The following is the sense of the conferees—about what public health means to them, their colleagues and the general public; how perceptions of public health have evolved within the past decade; how the media have treated the subject; and what’s necessary to clarify the role of public health in the U.S.

There’s clearly a disconnect between how rank-and-file citizens and public health professionals think of public health. Laypeople often see it as health care for poor persons – including government insurance for indigents – and therefore part of the social safety net. While Americans may also be aware that public health is associated with specific functions—like health promotion, communicable disease prevention, food safety and sanitation—their overriding impression is that public health only applies to them in isolated, strictly personal instances: they need a vaccination for travel, or information to take precautions against the outbreak of a disease.

When public health officials ask audiences of non-professionals if they’ve used public health services recently, nobody responds, because the question baffles them. Then, they narrow the questioning to specifics—did you drink water? eat in restaurants? send your kids to schools that are safe, disease-free environments?—and everybody has an answer. “People don’t connect things that they take for granted with the benefits of a public health system that’s in place,” lamented one conferee. That only changes when the system has a breakdown that creates a broad-based risk.

Why is this a problem? Among other things, because that confusion lines up with the widespread view among Americans that public health is “services to people in lower classes or in need, and they’re not one of those people,” explained another participant. “Then we run the risk of having them think ‘those people’—quote , unquote—ought to be able to do this for themselves and we don’t really need to have it.” The perception fault line splits haves from have-nots – the former thinking public health is irrelevant, the latter thinking public health is very beneficial, if not crucial, to their lives.

The corollary here is that the scope of what public health encompasses makes it difficult for public health to develop a consensus about what it is. (When he was U.S. ambassador to France, Thomas Jefferson was asked by a French noblewoman to tell her about America. “Why madam!” he exclaimed. “The subject is as vast as the land itself.” So it is with public health.)

By any other name: talking about public health

Public health means different things to different constituent groups: to big-city residents, especially poorer ones, it’s a personal-care clinic; to regulated businesses, it’s industry-specific monitoring, like health inspections for restaurants or environmental and sanitation controls for septic installers and water system operators.

So the general public, and even public health practitioners themselves, look at public health through a variety of prisms. That has created misconceptions about what public health really is and what functions it encompasses. The phrase “public health” leaves people cold. As one conferee put it, “if you ask [people] to be engaged [in a discussion] about things that help improve their health [or] the collective health of their communities, or protect them, then [they’ll say] yes. If you ask them to engage in a discussion about public health, then probably no.”

There isn’t much enthusiasm among public health professionals for giving public health a different name. Some focus groups that were asked about possible substitutes liked the words “health protection”. Perhaps inserting an apostrophe – making it “public’s health”—might make public health more user-friendly. But calling public health by some other name won’t necessarily replace all the divergent and sometimes muddled perspectives with a commonly-understood meaning. Changing the name to something else could do more harm than good—ironically, because the term has been in common use for so long.

What can effectively raise the level of understanding, and the profile of public health, is aggressive communication—frequent, repetitive, simply-stated messages that discuss and provide examples of core public health themes and practices, with a particular emphasis on prevention and the concept of “safer and healthier.”

Indeed, most people in public health use the words as often as possible. Yet some practitioners have the sense that the phrase “public health” isn’t talked up enough by the public health community when it’s communicating with the larger society. So, public health has become insider jargon. “If we don’t…use [the words] all the time we can’t expect people to know what it means,” a conferee observed. So those who are in public health positions need to share whatever positive experiences they’ve had in successfully conveying what public health is to groups of people.

What has to be central to any consciousness-raising conversation about public health is the fact—the fact—that public health is for everybody. It touches the lives of everyone. Public health services are so convenient, but many people—including public health professionals—never realize that. “I can get into the health department in 10 minutes [to get] my kids’ physicals and shots,” told another participant. “It will take me two weeks to get into the doctor’s office. But until I was physically located in the health department for my job, I didn’t even know any of that was out there.”

Government agencies on every level—local, state, federal—provide the lion’s share of public health services: some professionals believe public health is exclusively about the public sector. Nevertheless, using the words “public health” in the conversation about the subject isn’t always advisable, because public health’s relationship to government makes it guilty by association for citizens who have negative opinions about government in general. In some cases, it’s better to talk about actions and results, not the words themselves.

Even the pros differ on definitions

Certainly, many public health officials have more comprehensive definitions of public health than the public at large. Those definitions reflect their specialized knowledge of the subject. Hence, they talk about functions like collective action; data tracking, collection and analysis; epidemiology; planning; health education; newborn screenings; and citizen engagement. There’s also reference to the more mundane everyday activities that are visible in the community, like garbage pickup and water/sewer service.

Yet, even though public health professionals can discuss, and understand, public health issues in depth, they, too, have trouble coalescing around an agreed-upon definition. Most of them will take a long view of public health, as work that includes disease prevention along with maintaining wellness, or well-being, in the larger society. But some in the profession have a narrowly-drawn view of public health that is confined to their own specialty or service function. What public health encompasses is understood differently from state to state. “I don’t think any of us could come up with a very succinct description of public health that would be consistent across the country,” suggested a participant.

There’s another dilemma that public health professionals haven’t resolved either: is public health, as some providers insist, solely the domain of government, or is it more holistic, where the faith-based, civic and business communities also make contributions to societal health and well-being? There isn’t even a consensus about what the CDC thinks about that question. The Institute of Medicine defined public health in terms of community assessment, policy development and program assurance. “That’s my view of public health,” said a conferee. “And that’s what I thought we were talking about. But maybe not.”

