The Public Health Economy: The Other Economy

“The hard-nosed truth is that the public health economy lacks order.”

I. BACKGROUND

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 has become apparent 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 transdisciplinary synthesis and practice. 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 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 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 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.”

II. EXAMPLES OF PUBLIC HEALTH ECONOMIC CONCERNS

A. 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?”

B. Political Theory

What are pathways to health equity given party politics?

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? 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)?

C. Economics

What are economic failures or gaps that require government intervention and reforms to address major gaps in health opportunity and access - public health?

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?

D. 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?

E. Research

How can research approaches and funding be leveraged for real-time challenges within the public health economy?

Is the current research approach best positioned for accelerating health equity? 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?

F. Ethics and Morality

Do people, corporations, and governments have clear moral reasoning concerning their contribution to the public health economy?

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?

III. 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. These professional associations generate much of their income from annual meetings. Second, knowledge gains and tool development can benefit these conference attendees as opposed to making breakthroughs for the public health economy. Given the high specialization in public health, we should be concerned with conferencing as an effect of public health realism.

IV. DOES PUBLIC HEALTH ECONOMIC ANALYSIS MAKE A DIFFERENCE?

A. 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.

B. 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

C. 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

D. 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.

E. What Moves Governments to Act?
Federal Government.

DC Housing Authority Only Abated Harm Once Federal Government Intervenes

The District of Columbia Housing Authority (DCHA) is a powerful illustration of the public health economy. For decades, it 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. It 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.

“Only the US government could have stopped the District’s bad behavior by conducting an audit and requiring a corrective action plan.”

The local DC government was engaged in a high level of incessant structural racism directly aimed at the most vulnerable housed populations. The agency should have been placed under receivership since housing authorities with far fewer citations had been. With this case, we can learn about how the public health economy performs.”

V. ILLUSTRATING THE PUBLIC HEALTH ECONOMIC FRAMEWORK

A. Research Ethics and Conduct

A working assumption of biomedical and public health research and surveillance is that more data will elicit political attention and action. Another assumption concerns epistemic arrogance. Public health researchers can have an incomplete knowledge and unjustified explanatory models without an understanding of the public health economy. Public health economic analysis draws our attention to the research industrial complex, including its assumptions, orientation to affected communities, translatability of scientific findings, restrictions on access (e.g., journal paywalling), organization of new knowledge, and estrangement from real-world challenges in the public health economy. Fierce competition for grant and philanthropic dollars defines the underlying dynamic of the research industrial complex.

”Drive-by” research has been a noted problem in the research enterprise in the US. This occurs when a researcher goes into a community, extracts data, then leaves never to return. That researcher can usually reap major benefits from this research for career promotion and academic tenure, not to mention publications and speakerships, even books. Often, researchers or their employers do not assume any responsibility for community dissemination of study findings or to engage in policymaking to support health equity. Further, the study results from this research may be beyond public access because it is put behind a journal paywall. Publicly funded research that is hidden behind a paywall raises serious ethical and democratic concerns. Until Public Health Liberation theory, no public health theory incorporated these research practices within a transdisciplinary umbrella as a barrier to health equity. That can be explained by public health realism given self-interests.

B. Regulatory Framework, Workforce, and Enforcement

Public health economic analysis draws upon the regulatory ecosystem - policymaking, rulemaking, enforcement, and legislative oversight. While regulation-related conduct may intersect with the profit motive at the heart of economic theory (e.g., lax regulation to minimize costs), economic theory does not adequately explain actions across a broad set of attitudes and behaviors that impact public health.

We have seen in our community of practice in Washington, DC that environmental regulators do not fully implement environmental laws. The laws on regulating the regulator call for the agency to establish findings of fact to minimize risks to public health and safety as a condition of issuing air pollution permits. The regulator is not doing this. It also turns out that the legislature, which is obligated to provide oversight of government agencies’ adherence to the law, does not fully exercise that authority and responsibility. Government employees who take documents home that should be available to public discoverability (“FOIA”) and the government stonewalling FOIA request are altogether other issues.

