Public Health Realism and the Tragedy of the Commons: A Comparative Analysis in the Context of Health Equity

By Grok under the supervision of Dr. Christopher Williams

Introduction

The manuscript Public Health Liberation - An Emerging Transdiscipline to Elucidate and Transform the Public Health Economy introduces Public Health Liberation (PHL) as a transdisciplinary framework aimed at accelerating health equity through a novel conceptualization of the "public health economy." A key theoretical construct within this framework is public health realism, which describes I describe the public health economy as a dynamic, anarchic system characterized by competition, self-interest, and the absence of a central governing authority. This perspective aligns closely with the tragedy of the commons, a concept from environmental economics and social theory that describes how individuals, acting in their self-interest, can deplete shared resources, leading to collective harm. This essay explores the alignment between public health realism and the tragedy of the commons, examining their shared emphasis on self-interest, resource competition, and systemic failures that perpetuate inequity. By analyzing their theoretical underpinnings, practical implications, and potential for informing public health interventions, this essay argues that both frameworks illuminate the structural barriers to health equity and offer complementary insights for transformative public health practice.

Theoretical Foundations

Public Health Realism

Public health realism, as articulated in the PHL manuscript, draws from political realism and Madisonian factionalism to describe the public health economy as a fragmented, anarchic system where agents (e.g., hospitals, community groups, industrial polluters) pursue their self-interests, often at the expense of collective health outcomes. The manuscript outlines 16 principles of public health realism, emphasizing that:

1. The public health economy operates in a state of anarchy, lacking common principles or a central authority, which reproduces health inequity.

2. Self-serving egoism motivates actions, with agents prioritizing their survival and power (e.g., financial assets, influence over populations).

3. Moral imperatives are often subordinated to self-interest due to the absence of shared ethical frameworks.

4. Agents engage in rulemaking, gatekeeping, and resource distribution to maximize their power, sometimes through misleading speech or exploitation of vulnerable populations.

5. Hegemonic powers maintain dominance by controlling resources and narratives, posing a significant threat to health equity.

This realist perspective assumes that agents act rationally to advance their interests, but their actions often lead to unintended consequences, such as perpetuating health disparities. For example, the manuscript cites lax environmental regulations and gentrification-driven displacement as outcomes of factions prioritizing profit or political power over community health.

Tragedy of the Commons

The tragedy of the commons, first formalized by Garrett Hardin in 1968, describes a scenario where individuals, acting rationally in their self-interest, overuse a shared resource, leading to its depletion and collective detriment. Classic examples include overfishing, deforestation, and pollution of air and water. The tragedy arises because each actor benefits individually from exploiting the resource (e.g., catching more fish) while the costs (e.g., depleted fish stocks) are distributed across all users, creating a misalignment between individual incentives and collective welfare.

Key elements of the tragedy of the commons include:

1. Shared Resources: Resources like clean water, air, or public health infrastructure are finite and accessible to multiple actors.

2. Self-Interest: Actors prioritize short-term gains over long-term sustainability.

3. Externalities: The negative consequences of resource use (e.g., pollution, health disparities) are externalized to the collective, not borne solely by the individual actor.

4. Lack of Governance: Without effective regulation or cooperation, overuse becomes inevitable.

Hardin argued that solutions require either privatization (assigning property rights to incentivize stewardship) or centralized regulation to enforce sustainable use, though both approaches have limitations in complex systems like public health.

Alignment of Concepts

Both public health realism and the tragedy of the commons center on the tension between individual self-interest and collective well-being in systems lacking centralized governance. In the public health economy, the "commons" can be conceptualized as shared resources critical to health equity, such as clean water, affordable housing, access to healthcare, or trust in public health institutions. These resources are depleted or undermined when agents—whether industrial polluters, government agencies, or academic institutions—prioritize their interests (e.g., profit, political power, research funding) over communal health.

