The Arts and Public Health: Changing the Conversation on Health

This argument rests on how we define public health. Fundamentally public health is a collective act, aimed at assuring that populations are as healthy as possible (Institute of Medicine, 1998). This then requires a reckoning with what it is that makes populations healthy to begin with. The health of populations is a product of multiple levels of influence. Political decisions begat policies that ultimately affect health. Our health is influenced by the conditions of the cities in which we live and by the state of our neighborhoods and the places where we live, work, and play. While our behaviors, whether we exercise, eat healthy foods, or refrain from risky behaviors, clearly have a role in shaping our health, many of these behaviors are constrained and are shaped by these same environments. We are more likely to exercise if we are living in a safe neighborhood where we can walk without fear of personal harm. Therefore, the health of populations is a product as much of the world around us, the conditions that characterize where we live and how we live, than it is about personal characteristics or, certainly, genetic predispositions.

This is perhaps best illustrated by focusing on a concrete example. Let us consider the challenge of noncommunicable disease (NCD) such as heart disease or cancers. One of the central risk factors that has driven a rise in the import of NCDs in the past decades has been an increase in obesity. Obesity is in turn influenced by federal policies that incentivize the production of calorie-dense, nutrient-poor foods, making these foods more widely available and supplanting the availability of foods that can be part of nourishing, balanced diets (Siegel et al., 2016). It is also influenced by the availability of healthy foods, by whether local stores provide access to nutritious foods, or by whether our neighborhoods are in food deserts, areas without access to such foods. We know that such areas are endemic in low-income neighborhoods (Hsiao et al., 2019). And ultimately, obesity is influenced by education, by dietary habits engrained in early childhood that determine our eating patterns, what we eat and how we eat throughout our life (Newton et al., 2017). There is little controversy about this understanding. It does, however, call for attention to where public health should act and how it can work to combat the obesity epidemic—that has grown dramatically over the past several decades—as effectively as possible (Hruby & Hu, 2015). When we understand that the determinants of obesity start from politics, extend to include policies, urban conditions, qualities of neighborhoods, and early childhood education, it becomes readily clear that efforts to reduce the burden of obesity that focus only, for example, on adult behavioral modification efforts are going to be inadequate at best, stigmatizing and having adverse consequences at worst (Lee & Pause, 2016). A forward-looking conception of public health then puts public health action at the heart of a multilevel, life course–based understanding of how health is produced and suggests that we cannot improve the health of populations unless we engage with politics and policies and unless we contribute to create better urban conditions that encourage exercise, address neighborhood circumstances to make nutritious foods readily available, and promote learning and teaching in early childhood that set us on a life course path of healthy eating habits (Shultz et al., 2019).

While this approach to public health is, at some level, intuitive, it is also a departure from how public health has operated for most of the past several decades. Academic public health and public health practice have long focused predominantly on individual conditions and behaviors, with substantial resources being devoted to efforts to change behaviors of adults who are already at risk of disease. The shortcoming of this approach is perhaps best illustrated by the stigma that has been affixed to obesity that has its own harmful health consequences. Stigma—the attribution of negative labels and othering of those with these attributes—arises from efforts to change behaviors that are intractable and simply unchangeable without addressing the circumstances that produce these behaviors (Hatzenbuehler et al., 2013). It is a personalizing of behaviors, a finger-pointing that then lends itself readily to creating adverse consequences as narrative evolves that those with a behavior are somehow “at fault.” It is an embedding of the notion of personal agency, at the expense of a sophisticated understanding of how all our actions are ultimately produced by nested influences, absent action on which we will fail in our efforts to improve the health of populations.

Therefore, a forward-looking public health recognizes this and engages with action at all levels of influence that determine the forces that shape health (Galea & Annas, 2016). This statement is, however, far easier said than done. The forces that shape health include politics, power, place, the role of deep-seated historical forces, including racism and misogyny, violence and structural inequities in wages, limited affordable housing, and subpar public educational systems that preserve and deepen social and economic divides. These forces are far outside the scope of traditional public health and, indeed, most academics within schools of public health, and practitioners within departments of public health have little expertise in engaging around these areas. In addition, action on these forces extends well beyond the scope of any one set of actors. Improving urban environments, by way of example, requires the multisectoral engagement of urban planners, housing developers, the financial sector, and transportation, to name a few. And, if we are to improve urban environments to the end of improving health, we must be able to bring along partners in these sectors who understand that improving these sectors will improve health.

This understanding, perhaps relatively familiar to readers of articles like this one, lies far outside the public understanding of health, and substantially stretches what partners in other sectors may consider to be relevant to health. It is one matter to discuss, within public health sectors, that we need to improve transportation routes to make salutary resources available to all, particularly to persons with low income, and it is quite another matter to have such a conversation with transportation engineers who have never studied health, and only think about health through a personal lens that is typically medical and curative, centered on doctors and nurses, and revolving around sickness rather than around health. Therefore, a vision of public health as one that engages multiple sectors, aiming to improve circumstances that surround us and conditions that affect us over the life course, must rest on an improved understanding of health extending beyond the shores of public health and needs to engage more broadly with a rethinking of health, fundamentally changing what we as a society talk about when we talk about health.

