Saturday, February 28, 2009

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?

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