Monday, April 23, 2012

The Other America

Next weekend (legislature willing) I plan to be in Madison, Wisconsin for the 40 year celebration of my graduation from medical school. As I’ve been looking forward to this event, I’ve also been looking backward at how I got interested in medicine and how things have changed or stayed the same since that time. In the process, I’ve learned a lot about the truth of the quotation of George Santayana that "Those who cannot remember the past are condemned to repeat it." 

When I was a sophomore in high school trying to decide whether I should be a lawyer, a physician, or a priest, I came across a book by Michael Harrington that had just been printed. It was “The Other America.” It started out like this in talking about America of the 1950s: 

“There is a familiar America. It is celebrated in speeches and advertised on television and in the magazines. It has the highest mass standard of living the world has ever known… but, there was another America. In it dwelt somewhere between 40,000,000 and 50,000,000 citizens of this land. They were poor. They still are.

To be sure, the other America is not impoverished in the same sense as those poor nations where millions cling to hunger as a defense against starvation. This country has escaped such extremes. That does not change the fact that tens of millions of Americans are, at this very moment, maimed in body and spirit, existing at levels beneath those necessary for human decency. If these people are not starving, they are hungry, and sometimes fat with hunger, for that is what cheap foods do. They are without adequate housing and education and medical care.” 

Remember, this was written in 1962.

This book resonated with me in a way no other book has. The book was also influential with President Kennedy who used the book as a basis for some of his economic and social policies. It is thought that the book was responsible for President Johnson’s War on Poverty and that Medicare, Medicaid, food stamps, expansion of Title V, and multiple other programs were the direct result of the publication of “The Other America.” It was this proactive approach to eliminating the “Other America” that convinced me medicine should be my career. 

The passage of Medicare and Medicaid brought millions of people into the health care system and it became evident that there was a shortage of primary care physicians. This led to the development of the specialty of family medicine and it led Henry Silver and Loretta Ford to develop a program to train Advanced Practice RNs. The maldistribution of physicians also led to the formation of the National Health Service Corps (NHSC) and loan forgiveness programs. 

During medical school I became convince of the need for primary care. Although I didn’t take the Family Medicine route, I did join in the NHSC and spent 2 years in an underserved area. It was that experience that convinced me of the importance of primary care and public health and the need to integrate the two. 

Fast forward to today. “The Other America” is just as accurate a statement of our current condition as it was when it was written 50 years ago. We made progress in the 1960s and 1970s in eliminating poverty and hunger and improving access to healthcare but in the last 30 years we have reversed direction.  In today’s America income inequality is greater than at any time since the 1920s, hunger is widely prevalent, homelessness is epidemic, and over 50,000,000 people are uninsured. Only the elderly, because of Medicare, are doing better in some ways than they were in the 1960s. The same cannot be said for other age groups, particularly children. 

In addition, we still don’t have enough primary care providers; we continue to have maldistribution of resources; and it’s not because we aren’t spending enough money. In 1962 about 6% of our GDP was devoted to healthcare. Today it’s over 17%. 

Why have we not made more progress in eliminating the “other America?” Possible causes are in passages from the closing chapter of “The Other America.” 

“…the invisibility of poverty in American life is a result of this (political) party structure…politics have an issueless character. And where issues were not discussed, the poor did not have a chance.  They could benefit only if elections were designed to bring new information to the people to wake up the nation, to challenge, and to call to action.

“… the other America cannot be abolished through concessions and compromises that are almost inevitably made at the expense of the poor. 

“What is needed if poverty is to be abolished is a return of political debate, a restructuring of the party system so that there can be clear choices, a new mood of social idealism.

“This country seems to be caught in a paradox. Because its poverty is not so deadly, because so many are enjoying a decent standard of life, there are indifference and blindness to the plight of the poor… At precisely that moment in history where for the first time a people have the material ability to end poverty, they lack the will to do so. They cannot see; they cannot act.

The problem, then, is to a great extent one of vision…And there must be vision in the sense of purpose, of aspiration.”

