Public health: how to join the conversation

The Holiday Season is upon us so we won't post daily on the Public Health Conversation series. But you can join in at any time, in two ways. Effect Measure and The Pump Handle, the two blog sites hosting the discussion, have comment threads for each post. You can make a comment at any time on any post. If you want to see all the posts on this topic, just click the Progressive public health category on the left sidebar on Effect Measure. We will put an appropriate tag on The Pump Handle posts as well. If you have produced a more polished piece, send it by email to The Pump Handle. We will be posting some on the Front Page we think are especially pertinent to various points in the conversation. Get your 15 minutes of fame!

We want people to be part of this conversation. I know from my own experience it can be discouraging to leave a comment that seems to draw no response. If you leave a couple of comments and no one seems to care, it is tempting to stop commenting. But the comments really are read by people. One of the most common reasons a comment doesn't draw a response is that people agree with it and don't have anything to add. Comments people disagree with often draw responses, so be careful what you wish for! Either way we hope you join the conversation by reading, responding, thinking or contributing.

Our image of the public health system is of a huge chess board, with pieces of all varieties (elaborate to simple), all ranks and status, and a huge range of inherent powers. The rules are complicated and the moves made by unseen hands. What we want to do here is take our arm and sweep it across the board, wiping it clean and starting over (metaphorically, of course). We are asking fundamental questions about public health, what it is, what it's for. And it's not just US public health. We have readers on every continent (except maybe Antarctica). Public health knows no borders. Wo while there may be different views as to whether health is a Right or not, and I think that's worth discussing, we aren't interested here whether it is a Right under the US Constitution. It's not a legal question but a question about what we think our mission is in public health. And when I say "we" I am including anybody who sees themselves as engaged in or interested in or working in public health. I don't care if you are the head of a hospital, a nurse, a homemaker, a teacher, a doctor, an engineer, a laborer. If you have something to contribute, that's the point. And most people who are genuinely concerned about public health will have something to contribute, even if it is agreement or disagreement with what someone else said.

Panning for gold in this muddy river will take time and patience. We might go around in circles (although I hope they are at least ascending spirals) as we try to clarify our thoughts, examine proposals for their consequences, argue about basic concepts and words. It's hard work and frustrating.

But someone needs to do it sometime. Soon. Why not us, why not now?

More like this

revere, I've written a blog, partially in response to your call for comments about public health. Hope it is OK to cross-post it here.

Public Health, Politics and Pandemic Preparedness

We are often told that the Public Health establishment will play a key role in responding to a pandemic. If so, how are they likely to perform? We can get some estimate of the quality of their response by assessing how good a job they have done in preparing for a pandemic.

The public health establishment is strongly hierarchical. The lead agency is the World Health Organisation (WHO). The top US agency is the Centers for Disease Control and Prevention (CDC). In the US, there are State Health Agencies. The actual providers of public health are at the County and City level. The hierarchical nature of these relationships is illustrated by the pandemic alert phase levels. The WHO establishes what level of alert is appropriate at any given time. Most nation-states base their responses on information they receive from the WHO. States receive their alert information from the CDC and counties and cities receive their information from the State public health agencies. Thus, the smallest public health organisation in the US ultimately depends on the information provided by the WHO.

The public health establishment is surprisingly political. Although the general public thinks most in public health are acting as scientists or physicians, this is not the case at any but the lowest levels. In fact, the decision-makers are almost always career politician/bureaucrats who may or may not have any training in medicine or science. Appointment to key positions in public health is dependent on keeping politicians happy, not in serving the public interest.

The mix of rigid hierarchy and politics has produced a public health system that is not responsive to the public and which does not function as if the health of the public is the primary objective.

