“The hard-nosed truth is that the public health economy lacks order.”
| Inmates accuse Alabama prison system of state-sanctioned slavery | Self-reported emission inventories by large oil and gas (O&G) operators in the United States are significantly underreported, inhibiting climate progress. | Family of Man Who Died After Inhaler Cost Spiked Sues: Cost of asthma med for Cole Schmidtknecht, 22, rose from $66 to $539 after insurance changes | “At the direction of the Trump administration, the federal Department of Health and Human Services and its agencies are purging its websites of information and data on a broad array of topics — from adolescent health to LGBTQ+ rights to HIV.” | The confidential database was obtained by lawyers representing 3,000 cities, towns, counties and tribal nations in a civil action alleging that nearly two dozen drug companies conspired to saturate the nation with opioids. | “Toxic Gaslighting: How 3M Executives Convinced a Scientist the Forever Chemicals She Found in Human Blood Were Safe” | Chairman Arrington Delivers Opening Statement on Healthcare Consolidation | Our analysis also suggests that the NIH is remarkably efficient at funding research that is utilized in the discovery or development of new drugs, commercialized, and publicly available. The $230 billion in NIH funding (2000-2019) that was directly or indirectly related to these drugs represents 40% of NIH budget allocations over this period. | For instance, a PNAS study from 2018 found that NIH was “directly or indirectly associated with every one of 210 NMEs [new molecular entities] approved from 2010-2016.” | was treated like a murderer for suffering a personal tragedy. | Only One Conclusion: Washington, DC Resembles Apartheid | Medical tests are being adjusted according to patients’ skin color – with shocking consequences. | US health care costs nearly twice as much as care in any other developed nation, whereas US health status, equity, and longevity lag far behind. | Months Later, No One Has Responded. The syphilis rate among Indigenous people in the Great Plains is higher than at any point in 80 years of records. | School hate crimes targeting LGBTQ+ people have sharply risen in recent years, climbing fastest in states that have passed laws restricting LGBTQ+ student rights | At the height of the epidemic, Congress effectively stripped the DEA of its most potent weapon against large drug companies and personally attacked the leader of the agency anti-opioid campaign, who was forced into retirement. | Trump’s shocking purge of public health data, explained. All of us will be collateral damage in MAGA’s war on “DEI.” | Experts noted that Governor DeSantis’ administration has used a COVID-19 infection rate that gives “more weight to negative test” results, and thus skews the results. Governor DeSantis has used the skewed rate to justify reopening schools and businesses. | Equality is essential for sustainability. The science is clear — people in more-equal societies are more trusting and more likely to protect the environment than are those in unequal, consumer-driven ones. | The Kinsey Institute, the world’s top sex research center, faces existential threat from conservative attacks | Four major nonprofits that rose to prominence during the coronavirus pandemic by capitalizing on the spread of medical misinformation | Fossil fuel industry knew of climate danger as early as 1954 | Metal increasingly found in tap water causes cancer and is rife in Arizona, Nevada and New Mexico | A filmmaker cracks a four-year-old cold case dealing with the racially charged murder of a teen found rolled up in a gym mat in his high school gym. | We also describe the consequences of health equity tourism – namely, recapitulating systems of inequity within the academy | One in five Black men born in 2001 is likely to experience imprisonment within their lifetime. | Prisoner workforce: “You can’t call it anything else. It’s just slavery.” | Almost 6,000 Dead in 6 Years: How Baltimore Became the U.S. Overdose Capital | GOP Sen. Josh Hawley Warns Against 'Massive' Medicaid Cuts: 'I Don't Like The Idea': The Missouri Republican said large cuts to Medicaid would harm many people who voted for President Donald Trump. | Dozens of top officials from the DEA and Justice Department have stepped through Washington’s revolving door to work for drug companies. | Gov. Ron DeSantis of Florida and Gov. Greg Abbott of Texas, both Republicans, signed legislation to prevent local governments from requiring heat protections for outdoor workers. | Mass firings continue across nation’s health agencies | Contrary to what the NRA would have the public believe, more permissive gun laws are making people less safe. | Texas Attorney General Ken Paxton and Kansas Attorney General Kris Kobach are suing the Bureau of Alcohol, Tobacco, Firearms, and Explosives, to block the “gun show loophole.” | CDC cuts expected to devastate Epidemic Intelligence Service, a ‘crown jewel’ of public health | A striking disconnect remains in the US economy: continued growth and softening inflation along with Americans' pervasive pessimism and uncertainty about the future. | Many chemicals in the US are approved with limited scrutiny under the US Food and Drug Administration’s “generally regarded as safe” rule, which allows chemicals to be used for food contact with very little agency scrutiny. | Feds accuse Hyundai and two suppliers of using child labor | Gun death rates in some U.S. states comparable to conflict zones, study finds | The majority of de minimis packages come from China — some 60% last year. | The report attributed the historically high number to several factors, including a multi-year surge in home prices and a reduction in covid-era assistance. | Baltimore addiction programs draw patients with free housing while collecting millions. Some say one company offered little help…top city officials reacted with little urgency as the death rate mounted | A Washington Post investigation into police use of facial recognition software found that law enforcement agencies across the nation are using the artificial intelligence tools in a way they were never intended to be used: as a shortcut to finding and arresting suspects without other evidence. | DOJ: FBI Failing to Report Sex Crimes Against Kids | In 2003, the agency learned from 3M, which makes toxic “forever chemicals,” that they were contained in the raw material for the fertilizer. | Surviving workers at a plastics factory in eastern Tennessee say that as floodwaters rose on Friday, managers didn't let them leave until it was too late. | Profiling of pesticide industry opponents halted after company practices exposed | The FBI has agreed to pay more than $22 million to settle a class-action lawsuit alleging female recruits were singled out for dismissal in training and routinely harassed by instructors with sexually charged comments about their breast size, false allegations of infidelity, and the need to take contraception "to control their moods. | More than 100 pregnant women in medical distress who sought help from emergency rooms have been turned away or negligently treated since 2022. | Since 2007, MedPAC estimates Medicare Advantage insurers have reaped $217 billion in coding overpayments from the federal government. | "Ambetter’s parent company, Centene, has been accused numerous times of presiding over ghost networks. One of the 25 largest corporations in America, Centene brings in more revenue than Disney, FedEx or PepsiCo, but it is less known because its hundreds of subsidiaries use different names." | Millions of Americans' Mental Health Associated with Leaded Gasoline exhaust
