Outbreak – Law Street

Are We Spending Enough on Public Health?

Ashley Bell — Sat, 16 May 2015 12:00:00 +0000

Image courtesy of [Teletran14 via WikiMedia Commons]

Treating people when they’re already sick is like beating back invaders who have already breached your defenses. In either scenario, prevention through good defense saves money, time, and lives. But when it comes to boosting our nation’s wellness defenses through public health spending, America falls short.

When it comes to health, concerns abound that we’re wasting money, time, and lives by spending too much on treatment and recovery and not enough on prevention. Public health interventions like smoking cessation programs and disaster preparedness initiatives save lives. The more we learn about the power of these interventions, the more experts call to keep them afloat with better funding. Spending a few dollars to get a person to quit smoking makes more sense than spending thousands of dollars to try to treat their lung cancer several years down the road. Preparing for a natural disaster beforehand is preferable to picking up the pieces afterwards.

So what is public health? It’s something that aims to keep you alive as long as possible. From preventing diseases to preparing for disasters, public health programs keep a wary eye out for threats and then help populations avoid or mitigate them. For example, if data shows a high diabetes risk for a certain population, public health programs will target that population with preventative messages about diet and exercise. Public health departments might also help local school systems prepare for potential natural disasters, like Florida does with its Children’s Disaster Preparedness Program.

Read on to learn about public health spending in the United States, and where we might need to invest some more time and money.

Where’s the money?

In April, the Trust for America’s Health (TFAH) released its report Investing in America’s Health: A State-by-State Look at Public Health Funding and Key Health Facts. The report highlights many ways America falls short on public health spending. They say America’s public health system “has been chronically underfunded for decades.” In Why We Don’t Spend Enough on Public Health, author David Hemenway says this is because the benefits of public health spending today aren’t seen until potentially far in the future. Governments and politicians want to see the benefits of their investments in the present day, so they favor spending on medical treatment and other immediately fulfilling initiatives.

Here are some of the key findings:

Public Health Spending is Actually Shrinking

According to TFAH, when you adjust for inflation, public health spending in 2013 has sunk 10 percent from 2009. Many simply don’t see the benefits of spending on public health programs that yield intangible, future benefits when money could be spent on initiatives that produce immediate results like transportation or construction projects.

All States are Not Created Equal

States vary widely in what they spend on public health as funding is determined by the set-up of each state’s unique public health department. Indiana came in at a low of $15.14 per person, while Alaska spends $50.09 per person. This could be why health levels also vary widely from state to state.

Communities Aren’t Prepared for Public Health Emergencies

Public Health Emergency Preparedness (PHEP) Cooperative Agreement Funding helps communities respond to natural disasters, epidemics, and outbreaks. It was backed by $919 million in 2005. In 2013, it was supported by just $643 million.

Hospitals Aren’t Prepared for Public Health Emergencies

The Hospital Preparedness Program (HPP) gives healthcare facilities funding to beef up their preparedness measures. Funding for this program has been slashed by almost half, dropping from $515 million in 2004 to $255 million in 2015.

It’s estimated that 2/3 of all deaths in the United States result from chronic diseases typically linked to behaviors like diet or substance abuse. These diseases could be prevented by well funded intervention programs to decrease the behaviors that eventually lead to chronic diseases. Public health spending could save Americans millions in treatments for preventable diseases. Likewise public health under-spending could be costing us more than we’re saving.

In this video, the American Public Health Association outlines financial returns on every dollar of public health spending for different activities:

The above video states that every dollar spent on fluoride in our water supply could save $40 in dental care costs and that a dollar spent on nutrition education could save $10 in health care costs. The main point? Public health programs make for a smart investment.

The Consequences of Meagre Public Health Budgets

So, America spends too much money on treatment and not enough on prevention. The results aren’t pretty. In Integrating Public Health and Personal Care in a Reformed US Health Care System, authors Chernichovsky and Leibowitz write,

Compared with other developed countries, the United States has an inefficient and expensive health care system with poor outcomes and many citizens who are denied access.

The State of U.S. Health, 1990-2010 report put the U.S. up against other members of the Organization for Economic Cooperation and Development (O.E.C.D.), a program that advocates to improve economic and social outcomes. Since 1990, the U.S. has fallen in rankings for both life expectancy and healthy life expectancy. In 1990, the U.S. stood at the number 20 spot for life expectancy. By 2010, it was down to number 27. In 1990, the U.S. also enjoyed the number 14 spot for healthy life expectancy. The year 2010 found us in the 26th spot.

