Estimates put the primary care physician deficit at 200,000 by 2025.[1] The percentage of U.S. medical students pursuing a career in adult primary care, for example, has declined significantly in the last decade, by about 20%.[2] Instead, more and more students are going into specialties, becoming hospitalists or emergency medicine physicians where they can expect to have greater control over their lives and adequate salary to pay off student debt.[3] Long term gains are also impressive, over a 35-year career the earning gap between a specialist and PCP is approximately $3.5 million.[4]

The impact of PCPs on public health is significant. In a review of 10 studies on the impact of PCPs on health outcomes between 1985-2005, PCP supply was associated with improved outcomes for cancer, CVD, infant mortality, low birth weight, life expectancy and self-rated health.1 For all-cause mortality, the addition of one PCP per 10,000 people would reduce mortality an average of 5.3% (49 fewer deaths).[5] The benefits of additional PCPs is not uniform across ethnic groups. The addition of one PCP for 10,000 results in approximately a fourfold reduction in mortality for black populations in comparison to white.1 Nationally, such an increase would have a significant effect: 128,835 deaths potentially averted.4 Of course, these outcomes would fall into line with the goals of Healthy People 2010, particularly in terms of reducing health disparities.[6]

As our nation faces more and more chronic illness, most commonly heart disease, diabetes and cancer[7] we find ourselves armed with specialists who are excellent for our tertiary care needs but ineffective for the prevention or long-term management of the chronic illness. PCPs, long seen as the “gatekeepers” to the health system, are in increasingly short supply. We must address this shortage before we see the consequences: increased mortality, morbidity and lower quality of life and longer waiting times for preventive care appointments.1 We must make it feasible and attractive for medical students to become PCPs. The gap between primary and specialty practitioners’ salaries must be reduced. To do this, reimbursement for primary care services must increase to reflect the value of the service being provided.[8] It is irresponsible to put the burden of primary care for millions of people on overworked and underpaid PCPs. Legislation that guarantees debt repayment for new PCPs as well as higher salaries is crucial. We must expand programs like the National Health Service Corps, providing debt relief for new medical school graduates so that they see primary care as a feasible career choice.

Our nation’s obesity epidemic is resulting in significantly increased rates of morbidity and mortality as well as in cost to our nation ($92.6 billion in 2002 dollars).[9] There are currently many programs aimed at combating obesity including bans on trans-fat, prohibitions on unhealthy food at schools and nutrition label requirements in restaurants and on packaged foods. However none of these target the source of widely available, nutrient-deficient foods. If we really want people to eat well we have to make it easier to do so while at the same time making it more difficult to eat unhealthy foods. The relative low cost and convenience of energy-dense foods has been cited as a main contributor to overweight status,6 particularly in those of low socio-economic status.[10]

The root of the problem lies in our food and agriculture system. Government subsidy programs pump millions of dollars each year into the soy, corn and wheat industries, which leads to mass production of high-fructose corn syrup, hydrogenated fats (from soybeans) and feed for pigs and cattle.[11] The result of this is low-price fattening food such as prepackaged snacks, fast food, corn-fed meats and soft drinks.7 The problem is exacerbated by the lack of funding for fruits and vegetables. Barry Popkin at Carolina Population Center, UNC-CH states, “We put maybe one-tenth of one percent of our dollar that we put into subsidizing and promoting foods through the Department of Agriculture into fruits and vegetables.”[12] Consequently, “the price gap between high-sugar, high-fat foods and more nutritionally valuable fruits and vegetables is artificially large.” [13]

As long as we are promoting agricultural policies that incentivize farmers to grow mass quantities of corn, soy and wheat we will have an endless supply of cheap, unhealthy foods. America’s poor, no matter how great our obesity prevention and reduction programs, will continue to be faced with the reality that eating healthfully in this country is out of their price range and it is far easier to find and afford sweet, fattening foods.

The U.S. Department of Agriculture, which subsidizes America’s farms, must change its policies. Subsidies must flow from the current crops to fruits and vegetables. While reducing current subsidies will probably not change the retail prices of fattening foods appreciably,7an increase in price of these foods combined with price reductions in healthier fare will make it easier for everyone, particularly those of lower socioeconomic status, to buy foods that will give them nourishment, not just empty calories and an expanding waistline.

Our nation’s PCP shortage and obesity epidemic are two major problems that will not be resolved through policy change alone. However, if we make it a priority to compensate PCPs fairly and reduce medical students’ debt we will be on the right track towards bolstering the number of PCPs in this country and improving health outcomes as a result. Similarly, policy change will not necessarily lower the obesity prevalence in this country but it will help to remove one of the major barriers to healthful eating: cost and accessibility. With such policy reform our current culture of eating will begin to change and interventions focusing on behavior and environmental change can take effect.