Deflating Conflating

The Commonwealth Fund, which I love and which also loves me, offers the Top Ten Health Policy Stories of 2006. There's nothing wrong with this list (albeit it is a bit Commonwealth Fundocentric) except for the title.

These are in fact a Top Ten Health Care Policy Stories. As I have attempted here to hammer like a spike into the reader's brain, health care (which I would prefer to call medical services anyway) is only a minor determinant of health, even in wealthy countries where it does make a substantial contribution to longevity. In poor countries, except for certain very basic interventions that don't even require an M.D., it's well down the list of priorities. Yet this habit of thought is so powerfully ingrained that even among sophisticated interlocutors we find ourselves focusing on health care when we meant to be talking about public health and health disparities.

Any top ten health policy stories of 2006 ought to include the extension of workplace smoking bans to more cities and states; the growing movement to improve the nutritional quality of foods available in schools; the NYC ban on trans fats in restaurant foods. On the downside, the failure to eradicate polio as predicted in January; the ongoing destruction of the public health infrastructure in Iraq (meaning nutrition, potable water, and of course public safety, as well as the deterioration of the health care system); the controversy over EPA standards for airborne particulates, mercury and other pollutants; rising rates of violent crime in the U.S.; and many other developments would have to merit consideration.

But the Commonwealth Fund gives us only stories about the organization, financing and provision of health care. One reason is, of course, that so-called health care is the largest industry and the largest public enterprise (outside of war and its sequelae) in the United States. A lot of money falls off that gravy train into the laps of policy analysts, researchers and consultants, including people who work for foundations and write reports. Public health beyond the realm of medical services is diffuse and unprofitable, because it's mostly about public goods that nobody owns, and nobody makes money from. They make us all better off, but they don't support lobbyists and they only get a little bit of think tank attention because of the oddball philanthropist or two.

I'm going to make more of an effort in 2007 to be fair and balanced when it comes to medical services, and everything that really makes us healthy. Don't be afraid to call me out if I seem to be succumbing to the usual intellectual sloppiness.