Two Page paper. (Senior level college)

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The Role of the Public Health Official in Communicating Public Health Information

| Enrique Regidor, PhD, Luis de la Fuente, PhD, Juan L. Gutiérrez-Fisac, PhD, Salvador de Mateo, PhD, Cruz Pascual, BSc, José Sánchez-Payá, PhD, and Elena Ronda, PhD

The prevailing views on the role of public health pro- fessionals refer to profes- sionals in the academic world, without taking into account the fact that many public health professionals are government employees. For example, the American Pub- lic Health Association states that public health profes- sionals play an active role in communicating public health information to nonscientific audiences, such as the gen- eral population or the mass media.

We propose that public health officials have an im- portant responsibility to pro- mote the practice of public health. However, they must do so within the bureaucracy. Any actions that public health officials wish to take as ad- vocates of particular public health activities should be carried out independent of their role as government of- ficials. (Am J Public Health. 2007;97:S93–S97. doi:10.2105/ AJPH.2006.094623)

ONE OF THE GOALS OF PUBLIC health is to communicate health information in such a way that it can be interpreted appropriately by individuals and society. One need only recall several articles on public health surveillance in the United States published at the end of the last century. These articles state that local and state health departments, as well as various governmental public health agencies, have traditionally disseminated their public health findings and surveillance informa- tion through reports of state and local health departments, federal publications like the Morbidity and Mortality Weekly Report, and peer-reviewed public health and clinical journals. At the same time, however, the authors of these works recognize the need to change the way such informa- tion is disseminated so that it reaches different users in the most appropriate way.1–4

These articles propose that the dissemination of public health findings and surveillance infor- mation requires previous identi- fication of the audience and tak- ing advantage of all channels of communication to assure that the information is communi- cated and marketed—not merely disseminated—to those who need to know. The different groups of users to whom they refer are public health practitioners, physi- cians, policymakers, the general public, laboratories and other health care providers, the mass media, and researchers, whereas the spectrum of communications

options includes, in addition to the publications mentioned, elec- tronic channels, broadcast media, print media, and public forums.3,4

The authors of these propos- als recognize that communica- tion is a loop involving at least a sender and a receiver. But al- though they clearly identify those who are the receivers of the information—those who need to know—they do not do the same with the senders. The incorporation of new audiences and channels of communication that have not traditionally been included in the communication of surveillance results raises great uncertainty about the role that these authors assign to pub- lic health officials. These works do not make it sufficiently clear whether the information is to be disseminated by the health de- partment or government public health agency or by the person or public health official responsi- ble for surveillance of each health condition being moni- tored. The impression given is that the health department or government public health agency is embodied in the public health official.

PERSONS RESPONSIBLE FOR COMMUNICATING HEALTH INFORMATION

This ambiguity was resolved in 2002 when the American Public Health Association published a book titled Communicating Public Health Information Effectively. A Guide for Practitioners.5 The

authors stated that 1 of the main activities of public health profes- sionals is to convey public health information to different users. In the preface they noted that the book is aimed at public health professionals—those in the aca- demic world as well as govern- ment employees—including per- sons in both the private and public sectors.

The authors mentioned some typical examples to show why public health professionals need to acquire skill in communicat- ing information to nonscientific audiences, such as the general population or the mass media. They mentioned the relatively frequent situation in which pub- lic health professionals find that they must express the level of risk to a community whose resi- dents are convinced that the in- creased risk of a certain type of cancer is caused by the presence of a nearby factory or the typical case of a journalist calling to ask how many people have been af- fected by food poisoning in a fa- mous restaurant and which food was responsible. In this regard, the objective of the book is to teach public health professionals to communicate public health information to nonscientific audiences.

Public health information, as used in this book, is a broader term that encompasses data but also includes interpretations and recommendations based on scien- tific knowledge.6 For the authors, public health professionals convey information with 2 purposes in

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mind: to inform and to persuade. Informing means providing fac- tual information with no intent of influencing a decision. Persuading refers to using information to help change opinions, attitudes, or be- haviors and is probably the most common purpose for communica- tion in public health practice. Ex- amples of persuasion in public health are legion, such as encour- aging smoking prevention and cessation, condom use, early pre- natal care, prevention of driving under the influence of drugs or alcohol, or the immunization of young children.

