomfort in fact either directly through their
participation support cases as expert witnesses or indirectly through the
opinions offered there see our sneaked into evidence the views of Rosner and
Markowitz have become part of the passion play we call environmental
litigation that was the next slide next page this
is kind of an interesting argument because what we’re arguing about is how
people think about disease and who has a right to make a judgment about disease
I’m going to go through this very quickly I guess these are just articles
in which were being recruited to testify for the lead industry they’re recruiting
historians and and also an attack that occurred upon us in which ten of the
largest corporations in the world decided to to go after two little
historians because it seemed like there was a real impact there right now I’m
gonna just stop with this one they’ve tried to show you the the website very
very quickly so you can all take a look at it at your leisure the there’s
presently a lawsuit that was just heard before the appeals court the appeals
court in California based on the same principle that Rhode Island had brought
their four billion dollar suit last year two years ago a California jury largely
based on historical evidence decided that the industry should pay California
the cities of San Francisco San Diego and Los Angeles and Oakland of a billion
two hundred thousand dollars to take light off the walls of their state this
is another very similar suit of the Rhode Island sea with few little legal
Jags to try to get over some objections of Supreme Court ad but they heard the
PLS guests last month and we’re all waiting for a legally if I have to make
a decision but if this goes through this will be a mammoth change not only for
lead poisoning but for all sorts of environmental lawsuits because the
environmental law community world is watching very carefully as this debate
between who has the right to decide what is a danger and who should be held
accountable for the past is fought off in every in every way so these are let
me just see if I can get I don’t know how I get on this thing click it click what you can’t assume don’t assume
you don’t know who you’re talking to but I just want to very quickly show you
this website and then you can all play with it and see all sorts of great
things oh you didn’t tell me about okay Lissa I’m not gonna show you okay go to
toxic Doc’s org and play look up your favorite chemicals look up your favorite
industries look at your favorite companies and look back at forty to
fifty to sixty years of records in which they in their grand design discuss the
various ways the various problems okay let me just show you a couple of the
word eternal I’m it’s really my favorite thing we’re about to launch it just one
minute just one minute okay then we’ll get the discussion I’m sorry well it
doesn’t work look it out I was really talked about what these four
countries what all of what we know each other I know this is technical
literature on public good and some people take public foods and all that is
very poor but I think what is critical whether they talking about the
environment or whether we’re talking about exposure to environmental toxins
is quietly so difficult to start a sentence what do we know each other
not unless we’ve painted you something but because I what not what I think the enemy tries to the
NA em has tried to deal with this by talking about what we do collectively
but I think the language of what we owe each other this is kind of I’m less
interested in the technicalities of philosophical discourse or economic
discourse but if we could join a discourse that began to talk about what
we owe each other and how we fail each other that would really advance this
conversation across disciplines it seems to me I’m not sure whether that’s true
about across kind of political lines but we don’t have a voice that talks about
that we know what it means when we talk about national defense but we don’t know
what it means when we talk about our social welfare and that’s what I’d like
to see the Cubs where I’d like to see the conversation go so I’d like to
invite your thoughts Kim has a mic or their mics on the side Bhavan do you
want to start so so Ron excellent point is excellent
point as always and I think we are you know I am very much in agreement with
you that I think actually when we use the term public good in an economic
sense I mean I think once you do that you kind of have to play by the rules of
using it in the economic sense but I think that crowds out a lot of the the
kind of concepts that that you raise which I think in our gut when we think
of public health as a public good or anything as a public good are kind of
kind of resonate resonate more but something you said near the end about
what would have traction politically I mean I think the economic argument in
the current political environment and maybe in many political or environment
the economic sense of the public good kind of crosses aisles in a way whereas
the the concept of the public good that you articulated is a harder one to sell
and I agree that’s something that we need to work hard a little bit to go
back to a point that you made before which is that even economists need to
find an additional language to express public health as the right thing to do I
can’t quote what does that really mean to you well I’m not sure I mean I don’t
think we’ve we’ve done it so I’ll say it I’ll say a couple of things I’ll say a
couple of things there’s an excuse me Ron and others for being a little bit
kind of technical with the terms I mean there are things where the social
returns are greater than the private returns where there are not public goods
so you know not everything where social returns are greater than price I mean
those are just cases where the market will fail and I think economists and
