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A note for our readers: the views reflected by the authors do not reflect the views of ASPA.
By Burden Lundgren
We have all just been through, and are still enduring, the great Obamacare wars. But the wars are doing us a disservice. They are further solidifying our belief that health care produces health. In spite of the fact that 45,000 American lives are lost yearly because of lack of access to health care, that care does not in fact, drive population health.
Indeed, I could point out the 100,000 (one recent study says 400,000) deaths caused by errors in American hospitals yearly as a counterargument to the desirability of access. Health care, the topic of endless political argument (logical or not), endless public and private financing (worthwhile or not), endless technological innovations (useful or not) consumes 95 percent of U.S. health spending and makes a relatively puny contribution to our health. We need to be concentrating on the factors that actually create health. Health care is the mop-up operation. What should we be doing instead? Fortunately, there are lessons from the past.
Starting in the latter part of the 19th century, in this country (and most of the developed world), life expectancy rose from about 45 years to approximately 80 years. How did this impressive phenomenon come about? Thomas McKeown, a British researcher, traced the mortality rates in England and Wales during this period. What he found was a precipitous decline beginning early in this period, a decline seen here also. Scientific medicine made significant gains during this time, but improvements in health care were far from the major contributor to the increase in life expectancy. Indeed, widely successful therapeutic interventions, e.g., antibiotics, were not even available until the mid-20th century. What caused the steep decline in mortality?
Several factors, separate, but linked, are believed to be responsible. One important contributor was improving standards of living. Although the early health effects of the Industrial Revolution were devastating, the late effects put money into people’s pockets who had never had it before. The ability to buy better food and housing brought about concomitant health improvements. Technology contributed too. For instance, trains traveling from the South meant that those in northern areas could have access to fresh fruits and vegetables year-round. When basic living conditions improve, so does health.
But the other important reason for health improvements was direct government action, which was backed by the burgeoning science of public health. Sanitation systems were built to prevent waterborne diseases. Housing codes (e.g., setting minimal standards for ventilation) were put in place. Occupational and traffic safety laws were written, and states began setting minimum wage provisions. The Food and Drug Administration was founded to ensure the safety of food and pharmaceuticals. Standards were set for clean air and water.
And the last two paragraphs bring us to a consideration of what constitutes or should constitute, public health. William Henry Welch, founding Dean of the Johns Hopkins School of Hygiene and Public Health, stated it best. “There are no social, no industrial, no economic problems which are not related to problems of health.”
There are also no social, no industrial and no economic problems, which do not come under the jurisdiction of a public agency. Crime, transportation, banking, commerce, education, urban planning, fire protection, everything from the disposal of nuclear waste to the kiosks in my local mall are subject to regulations. Public administration touches every facet of our lives and public administration decisions are public health decisions. That means looking beyond our current restricted definition of public health functions (e.g., restaurant inspections, epidemic surveillance) and thinking about the health effects of every public policy, an approach known as “health in all policies.”
Let us look at just two examples. The U.S. spends 90 cents for social services for every dollar spent on health care. Other industrialized countries spend twice as much on social services as on health care. Countries like us with high health care spending relative to social services spending have lower life expectancies. Providing nutritious food and safe housing to vulnerable populations is public health.
The World Health Organization has identified the best predictive indicator for the health of a child as the educational level of that child’s mother. Universally, health status tracks education. Better-educated populations are healthier populations. Building schools is building health. Building hospitals to serve poorly educated populations is just more money spent on mopping up. Education is public health.
Health in all policies requires us to leave our individual administrative smoke stacks and think big. What are the population health consequences of regulations concerning urban development, road-building, advertising, commerce, immigration, interstate and international trade and maybe even those kiosks in the mall? That kind of assessment is hard. It costs money too – but it’s easier than spending ever more of the public treasury on mop-up. Public administration is public health.