Public Health Leaders On Past Achievements and Future Challenges

October 12, 2017|3:52 p.m.| ASTHO Staff

With ASTHO's 75th anniversary drawing to a close, it is important to look back and reflect on the most important public health achievements from the past 75 years, as well as anticipate issues and challenges the public health community might need to address in the coming years. To help answer these questions, ASTHO reached out to several public health leaders and keynote speakers from this year’s annual meeting, including: 

  • Jack Shonkoff, MD, director of Harvard's Center on the Developing Child. 
  • Estella Geraghty, MD, chief medical officer and health solutions director at Esri. 
  • Sanjeev Arora, MD, director of Project ECHO. 
  • Anna Lembke, MD, author of Drug Dealer, MD. 
  • Andrew Gurman, MD, past president of the American Medical Association. 

Jack Shonkoff, Estella Geraghty, and Sanjeev Arora

 Anna Lembke and Andrew Gurman  

What are the most important public health achievements from the past 75 years?

Shonkoff: The prevention and treatment of infectious disease. That’s clearly one of public health’s crown jewels and much of that progress has been in the realm of immunizations and drug treatment. Over the past 75 years, vaccines have been developed and immunization programs implemented that have helped build resistance to infections in individuals, communities, and nations. In addition to major gains in treating disease at a population level, the public health community has made considerable progress in dealing with individuals and population subgroups for whom conventional treatments are not successful.

Geraghty: The development of infrastructure. What I mean by that is, the development of public health competencies through training, and accountability to standards. When you have infrastructures that promote standard approaches, you enhance opportunities for coordination and collaboration. This has been key to making the public health system as robust as it is today. Of course, in addition, we can’t overlook the achievement of the near eradication of certain diseases through vaccination. For instance, the polio vaccine, which was created in the late-1940s and made regularly available by the mid-1950s—nearly 75 years ago is a great public health success. In 2016, the World Health Organization reported 37 cases of polio, which means that 16 million cases of paralysis have been avoided due largely to public health programs and interventions. That’s a pretty amazing accomplishment! 

Arora: For me it would also have to be the prevention of disease with vaccines. A few examples would be the polio vaccine, which led to the eradication of polio, the HPV vaccination, which has the potential to prevent a vast majority of cervical cancers worldwide (if applied globally), and the smallpox vaccination, which happened a bit earlier but still within the past 75 years. 

Lembke: Human longevity. Human life expectancy has remained remarkably constant through most of human history, but beginning approximately 150 years ago, average life expectancy began to rise. On average, until very recently, a newborn could count on about three decades. By 1950, average life expectancy jumped to 48. By 2016, it has reached 70 years old, more than double the lifespan for most of human existence. Major achievements in public health, beginning in the 19th century—ranging from vaccines and antibiotics, to safe water and sanitation, as well as improvements in global road safety—are responsible for this increase in the human lifespan. 

Gurman: The past 75 years have seen significant achievements in health—revolutionary advances that are saving lives and changing the way we live. Vaccines for diseases such as polio and measles, coupled with the push for universal vaccination, are reducing disability and death, while creating economic opportunity worldwide.

What advice would you give public health leaders of the future?

Shonkoff: A major frontier moving forward must be the prevention and treatment of diseases that are affected by significant adversity. The social determinants of health—i.e., outcomes related to income, education, social class, and racial and ethnic discrimination—are well understood from an epidemiologic perspective. What we now need is a comparable level of progress in preventing or at least reducing stress-related disease. Breath-taking advances in molecular biology, neuroscience, and epigenomics are opening up the black box of the social determinants of health. These advances are waiting to be used to inform more effective public health policies in a comparable way to how advances in immunology have produced dramatic impacts on infectious disease—by addressing causal agents directly, building resistance at the individual and community levels, and developing multiple strategies that match differential response to interventions.

Geraghty: Leverage geography as a way to focus and streamline public health efforts. I like to think of this as a transition from the microscopic to the telescopic. Since the early 1950s, when Watson and Crick discovered DNA, there has been a focus on the micro—i.e., this belief that the way to ‘fix’ health worldwide is through a micro-scale approach. I would argue that, in the future, what public health has been practicing for so long—that is, approaching health from a macro, population-scale viewpoint—will become ever more important. Leveraging location allows us to better understand the environments we spend our lives in (exposomes and the built environment), and how those different factors that can impact our health, either directly or even indirectly as they influence our behaviors or our access to health resources. The public health community understands this better than anyone else. Geography provides a context to better understanding multiple and often complex levels of interaction. Geographic science provides a basis for analysis, visualization (mapping) and decision support for determining where to intervene and where to allocate resources, so that they can serve exactly the right need in exactly the right place for exactly the right people. 

Arora: A larger amount of emphasis needs to be placed on reducing disparities in healthcare. The benefits coming from all of our scientific advances must translate to underserved populations. For example, we now know that colorectal cancer screening can prevent the vast majority of colon cancer, and the goal is to screen 80 percent of people at risk by 2018. However, if you look at federally qualified health centers in the United States, only 38 percent have patients who have been screened. In addition, in underserved communities, there is significant disparity when it comes to HPV vaccination, which can completely prevent the development of this fatal disease. So, correcting uneven implementation of public health best practices among minorities and low-income individuals will be incredibly important moving forward. 

Lembke: Yesterday I walked into student health services at Stanford. I was meeting someone at noon. We were scheduled to give a brief presentation on drug and alcohol misuse among college students living on campus. I was ten minutes early. I wandered over to a set of brochures attached to a bulletin board. There were four brochures, each with some variation of the word “happiness” in its title: “The Habit of Happiness,” “Sleep Your Way to Happiness,” “Happiness within Reach,” and “Seven Days to a Happier You.” As a psychiatrist, I should approve of this focus on student mental health, but I can’t help feeling the wrongness of these brochures. Is striving for our own personal happiness really the best we can do? Is this the highest goal we can hold out to the next generation? What we all need is not more happiness, but more meaning and purpose; not a smoother road, but a rougher one; more, not less, friction in our daily lives. Yet everywhere we turn, we are encouraged to seek happiness, and we feel like failures if we don’t achieve it. We look for happiness wherever we can find it—in shopping, gaming, sex, alcohol, and drugs—and find only misery. With that said, the advice I would give to public health leaders of the future would be to figure out how to compel citizens to do good, not simply feel good. Figure out how to make them care about each other and the planet. That means restraint, discipline, modesty, and humility. These are the values that are most demanded of us now and in the future. 

Gurman: I firmly believe that all physicians—not just leaders—need to participate in advocacy as a professional responsibility, just as they participate in lifelong learning. As president of the American Medical Association, that was precisely the message I shared as I traveled across the country and around the world speaking to physicians and medical students. I can tell you from experience that what happens in the halls of our state legislatures and national Congress is as important to public health as what happens in our hospitals and clinics. In social networks and on our phones—literally in the palms of our hands—we have powerful tools to affect change. We must work together, for our patients and for each other, to speak strongly and advocate for the important mission of public health.