Clinical medicine is very much a one-on-one interaction. A doctor will sit with a patient to make a diagnosis and/or discuss treatment. A nurse will sit with a patient with newly diagnosed diabetes and teach them how to manage their insulin. Even very complex medical interactions such as major surgery may involve multiple professionals but only one patient. Very rarely in clinical medicine is the health of the broad community considered. Public health comes at health problems from the opposite perspective: the health of populations: local, national or world-wide.
John Snow, M.D. (1813--1858), a legendary figure in epidemiology, provided one of the earliest examples of using epidemiologic methods to identify risk for disease and recommend preventive action. Snow had an interest in cholera and supported the unpopular theory that cholera was transmitted by water rather than through “miasma” (i.e., bad air).
On August 31, 1854, London experienced a recurrent epidemic of cholera; Snow suspected water from the Broad Street pump as the source of disease. To test his theory, Snow reviewed death records of area residents who died from cholera and interviewed household members, documenting that most deceased persons had lived near and had drunk water from the pump. Snow presented his findings to community leaders, and the pump handle was removed on September 8, 1854. Removal of the handle prevented additional cholera deaths, supporting Snow's theory that cholera was a waterborne, contagious disease. This became a model for modern epidemiology.
Because communities, rather than individuals, benefit from public health, it must be taxpayer-supported, and this is its Achilles heel. Whether you believe, as I do, that medical care is a basic human right, or that it is just another service that people should be prepared to pay for, needed medical services are usually provided and charged for. Those without or with poor insurance may be bankrupted, but they usually get the services they need. As a taxpayer-funded activity, public health must compete with myriad other demands for public funds, and since its successes are usually invisible, it does not have the same constituent pressure that do police, fire or public works.
At the local level, public health staff work to make sure restaurants are serving sanitary food; unless you have suffered from a food-borne illness caught at a restaurant, the need for this surveillance is probably not high on your radar. The very success of disease prevention makes it less visible. At the national and international level, public health agencies should protect us from major disease outbreaks such a Covid-19, or at least limit the damage. Again, since pandemics are thankfully rare events, it is easy for governments to cut the funding of public health agencies without much pushback from the citizenry.
A huge problem at the national level is the conflict between politics and science. We saw this early on in China, when Wuhan authorities tried to hide the emergence of the novel coronavirus. We saw it in spades in the United States when the warnings of the lead scientists at the renowned CDC (Communicable Disease Center) were ignored by Trump and his administration because their advice to slow down economic activity did not fit with his desire for a booming economy. We saw it in the wholesale rewriting of various CDC guidelines when they did not fit the narrative that Trump wanted to present.
The United States should have been among the countries best prepared to deal with Covid-19: our hospitals are first rate, our financial resources are more than adequate, and we have the world’s leading agency in dealing with disease outbreaks. We did not have adequate stockpiles of things like ventilators and personal protective equipment, because carrying rarely used inventory was bad for a hospital’s “bottom line,” and because other needs for public funds were given higher priority. What we also lacked, and still lack, is public trust in the government, a factor made worse by the actions of Trump and his enablers.
Countries such as Taiwan, Korea and Canada, all of which have performed much better than did we, had credible spokespeople, a consistent message, and a public inclined to listen. We thus find ourselves with 4% of the world’s population but 25% of the world’s Covid-19 cases and are among the top 10 in per capita deaths.
Covid-19 will eventually be tamed, through some combination of vaccines, better treatments and eventual “herd immunity.” Unfortunately, the next pandemic is almost certainly brewing in some animal species, ready to make the jump to humans. NOW is the time to ensure that we do better next time. Public health must be adequately funded, and scientists must be allowed to have a leading voice (though not the only voice) in making public health policy.
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