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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.
In this country, we have endless chatter about health care. It costs too much. It doesn’t do the job. It’s the “best in the world.” It’s dangerous. And again, it costs too much. We discuss health care as though it were an end in itself. It isn’t. It is only a means to an end, in some ways the least important means to achieve a healthy population. We should be discussing health, not health care – and more than discussing it, we ought to be redirecting our resources to what will achieve health. Health care is largely a mop-up operation.
We spend 95 percent of our health budgets on health care. What should we be doing instead? First, we can look at what has worked in the past. From the mid-19th to the mid- 20th century, life expectancy in this country (and most of the developed world) rose from about 45 years to close to 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 also 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 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 the 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 perhaps the most important reason for health improvements was direct government action. Sanitation systems were built to prevent waterborne diseases. Housing codes (e.g., setting minimal standards for ventilation) were put in place. Occupational 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. Health care too was regulated. State licensure became mandatory for most health care professionals. Standards were set for hospitals.
But now we have a situation where the intervention (improved health care) that produced little (probably less than 20 percent, some say 10 percent) of the improvement in life expectancy is expected to carry the weight of improving it further. It’s not working – but we can change it. Learning from the lessons of the past, we can look to solutions that improve life conditions. Simply put – populations whose basic physical and social needs are met are healthier than those whose needs are not met. 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 ninety 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.
There are few regulatory decisions that do not affect population health. Health in all policies requires us to leave our individual administrative smoke stacks and think big. That’s hard – but it’s easier than spending ever more of the public treasury on mop-up. Public administration is public health.
Author: Burden S. Lundgren, MPH, PhD, RN