Jul 6 2011
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NewPublicHealth Q&A with Steven Woolf

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A recent commentary article in the Journal of the American Medical Association suggests that the biggest threat to public health actually may be funding cuts to programs outside the health sector. The author, Steven Woolf, M.D. , M.P.H., director of the Virginia Commonwealth University Center on Human Needs, says certain budget decisions such as those that affect basic living conditions, removing opportunities for education, employment, food security, and stable neighborhoods, could have far greater health implications than disruptions in health care. NewPublicHealth spoke with Dr. Woolf about the article and its implications.

NewPublicHealth: What was the essence of the commentary article you published in the Journal of the American Medical Association?

Steven Woolf: The commentary explains the fact that policy issues outside the conventional silo of health care have very large influences on health. Other sectors such as education, income and the conditions of neighborhoods and communities, for example have been shown through a large body of research to increase our risk of developing diseases. Unfortunately, the tendency in policy-making is to divide up topics into silos and so policy concerned with health care, such as health insurance reform or strategies to reduce the cost of medical care, are deferred to the health committees to deal with. Education reform, jobs, and other programs related to economic revitalization are assumed to be not the concern of the health policy community. One of the purposes of my commentary was to try to help connect the dots and make the point that not only is the social policies relevant to health, but they actually are a very big deal.

NPH: What prompted you to write the commentary?

Steven Woolf: I was prompted to write it after watching protests around the country over proposed budget cuts. The concern that those of us in the Public Health community have is that often policy-makers and advocates who are having their debates about the merits of making these budget cuts forget about the connection to health. And it’s not a marginal concern--those programs that are outside the health sector have--in many cases--very large health implications. We’re talking about education programs that help people remain employed and earn a decent living, for example. These have huge connections to the risk of death and the development of chronic disease.

NPH: Has it been difficult to get thought leaders to pay attention to the idea that improved health goes beyond health care?

Steven Woolf: Well, yes. An interesting anecdote I’ll share is that when I have contacted Congressional staff members dealing with these issues, very typically about halfway through my first sentence they would put me on hold and connect me to their health staffer. And I realized that I needed to interrupt them before they did that to tell them this is really for the education desk. Because one of the main messages of my commentary was that educational attainment and what we’re doing around education reform and helping people attend college is a health issue.

NPH: What have you heard about the commentary since it was published?

Steven Woolf: I’ve received positive feedback from colleagues mainly in the Public Health community for articulating the argument. I originally wanted to write this piece as an op-ed in The Washington Post, The New York Times, The LA Times--I shopped it around there and they weren’t interested. I think that’s partly reflective of the tendency of editors to not connect the dots any more effectively than policy-makers do. It’s a connection that people are still not used to making.

NPH: A recent study from the University of Minnesota found that kids who went to pre-school were found to have a higher economic status twenty five years later. They have more health insurance coverage; they have a better quality of life. Do you think studies like that will be able to help you push this argument forward?

Steven Woolf: In fact, there have been studies like that in the education literature for many years--randomized trials done twenty years ago that have shown similar outcomes. We’ve actually taken that kind of evidence a step further. We published a study [in the American Journal of Public Health] several years ago in which we used modeling techniques to actually examine the business case for some of those educational interventions. We looked at what would happen if you reduced classroom sizes from kindergarten through third grade. Studies had already shown by that point that doing that would actually improve outcomes for high school graduation and college attendance. We then factored in what the health implications would be of having a larger proportion of students attend college and achieve higher educational attainment, in terms of reduced medical spending and health care costs later in life. And we demonstrated that the economic benefits off-set the upfront expense of the education reform changes in classroom size, the teachers’ salaries, and so forth. That type of business argument--return on investment analysis--is what we think the way forward is in more sophisticated policy-making. Not only connect the dots and understand that education is a connection to health--but actually run the numbers and figure out what’s ultimately best for the American public in terms of economic benefit and what’s ultimately better for the nation’s well-being.

NPH: The 2011 County Health Rankings, developed by the University of Wisconsin and the Robert Wood Johnson Foundation, were released in March for the second straight year. You had a very important tool for the rankings this year--a calculator--that looked at certain social determinants of health. Can you talk about that calculator and also talk about how it might be applicable to some of the issues you raised in the commentary?

Steven Woolf: Well, the calculator basically allows people to select any county and examine how changing the levels of education and income might affect the number of deaths in the chosen area. It’s a tool that helps people understand the relationship between education and income and health. Most people get this. They already know that education and income have some health association but they probably don’t realize the scale of the impact. This tool shows you that achieving the educational attainment in a neighboring county can potentially reduce mortality rates by ten to twenty percent. So literally, lives are at stake because of these social conditions. And arguably, the potential health benefit in saving lives eclipses anything that we really do in the medical field. There’s very little that doctors do or hospitals do that can achieve those kinds of reductions in death rates or disease rates.

NPH: What’s your next step?

Steven Woolf: People like me tend to work on multiple fronts. So to some extent there’s an effort to try to reach out to the public and to policy-makers. But I’m also a researcher--so a large part of our scholarship and scientific work is around trying to examine the health implications of these policies outside the health sector to produce valid data and then to package that in ways that are meaningful to the general public, decision-makers, and the media. So we publish our articles in scientific journals and present them at conferences, but try to convey these ideas to other audiences as well.

NPH: Do you think a greater understanding about how everything is inter-connected could reduce some of the budget cuts being made to health departments currently?

Steven Woolf: I’d like to think so. I think more rational choices would be made if people had a better awareness of how those different domains are connected. A very common scenario right now, for example, is that Medicaid and other health-related expenditures for states are so huge and growing so fast that governors and other state legislators feel a compulsion to make cuts in education and other social programs to help pay for health care. They view health and other social needs as separate pockets that they’re taking the money out of. The challenge on a political level, though, is that those outcomes are years away from when those budget cuts are made--well after these folks have left office. And their tendency is to focus on re-election and their return to office. Even scoring of legislation that’s done by the Congressional Budget Office and other similar entities have a narrow time horizon that often fails to take those long-term impacts into consideration.

Read previous NewPublicHealth.org Q&As with newsmakers and difference makers in public health.

Tags: County Health Rankings, Disease Prevention and Health Promotion, Health disparities, Public Health Departments, Q&A, Social Determinants of Health