The following is the President’s Message from Health Planning Today, 1^st Quarter 2007 issue. Reprinted with permission.

Over 10 days in January, the British Medical Journal (BMJ) conducted a poll among its readers to determine what they thought is the most important medical advance since 1840, the year of its founding. From a list initially suggested by its readers, an expert panel chose the top 15, which formed the basis for the vote. It also published a supplement in which experts argued the merits of each individual advance.

Among the 15, just four advances each received over 10 percent of the vote. They are:

1. Sanitation (clean water and sewage disposal): 15.8 percent.

2. Antibiotics: 14.5 percent.

3. Anesthesia: 13.9 percent.

4. Vaccines: 11.8 percen.t

The knowledgeable readers of the BMJ who voted (11,341) include physicians (28.6 percent), members of the public (22.8 percent), students (14.2 percent), and academic researchers (10.2 percent), and live largely in the United Kingdom (37.7 percent) and the United States (20.0 percent). Once again, its readers find that public health is principally responsible for the advance of medicine in that sanitation and vaccines are its province, while antibiotics are shared by public health and personal health care.

Here in the United States, our media are full of articles about the need to improve health status, reduce racial and ethnic disparities, and reduce national health spending, with nary a one about the value of public health. It would seem that they should be addressing the need for public policy that gets at the root determinants of premature death and disability. In a now classic 1993 research article,[1] J. Michael McGinnis and William H. Foege related the 10 leading diagnoses of death in the United States in 1990 to the actual causes of those deaths. They found that 50 percent of deaths were attributable to behavioral choices – as opposed to genetic and external factors – and therefore were potentially responsive to public health education and prevention interventions. The distribution of causes of death was found to be essentially the same 10 years later when assessed again by Mokdad and colleagues in 2000.[2]

The most prominent contributors to mortality in the United States in 1990 were tobacco (an estimated 400,000 deaths), diet and activity patterns (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behavior (30,000), motor vehicles (25,000), and illicit use of drugs (20,000).

The leading causes of death in 2000 were tobacco (435,000 deaths; 18.1 percent of total U.S. deaths), poor diet and physical inactivity (365,000 deaths; 15.2 percent), and alcohol consumption (85,000 deaths; 3.5 percent). Other actual causes of death were microbial agents (75,000), toxic agents (55,000), motor vehicle crashes (43,000), incidents involving firearms (29,000), sexual behaviors (20,000), and illicit use of drugs (17,000).

Since 1900, the average life expectancy for Americans has increased by about 30 years. More than 25 of the 30 years can be accredited to public health initiatives, while medical advances account for fewer than four years.[3] How bizarre it is that U.S. health care expenditures total nearly $7,000 annually for every man, woman, and child, whereas in 2005, federal support for CDC was roughly $25 per person per year, and state support for public health averaged $35 per person. It has been estimated that a "fully effective" population-based public health program could be implemented with about 3 percent of our national health care expenditures.[4]  

Public health’s top 10 achievements in the 20^th Century include:[5]

    • Vaccinations                 

    • Safer and healthier foods

    • Motor-vehicle safety 

    • Healthier mothers and babies

    • Safer workplaces           

    • Family planning                                   

    • Control of infectious diseases 

    • Fluoridation of drinking water

    • Decline in deaths from coronary heart    

    • Recognition of tobacco use as a health disease/stroke hazard

So what are the factors that influence health status? Here they are:[6]

    • Health Behaviors – 50 percent

    • Genetics – 20 percent

    • Environment – 20 percent

    • Access to Care –10 percent 

Eighty percent of health status, including the prevention of premature deaths, is preventable, 70 percent by public health, and 10 percent by medical treatment. All of these factors assume that an infant has survived its first year of life, but the U.S. rate for infant mortality is among the worst of all large industrialized nations. Among 33 industrialized nations, the United States is tied with Hungary, Malta, Poland, and Slovakia, with a death rate of nearly 5 per 1,000 babies. That is primarily a reflection of barriers to prenatal care and maternal health, a consequence of our lack of universal health care, and of racial and income health care disparities. Among U.S. blacks, there are 9 deaths per 1,000 live births, closer to rates in developing nations than to those in the industrialized world.

Public Health Is the Answer, Just Ask the Right Question

I can think of no more stirring symbol of man’s humanity to man than a fire engine.

                                                               -- Kurt Vonnegut 

What we need is basic primary and preventive health care services, but we do not have a delivery system that is designed to provide primary prevention. We don’t even have one that has been designed at all, just co-opted and driven by profitmaking.  However, there is no profit for business in prevention, just for people. That is what public health does, and it is uniquely a government function.[7] Our poor health rankings are pointed testimony to its underappreciation and underfunding. It is the misfortune of public health that its greatest benefits are invisible. While it protects everyone against maladies unimagined today, its detractors are able to criticize it with impunity.[8]

That was not always so, but we forget. The mistrust of government clouds public health in its role of primary prevention, but that view is only a generation old. Before the advent of good sanitation and vaccines, plagues were feared far more than cancer is today, and childhood was something more to be survived than enjoyed.  In 1796, when Edward Jenner first successfully immunized a child against smallpox, it was the world’s deadliest infectious disease. For the next century and a half, medicine and public health systematically eradicated all those deadly childhood diseases save one, polio.

The Salk vaccine (1955) was both the triumph of this process and its last effective publicity. A generation later, we had already become used to the luxury of our ignorance, that luxury underwritten by the effectiveness of public health. And the fastest growing sector of the health care industry thrives in the shadow of that ignorance, offering its sham procedures and cures as wish fulfillment for those age-old yearnings of mankind continually being addressed in much more practical ways by public health. Today, it would take a vaccine against all cancers, a newly virulent smallpox, or the Ebola or Marburg viruses to remind us how to be grateful for primary prevention.[9]

Public Health in the 21^st Century: A Better Society                                                                                        

What would it take to get us to see that our best interest is served by strong support for public health? What would it take to get us to see that our support for the highest standards for education is far more fundamental… to everything? A recent research article[10] looked at vital statistics data for 1996-2002 in order to determine the number of averted deaths attributable to medical advances and the number of deaths that would have been averted if adults with lesser education had experienced the mortality rates of college-educated adults. The result: medical advances prevented 178,193 deaths, whereas giving all adults the death rate of those with a college education would have saved eight times as many, 1,369,335 lives. "On the basis of how many lives can be saved, our data suggest that efforts to correct the social conditions causing education-associated excess mortality should be proportionately greater than society's investment in medical advances.” The authors concluded. “Formidable efforts at social change would be necessary to eliminate disparities, but the changes would save more lives than would society’s current heavy investment in medical advances. Spending large sums of money on such advances at the expense of social change may be jeopardizing public health.”