Although she probably would not object to adding obesity (with its tight connection to poor food, inadequate physical activity, and too much TV) and greater equity to the list, Commissioner Ferrer’s three challenges begin to frame a Public Health approach to livability. Safety, at home and on the street, is the prerequisite for nearly everything from personal wellbeing to neighborhood life to economic prosperity. Our health is not a separate phenomenon from everything else in our lives – our homes, neighborhoods, transportation methods, jobs, recreation, family and social life have a powerful effect on our well-being: policy makers dealing with any other those areas have to make health impact a visible consideration. No public agency or department should be allowed to narrow their focus in ways that externalize burdens and costs – every program has to include a broad range of goals. And we have to start forcing our health care system – the most technologically advance, most expensive, and least cost-effective in terms of population wellbeing of any industrialized nation in history – to pivot from prioritizing medicalized sickness treatment to helping keep people from getting sick in the first place.
Public Health is not just about living longer, but living better; not only about meeting basic needs, but the quality of people’s interactions; not just about individual health, but about population-societal well-being and equity. In this era of political polarization and cultural anxiety, Public Health provides powerful strategic insights for a variety of public issues. So it’s probably no accident that MassDOT’s latest advance towards transportation reform is titled the “Healthy Transportation Policy Directive.” It’s not just that Secretary Davey is using words required by the 2009 Transportation Reform Act, and it’s not that economics aren’t the most powerful underlying driver of politics. Just the opposite: it’s that he recognizes that for transportation – as for a huge number of other sectors – having access to basic daily needs such as jobs, healthcare, food and school is a catalyst for being healthy and is a critical part of the path to economic development with a high return on investment.
But too often, invoking health is a marketing ploy, not a programmatic or policy direction. Some of the misappropriation of the term is deliberate. Some of it comes from the confusion between Medicine’s focus (at least in our cultural image) on dramatic and quick results – the “magic pill” we all wish would solve our every problem – and Public Health’s focus on longer-term solutions and population wellness within its three themes of Prevent, Promote, Protect. Related to this is that most of us have little understanding of what Public Health encompasses. Rather than Medicine’s traditional focus on individualized treatment, Public Health is about maintaining wellness – prevention – and it focuses on interventions that increase resilience and reduce exposure to health risks for an entire population. Public health is not just about improving our overall health statistics, but also about the distribution of that improvement through every sector of society.
Public Health can be thought of as having three major components: Preventive Medicine, Standards Enforcement, and Primary Prevention, all in a context of reducing outcome disparities between subgroups. Preventive Medicine, such vaccinations and helping patients continue taking prescribed drugs, is what hospitals and other health service providers are beginning to do, but need to be forced to do more. Standards Enforcement, such as restaurant and housing code inspections, is one of the functions of government that we have to make sure declining budgets don’t cut into ineffectiveness. But Primary Prevention is the most fundamental, powerful, and difficult.
Preventive Medicine is the most well-known component of Public Health. Infectious diseases are the world’s most deadly illness, particularly to young children and new mothers. Even today, respiratory and diarrheal infections, HIV/AIDS, malaria, and TB are responsible for over two-thirds of all deaths globally. The threat of new pandemics continues to be a major Preventive Medicine focus, with modern vaccination part of the bedrocks of past and hopeful future success.
In addition to vaccination, early detection and treatment, medical providers have been paying much more attention to increasing patients’ compliance with doctor’s orders and drug prescriptions, and some have even been working to improve their staff’s cultural competency in dealing with diverse populations. While expanding health coverage is what is best known about both Massachusetts’ Health Care Reform laws and the federal Patient Protection and Affordable Care Act (aka the ACA or Obamacare), both are also designed to push the medical community, particularly hospitals, to pay even more attention to these pre-admittance and follow-up preventive functions, including ensuring that patients are able to travel to their appointments, as well as to lowering the number of in-hospital infections and treatment mistakes.
(The ACA is the most important public health legislation in more than half a century. Among its accomplishments are the creation of both a National Prevention Strategy and a Prevention And Public Health Fund includes the Community Transformation Grant program, which address both primary community-based prevention and clinical preventive services.)
Unless start-up missteps with Obamacare allow enemies to kill the entire program, some segments of our national sickness-treatment system will be switching from pay-per-procedure to pay-per-person reimbursements. The law also creates a broader definition of the Community Benefits that non-profit hospitals are required to provide to retain their tax-exempt IRS status. In Massachusetts, the pioneering Prevention And Wellness Trust Fund seeks to lower health care costs by reducing the impact of chronic illness. As a result hospitals and some other medical-care providers will have a greater financial interest in helping people not get sick in the first place. As part of this, there will have to be an increased focus on coordination between different components of the health care system, anchored by the technology-enabled idea of a “medical home” or even the more expansive “health home.”
Most branches of the medical profession already understand that life-style changes are a necessary component of both Prevention and Treatment. So one component of Preventive Medicine are supportive services – programs that help people entrapped in tobacco and nicotine addiction, alcoholism and drug abuse, and obsessive gambling; programs that help people pull themselves together when faced with domestic and street violence or by the effects of war; services that help families cope with the multiple problems emanating from chronic illness or injuries. At their best, these services are structured to encourage mutual support rather than just professional ministrations, and to empower people to go beyond coping to pro-active prevention through healthy behaviors.
But even supportive services are after-the-fact. So some progressive medical practitioners and researchers are looking for ways to reach “upstream” to where the injuries and diseases they treat really begin. In The UpStream Doctors, Albert Schweitzer Fellow-for-Life Rishi Manchanda says that hospitals and medical practices need to change their intake questionnaires to include a broader scan for problems beyond the body in the reality of people’s homes, work, food, play, and relationships. They need to have a person on staff whose job is to work with patients on these pre-clinical problem sources, or at least connect patients with other service and advocacy groups who can.
This is not just about medical altruism or idealism. To keep health care costs from bankrupting their budgets, Mayors and Governors are going to be using the Patient Protection and Affordable Care Act to redirect some of the enormous sums now flowing through the high-end of the hospital, medical specialist, and medical technology industries towards community services. Change is coming; the only question is how deep it goes.
Consumers, workers, the general public, and our natural environment are regularly endangered by bad products, unsafe working conditions, and polluting emissions. As a result, government has become responsible for setting and enforcing a broad array of standards including health and safety standards for restaurants, housing, workplaces, food stores, as well as for air, water, and noise quality – and transportation-related air/water quality controls. The recent exposure of tainted drug-compounding procedures at various manufacturing firms is an example of what happens when this function is underfunded or cut-back in the name of either tax relief or reducing bureaucracy.
All this is sometimes described as “public health infrastructure.” It has a huge impact on people’s live and it’s incredibly unsexy, and therefore, tremendously at risk of being underfunded.
The ultimate goal of Public Health is to reduce the odds that people get sick in the first place, and improve their chances of successful recovery if they do succumb. This doesn’t happen through one-on-one interactions but rather, through changing the larger context and environment – the things that “tilt the playing field” so that certain behaviors become easier and more frequent than others, more the general default. Primary Prevention is a key strategy for reducing the incidence of chronic disease – the largest and most expensive type of illness. According to the Centers for Disease Control nearly half of American adults live with at least one chronic illness which absorbs more than 75% of our total health care costs and significantly reduces the sufferer’s ability to function either at work or at home.
Mandating speed limits for cars and the use of seat belts reduces the risk of accidents and injuries on a population-wide basis. Overall behavior patterns are more indirectly nudged by taxes (such as that on sugar-sweetened beverages) and subsidies (such as providing school lunches or creating incentives for supermarkets to locate in “food deserts”) that reshape the marketplace away from its current tilt towards unhealthy to healthier choices (such as from high-profit, empty-calorie foods to fresh fruit and vegetables). The odds that people will have some every day physical activity is increased by inserting parks and playgrounds into the built environment, and prioritizing walking and bicycling facilities in transportation planning. Anti-smoking programs combine all these approaches: forbidding smoking in many places, making it harder to buy cigarettes, raising the cost of cigarettes, and conducting media campaigns to make smoking look uncool.
