What the Experts Want Us to Know About Public Health

The following originally appeared on The Upshot (copyright 2018, The New York Times Company) and is coauthored by Austin Frakt and Aaron Carroll.

The United States receives tremendous benefits from public health spending — with far more value per dollar than with most other types of health care spending.

We reviewed those benefits in a recent article, suggesting that more such spending should be considered. Then Upshot readers weighed in with their choices of what public health campaigns they’d like to see. Those included more help for mothers and babies (the Nurse-Family Partnership), and a greater focus on diabetes, nutrition, gun deaths (including suicide), loneliness and the harms of sharing hypodermic needles.

We asked some experts — officials who run public health departments, academics and leaders of funding organizations — what they think we should be doing in public health, and a few themes emerged.

Overrating doctors and hospitals

Although we spend huge sums on health care, it’s not always on the right things.

“The key to better health isn’t always to build more hospitals and train more specialists,” said Vivek Murthy, the former surgeon general. “In fact, it usually is not.”

That’s where public health comes in. Consider antismoking commercials late in the last century, for example. Or as Richard Besser, the president and chief executive of the Robert Wood Johnson Foundation, put it, public health has kept us safe “from infectious diseases through immunizations, information, mosquito control and food safety.”

“It ensures that our water is safe to drink and our pools and lakes are safe for swimming,” he added. “It provides screening for cancer and works to prevent injuries.”

Karen DeSalvo, a former New Orleans health commissioner, said: “Of the $1 trillion in federal spending, only 1 percent is on public health — an infrastructure that saves lives” and that can “reduce suffering and improve community well-being and vitality.”

We could do a better job at providing access to the things we know that already work. Ursula Bauer, who manages the nation’s chronic disease prevention portfolio at the Centers for Disease Control and Prevention, said, “Not all adults have access to appropriate cancer screenings, and we don’t do a good job of managing high blood pressure.” She added: “It’s very difficult for most Americans to integrate routine physical activity into our lives. We don’t have destinations within walking distance or sidewalks to get there. We can’t find the stairs to use in most buildings.”

Thomas Farley, the health commissioner for Philadelphia, said, “There’s a lot of money to be made selling products that, over the long term, kill people.” These include tobacco, alcohol, unhealthy food, addictive drugs (legal and illegal) and guns.

Dr. Bauer said policies could do better at using carrots and sticks, including taxes and subsidies, in these cases: “There are more incentives and opportunities for people to consume unhealthy foods and beverages than there are for them to make healthy food and beverage choices.”

‘Deep divides of race and income’

Another theme that emerged was that we could do a lot more in addressing disparities across race and class.

“Public health needs to take a leadership role in confronting and influencing the social, political and economic factors that determine population health,” said Sandro Galea, the Robert A. Knox professor and dean of Boston University’s School of Public Health.

“The patterns of disease and death track along this nation’s deep divides of race and income,” said Mary Travis Bassett, the former New York City health commissioner, who recently took a position at Harvard. She said America needed to divest in prisons and “put that funding toward new systems of justice, better housing or universal child care.”

The opioid crisis is one of America’s most urgent problems. Rhode Island has shown promise in being able to reduce overdose deaths by offering prisoners medications to treat addiction while they’re incarcerated and after they’re released.

Other initiatives can be tailored to meet the needs of various populations. Older and low-income residents of Boston have benefited from the receipt of specially formulated meals — such as those with soft food or with low cholesterol. According to a study in Health Affairs, those receiving such meals had fewer hospital admissions than those who didn’t.

For others, housing assistance may be the most direct way to improve health. That’s why the Boston Medical Center — the city’s principal hospital for low-income and underinsured residents — is investing in affordable housing and referring patients to community housing programs.

Such efforts aren’t unique to Boston. A project in California is providing meals to Medicaid-enrolled cancer patients. In Ohio, a program backed by Nationwide Children’s Hospital, which serves low-income children, is helping finance its affordable housing initiatives, including rehabilitating run-down housing units.

Public health needs better public relations

We could also do a better job addressing things we know that kill. Gun safety and education could decrease accidents and deaths, Monica Bharel, commissioner of the Massachusetts Department of Public Health, told us.

She also pointed out likely problem areas in the future, including e-cigarettes and vaping; the consequences of marijuana legalization; and social isolation.

Dr. Murthy said a shift toward school- and community-based programs to strengthen emotional health would be worthwhile. “Such programs have been shown to reduce violence, smoking, alcohol and drug addiction and mental illness,” he said.

The 2016 Surgeon General’s Report by Dr. Murthy lists several evidence-based school and community programs to address these issues. They include, for example, The Fast Track Program, which identifies children with high rates of aggression and aims to improve their social and educational skills.

Dr. Murthy also argued that “the way the Congressional Budget Office scores health legislation does not recognize much of the cost savings from prevention, which creates a further disincentive for legislators to pursue prevention-oriented legislation.”

Perhaps the biggest change needed is for public health to do a better job at trumpeting its success. Too often, it seems to be the unsung hero. “It can be difficult to maintain support for public health systems when they are so often invisible,” Dr. Besser said.

Few public health initiatives will make anyone wealthy. In the American political environment, that makes it difficult to organize a winning coalition for any specific policy.

But that outlook misses a crucial fact about public health: Many campaigns have achieved a rare double victory: They have lengthened and improved lives, and they have also saved more money than they’ve cost.

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