Boston Globe  [Printer-friendly version]
February 11, 2006


[Rachel's introduction: For 100 years, the cornerstone of public
health theory and practise has been "primary prevention" --
preventing disease instead of having to cure it. Really, the
precautionary principle is nothing more than a traditional public
health approach. If they ever got together, citizens who favor the
precautionary approach and public health specialists in every county
and municipality might discover that they are natural allies.]

By Madeline Drexler

Last week, in his State of the Union address, President Bush bemoaned
spiraling medical costs -- and rightly so. What he didn't say was that
99 percent of US healthcare dollars are spent on treating and curing
disease, and only 1 percent on preventing disease. That logic is
backward -- and the president's proposed 2007 budget makes matters
even worse.

Health savings accounts, medical liability reform, and token infusions
of cash are the wrong medicine for what ails Americans. If the
president were sincere about nurturing a "compassionate, decent,
hopeful society," he would reinvigorate our public health system.
Public health, after all, is both morally enlightened and economically
prudent. It rests on the idea that promoting health and averting
disease saves more lives more cheaply than does high-tech medicine.

It's a concept Bush has consistently weakened. "This is probably the
worst administration ever for public health," said Dr. Walter Tsou,
immediate past president of the American Public Health Association, at
the group's annual meeting in December. "They're constantly cutting
back money -- with the exception of things that actually scare them,
like bioterrorism and pandemic flu." What's killing us now, as opposed
to what we fear will kill us, is cancer, heart disease, tobacco-
related afflictions, complications of obesity, drug-resistant
infections, and other ills, both chronic and acute.

In fiscal 2006, the Centers for Disease Control and Prevention's core
programs suffered a 4 percent funding cut, compared with the previous
year; Bush's proposed 2007 budget lops off another 4 percent. These
core programs -- that is, nonterrorism-related activities -- are the
bread and butter of public health. Among the programmatic victims are
chronic disease prevention and health promotion, occupational safety
and health, environmental health, and health services block grants to
states, which cover everything from cancer screening to flu shots.

These aren't just meaningless line items; they're people's lives. In
2004, Dr. Julie Gerberding, the CDC director, stated that "robust"
funding of disease prevention programs could each year save diabetics
from 43,000 amputations, 165,000 kidney failures, and more than 10,000
cases of eye disease; reduce by half 40,000 new HIV infections; and
forestall two-thirds of alcohol-exposed pregnancies.

Healthcare coverage is another foundation stone of public health. In
his enthusiasm about insurance portability, Bush forgets to mention
that 46 million Americans don't have health insurance to haul around.
That's a death sentence. According to a 2004 Institute of Medicine
report, 18,000 adults die unnecessarily each year because they lack

So what's the alternative? How can the administration truly improve
the state of the union's health?

First, it must follow its own advice. Every decade, the US Department
of Health and Human Services publishes a document that sets national
objectives for curbing disease and improving health. Its "Healthy
People 2010" report calls for reducing obesity levels to 15 percent of
the adult population and 5 percent of children and adolescents;
cutting tobacco use to 12 percent of adults and 16 percent of
adolescents; and eliminating exposure to hazardous ozone levels. These
official goals are so far out of reach as to be cynical. Achieving
them requires action -- not 11 brief sentences of prime-time

Second, the administration must think as globally about health as Bush
is fond of boasting he does about the economy. Many nations, both rich
and poor, have a keener sense of the value of comprehensive health
measures than does the United States -- and we should learn from them.
In Sweden, for example, the national agenda is to "Create social
conditions to ensure good health, on equal terms, for the entire
population." That includes not just wholesome foods and local parks in
which to exercise, but also jobs and a good education. In the United
Kingdom, far-flung government authorities are required to collaborate
on ambitious health targets.

Finally, our history-loving president might borrow a page from the
annals of public health. During the late 19th and early 20th centuries
-- the profession's golden age -- its leaders thought big. They didn't
dole out scraps of rhetoric; the language of social reform came
naturally. In 1905, Hermann Biggs, New York City's legendary health
commissioner, famously asserted: "Public health is purchasable. Within
natural limitations a community can determine its own death rate."

And no, he wasn't talking about tax-deductible health savings

Madeline Drexler is a Boston-based journalist and author of "Secret
Agents: The Menace of Emerging Infections." She has a visiting
appointment at the Harvard School of Public Health.

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