Mark Pertschuk: Grassroots Public Health and Preemption
“All public health is local—it’s got to start and be sustained at the local level.” – Howard Koh, Assistant Secretary, U.S. Department of Health and Human Services
Public health is not just about programs—it’s about a ground swell of people getting together to create healthier communities. Grassroots movement building is essential to meaningful, long-term change for any public health initiative. Recent research has even uncovered a link between local policy campaigns and healthy social norms. In other words, when public health movements build from the ground up and lead to local policy, the community is more likely to experience a shift in thinking around the issue at hand, whether it’s tobacco control or obesity prevention.
However, policy-makers may not always understand the full range of policy options at all levels of government, and some federal legislation can actually pose a significant barrier to grassroots movement building. Preemption can take away the ability of states and local communities to adopt innovative solutions to their own public health problems in a way that responds to each community’s unique needs, such as a state smoke-free law on office workplaces preempting communities who may want to pass a stronger ordinance to cover all workplaces including restaurants and bars. Preemption can also undermine grassroots public health movements.
Mark Pertschuk, project director of Grassroots Public Health: Preemption and Movement Building in Public Health, Phase 2, a new program supported by the Robert Wood Johnson Foundation (RWJF), says nurturing grassroots movements, and avoiding barriers to movement building such as preemption, are strategic policy decisions with long-term consequences.
In a new article in the Journal of Public Health Management and Practice, Mark Pertschuk and his co-authors look at the consequences that preemption can have for grassroots public health efforts. NewPublicHealth recently spoke with Pertschuk about the new initiative and the article.
NewPublicHealth: Tell us about the origin, scope and purpose of the Grassroots Public Health project.
Mark Pertschuk: Our project is a continuation of a project that was started by the Robert Wood Johnson Foundation in 2009. We looked at two related issues—the role that grassroots movements play in promoting major progress in public health, and the issue of local authority and whether or not communities have control over their health and environments. In other words, to what extent communities are able to determine their own laws and their own policies to protect themselves and their families and their children—that’s the issue of preemption.
The new project, which continues our work, is really focused on building and supporting grassroots movements across all public health issues. We’re looking at the ways in which we can succeed in public health that are universal across issues. What is the same? What can we learn from one issue that applies to all issues? So we’ve moved in the direction of two things, providing a voice for grassroots advocates working across dozens of different public health issues and also a set of resources and tools for grassroots advocates to help them do their job of making major progress in public health policies and ultimately changes in society.
NPH: Tobacco control is such a vibrant example of using grassroots movement building to change social norms. Can you talk a bit about the history of grassroots movements and why this is an important tool in the public health tool belt?
Mark Pertschuk: One of the first things that we set out to do was to really define what a public health movement is, as distinct from a program or other kinds of activities that the public health field engages in, such as building coalitions. The definition we came up with is “an organized effort to address threats to the health and safety of the community led by activated citizens and organizations that devote resources to building grassroots capacity.” Grassroots movements usually form around a single issue that folks are passionate about, such as environmental justice or preventing gun violence.
What that really means is that a grassroots movement is different from other forms of advocacy, such as community organizing or building a coalition. A grassroots movement is always bottom up. Individual health advocates and community-based organizations are core decision-makers in how a grassroots movement moves forward. So it’s never someone in Washington or a state capital making a decision about a policy or an activity and then going out to try to “get support” from the grassroots. A true grassroots movement, such as that built over time in tobacco control, has leadership that can coordinate local and state and national, or even international, activities, but it also has its roots in individual activists who are energized and who are involved in deciding on the direction of the movement.
NPH: Why is it so important to preserve state and local public health authority?
Mark Pertschuk: The reality is that it is often much easier to get strong, effective public health policies adopted at the local level than at the federal or state level. Of course, great things have been accomplished at all levels of the federal system. But the way that the American system was designed was that there would be a lot of authority and a lot of action that occurred at the local level and at the state level.
It’s how progress has been made throughout our history. Often a city innovates and moves an agenda forward, and that may lead ultimately 20 years or 30 years down the road to federal legislation.
Especially today, with the limited resources that federal and state governments have, most of public health occurs at the local level, and it’s especially true with progress and change in public health. So if you preempt local authority over, for example, firearm violence, that takes away, arguably, the major engine for change and progress in public health. That’s one of the big problems with preemption.
The other one, which we address in our article on the Preemption Framework, is that preemption takes away the mechanism by which grassroots movements form, which is to take action at the local level.
Many of us in the public health field have suspected for years that grassroots movements don’t just change policies, but that they also change society, and they do that by changing social norms around a specific public health problem. The kind of social norms change we saw around cigarette smoking from the days of Mad Men to the present day—that kind of radical 180 degree turn from unhealthy social norms to healthy social norms—occurred because tobacco control is a grassroots movement. It became very powerful in the 1980’s and 90’s, and it remains a powerful movement today.
NPH: What does the research say about the link between preemption and social norms?
Mark Pertschuk: Recently an article published by researchers associated with the Centers for Disease Control and Prevention finds that preemption has a negative impact on social norms. Specifically in tobacco control, those states that preempted local authority over smoke-free policies had fewer improvements in social norms around cigarettes and other tobacco products than states that did not have preemption.
Another way of putting that is that when communities and advocates can join together to form a grassroots movement to change laws, there’s a whole community process of media, education, discussion, and debate that occurs, and what the research is now confirming is that this conversation at the local level–which happens because of local control–is one of the few things we know can actually change social norms for the better.
NPH: What does the Preemption Framework add to the body of knowledge around this in the public health community?
Mark Pertschuk: In tobacco control, the leadership has understood for many years that preemption is not an acceptable compromise, but outside of tobacco control in other public health issues, there’s been more confusion and less agreement about the impact of preemption. So, we set out to provide a simple framework for advocates working across all public health issues to use to decide whether agreeing to preemption in a federal or state law is a good idea. We set out a series of questions and concerns that we feel members of the public health field should use in analyzing any piece of health or public health legislation that contains preemption to make an informed decision about whether or not preemption is going to hurt public health or is going to help.
NPH: Do you have any specific examples of how preemption has impacted progress in addressing local public health problems or addressing problems more broadly?
Mark Pertschuk: One example is in the arena of alcohol policy. We know there are a lot of ways that alcohol use and abuse can contribute to some very significant public health and safety problems ranging from domestic violence to chronic disease. But we have not been able to do as good a job preventing alcohol-related problems as we have with tobacco-related problems. I believe that one of the major reasons for that is that more than 40 states preempt local regulation of alcohol marketing and sales. So in stark contrast to tobacco control, in which most cities and counties have the local control to protect themselves from tobacco smoke and from the tobacco industry, most local communities have virtually no control, no authority to address alcohol problems. If preemption did not exist in the vast majority of states, many communities across America would adopt laws that reduce and prevent alcohol-related problems—for example, the over service of alcohol in college towns.
NPH: What’s ahead for Grassroots Public Health?
Mark Pertschuk: We’re just starting now on a two-year project to move from the research we’ve done to learn about grassroots movements and the impact of preemption into a stage of communication and education. We are creating a new website, GrassrootsPublicHealth.org, as a resource and a voice for grassroots advocates working on a whole range of public health issues. And we’re also going to be taking our message to public health leadership, and advocating for putting more resources into building grassroots movements across different public health issues.
One example is the Advocacy Academy in childhood obesity prevention in Mississippi, Alabama, and other Southern states, which is funded by RWJF. That’s a prime example of an enormously successful grassroots project that builds the capacity of community advocates. RWJF has provided that network of advocates with training and tools and resources that will make them much more effective at supporting strong policies around nutrition and physical activity.
One of the things we’re going to do is highlight success stories, so that others can learn from these sorts of examples and advocates can join together and form a national network of grassroots public health advocates who deserve a stronger voice in decisions in public health.
NPH: What’s the takeaway message you’d like public health professionals to know about grassroots movements?
Mark Pertschuk: We in public health need to take charge in our own communities, support up-start movements for bold change, and build that from the bottom up because we’re not going to be able to make the changes we ultimately need in prevention without such movements.
We believe that these grassroots movements have enormous potential for improving health and social norms, and that ultimately grassroots movements can change society permanently for the better around specific public health issues.