What is public health?
The fact of life is that very few Americans have any concept of what public health is. To a lot of people, public health means disaster response. And this is certainly true since 9/11. Here we are on the 11th anniversary of 9-11. Certainly true since then that an awful lot of people think it’s just responding to a crisis, to a disaster.
A lot of people think public health is health care for the poor. People who maybe can’t afford it otherwise themselves. Any number of people will tell you public health is a behavior nanny, which is one of the kinder expressions. Sometimes it gets a little nastier than that. For example, New York City deciding to limit the size of soft drinks to 16 ounces, which has been the subject of both of mirth on the part of some, anger on the part of others. And congratulations to the mayor on the part of still other people. We’re going to talk about that one later on as an interesting example.
When I say the behavior nannies…I should tell you, by the way, it doesn’t matter, but politically I stand kind of in the middle, and maybe even slightly right of many of my colleagues in public health. Public health is a field where I think it’s fair to say on average people are pretty far left. And you don’t find too many people on the right, the right side of the spectrum. Although, there definitely are some very important people in public health.
There are other people who think public health does nothing but restaurant inspections, looking for cockroaches. That’s actually a fairly important function of local public health. There’ve been some very famous restaurants.
For example: Pretzel Bell in New York.
The Pretzel Bell was the place to go on a Friday or Saturday night. In fact, it was a place you went on your 21st birthday when you were allowed to drink and you would stand on a table in front of all your friends, and all the other people there, and chug a beer. Wonderful place for all kinds of entertainment.
It was shut down by the health department and eventually went out of business, precisely because they had problems with cockroaches and a number of other insects. It really wasn’t their fault, as much as the structure of the building.
Is that closed?
Okay, well, that’s where it was. And that replaced it, and it was there for many years after.
Now, here’s a common reaction: “I don’t have any idea what public health is.”
So, today we’re going to learn what public health is.
Alright, how do public health professionals think about public health?
My way of thinking about it, and I think many health professionals, is by its purpose. And we’re going to talk about its purpose momentarily. But there are others who will talk about the professionals who are active in the field of public health.
One problem I have with doing that and we’ll talk about the five core groups of professionals a little bit later but one problem I have with that is, I think of people who run fitness centers for-profit as being in public health. I think of people who make athletic equipment as being in public health.
That doesn’t mean that’s their principal focus, but they’re contributing to public health. So, I think of it as being much broader than the professions we tend to associate with public health. Some people think of it narrowly as associated with the two methods most closely identified with the field–epidemiology and biostatistics.
Other people, even within the field of public health, again, think of it as governmental health services for the poor. And then there are some people who think of public health simply as the outcome–the health of the public.
Now, I said I like that first one purpose. I’m not going to read you this rather lengthy definition, but I urge you to read it. It’s from CEO, CEA Winslow–one of the really famous folks in American public health history–Back in 1920, and aside from an occasional stilted word here or there, this is a brilliant definition, a very comprehensive definition, of what public health is.
“Public health is the set of activities a society undertakes to monitor and improve the health of its collective membership”.
So, just a few words there. But the critical pieces of this set of activities that the society undertakes to monitor. So one of the important functions in public health is simply observing what’s going on and thereby being able to analyze what’s going on and improve the health of the collective membership.
So what distinguishes public health from the other fields of health science?
Well, one is, there’s a very, almost laser-like, focus on disease prevention and health promotion. Trying to prevent disease and injury from occurring in the first place. Second–and I put the word patient in quotes–there’s no individual “patient.” The patient is the community. If I am in public health,
I’m thinking bigger than individuals. I’m thinking about collections of individuals–the community.
The same thing about the provider. The provider is the society itself, organized however we choose to do that, not individual professionals. So, think about the other health professions. And, by the way, this is going to overlap. I’ll give you an example of that in a moment.
But, if you think about all the other health professions, they almost all consist of an individual provider who is providing services to an individual patient. And, more often than not, the emphasis is on dealing with an existing condition–some kind of health problem.
Now, obviously you go to the doctor for preventive services, or the dentist for preventive services as well. But, more often than not all of these fields are focusing on treating existing conditions, trying to ameliorate their effects, trying to make things better.
So, here’s an example. And this actually is a very important one.
Think about the difference between what a dentist does and what the government does when we think of dental health or dental public health. You go to the dentist to have dental caries, dental cavities, treated in individual patients. Public health fluoridates the water supply, which we then all consume, and confers protection on us so that we don’t get the cavities in the first place.
Now again, it’s not perfect. I go to the dentist twice a year for a preventive maintenance checkup. I assume that many of you do that as well. And the dentist actually will teach me health behavior things. They’ll make sure I’m flossing regularly and do other things like that. But on average, the difference is the focus on problems that exist, versus trying to prevent the problem from existing at all.
I said this is an important example, and the reason for that is, we tend to think of the hierarchy of health problems–most of you all probably don’t think of dental problems is very high on that list. Actually, it’s very high for a variety of reasons.
But, this is a field, one of the fields, where public health has been extraordinarily successful. How many people in here have had more than five cavities in their mouths? Got to be some of you. So how many of you had more than five cavities but won’t admit it? There are very few people of my generation who wouldn’t have had their hands up. Why is that? Because the water supply wasn’t fluoridated when I was growing up as a kid. We all got cavities, we got lots of them. You all, in general, don’t. You might have one or two, three, but you’re not going to have five or more.
And that was commonplace. This is an area where public health through a community activity that was not delivered to individual people has been enormously successful. Alright, I want to think conceptually about the role of public health.
