a fork in the road, part two
2003-11-12
"Life asks of every individual a contribution and it is up to that individual to discover what it should be." -Victor Frankl
In many ways, I doubt my passion for public health as a possible career path. That passion has grown duller, blunter, dampened by the passing of time, the cynicism of the ‘real world’, and the politics and bureaucracy that bury idealism and the naïve drive to change things under inestimable tons of red tape and futility. With each passing year, I feel more and more akin to Camus’ beloved iconic figure: the rock-pushing Sisyphus. Will I, like Sisyphus, continue on my course in spite of its inherent futility? Will I persist in that existential struggle against ‘absurdity’? Will I reach for what I want, even if in the balance of things, it is meaningless? Do I know what I want? That is the quintessential question.
This year, I have had to justify my interest in public health. I have had to think of why I gravitated towards it, why I am willing to forsake my law degree in order to pursue it. I have doubted my ability to become a ‘public health professional’ many times. I have struggled - as do all people who adopt a public health framework in their approach towards health - with providing the ‘layman’, or even a professional, with a definition of what it involves. I have even wondered whether it is really worth the trouble anymore, whether I still have the passion that so inspired me in first year; the naïve desire to bring greater social justice to my corner of the world; to set myself up as some sort of defender of the ‘common good’. Was it all idealism? Do I really care that much about other people? Can a single person ‘make a difference’, or even make a dent? Is that really what I’m aiming for?
Although there is certainly a public health ‘workforce’, it is as varied and diverse as society itself, almost to the point of losing its identity as a specific discipline. Epidemiologists, sociologists, social workers, doctors, nurses, academics, historians, anthropologists, community health workers, engineers, economists, lawyers, demographers, statisticians, volunteers, charities, corporations, health departments, the state and federal governments, health inspectors, psychologists, politicians, health promoters, public servants, the UN, the World Health Organisation, scientists…So long as someone approaches their work from the perspective of prevention and health promotion, of benefiting the common good, they will make up a part of the public health workforce. They do not even have to know anything about the WHO Ottawa Charter, social capital, social justice, economic theory or the principles of epidemiology. They just need to believe in the value of prevention and health promotion, in a population rather than strictly individual focus, in the right of everyone to basic health and happiness, and to apply that to their work.
Perhaps the simplest, but most precise definition of public health that I have ever found was written by Charles-Edward A. Winslow – an American theoretician and public health professional - in 1923: ‘public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.’ Organised efforts of society. Throughout my studies of public health, collective effort has remained the cornerstone of the ‘discipline’. Public health is a massive social effort. It is not limited to people who go around sticking up posters with corny catchphrases intended to somehow prevent someone from having unsafe sex or driving too fast or lighting up a cigarette. Nor is it, as so many people I know tend to think, being the administrator of a public hospital. It is a notoriously invisible, contentious, political and much ill-applied and misinterpreted social framework aimed at improving the health of the public as a whole by preventing disease and promoting health, rather than, as with doctors and medicine, providing a cure or a treatment or a therapy for individuals once they have become sick.
Public health is, in its most ideal form, intended to be a defence against suffering, disease and injury – for the mind, the body, and for society as a whole. It is a shield designed to minimise harm, rather than an arsenal of drugs or surgical procedures designed to blast away harm once it has been inflicted. It is the ‘first line of defence’; more often defensive than it is offensive; loathe to declare war before a democratic resolution has first been attempted. Public health, by its very nature, is more about social change than band-aid solutions, although in practice, it is far easier and more visible to find a quick fix than to work for fundamental changes which are inherently invisible, slow to bring results, can span generations, and often require expenditure and change on behalf of those not intended to directly benefit from the change.
