University Times

Is the public health system on the right track? Or does it need an extreme makeover?

“I’d argue that public health has lost enough focus and is not looking enough to really make the solid outcomes,” said Ronald E. Voorhees, a visiting faculty member in the Graduate School of Public Health, in a Dec. 8 epidemiology lecture, “Lost Ground: Can Public Health Really Improve Health?”

“Public health fundamentally is about change,” said Voorhees, chief of the Allegheny County Health Department Office of Epidemiology and Biostatistics. “If the population is healthy, there’s not much to do. But we are seeking change,” he told the mostly-student audience.

Voorhees cited British social systems analyst Geoffrey Vickers’s characterization of the history of public health as “successive redefinings of the unacceptable,” adding that public health’s progress is beginning to lag behind that of other disciplines.

Public health practice is similar to medicine in that practitioners define a problem and seek to solve it by developing a treatment plan and assessing the plan’s progress, Voorhees said. A patient sees the doctor not merely to receive a diagnosis and treatment plan, “but ultimately to make things better.”

In some areas, such as immunization, public health does a good job, Voorhees said. However, in other areas  he argued that public health often fails to examine its interventions afterward to determine whether they really did make things better.

Defining the problem

Voorhees said that public health problems need to be defined in a better way with more thought about causality and the interrelatedness of public health issues.

In defining a problem, “We tend to pick and choose measures based on what we’ve preconceived,” he said. “We often pick a measure that suits the problem we’re concerned about.” For instance, in the case of chronic diseases, the measure likely would be related to leading causes of death. In assessing injuries as a public health concern, the measure likely would relate to years of potential life lost. In behavioral health, quality of life measures might be more common, he said.

“We can have lots of measures in public health,” Voorhees said. But are such factors as longevity, morbidity and quality of life the right measures? Or should other factors such as safety and security, hope and happiness, play a role in assessing outcomes, even though such factors are harder to measure?

Problem analysis

While defining a problem is important, Voorhees said problem analysis is another crucial factor. “We need to think ‘upstream’ and find out what causes underlie the problem,” he said.

For instance, in studying the circumstances under which polio might recur in the United States, Voorhees said that both unvaccinated individuals and circulating disease would need to be present.

Thinking upstream, he said, what would cause there to be unvaccinated individuals? They could refuse the immunization or simply lack access to the vaccine. What would cause circulating disease? There could be domestic sources, or imported cases.

Digging deeper, he said, the questions turn to the contributing elements that spark those situations. Why would individuals refuse the vaccine? Fear of the disease, lack of education, poor school enforcement or low vaccine supplies all might be factors.

Thinking upstream, one must go to the tributaries and find the elements that something can be done about.

He said public health professionals must look not only at the problem, but also examine potential interventions. Efforts could focus on better health care access, improved school enforcement or better education to encourage more people to be vaccinated.

Voorhees noted that for chronic diseases such as diabetes, downstream consequences as well as upstream factors should be taken into consideration.

“The models start getting complicated, but at least it’s a framework that helps us assess what the actual causes are.”

Causal analyses are useful, he said, but they need to be expanded, and quantitative assessments for both causes and interventions must be done.

“We need the same sort of detail about the cause of the public health problem as you do for a clinical diagnosis if you went to see a health-care provider,” Voorhees said.

Measuring impact

After defining a problem and examining the causes behind it, assessing impact is important. “We’re really not doing a good job of measuring impact at the population level,” he said.

Focusing on whether a certain intervention is effective is merely the first step, Voorhees said. In addition to considering whether an intervention is effective, the number of people being reached is important as well.

Ideally, interventions should reach lots of people and be highly effective, he said. Realistically, he acknowledged, resources can be an issue.

Some interventions may work, but they’re still in demonstration models. “So we end up having an intervention that might be highly effective, but doesn’t reach enough people,” he said.

“If we had a vaccine for measles and only gave it to 10 percent of the population, we’d be wasting our time. And in fact we would conclude that at the population level it doesn’t have impact and we should go on to something else,” Voorhees said.

Public health is falling behind in terms of effectiveness, he said.

Examining different interventions to determine which have the highest value is difficult to do, he said.

In attempting to establish effectiveness, “The evidence often looks at different outcomes, different interventions, different populations.” That can lead to a reverse ecologic fallacy, Voorhees said.

“The primary mode of funding for many things is to fund demonstration projects, but then we expect there to be a population parameter change. We’re looking not at impact but effectiveness, and competitive funding really leads into that,” he said.

“I think public health needs to focus on impact, needs to use its tools more effectively and really has to look at funding that really would allow assurance so that if we have something that really is appropriate, that people really get it.”

Tough problems

“We need to stop avoiding tough problems,” Voorhees admonished. When causal analyses of a public health issue reveals that factors such as poverty, access to care or race are at the root, “we say, ‘We can’t do anything about that,’” he said. “We need to stop that approach.”

Better modeling can help answer questions about an intervention: In which populations is it effective? Under what circumstances?

The life course approach

As an example, Voorhees cited the racial disparities found in infant mortality rates in Allegheny County. While the county has seen a decline in infant mortality in absolute numbers over the past four decades, the gap between black and white infant mortality rates is greater.

“In recent years there seems to be a gradual increase in low birth weight for black infants and a decrease in whites, further exacerbating the disparity,” he said, citing one common cause of infant mortality.

But what underlies the disparity? For both black and white mothers, infant mortality decreases as education levels rise. “It’s a much stronger relationship for blacks,” he said.

