by revere, cross-posted at Effect Measure

Yesterday Flu Wiki founding editor and DailyKos frontpager DemFromCT reviewed three recent report cards on public health, one each by the American Public Health Association (APHA), The Trust for America’s Health (TFAH) and the American College Of Emergency Physicians (ACEP). It was a great a service in two ways. The first is to remind us that “health reform” is hollow without making sure the public health infrastructure is sound. And second, he reviewed these reports so the rest of us don’t have to. Believe me, that’s a service in my eyes. My patience gets pretty short when I see these tomes, full of platitudes, generalities or special pleading from a public health establishment that has lost its way, its mission and its ability to think out of the box. Too many years in the wilderness, perhaps. I’m guilty, too. I’ve been carrying on for years (literally) that the way to prepare for a pandemic is to shore up the public health and social service infrastructure.Dem and others have gently pressed me for some specifics, but I have resisted, mainly because I am not completely sure what I mean. It’s hard to explain things you don’t understand yourself (although teachers do it all the time).

I know I can’t do it alone. When I started the Effect Measure blog four plus years ago, just after the Bush re-election catastrophe, I hoped it would be a gathering place for serious discussion about public health from a progressive viewpoint. Specifically I wanted to begin a rethinking of public health, from the ground up, questioning all assumptions, ideological and practical, and not settling for the kind of slogans we in public health had been ritually mouthing for years (e.g., “prevention pays”; what if id din’t? does that mean we wouldn’t do it?). One of my very early ideas was to view public health through a specific lens and I decided to use the potential for an influenza pandemic with H5N1 as concrete example to focus things. I was among the first in the blogosphere to talk in any depth about bird flu, although I soon discovered two others, DemFromCT and the late (and much missed) Melanie Mattson of Just a Bump in the Beltway blog. The three of us, with the technical expertise of pogge, started The Flu Wiki in June 2005 and it has remained one of the “go to” sources for pandemic prep information since then (without much help from me, I might add). As time went on bird flu became the tail wagging the dog (pardon the mixed animal images). We still write about bird flu here, but it is time to put our shoulders to the wheel and start re-thinking public health. The three reports Dem discusses brought this home to me. All three sounded like tired nonsense.

Take APHA’s view, for example:

During the 1990s, health improved at an average rate of 1.5 percent per year, but improvements against national health measurements have remained flat for the last four years. Smoking, obesity, and the uninsured are the nation’s three most critical challenges…

No doubt those are three important health problems. But this strikes me as extraordinarily shallow thinking. I wasn’t any happier about the TFAH report:

“The economic crisis could result in a serious rollback of the progress we’ve made since September 11, 2001 and Hurricane Katrina to better prepare the nation for emergencies,” said Jeff Levi, PhD, Executive Director of TFAH. “The 25 percent cut in federal support to protect Americans from diseases, disasters, and bioterrorism is already hurting state response capabilities. The cuts to state budgets in the next few years could lead to a disaster for the nation’s disaster preparedness.”

This made me gasp. “Progress since September 11”? As Jon Stewart might say, “And do unicorns talk in your world, too, Dr. Levi?” The public health infrastructure — meaning the sinews and muscle of our state and local health departments haven’t been in such bad shape in my 40 year career in medicine and public health. TFAH is so narrowly focussed on disaster response they can’t see the trees for the leaves, much less the forest. The influx of federal funds for disaster preparedness has been one of the problems, not one of the solutions (we have made that point here before).

I am a little more forgiving of ACEP’s narrow Report Card. Representing the nation’s emergency room physicians they are on the front line of the crisis in health care, public health, social services, the economy and everything else that is falling apart around us. They viewed things in a characteristically narrow way:

The overall grade for the nation across all five categories is a C-. This low grade is particularly reflective of the poor score in Access to Emergency Care (D-). Because of its direct impact on emergency services and capacity for patient care, this category of indicators accounts for 30 percent of the Report Card grade, so the poor score is especially relevant.

At the moment I admit I can’t do better. But we have to do better. These “reports” are not much more than demanding we do more, and again, what we did in the past that didn’t work.

So let’s start over in thinking about this. The easy stuff, first. Public health and social services are an essential part of the country’s infrastructure, as much or more than roads and bridges. We have been disinvesting in them. We need to start re-investing in the routine stuff: substance abuse programs, maternal and child health, surveillance and vital records, environmental health and the rest of it. We need to do the same for social services. Yes, this is more of what we did before, but the first step in investing in our physical infrastructure (which should include the water and sewer systems, by the way, not just roads and the electrical grid) is to keep the bridges from falling down and the roadway from developing huge potholes.

But we don’t want to just recreate the old transportation infrastructure and we shouldn’t want to recreate the old public health system, either. It was based on different premises in a different world than the one we are heading into. The economic meltdown is a catastrophe but it is also an opportunity. All the cards have been thrown in the air and will come down in a different configuration and we should be prepared.

What’s the goal of public health? Surely it isn’t simply that I should be thinner and not smoke and be able to buy medical care. Surely it can’t be that we are ready for a bioterrorist attack. Can it possibly be that it is that I get seen much faster in the emergency room? I know these are caricatures, but not by much. What else do we want?

If I am an ordinary person, I don’t want to have to think about public health. I want it to work well but in the background, like the water system. I’ve got too many other things to think about and worry about. But if I am not looking at it all the time I also want to feel confident that those who are thinking about it are (a) competent, (b) making judgments and decisions for the welfare of the community. In substance, I want a system that is going to keep me and my family and my community as safe as they know how, all things being equal. Especially (but not solely) in the Bush years we couldn’t be assured of either of these elementary desiderata. Somehow we have to restore trust in the system.

What else? When I or the community have a problem, I want somebody to fix it. If it’s a health problem, that might or might not mean paying for expensive technology. Expensive health care is not always the best health care. We should be asking, for health problems, what is the best way to solve them. If the only way is very expensive, then so be it. But the system is now designed and favors expensive over less expensive solutions, and not necessarily because they are better. We have let the private sector drive the technology, as a matter of ideology. It has worked in some ways but failed miserably in others. We need to rethink the system of licensing and patenting of publicly financed research and we need to put public monies into finding the best solutions. When I say this I am saying something different than, “The best solutions, no matter how expensive they are.” I am saying, “The best solutions, no matter how cheap they are.” We currently do the former, not the latter.

That’s the merest of starting points: Make my world as safe as you can make it, all other things being equal (and that might mean taking other high priority factors into account), and when I get sick, help me to get well. But the starting point is not, how do we get people to stop smoking (although doing that is part of making their world safer) or thinner (although doing that is part of making their world safer) or giving them health insurance (because insurance is only a means to another goal, so let’s talk about that goal instead).

When I started the blog we were pretty much alone in the public health blogosphere. Now we have a steady readership in health departments all over the world, and more important, there is The Pump Handle, where this is cross posted and which I hope will become the lunch table around which public health professionals can start to talk seriously about what the hell we are doing and what the hell we want to do, without any preconceived notions.