The leftwing website, Salon, reported on the demise of public health. According to Salon, public health lost its way in the mid-20th Century. It failed to adapt to a changing environment, but more on that later. Public health has a long history of success. Sanitation is chief among them. Yes, sanitation reduced disease.
U.S. public health efforts began in a vastly different era. In 19th century New York City, for example, diarrhea was a larger health threat than cancer or heart disease. And across the U.S., it was common for families to lose multiple children before their fifth birthday. Medicine offered little reprieve. Doctors’ orders could be more harmful than beneficial, and hospitals were only for the lower classes, while the wealthy received medical care at home.
In the period after the Civil War, many states and cities founded public health departments with an objective to prevent disease, especially because medical treatments were so ineffective. Boosted by the discovery of germ theory in the mid-1800s, these departments prevented disease through large-scale projects. They supported implementing water sanitation, trash removal services, housing regulations, and plumbing standards, along with distributing pasteurized milk to poor families and educating the public about personal hygiene.
Note that none of the above require the service of a doctor. Indeed, these initiatives began before medical doctors had effective tools to treat most diseases. Of the ten great public health achievements of the past 100 years, most were not related to medical science.
Comprehensive national statistics do not exist but a snapshot of life (and death) in New York City is a good example. Between 1875 and 1925, the death rate in NYC fell by a whopping 60%. During about that same period, life expectancy increased by 50% to 53 years of age. More from Salon:
The improvements were due primarily to decreasing deaths from communicable diseases — at least one of which declined by 99 percent. However, as fewer people died from communicable diseases, more deaths were due to chronic diseases such as cancer and cardiovascular disease — the same health issues we see today.
Salon goes on to say that public health was not equipped to tackle chronic disease, such as those that plague Americans today. Approximately 100 years ago the president of the American Public Health Association believed that public health was at a crossroads, saying: “the major problems of public health have fundamentally changed in 50 years,” and “we must adopt new methods if we are to meet it with any measure of success.”.
The writer, Eric Coles, DrPH, blames the lack of a National Health Program as a failure of public health. In other words, the public health establishment of the early-to-mid 20th Century failed to seize control of the U.S. health care system. Up to that point, public health was about education and infrastructure. For instance, preventing the spread of cholera by making sure latrines were not too close to wells or water supplies. Making sure garbage did not fester and breed rats that carried plague. Does any of this sound remotely like medicine?
Dr. Coles believes public health failed in the United States when it failed to convince Congress to pass Medicaid for All back when other social insurance schemes were established. If the U.S. had passed a National Health Program, all the money spent on medical care would be in the hands of the public health establishment and funded by taxpayers. Only then could public health advocates decide on priorities. Put another way, the failure of public health supposedly occurred when the public health establishment failed to transition from garbage collection and sewage control and stage a successful coup to seize power over the entire health care system.
What could be wrong with this? The writer confuses private health with public health. As illustrated above, public health in the late 1800s was not about medicine. It was about preventing diseases through food safety and sanitation. Public health was in effect a public good. Public goods are provided by the government when private actors would otherwise underproduce them. The reason public goods are underprovided by private actors is because the producer is unable to capture all the benefits of their efforts. The best example is national defense. On my own I can do nothing to improve national defense in a way that benefits me personally. Therefore, my incentive is to “free ride” off the efforts of others, who have the same perverse incentives I do. Public health is similar. Garbage collection, safe drinking water, vaccines to stop the spread of disease were collective actions done to reduce sickness and disease in late 19th / early 20th Century America. Heart disease, cancer, diabetes, and hypertension are different stories. They are individual diseases that are not communicable from one person to the next. The benefits of treating heart disease are captured by individual patients; thus, the efforts to prevent heart disease are most efficiently initiated by individuals and their private doctors.
Health care is personal. Very personal. Covid notwithstanding (which really was a public health threat), a better strategy than beefing up public health would be to empower and beef up personal/private health. As an individual, I have control over hypertension, high cholesterol and diabetes in ways that public health officials do not. The problem is that too many health officials confuse health interventions that should be private with those that should be public. What public health advocates of a National Health Program really envision is taking away private health and controlling the resources to use as they see fit.
Read more at: Where did U.S. public health go wrong? The article was originally published in Undark.