The IOM’s influential 1988 report, The Future of Public Health, defined the mission of public health as “fulfilling society’s interest in assuring conditions in which people can be healthy”. The report identified three core functions of “governmental” public health towards fulfilling its mission as: (1) assessment, (2) policy development, and (3) assurance.
Strikingly absent from these core functions yet necessary for the realization of conditions in which all people can be healthy? Advocacy for social justice and health equity. As the Ottawa Charter for Health Promotion asserts, “The fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.” These conditions are beyond the capacity of current governmental public health in the United States to assure. To bridge this gap between assessed, unmet needs for essential conditions and resources for health and their assurance when policy development has failed, public health must come to recognize and embrace advocacy as the 4th core function necessary to its mission.
Advocacy is not an act of assessment (though it may depend on assessment to identify and characterize injustice or inequity), nor policy development (though policy change may be its goal), nor assurance (though it may seek service or resource access for a group or population). Because of the structural organization, legal parameters, and limited resources of public health in the United States, public health departments and agencies can never assure equitable and just access or distribution of all the necessary conditions for health. But where assurance falls short, advocacy may proceed in areas such as classism, predatory capitalism, and poverty; institutional racism, housing and homelessness; incarceration and access to education. In all these cases, where assessment demonstrates need and inequity, but political will is lacking and assurance impossible, advocacy for social justice and health equity is necessary and essential towards fulfilling public health’s mission.