America has an astonishingly narrow view of "health" — and that was reflected in the rhetoric from this season’s presidential candidates, Hillary Clinton and Donald Trump.
When the topic of health was broached, which was rare, the focus was mostly on health care — access to doctors, hospitals, and medicines to treat people when they’re sick. There was very little discussion of public health, the goods and regulations that give us clean air and water, safe roads, and mosquito control. Unlike health care providers, public health officials work on preventing illness and injury. They devise plans to prepare for those increasingly frequent pandemic threats, like Ebola and Zika, and regulate tobacco use to give us smoke-free environments.
Last night, the closest the candidates got to a conversation about a public health issue was a brief debate about gun control. "I think we need comprehensive background checks," Clinton argued. In the September 26 debate, the only mention of obesity — one of the most pressing public health challenges America is currently facing — came with Trump’s fat-shaming reference to a "400-pound hacker."
Instead, the debates largely centered around Trump’s tax returns, Clinton’s emails, and the national deficit, with a tiny slice of health care, and public health was mostly ignored.
And that's a shame. Health care is obviously hugely important, but it’s public health — vaccine programs, improved sanitation, clean drinking water — that has given us the greatest gains in longevity over the last century. By ignoring these issues, politicians are missing an immense opportunity to impact the health and well-being of millions of Americans, and even prevent sickness and injury before they happen.
Let’s do a quick tally of the American lives affected by some of these things:
On this chart, I didn’t mention the 48 million Americans who get food poisoning every year, or the millions more who are imperiled by pollution and natural disasters linked to climate change (in part because they are admittedly more difficult to quantify).
It’s not surprising that, like climate change, public health issues don’t tend to get air time.
In an op-ed in the New England Journal of Medicine, Harvard’s David Hemenway explained that our brains are wired to focus on short-term issues, which deliver more immediate rewards, instead of long-term challenges, like public health. "Since it takes willpower to delay gratification, individually and collectively we sometimes underinvest in the future," he wrote. Whether its improving road safety, preventing a pandemic, or limiting the effects of climate change — all of which fall under the remit of public health — they "incur costs today but don't provide benefits until sometime in the future."
It’s also difficult to quantify the benefits of public health measures, so we tend to under-appreciate how important they are. How do you determine how many lives that have been saved and accidents averted because of clean drinking water or safe roads?
"Public health has little news value — saving statistical lives doesn't make for good human-interest stories or photo ops," Hemenway writes. "In the United States today, it is easy for people to take it for granted when, on any particular day, they don't get sick at work (because of air-quality improvements), aren't poisoned (because the food is safe), or don't get run over (because the walkway has been separated from the road)."
Public health simply isn’t as lucrative as health care, and it tends to face well-funded opposition from industry groups, Vox contributor Steven Hoffman explained in a Toronto Star op-ed. "We can’t commercialize or patent public health in the same way as we can medical drugs and devices," Hoffman writes. There are industries with powerful lobbying, such as tobacco and the beverage industry, that fight back against public health policies that could impact their profits. (We’re seeing this play out in the fights over soda taxes right now.)
As a result, we don’t talk much about public health in America. (Hemenway argues most Americans don’t even know what it means.) We also underfund it relative to health care. As of 2012, more than 17 percent of US GDP was spent on health care — drugs, doctors, hospitals — while only 3 percent went to public health measures.
If we want to begin to address the issues that affect most Americans, we better start talking about public health.