The Promise and Potential of Automatic Public Health
by Dr. Mark B. Johnson, M.D., M.P.H.

One of the lessons I learned in an Injury Control course I took in graduate school was that the fewer intentional steps an individual has to take to protect him- or herself from a potentially harmful situation, the greater the likelihood that an injury will be prevented. It’s a principle that has applications in many arenas of prevention. For example, the fewer steps that one has to consciously take to make sure their water is potable, the less cases of cholera there will be. I like to call this concept “automatic public health.”

Automatic prevention is a term that is used in computer science, but it has not been frequently used to describe public health activities. I am not talking about habitual activities that one might learn through repeated practice, like always fastening your safety belt in a car without even thinking about it. I’m talking about unobserved, behind-the-scenes public health activities that protect you without your conscious involvement, and potentially without your awareness or knowledge.

Access to safe or potable water in most developed countries is one example of automatic public health. In the United States, public water supplies that are unsafe to drink are so rare that they have to clearly identify the fact to ensure that people don’t drink the water. Americans “automatically” assume that water coming from public faucets is safe to drink. They do not have to filter, boil, or chemically treat the water before they consume it. A great deal of unnoticed work has gone into providing this potable water to the public, but no individual consumer has to do anything to ensure that it is safe. This is automatic public health at work.

Another example of automatic public health is the addition of folic acid to cereals in the United States. There is good scientific evidence that if a woman has enough folic acid in her body before and during pregnancy, it can help prevent major birth defects of the baby’s brain and spine. Various surveys of American women of childbearing age have shown that over 80% know about folic acid and its effects and almost 90% would take folic acid supplements if their health care provider recommended it, yet only 40% of them take folic acid supplements and only 37% of the health care providers do, in fact, recommend the supplementation. The most common reasons given for not taking folic acid supplements were that they forgot, they didn’t think they needed it or they thought they were getting enough from their regular diet. Only 12% of the women took folic acid supplements before they knew they were pregnant, but many of these types of birth defects occur, and therefore must be prevented, before a woman knows she is pregnant.

In January of 1998, automatic public health was put in place. It was mandated by the U. S. federal government that cereals be fortified with folic acid. One serving of many commercial breakfast cereals now provides 100% of the recommended daily value of folic acid. During the first year of this program over 1,000 major birth defects were prevented, saving an estimated $560,000,000 (in 2003 dollars) in direct costs for the care of these infants. The women did not have to remember to take an additional pill and they did not have to wait to have their health care provider recommend the addition of folic acid to their diet; they just continued eating the diet to which they were accustomed. This, too, is automatic public health at work.

One of the areas where automatic public health has been the most successful is in the reduction of motor-vehicle crash fatalities. Numerous alterations and modifications have been made, both in vehicles themselves and in the roads and roadways on which they travel. Dashboards which used to have many sharp and rigid items protruding toward the passengers have given way to soft, molded contours with flat buttons and dials. Steering wheels have been modified to collapse and move away from drivers during impacts. Engines, too, are directed down and under the car instead of moving straight into the passenger compartment. Windshields, which were originally made of ordinary window glass that could shatter and lead to serious injuries, are now laminated with an inner layer of cellulose to hold the glass together even when it fractures. Brake lights have been added in a raised position more likely to catch the attention of those behind the vehicle. Car frames are now made with stronger, yet lighter components.

In 1989, U.S. federal law mandated automatic restraint systems with either airbags or automatic seat belts. Since that time, advanced generations of airbags have been devised, and many new cars have several airbags that protect from multiple angles. The National Highway Traffic Safety Administration (NHTSA) estimates that between 1988 and 2008, airbags, while possibly causing 175 fatalities, saved more than 6,377 lives and prevented countless injuries.

In addition to the many modifications that have been made to vehicles, modern roads and roadways have been improved. The slopes and slants of roads have been altered to help hold vehicles on the road. Guardrails crumple when hit or are the ends extend into the ground so they do not slice into cars and their occupants as many used to do. Signs and light poles are lighter and now break away when struck instead of impaling occupants or causing rapid-deceleration injuries.

All of these automatic public health alterations and adaptations have had a significant impact on motor-vehicle safety. Between 1994 and 2008 fatality rates per 100 million vehicle miles traveled in passenger cars decreased by 38%. At the same time, motorcycle fatality rates per 100 million vehicle miles traveled, which did not benefit to the same degree from the automatic public health measures taken, increased by 62%.

Automatic public health activities have the advantage of repeatedly producing positive health and safety consequences for individuals and populations who do not have to consciously and intentionally take single or multiple steps to produce the beneficial outcomes. I believe more public health research should be devoted to identifying automatic public health activities that have the potential of improving safety and saving lives without unduly increasing costs or limiting personal freedoms. Health education and behavior change, while recording numerous historical successes and having honored roles in public health’s armamentarium are severely limited when working with unmotivated, preoccupied or overstressed individuals and populations. Informed automatic public health has the potential of circumventing the common deterrents and disincentives for healthful activities, not by manipulation or exploitation, but by aligning incentives and making healthy choices and activities the paths of least resistance.

