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Commentary

Can Public Health And Medicine Partner In The Public Interest?

Abstract

 
The dominant issues for health and health care today can be effectively engaged only if public health and medicine work together as better partners. Yet historical, professional, organizational, operational, and financial barriers exist to closer relationships. Fostering the necessary collaboration will require changes for both public health and medicine in leadership styles, professional education, practice incentives, accountability measures, and financing structures.

10: Innovation in diagnostic, monitoring, and treatment technologies. Even though there is a certain enduring, transcendent character to the central importance of the clinician-patient interaction in medical care and to the shoe-leather, disease-detective mind set in public health, increasingly the tools matter. If the past two decades are predictive of the pace, introduction of new approaches to diagnosis, monitoring, and treatment will continue to quicken. And in public health, new developments in biotechnology, nanotechnology, and monitoring devices offer the prospect of improved food, water, and environmental monitoring and intervention, as well as more reliable awareness of the locus and status of vulnerable population groups in need of public health and personal care interventions. The nature and expense of many of these tools, and the consequences and results of their application, compel the close engagement of public health and medicine if they are to be used with optimal efficiency and effectiveness.

9: Potential for bioterrorism. Although concern about terrorists’ use of biological or chemical agents has receded slightly in the public consciousness, preparedness for the possibility is a practical reality for both public health and health care. Indeed, public health and medicine are the only responses possible to this challenge. Whereas the principles of preparedness and coordination are similar to those for new and emerging diseases, with bioterrorism the response times are much more compressed, the surge capacity required much greater, and the need to engage law enforcement more immediate. All compel tightly linked and well-practiced relationships between public health and health care, as well as with law enforcement.

8: New and emerging infectious diseases. The challenge of new and emerging infectious diseases could be the one most obviously requiring seamless action by public health and health care. HIV was unknown just twenty-five years ago and now is a pandemic killer, draining resources across the world and threatening the viability of an entire continent. Already displacing bioterrorism as the primary focus of policy attention in public health is the possibility of pandemic avian flu, should H5N1 alter enough to facilitate human-to-human transmission. Control of any disease with the potential for explosive entry and spread requires that the public health and health care systems each have the knowledge and systems in place to identify a problem early and the ability to quickly expand their capacities to work together.

7: Quality and safety concerns. The responsibility to monitor and safeguard the quality and safety of health care services is shared. Health care must develop and implement the standards and systems necessary to ensure the quality and competence of providers and facilities and the services they deliver. But public health bears ultimate responsibility to warrant the adequacy and implementation of the standards. The Institute of Medicine (IOM) report To Err Is Human, and the very public failures of the safeguards with the rapid adoption the COX-2 inhibitors and the use of bone marrow transplants for breast cancer are testimony to both the importance of the issues and the growing public awareness of safety concerns.¹ These concerns will only increase with greater numbers and complexity of interventions, compelling ever-closer cooperation between public health and medicine for the monitoring, assessment, and interpretive responsibilities necessary.

6: Information technology. Information technology (IT) has the potential to revolutionize direct patient care management—with automated access to patient information, remote-site diagnosis and treatment, and algorithms for intelligent medical record systems. With its capacity to manage large amounts of patient care information, IT will also move our approach to clinical research into the routine practice encounter and greatly facilitate the coordination necessary for public health and health care to identify emerging health threats at their earliest stages. The ability to simultaneously process and electronically triage information seamlessly among patients, providers, and public health agencies will transform the ways public health and health care identify problems, set priorities, and target interventions.

5: Advances in genomics. Developments in genomics hold prospects not only for personalized medicine but for personalized public health as well. The 99.9 percent of the human genome that is essentially identical for all of us has now been sequenced. In the next decade, haplotype mapping will reveal the 0.1 percent that makes us each different, and with that knowledge will come an approach to medicine that accounts for the differences in our susceptibilities to disease, in the ways we respond to medicines, in the ways we heal, but also in the potential individual vulnerabilities from our behavior, our environments, our social circumstances—with all of the potential for altered strategies in both health care and public health. The extent to which public health strategies will need to be tailored to variation in susceptibilities will require close links with health care.

