Friday, May 20, 2022

Public Health vs Health Care (part 1 of 4)

Okay what is public health sounds like a simple question the fact of life is that very few Americans have any concept of what public health is to a lot of people public health means disaster response and this is certainly true since 9/11 here we are on the 11th anniversary of 9/11 certainly true since then that an awful lot of people think it's just .

Responding to a crisis to a disaster a lot of people think public health is health care for the poor people who maybe can't afford it otherwise themselves any number of people tell you a public health is behavior nany's is one of the kinder expressions sometimes it gets a little nastier than that for example New York City deciding to limit .

The size of soft drinks to 16 ounces which has been the subject both of Mirth and the part of some anger on the part of others and and congratulations to the mayor and the part of still other people we're going to talk about that one later on as a an interesting example when I say the behavior nannies I'll never if we should tell you by the way just .

Doesn't matter but politically I stand kind of in the middle and maybe even slightly right of many of my colleagues in public health public health is a field where I think it's fair to say on average people are pretty far left and you don't find too many people on the right the right side of the spectrum although there definitely are some .

There's some very important people in public health but I'll never forget the time I went to an American Public Health Association meeting in Florida in Miami and I had my badge American Public Health Association badge I was walking along and there's some guy had a different badge for a different convention and he said to me oh you at .

That public health meeting I said yes and he said communists and he walked right away so that's a perspective it's not a fair one but but that's one perspective there are other people who think public health does nothing but restaurant inspections looking for cockroaches it's actually a fairly important function of local Public .

Health there have been some very famous restaurants how many of you had parents who went to school here as undergrads okay ask him if they ever went to the pretzel bell and I'll bet you anything that they did the pretzel Bell was the place to go on a Friday or Saturday night in fact it was a place you went on .

Your 21st birthday when you were allowed to drink and you would stand on a table in front of all your friends and all the other people in masks there and chug a beer I it was a wonderful place for all kinds of entertainment it was shut down by the Health Department and eventually went out of business precisely because they had problems with cockroaches and a .

Number of other insects they really weren't their fault as as much as the structure of the building as champion house still downtown the Asian was that closed ok well that's where it was and that replaced it was there for many years thereafter now here's a common reaction I don't have any idea what public health is so .

Today we're going to learn what public health is all right how do public health professionals think about public health my way of thinking about it and I think many professionals is by its purpose and we're going to talk about its purpose momentarily but there are others who will talk about the professionals who are active in the field of public health .

One problem I have with doing that and we'll talk about the five core groups of professionals a little bit later but one problem I have with that is I think of people who run fitness centers for profit as being in public health I think of people who make athletic equipment as being in public health that doesn't mean that's their principal focus but they're .

Contributing to public health so I think of as being much broader than the professions we tend to associate with public health some people think of it narrowly as associated with the two methods most closely identified with the field epidemiology and biostatistics other people even within the field of public health again think of it as .

Governmental health services for the poor and then there's some people who think of Public Health simply as the the health of the public and I said I like that first one purpose I'm not going to read you this rather lengthy definition but I urge you to read it it's from CEO Wendt CEA Winslow one of the really famous folks in American .

Public health history back in 1920 and aside from an occasional stilted word here or there this is a brilliant definition a very comprehensive definition of what public health is now again I'm going to save myself and you the time of reading through it but I urge you to do so on your own let me give you a much more concise definition .

Public health is the set of activities a society undertakes to monitor and improve the health of its collective membership so just a few words there but the critical pieces of this set of activities that the society undertakes to monitor so one of the important functions in public health is simply observing what's going on and thereby .

Being able to analyze what's going on and improve the health of the collective membership so what distinguishes public health from the other fields of health science well one is there's a very almost laser-like focus on disease prevention and health promotion trying to prevent disease and injury from occurring in the first place second and .

I put the word patient in quotes there's no individual patient the patient is the community if I'm in public health I'm thinking bigger than individuals I'm thinking about collections of individuals the community the same thing about the provider the provider is the society itself organized however we choose to do that not individual .

Professionals so think about the other Health Professions and by the way this is going to be overlap and I'll give you an example that in a moment but if you think about all the other Health Professions listed up here and I hope I haven't missed somebody they almost all consist of an individual provider who is providing services to an .

