The Biggest Problem With U.S. Health Care

July 10, 2017, 6:44 PM UTC

The United States spends more on health than any other economically comparable country, yet sees a consistently mediocre return on this investment. In my last piece, I argued that this is because the U.S. invests overwhelmingly in medicine and curative care, at the expense of the social, economic, and environmental determinants of health—factors like quality education and housing, air and water safety, and nutritious food. A deeper investment in contextual factors like these can help create healthy societies and prevent disease before it occurs.

In making the case for this investment, it is important to make clear that a shift toward stopping disease before it starts does not mean pulling resources away from doctors and hospitals—our first line of defense when disease strikes. The history of fire prevention in the U.S. is perhaps the best example of how prevention does not have to come at the expense of cure.

Firefighting has a long history, dating back to the Roman era. However, modern fire prevention is largely the result of two tragedies that occurred on October 8, 1871. That was the day that both the Great Chicago Fire and the Wisconsin Peshtigo Fire broke out. The Great Chicago Fire took the lives of over 300 people, left 100,000 homeless, destroyed over 17,400 structures, and burned through over 2,000 acres. The Peshtigo Fire—the worst forest fire in U.S. history—destroyed 16 towns and claimed over 1,000 lives.

These blazes were so destructive that they changed attitudes toward fire safety in the U.S. Not long after the Great Chicago Fire, the city began to mark the anniversary of the event with festivities. On the fire’s 40th anniversary, the Fire Marshals Association of North America chose to formalize the occasion, using the day to promote fire prevention education. Starting in the early 1920s, Fire Prevention Week has been marked annually on the Sunday through Saturday period during which October 9 falls, and went on to become the longest-running public health and safety observance on record. Calls for a prevention focus, with firefighters taking a leading role in these efforts, were also amplified in the media during the 1920s, further publicizing the call to stop fires before they start.

Since then, fire prevention has become an important part of how we view fire safety in the U.S. and made a clear difference in the number of deaths and injuries caused by fires. In 1977, there were 723,500 home fires in this country, with 5,865 civilian deaths and 21,640 injuries. In 2015, those numbers had been cut to 365,500 home fires, with 2,650 civilian deaths and 11,075 injuries.

The success of prevention has not been limited to reducing home fires. Between 1980 and 2013, vehicle fires declined by 64%, and building fires declined by 54%.

Why has prevention been so effective? Most fires are caused by correctable human error, or the absence of safety systems like smoke alarms and sprinklers. For this reason, preventive steps like fire education and installing smoke alarms can do much to create a safer environment. Simply adding smoke alarms, for example, can reduce the risk of dying in a reported home fire by half. Fire education can help to discourage unsafe behavior, and encourage individuals and families to develop a means of escape in the event of fire.

Critically, the success of these efforts has not come at the expense of the people and organizations that fight fires when prevention falls short. Quite the opposite—as we have reduced the number of fires, the number of firefighters has actually increased. Despite the fact that there are 50% fewer home fires than there were 30 years ago, there are about 50% more career firefighters; 237,750 in 1986 to 345,600 in 2015.

This increase has roughly coincided with a rise in government expenditures on local fire protection. Adjusted for inflation, this spending increased by 170% between 1980 and 2014, rising from $16.4 billion to $44.2 billion.

The history of fire prevention in the U.S. demonstrates that the rise of prevention does not necessitate the decline of cure. Our investment in reducing fires by creating an environment where they are less likely to occur has clearly paid off, yet this success has not changed our commitment to maintaining a network of professional firefighters, ready to respond in case of emergency. Further, we have managed to integrate a prevention focus into the work of these professionals—local fire departments often play a leading role in promoting prevention—demonstrating that the priorities of prevention and cure are not mutually exclusive.


What is the takeaway here for health? In the U.S., our investment in population health vs. curative care does not come anywhere near the balance struck by our fire preparedness infrastructure. Rather, our investment is deeply lopsided in favor of cure. The argument for greater focus on population health is not a case against this investment; it is a case against this lopsidedness. It stresses that a world with fewer “fires”—less disease—is beneficial to us all, even as we wish to always have well-resourced professionals on hand who can put out fires when they happen, and cure disease when it strikes. Such a world would reflect the high value we place on health, as we pursue wellbeing using every tool at our disposal, with prevention and cure working together to create a safer, healthier society.

Sandro Galea is a professor and Dean of Boston University School of Public Health. His book, Healthier: Fifty thoughts on the foundations of population health, was published in June. Follow him on Twitter: @sandrogalea.

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