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The Next 50 Years Arthur L. Keltermarm, MD, MPH Last January, I stood in the rain at Arlington National Cemetery with other onlookers as Dr. Boris Lushniak (Acting Surgeon General of the United States) and Dr. David Satcher (16th Surgeon General of the United States) placed a wreath at the gravesite of Dr. Luther Terry (9th Surgeon General of the United States) to commemorate the 50th Anniversary of the release of the “Surgeon General’s Report on Smoking and Health.” Few could have envisioned how influential this report would be. In the decades that followed its release, public health built an airtight case on the harmful effects of tobacco— smokeless as well as smoked, and passively as well as actively inhaled. On the strength of the science, thousands of public health professionals—including many in the U.S. Public Health Service (PHS)—developed, implemented, or championed programs that discourage initiation of smoking, promote cessation, and limit the harmful consequences of smoking on others.1'2 Examples include, but are not limited to: — Designation of “smoke-free” environments — Indoor air ordinances — Increased tobacco taxes—a particularly effective way to discourage young people from starting to smoke — Antitobacco advertising — Improved approaches to cessation — And most recently, Food and Drug Administration authority to regulate tobacco Efforts like these paid off. National rates of smoking steadily declined from a peak of 45% in 1954 to 18% today. As a result, some 8 million people3 have been spared the sorts of early and agonizing deaths that claimed my father (lung cancer), mother (multiple strokes), and stalk my oldest brother (laryngeal cancer). Dr. Terry’s report is but one of a string of spectacular achievements the PHS and your many public health allies have accomplished over the past 50 years.4’5 For example, new vaccines dramatically reduced or nearly eliminated the harm caused by a string of devastating diseases, including hepatitis A and B, pneumococcal sepsis, rotavirus, and
Dean, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. Presented as the Luther Terry Lecture at the 2014 Symposium of the Public Health Service Commissioned Officers Foundation for the Advance ment of Public Health, Raleigh, NC, June 11, 2014. The views expressed are the author’s and do not necessarily represent those of the Hebert School of Medicine, the Uniformed Services University of the Health Sciences, or the U.S. Department of Defense. doi: 10.7205/MILMED-D-14-00495
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Haemophilus influenzae type b (once the leading cause of acquired developmental disability in the United States).6 Public health had other infectious disease triumphs. You made stunning progress in HIV diagnosis, treatment, and prophylaxis. Canine rabies in the United States has been virtually eradicated You’ve also made progress—albeit modest progress in reducing health care-associated infections.7 And working in concert with the World Health Organization and other colleagues, members of the PHS Commissioned Corps eradicated smallpox from the planet—one of the greatest achievements in human history.8 You’ve made remarkable gains in noncommunicable dis eases as well. Thanks to folic acid fortification, neural tube defects have been dramatically reduced.9 Safer workplaces have lessened the burden of occupational illness and inju ries.10 Deaths and disability from heart attacks and strokes has fallen dramatically,11 and the rate of motor vehicle fatalities per million vehicle miles traveled has been cut by more than 90%!12 The collective impact of these advances, and many others, is astonishing. Since 1900, average life expectancy in the United States has increased by 30 years; 25 of these added years can be attributed to advances in public health.13 In light of the millions of deaths averted, and trillions of dollars saved, one might think that you’d be the “rock stars” of American health care. But let’s face it. Nobody is going to mistake you for rock stars anytime soon. In fact, while public health has won several notable battles, there are ominous signs that it is losing the war.14 In many respects, public health is a victim of its own success. Once the big scourges were dealt with, the public, the news media, and policy makers got complacent. It’s hard to get worked up about tragedies that don’t happen. The Great Recession delivered a body blow to public health. Between 2009 and 2011, local health departments cut nearly 30,000 jobs (about 19% of their workforce). State health departments slashed an additional 16,000 jobs.15 The economy has largely recovered, but these jobs haven’t come back. Ironically, while public health was getting clobbered, spending on doctors, hospitals, and health care services con tinued to grow at a steady pace. In 2009, the year the U.S. economy contracted and 7 million Americans lost their jobs, the United States spent nearly $100 billion “more” on health care than it had the year before.16 This came on the heels of a decade (1999-2009) when national health care spending nearly doubled, driving the federal budget deficit skyward and distorting the spending priorities of many state governments.17 In 2011, a former RAND colleague and I calculated that the health care cost
