The Public Health Journey

The Meaning

I believe we will see public health only grow as a global community, with many more joining us on this journey in the future. A number of vital reasons will be driving this growth.

First, every day, we have the privilege of standing for something. As the saying goes, “If you don’t stand for something, you will fall for anything!” (Marshall, 1947). And often, standing for something means venturing off the ledge of neutrality. As Archbishop Desmond Tutu has said, “If an elephant has its foot on the tail of a mouse and you say that you are neutral—the mouse will not appreciate your neutrality!” (Tutu, year unknown). Public health requires, and indeed demands, that we stand for something bigger than ourselves. So when we promote the health of others, we stand for the health of our neighborhood and our community. We stand for the health of our nation and indeed our world. In short, we stand to help all people reach what the World Health Organization has called the “highest attainable standard of health” (World Health Organization, n.d.). And reaching that highest attainable standard for any individual represents true public health success—when we can all celebrate the joy of a human being fully alive (Coffin, year unknown).

Second, comprehending the mysteries of sickness and health requires the willingness to broaden our minds and souls in almost unimaginable ways (Koh, 2009). Indeed, the definition of health encompasses much more than just physical well-being but also emotional well-being, social well-being, and spiritual well-being. Hence, we embrace the overarching goal of Healthy People 2020—to improve both quality of life as well as quantity of life (Healthy People 2020 Framework, n.d.; Koh, 2010a). In short, public health adds years to all of our lives, and quality of life to all of our years. In addition, we embrace the goal of eliminating health disparities, recognizing that every person should enjoy what Reverend Martin Luther King has described as “the sunlight of opportunity” (Martin Luther King Jr., Grosse Pointe High School, March 14, 1968). This commitment is one I feel passionately, not only as the Assistant Secretary for Health but also as a Korean American son of immigrants who journeyed to this country a generation ago searching for the American dream.

As a physician who has cared for patients for more than 30 years, I learned that health is much more than what happens in a doctor’s office. Rather, in addition, health starts where people live, labor, learn, play, and pray (Koh, 2011). That’s what the social determinants of health are all about (WHO Commission on Social Determinants of Health, 2008). That’s why Healthy People states, “The health of the individual is almost inseparable from the health of the greater community.” In short, we all are interdependent and interconnected. We all have promises to keep (Koh & Nowinski, 2010).

Third, over time, many of us have discovered that public health is not just our work but rather our calling. Some of us choose public health, but many of us also feel called. Something irresistibly draws us in, seeps into our soul, and won’t let go (Koh, 2010b); our field is about “encouraging the heart” (Kouzes & Posner, 2008). Many in public health have felt wounded in their lives, having experienced the agony of illness, injury, or injustice. Such individuals could have justifiably spent the rest of their years focusing inwardly on their pain. But instead, they have turned pain into power, and grown from being wounded to becoming “wounded healers” (Nouwen, 1979). Hence, the public health journey is fundamentally a spiritual journey, filled with meaning and purpose, with spirituality defined as “living the ordinary life extraordinarily well” (Coffin, year unknown). That’s why public health is not only public but also profoundly personal.

In my case, public health called to me throughout a long career of patient care. As a young physician, I started my journey determined to cure everyone; the mission of direct patient care will always be a noble, if not sacred, enterprise for me. But I quickly discovered that far too many of my patients were succumbing to preventable illnesses, such as tobacco addiction, cancer, HIV, obesity-related diabetes, and much more. This realization was a source of great personal and professional anguish. I have since found that many others have similarly shared such agonizing moments of frustration when we see disease and try to heal it; when we see pain and try to prevent it; or when we see suffering and try to stop it. After caring for many patients suffering preventable suffering and dying preventable deaths, I eventually concluded that “there’s got to be a better way.” Reaching that conclusion marked the beginning of my journey into public health.

This journey has led me to public service, first as Massachusetts Commissioner of Public Health (from 1997 to 2003) and now as Assistant Secretary for Health for the U.S. Department of Health and Human Services (HHS). This journey has also led me to work with many dedicated and committed public health groups such as SOPHE and now to stand before you today.

The Moment

So now, we are all poised at the dawn of the full implementation of the Affordable Care Act, first signed into law on March 23, 2010. Beginning in January 2014, the country can finally bear witness to the full potential of this historic opportunity. The Affordable Care Act offers a transformative moment to widen our traditional national focus from sick care to begin to build a system of prevention and public health (Koh & Sebelius, 2010). It provides the promise of better insurance, better care, and better prevention and public health. Health educators, led by SOPHE, can leverage this moment to help people realize the promise of health reform in their own lives.

First, health reform offers better insurance through the added security in coverage that is essential for health and wellness. Over the past decade, a series of Institute of Medicine reports documented that the uninsured are less likely than the insured to have a usual source of care and receive preventive services (Institute of Medicine, 2009). The uninsured are also more likely than the insured to be diagnosed at advanced stages of cancer and die of stroke and myocardial infarction (Koh & Tavenner, 2013). From my early days as a medical intern and resident at Boston City Hospital, I was profoundly affected by witnessing how the lack of insurance ruined the lives of so many. I saw too many patients unable to focus fully on overcoming a serious illness because they were so consumed by the specter of their insurance being snatched away.

That sense of insecurity should recede greatly after 2014 when the new law brings better coverage for all of us. Everyone will have access to insurance, regardless of preexisting condition; no one can be turned away (Koh & Tavenner, 2013). Women can’t be charged more because of their gender; discrimination should end (Healthcare.gov, n.d.). And after 2014, the law also substantially reduces the possibility of medical bankruptcy by prohibiting insurance companies from imposing annual limits on most benefits.