4: An aging population. In ten years, fifty million Americans will be over age sixty-five. Although, for any given age, disability is declining among older people because of better prevention and treatment, still nearly a third have some difficulty with an activity of daily living. The result for health care is the need for more capacity and attention to the chronic conditions that confront an aging population. A central tenet of the chronic care model is a solidly established and fully accessible network of activities and support from community resources.² A society growing old gracefully and healthfully requires skill in the clinic, support and vigilance in the home and community, and strong communication between the two.

3: Behavior-related illness and injury. With the ascendance during the twentieth century of chronic diseases as the leading contributors to death and disability among Americans came the realization that our behavior patterns are the root causes of many of these conditions.³ Behavior (primarily tobacco use, diet and activity patterns, and alcohol misuse) accounts for an estimated 40 percent of early deaths.⁴ Of these, the issues of diet and activity patterns are ascending most rapidly as matters of pressing public health concern. Behavioral interventions offer the classic example of the need for broad public health incentives and education to be partnered with strong reinforcement and monitoring by health care providers. Carefully designed interventions to foster behavior change have been proved to work in both clinical and community settings, but the nature, urgency, and impact of the issues compel coordinated work in public health and in medical care.

2: Impact of unchecked health care costs. Clearly among the most pressing challenges binding health and health care to each other is the impact of unchecked health care costs. In 2005 Americans spent nearly $2 trillion for treatment of illness and injury—16 percent of gross domestic product (GDP). With employers watching their resources drained by insurance premiums; patients confronting rising copayments, uncovered care, and paperwork; and the federal government soon to be paying 50 percent of all medical bills, it is possible that the sense of urgency could focus more interest in public health and prevention to keep people healthier. More likely, however, will be yet additional pressures to reduce the already strained discretionary public health resources. And those pressures will be compounded by the reality of public health’s having to address the health care needs of those whose health insurance coverage has been lost or eroded by the pressure of rising costs.

1: Social determinants and intractable disparities. Disparities in the health and health prospects among different groups in the United States compel closely coordinated responses by public health and health care. Today, one of every six Americans has no insurance coverage. The death rate for African American babies is more than twice that for white babies.⁵ Diabetes deaths are also about twice as high for blacks as for whites; and cancer survival is about 20 percent lower in blacks than in whites.⁶ The impact of social circumstances on health prospects has long been appreciated, but an emerging notion of cumulative stresses from various sources—social class, income, employment, housing, home environment—operating measurably through common physiologic pathways to affect vulnerability to disease, holds implications not only for better understanding of the ways social factors affect health, but also for identifying at earlier stages those with special susceptibilities. It is clear that work to close the gaps, or deal with the consequences, can be accomplished only through vigorous, sustained, and well-integrated initiatives by public health and health care. This includes outreach and community support fostered through public health agencies, the marshaling of targeted services and careful follow-up by health care, and concerted work by both to identify and commit the necessary resources.

With the need so clear for collaborative work between public health and medicine, the question is: What will it take to forge and nurture the partnerships?

The Historical Divide Between Public Health And Medicine

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Early contributions to public health. The greatest health gains for populations have derived from initiatives that had little to do with treatment of illness. The earliest public health actions date back at least 4,000 years to the work of ancient engineers who constructed bathrooms, drains, and covered sewers in the towns of the Indus Valley and Punjab on the Indian subcontinent, limiting the sources of contamination. Agricultural advances bolstered nutritional status by making food more available, and improvements in preservation and transportation made it more accessible. This pattern has remained true even to relatively contemporary times. An analysis by England’s Thomas McKeown suggests that the major contributions to improved health during the nineteenth and much of the twentieth centuries likely came more from changes in food supplies, sanitary conditions, and family size than from medical interventions.⁷

The importance of preventive measures has not been entirely unrecognized by physicians. Hippocrates, considered a founding father of medicine, emphasized the relationship and in some ways launched the formal pursuit of public health with his treatise in 400 B.C. on "Air, Waters, and Places": "Whoever wishes to investigate medicine properly [must learn of]...the effects of winds, ...waters, ...city, ...ground, ...[and] the mode in which [people] live."⁸ But the notion of looking beyond treatment of the illness at hand to engage its prevention has struggled to gain traction as a professional focus. Even those physicians who made important contributions to population health and prevention often were ignored or subjected to criticism by the medical establishment.