Radical change over the past decade

9/11. Katrina. The alarming ratcheting-up of violence in America life. The war on terror. Especially 9/11. These cataclysmic events and trends have drastically changed the way Americans look at the world. Public health hasn’t escaped that altered scrutiny—and both consumers and providers of public health view it very differently.

Emergency and disaster planning have a much higher priority than before. So does prevention as opposed to after-the-fact reaction—or, as another conferee said, public health has “more of a pro-active connotation now”. Americans may not know what public health is, or make the linkage between public health service delivery and the mission of particular agencies, but they are more aware that those agencies are heavily involved in preparedness and cooperate closely with first responders to an emergency. People also think public health has something to do with the environment. That wasn’t true 10 years ago.

The public may be wary of government institutions, yet they’re more trusting of public health providers to put the public interest first instead of politics. People now believe that devastating hurricanes, pandemics or terrorist incidents can hurt them, so they look to the public health establishment for the protection, reassurance or information they need. This is an opportunity for providers to influence people to think favorably about public health. If something bad does happen, public health leaders should be visible throughout the crisis. Their visibility, or lack thereof, is one of the two biggest factors in forming popular viewpoints about public health. The other is the amount of time that elapses between issuing a public health alert and resolving the problem that led to it. Perceived delays between the alert and the solution can sour public opinion, even though it can legitimately take a long time to close a case (e.g., the e-coli contamination of spinach).

Public health officials think the emphasis on natural or man-made disasters has a drawback, namely, that more traditional public health activities, like providing clean water and clean air, have been devalued. But that’s not the only sobering reality that public health providers have had to cope with in the new order of things.

Government funding cutbacks have hurt public health functions, so public health entities have to be much more business-minded in how they budget their monies. (One silver lining around this cloud is that the raised public health profile has brought to light that public health has been under-funded for such a long time.) And, in smaller counties across America, there’s been a big influx of public health employees who have no formal public health training, so experienced staff have to spend more time in on-the-job orientation and instruction.

What’s very frustrating is that legislators who control the purse strings are caught in a cognitive dissonance: they know public health needs and deserves the money, but they don’t think it’s a high budget priority.

Misunderstandings about the role of public health vis-à-vis Katrina may have contributed to that reluctance. “In many ways, I think public health actually performed quite well throughout a lot of what happened in Katrina. And the failures were really in other parts of the preparedness system,” contended one participant. “I worry about us getting tarnished by that.” People want immediate results, not results over the long-term, but public health doesn’t necessarily work that way.

There is good news here. Organizations that partner with public health institutions aren’t just exhorting people to take care of their health. Rather, they’re finding ways to influence behavior by joining in symbiotic public health partnerships, where a challenge is being confronted from multiple directions. The push for livable communities is one example of this synergistic approach.

The CDC’s role: spokesperson, not micro-manager

Inevitably, 9/11, the big hurricanes, the anthrax and e-coli scares and the scary talk about avian flu pandemics has put a much brighter, and harsher, spotlight on how the CDC fits into public health today.

Public health practitioners look to the CDC for high-value functions like advocacy for public health funding at all three levels. They believe there’s a critical need for CDC to explain to funding bodies why public health is so vital. The CDC also gets good marks for doing laboratory work that’s too costly, rarely used or unnecessary for states to conduct themselves.

Beyond that, the CDC has great value in getting states to share data and best practices, providing expertise and being the clearinghouse for updated and reliable public health information. The CDC’s website is an invaluable public information resource. At its best, the CDC is seen as the national leadership center in identifying and prioritizing public health challenges and what should be done about them. It’s the place that monitors the occurrence of disease throughout the world and major health trends.

But the CDC needs to be something more, and something less.

For whatever reason, the CDC hasn’t taken the point in telling Americans need-to-know information when a critical event is happening or a potential crisis is looming. Pandemic influenza is a case in point. “Who is going to speak to us with a national public health voice unless it’s the CDC?” asked one participant. “Certainly we’re going to have well-prepared state and local public health officers, but people are going to look for something at the CDC level. And I don’t think that has been or is being developed.”

In some areas, the CDC’s prominence is counter-productive. It doesn’t always engage effectively with other Federal departments. It conducts surveillance activities that sometimes poach on state and local government territory.

Public health providers really want the CDC to get away from the tendency to act as a Lone Ranger and promise more than it can deliver. They don’t want the CDC funding non-profits who act independently of government public health authorities. They don’t want the CDC to bypass local entities and speak or act as if it is the direct community resource provider. They don’t want the CDC positioning itself outside of the tripartite national public health structure, because it unsettles citizens who expect local governments to deliver and be accountable for services.

The media, education and enhanced communication

For Americans to see the big picture on public health, the media has to see it, too. Public health officials would like the media to pay more attention to the need for funding and infrastructure improvements so that governments end their neglect of public health services. Too often, the media focus on tangential issues rather than educate the public about core public health functions. Or else, they stoop to fear-mongering to dramatize big issues. Since 9/11, though, journalists have become more conscious of the public health infrastructure and how much more investment it requires.

Public health providers can’t just depend on media coverage, though. They have to create their own advertising messages and put them in print media, like newspapers (e.g., special clean water inserts. Print also gives the reporter much more time and space to discuss a public health concern in depth than a short broadcast spot. Visual branding of public health, through media like billboards, can also be effective.

Communication should establish greater awareness among the public, certainly, but also among funding sources, such as private donors and governments. It’s even better if you can get an elected official to tell your story, because it gives the message more credibility.

The story of what public health is all about does have to be told—over and over again, where the many and disparate public health providers emphasize their unity of purpose—not how different they all are. As one conferee concluded, “Any time you try to distinguish yourself from each other, you just lose the power of what you are trying to say.”