Libertarians often mistrust public health interventions precisely because they ask us to give up certain liberties in the pursuit of a common good that isn’t automatically apparent to us. A drug has instant effects. It is quantifiable. You either get better or you don’t, you are fully aware of these results, and the intervention mostly imposes only on the individual taking the drug. Attempts to change social policy or introduce laws to wear seatbelts or immunise against disease, on the other hand, do not carry immediate, flashing neon sign benefits. They are not always strictly quantifiable in terms of cost-benefit analysis, and they do not directly benefit everyone. For instance, everyone is required by law to wear a seatbelt in order to reduce overall harm from road accidents, but only a fraction of the total population wearing seat belts are statistically going to gain actual benefit from such laws. The rest of us are being ‘imposed’ upon for the sake of overall health gains.
Public health ideally aims for overall benefit, and it works on society and social groups, rather than individuals. It is intended to be a patient, dynamic, stalwart driver of positive political, economic and social change in the pursuit of social justice and health. It is the invisible hero, the unseen supports in our social architecture, hidden behind the plaster. Unfortunately, it is also commonly misunderstood, overlooked, resisted, or simply corrupted by our near-sighted drive for instant effects.
Throughout history, many groups have resisted public health interventions and ideas, either not believing they will work or not prepared to accept change. Pasteurisation of milk was resisted by the dairy industry; many groups did not believe that wearing seat belts would save lives; the tobacco industry, defending its vested interest, was most notorious in its efforts to dispel evidence linking smoking to lung cancer. Back in the 19th Century, the medical community laughed at John Snow when he linked an outbreak of cholera to infected water being taken from the Broad Street water pump in London. Disease back then was thought to be caused by ‘miasma’ (bad smells). To suggest that cholera was somehow a microscopic agent carried in water was simply too unfashionable and left field to be embraced. A similar reception was given to Ignatz Semmelweis, a Hungarian obstetrician, when he linked the higher mortality rates from puerperal fever in women in the ward attended by medical students versus that attended by mid-wives to the fact that the medical students, having come straight from the morgue, were not washing their hands. Even after mortality rates fell in that ward due to his efforts in introducing a policy of hand-washing, many doctors refused to accept his hypothesis and even attempted to sabotage his work.
Today, politicians push for flashy, short-term programs that may have gains in the foreground of time, and that may make them look good for their four-year terms in office, but that in the long-run are simply ineffectual money-wasters. Medicine tends to view public health as its poorer cousin. Anyone who admits of their ‘discipline’ to a med student, or sits on a board of medical professionals to provide a public health perspective will become acutely aware of the power imbalance. Public health ‘professionals’ are more often than not viewed as medicine’s hapless sidekicks, the legal aid lawyers rather than the corporate hotshots.
Anyone looking to ‘find a voice’ in the realm of public health must first realise that they will not have the same power or influence in getting their views across as an eminent surgeon or scientist might. This is not to say of course that the views of surgeons or scientists are inherently anti-public health or less valuable. Everything has its place, its context. More often than not, surgeons and scientists – in fact, most members of the medical profession – have simply been reared on a biomedical viewpoint that, by its nature, runs in a different vein to the public health way of thinking. A surgeon asked by a committee to suggest ways of reducing harm from road accidents would be more likely – by virtue of their training – to focus on the immediate after-effects of a road accident. They would suggest improved trauma services and greater training of the general public in first aid. They would suggest improvements in the availability and effectiveness of emergency services, better triage systems in casualty wards, and new developments in the treatment and rehabilitation of road accident victims; anything to stem the flow of harm once it has been unleashed.
A public health professional asked the same question would, on the other hand, first and foremost think about ways of preventing road accidents and preventing harm. They would think of improved safety in the design of vehicles, roads and infrastructure. They would suggest ways of changing attitudes towards driving and enforcing safe driving practices through legal reform, policing and social and political change. They would think of campaigns to discourage unsafe driving and to build a ‘culture’ of responsible, well-informed drivers. At the other end of the spectrum, they would also think of having good systems of ‘tertiary’ prevention. Despite the best efforts of primary prevention and health promotion, there will still be accidents. In the real world, harm can only be minimised. It cannot be eliminated entirely. Consequently, a public health professional will also take into account strategies that will reduce the amount of harm that befalls those who do find themselves involved in an accident – just like a surgeon would, with one obvious exception: a public health professional tends to consider prevention and health promotion before harm mitigation, whereas a medical professional, by virtue of their occupation, would be more inclined to first think of medical interventions which occur directly after the harmful event.