The law has already improved insurance benefits for many (Koh &Tavenner, 2013). Since young working adults comprise a major portion of the uninsured, a notable advance has been increased coverage to adult dependent children up to age 26 on their parents’ plans (Office of the Assistant Secretary for Planning and Evaluation, 2012). In fact, the number of such covered young adults has now risen to nearly 7 million; nearly half of them have received coverage since the Affordable Care Act was passed in 2010 (Sommers & Kronick, 2012). In 2014, all states will see marketplaces (exchanges) having been established, whether they are state based, federally facilitated, or a partnership of the two. In addition, states continue to weigh the decision to expand Medicaid. Furthermore, health reform has strengthened Medicare by extending the life of the Trust Fund and granting 6.3 million beneficiaries prescription drug discounts that have saved more than $6.1 billion. To access readily updated information about coverage options and benefits, everyone can consult www.healthcare.gov. Open enrollment into Marketplaces begins October 1, 2013.

Second, health reform promises better care. Passage of the law has accelerated new models for coordinated care approaches, such as Accountable Care Organizations and Patient-Centered Medical Homes. Such models strive to integrate clinical care and community resources and improve quality of care for all. In this regard, SOPHE has just released an issue brief “The Affordable Care Act—Opportunities and Challenges for Health Education Specialists” (SOPHE, 2013). The brief highlights how health educators can contribute to decrease hospital readmissions, improve chronic disease self-management, provide better care for people with multiple chronic conditions (Parekh, Goodman, & Koh, 2011), and connect people to the resources they need and deserve.

Third, health reform offers the promise of better prevention and public health. This promise is coming alive at the individual, community, and national levels. For the individual, the law removes cost as a barrier to accessing high-value prevention services; new private health plans established after September 2010 are required to cover services ranked “A and B” by the U.S. Preventive Services Task Force, vaccine recommendations from the Advisory Committee on Immunization Practices, and Guidelines for Children and Women provided by the Health Resources and Services Administration (Koh & Sebelius, 2010). Such coverage makes preventive services, such as cancer screening (e.g., breast, cervix, colorectal), HIV screening, alcohol counseling, and tobacco counseling and cessation, available to patients at no added cost. Already, 71 million Americans newly covered in private plans have begun to enjoy this benefit (Sommers & Skopec, 2013). In addition, after the Affordable Care Act, Medicare now covers wellness visits and many preventive services without cost-sharing.

For the community, the Affordable Care Act has funded prevention initiatives that include Community Transformation Grants focusing on tobacco control, obesity prevention, and elimination of health disparities. And on the national level, health reform has helped establish a new National Prevention Strategy (built on the foundation of Healthy People 2020) that unifies efforts across 17 federal agencies. A new Prevention and Public Health Fund, already in its fourth year, has supported key initiatives such as integration of behavioral health and primary care, tobacco quit lines, and updating data collection standards on health disparities.

In addition, HHS has not only supported the First Lady’s Let’s Move campaign, which aims to solve the challenge of childhood obesity in the next generation, but also has unveiled a host of prevention-related strategic plans (see Healthy People 2020 Framework, n.d.). These include the National HIV/AIDS Strategy (The White House, 2010); the HHS Action Plan to Reduce Racial and Ethnic Disparities (Koh, Graham, & Glied, 2011); the HHS National Vaccine Plan (HHS, 2010b); the HHS national Action Plan for the Prevention, Care and Treatment of Viral Hepatitis (HHS, 2011); and the first ever Tobacco Control Strategic Action Plan (HHS, 2010a). With respect to the latter, we are grateful to SOPHE for contributing the SCRIPT program (Smoking Cessation and Reduction in Pregnancy Treatment), a key initiative for a vulnerable subpopulation.

Throughout these public health efforts, SOPHE has championed health literacy as a gateway to improve public health (SOPHE Board Resolution, 2010). In this increasingly complex health environment, a wide gap often separates what providers intend to convey and what patients understand. In fact, estimates are that only 12% of Americans are proficient in completing tasks considered essential to successfully navigating the health system and acting on health information (Agency for Healthcare Research and Quality, 2011). In particular, too many patients demonstrate insufficient knowledge in understanding their medical condition, taking medications, and completing basic forms.

Until now, health care organizations have assumed that patients routinely understand their health care conditions and can act appropriately, unless there is indication otherwise. Instead, we need to move toward a new paradigm that assumes that every person is at risk of not understanding his health conditions, unless there is indication otherwise. In that regard, in 2010, the Agency for Healthcare Research and Quality released the Universal Precautions Toolkit that incorporates best practices in health literacy improvement for health care organizations. Furthermore, my colleagues and I have recently proposed a Health Literate Care Model that provides a cross-walk between system components from the Universal Precautions Toolkit and the time-honored Care Model (Koh, Brach, Harris, & Parchman, 2013). Our nation needs to enhance efforts in training and education in health literacy and support practices everywhere to communicate in plain language during this increasingly complex time.

Conclusion

Thank you for answering the call to public health. This journey has profound meaning, especially at a moment like this. But the work is never easy. Committing to the lifetime journey of public health requires supreme patience, perseverance, will, and skill. Our mission requires that we all are willing to dig even deeper to build uncommon bonds with new partners, understand the constraints of the present while aspiring for a better future, and withstand the creative tensions of each day. In our world, even the ordinary day is extraordinary. Our field requires turning “no hope” into “new hope” (unknown) since “he who has health has hope; and he who has hope has everything” (Arabian Proverb). Thank you again for the honor of the 2013 Honorary Fellow Award. I look forward to continuing this extraordinary journey with you.