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n engl j med 362;18 nejm.org may 6, 2010

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Why We Dont Spend Enough on Public HealthDavid Hemenway, Ph.D.

Why We Dont Spend Enough on Public Health

The field of public health haslong been the poor relation ofmedicine. Medicine in which

most resources are used to helpcure individual patients after theyhave become sick or injured orto help manage already-existingchronic conditions is flashy,its master practitioners and in-novators lionized, and its accom-plishments widely celebrated. Incontrast, public health in whichmost resources are focused ontrying to keep something badfrom happening in the first place

is seemingly mundane, its ef-forts and prime movers often allbut invisible.

Medicine is primarily a privategood the patient receives themain benefit of any care provid-ed. Payments usually come fromthe individual patient and, in thedeveloped world, from private andgovernmental insurance. Publichealth, on the other hand, pro-vides public goods such as agood sewer system and reliesalmost exclusively on governmentfunding. It is generally acknowl-edged that public health is sys-tematically underfunded and thatshifting resources at the marginfrom cures to prevention couldreduce the populations morbidi-ty and mortality. I believe thereare four key reasons for suchunderfunding.

First, the benefits of publichealth programs lie in the future.Our brains are structured so thatwe use different neural systemswhen considering the present andthe future.1The problems of temp-tation, procrastination, and im-

patience exist in large part be-cause of the desire of the ancientpart of our brain, the paralimbic

cortex, for immediate gratifica-tion. Since it takes willpower todelay gratification, individually andcollectively we sometimes under-invest in the future. People typi-cally seek medical care becausethey want quick relief for imme-diate concerns current illnessor injury. Most public health mea-sures, however, incur costs todaybut dont provide benefits untilsometime in the future.

When considering a publichealth investment today (e.g., im-proving road safety, preventingmad cow disease, or limiting cli-mate change) that will potentiallyyield benefits in the future, manypoliticians correctly understandthat their administrations willbear the costs, but the benefitswill be reaped on someone elseswatch. They therefore put greateffort into putting out todaysfires and relatively little into pre-venting tomorrows conflagra-tions.

Second, the beneficiaries ofpublic health measures are gen-erally unknown. Whereas medi-cine typically deals with identifi-able people (patients), public healthtypically deals with statisticallives. The medical care you re-ceive is directed at helping you.

Public health interventions, on theother hand, are aimed at improv-ing the health of a group of peo-ple; when lives are saved, its oftenunclear whose lives they were.

People have stronger emotionaland moral reactions to the plights

of identifiable victims than tothose of statistical victims.2 In1987, when 18-month-old Jessica

McClure fell down a well in Texas,the country was enthralled. As anation, we will spend tens of mil-lions of dollars to save one BabyJessica but are often unwilling tospend an equivalent amount toprevent the deaths of many statis-tical babies. We willingly provideresources for relief when publi-cized catastrophes affect specificindividuals or communities, fromNew Orleans to Haiti. We are less

wil ling to provide resources forthe prevention of such widespreaddevastation. The scandal that peo-ple remember about Hurricane Ka-trina is not so much the lack ofpreventive measures (e.g., strongerlevees) that would have avertedthe calamity but the inadequaterescue efforts.

Third, in public health, thebenefactors, too, are often un-known. Although public healthefforts are recognized by some ashaving played a more importantrole than curative care in im-proving our countrys health overthe past century,3 the Americanpublic, through no fault of itsown, has almost no idea whatpublic health professionals andprograms do. Public health haslittle news value saving statis-tical lives doesnt make for good

human-interest stories or photoops. Public health also has fewwell-known scientists or leaders.Whereas many people have heardof such medical giants as MichaelDeBakey and Christiaan Barnard,I would venture to guess that few

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8/11/2019 Why We Do Not Spend Enough on Public Health

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n engl j med 362;18 nejm.org may 6, 20101658

know about their contemporary,Maurice Hilleman, a researcherwho developed more than 30 vac-cines (including those for mea-sles, mumps, and chickenpox)and who is credited with savingmore lives than any other 20th-

century scientist.When people benefit from

public health measures, they of-ten dont recognize that theyhave been helped. In the UnitedStates today, it is easy for peopleto take it for granted when, onany particular day, they dont getsick at work (because of air-quality improvements), arentpoisoned (because the food issafe), or dont get run over (be-

cause the walkway has been sep-arated from the road). In the fewcases in which people do recog-nize that theyve been helped bypreventive measures, they rarelyknow who provided the benefit.In contrast, the help provided bycurative physicians is more eas-ily identified. So whereas grate-ful patients, in turn, providemuch financial support for hos-pitals, there is generally no grate-ful public providing substantialsupport for public health initia-tives.

