Tag Archives: public health funding

Public Health’s ‘Moonshot’ – Part 1

Advocates for cancer research and prevention efforts converged in Washington, D.C. last week for One Voice Against Cancer’s (OVAC) annual lobby day on Capitol Hill. OVAC, a collaboration of roughly 50 national non-profit organizations, delivered a unified message to Members of Congress on June 6 on the need for increased cancer-related appropriations. A point of discussion in my meetings with legislative staff was the President’s Budget Proposal for FY 2018, which featured budget cuts at both the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) and increases for the Department of Defense. Armed with OVAC “asks”, I decided to focus my meetings with legislative staff from Senators Burr and Tillis and Representative Butterfield on the economic impact in North Carolina if funding levels were reduced. North Carolina is home to three National Cancer Institute (NCI)-designated cancer centers, which are awarded over $2B in annual NIH funding and employs thousands of employees.

Our advocacy training included a presentation by Dr. Warren Kibbe from NCI on the state of NIH funding and a quick brief on the Cancer Moonshot Initiative. Led by former Vice President Joe Biden, the initiative focused on concentrated and collective action to accelerate a decade’s worth of progress in preventing, diagnosing and treating cancer into a five-year time frame. The Cancer Moonshot has buy-in from academic, public and private sector partnerships. My immediate thought: why doesn’t public health have this type of dedicated initiative with annual federally-appropriated funds?

The Robert Wood Johnson Foundation’s Culture of Health initiative is public health’s “moonshot”. Its Action Framework parallels the Cancer Moonshot Initiative in identifying focus areas and key performance metrics to measure progress. RWJF’s Culture of Health has achieved significant buy-in from a myriad of cross-sector stakeholders. The only distinction between the two initiatives, from my perspective, is dedicated federal support. Imagine the possibilities if public health’s “moonshot” received the same attention and resources as the Cancer Moonshot Initiative. A decade’s worth of progress in a 5-year timeline for the social determinants of health would really change the trajectory of the field of public health.

In the next few posts, I plan to take a deeper dive on exploring innovative ways to address the social determinants of health, specifically at the local level, in the city where I currently live – Durham, North Carolina.

Below, I offer background on the U.S.’s healthcare system to provide a larger context the many layers and contributors to an individual’s health outcomes.

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Healthcare expenditures in the United States was approximately $3.2T, or $9,900 per capita, in 2015 which accounted for 17.8% of its gross domestic product (GDP). When compared to 12 other high-income member countries of the Organization for Economic Cooperation and Development (OECD), the U.S. spent significantly more annually. According to the Commonwealth Fund, the U.S. spent roughly $3000 more than Switzerland, the runner-up in per capita spending, in 2013. As a result, it outspent the next highest spender, France, by 5.5% of GDP in 2013. But despite its additional spending, the U.S. underperforms on population health outcomes such as life expectancy and chronic disease prevalence when compared with other OECD countries. Additionally in its analysis, the Commonwealth Fund compared healthcare expenditures to those spent on social services – retirement, disability benefits, employment programs and supportive housing, among others – for 11 OECD countries. In this comparison, the U.S. spent the least on social services at 9% of GDP, with Canada and Australia spending 10% and 11% of GDP, respectively. France and Sweden spent the most on social services at 21% of GDP. This imbalance in spending, posit the authors, may contribute to the country’s poor health outcomes.

Policies to improve population health have historically focused on the healthcare system according to Kaiser Family Foundation’s Heiman and Artiga. The Affordable Care Act, signed into law in 2010, expanded access to healthcare services for millions of Americans. However, as the authors explain, research demonstrates that healthcare is a relatively weak health determinant. Individual health behaviors, genetics and a broad range of social and environmental factors account for 90% of an individual’s risk for premature death. Thus, addressing the factors outside of the healthcare system may play a key role in improving population health outcomes, and the value it generates could justify reallocation of current spending levels.

Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age”. Examples of social determinants of health include social economic status, educational attainment, the physical environment, employment and social support networks. Social determinants form the basic foundation for each individual and his/her life experience. It also sets a baseline for future health outcomes. For example, an individual who is unemployed for an extended period of time may become homeless, food insecure and have limited access to healthcare services. It’s reasonable to conclude that this individual may be at higher risk of premature death due to his/her life experience. Unfortunately people all over the world have lives filled with adversity and struggle. Social, economic and/or environmental disadvantage creates differences in health outcomes, also known as health disparities, in populations across the world. One goal of Healthy People 2020, a strategic 10-year plan to improve U.S. population health, is to achieve the highest level of health for all people. Health equity includes the elimination of health and healthcare disparities.