Public health should be at the very top of the pyramid when we think of how we organize our health and health services–our public health services. Public health should be at the top overviewing all of it, overseeing all of it. That means the collective health services that we’ll be talking more and more about and the individual health services. There is an important role for public health in overseeing those individual health services. You see them here. That’s in concept.
How do we behave in practice?
Well, it kind of looks like this: So, medical care is at the top of the list. That’s followed by the other individual health services. And public health not only gets the least money, it gets the smallest font. Alright, medicine clearly dominates our public health horizon, if you will.
Why does it matter?
First of all, it’s because public health is so very important. This comes from any number of studies. I’ve written down several of them. These are some of the original ones from the Centers for Disease Control and Prevention, Institute of Medicine, Public Health Service– there have been many others since then.
Here’s the question: If you could prevent avoidable premature mortality, what would you have to do to prevent it, and what would be the contribution of each of these factors?
Well, this is telling us that lifestyle and behavior changes could account for a reduction of half of that. In other words, half of that preventable death and disability could be avoided by lifestyle behavior changes.
Environmental improvements could address about a fifth of the problem. Dealing with human biology and genetics, another fifth. And better and more medical care could only decrease that toll by about ten percent. I would say this is widely accepted among pretty much all health professionals. Now, this is from a study by an anesthesiologist of all folks, John Bunker, and his colleagues from 1994.
There have been others like it, but he estimated that of a 30 year gain in life expectancy in the U.S. during the 20th century—remember life expectancy went from about 47 up to about 77 at the end of the century–five years of it were attributable to the medical care system, 25 years to health improvements and sanitation, housing, nutrition, and job safety.
Now, you know, those of you that have ever bought stocks, or read anything about stocks, they always tell you that past performance is not a guarantee of future performance. That doesn’t mean that going forward we’d have the same kinds of ratios, but the best evidence suggests that we still have a lot of room to gain much more from public-health efforts and we can certainly through health care.
So, think about it this way, of this simple Venn diagram. If this is the importance of public health and medical care to health, and this is qualitatively speaking–and note that there is an intersection in these two because there are things done in medical care that certainly qualifies public-health: immunizations, health behavior counseling—pediatricians are very good at counseling about health behavior.
That’s a good example. But, then we say, “Where do we put our resources?”
And here’s the answer. And in the last year, we spent something in the order of $2.6 trillion on health care services in the United States. If you wonder how much that is divided by 308 billion people, you get a large number. Look at all those zeros. This is a huge number.
It’s about 50 billion, roughly. Nobody has a very good figure for public health because they don’t know exactly how to define it for accounting purposes. About 2% of that total has gone to public health. So, something is out of whack here. We’ve got the importance of public health, the enormity of it, we’ve got the funding that goes to it, which is tightening.
Why is there this imbalance?
Market systems and economic interests
They’re all associated with cater to services for individuals, that the market responds to what individuals want to spend their money on. Public health is something we refer to as a public good or externality. Those are terms that, if you haven’t taken economics, you may not be familiar with. We will be coming to them. But suffice it to say, that the conventional marketplace will not provide public goods and externalities–not address externalities–in the marketplace. That requires government. That requires governmental intervention. So, the market doesn’t work with it.
Interest group politics
There are a lot of contentious issues in public health, and one of the things that we’re going to see as we go through the term is that public health is a contentious field. There really aren’t very many interesting questions in public health, interesting issues, that don’t involve a lot of very challenging politics. And then there’s this thing called the “Rule of Rescue.” I don’t remember the name of the author, but somebody wrote an article many years ago where he referred to this as the Rule of Rescue, and he said, “What do people want?” “What people want when it comes to healthcare is to be saved when they’re in dire trouble.”
They’ve had an automobile collision they’ve got cancer, they just had a heart attack. Whatever it is, they want to be saved, and they’re willing to put big bucks into trying to get saved. Public health involves an abstract future benefit.
Public health, when it works very well, means the problems don’t exist. Successful public health is the avoidance of problems, and people don’t ever necessarily know that they have benefited.
You’ve got a health promotion program. You’ve got an exercise program. Well, think about what that means. The benefits of exercising are somewhat abstract, and they’re certainly deferred. The concept is, “If I exercise regularly for the next twenty years I’m going to avoid a heart attack” “you know, at some point during that time, or ten years later, or something like that.” That’s an abstraction, and it’s a deferred benefit.
The costs are real and they’re immediate. I have to find time in my busy life to exercise. I have to go out and work on some machines and sweat do all kinds of things that I don’t want to do. But those…think about the balance between the benefits and costs. It takes a special kind of person to make a commitment to endure those costs in exchange for this deferred and abstract benefit.
Benefits and costs of disease promotion
I don’t know about you all, I am, I’ll confess, something of a chocoholic. And every year when I look at this picture it just drives me crazy. I mean, does that look good or what? Now think about that. The benefits that she’s enjoying right now are totally tangible. You can feel them, you can taste it, you can get it smeared all over your mouth. I’m not sure that part’s a benefit. And they are immediate.
How about the cause?
They’re kind of abstract, you know. Am I increasing my risk of a heart attack as a result of doing this a month from now? Tomorrow? A year from now? Well, if I do this, you know, maybe once a week there’s no harm in it. Maybe twice a week there’s no harm. How about three times? That’s probably okay. And then, all of a sudden, I’m 40, 50 years old, 55 years old and I’ve got these clogged arteries. It’s hard to make that connection.