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growth that occurred during this decade wiped out the hardwon income gains of middle-class Americans.18 Most distressing of all, this massive increase in health care spending did little to improve Americans’ health. In 2013, the Institute of Medicine (IOM) examined U.S. health from an international perspective and noted that “Americans die sooner, and experience higher rates of disease and injury, than people in other high-income countries.” Lest you assume that our performance was dragged down by America’s poor and uninsured, consider this: IOM reported that “Even Americans fortunate enough to have health insur ance, a college education & higher incomes do worse than their peers in other countries.”19 Where, for God’s sake, is public health? You’re not only being kept off the playing field, you’ve been locked out of the stadium: — In 2012, thought leaders from the Left and the Right published competing visions for containing health care spending in The New England Journal of Medicine. Neither side mentioned public health.20'21 — That same year, after he left his position as director of the Congressional Budget Office for President Obama, Peter Orszag published an essay in Foreign Affairs, entitled, “How Health Care Can Save or Sink America: The Case for Reform and Fiscal Sustainability.” In it, he noted that there are only 4 basic ways to reduce health care spending. None of his options involved decreasing the need for costly care through prevention.22 14 years ago, another IOM committee observed that although 70% of premature deaths have a social or environ mental cause, less than 5% of national health spending is devoted to preventing these deaths through population health.23 The ratio may be even more lopsided today. The potential for public health to help is huge. After all, even modest reductions in our national rate of obesity and further declines in smoking could generate large downstream savings.24 If you think our overburdened and undermanned primary care workforce is going to pull this off during 10-minute office visits, I’ve got a bridge to sell you. Our nation needs public health. To get public health back in the game, we must make it more visible and relevant. The problem isn’t a lack of inge nuity; it’s the loss of public understanding. The “hard science” of public health has never been stronger. Across America and around the world, PHS scientists are unraveling the mysteries of molecular biology, developing effective vaccines, conducting brilliant epidemiological inves tigations, and analyzing their results with rigorous statistics. Unfortunately, technical brilliance is not enough. If the public doesn’t believe in what you’re doing, they’re not going to buy what you have to sell. And as a result of declin ing health literacy, growing skepticism of science, and con scious efforts to misinform the public, public health is losing more customers every day.
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EXHIBIT 1 — The 2009 H1N1 influenza pandemic prompted an unprecedented public education campaign to promote uptake of the pandemic vaccine. Despite this all-out effort, only 1 U.S. adult in 5 got vaccinated against pandemic flu. Less than half of health care workers got vaccinated.25 — Although, it should be obvious by now that we aren’t doing a good job of convincing the public of the impor tance of vaccines, we continue to pour the bulk of our research efforts into devising new ones, rather than discovering how to boost public acceptance of vaccines. Over the past decade, more than 95% of National Institutes of Health spending on influenza research went to biomedical discovery. Less than 5% went to behavioral science.24
EXHIBIT 2 — Measles cases in the United States are at a 20-year high.26 The virus hasn’t grown smarter; we’ve gotten dumber. The efforts of antivaccine activists have seriously undermined Americans’ confidence in one of public health’s most powerful tools.27 Equally concerning, a growing number of state legislatures are allowing parents to opt out of mandatory childhood vaccinations on reli gious grounds. This stance endangers not only the chil dren of these parents but also everyone else’s children. — On the world stage, polio is making a comeback too, as religious extremists deliberately target vaccinators who are trying to eradicate the last pockets of this dread disease.28 This is a global tragedy.
EXHIBIT 3 — Thanks to sloppy antibiotic prescribing and the wide spread lacing of animal feed with these powerful drugs, once-defeated microbes are developing resistance at an alarming rate. These practices, plus an anemic pipeline of new antimicrobials, are rapidly depleting the avail able options to treat a wide range of deadly diseases.29
EXHIBIT 4 — Raw milk is making a comeback!30
EXHIBIT 5 — Fifty years after Luther Terry’s report, big tobacco is recruiting a new generation of nicotine addicts with e-cigarettes and e-hookahs. Because “vaping” exposes users to a less harmful mix of chemicals than tobacco, there’s a lively debate over whether they are a net positive or a net negative to public health.31 Will we figure it out in time? Buxton’s Law states that “It’s always too early [for rigorous evaluation] until, unfortunately, it is suddenly too late.” So what we need to do to turn things around?