| Inmates accuse Alabama prison system of state-sanctioned slavery | Self-reported emission inventories by large oil and gas (O&G) operators in the United States are significantly underreported, inhibiting climate progress. | Family of Man Who Died After Inhaler Cost Spiked Sues: Cost of asthma med for Cole Schmidtknecht, 22, rose from $66 to $539 after insurance changes | “At the direction of the Trump administration, the federal Department of Health and Human Services and its agencies are purging its websites of information and data on a broad array of topics — from adolescent health to LGBTQ+ rights to HIV.” | The confidential database was obtained by lawyers representing 3,000 cities, towns, counties and tribal nations in a civil action alleging that nearly two dozen drug companies conspired to saturate the nation with opioids. | “Toxic Gaslighting: How 3M Executives Convinced a Scientist the Forever Chemicals She Found in Human Blood Were Safe” | Chairman Arrington Delivers Opening Statement on Healthcare Consolidation | Our analysis also suggests that the NIH is remarkably efficient at funding research that is utilized in the discovery or development of new drugs, commercialized, and publicly available. The $230 billion in NIH funding (2000-2019) that was directly or indirectly related to these drugs represents 40% of NIH budget allocations over this period. | For instance, a PNAS study from 2018 found that NIH was “directly or indirectly associated with every one of 210 NMEs [new molecular entities] approved from 2010-2016.” | was treated like a murderer for suffering a personal tragedy. | Only One Conclusion: Washington, DC Resembles Apartheid | Medical tests are being adjusted according to patients’ skin color – with shocking consequences. | US health care costs nearly twice as much as care in any other developed nation, whereas US health status, equity, and longevity lag far behind. | Months Later, No One Has Responded. The syphilis rate among Indigenous people in the Great Plains is higher than at any point in 80 years of records. | School hate crimes targeting LGBTQ+ people have sharply risen in recent years, climbing fastest in states that have passed laws restricting LGBTQ+ student rights | At the height of the epidemic, Congress effectively stripped the DEA of its most potent weapon against large drug companies and personally attacked the leader of the agency anti-opioid campaign, who was forced into retirement. | Trump’s shocking purge of public health data, explained. All of us will be collateral damage in MAGA’s war on “DEI.” | Experts noted that Governor DeSantis’ administration has used a COVID-19 infection rate that gives “more weight to negative test” results, and thus skews the results. Governor DeSantis has used the skewed rate to justify reopening schools and businesses. | Equality is essential for sustainability. The science is clear — people in more-equal societies are more trusting and more likely to protect the environment than are those in unequal, consumer-driven ones. | The Kinsey Institute, the world’s top sex research center, faces existential threat from conservative attacks | Four major nonprofits that rose to prominence during the coronavirus pandemic by capitalizing on the spread of medical misinformation | Fossil fuel industry knew of climate danger as early as 1954 | Metal increasingly found in tap water causes cancer and is rife in Arizona, Nevada and New Mexico | A filmmaker cracks a four-year-old cold case dealing with the racially charged murder of a teen found rolled up in a gym mat in his high school gym. | We also describe the consequences of health equity tourism – namely, recapitulating systems of inequity within the academy | One in five Black men born in 2001 is likely to experience imprisonment within their lifetime. | Prisoner workforce: “You can’t call it anything else. It’s just slavery.” | Almost 6,000 Dead in 6 Years: How Baltimore Became the U.S. Overdose Capital | GOP Sen. Josh Hawley Warns Against 'Massive' Medicaid Cuts: 'I Don't Like The Idea': The Missouri Republican said large cuts to Medicaid would harm many people who voted for President Donald Trump. | Dozens of top officials from the DEA and Justice Department have stepped through Washington’s revolving door to work for drug companies. | Gov. Ron DeSantis of Florida and Gov. Greg Abbott of Texas, both Republicans, signed legislation to prevent local governments from requiring heat protections for outdoor workers. | Mass firings continue across nation’s health agencies | Contrary to what the NRA would have the public believe, more permissive gun laws are making people less safe. | Texas Attorney General Ken Paxton and Kansas Attorney General Kris Kobach are suing the Bureau of Alcohol, Tobacco, Firearms, and Explosives, to block the “gun show loophole.” | CDC cuts expected to devastate Epidemic Intelligence Service, a ‘crown jewel’ of public health | A striking disconnect remains in the US economy: continued growth and softening inflation along with Americans' pervasive pessimism and uncertainty about the future. | Many chemicals in the US are approved with limited scrutiny under the US Food and Drug Administration’s “generally regarded as safe” rule, which allows chemicals to be used for food contact with very little agency scrutiny. | Feds accuse Hyundai and two suppliers of using child labor | Gun death rates in some U.S. states comparable to conflict zones, study finds | The majority of de minimis packages come from China — some 60% last year. | The report attributed the historically high number to several factors, including a multi-year surge in home prices and a reduction in covid-era assistance. | Baltimore addiction programs draw patients with free housing while collecting millions. Some say one company offered little help…top city officials reacted with little urgency as the death rate mounted | A Washington Post investigation into police use of facial recognition software found that law enforcement agencies across the nation are using the artificial intelligence tools in a way they were never intended to be used: as a shortcut to finding and arresting suspects without other evidence. | DOJ: FBI Failing to Report Sex Crimes Against Kids | In 2003, the agency learned from 3M, which makes toxic “forever chemicals,” that they were contained in the raw material for the fertilizer. | Surviving workers at a plastics factory in eastern Tennessee say that as floodwaters rose on Friday, managers didn't let them leave until it was too late. | Profiling of pesticide industry opponents halted after company practices exposed | The FBI has agreed to pay more than $22 million to settle a class-action lawsuit alleging female recruits were singled out for dismissal in training and routinely harassed by instructors with sexually charged comments about their breast size, false allegations of infidelity, and the need to take contraception "to control their moods. | More than 100 pregnant women in medical distress who sought help from emergency rooms have been turned away or negligently treated since 2022. | Since 2007, MedPAC estimates Medicare Advantage insurers have reaped $217 billion in coding overpayments from the federal government. | "Ambetter’s parent company, Centene, has been accused numerous times of presiding over ghost networks. One of the 25 largest corporations in America, Centene brings in more revenue than Disney, FedEx or PepsiCo, but it is less known because its hundreds of subsidiaries use different names." | Millions of Americans' Mental Health Associated with Leaded Gasoline exhaust
The Public Health Economy:
the “Other” Economy
January 28, 2025
By Christopher Williams, PhD
The public health economy is a long overdue framework. Its reconceptualization of public health theory and practice, including workforce training and reform, is a call to action and radical reform. As public health discourse has expanded to include social and political determinants of health in the last decade, it is clear that an “economy” animates how these and other determinants interact to impact public health. Public health economic analysis draws on wide-ranging disciplinary knowledge and research, including traditional public health methodologies, to make sense of health disparities and their causes.
