Thursday, April 7, 2016
Public health and citizens, truly united
There are just 2 problems with the prevailing conception of “public health,” the public, and health. Neither means what we think it means.
For starters, there is no public. The public is an anonymous mass, a statistical conception, nameless, faceless, unknowable, and unlovable. I have made the case before that laboring under this crippling fiction, the potential good that all things “public health” might do is much forestalled. We talk, for instance, about the genuine potential to eliminate up to 80% of the total global burden of chronic disease—heart disease, cancer, stroke, diabetes, dementia—but somehow evoke a yawn, rather than shock, awe, and eager passion. We might fix this by putting faces on public health more reliably, demonstrating vividly the skin we all have in the game. That, however, is a topic for other columns.
Health is not what happens in hospitals. I am among the growing number of “health care” professionals who sing out at every opportunity that we do not have a “health care system,” we have a disease care system. My esteemed colleague and good friend, Dr. Richard Carmona, 17th Surgeon General of the United States, said the same, although he said “sick” rather than “disease” at a podium we shared last week.
This may seem a minor matter of terminology, but it is far graver than that, if not even terminal to the pursuit of better medical destinies. We invest fortunes in new ways to treat diseases that never need to happen, and by calling that “health care,” we foster the perception that it's the best we can do. As an Internist with 25 years of patient care in my rear view mirror, I proudly attest to the great prowess of modern medicine in diverse moments of acute need. But as a Preventive Medicine specialist, I append readily, and with great humility, that all the technology and drugs in the modern court of medicine can no more unscramble an egg than all the king's horses and all the king's men. We do much to treat disease, all but nothing to cultivate health at its origins. They are not the same.
This is relevant, because health, then, is more the stuff of culture than clinics. Health is cultivated, or corroded, in the places and ways we spend our days and weeks, hours, years, and lifetimes. It plays out in schools and worksites; supermarkets and churches; restaurants and shopping malls; on radio, television, and the Internet.
All of these are about health: economy; education; the environment; security, and thus the military; and even art, which feeds the human spirit that animates the human body.
This all becomes a bit clearer if we ever pause to ask: what is health for?
Health is not the prize. There is a lamentable tendency for discussions of health to take on moral overtones, the image of an admonishing finger taking shape in our conscience. But being healthy is not in the service of occupying the moral high ground. Being healthy is about having a better life. A better life is the prize. Healthy people have more fun.
Health is about more years in life, yes, but even more importantly, more life in years. You can't get that without education and opportunity; security and a nurturing environment; shelter; and the enrichment of the arts. Every policy and political decision reverberates its influence to health.
Those places around the world where people live the longest, most vital, and to all appearances best and “richest” lives do so by virtue not of supreme personal effort in spite of it all, but by virtue of a culture that leads to just such treasure.
So the public is us, and health is, really, a product of everything that affects us.
I am making that point now, in this season of simmering politics, as we all stand poised to wield or neglect the power democracy accords us. I am in good company.
There was a brilliant, in my opinion, column in the New York Times recently entitled The Conservative Case for Campaign Finance Reform. The author, whom I do not know, is a law professor, and obviously, a conservative.
I love that this well-crafted, citizen-centric essay is from a place in the political spectrum with which I am not associated. I am not shy about expressing my views, and admittedly, I do tend to lean left of center. But I follow the evidence where it leads, and refuse to be held hostage by the confines of any given political pigeonhole. I am not inevitably “liberal,” although when I am, I am proudly so. I am not afraid to be “conservative” when it seems the right answer.
That's the point. None of us should be held hostage by any such partisan designations. At the extreme, the constraints of such labels are like being obligated to choose one favored letter as the answer to every multiple choice question, no matter how obviously wrong. I am a “b” guy, so I must choose “b” even though “a” sure looks like the right choice this time … is nonsense we should all renounce. We might also consider that we are far more likely to learn something when attending closely to a well-articulated point of view we don't already own. I commend Professor Painter's fine column to my “liberal” readers accordingly.
In this season of roiling politics and abundant cause for discontent, we should advance our ideals. When a label reflects what we care about, fine. When what we care about is subordinated to the tyrannies of a label, something has gone badly awry.
Richard Painter and I agree; it's as simple as that. How silly it would be to overlook or discount that agreement because our divergent labels don't allow for it.
Public health is all about doing the best we can for actual people, not a statistical and anonymous horde that exists nowhere outside of actuarial tables. That doesn't always align with the greatest profits for some large corporation. In fact, it almost never does, because of the time horizons involved.
Politicians work in election cycles. Companies work in financial quarters. Companies may have a 1, 2, or even 5-year plan, even as they focus on the next quarterly statement, if not today's stock price. But they almost never have a 30-year plan, or, for that matter, a 100-year plan. And yes, companies spin off other companies that then go on to have their own 5-year plan and focus on quarterly statements.
But human beings spin off other human beings, with a good chance of living the better part of 100 years. Those human beings spin off more human beings. These divestments go by names we all know, worn by the very people we love most in the world: children, and grandchildren.
If you care deeply only about yourself, your own children, and your own grandchildren, you still have a time horizon of acute concern about 140 years longer than even the most far-sighted of companies.
Companies are not people. And the time horizon of almost everything that matters most to health is too long for companies to notice or care. They care a bit about productivity in the next quarter. But climate change? The slow toll of a culture pretending that multicolored marshmallows are a reasonable part of anyone's complete breakfast? The hypocrisy in marketing implying that copiously sugar-sweetened beverages are all about fun rather than trips to the endocrinologist in an age of epidemic obesity and type 2 diabetes among adults and children alike? The fact that cutting down rain forests will not only scar the lungs of the world, but inevitably crash us into the next, new, devastating pathogen? Somebody else's problem.
It doesn't take a Constitutional scholar to know that our founders, fiercely devoted to individual liberty, would be appalled at the concentration of power not only in huge corporations that behave nothing like individual citizens, but huge corporations that at times preferentially send jobs and money offshore, while sidestepping the taxes we citizens pay to help protect the rights we relish. Spin this any way you like, left, right, or center, the founders are turning in their graves.
For us, actual people, the timeline that matters runs cradle to grave. What matters most to us, the people, involves both the immediacy of our days, and also the legacy of our generations. We care a whole lot about the world our children and grandchildren will inherit from us. We citizens, loving parents and grandparents all, of whatever political stripe, are surely united in that.
Everything is public health, and political decisions all matter accordingly. Renouncing control over the flow of cash that controls those decisions is not just calamitous folly toxic to the spirit of democracy, it is a veritable cancer we let grow unchecked in the body politic.
So go the arguments from both poles of the political spectrum. Because we, the people, are truly united by the love of family and in our deep devotion to the common imperatives of our humanity. Because no corporation has ever had a child.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
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Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
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One of the most popular anonymous blogs written by an emergency room physician.