Improving Population Health: Continuing the Journey

I am honored to have been asked to kick off the new IAPHS Forum with some reflections on population health and blogging. Some of you will recall my own weekly blog, ImprovingPopulationHealth, which I ran with Kirstin Siemering for 3 years.

The initial post on my 70th birthday in 2010 began this way: “Why am I starting a blog on issues and perspectives in the field of population health? It is because I believe we are at a tipping point in which a convergence of scholarship policy and practice initiatives seem poised to bring an overdue population health perspective to thinking about and acting on health and health improvement. The challenge of the next decade will be to find practical ways in which new approaches to financial and nonfinancial incentives and multi-sectoral partnerships can be applied to improve population health outcomes here and elsewhere.”

Today, as IAPHS and this Forum take up the responsibility and opportunity to help lead scholarship and advocacy for our field, I’m not sure I would say it any differently. I almost said “our emerging field” but paused to ask myself: Is “emerging” still an appropriate adjective?

No and yes. No, in that the field certainly seems less emergent and more established, with major activities like the Robert Wood Johnson Foundation Culture of Health framework and the California Endowment Building Healthy Communities program; the 4 years of the National Academies of Sciences, Engineering, and Medicine Roundtable on Population Health Improvement; the population health promotion activities at the Center for Medicare & Medicaid Services, now led by former Health & Society scholar Dawn Alley; the burgeoning research in many universities and think tanks across the country, including our own County Health Rankings and Roadmaps; the growing importance of the health equity movement; and the establishment of IAPHS itself.

But yes, in that with the ambitious and challenging goals of improving health overall and reducing the often still growing gaps—and the persistent and unrelenting dominance of the medical model—it can seem like we are just beginning. Although we have done a good job of describing the challenges and failings of our system, we have not yet produced adequate evidence to support the path forward. I sometimes think the Achilles heel of our movement is the difficulty and slowness of answering what I think remains THE population health question: “What is the optimal balance of investments (e.g., dollars, time, policies) in the multiple determinants of health over the life course that will maximize overall health outcomes and minimize health inequities at the population level?” Victor Fuchs put the same question another way in 1974: “How much, then, should go for medical care and how much for other programs affecting health, such as pollution control, fluoridation of water, accident prevention and the like. There is no simple answer, partly because the question has rarely been explicitly asked.”

Progress often seems slow, for reasons of data, analytic methods, and limited funding for something lacking a specific disease label. And establishing causality in social science is challenging… This is why Greg Stoddart called his field model “the fantasy equation.” But we are asking the optimal-balance-of-investments question more often, and answers are beginning to emerge. Recently, my own thinking has focused on how we can move from determinant benchmarks, such as smoking or poverty rates, to investment benchmarks for optimal resource allocation, and how we can find common ground across ideologies to make the substantial investment changes that our goals will require.

Of course I’m writing this at a time of significant transition at the federal level. The rhetoric and policy directions are extremely concerning, and retreating from a national standard for healthcare access would be a major setback. It is also important to keep in mind, however, that we have not yet achieved healthcare affordability or value, and that health care is not the most important determinant of health. Much work remains to be done if we are to improve population health, not all of it focused on healthcare. In addition, we must not forget that population health improvement is a long-term journey: recall that the widening life-expectancy gap with Europe has been worsening since 1980. Population health problems are often decades in the making, and solutions will probably take similarly long periods to implement. Therefore, it is crucial to continue our work in the coming years, and to find openings where we can. Although we must vigorously oppose harmful federal policies, perhaps the next 4 years can also be an opportunity for state-level innovation, enhancing partnerships with the business community, and making sure that job creation and economic development are done equitably and in health promoting ways.

This new association is one important part of the answer to the full maturity of this field, and I am bullish and hopeful that your contributions to the IAPHS Forum will both inspire and challenge us for the critical work ahead. I was honored to be elected to our new Board and I look forward to continuing these discussions in the coming years.