There is also the “revolving door,” in which individuals move from representing an industry into a government regulatory position for that industry, then back to industry. This can certainly be related to economic motives, but high tolerance for the revolving door reflects entrenched political and societal norms and acceptability. A Washington Post story on the opioid crisis noted in 2017, “When (DEA’sformer associate chief counsel, D. Linden) Barber went to work for the drug industry in 2011, he brought an intimate knowledge of the DEA’s strategy and how it could be attacked to protect the companies. He was one of dozens of DEA officials recruited by the drug industry during the past decade...Barber played a key role in crafting an early version of the legislation that would eventually curtail the DEA’s power, according to an internal email written by a Justice Department official to a colleague. “He wrote the Marino bill,” the official wrote in 2014.”

C. Auditor for the Auditor

Public agencies frequently are subjected to an investigation or audit by a separate objective or apolitical government agency (e.g., inspector general, accountability office) that has statutory authority to assess fraud, waste, and abuse. Agencies charged with public health and safety missions and functions can weakly or unlawfully carry out their legal obligations, so an audit of that agency can help to ensure public accountability and transparency. For example, a Government Accountability Office report found that the IRS failed to review hospital community benefits activities once every three years. Nonprofit hospitals are tax-exempt and must operate with a charitable purpose.

D. Lax Legislative Oversight

We see many major gaps in legislative oversight of government agencies that have public health roles and functions. Public health economic analysis seeks to address a major gap in the literature on the quality of legislative oversight in areas pertaining to the public health economy - both traditional public health agencies like environmental regulations and those not within the traditional domain of public health like education.

The unlawful issuance of air permits without establishing findings of face is part of a slew of cases in which the DC legislature has been lax in our community of practice. We have also had a housing authority - the city’s largest landlord - that has been subject of suits and federal audits due to corruption, ghettoization of public housing, declining housing quality, and high vacancy rates, not to mention the physical and emotional harm to residents. However, legislatures that exercise quality oversight may find limited options for enforcement.

E. Research Darwinism

Another issue with the biomedical and public health research enterprise is that researchers are forced into competition for public and private dollars, spurring a zero-sum game in the public health economy (e.g., receiving or not receiving grant funding). In turn, it becomes a self-reinforcing system of greater research enterprise. Researchers are often positioned as experts and advocates for their research as opposed to attention to the performance and health of the public health economy, which has often led to specialty-driven, PI-directed public health resource priorities and agenda-setting. Economic principles that undergird activities (e.g., maximizing profit and survivalism) are inappropriate for the optimal performance of the public health economy because economics and public health economics have diametrically opposed motives. The traditional economic approaches to profit and wealth-building privilege survivalist, even hegemonic, conduct and tend to eschew collective ownership and responsibility for the whole of the economy - a commonality with the current configuration of the public health economy. According to economic theory, individual actors are free to pursue actions that ensure survival, permanence, and influence - above all, profit. On the other hand, the public health economy cannot operate by these same principles because of the public health mandate to pursue a fully inclusive public health economic agenda that guarantees the health of the public - for everyone, everywhere, at all times.

“At issue is shifting the balance of power, as tied to the work of community organizers, and not to have epidemiologists serve as gatekeepers of what is possible, which will not lead to increased trust in the research results.” - Zinzi Bailey (paraphrased) (spiritof1848.org)

F. Public Health Realism

Public health realism establishes a theory of universal motivations and rationality (“self-interests”) in the public health economy. Without a unifying framework, we cannot explain health inequity reproduction. While the theory seems stark and ungenerous, “self-interests” is, in fact, intended as neutral - meaning that each agent has a finite scope and population to which they are accountable. Further, action across the public health economy appears random, unrelated, and unpredictable without a “grand theory”. By drawing on the lead water crises in Flint, Michigan and Washington, DC, public health liberation theory posits that the public health economy is characterized by public health realism, a warring state of competing factions, worldviews, and self-interests that are not compatible or cohering around a common morality or goal-seeking. Self-defense, survival, and accrual can manifest in selective data sourcing, denial of public health harm, obstruction, and illegalities. To accelerate health equity, it requires that the public health economy becomes more horizontally and vertically integrated and seeks to safeguard public health through morally- and justice-grounded action.

