The novel coronavirus (COVID-19) pandemic has given many people around the world a firsthand account of the importance of public health. The outbreak has put a spotlight on the importance of public health, health care, and the overall health of the population. This particular challenge has reinforced the effects of health on virtually every aspect of our society, including education; food supply; work and employment; and the daily operations of key services we come to rely upon usually without thinking about them.
While the spread of a communicable disease is not the ideal circumstance to reexamine global health, it does provide an important opportunity for us to think more broadly about underlying factors that contribute to our health as an individual and as a nation. Despite the importance of a myriad of factors like strategic planning and emergency preparedness; system capacity, technology and infrastructure; disease surveillance and monitoring; and community resilience among a host of other things, I would like to reflect on the case for why the larger issue of population health is crucial to our advancement as a nation.
I am certain that many qualified subject matter experts, journalists, and other writers will be addressing this topic as it continues to unfold over the next 9-12 months. Instead, the outbreak has personally prompted me to rethink my commonly held assumptions about what matters and to ask whether we are missing greater opportunities to strengthen the health of all citizens of the global community. I believe there are things we can do that will really matter for future generations to come. As an American, my reflections include but are not limited to the following areas the United States can address in making improvements in the population’s health:
- Make health a shared value. I really like the Robert Wood Johnson Foundation’s (RWJF) Culture of Health Action Framework which places a special emphasis on a core question, “Is health really a shared value in our country?”1 Since shared values have been central to many social movements in this country, the RWJF asserts that as a nation our discussions about the value of health have not been able to garner more unity and cohesion about its importance. Thus, we have struggled with clarifying those values for all of the citizens of this country. Additionally, values regarding health have put a greater emphasis on care and not on health or well-being.2
- Shift our policy focus beyond the provision of medical care as the primary means of improvement of health to include other social and ecological factors.3,4 The Affordable Care Act (ACA), whether you like it and believe that it has helped our country or dislike it because you feel it has negatively affected people, should be more than a political stance that polarizes us. There are insights to be gained from the evidence resulting from this health reform,5 and we should be able to address what works and has not, as well as clear up persistent misinformation and confusion. Besides, the more important point for me is that our preoccupation with getting people access to medical care services has interfered with our understanding of the underlying factors that really contribute to our health. Medical care, while important, represents a smaller portion of that contribution. Focusing on it to the exclusion of those other factors may marginalize and create inequities we do not want.
- Seek system strategies that involve multiple areas and sectors outside of health care. Since the factors that contribute to health extend beyond the delivery of medical care, we should place greater efforts on integrating and coordinating efforts across these other social and economic systems to transform the health of all of our citizens.6 This area is very important but perhaps one of the most challenging because of how things are structured within those separate systems. However, as we continue to place greater emphasis on addressing the needs of the whole person and view the needs of communities as a group, it will help us to see what kinds of changes are necessary if we are to be more effective in meeting those needs around the country and as a nation.
- Increase our scientific-knowledge-to-action cycles for greater impact. Our nation’s significant investments in research and development through scientific discovery must continue but be coupled with more systematic efforts that allow discovery and evidence to quickly make its way into action. This actionable knowledge must continue to fuel our ability to innovate, adopt, spread, and put into place practices that can be readily applied in the real world and in diverse settings. We need to know what works and under what circumstances, not just what works in an ideal setting.
- Put more investments in prevention efforts at the population or community level. The Centers for Disease Control and Prevention (CDC) emphasizes the three buckets of prevention.7 When we examine the large financial investments that are made in our health care system relative to other investments in community-based or population level investments, one could ask if those investments are really paying off. If we seek to gain a much better return of our investment as a nation, then we cannot simply rely on the current allocations of resources. Specifically, our traditional investments in those settings have not produced the same benefits in health improvements when compared to similar industrialized nations around the world that make similar investments. In other words, we are at a “health disadvantage” compared to other countries that invest less and have a population that is healthier than the U.S.8
- Support national health planning efforts through regional and local participation in community health improvement efforts. Healthy People 2030,9 along with its history of our country’s efforts to help us identify and address areas that will improve the overall health of the nation, represents one of numerous efforts (public and private) to monitor and track how we are doing. Such strategic initiatives around the country foster an awareness of how we are doing relative to our goals of achieving greater equity in health across the country. With geographic information systems and advanced data analytics, we are able to view vast amounts of information (often displayed through interactive reports and graphics) that display rankings and report variations on a number of health, social, and economic measures. By tracking how we are doing, both within and across communities, we are better armed with the information we need to act locally. For me, the old saying rings true: “What gets measured gets managed.” Without these efforts, we are less compelled to do something about improving our community’s health.
- Remember that making a difference is not just for the professionals. While I have dedicated a significant portion of my life to training the future workforce of public health professionals and advocate for their ongoing role in contributing to our nation’s health, we really need every citizen’s participation and engagement in local communities across the country. We all have a stake in the health of our country, and we do not need another disease outbreak to remind us of our importance to each other. Participation by professionals and citizens alike is vital to our success. Mutual accountability in these efforts will propel greater progress toward our nation’s health goals. Remember: the outcome is way more important that we think.
Karl J. McCleary, PhD, MPH
Dr. McCleary is the Associate Dean for Strategy, Director of the Center for Health Strategy and Innovation, and Professor of Health Policy and Leadership at Loma Linda University School of Public Health. His research interests include health policy; transformation and strategic change; innovation, systems thinking and redesign; and population health.
- Robert Wood Johnson Foundation (2020, March 15). Building a Culture of Health. https://www.rwjf.org/en/cultureofhealth.html
- Chandra, A., Miller C.E., Acosta, J.D., Weilant, S., Trujillo, M., & Plough, A. (2016). Drivers of health as a shared value: Mindset, expectations, sense of community, and civic engagement. Health Affairs, 35(11), 1959-1975.
- Lantz, P.M., Lichtenstein, R.L., & Pollack, H.A. (2007). Health policy approaches to population health: The limits of medicalization. Health Affairs, 26(5) 1253-1257.
- Tarlov, A.R. (1999). Public policy frameworks for improving population health. Annuals of New York Academy of Sciences, 896, 281-293.
- Brodie, M. Hamel, E.C., Kirzinger, A., & Altman, D.E. (2020). The past, present, and possible future of public opinion on the ACA. Health Affairs, 39(3), 462-470.
- McGinnis, J.M., Berwick, D.M., Daschle, T.A., Diaz, A, Fineberg, H.V., Frist, W.H., Gawande, A., Halfon, N., & Lavizzo-Mourey, R. (2017). Systems strategies for better health throughout the life course, Chapter 2. In Dzau, V.J., McClellan, M., McGinnis, J.M., and Finkelman (Eds.), Vital directions for health and health care: An initiative of the National Academy of Medicine. Washington, D.C.: National Academy of Medicine.
- Auerbach, A. (2016). The 3 buckets of prevention. Journal of Public Health Management and Practice, 22(3), 215-218.
- National Research Council and Institute of Medicine (2013). U.S. Health in International Perspectives: Shorter Livers, Poorer Health. Panel on Understanding Cross-National Health Differences Among High-Income Countries, Steven H. Woolf and Laudan Aron (Eds.), Committee on Population, Division of Behavioral and Social Sciences and Education, and Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: The National Academies Press.
- Office of Disease Promotion and Health Prevention (2020, March 15). Healthy People 2030 Framework. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework