Review of Jonathan ’s book:
For Harvard Medical School class of ’68:
One might not expect to be thrilled by a book entitled Public Health Practice (edited by Jonathan E. Fielding, MD MPH and Steven M. Teutch, MD, MPH, Oxford University Press, New York, 2013 available from Amazon, 12 in stock) but the subtitle gives it away: What Works.
On the other hand I think this is a good time to mention that I had a wonderful time at Harvard Medical School. I liked my classmates immensely. The only time in my life comparable was two months I spent in the radiology department in Lund, Sweden. There, too, I found extraordinarily talented and sociable friends, but the circle of friends was much smaller. You wouldn’t have guessed from my grades how happy I was. I repeated the second year. I was haunted by the conviction that I was missing something, and I was thoroughly distracted. That turned around the second year. After each lecture Judy Levine would come sit beside me and start, “The major points in that lecture were…” and bring me up to speed. I’ve never properly thanked Judy so if anybody is in contact with her do give her my very best.
Jonathan was among the most sociable. Although the story of the administration of a public health department might seem dull in prospect; dull was not what I expected. Jonathan was quite the opposite. I trust I violate no sacred trust in recalling that he taught himself how to drive with only his legs (I don’t know how he managed to signal left turns.) so as to have both arms free to hug his date. DON’T TRY IT. It’s dangerous. Besides I can’t afford to lose any readers. In my expectation of a worthwhile read I was not disappointed.
The editors have accepted input from some eighty five experts, coming pretty close to Eric Chivian’s hundred. The tone is consistent throughout. The proofreading and grammar are above reproach. This is a monumental accomplishment. The book breaks down into an introduction describing Los Angeles County, the biggest in the country and by population bigger than several states with enormous diversity among that population and their health care needs. Then it proceeds from crisis to crisis detailing the background, the problem, the administrative actions that were needed and what was learned.
If you asked me what a public health department did before I embarked on my reading I would have said they set up clinics that provide care for poor people. I should have known better. I work in a public health department in Pinellas County. And caring for the poor is what I do, except when I am doing chart reviews.
You remember the story of Buddha. When he was young he was Prince Siddhartha Gautama. He lived in a palace, where he had tutors and could have anything he wanted brought in. Then one day he asked to go for a walk. The tutors could not discourage him, and on the stroll they passed a poor man, a sick man and an old man. The young Siddhartha asked of the poor man, “Is that going to happen to me?” He was told it was most unlikely. He found the sick man to be more troubling and upon inquiring was told he might indeed become sick, but he’d probably get over it. The old man seemed worse than being poor and sick at the same time and the prince learned that he would become old, if he lived, and there was no escape. There are other stories and other versions, but this one was told me with a straight face.
Anyway, for me to help you, you have to be poor, else you have insurance, but not too poor, else there is Medicaid. You have to be older than pediatric, for whom there are other resources, but younger than 65, else there is Medicare. And you have to be sick but not too sick, else you go to a hospital.
As it turns out, I see few under 45 – they think they’re gods – and few over 55, by which time they probably have something really wrong and are attending some clinic regularly. Don’t pin me down on that any more than the legend of Buddha. But our little clinic is a small part of the building where I work.
I should have noticed something else. My professional swansong is in public health. Bill Morain’s Sword of Laban addresses mental dissociation, bane of the wretched of the earth, as does Rick Kluft’s Good Shrink – Bad Shrink from an entirely different perspective. Art Boylston’s Defying Providence is about the early stages of public health’s greatest victory. Hatim Kanaaneh’s Chief Complaint is public health from the clinical side. Eric Chivian’s Sustaining Life, is all about keeping the population healthy. It seems that anybody in the class who has been passionate enough to write a book I’ve heard of gets into public health one way or another. Oh, yeah. There’s I. Mine is the ghostwriting of the autobiography of a professional wrestler. Oh, well. All I can conclude is that the rest of you are a bunch of irredeemable idealists.
Fielding’s attitude is, “Taxpayer money goes into public health, and they have the right to get value on their dollar. The obligation of a public health department is the health and well being of everybody in the region served. In order to serve that region it is necessary to have objective measurements of that health and well being and then to follow how those measurements change, if they do, after resources have been committed to some intervention.”
This is evidence based public health. When I first heard about evidence based medicine,” I thought, “But that’s redundant. Medicine has been based on science ever since the Flexner Report, and science is evidence based. If you are going to prescribe a drug you want to know what the evidence is for its working in present circumstance. If you want all evidence gathered with the help of tax money to be made available whether publishable as a paper or not, more power to you. But it’s still science.”
Ah, but stay. Science works to build a coherent picture of the universe. A lot of us think that picture is fundamentally limited, but it is a valid pursuit of truth. On the other hand, the work of the health department does not go that way. For instance, and I hope I do not spoil the story, but at one point four million gallons of untreated sewage were discharged into the bay. This is not the kind of public health issue that would normally come across my own desk. When an investigation was done a further twenty-seven million gallons of spill from many events were unearthed, fewer than one in ten ever reported to the public health department. Steps were taken to assure rapid reporting, beach closure, repair, monitoring of the bacterial count in the polluted water and reopening the beach when levels returned to a safe level. The people of the county thus had their tax dollars justified by safer water. But it’s not exactly a scientific discovery.
