Public Health Versus Private Health: The Coming Battle: 1. The Difference Has Little to do With Government and the Private Sector.

November 23, 2009 at 5:35 PM Leave a comment

Former Surgeon General C. Everett Koop

Written by Lewis D. Eigen

Public health workers are generally unrecognized heroes of our society.  They have saved the lives of countless millions of American citizens and improved the quality of life of many more.  But few of us ever come into contact with a public health professional.  Most of us interact with physicians and other medical personal in offices, hospitals and in occasional emergencies elsewhere.  The only public health scientists the public usually sees are the Surgeon General of the United States and the spokespeople who appear on TV and radio when there is a pandemic or other health emergency.

The distinction between public and private health is not one of officials of government versus the private sector personnel.  The term “private” means something quite different when discussing public health.  Public health professionals may work for government agencies, but they might just as well work for private companies or teach public health in medical schools and special schools of public health throughout the nation.  Some private hospitals might employ a public health professional and some have none.  Public hospitals, likewise.

The distinction between public and private health however is one of perspective and nature of their work.  A private physician, as we perceive him or her, serves an individual patient and owes through tradition and law his greatest duty to the individual patient he/she is treating.  A public health doctor may never treat anyone after her initial training.  His goal is to treat the public as a whole.

The most classic difference we see is with the flu each year.  Public health doctors and other scientists gather the data from the world over, analyze the patterns of flu outbreak, sample the specimens that have been taken by private physicians all over the country, analyze them, develop vaccines, test them, study the nature of the flu each year, determine what drugs are useful for treatment and which are not, measure the lethality and recommend to private health professionals how to treat the flu that year and when to vaccinate and who should be and not be vaccinated.  At a local level, a public health physician or nurse may provide injections of vaccines, but the vast majority of us are inoculated by private physicians or nurses.  And those of us who do contract the flu are almost always treated by private physicians.  They may be working at a public hospital where we are treated, but they are not public health professionals, have rarely been trained as such, and generally have a very different medical outlook.  Public health professionals have basic training as physicians, nurses, dentists, biologists, and then go through special training and receive additional and separate degrees.  The two in public health are the MPH (Masters of Public Health) and the DPH (Doctor of Public Health).

The additional public health training provides professionals with specialized skills and techniques, but most important, it changes their outlook and perspective.  Most often the public health and private health professionals in America work hand in hand with mutual appreciation of the other’s critical role of keeping America (and likewise in other countries) medically safe.  However, there are occasions where the different perspectives lead to friction between the two, and as medical science becomes more and more sophisticated and complex, there has tended to be an increase in that friction.  Moreover, there have been serious clashes, and these are coming with greater frequency.

Let’s start with a simple hypothetical example to illustrate the difference in point of view.  Assume that there is a technique developed that could identify some people who had a genetic characteristic that would weaken a particular brain blood vessel that would have a good probability of busting and causing a deadly brain hemorrhage in the next 40 years.  Some scientist wins a prize for the excellent research.  A test is developed, and if that is administered by every adult’s physician, those with the congenital weakness can be identified so that they can have surgery immediately to repair the weak vessel and prevent death from an aneurism.  Every physician has to decide whether or not to recommend the test to his/her adult patients.  However, those private physicians are incredibly busy treating patients; they have little time to read all the research and the scientific studies to decide who should be screened, when, how often, and for what period of time.  Most physicians are not scientists and often cannot understand the modern research with its techniques of genetics and molecular biology or the subtleties of modern probability and statistical analysis.  The public health professionals have the time and indeed it is their job to investigate the new technique, and other new research and data, and come up with recommendations to allow the public to benefit from the new research.

Now consider this possibility.  The research data shows the public health professionals that the new test will identify 10 percent of all the aneurysms that will occur from this particular cause.  And in our hypothetical example, out of every 1 million Americans 100 will normally develop this aneurism problem.  So if we were to screen 1 million Americans with this new test, say at age 21, we will identify 10% or 10 people.  These folk can then have the surgery and they might not die of the aneurism problem.  So by instituting this screening program, we might save 10 lives for every million people screened.  Each year we have about 4 million Americans reach age 21, so we might save 40 American lives with such a screening program.

Now the instinct of the private physician is that this is a “no brainer.” “I will screen all my patients when they become 21.  It is not a common problem, but no patient of mine is going to die from something that I and medical science can prevent.”

The public health physician however uses the same data but has a slightly different perspective.  He asks, how much does the screening test cost?  If the answer is $1000 (more than a mammogram and less than a PET/CT scan), the public health analyst looks at the larger picture.  Each year, we as a society will spend $4 billion ($1000 X 4 million people scanned) and we will save 40 lives.  That is a cost of $100 million per individual life saved.  The public health analyst observes that in America we have one of the highest infant mortality rates of the industrialized world.  And that is almost totally due to the many pregnant women who, under our system or lack thereof, get NO PRENATAL CARE.  $5000 spent on prenatal care for pregnant women would save a an average of one life.  So from society’s point of view, we could save 20,000 children’s lives for every aneurism life saved by the screening program.

Ideally we would do BOTH, but the stark reality is that resources are limited, and we are not now spending the money to provide prenatal care to all pregnant women.  To the public health professional, it is also a “no brainer”.  Don’t do the aneurism screening and spend the equivalent money on prenatal care.  To their perspective, if society would actually fund an aneurism screening program, it would be tantamount to allowing hundreds of thousands of children to die in order to save 40 adults.

Much of the public-private health conflict is fact-driven.  For example, if the screening test would only cost $1 each, the cost to society would be only $4 million, and we would save 40 lives at a cost of $100, 000 a person.  That almost all would say was a reasonable figure.  The conflict increases as the cost increases.