Public health liberation theory assumes that laboratory incubators for epistemic and policy reform, while essential, are inadequate on the central question of transformative change. No single theory or solution will reasonably put the nation on a different course. It will take greater knowledge synthesis. Expanding the theoretical foundation for health disparities is a promising and necessary endeavor to spur health equity.
Public Health Liberation theorizes that there are two major economies - 1) the traditional economy as defined by growth, GDP, employment, supply and demand and 2) the public health economy. The public health economy brings the structural and contextual determinants that pertain to public health, in all its permutations, under a single transdisciplinary umbrella through rich insight and analysis. It includes the establishment of a framework to rationalize motivations and behaviors. It helps to elucidate public health challenges to achieve health equity, especially for vulnerable populations. Relevant knowledge encompasses a wide range of ideas and approaches not typically associated with public health interventions and necessarily requires disciplinary synthesis to accelerate health equity.’ This webpage is available in simple text. Read here.
The Public Health Economy?
Public health is a function of complex systems, behaviors, and outcomes - defined as the public health economy. This transdiscipline places wide-ranging disciplinary knowledge under a single conceptual framework.
“This theory regards the public health economy as reproducing health inequity.”
A careful observer will note that the public health economy is not synonymous with the public health infrastructure or workforce. Public Health Liberation theory posits that health equity cannot be achieved without affecting the public health economy because the disorder of the public health economy rests in the anarchical nature of this economy, - a Douglassian phenomenology wherein tensions and contradictions flourish alongside the absence of a central authority or common moral principles. Public health liberation theory does not judge individual actors, other than having an interest-driven agenda. Now, defining those interests beyond the theory is a challenging task because speech and conduct are not inherently trustworthy and relies on observation of “deeds”. Jesus put it this way, “As the body without the spirit is dead, so faith without deeds is dead.” (James 2:26) Public health realism describes the dynamics of a system, an economy - the public health economy. Public health economic theory concerns systems theory and behavior. Anything to the contrary is an ecological fallacy.
Economic and public health theories have major limitations that do not account for vast sources of health inequity that are not reducible to economic principles and indicators - profit, supply and demand, employment, GDP, etc. Ecosocial and embodiment theory, which come close to public health economic theory, leaves much to be desired, as they do not contend with an array of actors and actions in the public health economy. s, public health is political. Health is embodiment of politically driven, socially conditioned structures and conditions - the embodiment of the public health economy in its totality. Integration of political theory into public health theory is lacking and generally avoided in much of public health research. Yet, it forms a vital area to understand. An intervention that accounts for likely political pressures and philosophies would be more translatable and valid. A major gap exists in the literature between research and contextual factors within micro- and macro-public health economies. Insight into political reasoning and motivations at all levels of government can be leveraged to tailor public health priorities and policy recommendations consistent with political realities. In our community of practice, we can point to a political leadership class that is often estranged from community lived experiences.
The future of public health is the focused study on macro- and micro-Public Health Economies.
The public health workforce has a broad base of knowledge and skills stretching across various disciplines with an aim to more fully study the public health economy as a system and to accelerate health equity.
Feeling the Anarchy of the Public Health Economy
Most Americans will feel the anarchy of the public health economy at some point in their lives. Many will feel it for sustained periods. For others, it will be a matter of life and death.
Anarchy can manifest when a family member becomes a victim of addiction caused by multiple system failures - lack of affordable and available effective treatment, greed to push addictive substances, poor border control, and legislative apathy. Poor health can arise from financial insecurity and unemployment. This anarchy can also show up with toxic employment and neighborhood environments.
In my community of practice, I have witnessed government agency dysfunction and policy neglect directly contributing to poor public health. Public housing residents have been subjected to relentless ghettoization and landlord neglect in Washington, DC.
Will West was a third-year ophthalmology surgical resident at George Washington University School of Medicine and Health Sciences in D.C. He committed suicide, which was covered in the Washington Post, shining a spotlight on barriers for physicians’ access to mental health care.
“To those who will be negatively affected by my actions, I’m so sorry. I have simply run out of gas and have nothing left to give…To those in a position of authority over residents, a simple reminder that we come to you seeking the possibility of a better life. Some of us with challenges you do not see or backgrounds of which you are not aware.”
“The key goal in public health economic analysis is to apply disciplinary knowledge to explain and affect the public health economy, not simply to regurgitate a theory or data.”
— Christopher Williams
Public Health Economic Realms of Inquiry: Examples
Implementation
If we increased spending on the determinants of health, would those dollars be planned and spent to maximize public health outcomes?