others in this room are pretty good at thinking about doing sort of
cost-benefit analysis in those sorts of cases so you know you can think of
public goods as being a subset of that but that too I mean that wouldn’t
respond to Ron’s question that too is going to leave a lot out I guess I can’t
answer your question I’ll say this that way back when in the 19th
when paul samuelson kind of developed the idea of public goods simultaneously
and we talked about this there was a guy named Richard Musgrave he was a graduate
student with Samuelson and he’s got he’s kind of like the Forgotten co-inventor
of public goods but he’s also he makes two kind of interesting points one is
that the whole kind of market failure public good framing is dangerous because
it kind of makes government and the public sector you know unnecessary evil
as opposed to kind of a useful actor in its own in its own right that has
certain institutional advantages over over markets and then second he coins
another term this is I you know I hesitate to introduce it but I will he
coins yet another term called merit goods which are things that we kind of
think that the public should provide because it’s it’s the right thing to do
and you know I don’t know where that literature is good but that’s one place
where I look I’ll say that modern neoclassical economist which is the
mainstream economics it’s taught you know in most universities beyond public
goods and beyond thinking about market failures we don’t have much of an
apparatus which is exactly why I think an interdisciplinary conversation would
be useful because there are gains from trade so I I would love to have many
people weigh engineer ale has the mic okay you know I want to pick up on
something Ron said because I think it’s really the same thing that you’re
talking about David in terms of trying to get this information out I would like
to link that back to something Mary Ann has said about really reaching certain
kinds of people so you it’s not so much we don’t have a voice I can relate to
the what what Ron said about perhaps people not having a sense of
responsibility or caring as much about their neighbors health which is
essentially the essence of it so I would sort of throw back to you we do have a
public voice we speak loudly but people don’t hear and so the question is and I
think since November we’ve learned something there are a lot
of people who don’t hear or don’t believe so
you know you you do this fantastic effort who will read it will they
understand it and is there a way of you know enabling people to care about their
neighbors health essentially I mean we are in some ways a very selfish society
and it troubles me a lot that you know there’s so much effort that science you
know is putting into into this work and I think many of us are concerned about
dissemination and new ways of having a public voice but I discouraged about who
is actually picking it up Wow the what comes to mind is a book I just
read called strangers in their own land does anybody else read that book no one
you have it’s a very disturbing book because it starts out with that question
how could really a community that is totally in need of help from the
government from EPA it’s about environment it’s about environmental
disaster in Louisiana basically see their allies their enemies as the
government itself and their allies as as the chemical companies who caused the
crater to destroy their community I mean literally literally the crater if F to
destroy their community so she had no answers but a hawk Scyld
really raised that question about the kind of contradictory impulses and she
has some historical arguments but I think it’s a somewhat a cynical view of
it because I think if we look back historically as Marianne tha’s pointed
out we’ve come a long way an enormous long the longest way between our
understanding of what who is responsible for illnesses and what environmental
damage means and what environmental pollution is
since the days of the you know the Donora air inversion and the London Fog
it’s just something we’ve all learned and I don’t know whether it comes from
us so much as it comes from this much larger public discourse that maybe began
with Silent Spring and the popular notions of what what industry was doing
during the Vietnam War to us and to other people and the whole history that
kind of followed that so I’m not nearly as upset I mean I see those I see
concerns about environmental damage all over the country and the you know the
attempt in these court cases to ascribe responsibility to try to find new ways
outside of government outside of the EPA and Pruitt’s EPA to actually try to
remedy this so I’m not now I’m depressed in the short run of course but I know I
I’ve just been reading too much history and knowing how bad things used to be
when you couldn’t see across the river from this room because of the fog so
maybe if I could stay on the environmental theme for a minute as a
good case example Merion see you and the sense made a plea for learning new ways and the urgency of these two species but
is it as long as it could have gone and will we continue going longer which i
think is but this whole thing is about it’s not how far we’ve come but where we
go from here and I guess this is the response as well to this I think I’m an
air pollution epidemiologist I take numbers analyze them report the results
and for whatever reason maybe this way of doing research and reporting our
findings maybe it doesn’t work so maybe it’s not that we don’t have these
science we don’t have the evidence my Bateman maybe we need more research and
more collaborations to present our findings differently for example if I
collaborate with someone at HP F for example and we together identify a
policy that has been working very well and we show that change the way you know what I mean just
