Bringing Medicine and Public Health Together  Author: Richard F. Southby, Ph.D., Hon M.F.P.H. Executive Dean and Distinguished Professor of Global Health at The George Washington University Medical Center, Washington, D.C., and President-Elect of the Asia Pacific Academic Consortium for Public Health.
Introduction In this Leadership Forum I will focus on an area where I believe we must do all that we can, as teachers, researchers and practicing health professionals, to break down the ‘silos’ of medicine and public health and bring them together as strong partners in health care teams throughout the world. The discussion is divided in two parts: (a) the need for bringing medicine and public health together; and (b) some illustrations of what can be done to bring medicine and public health together. The Need for Bringing Medicine and Public Health Together On the basis of all that we know from research and practice over a long period of time, it is rather sad that this is still an important issue and challenge throughout the world in 2004, especially as Hippocrates emphasized the importance of the broader factors as influences on health, such as the environment and families, in 300 BC! In very basic terms, Clinical Medicine and Public Health are both concerned with achieving the same common goal: improving the health status of individuals, families, communities and nations. Clinical Medicine’s traditional focus has been on individual patients, although for many physicians this has also included an appreciation of the important influences that families and communities have on the health of their patients. Public Health has focused on the collective, societal responses to disease, illness, and disability brought about by epidemics of infectious diseases, the consequences of demographic and epidemiological transitions, industrialization, urbanization and now globalization. Over the years we have slowly come to accept that there are multiple factors which, in very complex ways, influence how healthy we are as individuals and as societies. Not only are these multiple factors important in themselves, but they interact with each other and, in doing so, have impacts on our individual behaviors, the patterns of health services, and the murky world of policy. This point was demonstrated very clearly many years ago in the Canadian study, the Determinants of Health, which stated “for more than half a century the understanding that there is much more to health than health care has been largely ignored, despite the fact that increased spending on the formal health care system is no longer having a corresponding positive impact on overall population health”. In addition, we are slowly recognizing the importance of the global perspective when it comes to understanding what influences our health and how these influences may be controlled. For example, we have been reminded in recent years, by SARS, influenza, tuberculosis, terrorism and environmental and sanitary problems, that global health is not just an academic concept. Diseases do not recognize geo-political boundaries so we need to adopt a global view if we are to deal effectively with these challenges. This ‘global view’ is also vital in education, economics, immigration, etc, not just in relation to health! Another way to consider the inter-relatedness of medicine and public health is by looking at the major burden of disease globally. It was pointed out by Murray and Lopez in 1996, that the disease burden for fifteen leading causes in 2020, measured in DALY’s, may be ranked as follows: ischaemic heart disease, unipolar major depression, road traffic accidents, erebrovascular disease, chronic obstructive pulmonary disease, lower respiratory infections, tuberculosis, war, diarrhoeal diseases, HIV, conditions arising during the perinatal period, violence, congenital anomalies, self-inflicted injuries, and trachea, bronchus and lung cancers, etc. A clear message from this research is that effective strategies for dealing with these diseases must include the combined efforts of increased individual responsibility for health behaviors, better surveillance, more effective health promotion and disease prevention programs, sound clinical interventions, and well designed organizational and policy initiatives. In other words, a logical combination of clinical medicine and public health approaches! In addition to the changing global patterns of the burden of disease, there are significant health problems associated with ageing populations, increased urbanization, obesity, the disastrous consequences of bioterrorism, and the physical and mental health effects associated with terrorism, war and violence generally. The 25 November, 2004 release of the draft research report by the Productivity Commission on the Economic Implications of an Ageing Australia is an example of the latter trends. This report urges the Australian Federal Government to do more to meet the economic challenges posed by Australia'srapidly ageing population, and this includes a strong focus on health issues. As we all know, for a long period of time tobacco has had the dubious distinction of being the Number 1 Public Health Enemy in many countries. Although we have witnessed many successes in reducing smoking and its disastrous effects on our health, it still kills 440,000 Americans a year and the annual costs in direct medical expenses and lost economic productivity due to smoking-related illnesses and premature deaths was estimated by the Centers for Disease Control in the late 1990’s to be $157 billion. But now a new problem is challenging tobacco in the ‘Public Health Enemy Stakes’ and it is obesity. In March, 2004 a CDC study showed that poor diet and physical inactivity were about to displace tobacco as the leading preventable cause of death in the U.S.A.. As far back as the 1950’s it was recognized that being overweight was a major contributor to heart disease. Since 1980, United States public health policy has included the prevention of obesity as an important public health goal. Nearly two out of three Americans are now overweight or obese, which is a 60% increase over a ten year period. According to the CDC, every 90 seconds an American dies from an illness related to being fat. This adds up to 1,000 people every day and nearly 400,000 every year. And, before overweight people die, they often suffer for years with medical conditions including diabetes, heart disease, sleep apnea, gallbladder disease, hypertension, arthritis, pregnancy problems, and cancer. All of these conditions are caused or worsened by being overweight! It is also important to recognize that 15% of children aged 6-19 years are now overweight or obese. Minorities, both adults and children, are more overweight than whites. The inter-relatedness of obesity and physical fitness is once again attracting attention as an important health issue. A CDC report, released in May, 2003, showed that only 1 in 5 American adults engage in a high level of physical activity at work or at leisure, and 1 in 4 engages in little or no physical activity. Looking at the changes in obesity in the United States over recent years should be a wake up call to everyone, not just health professionals. 