Slow acceptance by the medical establishment. James Lind discovered in 1748 that citrus fruit would prevent scurvy, but it was nearly a half-century before an admiralty order required lemon juice on ships. Edward Jenner demonstrated in 1796 that inoculation with cowpox protected against smallpox, but the London medical world could not accept the views of a country doctor, and it was forty years before vaccination was made official policy. In 1847, when Ignaz Semmelweis reduced maternal postpartum infection deaths from 12 percent to 2 percent through hand washing, it took fifteen years before the medical establishment in Vienna would accept the findings. In 1914, Joseph Goldberger, studying prisoners in Mississippi, discovered that a niacin deficiency caused pellagra, but he was dismissed there as a northerner pointing out problems in southern society. Even London physician John Snow, whose observations on the spread of cholera had been rejected by the medical journals, might not have convinced authorities to take action in 1854 against a contaminated well had he not been a physician to Queen Victoria.

As the science took hold with the discoveries in the 1880s of Robert Koch and Louis Pasteur on the nature of the causes and the spread of infectious diseases, and the need to track and contain them, the impetus grew for the development of local public health agencies and for closer involvement of the medical community. By the middle of the twentieth century, however, impressive progress against many infectious diseases and the ascendance of chronic diseases as the dominant sources of U.S. morbidity and mortality reinforced the natural and historical propensity of medical practitioners to be largely unengaged with public health.

Growth of medical care resources. Prompted by growing demand to treat complicated chronic diseases, the health care sector developed new diagnostic and treatment approaches; Congress passed the Hill-Burton Act in 1946, which directed sizable resources to the construction of hospitals and other health care facilities; and in 1965, Congress passed Medicare and Medicaid to relieve some of the growing expense burden. Annual appropriations to the National Institutes of Health (NIH), fueling medical care innovation, increased from less than $15 million in the late 1940s to more than $27 billion in 2005. Resources for medical care grew dramatically, from less than 5 percent of GDP in the 1950s to the current 16 percent.

Results for public health. The result for the public health community has been challenging. Not only has public health had to bear its ongoing responsibilities for monitoring and protecting the public against threats to health and safety, but it also has had to take on new responsibilities for promotion of healthier lifestyles, the provision of safety-net health care services for those unable to afford the growing expense of care, and a role as a watchdog to ensure the quality and effectiveness for a rapidly expanding medical care enterprise—all while commanding a shrinking share of the health care dollar. Medicine, in the meanwhile, contending with growth in its science and therapeutic base, has tended to become more specialized, narrowly focused, and less aware of the work of public health.

These perspectives reflect very different lenses through which priorities are seen. Compounding the differences is the resentment developed on the part of medicine by the perception that public health and government too often meddle in their prerogatives, and on the part of public health that resources and public attention are directed dominantly to health care, to the detriment of support for public health. These perceptions do not make for easy relationships.

Some Encouraging Examples Of Collaboration

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Enlightened leadership has allowed some interesting, innovative, and productive collaboration and partnerships between medicine and public health. Public health efforts to control vaccine-preventable childhood diseases, sexually transmitted diseases, and HIV infection have all been anchored in strong partnerships with providers for immunization, case reporting, and education. Community campaigns for problems such as childhood obesity, diabetes, tobacco cessation, control of high blood pressure, cholesterol education, early cancer detection and intervention, control of pneumonia and influenza, and lead abatement also have drawn on leadership and involvement of the health care community.

Health care providers in various places have worked to pass state legislation requiring the use of child passenger restraints and local ordinances ensuring smoke-free environments. They have worked with parents and officials on childhood injury prevention programs, with supermarkets and schools on nutrition standards and education, and with city planners on initiatives to buildings and parks that encourage physical activity. Work of public health agencies to organize providers for the delivery of services to the uninsured and underinsured has helped meet vital needs in many communities.

