Getting What We Deserve: Health & Medical Care in America By Alfred Sommer

It seems like anybody who is anybody has written a book on the ills of health care in America. Is there anything more to say? That was my attitude upon reading the title of Dr. Al Sommer's new book, Getting What We Deserve: Health & Medical Care in America. But my skepticism was unwarranted; in fact, there is a good bit more to this discussion. Al Sommer, former Dean of the Johns Hopkins Bloomberg School of Public Health and a giant in the world of public health, has written a thought-provoking and insightful short course on the power of prevention. Indeed, the book is delightfully not just another treatise on universal access or the complexities of health insurance. Instead, it is a commonsense and concise (only 133 pages) case for the health benefits and cost savings that accrue from public health in all its breadth. Indeed, the case for prevention is made so convincingly and entertainingly in this slim volume that I wondered if it should be required reading for students of public health or, even better, required reading for legislators. In terms easily understandable to the lay reader, Dr. Sommer introduces topics such as demography and surveillance, social epidemiology, infectious disease epidemiology, causality, health behavior, and health policy, among others. Ultimately, he weaves these topics into solutions to improve American health care, but we'll get to that later. The book starts with the historical reality that, for most of human existence, life was nasty, brutish, and short. As a result, population size remained remarkably stable until the 1700s. Dr. Sommer shows how, since then, a massive increase in population has resulted from a “sudden and dramatic” increase in life expectancy. Why? Dominantly because of the social improvements brought about by the hygiene movement, which, as Dr. Sommer reminds us, meant that the average age at death came to exceed age at marriage. When that happened, population size began to enlarge. Indeed, when the infant death rate started to decline at the outset of the 20th century, the mass of humanity began to explode. Said another way, population health was already improving well before the advent of modern medicine. The point is that public health (clean water, clean air, safe food, waste removal) contributed mightily to the enormous improvement in quantity and quality of life enjoyed by modern society. The Centers for Disease Control and Prevention claims that of the 30 years of life gained in the past century, 25 years are attributable to public health interventions. In other words, it has been estimated that 90% of modern-day hospitalizations could be prevented by changes in lifestyle and environment. Beyond basic public health measures, Dr. Sommer reminds us of the power of infection control. He briefly tells the stories of smallpox eradication; polio control; the current scourges of human immunodeficiency virus and influenza; and the links between infections and chronic conditions such as cervical, liver, and gastric cancers. Again, the point is the power of public health, this time in the form of surveillance and vaccine-based control, and the enormous impact they have had on the health of populations. Health behaviors and their influence on health is Dr. Sommer's next topic. This story is less one of triumph than one of slow and unsteady progress. Major challenges to America's health, such as obesity, are appropriately seen as diseases of lifestyles that we have been, as a society, unable to control. Dr. Sommer briefly points the finger at social institutions such as fast-food establishments, the media, and, yes, even news-mongering scientists, but he more generally tells us what we all know too well: “Treatment is tough; prevention is tougher.” Having made much ado (and convincingly so) about public health, Dr. Sommer finally makes a frontal assault on American health care. After a salvo about the fact that health policy is heavily influenced by politics, he makes the important point that, “Calling US medicine either ‘health care’ or a ‘system’ is an exaggeration.” He describes the downsides of the fragmented, specialist-oriented, fee-for-service structure that constitutes American health care. He also points out our overdependence on technology and our underuse of preventative services. Ultimately, Dr. Sommer leaves us with a list of attributes to which the American health care system should aspire. I don't want to list all of them here or you won't feel compelled to read the book, but they range from universal access to an informed debate about what constitutes a “basic health care package.” For an epidemiologist, nothing in the book will be surprising. For nonepidemiologists, this book is a great read and offers an important set of principles. So, here's my advice: read it on your next plane ride and then lend it to a nonprofessional friend. And another. And another.