I was in New York City a couple of weeks ago giving several lectures. How strange it was to fly in over the city lights, cab through a recently flooded tunnel, and find my hotel without incident. Only after talking to cab drivers and old professional friends did the impact on so many reveal itself, including major hospitals still closed, and particularly the many, many stories of how those spared immediate devastation reached out to those not so fortunate.
At the beginning of my talks I acknowledged this terrible devastation, but asked if there could be a silver lining in that finally the greater public and policy makers will have to confront the realities of climate change in increasingly frequent extreme weather events. Ideally, this increased attention will lead not only to short run defensive measures like seawalls but also the more difficult but critical upstream policies like taxing carbon that will be needed to save the planet for our grandchildren.
Both natural and man-made threats can catalyze impressive responses, such as the rapid expansion in scientific research and training after the Russians launched Sputnik. With climate change, we might choose to focus all of our efforts on CO2 emissions; unfortunately, there is no similar magic bullet for improving population health, given the very complex factors that determine health outcomes and health inequities.
Part of the problem is that our threats to population health are seldom cataclysmic; instead, they tend to result in declines in quality of life and economic productivity over generations. Even the recent finding that a large fraction of U.S. counties have falling female mortality rates over the past decade doesn’t seem to rise to policy attention. I am reminded of the initial work on mortality from hospital errors; the national daily loss was estimated as equivalent to a Boeing 747 crashing daily. While such a visible loss would have certainly resulted in policy change, it’s more difficult to generate attention when it happens quietly and one-at-a-time behind hospital walls.
A year ago, I blogged on Thomas Friedman and Michael Mandelbaum’s That Used to Be Us: How America Fell Behind in the World It Invented and How We Can Come Back, which assesses the U.S. position in the world and what needs to be done to regain lost economic and social competitiveness. They argue that the current political paralysis is not up to these challenges and that the system calls for political shock therapy -- a direct analogy to its once classic use in psychiatry -- defined by the authors as a radical centrist third party.
I observed then that I couldn’t imagine a shock therapy for population health, but that the following steps were needed over the coming decade.
- Be clear on our metrics for achievement and improvement, including disparity reduction.
- Find savings from ineffective health care spending, and reallocate them to other population health determinants through such mechanisms as IRS Community Benefit reform and ACO shared savings.
- Identify and enhance health promoting policies and programs in non-health care areas (Health in All Policies, Health Impact Assessments).
- Identify cross-sectoral national and local partnership models with business models and financial teeth to leverage additional resources and policies.
I believe these remain worthy goals, but worry about our slow progress. Is there a way to induce a cataclysmic call to action without the cataclysm?David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.