Paradox of health care in the world's greatest nation: commentary on the 2013 Annual American Public Health Association Conference in Boston

The American Public Health Association’s (APHA) annual meeting with over 12 000 participants is the world’s largest public health gathering, bringing together some of the most influential health advocates, researchers, practitioners and other specialists.¹

Boston was a laudable location for the 141st Annual APHA conference in November 2013.^† The city after all was the ‘birthplace’ of the United States of America with the American Revolutionary War (War of Independence) being ignited there in 1775. Throughout history Boston has contributed admirably to the American public health movement. Pre Revolutionary War, Bostonians became masters of political advocacy fighting for ‘liberty’. The Sons of Liberty, an organisation of American patriots was formed to protect the rights of colonists and to stand up to what they perceived as abuses of the British government. They are renowned for the Boston Tea Party in 1773 in reaction to British imposed taxes on tea and other imported goods. The Sons of Liberty groups purportedly exerted substantial political influence at this time and during the early years of the new nation.²

The Boston Public Health Commission is the oldest health department in the United States. It began as The Boston Board of Health in 1799, established to combat potential cholera outbreaks. The well-known revolutionary, Paul Revere, was Boston’s first Health Commissioner.²

Ideals of Boston’s local government officials that are consistent with those of the advocates of the 1770s have seen public health prosper in modern Boston. The opening session at the APHA conference heard from current Boston Executive Director in the Public Health Commission, Dr Barbara Ferrer, about the successes of public health under the 20-year leadership of recently retired Mayor Thomas Menino, who also spoke about their successes. These included banning trans-fats in restaurants and banning soda machines in schools. This, Menino referred to as the biggest political fight of his career, ‘Teachers and parents were against me – they wanted those soda machines so bad.’ Tobacco-control measures included bans on smoking in bars and workplaces, along with new bans in all parks, scheduled for introduction in January 2014. Initially Menino’s administration was criticised for its bans on smoking, but a drop in smoking from 25 to15% ultimately quietened the opposition. He also spoke about initiatives to end gun violence, and violence-prevention programs that he attributed substantial drops in violent crime to. Fittingly, Mayor Menino emphasised the importance of advocacy for public health – as epitomised by his own illustrious record over 20 years.¹ This positive spin on public health for the city of Boston is paradoxical with many other parts of America lacking such sensible public health measures.

In contrast to the upbeat view on public health by the Boston leadership was a conference keynote address by Professor, Sir Michael Marmot (a University of Sydney graduate). The recent release of figures showing that 47 million Americans now fall below the official poverty level³ was accentuated by Marmot’s equally sobering commentary that illustrated the massive paradox in health and living standards of many American people. In reference to his recent review of social determinants in Europe, Marmot made comparisons with the USA, illustrating that 37 European countries have lower maternal mortality ratios than the USA. He emphasised that it was the disadvantaged and poor who bore the brunt of the ‘avoidable maternal deaths’. ‘Much of the differences in health … inequalities … is due to the operation of the social determinants of health … social injustice is killing on a grand scale’. He claimed that a toxic combination of poor social policies and programs and unfair economic arrangements and bad governance was responsible for most of the health inequities. Among solutions, Marmot emphasised that in a rich society everyone should have a minimum income sufficient for a healthy life.

As if to accentuate the failings of the USA health care system in general, the APHA conference website displayed a list of data showing that in comparison to other developed countries, the USA is ranked only 17th in health status, has the highest death rate by violence, and the second-highest death rate for heart and lung disease.¹ About 75% of USA health spending is on preventable conditions and the $190 billion annual cost⁴ of obesity is enough to buy a health club membership for every American.¹ The flagship publication of APHA, The American Journal of Public Health, confirmed in a recent article, the problematic nature of the American health care system, ranking it near the bottom among industrialised nations in efficiency of health care spending (22nd out of 27 high-income countries).⁵ Expert analysts sum up the paradox of the quality of the health care system in the US:

on the one hand it is the best medical care system in the world, on the other it is one of the worst among developed countries because of how it is organised.⁶

