2008 Public Health Action Plan Update: Celebrating Our First Five Years

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Making Connections: The Conceptual Basis of Effective Action

Betty Sue Flowers, PhD
Director, Lyndon Baines Johnson Library and Musuem

In 2002, I was a participant in the early planning meetings and content reviews for A Public Health Action Plan to Prevent Heart Disease and Stroke. It is inspiring to see how much has been accomplished since then. And it is interesting to see the emphasis on the importance of the economics of prevention, since one of the key points I raised briefly in 2002 was the need to speak from within the economic myth or story that we all share.

As a humanist approaching this work, I have been contemplating two central questions.

First, what if we stepped outside the economic myth within which we lived when we addressed the economic aspects of heart disease and stroke prevention?

The question I am posing is not the same as this question: why should we address the economic aspects of heart disease and stroke prevention? The answer to that question is self-evident simply because everything comes with a price tag. And price tags raise the question: if we pay for X or Y, what can we now not afford? I am not talking about the kind of cost-benefit analysis that leads us to choose to do some things before others. I am talking about a fundamental viewpoint from which certain arguments about public policy can be made.

In addition to our personal stories, we also have big cultural stories that shape us. These cultural stories I call myths, not because they aren’t true — they are all true in their own way — but because we live with them unconsciously. In the west, we have four of these myths, although one is always ascendant. These are the hero myth, the religious myth — I remind you that by myth I do not mean untrue — the science myth, and the economic myth, which is the myth we are in now.

Our medical practice works within the science myth — or the science culture of today, if you prefer. Anyone wanting to be a doctor gets a science education. The medium for this myth — or culture — is numbers, which is why it is an international story, although an elite one and therefore not the dominant myth of our culture.

Originally, medicine — the art of healing — came out of the religious myth, not the scientific myth. In ancient days, medicine was in the realm of the sacred. The Iliad begins with Achilles sulking in his tent. But he is sulking because his prize has been taken away from him in order to appease Apollo who is raining his arrows of sickness on the Greek army. Of all the professions, medicine is still closest to the religious domain — at least, I often see chaplains in hospital corridors and never in an active role in the law firms or banks.

Now we are in the economic myth, whose ideal is growth. More. Health care is a commodity — like almost everything else — competing in the marketplace with other commodities. An argument for good public health, if made as a “should” argument — we should care for our fellow human beings — falls within the realm of the religious myth and therefore outside the range of what many people can hear in our present global culture. This is not to say that, as individuals, we are not good or caring; it is to say that because public policy is made from within the economic myth, an argument based on goodness (the religious myth) or charismatic personalities (the hero myth), or even scientific evidence (the scientific myth), will not have much traction. Clearly, I am not talking here about the good people who make donations to hospitals, or the scientific advances that help us provide better treatment, or the changes we adopt within our own hospitals and treatment centers. I am talking about large-scale public policy action.

What is the argument that has trumped all others in public conversation about universal health insurance, for example? Not “we shouldn’t do it” or “it can’t be done.” It is that “we cannot afford it.”

Why is the economic myth so powerful?

• It seems to explain everything. Self-interest.
• It seems natural because many people are sold on the idea that growth and competition are good.
• It is the first truly global myth, with numbers and pictures as its mode of communication.
• It connects powerfully to the bottom of Maslow’s hierarchy of human needs. It connects to security, survival, and fear.

For success in our campaign to reduce heart disease and stroke, we need two factors:

• An economic view of the entire system we want to change, with a cost-benefit analysis for the preventive measures that would make a difference. I think you are well on your way to creating this.
• An image or slogan that is immediately comprehensible to the public — and through the public, to public policymakers — if changing public policy is the aim. For each separate campaign designed to change behavior, we need a separate slogan. The reason is two-fold: the economic myth works with numbers behind the scenes and works with images when communicating with the public. An example of an effective campaign slogan is "Don’t mess with Texas." It is effective because it goes with the macho flow of a cultural self-image in a way that "Please don’t litter our highways" does not.

The second question I am posing is this: when we know the science, what stops us from making the needed changes at every level, from government policies to individual behavior?

I could answer with one word—inertia—but that would not be helpful.

• We need the structures for change . We know, for example, that structured exercise programs with buddies work better than solitary will power. When it comes to public policy, we need to create a structure for rewarding investment in prevention. Our incentive structure sometimes works against prevention — unlike the system in ancient China, where doctors were paid as long as their patients stayed well.
• We need different analogies. Whatever you think of mandated individual health insurance, it was sold as a public policy through an analogy to mandated individual car insurance.
• We need to involve people in seeing as well as in the action part of the plan. And we need to help them see their economic self-interest, not just their health interest.
• We need different stories of possibility. It is possible. We can do it.

— Adapted from remarks made at the 5th National Forum.

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Page last reviewed: August 8, 2008
Page last modified: August 8, 2008
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion