Public Health and Population Health
“The goals of public health consist of successive redefinitions of the unacceptable.”
–Sir Geoffrey Vickers (1894-1982), International public figure
There are three perspectives and venues from which to address health and disease.
- Clinical—one-to-one care of individuals
- Population—studies of groups and communities
- Biomedical—laboratory investigations at organ, cellular and molecular levels
During the 19th and early 20th centuries the first perspective dominated medical thinking and action. The paradigm-shifting discoveries of Koch and Pasteur, for example, with their spectacular results from the study of microorganisms, brought the laboratory to the forefront and emphasized the need for collective public measures to prevent and control infectious disease. Others emphasized the critical roles of poverty, famine, filth, unemployment, poor housing and environmental desecration in the genesis of disease. White’s volume, Healing the Schism: Epidemiology, Medicine and the Public’s Health, recounts the history of these transitions.
With biomedical research in the ascendancy, the population perspective languished until 1916 when the Rockefeller Foundation began a lavish global program that created and funded schools of public health apart from medical schools. Cohorts of health officers were trained and the underlying disciplines of epidemiology, statistics, and even the emerging medically-oriented social sciences were hijacked from medical schools to the new expanding public health schools. Many good things resulted but much was also lost. Medicine focused increasingly on molecular research; both clinical and population health research suffered.
That may be changing as barriers among the three perspectives disappear. To study disease, clinicians are analyzing their practices as networks of primary care doctors pool their data in surveys. Public health officials recognize that clinicians are the first-line of observation and reporting for early detection of pandemics and bioterrorism attacks. Geneticists require populations to assess the impact and transmission of much gene-mediated disease. There is no end to the need for collaboration and the “stove-pipe” isolation between the three perspectives will soon be history.
Roughly 45 million Americans lack health insurance and are without universal coverage or “Evidence-based Medicare for All” (as some have proposed), and there are lessons to be learned from experiences in other developed countries. Some such as Britain have a National Health Service or a publicly managed insurance and privately provided service like Canada’s Medicare or those in Australia, New Zealand, Germany, or the Netherlands. Overhead for U.S. Medicare and many of these systems runs 3-5% versus 30-35% for our for-profit schemes. President Truman put forward one of the first proposals for a national health insurance program but it and those since failed. Why?
There is an urgent need in developing countries to improve basic health services for vast populations and to improve the education of physicians and other health personnel in order to effectively address both indigenous and man-made diseases that threaten their people. International health or global health, as it is currently labeled, is finally being addressed vigorously not only by government to government aid and philanthropic foundations, but now by the huge new Gates Foundation.
The International Clinical Epidemiology Network (INCLEN) supports population-based research and education and is directed at expanding the perspectives of clinical faculty beyond that of the hospital. Since its inception in 1979, it has trained some 1,400 young physicians and their statistical, economic, and social science colleagues from over 80 medical schools in 33 developing countries on five continents.
Another global initiative embracing medical schools throughout the world is The Network: Towards Unity for Health (TUFH). International meetings, workshops, and a journal support efforts to improve the care of the under-privileged and disadvantaged largely in the developing world but also in developed countries. It too has continued to flourish for over a quarter of a century. The population perspective and accompanying skills and practices is gradually assuming its essential place beside the clinical and biomedical perspectives.