The field of public health seems like a recent invention, but epidemiology is as old as hippocrates and the Chinese tried to immunize in 1000 BC. what is public health? How did it come about as a field and what attracted you to it?
Public health is the way in which society maximizes health. when it comes to your personal health, you might think about eating well or exercising. in public health we think about the structure of society and how to encourage people to be healthier, how to make the default value the healthiest value. Hippocrates said something to the effect that prevention is always better than cure. public health is the science of prevention. it goes far beyond healthcare – it includes workplace health, healthy water, food and air, and more. Vaccines provide one of the key approaches to public health and are one of the key aspects that make public health so successful.
You are reading: Books about public health
“in public health we think about the structure of society and how to encourage people to be healthier, how to make the default value the healthiest value”
What attracted me to public health was simply that I loved taking care of individual patients as a doctor, but I wanted to be able to help more people by caring for entire communities and empowering entire communities to live healthier.
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Before becoming director of the Centers for Disease Control and Prevention, he was head of the New York City Department of Health. what is the cdc doing to promote public health? how does it function in relation to other health actors, such as the city health agency you once headed?
First, we find out what’s going on and tell it like it is. We are a health sentinel, just as a doctor checks a patient’s vital signs, we check the vital signs of every community, state and nation, to detect ongoing and emerging health problems, whether acute or chronic, cancers, diseases of the heart or infections. We work 24/7 to keep Americans safe and healthy.
Second, we support local, state and international health entities to help them work more effectively. In the United States, most of our resources actually go to state and local entities to help them detect and respond to threats. Third, we advance science. we detect and diagnose diseases, help develop new vaccines, scale up programs that work, and then communicate that information to those who need it.
Let’s look at just one example: Tobacco is the leading preventable cause of death worldwide. in fact, globally, tobacco will kill more people than hiv, tuberculosis and malaria combined. in this century, if nothing is done, tobacco will kill a billion people. it is difficult for a person to quit smoking. However, most people who smoke in the United States have already quit, and anyone who smokes can quit. Whether a person stops smoking depends not only on his individual willpower, but on a whole range of influences.
“in fact, globally, tobacco will kill more people than hiv, tuberculosis and malaria combined”
Those factors include how much nicotine the tobacco industry puts in their cigarettes and how they design the cigarette to make it more addictive, how good the services are at encouraging people to quit smoking, what the price of tobacco is, where they can people smoke and whether the government is running effective anti-tobacco ads on television and social media that make clear the human cost of smoking. Two-thirds of Americans who smoke want to quit and most Americans who smoke try to quit every year, but without the public health impetus for that and public health action they will be much less likely to succeed.
someone who quits smoking in a state that has very good public health policies on tobacco is much less likely to relapse than someone who quits smoking in a us state. uu. that does not have good public health policies. so there is an intersection and interaction between individual action and community action, between medical care and public health actions.
and tell us why your $10 billion budget is a good investment.
Public health is the best buy. for every dollar we spend on immunization we save the health system $3 and society $10. public health is about getting the most value out of our healthcare system. typically, we spend pennies on prevention for every dollar we spend on treatment. Prevention not only saves lives for less money, it also helps prevent disabilities and helps people live independently longer.
Vaccines are known as the most cost-effective public health tool. Vaccinated: One Man’s Quest to Conquer the World’s Deadliest Diseases by Paul Offit is his first pick. please tell us about the book and its author.
It’s a wonderful book because it offers both the history of vaccines and the biography of a man most people have probably never heard of: Maurice Hilleman. Although he was not an easy man to work with, there are few people in human history who have saved more lives than Maurice Hilleman. This book tells his story well.
“although he was not an easy man to work with, there are few people in human history who have saved more lives than maurice hilleman”
There are tens of millions of people alive and well today because there are vaccines. the success of vaccines in addressing a wide range of health problems is staggering. take polio there is a generation that has grown up without fear of polio, but it wasn’t long ago that everyone knew someone who lived in an iron lung, all the children knew that you couldn’t swim for fear of getting it, and everyone knew that fdr was in a wheelchair because of it.
When I went to med school there was still an iron lung in the hospital ward. Polio used to cripple 1,000 children a day around the world when the CDC, along with our global partners, began a campaign to vaccinate against it, and now we are on the verge of eradication. Huge challenges lie ahead, but I am confident that we will get over the finish line, and when polio is eradicated, it will be a gift to every child born on the face of the earth for the future of humanity.
offit is also the author of Deadly Choices: How the Anti-Vaccine Movement Threatens Us All. many members of the public persist in believing that there is a link between autism and vaccination. How has the anti-vaccine movement impacted public health and how is this impact combated?
