The Promise of Public Health: Q&A with Dean Lynn Goldman

Caitlin Cotter, DVM, MPH

In an exclusive Q&A, Lynn Goldman, M.D., MPH, Michael and Lori Milken Dean of Milken Institute School of Public Health at the George Washington University talks to Research!America about the achievements and gaps in the field of public health.

You’ve published a  paper as part of the Institute of Medicine’s Vital Directions initiative that says we have a long way to go to strengthen our public health system. Why is a strong public health system so important?

Despite the fact that we spend a disproportionate amount of our GDP per capita on health and health care in this country, we do not enjoy the highest level of health as measured by basic metrics like life expectancy and infant mortality. We have a wonderful medical care system, but many of us lack access to care, including preventive care. In many basic ways we are not providing communities with the conditions that we all need to stay healthy. We all need clean air, safe drinking water, access to healthy food/physical activity, strong social supports and other factors that make it easier to stay healthy.

Can you give a few examples of public health emergencies that exposed some of the weak links in our system? For example, the water crisis that recently occurred in Flint, Michigan. Tell us how it could have been prevented?

The water crisis in Flint exposed a number of gaps in our system. In the first place, on the basis of cost alone, the water supply for that town was switched from a relatively safe source, a lake, to a questionable source, the Flint River. They made this switch without correctly engineering the system, using an older water treatment plant that is not state-of-the-art. As community members began to complain about problems with the water, those who were responsible were, at first, indifferent. There were many warning signs of a problem, but it wasn’t until a local pediatrician began to report the test results for lead poisoning in Flint children that anything was done. I wish I could say this situation was unique. What was unusual about Flint was how a number of safety gaps lined up at the same time: an aging infrastructure; a stressed budget for public health; and an inadequate monitoring system to test the water’s safety.

None of this is rocket science; not one of those gaps should have existed.

One thing I have found encouraging in this presidential campaign is the recognition that we need to address the decaying infrastructure in our country. An aging infrastructure impacts health when it comes to water traveling through corroded lead pipes; inadequate sewage treatment systems; or unsafe roads, bridges and highways. Many aspects of our infrastructure need to be improved so that some of the basic underpinnings of good health are in place for all of us.

Everyone understands how medical care helps individual patients, but why is it important for communities to be healthy? Explain why some of the conditions in places where people live, work and play can lead to health risks.

We have wonderful success stories for public health. Over the past few decades we have cleaned up some of the most dangerous air pollutants from the combustion of fuels and other sources—and those efforts have saved tens of thousands of lives. The same goes for getting industrial pollutants out of the air. Today we’re seeing remarkably high levels of pollution in places like India. Here in the United States, so many lives have been saved just by making the air cleaner. We have reduced lead exposure for children 20-fold. We have eliminated smoking in public places and in the workplace smoking rates are going down, and we can already see lower rates of smoking-related cancers. When I first went to work in public health and pediatrics, people used to smoke inside of the health department; they smoked inside of hospitals and in the doctors’ lounge! Vaccines are working and formerly common serious diseases like meningitis and cervical cancer are dropping sharply. Our diets have been improving and heart attacks are declining. All of that has changed and we are all healthier, for two reasons. First and foremost, we have the research to understand the linkages between exposures and disease, and to create strategies for removing pollutants from the air, as well as developing and delivering new vaccines and successful smoking cessation programs. Second, many of us individually, and as a society have taken steps toward health whether it is through support of efforts to clean the air, taking steps to assure that our children are healthy, or agreeing to join together to immunize ourselves, our families and our communities.

While a lot of progress has been made, there are still many unhealthy conditions in the environment that can trigger or exacerbate serious health conditions. Today, in the United States and globally, there is easy access to foods with too much salt and sugar and we have become sedentary. These are complex problems. We can’t just quit eating like we can quit smoking, and many of us naturally seek out very sweet and salty foods. In a way, we are prisoners of our own genetic propensity to look for sweet and salty foods. And that’s a new challenge for public health, a challenge for which we are still seeking answers to understand how we can eat healthier, and become more active.  Food labels both in stores and restaurants will probably help but at this juncture it appears that we will need a multifaceted approach that includes not only the food industry but also employers, schools and communities. 

We’ve talked about some of the problems with our public health system, in what way do we have it right? Pick a recent public health emergency and tell us who would you thank for protecting the public and why?

If you think about the Zika virus situation right now, and how rapidly the U.S. Centers for Disease Control and Prevention (CDC) and state and local governments have mobilized to protect the public--that is an example of a strong public health response. The National Institutes of Health and Food and Drug Administration have stepped forward to speed the research and regulatory science that has been needed to (hopefully) develop vaccines and cures and new clinical tests for Zika. The CDC is doing an excellent job in Puerto Rico and Florida to stop the virus and prevent it from spreading and across the southern U.S. in identifying and controlling the Aedes mosquito vector. Their response to this situation has really been amazing: several well conducted studies that proved beyond doubt the existence of Zika Virus syndrome in babies; guidance to travelers, pregnant women and their doctors; and the development of completely new testing strategies for the virus in humans and mosquitos. At the same time, it has been frustrating to watch how poorly prepared we have been. We have allowed our vector control programs to be downsized and even mothballed despite the fact that, with climate change, spread of disease vectors northward has already been occurring. The supplemental appropriations process is always frustrating; however, it was particularly slow in this case. I think that we really need a different mechanism, perhaps modeled on the Federal Emergency Management Agency, to declare a public health emergency and to move funds to the CDC and the states so that these responses are not caught up in the politics of the moment. The CDC and other U.S. Health and Human Service agencies deserve a shout out, not just for their rapid response to Zika, but for their work every day on a wide range of public health issues. 

This blog post is part of a series focusing on different aspects of public health in recognition of Public Health Thank You Day, held each year othe Monday before Thanksgiving. Visit www.publichealththankyouday.org for more information, and join us on social media using the hashtag #PHTYD.

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Without continued support for health research, many of the most promising young scientists, their ideas and a myriad of potentially life-changing scientific breakthroughs will vanish into oblivion.
Paul Marinec, PhD; University of California San Francisco