By Gary Goldbaum, MD.
Public health is about the diseases we spread and the conditions that keep us healthy — the food we eat, the water we drink, healthy mothers and children, our community safety net, and our ability to monitor the community’s health so we know when new actions are needed. Public health is so basic, you’d think it would be immutable — yet it’s not what our parents or grandparents knew. And in the future it won’t be what we know it as today. To understand why, let’s look at how “health” has changed over time.
A hundred years ago, people died young. In 1900, white people in this country could expect to live to age 48, black people to 33. By 2000, life expectancy was 78 years for whites and 71 for blacks. And the causes of death changed hugely. A hundred years ago, 5 of the 10 leading causes of death in the U.S. were infectious diseases. By 2006, only one of the 10 leading causes of death was due to infectious disease (influenza/ pneumonia).
Most of the gains in life expectancy are due to public health-related changes to our environment and to our behaviors. Cholera killed an estimated 150,000 Americans in the early 1800s and still kills people worldwide today. However, improved sanitation and chlorination of municipal water supplies has virtually eliminated this devastating disease in the United States.
Public health advances in food handling have cut the chances of deadly food-borne illness. Hand washing, sanitation, refrigeration and pasteurization have made food consumption much safer. But public health can also intervene by watching for and responding to outbreaks of infectious disease, such as E. coli. These bacteria first came to the public’s attention in 1993 after hundreds of people in Washington state became ill from eating undercooked hamburgers at Jack in the Box restaurants. The bacteria can also be spread in child care settings, through improper food handling or from contaminated water. Public health agencies such as Snohomish Health District prevent the spread of disease through regulation and education in all of these areas.
Public health immunization programs have eliminated smallpox and polio and impressively reduced illness from measles and other childhood diseases in this country.
Tobacco use, our most preventable cause of disease, is a health problem that has not been as easy to solve. There was a dramatic decline in smoking and tobacco-related deaths following the 1964 Surgeon General’s report clearly identifying tobacco use as a major risk factor for lung cancer, bronchitis, heart disease, and emphysema. Unfortunately, approximately 15 percent of Washington state adults and 13 percent of high school students still smoke and declines in smoking have leveled. Meanwhile, state funding for prevention and quit tobacco programs has been virtually zeroed out — despite continued revenues from cigarette taxes and the tobacco settlement. Where we used to have multiple programs to prevent youth from starting to smoke and to help smokers to quit, the Snohomish Health District is now largely limited to compliance checks and retailer education related to sales to minors. Even so, progress on improving the environment for all has continued thanks to smoke-free policies such as the voter-approved Smoking in Indoor Public Places law — another public health success.
Changes to the environment or systems in which we operate have led to other public health advances. Consider the decreases in motor-vehicle-related deaths despite huge increases in the number of miles people travel in motor vehicles. These decreases are largely due to safer roads, safer vehicles, heightened attention to drunken driving and laws requiring safety belt use.
Public health has addressed the most dramatic and immediate causes of death and disease — but new problems are harder to solve. A 100 years ago, falls from horses or down elevator shafts caused injuries that killed people. Today, poisonings — mostly due to prescription drug overdoses — are the leading cause of unintentional injury deaths in Snohomish County. A 100 years ago, few people died of complications of obesity. Today obesity often leads to heart disease, diabetes and cancers that ultimately lead to premature deaths. While these diseases affect individuals, many have environmental roots and must be addressed at the community level, as for past public health efforts.
In 2009, a new strain of flu began to spread around the globe. The H1N1 “swine flu” pandemic demanded an extraordinary response to get people vaccinated as quickly as possible. The Snohomish Health District convened partners from the medical and pharmacy communities to quickly plan and then carry out huge mass vaccination clinics. On two consecutive Saturdays in October 2009, we vaccinated more than 25,000 people! I do not believe any other county in the United States achieved this.
In recent months we have been responding locally to a major outbreak of whooping cough. Although most children are up to date on their vaccinations, most adults have not had the booster. We again organized vaccination clinics with community partners, but we have also engaged nearly two dozen pharmacies to make vaccine available to people who don’t have insurance. These are creative solutions to recent emerging disease concerns. These are also approaches that recognize the new realities of public health practice.
That brings me to the present. I see six things happening today that will dramatically reshape the public health concerns of the future and how public health must respond.
First, local public health needs to pay close attention to what happens globally. It takes less than a day for people and their diseases to get anywhere in the world.
Second, our community is aging. In 1990, 22 percent of Snohomish County residents were 50 years old and older; that increased to 32 percent in 2010. This significant demographic change will influence the health issues that the medical and public health communities must address.
Third, chronic diseases due to a few key behaviors are killing and disabling us. Tobacco use remains the leading underlying preventable cause of death in our county. However, obesity is also a serious threat. Some experts worry that, if the obesity epidemic is not reversed, youth born since 2000 could be the first generation to have a lower life expectancy than their parents’ generation. To address these concerns, public health must focus on how to further reduce tobacco use, improve diet choices, and increase physical activity.
Fourth, the health care system is changing. Medical providers report to public health the disease conditions requiring public health’s immediate intervention, such as medicine to prevent the spread of illness. However, given the demands chronic diseases such as diabetes will increasingly place on the medical system, public health interventions are needed to assure that what a doctor offers in the office is not sabotaged by the environment outside the office. That means closer linkages.
Fifth, how we all connect to our world is evolving rapidly. Public health must take up new communication tools to deliver prevention education. Public health needs to adapt.
Finally, the resources to assure the public’s good health are shrinking even as the needs grow. The Snohomish Health District cut its expenditures and staffing from nearly $23 million and 227 full-time equivalent staff (FTEs) in 2009 to $16 million and 160 FTEs in 2012. We simply must do business differently.
I believe that addressing these issues demands action from an entire community. Clearly, the medical system of hospitals, clinics, and individual providers has an important role in public health. Senior services organizations, already engaged, will need to do even more as baby boomers age. Our schools are where children eat, play and learn, so we need schools at the table talking nutrition, activity and health.
Building infrastructure that supports healthy lifestyles means city and county planners also need to be at the table. Business needs to realize that illness impacts productivity, and then to consider its role in supporting employee health.
To help get all these groups to the table, the Snohomish Health District has embarked on a process to create a Community Health Improvement Plan. The process is being guided by our Public Health Advisory Council, a group of community leaders appointed by the Snohomish County Board of Health. Ultimately, the plan will be one that community members build, that speaks to the highest priorities for improving health, and to which community partners commit resources.
The Snohomish Health District will convene the partners and facilitate the process, but this is about much more than what a single governmental agency can do. When the entire community engages, we will have created the new public health.
About the author
Gary M. Goldbaum, MD, MPH, is the Health Officer and Director of the Snohomish Health District — the local public health agency for Snohomish County. Dr. Goldbaum has led the Health District since 2007.