Why Public Health Matters

Photo by Forest Simon on Unsplash

Because of Covid-19, awareness of epidemiology and public health has blossomed this past year. With this increased focus has come increased criticism: never in our lifetimes has there been as much controversy about public health action.

Few Americans question the role of government in preventing the sale of contaminated food, providing safe drinking water, reducing alcohol-impaired driving, or protecting workers and communities from industrial toxins — all of which are matters of public health. Control of infectious diseases is the reason public health practices were developed in the first place.

Good governance matters

Covid has shown the importance of good governance when it comes to public health action — and the steep price we all pay for bad governance. Bad politics can undermine even the best public health systems. Government has a responsibility to implement effective public health measures that protect people from harm and create environments that support healthy behaviors. There are three fundamental areas where public health action reflects a responsible and responsive government.

The first involves promoting free, open, and accurate communication based on the best available medical and scientific evidence. For Covid, this has meant regularly communicating information about level of spread in each area and vaccination rates by community and demographic group. Finland, Germany, and South Africa have excelled at clear communication by sharing vital information with the public widely and transparently, as well as addressing rumors and distrust rapidly.

A second core role of government is protecting people from harms caused by others. An old adage sums it up well: Your right to swing your fist ends at my nose. Laws requiring smoke-free workplaces are a recent example. When we proposed this measure in New York City in 2002, it was considered revolutionary. Now, more than 80% of Americans are protected by at least some restrictions on smoking in public places, more than half of all people in the U.S. live in places with smoke-free workplaces, and smoke-free laws are spreading around the world.

With regard to Covid, masking, distancing, and business restrictions save lives by reducing transmission. South Korea, New Zealand and Australia, which all implemented effective mask policies, closures, and travel restrictions, are exemplars of good governance in this domain.

A third key role of government is to protect and promote health through population-wide action, achieving healthy outcomes that individuals cannot achieve on their own. Immunization mandates, fluoridation of water, and iodization of salt are classic examples of this type of action; many were controversial initially but are widely accepted today because they save money and reduce illness, disability, and death. Examples from Covid include production and distribution of personal protective equipment and vaccines. Israel and the United Arab Emirates have moved faster than any other countries in getting their populations vaccinated.

The public health impact pyramid

A 5-tier pyramid describes the impact of different types of public health interventions, and provides a framework to improve health. Implementing interventions at each of the levels can achieve the maximum sustained public health benefit.

At the base of this pyramid are interventions which reach all or nearly all of society. This includes efforts to address socioeconomic determinants of health including income, education, and place of residence. Policies that effectively address poverty, low educational attainment, or improve housing drive substantial health progress.

The second level of the pyramid are public health interventions that change the context for health by making healthy options the easiest, default choice for individuals. Good examples of this are government regulation to ensure clean air and water, standards for road and vehicle design, and community and building design that encourages physical activity and active transportation.

The third level are one-time protective interventions with long-term benefits; these have less impact than the bottom two interventions because they necessitate reaching people on an individual level. Immunization, which prevents 2.5 million global childhood deaths annually, falls into this category.

Direct clinical care requires health care systems that work well for large numbers of patients most or all of the time. Comprehensive strategies to improve health system performance and health outcomes are essential. At the top of the pyramid are counseling and education, which is generally the least effective intervention, as it requires the difficult process of individual behavioral change.

Many effective programs work at several or all levels of the pyramid; a blockage at a lower level doesn’t rule out progress at a higher level, and actions at higher levels may pave the way for broader action at lower levels.

Public health saves lives

Resolve to Save Lives (RTSL) has the singular mission of saving lives. By working with partners to accelerate action with speed, simplicity, and scale in low- and middle-income countries, we are improving epidemic preparedness and heart health globally.

Through our Prevent Epidemics initiative, RTSL provides technical assistance to countries at greatest risk of disease outbreaks directly or through partners, mobilizes resources to support preparedness, and catalyzes political will to close gaps in epidemic preparedness. During Covid, our team has helped build local capacity, improve global policy, and supported robust systems to enable decision-makers to manage and adapt their pandemic response in a way that protects their people.

RTSL is also determined to save 100 million lives from cardiovascular disease over the next 30 years. Despite being the leading cause of global mortality and premature death, cardiovascular disease is largely preventable through simple, inexpensive, but underused actions. It takes financial and political capital, but with this, strategic action can save lives. Our three goals — improving hypertension control, reducing dietary sodium, and eliminating artificial trans fat from the food supply — are the public health interventions best able to be rapidly scaled up to cover large populations and reduce cardiovascular disease. These programs parallel and complement the Bloomberg Initiative to Reduce Tobacco Use, which is addressing the world’s leading preventable cause of death.

Heart attacks and strokes are so common that they seem like just a regular part of modern life. But it doesn’t have to be that way. Likewise, we must not accept losing thousands or millions of lives to a preventable virus, or being unprepared for future epidemics. Saving millions of lives is possible, but we need good governance that combines rigorous application of public health science and effective management.

We need to leverage this moment in global health history to build back healthier and more prosperous societies, starting with interventions that improve health for all of society.

Resolved: to save lives.

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Dr. Tom Frieden

Dr. Tom Frieden

President and CEO, Resolve to Save Lives | Former CDC Director and NYC Health Commissioner | Focused on saving lives. twitter.com/drtomfrieden