On the Very Idea of Health

Julie Gerberding, Director of the Centers for Disease Control, understands that by reducing discourse over public health policy to concerns about access, we are substantially undermining any hope of improving population health.  Speaking in an interview with USA Today announcing the launch of the CDC's "Healthiest Nation Campaign," she notes:

Health care isn't only what takes place in a doctor's office, a clinic or a hospital.

"We put way too much emphasis on treating disease rather than protecting health in the first place," Gerberding said in an interview.

As a result, the United States doesn't even muster a spot in the top 10 on rankings of nations' health. On one list it's 26th, the CDC says; on another, 47th.

Indeed.  I have noted here my wonderment that so many seem to be genuinely puzzled at how the richest nation in the world could perform so poorly in caring for the health of its population by almost any measure at all.  The answers, to me, at least, seem painfully obvious: an unjustifiable allocation of resources to treatment in comparison to those devoted to prevention and public health, and a failure to incorporate the substantial evidence base relating to inequality and the SDOH into our public health policies.  Gerberding concurs:

A main goal of the Healthiest Nation Campaign is to keep Americans healthy by integrating health into social policies across all sectors and at all levels of government, Gerberding says.

"It's basically about changing the conversation," she says. "People are talking about health care reform, but they're not really talking about health."

Today, only a nickel out of every medical-care dollar spent in the USA goes toward keeping Americans healthy, Gerberding notes. "Many countries have put more emphasis on health promotion than the United States."

Yes, this is key.  Health care reform -- construed in terms of access -- and health are not remotely equivalent.  We can and should debate the significance of the former -- and on moral grounds, it is extremely important -- but it doesn't follow that improving the former will substantially improve the latter.  Very good evidence suggests that it will not.  Moreover, Gerberding takes care to note the distinction between "prevention" in the context of screenings and check-ups, and prevention in the sense of primary prevention -- activities and policies going far back over the lifespan to early childhood development and even prenatal care:

When people talk about investing in prevention, she says, "typically what they're talking about is 'let's invest in screening for early detection of disease.' That's secondary prevention. We're not really talking about the things we need to do before we get to the doctor's office."

This is the subject of a very recent (and excellent) article by Starfield et al. in the Journal of Epidemiology and Community Health.  Barbara Starfield is among the very best researchers working on prevention and health policy, and her work merits close study.  The Abstract for the essay is here:

Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of "diseases" for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health. 

This is one of the better recent essays I have read on the unfortunate elasiticity that has followed the concept of prevention.  Prevention, understood in the sense Starfield et al. intend it, is too important a concept to let become so conceptually diffuse.

In any case, Gerberding cites the well-known evidence that eliminating access problems would resolve -- at best -- 25% of health disparities.  Access issues are profoundly important for moral reasons; but inasmuch as we reduce discussion about how best to improve health to such access, we are unlikely to reduce human suffering as much as we ought to.  

Comments

[Bob Walton]

The Healthiest Nation Campaign is a worthy cause, though having been to Europe several times, the culture there is decidedly different than here in the U.S. The national movement hear towards health is commendable, but we've got a long, long way to go.