Healthy People 2010: Not quite there yet
Two articles in the Perspectives section of a recent issue of the New England Journal of Medicine (May 6, 2010) provide an interesting view into the state of the U. S. public health system. In the first, Dr. Howard Koh provides an evaluation and reaffirmation of the Healthy People initiative, started in 1979 by the Department of Health and Human Services as a way of systematically setting health goals, collecting relevant data, and monitoring outcomes for health-improvement activities in the U.S.(1) He points out that while small but measurable improvements in quality of life have been acheived in the last decade, the goal of eliminating disparities in health outcomes has been largely unmet. In the second, Dr. David Hemenway, laments the state of funding for public health in the U.S. and attempts to explain the underfunding of public health measures.(2) Taken together, they highlight a trend that is widely understood by advocates in social medicine: underfunding of public health initiatives directly impacts the level of disparity in health outcomes.
Healthy People 2010 focused on two main goals: increasing quality (and quantity) of life for Americans and eliminating health disparities. Dr. Koh demonstrates that the results have been mixed. For 28 focus areas, ranging from access to quality health services to oral health to vision and hearing, just over half have seen improvement and nearly 20% have seen their target met. By some measures, we have either remained discouragingly far from stated goals or actually worsened. Cigarette smoking, for example, which is the leading cause of preventable death worldwide, decreased from a baseline of 24% in 1998 to 21% in 2008, far from the stated goal of 12%. We are significantly more obese as a nation than we were ten years ago. Approximately 1/3 of all adults over 20 years of age are obese, up from under ¼ two decades ago. Unfortunately, the gains and losses in the health of Americans are not equally shared. The goal of eliminating disparities remains, according to Koh, “unmet.” Increased rates of obesity, for example, are greater in Blacks and Mexican Americans than they are in Whites. Dr. Koh cites a review by Sondik et al (3), who demonstrate numerous examples of increased disparities in indicators of quality of life and overall health. They conclude that “overall, in the area of disparity reduction, there is not much good news.”
Dr. Hemenway points out that “it is generally acknowledged that public health is systematically underfunded and that shifting resources at the margin from cures to prevention could reduce the population’s morbidity and mortality.” He cites four reasons for the underfunding of public health: first, the benefits of public health measures are not immediate and therefore require a delay of gratification. The costs are immediate but the results are both distant and unpredictable. Second, “the beneficiaries of public health measures are generally unknown.” Money flows more readily towards identifiable victims than hypothetical victims of future events. Third, the benefactors of public health intitiatives are unknown by the beneficiaries: “when people benefit from public health measures, they often don’t recognize that they have been helped.” The current TEA party movement provides a wonderful, if tragic, example of this, blind as it is to the concrete benefits of taxes and government. Fourth, public health efforts often suffer from disinterest or, worse, outright opposition. Hemenway cites “status quo bias” and “tradition-bound resistance” as examples of human characteristics that impede progress in public health initiatives.
It is reasonable to hypothesize that the systematic underfunding of public health initiatives contributes directly to disparities in health care. And it is likely that the Healthy People Initiative will never realize the goal of eliminating disparities until public health funding can be consistently and meaningfully funded. After all, it is the poor, the under- and un-insured, who tend to benefit most from public health initiatives like vaccinations, clean water supply, and clean air, and who suffer disproportionately in their absence. Michael Harrington, in his landmark book, The Other America (1962), wrote about an America that was “hungry, and sometimes fat with hunger, for that is what cheap foods do. They are without adequate housing and education and medical care.” Nearly five decades later, these problems have not gone away. As Healthy People 2010 comes to an end, in some cases they are worse.
It might be tempting to use Healthy People 2010 as an example of the ineffectiveness of public health initiatives. Or one could argue that the Healthy People initiative sets unrealistic goals. I would argue that the US government has a chance to prove otherwise with Healthy People 2020. As the DHHS plans for the next decade, healthcare professionals must push our legislators to assure adequate funding for the public health initiatives that improve all of our lives in unseen but measurable ways. We must urge them to block out the loud voices of those who would stop paying taxes without knowing what taxes pay for. Finally, and most importantly, we must ask for more coordination between those that initiate public health interventions and those that measure the results. Those who implement public health programs must work directly with those who establish goals for their efficacy. Measuring our own failure can only be of value if we have the means to turn it around.
1. Koh H. A 2020 Vision for Health People. NEJM 2010;362:1653-6.
2. Hemenway D. Why We Don’t Spend Enough on Public Health. NEJM 2010;362:1657-8.
3. Sondik EJ, Huang DT, Klein RJ, Satcher D. Progress toward the Healthy People 2010 goals and objectives. Annu Rev Public Health 2010;31:271-81.
0 Responses to “Healthy People 2010: Not quite there yet”