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Putting things in perspective when all things are not equal

One of the classes that I’m taking in the term that begins tomorrow is “Professional Epidemiological Methods.” The class is supposed to give us a taste for the kind of things that epidemiologists in public health practice are supposed to do. As you may or may not know, I already spent 7 years as a professional epidemiologist at the state health department. During that time, I learned very little about the science of epidemiology itself. Instead, I learned a lot about being a professional, about playing the game of politics, and about ranking public health issues from “most urgent” to “we can deal with that next fiscal year.”

You would think that obesity and heart disease would be at the top of the list of things to tackle when these two disease combined kill about 600,000 people a year in the United States (between heart disease, diabetes, and stroke). According to the Centers for Disease Control and Prevention, the top ten killers in the United States (in 2010) are:

  1. Heart disease: 596,577
  2. Cancer: 576,691
  3. Chronic lower respiratory diseases: 142,943
  4. Stroke (cerebrovascular diseases): 128,932
  5. Accidents (unintentional injuries): 126,438
  6. Alzheimer’s disease: 84,974
  7. Diabetes: 73,831
  8. Influenza and Pneumonia: 53,826
  9. Nephritis, nephrotic syndrome, and nephrosis: 45,591
  10. Intentional self-harm (suicide): 39,518

The 2013 data are not that much different:

But do you see CDC or any other public health agency having press releases or briefing lawmakers daily on the status of any of these? Maybe during a pandemic or a really bad influenza season do policymakers get briefed on the number of deaths from influenza and pneumonia. Or maybe when a lot of “unintentional injuries” occur because of a faulty car’s ignition or braking system does Congress hold hearings. Just by looking at CSPAN or CNN, you would think that the top causes of death are terrorist attacks and aviation accidents.

As human beings, some things capture our imagination more than others. Being a passenger on a disintegrating plane seems like a horrible way to die, so — much like we do with accidents on the road — we slow down our lives and watch what’s going on. Seriously, tune into CNN any time and it’s all about the plane crash in the Java Sea. Indeed, with social media being what it is, we are quick to want to watch other people die. It seems to be one of those things about being human, you know?

Admit it, deaths from heart attacks and cancer are not that “interesting.” Perhaps if you see someone being worked on by paramedics do you get your adrenaline going, but not very many people get hyped-up over someone slowly dying over the course of months or years from cancer. We just don’t see that many people dying from those things as a national emergency because, on average, people who die from heart disease, stroke, chronic lung disease and cancer are older. As heartbreaking as it is, children don’t make up a big proportion of deaths from cancer:

Screen Shot 2015-01-19 at 10.31.51 AMSo back to the original question of this post: How do you triage public health issues? How do you allocate your resources as best as possible in order to take care of what matters?

Note that I’ve written about deaths so far. The incident and prevalent number of cases of all these diseases is much greater, especially when we’re getting very good at keeping people alive past their first heart attack (in this country) and alive after suicide attempts or accidents (in this country). When it comes to public health problems that don’t end in death the majority of the time, the calculations are entirely different. You need to look at disability, at the investment in taking care of the person (especially if it they convalesce for a while), and at all the other “intangibles” that come with diseases and conditions which zap our ability to be healthy, happy, and productive.

We also have to be aware that governments have a lot of control over what is a public health priority. Because so many of those governments are elected by the people, whatever the people perceive as an urgency is put to the top of the list. Even when we knew that it was very hard for Ebola to leave West Africa and start an epidemic here in the United States, people still lost their minds over Ebola. All sorts of nonsensical public health measures were put into place. Returning healthcare providers were put into unnecessary quarantines… All while a very bad flu season was heading our way and will end with more people dead from it than from Ebola in the US.

There is a balance that epidemiologists need to do achieve when determining how to proceed on a public health problem. On the one hand, we want to understand diseases and conditions that kill or maim the most number of people and respond to them immediately. On the other hand, many of us are employed at the service of an elected official, so whatever the people that elected (or will re-elect) that official see as urgent needs to be taken care of right away. Sometimes things that kill half a million people a year are put in the back burner because someone got the sniffles while on a trip overseas. Other times, just a few cases of a vaccine-preventable disease becomes an emergency because we know how quickly that can get out of control, politics be damned.

Classes start again tomorrow. Blog posts may slow down for a bit, but I’m always around.

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René F. Najera, DrPH

I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
About History of Vaccines: I am the editor of the History of Vaccines site, a project of the College of Physicians of Philadelphia. Please read the About page on the site for more information.
About Epidemiological: I am the sole contributor to Epidemiological, my personal blog to discuss all sorts of issues. It also has an About page you should check out.

9 replies

      1. Doesnt cause it, but sure hampers the ability to fight it. More research is also necessary to discover underlying dynamics that seem to excacerbate cancer growth, which may or may not be linked to wealth and health, and happiness.


        1. You’re talking about the social determinants of health. Yes, there is plenty of evidence that where you live and how much access you have to things determines your outcomes. But how does public health address debt?


          1. I would argue he is VERY much involved in public health, psychological treatment, mental therapy, etc. Which directly addresses debt and corresponding relationship to mental health and welfare of real human beings. You cant separate the two. Apparently, you consider health as totally separate and uninfluenced by fiscal management. You should reconsider.


          2. Apparently, you haven’t read the blog before. I encourage you to read what I have written about the social determinants of health. Thanks for your comments, though.


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