Under-spending in public health doesn’t just lead to generally poor health, it also impedes our ability to respond to emergencies. Assistant professor at the Harvard Business School, Gautam Mukunda, referred to Ebola as a “wake-up call” for the state of U.S. health preparedness. In Ebola as a Wake-Up Call he wrote,

Ebola may serve as a badly needed wake-up call about something the public health and biosecurity community has been banging the drum about for years: the U.S. has massively underinvested in public health.

Mukunda says the Ebola situation highlighted the measly number of extreme disease cases our U.S. hospitals can handle. Hospitals have decreased their capacity for extreme cases to increase their efficiency, only to lose the ability to treat patients when rare diseases strike. Although the need for extreme treatments arises only occasionally, hospitals should always be prepared for them. But with limited funding, it’s hard to be prepared for the unlikely “worst case scenarios.”

How does the future look?

The good news: The Senate finally passed a joint budget resolution after a five year absence of agreement.

The bad news: Their budget slahes non-defense government spending by about $500 billion over the next 10 years.

The budget cuts spell trouble for discretionary educational public health programs. From disease prevention to health care worker training, programs to promote good health may suffer across the board.

In an APHA press release opposing the measure, Georges Benjamin, executive director of APHA, says,

Simply put, our federal, state and local public health agencies will not be able to do their jobs to protect the health of the American people if these drastic cuts are enacted.

The budget would also annihilate the Affordable Care Act, including the Prevention and Public Health Fund, a program that focused on moving America towards a preventative health model by funding prevention communications, research, surveillance, immunizations, tobacco cessation programs, health-care training, and more.

The resolution isn’t yet a binding law, but indicates a set of collective and alarming priorities that steer America farther from the path of an integrated, preventative public health system. The Appropriations Committee still has to draft the spending bills, so there’s room for opposition. President Obama for one said he’ll veto bills following the restrictive budget.

Evidence to Inform the Future

According to the article, Evidence Links Increases In Public Health Spending To Declines In Preventable Deaths, published in Health Affairs, mortality rates fall anywhere from 1.1 – 6.9 percent for every 10 percent uptick in public health spend. The researchers made observations over thirteen years and found that the localities with the highest upsurges in public health spending had the most significant reductions in preventable deaths. The relationship held true in multiple causes of death and across different demographics. While the study is only a correlation, the linkage presents compelling evidence for the death-decreasing value of public health spending. The researchers believe a lack of substantial evidence for the ROI of public health campaigns may have hindered spending in the past, and their report takes one step towards getting that evidence.

The Trust for America’s Health (TFAH) advocates for an America with increased core public health spending. They also recommend ways to spend the money correctly. They call for a solid public health foundation for all populations in all states so everyone can be healthy no matter where they live. After that’s established, they advise investing in strong, evidence-backed public health programs and efforts to fortify emergency preparedness. Finally, they believe public health expenditures should be completely transparent and accessible to the American public.

Experts at a recent forum of National Public Health Week looked past mere spending to consider the future of public health and consider novel ways of approaching health to make America a healthier nation. The speakers want to stretch health thinking beyond the doctor’s office to focus on environmental and lifestyle factors that promote well-being like employment, housing, education, and even racism.

These experts dream of an improved, 360 degree view of public health. But sadly, their dreams need funding to become reality. If we continue on this path, it will be very hard to become a more healthful nation.

Resources

Primary

U.S. Department of Health and Human Services: Prevention and Public Health Fund

Additional

American Journal of Public Health: Integrating Public Health and Personal Care in a Reformed US Health Care System

The New Yorker: Why America is Losing the Health Race

Harvard Business School: Ebola as a Wake Up Call

Public Health Newswire: NPHW Forum: Creating Healthiest Nation Requires Addressing Social Determinants of Health

The Trust for America’s Health: Investing in America’s Health

The Washington Post: Senate Passes Budget Even as Impasse on Spending Continues

Public Health Newswire: House Adopts ‘Devastating’ Budget Agreement

Public Health Newswire: Senate Passes Budget that Batters Public Health

American Public Health Association: APHA Calls Budget Agreement Devastating

The Trust for America’s Health: Investing in America’s Health: A State-by-State Look at Public Health Funding & Key Health Facts

Health Affairs: Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths

The National Priorities Project: Military Spending in the United States

New England Journal of Medicine: Why We Don’t Spend Enough on Public Health

Ashley Bell

Ashley Bell communicates about health and wellness every day as a non-profit Program Manager. She has a Bachelor’s degree in Business and Economics from the College of William and Mary, and loves to investigate what changes in healthy policy and research might mean for the future. Contact Ashley at staff@LawStreetMedia.com.

The post Are We Spending Enough on Public Health? appeared first on Law Street.

Measles: Why is it Back and What Can Be Done?

