by Rodrigo Monterrey, McCormack MPA Student
Most Americans agree, regardless of their views on Obamacare, that good health is critical to their well-being. A Gallup poll shows an overwhelming majority of people in the United States (84%), when asked how important healthcare is, responded “very” or “extremely”.
But health and healthcare are two different things. Having healthcare does not mean you will not get sick—and not having it does not mean you will. In fact, while the United States spends more per capita on healthcare than any other nation, our health rankings keep slipping downward – currently 38th in World Health Organization (WHO) findings. Could our efforts, in some way, be making things worse?
Genetics, biology—these only explain individual health risk factors. It is the reason doctors ask about a family history to know what to monitor. However, they do not explain the disparities in health we see between entire segments of the U.S. population. There is no genetic marker for breast cancer or asthma that relates to income or nationality, but in the United States we see higher rates of these and other health issues among people of color and the poor. In fact, many immigrant groups report better health outcomes in their countries of origin. Something about living in the United States is making us sick.
Policy focus and public investment for improving health in our country focuses mostly on treating disease, not on what makes people sick or keeps them healthy. Don’t get me wrong: medical care is important. But a strictly medical model is not only unfeasible, it is also misguided—it defines success by the number of people enrolled in healthcare, or receiving treatment. Further, it creates a reinforcing loop: the more people get sick, the more they need but can’t afford expensive treatments that fail to address the cause of their illnesses.
The alternative is a “public health” approach, which shifts the focus away from individual treatment to address the determinants of health—the things that contribute to keeping people healthy or making people sick. These include healthy foods, breathable air, stable housing, and drinkable water, but also public safety, employment, education, social justice, and community empowerment.
In the first half of the 19th century, a cholera epidemic swept through London. Initially, they blamed the poor, their lack of hygiene, the “miasma” (bad smell) in the air. An obstetrician named John Snow, however, believed sewage might be contaminating the drinking water. He stepped out of his medical role and, for months, conducted studies that eventually led him to a frequented pump on Broad Street in Soho (back then everyone went to the neighborhood pump to get their water). He presented his findings to town officials. Though skeptical, they removed the handle to that pump. As a result, the cholera epidemic was finally stemmed and public health as the field of study we know today was born.
Public health is what we, as a society, do to ensure the health of our communities. As individuals, this means covering our cough, washing our hands, obeying traffic laws, not polluting. As public managers, it means working across sectors, engaging “non-traditional” stakeholders—those outside the medical field, including community members—to consider the health impact of policy decisions. To address infant mortality related to lead poisoning, for instance, it is not enough for doctors to educate parents—we must also involve housing inspectors and tenant associations to eliminate lead paint from homes.
Using a social justice framework, three questions must be thoughtfully considered when analyzing both problems and potential solutions:
What is the fundamental issue?
Who benefits and who is left out?
Who else needs to inform the discussion?
Perhaps the fundamental issue is health, not healthcare. Perhaps, in the medical model, the pharmaceutical and health insurance industries benefit, and to a lesser degree, those who can afford treatment. But those who cannot, the ones most impacted by health disparities, are left without the resources, and without a voice in the discussion of the problem and the solution.
We all know that illness creates a significant barrier for contributing to society and the economy. Our role as policymakers and public managers is to ensure that communities are able to thrive. Therefore, we must consider the health implications that every policy and project will have. If we focus solely on treatment, we fail to address the factors that contribute to people needing healthcare in the first place. These factors (violence, poverty, etc.) work together as a system—and systemic problems require systemic solutions.
Rodrigo Monterrey is the Deputy Director of the Office of Health Equity at the MA Department of Public Health. He studies public administration at UMass Boston’s McCormack Graduate School of Policy and Global Studies.