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Marriage Counseling for Medicine and Public Health
Editorials and Commentary
Marriage Counseling for Medicine and Public Health Strengthening the Bond Between These Two Health Sectors Ronald M. Davis, MD
E
fforts to establish close relations between medicine and public health date back to the 4th century B.C., when Hippocrates urged physicians to recognize the environmental, social, and behavioral determinants of disease: the airs “peculiar to each particular region”; the “properties of the waters” that the inhabitants drink and use; and “the mode of life of the inhabitants, whether they are heavy drinkers, taking lunch, and inactive, or athletic, industrious, eating much and drinking little.”1,2 Rudolf Virchow (1821–1902), although considered the founder of cellular pathology, understood that the causes of premature death and disease were typically found outside the laboratory: Should medicine ever fulfill its great ends, it must enter into the larger political and social life of our time; it must indicate the barriers which obstruct the normal completion of the life-cycle and remove them. Should this ever come to pass, Medicine, whatever it may then be, will become the common good of all.3 The professionalization of the fields of medicine and public health in the late 19th century and early 20th century, spurred by the emergence of bacteriology, provided many opportunities for collaboration across these two spheres.2 Reflecting this strengthened partnership, the American Medical Association (AMA) amended its constitution in 1920 to indicate that “the objects of the Association are to promote the science and art of medicine and the betterment of public health.” That concise mission statement, with its weighty emphasis on public health, has remained unchanged to the present. Regrettably, the bond between medicine and public health weakened later in the 20th century, especially during the post–World War II era. Lasker and the Committee on Medicine and Public Health2 attributed this estrangement to several factors:
From the Center for Health Promotion and Disease Prevention, Henry Ford Health System, Detroit, Michigan. The author is a member of the Board of Trustees of the American Medical Association. Address correspondence and reprint requests to: Ronald M. Davis, MD, Center for Health Promotion and Disease Prevention, Henry Ford Health System, One Ford Place, 5C, Detroit MI 48202-3450. E-mail: [email protected]
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1. The diverse and dispersed health system in the United States has not provided a strong structural foundation to support cross-sectoral interactions. 2. The delivery of personal health services by public health agencies was seen by many physicians as an intrusion into the medical domain and interference with the doctor–patient relationship. 3. Rapid advances in scientific knowledge, and the development of new medical technologies and public health programs, “made each health sector feel considerably more independent, dramatically reducing their perceived need to work together.” 4. The proliferation of medical specialties and the fragmentation of public health created logistical impediments to collaboration. 5. Cultural differences and growing disparities in funding between the two health sectors diminished the level of trust, respect, and communication between them. Eventually, medicine and public health “functioned as separate, and virtually independent, parts of the larger health system.”2
The Medicine and Public Health Initiative To bridge this gulf, the AMA and the American Public Health Association (APHA) collaborated in creating the Medicine and Public Health Initiative (MPHI) in 1994. In an article in this issue of the American Journal of Preventive Medicine, Beitsch et al.4 review the history of the MPHI and its activities in three bellwether states (California, Florida, and Texas) and abroad. They point out that the initiative generated impressive accomplishments in its early years, stimulated by grants provided for collaborative projects in 19 states. Nevertheless, they conclude, a “cultural and institutional divide” between medicine and public health persists in many localities, and the momentum of the MPHI has been difficult to sustain. Beitsch et al.4 point out that bioterrorism and disaster preparedness, the growing burden of chronic diseases, health disparities, patient safety, and healthcare access for the uninsured are urgent matters requiring effective collaboration between medicine and public health. In some of these areas, the complementary contributions of medicine and public health are obvious. In the area of chronic disease, for example, public