Would those dollars be susceptible to political (e.g., patronage, work requirements), industry, or hegemonic influences? Is a sizable workforce available with requisite skill sets? Would public health spending result in fierce competition for dollars and what is the result of this competition on public health spending effectiveness?”
Political Theory
What are pathways to health equity given the nature of politics and partisanship?
If health is political, what can explain the high costs of health insurance, lack of affordable plans, and major gaps in accessibility? With 43% of Americans identified as independent, does this suggest the major parties have drifted from the electorate? How can elected officials be persuaded to positively affect the public health economy given ideological and partisan positions? What to do about political apathy and non-responsiveness? What is driving political elitism? Is poor and estranged political governance entangled with party shifts to their respective poles of their ideology? Under what conditions can political speech be trusted? What can political theories offer that might be meaningful and relevant? Is perceived criticism of administration policy regarded as anathema or helpful? What can political theory of stimulus-response be studied and applied? What are some issues of health equity that would require nothing short of a historic change on par with major protest movements or war in the US (e.g., massive protests, non-violent resistance)?
Economics
What are economic failures or gaps that require government intervention and reforms to address major gaps in health opportunity and access - public health?
Are public health economics being optimized for better public health - to shift from the sick care model? Major economic failures are widely noted in housing, food access, environmental regulation, and healthcare that have resulted in direct government involvement to deal with these structural failures (e.g., SNAP, public housing, vouchers, LIHTC, Clean Air Act, Clean Water Act, Medicare, Medicaid, etc.). What is the state of the economy as a major contributor to public health economic performance? How does intense income inequality hinder health equity? Have economists developed new theories to account for major changes in the economy - deficit spending, national debt, income inequality, etc. - and their public health impact?
Social Theory
What are alliances across local public health economies? What is their role in describing and affecting health?
How do political leaders build and control political networks? How might hospitals, universities, for-profit corporations, media, and community groups define public perceptions of the public health economy? What are the functions of this system (e.g., downplay harm, discredit dissent, facilitate a spoils system)? How do these systems typically handle fraud, waste, and abuse - of authority, power, statutory privileges? How might politicians use coercive powers to prevent public disclosure and debate over issues or crises that would reflect poorly on political leadership?
Religious Studies
How does faith support resilience and vital energy?
How did famine during the time of Joseph lead to the loss of self-sufficiency - including selling of livestock and land? (Genesis 47:13) How did famine lead to migration? How should residents in the destination region exercise moral decision making on account of the migration brought about by public health needs? How did the conditions of the public health economy - both famine and royal rule - shape Elijah’s conduct with the prophets of Baal? Is faith a key to negate embodiment of the anarchy within the public health economy? How can highly religious traditions such as African American churches teach us about collective resilience?
You make your saving help my shield,
and your right hand sustains me;
your help has made me great.
You provide a broad path for my feet,
so that my ankles do not give way.
- Psalm 18:35-36
Physics
Can energy states and flow help us understand the public health economy?
How can we apply energy theory to public health? How might potential forms of energy explain violence? What are its inputs using interdisciplinary analysis that explains accumulated destructive energy? How is energy dissipated or reverberated beyond individuals in an incident? How does entropy in energy theory disrupt order and harmony? Can we better understand the vast sources of health inequity reproduction a la public health economic analysis through application of entanglement? How does income inequality produce vital energy - economic freedom and innovation investment - and destructive energy - class and racial conflict and resent, diminishing economic futures, income determinism and stratification? How can we understand public health breakthroughs as tipping points - superposition? What is drag on the speed of “Light” and vital energies - apathy, corruption, neglect…entropy? Can we recast public health theory as the probabilities of health at any point in time wherein individual and public health can be explained by their bodily absorption or resonance of energy, Light,…?
Education
What are barriers that cause deep educational disparities to persist although education is widely regarded as a major social determinant of health?
Why do many municipalities struggle with addressing poor educational performance and disparities? Why aren’t increased education budgets affecting these disparities in many localities? What are the public health consequences of a return to school segregation across the nation? What do many school districts struggle to even articulate the disparities, particularly if they are racial?
Research and Epistemology
How can research approaches and funding be leveraged for real-time challenges within the public health economy?
How could research and researchers be leveraged to prevent crises such the lead water crises in Flint, Michigan and Washington, DC? Is the current research approach best positioned for accelerating health equity? Is research too acontextual - lacking insight into the public health economy? How can a workforce be trained and deployed for proactive practice à la public health economic practice? How could a workforce evolve with expertise and skills that transcend current models of disciplinary focus and training? How can public health transcend disciplinary focus to study, analyze, and affect the public health economy? Are statistical and data models adequate for public health economic analysis? What would it take to innovate new analytical models? Is race science wasteful research?
Ethics and Morality
Is conduct in the public health economy governed by a common morality? If not, why not?
What is the role of ethics, moral reasoning, religion, and spirituality? What are considered human rights (e.g., right to healthcare, “Everyone should have ready access to all necessary medical, hospital and related services.” - Truman)? What role does and should profit-driven motives play in the public health economy? What ethical and moral framing can be used as tools of persuasive to encourage ethical conduct? For which elected officials? Under what circumstances? How can universal beliefs of truth, justice, mercy, and love be made relevant to public health economic discourse?
Social and Democratic Theory
What are the consequences for a well-documented decline in social cohesion and participation?
What might the issues raised by Robert Putnam more than 20 years ago tell us about the desire and capacity for society to address dysfunction in the public health economy? Is the shift from social clubs and organizations a shift toward hyper-individualism? Would action on pressing issues in the public health economy be contingent upon one being directly impacted?
News, Media, Information Ecosystem
How well do news and media organizations cover the lived experiences of those experiencing the anarchy of the public health economy?
