Words Matter: Public Health Economy vs. Ecosystem
By Christopher Williams
Founder, Public Health Liberation
Public Health Liberation (PHL) theory instigated a debate as to the appropriate conceptual framing of public health. The PHL notion of the Public Health Economy contrasts with other conceptualizations, including the “public health ecosystem”. This debate is important because PHL posits that the Public Health Economy is a major economy equal to the traditional economy in significance and compelling government interest. This article argues that the Public Health Economy has many advantages over the “public health ecosystem” in theory and practice. The Public Health Economy best positions public health to achieve health equity and justice by recognizing that societal structures are failing to produce health outcomes consistent with growth and economic expansion. Transdisciplinary transformation à la Public Health Liberation theory wherein public health assumes leadership across the Public Health Economy is the new frontier of health equity.
In contrast to the traditional economy that emphasizes jobs and investment, the Public Health Economy regards achievement of health equity as its central principle and basis for action. The traditional economy can perform well in public opinion yet perpetuate deep inequity, as is characteristic of the current US economy. The Public Health Economy has egalitarian and democratic commitment wherein the public health mission can be fulfilled. Challenged by existential crises, public health would benefit from a pivot around the Public Health Economy.
As in the traditional economy, there are micro- and macroeconomies. These typologies need research support because public health may be conducting research under unrealistic conditions that lack insight into practical translation. We need greater evidence- and practice-based research to understand how Public Health Economies function. Cities and states differ in PH economic performance. Public health would benefit from knowing how and why. Here in Washington, DC, the mayor recently lauded, “The District’s finances continue to be the envy, and among the strongest, of any jurisdiction in the nation.” Yet, Washington, DC has growing and vast health and income inequality, hardened by runaway development and displacement policies. It was among a handful of states that saw a 15 to 30% decrease in birthing hospitals from 2019 to 2020.
The Public Health Economy seeks to examine the interplay and interdependencies of social, political, and economic structural factors to reproduce health inequity using place-based phenomenology and policy synthesis. To accelerate health equity, it is vital to have a bird eye’s view and to regulate the Public Health Economy in a systematic and thorough fashion across sectors. For example, an independent health impact assessment for all proposed legislation would be consistent with this approach. A major goal of Public Health Economic theory is to encourage judicious use of resources for optimal health gains by eliminating contradictory or neutralizing effects of public investments. Waste in public spending can occur when government increases spending in healthcare while supporting policies that worsen the social determinants of health. Failing to enforce existing laws is another. Increasing hyper-politicalization of the judiciary portends a dire future for the Public Health Economy.
On the other hand, the notion of the public health ecosystem implies a state of fragmentation and disparate parts within a loosely-held system. The term '“ecosystem” is most closely associated with the environmental sciences - plants, animals, weather, and nature. In this view, an imperative to “regulate” an ecosystem reads as an error in diction. Ecosystem forms from “eco” and “system”. The etymology of “eco” is “referring to the environment and man's relation to it”. The etymology of “system” is, “the whole creation, the universe," “from Late Latin systema - an arrangement, system" and from the “Greek systema - organized whole, a whole compounded of parts". The emphasis on “arrangement” and “organized” is diametrically opposed to the premise of the Public Health Economy. Public Health Realism theory posits that the Public Health Economy is “a state of anarchy characterized by perpetual competition for resources where there exists no common principles or central authority. The public health economy reproduces health inequity.” Arthur Tansley coined “ecosystem” in 1935 to provide “a unified framework within which to study both plant and animal communities together, their interactions with inorganic nature, and their interrelations with human communities also.” Although Tansley suggested that “ecosystems are dynamic, interacting systems,” the public health ecosystem is severely limited in theoretical reach.
Take this conceptual model of the public health ecosystem from the Centers for Disease Control and Prevention (left). It considers a narrow set of agents: 1) states, tribes, localities, and territories (STLTs); 2) national public health (CDC, federal partners); 3) public; 4) healthcare (labs, providers). It is a highly limited model to effectuate pathways to health equity. It does not capture “dynamic, interacting systems” contributing to the poor performance of the Public Health Economy across public and private sectors.
Some organizations have a broader view of the public health ecosystem. The Prevention Institute defines public health ecosystem as “recognizes and incorporates the essential roles and leadership of all the contributors to the system. From public health departments and other government agencies to non-governmental organizations; from community-based organizations and community residents to racial justice organizers and advocates, all are valued and included.” Their view, though more aligned with the Public Health Economy, would benefit from a departure from the disambiguation of the public health ecosystem and toward a PHL transdisciplinary shift. In addition to the community engagement supported by the Prevention Institute, Public Health Liberation underscores all manner of horizontal and vertical integration - litigation, regulatory appeals, policy tracking, theory-building, political engagement, coalition-building, resource-limited research, and liberation space-making. PHL practitioners are most effective when they are conversant in regulations, policies, and community organizing and seek values-centered reform toward health equity.
On the other hand, the etymology of “economy” fits well with Public Health Economy theory.
1530s, "household management," from Latin oeconomia (source of French économie, Spanish economia, German Ökonomie, etc.), from Greek oikonomia "household management, thrift," from oikonomos "manager, steward," from oikos "house, abode, dwelling"
The meaning "frugality, judicious use of resources" is from 1660s. The sense of "wealth and resources of a country" (short for political economy) is attested from 1650s, but even in the 1780s the American Founders in laying out the new republic generally used economy only as "frugality." So also in that sense in the Federalist, except in one place where full political economy is used.
From this etymology, there is an association of economy with frugality, management, and judiciousness. The assumption of the Public Health Economy is that management and regulation provide for efficient spending and shared growth - in a sense, frugality for health equity's sake.
An economic position, rather an ecosystem approach, opens many more opportunities for transformative practice (“praxis”). Indeed, it invites scientific innovation for assessing return on investment, political and bureaucratic barriers, political inaction, the relationship between liberation/illiberation and the health of the Public Health Economy, and the relationship between the traditional economy and the Public Health Economy. Members of Public Health Liberation have begun a work group on adaptive stimulus-response theory - reviewing the political science literature on what motivates politicians to act and will extrapolate those theories to public health.
In sum, the Public Health Economy seeks to square with the world as it is. All agents or classes of agents in the Public Health Economy are subject to study and engagement. US healthcare alone is vastly encumbered - a $4 trillion economy in which higher prices do not correlate to better quality. The Public Health Economy is more complex, but health equity requires a radical shift in research and practice. In time, we believe that this will accelerate health equity.