Individual all patient and more often than not the emphasis is on dealing with an existing condition some kind of health problem now obviously you go to the doctor for preventive services or the dentist for preventive services as well but more often than not all of these fields are focusing on treating existing conditions .

Trying to ameliorate their effects trying to make things better so here's an example this actually is a very important one for a reason that I will give you later think about the difference between what a dentist does and what government does when we think of dental health or dental public health you go to the dentist to have dental .

Caries dental cavities treated in individual patients public health flora dates the water supply which we then all consumed and confers protection on us so that we don't get the cavities in the first place now again it's not perfect I go to the dentist twice a year for a preventive maintenance checkup I assume that many of you do that as well and the .

Dentist actually will teach me health behavior things he'll make sure I'm flossing regularly and do other things like that but on average the difference is the focus on problem that exists versus trying to prevent the problem from existing at all I said this is an important example and and the reason for we tend to you know you think of the .

Hierarchy of health problems most of you all probably don't think of dental problems being very high on that list actually very high for a variety of reasons but this is the field one of the fields where Public Health has been extraordinarily successful how many people in here have had more than five cavities in their mouths got to be some .

Of you how many of you have had more than five cavities but won't admit it all right you look around you didn't see many hands up there did you there are very few people of my generation who wouldn't have had their hands up why is that because a water supply wasn't fluoridated when I was growing up as a kid we all got cavity .

We got lots of them you all in general don't you might have one or two three but you're not going to have five or more and that was commonplace this is an area where public health through a community activity that was not delivered to individual people has been enormous ly successful all right I want you to think conceptually about the role .

Of Public Health public health should be at the very top of the pyramid when we think of how we organize our health and health services our public health health services Public Health's should be at the top over viewing all of it overseeing all of it that means the collective health services that we'll be talking more and more about and the .

Individual health services there is a important role for Public Health and overseeing those individual health services you see them here that's in concept how do we behave in practice well kind of looks like this so medical care is at the top of the list that's followed by other individual health services and public health not only gets .

The least money it gets the smallest font all right I'm gonna have to have somebody rewrite some of my material here obviously but that actually indicates we're gonna look some more at some of these figures medicine clearly dominates our public health horizon if you will why does it matter well first of all it's because public health is so .

Very important this comes from any number of studies I've written down several of them these are sort of the original ones from the Centers for Disease Control and Prevention the Institute of Medicine Public Health Service they've been many others since then here's the question if you could prevent avoidable premature mortality .

What would you have to do to prevent it and what would be the contribution of each of these factors now I remember the other day we talked about the fact that almost half of all deaths in the United States are premature preventable deaths that's a lot well this is telling us that life's behavior changes could account for a .

Reduction of half of that in other words half of that preventable death and and disability could be avoided by lifestyle and behavior changes environmental improvements could address about a fifth of the problem dealing with human biology and genetics another fifth and better and more medical care could only decrease that toll by about ten percent .

Right and say this is widely accepted among pretty much all health professionals now this is from a study by an anesthesiologist of all folks John bunker and his colleagues from 1994 there have been others like it but he estimated that of a 30-year gain in life expectance in the US during the 20th century remember life expectancy went .

From about 47 up to about 77 at the end of the century five years of it were attributable to the medical care system 25 years to health improvements in sanitation housing nutrition and job safety now you know at those of you who have ever bought stocks or read anything about stocks they always tell you that past performance is not a guarantee of .

Future performance that doesn't mean that going forward we'd have these same kinds of ratios but the best evidence suggests that we still have a lot of room to gain much more from public health efforts than we can certainly through healthcare so think about it this way it's the simple Venn diagram if this is the importance of public health .

And medical care to health and this is qualitatively speaking and note that there is an intersection of these two because there are things done in medical care that certainly qualifies public health immunizations health behavior counseling pediatricians are very good at counseling about health behavior that's a good example but then we say .

Where do we put our resources and here's the answer and in the last year we spent something in the order of two point six trillion dollars on health care services in the United States if you wonder how much that is divided by three hundred and eight billion people and you've got a large number look at all those zeros this is a huge .