Ashley Bell — Fri, 13 Feb 2015 19:35:09 +0000

Image courtesy of [frankieleon via Flickr]

Measles probably doesn’t make your list of top Disneyland souvenirs. Unfortunately, many unvaccinated visitors to Disneyland in California brought measles home along with mouse ears this season. It gets worse, because these people unknowingly shared their viral souvenir with other unvaccinated people in schools, banks, and even on public transportation. The result? A multi-state measles outbreak that has sparked a tirade of vaccination discourse. If measles can happen in the “happiest place on Earth” of all settings, we’re all in trouble.

Read on to find out more about these measles everyone’s talking about and why some people choose to opt out of a vaccine that most experts agree is safe and effective.

Why We’re Seeing Cases Now

Once upon a time (in the year 2000), the United States declared measles eliminated. Don’t get too excited. Eliminated in this sense doesn’t mean annihilated or wiped out completely like Dodo birds or Blockbuster stores. In 2000, measles was no longer endemic, or transmitted in the United States for twelve months or more. That happily ever after did not last long. Since then, measles cases have slowly but surely crawled back up; check out the CDC’s breakdown here. Overall, there have been 121 cases reported from January 1 to February 6, 2015.

Why the climbing cases? Although measles was eliminated in the United States, there was still plenty of it going around the rest of the world, especially in places without the same vaccination resources as the United States. In developing countries, measles causes about one million deaths each year.

Measles from the rest of the globe crept back into the United States on the coattails of international visitors or jet-setting residents. For example, experts trace the California outbreak to a traveler who was infected overseas. This person exposed other Disneyland visitors and the virus quickly spread throughout unvaccinated clusters in California.

Why is measles so hard to fight?

We’ll chalk it up to two basic reasons, each individually complicated:

Measles spreads like wildfire.
Our defenses have some holes, especially from the decrease in herd immunity caused by a growing number of unvaccinated children.

Let’s talk about each in more detail.

Measles is Viral Wildfire

In this most recent outbreak, cases of measles grew by 19 percent in just one week according to the Centers for Disease Control and Prevention.

Here are some other reasons that measles is viral wildfire:

Measles infects about 90 percent of the unvaccinated people it reaches, making it one of the world’s most contagious diseases.
It doesn’t require direct contact to spread; the airborne virus jumps easily from person to person through aerosol droplets. (One germ-laden cough or sneeze is all it takes.)
The first symptoms of measles include coughing, runny nose, and fever–pretty much the same as any other regular, old cold. Infected people will probably still be out and about, infecting other people.
It has a high reproduction factor. One person can infect about 12 to 18 others. That’s six to nine times more infectious than the flu virus that caused the 1918 flu pandemic.
Many young doctors have never seen a measles case, so infected people go undiagnosed and spread the disease.
It’s hard to contain. Health workers have to track down exposed people, a task that gets harder as more become infected.
It’s also expensive. The National Vaccine Advisory Committee says that Arizona hospitals spent $800,000 to isolate seven measles cases.

What’s more, measles can be severe. Before vaccinations, measles caused about 2.6 million deaths worldwide each year. In populations with malnutrition and poor health care, almost ten percent of measles cases end in death. Death occurs because of complications that result from measles, including encephalitis, pneumonia, and even blindness.

The World Health Organization calls the measles vaccine one of the best buys in public health, attributed to preventing about 15.6 million deaths in 13 years. Vaccines work because measles is considered antigenically stable; it doesn’t shift or drift to get around our immune system like the flu can. So one shot pretty much leads to lifetime immunity.

No antiviral treatment for measles exists. Most often it’s treated with supplements of Vitamin A and proper hydration, but you still have to let the disease run its course. Prevention through vaccinations avoids all of this.

The Breach in Herd Immunity

Tiny, adorable babies (and other vulnerable groups) physically can’t get vaccinated. Without immunization, measles plows through the population, causing the most harm to babies with developing immune systems; however, if many people are immunized, they create a buffer that keeps those who can’t get immunized safe from the disease. It’s call herd immunity.

Anti-vaccination sentiments cluster in certain geographical areas, breaching herd immunity on a local level. California is one area with clusters of unvaccinated people, thus why the most recent outbreak is so difficult to control. Clusters of unvaccinated people make ideal kindling for measles wildfire.

Watch the video below for a great explanation of why vaccines are important and how opting out is bad for the herd.

The idea of herd immunity puts the public health context back in the very personal choice of vaccination. Cooperation leads to successful herd immunity. The World Health Organization says 95 percent of people should be vaccinated to eliminate measles.

So, why don’t people just get vaccinated?

Downward trends in vaccination rates leave the United States vulnerable to measles attacks as we’re exposed to measles by global visitors and travel. If measles is so serious yet preventable, why do people still opt out?