Vaccines are, in a way, victims of their own success. before people were terrified by polio and measles; they are now so rare that some parents may mistakenly believe that the vaccine is more risky than the risk of disease. That is not the case. the more the public understands about vaccines and diseases, the better for everyone. so I think one of the things the anti-vaccination movement has done is push us to be even more open and transparent. we have nothing to hide.
“Before, people were terrified by polio and measles; they are now so rare that some parents may mistakenly believe that the vaccine is more risky than the risk of disease. that is not the case”
Some people take the view that if my child only has a one in a million chance of having an adverse reaction to a vaccine, but all other children are vaccinated, my child does not need to be vaccinated. there are people in the movement who sincerely believe in the danger of vaccines, but there are many parents who may unconsciously assume that I can protect my child as long as everyone else protects their child. what brings us back is the need to understand that we all live together, we are all connected by the air we breathe, the water we drink, the food we eat and the health of any one of us can affect the health of other people. .
tuberculosis was rampant in the slums of new york city for many years and no one cared. Because no one cared much about what went on in the slums, tuberculosis developed drug resistance and spread widely throughout New York City, infecting health care workers, prison guards, and many others. if we had cared about those inner city communities suffering from TB sooner, it would never have become such a big citywide problem. public health is about the connections within communities and strengthening those connections so that we can empower communities and empower people to live the life they want to live.
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your next pick is an autobiography by former cdc director william foege. tell us about the burning house.
House on Fire is a fantastic book about the fight to eradicate smallpox. Before becoming director, Foege led efforts to eradicate smallpox in India and Africa and devised a key innovation that led to eradication. As one of the CDC staff said about this book, “Even though we know how it comes out, it’s still a page turner.” it’s very exciting.
One of the things this book really made me realize was how important innovation is. the eradication of smallpox was not inevitable. when we remember what happened, we can assume that we knew what to do, we did it, and the smallpox disappeared. that was not all. they were continually innovating, devising new ways to vaccinate, a new real needle to vaccinate. It wasn’t high tech, it was low tech.
It turned out that high-velocity, pump-powered vaccine guns, where you could vaccinate huge numbers of people in a short time, didn’t work well. what worked was a very simple bifurcated needle. they figured out if you put that in the smallpox vaccine it had exactly the right amount of fluid in it and then if you shove it into the person’s arm 15 times it would result in what’s called a “shot” of the smallpox vaccine to a much higher amount. speed, and you could teach an illiterate person to do it in 10 minutes.
It wasn’t just about innovations like that, it was about who to vaccinate, how to vaccinate, and how to administer the programs. this book gives the reader a wonderful idea of what it took to get the job done.
What lessons do you take from that book and how do you apply them?
First, we have to cross the finish line on polio. Second, we need to continually innovate in ways big and small to figure out, for example, how to get to places where it’s not safe to vaccinate or where health workers may be under attack. for all of our health programs, we need to figure out how to organize community mobilization. if you look at india, which has been polio free for over a year, india made polio eradication a social mission and those are the kind of things that make a public health program successful.
Foege’s leadership is strongly associated with his development of a plan for mass vaccination and smallpox elimination, which Bill Gates has called “the world’s greatest public health triumph.” what do you want your legacy to be?
cdc is a wonderful institution. one of the areas where we can always do better is integrating our science and experience with frontline public health practice. we need to make sure the gears are turned, that when we take action, when we make recommendations, when we provide funding, the result is a program that keeps people safer and healthier.
He began his career as an officer with the CDC Epidemic Intelligence Service. EIS is the subject of the next book he selected, within Outbreaks: The Epidemic Intelligence Service’s Elite Medical Detectives. tell us about the book and eis: is it like csi for communicable diseases?
it really is. This book is to a new generation what was a book written by Berton Roueché called The Medical Detectives, which I remember reading as a child. they’re detective stories and they’re interesting and they’re human interest and they’re about saving lives. it’s really exciting.
in eis, you have a problem, you don’t know if it’s going to be a big or a small problem, you don’t know if it’s going to spread or not, you don’t know if you can stop it or not, and you’re working against time. Kate Winslet played an EIS officer in the movie Contagion. there is a drama in this work that is real and exciting. eis takes young doctors and as alex langmuir who created the show said, basically we throw the eis officers into the water and see if they can swim, and if they start drowning we pull them out and then throw them back in. so you’re taking young doctors and putting them in charge of huge research.
