The Public Health Model

There is no health without mental health. This simple yet profound statement is at the heart of transformation not only of the mental health system in the United States but of health care itself [1].
The public health model is characterized by a focus on the health of the entire population, the inclusion of preventative care, and the promotion of social supports. According to the Surgeon General’s report on Mental Health (1999) [2,3]:
“The public health model is characterized by concern for the health of a population in its entirety and by awareness of the linkage between health and the physical and psycho- social environment. Public health focuses not only on traditional areas of diagnosis, treatment, and etiology, but also on epidemiologic surveillance of the health of the population at large, health promotion, disease prevention, and access to and evaluation of services (Last & Wallace, 1992)….”
Implicit in this definition is the concept of enhancing the quality of life of individuals and the public at large. The mission of public health, as defined by the Institute of Medicine (IOM), is to assure “the conditions for people to be healthy,” as pursued by governmental agencies, public and private health care organizations, academic institutions, and community-based organizations [4-8].
The American Public Health Association (APHA) has developed 10 performance standards for states to be judged on their public health approach.

A. Inform, educate, and empower people about health issues.
B. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
C. Assure a competent public health and personal healthcare workforce.
D. Enforce laws and regulations that protect health and ensure safety.
E. Develop policies and plans that support individual and community health efforts.
F. Diagnose and investigate health problems and health hazards in the community.
G. Mobilize community partnerships to identify and solve health problems.
H. Monitor health status to identify community health problems.
I. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
J. Research for new insights and innovative solutions to health problems.

Haggerty, 1994 defined five levels of public mental health. Traditional psychiatric systems usually have two levels: inpatient and outpatient. If an individual is not a “patient,” then there is no place for him/her in the system. The public health model adds three levels: universal preventative, selective preventative, and indicated preventative.
Universal preventive interventions are delivered to an entire population. For example, an anti-stigma campaign (eg., consumer/family discussions with religious institutions) would reduce institutional fear and discrimination, and the resultant loss of social status often experienced by people with mental illness. Another example: Department of Mental Health (DMH) could effectively publicize community services that offer treatment, support, or advocacy, such as support groups, legal aid, and local counselors (eg., social workers, psychologists, and psychiatrists).
Selective interventions are offered to those adults/children who are at a high risk of developing mental health problems due to group characteristics. An example is DMH’s setting up mental health assistance centers in places where homeless people congregate. Jail diversion programs, such as the Framingham model, offer mental health assistance to people with mental illness who are at risk for jail.
Indicated interventions are offered to adults/children who have an individual risk of developing a disorder and are manifesting symptoms at low but noticeable levels. Respite is an excellent example of this. For many consumers, it’s a caring place to spend a few nights with peers, and with access to a psychiatrist as they need one, but without being locked up in an expensive hospital unit. For parents of youth with a serious emotional disorder, it’s having as little as a few hours without their children in order to regroup. Another example is assisting a consumer with difficult vocational or housing situations (eg, reasonable accommodation requests).
Health promotion, Disease Prevention Psychiatry has often focused on the treatment of mental illness symptoms, often to the exclusion of the patient’s physical health status. For example, psychiatrists may prescribe medications that alleviate psychiatric symptoms, but contribute to short-term physical distress and/or long term chronic physical illness.
Mental illness contributes a substantial burden of disease worldwide. Globally, approximately 450 million persons suffer from mental disorders, and one fourth of the world’s population will develop a mental or behavioral disorder at some point during their lives
Mental health is integral to overall health and well-being and should be treated with the same urgency as physical health. Mental illness can influence the onset, progression, and outcome of other illnesses and often correlates with health risk behaviors such as substance abuse, tobacco use, and physical inactivity.
Depression has emerged as a risk factor for such chronic illnesses as hypertension, cardiovascular disease, and diabetes and can adversely affect the course and management of these conditions. Treatment for mental disorders is available and effective, However, the majority of persons with diagnosed mental disorders do not receive treatment. The challenges for public health are to identify risk factors, increase awareness about mental disorders and the effectiveness of treatment, remove the stigma associated with receiving treatment, eliminate health disparities, and improve access to mental health services for all persons, particularly among populations that are disproportionately affected.
Public health agencies can incorporate mental health promotion into chronic disease prevention efforts, conduct surveillance and research to improve the evidence base about mental health.
The philosophy behind the public health model of community organizing is that the primary obstacles to engagement are ideological, and that the primary task in overcoming these obstacles is a communicative one. Civil society leaders, as such, are burdened with the responsibility to plan and prepare for the eventuality of attack, consciously preparing themselves, their followers, and their allies to both endure and oppose the use of fear, hate, and revenge. Isolation of these social pathogens, inoculation of vulnerable populations, and education of those looking for certainty, comprise key elements of the public health model. A more complete definition of this model of social organization follows.

