By: Dr Bob England & Will Humble April 1, 2019
E pluribus unum. Out of many, one. Our de facto national motto calls upon all of us to work for the good of the whole.
Perhaps nowhere is this better demonstrated than in public health. And in many ways, we’ve been wildly successful. Yet in our current policy discussions, we seem to have forgotten the history of how we created that success.
Our health-related discussions have become dominated by how we pay for health care. Right or left, Democrat, Republican, or other, all we seem to talk about is health care finance reform of some sort. Health care has become more complex and expensive and in innumerable ways much better than in our distant past. But most of the significant improvements in our health and our lifespan have nothing to do with health care per se.
Since the mid-19th century, our average life expectancy at birth has boomed from around 38 years to 79, more than doubling our time on Earth. But the vast majority of that improvement is because of public health measures that reduced deaths early in life.
A person who made it to age 70 in the mid-19th century could expect to live another 11 years – to 81 years of age. Now, a person who makes it to age 70 can expect to live another 15 years – only four years longer than our ancestors more than 150 years ago.
This is despite our increasing use of health care in our later years. In other words, our enormous health care expenditure has only marginally added to life expectancy.
The obvious question is, how did we achieve the rest of it? We used evidence to drive policy, systems, and environmental improvements.
Water and sewer sanitation dramatically decreased intestinal disease (little more than a century ago, one in ten of us died from a waterborne disease). Food safety greatly reduced dangerous intestinal illnesses. Improvements in housing and working conditions reduced overcrowding and led to plummeting rates of tuberculosis and other infectious diseases long before we had medical treatment for them. Universal vaccination programs (and the “herd immunity” that resulted) made once widespread diseases rare. Workplace and motor vehicle safety standards dramatically cut deaths from accidents.
All of the above were achieved through various policies, laws, and regulations. What they all have in common is that these public policies were informed by scientific evidence and implemented in ways that dramatically benefitted us all. Sure, those policy decisions were controversial in their day. Of course there were political debates. But eventually, the evidence, the truth, won out. And we all reap the benefits today.
We have a long way to go, of course. All manner of health indicators vary dramatically by race, ethnicity, and socioeconomic status. Residents of a zip code only two miles from our state Capitol die an average of 14 years earlier than those in another zip code a mere 20 miles away. Fourteen years! Sure, some of these differences are the result of our crazy-quilt health care system, but most of it can be laid at the feet of those same social determinants of health that we’ve been addressing over centuries – differences in our physical and social environment, such as crowding, sanitation, economic status, educational opportunity, and so forth.
It’s not that we don’t know how to address these problems. We have good evidence about what interventions work. Our economic impact evaluations often tell us with reasonable accuracy that the cost of an intervention is less than the cost of the illness we can prevent.
Yet we’ve stopped our progress. Life expectancies are beginning to slightly decline. And many of our disparities in health, with causes largely rooted in social inequities, are growing wider. We’ve ignored opportunities to further improve health, and we’ve cut our public health efforts even in some long-standing areas that have benefitted us all. We’ve lost sight of what got us here.
Sadly, it seems like we’re living in an era in which evidence is often considered “just another opinion.” Many of our decision-makers have lost the ability to know which recommendations to trust. And we seem to have fallen back into our preconceived worldview – reinforced by watching, reading, and listening only to opinions which we already hold, evidence to the contrary be damned.
It’s time to get back to using objective evidence to drive our public policy in ways that further the health of us all. Of us all. E pluribus Unum.
—Bob England, MD, MPH was director of the Maricopa County Department of Public Health from 2006-2018. He can be reached at benglandaz@gmail.com.
—Will Humble, MPH is the executive director of the Arizona Public Health Association and former director for the Arizona Department of Health Services. He can be reached at willhumble@azpha.org.
