The Two Faces of Public Health
December 19, 2016
Many years ago as a pediatrician in training at the largest children’s hospital in Argentina, I joined a group of first year residents who advocated for resident rotations through primary care centers in the poor neighborhoods—“villas”—that surrounded the city of Buenos Aires. We had two reasons. One was purely selfish, we knew we would get better training and learn more things than if we stayed within the confines of the hospital. But the other, and the one that really drove us as we signed petitions and advocated to the hospital authorities, was that we thought that through practicing in these neighborhoods we could make a difference in our society.
We believed in action, in service, we somewhat naively thought that our medical practice could make a real difference to the children and families of these neighborhoods. And sometimes it did, we diagnosed and treated infections and set dislocated hips in babies. But many times it fell far short, as I discovered when the many young patients I treated for diarrhea or respiratory infections returned week after week with the same problems.
In a foreshadowing of the recent rediscovery of the “social determinants of health” in clinical practice today, when we presented cases we discussed the patient’s social circumstances, housing, and family situation. We gave these much more importance than the medical record itself. We walked through the “villa” vaccinating children for measles, we drank mate with our patients, we organized and attended demonstrations, we had long philosophical and political discussions. We were physician social activists in the tradition of so many Latin American young professionals before us.
It was about this time, as I was rotating through intensive care, that a senior resident and friend, his name was Fernando, gave me a copy of a research article published in a pediatric journal. Read it, Fernando said (he knew I spoke English and could), you’ll see. I still remember the green highlights in the copy he gave me and his notes on the margins (there were no pdfs then and copies were expensive). The article was about pediatric pneumonia, it described prevalence and incidence (something new to me) and reviewed evidence of effective treatments. The article claimed, with supporting evidence, that many things that we were doing at the hospital or at the primary care centers to treat pediatric pneumonia were probably wrong. It was eye opening and shocking. And I got hooked.
Fernando and I began to spend our breaks reading in the hospital library (this was just a single room with wooden bookcases lining the walls) or in a café across the street over an espresso. We shared Xerox copies of articles we obtained from medical libraries scattered across Buenos Aires. Fernando told me that the articles were part of a new trend, called “evidence-based medicine”. What we read in the articles questioned everything we did, it felt almost revolutionary. The idea that evidence and facts could be so powerful and transformative was refreshing and empowering.
Many years later, what attracted me to public health was the balance of action and science, the strong commitment to both making a difference and using data and facts to diagnose the situation and identify the best course of action. Certainly this was true of medicine as well, but by moving beyond the individual patient to the population, public health requires a much broader view of science and action.
Science and action are the two faces of public health: each is strengthened and reinforced by the other. Facts and science can motivate and support action; effective action requires facts and the need to act motivates our search for facts.
Today, at the end of 2016, at a time of fake news and the frequent decoupling of political discourse from truth and facts, we need to redouble our commitment to the two faces of public health: yes to action and activism, and yes also to the facts than describe reality, speak truth, and thus empower and sustain action.
May the year 2017 be one of renewed commitment to what we in public health, through action and facts, can do to make our societies healthier and more fulfilling for all.