This transcript is useful for a small group exercise when participants are listening to Dr. Linda Rae Murry discuss her critique of the Ten Essential Services as a frame popular in the USA for describing what public health is and should do. It was used along with a worksheet to successfully generate small group discussion on September 12, 2019. Available at RootsofHealthInequity.org

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Murray Interview
Interviewer, Interviewee
Linda Rae Murray M.D. MPH
Chief Medical Officer
Cook County Department of Public Health
Cook County Bureau of Health Services
Dr. Murray discusses the origins and implications of the Ten Essential Services
model for advancing or limiting public health practice for health equity.
One of the most common frames, mental models, or frameworks for practice that
often guides our thinking in public health today is the Ten Essential Services. In
thinking about how it helps or hinders designing a practice for health equity, it is
important that we remember the history of the Services. They were constructed
during the discussion around President Clinton’s health care reform efforts. It was
an attempt on the part of public health, governmental public health, CDC, and
American Public Health Association, and many others to explain to people not in
public health what we did. And what was critical or essential about what we did.
The list has varied over time. But it was really designed, almost like a marketing
plan, to communicate to the Clinton Administration what it was public health did and
why it was important that it be considered in health reform.
It’s important to remember that the Essential Services were considered a critical list
of services and program areas that public health engaged in. But they didn’t really
speak to the core of what public health actually did. They were more like a list.
People will remember that we also often talk about the core functions of public
health, which are assessing a problem, developing policy around health issues and
problems, and trying to assure that people’s health is protected.

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But all these frames and themes ignore what I think are the foundation of the field,
why we’re doing this work and what we know determines health. So if we think
about health equity in that light, health equity is the goal; that’s what we’re trying to
achieve. That’s the purpose of all of public health. We want to make sure that
people are as healthy as they possibly can be, and that it’s done in a way that
ensures that health is not determined by what neighborhood you live in, what race
you are, what class you are. That we can achieve the optimal health in a fair and
equitable manner.
That’s a very different framework for public health. It’s a difference between thinking
about building a house to protect people as opposed to arguing about whether it’s
five stories or eight stories, and whether the walls are green or red or yellow. Those
are two very different approaches, and it’s obviously important what color the walls
are, but it’s not critical. The most critical thing is deciding on the structure and the
purpose of the structure.
So a question is: what is excluded from appropriate practice or what distracts
people’s attention away from health equity when they focus on the Essential
Services? The first problem of the Ten Essential Services is that the history of this
list was really to try to explain why public health was important, and why population
health issues were important when you thought about health reform. We know, just
giving
everybody medical care would not solve the health problems the American people
face.
Right away it is a defensive stance to say that these are functions which you cannot
take away because it’ll make things much worse. What we need to be addressing is
what public health needs to be about, which is how do we make sure that the
populations we serve are as healthy as possible? It takes the focus away from what

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produces health, what conditions create health. We need to ask different questions
like: What’s the economic structure? What’s the educational system? How are
people stratified? Does racism exist and is it increasing or decreasing? Are
differences in class exaggerated or are they narrowing? What about gender
discrimination and gender differences, are they increasing or decreasing? These
are the most important drivers of the social stratification in many countries and in the
United States. It is these factors, race/ethnicity, class, gender and how power
functions that causes differences in health status.
So to the extent that this listing of services takes us away from that, it’s not helpful. I
would much prefer health departments to think about their work in relation to what
are we really trying to do. If we’re really trying to improve people’s health, then we
have to address those underlying fundamental conditions in a society. What is it in a
society that creates the social stratifications?
In the United States, I believe these are predominantly race, class and gender, but
whatever they are they may differ in different societies. What are those drivers that
are stratifying people in ways that are unjust, and then how can we address that?
How can we reverse those factors and change the power relationships? How can
we reach our real goal in public health of making sure that we have a country with
social justice and health equity?
The Ten Essential Services were never meant to be a complete description of what
public health does today. It certainly was not meant to be a description of what we
ought to be doing in 10, 15 or 50 years. There’s no reason to hang on to this
specific framework. But most importantly, I think we have to start with our basic
fundamental beliefs in public health. We believe health is a right, a basic human
right. The international community (the United Nations, WHO, all the international
organizations) agree with that.

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If we believe that health is a basic human right, in order for us to achieve it, we have
to have social justice. That means we have to create the underlying social conditions
in a just way, so, for example, we don’t have huge income gaps or huge gaps by
race. By embracing the concept that health is a human right, our outcome measure
is health equity. Social justice is the way we guarantee health equity and good
health for all.
[End of Audio]