“Sadly, it takes a cluster of casualties to alert the world that humans are once more under attack and that we need to marshal our scientific forces,” writes Julio Frenk, Mexico’s minister of health from 2000 to 2006, and dean of the Harvard School of Public Health.

Let’s put aside the told-you-so politics bemoaning the pandemic preparedness dollars ripped from the stimulus bill. The fact is, we’ve known that the U.S. public health system has been malnourished for years. There’s also compelling evidence that revitalizing this system might be our most cost-effective route to health.

As noted in an earlier blog posting, a 2008 study by Trust for America’s Health found that a $10 per person annual investment in community-based prevention over five years could produce 5 percent reductions in type 2 diabetes, high blood pressure, heart and kidney disease, and stroke — with an estimated ROI of $5.60 for every dollar invested.

Another study showed that for each 10 percent increase in public health spending, mortality rates fall as much as 6.9 percent. In one example, health policy experts calculate that it would cost eight times as much to achieve the same outcome through medical care than it would through public health investment.

Somehow we’ve lost sight of what Hippocrates advised 2,400 years ago. We’ve got the whole “ounce of prevention is worth a pound of cure” thing backwards; almost 95 cents of every health care dollar is spent treating those who are already sick, while only about 2 cents goes to prevent illness. And it costs a lot more to restore health one sick patient, one pill at a time than it does to invest in healthy environments and popultations.

Will we make different choices post (near) pandemic? Breakdowns can lead to breakthroughs, only when we see through the devastation to some new future possibility and make a different choice. Yet, even in the years following Hurricane Katrina, public health funding at every level has been reduced radically, with shortfalls estimated at $20 billion a year.

So, what is the best way to invest in our nation’s health? There are plenty of creative ideas – from bike paths and indoor farmer’s markets to smoker quit lines and housing coops for ex-offenders. There’s even a new $10-million X Prize that will have communities compete for health improvement.

The choice is ours: We either pay now, or pay much, much more later.

While the search for “pig zero” continues, there is still uncertainty about whether H1N1 (swine flu) was ever in a pig. There is some buzz that the outbreak might be traced to contamination from pig breeding farms polluting the atmosphere and local water bodies of what seems to be the source town of La Gloria, Mexico.

As world health agencies work to reduce transmission and severity of the illness, it will be equally important to follow the trail back to the beginning. Not just to the village or the farm or the pig. But what created the conditions that led to the virus (e.g., a suspect farm that raises nearly 1 million hogs per year)? Why were we vulnerable to its spread? And what unraveling might the alternative choices entail if we are to create a different scenario in the future?

In his recent blog post, Robert Wood Johnson Foundation’s Dr. James Marks writes: “What are the barriers to better health…and where does health really start? Only when we answer these questions honestly and see health in this broader context, will we begin the real work…”

We couldn’t agree more — and this “real work” must be an ongoing and participative process, like peeling back a never-ending and infinitely complex onion to see what’s inside.

The RWJF Commission to Build a Healthier America’s recommendations report is a wonderful milepost, filled with evidence and stories of hope. Also wonderful is an open question (overheard as a candid aside between Commissioners at one of RWJF’s public hearings): Is anyone even listening? And if not, we might ask, Why is this so? Questions like these invite a deeper inquiry that must unfold if we are to begin the real work of profound and sustainable change.

As we examine the societal, structural and contextual conditions that lead to poor health, we must also consider what values — what ways of thinking and acting and being — led to these conditions in the first place. As Churchill said, “We shape our buildings, then our buildings shape us.”

The good news is that coming together to consider questions that matter is intrinsically healthy. In coming together we re-connect with what is most important. We create inclusive environments where every voice can be heard. And we begin to see that the exterior conditions in which we live and work are manifestations of our collective interior conditions, and that means we can change them together.

The “real work” is interior work. And this work is always now.

Last night’s 60 Minutes was a powerful reminder of the interconnectedness of it all: “It’s the next thing in the recession: communities cutting back on services like schools or cops or public hospitals because tax revenues have fallen with the economy.”

