Featuring a single article of ongoing health relevance
Sometimes errors are instructive.
We made an ambitious goal of protecting 1 million heart attacks and strokes over a 5-year period through the Million Hearts program. We failed.
What's the diagnosis of our failure? Politics. It's not just in the Covid pandemic that political interference with public health science costs lives. It happens every day, and sometimes causes even more deaths than caused by the toxic combination of Covid+politics.
This month we published this analysis of failure – and specific, actionable recommendations for how to make progress.
Let's start with the basics: The US has a shorter life expectancy, with more disability, and higher health care spending, than any other country in our income bracket. Have a good look at the figure below to see how the US has become a negative outlier.
The U.S. has become a negative outlier in life expectancy. Data: Commonwealth Foundation
(And don't think shorter life means less time lived with disability. The opposite is true. On average, the shorter the life, the more of it is lived with disability.)
It's not a small problem. Average life expectancy in the US is 6 years shorter than the places like Hong Kong and Japan and Italy, Spain and Australia.
There are a lot of reasons for the shorter life expectancy, in particular health disparities by race, sex, and location.
Two actions would make big improvements in life expectancy (as would improving economic opportunity, education, and other fundamental changes that are needed but likely to take longer).
- 1.Comprehensive tobacco control, including regulation of the amount of nicotine in all forms of tobacco, including cigarettes and e-cigarettes. (Basically, make smoked tobacco non-addictive and limit the addictive potential of all forms of nicotine sold legally. The latter is already done in some countries, the former would be a world first – and long overdue.)
- 2.Reduce sodium consumption through mandatory limits on the amount of sodium in food, as well as other comprehensive interventions.
In addition, improvement in hypertension treatment – the health care intervention that can save the most lives – could greatly reduce health disparities and improve life expectancy.
Here's the full article. Now, how can we have the societal will to get this implemented?
Hope you enjoy it!
Public health is, to a great degree, a management problem. What needs to get done is often clear, but the gap between what we as a society know we should do, and what we actually do, is great. Why?
- 1.Innovation. Innovation is essential, ranging from new vaccines and medicines, to information systems, communication techniques, and more. Smallpox was eradicated through continuous introduction and implementation of innovations, including new organizational methods, new ways to find smallpox cases, new approaches to targeting which groups to vaccinate, new types of needles, and new ways to vaccinate different groups of people.
- 2.Technical package. The most effective public health programs are based on an evidence-based technical package: a selected group of related interventions that, together, will achieve and sustain substantial and sometimes synergistic improvements. A technical package of proven interventions sharpens and focuses what otherwise might be vague commitments to “action” by committing to implementation of specific interventions known to be effective. It avoids a scattershot approach of using a large number of interventions, many of which have only a small impact. Simplicity is key to success.
- 3.Management. Management of public health activities is particularly difficult because, unlike in the private sector where metrics such as product sales provide prompt feedback on performance, there is often no automatic, accurate, and affordable way to track public health program performance in real time. In addition, the impact of public health programs may not be evident for months or years. Honest and transparent assessment of progress or the lack thereof—even or especially if temporarily inconvenient or embarrassing because of lack of progress—is critical to allow continuous improvement.
- 4.Partnerships. Coalitions are essential to progress. Getting many organizations to collaborate can be slow and frustrating, but is needed to support budgetary, legislative, or regulatory change and to implement new or improved programs. Government programs are more likely to succeed—and to be sustained—when organizations outside of government advocate for them.
- 5.Communication. Effective communication includes not only conveying but also absorbing and acting on information from media, social media, and in-person communication. Of all the many failures of the US federal response to Covid in 2020, perhaps the most damaging was the failure to communicate effectively.
- 6.Political commitment. Public health programs are sometimes not adopted because of the “prevention paradox,” according to which “a preventive measure that brings large benefits to the community offers little to each participating individual.” Large gains in population health often come from small changes for many people rather than from large changes for fewer people. For this reason, leadership, communication, and partnerships are essential for progress.