Despite the blatant shortcomings of the USA health system, APHA is keen to point out its public health successes. Every year in the USA, public health saves 33 000 deaths via vaccines, and 13 000 deaths via seatbelt use and countless others through drink-driving legislation and tobacco-control measures. Public health initiatives in the USA are estimated to have reduced HIV/AIDS deaths by 70%; and added 25 years to the American life span. Every $1 spent on prevention is purported to save an estimated $5.60 in health spending.¹

Another admirable conference keynote address by Sarah Weddington revisited the celebrated 1973 Roe v. Wade case. As a young attorney over 40 years ago, Weddington took on the might of the Supreme Court and won the landmark case that established USA law firmly on pro-choice principles with respect to abortion and is credited with saving millions of lives of young women who were subsequently spared the necessity of dangerous, illegal backstreet or Mexican abortions. This case is claimed to have had a massive influence in the USA, as well as global ramifications for the provision of safe, legal access to reproductive care, providing some protection to the mental and physical health of countless young women, particularly for those of low socioeconomic status.⁷

The health of veterans (returned servicemen) is now an established American public health issue with both the APHA conference and the national media focussing attention on the thousands of veterans ‘demobilised’ from the Iraq and Afghanistan ‘conflicts’. Questions are being asked about what future they are likely to have as they return to civilian life. More than 18 veterans commit suicide every day, and about one active GI deployed in Iraq and Afghanistan killed themselves daily. It is estimated that more GIs deployed in these two wars will ultimately die from suicide rather than from combat.⁸ It was sad to be encountered by dirty and dishevelled veterans begging on the streets of Boston during the conference period, often with placards of the ilk ‘unemployed and homeless veteran.’ This in the world’s richest country!

As expected of a conference of such huge magnitude, there were many other oral and poster sessions relevant to health promotion. The full gamut of risk factors got a hearing with obesity, physical activity, and nutrition getting a fair share. There were indications that the front-of-pack food labelling issue is attracting strong research interest, as was tobacco use in relation to mentholated and flavoured cigarettes, and e-cigarettes and their attraction to youth. Australian authorities might be wise to keep an eye on this latter issue in the future?⁹

Consistent with the historical record of Boston and Boston Mayor Menino, advocacy-focused sessions also featured on the APHA conference program. As well as case studies, there were presentations such as: ‘Breaking through the crowded news cycle’, ‘The how of advocacy’, and ‘Mobilising public health campaigns’.

Commentary and debate on The Patient Protection and Affordable Care Act, commonly called the Affordable Care Act (ACA) or ‘Obamacare’, dominated the local and national news media for the duration of the AHPA conference period in November. It was also a popular topic on the AHPA conference program. Despite a report that 48 million people in the USA were uninsured,³ there is widespread opposition to the Act, led by a vocal right-wing Tea Party faction epitomising again the paradox in health care and prevention in the USA! The ACA, signed into law on 23 March 2010, is purported to represent the most significant regulatory overhaul of the USA healthcare system since the 1960s that should ensure that millions of American citizens will gain access to affordable health care (something that every Australian takes for granted). The Act offers opportunity to close gaps in health care disparities by expanding health insurance as a centre piece in achieving this goal. The ACA includes many provisions aimed at improving quality and outcomes for the racially and ethnically diverse and other vulnerable populations. It will provide important incentives intended to advance health equity in the safety net, health professions, public health research and prevention, among other priorities.⁶ It is worth noting that the benefits of the ACA would be regarded as a basic right in every other advanced Western country. The majority already have far more comprehensive systems than the USA.

Periodic exposure to the failings as well as the successes of the American health care system provides a useful lesson to Australian health authorities and politicians about keeping our system effective and efficient. The best advice is for Australia to avoid copying the USA health system! The massive disparity in the USA between the ‘haves’ and ‘have nots’ highlights the importance of ensuring we continue to provide an equitable system with accessible and affordable health care for all our citizens.

The importance of health-related policies with a much stronger focus on prevention is a message that needs continual reinforcement. The ongoing role and obligation of the Australian health promotion fraternity to provide leadership in this area will never diminish. It is worth looking to the past to see what can be achieved.