This is where the synergy between the arts and public health comes in.

Art is the aesthetic representation of human creativity, be it in visual or verbal form. It provides an expression of complex human emotions, an opportunity to elevate our ideas and represent them in a form that is accessible to all of us. In many respects, art depicts concepts and ideas that cannot be portrayed in other forms. It captures who we are as a species, and perhaps better yet, who we wish to be. In so doing, art gives voice to how we think and see the world in a way that no other human expression can. This gives art the opportunity to shape our collective thinking, to frame, consciously or unconsciously, our conversation.

Understanding that, it is then not difficult to see how art can contribute to the foundational task of public health: to changing the public conversation so that we can focus attention on the forces that shape health. Art stands to fill a unique role in shifting our norms, how we see health, and helping align our actions toward bringing all sectors into the public health conversation. This represents an enormous opportunity, even if one that has not yet seen full flower in our artistic expression.

Insofar as art has played a role in shaping the health of populations thus far, it has largely been to reinforce our understanding of health at the individual level. Graphic representations of disease warnings and exhortations toward healthier behavior abound. From wartime admonitions for soldiers to be careful about their sexual behavior to avoid the transmission of sexually transmitted disease, to video advertisement that reinforces health messages (often in the form of public service announcements) such as cautions about drug use, to narratives about the role of doctors and nurses in treating illness, artistic expression has largely focused on a personal view of health, and specifically on the amelioration of sickness after it has already started. We need look no further than contemporaneous artistic engagement with the COVID-19 pandemic that emerged so quickly, telling the stories of clinicians who dealt with patients who were sick due to COVID-19, and using compelling graphics to render complex information about disease transmission accessible to the broader public. All of this plays a role, but it also falls short of a more ambitious view of health, one that asks us to engage sectors outside the typical health domains of medicine, or preventive individual health, to the sectors that generate health across the life course, to represent how safe housing, good schools, livable wages, gender equity, clean air, drinkable water, and a fair economy are all key elements of generating health in populations.

How does art then help bridge this gap? How can artistic expression begin to tell a fuller story of health? How can art tell the story of health across the life course, generated through the multiple forces that create the circumstances of our health, toward creating a better, healthier world? I suggest that three steps may help us achieve this goal.

First, efforts to bridge the gap between art and public health are needed, where artists are engaged in the conversation around the production of health. This special issue of Health Promotion Practice is a good step in that direction. There are enormous gaps between those whose core engagement is with art and those whose core engagement is public health. In some respects, the two groups speak different languages, starting early in our education where children who are interested in art follow different educational paths than those interested in science, with ever fewer opportunities for intersection through the educational life course. This makes it difficult for artists to be part of the public health conversation, and similarly challenges public health professionals in knowing how best to engage artists toward their goals. This calls for formal efforts to bridge the gap and joint programs and efforts to bridge fields, to translate what each group knows, and to bring the two groups together. Academic journals stand to play a role here as do formal programs within universities and institutes that aim to forge synergies across disciplines that do not otherwise arise readily.

Second, both artists and public health professionals could benefit from interventions earlier in the life course, from education early on, starting perhaps in elementary school, that tell a more expansive story of health, that creates a narrative that then shifts the conversation early in childhood, narrowing the gap to bridge when artists and public health professionals are well ensconced in each of their professional spheres. This is a long-term effort that will require teaching in schools that presents a story of health that extends well beyond sick-care, that has books at its disposal that educate future generations on an expansive view of health, and that encourages children from early years to think about how transportation and housing shape our health, to create a generation of native public health thinkers that will then carry forward in artistic expression that can further shift conversations in future years. This effort shall require forward thinking on the part of educators and an altruistic engagement on the part of professionals today in creating the resources that can help future generations.

Third, it stands to benefit all of us to work toward melting disciplinary boundaries in our formal graduate education, where most public health professionals and artists receive their final formal training. This will require both creativity by those within the academy and also among accreditors. Many graduate training programs in both arts and public health must meet requirements set by accreditation bodies, often leaving little room for variation in syllabi and course requirements. This creates a dynamic that reinforces dominant paradigms, with little opportunity for creativity in educational material. Similarly, this would require that faculty are rewarded for teaching outside of their home schools or disciplines, a flexibility that is often difficult to achieve within existing higher educational structures. The essential needs of public health to reach out beyond its disciplinary bounds to achieve its goals of changing how we, collectively, think and talk about health may be a useful spur to this type of innovation and may represent an opportunity for creative thinking about such structures in coming years.

Creating a healthier world will require a retelling of the story of health. Art, in its role as a communicator of our better ideas, stands to play a unique role in that aspiration. There are substantial structural challenges that limit the role that art can play in engaging with public health. The creation of formal efforts to bridge this gap, including efforts early in the educational life course and at advanced stages of graduate education, can help move us closer to this goal. This stands to advance the goals both of art and of public health.