64% of Americans are overweight or obese and this is about the same percentage not getting enough physical activity. The direct financial cost to society due to overweight and obese employees is estimated to be $136 billion in health care expenditures for hospital stays, lost productivity and drugs to treat chronic conditions. A 2003 study showed that more than $78 billion, out of total health care spending of $1.5 trillion, was caused by obesity-related illnesses. As so often happens, there are additional multiplier effects associated with problems such as obesity. For example, it was reported in the press recently that airlines in the United States have had to pay $275 million for additional fuel costs due to the weight of obese passengers! Obesity, which obviously has serious ramifications for negatively impacting health status, is not just an American problem. It is now recognized as an international pandemic. Unfortunately, many health professionals, policy makers and politicians were, and continue to be, slow in recognizing the significance of the epidemiological and demographic transitions which have been in progress for some time. Epidemiologists have shown that the acute and communicable diseases are being replaced as the major causes of death and disability by the chronic/degenerative conditions. Yet, at the same time, we have to deal with the re-emergence of certain infectious diseases and the problem of drug resistance in some diseases. The demographic profiles of many countries are increasingly becoming profiles of ageing populations, with all the implications related to the types and volume of health and social services, housing, retirement benefits and family responsibilities. The consequences of these changes are clearly evident throughout the world today. The health and community services appropriate for ageing populations are scrambling to meet the changing needs and demands. And while this applies to developed and developing societies, the latter are increasingly faced with the simultaneous burdens of infectious diseases plus the growing demands of ageing populations, increasing numbers of people with mental health problems and chronic conditions, but without sufficient resources to deal with them. Internationally, it is almost a situation of “too little too late” when one considers the capacity and sustainability of many nations’ health systems! In parallel with these epidemiological and demographic transitions, most societies have been experiencing increased demands for higher quality, measurable outcomes, greater accountability and improved access to health care, ranging from the most basic preventive and primary health care services to the most sophisticated tertiary levels. Between 1987 and 2000 in the U.S., health care spending rose from $429 billion to $628 billion (in inflation-adjusted dollars) but a small number of diseases accounted for more than half of the increase. An economist, Kenneth Thorpe, tracked 370 conditions and found that 15 diseases accounted for 56% of the $200 billion rise in health spending over this period. In response to the increased costs and increased demands for health care, both governments and the private sector in some countries are moving in the opposite direction and implementing measures to contain overall expenditures. These are periods characterized by declining budgets for health and social programs, but expanding budgets for defense expenditures. Many nations are also experiencing serious personnel shortages in a number of health occupations, especially nursing. Some Illustrations of What Can Be Done to Bring Medicine and Public Health Together In order to bring about closer relationships between medicine and public health, I believe there are four areas to place increased emphasis. These are Teaching, Research, Health Care Organization, and the Role of Professional Associations. Teaching. In most professional schools today, the students who are being prepared to enter the various health professions are still being taught in almost total isolation from each other, another illustration of the historical ‘silo characteristic’. We must institute more opportunities for students to learn together, as undergraduate and graduate students. If they learn together they might be willing to work together, collaborate and respect each other’s contributions when they become practicing health professionals! The Committee on the Health Professions Education of the Institute of Medicine has recommended an overarching vision for all programs and institutions engaged in the education of health professionals. In order to attain this vision, the Committee proposed a set of five core competencies that all health clinicians should possess, regardless of their discipline, to meet the needs of the 21st century health care system. These overlapping competencies are: Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics
It should be possible in academic health centers, especially where there are schools of medicine, nursing, public health, social work, and health services management, for students to take the appropriate core courses, including epidemiology; culture and society; ethics; health policy; and health services organization, together. In the clinical years the value of teamwork can be demonstrated by interdisciplinary teaching in inpatient and ambulatory settings, participating in patient care planning sessions, and following up patients in home and community settings. Effective interdisciplinary teaching does not happen, however, unless there is a general acceptance of the broader definition of health, and the multiplicity of factors influencing health; strong commitments from faculty members and practitioners to work together as colleagues; and effective academic and clinical leadership. For some years now we have been offering an interdisciplinary program called ISCOPES, on an elective basis, at The George Washington University Medical Center. Students work in interdisciplinary teams with interdisciplinary faculty members in a wide