WHAT’S NEEDED TO FIGHT CHRONIC DISEASE

In “Asleep at the Switch: Local Public Health and Chronic Disease,”1 Frieden has identified almost all of the many important targets for departments of public health wanting to do something about the burden of chronic disease. He is absolutely right that there are proven effective measures at hand that could greatly reduce this burden. But one could come away from the editorial with the idea that, given the right priorities and enough funds, public health departments can do the job. It’s more complicated than that.

Certainly, funding for chronic disease control in public health departments is inadequate. But it is not just a question of more funds to educate the public and the health care providers to do the right thing. There are forces out there that actively and passively resist many of the actions that must be taken to get at the causes of chronic disease. To take a few examples:

• Diet—Trans fat consumption is a major new public health problem. Almost all of the trans fat consumed is commercially produced by alteration of natural vegetable oils. Some companies are taking steps to eliminate this kind of oil from their products, but most are resisting. The only way to level the playing field and eliminate this health risk is through legal action to prohibit the production and sale of food with more than 2% of its fat content consisting of trans fat. Denmark has passed a law that does this.

• Physical activity—Everybody wants children to exercise more. New York State Education Department regulations require frequent and regular physical education classes in the schools. Almost none of the New York City schools comply with this regulation. To be in compliance will cost money, which will need to come from somewhere.

• Cancer—Colon cancer is a preventable disease. At least 50% of Americans older than 50 years have not had effective screening for colon cancer. Cost is the most important barrier, because reimbursement levels are not equal to the costs billed for services. The medical profession needs to take action to bring down the cost and the insurance companies need to assure coverage at a reasonable cost.

• Cost of essential drugs—Cost has come to be the most important barrier to the widespread use of statins and other drugs known to effectively prevent heart disease and stroke. The drug industry is not going to reduce the price of these “blockbuster” drugs without strong and persistent pressure.

Of course, a department of public health is part of a government and can’t take on all targets at the same time. But advocacy and health education need to include public action to take on the corporate and government forces that resist needed change. The public and, especially, public health professionals should recognize that there will be some battles.