Am J Prev Med 2005;29(2) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.04.015
health conducts surveillance and epidemiologic research on chronic diseases and their determinants. Medicine, in turn, must deliver effective interventions to people who have— or are at risk of developing— these conditions (including prevention, diagnosis, treatment, and palliation). In addition, medicine and public health can work together—through individual counseling and community outreach—to educate patients with chronic illness on how to achieve good self-care. Bioterrorism and disaster preparedness comprise another area where the need for collaboration is essential. Physicians must be able to diagnose and treat illnesses caused by exposure to biological, chemical, or radiologic agents, and hospitals must be prepared to accommodate the victims of mass casualty events. Public health deals with myriad issues including environmental hazard identification, laboratory support, surveillance, containment (e.g., isolation and quarantine), public education, and risk communication. The AMA Center for Public Health Preparedness and Disaster Response has developed a National Disaster Life Support training program to enhance the response capabilities of civilian and military healthcare providers (www.ama-assn.org/go/disasterpreparedness). In July 2004, the AMA and the Centers for Disease Control and Prevention (CDC) co-sponsored the First National Congress on Public Health Readiness, which brought together almost one thousand national, state, and local leaders in clinical medicine and public health. Patient safety is a high priority on the agenda of the medical profession, but the role of public health in this domain might not be immediately obvious to many public health practitioners. However, public health officials and preventive medicine physicians are in a position to contribute to the prevention of medical errors through their knowledge and expertise in injury control, surveillance, systems change, health communications, and (in the case of aerospace medicine physicians) aviation safety, which has parallels to patient safety.5 To reinvigorate the MPHI, Beitsch et al.4 offer several recommendations deserving of implementation: (1) a visible renewal of the shared commitment to partnership through the MPHI among the AMA, the APHA, the American College of Preventive Medicine (ACPM), the Association of Teachers of Preventive Medicine, the CDC, and others; (2) professional education to integrate the elements of public health and medicine into each other’s curriculum; (3) research into “effective strategies that improve understanding and overcome barriers across the medicine–public health chasm”; and (4) leadership by local medical and public health communities to translate the MPHI into meaningful action. The AMA is enhancing its commitment to public health in a number of ways. The Association has
developed a healthcare advocacy agenda with seven items, one of which is to improve public health through promoting healthy lifestyles and eliminating health disparities.6 In partnership with the National Medical Association and the National Hispanic Medical Association, the AMA has convened the Commission to End Health Care Disparities.7 In addition to initiatives mentioned above, the AMA continues to work actively in several other important areas of health promotion and disease prevention, including tobacco, alcohol, obesity, violence, and immunization. The AMA Council on Scientific Affairs, one of the Association’s seven standing committees, is proposing to change its name to “Council on Science and Public Health.” In recent months, this Council and other AMA officials have met with leaders of the APHA, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials (NACCHO) to discuss common interests and opportunities for collaboration. As pointed out by Beitsch et al.,4 collaboration and partnerships at the local level are essential in order to strengthen the marriage between medicine and public health. At its 1996 annual meeting, the AMA House of Delegates endorsed seven broad-ranging recommendations developed by MPHI task forces, which were “intended to lead to local initiatives and activities in directions that will bring about a functional merger of public health and medicine.”8 Below I offer additional suggestions to assist local players from the two health sectors in renewing their vows, focusing on “operational” strategies to promote communication, cooperation, and collaboration between them. Several of these ideas are embodied in existing AMA policy.
