RE: Shared Language for Shared Work in Population Health

Thank you to the authors of “Shared Language for Shared Work in Population Health”1 for their efforts to break down barriers to collaboration between primary care and public health. I would like to add to the conversation by suggesting that the role and definition of policy be pulled into the foreground of the framework provided.

In selecting which terms to define, the authors call attention to the “goals”, “realities”, and “ways to get the job done” they have determined to be of fundamental importance for those involved in collaborations for population health. In this framework, the role of policy is presented as one aspect of the social determinants of health, and as a product of public health activities. Naming policy explicitly as a “general way to get the job done”, would place a more substantial emphasis on what is a powerful mechanism to improve (or erode) the health of populations and communities. This adjustment to the framework would open the door for participation from other sectors that profoundly influence population and community health (education, transportation, justice system, etc.). It would also serve to underscore that primary care physicians have a responsibility to advocate for their patients and the policies that support the “Vital Conditions for Well-Being.”2-4

A shared definition of the term “policy” may also be helpful. The CDC defines policy as “a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions.”5 This particular definition, while it has the benefit of requiring only a single sentence, obscures the practical distinction between “big P” policy (national, state, or city level ordinances that often require legislation) and “little p” policy (organizational practices or rules).6 Greater precision with this terminology would better characterize the range of health-promoting strategies that can fall under the broad category of “policy”. Further, drawing attention to the significance of “little p” policy would be an important reminder that we all must examine how our own institutions contribute to population health or propagate health inequities.7

These ideas may broaden what was meant to be narrow, or split what was intentionally lumped. I look forward to continuing this dialogue as we move forward towards a shared vision of health and wellbeing for all.

1. Peek CJ, Westfall JM, Stange KC, et al. Shared Language for Shared Work in Population Health. Ann Fam Med. Sep-Oct 2021;19(5):450-457. doi:10.1370/afm.2708
2. Win Network. Vital Conditions for Well-Being. Accessed November 17, 2021. https://winnetwork.org/vital-conditions
3. American Academy of Family Physicians. Advancing Health Equity by Addressing the Social Determinants of Health in Family Medicine (Position Paper). Accessed November 17, 2021. https://www.aafp.org/about/policies/all/social-determinants-health-famil...
4. Declaration of Professional Responsibility: Medicine's Social Contract with Humanity. Mo Med. May 2002;99(5):195.
5. Centers for Disease Control and Prevention. CDC Definition of Policy. Updated May 29, 2015. Accessed November 8, 2021. https://www.cdc.gov/policy/analysis/process/definition.html
6. Collins S. Big P, Little P - A Guide to Policy Engagement at All Levels. Accessed 2021, November 10. http://www.amchp.org/AboutAMCHP/Newsletters/Pulse/MarchApr19/Pages/Big-P...
7. American Academy of Family Physicians. Institutional Racism in the Health Care System. Accessed November 17, 2021. https://www.aafp.org/about/policies/all/institutional-racism.html