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November 22, 2006

What's the Rx for America's public health system?

Those in public health are well aware that the United States has widespread health disparities and inequitable and inadequate health insurance coverage and that money is being poured into treatment instead of prevention.

But the question remains: Is anyone else paying attention?

“Recently, I was asked to talk about the American system of public health and my first reaction was, ‘What system?’” said Susan C. Scrimshaw, president of Simmons College in Boston and a public health scholar whose research includes community participatory research methods, addressing health disparities, improving pregnancy outcomes, and promoting health literacy and culturally appropriate delivery of health care.

“We don’t have national-level funding, for instance. And there is a wide variation in how states spend federal money,” Scrimshaw said. “We also have inadequate coverage of the population. We’re spending most of our money on treatment, which drives all us in public health nuts — only 3-5 percent of health dollars are spent on prevention — and until recently we were not engaged in evidence-based decision-making.”

In addition, wide health disparities continue for a number of populations, including differences by ethnicity/race, gender, age, economic status, social class and sexual orientation, said Scrimshaw, who delivered a reflective, rather than statistic-laden, Parran Lecture Nov. 13 at the Graduate School of Public Health (GSPH).

“We have to make a hue and cry about all this,” she said. “It’s a disjuncture we live with. We have too much complacency in this country.”

Public health in the United States has multiple, disjointed funding agencies, a fact that actually contributes to unequal access to care and suppresses the emphasis on preventive care, Scrimshaw said. “If you are an underrepresented minority you are less likely to have access to care. When I talk about care, I like to say ‘access to prevention’ and ‘access to care services,’ and I continue to make that distinction as a way to get it into people’s heads that not all we’re talking about is care.”

The greatest problems caused by health disparity are differential rates in infant mortality, cancer screening, cardiovascular disease, diabetes, HIV/AIDS and child and adult immunization, said Scrimshaw, who also is an elected member of the governing council of the Institute of Medicine (IOM) of the National Academies.

Among the factors that underlie health disparities, she said, are a difference in behavior in response to illness.

“A few years ago, the black caucus in Congress asked the IOM, ‘Are there disparities in cancer?’ The title of the IOM report answers the question. ‘The Unequal Burden of Cancer’ report revealed the fact that we have 30 percent higher death rate for all cancers for African Americans, and that there is a higher death rate from breast cancer despite a mammography screening rate that’s nearly the same,” Scrimshaw said.

Many of the multiple funding sources are reluctant to take a long-term view regarding public health, she said. “Funders often don’t want to fund preventative work. They say, ‘That’s somebody else’s problem. I’m funding to provide, say, occupational health care, why should I be worrying about long-term prevention and screening? Why add that cost?’”

The problem also is a legislative issue, Scrimshaw said. “One of our toughest jobs in public health is getting legislators to look at the concept of prevention, because they want to go back to their constituents and say, ‘I built you a bridge. I built you a youth center.’ And it’s a little harder to say, ‘I built obesity prevention in young children so that you won’t be dealing with their diabetes when they get to their 30s and 40s.’ That’s a much harder sell, even though we’re beginning to successfully make that sale.”

With 47 million Americans without health insurance, the consequences include 18,000 unnecessary deaths a year, according to a recent IOM report, Scrimshaw pointed out.

“This is when you start getting to the legislators,” she said. “When I talk to legislators about this, I tell them that when we see a drop in funding for prenatal care we see an increase in prematurity and the cost of the prematurity far outweighs the money we, quote, saved.”

Any attempts at reform, though, need centralizing authority, support and accountability, and public health research that addresses gaps in knowledge. “For every evidence-based recommendation for interventions, we probably have five or six where there is simply insufficient evidence,” she said.

“We in public health know all these things about the problems. But the bottom line is: Is anyone listening? What are we doing about it? What are we going to do about it?”

A recent National Institutes of Health bill in Congress mandated that NIH had to report how much of its funding went to prevention, Scrimshaw said. “First they tried to say, ‘Everything we do is prevention,’ but [Congress] didn’t let them get away with that. And that began a cultural shift toward funding for prevention and for a more involved community.”

So, there are some encouraging signs, including a new emphasis on risk behaviors and their influence on public health, Scrimshaw said.

