An Ounce of Prevention is Worth a Pound of Cure: Investing in Prevention Saves Lives

The ongoing debate about health, health care and our current health care system rages on. It was a major flashpoint during the elections and it continues to be a source of controversy and confusion. There are no simple answers, but there are some basic facts that we should all understand.

The ongoing debate about health, health care and our current health care system rages on. It was a major flashpoint during the elections and it continues to be a source of controversy and confusion. There are no simple answers, but there are some basic facts that we should all understand:

We spend more on our health care then any other industrialized nation and we are sicker than most.

Nearly half of all Americans have one or more chronic diseases.

For the first time in decades, our nation is seeing a decline in life expectancy.

We are clearly doing something wrong! For starters, we continue to under-invest in prevention while our spending on treatment continues to skyrocket.

Earlier this month public health professionals celebrated National Public Health Week, April 3–9 to shine a spotlight on public health through organizing educational events and disseminating messages about the importance of public health. Congress even got in on the action by introducing resolutions in both houses to urge greater support for public health. The resolutions recognize the tremendous need for sustained investment in prevention and that the goal of “making America the healthiest nation in one generation” is achievable.

Resolutions aside, it’s ironic that the American Health Care Act, which failed to pass last month, proposed eliminating the Prevention and Public Health Fund, the nation’s first mandatory funding stream dedicated to prevention and improving our public health system. Thousands and thousands of Americans have benefitted from this fund since it was established in 2010. However, federal funding for public health has been on a steady decline during the last decade and the President’s Budget Blueprint issued in March proposes additional cuts.

The Prevention and Public Health Fund, which was created as part of the Affordable Care Act or “Obamacare,” was initially allotted $15 billion. Most of the money is routed through the Centers for Disease Control and Prevention (CDC) and goes toward activities and programs designed to keep people from becoming sick with preventable diseases and protecting children and adults through immunization. “By law, the Prevention Fund must be used ‘to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public health care costs’.”

If this sounds like a rational investment strategy and common sense approach that’s because it is. We have the information and data to prove it. Ensuring everyone has opportunities to achieve good health means we must move beyond our current medical model and invest in programs that make it easier for people to live healthy lives starting at the community level where we live, work, and raise our families. The Prevention and Public Health Fund has done just that by enabling a series of grants targeted at the community level to address the leading preventable causes of death and disability using evidence- and practice-based strategies.

In New York City, the grants enabled under the Fund, such as Communities Putting Prevention to WorkCommunity Transformation Grants, and the current grant called Partnership to Improve Community Health have all contributed to major health improvements. One great example is in the decline in adult smoking rates which resulted from a sustained, multi-pronged approach including legislation, like smoking bans in public spaces and higher cigarette taxes, access to treatment, and media campaigns, all of which made it harder to smoke and easier to quit. Smoking rates in NYC are down from a high of 21.6 percent of adult residents who smoked to the current 14.3.

We have been making similar strides with our efforts to combat obesity and increase health and wellness activities for communities throughout NYC. Architects, community organizations, and design professionals are creating healthier urban spaces and programs that promote stair use, active recreation, and healthy eating. Greater access to healthier food options through SNAP and Healthy Bucks programs have contributed to a 12 percent drop in sugary drink consumption and a record $1 million dollars spent on fruit and vegetables at greenmarkets throughout NYC.

It may be a slow climb, but public health works. If the cuts continue, many of the positive effects may be lost, and efforts to prevent chronic and infectious diseases will lose strength. Though the ongoing narrative about our nation’s health and our healthcare system is extremely complex, one solution is relatively simple. Benjamin Franklin understood this when he said: “an ounce of prevention is worth a pound of cure.” As the healthcare debate rages on, we could use a little of Ben’s wisdom. Prevention works.

Back to the Basics: What is a Social Determinant of Health Anyway?

As a fourth grade social studies student, I was taught the difference between a “need” and a “want,” a simple economic concept. Years later, when my children were in elementary school and taught the same concept in their social studies class, we had many rousing conversations around the dinner table debating the difference. Put simply, a need is defined as something people have to have to survive. A want, on the other hand, is something people would like to have but they don’t need it to survive.

As a fourth grade social studies student, I was taught the difference between a “need” and a “want,” a simple economic concept. Years later, when my children were in elementary school and taught the same concept in their social studies class, we had many rousing conversations around the dinner table debating the difference. Put simply, a need is defined as something people have to have to survive. A want, on the other hand, is something people would like to have but they don’t need it to survive.