Operational Strategies to Bridge the Gap State and local medical societies should establish public health committees if they do not already have them. At its 2002 annual meeting, the AMA House of Delegates adopted the following resolution, introduced by the American Association of Public Health Physicians: [I]n order to foster a greater understanding and collaboration between the practice of public health and the clinical practice of medicine, particularly in this time of national crisis, and to increase awareness of and participation of clinical practitioners in public health issues, [our AMA] encourages local, state and specialty medical societies to form public health committees within their respective societies, when practical . . . . In a follow-up report, the AMA Board of Trustees described the results of a survey that collected data from state and local medical societies and national medical specialty societies on whether they had public health committees.9 Among the respondents, public Am J Prev Med 2005;29(2)
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health committees were used by 29 (66%) of 44 state societies, 47 (58%) of 81 staffed county societies, and seven (15%) of 48 specialty societies. These committees deal with issues such as bioterrorism, violence, tobacco, alcohol, obesity, and immunization. Public health agencies should give representation to organized medicine on their advisory committees, and those who appoint members of boards of health should do the same. Many state and local public health agencies have public health advisory committees, which are intended to provide advice to agency officials from external experts and stakeholders. Some of these committees cover the entire scope of the agency’s activities, whereas others address specific areas such as immunization and HIV/AIDS. About 70% of local health departments have boards of health in their jurisdictions, and ⬎70% of the local boards have roles extending beyond making recommendations—namely, the adoption and enforcement of public health regulations.10 Giving representation to the medical community on these committees and boards will improve public health policymaking, will enhance physicians’ cooperation with public health programs and policies, and will help to engage medicine’s advocacy for public health funding and priorities. State and local medical societies should give public health officials representation on their governing and policymaking bodies. For many years the AMA has had a designated seat (with full voting privileges) in its policymaking House of Delegates for the Surgeon General of the U.S. Public Health Service. Staff from various agencies in the U.S. Department of Health and Human Services attend meetings of the House of Delegates to support the Surgeon General and to provide testimony on resolutions and reports based on input obtained from agency experts before the meeting. The AMA has nonvoting “official observer” seats in its House of Delegates for several health organizations that are not considered medical societies, including APHA and NACCHO. Following the AMA model, the Michigan State Medical Society provides a voting seat in its House of Delegates for the chief medical executive of the Michigan Department of Community Health. This interaction between medicine and public health informs policymaking by the medical associations, educates public health practitioners about activities in medicine, and facilitates networking and relationship building across the two sectors. Hoping to take this representation one step further, AMA policy (H-440.936) “urges county and state medical societies to create an ex officio position without vote on their governing bodies for the respective public health officer of their jurisdiction so that proper interchange between the private and public health communities can take place.” Medical associations should consider forming foundations to expand their involvement, and their mem156
bers’ involvement, in public health activities. The AMA Foundation has a major program in health literacy, and funds public health projects through its “Fund for Better Health” initiative (www.ama-assn.org/go/ amafoundation). Some state and local medical societies and national medical specialty societies have foundations to support research, education, and community service. As 501(c)(3) tax-exempt organizations, foundations may be better able than their parent societies to attract outside funding, which can be used to support public health programming. Leaders in medicine and public health should offer speaking opportunities to their counterparts at meetings and conferences, and these speaking engagements should be institutionalized. AMA policy H-440.942, resulting from a resolution introduced by ACPM in 1991, “urges each state medical society to extend to their respective state health officer a standing invitation to participate in and report to the annual meeting of their house of delegates upon issues, accomplishments, problems, and needs of public health significance within the state.” Much as a governor delivers a “state of the state” address to the state legislature each year, a state health officer could deliver a “state of the public’s health” address at each annual meeting of the state medical association’s house of delegates. State public health agencies and associations should reciprocate by inviting state medical society leaders to address their major conferences about issues of concern to medicine. Similar exchanges should occur at the national and local levels. Public health and preventive medicine physicians need to join their county and state medical associations and the AMA. Leaders of organized medicine will be more enthusiastic about working with the public health sector if its physicians are members of the medical association. AMA data show that about 4600 physicians in the United States designate their specialty as preventive medicine, but only about one fifth are members of the association. Public health and preventive medicine physicians have every reason to join, given the AMA’s devotion to the principles and practices of public health—a devotion shared by many county and state medical societies. As the AMA’s new slogan states, “together we are stronger.”
An Issue to Rally Around Perhaps the most compelling force to unite medicine and public health is the opportunity to work together to bolster the funding of each sector. Medicine is under financial siege from Medicare and Medicaid cuts in physician payment, skyrocketing medical liability insurance premiums, fee constraints from managed care, the costs of new medical technologies and converting to electronic health records, and the aging of the population with the concomitant burden of chronic disease.
