Public health: starting the conversation in earnest

Yesterday Flu Wiki founding editor and DailyKos frontpager DemFromCT reviewed three recent report cards on public health, one each by the American Public Health Association (APHA), The Trust for America's Health (TFAH) and the American College Of Emergency Physicians (ACEP). It was a great a service in two ways. The first is to remind us that "health reform" is hollow without making sure the public health infrastructure is sound. And second, he reviewed these reports so the rest of us don't have to. Believe me, that's a service in my eyes. My patience gets pretty short when I see these tomes, full of platitudes, generalities or special pleading from a public health establishment that has lost its way, its mission and its ability to think out of the box. Too many years in the wilderness, perhaps. I'm guilty, too. I've been carrying on for years (literally) that the way to prepare for a pandemic is to shore up the public health and social service infrastructure.Dem and others have gently pressed me for some specifics, but I have resisted, mainly because I am not completely sure what I mean. It's hard to explain things you don't understand yourself (although teachers do it all the time).

I know I can't do it alone. When I started the Effect Measure blog four plus years ago, just after the Bush re-election catastrophe, I hoped it would be a gathering place for serious discussion about public health from a progressive viewpoint. Specifically I wanted to begin a rethinking of public health, from the ground up, questioning all assumptions, ideological and practical, and not settling for the kind of slogans we in public health had been ritually mouthing for years (e.g., "prevention pays"; what if it didn't? does that mean we wouldn't do it?). One of my very early ideas was to view public health through a specific lens and I decided to use the potential for an influenza pandemic with H5N1 as concrete example to focus things. I was among the first in the blogosphere to talk in any depth about bird flu, although I soon discovered two others, DemFromCT and the late (and much missed) Melanie Mattson of Just a Bump in the Beltway blog. The three of us, with the technical expertise of pogge, started The Flu Wiki in June 2005 and it has remained one of the "go to" sources for pandemic prep information since then (without much help from me, I might add). As time went on bird flu became the tail wagging the dog (pardon the mixed animal images). We still write about bird flu here, but it is time to put our shoulders to the wheel and start re-thinking public health. The three reports Dem discusses brought this home to me. All three sounded like tired nonsense.

Take APHA's view, for example:

During the 1990s, health improved at an average rate of 1.5 percent per year, but improvements against national health measurements have remained flat for the last four years. Smoking, obesity, and the uninsured are the nation's three most critical challenges...

No doubt those are three important health problems. But this strikes me as extraordinarily shallow thinking. I wasn't any happier about the TFAH report:

"The economic crisis could result in a serious rollback of the progress we've made since September 11, 2001 and Hurricane Katrina to better prepare the nation for emergencies," said Jeff Levi, PhD, Executive Director of TFAH. "The 25 percent cut in federal support to protect Americans from diseases, disasters, and bioterrorism is already hurting state response capabilities. The cuts to state budgets in the next few years could lead to a disaster for the nation's disaster preparedness."

This made me gasp. "Progress since September 11"? As Jon Stewart might say, "And do unicorns talk in your world, too, Dr. Levi?" The public health infrastructure -- meaning the sinews and muscle of our state and local health departments haven't been in such bad shape in my 40 year career in medicine and public health. TFAH is so narrowly focussed on disaster response they can't see the trees for the leaves, much less the forest. The influx of federal funds for disaster preparedness has been one of the problems, not one of the solutions (we have made that point here before).

I am a little more forgiving of ACEP's narrow Report Card. Representing the nation's emergency room physicians they are on the front line of the crisis in health care, public health, social services, the economy and everything else that is falling apart around us. They viewed things in a characteristically narrow way:

The overall grade for the nation across all five categories is a C-. This low grade is particularly reflective of the poor score in Access to Emergency Care (D-). Because of its direct impact on emergency services and capacity for patient care, this category of indicators accounts for 30 percent of the Report Card grade, so the poor score is especially relevant.

At the moment I admit I can't do better. But we have to do better. These "reports" are not much more than demanding we do more, and again, what we did in the past that didn't work.

So let's start over in thinking about this. The easy stuff, first. Public health and social services are an essential part of the country's infrastructure, as much or more than roads and bridges. We have been disinvesting in them. We need to start re-investing in the routine stuff: substance abuse programs, maternal and child health, surveillance and vital records, environmental health and the rest of it. We need to do the same for social services. Yes, this is more of what we did before, but the first step in investing in our physical infrastructure (which should include the water and sewer systems, by the way, not just roads and the electrical grid) is to keep the bridges from falling down and the roadway from developing huge potholes.

But we don't want to just recreate the old transportation infrastructure and we shouldn't want to recreate the old public health system, either. It was based on different premises in a different world than the one we are heading into. The economic meltdown is a catastrophe but it is also an opportunity. All the cards have been thrown in the air and will come down in a different configuration and we should be prepared.

