Public health must be more than infectious disease control
Several recent commentaries have suggested that public health practitioners should ‘keep out of politics’. Commentators have suggested that public health should focus on its traditional roots of controlling the spread of infectious diseases, such as Ebola, rather than on social issues, such as poverty reduction.
The work of public health should be evidence-informed and focus on key health challenges. That means that those working in public health use data and research results in selecting which health challenges to focus on and the means by which they should be addressed.
There is no doubt that the spread of Ebola has resulted in devastating consequences in the affected countries in Africa. There is also no doubt that there have been gaps in the leadership demonstrated by a range of agencies, including the World Health Organization. With the benefit of hindsight, more could have and should have been done earlier as the red flags about Ebola were raised in the spring. It is likely that the WHO moved too late and too slow. But to criticize Director-General Margaret Chan for pointing out that tobacco control remains the world’s number one health challenge is simply absurd. No matter how you dice and slice the data, there is no way to ignore the fact that she is right!
Smoking IS a major threat to global health. A recent report by McKinsey also demonstrated that it is the most significant in terms of economic impact, accounting for 2.9% of global GDP, ahead of armed violence, war and terrorism. As an aside, if we really want to focus on the absurd we should be discussing why spending on public health is such a tiny fraction of spending on defense. In the same study, obesity and alcoholism came in as third and fourth in economic impact.
For clarity, public health has to ensure it gets its basics right in areas like controlling the spread of infectious diseases. Time and time over, we have seen the critical importance of sound public health measures in this area. But, we need to consider carefully that the major advances against the spread of infectious diseases in the last century were not only the result of medical interventions such as antibiotics or vaccines. Nor did they come about through the use of quarantines and travel restrictions. The major reductions in infectious diseases are the result of population level interventions in areas such as sanitation and supply of safe food and water. These interventions were largely done through social and political means.
While the global burden of infectious disease remains significant, chronic diseases and mental illness represent far greater challenges in higher income countries and are rapidly become the most significant in middle and lower income countries.
While there are many causes for these chronic diseases, smoking, diet, alcohol consumption and physical activity account for the majority of cases. These are often considered to be “lifestyle” or behavioural factors in the domain of individual personal responsibility. As a result, commentators often suggest public health should butt out of trying to influence these through broader social tools, such as economic or regulatory interventions. This naïve perspective ignores decades of solid research that demonstrates that individual choices around such behaviours are made within a much broader social and community context. If we don’t address such social and community environments, we will not be successful in addressing these significant chronic disease risk factors. For example, are we going to prevent childhood obesity by haranguing children and their parents to eat well and be physically active. It is extremely unlikely that such measures alone will be successful. We will also need to address areas such as the accessibility of healthy food, active transportation, and communities that encourage physical activity.
Finally, let me turn to the issue of poverty reduction. This seems to draw the greatest ire from those critical of public health. It is not possible to ignore the vast body of research that consistently demonstrates, across risk factors and diseases and throughout the world, significant relationships of health outcomes with income and social conditions. This is true for both infectious diseases and chronic conditions. Those concerned about public health neglecting infectious diseases should ask why Ebola is rampaging through the poorest countries in the world, or why tuberculosis is so prevalent in our most disenfranchised First Nations communities?
Income is also strongly associated with the major risk factors for chronic diseases. For example, it is easy to exhort that individuals should have a healthier diet, consuming more fruits and vegetables and less processed foods. But how does someone with limited income do this when the processed food options are cheaper? Or as repeatedly shown, healthier options are less likely to be available in our most disadvantaged communities?
So if public health is to address the greatest challenges in our communities and globally it must operate in arenas that are seen by some to be outside the scope of health care and medicine. Those in public health must advocate for the proven interventions that will address our most significant challenges. The domain of effective public health interventions includes policies, regulations and taxation. This doesn’t mean getting involved directly in politics. Public health must continue to play the role of honest broker by providing clear evidence to inform policy decisions. This includes presenting the data in a clear manner that demonstrates what the most significant health challenges are. It includes presenting the research evidence that shows what works to address these challenges. Public health can not shy away from presenting such solutions to our greatest challenges.
Vivek Goel is a Professor at the Institute for Health Policy, Management and Evaluation and the Dalla Lana School of Public Health at the University of Toronto. He is the former CEO of Public Health Ontario.