The Public Health

The Public Health

George W. Sledge, MD, FASCO

Jul 07, 2011
The July 6th issue of JAMA (306: 36-38, 2011) contains the CDC’s listing of the ten top public health achievements in the United States in the past decade. It makes an interesting read. The listing of areas of significant progress include: vaccine-preventable disease, prevention and control of infectious disease, tobacco control, maternal and infant health, motor vehicle safety, cardiovascular disease prevention, cancer prevention, childhood lead poisoning prevention, and public health preparedness and response.

To enter the world of public health is, by and large, to exit the clinic. Practicing physicians tend to view public health as the summation of innumerable doctor-patient interactions, a view that is reasonable from where we sit but generally wrong. A large proportion of successful public health interventions occur elsewhere. Just to look over the JAMA list, one sees anti-smoking efforts related to reducing smoking in public venues and increasing cigarette taxes, folic acid fortification of cereal grain products to prevent neural tube defects, the use of safer vehicles and safer roadways to reduce motor vehicle deaths, the introduction of safety guidelines to reduce farm-associated and fishing industry deaths, and the introduction of lead-poisoning prevention laws.

Where there has been a public health impact coming from the clinic, the CDC’s listing is largely focused on prevention and early diagnosis: vaccines, anti-hypertensives, cholesterol-lowering medications, colonoscopies, HIV testing, and the like. Targeted therapies for CML (chronic myelogenous leukemia) and breast cancer do not make the list.

That the public health is not the same thing as individual health is not exactly news. It relies to a much greater degree on political and social interventions, and on epidemiology as opposed to prospective randomized trials. As such, it is routinely mired in controversy, as stories such as the (fraudulent) autism/vaccine link or the current cell phone/glioma link suggest.

The interventions themselves regularly (and appropriately) raise issues about personal freedom and personal finances: I remember the fight we had in my own hospital when we exiled the cigarette smokers from the building. As head of the Smoking Cessation Committee, I received irate phone calls from physicians (physicians!) telling me what an awful person I was for not allowing them to smoke in their “private” office, thus violating their constitutional right to puff on a Camel. And there is, of course, a significant percentage of the American population that believes that all taxes are evil, even when those taxes are a major deterrent to their child buying a pack of cigarettes and instituting a lifetime of addiction culminating in a premature death.

That people feel passionately about these issues, even to their own detriment, is also not news. Just a few days ago I read of a motorcyclist in Onondaga, New York, who, while participating in a protest ride against his state’s helmet laws, flipped over his Harley’s handlebars and suffered a life-ending brain injury.

But these interventions work. From 1999 to 2009, the JAMA article states, “age-adjusted death rate in the United States declined from 881.9 per 100,000 population to 741.0.” How much of that achievement represents new treatment, and how much disease avoidance through public health measures? Both were important, I am sure, but that dramatic a fall is likely driven primarily via public health measures.

I love my profession, and I am proud of the real advances we have made in understanding cancer biology and how this has allowed us to make progress in cancer treatments for our patients. But I do not delude myself. Early diagnosis of lung cancer by CAT scan or the addition of crizotinib to our therapeutic armamentarium are far less likely to improve lung cancer mortality than a halving of cigarette-smoking rates. Hepatitis B and HPV vaccines will have a greater effect on hepatic and cervical cancer mortality worldwide than any new biologic therapy.

I believe that clinical practitioners have a professional obligation to support public health measures, even as we support improved access to care for our patients, as population-based measures that will reduce cancer morbidity and mortality. I want public health measures to complement therapeutics and see no fundamental division between the two. Bedside and curbside!


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