The public health model of community organizing assumes a constant, aggressive opposition committed to undermining and silencing good faith participation in societal problem-solving. As such, activists who approach organizing by bolstering community safeguards and regulating mechanisms have a powerful asset in moral sanction. As guardians of a fair and open process, they can claim the high ground over anti-democratic opponents, whose behavior, if not agenda, violates societal norms. In this way, prodemocracy activists and organizers can increase the likelihood of broad-based conscientious involvement in public policy decisionmaking.
Moral sanction alone (especially in the present where citizenship is so rare), may be insufficient to constrain political violence or official repression, but it can bring significant pressures to bear on public behavior as well as within institutions under the control or influence of civil society. Indeed, reform and revolutionary movements, as well as other forms of resistance in fundamental conflict with despotic powers, rely on moral sanction as an essential component of political warfare.
In fact, the commitment of social movement participants and the approbation of non- combatants and potential recruits are largely determined by the ability of resistance leaders to articulate and disseminate the moral values at issue. In this way, resistors and allied advocates can gain not only attention, but also recognition of the validity of their grievances. At the same time, the moral prestige of oppressive institutions is diminished, and opportunities to obtain concessions or to leverage discussion are enhanced.
Communication of core values leads to the empowering acts of individuals that develop commitment to a process of transformation they believe will lead to greater fulfillment of these values. Faith in the possibility of justice, by a process that transcends issues, acknowledges the supremacy of human dignity and the ethical imperative to act.

The strength of the public health model, when applied to community organizing, is in its view of the body politic as an organic, dynamic system of adjustment and evolution that, like the human body, requires maintenance, nurturing, and protection from external threat. The central perspective of this model is a faith in humanity to resolve conflict given the opportunity to work. Cycles of subversion and integration, when functioning organically, strengthen a society’s immune system allowing it to adapt to new circumstances with greater resilience.
The weakness of the public health model lies in the vulnerability of its practitioners to accusations of conspiracies, and the tendency of overzealous devotees to neglect the holistic requirement of integrating their practice with those engaged in reform advocacy, political diplomacy, law enforcement, and military deterrence. Actors accustomed to functioning as the white blood cells of society, by definition, are programmed to be on the lookout for social viruses. The difficulties of integration with sympathetic actors not so inclined, arises when these threats successfully elude popular detection and are able to spread covertly, infecting unsuspecting target populations -- including one’s allies -- through lazy and corrupt media habits.

Research

As noted, the successful application of the public health model to ideological disease control depends on the early detection and analysis of organized anti-democratic aggression, systematic study of and intervention with vulnerable populations, and educational campaigns aimed at broadening public support for the investments required. We will now examine the essential integrative techniques used to construct the working relationships needed for building a community of sociopolitical health practitioners.
The first thing to recognize in this endeavor is that this is sensitive, potentially dangerous work that should not be undertaken haphazardly, or alone. The creation of enduring institutionalized programs critical to its effectiveness does not come about by bureaucratic means - they are created from the ground up, and rely on the participation of local moral authorities.
Consequently, concerned citizens as well as community organizers interested in personal security, movement continuity, and a politically healthy community, must establish and operate within a network that involves intentional collaboration between churches, schools, human rights groups, neighborhood associations, labor and civic organizations, and individuals who perform research and investigative functions. The face-to-face networking that takes place in communicating the need for and agenda of such a network is the adhesive of community-building.
Lengthy discussions, socials, and workshops organized around timely, accurate, and relevant information that makes a community threat visible and understandable, generates concern and allows a nascent network to determine its educational and organizing needs. Local research, linked with regional and national resources, provides historical background and political context, as well as presents options and locates targets for community action. Network solidarity, cemented by well-articulated ideas and based on the experience of other communities, then becomes the foundation for engaging in personal reflection and community education.

