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How schools of public health can contribute to health care reform

| 25 June 2009

Probably the biggest lever for containing health care costs over time is public-health interventions. The Association of Schools of Public Health has a position statement to that effect; we have weighed in. But here's the thing to understand: not all prevention practices save money. Cost-benefit studies have shown that some prevention practices actually increase health care costs over time — because people live longer, number one, and also because some of the practices themselves are quite costly. So the naïve public-health message — which we don't buy here at Berkeley — is that everything preventive is good and everything preventive will save money. It's simply not true. So we have to be much more sophisticated in talking about disease prevention.

There are interventions that will over time (and some in the short run) save money and improve quality of life. Many of these have to do with diet, nutrition, exercise, physical activity, and very early on in childhood. In some cases the payback is dramatic — something like 10 dollars to every one dollar spent — because the person is able to work longer, with less absenteeism. Sometimes it's over the course of a lifetime; in other cases you get this kind of return in five years.

So schools of public health are saying that part of health reform has to be investment in targeted disease prevention and health promotion. That's part of what we hope will come out of the health care reform legislation.

We can also offer an alternative vision. In terms of how we pay for health care, for example, what if additional funding were made to the local public-health department — the Berkeley City Health Department or the Alameda County Health Department? With this idea: that the way we're really going to prevent excess hospitalizations and excess visits to doctors offices is to use some of our public health care dollars to work with the schools, with the children (and through them their parents). To get them eating healthy food, to make sure they have their immunizations. That would be a grassroots public-health based intervention, very upstream.

Public health is impacted not only by education but by transportation and housing, the "built environment." In many poor neighborhoods you don't have grocery stores with fresh vegetables. You don't have parks. You have a lot of streets with potholes. You're far away from schools; students have to be bussed. We need to re-design communities. So some of the money to improve our health should be invested in education, transportation, housing, the design of our highways, freeways, and exit ramps.

I've suggested, for example, that the administration appoint a high-level, cross-agency task force — involving not only the Department of Health and Human Services but labor, education, housing, transportation, and agriculture — to confront obesity. It's going to take federal action, involving all those agencies, to address some of these issues.