very briefly I guess one of the ideas that kind of animates me is that we’re
gonna be forced to do things that it not doesn’t necessarily come from inside the
institution that we pay attention different issues historically you know
when I got my masters in public health environmental science was how to put
lining on a dump site that was really what environmental science was and we
are no longer at that point we’re now discussing a whole host of other issues
the curriculum it doesn’t look anything like it did in 1972 so what I’m saying
is that that change probably reflects more of a of a popular re understanding
that it does necessarily a new kind of research that we’ve developed we’re
going to we’re going to move along and we do important research and it’s great
to have that evidence and we should be getting that evidence after the
populations that actually will force us to do something not us but government to
do something I’ll just comment I don’t know if anybody is here from the learner
center but we’ve just started this new center whose goal is to develop a
science of how to communicate more effectively and it might be a very
interesting follow-up discussion to see how we could build that to help partner
on these issues Bruce Thank You panelists for a very
stimulating conversation so far I have two questions I guess the first directed
to David and then my more general question to all of you I really like
thinking about the theme of disruptive thinking I really like the example David
has set because if you imagine a spectrum of thinking being what we all
do in our role as professors at the other extreme disruption you know think
of Occupy Wall Street for sample David’s path working with
advocates in the legal system and using your scholarship of history to affect
action you know is really a shining example I I wonder though about the
connection between the thinking part and the action part you know also coming to
mind we have politicians who shall remain nameless we have others like
Steven K Bannon who I must name as the evil doer that is who have spent a great
deal of time thinking and also implementing and causing great harm so
my general question well my specific question today vyd is on the assumption
that the Ninth Circuit Court of Appeals upholds the award and on the assumption
that the industry will then appeal that to the Supreme Court what what are your
expectations there and and my more general question is how as professors
and students should we take the theme of disruption and move it from thinking
into action Wow you know you hit on all my nightmares I mean I the happiest
moment in my life literally well my wife used to say say your professional life
you know curacy got married yet kids but my in my professional life is the moment
when the jury came back for the four billion dollar decision against these
were companies there having literally polluted they included entire cities
that was the happiest moment the most depressing moment was when the Supreme
Court came back for the decision to forget it and they did it on the most
narrow technical grounds you can imagine after a 10-year lawsuit lawsuit that
went on for 10 years so yeah I am not necessarily sanguine but what’s
interesting is that there are people out there that are trying new angles and you
just have to assume for whatever reasons there’s going to be an answer someday
to be and that’s you know my kind of fundamental to faith the other part of
your question I think well IIIi gets into you know how we don’t necessarily
understand what’s going on on the outside and that sometimes the very work
I’m working at you only because Bruce I love you and I can say that you honestly
sometimes I really can strangle statisticians you know who are brought
into lawsuits where passions are running high and a statistician comes in and
says it’s not statistically reliable and shoots down the arguments that are being
made about that about the problem so we don’t always take the right side on
issues and that’s the problem we don’t have a clear mandate and idea about what
is a public good and what our responsibilities in this community is
are so I just want to you know remind us so we had to really be sensitive that
there’s a debate going on outside that that sooner or later may just say you
know you guys have nothing to say to what the big questions that we’re
dealing with here really are because all you can do is add confusion right
there’s a really good roll academics have historians academics of all kinds
so I guess what I’m it’s my plea is to not not think of it as just a one-way
street where we’re delivering good information and those people should
understand us but that we have to really understand what’s going on the outside
and incorporate into our very thinking and even our Mis methodologies to make
sure that we’re not left behind it was an early Earth well says the mic yes
please say your name I just thought that all of this
especially centered around reviewing these terrible in that companies have
done actually today one of the problems that we’re facing is how do we
disentangle ourselves from the industries that are making some of the
products that were using for Public Health like the notion that oh we pushed
out the vaccines because it’s big fun or we have this national opioid epidemic
and those hope you and Rex have been prescribed by people that she’ll go watch dr. Strangelove who is
her who’s the movie in 1962 is built around
the idea that our precious bodily fluids are being polluted by vaccinations as’
and communists so we’ve got a big problem in this country who else has the
microphone okay just just another disruptive thought possibly is that
sometimes we think coming from within the health science community to Health
System that it is an obvious highest-value health and I don’t think
