Transcript Preparation for Public Health Practice: How it Was, Is and Could Be.

Public Health Practice: How it Was, Is and
Could Be.
CMG Buttery, MBBS, MPH, FACPM
Adjunct Professor of Public Health
Dept. Epidemiology & Community
Health
Virginia Commonwealth University
How I started.
1946 Completed High School
Military Service-RAMC-Lab.Tech.
1948 Completed Military Service
entered Med School
1954 graduated
Besides skills in trauma medicine,
20-30 major diseases for which we
had reasonable intervention.
Hospitals filled with children with
communicable disease
Public Health in the 1950s
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MCH
DPT
Waste disposal, potable water, food service
Primary care access assured for all in UK
Physicians trained to deliver primary care
Hospitals full of children with infectious diseases
Average life span just over 60 years
Many PHNs worked out of primary care practices
Private Practice
1957-1966
• I started practice with a set of punch cards to
– Track my patients
– Ensure quality control.
"Clinical investigation in general practice: the use of a
simplified data-recording system.” Southern Medical
Journal, 1963
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Most of my practice related to a few conditions
Much of the care I gave revolved around chronic diseases.
There were few useful interventions
The outcome of these interventions was mostly poor.
Public Health 1966-1995
Strategic Interventions:
Portsmouth: Rental Housing Reform
Norfolk (EVMS): Primary care. Prevention
clerkship
Corpus Christi: Restaurant Code enforced jointly
by Restaurant Association and PHD
State of Virginia: Study on Primary Care Access
Where we Are Today-I
• 100’s of disease for which we intervene, some
more successfully than others.
• Relatively few communicable diseases due to a
multitude of vaccines and improved sanitation
• Large numbers of people living past 80 years of
age
• Many dying after paying for extensive medical
intervention with minimal success in last 6-12
months of life.
• Limited access to Primary Care for 15% of
population
Today -II
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Physicians in the US trained as Specialists.
Many Primary Care MDs imported.
Focus of medical care on ‘premies’ and Elderly
Doctors reimbursed for procedures not
prevention.
• NO universal point of access for care other
than ERs.
Today -III
• MCH still dominant, but interventions only
mildly successful in reducing premature
deliveries
• Multiple Vaccinations with schedules that
change several times a year (see comments in March 15 ‘08
issue of the Lancet. Prioritization of routine vaccines: a mistake for the USA)
• Immunization rates improved but not good
enough
• Focus on sewage and water, food service
Current Philosophical Concerns
• Concern about no-one being exposed to any
hazard however remote
• Dominated by activist politics rather than
disease epidemiology
– Hurricane Preparedness
– Pandemic Preparedness
– Food borne outbreaks
– Vaccines linked to autism
• Domination by the ‘WE’ generation.
Where should we be Going?
• Public Health equivalence of clinical
excellence, E.G. epidemiology based (AHRQ)
– US Preventive Services Task Force
– Outcomes and Effectiveness practices.
– Local Health Department Accreditation.
• IOM study: Who Will Keep the Public Healthy?
• IOM study: Future of PH in the 21st Century
– Translation research to be improved
Future PH training - 2010+
• Ecological Analysis
– Concern for culture & differences
• Linkages between PH and Primary Care
– to ensure access and prevention priorities
• Non-Traditional Research
– Community Based
• Team Practice
– Nurse, social workers, mental health workers,
aging workers: Removing the Silos
Important new skills needed
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Data-based decision-making
Focus on Genomics
Focus on chronic disease
Use of the WWW 1 & 2
Distance Training (live classroom. Camtasia,
internet)
• Effects of Globalization (travel/climate
effects, Chikungunya)
• Use of GIS e.g. Global Cancer Atlas
My Concerns for the Future
• Is Public Health changing from an educational enterprise into a policing
enterprise?
We have always used laws to support Public Health
– Quarantine, people and animals
– Condemnation, food, water sources, lead paint
• But – Do we use police powers to decide who can eat what?
• Do we continue to let the population expand exponentially? What
does Genetic life extension and massive infectious disease prevention
do to population (see Science, March 14 –Dueling Visions of a hungry
World)?
• Do we start to require genetic counseling prior to procreation?
• Where does all this fit into Chronic disease prevention.
• Role in Community Planning
This presentation can be found at
http://www.commed.vcu.edu