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First, we need to develop effective communicators—Modem public health leaders need more than skills in management, finance, and strategic planning—they must be highly engaging communicators as well.32 Dr. C. Everett Koop (13th Surgeon General of the United States) didn’t grab the imagination of the public because he was a pediatric surgeon. He was able to do so because he was a plainspoken, principled and highly effective communicator.33 Second, we need to recruit new talent— Schools of Public Health should expand their recruiting efforts beyond kids who are good at epidemiology, biostatistics, and global health to attract young people who have a knack for marketing and communications. The PHS should also build partnerships with nongovernmental organizations and media startups that are developing effective new approaches to health promotion. To reach a distracted and increasingly skeptical public, we must outthink, outwit, and outwork the competition. Third, we need high-quality social science—To determine how best to engage the public, public health needs to invest in high-quality social and behavioral science. That won’t happen unless PHS agencies devote a larger share of their research budgets to this kind of work. Fourth, we need allies—Public health can’t win this fight alone. You need the support of community groups, doctors, nurses, employers, and the faith community. I was drawn to public health because each time I worked a shift in the Emer gency Room, I saw what happens when public health fails. It’s heartbreaking, costly, and most important—preventable.34 Last but not least: we need courage—Public health is a contact sport. Luther Terry knew he could lose his job over the Surgeon General’s Report, but he didn’t let that stop him. From time to time, public health inevitably bumps up against powerful economic, philosophical, and political interests that hold strongly opposing views. And when it does, they hit back.35 It’s always been that way, and it always will be. Can public health get its mojo back? You bet. It’s inside each of you, right now, and its yearning to break out. Members of the PHS Commissioned Corps, I admire you for what you do. In any given year, you save more lives than a busload of cardiac surgeons, but rarely get your due. Still, you never give up. In the last few years, the PHS Commissioned Corps has taken its lumps, but the qualities that define you: integrity, idealism, courage, and conviction—are as strong as ever. If you are willing to adapt to meet the challenges you face, the next 50 years of public health will be even more impactful and beneficial than the last. So stand tall, enjoy the meeting, and get ready to move out! Because you’ve got work to do!
REFERENCES 1. Centers for Disease Control and Prevention: Achievements in Public Health, 1900-1999: Tobacco Use—United States, 1900-1999. MMWR Wkly 1999; 48(43): 986-93. Available at http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm4843a2.htm; accessed June 15, 2014.
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2. Surgeon General’s Report: The Health Consequences of Smoking— 50 Years of Progress: A Report of the Surgeon General, 2014. Available at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/ index.html; accessed June 15, 2014. 3. Holford TR. Meza R, Warner KE, et al: Tobacco control and the reduc tion in smoking-related premature deaths in the United States, 19642012. JAMA 2014; 311(2): 164-71. 4. Centers for Disease Control and Prevention: Ten Great Public Health Achievements—United States, 1900-1999. MMWR Wkly 1999; 48(12): 241-3. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ 00056796.htm; accessed October 8, 2014. 5. Centers for Disease Control and Prevention: Ten Great Public Health Achievements—United States, 2001-2010. MMWR Wkly 2011; 60(19): 619-23. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6019a5.htm; accessed October 8, 2014. 6. Centers for Disease Control and Prevention: Achievements in Public Health, 1900-1999 Impact of Vaccines Universally Recommended for Children—United States, 1990-1998. MMWR Wkly 1999; 48(12); 243-8. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ 00056803.htm; accessed October 8, 2014. 