American Journal of Preventive Medicine, Volume 29, Number 2
Public health is under similar pressure—from cuts in federal and state funding in the face of new responsibilities and worsening threats such as bioterrorism and disaster preparedness, emerging infectious diseases, and the growing epidemic of obesity and diabetes. Fifteen states cut their funding for public health in fiscal year 2004, and 31 states and the District of Columbia did so the previous year.11,12 Medicine and public health need to work together to ensure adequate funding for the care of our patients and populations. We must, of course, continue to fight for funding from the traditional sources that pay for these services. But as those sources shrink, we must turn our attention to other wells that are untapped or not fully tapped. Four areas, in my judgment, deserve special attention: tobacco taxes, tobacco settlement funds, alcohol taxes, and taxes on soft drinks sweetened with caloric sugars. Smoking-attributable disease, alcohol abuse, and obesity impose huge burdens on healthcare programs such as Medicare and Medicaid.13–15 Sugar-sweetened soft drinks are the largest single food source of calories in the American diet, and sugar-sweetened beverages have been linked to obesity in children and weight gain and type 2 diabetes in women.16 –19 So it is only fitting to use “sin taxes” to help pay for those burdens and efforts to mitigate them. Many states have increased tobacco taxes in recent years, but the federal cigarette excise tax is still low, and many states have not earmarked tobacco tax revenue to medical and public health programs.20 Huge portions of state tobacco settlement funds have been allocated to deficit reduction and programs that have nothing to do with medicine and public health.21 Most states have not increased alcohol taxes in decades.22 Furthermore, a minority of states impose specific taxes on soft drinks, and among those that do so, very few earmark tax revenues for health purposes.23 In any given state, medicine and public health can target one of these funding sources, develop a proposal for allocating the funds to be captured, form a coalition (or use an existing one), and then plan and carry out a legislative campaign. If unable to overcome political obstacles and special interests, the two health sectors and their allies can wage the next battle by pursuing a ballot initiative—if they reside in one of the 24 states that allow ballot initiatives.24 The challenges to qualify a measure for the ballot and to get it passed are daunting, of course. But the potential payoff is enormous. And nothing will more effectively cement the relationship between medicine and public health than for the two sectors to fight shoulder to shoulder, for a worthy cause, in the trenches of a political campaign.
References 1. Jones WHS. Hippocrates. Cambridge, MA: Harvard University Press, 1923.
2. Lasker RD. Committee on Medicine and Public Health. Medicine and public health: the power of collaboration. New York: New York Academy of Medicine, 1997. 3. Ackerkrecht EH. Rudolf Virchow. Madison: University of Wisconsin Press, 1953. 4. Beitsch LM, Brooks RG, Glasser JH, Coble YD. The Medicine and Public Health initiative: ten years later. Am J Prev Med 2005;29:149 –53. 5. Davis RM. Barach P. Enhancing patient safety and reducing medical error: the role of preventive medicine. Am J Prev Med 2000;19:202–5. 6. Anonymous. AMA’s advocacy agenda: 7 goals requiring medicine’s strength [editorial]. American Medical News, January 24, 2005. Available at: www.ama-assn.org/amednews/2005/01/24/edsa0124.htm. Accessed April 26, 2005. 7. Anonymous. Ending health care disparities: equal access to quality care [editorial]. American Medical News, February 28, 2005. Available at: www.ama-assn.org/amednews/2005/02/28/edsa0228.htm. Accessed April 26, 2005. 8. AMA Board of Trustees. Medicine/public health initiative (report 4 [A-96]). In: Proceedings of the House of Delegates, 145th Annual Meeting, June 23–27, 1996. Chicago: American Medical Association, 1996. Recommendations in the report (Policy H-440.911) are available at: www.amaassn.org/apps/pf_new/pf_online. Accessed May 31, 2005. 9. AMA Board of Trustees. Report on the number of federation public health committees (report 6 [A-03]). Proceedings of the 2003 Annual Meeting of the AMA House of Delegates. Chicago: American Medical Association, 2003. Available at: www.ama-assn.org/ama/pub/category/11740.html. Accessed April 26, 2004. 10. National Association of Local Boards of Health. About local boards of health. Available at: www.nalboh.org/publications/aboutlboh.PDF. Accessed April 26, 2005. 11. Hearne SA, Segal LM, Earls MJ, Unruh PJ. Ready or not? Protecting the public’s health in the age of bioterrorism. Washington DC: Trust for America’s Health, 2004. Available at: http://healthyamericans.org/reports/bioterror04/BioTerror04Report.pdf. Accessed April 26, 2005. 12. Elliott VS. Crisis vs. chronic: paying the price of public health. American Medical News, May 2, 2005. Available at: www.ama-assn.org/amednews/ 2005/05/02/hlsa0502.htm. Accessed April 26, 2005. 13. Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995–1999. MMWR 2002;51:300 –3. 14. National Institute on Alcohol Abuse and Alcoholism. Economic perspectives in alcoholism research. Alcohol Alert No. 51, January 2001. Available at: www.niaaa.nih.gov/publications/aa51.htm. Accessed April 26, 2005. 