Public health advances vital, but not always glitzy

When we think of innovation in modern biomedical research, what likely comes to mind is development of new high-tech drugs, biologics, surgical techniques and devices. Far less often do we include public health research and policy.

We have it wrong. For proof, we need look no further than the extraordinary success of taking a simple vitamin supplement, folic acid, to prevent disease.

Folic acid supplements prevent serious brain and spinal cord abnormalities called neural tube defects. These are a major cause of permanent disability, high health-care costs and diminished quality of life. The most common neural tube defect is spina bifida — an open spine. Many affected children have paralyzed legs and use a wheelchair.

In the 1980s, scientists discovered supplementation with a B vitamin, folic acid, could prevent spina bifida. For this reason, in the early 1990s, the U.S. Public Health Service recommended that every woman of childbearing age take a daily folic acid supplement. Because of cost and inconvenience, many women were unable to do this regularly, and the occurrence of spina bifida did not change.

But in the late 1990s, the U.S. Food and Drug Administration mandated that enriched cereal grain foods be fortified with folic acid. If you have flour or pasta in your home, take a look at the nutrition label. It includes folic acid.

After mandated fortification, the occurrence of neural tube defects fell significantly. An estimated 1,300 fewer cases of spina bifida occur annually in the United States as a result of this innovation. In Europe, where fortification is not required, the number of cases has not changed.

Extensive studies have been conducted to determine if there are other benefits, or harmful consequences, from folic acid fortification of certain foods. None has been found.

Unfortunately, some cases of spina bifida still occur. We are not sure why, but maybe some women need more folate than they can get from their fortified diet.

For this reason, in 2017, the U.S. Preventive Services Task Force, an independent body of scientific experts, recommended that all women who are planning or capable of a pregnancy take a daily supplement containing 400 to 800 micrograms of folic acid, the amount present in most over-thecounter multivitamins.

Because neural tube defects occur in the first month of pregnancy, before most women even know they are pregnant, it is important that the vitamin be taken before pregnancy.

Public health measures have the potential to help thousands or even millions of people avoid diseases. More often than not, these measures are simple, at least in concept. The health-care industry does not think of them as glitzy or dazzling. The profit motive is not there. There are few or no patents. Once implemented, they can be quickly taken for granted. Nonetheless, this sort of innovation seems extremely exciting, and impactful, to me.

Since cereal grains were fortified with folic acid, about 25,000 fewer people in the United States have been born with spina bifida. My family, and your family, might have benefited from this major public health advance, but of course we will never know. And this is the elegant essence of public health innovation.