In 2017, the United States spent $3.5 trillion on health care. Only 2.5% of this total was dedicated to government public health activities designed to prevent illness.
The renowned medical historian Henry Sigerist, writing in 1941, listed the main items that must be included in a national health program. The first three items were free education, including health education, for all; the best possible working and living conditions; and the best possible means of rest and recreation. Medical care rated only fourth on his list (Terris, 1992a). For Sigerist (1941), medical care was this:
A system of health institutions and medical personnel, available to all, responsible for the people’s health, ready and able to advise and help them in the maintenance of health and in its restoration when prevention has broken down.
Many people working in the fields of medical care and public health believe that “prevention has broken down” too often because society has dedicated insufficient resources and commitment to prevention. A serious trend has emerged in the United States: after decades of gains, the average life expectancy has been declining since 2015, driven by increases in midlife mortality rates related to such preventable conditions as drug overdose, alcohol-related diseases, suicide, homicide, hypertensive disease, and chronic respiratory illness (Woolf et al., 2018).
Primary prevention seeks to avert the occurrence of a disease or injury (e.g., immunization against polio; taxes on the sale of cigarettes to reduce their affordability, and thereby their use). Secondary prevention refers to early detection of a disease process and intervention to reverse or retard the condition from progressing (e.g., Pap smears to screen for premalignant and malignant lesions of the cervix, and mammograms for early detection of breast cancer).
The promotion of good health and the prevention of illness encompass three distinct levels or strategies (Terris, 1986; Table 11–1):
The first and broadest level includes measures to address the fundamental social determinants of illness; as evidence presented in Chapter 3 shows, lower income is associated with higher morbidity and mortality rates. Improvement in the standard of living and social equity (e.g., through job creation programs to reduce or eliminate unemployment) may have a greater impact on preventing disease than specific public health programs or medical care services.
The second level of prevention involves public health interventions to reduce the incidence of illness in the population as a whole. Examples are water purification systems, the banning of cigarette smoking in the workplace, and public health education on human immunodeficiency virus (HIV) prevention in the schools. These strategies generally consist of primary prevention. The 2.5% figure cited in the opening paragraph represents these public health activities.
The third level of prevention involves individual health care providers performing preventive interventions for individual patients; these activities can be either primary or secondary prevention. The US Preventive Services Task ...