On Looking Ahead to Mitigate Threats to Population Health: A Public Health of Consequence, June 2018

It is now abundantly well established and widely recognized that the United States is facing an epidemic of opioid-related deaths. In 2016, 63 632 people died from drug overdose in the United States¹; that is substantially higher than the peak year number of deaths from HIV/AIDS, firearms, or motor vehicle accidents. The past year has seen an extraordinary increase in public comment on the opioid epidemic, and the president’s most recent budget promises more than $10 billion over two years to help address the epidemic.² Importantly, this large number of deaths that are captivating political and public attention in this moment did not emerge suddenly. Whereas more than 60 000 people died from drug overdose in 2016, 52 404 died in 2015 and 47 055 in 2014. As far back as 2010, 38 329 people died from overdoses—more than ever died from any comparable epidemic in recent years.

That we are recognizing the importance of the opioid epidemic is all to the good, but it is not our role in this editorial to discuss whether the proposed new funding will be sufficient or properly allocated to meet its stated goal. Instead, inspired by the topic and the conversation appearing last month in AJPH,³ we ask a different question: can we adopt approaches that anticipate health consequences before they reach epidemic proportions?

LOOKING AHEAD

Three articles in this issue of AJPH provide ideas that can help us do just that in very different ways, while tackling rather different challenges to public health. First, and most directly linked to the opioid epidemic, Horon et al. (p. 777) examine death certificates in Maryland and show that standard death certificates may be underestimating heroin-related mortality and that enhanced surveillance approaches that take into account cause of death, toxicology, and scene investigation findings can better identify heroin; this identification may be important in the face of this national epidemic.

Epstein et al. (p. 822) explore a different challenge altogether: the contribution of early sexual initiation to subsequent health. Using data from Seattle, Washington, they show that early sexual initiation is associated with substance use behavior and obesity, with some—but not all—of these associations mediated through the direct consequences of sexual behavior (sexually transmitted infections, pregnancies).

Clark et al. (p. 808), using Medicaid data from Massachusetts, track health care expenditures in the 12 months before families became homeless and show that emergency department visits, hospital admissions, and expenditures rose steadily for these families before entering homeless shelters; these are potential early indicators that can provide an intervention point to anticipate, and prevent, impending homelessness.

These three articles take different approaches to very different challenges but have in common, to our mind, a forward-looking approach that anticipates the nature of a potential problem so that we can mitigate it. In some ways this is consistent with the core tenets of prevention—looking forward to avoid health problems before they happen or, in the case of the opioid epidemic, before they spread further in the population. All, however, offer some information that we think is broadly applicable and useful for mitigating challenges to public health. We outline three such takeaways below.

NOVEL APPROACHES, NIMBLE THINKING

First, lives unfold on life course trajectories, and, similarly, health patterns are the consequence of earlier exposures and cumulative influences that ultimately manifest as health at any point in time. The links between homelessness and health are abundantly well documented,⁴ as are the social and economic costs associated with homelessness.⁵ Efforts that aim to anticipate homelessness and mitigate trajectories of behavior that will result in homelessness stand to prevent both substantial morbidity and mortality and the societal costs that accompany poor health. Similarly, the health costs of obesity and depression, two of the health conditions explored in the Clark et al. article, result in an enormous population health burden. Efforts to anticipate the earlier life course factors that lead to these poor health outcomes stand to generate substantial improvements in population health.

Second, although we frequently lean on established systems to understand and intervene in unfolding epidemics, these systems are often poorly suited to the challenge of a rapidly changing epidemic. This is best illustrated by the Horon et al. article in the case of the opioid epidemic, but we suggest that it is also the case for homelessness as explored by Clark et al. Although the opioid epidemic had its roots in overprescription, ready availability of illicitly obtained drugs—including heroin—quickly fanned the flames, leading to the current epidemic. It is not surprising, then, that standard medical examiner procedures are not providing the most relevant information that can help inform an evolving epidemic. Similarly, whereas the total homeless population in the United States has dropped in the past decade, it would not be surprising if, in the case of an upswing in the epidemic, we are similarly ill prepared to use the data at our disposal that can help us anticipate and better understand an unfolding epidemic.

Third, unfolding epidemics do not happen in a vacuum. They take place over population life course trajectories, and our response to them is nested within health systems, data gathering processes, and systems of access to health care. This provides us with both an opportunity and a set of potential challenges. The opportunity, of course, lies in thinking ahead so that we can develop the best possible data systems to anticipate and mitigate potential population health burdens. The challenge is that threats to these systems are directly linked to emerging epidemics. Although the currently proposed federal budget dedicates resources to the opioid epidemic, it also limits the reach of health care offered by the Affordable Care Act, including reducing the number of people on Medicaid. This creates a context that is likely to fuel the opioid epidemic rather than mitigate it.

LESSONS TO LEARN

It is helpful to think of the challenges to population health as nested within an ongoing trajectory of causes and their consequences³; this affords us an opportunity to detect, anticipate, and mitigate these challenges. How many fewer lives would the opioid epidemic have taken had we done this in 2010, when there were more than 50% fewer overdose deaths in the country?