At its deepest level, Primary Prevention is about the way society’s institutional and cultural structures shape the way we live, eat, work, play, raise families, grow old, and even how we feel. Our behaviors and wellbeing are both influenced, if not determined, by the surrounding environment. The external, non-biologically inheritable, factors that promote wellness and resilience or put a person or population at risk of injury and disease are called the Social Determinants of Health. It is illustrated through a Social-Ecological Model of concentric circles with the individual in the center surrounded by Interpersonal Relationships, then Community Customs, Institutional Operations, and Societal Structures.
The most powerful insight of this approach is its understanding that statistically improving the health of a society involves more than good sewerage and garbage collection, safe and affordable housing and food and working conditions, even more than clean air and water. It also requires addressing poverty, discrimination, racism, and violence – which can be at least partly thought of as what comes out under the dysfunctionalizing pressure of the previous two. Violence, and the fear of violence — domestic and street, against people or things, direct and indirect – isolates people, forces parents to keep their children indoors, and saps both our collective resources and good will. Violence, like corruption, pulls the ground out from sustainability and leads only to the type of predatory interpersonal relationships and businesses that keep us poor and spiritually broken.
In the breath of its scope, Primary Prevention can be dauntingly complex. In the Commonwealth, the Department of Public Health’s Mass In Motion program encourages municipalities to create local Coordinating Committees pulling together police, Parks and Recreation, Schools, Social Services, Transportation, Public Health, and other departments that develop holistic programs to address obesity, safety, better nutrition, increased physical activity, and other risk-reducing environmental changes. (Mass In Motion also has an important workplace wellness component.) At both the local and state levels, at both the Cabinet and Agency levels, there is a move towards using a Health In All Policies strategy to leverage the organization’s entire portfolio of programs to create a solid floor of support for everyone. (See the new APHA material: Health In All Policies: A Guide for State and Local Governments.) Zoning, street design, school activities, police programs, and more – each needs to see itself as part of the solution – an understanding that is often expressed through developing a Health Impact Assessment of a proposed policy or program.
PUBLIC HEALTH & TRANSPORTATION
All of which brings us back to transportation, the other theme of this blog. Lurking inside each of Commissioner Ferrer’s public health challenges is the need to continue changing the way we move around – because how we move around significantly impacts not only our personal but our economic health, not only our neighborhoods but our global environment. It’s not just the quantity of moving things, information, and people that’s important, it’s also the impact both what is in motion and on the surrounding environment. Yes, we want our packages to arrive quickly and unbroken, our data to arrive unscrambled (and unread!), ourselves to arrive dry and safe. But we also want the traveling process to have the least possible negative, or even the most possible positive, effect on ourselves and on overall conditions.
Even more, our ability to be active shapers of our social-ecological environment is deeply related to our ability to get to potential jobs, family, or friends, as well as the “externalized” impacts of that activity on air, water, and noise pollution. Safe streets – safe to cross, safe to be on, safe to be around – are part of a “virtuous circle:” the safer a street is the more people will use it, the more people who use it the more it becomes part of the community, unavailable for anti-social behavior, and a launching pad for empowerment. Transportation-related Health Impact Assessments have shown the broad impact and relative ease of addressing these issues.
Transportation is a high-leverage approach to creating a built-environment that makes it more likely that people are physically active as part of their daily routines, a key strategy for improved resilience and both physical and emotional wellness. And the better condition people are in the more productive they are at work and the less expensive they are to treat when sick. Easy movement is good for both personal health and economic vitality, which makes transportation such a core issue for the livability and sustainability of our communities. It is the interweaving of the themes of health, economic development, and environmental protection – along with their equitable distribution – that make transportation such an important issue for the livability and sustainability of our communities in these stage-setting years of the early 21st century.
Thanks to Andrea Freeman, Maddie Ribble, and Jessica Collins for comments on earlier drafts.
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