We all know that the most essential needs are food, water, and shelter. In civil society, basic human needs also include equitable access to education, health care, jobs, transportation, and a safe and clean environment in which to live. Without food and water we know we can’t survive. Without the rest of these things, though we may survive, we probably won’t thrive. Although my fourth grade social studies teacher might not agree, we now know they are basic needs, and we call them the social determinants of health.

When I was in my twenties, as a Peace Corps volunteer living in rural Honduras, I experienced first-hand how profoundly social and environmental influences impact the health of a population. On a number of occasions, I had the opportunity to serve as translator for US doctors who came and volunteered their time as part of a medical brigade to bring health care to rural areas of the country without it. On the mornings when the US doctors held their clinics, people from miles and miles away would arrive before dawn, hundreds and hundreds seeking a cure for what ailed them and a chance to see the American doctors.

The doctors would work feverishly all day examining patients, doling out advice and aspirin and then send them back on their way. In some cases the doctors were able to diagnose an acutely ill patient — a child with a cleft palette or a person with cataracts — and refer that patient for treatment in the big city. Most of the time, though, the patient was just run down and sick from hard physical labor, lack of nutritious food, and exposure to environmental hazards like cooking fires and unclean water. The antidote boiled down to some pretty basic things like access to clean water, healthy food, and a safe place to live but most of the people who came flooding out of the mountains to see the US doctors believed that medical care was the answer to everything. In 2017 in the United States of America most of us believe this too!

So let’s go back to the “needs” versus “wants” and the social determinants of health. In Public Health we know the impact of good housing and public infrastructure, access to healthy food and good jobs on the health of a population. For example, investments in housing and sanitation during the 19th century helped defeat the communicable disease epidemics of the time. Today, too, there is ample evidence supporting the direct relationship between housing interventions and health outcomes within low-income or otherwise vulnerable populations.

A recent review of seven distinct housing interventions shows that providing housing support for low-income, high-need individuals results in net savings due to reduced health care costs. There is further evidence that the integration of housing with some health care services can further improve health. One of these interventions, the 10th Decile Project in Los Angeles saw a 72% reduction in total health care costs based on two years of observation, from $58,962 per person when homeless to $16,474 per person when housed. Which health effects are related to housing? Many. Studies conducted by Children’s Health Watch found that frequent moving or low-quality housing can increase a child’s risk for obesity, type 2 diabetes, asthma, stunted brain development, and mental health problems such as depression and post-traumatic stress syndrome.

Access to stable and safe housing is certainly a basic human need and one of the social determinants of health. Good medical care is essential but not the primary cause of good health. Good health is nurtured through a healthy environment including a stable place to call home. It is time to re-evaluate our investments in heath and get back to the basics.

Our New Year’s Resolutions and Pubic Health: We Are Not Alone!

Google “top ten New Year’s resolutions for 2017” and many of the search results are related to health:   eat healthier, exercise more, lose weight, quit smoking, and drink less alcohol. Like millions of others, I always stop to ponder life and the things I would like to change as we enter a new year. I usually draft a list of resolutions and begin the year in enthusiastic pursuit, though my odds of being successful are fairly low.

Google “top ten New Year’s resolutions for 2017” and many of the search results are related to health:   eat healthier, exercise more, lose weight, quit smoking, and drink less alcohol. Like millions of others, I always stop to ponder life and the things I would like to change as we enter a new year. I usually draft a list of resolutions and begin the year in enthusiastic pursuit, though my odds of being successful are fairly low.

Often, by February, resolutions are broken and we settle back into our old patterns. The good news is that we are not alone in our quest for good health. Individual behavior is really only about 30% responsible for what makes us healthy or not. Though personal behavior and responsibility are important we also need a strong public health system for the promotion of healthy lifestyles and to respond to everyday health threats as well as unexpected emergencies.

If you look back over the last 100 years, major advances in human health can be attributed to public health innovations. Take vaccines for example. Without a doubt one of the most important public health achievements in human history, vaccines have helped to eradicate small pox globally, eliminate polio in the U.S., and significantly reduce illness and death from other diseases such as measles, rubella, and pertussis. Vaccines have saved millions and millions of lives.

Another area of major public health advancement during the last century is related to motor-vehicle safety. In 1966, the Federal Government passed two important acts that have had huge impact in terms of quality of life and lives saved: the Highway Safety Act and the National Traffic and Motor Vehicle Safety Act. These two acts set and regulate standards for cars and for highways.