Building Health Care a Foundation

Health depends more on what you eat and drink, where you live, whether or not you have a job, how often you wash your hands, whether or not you smoke, how far you got in school, and where the factory next door dumps its waste than it does on high tech surgical procedures or the newest pharmaceutical drugs.

This is where public health fits in. Public health is the foundation of health care. As the Institute of Medicine has said, “The mission of public health is to fulfill society’s interest in assuring conditions in which people can be healthy.”

So how do the “conditions in which people can be healthy” relate to health care reform?

Let me give an example.

Let’s say two children are born on the same day, but in different communities. One is born to a mother who has carefully watched her diet throughout pregnancy and has abstained from alcohol and smoking. She lives in a village with pristine water and unpolluted air. The sewage and garbage in her village are transported far from town, where they are carefully processed and recycled. As she grows, her mother carefully teaches her about health and personal hygiene, and makes sure there is always plenty of nutritious food, soap and toothpaste in the house.

The second child is born a bit premature and is small for his age, due to his mother’s inadequate diet and heavy smoking throughout her pregnancy. He grows slowly because of his frequent coughs and bouts of gastrointestinal disease, and because he shares his limited nutrition with the hookworms he has acquired from running barefoot in the village. The water he drinks is questionable, and the air in his home is polluted from the coal-powered stove on which his mother cooks the meager fare which she is able to find in the marketplace. Outside, the stench is almost palpable from the garbage on the streets and the cracked and leaking sewage pipes. His mother knows little about hygiene, and is too busy with her other babies to teach him what she does know.

This exaggerated picture does have a message: It makes a big difference how much effort and the level of resources your community puts into assuring healthy conditions for you and your family. In fact, Dr. Herman Biggs, the Commissioner of Health for New York City in the late 1800s claimed, “Public health is purchasable. Within natural limitations a community can determine its own death rate.”

Now, if these two families came to buy health insurance from you, which would you prefer to insure? Before either child has even entered the “health care system,” you already know which one is going to have the highest health care costs. One has grown up in a community with a rock solid foundation of public health, and the other is attempting to survive in a community that is falling apart.

The choice is ours. “Within natural limitations, (we) can determine (our) own death rate.”

Treating STD's . . . A community Concern

I met your daughter’s boyfriend last night. Seems to have a good head on his shoulders. He says he wants to get into college on a football scholarship and plans on becoming an engineer. Nice kid. Good family. Bright future.

I felt bad I couldn’t do more for him, but you know how it is. With all the budget cuts lately, we really can’t afford to just give away medications in our sexually transmitted disease (STD) clinics. I’m sure he’ll come up with the funds somehow.

Seems funny now how things used to be. We used to get state and federal funds to treat kids like this. It had something to do with the old-fashioned concept that communicable diseases somehow impact the whole community. In fact, we were forbidden by the state legislature to charge for these services if the person couldn’t pay. How naïve we all were!

What a waste of money, trying to control things like syphilis, gonorrhea, tuberculosis, hepatitis and AIDS. Of course, we didn’t have things like HDTV plasma screen televisions to spend our tax rebates on in those days. I guess we could afford to be a bit more community minded back then.

But I wouldn’t worry too much if I were you. Like I said, your daughter’s boyfriend seems like a really nice kid. And I’m sure that “Just say, ‘No!’” lecture you gave her really sank in. It would be a real stretch to imagine she might be in that group of women (74%) who say they had sex before they turned 19. Besides, I’m sure he’ll come up with the money for the medications somewhere.

When Someone Sneezes

by Mark B. Johnson, MD, MPH
When someone sneezes, I usually say, “Bless you!” It’s a habit. And I want to seem polite. But what I’m usually thinking is, “Curse you!” Especially if they don’t cover, or if they sneeze into their hands.

I really get upset if someone near me on an airplane sneezes. By “near me” I mean in the same airplane. We all know they don’t circulate the air much, to save on fuel costs. But it’s really the dry humidity that messes up our sinuses. I almost always get a cold or a sinus infection after I’ve been on a long flight. I don’t know anybody cool who gets sinus infections.

I’ve heard we say “Bless you!” because people used to think we sneezed our souls out. The blessing was a way of protecting the soul while it was loose and vulnerable. Others thought the heart stopped when we sneezed. It doesn’t. During the Black Plague some believed a sneeze was a signal of impending death. A blessing was critical. It was a benediction for the soon-to-be departed.

But now we know better. Now we know those sneezing Black Plague victims killed a lot of those who were blessing them. They should have been cursing them instead.

I tell my staff that the most common bioterrorist is someone coming to work with a cold. Most of my staff hide from me if they have a cold. They think I’ll get mad and send them home. I probably would, but what I really want is for them to stay away from me. It seems to be working.

I’ve got to fly tomorrow. I’ll probably take some saline spray. I wish I could take more than just 3 ounces. The Transportation Security Agency guys will probably examine my bottle in the little plastic bag and then say, “Okay! Have a nice day!” I’ll probably say, “Okay! Thank you!” But inside, I’ll really be saying, “Curse you!”