Can Americans gain a basic understanding of the public health economy based on current media coverage? How well and with what regularity are topics discussing challenges of the poor covered? Has science, economics, and religious studies perpetuated information bias? Is social media discourse helping with defining specific challenges in the public health economy as related to specific populations?
Intersection of Physics and Democratic Theory
What is the role that a few - uber-wealthy elites - have on the energy state, eroding majoritarian democratic rule?
With concentrated wealth, power, social and political influence, the richest Americans and corporations have a strong hold on the energy state of the country. Their social and economic position assumes a democratic role and function. How can we measure and define the destructive energies of income inequality and concentrated wealth on democracy itself? How is their unlimited campaign spending and hold within political parties leading to political inaction on salient social, health, and economic issues? How do their destructive energies within parties, elections, and the PACs drive out vital energies - voices of Light and suffering?
History
In what ways can we understand history repeating a la the public health economy?
How did the US overcome similar health crises? Can the resistance to change be comparable as in prior periods in which structural health inequity was normalized? What industries felt beyond the reach of government (e.g., chemical companies, lead lobby, polluters, tobacco companies)? How did they fold? What can mass suffering tell us about the nature and character of the public health economy in the US (The suicide rate increased across all age groups during the Great Depression)? “Business cycles may affect suicide rates, although different age groups responded differently. Our findings suggest that public health responses are a necessary component of suicide prevention during recessions.” (Luo et al, 2011)
Leaded gasoline calculation to have stolen over 800 million cumulative IQ points since 1940s
”Millions of us are walking around with a history of lead exposure.”
-Aaron Reuben, a PhD candidate in clinical psychology at Duke University
There is a need for major reform in the Public Health Economy, but it seems every major player wants someone else to change.
No concession of power, no responsibility, or no sacrifice for the greater good…only impedes change.
”The persistence of deep health inequality in the US should give us pause. Making room for mysterious and daunting realms of discovery in public health is not just necessary but morally obligatory.
Perhaps, our theories are too limiting.”
Employment powers shape not only the economic structure but also the collective consciousness.
People will be influenced on what matters, who matters, and what action to take. Everyone requires employment or a source of income. That employment power may or may not favor justice.
Is High Divergence and Autonomy Problems in the Public Health Economy?
The United States is characterized as a society with high individual autonomy and agency. Its variety of agendas, forms of practice and expression, and social organization is apparent - from art, PI-initiated research to entrepreneurship. There are few guardrails that mandate efficiency, individual constraints in favor of collective uplift, or even disciplinary focus. Does this system lead to high inefficiency in the public health economy to explain health inequity reproduction? That is a topic of interest to public health economic theory. Are our exercises in individual liberty and freedom themselves eroding the needs we have in collective problem-solving? When we come together (e.g., conferences), are we engaging in specific, action-orientated, collective planning often enough?
Rutherford B. Hayes on “Danger” of Concentrated Wealth (1887)
“In church it occurred to me that it is time for the public to hear that the giant evil and danger in this country, the danger which transcends all others, is the vast wealth owned or controlled by a few persons. Money is power. In Congress, in state legislatures, in city councils, in the courts, in the political conventions, in the press, in the pulpit, in the circles of the educated and the talented, its influence is growing greater and greater. Excessive wealth in the hands of the few means extreme poverty, ignorance, vice, and wretchedness as the lot of the many. It is not yet time to debate about the remedy. The previous question is as to the danger—the evil. Let the people be fully informed and convinced as to the evil. Let them earnestly seek the remedy and it will be found. Fully to know the evil is the first step towards reaching its eradication. Henry George is strong when he portrays the rottenness of the present system. We are, to say the least, not yet ready for his remedy. We may reach and remove the difficulty by changes in the laws regulating corporations, descents of property, wills, trusts, taxation, and a host of other important interests, not omitting lands and other property.” [Source]
Public Health Economic Writing
Christopher Williams, Post on Spirit of 1848 listserv, August 15, 2024
Thanks for sharing. I wish to share applied public health economic analysis as part of understanding health inequity reproduction. Racial equity laws can be highly beneficial but depends on the overall health of the public health economy. An example from Washington, DC is instructive to elucidate the concept of the public health economy. This economy contrasts with the traditional growth and employment economy. Public health economic theory levels with the political, economic, and social realities to enrich public health understanding of health inequity reproduction. While it takes public health well beyond its traditional disciplinary boundaries, the notion of the public health economy seeks fuller explanations for persistent disparities.
What Happened to City Planning?
The District of Columbia government said in 2006 that comprehensive planning should entail understanding the benefits and risks of spurring neighborhood change. Council passed a law that required an environmental assessment whenever there were changes to the Comprehensive Plan - the central planning document for the city. The legislative intent was to capture social and economic costs (what economists call "externalities"). When the District passed major revisions to its Comp Plan in 2021, the Council and mayor did not submit this assessment. Instead, the District sought to pass off a six-page document as the legally required environmental assessment. It lacked analysis consistent with laws on conducting environmental assessments. Here "environmental" is contextual or neighborhood, as opposed to just ecological, though that is a part of it too. The last assessment in 2006 was about 300 pages and conveyed a comprehensive understanding of what may arise from acute urbanization. In 2021, the city gave matter-of-right redevelopment for 200 million square feet of real estate, despite that the city was the top US city for African American displacement in the 21st century due to eroding affordability, higher housing costs, and deep income disparities.
We can’t just advocate for reform when the Public Health Economy doesn’t work for us individually or disciplinarily.
It has to be a tireless pursuit of order through vertical and horizontal integration. When threats arise in the public health economy, there may be little social capital to draw from.
Is Conferencing an Efficient and Inclusive Strategy for Public Health Improvement?
Public health has no shortage of national and regional conferencing, but is this model leading to better public health? There is room for much improvement. First, these conferences typically only seek to organize professionals, leaving lay people on the outside of agenda-setting and networking. Public health realism offers an explanation. These professional associations generate much of their income from annual meetings, meaning that driving costs and attendance consistent with past practices may be primary motivations. Second, knowledge gains and tool development benefit conference attendees. Although, vulnerable populations would benefit from social capital exchange. Given the high specialization in public health, we should be concerned with conferencing as an effect of public health realism.