The conduct of government, corporations, and nonprofits all matters in the public health economy, however well-meaning, beneficial, and inclusive. Public health realism forces rationality and circumspection upon all agents. They are not without limitless potential, issue areas, scope, and resources. In terms of systems behavior, this imposed rationality explains the fundamental dynamic within the public health economy. Public health realism explains conduct of agents as related to external and internal relations (e.g., employee relations and workplace culture). The public health economy is concerned with the whole economy, so mistreatment of workers or occupational hazards are equally concerning in relation to how that agent might engage with external bodies (e.g., legislators, regulators, funders).

“If it ever comes down to the reputation of a government agency and the truth, something has to give. It's always the truth.” - Dr. Marc Edwards

G. Government Defense of Poor Government Conduct

Whenever a petitioner files a civil complaint against a government (e.g., local, state, or federal) or government employee, the government’s legal counsel is legally obligated to defend the government against a lawsuit - a pattern across liberal- and conservative-leaning jurisdictions. These legal counsels could be the state attorneys general and their assistants, US attorneys or assistants, or local government lawyers. Their role is to seek dismissal of the lawsuit by using any number of legal maneuvers (e.g., denying the plaintiff has standing, plaintiff did not refute the defendant’s allegation). If the case survives the first motion to dismiss and moves to discovery, then the government’s legal counsel may seek to dismiss it after discovery or on appeal. Although there can be many frivolous lawsuits against the government, the posture of the government does not generally base its defense of the state on the merits of the case. This means that cases of inequity (e.g., violations of the law, government-backed environmental racism, government-driven housing discrimination and displacement) against the government face the full powers and resources of the state - a taxpayer-funded entity. Even in the face of government-directed harm, it can be common for cases to extend for well over 10 years before any resolution or settlement - dismissal.

H. 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.

I. 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.

A. 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? “ - Ronald Reagan

“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 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.

B. 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

C. SLAVERY COMPROMISE: A CAUTIONARY TALE FOR THE MODERN AGE

i. 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 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.

ii. 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?

iii. 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.
Laissez-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 of 1861 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.

“History proves time and again that only mass mobilization and protests will move the political leadership class on certain major reforms.”

J. Poor Program Planning and Implementation
Ensuring quality public health program planning and implementation is essential to preventing waste and for justifying public health spending. It is possible that no amount of public health spending can accelerate health inequity if public health interventions are rendered ineffective due to poor planning and implementation across different contexts and settings, particularly outside of highly controlled research studies. This is an area of immense concern to public health economic analysis since planning, implementation, and evaluation outside of and within formal research can be susceptible to political (i.e., projects within government) and institutional considerations, including the public health realist principles of self-protectionism. Public health realism pervades the public health economy.

On a notable research center: "It's pretty hard for me to imagine they blew through $30 million in two years," associate professor [redacted]. "There's been a lack of transparency about how much money comes in and how it's spent from the beginning, which comports with a larger culture of secrecy."

K. Social Theory: Social and Economic Stratification
Health inequity is not merely a function of economics, politics, or law but society as a whole. These social systems and norms play a major role in health equity progress because health burdens are not evenly distributed. Reform requires that non-affected populations are co-engaged in the struggle for health justice beyond their own economic and social interests. Class, social networks, ethnicity/”race”, income geography, gender, occupational type, “soil,” and other social identities influence worldviews and action within the public health economy. In our community of practice, we can see how lines of demarcation have been drawn based on neighborhood location, income, and social circles. One part of the neighborhood is associated with mass protests and active political engagement on issues such as housing and environmental justice while the other is closely associated with the political establishment that sees no major urgency or problem. In fact, this latter group tends to be critical of, even recriminate and mock, those who voice dissatisfaction with the status quo. “I have been called a lot of things in my work. “Radical” is most often used disparagingly,” said Christopher Williams. “It is as if they are saying that advocating for public housing residents when one does not live in public housing is a faux pas.”