Fourth, some public healthefforts encounter not just disin-terest but out-and-out opposition.Such initiatives often require so-cietal change, which runs coun-ter to the well-documented hu-man characteristics of status quobias and tradition-bound resis-

tance. Even the most successful

public health initiatives, such asthe great sanitary awakeningof the 19th century, which dra-matically reduced the spread oftuberculosis, were met with fierceopposition.4

Societal change is hard, and

it is especially difficult when itimposes costs on powerful spe-cial interests. In the past half-century, those opposing benefi-cial public health measures haveincluded some of our most po-tent political lobbies, represent-ing the interests of the alcohol,tobacco, firearm, automobile, coal,and oil industries. For instance,Americans who die before 40years of age are more likely to

be killed by an injury than a dis-ease. In the early 1990s, firearmswere the second-leading cause ofinjury-related death in the UnitedStates, killing 100 civilians perday. The Centers for Disease Con-trol and Prevention (CDC) beganspending a disproportionatelysmall amount of money on thisenormous issue $2.6 million(about a penny per person) ondata collection and research eachyear. One CDC-funded study ofviolent deaths in the home showedthat the presence of a gun in thehousehold was a risk factor forsuch deaths.5But congressionaldelegates on the CDC appropria-tions committee, bowing to thewishes of an outraged gun lobby,tried to shut down firearm-relatedactivities at the CDC. Althoughinitially unsuccessful, their at-

tempt had such a chilling effect

that the CDC has effectivelystopped funding research on thismajor public health problem.

In contrast, increases in re-sources for medical care are usu-ally promoted rather than op-posed by large special interests,

from pharmaceutical and medicalinsurance companies to physi-cians, nursing homes, and hos-pitals.

Epidemiologists are taught torecognize and address the prob-lems of systematic error. Hospi-tals are learning to detect andprevent systematic errors in pro-viding medications and otherpractices. Similarly, our countryneeds to understand and try to

correct systematic policy errors including the tendency to under-invest in public health.

Disclosure forms provided by the authorare available with the full text of this articleat NEJM.org.

From the Harvard Injury Control ResearchCenter, Harvard School of Public Health,Boston.

McClure SM, Laibson DI, Loewenstein G,1.Cohen JD. Separate neural systems value im-mediate and delayed monetary rewards. Sci-ence 2004;306:503-7.

Small DA, Loewenstein G. Helping2. avic-tim or helping thevictim: altruism and iden-tifiability. J Risk Uncertain 2003;26:5-16.

Evans RG, Barer ML, Marmor TR, eds.3.Why are some people healthy and othersnot? The determinants of health of popula-tions. New York: Aldine de Gruyter, 1994.

Winslow CEA. The evolution and signifi-4.cance of the modern public health campaign.New Haven, CT: Yale University Press, 1923.

Kellermann AL, Rivara FP, Rushforth SB, et5.al. Gun ownership as a risk factor for homi-cide in the home. N Engl J Med 1993;329:1084-91. [Erratum, N Engl J Med 1998;339:928-9.]

Copyright 2010 Massachusetts Medical Society.

Why We Dont Spend Enough on Public Health

Syphilis and Social Upheaval in ChinaJoseph D. Tucker, M.D., Xiang-Sheng Chen, M.D., Ph.D., and Rosanna W. Peeling, Ph.D.

Syphilis, a sexually transmittedinfection (STI) that was nearlyeliminated from China 50 years

ago,1is now the most commonlyreported communicable disease inShanghai, Chinas largest city.2

No other country has seen sucha precipitous increase in reportedsyphilis cases in the penicillin era.

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