Diminishing Returns In Public Health
What important challenge will the field of public health face in the near future?
Diminishing Returns in Public Health
Are we victims of our own success? Over the past century, we have reaped huge public health dividends. Has this growing field progressed to the point where our success threatens the very field that made it possible?
Public health initiatives in the 20th century addressed issues such as smoking, occupational safety, and vaccination, resulting in a significant improvement in the expected average lifespan of an American adult. These results are extremely encouraging for the public health field and cast a positive outlook on the work going forward.
However, the successes of the 20th century pose unique challenges for the future of public health. One of the biggest challenges I believe that public health will face soon (or is already facing) is diminishing returns on new policies.
Part of the reason for the successes in the 20th century was due to the combination of new medical technologies like antibiotics and vaccines and the little previous knowledge of the behavior of diseases at the population level.
With these new tools in hand, we were able to address some of the most glaring issues in our health care. However, these issues may well have been the low-hanging fruits that are present in any young field.
Going forward, the public health system will face increasingly difficult diseases and complex disease and behavior patterns that will likely prove to be strong obstacles for the goal of a healthy public.
An example of this can be seen in the fight against cigarette smoking. From 1965 to 2004, public health initiatives (such as the Surgeon General’s report on tobacco, cigarette taxes, and public health education campaigns) were extremely effective, decreasing the prevalence of smoking in adults from 42.4% to 20.9%.
However, in the years from 2004–2009, smoking rates among adults in the US have remained relatively constant. This is at least in part due to the more difficult challenge of convincing the final 20% of adults who smoke to quit. Fortunately, we have seen more of a decline in the past decade; however, as smoking prevalence decreases, it will take more resources to address the residual smoking problem.
Public health vaccination programs are another example of the diminishing return phenomenon. In the 20th century, the medical community and the public health field accomplished unprecedented feats against some of the deadliest bacteria and viruses that humanity has ever known, such as those that cause smallpox, diphtheria, and polio.
However, as the prevalence of these diseases has decreased, the focus has shifted to other infectious diseases such as HIV, influenza, and tuberculosis. Unfortunately, vaccination against these diseases is much more complex and difficult, resulting in less effective vaccines or even our failure to develop a vaccine. Unless we have a breakthrough in vaccine technology (such as successful mRNA vaccines), we will continue to face this challenge.
Further, some viruses that we are targeting now are less of a public health threat, and therefore even with an effective vaccine, fewer lives will be saved in an absolute sense. This is not to say it is unimportant to target these viruses, only that the public perception of our vaccination program might be negatively affected.
Diminishing returns are common, even expected, as a young field matures. However, they pose a significant challenge for Public Health in particular due to the public nature and perception of the discipline. Facing more difficult challenges and showing relatively fewer results could erode the public’s confidence in the public health system, even to the point where a significant portion of the population doesn’t see the need for the system at all.
This can already be seen in the growing anti-vaxx movement, where trust in public health officials has been all but lost. Let me stress here that the reason that this community exists (at least in the numbers that it does today) is in large part due to the success of the public health system’s vaccination program.
If polio were still a major issue for Americans today, the anti-vaxx community would likely be much smaller, as polio disease would be a relevant and tangible problem. Further, any mild or rare adverse events resulting from vaccination would be drowned out by the overwhelming toll the actual disease would have on our country.
This would result in much less ammo for anti-vaxxers to use against vaccines. However, due to the success of the vaccination program, and the relatively harder challenges we face going forward, room for criticism has emerged. In 2019, the World Health Organization (WHO) listed ‘Vaccine Hesitancy’ as one of the top ten threats facing global health.
Further, there is a growing sentiment of public distrust and anti-intellectualism in our country that is at least in part driven by political polarization.
A major barrier to public health policies going forward will be communicating policy decisions to an increasingly skeptical and uninformed (or worse, misinformed) public, especially if terms such as ‘social justice’, ‘health disparities’, and ‘social determinates of health’ are co-opted by a particular political party, effectively creating an immediate bias against them by the other party.
If effective communication and education cannot be achieved, then policy compliance will decrease. It doesn’t matter how well a policy addresses a specific public health crisis if the public does not (in practice) adopt that policy.
I believe there are several actions that public health officials must adapt to meet these challenges.
If we do not make evidence-based decisions, then the public will lose their faith in our judgment. However, if we use data to back up our policy decisions, then it will be more difficult to make a case against the policy.
2. Transparent policies
It is not enough to simply make evidence-based policies, but we must have clear and effective communication of the policies and how we came to our conclusions.
Public Health relies just as heavily on effective scientific communication to the public as it does on data-driven research and results. This is particularly important in the turbid political climate that we find ourselves in today.
3. Continued health outreach
We need to continue to develop health educational outreach to inform the public of health behaviors and threats to our health. Again, effective communication is key.
We must be honest with ourselves and the public about the challenges we face and our own biases. We all have biases that condition us to be either more or less ready to accept a particular interpretation of data. It is important that we are honest here, perhaps even explicitly acknowledging our bias, and then reasoning through our judgments.
This process can build public trust, even when there is disagreement. I believe this is one of the most important steps that we must take as public health officials. It also may well be the hardest as our political system becomes more and more polarized.
As this field continues to mature, the way we face upcoming challenges will shape the public perception and effectiveness of public health policies.