that is true I think there’s a very interesting example when we turn to the
global debate about climate change and how deep the divides were between the
developed so-called developed world and the threshold countries where it’s very
clear we are the developing countries were saying they are willing to
sacrifice health to make the living standard and this is also true within
this country when we go to West Virginia when we go
to some of these people described in strangers in their own land their prime
goal is not it’s not the highest value for themselves health their highest
values to have an income to become visible by having work and so I think
this this deep struggle between different values and priorities in
different subgroups of society is is a big wall we run against and so I’m
wondering but a part of this communication effort that you were
referring to also a little bit to deal to deal with this
negotiation between where people stand and that when we come as public health
professionals they look at us and think you don’t even know what I’m about it’s
sort of like that’s not my problem and and so I don’t know it’s just you
know it’s very important common anybody else will the microphone well I hope
you’ll ask for one a night while you is there a comment in the back I can’t
quite see yes can I just try to respond to that to that comment in it I’m afraid
I’m not going to be able to do so in a very opted me before so yeah I mean I
think I think both you know one of the criticisms of the public good concept in
economics from libertarian economists in public choice economies is it it’s all
up like it’s a blast it’s got so much plasticity that you know whoever’s in
power can kind of define you know this is the public good and you can kind of
squeeze anything into it I suspect that’s probably also true for non
economic concepts of the public good and yeah so I think that’s I think that’s
interesting I don’t know where to go from there but one of the things I worry
about so I mean I study science and science funding for science and
everybody you know the the genomicist genomics is a public you know the NASA
folks space exploration is a public and I wonder and you know maybe to put a
fine point on it if you know we as public health professors are the kind of
in the best position to objectively make decisions about whether public health is
a public good or not and and if you know and maybe like talking to people from
the bottom up in ways that the David suggested might might be one one way to
think about that so I hope I wasn’t too long term
other question for you so this is a moment in time when science isn’t being
thought very highly of either or as a public good and yet you have thought a
lot button about the role of science even verging on whether it’s a public
good particularly and focused on biomedical research so how would you how
would you handle that dichotomy Wow it’s gonna did you want to add to that I
don’t want it like right I wanna run out the clock here so did you want to add to
the last point first so we could finish I’ll just say well we’ll finish this
topic there’s one other question in the back and I hope which we’ll get to in
just a second and then I hope everybody will continue this outside and the
reception that we have two super quick thoughts just make sure so I think it’s
if we go and ask its individual if they put first their health or their income I
don’t think any thinking person would pick their income over their health or
their kids health but if they’re dead okay oh yes so that’s why I said then
also maybe not their own but their kids health right because maybe then it’s a
matter of communication on if you lose your health think going back to thinking
about our neighbors okay nevermind wrong not a good argument yes read that book I
sometimes I think that’s good to raise I think sorry before you answer that I I
think that science is not a public good just because it’s excludable nowadays so
I don’t drink even though it should it should definitely be yeah I think let me
let me let me just pick up on that theme because it’s something I actually wanted
it to bring up earlier as well I mean this is kind of one of the problems with
the concept but also kind of a practical issue which is you know the thing about
information it’s not just scientists it’s non-rival in the sense that you can
use the quadratic formula the same way at same
time I can use the quadratic formula and that it kind of leaks out but
excludability is a choice variable we have institutions that decide you know
whether you know who gets to see the information so like I think what’s kind
of cool about I bashed the economic concept but I think what’s neat is it
makes the point that for things that are non rival it’s inefficient to exclude
right and so that ties in very nicely with the idea that we should be doing
not only the research but like you know as having the privilege of getting funds
to do to generate these kind of public goods the second half of that is to
disseminate them widely to kind of make them public good or you know it’s a
really kind of to really kind of diffuse the benefits and in fact that’s partly
what attracts me to school of public health since that’s very much part of
the mission right and in creating public databases I mean I think that’s all so
we’ll take the last comment in the back and then I hope everybody joins us
outside yes my question was directed to dr. Sam hat I don’t want to widen this
fascinating debate too much but I would like to have your opinion on about how
society decides to prioritize a specific component of public health or or not I
it is clear that communication is crucial but I would be curious to know
your opinion about which scientific and economic approaches
in your eyes should be privileged to to help society make these public health