When I was in New York City, I worked on a typhoid outbreak and helped stop it. I worked on a cryptosporidium outbreak at a homeless shelter. but my time was really dominated by the tuberculosis outbreak: a large, massive outbreak of multidrug-resistant tuberculosis that spread through multiple hospitals in various parts of the city. I came out of my training program and was basically in charge of how to detect and stop it.
At cdc we also have a global mandate, because we can’t keep Americans safe unless we work globally. so what we have done is create programs similar to eis in more than 30 countries. we’ve helped over 2,500 disease detectives graduate in over 40 countries around the world, where many diseases go undetected and unstopped. about 80% of the graduates of these programs remain in those countries in leadership positions in public health. therefore, eis is, in many ways, at the heart of cdc’s work.
you mentioned
contagion
. In 2011, EIS and CDC received the Hollywood treatment in that Steven Soderbergh movie. you called it “a fair and accurate representation.” so I guess readers can watch it to get a glimpse of what you do, but I’m wondering, what are the most common misperceptions about how the public health community works?
i think there is a misperception that the cdc only deals with infectious diseases and only the united states. i am a doctor trained in infectious diseases: i did my job in tuberculosis control, cared for hundreds of hiv patients. But public health is about empowering people and communities to live longer, healthier lives. it’s about protecting people and keeping them safe from threats.
Those threats include being hit by a drunk driver. those threats include eating foods that he thought were safe but will give him a heart attack or deadly infection. CDC has 2,000 employees working in 50 countries around the world keeping Americans safe and saving lives in those countries. that’s a key part of cdc because we’re all connected. not just within communities, where not vaccinating your children can put my children at risk, but around the world, because a community that doesn’t know the disease is spreading or doesn’t control it is just a plane ride away. plane to make people sick or kill them here. .
then a book by sir john crofton, who was knighted for establishing a cure for tuberculosis. tell us about tobacco: a global threat.
sir john crofton was a wonderful man and became my mentor. he’s the one who really figured out how we should treat tuberculosis and basically cure everyone. he not only wrote standard textbooks on pulmonary medicine, but also a very simple and inexpensive text that became the guide for doctors and other health workers around the world on how to treat lung disease. he then he turned to tobacco and wrote this book.
I had gone from working with tuberculosis to working with tobacco and spent maybe a year working with tobacco before I came across this book. it’s only about 120 pages and it’s just wonderful because it’s so simple and clear. In just a few pages you get the full gist of what it takes to tackle the tobacco epidemic, the threat of tobacco. tobacco is a terrible problem.
I had a very active correspondence with Sir John for many years. he brought it to india because there was some resistance to the tuberculosis recommendations in the world health organization. as a British gentleman, he had much standing with Indian medical professionals and was able to be of great use there. we became friends and communicated regularly. a couple of years ago i gave the crofton lecture and in that talk i showed that sir john had laid out all the essentials of how to reduce the threat of tobacco in a simple letter that he sent to me a few years before the world community prepared this.
This is a book I wish every healthcare worker and everyone who cares about saving lives would read. one of the things sir john points out is that it has been said that a doctor who smokes is worth $100,000 to the tobacco industry. therefore, it is essential to get all health workers around the world to quit smoking and advocate for tobacco control. The book also shows how important it is that we limit the tobacco industry’s ability to do marketing and promotion, which leads to children becoming addicted before they reach the age of maturity. is just a wonderful book about the burden of tobacco and what to do about it.
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Which is more difficult to alleviate, public health problems that come from microbes or from human behavior?
I’m afraid the answer is human behavior. microbes are truly resistant and we have real challenges ahead, including the spread of antimicrobial resistance. but even that is largely the result of human behaviour: we have not safeguarded antibiotics as we should have. this is a nice transition to the last of the books.
rose strategies for preventive medicine
by geoffrey rose is his final recommendation. tell us.
I’m sorry I didn’t know about this book until well into my career, but it’s a fantastic book that explains why and how disease occurs in society. we think about the need to treat people who are very sick and, of course, we must. what rose is talking about is that for most human diseases there is a bell curve distribution. if we just treat people for diseases, that will do some good, but we can do a lot more good by changing the distribution of that bell curve. that’s the essence of prevention, that’s the essence of maximizing health by reducing the number of heart attacks and strokes.
It’s not one or the other, we can do both. so, for example, to reduce the number of heart attacks and strokes, we can treat people who have high blood pressure and that’s very effective, but we can also get people to exercise more, have a healthier weight, eat low-sodium foods and that will change the bell curve so that far fewer people need treatment and people who need treatment don’t need it as much.
