Public health: A victim of its own success?

An examination of the recent history of the public health system offers insights into why steps are now necessary to shore up its foundation.

By Kathleen Phalen, AMNews correspondent. Dec. 24/31, 2001.

Public Health: Renewed Attention
A six-part series exploring the role of the public health system in the context of our nation's newfound state of alert.

1. From the front lines
2. Recent history
3. Greater expectations
4. The risk-benefit ratio
5. New promises
6. Homeland security

The nation's public health system has been quietly crumbling for decades. "Ask the American people about public health, and they can't define it," says Quentin Young, MD, a Chicago internist and past president of the American Public Health Assn.

But when America experienced the reality of biological attack this fall, the cracks in the system's foundation were exposed, and repairs have taken on a new urgency.

"It all has to do with undersupport," Dr. Young says. "Public health enjoyed a much higher value in the first half of the 20th century. But now I call it the Cinderella of American medicine."

In the 1800s and early 1900s, wave after of wave of infection robbed mothers of babies, husbands of wives and children of parents. Families lived in constant fear that a virus or bacteria would kill or cripple. Public health efforts stopped these epidemics by putting toilets in tenements, separating sewage from drinking water, inspecting food and controlling and containing disease. As environmental conditions improved, people got healthier. Life expectancy increased. And fear diminished along with premature death.

Perhaps a victim of its success, public health's significance dwindled. Few thought of public health as life expectancy nearly doubled during the last century. Few thought of public health when drinking a glass of clean water, washing hands before eating or getting children immunized. And few thought of public health when allocating funds: Initiatives get a minuscule slice of the pie, about 9% of all health care expenditures, and that includes the National Institutes of Health and the Centers for Disease Control and Prevention. "We've forgotten about how important preventing disease is because it's not glamorous," says Shelley Hearne, DrPH, executive director of Trust for America's Health. "Some argue that if 100 die of anthrax, then it's a big issue. But if 100 are prevented from getting sick, then it never gets the attention." [...]