I've had a bad week. Conservative and moderate senators are trying to strip key public health measures from the House stimulus bill. I've gotten cranky about the way critics disparage sound public health measures that, in the current climate, could provide needed employment. In the middle of an economic catastrophe, we face the dismaying spectacle of Senators who supported spendthrift tax and regulatory policies suddenly aghast that 0.05 percent of the House bill was allocated to creating jobs in such boondoggles as smoking cessation and HIV/STI prevention services. One of the most frustrating developments is the relative silence of many potential allies and advocacy groups who are apparently waiting on the sidelines and keeping their powder dry.
Wanting to light a candle rather than to curse the darkness, I got together with some health activists and especially the leadership team at Doctors for Obama (DFO) to organize a quick petition drive. During the 2008 campaign, DFO was formed with the naively optimistic goal of recruiting 10,000 members. I recently attended a dinner at which speakers described how volunteers rode up and down interstates taping Doctors for Obama posters on hospital bulletin boards in deeply red states. They were an incredible grassroots asset to the campaign. Wouldn't you know it: 10,029 people signed up.
Most of these men and women are medical students, residents, and physicians at the start of their careers. It's humbling to work with professionals who weren't alive when I first kissed a girl. A distressing number are doctor-lawyers, doctor-chemists, or doctor-MBAs. And they are good. If you don't know this group, check out their website.
Over the weekend, we assembled 670 signatures on a simple petition asking the Senate to rescind its public health cuts. Many of our signatories are distinguished leaders in medicine and public health. I spent a frenetic unshaven Sunday at my basement fax machine sending tart messages to Congressional leaders and dozens of Senators.
We must have screwed up the faxes, since the Senate gutted key public health measures. They still passed a progressive bill, but a disappointingly limited and uncreative one. All along, Senators attacked measures such as HIV screening and STI prevention by asking: "What does this have to do with stimulus?" Yet they replaced such measures with other spending that occasions precisely the same question. The rejected items could provide tens of thousandsof jobs and economic stimulus in communities that sorely need it: Jobs for health educators doing HIV and smoking cessation counseling, construction jobs building simple structures to house farmers' markets, jobs at currently-overstretched substance abuse treatment facilities, rental of abandoned storefronts for community-based health interventions.
The House bill included $5.8 billion for prevention and health workforce training. I wanted to see the bill go even further to embrace a prevention perspective on population health. Yet HR-1 contained significant prevention investments in smoking cessation services, counseling and screening for infection and chronic illness, almost $1 billion for immunizations, $600 million for National Health Service Corps training of nurses, dentists, and primary care physicians serving underserved patients, and even $400 million for CDC's Healthy Communities program. (The House bill also included $870 million for flu immunization. I don't know very much about that one.) All of these smart investments are apparently gone.
The Senate bill isn't terrible. It shifts some of these prevention funds to increase subsidies to Federally Qualified Health Centers. It increases spending at the National Institutes of Health by $6.5 billion. Even in these good things, the Senate perpetuates a misguided view of improving population health. I'm glad NIH is getting more money for cancer and AIDS research. It remains frustrating to see politicians strip money from smoking cessation and HIV/STI prevention programs, while providing larger sums to develop advanced therapies that treat illnesses we should often prevent. FQHC's provide needed care, and they certainly require increased resources. These facilities are not positioned to address social determinants of health in the communities they serve.
I'm glad the stimulus will pass, though much should be done in conference to salvage what was once a strong bill. This bill spends $800 billion yet does conspicuously little to address our nation's worsening obesity epidemic, our rising rate of new HIV infections, our prevalent misuse of alcohol, tobacco, and other substances, the large number of accidental or deliberate injuries that might be prevented through public health efforts.
I fear that a huge opportunity has been lost. Public health activists and researchers proposed many creative ideas that would create jobs while improving population health. Too bad their advice was not taken.
I should not end on a sour note. The Obama presidency has barely started. It can already count important victories on children's health insurance, women's rights, and other matters. The President has also inspired a new generation of idealistic and smart activists who get things done. When I speak with my DFO colleagues --Alex Blum, Alice Chen, Mandy Krauthamer, Vivek Murthy, Arun Patel, Nina Vasan, Milan De Jay Bhatt--I know the future is bright. I wouldn't be surprised if one of these men and women goes very, very far.
So we should be happy warriors, fighting hard without getting discouraged when we sometimes fall short. Tomorrow we will fax our fat petition to every Senator and Congressman. I hope you write or email your Senator and Representative to help us.
The odds are against us this week. Yet growing numbers of people are coming to see that our nation must take prevention much more seriously than we currently do. As Sigmund Freud once put it, the voice of reason is quiet but insistent. It will not rest until it gains a hearing.