“I can’t begin to describe what it was like to be a behavioral scientist, in this case working on pregnancy outcomes, and trying to talk to obstetricians about the fact that some of the effects we were observing with low birth weight were related to things like anxiety and could be mitigated by social support — and we had very good data, we had biological markers on anxiety — and they didn’t want to believe it. That anything other than a medical intervention, or a pill, could matter was so alien to them. Well, that is changing,” she said.

She added that the human genome project will strengthen the emphasis on risk behaviors in public health.

“Some people think because we’ll know where the genes are we can just fix everything,” Scrimshaw said. “But a lot of the genetic history tells you what you’re at risk for and behaviorally you have to try to prevent.”

Other positive signs include the rise of community-based coalitions, such as Allies Against Asthma, a national organization, and CLOCC (Consortium to Lower Obesity in Chicago Children), a local organization that has become a model for other cities, she said.

On the national level, Scrimshaw said, “This is something I didn’t know I could mention a week ago, and that is the potential for change in Congress due to the November election. It’s not so much about party affiliation as it is about paying attention to the kinds of things we already know in public health. A key thing is the need for advocacy and leadership for change.”

Massachusetts and Maine recently passed legislation that moves those states toward universal health care, she noted.

“In terms of solutions and trends, people did get alerted, finally, by, unfortunately, emerging and re-emerging infectious diseases,” Scrimshaw said. “People had gotten very complacent about public health and prevention, and AIDS and SARS and now avian flu have woken people up.”

Events in fall 2001 also provided a national wake-up call, she said.

“Both the anthrax scare and the fear of things that could be used as ways to ‘invade’ the U.S. that might involve infectious disease and contamination woke people up a little bit more,” she maintained.

“Public health, historically, has been concerned with health promotion and disease prevention,” Scrimshaw said. “This originally was the whole domain of our discipline. Now, we’re asking to look at these other things: the socio-cultural environment, including neighborhood living conditions;

opportunities for learning and for employment; community development; social cohesion; civic engagement; collective efficacy, and especially the concept that equity and justice are part of public health.

“This is absolutely critical. You might say, ‘Well I didn’t come to a school of public health to work on equity or social justice.’ My response is, ‘Yes, you did!’”

The new public health paradigm involves adopting a population health approach that considers multiple environmental factors and focuses on evidence-based decision-making, as well as community participation, strategies for changing behavior and social marketing, Scrimshaw said.

To implement this sea change will require strengthening governmental infrastructure, building new partnerships, enforcing accountability, and enhancing and facilitating communication within the public health system, she said.

“Let me ask a question. If we are talking about really changing our health system, what has produced major social change, historically, in this country, such as women’s right to vote, the civil rights movement or ending the Vietnam War?”

In these examples, the country had citizens committed to change, said Scrimshaw, who noted her grandmother chained herself to a fire hydrant on Broadway in Manhattan to protest the denial of women’s voting rights.

“We had initial resistance by political leadership, which was followed by some champions emerging. We had the mass mobilization of citizens, who pressured for change with the help of the champions. We had altruism: ‘I believe this is right.’ And we had self-interest in some cases,” Scrimshaw said.

“Who are today’s champions for the changes we need in public health? Do we have a Martin Luther King for public health? Do we have citizens mobilizing, like we did for the civil rights movement and the Vietnam War? Across the U.S., do enough people feel altruism or self-interest or both? Should we go state by state because we couldn’t do it nationally?” Scrimshaw asked.

“Are people listening? Well … they’re starting to. Are we ready to mobilize for public health equity? We’re not quite there yet. I think Frederick Douglass is absolutely right when he said, ‘Power concedes nothing without a demand. It never has, and it never will,’” she concluded.

During the question-and-answer session following Scrimshaw’s lecture, Bernard Goldstein, former GSPH dean, picked up on the speaker’s question about a state by state movement versus a national approach.

“Simplification is to me part of the problem,” Goldstein said. “Health is a very simple term, but if we mobilize, we get bogged down very quickly with all the details about how to improve it. Other countries have centralized health approaches.

“We have the Constitution that essentially gives everything to the states that the feds don’t have in there. Why don’t we aim for a constitutional amendment? Remember that’s how your grandmother got the right to vote. It’s a very simple idea: A constitutional amendment that guarantees the right to health. We can get people behind that.”

“That’s a very interesting idea,” Scrimshaw said, adding that she would promote it in her various roles in the public health field.

—Peter Hart

Filed under: Feature,Volume 39 Issue 7

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