3. Educational Apartheid Flourishes: Little Upset
“The educational disparities in Washington, DC are quite remarkable. More than two-thirds of certain groups of students are failing to meet grade-level expectations - “below basic”. What is equally remarkable is that there are few visible activist calls for reform. Is it because of apathy? Lack of awareness? The threat of political retaliation? It is not clear, but social theory can offer insight” - Christopher Williams, PhD
Q: Does Public Health Economic Analysis Make a Difference?
1. Environmental Racism
I used public health economic analysis to evaluate a bill on environmental justice bill. Although the spirit of the bill was well-meaning, it did not account for a political reality that the government rarely produced objective, justice-grounded environmental assessments. The bill also allowed for the government to limit a cumulative impact assessment to comparison groups within the ward, which would not produce major gains in environmental equity since Black wards or neighborhoods shouldered environmental racism. My finding that the bill needed to be strengthened considerably differed from a prominent environmental researcher. He was unfamiliar with the city’s public health economy and did not demonstrate deep insight about policy translation.
2. Housing Determinants of Health
I used economic principles to argue to city council that its housing policies on subsidies to developers and support for overwhelming market housing were too generous and causing the market to work less well. There is such a thing as too little incentive and too much. Flooding the housing market with Class A luxury housing inflates rents across the city and exerting upward pressures on historically stable rental housing in older buildings. It was also leading to a real estate speculation frenzy and declining housing conditions since owners were poised to sell. This was a particularly acute problem in public housing, with profound public health and safety implications. I used data, including residents’ personal struggles with health due to declining conditions, connections between gentrification and housing code violations, and a Pennsylvania Federal Reserve Board report. - Christopher Williams, PhD
4. Policy Statements Show System Weaknesses
In 2024, the National Academies of Sciences, Engineering, and Medicine found that there was little change in racial and ethnic disparities since its groundbreaking 2003 study, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.”
Should it have been surprising? No. Public health economic analysis would say that NASEM should have horizontally and vertically integrated through diversification of stakeholders and strategies. A research report and policy recommendations, however well-meaning and justice-grounded, are inadequate to address health inequity because data in and of itself is not self-executing and catalytic. Biomedicine and public health must pull other levers beyond publication to bring about change.
5. Financial, Social Capital, and Knowledge Hording
Financial capital hording occurs when entities, such as people and corporations, within the public health economy concentrate increasingly greater financial assets. These can be in the form of savings, investments, property, and equity, facilitated by “rulemaking” and norms in the public health economy.
Social hording occurs when entities within the public health economy increasingly withhold sharing of social capital and access beyond a small group. This is a social phenomenon that we commonly see with conferencing.
Knowledge hording occurs when established or new knowledge is not widely shared with important stakeholders (e.g., communities, the public, etc.) or made available to the public. This can be due to paywalling (e.g., journal subscriptions) or proprietary restrictions.
Epistemology: Unifying Knowledge for Real-World Application and Empowerment
Universe of Knowledge is Expanding and Disorderly
The infinite universe of information is expanding more than at any time in human history. With growing educational attainment, universal accessibility to information via the Internet, and evolving non-human forms of knowledge generation, humankind is struggling to organize and apply knowledge to address urgent issues in the public health economy. In recent memory, there has been no greater threat and clear demonstration of the political determinants of health. Yet, few could accurately predict the full dismantling and discrediting of public health. This moment requires a radical repositioning of public health theory - a counterweight - to integrate and evolve disciplines within the umbrella of public health - the Public Health Economy. It also means that we set about the work of reform within and beyond public health to recognize and act while rejecting the central competition and egoism inherent in public health economic dynamics.
What Caused DC Government to Act?
The Federal Government.
US Government Intervention Stops DC Agency from Continued Harm
The District of Columbia Housing Authority (DCHA) is a powerful illustration of the anarchy inherent within the public health economy. For decades, DCHA had withdrawn from its landlord obligations in public health and safety, maintaining living standards up to code, and enforcement. Each month for years, dozens of residents appeared before the Board of Commissioners to demand action. But it was only until the US Department of Housing and Urban Development issued results from an audit that DCHA was forced to get its act together. Several years earlier, a legal suit by the DC Office of Attorney General settled some issues but did not rectify the agency. DCHA had the lowest occupancy rates for any housing authority in the US. A senior official during the Biden administration called DCHA the “worst housing authority in the country”. How did this agency rot come to be? This is why public health economic analysis is needed.
Illustrating the Public Health Economic Framework
Public Health Economic Theory implicitly calls for a better organization of knowledge and research to explain and affect health inequity.
In addition, our challenge is better saturation or dissemination of knowledge in the population.
Education is a Social Determinant of Health: Why Are School Districts Struggling?
It is well-established that education is a major social determinant of health, but addressing educational disparities and learning loss are major challenges in the US - exacerbated the Covid-19 pandemic. Results from the 2024 NAEP Reading and Mathematics Assessments at Grades 4 and 8 [Source]
Compared to 2022:
Average score increased in mathematics at grade 4; no significant change at grade 8. Average scores declined in reading at both grades. No significant change for most states in both subjects and grades. Lower percentages of students absent 5 or more days in both subjects and grades.
In fourth-grade mathematics, the gap also grew as the scores of the lowest performing students did not change significantly from 2022, while the highest performing students’ scores increased.
In reading, lower-performing students struggled the most. At both fourth and eighth grades, the scores of students at the 10th and 25th percentiles in 2024 were lower than the first NAEP reading assessment in 1992.
