In addition to promoting prevention and healthy living, the field of public health addresses the root causes of poor health, from income, employment, housing and nutrition, to genetics and access to quality health care services. Yet treating the root causes of poor health rather than the symptoms of poor health receives remarkably little support in public policy. Public health operates largely at the margins of health policy in the United States, where health spending devoted to public health pales in comparison to spending on medical research and delivery of care for illnesses that are preventable. By one measure, government public health activities in the United States in 2012 comprised less than 3% of national health expenditures (CMS, 2014).

Why? Harvey Fineberg, MD, President of the Institute of Medicine, describes the “paradox of disease prevention” as the fact that prevention is celebrated in principle, but resisted in practice. Reasons for this include the long-term nature of solutions, the diffuseness of the beneficiaries in contrast to the clearly identifiable beneficiaries of clinical health care, the relative lack of drama of prevention, opposition from commercial interests and personal beliefs, and the invisibility of public health leaders and organizations (Fineberg, 2013). In addition, public health solutions require change in institutions that are powerful and are opposed to more investment in public health solutions. Such conditions add up to a disconcerting underinvestment in public health.

Public health offers the best hope for cost-effective and value-adding solutions to intractable population health challenges in the United States and around the globe. The mismatch between the amount of resources devoted to public health and the influence of public health approaches on ultimate health status outcomes ought to frustrate and be a rallying cry for strengthened public health leadership at all levels.

What to do? We can entreat the public and policy makers to employ root cause thinking and evidence-based policy making. We can push harder and not be content with the status quo. Empowering and energizing public health proponents is the purpose of our new book, Leading Public Health: A Competency Framework. Defining public health leadership as “mobilizing people, organizations, and communities to effectively tackle tough public health challenges,” we argue that leadership activities leverage the impact of every public health practitioner and advance the power and influence of public health. Five competency sets form the basis for leadership development:

  1. Invigorate bold(er) pursuit of population health
  2. Engage diverse others
  3. Effectively wield power
  4. Prepare for surprise
  5. Drive for execution and continuous improvement

Can you imagine if in ten years the 3% were to grow to 10%? Or 25%? Or more? Would the U.S. still rank so poorly on a wide array of health indicators?


Centers for Medicare & Medicaid Services (CMS). (2014). National Health Expenditure Data. NHE tables, Table 1. Accessed June 5, 2014.

Fineberg, H.V. (2013). The paradox of disease prevention: Celebrated in principle, resisted in practice. Journal of the American Medical Association, 310, 85-90.