Public health is withering away

States and cities continue to hollow out the public health workforce. Officials at the Association of State and Territorial Health say an analysis of 55 health agencies shows a loss of 16,380 jobs since 2008. The health agencies also had nearly a quarter of a million furlough days in the last two years – the equivalent of 1,000 full-time jobs.

Public health gets no respect despite its considerable historical impact.

Of the 30-year increase in U.S. average life expectancy in the last century, only five years can be credited to advances in medical care. The 25 other years are credited to public health, yet less than 1 percent of Americans can define the mission of public health.

Public-health measures virtually eliminated the scourge of infectious disease through efforts to provide clean and fluoridated drinking water, better sanitation, widespread immunization, motor-vehicle and occupational safety, family planning, smoke-free public places and chronic-disease management.

Public health differs from medical care in two distinctive ways. First, public health is aimed at prevention rather than the curative aspects of health. Second, it deals with collective, population-level health, while medical care generally is individual.

Public health more broadly promotes healthier lifestyles and addresses environmental factors to prevent widespread illness on a community level. Medicine focuses on diagnosis and treatment of specific diseases with drugs, surgery and medical technology.

Because public health addresses large populations, it has more potential to lessen health disparities cost-effectively. Research has repeatedly shown that effective public-health programs and disease-prevention initiatives can reduce cancer, heart disease and diabetes, as well as continue to suppress infectious diseases.

Despite widespread support for disease prevention, less than 5 percent of U.S. health-care spending goes toward public health. Public-health activities primarily are carried out by state and local governments. Departments vie for scarce resources from government entities that by law usually must balance their budgets. As a result, public health is destined to be underfunded, especially in a difficult economy.

By contrast, the economics of medicine are immune from these constraints, as evidenced by the fact that health-care costs rise at a significantly higher rate annually than the overall Consumer Price Index.

 Trust for America’s Health (TFAH), a nonpartisan advocacy group, estimates that an annual $10-per-person investment in proven disease-prevention programs based in communities could save more than $16 billion annually in medical costs within five years – a return on investment of more than 5 to 1.

Local public-health funding varies dramatically. The top 20 percent of communities in public-health funding spend more than 13 times the amount of the lowest 20 percent. More spending translates into better health surveillance and research, and lower mortality rates.  A 2011 Health Affairs journal study found that death rates fell between 1 and 7 percent for each 10 percent increase in local public health spending.

More than half of local health department budgets are funded by federal and state governments. Federal funding in recent years has remained relatively flat, while state and local support has waned because of the recession. The average state budget’s projected deficit was 24 percent in 2010, and 29 states projected deficits for 2011.

The $35 billion spent on U.S. public health each year is about $20 billion short of optimum funding for critical programs, according to a 2008 analysis by TFAH and the New York Academy of Medicine.