Dr. Margaret Chan's appointment as Director-General of the WHO illustrates the ugly reality of politics in public health and the potentially catastrophic outcome we can expect as a result. Dr. Chan was a public health official in Hong Kong during the SARS outbreak. She was judged by the Hong Kong legislature to have failed in her responsibilities and publicly rebuked. She is thought to have been more concerned with protecting the reputation of the Chinese Communist Government in Beijing than in saving lives of her fellow Hong Kongers. An impartial observer might have thought this would end her career in public health. Instead, she was appointed Pandemic Flu Czar at the WHO. After the unexpected death of the then Director of the WHO, Dr. Chan launched an aggressive campaign to become the next Director-General. She assiduously courted the Chinese Communist Party leaders and received their strong backing. Although there were many rumors of bribes and other unsavory practices, Dr. Chan became Director-General of the WHO. Under her leadership, international cooperation on pandemic surveillance has reached new lows. The head of the Indonesian Heath Department, . Dr Supari, has publicly declared her unwillingness to share sequences or even acknowledge confirmed human cases. Further, Dr. Chan is alleged to have accused the US of "stealing" sequences from the WHO. Dr. Supari, a member of the WHO Executive Board, as accused the US of using these sequences for the production of biological weaponsh. Dr. Chan has not denied any of these charges. The damage to the reputation of the US in the undeveloped world is likely substantial. Further, Dr. Supari's conspiracy theories may well have discouraged other countries from reporting their cases and providing critical samples.

In the US, the most powerful member of the public health establishment is Dr. Gerberding, Director of the CDC. The Director of the CDC is appointed by the President and answers to the Secretary of Health and Human Services (HHS). Gerberding is widely considered to be the worst Director of the CDC in its entire history. Five past Directors of the CDC have taken the unprecedented step of publicly criticising her performance. Many have accused her of gutting the science base of the CDC while rewarding professional "risk communicators". And how have they done? One of them, Dr. Sandman is famous for suggesting that the public put pandemic preparedness on the "backburner". Although an TV ad was created to urge people to prepare, almost no-one has seen it. The HHS pandemic site advocates stockpiling food and other essentials for 2 weeks, but again, almost no-one in the general public is aware of this. Dr. Gerberding's mismanagement of the CDC has not gone unnoticed by the US Senate. Senators Grassley and Coburn have publicly criticised her performance.

One would think with this sort of track record, that Dr. Gerberding's chance of being reappointed to her position in the next administration would be low. In fact, she has made it clear that she would like to be retained:

From The New York Times, December 16, 2008 [hat-tip, Helblindi at PFI_Forum]

At the disease centers, Dr. Gerberding is said to be interested in keeping her job.

But Dr. Jeffrey P. Koplan, who preceded Dr. Gerberding as director of the disease centers, is leading the Obama administration s C.D.C. transition team. Dr. Koplan has publicly criticized Dr. Gerberding s leadership.

Although we can hope that Dr. Koplan will favor a new Director for the CDC, he will not make the decision. President-elect Obama will, perhaps with input from Senator Daschle, who he has selected as Secretary of HHS. Comments by some at CDC Chatter indicate that the Senator has a good working relationship with Dr. Gerberding and may favor her retention. Also in Dr. Gerberding's favor is her team of "risk communicators" who may have been using their considerable skills to smooth her path. I have found it quite remarkable that political blogs that are intensely critical of almost all of President Bush's administration have been largely silent on Dr. Gerberding's performance. This includes high-profile blogs with experts in public health and pandemic preparedness.

At this point, it is difficult to know what is going on behind the scenes. One can hope that a qualified public health official will be chosen as Director of the CDC. My own preference, Dr. Roz Lasker, has shown a refreshing willingness to engage in genuine conversation with the public about pandemic preparedness.

There is little we can do about Dr. Chan's position as Director-General of the WHO. However, we have a small window of opportunity in which we can make our voice heard regarding the next Director of the CDC. President-elect Obama has created a website to solicit suggestions from the public about the transition: I would urge everyone with an opinion about the CDC's leadership on pandemic preparedness to express it at this site. Whether you voted for President-elect Obama or not, we all have a stake in the CDC's leadership.

This may be our last chance to influence the selection of a public health official who will be making life or death decisions about pandemic preparedness. Let's not waste it.