Public Health in Perspective

One of the concerns of public health is indeed preparing for and responding to infectious disease outbreaks and epidemics. However, I fear that some of the leading voices for public health in the blogosphere have put far too much emphasis on this small slice of a big field and the result has been a huge missed opportunity to frame some strong progressive messages. Influenza control is a wonky issue that is pretty thin on political resonance compared to most of what public health is all about.

Public health is the endeavour -- more than a scientific discipline, or a profession, it's a unifying philosophy -- that treats human health at the level of populations rather than individuals. The latter is the province of medicine. Many people think that public health means "providing medical services to poor people." Not so. In fact, the intersection between medicine and public health is fairly narrow on both sides.

Until fairly recently, the most rigorous analysis showed that health care -- a mismomer, in my view -- made an almost undectable contribution to population health, particularly as measured by longevity but also in terms of disability and quality of life. More recent analyses give more credit to medical services, and it is also undoubtedly the case that immunization, which is a biomedical intervention, has made a huge contribution to human health and longevity, although it doesn't require a doctor or even a health care infrastructure per se to deliver. Nevertheless it remains true that the most important determinants of our health lie in the social order.

Those include the obvious. Rich people don't have to drink contaminated water, their kids don't go hungry, they don't have to live next to air polluting factories or highways, they don't do dangerous jobs, and so on. And they include the less obvious. There is an increment in health and longevity associated with social status that remains even after we control for every known factor we can think of. There's actually a cost of inequality within societies, independent of absolute deprivation. Even though poor people here in the U.S. have less material deprivation than poor people in poor countries, their relative health disadvantage is as great -- or even greater, compared to countries with less overall inequality.

Poor people also do worse on those determinants of health that my libertarian visitors are inclined to assign to personal responsibility -- tobacco, obesity. But they forget that corporations have engaged in decades long marketing and disinformation campaigns to promote tobacco addiction and consumption of calorie-dense, low nutrition foods, in order to enrich their executives. Our agriculture policy subsidizes corn syrup, but not vegetables or even healthful whole grains. That's why bad foods are the cheapest. Our schools feed junk food to our kids, in part because corporations actually bribe them to do so. Poor kids in the city don't have the chance to engage in physical play because it isn't safe for them to go out. These are all political issues.

Health equity is potentially the new civil rights movement. Everybody has the right to a chance at a healthy life and a natural life span. Try arguing with that, Cato Institute. But the only way to get there is through a just society. By the time people bring their problems to the doctor, it's already too late.

Unfortunately, the public health content on Daily Kos and elsewhere is all about influenza epidemics and universal health care. If the absolute worst case scenario happens with this swine flu flapdoodle -- and I mean the worst, the absolute most improbable catastrophe anybody is imagining -- it will be completely over in less than a year. It will have caused some tens of millions of people to spend a miserable week wrapped up in the snuggy slurping chicken soup, and it might cause the premature death of a few tens of thousands of people. Hundreds of thousands? Doesn't look that way from anything I've seen so far, but let's stipulate it just for the sake of argument.

Well then, that's on the order of 10% of the little kids who will die this year from malnutrition and not having clean water. Which of those should be on the front page of Daily Kos?