The next big thing: Public health's biggest concerns

Experts worry about the future impact of the nation's obesity epidemic. But what other scary possibilities -- exotic infections, systemic gaps or the altogether unknown -- keep them up at night?

By — Posted May 17, 2004

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When it comes to the future, public health experts have a lot to worry about. Obesity and chronic disease, already high-ranking causes of death and disability, threaten to increase at exponential rates.

But what other scary possibilities keep them up at night?

There's the gnawing reality that everything old could be new again. Diseases once thought conquered have the potential to find new footing if complacency takes over.

Societal changes also might give rise to new or stronger infections -- a chance that leads to questions about the health system's ability to respond. Meanwhile, there is the recognition that biological attacks once unimaginable are no longer so.

Those in the know agree that contemplating these kinds of threats and challenges could be useful. Still, crystal ball gazing has its limits.

"If you would have asked someone in the 1970s what big problem was going to happen, I don't think anyone would have predicted AIDS," said Peter Beilenson, MD, MPH, Baltimore's health commissioner. So with all of today's unknowns, prevention and planning are more important than ever. "As long as we have a decent public health infrastructure and are fairly flexible, hopefully, we'll be able to deal with [whatever comes]."

High on almost everyone's list of concerns is obesity -- a current epidemic that literally looms even larger in the future.

Results of the 1999-2000 National Health and Nutrition Survey indicate that an estimated 64% of Americans are now overweight or obese. And despite national health objectives to reverse the obesity trend, research shows that the problem is worsening.

"It is going to shorten life. And it is going to add extraordinarily to health care costs," said Shelley Hearne, PhD, executive director of the Trust for America's Health, a Washington, D.C.-based nonprofit organization. "We're just seeing the tip of the iceberg."

"Obesity is an example of [something] that is just now waking up public health," agreed Steven Zeisel, MD, PhD, associate dean for research at the University of North Carolina, Chapel Hill, School of Public Health. "For the next 10 years it will take a major effort to develop the integrated and complex approaches to deal with the problem."

The fact that two-thirds of American adults are saddled with extra heft is clearly alarming. "But what worries me the most is compelling data coming out now that children who are obese, even when they lose weight, seem to have a higher risk of heart disease later on in life," Dr. Zeisel said.

According to the Centers for Disease Control and Prevention, the number of American children considered overweight has more than doubled since the early 1970s.

"So we may already have created a major increase in chronic diseases that is going to appear later because our children are so overweight right now," he added.

Public health experts also worry that the co-morbidities associated with the nation's weight problem are adding momentum to another brewing crisis. "We have an epidemic of chronic disease, and the reality is that in a five-year time frame you will have four of five Americans facing death or disability from [it]," Dr. Hearne said.

The numbers are staggering. The combined direct and indirect health care costs of heart disease, stroke and diabetes, for example, were estimated to be $483 billion in 2003, according to the CDC. That's a huge price tag, especially when about 70% of chronic conditions are preventable, Dr. Hearne said. "We need to be doing a better job at reducing those numbers so that it is not adding additional burdens to an already overwhelmed health care system," she added.

Richard Raymond, MD, the chief medical officer for the State of Nebraska Health and Human Services System, offers an even more dire view because of the graying of the population. Specifically, the baby boomers are fast approaching the age range that puts them at highest risk for confronting multiple chronic conditions.

The wild card: Infectious disease

In the midst of these forces, the threat of infectious disease is viewed as a wild card that creates another set of public health challenges. "We need to be far better prepared to deal with new and emerging organisms such as we have not seen in probably 50 years," said Donald A. Henderson, MD, MPH, who directed the World Health Organization's smallpox eradication program during the 1960s and 1970s.

If he is right, West Nile virus, monkey pox, SARS, avian flu and the problem of antibiotic-resistant bugs are only the beginning. It's all part of what's often called "the new normal." The reasons for this changing world order are multiple, Dr. Henderson said.

One is rapid population growth in cities -- many of which are in tropical or subtropical areas and lesser developed nations marked by poverty and poor sanitation. In these circumstances, Dr. Henderson said, "you've got a large number of different organisms that are constantly mutating. If one of them happens to be particularly virulent for humans, it has a good chance of getting established."

The growth of hospitals in developing countries is also on his list. These facilities don't have a lot of money or equipment and seem to struggle with sterilization and isolation procedures. Thus, opportunities for disease spread from cross contamination of blood and exposure to unclean instruments are many.

And, although the risk begins in distant places, these illnesses are actually just a plane ride away, Dr. Henderson cautioned. For these reasons, he argues that the United States needs to pay more attention to tropical and subtropical diseases and become more engaged in health and science issues at the international level.

Meanwhile, in mid-April, health officials in New York were investigating the cause of an avian flu case occurring there late in 2003. The CDC confirmed a man's infection with an H7 strain -- weaker than the H5N1 variety that caused deaths last winter in Southeast Asia. But his exposure to infected birds, the known route of transmission, has not yet been established.

It's a matter of concern because health officials have worried that a new variety will surface that can jump from human to human. Some view this emerging illness in combination with last year's hard-hitting influenza season as a harbinger of the long-dreaded pandemic. "That would knock our socks off," Dr. Hearne said.

It is bioterrorism, though, that still has the highest profile among the dangerous scenarios posed by unknown or unexpected biological agents. "Like it or not, I'm afraid [the threat] is with us forever," said Dr. Henderson, who directed the Dept. of Health and Human Services Office of Public Health Preparedness from November 2001 to May 2002 and is now a senior adviser of the Center for Biosecurity at the University of Pittsburgh Medical Center.

Issues and infrastructure

Some of the debate about how to meet this range of challenges focuses on the gaps that plague the public health system. There is concern that weaknesses have to be confronted -- especially for those who are disenfranchised.

In this context, efforts to tackle ethnic and racial health disparities and raise cultural competency and sensitivity are expected to take on even more significance.

Nebraska's demographics are a case in point. There, the Hispanic community has grown from less than 1% of the population to more than 5% in the last decade. "Most of those people still have Spanish as their primary language," said Dr. Raymond, the president-elect of the Assn. of State and Territorial Health Officials. The state also has witnessed a new wave of immigration from other places.

"It's difficult for the third-generation Nebraskan to provide good-quality health care ... going through an interpreter and maybe not understanding some of the cultural barriers," he said. But when people fall through the cracks, it puts everyone at risk -- whether it's missed immunizations and vaccinations, influenza outbreaks or the potential spread of an emerging infection. "We have to address those issues quickly and properly for all of our safety," he added.

In some ways, the newfound infusion of dollars as a result of bioterrorism awareness has helped to improve the public health system's capacity to do better on this and other tests.

"As long as it continues to be a scare, we'll continue to see a marked improvement in public health's ability to respond to emergencies, whether they be intentional or naturally occurring," Dr. Raymond said. But work must be done to apply resources in ways that make public health more agile and better able to multitask.

"How do we have that national vision for a health defense system in this country that protects us from the potential of bioterrorism, that will have us prepared for the pandemic influenza, but also is smartly configured so it is able to deal with chronic disease?" Dr. Hearne asked.

Georges Benjamin, MD, executive director of the American Public Health Assn., describes the task as expanding the discussion from acute infectious disease events to encompass the better management and prevention of chronic conditions. It is not an easy translation to make. And in the meantime, the everyday issues are not going away.

"Smoking. Lead. Violence. HIV/AIDS. There's still plenty to work on," said Baltimore's Dr. Beilenson. "I really don't know what the next emerging public health threat is. But no matter what, one of the most important things we can do is have plans to deal with the outbreaks, the disasters, and any other future issue."

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External links

American Public Health Assn. (link)

Trust for America's Health (link)

Assn. of State and Territorial Health Officials (link)

Nebraska Health and Human Services System (link)

Baltimore Health Dept. (link)

School of Public Health at the University of North Carolina, Chapel Hill (link)

Division of Infectious Disease of the University of Pittsburgh Medical Center, which includes the Center for Biosecurity (link)

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