The District of Columbia struggles to educate low-income and minority students - a longstanding issue captured in this 2013 documentary about former DC Chancellor Michelle Rhee. The poor quality of schools and hardened racial disparities have hardly changed. Math and English language proficiency rates in high schools in Washington, DC are very poor. Fifteen (15) high schools have 5%or fewer students with math proficiency. Whatever economic theory may say about why educational disparities persist (e.g., lack of market demand for college education), the moral imperative of public education and the public health economy does not allow us to tolerate severe underperformance of public schools. These data (not shown) also are racialized, meaning that the District struggles to educate low-income, Black students. “The gap between rich White students and low-income Black students is embarrassingly huge,” bemoaned DC Council chairman Phil Mendelson.
“Neurons in corresponding locations of the different brains fire at the same time, creating matching patterns, like dancers moving together.”
The implications of collective neuroscience can tell us about workplace and social cultures - including how systems become closed to new ideas and approaches.
Political Theory
Dating to antiquity, political theory helps us to understand how political choices and leadership take shape to impact the health of our communities of practice. Public health has root causes in political theories (“politics”) that are informed by multiple levels of analysis. Voters who entrust leaders to safeguard the rule of law, liberty, justice, freedom, and opportunity need to vigilant about political power and leadership.
Public Health Economic Topics
Citizenship and civic engagement - "Politics ought to be the part-time profession of every citizen who would protect the rights and privileges of free men." - Dwight Eisenhower
“From time to time, we've been tempted to believe that society has become too complex to be managed by self-rule, that government by an elite group is superior to government for, by, and of the people. Well, if no one among us is capable of governing himself, then who among us has the capacity to govern someone else? All of us together, in and out of government, must bear the burden. The solutions we seek must be equitable, with no one group singled out to pay a higher price.” - Ronald Reagan
Making government listen and respond - “Successful marches draw public and government attention to grave forms of injustice, cause disruptions in the daily functions of society, and communicate social resistance. They also place pressure on the offending parties to rethink various forms of injustice, including domestic violence against women.” - CAWC
Political axioms or rules of thumb - “The only poll that matters is the one on Election Day"; "There's no such thing as a free lunch."
Theories on democratic restraint - “A dependence on the people is, no doubt, the primary control on the government; but experience has taught mankind the necessity of auxiliary precautions.” - James Madison, Federalist Papers
National Norms, Ethos, and Identity - “Our society suffers from a crisis of connection, a crisis of solidarity. We live in a culture of hyper-individualism…Over the past sixty years we have swung too far toward the self. The only way out is to rebalance, to build a culture that steers people toward relation, community, and commitment...” - David Brooks
Theories on the perceived and proper role of government - “Socialized medicine means that all doctors work as employees of government. The American people want no such system. No such system is here proposed.” - Harry Truman
Forms of government - “We see in the world’s superpowers different forms of government and similar maldistribution of wealth and income.”
For all practical purposes, public health is political. Health is embodiment of politically driven, socially constructed structures and conditions. Integration of political theory into public health theory is lacking and generally avoided in much of public health research. Yet, it forms a vital area to understand. An intervention that accounts for likely political pressures and philosophies would be more translatable and valid, for example. A major gap exists in the literature between research and contextual factors within micro- and macro-public health economies. Insight into political reasoning and motivations at all levels of government can be leveraged to tailor public health priorities and policy recommendations consistent with political realities. Some public health economies simply would not be expected to implement an intervention with fidelity based on past performance.
Political Theory in Antiquity
”Yes, the natural order. And so tyranny naturally arises out of democracy, and the most aggravated form of tyranny and slavery out of the most extreme form of liberty? …The people have always some champion whom they set over them and nurse into greatness…This and no other is the root from which a tyrant springs; when he first appears above ground he is a protector.” -Plato (Plato’s Republic, 380-350 B.C.)
"Confucius strongly believed that morality should take precedence over law, advocating that leaders should primarily guide their people through ethical example and virtue rather than relying solely on legal enforcement; essentially, a good leader should lead by moral character, setting a virtuous example for others to follow, rather than relying on strict rules and punishments to maintain order." - Google AI
Slavery Compromise: A Cautionary Tale for the Modern Age
Conceded Too Much, Too Long
No matter how unjust or undemocratic a government or society might be, you can usually identify a certain degree of normalization and deference. Perhaps due to survival instinct and paralyzing fear, people may strive for stability above all else. When change is necessary, they may be more apt to tune out dissension than contend with economic and social realities. They assume that any change in current conditions can carry risks. On a macro-scale, transitioning to a new social order might involve war and conflict. Violence and retribution are common forms of counter-resistance. Still, there may not yet be sufficient revolutionary energy (superposition) and unrest to challenge the status quo. Here, John Brown’s raid and Robert Emmet are instructive. Fear of being on the forefront of social change can be intimidating. It is not for the faint of heart. Rather than muster moral courage, it can be easier to “go along to get along”. This essay uses the historical lens of slavery to suggest that the long-term consequences of internalized injustice and immorality will be deleterious.
It goes without saying that war poses an existential threat and is generally understood to be undesirable, but lesser forms of direct confrontation too may be viewed skeptically. This reticence to square with lived experiences and contend with moral and social issues is dangerous to the social fabric and political stability of the nation. It isn’t a dynamic that only plays out on the national political stage, but colors every neighborhood, boardroom, and church. We’ve normalized and conceded too much just to stay the course. Just to keep friends and political access. Just to keep donors. Just to keep the lights on.
From the nation’s founding, slavery was the compromise that the nation was willing to make for national unity. Into the 1850s, the nation felt it could compromise its way out of the slavery issue as it pushed westward: Preamble to the United States Constitution, the Constitution, Fugitive Slave Act (1793), Missouri Compromise (1820), Second Missouri Compromise (1821), “Gag rule” in Congress (1831-1844), Compromise of 1850, and Kansas-Nebraska Act (1854).
When William Lloyd Garrison began advocating for the immediate end of US slavery in the 1830s, he found himself on the outside of societal norms, even among anti-slavery proponents, “In speaking engagements and through the Liberator and other publications, Garrison advocated the immediate emancipation of all slaves. This was an unpopular view during the 1830s, even with northerners who were against slavery.” [1] Garrison faced a society that had accepted slavery. They may have held their nose, but slavery was the order of the day, nonetheless.
