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Public Health – Do Too Many Docs Spoil the Soup?

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden S. Lundgren
February 17, 2023

If the origin of modern public health can be pinpointed, it might well be with water.  In 1854, in the midst of a raging cholera epidemic in London, an obstetrician with the unusual notion that the disease might be due to contaminated water rather than bad air identified the most affected neighborhoods and persuaded town officials to remove the handle of the pump that delivered water to one of those areas—which stopped the epidemic in that neighborhood.

The legend of Dr. John Snow and the pump handle has attained near mythical status in the public health community, and it demonstrates some of the common characteristics of the discipline: its particular identification with infectious disease, population definition, epidemiological theorizing, political persuasion, government action and a surprisingly modern feature, mapping. Snow’s intervention was opposed by much of the medical community, by many clergy and by government officials themselves—not surprising since the causative water-borne microorganism was not identified for another 30 years.  But in many ways, the fear of water-borne diseases powered the potential development of public health as a profession with sanitary engineering, not medicine, as its premier discipline.

But that was not to be. The first school of public health, the Johns Hopkins School of Hygiene and Public Health was founded in 1916 with the same founding dean as the medical school, but as an institution completely different from the medical school. This set up an uncomfortable dichotomy that still exists between clinical practitioners and those more interested in what we usually label as social medicine.  

In her 1987 work Disease & Discovery: A History of the Johns Hopkins School of Hygiene and Public Health, 1916-1939, historian Elizabeth Fee describes the competition among disciplines for primacy in public health but, most of all, the struggle between medicine and other professions. She states that “few physicians had any knowledge of bacteriology or sanitary engineering, much less of occupational or environmental health, epidemiology or statistics.” However, the new professionals were expected to “…solve the worst social and health problems of industrial cities, raise the health status of agricultural laborers, mitigate extremes of health and poverty, raise levels of productivity and efficiency and conserve human resources, the source of national wealth.” Not one of these goals has anything to do with the practice of medicine. Only the fact that the school was founded by a physician educator tied the new discipline to medicine.

The field is still medically led, and that fueled the failures of the profession during the pandemic. As I have stated in a previous column (5/6/22), there is public confusion as to the difference between health care and public health even to the extent that the president of a university that was planning a school of public health embarrassed himself recently by proclaiming that its graduates would be “health care warriors” thereby proving that he had no understanding of what public health actually is.

Medical discoveries were the basis of our understanding of COVID, but understanding does not automatically translate into effective policies and programs. Instead of the constant information barrage from physicians, we needed specialists in communication, politics, public health law and public programs. After all, Dr. Snow didn’t stop the cholera epidemic by medical theorizing. The epidemic was stopped by persuading local authorities to disable the pump and forcing the population to get their water elsewhere.

Placing physicians as the lead communicators for government action presented two nearly insurmountable problems. First, doctors are not often good communicators. As a native New Yorker, I enjoyed Dr. Fauci’s mellifluous Brooklyn accent, but he was losing people with every word. Second, the presence of so many doctors giving advice enabled the public to believe that this was a situation like that in their doctors’ offices where they had a choice as to whether to follow the advice given. The CDC has just issued information as to their reorganization after their acknowledged COVID failures—information that was even more unintelligible than their press releases during the epidemic. It seems they learned nothing.

With a profession as multi-disciplinary as public health, it is difficult to identify its core. But surely, it is  closer to public administration than it is to medicine. The science has to be there, but without execution, the science helps no one. How do we get more administration and less medicalization in public health? The discipline of public administration could simply absorb public health within it—sure to be bitterly fought by the doctors who believe they own public health and by the public that sees medicine and public health as the same thing. 

But there is a movement underway that may solve the issue. When I entered the field, I was a typical clinician entering into an MPH program mid-career—and programs were fairly scarce. In the decades since, public health has become far more popular not only as a graduate program, but also as an undergraduate degree. Clearly, undergraduates are not clinicians. It is not unreasonable to expect that they may see public health as an administrative practice untethered to clinical practice. And that will be a good thing.

AuthorBurden S Lundgren, MPH, PhD, RN practiced as a registered nurse specializing in acute and critical care.  After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk VA.  She has served as a consultant to a number of non-profit groups.  Presently, she divides her time between Virginia and Maryland. She can be reached at [email protected].

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