Number public health again you can't read it it's that font problem it's about fifty billion roughly nobody has a very good figure for public health because they don't know exactly how to define it for accounting purposes about two percent of that total has go into public health so something is out of whack here we've got .

The importance of public health the enormity of it we've got the funding that goes to it which is tiny all right why why is there this imbalance well first of all market systems and the economic interests they're all associated with cater to services for individuals that the market responds to what individuals want to spend their .

Money on public health is something we refer to as a public good or an externality those are terms that if you haven't taken economics you may not be familiar with we will be coming to them but suffice it to say that the conventional marketplace will not provide public goods and externalities not address externalities in the .

Marketplace that requires government that requires governmental intervention so the market doesn't work with it all right interest group politics there are a lot of contentious issues in public health and one of the things that we're going to see as we go through the term is that public health is a contentious field there really aren't very many .

Interesting questions in public health interesting issues that don't involve a lot of very challenging politics and then there's this thing called the rule of rescue I don't remember the name of the author but somebody wrote an article many years ago where he referred to this as the rule of rescue and he said what do people want what people want when it .

Comes to health care is to be saved when they're in dire trouble they've had an automobile collision they've got cancer they just had a heart attack whatever it is they to be saved and they're willing to put big bucks into trying to get saved public health involves an abstract future benefit again you all don't think .

Of water fluoridation is a big deal but you all don't have five to ten cavities in your mouths and let's try one more little experiment here let me see the hands of everybody in the room who's had smallpox okay I hope we wouldn't see anybody because that disease has been wiped off the face of the earth since before you were born .

How about polio how many hands nope okay I was lucky I didn't have polio although for my first five or six years I was exposed to it I could have had it because we didn't have the vaccine at that point how many people have had mumps JJ I'm the only one how about measles nobody had mumps or measles how about chicken pox oh I .

Finally found one you've had guess what if you're teaching this course 30 years from now and your kids are in the audience and they ask the same question there won't be a hand that's going to go up not one because we now have a vaccine for chickenpox so think about what this means these people who are in having a car crashes and all that they are .

Identifiable human beings we feel terrible for them those of you who would have had 5 to 10 cavities or like me would have had measles and mumps you don't know who you are you don't know which ones of you would have had that which once if you would not have had that what we're talking about with a lot of public health is what we call .

Statistical lives they're statistical in the sense that we can make some pretty good projections as to how many people are going to benefit from this but those people are never going to know it themselves they won't have any idea about it personally it's just kind of out there and again my guess is that very few of you have ever .

Said thank you public health for helping me not have mumps or Thank You Public Health because my teeth look nice and shiny and I don't have stuff stuck in them by a dentist over years and years of care you haven't said that because you don't think about it why because a lot of public health success is invisible .

Public health when it works very well means that problems don't exist successful public health is the avoidance of problems and people don't ever necessarily know that they have benefited all right so think about this you've got a health promotion program you've got exercise program we're trying to get all the University faculty and .

Staff to to exercise they have a big program at the University now well think about what that means the benefits of exercising are somewhat abstract and they're certainly deferred the concept is if I exercise regularly for the next 20 years I'm going to avoid a heart attack you know at some point during that time or ten years later or .

Something like that that's an abstraction and it's a deferred benefit the costs are real and they're immediate I have to find time in my busy life to exercise I have to go out and work on some machines and sweat and do all kinds of things that I don't want to do but those think about the balance between the benefits and costs it takes a .

Special kind of person to make a commitment to endure those costs in exchange for this deferred and abstract benefit now think about the benefits and costs of disease promotion I don't know about you all I am I'll confess something of a chocoholic and every year when I look at this picture it just drives me crazy I mean does that look .

Good or what now think about that the benefits that she's enjoying right now are totally tangible you can feel them you can taste it you can get a smeared all over your mouth I'm not sure that part's a benefit but and they are immediate how about the costs well come on they're kind of abstract you know am i increasing my risk of a .

Heart attack as a result of doing this a month from now tomorrow a year from now if I do this you know maybe once a week there's no harm in it maybe twice a week there's no arm how about three times that's probably okay and then all of a sudden I'm 40 50 years old 55 years old and I've got these clogged arteries it's hard to make that connection .

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