Lecture 1-Spending in Public Health NEJM

Lecture 1-Spending in Public Health NEJM - PE R S PE C T IV...

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n engl j med 362;18 nejm.org may 6 , 2010 PERSPECTIVE 1657 Why We Don’t Spend Enough on Public Health David Hemenway, Ph.D. Why We Don’t Spend Enough on Public Health T he field of public health has long been the poor relation of medicine. Medicine — in which most resources are used to help cure individual patients after they have become sick or injured or to help manage already-existing chronic conditions — is flashy, its master practitioners and in- novators lionized, and its accom- plishments widely celebrated. In contrast, public health — in which most resources are focused on trying to keep something bad from happening in the first place — is seemingly mundane, its ef- forts and prime movers often all but invisible. Medicine is primarily a private good — the patient receives the main benefit of any care provid- ed. Payments usually come from the individual patient and, in the developed world, from private and governmental insurance. Public health, on the other hand, pro- vides public goods — such as a good sewer system — and relies almost exclusively on government funding. It is generally acknowl- edged that public health is sys- tematically underfunded and that shifting resources at the margin from cures to prevention could reduce the population’s morbidi- ty and mortality. I believe there are four key reasons for such under funding. First, the benefits of public health programs lie in the future. Our brains are structured so that we use different neural systems when considering the present and the future. 1 The problems of temp- tation, procrastination, and im- patience exist in large part be- cause of the desire of the ancient part of our brain, the paralimbic cortex, for immediate gratifica- tion. Since it takes willpower to delay gratification, individually and collectively we sometimes under- invest in the future. People typi- cally seek medical care because they want quick relief for imme- diate concerns — current illness or injury. Most public health mea- sures, however, incur costs today but don’t provide benefits until sometime in the future. When considering a public health investment today (e.g., im- proving road safety, preventing mad cow disease, or limiting cli- mate change) that will potentially yield benefits in the future, many politicians correctly understand that their administrations will bear the costs, but the benefits will be reaped on someone else’s watch. They therefore put great
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This note was uploaded on 11/09/2011 for the course PUBLIC HEA 232 taught by Professor Berger during the Fall '11 term at Rutgers.

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Lecture 1-Spending in Public Health NEJM - PE R S PE C T IV...

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