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 Completed High School Military Service-RAMC-Lab.Tech Completed Military Service entered Med School 1954 graduated Besides skills in trauma medicine, major diseases for which we had reasonable intervention. Hospitals filled with children with communicable disease

Public Health in the 1950s 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 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 I found: – 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 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 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?Who Will Keep the Public Healthy? IOM study: Future of PH in the 21 st CenturyFuture of PH in the 21 st Century – Translation research to be improved

Future PH training Ecological Analysis – Concern for culture & differences Linkages between PH and Primary Care – to ensure access and prevention priorities Non-Traditional Research – Community Based Community Based Team Practice – Nurse, social workers, mental health workers, aging workers: Removing the Silos

Important new skills needed Data-based decision-making Focus on GenomicsGenomics Focus on chronic diseasechronic 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 AtlasGlobal 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

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