Cancer Survival Is (Mostly) Improving

This chapter discusses how the 5-year survival rates for the most common cancers in the United States improved by nearly 20% since the 1970s. While promising overall, low survival rates persist for pancreatic, liver, lung, esophageal, brain, and many other cancers. Meanwhile, 5-year survival for uterine and cervical cancers worsened. Pancreatic cancer has the lowest 5-year survival rate at 8.2%. In contrast, prostate cancer had the greatest 5-year survival increase from 67.8% to 98.6%, most likely reflecting a substantial uptick in prostate cancer screening and early detection. Five-year survival with leukemia also improved significantly, from 34.2% to 60.6%, likely resulting from improved treatments. As such, in both detection and treatment, the United States is making progress. For the millions of Americans who face a cancer diagnosis, this is cause for hope.

Police and the Public’s Health

This chapter describes how police work shapes the health context of cities and neighborhoods, and affects the lives and behaviors of countless citizens. While there has been much concern in recent years about how some police activity has harmed health, particularly among minority communities, police have the potential to improve the health of the communities they serve. Police beat work is filled with low-intensity interactions in which officers serve as problem-solvers; these problems often involve public health. Police are first responders to opioid overdoses; they also intercede in intimate partner violence, and they engage with the homeless. As such, leveraging police involvement into better health outcomes could go a long way toward helping people solve these crises. Increasingly, large cities are developing crisis intervention teams (CITs) to improve safety and divert individuals from criminal justice involvement.

The Promise of Palliative Care

This chapter assesses palliative care. Palliative care focuses on improving the quality of life for people with life-threatening illnesses by involving a team of nurses, doctors, social workers, and clergy in a care plan. Hospice care—administered in dedicated units and in services delivered at home—has been slowly expanding over the past two decades, but the increasing percentage of patients who use hospice for less than 7 days suggests that the full benefits of end-of-life palliative care are not being realized. Meanwhile, the use of unwanted, aggressive end-of-life care, often inconsistent with patient preferences, remains pervasive. For palliative care to be effective, it must be supported by government policies and insurer incentives; it must also be owned by communities, which must continue to ask for help in designing and paying for high-quality palliative care for patients and their caregiving families.

Good App Hunting

This chapter highlights health apps. Health apps primarily perform three functions: they monitor, measure, and manage. The first generation of apps were largely about self-monitoring. These “do it yourself” kinds of apps had users record and consider their own data—food ingested, mood, glucose levels—and offered these users opportunities to modify their behavior. Next came measuring, quantifying apps, which soon became sensor-based, including recordings of heart rate, steps walked, sleep stages, and food labels. Such sensors limited manual input and offered novel “health” markers to monitor. It is now the era of the “prescribable” app—an app for the treatment of managing conditions anytime, anywhere. Some of these apps have even been recommended by health providers. The most commonly trialed apps are those that are designed to address conditions with the largest global health burden: diabetes, mental health, and obesity. However, of all the health apps on the market, only a few dozen have ever been tested using randomized trials. Thus, there is a need for efficacy assessment, a reliable source of quality information—a Consumer Reports for health-related apps—and a recognized national organization that can evaluate and decide which are useful and safe. Even a modestly effective app, if available to millions of users, could have an enormous impact on the public’s health.

Maybe the End of HIV

This chapter focuses on HIV, which has been our most politically charged illness and a defining health challenge of our time. The world of HIV care over the last two decades has seen a great, almost miraculous, revolution. Today, a 35-year-old who was HIV-infected in 2018 and takes her daily medication adherently has the life expectancy of a 35-year-old without HIV infection. Monthly injections of long-acting HIV drugs look to be as good as daily pills at suppressing the virus, creating easier treatment. Despite these stunning advances, disparities in detection and care characterize the disease. The epidemic has shifted to groups that are hard to test, hard to get started on preventive care, and hard to keep on daily medication—persons who inject stimulants, men on the down-low, the mentally ill, the homeless, and the rural poor with no health insurance. Lack of information, lack of trust of providers, unfamiliarity with services, and refusals of testing and treatment due to social rejection and privacy concerns make the delivery of care more challenging for these groups. Even among persons enrolled in AIDS clinical trials who have found their way to cutting-edge medical treatment, blacks and Hispanics have poorer outcomes. As such, reaching an end to HIV will require new attention to health systems and social stigma, to geography, to housing and outreach, to the long work of public health.

