For Want of a Nail in Public Health

In preparation for this summer’s “Pitch the Commissioner (PTC)” tour around Minnesota, I managed to find some time between rain showers this weekend to pitch a few horseshoes. Although the PTC events are non-competitive, I wanted to practice in hopes of not embarrassing myself in front of county commissioners, local public health officials, state senators and representatives, health care providers, and community activists who usually attend these functions. I discovered the 40 feet between stakes seems to be getting longer each year.

As I pitched shoe after shoe, an old proverb my mother frequently cited while I was growing up kept looping through my mind:

For want of a nail the shoe was lost.

For want of a shoe the horse was lost.

For want of a horse the rider was lost.

For want of a rider the message was lost

For want of a message the battle was lost.

For want of a battle the kingdom was lost.

And all for the want of a horseshoe nail.

I was hoping this proverb might be a sign that I would “nail” a few ringers but my errant throws quickly dispelled that notion. Obviously, the message was not about horseshoes but prevention. The more I pitched and the more I thought about the proverb the more I appreciated the appropriateness of the horseshoe metaphor in public health.

Getting a ringer in horseshoes requires the shoe to end up in the center of the pit. That means the shoe can’t be too far left or right and it can’t be too long or too short. Given the presence of those parameters, the shoe must also have the right orientation to encircle the stake.

Similarly, to achieve good health, among other things, there needs to be a balance between treatment and prevention and between innovation and regulation. With those conditions in place, optimal health also requires good choices by an individual.

The game of horseshoes is governed by rules that assure the match is played fairly. To provide equitable opportunity for everyone to compete, the rules allow a shorter pitching distance to accommodate age, gender, and disability. While not in the rules, it’s assumed that everyone who wants to play horseshoes has access to a horseshoe pitching venue. In Minnesota that assumption is accurate because most pitches are in parks or public spaces; free and open to everyone.

The rules and assumptions related to health in our society are not as accommodating and equitable as in horseshoes. As our 2014 Advancing Health Equity report notes, “…the opportunity to be healthy is not equally available everywhere or for everyone in the state.” Whether it’s housing, transportation, health care, education, food, or employment (the determinants of health), the opportunities to be healthy are too often governed by one’s race, income, education, sexual orientation, and geography. Unlike horseshoes, few accommodations are made to allow everyone equal opportunity to be health winners.

Having taken that metaphor as far as I could, my mind went back to the proverb my mother taught me. I began to wonder how each component in that verse linked with public health. It then struck me that the horseshoe could represent the principle of social justice upon which public health stands. And social justice is held in place by the nail of the narrative that what creates health is investment in the public good (the commons) and the social, economic, and environmental circumstances in which people live. Sadly, this public health narrative has been displaced by the currently dominant narrative which states that rugged individualism and market forces are preeminent in determining health and prosperity; a narrative that has brought us great disparities and inequities and limited the opportunities for many to be optimally healthy.

With that in mind, each pitch of a horseshoe brought forward a different line for the old proverb.

For want of a public health narrative social justice was lost.

For want of social justice equity was lost.

For want of equity opportunity was lost.

For want of opportunity hope was lost.

For want of hope health was lost.

For want of health the community was lost.

All for the want of a public health narrative.

Our job is to create and sustain (nail down) a public health narrative about what really creates health and then pitch that to as many people as possible. The “ringer” will be health equity and optimal health for all.

Ed