To build on these efforts, and to stimulate other such collaborations, in 1994 the presidents of the American Medical Association (AMA) and the American Public Health Association (APHA) agreed to launch what officially became the Medicine and Public Health Initiative, convened through a national congress in Chicago in 1996.⁹ Support was provided by the Josiah Macy Jr. Foundation, W.K. Kellogg Foundation, Robert Wood Johnson Foundation, and Agency for Healthcare Research and Quality. The New York Academy of Medicine undertook an assessment of the various models of collaboration.¹⁰

Examples reviewed include operation by the health department and the University of Alabama-Birmingham of the sexually transmitted disease (STD) prevention training center in Jefferson County, Alabama; the Healthy Seniors Program in Tucson, Arizona, to coordinate community services for Medicare beneficiaries; the California Tobacco Control Coalition to raise tobacco taxes in the state; the Healthy Valley 2000 coalition in Derby, Connecticut, to identify and address the major health challenges in a six-town region of southern Connecticut; the Leon County Breast Cancer Screening Program in Tallahassee, Florida; the Northwest Georgia Healthcare Partnership in Murray and Whitfield Counties to identify key community needs and launch responses; the Healthy Linn Care Network, growing out of Healthy People 2000, to assess health needs in the Cedar Rapids, Iowa, region and to initiate action against the top ten; the Metropolitan Chicago Community Care Alliance to create health services for a low-income Latino community; the Wichita Public Health Summit in Kansas; the Chelsea Asthma Partnership in Boston, Massachusetts; the Well-Child Outreach Partnership in St. Mary’s County, Maryland; the Franklin Community Partnership in Farmington, Maine, to provide health education and services to a low-income rural population; the Detroit Immunization Campaign, sponsored by the city’s two largest health systems; the statewide Minnesota Heart Health Program; the Community Health Improvement Learning Collaborative in Camden, New Jersey; the Monroe County Women’s Health Partnership in Rochester, New York; Project Access in Buncombe County, North Carolina, in which providers and the public health agency have developed a program to ensure that all residents have access to medical care; the Marion County Child Health Initiative in Salem, Oregon; the Philadelphia (Pennsylvania) Healthy Start and Lay Home Visiting Program; the Aiken Infant Mortality Task Force in Aiken, South Carolina; the Houston/Harris County (Texas) Senior Wellness Days; the Eastern Shore Coordinated HIV Care project in Accomac, Virginia; and the Seattle (Washington) Bike Helmet Campaign.

Reviewers characterized the projects as falling into six modes of synergy: (1) improving health care by coordinating medical care with individual-level support services; (2) improving access to care by establishing frameworks to provide care for un- or underinsured people; (3) improving the quality and cost-effectiveness of care by applying a population perspective to medical practice; (4) using clinical practice to identify and address community health problems; (5) strengthening health promotion and protection by mobilizing community campaigns; and (6) shaping the future direction of the health system by collaborating around health system policy, health professions training, and health-related research.¹¹

Despite the encouraging nature of these activities, and the fact that several states have ongoing Medicine and Public Health Initiatives—including California, Florida, and Texas—they are in some ways so notable because they are exceptions.¹² They struggle against strong forces of inertia and are difficult to sustain without more conducive professional cultures, environments, and support bases.

Changes Necessary For Partnerships To Flourish

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For cooperative activities to evolve from the occasional and anecdotal to the sustained and systemic, some basic operational changes are indicated.

Collaborative leadership. For public health, no partner is more important than health care; for health care, none is more important than public health. The tone for collaboration is set at the top. With the public keenly interested in health matters, and with the media eager to report on them, ample opportunities exist for visible collaboration. If leaders from public health and health care at the local, state, and national levels can work side by side as a matter of routine in the establishment of a shared vision for health—and in the planning, announcement, and execution of related initiatives—important signals can be sent throughout their communities and new approaches engaging key issues can emerge.

Professional education. Attitudes and practices are shaped early. Until professional education for health and health care takes on a philosophy that supports and underscores the centrality of the relationship between the two, the natural tendency to operate in different spheres will prevail. Apart from some recent material introduced on bioterrorism preparedness, education in medicine, nursing, and other health care professions generally has little content on the public health and community resources that can be vital to effective management of many conditions, or on the ways that health care professionals can play leadership roles in communitywide health initiatives. Similarly, education in public health generally conveys little about the practical minute-to-minute challenges of patient care. Greater familiarity in the formative stages of professional development should improve the comfort levels of the relationships.¹³

Performance measures. What gets measured gets done. Performance measures that gauge the effectiveness of health care professionals should reflect their effectiveness in linking to community and public health resources, as appropriate for their patients. Infectious disease reporting, initiation of containment procedures, comprehensive management of chronic conditions all require solid relationships and referrals outside the clinical arena that should be embedded in standards. At the organization level, performance measures for health care systems should include components that characterize the ways they engage their public health responsibilities, foster their community linkages, and reward relevant provider activities. Similarly, public health system performance should be measured according to indices that reveal clearly and accurately the degree and effectiveness of the working relationships with the provider community on public health priorities, ranging from policy planning, health protection, and health status assessment to meeting the needs of the underserved.

