public health reform jonathan mann lecture 2011 david fleming, md director and health officer
TRANSCRIPT
Public Health ReformJonathan Mann Lecture 2011
David Fleming, MDDirector and Health Officer
Recent history
“ The desperate diseaserequires a dangerousremedy”
Guy FawkesNovember 6, 1605
Life Expectancy in the U.S. (1900 – 2009)
78.277.476.875.875.474.773.772.6
70.870.269.769.668.265.9
62.961.759.759
54.154.55048.747.3
0
10
20
30
40
50
60
70
80
90
Exp
ecte
d Y
ears
of
Lif
e at
Bir
th
Leading causes of death – United States
Mor
talit
y R
ate
Epidemiologic Transition
1900
Pneumonia
Tuberculosis
Diarrhea
2010
Heart Disease
Cancer
Stroke
Life expectancy, by county, compared to the world’s 10 best countries
Comparison funding for disease prevention withpremature deaths, King County, WA 2009
2000
1500
1000
500
0
$8.0
$6.0
$4.0
$2.0
$0.0
$8.0
$7.7
$4.7$4.4
$1.6
$0.4 112
$1.4
440
$0.3
600$2.0
911
$1.8
1990
HIV Prevention
EmergencyPreparedness
Tuberculosis Sexually Transmitted
Diseases
Vaccine Preventable
Diseases
Diabetes Heart Disease
Injury Cancer Tobacco
Fun
ding
in M
illio
ns
46 16 1 0 53
Pre
mat
ure
Dea
ths
Disease in the US has undergone an epidemiologic transition … it’s time epidemiologists did too
1. Align resources to the current burden of preventable diseases (that means chronic diseases, injury, and health disparities)
– Make new friends with the health care system
2. Build an epidemiological work force able to perform in a world of policy, systems, and environment change
– The future of epidemiology is less about guiding ourselves and more about convincing others
Surveillance
In a perfect world we’d be accountable for quantifiable improvements in health outcomes.
Four inconvenient truths make accountability more complicated than merely promising outcomes.
2: The exact effects of even proven interventions are uncertain
3: For many important public health problems we do not yet have a full tool box of proven interventions
4: Changes in health outcomes may occur only years after intervention
1: Future health outcomes are unpredictable even if we do nothing
Shift from pseudo-accountability for health outcomes to real accountability for execution of strategy
The Three Part Plan
1) Joint agreement between accountable parties on specified strategies
2) Strict accountability for execution and measurement of strategies
3) Measurement of outcomes and strategy revisions as indicated
Health Indicators
Cancer SuicideInfant
MortalityAIDS
Health Indicator Health Indicator Health Indicator Health Indicator
AIDS
Health Indicator
Suicide
Infant Mortality
Health Indicator
Health Indicator
Health Indicator
CancerResources($, people) Programs Product Short term
Outcomes
Resources($, people) Programs Product Short term
Outcomes
Resources($, people) Programs Product Short term
Outcomes
Resources($, people) Programs Product Short term
Outcomes
AIDS
Health Indicator
Suicide
Infant Mortality
Health Indicator
Health Indicator
Health Indicator
CancerResources($, people) Programs Product Short term
Outcomes
Resources($, people) Programs Product Short term
Outcomes
Resources($, people) Programs Product Short term
Outcomes
Resources($, people) Programs Product Short term
Outcomes
Demonstrate a causal pathway between public health and better health outcomes
1. Embrace accountability for rationally-defined performance
– Be prepared for initial tough going
2. Define, standardize and measure the public health value chain
– A new full-employment strategy for futureepidemiologists
Causality
chart of accounts \'chärt\of 'äv\account ə-'kaünt\ : system of accounting records developed by every organization to be compatible with its particular financial structure, and in agreement with the amount of detail required in its financial statements. It consists of a list of ledger account names and numbers showing classification sand sub-classifications, and serves as an index to locate a given account within the ledger. See also class of accounts.
Control the system in which we work so that we can get the job done
1. Increase the coherence, integration, and base capability of our public health system
– Define basic public health capabilities, accredit health departments, and regionalize services where appropriate
2. Stabilize and rationalize public health financing
– Create a public health chart of accounts; fund core capacities; reform CDC funding mechanisms; define financing roles; advocate for stable revenue sources
Control ofextraneous variables
+ _
Leadership Skills
+
_
Epidemiologists
You are here
The real world
Epidemiologist Everybody else
■ Conclusion
■ Keep it simple
■ Sound bite
■ Stories
■ Methods … results … discussion
■ Caveat
■ Complete explanation
■ Data
■ Answers questions ■ Stays on message
Communication
■ Based on science and evidence
■ Focused on prevention
■ Centered on the community
■ Driven by social justice
■ Really?
Navigating our values
■ Will always finish second
■ Rugged individualism
■ Majority rules
Increase concordance between epidemiologic skills and leadership skills
1. Take the plunge. Practice talking work with non-epidemiologists
– Use passion and be driven by data, not just data driven
2. Recognize the liability of our underlying values in today’s world
– Think like a politician (when it is called for), strategically crafting messages and approaches
+_
+_
2 X 2 Association
