Boston Globe, 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 coverage.

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 speechifying.

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 accounts.

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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