Organized public health: bland and toothless

My public health colleague DemFromCT continues his public health interview series on the front page of DailyKos today, talking to Dr. Georges Benjamin, Executive Director of the American Public Health Association (APHA). Dem clearly likes Dr. Benjamin, which is not a surprise. He is a very likable person. I have been a member of APHA (on and off; I keep forgetting to renew) for over 40 years, have served on one of its top policy boards and been a member of its Governing Council. But in recent years I have had little to do with APHA, and Dem's interview today illustrates one of the reasons.

The Association has been around for well over a century (established 1872) and in its early years was more powerful than the American Medical Association, which at that time represented a small minority of practicing physicians and was more of a clique than a social force. The Reed re-organized it in its modern form in 1900 and things changed. In the decades between 1900 and 1920 (the Progressive Era) public health also changed dramatically, adopting bacteriologic science that relocated the origin of disease from the physical and social environment (tainted water and food, bad housing, poverty) to dangerous people (disease carriers like Typhoid Mary). The social background was a widespread anxiety against political radicalism and xenophobia, with immigrants particularly viewed as dangerous anarchists. The step to individuals as dangerous foci of disease was easy. But this put public health in the same arena as organized medicine (and a newly powerful AMA), with the consequence that public health became subordinated to clinical medicine and marginalized by its identification with the outcasts of society (the poor, destitute and diseased). When I was in medical school, in the early sixties, the smart kids dismissed public health as an uninteresting grunt job like reading TB x-rays in the South Bronx. Then the social changes of the sixties also changed public health, infusing it with socially committed, energetic and dedicated young doctors and health care workers who wanted to make their professional life consistent with their commitment to social justice and reform. Suddenly public health was the place to be. I entered it as part of that sixties cohort. APHA was one of the places we were active, trying to move a fairly hidebound, unadventurous and conventional association into the world of social activism.

We were fairly successful. APHA became a moderately progressive voice for enlightened public health reform well into the Reagan era. But that was then. The Reagan/Bush/Clinton/BushII years again marginalized public health, although in a different way than 100 years ago. Instead of being under the thumb of organized medicine, public health is now a wing of "public safety" (police, fire, EMS). The effects on its culture have been profound. I recall our state epidemiologists wryly commenting on how when a meeting was called the police would send the Deputy Commissioner, the firefighters would send the Deputy Chief, the EMS would send the Commander of Emergency Medical Services -- and public health would send a committee. The reason was that public health has been horizontally, not vertically organized. Many different services -- maternal and child health, vital records, infectious disease, substance abuse programs, etc. -- worked together but not dominate each other. There was a lot to do. With the imposition of a public safety model in the wake of the bioterrorism hysteria, public health is now also organized vertically. Instead of a committee, public health sends their "incident commander" to the meetings. At least it has a seat at the table. Before 2001, it was largely absent, as the tail of health services wagged the rest of the public health dog.

That's where we are now. And when you read Dem's interview with Georges Benjamin what you will read is a bland recital of slogans and generalities. There is very little depth of thought about where public health fits in this rapidly changing landscape and no sense of an Association that is in there fighting for it, tooth and nail. APHA still exists, but there is no feeling of excitement of vitality. It has policies, but no one much cares what they are. It has slogans, an no one much cares what they are. What it doesn't have is influence, muscle or vision.

Some of us care about that.


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"My public health colleague DemFromCT"

Well, that's a compliment. I'm just a practicing doc deeply interested in the topic, though I love working with PH people.

Dem: It was intended as a matter of fact. What you are doing is public health. You also do clinical medicine. You are ambidextrous (that is, you have two left hands).

As a retired local jurisdiction Public Health Administrator and Nursing Director, you have hit it straight on. Public Health is not understood nor much respected in the political world.

Public health is severely silo-ized and CDC, among other funders, doesn't do much to help this. Social conditions and behaviors are constantly rediscovered as determinents of health and most of the biomedical interventions require consideration of infrastructure, factors related to adherence, etc. Much of what's "new" is poorly thought out and based on self-serving modeling studies based on ludircously simplistic assumptions, as in the case of CDC's poorly carried out HIV testing initiatives. Surveillance system often fail to address importanet sentinel populations and fail to identify variables that could help drive prevention interventions. Public health needs to be trult interdisciplinary and realistic of about politics (which many practitioners want to wish away).

Which important sentinel populations do surveillance systems often fail to address and why (in your opinion)? Bear in mind the fact that each new surveillance system usually adds to the 'form filling' burden on front line staff.