What's the goal of public health? Surely it isn't simply that I should be thinner and not smoke and be able to buy medical care. Surely it can't be that we are ready for a bioterrorist attack. Can it possibly be that it is that I get seen much faster in the emergency room? I know these are caricatures, but not by much. What else so we want?

If I am an ordinary person, I don't want to have to think about public health. I want it to work well but in the background, like the water system. I've got too many other things to think about and worry about. But if I am not looking at it all the time I also want to feel confident that those who are thinking about it are (a) competent, (b) making judgments and decisions for the welfare of the community. In substance, I want a system that is going to keep me and my family and my community as safe as they know how, all things being equal. Especially (but not solely) in the Bush years we couldn't be assured of either of these elementary desiderata. Somehow we have to restore trust in the system.

What else? When I or the community have a problem, I want somebody to fix it. If it's a health problem, that might or might not mean paying for expensive technology. Expensive health care is not always the best health care. We should be asking, for health problems, what is the best way to solve them. If the only way is very expensive, then so be it. But the system is now designed and favors expensive over less expensive solutions, and not necessarily because they are better. We have let the private sector drive the technology, as a matter of ideology. It has worked in some ways but failed miserably in others. We need to rethink the system of licensing and patenting of publicly financed research and we need to put public monies into finding the best solutions. When I say this I am saying something different than, "The best solutions, no matter how expensive they are." I am saying, "The best solutions, no matter how cheap they are." We currently do the former, not the latter.

That's the merest of starting points: Make my world as safe as you can make it, all other things being equal (and that might mean taking other high priority factors into account), and when I get sick, help me to get well. But the starting point is not, how do we get people to stop smoking (although doing that is part of making their world safer) or thinner (although doing that is part of making their world safer) or giving them health insurance (because insurance is only a means to another goal, so let's talk about that goal instead).

When I started the blog we were pretty much alone in the public health blogosphere. Now we have a steady readership in health departments all over the world, and more important, there is The Pump Handle, where this is cross posted and which I hope will become the lunch table around which public health professionals can start to talk seriously about what the hell we are doing and what the hell we want to do, without any preconceived notions.

More like this

Thoughts on health system reform --

I think any reform must gradually phase in an approach that focuses on prevention and health promotion. We can't simply tinker with the insurance system - this would be hugely expensive, politically difficult, would potentially overwhelm the current medical system (with extremely unhealthy people), and would not make our population much healthier. Here'a my plan...

1) Make a significant investment ($200B?) in providing the uninsured with a comprehensive set of preventive services (vaccinations, smoking cessation programs, prenatal care, drug abuse programs, etc.) AND catestrophic coverage (where the costs are high but the likelihood of the event is low)

2) Phase in basic primary care services (offered in outpatient clinics NOT emergency rooms), chronic disease programs (back pain and depression, primarily), mental health programs, etc.

This would obviously require an investment in the public health infrastructure and proven prevention and health promotion programs (see for example,

Once the population has become more healthy (in an aggregate sense, this might take 5-10 years), implement reasonable insurance (assuming that you are reforming our insurance-based medical coverage system in parallel). Insuranc reform is really a different problem with a different process and potential solutions. Let large employers worry about this. Pretty soon they will wake up and not want to pay what they have been paying for the services that their workers are receiving. THIS is also why organized labor is important - we have to avoid the potential of simply reducing benefits or passing the costs on to the employees (who are not in a position to negotiate them down).

The key issue is to not take on the whole mess at once - that's where Hillary failed and that's where the anxiety is currently in the system.

End the bogus War on Drugs and redirect that money to fund the changes sought.

In my state, the public health and Medicaid offices are part of the same agency. Indeed, most people here think that public health is the health care we provide to people who are medically un- and underinsured. As one might imagine with this configuration, public health issues are almost always overshadowed by those of the larger, more expensive payment system. For us, a start might be to separate these 2.

Generally, as we develop new ways to practice public health, we must also re-educate health care professionals, ideally when they're still in training.

I don't think this comment makes much of a contribution to your suggestion that we re-initiate our thinking on public health, revere, but I certainly look forward to the discussion.

By rotatingmass (not verified) on 15 Dec 2008 #permalink

Well, as an economist, I think public health should be completely rethought for a number of reasons. I am always amazed at the correlations that social changes have on health and how these are seldom considered "public health". For example, I know that a whole lot of Americans will have increasing health problems. How? Well, I know that unemployment is correlated with a lot adverse health effects (and over time you can show most of the causation goes from unemployment to adverse health). Yet, unemployment is never seen from a public health perspective (and one of the dirty little secrets of our economic policy is that some structural unemployment is "acceptable"--imagine if a public health document claimed that certain deaths are "acceptable").

Also, think of the correlation of education to health independent of the effect of income. It is very high and obvious, education allows people to be better producers and decision makers around their own health. Yet, when people slash education funding or pre-school programs they never acknowledge the premature death and loss of function that flows from that.

