From the Dean: Getting Respect for Public Health
Recently a prominent University of Michigan graduate told me that when he was an undergraduate in the late 1960s, he walked by the School of Public Health hundreds of times to and from his dormitory room in Markley. His conception of the school back then was that “that was where they taught people to do restaurant inspections.” If we polled today’s Markley residents, I suspect few would have a more informed conception of what we do.
Public health has contributed immeasurably to the welfare of the public. Well over half of the 30-year increase in U.S. life expectancy during the past century owes to public health. Yet while America devotes more than $1.5 trillion annually to treating disease, the nation tosses financial crumbs to the field that conquered polio and cut smoking in half. To pluralize Rodney Dangerfield, “We don’t get no respect.”
Why is this, and what can we do about it?
To address the question of why, we need to begin at home. Many of us within the field do not fully comprehend the meaning of “public health.” Ours is a collection of multiple, radically different functions, performed by professionals from disciplines as diverse as toxicology and sociology. If we do not always speak each other’s languages, how can we convey the unity of our broad, collective purpose to a public that speaks none of them? In truth, there is no simple definition of public health, or at least none that can be effectively conveyed to the public and to political influentials.
A 1994 SPH committee produced what I believe to be a comprehensible and useful description of the field. Space limitations preclude reproducing it here. In itself, that speaks volumes about the problem we face: in a sound-bite world, describing public health does not lend itself to a compact sentence.
So problem number one is that Americans do not understand public health and its importance. Problem number two is that public health is not “sexy.” Parts of public health do grab headlines, however. Hurricane Katrina, and before it September 11th, made the public appreciate the need for emergency response and the role of public health therein. Similarly, fears about avian flu have prompted a renewed interest in “public health.” Perhaps, like Great Britain, we need a Health Protection Agency. To a public fearful of monstrous forces outside its control, health protection sounds a whole lot more important—and therefore worthy of support—than “public health.”
Problem number three: Americans do not always want what public health has to offer. People want government to ensure that their beef is free of mad cow disease, but they don’t want “public health nannies” admonishing them to eat fewer burgers. Meanwhile, mad cow disease remains a minuscule risk, while obesity kills tens or hundreds of thousands of Americans every year. The public’s sense of risk is often wildly out of sync with reality.
Problem number four is a constellation of political problems: health promotion has no affluent, well-organized constituency, while dozens of rich and powerful industries vigorously defend “disease promotion” (tobacco and alcohol companies, purveyors of fast food, etc.). Further, politicians and their families, like “real people,” suffer from cancer, heart disease, and Alzheimer’s. None of them suffers from “public health.” Support for medical care inevitably trumps public health. Finally, politicians are rarely eager to support programs that produce real, tangible costs during their terms, while the programs’ benefits accrue—as do those of many public health interventions—long after they’re out of office. And public health’s great virtue—that its benefits are often invisible, the result of avoiding disease—is a liability in the political context: nothing to “show” for it.
What can we do about this? Clearly, we must find salient and compelling ways to market our field. We may need to reposition the field—health protection, anyone?—while not ourselves losing sight of the scope and depth of public health. We may need to exploit public concern about components of public health—terrorism and natural disaster readiness, for example—without allowing government to divert much-needed funds from the plethora of equally or more important public health endeavors (maternal and child health, health behavior, environmental health, mental health, etc.). We need to continue to develop our science and then effectively communicate its importance to those who matter, the latter constituting our biggest failure.
Selling a broad concept is undoubtedly challenging, but it isn’t impossible. The truth® anti-smoking media campaign has significantly reduced youth smoking. In 2001, young people voted truth®—a campaign selling an idea—the third best advertising campaign in the country. truth® demonstrates that, given the resources, hard concepts can be sold to the American public.
Coming up with truth®-like funding (a lot) is admittedly a daunting challenge, but it’s not inconceivable. A single penny per pack of an increased federal cigarette excise tax dedicated to a public health education campaign would generate close to $200 million per year. We could have fun spending that kind of money promoting public health. And if we could add one penny per bottle of beer. . . .
I don’t have the answers. But I do know the costs of failure to find answers. And I believe that creative minds working together can find a way to make progress. Even modest progress would have enormous value. In a country that spends nearly $2 trillion on medical care every year, we allocate a mere one percent of that amount—$20 billion—to population-based governmental public health services. Think what we could accomplish if some wise, powerful, and beneficent authority would transfer a mere one percent of health care expenditures to public health, doubling resources for the field! (Yes, I guess I’m asking for the impossible: Intelligent Design in national health policy.)
I’m eager to tackle this problem. I invite you to join me. Please share your thoughts, even your dreams, as together we work to figure out how to get public health the respect it deserves.