PUBLIC HEALTH OFFICIALS AS SENDERS OF INFORMATION

These proposals are likely to come as a surprise to most public health professionals who work as public health officials in devel- oped countries. We use the term “public health officials” to refer to individuals employed by local, regional or state, and national or federal health departments or government health agencies, who have attained their position in open competition or by contract through a public examination based on professional merit. We do not refer to politically ap- pointed high-level administrators or similar (directors general) or to the elected executive. We also exclude appointed public health officials who comprise the first step in the decisionmaking hier- archy and who, because they serve at the pleasure of the exec- utive, may be removed from their posts at any time—almost always when the person or their program is out of favor with the executive. Occasionally an ap- pointed public health official is also the only local health depart- ment employee.

One of the functions of public health officials is to communi- cate public health information provided by surveillance and health information systems to policymakers, health care pro- viders, and the administrative agencies involved in the control of public health problems. How- ever, in our opinion, it is not the task of the public health official to answer a journalist, private citizen, or deputy of parliament who asks about the frequency of a disease. And the same can be said of a situation giving rise to social alarm because of the unexpected emergence of a public health problem. Faced with a problem of disinfecting the city drinking water or of an unexpected increase in the number of deaths, the pharma- cist who monitors the physical and chemical properties of the drinking water or the statistician who monitors mortality are not the ones who communicate this information to the population or to the media. These public health officials, as part of their professional activity, gather data and transmit the information to their immediate superior. How- ever, the decision of whether or not to make that information public is the responsibility of those who represent the depart- ment at the institutional level.

Similarly, it is not the responsi- bility of the public health official to convey recommendations to persuade the population to mod- ify certain kinds of behavior. Pub- lic health officials transmit to their superiors the scientific evi- dence that is important for deci- sionmaking. It is those who are institutionally responsible who make the decision of whether or not to recommend a particular series of measures, based on a wide array of scientific, cultural,

economic, political, and ethical considerations. Public Health Officials also should not try to persuade members of legislative bodies. As Brownson and Malone7 remind us, persuasive communication efforts on the part of governmental employees toward legislators cannot occur without the permission of a higher-level administrator or an elected executive.

The role and obligations of public health professionals de- pend on their profession and, above all, on the work setting; working in a government health department is not the same as working in a university or a public-sector research organiza- tion. However, neither of these 2 characteristics is considered in the prevailing views in jour- nals and other publications dedicated to the exchange of knowledge related to public health practice. It is not surpris- ing that young professionals who join public health civil ser- vice in developed countries ex- press considerable uncertainty as time goes on when they com- pare their own daily profes- sional practice with what they read about in these journals. This uncertainty or confusion is legitimate considering that pub- lic health officials in these coun- tries represent the largest part of the workforce dedicated to this professional activity.

VIEWS ABOUT PUBLIC HEALTH PRACTICE IN SPECIALTY JOURNALS

In specialty journals, 2 charac- teristics define the views about public health practice: a reduc- tionist conception of public health practice and the idea that public health professionals should act as advocates regardless of their

work setting. For example, Susser and Susser,8 in an essay on the scientific paradigms of epidemiol- ogy, note that a basic function of schools of public health is to socialize students through the transmission of traditional public health values. In this way, epi- demiologists will keep alive the idea of improving the public health as a primary value. They believe that epidemiologists must be scientists but also professionals in the traditional meaning of medicine, law, or the clergy: soci- ety confers on them an au- tonomous and privileged function based on their specialized train- ing, but this autonomy carries with it reciprocal obligations of service to individuals and to society.