Take seat belts for example. The first mandatory seat belt use law was enacted in New York in 1984. Today, there are adult seat belt use laws in 49 States, the District of Columbia and Puerto Rico  and among passenger vehicle occupants 5 and older, seat belts saved an estimated 12,802 lives in 2014 (NHTSA, 2016).   Over time, most people have come to recognize the impact of the car seat belt use laws on lives saved and injury reduced. The National Highway Traffic Safety Administration (NHTSA) estimates that seat belts reduce the risk of fatal injury to front-seat passengers by 45% (Kahane, 2015) and the risk of moderate to critical injury by 50% (NHTSA, 2016).

There are numerous other car safety features that have been introduced and that have had immeasurable impact including shatter-resistant windshields, head rests, and air bags. Road improvements that have certainly reduced traffic accidents and fatalities include better delineation of curves, guard rails, and traffic lights. And speaking of road safety, since the introduction of the bike helmet in 1975, helmet use has been estimated to reduce the odds of head injury by 50%, and the odds of head, face, or neck injury by 33% (Elvik, 2013).

There are so many examples of public health innovation having a positive impact on our health. The refrigerator contributed to a drop in rates of food-borne infections, warning labels on cigarettes helped lead to a significant drop in smoking rates, and window screens protect against insect-borne diseases,. Though smoking is still the leading cause of preventable death in the United States, the 50 year war on tobacco use in this country is a rich example of public health at work and a major public health success. Since 1964, when the first issue of the Surgeon General’s report on Smoking and Health was released, there has been a comprehensive, multi-pronged effort to drive smoking rates down including warning labels, smoke-free spaces, a ban on cigarette advertising, and antismoking media campaigns. Over time, the result has been a drop in adult smoking rates from 42% in 1965 to 18% in 2012 (Surgeon General’s Report, 2014). In New York City, a similar, very aggressive  multi- pronged approach to combat tobacco has brought down adult smoking rates to 14.3%. (DOHMH, 2016)

Public health is everywhere around us. During the last century public health innovation has fueled tremendous advances in human health and impacted populations in so many ways. As we contemplate the New Year and resolve to live healthier, we can rest assured that public health is on our side working to create a world that protects our health and safety and supports our good intentions for a healthy life.

Health Is A Nonpartisan Issue That Requires A Bipartisan Solution

Last week, I listened to President Obama’s address to the nation following one of the most contentious and divisive election seasons in modern history. Whatever your political persuasion, I think most Americans are ready to move on from the election and get down to the business of trying to heal our very divided nation. President Obama rightfully reminded us that we are all on the same team, that first and foremost we are Americans and committed to some pretty basic rights for all people, the right to life, liberty and the pursuit of happiness for starters. As a public health professional, I know that good health, and the pursuit of health equity, is fundamental to all of it.

Last week, I listened to President Obama’s address to the nation following one of the most contentious and divisive election seasons in modern history. Whatever your political persuasion, I think most Americans are ready to move on from the election and get down to the business of trying to heal our very divided nation. President Obama rightfully reminded us that we are all on the same team, that first and foremost we are Americans and committed to some pretty basic rights for all people, the right to life, liberty and the pursuit of happiness for starters. As a public health professional, I know that good health, and the pursuit of health equity, is fundamental to all of it.

Health transcends party politics. Everybody wants to be healthy. Our ability to be productive, achieve our goals and be happy in life depends on it. Being unwell is not something anyone aspires to. As a parent, my hopes for my children include a good education, a successful and stimulating career, a home and a happy union. We raise our kids with these goals in mind and we plan and save to support our children to achieve them. We all hope our kids will grow up healthy, but when we’re planning for our kids’ future, we don’t necessarily make specific plans to avert diabetes or alcoholism or avoid gun violence. Despite spending $3 trillion on health care we are becoming a society of sick people, and instead of planning for health we try and buy it back when we become sick.

In the US we have a two-part health system with a treatment side and a public health side. Recently, we have begun to recognize that the two sides should be working together. This shift in thinking is playing out across the country and was articulated within the Affordable Care Act (ACA) by the inclusion of a number of provisions that support total population health. Provisions that might surprise many Americans.

