Smart, Targeted Public Health

One of the biggest challenges in US public health is that this is a huge nation, with numerous regional and demographic public health challenges. It’s not possible to locate easy, one size fits all solutions to public health issues, and relying on standardized practices inevitably leaves people in the dust. Troublingly, because the practice of medicine in the US is based on that of a mythical ‘standard patient,’ every level of health intervention is viewed through the lens of a fictionalised white, middle class, nondisabled man with a generally good medical history, which doesn’t actually describe very much of the population.

In recent decades, public health authorities have begun recognising that this is a problem, and focusing on individual community needs to tease out the best ways to help with ongoing public health crises. One such example can be seen in detailed mapping breaking down HIV incidence by Census tract. Such mapping can create the foundation of public health campaigns examining who is getting HIV and why, and what kind of care and information patients are receiving. These kinds of data can help practitioners develop carefully targeted initiatives that take the specific needs of communities into account.

One such initiative can be seen in Los Angeles, where a large grant was released earlier this year for a pilot project training Black barbers to check the blood pressure of their customers. There are several reasons why this public health initiative is innovative, unique, and heartening as a sign for what we could be doing in the future. It shows a smart way to collect public health surveillance data, it illustrates respect for the community involved, and it provides a means for immediate public health intervention as needed.

Collecting data can be extremely challenging, especially in marginalised communities, where people may be reluctant to share information with outsiders. By asking Black barbers to participate, the researchers are creating an internal, community-based surveillance system. The barbers learn about the importance of blood pressure checks and how to perform them, and they can approach their customers with offers to take their blood pressure and add the information to public health databases. While not all patients may choose to give consent, the body of evidence gathered this way will still be substantial, which will help researchers understand blood pressure trends in the population under surveillance. If the study proves successful, it could also be expanded to other regions of Los Angeles and other cities.

It also demonstrates a respect for the Black community, which has historically been wary of public health interventions and the medical establishment, with good reasons. Black men and women have been used as test subjects without consent, exploited for their value to the medical community, and treated like freaks for exhibition. The medical establishment is still dealing with problems of discrimination and abuse, making it hard for many members of the Black community to trust public health advocates. Even when researchers are organized, well-meaning, operating above-board, and working closely with local leaders and ethics committee, they may still be viewed with suspicion, while a barber or other member of the actual community can be trusted.

Furthermore, barbers can become early first-line public health actors when they see clients with dangerously high or low blood pressure who need medical attention. Since high blood pressure can be an early warning sign or an indicator that an illness is not well managed, a quick free blood pressure check at the barber’s can be a lifesaving event. A patient might not be willing or able to go all the way to the hospital or doctor’s clinic, but if a barber’s BP check indicates a problem, it can be apparent that immediate intervention is necessary and it’s time to see the doctor, even if it’s difficult. (Likewise, such programs should be associated with the creation of community clinics with extended hours to make it easier to see doctors without having to battle unreliable public transit or miss work.)

This is an example of thoughtfully targeted public health intervention that considers a known issue (high blood pressure is an ongoing problem in the Black community) and various ways to resolve it. Researchers know that monitoring blood pressure is key to identifying trends and spikes in communities and individuals, but they also know that it may not be logistically, economically, or culturally feasible to barge into a community, blood pressure cuffs in hand. By instead turning to an already existing community network of people who establish rich personal relationships with their clients, researchers are tapping a tremendous resource that could be helpful for years to come if it’s respected and treated seriously.

We need more smart, targeted, culturally-sensitive public health like this, which recognises the damage some campaigns have done to minority communities while working to improve conditions for communities known to have higher health risks. These communities have no particular reason to trust public health officials, but that could change if they see officials behaving respectfully and with caution, using their introductions into the community to create strong connections, rather than to dictate the community’s next steps. Turning everyday people into public health officers also has other benefits — the community can find new ways to look after itself and support people who need assistance, reducing dependence on outsiders and empowering people who might otherwise feel trapped in the medical system.

Photo: MEDRETE in the Bac Ninh Province of Vietnam, US Army, Flickr.