Wall9 also states that, “what the doctor is to patients, the epidemiologist is to society,” whereas Savitz et al10 add to this idea by reminding us that public health is far too complex to be considered merely applied epidemiology. They suggest that the term “public health worker” should be substituted for “epi- demiologist,” because it is the public health worker who accu- mulates information on society’s illnesses, develops a plan for treatment, and implements needed therapy. Weed11 also views epidemiology as a profes- sion similar to that of medicine or the clergy. The ethical code of physicians or the clergy, as persons who possess specialized knowledge, involves the obliga- tion to help others. In the case of the epidemiologist, the core of professional practice is a promise to help society by pre- venting disease and promoting health. Subsequently Weed and McKeown12 use these ideas in referring to public health prac- tice in general.

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These opinions reflect a reduc- tionism in the conception of pub- lic health practice by identifying it with epidemiology—and only in the academic world—but espe- cially by considering it similar to the practice of medicine and other liberal professions. The ex- istence of an ethical code in a profession requires a clear de- marcation of its role and obliga- tions but is also influenced by technical skill and daily practice. Medical practice contrasts sharply with the large variety of activities and disciplines that are part of public health practice, such as: monitoring the condition of pipes that conduct drinking water and sewage, surveillance of levels of atmospheric contamination and of environmental noise, supervis- ing city garbage collection, in- specting food sold in markets, set- ting hygienic–sanitary standards of habitability in homes, manag- ing home health care for the dis- abled, monitoring the prevalence of behaviors that pose a risk to health, estimating indicators of health status based on population health statistics, establishing norms for approval by parliament about maximum levels of blood alcohol in drivers, and so forth. It is highly unlikely that the physi- cists, chemists, architects, veteri- narians, pharmacists, epidemiolo- gists, or statisticians who carry out these activities identify their professional practice with the practice of medicine or that they would consider the code of medi- cine to be closest to their obliga- tions and principles.

On the other hand, physicians decide to act based on the avail- able scientific knowledge and other considerations that form part of the art of clinical practice, but this is not the case for public health professionals. Public health represents an organized effort of

the community to improve the health of the population, which requires a large variety of social, economic, environmental, and behavioral interventions. The dif- ference between public health and medicine is that public health is most often delivered by govern- ment institutions to a population rather than by 1 person to an- other.13 Decisions to intervene in democratic societies are made by governments in the name of the community, not by public health professionals. The Public Health Leadership Society in the United States has noted the need for a public health code of ethics to identify the distinctive elements of public health by making clear to populations and communities the ideals of the public health in- stitutions that serve them.14,15 For this reason, the society’s pro- posed code of 12 principles for the ethical practice of public health is directed to public health institutions and not to individuals.

With regard to the role of public health professionals as advocates, many,11,12,16–21 but not all,22,23 authors consider that public health professionals are responsible for recommend- ing public health interventions and making these interventions known to the public. We agree with the general viewpoint of these authors, which recognizes advocacy as a core skill needed in public health practitioners. Without advocacy, it is highly unlikely that the findings of high-quality research from the different disciplines that make up public health will be trans- lated into action to benefit pop- ulation health. However, we be- lieve that the failure of these authors to allow for exceptions to their overall position based on the characteristics of each job constitutes an important

limiting factor. Other authors have made this allowance, and they remind us that advocacy is especially difficult for public health practitioners who are employed by government agen- cies.19,21 For Beaglehold and Bonita,19 those who practice public health in university set- tings and, thus, have more inde- pendence have a special respon- sibility to speak publicly on the factors that influence levels of population health and on the most appropriate public health strategies. In their opinion, gov- ernment employees who wish to act should form advocacy groups outside the bureaucracy. According to Chapman,21 public health professionals who are government employees can par- ticipate in advocacy efforts in their professional capacities.