Public health professionals are more akin to engineers setting out systems of safety and thinking ahead, whereas medical professionals tend to act like mechanics, fixing a part when it has broken with the best efficiency they can achieve. Both disciplines have an obvious and valuable role in health. We need our engineers and our mechanics. It is simply a shame that the views of the engineers are often overlooked or given considerably less weight than the views of the powerful mechanics. Both views deserve equal attention, and there is no doubt that the health ‘system’ would greatly benefit from a more balanced mix of perspectives and approaches. Progress is being made, but like all things public health, that progress is slow.
These things I have learned from three years of studying public health as a discipline. As I grow closer to moving beyond the realm of the student and into the workforce, I have been confronted with an essential question: why public health? Why does it interest me? After all, it is a discipline fraught with conflict between ideology and the shortcomings of its practical application; a discipline so difficult to define that it requires an entire essay-length diary entry to explain. It is a discipline that receives little respect, recognition or awareness in the minds of most; a discipline that promises little personal reward in the short-term, and that yields invisible, contentious results. It is a vocation that smacks of futility for the individual attempting to find a niche within its unseen order. It has no central, identifying figurehead, and no iconic representation in the eyes of the public. It amounts to a rag-tag team of hopefuls and believers, its murky and uncertain title potentially attaching to anyone who holds a similar view of the world. Its principles defy the conservative capitalist’s ideal of a highly individualised society by predicating itself upon ‘collective efforts’. By its very nature, the public health discipline often runs counter to the status quo. For this reason, much of its potential is oppressed. Public health has too often been given a frontal lobotomy by bureaucrats, the professional elite, and those with vested interests. Its application in the real world has been sedated and watered down into quick fixes and band-aid solutions to appease the voters, the taxpayers, the shareholders and the medical profession. Why public health indeed?
There is of course no ‘simple answer’ to that question. But there is a central theme: a love for the underdog, a passion for the undervalued and the misunderstood, and an irrepressible desire to do my part for the ‘common good’ in the best way I know how. It sounds idealistic, a little naïve, but there is more to my attachment to public health than sheer childish dreams of a ‘better world’. Public health is all about dealing with conflict and change. It is defined by controversy and the struggle against stagnation. When something is unfair, when disease and injury needs to be addressed and understood, when society has become myopic, when social groups are suffering because of the way in which our physical, cultural and political environments are structured, it is the self-appointed duty of public health to augment change, prevent harm and promote health. Public health stirs me up inside; awakens me from the numbness of apathy, and gives me a constructive way of taking action. In that sense, it is just like the act and art of writing.
Learning the principles of public health for me has been comparable to encountering Socrates on his wanderings around ancient Athens, encouraging me to think for myself and to put that which I believe in up against the test of truth and reason. But more than pure rationality and evidence – which is the science of public health – it also has an art to it, a rallying force of will, voice and action that thinks ‘outside the box’ of a purely scientific method. Public health draws on a dizzying array of disciplines in order to speak of things that we are normally powerless to do anything about, or had no awareness of, and turns it all into something fallible and visible, something we can understand and defend against. It questions the validity of our social values and redefines our notions of health and wellbeing, but it also does something about it. It acts. It has a plan, many plans stretching out in an intricate spider’s web of design. It is rarely perfect action. It will never reach a pinnacle of completion. But it still acts. It embodies a constant, collective force of will towards the protection of our most precious asset: health. In spite of the inherent difficulties, uncertainties and misunderstandings, the rag tag assembly of public health workers has persisted at least since the early 19th Century in this constant, unyielding task of improvement, and their work will never stop.
