Throughout history and in most cultures, health has been valued
as one of the highest goods in life. Without health, the Greeks
believed that wealth, wisdom and talent would not be fully implemented
Health is, therefore, a desired state that permits individuals and
society to thrive. The mission of public health, as embodied in
the mandate of the office of the Surgeon General, is “to protect
and improve American health.” This mandate will be seriously
tested in the 21st century, and the key to success will be the integration
of behavioral and social sciences with medicine and public health.
By the year 2020, health care is projected to consume one-quarter
of this country’s Gross Domestic Product (GDP); it already
has become one of the most costly budget items for families and
government. At the moment, health care consumes about one-seventh
of the country’s GDP; whereas defense spending consumes about
4 percent and public education about 6 percent of GDP, health care
devours 13 percent.
As the baby boom generation ages, health care expenditures are projected
to rise. For the average American family, health care soon is likely
to rival the cost of the purchase of a home, which historically
has been a family’s greatest expenditure.
It doesn’t have to be this way. Much of the problem, along
with a possible solution, resides in the cost and effectiveness
of the health care system itself. Public health is a key agent of
the health system, which the World Health Organization (WHO) defines
to include “all activities whose primary purpose is to promote,
restore or maintain health.” According to the WHO’s
2000 World Health Report that ranked health care systems in 191
nations, America ranked first in per capita health expenditures—but
only 24th in life expectancy, 71st in level of health and 37th in
terms of overall health system performance.
To put this into perspective, France ranked fourth in health expenditures,
third in life expectancy, fourth in level of health and first in
health system performance. Compared to the French, Americans spend
more on health and get much less in return. Ironically, the United
States is a global leader in health technology and research and
training of health researchers and practitioners. Indeed, health
research, technology and training constitute an important sector
of the U.S. economy and the budgets of many universities.
While health technology and training have become ends unto themselves,
access to and utilization of health care and resources have eroded
over the past 20 years. The number of uninsured and inadequately
insured individuals has risen, and coverage for mental health services
remains incomplete. Access to and utilization of the array of health
care information and technology is among the most pressing issues
for public health, and the behavioral and social sciences have much
to contribute to this challenge.
Second, leaders in the U.S. have an “astigmatism” when
it comes to their vision of training and health outcomes. In the
behavioral and social sciences, we continue to train the best and
brightest minds to think as specialists in narrow fields of expertise.
Within public health, people become specialists in a disease, and
the National Institutes of Health (NIH) is classified by disease,
funds research accordingly, and is led primarily by individuals
trained in biomedical science (i.e., MDs).
This occurs despite countless articles and syntheses of the literature
that reveal that health is a many splendored thing, with determinants
at the biological, psychological and sociological levels and with
multiple pathways and interactions.
Of course, writings about the biopsychosocial model of health date
back to the late 1970s, and research continues to reveal that many
physical diseases are highly co-morbid which means they can occur
simultaneously, often one disease leading to another—and mental
illnesses tend to be cross-cutting conditions that in turn are highly
co-morbid with many physical diseases.
For these reasons, the future of medicine and public health rests
on their ability to genuinely integrate the behavioral
and social sciences. Yet we continue to train people and fund their
research unidisciplinarily (though with collaboration); public health
continues to study isolated diseases; and there have been no suggested
changes in the funding mechanisms or leadership at NIH that would
make truly interdisciplinary endeavors a reality.
Finally, medicine and public health continue to laud the accomplishment
of increased life expectancy and focus on the causes of mortality.
Life expect-ancy is a good indicator of the overall health of a
population. In this regard, the United States has much to celebrate,
because 30 years of life have been added to the life expectancy
of a child born at the close of the 20th century. Likewise, behavioral
and social scientists have much to celebrate because factors related
to social and personal hygiene were largely responsible for this.
As much as 85 percent of the drop in deaths due to infectious diseases
occurred prior to the introduction of vaccines and antibiotics
and could be traced to urban planning, nutrition and other hygienic
If people are living longer, why does this country focus so much
on death and the eradication of disease rather than health and well-being?
Moreover, why do we continue to think that biomedical science and
leadership will provide the “magic bullet,” when in
fact history tells us it did not lead the way to longer lives in
the 20th century.
This country faces vivid social inequalities, reflected in a dramatically
lower life expectancy for blacks than whites; the risk for almost
any disease is distributed unequally, and the brunt of it is shouldered
by the most disadvantaged. The objective of reducing inequalities
in death and disease is extremely important. Moreover, while most
people want to live a long life, many also aspire to live fulfilling,
meaningful, healthy lives. The term “promotion” must
achieve equal status with the reigning terms of “prevention”
and “eradication” in the lexicon of medicine and public
health. The addition of quality life years should be as
important as the addition of years of life.
My wish is that Atlanta and a consortium of its universities consider
hosting an annual series of events to convene leaders and members
of the leading societies of political science, sociology, anthropology,
economics and psychology, with the goal of applying their sciences
in a collective mission to solve the “challenge of 2020.”
This challenge includes improving the performance of the U.S. health
care system through promoting
access and utilization of it, so that health does not become the
economic albatross that brings down this country.
This objective will require the genuine integration of behavioral
and social science with medicine and public health at Emory and
beyond. Let us be part of the solution—not a contributor—to
the challenge of 2020.