There are many reasons that parents don’t get their kids vaccinated. They range from distrust of government to fear of negative side effects. In the California outbreak, people cite religious, philosophical, or personal reasons for opting out of vaccinations. Many doctors balk at the generally non-medical tone of these excuses.

Experts respond to doubts with a profusion of facts that counter most fears raised about vaccination. A 12-year study of Measles, Mumps, Rubella (MMR) vaccines found that it does not increase the risk for several suspected health outcomes. The World Health Organization published data that found no association between measles vaccines and Crohn’s disease. And plenty of other studies debunk common vaccination fears.

Here’s an alarming fact: in the anti-vaccination argument, facts don’t necessarily work. In some cases, arguing with facts as weapons makes the outcome worse. Research found that busting vaccine myths actually increases hesitancy around vaccination instead of raising intent to vaccinate. This all means that the sole strategy of many health communicators might actually backfire among this particularly skeptical target audience.

Why Facts Don’t Win the Vaccination Argument

People, unlike computers, pepper even their logical decisions with colorful human emotions. Many social and emotional factors influence how we perceive, interpret, and react to facts and science. Here are some reasons why cold facts don’t work in contentious arguments, like the vaccine debate.

We Cling to Naive Beliefs

People accept facts, but often cling to their intuitions with stunning zeal. This study demonstrates how even people with advanced scientific knowledge express natural delays when asked if the Earth orbits the Sun. From our humble perspective on Earth, this doesn’t look true. That simple intuition influences our initial gut reaction, even when we know facts to the contrary.

We’re Easily Influenced by Personal Anecdotes

Personal stories heighten naive beliefs. We’ll believe a friend’s anecdote about vaccines causing her child’s autism even when numerous facts state that it’s unlikely. Cold, hard facts can’t compete with your emotional reaction to the anecdote. A little intrigue might produce a similar effect. This study found parents less likely to vaccinate their kids after reading conspiracy theories on vaccination.

We Conform to Group Values

People make decisions that affirm their cultural identities and connections to people with shared values. It’s a tendency called cultural cognition. New info will pass through a pre-existing lens and if it’s contrary to fundamental beliefs, it might lead to even more polarization.

We Love to Be Right

The fancy word? Confirmation bias. It’s the tendency to seek out evidence that supports our current beliefs, regardless of accuracy. Emotionally charged issues inflate this tendency. The internet and on-demand television makes this force unstoppable. You can easily ensure you only hear what you want to hear.

Our Resources Hamper Our Decisions

Experts call it bounded rationality. We face difficult scientific issues, yet we still evaluate them with limited information, a fixed set of cognitive abilities, and limited time. Think of reading the terms and conditions before you buy a song on iTunes. You know it’s theoretically a good idea (just in case), but who has 45 minutes for that?

We Love Negative Talk

Negative information inspires more shares than positive information. One bit of negative news can eclipse five bits of positive news. In fact, negative talk about vaccines is more socially contagious than positive talk. Researchers have found that both positive and negative Tweets result in only more negative buzz.

So, now what?

To keep measles cases from increasing, more people need to be vaccinated. We could try to convince more people they should have their kids vaccinated or strengthen immunization laws and policy (e.g. making exemptions harder).

Convince More People They Should Vaccinate

As outlined above, the most avid vaccination opponents might be nearly impossible to turn. In fact, some vaccination opponents actively seek out measles infections for their children by hosting measles parties. The trial and error process involved in developing and testing new communications materials to target this finicky audience would be time consuming. Many experts believe we should move to strengthening immunization laws immediately before measles is able to become a more serious problem in the United States.

Strengthen Immunization Laws and Policy

Vaccination isn’t legally required and exemption allowances vary from state to state and can get pretty complicated. Lawmakers who recognize the need for change are proposing to overhaul vaccination laws in many states.

California is proposing to end personal (as opposed to medical or religious) exemptions. They’re also moving to require that public schools publish the percentage of enrolled children who are vaccinated, an effort that Arizona is also pursuing.

Other states are moving in the opposite direction. Montana and New York have introduced bills that would make parental exemptions easier. You can read more about recent vaccination-related legislation here. Be prepared for some interesting immunization debates in the coming months.

In addition to cracking down on state-by-state exemption policy, the Network for Public Health Law provides a few more suggestions, including pursuing tort claims, and taking a more active role in fighting measles globally.

Conclusion

Whatever path we take, vaccinations are here to stay. Unless we completely eradicate measles globally, vaccines will always be necessary to protect the United States from outbreaks. The recent outbreak in California (and other states) illustrates how important herd immunity really is. Vaccination is a personal choice that affects public health. How will we weigh personal rights against this public responsibility? Only time will tell.