To implement public health programs effectively, it's essential to get the science right – this leads to having an appropriate technical package and innovating to improve that package continuously. And it's also essential to manage well, including communicating effectively and creating coalitions. But unless the politics is aligned, even the best designed and best managed public health programs will fail. At Resolve, our team recently confirmed this finding in an assessment of the Covid response around the world. Strong public health programs can be undermined by bad governance. This doesn't make effective management of public health programs any less important, but does emphasize the importance of promoting governance based on science and facts, openly and objectively derived.
Never in our lifetimes has there been as much controversy about public health action as there is now, during the Covid pandemic. Irresponsible leadership accounts for much but not all of the failure of the response in the United States and elsewhere.
It's timely to review basic principles. I outlined these in an article for the New England Journal of Medicine a few years ago. Government’s Role in Protecting Health and Safety.* NEJM 2013;368(20):1857-9.
There are, fundamentally, three areas where public heath action reflects a responsible, responsive government. For each, there are long-standing, well-accepted examples as well as newer applications which are controversial now but which will likely be well accepted in future years.
First, promoting free and open information. We expect nutrition-facts panels on our food and inserts in our medications, but these are hard-won gains. Graphic pack warnings on cigarettes and public reporting of health care provider performance will likely become available in the future, but are being blocked now. In Covid, basic information about how each community is doing or even how much Covid is in each area, hasn't been available until now, but will be soon.
A second core role of government is protecting people from harms caused by other people. It's astounding to realize now, but drunk driving was once not taken seriously as a public health problem. There's a saying: “your right to swing your fist ends at my nose”.
Government has a responsibility to protect individuals from unhealthy environments, whether the sources of health risks are natural (e.g., mosquito infestation) or created by people or organizations. Few Americans now question government's role in preventing sale of contaminated food, water, and medications; reducing alcohol-impaired driving; or protecting workers and communities from industrial toxins.
Smokefree laws illustrate the growing acceptance of actions that protect people from others' behavior. Such laws are often controversial when introduced, with opponents predicting reduced hospitality-industry profits and decrying infringement of personal freedoms, but they gain acceptance as people see the health benefits — and no harm to businesses.
In Covid, mandates to wear masks protect us from other people and actions such as business limitations and closures can reduce spread, saving lives.
A third key role of government is to protect and promote health through population-wide action. Governmental action is often a more effective and efficient means of protecting health than the actions of individuals. Immunization mandates, fluoridation of water, iodization of salt, and micronutrient fortification of flour are classic examples of this type of action; many were controversial initially but are widely accepted today because they save money and reduce illness, disability, and death.
In Covid, examples of this type of action include government involvement to improve production and distribution of diagnostics, protective equipment, and vaccines. And, most importantly, vaccination. The more and sooner people get vaccinated, the safer and better protected we will all be.
When government fails to protect and improve people's health, society suffers. Opponents of public health action often fail to acknowledge the degree to which individual actions are influenced by marketing, promotion, and other external factors.
Government has a responsibility to implement effective public health measures that increase information available to the public and decision makers, protect people from harm, promote health, and create environments that support healthy behaviors. The health, financial, and productivity gains from public health actions benefit individuals and society.
Public health action to inform, protect, and preserve health
This article by Tom Farley, Mehul Dalal, Farzad Mostashari and me answered a question is easy to ask but that for some odd reason had not been answered in the scientific literature previously: How can you save the most lives through health care?
Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the U.S. by improvements in use of clinical preventive services. Am J Prev Med 2010;38:600-9.
Treatment of hypertension is, far and away, the most effective single intervention. When this article was written a decade ago, there was more belief in the value of aspirin for the primary prevention of heart disease. It is now clear that the benefit of aspirin for primary prevention is modest at best, although it is still very important for people who have had a heart attack or other vascular problem. My father, a cardiologist, used to say wryly that the best time to give a patient an aspirin is 30 minutes before they have their heart attack. But for blood pressure, control thoughout life is very important. Not for nothing is hypertension called the silent killer.
This article formed the basis of the Million Hearts program in the United States and of the effort of Resolve to Save Lives to save 100 million lives around the world.
Since 2010, the value of aspirin has been recognized to be smaller than shown here.
Reprints. Articles marked with * are available by request (all others are open source and available through the links). To request a reprint: