The Community As A Public Health Patient -
Reflections Of A Public Health Specialist

Dennis V. Cookro M.D., MPH
Dennis V. Cookro M.D., MPH is a Research Professor in the College of Public Health at the University of South Florida and Consultant to the Florida Department of Health.

Last month I was working with one of my patients. There were a number of problems. The patient did not have enough money, and needed tests and surveys that would be time-consuming, expensive, and difficult to analyze. I thought perhaps a local hospital could be convinced to help. However, even with adequate test results, the patient lacked the education needed to make the changes required to control risks and return to health. This was a tougher situation to deal with, as I was also faced with limited resources and could not easily provide the education needed. Fortunately, if we could make appropriate arrangements, a nearby University was willing to help. Finally, after completing most of the diagnostic picture, I found that some of my treatment plans could potentially cause accusations of ethnic bias that might get me into trouble with several local legislators who were very good friends of the patient! A typical patient? For me, yes. The patient is a large South Florida County. I specialize in Public Health.

Much like other physicians, Public Health Specialists need diagnostic, treatment and counseling skills. Unlike most other physicians, the Public Health Specialist's patient is the community. Practicing good Public Health means finding or stimulating the development of "therapeutic" tools for the community in order to carry out preventive measures in populations rather than individual patients. Everyday concerns of a Public Health Specialist might include dealing with tuberculosis, injury prevention, septic tanks, diabetes, smoking, healthy eating, teen pregnancy, HIV and other sexually transmitted diseases, drinking water, infant mortality, food-borne illness, media contacts, distance learning, business management, accounting, personnel management, grant proposals, contracts, community involvement, community collaboration, medical practice skills, and more!

The Public Health Specialist must have diagnostic skills in "history" taking which include community needs assessments (surveys), data analysis, mortality and morbidity (vital statistics) review, and review of other local health related data. Listening skills are critical but, while the Public Health Specialist may listen to individual patients, he or she must also listen to community groups, government agencies, voluntary health agencies, legislators, county and state officials, media representatives and other groups.

As in any practice, Public Health Specialists face major problems with patient "compliance." The Public Health Specialist may experience similar lack of compliance. Like the patient or parent you see in your office, legislators and special interest groups may not comply with the Public Health Specialist's advice. Indeed, as in the case of motorcycle helmets, they may actively attempt to undermine the Public Health Specialist's advice with a combination of spurious, unscientific, or illogical reasoning!

As physicians, we deal with our patient's diseases and risks, provide treatment, and counsel the patient appropriately at the time of the office visit. On a given day there may be a need to decide which patients to see that day and which can wait. For the Public Health Specialist, community triage decisions are the rule rather than the exception. Often serious problems must be set aside because other problems are more urgent. Worse yet, media pressure may artificially raise the priority of one problem over others. Some community sicknesses that seem urgent to a population group have to be temporarily ignored. Community risks and "sicknesses," unlike individual patient risks, cannot be diagnosed and treated whenever they "show up at the office."

In every physician's day important decisions are made — often affecting the lives of patients. The same is true for the Public Health Specialist, except that occasionally (sometimes frequently) the decisions affect the entire community or a large segment of the community. In recent history, neither public health nor medicine in general acted early and aggressively to limit the spread of HIV. In practice, it is not always easy to determine whether a patient's presenting problem is serious and requires early and aggressive intervention. The Public Health Specialist faces the same dilemma, but when Public Health Specialists underreact, as with HIV, the results can be devastating for the entire community, or in this example, the nation and the world.

Similarly in Public Health, overreaction can also be dangerous. Entire communities may "panic" due to Public Health overreaction. Consider HIV again. How many lives were ruined not by the disease itself, but by the community's unreasonable reaction to infected or "at risk" individuals?

Medicine And Public Health: Benefits Of Collaboration

As soon as several of the inhabitants of the United States have taken up an opinion or a feeling that they wish to promote in the world, they look out for mutual assistance, and as soon as they have found each other out, they combine. From that moment, they are no longer isolated men, but a power seen from afar whose actions serve as an example and whose language is listened to.

Alexis de Tocqueville, 1848

Often people incorrectly think all Public Health work is done at the health department building itself, or in satellite clinics. But the most important functions of the Health Department take place in collaboration with other community groups and health providers (especially physicians and physician groups). The health department should be thought of as a catalyst in the community to stimulate cooperation and coordinated preventive health care services.

Physicians have always been a major driving force behind preventive medicine and public health. Florida physicians help to assure an emphasis on preventive medicine in their practices and, through the FMA and local medical societies, play a significant role in setting public health policies for the population. Just two years ago the Florida Medical Association's lobbying efforts made it possible for Florida to have a new Department of Health. The new Department's goals (see Table 1) cover a wide range of prevention activities. Dr. Jim Howell, the Department secretary, has some high hopes for the future of Public Health in Florida and looks to County Medical Society and FMA members to help him prioritize and carry out Public Health initiatives.

How can medicine and public health continue to collaborate productively
for the benefit of individual practices and community health?

"For the medical sector, collaborative strategies make it possible for clinicians to have more far-reaching effects than they can by caring for patients on an individual basis. Working with the public health sector and other community partners gives clinicians the power to address health problems — such as HIV/AIDS, sexually transmitted diseases, cardiovascular disease, domestic violence, and substance abuse — that depend on more than what they can accomplish one-to-one in practice. Collaboration also enables medical practitioners to apply what they learn in their encounters with individual patients to broader populations. Both sectors find their policy voice strengthened through collaboration, giving them more control over health problems, their working environment, and the future direction of the health system."

Roz Lasker, M.D.
New York Academy of Medicine

Some examples of current or past collaboration:

• Special interest groups are fighting for funds resulting from Florida's successful anti-tobacco lawsuit. Medicine and Public Health are working hard together to see that this money is spent on improving health, especially for Florida's children.
• Immunization rates in Florida are up across the state thanks in part to collaboration and participation by practicing physicians with County Health Departments.
• Tuberculosis cases in Florida are decreasing, thanks to Directly Observed Therapy and greater awareness in practicing physicians of the need to contact and utilize local and State health department resources for treatment, follow-up, and contact investigation. (Unfortunately Florida still has the fourth highest TB rate among the states, and TB is still the number one killer in the world.)

Some examples of potential collaboration for Medicine and Public Health:

• Pressure to increase funding for HIV medications is outstripping the desperate need for prevention dollars. Can Medicine and Public Health put more pressure on Congress to increase funding for prevention, and not just for treatment?
• Congressional politicos and the American Cancer Society have argued about the age to start screening mammography. Yet, few seem interested in making screening mammography accessible to the millions of women at highest risk (over the age of 50, or with other risk factors such as being African -American). Health care dollars and especially preventive health care dollars are sorely limited. As a result, anytime we spend those preventive care dollars on one thing, we cannot help but limit the dollars available for something else. In Public Health, we are painfully aware of the economic and other barriers to breast cancer screening. It is disheartening to see more attention paid to getting a few younger women screened, in whom we may diagnose a few cancers early, while many older women and especially older African-American women (see related article in this issue) for whom evidence of benefit is abundantly clear, go without. Neither Medicine nor Public Health has stepped in to insist that screening mammography be promoted and made accessible to the population sectors for whom it does the most good! Can a collaborative effort by Medicine and Public Health in Florida help to decrease the devastating toll of breast cancer in high risk population groups?
• Florida's County Health Departments continue to struggle with communicable disease control. Public Health Nurses and other public health workers follow up on physician, hospital, and lab reported diseases. Physician reporting, early treatment and case management play an important role in limiting the spread of these diseases. As most physicians know, the local County Health Department is a valuable resource for communicable disease and offers helpful information on local disease rates as well as useful resources on diagnosis and prevention of diseases. Would closer Medicine and Public Health collaboration accelerate improvements in communicable disease control? Could collaborative efforts provide better reporting for Public Health and more clinically useful data and referrals for physicians in practice? Are we jointly taking advantage of new technology to communicate better with each other?
• "Health Maintenance Organizations," an idea whose very name speaks of prevention, now are called "Managed Care Organizations" (MCO's). The emphasis on prevention is losing ground as economic views take precedence. Both Medicine and Public Health have concerns. How can both groups collaborate to re-emphasize preventive care and quality medicine in these organizations? Are MCO's taking advantage of the prevention expertise at the County Health Department? Are County Health Departments collaborating with MCO's to assure community prevention?
• Onsite and other waste treatment systems are woefully inadequate throughout the State. Has Public Health failed to enlist the assistance of the practicing physician? Have physicians failed to emphasize the health risks to the public? Ask a few of your patients about the health consequences of poor sewage treatment and see how aware they are! This year El Nino-supplied rains have set all-time records in Florida. Water tables are barely below the surface. High water tables do not improve the function of onsite sewage systems (septic tanks). In order for a septic tank and drainfield to properly operate, percolation must occur. With the water tables so high, raw sewage is not effectively filtered and sewage can and does contaminate surface waters. Critical health problems will undoubtedly occur and worsen through the summer as a result. Pfisteria outbreaks are only an indicator of the disease-causing potential of our poor handling of waste. Sewage system improvements have been few and far between in Florida as Public Health regulators fight a losing battle without the needed "reinforcements" of practicing physicians and organized medicine, who can emphasize health consequences to the public.

An Invitation

As you go about your daily medical practice, be an advocate for sensible preventive health care spending. Express your ideas about how your work relates to the community's health. You may spark the next important Public Health initiative! It has happened in the past, and it will happen again in the future. Public Health will never work as well without you!

References

1. Lasker RD. Committee on Medicine and Public Health. Medicine and Public Health: The Power of Collaboration. New York, NY, New York Academy of Medicine, 1997.
2. Sumartojo EM, Geiter LJ, Miller B, Hale BE. Can physicians treat tuberculosis?: report on a national survey of physician practices. Am J Public Health. 1997; 87: 2008-2011.
3. Champion VL, Menon U, McQuillen DH, Scott C. Validity of self-reported mammography in low-income African-American women. Am J Prev Med. 1998; 14: 111-117.
4. Klabunde CN, O'Malley MS, Kaluzny AD. Physicians' reactions to change in recommendations for mammography screening. Am J Prev Med. 1997; 13: 432-438.
5. Cole SR, Bryant CA, McDermott RJ, et al. Beliefs and mammography screening. Am J Prev Med. 1997; 13: 439-443.

June, 1998/ Jacksonville Medicine

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