7. Centers for Disease Control and Prevention: 2012 National and State Healthcare-Associated Infections Progress Report, March 26, 2014. Available at http://www.cdc.gov/HAI/pdfs/progress-report/hai-progressreport.pdf; accessed June 15, 2014. 8. Foege W: House on Fire: The Fight to Eradicate Smallpox. California/ Milbank Books on Health and the Public, June 2011. Available at http://www.ucpress.edu/book.php7istarf780520268364; accessed October 8, 2014. 9. Centers for Disease Control and Prevention: Spina bifida and anencephaly before and after folic acid mandate— United States, 1995-1996 and 1999-2000. MMWR Morb Mortal Wkly Rep 2004; 53(17): 362-5. 10. Centers for Disease Control and Prevention: Achievements in Public Health, 1900-1999: Improvements in Workplace Safety—United States, 1900-1999 MMWR Wkly 1999; 48(22): 461-9. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4822al.htm; accessed October 8, 2014. 11. Centers for Disease Control and Prevention: Decline in deaths from heart disease and stroke—United States, 1900-1999. MMWR Wkly 1999; 48: 649-56. Available at http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm4830al.htm; accessed October 8, 2014. 12. Centers for Disease Control and Prevention: Achievements in Public Health, 1900-1999: Motor-Vehicle Safety: A 20th Century Public Health Achievement. MMWR Wkly 1999; 48(18); 369-74. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818al .htm; accessed October 8, 2014. 13. Bunker JP, Frazier HS, Mosteller F: Improving health: measuring the effects of medical care. Milbank Q 1994; 72: 225-58. 14. Institute of Medicine: The Future of Public Health in the 21st Century. Washington, DC, National Academies Press, 2002. 15. Kellermann A, Moore M: “Heed Film Lessons on Outbreak” The RAND Blog, December 29, 2011. Available at http://www.rand.org/blog/2011/ 12/heed-film-lessons-on-outbreak.html; accessed October 8, 2014. 16. Kellermann A: A Health Care Entitlement Worth Ending. Health Affairs Blog, February 27,2013. Available at http://healthaffairs.org/blog/2013/ 02/27/a-health-care-entitlement-worth-ending/; accessed October 8, 2014. 17. Kellermann AL, Vaiana ME, Hussey PS, Chari R, Lowsky D, Mulcahy A: Flattening the Trajectory of Health Care Spending: Insights from RAND Health Research. Document number RB-9690/1. Santa Monica, CA, RAND Corporation, 2012. 18. Auerbach DI, Kellermann AL: How Does Growth in Health Care Costs Affect the American Family? Document number RB-9605. Santa Monica, CA, RAND Corporation, 2011. 19. Institute of Medicine: U.S. Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC, National Academies Press, 2013.
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Commentary 20. Emanuel E, Tanden N, Altman S, et al: A systematic approach to con taining health care spending. N Engl J Med 2012; 367(10): 949-54. Available at http://www.nejm.org/doi/pdf/10.1056/NEJMsbl205901; accessed October 8, 2014. 21. Antos JR, Pauly MV, Wilensky GR: Bending the cost curve through market-based incentives. N Engl J Med 2012; 367(10): 954-8. Avail able at http://www.nejm.org/doi/pdf/10.1056/NEJMsbl207996; accessed October 8, 2014. 22. Orszag P: How health care can save or sink America: the case for reform and fiscal sustainability. Foreign Affairs 2011; 90(4): 42-57. 23. Smedley BD, Syme SL (editors); Institute of Medicine Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public’s Health: Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, DC, The National Academies Press, 2000. 24. Chari R, Hussey PS, Mulcahy A, Lowsky D, Vaiana ME, Kellermann AL: Flattening the Trajectory of Health Care Spending: Promote Popu lation Health. Document number RB-9690/4. Santa Monica, CA, RAND Corporation, 2012. 25. Harris KM, Maurer J, Kellermann AL: Influenza vaccine— safe, effec tive and mistrusted. N Engl J Med 2010; 363: 2183-5. 26. McNeil DG: Measles Cases in U.S. Reach a 20-Year High. The New York Times. May 29, 2014. Available at http://mobile.nytimes.com/ 2014/05/30/health/measles-cases-in-us-hit-a-20-year-high.html?hpw& rref=health&_r=0&referrer; accessed June 15, 2014. 27. Panhuis WG, Grefenstette J, Jung SY, et al: Contagious diseases in the United States from 1888 to the present. N Engl J Med 2013; 369(22): 2152-8.
