Public Health Reform Jonathan Mann Lecture 2011 David Fleming, MD Director and Health Officer

Recent history

“ The desperate disease requires a dangerous remedy” Guy Fawkes November 6, 1605

Life Expectancy in the U.S. (1900 – 2009)

Leading causes of death – United States Mortality Rate Epidemiologic Transition 1900 Pneumonia Tuberculosis Diarrhea 2010 Heart Disease Cancer Stroke

Life expectancy, by county, compared to the world’s 10 best countries

Comparison funding for disease prevention with premature deaths, King County, WA $8.0 $6.0 $4.0 $2.0 $0.0 $8.0 $7.7 $4.7 $4.4 $1.6 $ $ $ $ $ HIV Prevention Emergency Preparedness TuberculosisSexually Transmitted Diseases Vaccine Preventable Diseases Diabetes Heart Disease InjuryCancer Tobacco Funding in Millions Premature Deaths

Disease in the US has undergone an epidemiologic transition … it’s time epidemiologists did too 1.Align resources to the current burden of preventable diseases (that means chronic diseases, injury, and health disparities) –Make new friends with the health care system 2.Build an epidemiological work force able to perform in a world of policy, systems, and environment change –The future of epidemiology is less about guiding ourselves and more about convincing others Surveillance

In a perfect world we’d be accountable for quantifiable improvements in health outcomes. Four inconvenient truths make accountability more complicated than merely promising outcomes.

2: The exact effects of even proven interventions are uncertain 3:For many important public health problems we do not yet have a full tool box of proven interventions 4:Changes in health outcomes may occur only years after intervention 1:Future health outcomes are unpredictable even if we do nothing

Shift from pseudo- accountability for health outcomes to real accountability for execution of strategy The Three Part Plan 1) Joint agreement between accountable parties on specified strategies 2) Strict accountability for execution and measurement of strategies 3) Measurement of outcomes and strategy revisions as indicated

Health Indicators CancerSuicide Infant Mortality AIDS Health Indicator

AIDS Health Indicator Suicide Infant Mortality Health Indicator Cancer Resources ($, people) ProgramsProduct Short term Outcomes Resources ($, people) ProgramsProduct Short term Outcomes Resources ($, people) ProgramsProduct Short term Outcomes Resources ($, people) ProgramsProduct Short term Outcomes

AIDS Health Indicator Suicide Infant Mortality Health Indicator Cancer Resources ($, people) ProgramsProduct Short term Outcomes Resources ($, people) ProgramsProduct Short term Outcomes Resources ($, people) ProgramsProduct Short term Outcomes Resources ($, people) ProgramsProduct Short term Outcomes

Demonstrate a causal pathway between public health and better health outcomes 1.Embrace accountability for rationally-defined performance – Be prepared for initial tough going 2.Define, standardize and measure the public health value chain – A new full-employment strategy for future epidemiologists Causality

chart of accounts \'chärt\of 'äv\account ə -'kaünt\ : system of accounting records developed by every organization to be compatible with its particular financial structure, and in agreement with the amount of detail required in its financial statements. It consists of a list of ledger account names and numbers showing classification sand sub-classifications, and serves as an index to locate a given account within the ledger. See also class of accounts.

Control the system in which we work so that we can get the job done 1.Increase the coherence, integration, and base capability of our public health system –Define basic public health capabilities, accredit health departments, and regionalize services where appropriate 2.Stabilize and rationalize public health financing –Create a public health chart of accounts; fund core capacities; reform CDC funding mechanisms; define financing roles; advocate for stable revenue sources Control of extraneous variables

+ _ Leadership Skills + _ Epidemiologists

You are here The real world

EpidemiologistEverybody else ■Conclusion ■Keep it simple ■Sound bite ■Stories ■Methods … results … discussion ■Caveat ■Complete explanation ■Data ■Answers questions ■Stays on message Communication

■Based on science and evidence ■Focused on prevention ■Centered on the community ■Driven by social justice ■Really? Navigating our values ■Will always finish second ■Rugged individualism ■Majority rules

Increase concordance between epidemiologic skills and leadership skills 1.Take the plunge. Practice talking work with non- epidemiologists –Use passion and be driven by data, not just data driven 2.Recognize the liability of our underlying values in today’s world –Think like a politician (when it is called for), strategically crafting messages and approaches + _ + _ 2 X 2 Association