choices in the you where I come from there is a trend for a will for
generalizing this cost benefit or impact assessment studies do you think that
this this is a good idea and all this is debated between economists yeah I mean
it’s something it’s something I’ve thought about a lot so to answer very
quickly and it’s I thought about it in the context of the NIH which is how the
NIH decides what kinds of things to fawned in how responsive it is to
disease burden and things like that and I’ve also thought about
some of the cost-benefit kind of numbers and the question of you know is
prevention research underfunded I think you know an answer is that the you know
the public funding of research is not based on any kind of cost-benefit
principles there’s very little in the wave formal Congress does some priority
setting in its head but you can imagine how that goes there’s very little formal
priority setting historically there has been very little formal priority setting
within the agency itself they I think in general they fund they fund cool science
with some exceptions yeah how are those yeah even there I don’t I don’t think
actually cause benefit and cost-effectiveness though we do a lot of
it in places like this I don’t think it actually impacts a lot of policymaking
and when it does and maybe this ties together some something we started with
here when it does it kind of only does when it has
effective voice behind it essentially so and this is where the political
scientist in the crowd could probably help me out a little bit but it doesn’t
help it’s not enough that this is really beneficial relative to the cost you need
effective voice and or interest groups to kind of articulate that in order for
that to to work and unfortunately the distribution of that voice it’s not
always kind of even across different parts of societies so thank you so to
wrap this up I’d be interested in asking each of the panelists if you could throw
out any suggestions as going back to what Mary Ann thie said and about what
we should be doing together as a faculty or could do together that could really
advance our thinking and our impact on whatever definition of public health is
a public good we think is to be valued I don’t know we’ll go down David you want
to start and we’ll just go leftward well I don’t have any proof I know that
thank you rob that’s what I that’s why they’re just all over the place
the you know I I have nothing profound to say other than I mean I think we all
have to question ourselves and ask ourselves we all are in this game
because we think we’re part of some generalizable valued aspect of we’re all
helping each other and we all think that what we do is in the public good and the
public interest so to speak I think we have to ask ourselves whether we are I
mean that’s I think we have to constantly ask ourselves at what point
does our own kind of interest as a faculty as a grant driven institution as
an institution that demands certain kinds of loyalties to different parts of
our both the intellectual and political culture at what point are the tools were
developing really in the public interest so to speak I don’t I quit and I had a
formulated but I know we all believe that we’re doing the right thing and yet
somehow somehow I think everybody does I think every part even the most
conservative trumpian even sprue it thinks he’s working in the public
interest somehow and so it’s a such a plastic idea it’s I mean that term you
know plasticity of the idea that public good that I wonder whether we have to
really be much more specific and defining it and thinking about our role
in you know in this mixed-up culture we have right now I have nothing profound
to say so I I think there are several things we can do is engage the public as
much as from the public around here and there are people in the school that do
bubbling attachment for from us speaking to the press really and making sure that
our results are made known to the public try to engage not
only within the School of Public Health but try to engage with other parts of
the university so people do get exposed to public health at the school to
environmental health at the school and then try to collaborate as Sebastian but
with the industry to try and see how together we can work towards a common
goal but I’ll finish with a question because that thing I’m also struggling
with is that I think in theory I know the answers but every time I’m going to
write a new grant I pick the ones that are most personally of interest to me
which makes me feel as the most selfish person in this world right now but I
will pick the fantasy start to apply to because I want to develop a new method
and not something that engages the community so one is what we can do and
two is how can actually convince ourselves to do that so yeah thank you
another profound comment Evan the average here yeah so I also have a kind
of a practical answer which is we’ve talked about a number of the success
stories and the big wins in public health in terms of producing public
goods either from an economic perspective or in a more colloquial
sense I think it would be quite useful to understand how they happen to learn
from history so both what kinds of policy frames or successful what kind of
social movements were involved and that might provide some insight in wet into
whether this kind of frame of public health as a as a public good is a useful
one going forward well we would love to hear from all of you on other
suggestions you can send them to me and I’ll batch them and we’ll think about
whether that can offer us a frame for going forward this has been great fun
thank you to the three of you I love it and
please join us outside it’s cold out I’m sorry
I couldn’t give you my jacket

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