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28. Zulfiqar Ali: Pakistan Bombing is Latest in Wave of Attacks on Polio Workers. The Los Angeles Times. January 22, 2014. Available at http:// www.latimes.com/world/worldnow/la-fg-wn-pakistan-polio-attacks20140I22-story.htm l; accessed June 15, 2014. 29. Institute of Medicine: Antibiotic Resistance: Implications for Global Health and Novel Intervention Strategies—Workshop Summary. Washington, DC, National Academies Press, 2010. Available at http:// www.iom.edu/reports/2010/antibiotic-resistance-implications-for-globalhealth-and-novel-intervention-strategies.aspx; accessed June 15, 2014. 30. Lindy K: Political push for raw, unpasteurized milk is increasing access, but illnesses are up, too. The Washington Post. April 4, 2014. Available at http://www.washingtonpost.com/politics/political-push-forraw-unpasteurized-milk-is-increasing-access-but-illnesses-are-up-too/ 2014/04/04/e62bc884-b443-l Ie3-8020-b2d790b3c9el_story.htm l; accessed June 15, 2014. 31. Triggle E: E-cigarettes “help smokers to quit.” BBC News Health. Available at http://www.bbc.com/news/health-27485954#?utm_source= twitterfeed&utm_medium=twitter; accessed June 15, 2014. 32. Bernhardt J: Communication at the core of effective public health. Am J Public Health 2004; 94: 2051-3. 33. Profiles in Science: The C. Everett Koop Papers AIDS, the Surgeon General, and the Politics of Public Health. Bethesda, MD, U.S. National Library of Medicine. Available at http://profiles.nlm.nih.gov/ps/retrieve/ Narrative/QQ/p-nid/87; accessed October 8, 2014. 34. Kellermann AL: Emergency medicine and public health: stopping emergencies before the 9-1-1 call. Acad Emerg Med 2009; 16: 1060-4. 35. Mullen F: Plight of the surgeon general. Science 2007; 318: 169.
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The Next 50 Years Arthur L. Keltermarm, MD, MPH Last January, I stood in the rain at Arlington National Cemetery with other onlookers as Dr. Boris Lushniak (Acting Surgeon General of the United States) and Dr. David Satcher (16th Surgeon General of the United States) placed a wreath at the gravesite of Dr. Luther Terry (9th Surgeon General of the United States) to commemorate the 50th Anniversary of the release of the “Surgeon General’s Report on Smoking and Health.” Few could have envisioned how influential this report would be. In the decades that followed its release, public health built an airtight case on the harmful effects of tobacco— smokeless as well as smoked, and passively as well as actively inhaled. On the strength of the science, thousands of public health professionals—including many in the U.S. Public Health Service (PHS)—developed, implemented, or championed programs that discourage initiation of smoking, promote cessation, and limit the harmful consequences of smoking on others.1'2 Examples include, but are not limited to: — Designation of “smoke-free” environments — Indoor air ordinances — Increased tobacco taxes—a particularly effective way to discourage young people from starting to smoke — Antitobacco advertising — Improved approaches to cessation — And most recently, Food and Drug Administration authority to regulate tobacco Efforts like these paid off. National rates of smoking steadily declined from a peak of 45% in 1954 to 18% today. As a result, some 8 million people3 have been spared the sorts of early and agonizing deaths that claimed my father (lung cancer), mother (multiple strokes), and stalk my oldest brother (laryngeal cancer). Dr. Terry’s report is but one of a string of spectacular achievements the PHS and your many public health allies have accomplished over the past 50 years.4’5 For example, new vaccines dramatically reduced or nearly eliminated the harm caused by a string of devastating diseases, including hepatitis A and B, pneumococcal sepsis, rotavirus, and
Dean, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. Presented as the Luther Terry Lecture at the 2014 Symposium of the Public Health Service Commissioned Officers Foundation for the Advance ment of Public Health, Raleigh, NC, June 11, 2014. The views expressed are the author’s and do not necessarily represent those of the Hebert School of Medicine, the Uniformed Services University of the Health Sciences, or the U.S. Department of Defense. doi: 10.7205/MILMED-D-14-00495
