Map of life expectancy at birth from Global Education Project.

Tuesday, August 21, 2007

Standing at the bottom of the cliff

The news of the day is, of course, the Compassionless Radical vowing to veto the S-CHIP authorization, but everybody else in the world is talking about it so I'll let them do it.

I'd like to take a step back and point out something else that is fundamental. Last year in Health Affairs (sorry, subscription only, and the abstract is uninformative) Leslie M. Beitsch and colleagues analyzed data from surveys conducted by the Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO). These represent state departments of public health, and municipal boards of health. They concluded that in the United States, public spending on public health in 2004-2005, from federal, state and local sources, was $149 per person. This is likely an overestimate because some of the spending that was counted is probably for health care or other purposes which are not strictly public health. In 2005, the U.S. spent $6,423 per person on health care, so public health spending was 2.32% of that.

What do we mean by public health? The functions Beitsch et al list include emergency preparedness, maintenance of vital statistics, tobacco prevention, public health laboratories, environmental health, food safety, drinking water safety, environmental regulation, substance abuse prevention -- activities that prevent disease and promote health before you see the doctor. These are interventions at the level of communities and populations, rather than individuals. Some of medicine is preventive, such as immunization, and that is considered a public health intervention, although the truly public health part of it would be more properly construed as efforts to make sure that as many people as possible receive recommended immunizations or other preventive services, rather than the services per se.

As I have discussed here many times, the gains in life expectancy in the past century are mostly attributable to public health measures, with medicine contributing only a small proportion at first. Most observers argue that medical intervention has become more important in the past couple of decades and may account for about 50% of the gain in life expectancy since then, but still, is 43:1 really the correct ratio for spending on individual biomedical intervention vs. public health?

Why this gross disproportion? The economists would concede that it is a market failure, although, as you know if you believe me, markets always fail and it is nonsensical to expect markets to produce sensible amounts of public welfare in the first place. Public health is a public good. Individual consumers can buy very little of it, and in fact tobacco companies and "food" manufacturers spend billions to make sure people buy public sickness instead. I can't go out and spend out of my pocket to make sure the food in the supermarket or the water that comes out of my tap isn't contaminated, to make the air I breathe clean, to assure that my doctor is competent or my father's nursing home run safely, to prevent young people from taking up tobacco or heroin -- only government can do these things.

But once I'm sick, I'm going to demand health care. Furthermore, culturally, when we see people who are ill, we don't feel right if they don't get treatment. Seeing uninsured people expiring at the doorstep of the hospital because they can't pay would simply be unacceptable to the public. But we are much more tolerant of distant threats to health that might or might not affect a given individual. That isn't "rational" from a utilitarian or cost-benefit perspective, but it's how people work.

There is an allegory in public health, whose origins as far as I can tell are lost in the mist of time. There is a road that runs right up to a steep cliff, but there are no warning signs and no barriers. People keep driving right off the cliff and landing at the bottom seriously injured. So what do we do? Do we put up a sign, or a fence, or better yet rebuild the road so it turns away from the cliff? No, we wait at the bottom, and when the people fall, we take them to the hospital and patch them up. It's a good deal for us, because we get paid a lot to do it. If we built that fence or rebuilt the road, we'd stop our gravy train.

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