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Satcher and Higginbotham: NOT the public health response!
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Anthony L. Schlaff, physician, associate professor Tufts University School of Medicine
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anthony.schlaff{at}tufts.edu Anthony L. Schlaff
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The March 2008 Commentary by Satcher and Higginbotham was more notable for what it did not say than what it did (1). The authors claim to present “the public health approach” (italicize "the" [emphasis mine]) to eliminating disparities in health without offering any strategies directed at reducing what is widely understood to be the major underlying cause: disparities in socio-economic status (SES) (2). A true public health approach requires that we look beyond services and programs and seek to address causal factors in policy, in the environment, in our institutions, and in culture (3). Many health problems – and certainly many health disparities – have their causal roots in our economic system, in housing, in the jobs people do, in the natural and built environment, in politics, and in institutional systems and policies. The authors write that, “the public health approach must take place in the context of a balanced community health system, which includes health promotion, disease prevention, and early detection, moving towards universal access to health care.” This is laudable, but incomplete. Public health is a set of activities undertaken by society as a whole, and not just those taken by a community health system (4). In addition to the global omission of disparities in SES, the authors omit some specific and critically important approaches to understanding and addressing disparities. They promote school-based programs to address nutrition, physical activity, and wellness, but they make no note of the disparate funding structures upon which our public education system rests: the property tax. The inequities inherent in this method of financing are so glaring that several state courts have ruled it unconstitutional (5,6), and yet it merits no discussion in this public health approach to eliminating disparities. The authors write, "Human behavior is the single most important determinant of variations in health outcomes," with no reference to the literature documenting how little of the variation among SES groups is actually explained by behavior (7). Nor is there any mention or reference to the vast literature looking at the degree to which behavior might be shaped by poverty and the environment. There is no mention of the Barker hypothesis (8). The risk of obesity and diabetes, and subsequent early death from cardiovascular disease, are associated with low birth weight. This association may be mediated not purely by differences in behavior linked to poverty, but to a gene-environment interaction whereby scarcity in-utero increases the biological propensity to horde calories. Such a mechanism, if proven to be true, would have a profound effect on our understanding of and ultimately our approach to disparities in risk for obesity and diabetes. Most starkly, this hypothesis suggests that some behavioral tendencies associated with poverty are created and sustained by factors outside of the control of the individual, and that interventions directed at root causes must transcend those directed at the specific time and place where the outcomes are manifest. This and many other potentially profound notions of how low socioeconomic status and poor health might be linked are not touched upon or referenced in this Commentary. There was a time when public health leaders contributed to changing the world. They helped create the water and sewer infrastructures that sustain our cities. They waged a world wide campaign, both scientific and political, that eliminated smallpox. They challenged the tobacco industry. And they participated actively in the 1960’s war on poverty. Now they offer us programs. How sad. References: 1. Satcher D, Higginbotham EJ. The Public Health Approach to Understanding Disparities. Am J Public Health. 2008; 98: 400-403. 2. Evans, RG, Why Some People Are Healthy and Others Not?, The Determinants of Health of Populations. Robert G. Evans, Morris L. Barer, and Theodore R. Marmor, editors, Aldine de Gruyer, New York: 1994 3. Institute of Medicine. The Future of Public Health in the 21st Century: National Academy Press; 2003 4. Institute of Medicine. The Future of Public Health: National Academy Press; 1988 5. Blumenthal R. School Financing Fix Eludes Texas Lawmakers Again. The New York Times. May 31, 2005; Section A, p.14 6. Russell J. N.H. School Funding Ruled Unconstitutional; Judge Says Method Aids Communities Rich in Property. The Boston Globe. March 09, 2006; Metro/Region p. B2 7. Lantz PM, House JS, Lepkowsi JM, Williams DR, Mero RP, Chen J; Socioeconomic Factors, Health Behaviors, and Mortality JAMA. June 3, 1998; 279(21): 1703 - 8 8. Barker, DJ. Adult consequences of fetal growth restriction. Clin Obstet Gynecol. 2006 Jun ; 49(2):270-83 |
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