“You can say this is a strong relationship, but it doesn’t ask the real question. At every level there still is this huge disparity between black infant mortality and white. And in fact when you look at black mothers who have a graduate degree — professionals, PhDs, physicians, lawyers — they still have a higher infant mortality rate than white women who drop out of the eighth grade.”

Similarly, income and exposure to violence are related, he said. “These are correlations, but what are the real risk factors for violence?” For victims of domestic violence, he said, risks include having witnessed violence against their own mother, poor mental health, unemployment and other factors in their family of origin. Likewise, exposure to violence in their family of origin is a risk factor for becoming an abuser.

“What’s really happening here? What’s that impact?”

The “life course approach” is gaining popularity as a method for clarifying such questions.

The approach grew from an attempt to examine black-white health disparities.

“It really takes into account that we can’t just look at proximal events, we have to look at the upstream — not just in causes, but also in time.” Instead of just looking at disease and death, the life course model looks at events over the whole life of that person.

“You can’t expect to fix something that is a pre-existing condition just during the nine months of pregnancy,” he said. “It also takes into account timing, that there are certain critical times such as early childhood when an event happening has far more impact than it does later in life.”

The environment also is a factor. “We have to look at environmental factors and the social and physical environment and how that affects each of these developments,” Voorhees said.

“Finally, it really is about trying to establish equity in society.”

In examining violence through that lens, “There has to be a perpetrator and susceptible person,” he said. “Both are needed to have a domestic violence situation.”

Many factors feed the situation: mental illness, substance abuse, poverty, adverse childhood experiences, witnessing violence, combat trauma and racism. “All are traumas that can happen at different times,” Voorhees said.

While good data showing the effect of such risks exist, “It’s not clear how to tie them together,” he said.

Childhood trauma is one area in which much has been learned in this regard, Voorhees said.

The ACE Study, a collaboration between the Centers for Disease Control and Prevention and health insurer Kaiser Permanente, examines the correlation of adverse childhood events (ACE) such as abuse, mental illness, violence and other experiences, with various health outcomes in later life.

Through a questionnaire to patients who had come in for a health risk appraisal, researchers found that 3 percent of respondents had a parent who had been in jail; 11 percent had experienced physical abuse; 11 percent had experienced psychological abuse; 12 percent witnessed violence against their mother; 19 percent experienced a parent’s mental illness, hospitalization or suicide attempt; 22 percent reported sexual abuse as a child, and 26 percent reported substance abuse in their household.

“Any one of these represents a significant trauma,” he said, noting that respondents could report multiple ACEs. “If you had one, you were just as likely to have at least two,” Voorhees said.

More ACEs were related to higher incidence of certain health problems, he said.

For people with four or more ACEs, the risk of being a smoker increased three-fold compared to those with no ACEs. Depression, alcoholism and risk for sexually transmitted diseases all were higher among those with more ACEs, he said.

“We’re starting to see this pattern of things people are trying to use to perhaps cope with the pain and the stress of having these adverse childhood experiences,” he said.

Strongest of all was a 14-fold rise in the risk of suicide attempts: 1.4 percent in people with no reported ACEs to almost 20 percent for those with four or more ACEs, he said.

Traumatic events can alter a person’s development, he said. “People who were hurt themselves are more likely to hurt other people and themselves,” he said.

Individuals with these changes in stress responses are more likely to have affective disorders, substance abuse or to be physically ill or depressed, Voorhees said. People with those conditions are not as likely to get and keep a job, which in turn creates stress for their families and family dysfunction.

“We’ve got somebody who’s grown up in a traumatic situation. Now they’re grown older and are ready to have a family of their own, then bingo, we’ve closed the loop. In essence, we have transmission of a chronic disease and prime disease risk from one generation to the next,” he said.

“We should be able to model and think about interrupting different points of this life cycle if we’re going to have an impact,” he said. The individual cycle and its environmental context both must be examined, he said.

Home visit programs, early screening and treatment for substance abuse and mental health issues all would represent appropriate responses, he said. “And we can look at the overall society and say if we increase justice, if we increase equity and increase love in society that will also have an effect because those also are important factors.”

Downstream consequences also factor in. People with four or more ACEs have greater problems getting and keeping a job.

Staggering costs are associated with ACEs, Voorhees said.

For example, adult victims of child abuse were more likely to have physical and mental health problems, more likely to be poor and more likely to be on Medicaid, researchers have found.

St. Louis University estimated the annual cost in the United States of childhood abuse and neglect was some $94 billion. Extrapolating, Voorhees said that the annual cost in Allegheny County was more than $376 million.

“Are we focused on the right point?” Voorhees questioned. From a causal standpoint, what does it take to make something happen, he asked. “Not only do we have interventions that work to reduce these ACEs, but they save money.”

Citing a return estimated at 16 percent, Voorhees said, “We shouldn’t be building stadiums or giving tax breaks to companies. This is good economic development — good not only in the consequences, but to do these programs you have to have trained people, who are distributed around wherever people have babies, which is everywhere. It’s economic development that could really work.”

Creating change

So how can public health professionals create the change they’d like to see? Voorhees said it will require engagement, taking responsibility for the public health system and building systems to fix the gaps that have been identified.

“It’s also not enough to be looking at the small picture,” he said, quoting author Victor Sidel, who asked, “‘Can we hope to develop a just, caring, democratic and communal health care system in the midst of an unjust, technologized, depersonalized, hierarchical, fragmented country?’ He said the answer, of course, is no, but we have to try because the efforts to try to solve these very difficult problems will have value in themselves.”

—Kimberly K. Barlow