John Steen: We Need an education in public health

Editor’s note: This commentary is by John Steen, of South Burlington, who is now retired after being a scholar and teacher of philosophy, followed by a 20-year career in health care planning, health regulation and public health, ending as a professor of health policy and a private consultant. He is immediate past president of the American Health Planning Association. 

Since 1900, the average life expectancy for Americans has increased by about 30 years. Over 25 of the 30 years can be accredited to public health initiatives, while medical advances account for less than four years. Yet only about 3% of health spending in the United States is devoted to public health activities. Unlike medicine, which is about saving individual patients, public health is about protecting the wellbeing of entire communities.

Public health’s top 10 achievements in the 20th century, according to the CDC, include:

• Vaccinations                                        
• Safer and healthier foods
• Motor-vehicle safety                           
• Healthier mothers and babies
• Safer workplaces                                
• Family planning                                   
• Control of infectious diseases             
• Fluoridation of drinking water
• Decline in deaths from coronary heart disease and stroke
• Recognition of tobacco use as a health hazard 

And all of these factors assume that an infant has survived its first year of life, but the U.S. rate for infant mortality is among the worst of all large industrialized nations. That is primarily a reflection of barriers to prenatal care and maternal health, a consequence of our lack of universal health care, and of racial and income health care disparities. Among U.S. Black people, there are nine deaths per 1,000 live births, closer to rates in developing nations than to those in the industrialized world.

The mistrust of government clouds public health in its role of primary prevention, but that view is only a generation old. Before the advent of good sanitation and vaccines, plagues were feared far more than cancer is today, and childhood was something more to be survived than enjoyed. In 1796, when Edward Jenner first successfully immunized a child against smallpox, it was the world’s deadliest infectious disease. For the next century and a half, medicine and public health systematically eradicated all those deadly childhood diseases save one, polio. The Salk vaccine (1955) was both the triumph of this process and its last effective publicity. A generation later, we had already become used to the luxury of our ignorance, that luxury guaranteed by public health.

If the Covid-19 pandemic, and the desire for an effective vaccine against it, reminds us how to be grateful for primary prevention, that will at least be some recompense for the misery we have largely inflicted upon ourselves. And we might learn the greater lesson here, the cost to everyone of ignorance. What would it take to get us to see that our support for the highest standards for education are far more fundamental … to everything? A great deal of recent research shows that the greatest benefit for health is achieved by providing everyone with a college education, empowering people to make their own best decisions about their lives. Formidable efforts atsocial change would be necessary to eliminate social disparities, butthe changes would save more lives than would society’scurrent heavy investment in medical advances. Spending largesums of money on such advances at the expense of social changeis jeopardizing everyone’s public health.

It is my hope that we will emerge from the pandemic having learned very important lessons, and chief among them, the necessity of investing in prevention. If we are to be able to prevent the next pandemic, or marshal the resources to defeat it, we must prepare for that now. The first step in that should be to create a public health-literate population, one that knows and values what an epidemiologist does as much as what a physician does. Students now returning to school can be expected to desire, if not demand, a fundamental education in public health. And that must come with an education in ethics that promotes a communitarian approach to everyone’s wellbeing. 

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