Time to Embrace Public Health Approaches to National and Global Challenges

Many challenges face us today at the local, national, and global levels in assuring the health and security of all individuals. The population-based prevention focus of public health, which is the practice of social justice, offers an approach and potential solutions to major national and global challenges, such as universal health coverage, military investments, climate change, and women's and children's health. As Martin Luther King Jr stated in 1963, “An injustice anywhere is a threat to justice everywhere.” Today there is much to do at the local to global levels to address these injustices in health and well-being. At this critical time in our country's history, with a forthcoming change in administrations, the challenge for the public health community is to articulate how public health works and to develop the political will to invest in this approach.

UNIVERSAL HEALTH CARE

First and foremost, a public health approach is needed to address the crisis in our health care system. The growing number of the uninsured in this country is estimated to be 47 million people (for 2005)¹; at the same time, the cost of health care as a percentage of the gross national product continues to rise. Even if various cost-saving strategies, such as reductions in administrative costs and insurance company profits, competitive drug pricing, and chronic disease care management, were implemented, these savings would be within the “medical care box,” accounting for only 10% of health outcomes for the population.² The biggest savings can only come from prevention of chronic and communicable diseases in the first place, so that fewer individuals end up with health conditions that drive up the costs of medical care. This implies that major investment is needed in the public health system to address behavior and lifestyle changes, as well as environmental conditions that are necessary for population health improvements. The creation of a universal health care financing and coverage system, although a critical step and condition for better health, is necessary, but not sufficient, to improve the health of the public.

A public health infrastructure that embraces a population-based, systems development approach using the core three functions and ten essential services of public health is needed at the local, state, and federal level to prevent disease, promote health, and protect all residents.³ The public health approach uses a socioecological and social-determinants framework that assures key determinants of poor health—poverty, racism, unemployment, and a variety of conditions associated with unacceptable health disparities—are addressed. As our successes in combating tobacco use have shown, a multisector, multicomponent approach to supporting individual behavior change is critical. A key component of this strategy must include publicly funded marketing and the use of media to provide evidence-based information to the public to support individual- and population-level behavior change.

Three key messages should be included in the national and state debates occurring today concerning health care reform. First, health care is a public good that is necessary for a thriving economy and global development. Second, federal reforms that support a universal single-payer system and provide health services to all, as we currently do for those 65 years and older through Medicare, are critical and necessary to achieve universal health care for all Americans. Third, a fully funded public health infrastructure is needed at the local, state, and federal levels, because only this investment in public health can prevent disease and improve health for the population in the future. Public health practitioners and researchers must advocate forcefully for the inclusion of public health in state and federal health reform!

MILITARY EXPENDITURES AND FOREIGN POLICY

The second issue that cries out for a public health approach is the nation's military and foreign policy. First and foremost, we need to stop the war in Iraq as a first step in redefining American foreign and military policy, to be followed by a thorough reexamination of military priorities, which have not been seriously reevaluated since the end of the cold war almost 19 years ago. We need to stop major investments in weapons systems that are neither effective nor needed for our country's defense, and adhere to all global treaties on the containment and elimination of chemical and nuclear weapons, biological pathogens, and related systems.

A major reinvestment of much of the current $700 billion military budget (which is about 70% of all discretionary spending)⁴ should be made in priorities that address the social determinants of health necessary for our “common security.” These priorities include adequate housing, welfare, social services, education, transportation, bridges and roads, updated water systems, a public health infrastructure, and a variety of key community programs, many of which have been excluded from the presidential and congressional budgets in the past eight years. As is true with health care reform, public health offers solutions to conflicts and terrorism by building healthy communities; it also has the tools to alleviate the suffering and impacts of conflicts during the conflict and afterward.⁵ At a minimum, we must fight for the full range of mental health and other much-needed supports for all veterans returning home from the battlefield.

CLIMATE CHANGE

Another current challenge is the inevitability of global warming and climate change on human health and well-being. Recent articles and discussions have led to a tipping point, whereby most acknowledge that global warming is occurring. Examples of the impact are the disastrous hurricanes on the Gulf Coast (Katrina and Rita), the recent fires in California, and the growing concerns about adequate water supplies (including, most recently, in the state of Georgia). Global warming will have many impacts requiring public health solutions, including increased heat, severe weather, air pollution, allergies, vector-borne and water-borne diseases, as well as decreases in water and food supplies, challenges related to the resettlements of “environmental refugees,” and the resultant mental health issues associated with the stress from all of these conditions.⁶ Once again, however, public health has the tools to monitor the impact of climate change and provide solutions to mitigate the impact on human health.

WOMEN'S AND CHILDREN'S HEALTH

Finally, another challenge is the deteriorating situation for women and children in the United States and globally. A necessary condition for women to thrive and be healthy is to possess the right to control one's own reproductive choices and options. An investment in women's education and health leads to healthy children and healthy communities. We must assure that women have access to essential services for their health and well-being. The continued struggle for public health evidence-based strategies and reproductive rights must be a high priority for local to global action.

A woman pours tea boiled in a solar oven in the Iridimi refugee camp that was manufactured on-site by the Chad Sun company. Besides being emission free, the solar oven saves women from the risky and daunting task of gathering firewood. Printed with permission of Corbis.

Our children are obviously not doing as well as they should be, especially in light of the United States’ enormous wealth and economic power in the world. The US infant mortality rate continues to be at the bottom of all industrialized and developed countries (ranked 28th in 2003).⁷ Increasingly large numbers of children are born into and live in households in poverty. Chronic conditions of childhood, such as obesity, asthma, and a variety of mental health and developmental conditions, are increasing at alarming rates. Large numbers of children do not have access to the early childhood health and education programs shown to improve health and productivity across the lifespan. Although there is much evidence that shows what is needed to improve the health and development of children and youth,⁸ we have failed to use this knowledge. We need a transformation of the current health and development system to one that coordinates all investments for children and their families from all sectors (e.g., health, education, social services). This change is needed in every community, with a strong point of accountability for all children and youth at the local, state, and federal levels to ensure all children reach their optimal health and capabilities.⁹ These assurances for both women and children are necessary, not only because it is the right thing to do, but also to maintain the US leadership role in the global economy. Public health again has the solutions, both for prevention and health promotion of optimal health and development for women and children.

POLITICAL WILL NEEDED FOR CHANGE

In summary, current national and global challenges in a number of areas could benefit from public health approaches and solutions. The implementation of effective policies requires a public health knowledge base, as well as social strategies and political will.¹⁰ To achieve the major public health investments needed to address the current challenges requires a public health movement committed to the development of political will for change. It also requires public health approaches to the problems of health care, climate change, military and foreign policy, women's and children's health, as well as other related challenges. This movement needs the unity of all who work in public health, as well as many partners from academia, business, community-based organizations, unions, and others, including the general public. The forthcoming US presidential election offers us an opportunity for a new direction and approach to major inequities facing our country and our world. This is a critical time to articulate the importance of a public health approach and solutions. If we in public health do not do it, no one else will!