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PERSPECTIVEPutting The Public In Public Health: New Approaches
Improving health in the twenty-first century means adopting a new approach that engages the public, the business community, and public policymakers more than in the past. This approach depends on a well-informed public that practices individual wellness, values community health, and advocates achieving both. It requires a business community that views public health as an essential component of a healthy business climate and productive workforce. It also requires informed policymakers who agree that an investment in public health has important community benefit. Public health professionals must effectively engage these three groups if the public health system is to be transformed.
THE UNITED STATES SPENDS $1.9 trillion annually, more than any other country, on health care.1 Yet the United States ranks 37 out of 191 World Health Organization (WHO) member-nations as to eight health outcomes.2 There are many signs that the U.S. health care system is in trouble: rising costs, uneven quality, and decreasing access to care. The system strongly focuses on curing and treating disease but seems to place less value on preventing or delaying the onset of disease and ensuring wellness. For example, (1) cancer screenings have proved their worth in early detection and more effective treatment, and the death rate from colorectal cancer, the second-leading cause of U.S. cancer deaths, would be halved if all adults over age fifty were screened.3 (2) The opposition by many in the business community to smoking restrictions in restaurants and bars—despite the documented risks of second-hand smoke to the health of their employees and patrons—is perplexing. This is especially true when one considers the strong evidence that these restrictions do not have a negative effect on business.4 (3) The growth in the incidence of type 2 diabetes in children, which is directly linked to obesity, is a function of changing diets and inadequate exercise. A growing body of research tells us how effective prevention is, in both economic savings and healthy outcomes.5 Yet establishing a common focus on creating broader access to preventive programs and services continues to fail to get real traction. Because of this, public health advocates now argue that it is time to balance the investment with a greater emphasis on prevention and use a population-based approach to health. By refocusing the system toward wellness, one can prevent or delay the onset of disease, improve the quality of life, and increase individual productivity. The Institute of Medicine (IOM) defined the mission of public health as "the fulfillment of society’s interest in assuring the conditions in which people can be healthy."6 Achieving this mission would require the understanding and engagement of certain critical stakeholders such as the general public, the business community, and public policymakers. To date, public health supporters have not been as effective as they could be in engaging these groups in ways that allow them to understand their potential both for improving community health and for investing in it. To change this paradigm, each stakeholder group has to be approached with a clear understanding of their needs. A strong case must be made concerning the benefits of health and wellness to their interests and how they can achieve these benefits through a partnership with public health.
It is generally agreed that public health measures have been responsible for the greatest increase in human lifespan, yet this fact has been largely invisible to the public. It is often said that public health has done its best job when nothing happens. In an unpublished survey conducted in 2001, 78 percent of respondents said that they had never used a public health service.7 Since we all breathe the air, drink the water, eat the food, and have benefited from vaccines and safer automobiles, this notion is clearly false. It does, however, show the average person’s lack of understanding of the broader protection and prevention activities that public health achieves every day. Despite these advancements, there is a big gap between how healthy we are and how healthy we could be. Some of it has to do with who we are, some with the environments in which we live and work, some with access to care, and some with how we live our lives. Much of this is in our control, but we have failed to use the tools at our disposal to prevent disease or protect both our individual health and the health of our communities. It is often said that the public health community speaks to itself and fails to effectively communicate with the public. To date, most public communication is in the form of health advisories or focused social marketing efforts without direct engagement of the public. It is time to find ways to more effectively engage the public in the changing of community norms to support their health. To accomplish this, several new efforts are under way. A National Citizens’ Movement in Public Health. This grassroots, multiyear campaign of the American Public Health Association (APHA) seeks to engage the public in ensuring that all individuals can protect themselves, their families, and their communities from serious, preventable health threats. By reaching out directly to Americans, the APHA hopes to make the public aware of the substantial benefits of public health and change community expectations toward improving population health. Measures of success would be an increased awareness, engagement, and investment in the people, programs, procedures, and institutions that create healthy people in healthy communities. It would include a future where the Healthy People 2010 goals (and future iterations) would be realized. Alliance for a Healthier Generation. This joint effort of the American Heart Association and the William J. Clinton Foundation, with support from the Robert Wood Johnson Foundation, works with schools and the business community to change the food and beverage offerings to children and to increase physical activity. The initiative will also work with health care providers to improve clinical practice and directly engage children to "take charge of their own health." Activate America. This effort of the YMCA is designed to help its local organizations reach out and work with community members to improve individual and community health. It also plans to work with partners doing similar work to leverage its activities. These efforts and others like them are designed to reach out directly to the public and engage them in ways that both empower and motivate them to achieve individual wellness and advocate broadly for community health improvement.