THE RESPONSIBILITY TO COMMUNICATE PUBLIC HEALTH INFORMATION

Does this mean that public health officials cannot act as ad- vocates? Quite the contrary. In opposition to the previously men- tioned authors,19,21 we believe that public health officials have an important responsibility as ad- vocates within the bureaucracy. It is precisely within their own institutions that public health of- ficials should exercise efforts of persuasion. As public health pro- fessionals, public health officials have the obligation to promote and recommend to policymakers the most appropriate course of action in line with the available scientific knowledge and scien- tific uncertainty and after weighing whether the burdens to society are reasonable when compared with the probable benefits. This is neither easy nor comfortable, because it often

means going against the general principles that govern decision- making in the institutions where they work. However, once the decision is made, the responsibility of the public health official as an advocate ends.

We refer here to decisions that are ethically correct. As noted by Chapman,20 few areas in public health present morally conven- ient, undisputed “truths,” and what is ultimately being debated in public health disputes is the primacy of certain values over others. Public health officials have the obligation to implement decisions even when they do not agree with their values. An alto- gether different situation, but not the subject of the present work, is their obligation in the face of ethically incorrect decisions. Pub- lic health officials have an enor- mous responsibility to remove from policy debate decisions that are unethical, whether because of insufficient data, clearly dis- criminatory procedures, unjusti- fied limitations on personal liber- ties, mismanagement of public resources, or substantial risk to public health. Fortunately, many developed countries have legisla- tion known as “whistle-blower protection,” which protects gov- ernment employees who reveal information in the public interest.

Some authors have expressed the need for public health doc- tors to be independent of politi- cal authorities so that they can disseminate knowledge concern- ing risk factors for health and in- tervention measures. For this rea- son, they have proposed that the conditions of employment of public health doctors be pro- tected.24–26 However, we do not agree with this opinion. In the first place, biomedical knowledge is irrelevant for the control of many public health problems,

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such as traffic accidents or con- tamination of the drinking water supply. Secondly, these authors forget that public health officials, whether they are doctors or not, serve the democratically elected executive power and provide continuity to institutional func- tions, and there will always be changes in the persons and politi- cal groups who exercise execu- tive power and, consequently, in the decisionmakers. Faced with the same health problem, 1 dem- ocratically elected government may choose a way to communi- cate information or an interven- tion that is different from what another government would choose 4 years later.

Professional organizations have been of little help in this matter. None of the proposals made for ethical guidelines have considered the work setting of public health professionals.27,28

These guidelines are meant for professionals who work in the academic world, and the applica- tion of some principals to profes- sionals in the public sector is de- batable. For example, we do not consider the Public Health Pro- fessional Oath proposed by the American Public Health Associa- tion 29 to be appropriate for pub- lic health officials. The last state- ment of the oath says, “In all that I do I will put the health of the public first, even when doing so may threaten my own interests and those of my employer.” The electoral process is the means by which many societies provide themselves with govern- ments to decide the most appro- priate actions to achieve the common good. At the same time, societies provide themselves with a body of civil servants to exe- cute these government actions. Obligations to society as public health officials should prevail

over obligations to society as public health professionals, de- spite the fact that many govern- mental decisions related to public health may not agree with scien- tific knowledge or with the val- ues that they defend as profes- sionals. It must be borne in mind that resources are distributed through the political process and, in this regard, the political com- mitment to public health is not absolute.30 The obligation of the public health official at all times is to implement the decision, whatever that decision might be.

Let us suppose that the depart- ment of health of a country of the European Union is planning to increase the price of tobacco by raising taxes, with 2 objectives in mind: reducing the prevalence of smoking and financing a smoking cessation program. Most of the time these decisions will be made without considering whether the interventions work better in some population groups than in others or whether they work better in groups with the highest prevalence of the health problem.31 The intervention pro- posed is a clear example of this issue. In this case, the public health official should exercise his advocacy role within the institu- tion by warning decisionmakers that raising the price of tobacco may reduce the prevalence of smoking more in higher socio- economic groups than in lower ones—i.e., the ones who smoke the most.32,33 It should also be pointed out that smoking cessa- tion schemes have been found to be more effective in better-off groups of smokers.34 Thus, the public health official should ad- vise against this intervention, be- cause the benefits and costs are not equitably distributed: the poor pay for the health benefits of the rich, because the burden

of funding is concentrated on those who smoke most and who fail to quit, generally poorer peo- ple.31 However, once the decision to raise the price is made, the public health servant is obliged to implement the program.

