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Investing in the Science of Public Health

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A report released this month by the National Science Foundation raises concern about the declining level of science funding and its implications for further impairing U.S. economic leadership. Analysis of American leadership in science is appropriately framed in economic terms, because the jobs that result from scientific innovation are a powerful political motivator. But the implications are far broader and directly affect the health of the American people.

The report, titled Science and Engineering Indicators 2014, acknowledges, "As more countries around the world develop R&D and human capital infrastructure to sustain a knowledge-oriented economy, the United States, not surprisingly, is playing a less dominant role in many areas of S&E-related activity." A similar situation exists for health research. A recent report by Research America states: "As federal funding for medical and health R&D remains effectively stagnant, other countries are rapidly and doggedly increasing their capacity."

There is another aspect of the shrinking public investment in science research that we should be equally concerned about: the implications of underfunding the science of how to prevent disease and create a healthier population. This is the science of public health. Without good health, after all, American workers will not be able to hold those jobs.

When we think of science for health, we think first -- and invest mostly -- in curing diseases once they have occurred. This is vitally important. However, the greatest return on investment often comes from the science of preventing the disease in the first place. Between 60 and 70 percent of health comes from prevention approaches -- and the scientific knowledge that underpins this. At the present, we put 3 percent of our U.S. health dollars into public health science and practice, while 97 percent goes into medical care and science for cures. The U.S. has seriously underinvested for a long time in the science and practice of prevention, and the underinvestment, and loss of ROI for our population, is worsening.

Why is this a problem? We know a lot -- but we don't know enough. We know that we have an obesity epidemic in the U.S. (and globally), but we don't have knowledge about what each person, family, city and nation needs to do to turn it around. We know that 50 percent of cancers are preventable, and that the spread of HIV has to be stopped--but cancer and HIV diagnoses continue. Why? Some of it is because we do not put enough resources into our public health system to implement what we know; some of it is that we have to better understand where we are stuck.

The health of our population -- the responsibility of public health -- is evolving into a major economic concern as well. As a nation, we are facing epidemics of preventable chronic disease that threaten to bankrupt our healthcare systems; we are expecting hospitals to take responsibility for improving the health of our populations while not investing in public health science and systems to inform the medical care system as to what they need to accomplish.

All of this argues for greater investment in improving the health of populations and, therefore, in prevention science, which focuses on creating the best possible health at the population level. In prevention science -- or prevention research, as it is also known -- the population is the patient, whether a community, a country, or the world. But it is individuals who ultimately benefit. Why? Because there are some things that individuals can accomplish only if they are supported by environments and daily practices that enable their healthy practices. Prevention science creates the knowledge for each area, how to align them for success, and where the ROI is. Within prevention science, there are, broadly, four areas of specialty, which each deserve particular attention in terms of funding:

First, there's the science that studies causes of disease in populations. It seeks to understand the diseases or conditions that affect our health -- from heart disease and cancer to asthma and obesity -- and how they occur across populations. It is hypothesis-driven discovery science of a particular kind as it seeks to determine the preventable causes of disease. It looks at the relationship, for instance, between lung cancer and smoking, asthma and air pollution, or obesity and lack of access to healthy food. Then, it identifies the most effective approaches to prevention.

Second, there's the science that focuses on how to intervene to prevent disease. Those interventions include scientific methods to help smokers kick the habit or drugs designed to reduce cholesterol as well as policies that would support our ability to practice healthy habits. What do we need to do to help everyone stay healthy? What works best at a specific age? What subgroups particularly would benefit?

Third, there's the science of delivery: how do we take proven connections and prevention techniques and deliver them on a scale that will improve a society's health? This includes science-based regulatory initiatives; here, the New York City Department of Health and Mental Hygiene has become a true master. Its ban on smoking in bars and restaurants, for instance, worked with such success that it not only led to improvements in New Yorkers' health but an increase in the number of restaurants and related jobs in New York City. This winning formula has been copied by communities around the world.

Finally, there's the science of keeping healthy people healthy. What does science tell us about how we should design our health systems and our environments? How do we ensure access to healthy foods, increase opportunities for physical activity and exercise, enhance community and social interactions, and ensure clean air and water, among other things? What are the most effective approaches to prevention of disease and preserving the good health we are born with - at every age and stage of life?

Ensuring adequate funding for prevention science should be a high national priority, as it's the public's health that is at stake. As the Institute of Medicine states in summarizing "U.S. Health in International Perspective," "The United States is among the wealthiest nations in the world, but it is far from the healthiest. For many years, Americans have been dying at younger ages than people in almost all other high-income countries....The tragedy is not that the U.S. is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary."

America should be increasing its commitment to public health and prevention science and practice at a time when our fiscal strength depends increasingly on that commitment. The Institute of Medicine defines public health as "the actions we must take collectively to protect (all of) our health." What higher national priority should there be?