The magnitude of spending to repair damage from the mega-storm Hurricane Sandy is a useful reminder of how we allocate resources for health. We spend far more on repair or treatment of disease than on prevention. Population health focuses on improving the health of the entire population and reducing inequalities in health between populations. In general, the health of a population is measured by health status indicators, such as life expectancy and quality of life. Population health usually also addresses the determinants of health outcomes, such as medical care, public health interventions, the social and physical environment, genetics, and individual behavior. In the US, McGinnis and colleagues 1 estimated these determinants of population health and their contribution as follows:
- · Genetic predisposition (contributing to perhaps 30% of deaths)
- · Social circumstances and deprivations (15% of deaths)
- · Environmental exposures/conditions (5% of deaths)
- · Behavior choices and patterns (40% of deaths)
- · Shortfall in medical care (10% of deaths).
As McGinnis noted, only 10 percent of the overall population heath is impacted by access to heath care and the services that are delivered. (We might also note that historically 2% of deaths have been due to medical errors and consequences of health care services that are delivered – See Institute of Medicine report “To err is human:building a safer health system”).
However, this piece of the puzzle, collectively called health services, currently receives more like 90% of public funding in the US and other high-income economies 2. A greater investment in public health and prevention programs has great potential to improve health outcomes 3.
In fact, many public health interventions save money and many have cost-effectiveness ratios that are far better than those for treatment interventions 3. Tobacco control 4, immunization 5, and cardiovascular disease prevention 6 as well as workplace health promotion programs 7 all are extremely well supported by cost effectiveness and pay off in disease prevention. Immunization programs are already reducing the burden of liver cancer caused by hepatitis B in Asia, and represent a “best buy” as classified by the World Health Organization 8. Other best buys to provide population-wide benefits and improve population health include reduction in tobacco use. Based on these types of evidence Richardson calls for a greater investment in pubic health to improve the situation throughout the world 3.
Why do we allocate resources away from prevention and focus on disaster (disease) treatment and repair? Hemenway has suggested four reasons that we do not allocate resources to public health and prevention 9. These include:
- Benefits of public health programs lie in the future
- Beneficiaries are generally unknown
- Public has no idea what public health programs do. Thus, when people benefit from prevention they don’t recognize they have been helped
- Opposition to public health approaches that require societal change running counter to status quo
The ravages of large Atlantic storms (two in 14 months), forest fires in the Rocky Mountains, and so forth, attest to the need to invest in prevention. We all end up covering the costs of disaster relief through our collective national taxation system. A similar situation exists with treatment of cancer and other major chronic diseases. As Kristoff highlighted in his recent account of his friend with prostate cancer (New York Times Oct 12 and 17, 2012;) – who without insurance received care at the expense of premiums paid by the insured population.
Returning to this storm analogy, the beneficiaries of prevention programs are unknown, since we are not sure where the next storm or natural disease will strike. This contrasts with the identifiable patient with disease, or residents in a community after it is ravaged by a storm, or forest fire. Public health interventions are aimed at improving the health of a broader group of people, but it is often unclear who benefits, whose life is saved.
Another barrier noted in recent media coverage is the interest group – be they in NY or NJ or in health care. This fits with the 4th of Hemenway’s barriers, those opposing social change. We must improve our reporting of the benefits fo prevention and public heath interventions to better frame the debates going forward.
Surely we should make a stronger commitment as a nation to increase the allocation of resources to prevention of disease (and natural disasters) – improving the quality of life for all citizens.
1. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). Mar-Apr 2002;21(2):78-93.
2. Hale J, Phillips CJ, Jewell T. Making the economic case for prevention--a view from Wales. BMC Public Health. 2012;12:460.
3. Richardson AK. Investing in public health: barriers and possible solutions. J Public Health (Oxf). Aug 2012;34(3):322-327.
4. Lee K. Tobacco control yields clear dividends for health and wealth. PLoS Med. Sep 16 2008;5(9):e189.
5. Burls A, Jordan R, Barton P, et al. Vaccinating healthcare workers against influenza to protect the vulnerable--is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine. May 8 2006;24(19):4212-4221.
6. Unal B, Critchley JA, Fidan D, Capewell S. Life-years gained from modern cardiological treatments and population risk factor changes in England and Wales, 1981-2000. Am J Public Health. Jan 2005;95(1):103-108.
7. Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health. 2008;29:303-323.
8. World Health Organization. Global status report on noncommunicable diseases. Geneva, Switzerland: World Health Organization;2011.
9. Hemenway D. Why we don't spend enough on public health. N Engl J Med. May 6 2010;362(18):1657-1658.