David Hemenway is Professor of Health Policy at the Harvard School of Public Health, Director of the Harvard Injury Control Research Center, and Director of the Harvard Youth Violence Prevention Center. His previous books include Private Guns, Public Health. Hemenway is also the author of While We Were Sleeping: Success Stories in Injury and Violence Prevention, which was published by UC Press in March 2009. In his fourth blog installment, he explains how important and unappreciated public health is.
Underappreciated and Underfunded
By: David Hemenway
Public health has long been underappreciated; indeed, surveys show that few Americans have any idea what it is. Although public health has been far more important than medicine (curative care) in improving our nation’s health, all college undergraduates know about career possibilities in medicine, but few know about careers in public health.
Why did I decide to write While We Were Sleeping? It was to increase knowledge about public health by highlighting some of its successes. Public health involves assuring that drinking water is safe, that pollution does not despoil the air, and that diseases such as smallpox, polio, measles and tuberculosis are kept in check. It involves reducing rates of substance abuse, heart disease and obesity.
The book illuminates the public health approach for dealing with one particular subset of health issues—injuries (including violence). Although disease kills more people in the United States than injury, injury disproportionately kills the young. If you die before the age of 40, you are more likely to die of an injury rather than a disease.
The focus of public health is prevention. While almost all the resources for medical care go to treating individual patients after they become ill or injured, public health deals with entire populations— while they are healthy. The community is the patient, and the goal is to keep everyone in the community healthy.
To explain the difference in approach between public health and medicine, I often use an example from public health research on suicide. When I give presentations to psychiatrists and other mental health professionals in Massachusetts, I ask why they think Arizona and many other states have higher suicide rates than Massachusetts. The response is typically not an explanation, but a “they do? I didn’t know that.” The focus of mental health providers is on the treatment of individual patients. By contrast, public health is interested in understanding and improving the health of populations. Both approaches are important. By the way, the answer to the question is NOT that people in Massachusetts have better mental health than those in Arizona.
One reason that public health is so underappreciated is that we can’t usually identify which specific individuals have been helped by public health measures. If you don’t get sick at work because of improvements in indoor air quality, not only do you not know whom to thank, you rarely realize that you have been helped. The same is true if you don’t get poisoned because the food is safe, or you don’t get run over because the walkway has been separated from the road. These are all public health initiatives.
Thus a problem for public health funding, particularly compared to funding for medical care, is that there are no grateful public health patients. I recently spent a few days at one of the leading Boston teaching hospitals. Not only is every building named—after some rich benefactor rather than an outstanding physician or nurse– but so is virtually every wing, floor, alcove and seminar room. By contrast, two of the four buildings at Harvard School of Public Health remain unnamed.
The goal of While We Were Sleeping is to increase appreciation of, and maybe even funding for, an underappreciated activity that has been crucial for our societal advancement– public health.