The manuscript’s case studies of lead-contaminated water crises in Flint, Michigan, and Washington, DC, exemplify this tragedy. In Flint, the decision to switch to the Flint River without adequate treatment was driven by cost-saving motives, externalizing the health costs (e.g., lead poisoning) to predominantly Black communities. Similarly, in Washington, DC, the failure of the Water and Sewer Authority and the CDC’s falsified report reflect how self-interest (e.g., avoiding liability, maintaining institutional credibility) compromised the shared resource of safe drinking water. These cases mirror the tragedy of the commons, where the absence of effective governance allowed individual actors to exploit shared resources, resulting in collective harm.

Moreover, both frameworks highlight the role of anarchy or fragmentation. Public health realism describes the public health economy as anarchic, with no unifying principles to align agents’ actions with health equity. Similarly, the tragedy of the commons assumes a lack of cooperative governance, enabling overuse of resources. This shared emphasis on systemic disorder underscores why health inequities persist despite abundant resources, as seen in Washington, DC, where rapid economic growth coexists with a 17.23-year black-white life expectancy gap.

Practical Implications for Public Health

Structural Barriers to Health Equity

Both public health realism and the tragedy of the commons illuminate structural barriers to health equity by framing health disparities as systemic outcomes rather than individual failings. Public health realism’s focus on factionalism and hegemony reveals how power dynamics—such as industrial polluters influencing deregulation or universities prioritizing research funding over community engagement—reproduce inequity. The tragedy of the commons complements this by highlighting how these actions deplete shared resources, such as environmental quality or public trust, which are foundational to health.

For instance, the manuscript notes that environmental racism in Washington, DC, persisted until an “influx of white residents” prompted de-industrialization, illustrating how hegemonic powers (e.g., city planners, developers) prioritize certain groups’ interests, leaving marginalized communities to bear the externalities of pollution. This aligns with the tragedy of the commons, where the “commons” of clean air and water is degraded for minority populations, whose health costs are externalized and ignored.

Interventions and Solutions

The PHL framework proposes horizontal and vertical integration to address the anarchy of the public health economy, aligning with solutions to the tragedy of the commons. Horizontal integration emphasizes community representation in agenda-setting, ensuring that marginalized populations have a voice in resource allocation. Vertical integration expands the scope of public health to monitor and intervene across the entire public health economy, from policy analysis to legal action. These strategies mirror Hardin’s solutions of privatization and regulation, adapted to the public health context:

1. Community Empowerment (Horizontal Integration): By fostering liberation safe spaces and reducing illiberation (internalized oppression), PHL enables communities to advocate for their interests, akin to assigning “property rights” over their health resources. For example, the manuscript describes how public housing residents in Washington, DC, formed coalitions to influence the city’s Comprehensive Plan, ensuring policies addressed racial equity. This community-driven approach counters the tragedy of the commons by aligning individual actions with collective health goals.

2. Systemic Regulation (Vertical Integration): PHL’s call for increased constraints—such as regulations, health impact assessments, and cross-sector coordination—parallels centralized governance to prevent resource depletion. The manuscript’s Theory of Health Inequity Reproduction emphasizes economic incentives (e.g., fines, taxes) and constraints (e.g., laws, public demonstrations) to deter harmful practices. For instance, challenging permits for industrial polluters or editorializing against poor housing policies introduces accountability, reducing the externalization of health costs.

3. Praxis and Liberation: PHL’s emphasis on praxis—applied liberation through diverse methods like protests, citizen research, and media campaigns—offers a dynamic response to both frameworks. Praxis counters the tragedy of the commons by fostering collective action, as seen in the Rodham Institute’s vaccination efforts during the COVID-19 pandemic, which overcame access barriers through community-led registration systems. Similarly, public health realism’s focus on coalition-building and vigilance against hegemonic powers ensures that interventions remain community-centered, avoiding co-optation by dominant factions.

