Put Public Health Back on Top
The burden of care that overwhelms our medical system has largely resulted from providing expensive care for those suffering from illnesses that should have been prevented.
The top ten causes of death in Benton County from 2003 thru 2005 were cancer, heart disease, stroke, chronic respiratory disease, unintentional injuries, diabetes, Alzheimer’s disease, influenza & pneumonia, hypertension and suicide.
Although medical care may slow the progression of chronic conditions, the likelihood of developing such maladies is practically unrelated to clinical medical access. In point of fact, the health and life expectancy of people living in Benton County, like that of most Americans is overwhelmingly a result of whether or not an individual smokes, what and how much they eat, and their level of physical activity.
To assure a healthy population what we really need is less illness, not simply more access to treatment.
What’s missing from most conversations about “health reform” is attention to primary population-based prevention, which can reduce the overall risks of smoking, substance abuse, poor nutrition, obesity and injury by implementing community-wide, statewide and nationwide preventive health measures.
According to a 2004 article in the Journal of the American Medical Association, 18.1% of all deaths in the US during 2000 were related to tobacco use. The authors noted that deaths linked to poor diet and physical inactivity represented an additional 16.6% and wrote that those risks “may soon overtake tobacco as the leading cause of death.” Their commentary remarked that: “about half of all deaths that occurred in the United States in 2000 could be attributed to a limited number of largely preventable behaviors.”
Individual education about health risks such as smoking has proven expensive and relatively ineffective. Cessation classes and medical treatments unquestionably help individual smokers, but only at a high cost and with repeated interventions. What have really made a difference in overall tobacco consumption are higher taxes and no-smoking laws. Those are the tools that have reduced the percentage of smokers in Oregon from near 50% to below 20%.
Public health’s challenge is to convince lawmakers that like tobacco advertising and taxation, a wide range of policies and practices have direct impacts on health. And that the health risks associated with them can be mitigated in a similar manner. We can prevent young people from beginning to smoke through use of taxation and laws. We can improve diet choices through menu labeling and limitations on advertising. We can increase physical activity through urban design and planning decisions. Unfortunately few of these “evidence-based practices” have received the funding they require to move beyond localized demonstration projects and make significant impacts on the health of large populations.
We should work with policy makers and decision leaders to help them recognize that all policy is health policy. We now recognize that minimum wage, street lighting, gasoline taxes, urban renewal, and most, if not all social policies have links to behaviors and disparities that directly impact the overall health of populations .
Public health prevention experts should work with planners and developers to affect decisions favoring walkable communities with neighborhood shops and avoiding centers clustered in commercial zones that require cars. Median strips, safety islands, speed bumps, traffic circles and other traffic gentling devices encourage walking and bicycling by slowing automobiles and making crosswalks safer. Fewer automobiles mean less exposure to air pollutants that cause or worsen pulmonary diseases and cancer.
From an economic perspective, population-based prevention presents an opportunity for significant return on investment. There is a growing body of data demonstrating a direct link between what a community spends on public health and downstream savings in medical costs and improved health indicators. A 2008 study by Trust For America’s Health concluded that a $10 per person per year investment in evidence-based physical activity, nutrition and anti-tobacco programs could save the US over $16 billion per year in Medicare, Medicaid and private insurance costs. The potential annual savings in Oregon were estimated to be $193 million. That represents a return on investment of 5.4 to 1, a great return even before the economic bubble burst.
Investment in public health prevention represents a logical, rapid, and less expensive way to lower mortality than additional spending on the high technology, record keeping and infrastructure. Support for rebuilding and sustaining America’s public health infrastructure is long overdue and ought to be a central element of current health system reform efforts.
Charlie Fautin RN, MPH, is deputy director of the Benton County Health Department in Oregon. He administers the public health division which provides health promotion/ disease prevention, communicable disease investigation, maternal-child health, WIC nutrition, immunization, public health preparedness and school nursing services.