The maldistribution and exchange of social and political capital should garner public health attention. Because vulnerable communities are often subjected to bad policies (e.g., ghettoization, policy neglect, underinvestment) and exploitation (e.g., “drive-by” research), they can always benefit from outside experts and permanent allies. Researchers are often quick to suggest that low-income and vulnerable populations have low social capital; rarely, do these researchers and the public, generally, acknowledge that this undercapitalization can be explained by outsiders’ own hording of social and political capital. In fact, a feigned appearance of unity with vulnerable populations among community and political leadership classes - leveraging perceptions of leadership or representativeness without expending any social capital to challenge harmful agency policies or private misconduct - is a common observation.

Income and class have often been a fixture in this debate historically but took on new meaning with Karl Marx. According to Marx in German Ideology, “For each new class which puts itself in the place of one ruling before it, is compelled, merely in order to carry through its aim, to represent its interest as the common interest of all the members of society, that is, expressed in ideal form: it has to give its ideas the form of universality, and represent them as the only rational, universally valid ones.”

L. Social Theory: Social Capital and People Power
Social theory on social capital, organizing, and people power gives us insight into the current performance of the public health economy. It would benefit public health to understand whether and how society is organized, to affect what issues, and for whom. How does hopelessness, vast inequality, political inaction, longstanding neglect, economic disempowerment, and the heavy weight of determinants of health shape the desire and capacity for political and social organizing? In the context of community research, community-informed research questions, methodologies, and interpretations improve research quality.

Robert Putnam has been a major figure in studying a declining sense of community in the US.

“People divorced from community, occupation, and association are first and foremost among the supporters of extremism.”

“Social dislocation can easily breed a reactionary form of nostalgia.”

“Busy people tend to forgo the one activity - TV watching _ that is most lethal to community involvement”

“{The Progressives] outlook was activist and optimistic, not fatalist and despondent. The distinctive characteristic of the Progressives was their conviction that social evils would not remedy themselves and that it was foolhardy to wait passively for time's cure. As Herbert Croly put it, they did not believe that the future would take care of itself. Neither should we.”

M. Legal Frameworks and Unlawful or Injurious Government Action
Besides the legal defense mentioned earlier, legal frameworks play a key role in the public health economy. The law guides judicial decision-making, which can mean that governments can (and often do) violate the law for which a plaintiff has no recourse. For example, a plaintiff may fail to establish legal standing even if the government has plainly violated the law.

i. Legal standing - First, plaintiffs must have legal standing based on this multi-pronged standard: a “plaintiff must have (1) suffered an injury in fact that is particularized, (2) that is fairly traceable to the challenged conduct of the defendant, and (3) that is likely to be redressed by a favorable judicial decision.” If a plaintiff does not have standing, “the court lacks jurisdiction.” “To establish an "injury in fact," the plaintiff must show that he has "suffered 'an invasion of a legally protected interest' that is 'concrete and particularized' and 'actual or imminent, not conjectural or hypothetical.'"

ii. Sovereign Immunity “For most of the nation’s history, sovereign immunity barred the federal government from being sued for misconduct or negligence by federal employees. But in 1946, Congress passed the Federal Tort Claims Act, which waived immunity for some actions taken by federal employees that led to personal injury or property damage. The family points out that the law was amended in 1974 to include a provision for action by law enforcement after a pair of mistaken house raids.” [Washington Post]

Marc Edwards on Government
“When something goes wrong at these agencies, do not be surprised when no one is there to look out for your interests. Do not be surprised so there's no accountability. A class action which initiated in 2009 but you can't prove who has happened five years after the fact. It's kind of hard. (The lawsuit) was thrown out maybe in summer 2016. There's five kids still fighting in the lawsuit against the government to get some compensation for the damage that was done to them. This incident about 20 to 30 times worse by the way than the lead poisoning in Flint, not to downplay what happened in Flint and not one government official was ever fired or demoted for what happened in DC.” (Slide from Marc Edwards’ lecture)

A plaintiff in one of the individual cases and the government reached an undisclosed settlement in 2019, nearly 20 years after the crisis.

VI. Headlines

Inmates accuse Alabama prison system of state-sanctioned slavery

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.”

I was treated like a murderer for suffering a personal tragedy.

Only One Conclusion: Washington, DC Resembles Apartheid