After reading the article “Being Ron Preston” (Health Care Extra 2004), I was appalled to realize how little the cabinet secretary charged with protecting the health of the Commonwealth understands about public health. He states that public health advocates should work with him to integrate public health into primary care. One might wonder how Ron Preston would use primary care to guarantee a safe food and water supply, require that cars and roadways be engineered to reduce traffic fatalities, or protect the population from natural or bio-terrorism epidemics.

Primary care is health care delivered to individuals. Public health is organized efforts to protect the health of the community. As the examples above indicate, public health uses different tools, different people, and different organizations than does medical care. It is also spectacularly successful at reducing death and disease. Although some public health work (such as vaccination campaigns) can be coordinated with primary care, primary care can no more absorb the fundamental work of public health than could private lawyers replace a state Legislature or private tutors replace a public school system. Someone in Ron Preston’s position who doesn’t seem to know this is either woefully ignorant or acting in bad faith.

Mr. Preston goes on to trivialize one of the great successes of public health, the dramatic decrease in smoking and smoking-related illnesses, by saying, “Having billboards on buses to get people to stop smoking is nice, but if there’s someone in a wheelchair who needs a personal care assistant, I want to have the assistant.” As a result of the comprehensive tobacco control program in Massachusetts, overall adult smoking prevalence fell from 23 percent to 18 percent, resulting in 240,000 Massachusetts residents quitting and preventing the premature deaths of 120,000 citizens. The work of Ron Preston’s team to drop the funding of this program from $48 million to $2.5 million does a lot more than take down a few billboards—it kills thousand of people.

One might question why the richest society in history has to choose between such a program and an assistant for someone who needs it. This is a political choice, not a necessity, and it is ultimately a false one. Society will pay either for the tobacco control program or for the consequences of not having one, irrespective of whether it pays for personal health care assistants. The choice Mr. Preston would have us make is not for or against the personal assistant, but rather a specific choice for the unnecessary death, disease, and disability that comes from allowing the tobacco industry to promote itself unopposed by organized community effort. To my mind, that’s not in the job description of Secretary of the Executive Office of Health and Human Services.

Anthony L. Schlaff MD, MPH
Director, MPH Program
Tufts University School of Medicine