Investing in Preventative Healthcare and Public Health: An Ethical and Economical Choice

Ethics can sometimes seem at odds with decisions that are the most cost effective. However, it doesn't always have to be this way. What if there was a decision that was both ethical and economical? Here, we will explore the benefits of investing in public health, specifically in disease prevention. We will also consider how this could lead to lower healthcare costs (or at least more effective healthcare spending), and most importantly, a healthier country.

The United States spends more on healthcare than any other OECD nation, as a percentage of gross domestic product (GDP). 

Despite this investment in health, the U.S. falls short in many health metrics including life expectancy, avoidable mortality, and overweight/obesity compared to other OECD countries. This indicates that the U.S. healthcare system is inefficient. We are one of the wealthiest nations in the world, so it seems like a lack of resources is not the main issue. Though there could be many contributing factors for this discrepancy, one reason is the lack of investment in public health. Some researchers estimate that the U.S. spends as low as 1.5% of total health expenditures on population-level public health initiatives. This seems contradictory to evidence that suggests investing in public health can make more people healthier and reduce costs. After all, as Benjamin Franklin was known to say:

To consider why this may be the case, we must look at the view of health in the United States.

Healthcare can be generally divided into primary, secondary, and tertiary care:

• Primary care is where public health has the most influence. When successful, public health initiatives will promote health at a population and community-level and prevent people from getting sick in the first place. 
• Secondary care describes more specific screening measures, seeing primary care physicians, and getting short-term treatments to prevent health issues from growing e.g., responsible use of antibiotics in response to bacterial infections. 
• Tertiary care is where a disease has already been established and specialists work to manage long-term care to prevent the disease from worsening. This would include controlling diabetes, treating cancer, or managing COPD. 

Common sense tells us that investing the most in primary prevention strategies would be the most effective. These population based initiatives impact the most people and prevent disease from even occurring. However, the U.S. seems to have this "healthcare pyramid" flipped upside down, focusing primarily on tertiary care.

This needs to change if we want to be serious about not only making healthcare spending more efficient but also creating healthier communities. Neglecting public health can lead to dire consequences, and one of the most relevant examples can be found in the current pandemic. To be fair, health emergencies are difficult to plan for because there are many unknowns. However, ten plus years worth of underfunding U.S. public health is one of the reasons many states did not feel prepared for COVID-19.

Lately, public health, and medicine in general, have received a lot of attention from the general public and government leaders. Some hope that this could lead to a renewed effort to build up public health infrastructure. However, many fear that this will be the same cycle of neglect, panic, and repeat. When there is no current public health crisis (at least not on the surface), it is relatively easy to turn to other issues. A crisis such as the pandemic or ebola outbreaks, stirs the public and lawmakers enough to start making large investments. Then, the crisis goes away, and the cycle starts over. 

One of the reasons for this cycle is that when public health is working well, it is often invisible. It is like electricity, you don't think about it until it gets dark and the power goes out. 

With all this being said, it is important to note that a few studies have found that some prevention strategies could be extremely costly and might exceed the savings from preventing illness. However, objecting to public health initiatives based on these findings is problematic on multiple fronts: 

• For one thing, some of these studies made generalities, expecting programs to be implemented across the board regardless of matching interventions with specific populations. A relatively new concept called "Precision Public Health," could be a solution to this issue. It utilizes technology and large datasets to help make public health policies and initiatives more targeted and effective. 

• Another issue with this objection is related to ethics. Even if such prevention interventions were more costly than treating the disease itself, don't we have an ethical obligation to prevent disease when we have the power to do so? I am not talking about changing genomes of embryos or anything like that (I will leave that topic up to others). I am talking about having a clear intervention known to work and not using it solely due to financial considerations.

In addition to neglecting public health, a Harvard Study indicated that other areas have led to the high cost of U.S. healthcare, including administrative costs, expensive pharmaceuticals, and high physician and nurse salaries. This can be a complex situation to fix. Though looking at these issues more closely reveals that investment in the public health system could ultimately reduce the need for as many healthcare professionals and medication.

While it is clear that there is not a simple solution (there rarely is one), it would be extremely detrimental to forget about the need for public health. As citizens of this nation and the world, it should be our hope that all people get to live healthy and fulfilling lives. The fact that investing in public health could lower healthcare costs is a bonus but should not be the sole incentive. By utilizing precision public health techniques, we could increase health equity, prevent diseases, and promote a more community-centered approach to healthcare.

Discussion questions

1. What could the United States do better in terms of preventative care?
2. How can we make the accomplishments of public health more visible to the public on a everyday basis? 
3. Do you think we have an ethical obligation to invest in our public health system?
4. Do you think that focusing on primary prevention could make healthcare spending more efficient? Or do you think that this could be too narrowminded and not account for the complexities of the system?
5. What do you see as stepping stone to the larger issue of U.S. healthcare and public health reform?

Exam Question: The U.S. spends as low as what percentage of total health expenditures on population-level public health initiatives? 

Answer: 1.5%