We do not understand why many authors believe that public health officials are responsible for communicating public health messages. Similar to the previ- ously mentioned example about raising tobacco prices, policymak- ers sometimes decide to imple- ment an intervention or recom- mend a health behavior that public health officials have ad- vised against. Public health offi- cials would not appear in a public forum to defend such an inter- vention or to recommend a health behavior. Neither should they appear in a public forum to criticize or recommend against the measures adopted. Public health officials should not act publicly as advocates and defend- ers of public health actions, nor should they publicly disseminate health information. The legiti- macy of institutions in democra- tic societies could be threatened if health authorities and public health officials were to transmit contradictory messages. This also includes factual information, be- cause it is naïve to think there is some neutral, value-free way of presenting information.

Let us consider, for example, a regional health department that decides to carry out a school vaccination program to protect against an infectious disease or to disseminate a message in the mass media about the health risks of drinking more than a certain amount of alcohol. The health authorities will have made these decisions after a delicate process of weighing between the common good and individual

rights and liberties and between scientific knowledge and other types of evidence, within the framework of a series of values based on beliefs, ideologies, and legitimate interests. However, the program’s effectiveness or the impact of the message on the population may be seriously compromised if, in a newspaper interview or a radio or TV pro- gram, a public health official in the department raises doubts about the suitability of the vacci- nation program or suggests that a different amount of alcohol is a health risk. Because the public servant’s mission is to help his organization achieve its objec- tives, such behavior, other than being disloyal, generates distrust of public institutions on the part of the population, because they perceive a lack of agreement about objectives and inconsis- tency in the messages that they are receiving.

However, this does not mean that these public health profes- sionals cannot act independent of their status as civil servants. One is a person before one is a public health official. As individual citi- zens, or as citizens within their scientific societies, these profes- sionals may disseminate informa- tion on public health and pro- mote policies to improve the health of the population, based on their scientific knowledge, judgments, and values, although it must be recognized that this is not an easy decision. The acquisi- tion of knowledge, both scientific and nonscientific, is a continuous process, and it is not always pos- sible to separate what one has learned as a public health official and what one has learned as a re- sult of personal interests or as a public health professional in gen- eral. Decisions to participate in an advocacy effort may involve the

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resolution of personal ethical con- flicts between social responsibility as public health officials and so- cial responsibility as public health professionals.

Public health officials are re- sponsible for exercising tasks of persuasion within institutions, but they should not be responsi- ble for persuading audiences. As public health professionals, com- munication to encourage changes in health behaviors or to influ- ence support for public health programs or policies should be carried out independent of one’s position as a civil servant.

About the Authors Enrique Regidor and Cruz Pascual are with the Department of Preventive Medi- cine and Public Health, Universidad Com- plutense de Madrid, Spain. Luis de la Fuente and Salvador de Mateo are with the Center National for Epidemiology, In- stituto de Salud Carlos III, Madrid. Juan L. Gutiérrez-Fisac is with the Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid. José Sánchez-Payá is with Service of Preventive Medicine, Hospital Universi- tario de Alicante, Alicante, Spain. Elena Ronda is with the Department of Public Health, Universidad de Alicante, Alicante.

Requests for reprint should sent to En- rique Regidor, Department of Preventive Medicine and Public Health, Faculty of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria s/n, 28040 Madrid, Spain (e-mail: enriqueregidor@ hotmail.com).

This analytic essay was accepted De- cember, 19, 2006

Contributors E. Regidor developed the general idea and wrote a draft. All of the authors pro- vided new ideas and references and con- tributed to write the first version and the revision of the article.

Acknowledgments This article presents the conclusion of a seminar on scientific communication held on April 19, 2006, at the Univer- sity Venue of Cocentaina, University of Alicante, Alicante, Spain, titled “The role of the public health official in communi- cating public health information.”

Human Participation Protection No protocol approval was required.

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