I don’t think it’s an either/or issue for population health and individual health. but I do know that the health of the population tends to be underestimated. Until the middle of the 20th century, virtually all improvements in health were the result of prevention, not clinical care. sometimes clinical care could have saved someone through surgical or other interventions, but it was not effective enough or accessible enough to make a significant difference in the number of people who lived or died overall.
“until the mid-20th century, virtually all improvements in health were the result of prevention, not clinical care”
that began to improve with antibiotics and with the treatment of cardiovascular diseases. In the United States between 1980 and 2000, the death rate from heart disease was cut in half. half of that decline was due to community prevention, particularly tobacco control, and the other half was due to clinical care, such as caring for people while they had heart attacks. That tells me that both community and clinical care can make a big difference.
Interestingly, there was a similar study in the UK which showed that 80% of life years saved were saved through community prevention. community prevention measures save lives at a younger age. That’s really what Rose emphasizes: the tremendous power of even small changes in population prevalence to bring about big changes in health.
according to the criteria of dr. rose and your own, what diseases is the global community overspending on and what public health threats are not being adequately addressed?
I have my underlined copy of rose in front of me, open to a certain page, which I have often thought of because sir john crofton mentioned something similar. I underlined a passage where Rose wrote, “Of all the threats to human health, it is alcohol that causes the greatest variety of injuries. it shortens life and is considered to be responsible for between 1% and 10% of all adult deaths in industrialized countries. it shrinks the brain and impairs the intellect. causes failure of the liver, heart, and peripheral nerves. it contributes to depression, violence and the breakdown of personal and social life. it has been blamed for a quarter of all road deaths, split evenly between drunk drivers, drunk pedestrians and innocent victims.”
alcohol is a really difficult area. sir john always encouraged me to do more in alcohol control. the problem is the drinking problem. In the United States, excessive alcohol consumption causes a large proportion of the damage. however, the drinking problem is a challenge that needs to be addressed. I think we can at least start to address this problem by focusing on children and understanding that you want people to make decisions that will affect the rest of their lives when they are adults, not when they are children.
Are you willing to answer the question of which public health problems are you focusing too much on or spending too much on?
Several work has been done in economics suggesting that although we spend a lot on medical care, we get a lot for it. we want our hips or knees fixed so we can walk again. we want to stay healthy. this is a touchy area, but I will say that I wish we could have a more open discussion about end-of-life issues.
As a doctor, I’ve seen patients who suffered horrible deaths that they didn’t want because they hadn’t had a conversation with their families about what they wanted, and for some reason their families felt we should continue. to prolong the life of someone who does not really live but dies. and I will say that for my father and grandmother, to whom I was very close, the last two years of their lives were very unpleasant. This was really something that they would never have wanted, and yet we are not able as a society to have clear discussions and decisions about it so that people can choose how they want to live and how they want to die.
Your selections have highlighted some of the most acute and chronic threats to public health: what are the most acute and chronic problems of the international public health system? What are the biggest challenges you face?
I would highlight one: the need for strong public health institutions in the poorest countries. Improving health means getting data to drive decisions: data on what makes people sick, data on whether the programs that are designed to help actually work, data on whether the health system is doing what it should be doing, data on what that works across different communities to protect people from threats and data on what threats are spreading.
To get all that data, you need strong public health institutions. i think cdc does a great job in the united states. When I travel through Africa, Asia and Latin America, I am almost always asked: how can we create a CDC for our country? that’s the next big global public health challenge.
Going beyond the infectious disease agenda clearly appears to be a focus of his work. What challenges do you face in doing so? What are the political, cultural and social challenges?
there are economic interests that can make it difficult. the tobacco industry is a prime example. the tuberculosis bacterium does not pressure politicians. he doesn’t rename himself light too or get a movie star to look sexy too. then one is economic interests.
Second is the need to clarify responsibility. there are people who say that if the government does this it will undermine individual responsibility, or it is because you are not treating people as autonomous adults. it is not one or the other. Take driving as an example. The government has a responsibility to make sure that traffic lights work, that speed laws are followed, that people don’t drive drunk. But that doesn’t relieve people of their responsibility to drive safely, not to drink and drive: it’s a shared responsibility.
We need it for tobacco, alcohol, heart disease and cancer. now we can get vaccinated against hepatitis b cancer, so maybe one day we can use vaccines for heart disease, stroke, and smoking. but not yet and we should not wait because we have effective things we can do today that will save millions of lives.
saving lives requires good information, good management and focused action. these books really highlight that. They show how understanding what is causing the disease, finding the tools to stop it, and working together as a society can save millions of lives.
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