variety of community settings. The students present reports on their group projects to the entire class, and interested others, and learn first hand about the needs and opportunities for successful interventions in community health in the Washingtonmetropolitan area. Although similar approaches have been developed and implemented in many countries over the years, it is unfortunate that these interdisciplinary approaches are the exception rather than the norm. Another important illustration in the teaching area is the formal combination of MD/MPH, PA/MPH and MS/MPH degree programs. While this acquisition of dual degrees clearly provides the individuals involved with strong preparations in the clinical and public health disciplines, the programs generally have small enrollments. Research. Research, especially in clinical epidemiology, is a vital element in the process of bringing medicine and pubic health together. Clinical epidemiology has a broad mandate and includes the application of epidemiological principles and methods to the study of clinical problems, including those related to etiology, diagnosis, prognosis, treatment, patient management, and the costs of care. This research demonstrates the two-way relevance of population studies and clinical research. For example, it can illustrate the effectiveness of large scale, preventive medicine, health promotion and treatment programs for individual patients, and in the other direction, it can demonstrate that data from clinical practice can identify and address community health problems. Researchers in clinical medicine and public health will develop better understandings of the relevance of each other’s disciplines and these attitudes will hopefully be transmitted to students in the health professions. International clinical epidemiology networks, such as INCLEN and INDIACLEM, are providing strong support for the expansion of clinical epidemiological research and the Pfizer Scholars Grants in Clinical Epidemiology Program is also a major stimulus to this area of research. These approaches will go a long way in helping to bridge the two disciplines. Clinical epidemiology needs to be a high priority for expansion in academic medical centers throughout the world. Health Care Organization. The fragmentation and dysfunctional characteristics of many health care systems, along with the relative neglect of primary care at the expense of secondary and tertiary services, have been well documented throughout the world. The community health center model, in all its forms, offers a very practical mechanism for bringing medicine and public health programs together in a common organizational setting, with a strong emphasis on collaboration and teamwork. Research in many countries, including Australia, Canada, Israel, New Zealand, the United Kingdom and the United States of America, has demonstrated the value of this organizational setting in the following areas: Improved communications among health professionals Expansion of community health education programs Increased effectiveness of health promotion and disease prevention programs Better population health outcomes Increased opportunities for community-based, evaluation studies Expanded mechanisms for interdisciplinary teaching More efficient use of resources
In terms of bringing medicine and public health together, the community health center model has the best opportunity of reaching its full potential when it is a formal part of the academic health system. In this way it will be an important mechanism for the revitalization of primary health care within the larger health system. The Role of Professional Associations The last area I will address in this strategy may well be the most difficult one from a practical perspective. Professional associations play very important roles in recruiting, influencing educational institutions, continuing education programs, the structure of health service systems, compensation of health professionals and, at the political levels, the broad field of health policy. In the real world of health care, the professional associations representing the wide range of medical specialties and those representing public health see things very differently. Associations representing clinicians tend to be more conservative in their outlook while the public health associations usually hold more liberal views. An illustration of this divergence has been evident in the fierce battles fought over many years concerning health financing reforms in the United States and elsewhere. Over the years there have been numerous combined initiatives undertaken by the various health professional associations and these have resulted in significant improvements in education, research and the provision of health services. But these diverging views of the world, and markedly different prescriptions for addressing health care problems, continue to put serious obstacles along the path towards increased collaboration and cooperation between medicine and public health. One would hope, however, that the growing acceptance of the commonalities confronting medicine and public health, and the necessity for collaborative solutions, will encourage the leaders of the various professional associations to find ways to work together for the common good. As an organization, APACPH has done much to bring these diverging viewpoints together in this region. It is very encouraging to note the growth in our APACPH membership. We welcome new members to the APACPH family and I look forward to including greater representation from the Pacific Island nations in the future. One of the great strengths of APACPH is our very diverse membership but there is also an underlying commitment from our members to use our resources to build firm relationships with all the actors in the health care systems – public, non-governmental and private. I hope that in the future we will expand these efforts and reach out and build collaborative networks with other national and international health organizations. By doing so, the whole will surely be greater than the sum of its parts. ___________________________ Additional Reading Roz D. Lasker, MD, and the Committee on Medicine and Public Health, "Medicine and Public Health: The Power of Collaboration". New York Academy of Medicine, 1997. Fran Brown, The New Public Health (2nd Edition), Oxford University Press, 2002
top Related Event: International Health Policy and Management Institute Seminar, June 1-3, 2005, Washington, D.C. Program. Feature Reading: Oxford Textbook of Public Health, 4th ed., edited by James McEwen, Robert Beaglehole and Heizo Tanaka, 2002. |
RSS