The term "return on investment" (ROI) is frequently used in the business world to describe the relative value an investment has yielded. Its value means gain or loss relative to the starting point. Public health policymakers also use this term to understand the impact of an investment in a health intervention. Cost and ROI of health care. U.S. businesses pay 26 percent of the $1.9 trillion the country spends on health care—$450 billion a year. Yet despite this investment, productivity losses related to family and personal health problems cost U.S. businesses $225.8 billion, a clear business incentive to improve health.8 However, the real ROI for a country is not just the dollars it invests and the direct financial return it achieves but, rather, the total economic return to communities, which includes improved educational attainment, reduced crime, improved financial status, and greater business productivity. Advocates for a business–public health partnership. Simon and Fielding. Paul Simon and Jonathan Fielding in this issue of Health Affairs make an effective case for the importance of a stronger partnership between the business community and governmental public health.9 However, to realize this future requires a shift in the way that public health practitioners, who often shun talking directly with the business community, view the value of a relationship with business. The business community, which often views government and regulations as impediments to business, needs to value the assured community health as an economic engine that fuels a healthy business climate. Other benefits of a healthier population include improved productivity, reduced health care costs, and a better economic climate. By engaging the business community, public health gains a powerful ally in its quest to improve support for population-based initiatives. The business community can serve as the "unanticipated messenger." A knowledgeable, supportive, and well-respected member of the business community can be an important verifier of the value of population health. Such a partner can describe the importance of funding sanitation work that ensures food safety and prevents the closure of a food establishment and can point out the role of health insurance in reducing the incidence of personal bankruptcy. An informed employer can describe the attributes of a safe workplace and articulate the productivity benefits of preventing or delaying the onset of chronic diseases among workers and their families. By becoming strong advocates for wellness, the business community can help shape community expectations, drive fiscal investments, and rebalance the debate in positive ways that one can only begin to imagine. Simply said, employers can make the business case for health over the medical case for illness. CEO Roundtable. Another example of advocates for a business–public health partnership is the CEO Roundtable, a program initiated by Partnership for Prevention, a public health advocacy group based in Washington, D.C. This roundtable is a coalition of prominent business leaders who are dedicated to promoting wellness in the workplace.
Engaging public policymakers as partners in improving population health requires good data, patience, and both a clear understanding of and competence at working in a political environment. Policymakers need timely, factual public health information. By having reliable information, they can make better public policy that supports the best interests of the people they represent. Public health professionals can help improve public policy decision making by translating scientific information for a lay audience and by presenting data in a way that aids public debate. When policymakers decide to invest their political capital in system change, the effect can be very powerful. A recent effort of the National Governors Association (NGA), called Healthy America, designed to create healthy states "where we live, work and learn," illustrates this point.10 The NGA effort hopes to build healthy communities by educating the public about existing community resources, promoting individual and community health, and engaging community organizations as partners. It is also encouraging governors and their families to serve as role models of wellness. This effort also aims to build healthy workplaces by focusing on the state as an employer. By creating healthy workplaces, focusing on prevention, and ensuring the health of employees, the NGA hopes to provide a major investment in increasing employees’ awareness of the concepts of wellness. The NGA also is working to build healthy schools by encouraging parents’ engagement in their children’s health, supporting healthy school policies, and promoting annual student wellness assessments and regular physical activity during the school day. Governors are reaching out into the community to engage the public through public/private coalitions, advisory groups, local chefs, and farmers. New efforts like this at all levels of government offer unique opportunities for the public health community, particularly governmental public health, to work with policymakers to effect broad community change. ALMOST ANY WAY you look at the status of the U.S. health care system and the health status of Americans today, it is clear that something has to give. No other industrialized country so squanders its potential when it comes to keeping its citizens healthy; the United States has the human, financial, and technological resources to turn this around. We also have the knowledge to more fully integrate prevention, health promotion, and health protection into our lives. What are needed are the will and the focus to make it happen. It’s time for change.
Georges Benjamin (georges.benjamin{at}apha.org) is executive director of the American Public Health Association in Washington, D.C., and a professorial lecturer in the Department of Health Policy at the George Washington University School of Public Health and Health Services, also in Washington. The comments in this paper represent the personal views of the author and do not necessarily represent those of the American Public Health Association or its elected or appointed officials.
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