An Ounce of Prevention

Sometimes the public health field is a victim of its own success.
By David Tuller

In the Spring of 2001, several leading public health associations launched an ambitious effort to raise the profile of their field. Creating the Public Health Brand Identity Coalition–which I think we can all agree is not the sexiest name for an initiative to promote a sharper professional image–the group commissioned a poll about attitudes toward the phrase public health. Almost 80 percent of Americans, according to the survey, did not think that public health had touched their lives in any way.

That’s an astonishing figure in an age of smoking bans, safe-sex ad campaigns, and fluoridated water—all classic public health interventions. But these are not the kind of things most people think of when they hear the term. “The average person, when you talk about ‘public health,’ they zero in on clinical services for the uninsured and the underserved, and they think about public clinics and public hospitals,” said Dr. George Benjamin, executive director of the American Public Health Association, one of the members of the branding coalition.

The campaign dissolved in the aftermath of 9/11, when Dr. Benjamin’s APHA and other coalition member groups found themselves deeply immersed in the national response to the attacks. Subsequent events–the anthrax letters, the emergence of new infectious diseases such as SARS and H1N1, clusters of deaths from contaminated food–have focused some attention on the importance of investing in a trained workforce to prepare for and respond to large-scale medical emergencies. Less understood, however, is how crucial public-health professionals and strategies are in sustaining the day-to-day well being of both communities and individuals.

That’s a problem, because greater awareness of such basic and essential concepts as preventive care and shared or pooled risk could help ease what is likely to be the traumatic process of overhauling our health care system. Now that the United States has shed its pariah status among developed countries by actually declaring—legislatively—that people deserve access to insurance, we’ll be relying on public health workers and resources to play a central role in implementing the Obama vision of universal coverage.

Public health suffers from a built-in dilemma. When it works as it should, it’s invisible. Public health interventions seek to prevent bad things from happening in the first place; when such efforts are most successful, you don’t experience the catastrophe that’s been avoided and you don’t realize how awful it could have been. So the impact of public health is felt most clearly in the absence of negative consequences–which in turn reduces awareness of the vital functions it performs.

Vaccination is a great example: Because of the success of mass immunization campaigns in the second half of the 20th century, many potentially fatal infectious diseases, such as measles and whooping cough, have for decades seemed relics of the past. That has led some parents to believe that they can dispense with many childhood vaccines, which they fear–against all reasonable evidence–can cause autism. The outcome has been recent outbreaks among unvaccinated kids of measles and whooping cough, both of which are completely preventable.

So whatever the results of the branding coalition’s 2001 poll, everyone’s life has been touched by public health advances, mostly in ways unseen.

People understand that the treatment of illness is the province of medicine or medical care. They know that when they are sick they should go to their doctor or nurse. Public health practitioners, on the other hand, view situations from a population-level perspective, seeking strategies that bolster overall societal health rather than focusing on individual cases of disease. When he needs to explain this basic distinction, Dr. Benjamin of the APHA said he often cites his experience while training as an ER doc. “I tell people that when someone would come into the emergency room with a rat bite, I took care of the rat bite,” he said. “If ten people came in with rat bites, the best public health intervention I could do would be taking out the rats–solving the problem versus providing clinical care.”

The straightforward concept behind Dr. Benjamin’s illustration is one of the major tenets of public health: It is better to deal with a health threat (rat infestation) “upstream” before it causes disease and illness (many rat bites) “downstream.” All first-year public health students can recount the story of the cholera epidemic that raced through London’s Soho district in 1854, killing more than 600 people. A local physician there, John Snow, believed in the emerging but still controversial “germ theory” of disease; he speculated that water polluted with sewage was the source of the epidemic. By interviewing neighborhood residents and mapping the cholera cases, he eventually identified a particular public water pump on Broad Street as the suspected source. After authorities disabled the pump handle, the epidemic ended completely, although it was already subsiding on its own.

As a reporter at the San Francisco Chronicle in the early 1990s, I covered our last national battle over health reform. It was already clear–from the heartbreaking stories I heard of people who lost their insurance coverage after they or their kids fell ill–that we did not, in fact, have a functioning health care system. Today, from my current vantage point at Berkeley as the coordinator for a new concurrent masters program in both public health and journalism, I struggle to understand–and explain to students–how we as a society could have let things deteriorate so much since then.

