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Originally published on April 5, 2016
Public health has been consistently underfunded and neglected in this country. Will the interest in population health and the emergence of new infectious threats change that?
AIDS. Ebola. Zika. Side orders of norovirus, E. coli, and salmonella with your burrito at Chipotle. Lead and legionella in the tap water in Flint, Mich.
Our health care system has become infatuated with the concept of population health — even the insurers are expressing interest, although that appears to be rooted in financial concerns (it's less expensive to insure people if they are in good health) — and yet we continue to underfund, disdain and sometimes even dismiss the work of public health professionals and their agencies, even when they are the ones on the front lines of stopping these plagues before it's too late.
It's already too late in Flint. Hundreds of children have been poisoned and will have to be monitored for the rest of their lives for brain and neurological problems caused by contaminated water from the Flint River. The city, which is deeply in debt and whose population is largely African-American, was switched by an "emergency manager" appointed by the state from Lake Huron water to river water in order to save money. Residents soon noticed that the water smelled odd and came in a variety of colors. They were told not to worry. Flint is now a disaster area. When Flint officials tried to reconnect their water supply to the Detroit system, the new emergency manager refused the request. Flint was finally reconnected to the Detroit water system in October, but the damage was done. In addition to lead levels, there was evidence of Legionnaire's disease in some residents, 10 of whom died.
I can't help but wonder if this had happened in, say, the wealthy suburb of Grosse Pointe, Mich., something might have been done to stop this tragedy. As award-winning documentary filmmaker Michael Moore — a native of Flint — wrote in Time magazine on Feb. 1 of this year, "When the governor found out, he kept quiet and let the poor of Flint continue drinking the poison. Marie Antoinette would have been proud. Except this time no one offered any cake. 'Let them drink the Flint River' has a nice ring."
The governor of Michigan said he was real sorry.
Politicians have their foibles and preferences and priorities. What the American public has is a neglected public health system. Whether it's the U.S. Public Health Service, the Centers for Disease Control and Prevention or state and local public health departments, they are our first line of defense. And yet they have to scratch for money.
The CDC — a spectacular and elite agency that is called on by many nations to investigate and curb outbreaks of infectious disease — has already produced an easy-to-use test for Zika virus, which isn't bad, considering the virus just became a problem a few months ago. The CDC predicts 3 million to 4 million cases of Zika virus in the Americas within a year — a happy thought with the Olympics being held in Brazil.
Because the population who were at Ground Zero when AIDS emerged — that is, gay men — were not popular with political leaders at the time, the epidemic was ignored, and the world has paid the price. According to the Stephen Lewis Foundation, most of an entire generation in some parts of Africa has died. Grandmothers are raising their grandchildren, as there is no one left alive to do it other than them.
Tuberculosis is making a comeback. And the new strains are much more virulent and more resistant to existing antibiotics than the previously extant ones.
The Chipotle restaurant chain either didn't wash its vegetables or didn't care where they come from. The bugs don't care; they're just trying to make a living like the rest of us.
It's gotten to a point, with me, that I only drink bottled water and won't eat lettuce or any other fresh fruit or vegetable unless I have washed it personally. I have had all the episodes of food poisoning I care to experience, not to mention a bout of norovirus that was unforgettable. I can't imagine how dreadful it must be to get that disease on a cruise ship. And, in fact, some of Chipotle's suppliers also provide food to cruise lines. It's swell to proclaim that you are using foods free of genetically modified organisms and pesticides, but could you please check for bacteria and viruses?
The first state public health department was founded in Massachusetts in 1889, but the roots of public health go back much further than that, to hospitals for merchant seamen that were built as early as 1799. The idea behind this, not surprisingly, was that port cities (Hawaii also established a public health department early on) received visits from hundreds of merchant seamen who could have been carrying any one of a number of diseases.
Acknowledging that health care professionals had to be trained in the techniques of public health — such as they were back then — Johns Hopkins University established the first formal school of public health in the United States in 1916, soon followed by Harvard University and the University of Michigan.
We've been fighting over how much power public health authorities should have ever since. Generally speaking, public health agencies are the only powers that can impose quarantine, which goes back to the time when that was our only protection against infectious disease. Public health agencies can encourage better health habits — don't use tobacco, keep your weight down and so forth — but these are suggestions. There are also middle grounds where public health meets law enforcement — you can drink alcohol to excess if you want, but you cannot legally drive a motor vehicle if you are in that state. If you want to be promiscuous, we cannot stop you, but if you have AIDS or another sexually transmitted disease, use a condom. One of my mentors, a public health professional of the highest order, one day just went out and closed all the gay baths in his city in order to stop the spread of AIDS. It was probably illegal, but he was not in the habit of taking prisoners, and he wanted to prevent the kind of epidemic that had occurred in New York City, Los Angeles and San Francisco.
We fight over fluoridation of water, use of vehicle seat belts and helmets, immunization and numerous other activities involving the public's health that produce a collision of individualism and community. And we will keep on doing so.
The challenge that most public health agencies face is that if they are good at what they do, no one notices. It is very difficult to prove a negative. As I often tell the audiences to whom I speak, no one is going to make the news by pointing someone out and saying: "Look! She doesn't have measles!"
Public health work is, by its nature, mostly silent and unnoticed, which is why it is chronically underfunded and unappreciated. Its professionals do inspections, monitor food quality, watch for disease outbreaks and conduct laboratory analysis, and the rest of us don't notice. And then someone gets salmonella from the local delicatessen and everyone has kittens.
In a brilliant article in the Hastings Center Report in December 1985, Dan E. Beauchamp laid out the argument that public health lies at the heart of community, that it is one of those rare activities that supersedes the American embrace of individualism. In the article, he quotes Lemuel Shattuck, a Massachusetts legislator and early public health pioneer, who wrote in 1850:
"The condition of perfect public health requires such laws and regulations as will secure to man associated in society the same sanitary enjoyments that he would have as an isolated individual; and as will protect him from injury from any influences connected with his locality, his dwelling house, his occupation, or those of his associates or neighbors, or from any other social causes. It is under the control of public authority, and public administration; and life and health may be saved or lost, and they are actually saved or lost, as this authority is wisely or unwisely exercised."
We are all members of the human community, and there are times when we must make minor sacrifices — stopping at traffic lights, not socializing if infected with a contagious disease, being a responsible firearms owner — in order to protect the entire community. It really does not seem to be a lot to ask.
If we really are serious about population health — and I am not entirely convinced that we are — then we had better understand that public health is population health, and our public health folks are better at it than most of the private sector.
There are hospitals and health systems that have partnered with and championed public health agencies, and they should be congratulated for that effort. We are only going to stop unnecessary death and disability if we are all in this together. Just ask the people of Flint.
As Beauchamp also wrote, "In political individualism, seat belt legislation, or signs on the beach restricting swimming when a lifeguard is not present restrict the individual's liberty for his or her own good. In this circumstance, the appropriate language is 'the life you save may be your own.' But in the second language of public health, these restrictions define a common practice that shapes our life together, for the general or the common good. In the language of public health, the motto for such paternalistic legislation might be, 'The lives we save together might include your own.' "
Our public health colleagues devote themselves to protecting the rest of us. It's time we made a commitment to protect them.
Copyright © 2016 by Emily Friedman.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. Her website is EmilyFriedman.com.
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