One population of interest are known as “high utilizers” or vulnerable patients with complex social, behavioral and health needs. According to Anderson, the top 5% of individual utilizers account for about 50% of overall healthcare expenditures. Programs that pair patient navigators, community health workers and behavioral health resources with identified “high utilizers” have been implemented recently with hopes of improving health outcomes and generating value. A thorough review and analysis of the results for impact and effectiveness in improving health and cutting costs for this subset of patients is a critical next step.

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Engaged in Thought

cenrAugust 23

I was fortunate enough to attend the “Engaging Patients, Families and Communities in all Phases of Translational Research to Improve Health” Conference this past Thursday and Friday because it stimulated some serious thought and discussion amongst attendees, but most importantly myself.  Conferences are usually worthwhile because attendees are typically doing similar work.  An added feature is the sharing of ideas, best practices and stories – the dreaded “networking” – can actually be broken down into genuine conversations about helping each other perform their respective careers better.  Most conferences meet this basic expectation.  But this one was different.  It went above and beyond my expectations for several reasons, which I will describe below.

First, the size of this conference was extremely manageable.  Roughly 200 attendees registered to attend and all but a dozen or so made it to Bethesda to hear keynote speaker Dr. Chris Austin kick off Thursday with laughter and thought-provoking questions.  Out of the 180+ that attended, I can safely and confidently say that I was able to engage with 20 of them in meaningful conversation regarding potential opportunities to collaborate in the near future.  Contrast that with a larger conference, say APHA’s annual conference of a massive 30,000+ attendees, and it’s no wonder why attendees stay within their subsections and specialties.  This conference provided me with ample opportunities to engage with and learn from professionals doing completely different work.  And that to me was particularly valuable.

I touched on it earlier, but I was very impressed with the wide range of experts in the field of public health and community-based research.  One group showcased their work to improve health outcomes in Amish communities and another described relaying crucial health communication messages via text messages in rural health clinics at various sites in Kenya.  Talk about learning opportunities!  And this is my favorite way to learn – seeing problems being solved in the field as they relate to the realities of life and then interacting with the investigators to learn how these interventions could be replicated to improve health in other populations.

Lastly, the agenda was designed to introduce ideas via speaker presentations then move into smaller breakout groups to tackle more specific questions.  One specific breakout session that I attended dealt with the ethical implications of community-based research.  Here were a few questions that were left in my mind to sort out post-conference as I continue working at the community level:

*As researchers, what value can we provide back to communities in exchange for critical research data?  

*How can we make the relationship more mutually beneficial?

*What if the research results did not shed the community in a particularly positive way – think of the negative implications that could arise if the media reported on those same results

*The idea of research and the value of official academic research compared to “findings” or “observations” seen in communities…is one necessarily better than the other?

For the reasons aforementioned, I personally thought this conference was very valuable to my work as a public health professional.  But, similarly, it also leads me to think that much more work needs to be done outside of our own “public health bubble.”  Dr. Austin of the National Center for Advancing Translational Sciences at the National Institutes of Health illustrated this with a simple, yet extremely profound anecdote.  He described meeting with members of Congress recently and one of the members asked him about his work in linguistics.  Apparently that member read translational sciences in the title of his division and assumed it was translating language rather than public health science.  Viewing this from a public health lens, I would shake my head and laugh.  But viewing this outside our “public health bubble,” I probably would have said the same thing or asked, what does this really mean?  Even in my own experiences when trying to explain what public health is to people from all walks of life, to put it simply, it is a complex conversation to have.  Which is why I strongly believe that we as public health professionals need to do a better job at relating to and forgiving others for not understanding ideas and concepts from our perspective.  One example of this is public health funding.  Public health funding was increased under the support of President Obama and written into the Affordable Care Act back in 2010.  Shortly thereafter, resulting from the many tumultuous battles to reduce federal debt and annual federal budgets, public health funding was the first on the chopping block.  Many members chose to redistribute funds previously appropriated for public health work to budgets of the Department of Health and Human Services.  The same funds which were originally set aside to boost prevention efforts in communities nationwide.  This left public health professionals – including myself – outraged.  Why can’t the appropriations for the Department of Defense be on the chopping block instead?

But now it all makes sense.  The dots are finally connecting because of that anecdote Dr. Austin shared.  One of the main reasons that the field public health has trouble getting traction with funding streams is that the greater public – whose health we ironically serve to improve – doesn’t really know what we do.  And when a member of Congress sees a significant budget devoted to what appeared to them as “translating language,” then our efforts will always be reactive in nature – why are you taking from our much needed annual appropriation?  Therefore we must strive to espouse one of the basic principles of public health: take action for a proactive solution to funding – “Dear members of Congress, this is why we need what we are asking for.”

Until we get to that point, we’re still downstream on that river asking why there are so many people falling in.

I know we can do better and I am confident that we will.

“Anybody can become angry – that is easy, but to be angry with the right person and to the right degree and at the right time and for the right purpose, and in the right way – that is not within everybody’s power and is not easy.” — Aristotle