When most people think of the ACA (better known as “Obamacare”) they think of health insurance and expansion of coverage to more people — a good thing. They also think of rising premiums, which was a major issue during this presidential campaign. Many people are not aware that the ACA includes a vast array of reforms, multiple and complementary initiatives to transform our entire health care system with the aim of better health at lower cost. For example, the Prevention and Public Health Fund was established to provide funding to test new ways of preventing disease and encourage healthy behaviors to keep Americans well and out of the hospital.

Coming out of the election, it is pretty clear that the ACA is in for some changes, although a clear vision for what will replace the current law is yet unknown. Will there be a complete repeal or a rollback of some provisions? What we do know is that it took more than a century to create our current health system – one in which “sick care” is emphasized far more than wellness. The ACA has allowed our country to take some meaningful steps toward promoting prevention and population health. It would be tragic not to keep at it, and it will require ongoing investment from federal, state, and local governments, as well as the philanthropic community and the private sector.

Across the country there are many excellent efforts underway to improve population health. The movement to integrate our two-part health system, improve outcomes and reduce costs is just getting started, and it affects all of us regardless of politics and party affiliation. This movement must continue if we are to create and nurture a healthy society.

Public Health is Everybody’s Business

When most people think about health, they think health care—doctors, clinics, hospitals, and medications. The U.S. has some of the best health care money can buy. Good clinical care is important, but it accounts for only 10 to 20 percent of what makes a person healthy or unhealthy.

When most people think about health, they think health care—doctors, clinics, hospitals, and medications. The U.S. has some of the best health care money can buy. Good clinical care is important, but it accounts for only 10 to 20 percent of what makes a person healthy or unhealthy.

Social circumstances, environmental conditions, genetics, and behavioral choices (and how they intersect) account for the remaining 80 to 90 percent. Looking at this math, it makes absolutely no sense that we are spending the majority of our health-directed resources—some say 97 percent—on health care. That’s close to three trillion dollars. And we still rank 27thin the world in life expectancy and relatively low on many other health and wellness measures—not a great return on investment. Enter public health.

Public health is the science of promoting and protecting the health of people and their communities. Public health is prevention from sickness and injury. Public health creates environments where the healthy choice is the easier choice and nudges people toward healthy behaviors. It’s research for disease control and injury prevention and development of sound policies and regulations to keep us safe and to support well-being. Public health focuses on entire populations and affects everybody. Think this is solely the work of government officials and scientists? Think again. Public health is everybody’s business, and we all have a part to play.

Public Health is Everybody’s Business from FPHNYC on Vimeo.

In our current environment of health care reform, public health is repositioning itself at the national, state, and local levels to focus on the social determinants of health. Social determinants of health are conditions in the environments where we live, work, play, and learn. They affect a whole range of health and quality of life outcomes and risks and include access to education, jobs, and transportation, as well as social norms and attitudes. When we address these social determinants of health, the return on investment is significant.

With the lion’s share of investment in health going to clinical care, the social determinants of health—80 to 90 percent of what matters—goes underfunded. The private sector can and should play a crucial role in readjusting this balance, not only for the good of society, but for its own bottom line. Businesses are finding that corporate wellness programs save money on health care costs. Funding community-based and government-led efforts for wellness will save even more.

The Nurse-Family Partnership is a national nurse home visiting program committed to improving the health, well-being, and self-sufficiency of low-income, first-time mothers and their children. Specially trained nurses coach, educate, and listen to their clients and provide the support they need for healthy pregnancies, to competently care for their children, and to become more economically self-sufficient. Studies have shown an estimated $9.59 return on every dollar invested in this community-based initiative.

Another public health initiative, the Diabetes Prevention Program, helps people who are at risk for type 2 diabetes make lifestyle changes—eating better and exercising more—to reduce their risk of becoming diabetic. This program averages savings in health care costs from $4,250 to $6,300 per participant over 10 years.

This movement to focus on the social determinants of health requires nontraditional collaboration, participation, and investment across sectors. Government agencies and their nongovernmental partners must work together to address the conditions within the communities they serve through efficient and accountable processes. When the private sector invests in public health initiatives, innovation and entrepreneurial spirit animate the work. With more investment in preventive, upstream efforts, we can transform our current system of sick care to a system that nurtures health.

We must reevaluate how we invest in “health.” This new commitment starts with strategies and evidence-based action that will prevent disease and cut health care costs rather than attempting to “buy it back” when we are sick. Public health is an often misunderstood, underappreciated, and most definitely underfunded discipline which holds the key to bring down health care costs and elevate human health—our most precious commodity.