Public Health: a parable and two pickles

Two women are washing their laundry by the river. One looks up and sees a basket floating by, and in the basket is a baby! She wades in and pulls the basket to shore.

She’s cuddling the infant when another basket floats by with a baby in it. She wades in and grabs that one too. Then there’s another and another.

She calls to her companion to help, but instead of jumping into the water, the other woman is running upstream along the riverbank.  “Where are you going??? the wading woman yells. “We’ve got to save these babies.”

“I know,” yells back the second woman. “I’m going upstream to find out who’s putting the babies in the water. And I’m going to stop them.”

This story illustrates two very different approaches to solving a serious problem: the bandaid model (symptom relief for individuals), and the public health model (community-wide prevention strategies).

Our current medical system is still primarily based on the bandaid model. Folks get sick or hurt and the doctor fixes them. Take diabetes (please). Diabetes until recently was something that happened to you and then the doctor patched you up with insulin. And while it’s true that some folks have a genetic predisposition to diabetes, it turns out that today’s epidemic is a result of our eating too much (crap) and exercising too little – on a grand scale.

I came around to a public health perspective many years ago through my own personal experience of trying to lose weight. I tried about as many diets as there were weeks in the year, and failed at every one of them. It gradually dawned on me that specific diet programs (eat this, don’t eat that) were bandaids that covered up deeper issues – that only more awareness, an attitude shift and behavioral changes could fix, once and for all. Once I resolved those issues and changed my behavior the need for a special diet disappeared, as did the excess weight.

This got me thinking about how much trouble you could avoid if you could prevent the overeating in the first place. For example, working with kids before they developed bad eating habits, educating their parents about nutrition, improving school lunches and PE programs, and then going back even further in the chain to the suppliers of our food. (I was a few decades ahead of the curve here!).

Instead of trying to help individuals lose weight after they’d gained it, giving them insulin after they got diabetes or statins when their cholesterol was too high (bandaids), where could you shove a stick into the cogs of the machine to effect the greatest preventive benefit to a whole bunch of people?

These questions led me back to school for a masters in Public Health. Ever since, I’ve been the woman running upstream to find out where the babies are coming from.

The public health perspective asks foundational questions: Where does the problem begin? How could we prevent it from occurring in the first place? Here are a small sample of profoundly important measures that have come out of those questions: safe drinking water; sewage treatment systems; vaccinations (small pox, polio, measles, pertussis, hepatitis, etc etc), mosquito abatement projects (malaria), occupational safety regulations, food inspection programs, pre-natal care for women, family planning education programs….

Of course many of our public health problems are not caused by pathogens like polio or cholera. They are caused by money-making enterprises whose products turn out to be toxic. Tobacco. Asbestos. Certain medications like estrogen-replacement therapy. Foods made with trans fats. Leaded gas and paint.

Or they’re a result of toxic by-products of the manufacturing process:  nuclear waste, coal-fouled air, water fouled by all manner of manufacturing processes as well as grazing animals, and so on.

Business hates being told how to conduct itself and rarely ceases a practice unless under threat of penalties and lawsuits. This means the public’s safety is often at the mercy of our elected officials, many of whom (Republicans esp. under this disastrous Bush administration) do not have a public health perspective. For them it’s about the bottom line AND about getting re-elected.

Even Democrats, who are more sympathetic to prevention and regulation, need money to get re-elected. Unfortunately the very toxic industries that need regulating are often the biggest campaign contributors.

That’s the first pickle.

The second pickle is that public health campaigns are long-term investments. What we must pay out today to prevent a future epidemic or catastrophe seems like a huge chunk of change when the payoff could be decades in the future. Often we can’t begin to grasp what the catastrophe might be like that we’re paying to prevent.

When Al Gore suggests an investment of $5 trillion for us to make a switch to 100% renewable energy sources in ten years we balk. But when inaction may cost us the very survival of humans on earth: well, that’s a profoundly ponderous public health pickle.