What Is Public Health?

This week the semester starts, and the first class for the graduate students in public health takes place.  The primary agenda for the course is to help them understand the concept of public health.  It is difficult for students and others not immersed in public health because they have no academic exposure to the discipline prior to college and maybe not even until they enter a graduate program.  Furthermore, most people have only limited contact with the public health system, so their perspective will be very limited.  It is like the old fable about the three blind men who were asked to describe an elephant: each one described the elephant by the part of the elephant they were touching, but were not able to explain the full proportions.

Whereas clinical health care does tremendous good in the world, removing pain and helping people recover from illnesses minor to severe, public health is more concerned with measures to avoid those problems in the first place.  Like most human activities, both systems can point to astonishing accomplishments while also acknowledging stubborn barriers to achieving full potential.  All of us know people successfully treated in the 21st century who would not have survived their ailments a few decades ago.  On the other hand, we also know people who would have much better health if there was an open door to the system for them.

Public health can also point to lots of great success.  For example, what have been called Ten Great Public Health Achievements   Based on the ideas of public health and what is theoretically possible, we have high hopes of moving the nation and the world forward to better health and quality of life for all people. The following video gives just a small glimpse of that optimism. 
Healthiest Nation in One Generation



On the other hand, there are challenges to reaching the potential of the public health enterprise.  Perhaps the greatest one is a lack of appreciation for its potential among the public.  For example, in the U.S. we spend over $2 trillion on health and medical care, but only 4-5% of that is for public health and prevention.  We tend to make sure people have access to the most acute care for the most seriously ill, but don't assure that people have access to the primary care and preventive services which would go so much farther to keep the population well.

Another problem we face is a better trained workforce.  The march of progress has continued in public health just like every other field of interest.  We know more than ever what is best practice and what is best to be left behind.  In clinical care, there is a problem with this as well, but because of the economic incentives linked to good care versus bad care, health care institutions have business reasons to invest in training and upgrading of the workforce.  Because public health is mostly government sponsored, and because there are very limited economic incentives to reward more competent practice, we have lagged far behind.  In local public health departments small and large, there are people who do amazing work but many others who are really handicapped by deficient and out dated skills.

Another problem hampering the full potential of public health, particularly now, is the political climate.  Public health advances the proposition that there is a WE, not just ME and MINE.  It says that together we can take steps to benefit all, as opposed to the view that for society to improve, everyone should have the right to promote their own welfare, without being hampered by "the nanny state," imposing various kinds of restrictions.  Some of this battle will play out in the elections of this and the next couple of years.  A small example of this is taking place in Louisville.  For many years the local school system has bused children to schools other than the one closest to them for the sake of racial and ethnic diversity.  Recognizing that housing patterns are historically very segregated, it was believed that the community would be better served by trying to make schools more cross-cultural than they would be if the schools simply reflected the discrimination built into neighborhood patterns.  Many people believe that this has a profound impact on health conditions and status, as educational success and social development are some of the most powerful determinants of health.  In the last couple of years there has been loud and assertive opposition to the whole notion of busing:  It is about ME and MINE, not US.

I'm always excited about introducing a new crop of students to these issues, and look forward to seeing them accepting the challenge of making a small difference for a healthier generation.