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Dr. Michener,
Thank you so much for your thoughtful letter of 9/15/21 regarding our paper “Shared Language for Shared Work…”. I thought of you and the Practical Playbook many times as we came up with those definitions and illustration.
I am very pleased that you commended and thanked us for the paper and the need to move from common confusions to shared meanings. We have hoped the paper would help put that more in the foreground for conversation and evolution. Your letter helps fulfil that hope with its thoughtful observations and suggestions which are now the first entries on suggestions I am pooling for our authors to evolve that diagram. Thank you for those and the excellent references.
You will likely appreciate a balance our authors tried to strike in the definitions offered: A) to reflect today’s realities and common usage among professionals reading this article (what they actually encounter and talk about now when they show up); and B) depicting (proposing really) definitions and relationships among terms that are forward-looking to a better future even if not yet routinely encountered, AND that incorporate ordinary language used by people in communities.
Our authors differed, but finally decided to show definitions and meanings that most persons working in the crucibles of population health would routinely encounter every day—common terms in general widespread use. Because that’s the shared language and workspace they currently navigate. One author phrased it as a balance between being "descriptive of the usual now" and "prescriptive of a better later". To fully accommodate what the authors would like to see in the future, we once entertained the possibility of a follow-up paper that proposed such forward-looking improvements as a shift from this status quo, even if not yet that familiar to people out there. At the very least, we can evolve the diagram.
Not coincidentally, your two suggestions were both part of those “balance” discussions.
Social determinants. Some authors said they dislike that term because 1) they are influences not determinants; and 2) it is professional-speak not recognizable to people in real communities. The term you point out, “vital conditions for health” and the cited definition about “conditions in which people live, work and play” are in ordinary language and don’t carry the “you are determined” implication.
After some deliberation, the group decided to retain “social determinants” because it is such a common locution that everyone encounters; if readers didn’t see it, they’d wonder where it is. We tried to clarify with the subtitle “influences”, and ordinary English definitions about conditions and influences where people live, work, and play (with examples of those influences). But I think we need to shift common usage in the directions you and RWJF and others suggest—which would also speak in ordinary language to people in communities.
Public Health. This was a similar challenge to calibrate the paper between familiar commonly encountered reality such as the county, state or city public health office with more evolved things that are much broader in concept. We opted to emphasize the civic core of public health in contrast to the private core of care delivery, knowing neither is a pure type, with an almost limitless “broad zone of collaboration” possible and sometimes taking place.
The definitions you point to are much more inclusive of everything public health no matter who is doing it, which I imagine is where our authors would like to see things land in reality. A shift from public health commonly understood as operationally rooted in civic-based agencies to a more inclusive definition of public health as you say the “science of protecting and improving the health of people and their communities” and “all public, private, and voluntary entities that contribute to the delivery of essential public health services with a jurisdiction”. These definitions open both eligibility and obligation for everyone to be part of it, not just government agencies. That broader concept allows everyone to see themselves in the act and invites shared work, with some kind of division of labor. Yet it preserves the idea of specific communities or jurisdictions.
The suggestions you have made would make the diagram more forward-looking, even as the challenge will remain to balance the forward-looking with dominant usage—what people hear and see around them every day. Maybe there will be a time for an updated paper that goes all-in on the forward-looking picture, even if still unfamiliar in daily experience out there. And having such a paper and diagram might do a lot to make such a preferred future more familiar and recognizable.
Thanks once again for your thoughtful response and appreciation of our start.
C.J. Peek, PhD
Professor, University of Minnesota Department of Family Medicine and Community Health