Doctor's view of Public Health

Preventive maintenance is always cheaper than neglect and repairs following the flood, but it always is held in lower esteem.    The public perception of public health versus clinical medicine is no exception.

For example,  according to the US Centers for Disease Control and Prevention (CDC) in Atlanta,

Since 1900, the average lifespan of persons in the United States has lengthened by greater than 30 years; 25 years of this gain are attributable to advances in public health. [1]

Even most of the advances against infectious diseases, often mistakenly attributed to wonder drugs,  actually occurred between 1900 and 1950, before widespread use of antibiotics, and were due to improvements in sanitation - clean water and sewage disposal systems. Again, very important areas but held in very low regard.

And, looking at the well-documented fact that the Latter Day Saints in Cache County Utah have life expectancies about 10 years longer than the average US citizen, [3]  very likely related to their mutual social support and their prohibition against use of alcohol or tobacco,   there are further substantial advances in life-expectancy the rest of the country could experience that have nothing whatsoever to do with high-tech medicine.

Despite these undisputed facts, public health seems to have no public relations skills at all, compared to the American Medical Association marketing of clinical medicine.

Even an MD with a background in epidemiology at the CDC, such as Lawrence Altman, a writer for the New York Times, can speak of public health in a positive light only with great difficulty, even though it is where he ends his review of the century.

Here's an excerpt from Dr. Altman's "The Doctor's World" for Dec 26, 2006, in the New York times titled "So Many Advances in Medicine, so Many Yet to Come."

Though doctors have long stressed the importance of prevention and public health, they and society have been slow to take strong action. Our medical school class was lucky to have a good course in preventive medicine because epidemiology was not widely taught elsewhere. To me, Berton Rouche, the New Yorker writer, arguably taught doctors more about public health than all medical schools combined through his medical detective stories about infectious and communicable diseases.

At the time, anyone who went into preventive medicine and public health was assumed to have graduated at the bottom of the class. A shingle on Park Avenue was the measure of success, not saving lives in poor countries. Now students are eager to study global health.

We may snicker over Eisenhower’s treatment. But imagine the laughter in 2056 as people look back at the brand of medicine and public health that we consider so sophisticated today. For all that doctors have learned in the last half-century, we are ignorant about far more.

The good news is that the new president of the AMA, Ronald Davis MD,  has a specialty in preventive medicine, as the country is being forced, by the huge health care bill, to start looking at the evidence and hard facts of what constitutes cost-effective health care.

At the current time, under 2% of the country's 1.2 $trillion health care budget is spent on prevention - and the rest goes to heroic repair after the damage has been done. 

Maybe, we need to re-examine that equation and, as CIS's Gil Grissom might say,  "let the data speak to us."   Spending more on public health is undoubtedly the most cost-effective step we could take - it's just has such bad press that it seems to be counter-intuitive.

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references:

[1] This Health Fact from MedicineNet.com is based on:

Ten Great Public Health Achievements -- United States, 1900-1999
Published in MMWR (Morbidity and Mortality Weekly Report) by the U.S. Centers for Disease Control and Prevention (CDC)
Reference: MMWR 1999;48(12);241-243

Medical Detectives by Berton Rouche (paperback, 1991), is a great read, by the way, filled with fun and fascinating true CIS-type stories involving everything from blue people to poisonous tomatoes.

[3] Cache County study of Latter Day Saints (Mormons), (and many publications) from a
report appears in the February 2006 issue of the Journal of the American Geriatrics Society,
quoted at "Healthy LIfestyles Pay Dividents Well into Old Age".  Excerpt from the review

WEDNESDAY, Dec. 28 (HealthDay News) -- Americans are living longer than ever, and by modifying their lifestyles they can also live healthier, happier lives well into their 80s, researchers report.

In a new study, researchers found that in a predominantly Mormon county in Utah, the majority of people reported enjoying good or excellent health, even past age 85. In addition, their later life is not necessarily a steady decline in health, but rather more healthy years followed by a short period of ill health right before death.

Historical view: (about 20 years ago)

Testimony on the President's FY 1988 Budget Request for the Centers for Disease Control and Prevention by Dr. David Satcher
Director, Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Yet as the U.S. health care budget approaches $1 trillion, only one percent of health expenditures support population-based prevention (chart 2).

Current Statistics: CDC NCHS - National Center for Health Statistics

2003 total US Health expenditures: $1.7 trillion (15.3% of the GDP)

Percent of health expenditures for hospital care: 31

Percent of health expenditures for nursing home care: 7

Percent of health expenditures for physician and clinical services: 22

Percent of health expenditures for prescription drugs: 11

Health, United States, 2004 (comprehensive statistics and comparisons to other countries)

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