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Haemophilus influenzae type b (once the leading cause of acquired developmental disability in the United States).6 Public health had other infectious disease triumphs. You made stunning progress in HIV diagnosis, treatment, and prophylaxis. Canine rabies in the United States has been virtually eradicated You’ve also made progress—albeit modest progress in reducing health care-associated infections.7 And working in concert with the World Health Organization and other colleagues, members of the PHS Commissioned Corps eradicated smallpox from the planet—one of the greatest achievements in human history.8 You’ve made remarkable gains in noncommunicable dis eases as well. Thanks to folic acid fortification, neural tube defects have been dramatically reduced.9 Safer workplaces have lessened the burden of occupational illness and inju ries.10 Deaths and disability from heart attacks and strokes has fallen dramatically,11 and the rate of motor vehicle fatalities per million vehicle miles traveled has been cut by more than 90%!12 The collective impact of these advances, and many others, is astonishing. Since 1900, average life expectancy in the United States has increased by 30 years; 25 of these added years can be attributed to advances in public health.13 In light of the millions of deaths averted, and trillions of dollars saved, one might think that you’d be the “rock stars” of American health care. But let’s face it. Nobody is going to mistake you for rock stars anytime soon. In fact, while public health has won several notable battles, there are ominous signs that it is losing the war.14 In many respects, public health is a victim of its own success. Once the big scourges were dealt with, the public, the news media, and policy makers got complacent. It’s hard to get worked up about tragedies that don’t happen. The Great Recession delivered a body blow to public health. Between 2009 and 2011, local health departments cut nearly 30,000 jobs (about 19% of their workforce). State health departments slashed an additional 16,000 jobs.15 The economy has largely recovered, but these jobs haven’t come back. Ironically, while public health was getting clobbered, spending on doctors, hospitals, and health care services con tinued to grow at a steady pace. In 2009, the year the U.S. economy contracted and 7 million Americans lost their jobs, the United States spent nearly $100 billion “more” on health care than it had the year before.16 This came on the heels of a decade (1999-2009) when national health care spending nearly doubled, driving the federal budget deficit skyward and distorting the spending priorities of many state governments.17 In 2011, a former RAND colleague and I calculated that the health care cost
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growth that occurred during this decade wiped out the hardwon income gains of middle-class Americans.18 Most distressing of all, this massive increase in health care spending did little to improve Americans’ health. In 2013, the Institute of Medicine (IOM) examined U.S. health from an international perspective and noted that “Americans die sooner, and experience higher rates of disease and injury, than people in other high-income countries.” Lest you assume that our performance was dragged down by America’s poor and uninsured, consider this: IOM reported that “Even Americans fortunate enough to have health insur ance, a college education & higher incomes do worse than their peers in other countries.”19 Where, for God’s sake, is public health? You’re not only being kept off the playing field, you’ve been locked out of the stadium: — In 2012, thought leaders from the Left and the Right published competing visions for containing health care spending in The New England Journal of Medicine. Neither side mentioned public health.20'21 — That same year, after he left his position as director of the Congressional Budget Office for President Obama, Peter Orszag published an essay in Foreign Affairs, entitled, “How Health Care Can Save or Sink America: The Case for Reform and Fiscal Sustainability.” In it, he noted that there are only 4 basic ways to reduce health care spending. None of his options involved decreasing the need for costly care through prevention.22 14 years ago, another IOM committee observed that although 70% of premature deaths have a social or environ mental cause, less than 5% of national health spending is devoted to preventing these deaths through population health.23 The ratio may be even more lopsided today. The potential for public health to help is huge. After all, even modest reductions in our national rate of obesity and further declines in smoking could generate large downstream savings.24 If you think our overburdened and undermanned primary care workforce is going to pull this off during 10-minute office visits, I’ve got a bridge to sell you. Our nation needs public health. To get public health back in the game, we must make it more visible and relevant. The problem isn’t a lack of inge nuity; it’s the loss of public understanding. The “hard science” of public health has never been stronger. Across America and around the world, PHS scientists are unraveling the mysteries of molecular biology, developing effective vaccines, conducting brilliant epidemiological inves tigations, and analyzing their results with rigorous statistics. Unfortunately, technical brilliance is not enough. If the public doesn’t believe in what you’re doing, they’re not going to buy what you have to sell. And as a result of declin ing health literacy, growing skepticism of science, and con scious efforts to misinform the public, public health is losing more customers every day.