Incentive structures. Money might not be the only motivation, but it can help. People enter the helping professions because they want to help. Nonetheless, structuring economic incentives to identify and encourage action can be important to fostering desired outcomes. Public health programs supported with public funds should be required to forge collaborations with the provider community and be rewarded for doing so. Health care reimbursement should be structured not only to encourage and ensure the delivery of clinical preventive services, but also to make clearer the need to focus on maximizing value for health care investments, including the value of a population health perspective and engaging with the public health community as partner in health promotion and disease prevention. Pay-for-performance should include pay-for-better-community-health.

Linked financing. A partnership is only as strong as its weakest component. As long as the support base for the public health system continues to erode, both in absolute terms and relative to its expanded demands, the health security of the United States will continue to be fragile. Because success in achieving a healthy population is so dependent on public health leadership and initiative, a sustained and reliable support base is needed. It makes sense to tie that support base to the overall investment in health care. A small, dedicated set-aside from medical care spending could establish the principle, the fact, and the soundness of the relationship.

THE CHALLENGES AND CHANGES on the horizon for health and health care in the United States are substantial—some intimidating, some exciting, all formidable. If they are to be effectively engaged, the historical tendency of public health and medicine to operate in a loosely intersecting, sometimes unrelated, fashion, is not tenable. The public interest can be served only if a close partnership is forged, but doing so will require strong leadership, political will, and associations far closer and far more sustained than in the past. The result will be brighter, more affordable health prospects for Americans.

Editor's Notes

 
Michael McGinnis (mcginnis{at}nas.edu) is a senior scholar at the Institute of Medicine, the National Academies, in Washington, D.C.

The views expressed are solely those of the author and should not be interpreted as those of the Institute of Medicine of the National Academies.

NOTES

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1. L.T. Kohn, J.M. Corrigan, M.S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington: National Academies Press, 1999).
2. R. Glasgow, C.T. Orleans, and E.H. Wagner, "Does the Chronic Care Model Serve Also as a Template for Improving Prevention?" Milbank Quarterly 79, no. 4 (2001): 579–612.
3. A.H. Mokdad et al., "Actual Causes of Death in the United States, 2000," Journal of the American Medical Association 291, no. 10 (2004): 1238–1245.[Abstract/Free Full Text]
4. J.M. McGinnis, P. Williams-Russo, and J.R. Knickman, "The Case for More Active Policy Attention to Health Promotion," Health Affairs 21, no. 2 (2002): 78–93.[Abstract/Free Full Text]
5. National Center for Health Statistics, Health, United States, 2005, with Chartbook on Trends in the Health of Americans, 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed 31 May 2006).
6. Centers for Disease Control and Prevention, "Data and Trends: Diabetes Surveillance System," 1999, http://www.cdc.gov/diabetes/statistics/survl99/chap3/figure7.htm (accessed 31 May 2006); and Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov), "SEER Stat Database: Incidence—SEER 9 Regs Public-Use," November 2004 Submission (1973–2002), released April 2005.
7. T. McKeown, The Role of Medicine: Dream, Mirage, or Nemesis? (London: Nuffield Provincial Hospitals Trust, 1976).
8. Hippocrates, translated by F. Adams, "On Airs, Waters, and Places," eBooks@Adelaide, 2004, http://etext.library.adelaide.edu.au/h/hippocrates/h7w/airs_wat.html (accessed 30 May 2006).
9. L. Beitsch et al., "The Medicine and Public Health Initiative Ten Years Later," American Journal of Preventive Medicine 29, no. 2 (2005): 149–158.[CrossRef][Web of Science][Medline]
10. R. Lasker, D. Abramson, and G. Freedman, Pocket Guide to Cases of Medicine and Public Health Collaboration (New York: New York Academy of Medicine, 1998).
11. Ibid., 9–14.
12. Beitsch et al., "The Medicine and Public Health Initiative," 151.
13. K. Gebbie, L. Rosenstock, and L. Hernandez, Who Will Keep the Public Healthy? Educating Health Professionals in the Twenty-first Century (Washington: National Academies Press, 2003).

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