15. Finkelstein EA, Fiebelkorn IC, Wang G. State-level estimates of annual medical expenditures attributable to obesity. Obes Res 2004;12:18 –24. 16. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet 2001;357:505– 8. 17. Mrdjenovic G, Levitsky DA. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children. J Pediatr 2003;142:604 –10. 18. Schulze MB, Manson JE, Ludwig DS, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA 2004;292:927–34. 19. Apovian CM. Sugar-sweetened soft drinks, obesity, and type 2 diabetes. JAMA 2004;292:978 –9. 20. Campaign for Tobacco-Free Kids. Higher cigarette taxes: reduce smoking, save lives, save money. Washington DC: Campaign for Tobacco-Free Kids, 2005. Available at: http://tobaccofreekids.org/reports/prices/. Accessed April 26, 2005. 21. Center for Social Gerontology. Tobacco settlement funds. Ann Arbor MI: Center for Social Gerontology, 2005. Available at: www.tcsg.org/tobacco/ settlefunds.htm. Accessed April 26, 2005. 22. Center for Science in the Public Interest. Why raise alcohol excise taxes? Washington DC: Center for Science in the Public Interest, 2005. Available at: www.cspinet.org/booze/taxguide/TaxIndex.htm. Accessed April 26, 2005. 23. Jacobson MF, Brownell KD. Small taxes on soft drinks and snack foods to promote health. Am J Public Health 2000;90:854 –7. 24. Initiative and Referendum Institute, University of Southern California. Information on the statewide initiative process in the United States. Los Angeles: Initiative and Referendum Institute, University of Southern California, 2005. Available at: www.iandrinstitute.org/statewide_i&r.htm. Accessed April 26, 2005.
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Marriage Counseling for Medicine and Public Health Strengthening the Bond Between These Two Health Sectors Ronald M. Davis, MD
E
fforts to establish close relations between medicine and public health date back to the 4th century B.C., when Hippocrates urged physicians to recognize the environmental, social, and behavioral determinants of disease: the airs “peculiar to each particular region”; the “properties of the waters” that the inhabitants drink and use; and “the mode of life of the inhabitants, whether they are heavy drinkers, taking lunch, and inactive, or athletic, industrious, eating much and drinking little.”1,2 Rudolf Virchow (1821–1902), although considered the founder of cellular pathology, understood that the causes of premature death and disease were typically found outside the laboratory: Should medicine ever fulfill its great ends, it must enter into the larger political and social life of our time; it must indicate the barriers which obstruct the normal completion of the life-cycle and remove them. Should this ever come to pass, Medicine, whatever it may then be, will become the common good of all.3 The professionalization of the fields of medicine and public health in the late 19th century and early 20th century, spurred by the emergence of bacteriology, provided many opportunities for collaboration across these two spheres.2 Reflecting this strengthened partnership, the American Medical Association (AMA) amended its constitution in 1920 to indicate that “the objects of the Association are to promote the science and art of medicine and the betterment of public health.” That concise mission statement, with its weighty emphasis on public health, has remained unchanged to the present. Regrettably, the bond between medicine and public health weakened later in the 20th century, especially during the post–World War II era. Lasker and the Committee on Medicine and Public Health2 attributed this estrangement to several factors:
From the Center for Health Promotion and Disease Prevention, Henry Ford Health System, Detroit, Michigan. The author is a member of the Board of Trustees of the American Medical Association. Address correspondence and reprint requests to: Ronald M. Davis, MD, Center for Health Promotion and Disease Prevention, Henry Ford Health System, One Ford Place, 5C, Detroit MI 48202-3450. E-mail: [email protected]
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1. The diverse and dispersed health system in the United States has not provided a strong structural foundation to support cross-sectoral interactions. 2. The delivery of personal health services by public health agencies was seen by many physicians as an intrusion into the medical domain and interference with the doctor–patient relationship. 3. Rapid advances in scientific knowledge, and the development of new medical technologies and public health programs, “made each health sector feel considerably more independent, dramatically reducing their perceived need to work together.” 4. The proliferation of medical specialties and the fragmentation of public health created logistical impediments to collaboration. 5. Cultural differences and growing disparities in funding between the two health sectors diminished the level of trust, respect, and communication between them. Eventually, medicine and public health “functioned as separate, and virtually independent, parts of the larger health system.”2