So what changed between the 1830s and the 1860s? Extremism brought on by the issue of slavery - territorial expansion and fugitive laws.
The Civil War did not begin as a great contest between good and evil. As Lincoln stated in his first inaugural address, he did not seek to end slavery, “I have no purpose, directly or indirectly, to interfere with the institution of slavery in the States where it exists. I believe I have no lawful right to do so, and I have no inclination to do so.” Lincoln reflected national norms on the tolerance for slavery where it existed.
However, the backdrop of Lincoln’s address was greater extremism and capitulation to pro-slavery ideology and power. The Kansas-Nebraska act opened up vast areas to potentially new slave territory, repealing the Missouri Compromise. The Dred Scott decision came down in 1857, denying citizenship to Black people. In 1850, Congress conceded to the South by strengthening the Fugitive Slave Act with the Missouri Compromise. Slavery’s reach into free states meant these states were required to return escaped enslaved people. Still, the slave South felt existentially threatened by its relative decline with the election of Abraham Lincoln in 1860. Lincoln did not garner the support of any Southern state. The South’s voting bloc was split between John Breckinridge (Southern Democratic) and John Bell (Constitutional Union). Although the South had split its vote in presidential elections many times before in the first half of the 19th century, the institution of slavery was always secure. Lincoln’s election presented no immediate threat to slavery. Of course, the South begged to differ.
One lesson to draw from the political history of US slavery for the public health economy concerns extremism. Although favoring compromise might prove an immediate solution to a salient moral or political question, extremism can inevitably cross a red line. What does extremism look like in the modern era?
Extremism falls under two broad categories:
Laissez-faire permissiveness that is synonymous with hyper-individualism of natural persons and “pseudo”-natural persons (“corporations”). The US Supreme Court recognizes corporations as having the same rights as natural persons.
ANDLaissez-faire permissiveness of very powerful monied interests to reshape our democracy through power and wealth concentration.
These twin challenges are putting the US on a collision course. Even in liberal democracies, there must be checks on individuals and corporations to ensure the common welfare. “Government is instituted for the common good; for the protection, safety, prosperity and happiness of the people; and not for the profit, honor, or private interest of any one man, family, or class of men...,” said John Adams (Federalist 7, 1780).
We have tried several times throughout our history to privilege individual and corporate economic enterprise at the expense of justice and a common morality. The dire consequences for hyper-individualism have led to corrupt morals, greed, broken politics, and deep social resentment and division. Public health has not been spared either - war-related deaths, addictive, pharmaceutical pill-pushing, contaminated waterways and air quality, high environmental lead exposures that led to the most dramatic drops in human IQ. The list goes on. When progress has been made, the culture of excess still appears to be untreated. Obamacare was the greatest expansion of healthcare since the Great Society, following intense negotiations and compromise with the health care and insurance sectors. Except, the law that promised to have cost savings is now beset by escalating costs due to profit-driven motives - overbilling and industry consolidation.
Social inequality and moral decline are all tolerated until they aren’t. Compromising on slavery was favored until war arrived. The Gilded Age, then the rise of anarchism. Laissez-faire economics under Hoover, followed by the Great Depression. Industrialization and ecological devastation from which communities have yet to fully recover due to contaminated soils and waterways. In the modern era, income inequality and oligarchy are sowing seeds of inevitable rupture in the nation. War or outbreaks of violence spurred by a constitutional crisis seem inevitable. The January 6th insurrection has parallels with the violent upset with a perceived decline of relative power. The preconditions are all here and palpable.
Yet somehow, there is no great upset. No alarm ringing. We have allowed too much permissiveness. We’re only beginning to pay the price.
How Individualism Plays Out in the Public Health Economy
Competition for research dollars can be understood as a manifestation of hyper-individualism in US. This view that hyper-competition is the best model for public health is misplaced because the overall performance of the public health economy isn't necessarily improved.
The US is a highly litigious society that can give well-resourced individuals and corporations a view that any attempt at regulation, enforcement, or accountability can be contested. The US Supreme Court's decision to end the Chevron doctrine exacerbates this issue.
In the US context, every person pursing free enterprise is what is meant largely by freedom and liberty. However, this value can be taken to extremes to produce actors that deliberately engage in conduct to harm public health. Sometimes, government will permit it.
The Public Health Economy is Everywhere: Focusing on Medical Education
Public Health Liberation has posited a new major economy next to the traditional economy. As with the growth and jobs economy, the public health economy can be understood as omnipresent and profound, shaping daily lives. No order or common principles are associated with the public health economy.
Christopher Williams and colleagues’ work on inappropriate interview questions in medical education can be understood and explained by the anarchical dynamics of the public health economy. “Alliance (of Academic Internal Medicine) surveys also assessed the frequency of questions about relationship status, family planning, sexual orientation, and religion. Previous GME studies have shown that questions of an intense personal nature are a common feature of interview experiences. In 2016, women were more frequently asked about plans to have children and other programs to which they had applied.
The Public Health Economy is the “Other” Economy: Omnipresent in Daily Life
Resident Physicians: 80-hour workweeks, no social life, low pay, mental and physical stress, and mistreatment are all part of the conditions of the micro public health economy. Resident physicians' limited ability to access mental health services during office hours, stigma associated with help-seeking, and program scheduling inflexibility all shape the conditions of the public health economy. Reporting standards for physicians who have or are being treated for mental health have also deterred those from seeking help because of the impact that it can have on one's career. There is some traction among licensure boards and credentialing forms to remove questions on having sought mental health care.
Employment determinants of health pertain to the work conditions that impact employee health. Ultimately, this all is part of the public health economy. Employer practices on maximizing labor output and extraction, firing and workforce shrinkage, suppressing union negotiation, excessive work hours, and employees' limited ability to recharge and maintain health outside of work are all part of the public health economy.