In this story, it’s Las Vegas cancer patients who can no longer receive life-giving therapies from University Medical Center (UMC), a safety net for two million people that, due to state budget cuts, closed its outpatient clinic for chemotherapy.

As UMC CEO Kathy Silver explains, “Obviously, our gaming and tourism is tanking. The construction industry has been decimated. And all of those things cause big, gaping holes in the state budget. The hardest-hit area for us was the Medicaid budget.” While Las Vegas is experiencing its biggest downturn ever, the crisis is being felt by all cities, says Silver. “I think this is happening, to some degree, to probably every public hospital across the country. I think it’s happening to us to a greater degree because…we’re sort of the epicenter of what’s happening. We’re a demonstration project…of all the things that can go wrong at once.”

I remember reading a year ago about cuts to a small but vital resource in Portland, Maine, which helped that city’s growing number of Somali immigrants learn essentials like how to read a bus schedule and how to cook using an indoor gas stove, as well as more commonly considered guidance on local education, health and job programs. It was likely a $15K save to the budget, but the impact of helping new citizens regain a sense of belonging and control was invaluable (and, now missing, is likely showing up in all sorts of ways the city and its people are paying for many times over).

Back in Las Vegas, Dr. Nick Spiritos, who worked at UMC’s now-closed women’s clinic, continues to provide treatment to displaced cancer patients through his own upgraded facility, which he financed. Patients pay only if (and what) they can afford to; Dr. Spiritos and his partners cover the rest.

As the Nevada state legislature considers a proposal that would cut millions more from the UMC budget, public comments on the 60 Minutes site voice ideas, frustration, anger, and offers of support:

“One way many people can help out these patients is by simply coming back to Las Vegas (so that) more revenue from casinos is pumped back into our state budget.” … “Can you tell me how I can help the woman who does not have any insurance?” … “If we all encouraged everyone we know to send $1.00 to Dr. Spiritos foundation, imagine the help that could be done.” … “Considering its wealth, Nevada is already one of the worst states for funding education, mental health, and drug treatment. Tourists from around the world should consider boycotting Las Vegas and the casinos here until this city and state helps its people.” … “How do I get a hold of Roy Scales (profiled in the story)? He helped (me) through some of the most difficult days of my life…When he was in Pittsburgh about 14 years ago we were both down on our luck.”

There is something we can do, not just to ameliorate the impact of the current crisis but also to avoid another one. Remember that what we’re seeing and what we’re not seeing – all of it and all of us – we’re all connected. And, be there for each other.

On April 2, the Robert Wood Johnson Foundation Commission to Build a Healthier America releases 10 recommendations for dramatic improvements in the health of all Americans. The recommendations are rooted in a twin philosophy: good health requires each of us to make healthy choices and society to help remove the obstacles preventing too many Americans from making healthy decisions.

Commissioners release their report 9:30am-11:30am (Eastern) in Washington, DC, and will also host a live Twitter chat from the event (follow RWJFCommission or add to the conversation by using the event hashtag, #cbha).

CIGNA, which launched Communities of Health (CoH) last year, applauded the Commission’s recommendations, and called on all leaders to join in a movement to improve community conditions that influence health. 

The CoH team will be at the event and we look forward to working together with all toward real, sustainable change.

Health care reform recommendations, core tenets and “solutions” abound from every stakeholder group (a Google search returns more than 20 million references). Here’s one that’s worth a closer look.

Robert Wood Johnson Foundation (RWJF) lists six elements for comprehensive reform:

1. Cover the uninsured.
2. Improve the quality, value and equality of health care.
3. Bring down spending.
4. Prevent disease and promote healthier lifestyles.
5. Strengthen public health’s capacity to protect our health.
6. Address the social determinants of health.

Simple, optimistic and evidence-driven. And, unlike so many proposals that go after the symptoms of cost and coverage, RWJF’s blueprint recognizes that our health is connected to a broader, complex and interdependent system of forces that go beyond medical care.

The veil has been lifted on “the true causes and real cures,” says Risa Lavizzo-Mourey, M.D., in her President’s Message from the 2008 RWJF Annual Report. “Not knowing is no longer an excuse for inaction” to address “the full continuum of interconnected factors” linked to health and health care.

The “problems are too intricately interwoven to compartmentalize,” she notes. So, where to start?

Like most reform proposals, RWJF’s begins with health insurance coverage for all. We must get underneath the “chronic social and political malfunction that the economic meltdown compounds daily,” writes Dr. Lavizzo-Mourey. This is triage for what the Institute of Medicine estimated in 2004 to be nearly three American deaths every hour linked to lack of insurance.

Examining and redirecting spending also tops RWJF’s list: “The ‘value gap’ between what we spend on care and what we get in return is a fundamental cause of America’s joined health care and economic crises.”

For instance, while almost 95 cents of every health care dollar is spent treating those who are already sick, only about 2 cents goes to prevent illness. One study found that a $10 per person annual investment in community-based prevention over five years could produce 5 percent reductions in type 2 diabetes, high blood pressure, heart and kidney disease, and stroke — with an estimated ROI of $5.60 for every dollar invested.

Another study showed that for each 10 percent increase in public health spending, mortality rates fall as much as 6.9 percent. In one example, health policy experts calculate that it would cost eight times as much to achieve the same outcome through medical care than it would through public health investment.

The biggest difference in RWJF’s proposal is the inclusion of non-clinical social forces affecting health, which, Dr. Lavizzo-Mourey admits, call for heavy lifting over the long haul: “Where we live and work, buy groceries, go to school, who we know, what we earn all shape our behavior and health. It will take a lifetime to make a difference, but it must be done in our lifetime.”

In her January 27, 2009, testimony before the U.S. Senate Committee on Health, Education, Labor and Pensions, Dr. Lavizzo-Mourey urged Congress to address the social determinants of health in this year’s reform plans. She draws on compelling evidence and powerful models for change across schools, neighborhoods, and the workplace — “the places where health really happens.”

“The hardiest tests of our national character come when we are called upon to…confront truly ‘tipping point’ menaces to health, security and well-being,” she concludes in her annual report letter. “What has changed is that now we know what to do and how to do it. There is no responsible reason for not acting.”

As the stimulus bill moves through Congress, the pundits stay divided on whether the plan is too bloated or too thin to make a difference. Meanwhile, the national dialogue on health (care) is suffering malnourishment of another kind.

Yes, we need to expand access, increase efficiency and deliver consistent, quality medical care. But what’s causing people to need care in the first place? While healthy lifestyles, genetics, and medical care will always be important, research tells us that community forces – the social and environmental context in which we live and work – account for more than half of what makes us healthy or sick.

As Harvard sociologist David Williams points out in the documentary series, Unnatural Causes: “Housing policy is health policy. Educational policy is health policy. Anti-violence policy is health policy. Neighborhood improvement policies are health policies. Everything that we can do to improve the quality of life of individuals in our society has an impact on their health and is a health policy.”

So, will all this land on the desk of the soon-to-be-(re)named Health and Human Services secretary? Or, perhaps this order of change must be grown locally.

A good example is happening in Las Vegas. In collaboration with Communities of Health, members of the Nevada Alliance to Eliminate Health Disparities (NAEHD) gathered in a Policy Forum in December, and outlined four broad focus areas to support a new vision for a healthy Las Vegas:

1.   safe neighborhoods that allow for an active, vibrant community;

2.   effective education as a vehicle for economic opportunity;

3.   fair access to existing health care systems; and

4.   economic development and zoning of neighborhoods.

NAEHD is working to refine these areas into short-term, medium and long-term actions to influence policy change at the state and local levels, and to engage broader participation in creating community-driven solutions.

In addition to generating tangible action, engaged local participation like this creates “control of destiny” that is essential to health. And so perhaps the most powerful, health-giving policy is one that supports an ongoing participative process that allows people to come together in ways that are mutually supportive and empowering – because support and empowerment are fundamental determinants of health.