The Medicine and Public Health Initiative To bridge this gulf, the AMA and the American Public Health Association (APHA) collaborated in creating the Medicine and Public Health Initiative (MPHI) in 1994. In an article in this issue of the American Journal of Preventive Medicine, Beitsch et al.4 review the history of the MPHI and its activities in three bellwether states (California, Florida, and Texas) and abroad. They point out that the initiative generated impressive accomplishments in its early years, stimulated by grants provided for collaborative projects in 19 states. Nevertheless, they conclude, a “cultural and institutional divide” between medicine and public health persists in many localities, and the momentum of the MPHI has been difficult to sustain. Beitsch et al.4 point out that bioterrorism and disaster preparedness, the growing burden of chronic diseases, health disparities, patient safety, and healthcare access for the uninsured are urgent matters requiring effective collaboration between medicine and public health. In some of these areas, the complementary contributions of medicine and public health are obvious. In the area of chronic disease, for example, public
Am J Prev Med 2005;29(2) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.04.015
health conducts surveillance and epidemiologic research on chronic diseases and their determinants. Medicine, in turn, must deliver effective interventions to people who have— or are at risk of developing— these conditions (including prevention, diagnosis, treatment, and palliation). In addition, medicine and public health can work together—through individual counseling and community outreach—to educate patients with chronic illness on how to achieve good self-care. Bioterrorism and disaster preparedness comprise another area where the need for collaboration is essential. Physicians must be able to diagnose and treat illnesses caused by exposure to biological, chemical, or radiologic agents, and hospitals must be prepared to accommodate the victims of mass casualty events. Public health deals with myriad issues including environmental hazard identification, laboratory support, surveillance, containment (e.g., isolation and quarantine), public education, and risk communication. The AMA Center for Public Health Preparedness and Disaster Response has developed a National Disaster Life Support training program to enhance the response capabilities of civilian and military healthcare providers (www.ama-assn.org/go/disasterpreparedness). In July 2004, the AMA and the Centers for Disease Control and Prevention (CDC) co-sponsored the First National Congress on Public Health Readiness, which brought together almost one thousand national, state, and local leaders in clinical medicine and public health. Patient safety is a high priority on the agenda of the medical profession, but the role of public health in this domain might not be immediately obvious to many public health practitioners. However, public health officials and preventive medicine physicians are in a position to contribute to the prevention of medical errors through their knowledge and expertise in injury control, surveillance, systems change, health communications, and (in the case of aerospace medicine physicians) aviation safety, which has parallels to patient safety.5 To reinvigorate the MPHI, Beitsch et al.4 offer several recommendations deserving of implementation: (1) a visible renewal of the shared commitment to partnership through the MPHI among the AMA, the APHA, the American College of Preventive Medicine (ACPM), the Association of Teachers of Preventive Medicine, the CDC, and others; (2) professional education to integrate the elements of public health and medicine into each other’s curriculum; (3) research into “effective strategies that improve understanding and overcome barriers across the medicine–public health chasm”; and (4) leadership by local medical and public health communities to translate the MPHI into meaningful action. The AMA is enhancing its commitment to public health in a number of ways. The Association has
developed a healthcare advocacy agenda with seven items, one of which is to improve public health through promoting healthy lifestyles and eliminating health disparities.6 In partnership with the National Medical Association and the National Hispanic Medical Association, the AMA has convened the Commission to End Health Care Disparities.7 In addition to initiatives mentioned above, the AMA continues to work actively in several other important areas of health promotion and disease prevention, including tobacco, alcohol, obesity, violence, and immunization. The AMA Council on Scientific Affairs, one of the Association’s seven standing committees, is proposing to change its name to “Council on Science and Public Health.” In recent months, this Council and other AMA officials have met with leaders of the APHA, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials (NACCHO) to discuss common interests and opportunities for collaboration. As pointed out by Beitsch et al.,4 collaboration and partnerships at the local level are essential in order to strengthen the marriage between medicine and public health. At its 1996 annual meeting, the AMA House of Delegates endorsed seven broad-ranging recommendations developed by MPHI task forces, which were “intended to lead to local initiatives and activities in directions that will bring about a functional merger of public health and medicine.”8 Below I offer additional suggestions to assist local players from the two health sectors in renewing their vows, focusing on “operational” strategies to promote communication, cooperation, and collaboration between them. Several of these ideas are embodied in existing AMA policy.