Those who opposed the Democrats’ health care push appear to feel no embarrassment that the United States has recently ranked 30th out of 31 countries in child mortality rates, according to the Centers for Disease Control–that’s 22 places behind Portugal, 3 places behind Cuba, and ahead of only Slovakia. Instead, these opponents keep braying and bragging that U.S. health care is the envy of the world. And for those with access to American medicine’s most advanced and high-tech interventions–like, say, members of Congress–the claim may hold true. But if you believe that all people deserve a chance to enjoy good health, then you must think about what’s available to the least as well as the most advantaged among us, and ask yourself: “How can we share resources more fairly so that everyone has access to basic preventive and primary care?”

As a nation, we suffer from an appealing delusion: that rugged individualism and self-reliance define the American character and represent the source of our country’s greatness. Now, I have nothing against rugged individualism and self-reliance—better to possess those traits than not, I suppose. But the national fetish for Horatio Alger heroics and “pull-yourself-up-by-your-bootstraps”-ism implies that everything is possible for those who work hard, and that those who cannot overcome obstacles have only themselves to blame. This is preposterous, of course; it obliterates the weight of historical injustice in shaping today’s discriminatory landscape. It also ignores what public health researchers call “the social determinants of health”–the factors that influence patterns of disease and wellness in the first place: the neighborhoods where we live, our socioeconomic status, the quality of our food and water supplies, and our access to education and information.

Nonetheless, for reasons of history, culture, and some weird national sociopathy, we have been willing to tolerate levels of health care inequality unique in the developed world. No health insurance? Sorry, not my problem! Your kid has cancer? Too bad, get a job! Or, as our last president–the compassionate conservative–famously declared, “[P]eople have access to health care in America. After all, you just go to an emergency room.” Anyone who has ever spent time in an urban ER knows how ridiculous that statement sounds.

And to make a possibly impertinent observation, emergency rooms are designed to handle actual emergencies, not the runny noses, allergies, sprained ankles, and other primary care needs of the tens of millions of Americans who aren’t president, don’t live in a beautiful mansion at taxpayer expense, and don’t have insurance at all, much less gold-plated coverage paid for by the federal government. However much right-wing pundits complain about the sausage-making messiness of the legislative process that produced the health care bill, the enactment of a reform package guaranteeing access to all represents a profound shift in national perspective.

The bill is far from perfect; for one thing, I’d prefer a single-payer system to the prospect of delivering tens of millions of new customers to an industry that’s helped create the swamp we’re in. But by promising to cover everyone (oh, except the undocumented, who harvest our crops, raise our kids and construct our houses), the legislation is embracing a comprehensive, public health–oriented approach. And the ban on charging more or denying coverage altogether because of a “preexisting condition” is applying population-level strategies to the vexing problem of delivering medical care to individuals; bringing everyone into the insurance pool spreads the financial risk around so that no one is bulldozed by unaffordable medical costs.

It’s not at all surprising that the ferocious heart of the health-care debate has been outrage over the mandate that everyone purchase insurance. I understand why this upsets the Tea Partiers, given their distrust of the federal government and their belief that the bill will bankrupt the country. I get that they see forced participation as an infringement on the personal freedom they view as their birthright. So I’m thrilled about the money the country will save when these rugged and self-reliant patriots refuse to accept those government handouts known as Medicare and Social Security.

Beyond ensuring access to insurance, the new legislation incorporates an expansive view of health and well being–or at least a view more expansive than we’re used to. It acknowledges the obvious: that maintaining healthy communities means more than providing medical care for individuals, however crucial that step.

As Dr. Stephen Shortell, dean of the School of Public Health points out, the bill allocates about $10 billion for prevention and wellness over five years. It also supports education and training to bolster the ranks of the public health workforce, which in recent years has been severely stressed by increased demands and inadequate resources. “This is the first time in a long time that we should have additional financial support for our students,” he said.

