Colleagues in the University of Wisconsin-Milwaukee Public Health Council met on December 22, 2008 to discuss the President-Elect’s Health Care Plan and, in particular, its third goal-Improve Prevention and Public Health.Attendees generally applauded the goal’s second and third elements-to invest in community-based prevention that will lead to healthier schools, worksites, and communities as well as tackle the health and public health workforce shortage and bolster the public health infrastructure.   The following document grew out of that discussion and subsequent editing by the group.

 

After reading the questions meant to guide the discussion, the group thought that questions 6 and 7 and the examples of recommended preventive screenings did not represent either the scope or the focus of prevention and public health that lie at the heart of a healthy society.Instead, they seemed to be linked back to individual health care.So, we begin with a brief discussion to clarify our understanding of the underlined terms and their relationship to one another.  

 

IntroductionThe foundation of societal health resides in disease prevention not disease treatment. Thus, most chronic diseases have major environmental and behavioral determinants and, increasingly, mental health is understood to be a function of these general parameters as well.Disease prevention is founded in public health—the laws, policy, programs, community based collaborations, and infrastructure that foster the health of the total population and particular segments within (e.g., children, workers, elders) that are differentially affected by environmental and social determinants of health.All of these facets of public health need to be based on sound science—the product of public health (not biomedical) research.  They are applied and used by knowledgeable public health professionals who support health and disease prevention in community settings where people live their lives.As examples of such determinants, safe drinking water, clean outdoor and indoor air, uncontaminated and nutritious food immediately come to mind, as do laws governing tobacco and alcohol use.However, public health, properly understood, also includes “green” infrastructure (e.g. mass transit) and industries that minimize pollution. Most importantly, the public health infrastructure is led by not–for-profit governmental entities that form collaborative relationships with other entities including business, healthcare, and non-governmental agencies to serve _____ communities in highly cost-effective ways.Because the public health workforce is educated in schools of public health, it is educated broadly in the natural and social sciences, as well as public health in order to apply comprehensive, cooperative approaches that are tailored to particular communities and their needs.

 

RecommendationsThe following represent ourrecommendations for restructuring national health priorities and their funding.

 

Only 4% of health dollars are spent on public health/prevention; yet public health activities provide the foundation of society’s level of health by various measurements such as disease incidence, mortality (e.g., infant mortality), and person years of life lost before age 65.Redressing this distortion by drastically raising public health spending will lower health care costs substantially and, thereby, reduce overall expenditures.  New or additional public health spending should be devoted to the following areas, listed in order from support for science to application in the community:

 

1.Infusion of major research dollars into the National Institutes of Health, Centers for Disease Control, and the Environmental Protection Agency to understand the relationship between disease, environment, and behavior and develop/implement effective strategies to achieve healthy people in healthy communities.In comparison with studies of disease progression and treatment, the comprehension of disease onset is poorly understood.In order to develop public health policies that foster health and disease prevention, research into disease etiology must be given priority by funding agencies.Among other things, such an emphasis might put in place real time networks that measure and report exposures (broadly through air, water, food) and health outcomes so that robust scientific studies can be conducted that elucidate cause-and-effect relationships in disease incidence.

 

2.Support for Schools of Public Health so that they can conduct needed research in (1) and educate large numbers of new public health workers and retrain others already employed.There is a great need for public health professionals.  Funding would include support to upgrade research and teaching infrastructure and provision of research training grants and other scholarships to aid students, including professionals in the field who need skill development opportunities.

          

3.Support for public health systems of Milwaukee, other major Cities, and rural areas.Communities with major health disparities such as Milwaukee are plagued by adverse, intertwined social and health outcomes such as:

·        elevated prevalence of low birth weight infants who are at increased risk for later poor educational and health outcomes

·        high infant mortality rate (worse than most developed nations and some developing nations);

·        prevalence of teen pregnancy—and resulting poverty and adverse health and social effects to mothers and their children ;

·        high levels of unemployment linked to stress, unhealthy behaviors, and chronic diseases etc.

Components of public health systems such as the Milwaukee Health Department need major increases in resources to address problems such as those listed above as well as, for example, to remediate old houses so that they are lead-free and their indoor air is free of mold and insect dander, etc.  Another component, Milwaukee Metropolitan Sewerage District/Milwaukee Waterworks and their counterparts throughout the nation need infrastructure support to replace seriously aging sewer and water delivery pipe systems that leak like sieves and can mingle drinking water and sewage.

 

4.Support for outreach and education mechanisms that effectively transfer reliable health information from original sources to the public.Some years ago, it was said by the head of the National Cancer Institute that teen-smoking would continue to be a major problem until the communication skills of public health organizations matched those of tobacco companies.Thus, it is critical to link increasing public health knowledge with efforts to develop successful ways to communicate health information and messages to the public.

 

5.Support for policies and other organizations that contribute to the public’s health.  The Introduction alluded to the pervasive connections that health has to other facets of society and the economy.For example, a major health determinant is diet.There is a strong link between agriculture and the food industry.  Agricultural/food industry policy needs to be congruent with health policy.The childhood and adult obesity epidemic testifies to the lack of coordinated policy between these areas that results in all segments of society, particularly the poor, eating diets high in junk food.Another example is the prolific application of antibiotics to suppress disease in animals, particularly in agri-business, a major reason for microorganismal resistance to many antibiotics used to treat human disease.  The Government should coordinate its policies so that agriculture/food industry does not undermine the public’s health.It should also support organizations that foster the growth of diverse, high nutrient, quality foods that should be available to the economically disadvantaged as well as the middle class.Such an organization in Milwaukee is Growing Power, which focused on raising nutritious foods so they are available to inner city residents.

 

We strongly support linking the forthcoming health plan to metrics of success.Indicesfor bothdisease prevention and disease cure should be included.It seems to us that lowering disease incidence and premature mortality should be the goals of prevention and really the overall primary goal of the health plan.Lowering incidence would, in turn, lower all the indices of disease, itself, ultimately raise life expectancy, and in the process lead to a healthier society that spends less on health care.

 

Finally, we were asked to provide poignant narratives that support the need for health care reform.The need for health care reform lies in public health’s poignant stories as told by the dismal, community health statistics like those summarized in (3) above.These sad numbers reveal that whole segments of America are not healthy.Each segment is comprised of many individuals who suffer inordinately, often because public health policies and practices at the community level are lacking.The underlying poignant realization is this:a health reform plan focused only on changing the medical care system and its focus on disease treatment will not reduce disease incidence and the attendant pain and suffering.Nor will it improve the fundamentals of our societal health status.  Only a determined public health approach promises a healthier nation.