You may object that these are statistical points (and I would certainly agree that they are underresearched but the lack of research is based purely on the private profit calculation that funnels so much to medical disease fighting and pharma that even public priorities follow) but there is weaker statistical evidence that gets regularly paraded around hospital and physician planning with far fewer lives that benefit.

We spend so much money on "health care" that on the margin our health suffers. This will be made worse if cost control is not part of universalizing health care. This is also true if evidence is not central to "expanding the public health infrastructure" and it is just more greedy grabbing that TFAH want.

By floormaster squeeze (not verified) on 15 Dec 2008 #permalink

Facts that are believed to exist regarding the present U.S. Health Care System-
This may be why about 80 percent of U.S. citizens want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care cost presently is over 2 trillion dollars of our gross domestic product. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which causes about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children that covers about 7 million kids.
Our children
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA.
Our health care we offer citizens is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported. It is estimated that we need about 60 thousand more primary care physicians to satisfy the medical needs of the public health in the United States. And we have some greedy corporations that take advantage of our health care system. Over a billion dollars was recovered for medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up the U.S. Health Care System, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in existence , or tolerate it as it exists today any longer,
Dan Abshear

Wow. Just WOW! As a member of "the public" I am amazed at how insulated all the comments seem to be. In fact, the only one I can truly relate to is "I don't want to think about public health."

That may be true, but the fact is that I do think about it, almost every day.

*I worry that there are unvaccinated children coming in contact with my grandchild who isn't old enough to be vaccinated. --How can Public Health reassure me here?

*I have never lived in a community where there was not great appreciation for clean water and high degree of awareness that government provides it (for the most part) much cheaper than and better than we can for ourselves. If you want to see a big crowd of people show up for a city council meeting, let water be on the agenda.

*Ditto for waste removal and treatment.

*I'm not the only member of the "public" wondering why smoking and obesity (for example) are public health matters. They are not contagious. If pure cost (or perceived cost) is all it takes for something to be on the public health agenda, then everything is on it, and nothing will be accomplished on anything.

*The best way to solve any public health problem that unemployment creates is a strong economy. Government spending is not going to create a strong economy.

*I seriously doubt that unemployment is the major factor in people being on medicaid. Numbers, anyone?

In addition, if you want to be taken seriously, leave partisan politics out of the debate. It adds nothing and just might be distracting.

Many of the health problems we have are entirely preventable by proper nutrition, exercise and avoidance of harmful drugs (including nicotine and alcohol.) Money should be spent in our public schools to create new generations of knowledgeable, healthy children through daily PE programs, including intramural sports, as well as ongoing age-appropriate health classes as part of the regular curriculum all through elementary and secondary school. This IMO would be far cheaper in the long run than the drug rehab, diabetes maintenance, stomach stapling, lung cancer treatment and other medical solutions ten, twenty or thirty years down the road.

For that matter, why do we even still allow cigarettes to be sold when we know what they do to a person? Would we sell people sodas laced with rat poison? The public health authorities should ban cigarettes altogether: It shouldn't be an issue of personal right to choose when the result of that ill advised decision costs the taxpayers millions upon millions of dollars to then becomes everyone's problem and everyone's business, not just that one person's "individual choice."

Also much more research needs to be done and subsequent controls to be put in on the potentially harmful effects of such things as food additives, pharmaceuticals, and industrial pollutants in our air and water. Spend some money and time looking for the cures to public health problems at their source, then fix or prevent that source whereever possible: Much of what we suffer, I believe, may have its root cause in the toxic effects of modern technology.

As for making immediate health care more available and cost effective to the public, why doesn't the government offer a program in which it will pay the costs of medical school (or nursing school) for any would be doctor or nurse, who then agrees to go into public health medicine in underserved areas - working in state run hospitals or clinics for a set number of years at a fixed relatively low pay rate until his/her med school debt was repaid. This would bolster low cost public health services, as well as allow intelligent and motivated students of all races and genders who don't have the money to afford med school a chance to become doctors and nurses.

By maryinhawaii (not verified) on 18 Dec 2008 #permalink

For that matter, why do we even still allow cigarettes to be sold when we know what they do to a person?

for the same reason we still allow alcohol to be sold --- banning either one would be a cure worse than the disease.

that said, regulations and limits on the consumption of legal drugs can help a great deal. i'm gratified that smoking indoors is becoming more and more widely taboo, even banned where possible. making a habit inconvenient can do more to reduce it than ever making it illegal could hope to.


unemployment probably is a causative factor of ill health in the USA, because in this country employment is the key to paying for healthcare, including (especially!) preventative healthcare. break that link and unemployment would cease to cause deteriorating health --- which, by extension, could even help reduce unemployment. unfortunately, we don't seem to have any politicians with enough backbone to even suggest doing so.

By Nomen Nescio (not verified) on 19 Dec 2008 #permalink