The legislation mandates such health promotion measures as requiring chain restaurants to include calorie information on menus, and directing insurers to fully cover recommended screenings and vaccinations. These and other aspects of the overhaul represent significant improvements over current practices. The more we deploy such broad-based strategies to mitigate what are called “structural barriers” to health care access, treatment, and information–including barriers arising from poverty and discrimination–the more of a genuine public-health system we can claim to have.

This fall, I’ll once again teach my regular journalism course on health reporting. On the first day of class I’ll ask the students what I always do: Can anyone explain the difference between public health and medicine? Despite all the recent developments and speeches and news articles about health care reform, I suspect that the students will stare at me blankly, as they usually do when I pose that question. One or two might venture a comment about public STD clinics or Medicare, or maybe they’ll ask if I’m referring to swine flu.

So hey, public health associations! Seems like now might be a good time to rev up that whole brand-identity-coalition thing again. 

David Tuller is coordinator for public health and journalism at the School of Public Health and the Graduate School of Journalism. He covered health issues for many years at the San Francisco Chronicle and is a frequent contributor to The New York Times.
From the Summer 2010 Shelf Life issue of California.
Filed under: Law + Policy
Image source: Justin Sullivan/Getty Images
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If all of medicine could be viewed as an emergency room, then public health is a seat belt. There just aren’t going to be very many hour long TV shows about a seat belt. I find the field facinating, but only when things go wrong.
The best ad I’ve seen to this end says, “There is no such thing as a sudden heart attack” and below that is a picture of a man’s gut. Under the picture it reads, “It takes years of preparation.” We’re not talking about making riveting TV shows, we’re talking about what do you do in a country were the biggest killers of adults- heart disease, is largely preventable ?! Our lifestyle is killing us faster and before it kills us it significantly alters our quality of life. Children are suffering from diseases that were at one time only adult diseases- like Type II diabetes. We have an epidemic with obesity in this country and we need to do something about it!
As a public health major, I agree with much that was said in the article about the field. However, I feel that it turned into a “lets bash the republicans” article half way through. I am a republican and I appreciate some of the changes being made by the new health care bill. I also disagree with many changes like, as was stated in the article, forcing everyone to pay for insurance, because us right wing pundits feel that freedom in this country is our birthright. If it isn’t, which I felt the author was inferring, then since when did health care become everyones birthright while freedom to choose how we live our lives get tossed out the back door? I love public health because we help everyone, even those without money and resources, but I don’t feel that money redistribution or robbing from the middle class and up to give to the poor is fair for everyone.
The field of public health would benefit from more, authentic, community engagement practices, based on the development of sustainable relationships with diverse community members. The reason people do not understand or have a significant awareness to the field of public health is because public health practitioners operate from ivory towers/dungeons in government agencies, until a public health crisis occurs, requiring them to come down and interact with the masses. If instead, public health practitioners would regularly tap into the resources within communities to craft public health programs and interventions, people would be more aware of what it is. Further, communities of color are incredibly underrepresented in the profession. And, many Public Health practitioners lack the capacity for developing meaningful relationships across diverse populations. The best PR for public health is community relations —- skills which many practitioners are not trained in and do not effectively practice. Perhaps, PH education institutions should focus on community relations and community engagement at the educational level, as a new essential/core function of Public Health.
When things go wrong then Public health has not done it’s Job. A huge part of Public health is prevention.
As what doctors say, Prevention is always better than the cure. Giving medicines to cure a disease is only a short term solution. Giving vaccines or educating the people how to prevent the disease is one of the best solution. Not only you will save the lives of many people but also you will save a lot more money.
read it
From personal experience this new Obama Care will bankrupt this country and I have an example of why I believe this. I am 24 years old and attend a 4 year university, I was working two part-time jobs and one of them was strictly so that I could have health benefits. I made 7,000 a year as a server and 4,000 had gone towards my health care. With Obama care that started this new year I only qualified for medical. So I went from paying for my insurance to not having to pay. I am sure that many other people my age are in the same situation. So tell me how this is going to work for our country? Another thought I have is that there are so many government handouts that people are taking advantage of the system and abusing it. I am all for helping people in NEED and what I mean by that is there should be strict guidelines for government aid. Our country needs a major revamp in order for people to see that they’re truly lucky for what they’re recieving. There are people out there who are far worse and in real need and it is truly disgusting to see some of the people who are abusing the system.