Healthcare in Crisis: Focusing on Primary Healthcare and Public Health in the U.S.

Stephen Bezruchka


Primary healthcare is the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients and with families.

In the , most believe that better care is provided by specialists—nephrologists, cardiologists, cardiac surgeons, or endocrinologists— rather than a family doctor or generalist who practices primary healthcare. We have many more specialists than primary care doctors in this country. Most medical students say they want to pursue esoteric specialties.

Studies looking at primary care physicians among U.S. counties from 2005 to 2015 found that where the density of such doctors increased, life expectancy increased as well. But where their proportion to population decreased, life expectancy declined. This confirms the importance of primary healthcare to improve health in the United States. Since our health has been declining in the country overall, a part of the reason is that fewer doctors provide primary care services here. The countries with the healthiest populations have three times the proportion of general practitioners or primary care doctors as we do. Although the totality of medical care can’t adequately counter the corrosive health effects of social and economic hardships, access to quality primary care offers an important way of influencing mortality outcomes.



What is public health, and what is its role in producing health? In the United States, the phrase “public health” is generally considered to be something that benefits everybody. On their website, the American Public Health Association claims public health “promotes and protects the health of people and the communities where they live, learn, work, and play.”

The science of public health has evolved since the 18th century, when it focused on isolating the ill and quarantining those exposed to diseases to prevent transmission of infection. In the 19th century, the focus was on sanitation, especially separating fecal contamination from food and water. Living conditions improved tremendously as a result. With the understanding of infectious disease transmission in the early part of the 20th century, the focus shifted to immunizations and infection control. Later efforts centered on tobacco regulation and decreasing risk factors for chronic diseases such as heart disease and diabetes by promoting diet change and exercise. Efforts were also made to improve workplace conditions and motor vehicle safety. Such programs had definite health benefits that we take for granted today.

What directions should U.S. public health take today to continue health improvements? The IOM’s 1988 report, distilled its efforts into three pillars: assessment, policy development, and assurance. Translated, this means figuring out what the issues or problems are (assessment), doing something about them (policy development), and finally making sure the expected good outcomes occur (assurance). Has this approach been successful?



Assessment in the report asks for critical data collection at the local level: cities, counties, and states. These data include vital statistics such as births and deaths, a state responsibility. Other needed data are disease and health-related behavior surveys. While the Center for Disease Control and Prevention collects these data and makes them available to the public, they present almost no comparisons to assessments in other countries.

If we search the CDC website for life expectancy, we can see trends in the country and stratification by race/ethnicity subgroups. For maternal mortality, the CDC says that maternal mortality is increasing for 2019 over 2018 and Blacks are most impacted at almost four times the rate for Latinx. Infant mortality (IMR) is stated as being a good indicator of the overall health of a population and the website points out the IMR has dropped from 2017 to 2018, supposedly a good sign.

How does the CDC report American international rankings in recent years? The CDC’s Health USA report from 1960 to 2016 presented IMR rate and life expectancy data for OECD nations. The United States ranked 11th in 1960 but 24th in 2013! For subsequent reports, those rankings are no longer present although available on the CDC website for 2017 but not 2018. Why have they been omitted? The latest report for 2019 didn’t appear until the spring of 2021 when the CDC leadership had changed with the new federal administration. Yet still, there were no international comparisons.

In the IOM’s 2003 follow-up report, the first chapter launched into “Achievement and Disappointment. “For years, the life expectancies of both men and women in the United States have lagged behind those of their counterparts in most other industrialized nations.” Although they recognized the relative decline of the U.S. health compared to other nations, nowhere in their 34 policy recommendations for the future, did they suggest monitoring those trends.



There has been no comprehensive follow-up report along these lines looking at organized or institutionalized public health in the United States. Public health services have been drastically defunded throughout the United States. This reduction in services is in part responsible for our dismal COVID-19 mortality.

As our health status has continued to deteriorate in comparison to other countries, rarely do health or mainstream media publications acknowledge that astounding reality even in the COVIDian era. Public health has failed this nation, with its silence on our relatively low health status compared to what we know is possible. Public health is silent on what will be required to reduce this unprecedented, alarming trend.

When you ask people a general question of what can be done to improve health in this country responses tend to be, “focus on prevention.” But what is “prevention?” There are three common terms, primary, second, and tertiary prevention. Primary prevention halts the acquisition of a disease such as an immunization against polio. This makes us think in terms of diseases rather than of health. Secondary prevention refers to halting or slowing the progression of a disease once you have acquired it, such as catching breast cancer, or COVID-19 early. Then there is tertiary prevention to halt or reverse or delay disease progression, such as taking statins after a heart attack or dexamethasone for advanced COVID-19. Some have called for quaternary prevention, namely, limiting the harms of healthcare. Another concept is primordial prevention—preventing the emergence of predisposing social and environmental conditions that lead to disease or worse health. We have failed for all categories of prevention.

Spending on healthcare has not produced health.


Author Bio:                                

Stephen Bezruchka, MD, MPH, is Associate Teaching Professor Emeritus in the Departments of Health Systems & Population Health and of Global Health at the School of Public Health, University of Washington, and author of Inequality Kills Us All: COVID-19’s Health Lessons for the World.

This is adapted from Stephen Bezruchka’s new book, and is published here with permission.


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Image Sources:

--Darko Stejanovic (Pixabay, Creative Commons)

--Tumisu (Pixabay, Creative Commons)


--Qimono (Pixabay, Creative Commons)


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