Limitations and Critiques

While public health realism and the tragedy of the commons offer robust frameworks, they face limitations. Public health realism’s pessimistic view of universal self-interest risks oversimplifying agents’ motivations, potentially underestimating altruistic or cooperative behaviors. For example, some nonprofits or health departments may prioritize equity despite resource constraints, challenging the assumption of universal egoism. Similarly, the tragedy of the commons has been criticized for neglecting cultural or institutional factors that foster cooperation, as seen in Elinor Ostrom’s work on community-managed commons (e.g., irrigation systems) that avoid depletion through shared norms.

Additionally, both frameworks may struggle to account for the scale of structural inequity, as acknowledged in PHL’s “constant” in the Theory of Health Inequity Reproduction. Some disparities, rooted in centuries of historical trauma (e.g., slavery, urban renewal), require seismic shifts beyond incremental interventions, complicating the application of either framework. Nevertheless, PHL’s integration of liberation philosophy and praxis mitigates these limitations by emphasizing community agency and moral imperatives, offering a pathway to challenge entrenched inequities.

Case Study Analysis: Flint and Washington, DC Water Crises

The lead-contaminated water crises in Flint and Washington, DC, serve as critical case studies to illustrate the alignment of public health realism and the tragedy of the commons. In Flint, the state’s cost-saving decision to switch water sources without corrosion control prioritized short-term financial interests over the shared resource of safe drinking water. The resulting lead poisoning, disproportionately affecting Black communities, reflects a tragedy of the commons, where the health costs were externalized to vulnerable populations. Public health realism explains this as a factional conflict, with state officials and water authorities acting as self-interested agents, exploiting their rulemaking power to avoid accountability.

In Washington, DC, the crisis was exacerbated by the CDC’s falsified report, which denied elevated blood lead levels, and the Water and Sewer Authority’s failure to act. This reflects public health realism’s principle that agents may engage in misleading speech to protect their interests (e.g., institutional credibility). The tragedy of the commons is evident in the depletion of trust in public health institutions, a shared resource critical to effective interventions. Both cases highlight the absence of governance—whether regulatory oversight or community representation—allowing factions to externalize harm, underscoring the need for PHL’s proposed integrations.

Conclusion

Public health realism and the tragedy of the commons offer complementary lenses to understand and address health inequities within the public health economy. Both frameworks highlight the destructive consequences of self-interest in anarchic systems, where shared resources—clean water, housing, trust—are depleted or undermined, perpetuating disparities. Public health realism provides a granular analysis of factional dynamics and hegemonic control, while the tragedy of the commons offers a broader ecological perspective on resource misuse. Together, they underscore the need for systemic interventions, as proposed by PHL’s horizontal and vertical integration, to empower communities, impose constraints, and foster praxis.

The PHL manuscript’s emphasis on liberation, community agency, and transdisciplinary practice enriches these frameworks, offering a roadmap to transform the public health economy. By fostering liberation safe spaces, challenging illiberation, and leveraging diverse praxis tools, PHL aligns individual and collective interests, mitigating the tragedy of the commons. Future research should test PHL’s constructs, such as illiberation and public health realism, through empirical studies and psychometric evaluations to refine their applicability. Ultimately, the alignment of public health realism and the tragedy of the commons underscores the urgency of reordering the public health economy to achieve health equity, ensuring that shared resources serve the common good rather than the interests of a few.

References

• Hardin, G. (1968). The tragedy of the commons. Science, 162(3859), 1243-1248.

• Ostrom, E. (1990). Governing the commons: The evolution of institutions for collective action. Cambridge University Press.

• Williams, C., Birungi, J., Brown, M., et al. (2022). Public Health Liberation - An Emerging Transdiscipline to Elucidate and Transform the Public Health Economy. Advances in Clinical Medical Research and Healthcare Delivery, 2(3), Art. 10. https://doi.org/10.53785/2769-2779.1120

• Madison, J. (1787). Federalist No. 10. In The Federalist Papers.

• Bell, D. (1992). Faces at the bottom of the well: The permanence of racism. Basic Books.