by Mark Johnson, MD, MPH
Featured in the May-June 2020 Colorado Medicine Colorado Medicine.
Public health is the illegitimate offspring from a short romance between medicine and social work in the late 1800s. I say illegitimate because medicine promptly abandoned its lover and child, chasing after the tempting siren calls of technology and pharmacology. Social work, feeling used and exploited, regretted having ever been involved with medicine in the first place. The outcome of this union is a wayward ward of the state, begrudgingly nursed along whenever it cries loud enough or when it is found to be useful.
From such a pedigree, one should not be surprised to find that public health’s main field of interest is promoting health in groups of people. Its basic sciences are epidemiology – the study of how diseases and conditions move through populations – and biostatistics, the essential analytical tools necessary to study the large amounts of data collected on how living organisms are being impacted by these movements. Unfortunately, public health’s most effective tools are prevention and regulation, neither of which are very popular in a libertarian and individualistic free-market society.
As public health has aged, however, some of its children have attracted the attention of the grandparents. Medicine has recently been smitten with the promise of population health, and social work has found itself captivated by the idea of the social determinants of health. Together, however, they have lately discovered a new appreciation for one of their oldest grandchildren, community epidemic response.
The COVID-19 pandemic has impacted medicine and social work in ways that will change them both for the foreseeable future. Medicine, I believe, will be the one most greatly changed by the epidemic. The entrepreneurial spirit and economic forces that have been stealthily pushing medicine out of the professions and into the realm of business will need to be reassessed. Just-in-time inventories, global supply chains, profit-based decision-making and limited access to services by large portions of the most vulnerable in our society have put the health of our entire nation at risk. While the scandalous shortage of personal protective equipment (PPE) calls more for lessons to be learned than for investigations into persons to be blamed, the resulting loss of health care workers, emergency responders and law enforcement agents is a tragedy of unspeakable proportions.
Although technology has dramatically improved our abilities to test, track and treat patients, much of our technical expertise has been forced to sit idly by, and pharmacology has played little, if any, role in the response to COVID-19 thus far. Temperature scanners, applications for smartphones, rapid antibody tests and the creative cloud-based sharing of scientific data and innovative ideas have all played helpful roles, but we have been forced by the novelty of this disease to fall back onto late 19th- and early 20th-century means of prevention and control: public health stay-at-home orders, homemade masks, social distancing, epidemiologic tracing, isolation of the ill and the quarantining of close contacts.
We will survive this pandemic, just as we did the influenza pandemic of 1918, but the new normal for medicine will not be the old normal. Patients will most likely mandate many changes: washing hands before and after every examination; wearing masks during all close interactions; no handshakes or hugs; and probably a more professional appearance. Health care workers will demand adequate stocks of PPE at all times. Global pharmaceutical and equipment supply chains will be suspect. More research into antiviral medications, antibiotics and immunizations will be requested, even if the federal government must subsidize the developments.
We have become complacent in medicine and we are paying the price. Nature has a way of collecting what it is due. If we learn anything from this pandemic it must be that Mammon is a seductive but cruel and demanding god, and that science, while frustratingly ambiguous at times, must be practiced carefully and honestly, and then trusted above the wishes of the populace or the whims of the politicians.