Can We Promote Public Health and Generate Return on Our Investment?

This chapter looks at how the country’s health investment remains resolutely focused on curative care. Perhaps people spend more on cure than they do on prevention because they believe keeping people healthy is too expensive. But is this true? An analysis set out to assess the return on investment for high-income countries that adopt efforts to improve health. The authors found that the median return on investment for public health interventions was 14 to 1—that is, for every dollar invested, it yields the same dollar back and another 14. They also found that the more these interventions were established at the wider, national level, the higher the return, rising up to about 40 to 1 for the best investments. These interventions include vaccination programs, taxes on sugar-sweetened beverages, building better cities to reduce falls, and early youth interventions to limit teenage pregnancy and delinquency. In other words, these are classic efforts to promote the public’s health by shaping the conditions in which people live.

Misconceptions about Veterans and Health

This chapter studies the health of veterans and the military. Since the first Gulf War in 1990, veterans have had worse mortality than the general population. Aside from mortality, mental health problems are a particular concern. More soldiers kill themselves than are killed on the battlefield. Beyond suicide, key mental health concerns among veterans include posttraumatic stress disorder (PTSD). Itself disruptive, PTSD foreshadows increased risks of physical health problems, substance use/misuse, homelessness, and violence. Less studied, but equally important, are high rates of depression and anxiety among veterans. Rates of chronic pain and physical disability are also high. These challenges make the Veterans Health Administration’s unique expertise in mental health care provision and rehabilitation services all the more crucial. For these reasons, moves to privatize veterans’ health care and narrow access to these services do veterans a disservice, shortchanging a fundamental social contract. The health of soldiers is the public’s health.

Health Systems and Public Health Thinking

This chapter addresses how homelessness affects health. The disordered lives of homeless patients disrupt appointment-keeping and medication adherence, even as they generate need for more treatment by driving health challenges like depression, high blood pressure, and hospitalizations. As such, some health systems have begun to address the link between homelessness and health. One Boston health system, for example, announced plans to subsidize housing for the patients for whom it is accountable, to give this population some measure of the shelter and stability necessary for good health. As a society, people tend to forget that health is a public good supported by their collective investment in resources such as education, the environment, and, indeed, housing. Health systems can help people remember, by investing in these resources, to improve the health of patients. Indeed, health systems can direct people toward a better understanding of what truly shapes health, but it is ultimately the people’s responsibility to act on that knowledge and build a world that generates health.

We Cannot Have It All

This chapter discusses health gaps by giving an example of a campaign for flu vaccination. To improve the town’s flu vaccination rate, the mayor tasks the health commissioner to develop a strategy that communicates, primarily through doctors’ offices, the importance of flu vaccinations. The strategy works; the flu vaccination rate increased from 45% to 65%. This success is not as complete as it looks, however. At the level of what the mayor intended—that more residents would be vaccinated—the campaign worked. However, the health gaps in town between the rich and the poor residents also increased—substantially. Health inequities like these are the result of systematic injustice—in this case, the injustice of unequal access to health care settings where vaccine marketing and delivery take place, and the broader socioeconomic inequality this reflects. These inequities matter. After all, if a pocket of the town’s population remains unvaccinated, it puts the whole area at risk, even if vaccination rates go up among the rich. Public health must recognize that a healthy society is one where health is accessible to all—not some, or even most, but all.

What Kills Our Kids?

This chapter asks what kills children and what people can do about it. One of the greatest triumphs in health over the past century has been the dramatic decrease in childhood mortality, yet children still die. In 2016, there were, in the United States, about 38,000 deaths of children under the age of 19. Roughly half of deaths occur in early childhood due to genetic conditions, chromosomal abnormalities, and other perinatal conditions, many of which people do not know how to treat. However, we should be able to prevent most of the other half. The leading causes of injury deaths are motor vehicle deaths and gun-related deaths. Understanding how to prevent them can provide a template for stopping other childhood deaths. The chapter then considers the Vision Zero initiative, passed by the Swedish parliament 20 years ago, which aims to reduce traffic fatalities to zero. Just like motor vehicle accidents, childhood deaths from guns will not end until people work to create a safer environment by reducing the availability of firearms.