Is Population Health Finally Coming into Its Own?

By David A. Kindig, MD, PhD

Why am I starting a blog on issues and perspectives in the field of population health?  It is because I believe we are at a "tipping point" in which a convergence of scholarship, policy, and practice initiatives seem poised to bring an overdue population health perspective to thinking about and acting on health and health improvement. The challenge of the next decade will be to find practical ways in which new approaches to financial and non-financial incentives and multi-sectoral partnerships can be applied to improve population health outcomes here and elsewhere.

Although the roots of broad population health thinking go back for centuries, in the United States, the second half of the 20th century was dominated by the rise of biomedical science and clinical medicine. Many in public and population health (how are these different?) have been critics of the dominance of health care emphasis and investment, but these advances have been critical and will continue to be so. The end of the century has seen additional growing understanding and support that such behaviors as tobacco use, diet, and exercise also make substantial contributions to the health of individuals and populations. My own population health epiphany came with my exposure in the early 1990s to the thinking of Bob Evans and Greg Stoddart and their population health "field model" from the Canadian Institutes of Advanced Research (1). At once simple and profound, it captured the basic population health principles:

• that health outcomes were more than the absence of disease;
• that these outcomes were produced by complex interactions of multiple determinants (health care, behaviors, genetics, the social environment, the physical environment); and
• that in a resource-limited world, the relative cost effectiveness of these determinants was critical for policymakers.

While this Canadian work has provided an important framework for international population health scholarship and policy development, the last 15 years in the U.S. have been dominated by such issues as health care access and costs and pressing immediate public health issues like emerging communicable diseases (e.g., HIV-AIDS and H1N1). Periodic activity and reports from government agencies and foundations have addressed parts of the broad issue of outcomes and determinants, but not in visible and sustainable ways. Notable exceptions have been (A) the Institute of Medicine (IOM) and Centers for Disease Control and Prevention’s (CDC) emphasis on a broad public health “system,” (B) the creation of the Robert Wood Johnson Foundation's (RWJF) Health and Society Scholars Program to grow a new generation of multidisciplinary scholars for this emerging field, (C) the RWJF Commission to Build a Healthier America, and (D) the WHO Europe’s 2003 report on the social determinants of health. (I will return in a future post to the challenge the social determinants of health pose for policymakers.) In 2010, however, this emerging field has still not matured in either scholarship or policy. However, the last several years have seen growing attention from a policy perspective. Here are some examples:

• Decades of work from the Dartmouth group demonstrated how communities that spend the most on health care may not have the highest quality or outcomes.
• The groundbreaking documentary Unnatural Causes provided wide exposure to the multiple determinants of health.
• The California Endowment is making a major long term investment in the broad health of 10 communities in California.
• The State of Minnesota has invested $43M in its State Health Improvement Plan to create "accountable health communities" that address obesity and tobacco through policy, systems, and environmental changes.
• The Institute for Health Improvement has endorsed population health improvement as one of the three legs of its Triple Aim strategy and is considering moving to a regional strategy
• CDC has funded a cooperative agreement with the National Business Coalition on Health to work with business-led health coalitions and the business sector on building the capacity of members to be leaders of health reform and advance value based health and health care.
• Concerns about obesity have underscored the complexity of addressing this critical issue (look for a future post on the tension between free will and the social context with regard to behavior choices).
• Obama administration officials have been discussing a “place-based” approach for social investments as well as a major Community Health Data Initiative.
• The National Quality Forum and the National Priorities Partnership are discussing the need for new broad measurement tools such as a national index of health.
• Our own Robert Wood Johnson Foundation MATCH project in February released the first ever National County Health Rankings of 3,014 counties in all 50 states according to a broad population health model that has been used in Wisconsin since 2003. 

When I published Purchasing Population Health: Paying for Results in 1996, this list of activities was much shorter. Now every day we learn of some new policy, practice, or research finding that is aimed at population health improvement. Keeping track of and commenting on these exciting developments is the purpose of this blog. We plan to post on a weekly basis, with content from our own team as well as guest posts from prominent policy and practice leaders.The University of Wisconsin Robert Wood Johnson Health and Society Scholars Program will each month identify several recently published papers that make important contributions to policy, practice, or scholarship. All posts will in some way relate to our underlying population health model, including key concepts of outcomes and factors.

My hope is for this blog to prompt lively and provocative dialogue--and even action--toward improving population health.I welcome comments on this first post and all contributions to follow. I look forward to hearing from you!

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.

Reference:

 1. Evans R. Stoddart G. (1990). Producing health, consuming health care. Social Science and Medicine, 31(12), 1347-63.

 

 

 

 

Comments

[David Vanness]

This is great, Dave -- I look forward to seeing (and hopefully being a part of) many thought-provoking discussions here.

[Rriporte]

Indeed, a welcome opportunity to be a part of thought provoking discussions around the import of population health. I heartily agree that it deserves to be center stage in any discussions about what kind of health care system we need. My first comment and thought...I worry that the depth and reach of the social environmental context effect on lifestyle choices is often overshadowed by the personal responsibility context. I hear this not only from the general public, but see it in the way educational programs are often designed to "correct" individual behaviors when there is good evidence that societal corrections (no smoking laws, etc.) do more to affect change. So much of the argument that focuses so strongly on personal responsibility is antithetical to what I consider a fuller population health perspective yet that is most of the work I see. What am I missing? What efforts do folks see happening, what new research efforts are underway, how can we best add balance so that the public is aware of the strong role public policy can play in helping people make healthy choices? (maybe this is seminar and not blog material?)

[David Kindig]

> Roberta, thanks for the thoughtful comment. I think the issue of personal responsibility and environmental context with regard to behaviors is one of the most important in our field, and yes, could be a seminar or whole course. For now, to your comment that "so much of the argument that focuses so strongly on personal responsibility is antithetical to what I consider a fuller population health perspective yet that is most of the work I see. What am I missing?", I'd say that there is a growing movement to influence the environmental context (see MN's State Health Improvement Plan menu of interventions: http://www.health.state.mn.us/healthreform/ship/rfp/SHIPRFP_Section3.pdf) to complement efforts that have a more individual focus. The best evidence available to us shows, of course, that both are important. As Brownell and colleagues assert in their recent article (Health Affiars March 2010 p.379), "The challenge is to combine personal and collective responsibility approaches in ways that best serve the common good." We'll look forward to exploring on the blog how this challenge is being addressed across diverse communities and sectors.

[Rriporte]

Exactly the kind of cite I was looking for. Thanks Dave. (Guess I should be more careful as I review those T of Cs.)