So will I go to my 40threunion with a pessimistic attitude? Will I wear a mantle of failure? Will I pine at the fact that my generation didn’t change the world the way we had hoped? Absolutely not! 

The experiences of the last 40 years have taught me that, just as in the 60s, now is the time for some bold thinking and action. We have learned a great deal from our failures so we don’t have to worry about Santayana’s prediction – we are not “condemned to repeat” our history. We’ve learned over and over again that tinkering with the medical care system will not get us the results we need. We now know what needs to be done.   

What is needed is health and social reform based on the principles of public health. What is needed is a seamless integration of clinical care, social services, education, and public health. What is needed is to recognize that there is health in all public policies and that the social determinants of health must be addressed along with the physical and mental determinants. What is needed is a clear articulation of what is unacceptable in our society and leadership in resolving those issues. What is needed is vision, determination, and political will. 

Our job as public health workers is to figure out how to make all that happen. What could be a more important task and a more positive challenge?


Tuesday, April 3, 2012

This is Public Health Week


In 1995, President Clinton proclaimed the first full week of April as National Public Health Week. Each year since then, the public health community has celebrated this observance by focusing on an issue that is important to improving the public's health. This year the theme is “A Healthier America Begins Today: Join the Movement.” Minnesota is also observing Public Health Week with a proclamation by Governor Dayton ( Gov. Dayton’s Public Health Week proclamation ) and several events occurring throughout the state during the week.

I’m not sure why the first week of April was chosen as Public Health Week in America, but I do know that on April 3, 1855, the index case for the “Golden Square” cholera epidemic of London was identified at 40 Broad Street by Reverend Henry Whitehead. This is the epidemic made famous by the removal by John Snow of the pump handle from the Broad Street pump. Because of his persistent efforts to determine how cholera was spread and for the statistical and mapping methods he used, Dr. Snow is now considered the father of epidemiology, one of the basic tools of public health.

John Snow’s accomplishments alone would be as good a reason as any to celebrate public health in early April. But, the broader story around the Broad Street Pump highlights even more about public health that warrants celebration and provides some guidance for today. It highlights the fact that bringing the disease under control required contributions from people from multiple disciplines, most of whom were not in the health field, sharing information and learning from each other. It required the data collected by Reverend Henry Whitehead from his church logs and his home visits. It couldn’t have happened without the spot maps made by Edmund Cooper, an engineer for the Metropolitan Commission of Sewers, in response to the public’s complaints about foul smells in their neighborhoods. And the eventual elimination of cholera would not have occurred without the creation of the central London sewer system by Joseph Bazalgette, chief engineer of the Metropolitan London Board of Works.

Beyond the science and the hard work, conquering cholera in London also required that people keep an open mind about the cause of a killer disease until definitive objective evidence could be obtained. It also took a great deal of courage to advance new ideas that contradicted popular opinion and that were far from popular. Think of all the public health problems today that could benefit from the approach that was taken to combat cholera in the 19th century.

While John Snow gets most of the accolades, he wouldn’t have been able to do his epidemiology without the contributions of many others. And while he also gets credit for curtailing the cholera outbreak in 1854-1855, cholera kept coming back for several years. It was only when Joseph Bazalgette was able to create the sewer system did cholera eventually disappear. In true public health form, few people have heard of the guy who saved the most lives.

Given that history and the fact that 25 of the 30 years that have been added to our lifespan over the last 100 years were the result of public health activities it’s evident that the Public Health Week theme of “A Healthier America Begins Today: Join the Movement” is not totally accurate. Creating a healthier America and a healthier world began a long time ago. Because of that, I think we should expand a bit on that theme. During this Public Health Week we should be sure to honor the work of all of the workers that has occurred before we came on the public health scene – work that has formed the platform for what we do today. We should also take the opportunity of this week to encourage each other to keep working to keep the public health “movement” strong and going forward.

The world is a much healthier place than it was 100 years ago. And most of that improvement is due to the efforts of public health.

Enjoy Public Health Week,