Okay. What is public health? Sounds like a simple question. 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. uh… 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. But I’ll never forget the time I went to
an American Public Health Association meeting in Florida, in Miami, and I had my badge–American Public Health Association
badge. I was walking along and there’s some guy who
had a different badge for a different convention and he said to me, “Oh, were you at that
public health meeting?” and I said, “Yes.” And he said, “Communist!” and he walked right away. So that’s a perspective. Uh… it’s not a fair one, but, uh… but
that’s one perspective. 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. How many of you have parents who went to school here as undergrads? Okay. Ask them if they ever went to the Pretzel Bell. And I’ll bet you anything that they did.
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 en masse there, and chug a beer. uh… it was uh… 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 Champion House still downtown? It’s Asian. 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 gonna 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 gonna 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 principle
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’s 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. Again, I’m gonna save myself and you the
time of reading through it. But I urge you to do so on your own. Let me give you a much more concise
definition. 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 listed up here, and I hope I haven’t missed somebody, 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, for a reason I will give you later. Think about the difference between what a dentist does and what
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 being
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? Gotta be some of you. So how many of you had more than five cavities
but won’t admit it? Alright, you look around, you didn’t see many
hands up there did you? 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 gonna 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 health services. Public health should be at the top over viewing 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 a
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 kinda 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, I’m gonna have to have somebody
rewrite some of my material here obviously. But that actually indicates, we’re gonna
look some more at some of these figures, medicine clearly dominates our public health horizon, if you will. Why does it matter? Well, 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? Now, remember the other day we talked about the fact that almost half of all deaths
in the United States are premature preventable deaths? That’s a lot. 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 five 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. Public health? Now again, you can’t read it. It’s that font problem. 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? Well, first of all, 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. Alright, 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 health
care is to be saved when they’re in dire trouble.” They’ve have 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. Again, you all don’t think of water fluoridation as a
big deal, but you all don’t have five to ten
cavities in your mouth. Now let’s try one more little experiment here. Let me see the hands of everybody in the
room whose had smallpox. I hope we wouldn’t see anybody ’cause
that disease has been wiped off the face of the earth since before you were born. How about polio? How many hands? No? Okay. I was lucky I didn’t have polio.
Although, from my first five or six years I was exposed to it, and I could have had it because we didn’t have the vaccine at
that point. How many people have had mumps? Gee, I’m the only one. How about measles? Anybody have mumps or measles? How about chicken pox? Ooh, I finally found one! Yeah! Guess what? If you’re teaching this course 30 years from now and your kids are in the audience and you ask
the same question, there won’t be a hand that’s gonna go up. Not one. Because we now have a vaccine for
chicken pox. So, think about what this means. These people who are having car
crashes and all that, they are identifiable human beings. We feel
terrible for them. Those of you who would have had five to
ten cavities, or like me you would have had measles and mumps, you don’t know who you are. You don’t know which ones of you would have
had that, and which ones of you would not have had that. What we’re talking about with a lot of public
health is what we call statistical lives. They’re statistical in the sense that we can make some pretty good projections
as to how many people are going to benefit from this, but those people are never going to know what themselves. They won’t have any idea about it personally. It’s just kind of out there. And again, my
guess is that very few of you have ever said, “Thank you public health for helping me
not to have mumps,” or, “Thank you public health because my
teeth look nice and shiny and I don’t have stuff stuck in them by a dentist over
years and years of of care.” If you haven’t said that, you don’t think about it. Why? Because a lot of public health success
is invisible. 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. Alright. So, think about this. You’ve got a health
promotion program. You’ve got an exercise program. We’re trying to get all the
university faculty and staff to exercise. They have a big program at the
university now. 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. Now think about the 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 you 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? Well, come on. 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.