Should Prevention Trump Treatment?

I remember when I first started thinking about entering the field of public health. One of my major concerns was whether I needed to become a doctor in order to be respected and influential in the field. I was grateful for the advice I received from faculty (mostly doctors and nurses) at school that the path to clinical practice should not be done if you aren't passionate about becoming a clinician! While that may seem obvious, I think my concern was getting at something much deeper than that -- the enormous tension in public health to work within the health care system (a medical-driven, treatment intensive environment) and to work without it. 

The public health approach to health promotion is fundamentally about prevention. Its goal is to collaborate with multiple sectors to create environments where people can make healthy choices, to develop policies that protect peoples health, and to disseminate new finds and raise awareness about health damaging practices and products. 

Conversely, a clinical approach to health is to screen, identify, and treat disease. These clinical activities are vital and important to improve health of individuals. Ask anyone with high blood pressure, diabetes, or cancer, and they will agree that medicine plays an important role in helping them live their healthiest life possible. 

Sometimes people forget that clinical medicine and public health practice must be work in tandem. For example, when HIV/AIDS work began, there were many who wanted to prevent the spread of HIV/AIDS, but forgot the need to improve access to treatment for those already affected. Expanding access to antiretroviral therapy is now a major part of HIV/AIDS activities. 

The era of public health as a competency only for those in clinical medicine has past. What remains is a (growing?) tension between a growing number of public health professionals with no clinical training who reject the treatment-oriented focus of health work in this country and clinicians who believe that advancements within the health care system will be vital to improving the health of our nation. While both may believe that prevention is necessary, it is unclear whether -- when it really it comes down to it -- both believe that money spent on prevention is worth more than money spent on treatment. 

Our health care system is broken. Training more OB-GYN and orthopedic surgeons is not going to fix it. We need to create incentives for family physicians, primary care practitioners, and midwives. We need to invest more in prevention, in early life care, in parenting support, and healthy community initiatives to reduce violence and increase social capital. 

What does this tension mean for public health? Will it promote dialogue and lead to sustainable change or will it prevent us from accomplishing all that needs to be done to turn our health care system into a health promotion system?

What the Stimulus Means for Public Health

President Obama passed the Stimulus Bill (a.k.a. the American Recovery and Reinvestment Act) on Monday. Immediately, I got an email from APHA announcing how pleased they were "with the $1 billion investment in disease prevention and wellness activities...[and]with the inclusion of $2 billion to improve community health centers and expand services and $500 million for the training of primary care providers." Additionally, I received an email sent from the Director of Nutrition Policy at the Center for Science in the Public Interest who praised the inclusion of funding for community-based prevention and wellness programs, equipment for the National School Lunch Program to help schools prepare healthier meals, and increased support for WIC recipients. 

You make ask, "why is public health part of this stimulus plan?" or even argue that it has no place in it. I disagree.  Maintaining the health of our nation during this economic crisis must be a priority. Healthy workers are productive workers, just as healthy mothers have healthy babies. Healthy babies grow into healthy adults.

Just as the education system will suffer greatly as a result of budget cuts and spending freezes, so will those serving in public health see their budgets shrink and their resources dwindle. Thankfully, the education system will receive $100 billion in investment through the Stimulus Bill (see Nicholas Kristof's Sunday column for his take on this). The $3 billion for public health pales in comparison to that amount. Nonetheless, I think that the public health priorities included in this bill will speak volumes for the types of activities that the administration will pursue in the coming months and years.

It is worth noting that what is good for education is also good for public health. Higher educational attainment is associated with lower risk of disease and death for most health problems. Reducing disparities in education may serve to improve the public's health more than any technological innovation in medicine (e.g., electronic medical records) could hope to. I hope we do not lose focus of the fundamental causes of poor health, to do so would be a tragic misstep.

Life in the Camps

Life in the Camps

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Gender-based Violence in Darfur - New Website

Physicians for Human Rights recently announced the launch of a new website, DarfuriWomen.org. The website will be used to share stories and images of Darfuri refugee women and discuss how their lives have been affected by violence. 

Life in the camps has been anything but easy. The website's homepage describes how in June 2008 seven women in the Farchana camp were publicly tied-up, beaten, whipped, and humiliated after being accused of engaging in sex outside of marriage. A video entitled "Life in the Camps" can be found here. Check out this website. 

If you are interested in learning more about the violence in Darfur visit the Save Darfur website.

More Children in the US Insured

Today President Obama signed a bill to expand health insurance coverage to more low-income children across the United States through the State Children's Health Insurance Program (or SCHIP for short). As the New York Times reports, seven times the House has voted on the bill since August 2007 and none of those times did the bill pass. The bill did not have the support of the former Bush administration.

Several major changes to SCHIP follow the passage of this bill:

1. States can opt to extend coverage to legal immigrant children without the 5-year delay (verification of citizenship status is necessary).
2. Dental coverage is mandated.
3. Equal coverage for both mental health and physical health issues ("mental health parity") is required.

A criticism of the bill is that low-income individuals will switch from private to public insurance as a result of this expansion -- putting unnecessary burden on the government and tax payer dollars. While this may happen in certain cases, there is absolutely a need to ensure access to health insurance for more children in the US. 

Current estimates are that nearly 9 million children remain uninsured (from a Kaiser Family Foundation report published last month). Insurance will likely help children get access to vaccinations, primary care services, dental care, and other disease care services that can improve their health into adolescence and adulthood. The next step is to make sure that eligible families are enrolled in the program so that these efforts reach the children who need them most.