View from abroad: Time for US to learn from global public health community

Deborah Klein Walker is a vice president and senior fellow at Abt Associates, and  former president of the American Public Health Association and the Association of Maternal and Child Health Programs. Walker attended the 13th World Congress on Public Health, held April 23-27 in Ethiopia, which was organized by the World Federation of Public Health Associations, of which APHA is a member. She reflects on the meeting and discusses leading challenges in global public health and what is needed to achieve health equity for all.

By Deborah Klein Walker, EdD

I spent last week attending the 13^th World Congress on Public Health in Addis Ababa, Ethiopia, with colleagues from 116 countries around the world. Country and global public health leaders made many exciting presentations tied to the Congress’ theme — “Towards Global Health Equity: Opportunities and Threats.” At times, it has been a frustrating experience for me as an American, since many of the aspirations and goals of public health leaders and governments in Africa, Europe and other continents far outreach what we are doing in the U.S. Even though we spend more per capita in the world on health care, we do not meet the goals articulated by the global public health community.

Many countries, including the host country Ethiopia, have declared that health is a human right and that all should receive the health services they need, regardless of the ability to pay. A major initiative of the World Health Organization is universal access to health services in all countries. In contrast, the U.S. views health care as a privilege and not a basic human right. Except for states such as Massachusetts, which has made universal health care a reality for all its citizens, we have many Americans today without health coverage. The Affordable Care Act is a major achievement towards achieving universal health coverage, but is under attack.  

Much of the work presented here has emphasized reducing health disparities in many areas of public health, including maternal and child health, HIV/AIDS services, immunizations, clean water and more. Inequities within countries can be as large as inequities across borders. All countries have health inequities based on educational status, poverty and other factors.  

Although the United States overall has a relatively higher starting point for some health indices, we have many inequities within our country. Infant mortality is one example, where the black rate is more than 2.5 times larger than the white rate and our overall rate for infant mortality is 34^th in the world. And there are huge disparities in life expectancy depending on where you live in the United States. For example, recent research from the Institute for Health Metrics and Evaluation found that in Collier, Fla., women live 85.8 years on average. But in McDowell, W.Va., they live to be 74.1. We need more resources devoted to reducing racial, ethnic and socioeconomic disparities to fully implement the public health interventions needed to prevent disease and eliminate the inequities.  

Addressing the societal determinants of health is extremely important in improving the health of the public. In the United States, the medical care system only contributes 10 percent of the population health outcomes. Changing behaviors is the most important contributor, accounting for 50 percent for overall health status. What’s needed is a major commitment to addressing the underlying causes of optimal health.  

Why is it that poverty, a major determinant of health, is rarely discussed as a major issue in the United States today? We have entered a period where many of the major supports for the poor have eroded and the gap between the rich and the poor has never been larger. An emphasis on prevention in all settings in a community is a key public health strategy. Although the Affordable Care Act has a substantial investment in prevention by creating a prevention fund for community-based initiatives, it too is under attack.

I wish more Americans had the perspective of my global public health colleagues, who understand what is needed to achieve equity in health for all. We have the knowledge and the resources in our economy to do what is needed, but political will and understanding is lacking. I will return to the United States reenergized to continue to work for a stronger public health commitment so we can truly lead the world in improving population health and reducing health disparities.