In September 2017, Karen DeSalvo, SM ’02, published an article in Preventing Chronic Disease with the provocative title “Public Health 3.0.” It was premised on the idea that Public Health 1.0 encompassed the period from the late 19th century through much of the 20th century—when modern public health became an essential government function, comprising such activities as systematized sanitation, food and water safety, and vaccines and antibiotics. Public Health 2.0 was catalyzed by a 1988 report from the Institute of Medicine that described how public health authorities were constrained by the demands of providing safety-net care and were unprepared to address the rising burden of chronic diseases and new infectious threats such as HIV/AIDS.
Public Health 3.0, DeSalvo argues, must again transcend its own traditions. In a recent conversation with Madeline Drexler, editor of Harvard Public Health, DeSalvo elaborated on this vision.
Q: During the 20th century, the United States increased life expectancy by 25 years, cut smoking rates, boosted health insurance coverage, and improved health care quality. Can we equal or surpass those gains in the 21st century?
A: It’s possible. The problem is that we have forgotten about effective levers, such as public health law—which were responsible for many of our successes in reducing morbidity and mortality. We became enamored of therapeutics and vaccinations. Those are very important, but if you look at the interventions that increased life expectancy, because of their beneficial effects in such areas as motor vehicle accidents and smoking, it’s been in the regulatory and legal frame.
Q: How does Public Health 3.0 change our current mindset?
A: In our national Public Health 3.0 project, we visited model communities across the country. We found that there are some broad similarities across these communities. One is that their leaders and departments are willing to leverage social media or electronic health record data or retail data to get informed about the health and needs of their communities.
Traditional public health takes action based on randomized-control trial data and field survey work. Because those kinds of studies take so long, we typically rely on stale data. But if you’re doing real-world public health, you have to be nimble.
Q: Can you give me examples of this nimbleness?
A: Let’s say you were going to put calorie counts on menus in a community, and you wanted to know if that was making a difference in calorie consumption or in people’s awareness of calories. Rather than doing a field survey, we could look at social media like Twitter to see conversations about menu labeling. An epidemiologist at the University of Maryland, Quynh Nguyen, has shown that Twitter feeds from a community are well correlated with the community’s broad thinking and with the prevalence of conditions such as obesity.
A company called Carrot Health stratifies people according to the kind of car that they drive. People who drive a Toyota Highlander are least likely to smoke, and people who drive an Oldsmobile Cutlass Supreme are most likely to smoke. The company uses retail data that’s publicly available to create social and health risk profiles for individuals.
We are becoming more sophisticated in our ability to scrape together nonelectronic health record data—and I want public health to be a part of that.
Q: In a 2017 article in Health Affairs, you noted that of the $3 trillion in annual health spending in the U.S., public health receives at best 3 percent. How can public health function, given the financial odds against it?
A: On a per-person basis in the U.S., foundational public health capabilities cost about $32 per person per year. That’s less than a fancy cup of coffee a day. Even so, we’re only funding about 60 percent of our core public health infrastructure. The national gap number is about $5 billion.
In that financial context, health departments have to use up their limited bandwidth to do core public health—things like sitting in on sewage and water board meetings to listen for health challenges. That was the story of the Genesee County Health Department and the Flint, Michigan, water crisis. The health department just didn’t have the bandwidth or funding to do its job.
“In its best version, public health is about health and not politics. We need to go back to calling the services provided by doctors and hospitals ‘medical care,’ not ‘health care.’ Public health should take back the word ‘health.’”
—Karen DeSalvo, SM ’02
Q: Are these misplaced funding priorities a peculiarly American problem?
A: The U.K. and other countries treat the practice and leadership of public health as a career. But in the U.S., leadership in public health rotates in and out of medicine.
I am a great example of that. I was a doctor and the medical school was my primary place, and I rotated into public health practice without the benefits of a civil service career experience. But in the U.K., public health is treated as a civil service career—like the diplomatic corps. In Cuba, the public health system actually has primacy over the medical care system, and public health directs the budget of the medical care system.
Q: You started out working at the state lab in Massachusetts when you were 19 years old. Today, 34 years later, what do you understand about public health that you didn’t when you started out?
A: I relearned something that I had forgotten somewhere along the way: that public health is not just a set of practical skills but also a philosophical approach to the world. We are motivated by the idea that you don’t merely raise the mean, you’ve got to close the gap. There’s always an equity component in our work, a focus on lifting up the people at the bottom first.
In its best version, public health is about health and not about politics. We need to go back to calling the services provided by doctors and hospitals “medical care,” not “health care.” Public health should take back the word “health.”
Photo: Bron Moyi