Public health inspires me, even if it is fraught with difficulties and uncertainties. In the face of that inspiration, law has remained overshadowed in the ‘great scheme of things’. I have given up on law because it leaves me cold. More than that, it irritates me. My honours co-coordinator nailed it when she said that I was too broad-minded to enjoy the kind of close-knit, esoteric knowledge that a law degree imparts. Please note, I mean no offence to lawyers in writing this. I am merely expressing my own opinion, be it right or wrong. This is simply how I feel.
Law, to me, is predicated upon individual cases, individual laws. Its affinity for debating over the meaning of words may once have sounded okay to me, but in practice, I haven’t been able to see it as anything more than pedantic and coldly mechanical. To be a lawyer is to be a stage actor putting on a show of words to defeat the opposition with a flurry of facts and legal principles that have been twisted and moulded to suit the argument of the day. It is manipulative and showy, and while it is ideally supposed to be predicated upon values and principles of justice, it is too easy to lose oneself in the simple hunt and kill of the lawyer’s act, to regard the prosaic result of a ‘winning’ as the ultimate test of success.
I want to see past the manipulation of rules and definitions. I want to see past the dichotomy of ‘winning’ and ‘losing’. Thinking like a lawyer would personally render me too shortsighted, too narrow in thought. Law, for me, is simply too limited, too constricted, too bound up in code and precedent and verbosity to mean anything. I will not take up a career because it earns me bucket loads of cash. A career must inspire me somehow; stir my passion and my imagination. To be a lawyer, to be in a courtroom, is much too reminiscent of a duel. Really, courts do function as our more ‘civilised’ versions of a duel or a battle – they represent the ‘modern’ way of resolving age-old disputes or ‘righting’ wrongs. A person or organisation stands accused on a matter of law and fact, and must go to court to defend against the accuser. Instead of a rapier or a pistol, the weapon is a lawyer. Instead of the victor striking a literal coup de grace, a judge or a jury determines the losing party’s fate and the victor’s compensation in terms of a jail sentence or a sum of money.
It is all too black-and-white, too bound up in rigid formalities and process for my mind to value it. I like my tasks, my thoughts and my emotions to be broad and fluid; flexible and open, not bound up in the search for technicalities and maxims in order to ‘win’ an argument. I do not want to be a mercenary, hired to defend or condemn people in a formalised battle to the death. The world is so much larger than that, more detailed and intricate than a courtroom could address or a legal principle could capture. Although the law certainly has a valid, important and powerful role in society, I would be doing myself and the profession a disservice by entering it. I simply cannot believe in it. I cannot take it seriously.
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At the beginning of this entry, I asked myself: “what do I want?” Solidifying my thoughts upon this page has helped me to understand things that were not nearly as apparent to me before. I was overwhelmed by the barriers and the doubts, unable to find faith in myself or my decisions. But here, contained within this plethora of words, is the ‘answer’. What I want is to pursue that which stirs my mind and my passion. What I want is a career that so encompasses who I am that it is more an extension of myself than a mere vocation. There are few people I know who have the opportunity or the privilege to be able to claim that their ‘career’, or their ‘job’, is something they feel passionately about. To them, a job is simply a way of earning money, or ‘making ends meet’. To them, their jobs function as a ‘means to an end’. But I have found something that means much more than that. Public health, in whatever guise it may take for me upon graduation, is something truly special. Like writing, I might even say that it is a love of mine, something meaningful, something worthy of commitment and sacrifice.
Public health is, one way or another, my pigeonhole in life. In that respect, I have made the right decision to follow it, and to sacrifice a law degree. Who knows? One day I may return to finish the final two-and-a-half years of law I have left. But for now, the right thing to do is to go with public health, to see where my passion might lead me, and to write my first large body of work: a 20,000 word thesis. Megan was right when she said I was lucky. I have the opportunity to make a career out of something that moves and inspires me. There is, in the end, little reason at all to fear that transition into the ‘real world’.
“Your work is to discover your work and then with all your heart to give yourself to it.” – Buddha
