Viewpoint: Reflection and Learning

In early September I returned to Georgia to give a keynote at the annual meeting of the Georgia Public Health Association. I appreciated the opportunity to get away from the glare of the Northwest's fabled sun and re-moisturize via Savannah's humidity. At this stage of my public health career, people are asking me to reflect on one thing or another—on the "past" in Georgia or about "public health in the Northwest" in this editorial.

I recalled events during my three decades plus career with CDC and then the DeKalb County Board of Health. Then I checked my own fickle memory by having long and interesting phone conversations with eight DeKalb public health nurses. I was struck by the contrast between their insights gleaned from about 250 collective years of public health experience and the lessons I thought I had learned along the way.

In recent years many states have shifted public health in and out of super-agencies. A belief that underpinned one such reorganization in 1972 in Georgia was that those who were poor, or disadvantaged or who had specific needs because of their condition or stage of life would be best served by creating so-called "one-stop shops" for their service needs. The model chosen in Georgia had striking similarities to the primary care medical model, namely, that providing quality basic services to individuals would result in improved health of the public. In a real world of limited resources, should we apply these resources primarily to those most in need, or should we concentrate on those who would stand most to benefit when the population is considered as a whole? Debate around this question remains a major unsolved undercurrent in public health throughout the country, including the Northwest.

The authors of the Institute of Medicine's recent report, The Future of the Public's Health in the 21st Century, assert: "For nations to improve the health of their populations, some have cogently argued, they need to move beyond the clinical interventions with high risk groups. . . . Personal health care is only one, and perhaps the least powerful (my emphasis), of several types of determinants of health, among which are included genetic, behavioral, social, and environmental factors."

While policy wonks analyzed such reports, the nurses were engaged in the actual transactions of caring for people. They, in fact, cite the decade of the 1970s as a time of empowerment and not "disarray" as described by the reports. No single topic lit up the voices of my nurse interviewees more than home and community visitations. Home visits provided a presence for health not only in the home but also in many other settings like schools, churches, and recreation centers. The nurses felt responsible for the whole family and even for specific census tracks within the community. Home visits provided specific health assessments but, as important, opened the door to solving social challenges facing the families they visited, like heating, food, and transportation.

Each of these nurses could recall specific problems that they detected early: finding a heart murmur in a child who needed cardiac surgery, arranging a diagnostic workup for a new mother who had headaches from an undetected pituitary tumor, or assisting a young man with a spinal cord injury who eventually graduated from college. And just as moving were the stories of multigenerational relationships built and sustained: mothers coming into a health center to proudly announce the one major milestone or another of a child first visited as an infant.

In the 1970s public health had figured out how to do its version of the medical model. The most casual conversation with these public health nurses revealed how satisfying and "effective" it is to help the sick, to monitor their progress, to affect their lives in sometimes dramatic ways. For them, this was when public health was at its finest. I hope that attempts to change the systems themselves will be as satisfying and effective in the long run.

It is almost sophomoric to state that 9/11 has changed our world. In fact, my greatest fear about 9/11 is that preparedness has become the big daddy of all categorical programs, replacing the medical model as the great distracter from our core mission.

Public health is more than the sum of its parts, more than all the programs operated by state and local health departments, and certainly more than the caring ministrations for individual patients. Rather our responsibility is to assure that each and every neighborhood is served by a responsive public health system, so all can achieve their dreams of healthy people living in healthy communities.

Public health must be the prickly conscience of the community that continually redefines through scientific measurement what is unacceptable. We must be the catalyst for population health strategies and system changes. The Northwest can lead the way.

Author
Paul Wiesner, MD, is assistant clinical professor at the Northwest Center for Public Health Practice and senior associate with Milne and Associates, LLC.