Where better to start than with musings on this most fundamental question: what is public health?
When I was visiting grad schools, I remember overhearing a conversation another prospective student was having with a professor – the student was telling the professor that he could not make up his mind about what exactly he wanted to, and she responded, “Can’t make up your mind? This is the field for you.”
Indeed, public health sometimes seems like it has multiple-personality disorder – hospital administration and management, nutrition, environmental health, epidemiology, behavior health, health policy, biostatistics, health education, epigenetics – the list of subtopics within public health goes on and on, and sometimes there seems to be no tie but a connection (and that too, sometimes a very indirect connection) to protecting and improving health.
But there actually is an overarching approach that distinguishes public health from other fields (including medicine). The two key words: population and prevention.
As the Johns Hopkins Bloomberg School of Public Health’s motto so fittingly states, public health is about “protecting health, saving lives – millions at a time.” We design neighborhoods more conducive to exercise; we strive for improvements in hospital systems so as to reduce mistakes; we pursue policy changes to ban false marketing by cigarette companies – all these things affect not one or two people, but hundreds, thousands, and millions.
Public health is also largely about prevention – keeping bad things from happening in the first place, as opposed to solving or managing already-present problems (although public health does a fair bit of that too). We clean environments to prevent asthma, we don’t provide inhalers; we teach you to cough into your elbow to prevent the spread of flu, we don’t prescribe antiviral medicine; and we redesign cars and roads to prevent injury, we don’t perform surgery.
Interestingly (and unfortunately), the focus on population and prevention (which in many ways defines public health), may well be the very reason we don’t spend enough on public health, as David Hemenway eloquently points out in an issue of the New England Journal of Medicine from earlier this year.
He highlights four key reasons for underfunding:
- Because public health prevents, benefits lie in the future, and people prefer immediate gratification.
- Because public health addresses populations, beneficiaries are unknown – public health deals with statistical lives, not identifiable people – and people have stronger emotional and moral reactions to identifiable victims than statistical ones.
- Benefactors in public health are often unknown as well – public health has little news value (“saving statistical lives doesn’t make for good human-interest stories or photo ops”).
- Public health initiatives often require societal change – and that’s hard.
I could not agree more with this assessment, and sincerely hope the public health community makes a concerted effort to illustrate the importance of public health to our colleagues in medicine and other related disciplines, to our friends and family, and to our country and world. This blog is my little contribution towards that goal – a small step in the pursuit of public health.