Once a network has determined its educational needs, it can pool connections and resources to provide opportunities both separately and jointly for their organizational members, depending on the focus and comfort level that exists. Initially, the delivery style, references, and language used may differ significantly - eventually a mutually recognized set of values and purpose will develop.
Individuals and groups within the network will progress at their own pace in absorbing and adapting to altered perceptions of society and conflict. Network leaders who monitor and communicate this progress can best determine when and how their group is ready to act. Cross-pollenization between groups both accelerates the progress and breaks down barriers or misperceptions between groups that previously received only mediated impressions of their new allies. Public events that promote core values already shared by the network nodes serve as recruitment tools that can funnel the unaware into educational functions where deeper discussions that lead to conversion take place.
The private and popular education functions undertaken by the network thus become central organizing tools based on ongoing research and analysis in which all movement participants play a role through observation and dialogue. The formality or informality of the network is less important than its functionality - active communication will lead to some kind of community action.

Community action, whether a containment, prophylactic or remedial intervention, involves high profile events and public dramas that also serve as educational and recruitment venues. As such, they should be approached and designed with the assistance of people who have connections and experience in public relations, theater, media, and education. Plans, materials and scripts for associated press conferences, speaking engagements, and literature dissemination should be strategically developed. Timing and sequence of delivery, when rationally executed, helps to minimize confusion as well as disarm opposition.
Sticking to the network-adopted mission and objectives reduces the likelihood that wedges can be driven between network participants. Pre-selected, well-recognized spokespersons trained and prepared to deliver the message with confidence and conviction helps to avoid losing the initiative by lapsing into a defensive posture.
The first public impression of the meaning and importance of the action can not only be manufactured - it can help determine the course of the ensuing conflict and community discussion. Selfrestraint, a sense of humor, and controlled righteous indignation - being firm on principle, but fair in application -- are powerful attributes when delivered by or with the consent of visible moral authorities. Subsequent cycles of analysis, action, and reflection can then reinforce individual group actions initiated within the new political context, with the initial joint action and theme serving as the touchstone. Continuous network communication allows for spotting and assessing opportunities for advancing its agenda, extending its influence, and consolidating its power.
By focusing on policy to the exclusion of process, advocacy groups, perceived as guardians of democracy, fail in this task because they are not engaged in opposition activity. They are engaged in political diplomacy. Hence, much of the training work needed is of individuals already persuaded of the importance of opposition research. Acting from the public health model - which is to look at the causative mechanism, how the behavior is transmitted, and what sort of interventions can either prevent or modify it - enables these individuals to respond to the pathology of violence and intimidation that prevents community participation and conflict resolution.
Institutional change, currently based on the four inapplicable models, is a long way off. Government and philanthropic funding is almost exclusively restricted to the four ineffective models. Training around pressure group tactics used to get laws passed that will not be enforced might be considered a waste of time. Even human rights groups that do good training and education devoted to tolerance often view their work in building contacts with law enforcement as educational, when, in fact, they are often being used as an intelligence source - for political intelligence.
Looking at societies, cultures, and individuals as evolving, conscious organisms that possess organic “natures” and acquired characteristics, that are both responsive to conscience and vulnerable to manipulation, encourages research, analysis, and discussion of how social change happens. Scrutiny of movements, actions, and fundamental conflicts in multiple eras, societies, and venues provides a context for engagement that enables both holistic thinking and critical examination of often unquestioned perspectives and personal positions. Distinction of authentic grassroots activism from more socially acceptable elite-sponsored activities serves to both inspire and shield the kind-hearted who choose to engage in public affairs (Table 1).

Table 1:Core functions of the Center for Mental Health Services and associated steps.

1. Minkler M, Blackwell AG, Thompson M, Tamir H (2003) Community-based participatory action research: implications for public health funding. Am J of Public Health 93(8): 1210- 1213.
2. New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care: Final Report (2003) Department of Health and Human Services Pub. No. SMA-03-3832, Rockville, Maryland, USA.
3. United States Public Health Service Office of the Surgeon General (1999) Mental health: A report of the surgeon general. Department of Health and Human Services, US Public Health Service, Rockville, Maryland.
4. The focus group reports are not yet posted on the web.
5. http://www.apha.org/ppp/phipmain/statefinal.pdf
6. Lando J, Williams SM, Williams B, Sturgis S (2006) A logic model for the integration of mental health into chronic disease prevention and health promotion. Prev Chronic Dis.
7. Dori S, Hutchinson, Cheryl G, Alexandra B, Zlatka R, et al. (2006) A framework for health promotion services for people with psychiatric disabilities. Psychiatric Rehabilitation Journal 29(4): 241-250.
8. Jay Taber, recipient of the Defender of Democracy award -- is an author, columnist, and associate editor of Fourth World Journal.