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EXHIBIT 1 — The 2009 H1N1 influenza pandemic prompted an unprecedented public education campaign to promote uptake of the pandemic vaccine. Despite this all-out effort, only 1 U.S. adult in 5 got vaccinated against pandemic flu. Less than half of health care workers got vaccinated.25 — Although, it should be obvious by now that we aren’t doing a good job of convincing the public of the impor tance of vaccines, we continue to pour the bulk of our research efforts into devising new ones, rather than discovering how to boost public acceptance of vaccines. Over the past decade, more than 95% of National Institutes of Health spending on influenza research went to biomedical discovery. Less than 5% went to behavioral science.24
EXHIBIT 2 — Measles cases in the United States are at a 20-year high.26 The virus hasn’t grown smarter; we’ve gotten dumber. The efforts of antivaccine activists have seriously undermined Americans’ confidence in one of public health’s most powerful tools.27 Equally concerning, a growing number of state legislatures are allowing parents to opt out of mandatory childhood vaccinations on reli gious grounds. This stance endangers not only the chil dren of these parents but also everyone else’s children. — On the world stage, polio is making a comeback too, as religious extremists deliberately target vaccinators who are trying to eradicate the last pockets of this dread disease.28 This is a global tragedy.
EXHIBIT 3 — Thanks to sloppy antibiotic prescribing and the wide spread lacing of animal feed with these powerful drugs, once-defeated microbes are developing resistance at an alarming rate. These practices, plus an anemic pipeline of new antimicrobials, are rapidly depleting the avail able options to treat a wide range of deadly diseases.29
EXHIBIT 4 — Raw milk is making a comeback!30
EXHIBIT 5 — Fifty years after Luther Terry’s report, big tobacco is recruiting a new generation of nicotine addicts with e-cigarettes and e-hookahs. Because “vaping” exposes users to a less harmful mix of chemicals than tobacco, there’s a lively debate over whether they are a net positive or a net negative to public health.31 Will we figure it out in time? Buxton’s Law states that “It’s always too early [for rigorous evaluation] until, unfortunately, it is suddenly too late.” So what we need to do to turn things around?
MILITARY MEDICINE, Vol. 179, November 2014
Commentary
First, we need to develop effective communicators—Modem public health leaders need more than skills in management, finance, and strategic planning—they must be highly engaging communicators as well.32 Dr. C. Everett Koop (13th Surgeon General of the United States) didn’t grab the imagination of the public because he was a pediatric surgeon. He was able to do so because he was a plainspoken, principled and highly effective communicator.33 Second, we need to recruit new talent— Schools of Public Health should expand their recruiting efforts beyond kids who are good at epidemiology, biostatistics, and global health to attract young people who have a knack for marketing and communications. The PHS should also build partnerships with nongovernmental organizations and media startups that are developing effective new approaches to health promotion. To reach a distracted and increasingly skeptical public, we must outthink, outwit, and outwork the competition. Third, we need high-quality social science—To determine how best to engage the public, public health needs to invest in high-quality social and behavioral science. That won’t happen unless PHS agencies devote a larger share of their research budgets to this kind of work. Fourth, we need allies—Public health can’t win this fight alone. You need the support of community groups, doctors, nurses, employers, and the faith community. I was drawn to public health because each time I worked a shift in the Emer gency Room, I saw what happens when public health fails. It’s heartbreaking, costly, and most important—preventable.34 Last but not least: we need courage—Public health is a contact sport. Luther Terry knew he could lose his job over the Surgeon General’s Report, but he didn’t let that stop him. From time to time, public health inevitably bumps up against powerful economic, philosophical, and political interests that hold strongly opposing views. And when it does, they hit back.35 It’s always been that way, and it always will be. Can public health get its mojo back? You bet. It’s inside each of you, right now, and its yearning to break out. Members of the PHS Commissioned Corps, I admire you for what you do. In any given year, you save more lives than a busload of cardiac surgeons, but rarely get your due. Still, you never give up. In the last few years, the PHS Commissioned Corps has taken its lumps, but the qualities that define you: integrity, idealism, courage, and conviction—are as strong as ever. If you are willing to adapt to meet the challenges you face, the next 50 years of public health will be even more impactful and beneficial than the last. So stand tall, enjoy the meeting, and get ready to move out! Because you’ve got work to do!
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