You might think that this hypothetical example is so dramatic and far-fetched that it is not within the realm of reality, but it is really typical of several situations that face medical science .  There are several like this today, and there will be many more as scientific medical research continues at its amazing pace.

What is perhaps most dramatic in this example is how the one commonality from both the public and private health perspectives is that their opposite conclusions are each clear—”no brainers”.  The problem for our society is that THEY ARE BOTH RIGHT!

There is a saying in Washington, “Where you stand, depends on where you sit.”  In health and medicine, where you stand depends on which perspective you take—that of a public health professional concerned with the health of society as a whole or that of a private health provider primarily concerned with doing the best that can be done to preserve the health of her patients.

The most dramatic real recent example of this conflict was the recommendation [1] regarding mammograms and breast self-examinations that was made by  the U.S. Preventive Services Task Force, a committee of public health scientists (mostly from the private sector) formed years before under President George W. Bush, to advise the Department of Health and Human Services and presumably the private physicians treating women throughout the country.  Let’s consider just the latter issue—the recommendation to, in effect, abandon breast self-examination.  From the lay perspective this seemed “nuts”.  There are many documented cases of women who were trained to be aware of their bodies and felt nodules while in the shower.  The women reported this to their personal physician, who did a physical exam, confirmed the lump, ordered a biopsy which proved positive for cancer, and surgery followed, thus saving the woman’s life.  Laymen and women asked, “What could those fools be thinking to recommend that we abandon breast self-examination?”  Most private physicians also could not understand such a recommendation.  Every one of them has had a woman visit his/her office after breast self-examination and while not always, lives have been saved.

However, there was a method to the apparent madness of the recommendations of the group of public health physicians and other scientists who gave this advice.  They were sitting in a different place and examining the issue with a different perspective.  They first observed that there are, literally, millions of women who think that they have detected a malignant lump and so inform their physician.  Their physician examines them and is not certain.  So a mammography is ordered.  Unfortunately, the self-examination has a very high false positive finding.  Women honestly think that they may have found a cancer but it was not so.  The physician’s physical exam is considerably better, but also has a high false positive rate.  And the mammogram technology, unfortunately, also has a high false positive (and false negative) rate.  Therefore, in our country, millions of biopsies are done (cost is about $250 each in America) that are unnecessary.  Breast biopsies tend to have a much smaller false positive result, but they do have a false negative result. (The biopsy is negative, but there really was a tumor.)  This is where the clinician’s skills and the art of medicine enter the picture.  A family with a history of breast cancer, the existence of a certain genetic pattern might well argue for surgery even in the absence of a positive biopsy.  But from a public health perspective, women are making millions of doctor’s visits triggered by breast self-examination and the vast majority of them do not produce a finding of breast cancer.  The once a year physician physical exam at an annual checkup is a much more reliable methodology.  The number of cases that would be detected by self-exam in between annual physicals is very small.  Meanwhile, there will be a cost in terms of anxiety for women over false positives, the unnecessary additional biopsies that will be performed, and the anxiety they will provoke when almost all will prove negative.  Meanwhile, the public health  professionals observe that the media and messaging effort plus the unnecessary physician visits, and unneeded biopsy costs that have been spent–triggered by breast self-examination — could well better have been spent more productively on other tactics—with female cancer — with many more total lives saved.

Here is one way of interpreting the two different points of view regarding breast self-examination:

Women as a whole would be better off if breast self-examination were not promoted and the effort went into assuring that more (all) women would present for an annual check-up (many women do not now do this) at which a physician would do a thorough physical examination.  However, I as an individual woman would be much better off if I conducted my own breast self-examination as frequently as possible, so I could detect any slight changes.  I will make some unnecessary visits to my physician, and she will probably do some unnecessary mammograms or biopsies as a result of my thinking I detected something, but in that rare case where I might be right, we can catch things in time and my life can be preserved as a result.  In my personal value system, I will trade the anxiety of examinations and biopsies for the good chance that I will not die of the very rare case of an  undetected breast cancer growing too fast to be detected in time at my next physician annual checkup.  And my personal physician is more than willing to follow through if I think I detect something as she realizes that while the likelihood of my finding a real tumor may be very infrequent, it could save my life in the rare case that I detected a real tumor.

Note that the public health perspective tends to take costs into consideration if not overtly but in terms of alternative uses of resources.  However from a private fiscal point of view, there is the classic dilemma of investment in the protection of ourselves and our family verses considering all of society and weighing relative need or merit.  A husband might say, “If my wife and I can afford to make a potentially few unnecessary office visits, mammograms, and biopsies, and we are willing to risk the anxiety of the testing processes and even the very low risk of infection from a biopsy, and our physician is getting paid and independently agrees that this course will maximize my wife’s chances of living, who is some public health physician whom I have never met and who knows not a smidgen about my wife, to tell us that we should not practice breast self-examination and to tell the medical profession that they should not spend the time and effort to teach my wife how to do this?”

Both points of few are right and both are legitimate.  However, they conflict in this case and while often the two points of view reach the same conclusion (as in the recommendations of a similar public health group opining on cervical cancer and pap test screening), there are more and more seemingly irreconcilable conflicts emerging.  In a sense, this is the origin of the extremist, absurd characterization of public health advisory panels as “Death Panels”.

Future articles in this series will explore the critical role of the public health perspective, the political dilemma a democracy faces, the possible solutions and method of blending the two points of view.  American health will suffer markedly if either point of view would be silenced.  But we also suffer when they conflict as we must find processes for getting the best of both worlds and better health for Americans.

———————-

[1] The complete report was published by the Annals of Internal Medicine, 17 November 2009, http://www.annals.org/content/151/10/716.full

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Entry filed under: Health & Medicine, Politics, Science. Tags: , , , , , , , , , , , , , , , , , , , , , .

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