Then there is the story of the cheese, but I’ll not risk spoiling that one. It’s chapter 16, and it’s a true thriller.
I should also mention the Community Preventive Services Task Force (CPSTF), the first comprehensive effort to undertake systematic rigorous reviews of interventions (policies, programs and systems) that can improve health at the population level. Jonathan and others (and if Jon is not the guiding spirit here I am a monkey’s uncle … shouldn’t that be “nephew”?) have been at it for two decades. The work is ongoing and under-funded, which seems outrageous to me for something so important and – read the book before you consider not whole heartedly agreeing – productive. Their web site is
thecommunityguide.org.
The existence of the CPSTF is most heartening. My (perhaps over-emotional) feeling is that for many years Jonathan was a kind of a father figure for the whole of Los Angeles County, harkening carefully to their woes, intervening where he could and making a fine effort to help even when it seemed impossible. But careers are finite, as we are all currently aware. The existence of the CPSTF means that the work is ongoing on a larger scale and addresses all public health programs with the same astute aim as we can see has been the hallmark of the LA County program. In other words, if Jonathan is the (I need an adjective here to say just what kind of father – not literal of course. Even for a super-stud it would be impossible.) … father of LA County then CPSTF is the grandfather, overseeing the challenges and tribulations as well as triumphs of all those other public health programs as well.
Of course I read Jonathan’s book with my own orientation toward birthrate and demographics. This would seem to be a legitimate subject in public health. Where else would the poor go in hopes of limiting fertility? Or improving it? Of course I scream myself hoarse that our current usual mating strategy courts extinction; the birth rate is low and seems poised to collapse, but it is mentioned in the book that 42% of pregnancies in the county are unintended. Talk about a hard sell. On the other hand a number of European countries are trying to encourage people to have more babies. All they can think of is throwing money at the problem. That’s hardly rational for a disease of the rich. (Metabolic syndrome, that is to say obesity, hypertension and diabetes, is a scourge of the poor. Throw money at that one if you must. But be sure to establish measurements of success and follow them.) Unquestionably infertility is a public health issue.
I suspected that the birth rate in the county would be anomalously high, given the proportion of Hispanics and the widespread perception that they have a high birth rate. So I checked it out:
http://publichealth.lacounty.gov/epi/docs/Birth_Trends_Health_Brief_Final.pdf (At last a source of statistics I feel confident in.)
The number of births per woman in LA County had fallen to 1.8 per woman by 2010 and the fall appeared to be unabated. Among Latinas it was: 1990 – 3.6; 2000 – 2.7; 2010 – 2.2. Anything below 2.1 is unsustainable. On the face of it put no trust into the notion we can replenish our population at will by Hispanic immigration.
If anybody wants to get the birth rate back up, talk to me. I may or may not have something that works, but at least what I have is scientifically sound and different from the proven failure (save only a small and inadequate response to day care availability in England) of throwing money.
Taking a step back, overall this is a book edited by administrators and about the work of administration: what works. Obviously it should be of great interest to anybody in public health, and the greater their responsibilities the more useful the book.
Taking another step back, what do you need for a civilization that can survive? Priests? The US seems to be getting along okay by many measures without a High Priest. A military? The Minoans seemed to have none. Scientists? It’s hard to see them in any civilization before our own. Mathematicians? They are in evidence in some places you are likely to look, but mostly civilizations seem to have got along with arithmetic. Architects and engineers? You’re going to need them if you want heroic architecture, but there was quite a sizeable civilization in the Amazon basin not long before Columbus. They had some roads and canals, but to my thinking nothing that would require a great deal of training.
But you need administrators. You’ll always need administrators. Get a lot of people working together and you have to coordinate their efforts. And if you read the book you’ll see that it can take an incredible amount of effort, patience, courage, imagination, communication, abstract reasoning, honesty, flexibility on demand, iron rules on demand … doing it well takes a lot.
And those administrators have broad social horizons. All right. In China, the bureaucracy was run by eunuchs. There was not going to be a hereditary administrative class that was going to die out because they never married cousins. The imperial family? They follow the same rule as any other civilization. But the civilization seems to have gone on in defiance of the three century brick wall. They found talent by giving nationwide aptitude tests.
That might work for us, but by and large the best talent now seems to come from good families throughout our global civilization. And globally the middle class appears to be dying.
Sorry to tag my own obsession to a review of such a wonderful book.
Jonathan has further pointed out me, and I’m sure it’s meant for everybody, that as we get older we can keep such of our goals as are appropriate and relevant. He emphasizes that it is a privilege to have a public health school named after his wife and himself and to be able to help prepare the next generation of public health leaders. A key objective of that preparation should be – in the interest of having a healthy population – to understand the need to be concerned with and interact with other sectors: education, law, housing, transportation, social services and so forth.
Public Health Practice: What Works, is an excellent gateway to that larger universe.
There have been 149 visitors over the past month and YouTube has run “Babies Triumph over Evil” 125 times since it was first posted.