Making the Acceptable Unacceptable
We are concerned with the health of populations. Public health aims to improve all aspects of physical and mental health, locally and globally. We have relatively sophisticated methods of assessing burden of disease, including mortality, disability-adjusted life years, and several ways of assessing morbidity. Our understanding of the burden of disease contributes to the establishment of funding and research priorities. The mismatch between some aspects of burden of disease and health spending is well-documented, with ample evidence that health concerns such as mental health are funded far less well than are physical health concerns. While we can consider the barriers to broader concern with given health challenges, e.g., mental health, in the particular, the broader question seems to be of interest for priority setting in public health: how do societies articulate the goals that motivate us? How are the goals of public health set in such a way as to motivate policy action that aims to mitigate the consequences of a particular disease?
A useful framework in this regard comes from a paper published in 1958 by Sir Geoffrey Vickers, a pioneering systems scientist and former president of the society that was the precursor to the International Society for the Systems Science. In this paper, “What Sets the Goals of Public Health?” he argues that we are motivated by considering health challenges as intolerable, and that one of the effective paths to public health actions emerges when a condition we considered a “given” becomes indeed “intolerable.” This framework remains helpful to this day.
Let us consider a few illustrations. In 1832, cholera epidemics were commonplace throughout much of the world; that year, there were 3,500 deaths in two months in New York City alone. With the advent of better understanding of the germ theory, improvements in our capacity to deliver safe water and sanitation, political will to control cholera, and the economic means to implement cholera control measures, we have essentially eradicated cholera from the United States. Between 1995 and 2000, there was only one death in the entire United States and only 61 cases, the majority of which were acquired through international travel. This represents a remarkable example of a health challenge that was common and acceptable, that rapidly was considered unacceptable, and then was dealt with through public health interventions in this country.
Another of my favorite illustrations of public health action concerns the dramatic reduction in motor vehicle accidents. In 1963 there were 41,723 motor vehicle deaths in the US, with a fatality rate of 5.2 deaths per 100 million vehicle miles traveled. In 2011 there were 33,561 deaths, with a fatality rate of 1.1 per 100 (data acquired from the National Highway Traffic Safety Administration.) Despite a dramatic increase in number of vehicle miles traveled, we reduced, in just one generation, the risk of motor vehicle fatality five-fold. This reduction came about as a result of political will, road safety, advocacy for safer driving, and legal disincentives for unsafe driving. All of these contributed to a rapidly growing unacceptability of the rates of motor vehicle fatalities and an adoption of measures to change this.
We can consider other examples, including a drop in infant mortality rate in the US from 55.7 per 1,000 live births in 1935 to 6.1 per 1,000 live births today, a nearly ten-fold decrease in 80 years; and a drop in the prevalence of elevated blood lead levels in children from 8.6 percent 20 years ago to 1.4 percent during the subsequent 10-year period. Changes in smoking habits (and attendant declines in relevant cancers) over the past 50 years provide another dramatic example.
What confluence of circumstances contributes changes that result in the acceptable becoming unacceptable? Vickers himself notes:
“The landmarks of political, economic, and social history are the moments when some condition passed from the category of the given in the category of the intolerable…. I believe that the history of public health might well be written as a record of successful redefinings of the unacceptable.”
Each of the above examples can serve as a case study for public action, when particular conditions reached tipping points, becoming unacceptable and triggering action. All have in common a confluence—much as characterized by Vickers more than 50 years ago—of growing realization that a particular health condition should no longer be tolerated, and that we had the technical (often therapeutic or preventive) know-how and economic capacity to effect change. All of these cases provide dramatic examples of what public health efforts can indeed achieve when the time is right—when we as a society are no longer willing to tolerate particular health burdens.
However, in much the same way that we can identify many successful examples of public health action, we can also identify as many—if not more—examples where we have not triggered action even if we have both the technical know-how and the economic resources to do so. At the global level, many of the health conditions that we have substantially improved in the US remain at catastrophically high levels, particularly in low-income countries. The infant mortality rate in low-income countries is 76 per 1,000 live births, cholera continues to kill 2,102 annually, and 91 percent of the world’s motor vehicle fatalities occur in low- and middle-income countries, despite those countries only representing half of the world’s vehicles. Why is cholera unacceptable in the US but acceptable in Bangladesh? Why is it acceptable to have a 12-fold difference in infant mortality rate between the US and Cameroon? We do not even have to go global to find examples of health areas that are needlessly acceptable. Why is it acceptable, for example, that 33,636 Americans die annually from firearm deaths? Or that 4,169 Americans die in motorcycle crashes in the absence of helmet laws?
How do we contribute to the “successful redefining” that can shape the goals of social action on public health? How do we avoid backsliding when hard-won successes, such as the dramatic reduction in many early childhood diseases through vaccination, face anti-vaccination movements that reintroduce diseases? And, relatedly, how do we make sure that it is diseases that are unacceptable rather than people, minimizing stigma or marginalization of those with disease while working to ensure that population measures prevent future disease and that those with disease have access to needed curative services?
Vickers suggests that in many respects this redefining is core to our very function as population health scientists: “For public health has a unique opportunity, as well as a duty, to clarify our understanding of health and disease, and hence our attitude towards it.”
However, this places a tremendous onus and responsibility on us in public health to indeed “clarify our understanding of health and disease.” It suggests that we need to make a particular effort to ask ourselves, in Vickers’ formulation, “that critical and ubiquitous question: ‘What matters most now?’” and work towards clearly articulating the determinants of the health conditions that matter. And, it suggests that the formulation of what does cause health and disease indeed does matter. It does matter if we articulate that the commonest cause of death is heart disease, or being overweight, or low education, because the formulation of the causes of death contribute to changing how these causes are seen by society and whether these causes become unacceptable and subject to concerted effort.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Acknowledgement. I would like to acknowledge Assistant Dean for Public Health Practice Anne Fidler for introducing me to the Vickers paper and inspiring this Dean’s Note, and Laura Sampson for contributing to the examples discussed here.
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/