Operational Strategies to Bridge the Gap State and local medical societies should establish public health committees if they do not already have them. At its 2002 annual meeting, the AMA House of Delegates adopted the following resolution, introduced by the American Association of Public Health Physicians: [I]n order to foster a greater understanding and collaboration between the practice of public health and the clinical practice of medicine, particularly in this time of national crisis, and to increase awareness of and participation of clinical practitioners in public health issues, [our AMA] encourages local, state and specialty medical societies to form public health committees within their respective societies, when practical . . . . In a follow-up report, the AMA Board of Trustees described the results of a survey that collected data from state and local medical societies and national medical specialty societies on whether they had public health committees.9 Among the respondents, public Am J Prev Med 2005;29(2)
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health committees were used by 29 (66%) of 44 state societies, 47 (58%) of 81 staffed county societies, and seven (15%) of 48 specialty societies. These committees deal with issues such as bioterrorism, violence, tobacco, alcohol, obesity, and immunization. Public health agencies should give representation to organized medicine on their advisory committees, and those who appoint members of boards of health should do the same. Many state and local public health agencies have public health advisory committees, which are intended to provide advice to agency officials from external experts and stakeholders. Some of these committees cover the entire scope of the agency’s activities, whereas others address specific areas such as immunization and HIV/AIDS. About 70% of local health departments have boards of health in their jurisdictions, and ⬎70% of the local boards have roles extending beyond making recommendations—namely, the adoption and enforcement of public health regulations.10 Giving representation to the medical community on these committees and boards will improve public health policymaking, will enhance physicians’ cooperation with public health programs and policies, and will help to engage medicine’s advocacy for public health funding and priorities. State and local medical societies should give public health officials representation on their governing and policymaking bodies. For many years the AMA has had a designated seat (with full voting privileges) in its policymaking House of Delegates for the Surgeon General of the U.S. Public Health Service. Staff from various agencies in the U.S. Department of Health and Human Services attend meetings of the House of Delegates to support the Surgeon General and to provide testimony on resolutions and reports based on input obtained from agency experts before the meeting. The AMA has nonvoting “official observer” seats in its House of Delegates for several health organizations that are not considered medical societies, including APHA and NACCHO. Following the AMA model, the Michigan State Medical Society provides a voting seat in its House of Delegates for the chief medical executive of the Michigan Department of Community Health. This interaction between medicine and public health informs policymaking by the medical associations, educates public health practitioners about activities in medicine, and facilitates networking and relationship building across the two sectors. Hoping to take this representation one step further, AMA policy (H-440.936) “urges county and state medical societies to create an ex officio position without vote on their governing bodies for the respective public health officer of their jurisdiction so that proper interchange between the private and public health communities can take place.” Medical associations should consider forming foundations to expand their involvement, and their mem156
bers’ involvement, in public health activities. The AMA Foundation has a major program in health literacy, and funds public health projects through its “Fund for Better Health” initiative (www.ama-assn.org/go/ amafoundation). Some state and local medical societies and national medical specialty societies have foundations to support research, education, and community service. As 501(c)(3) tax-exempt organizations, foundations may be better able than their parent societies to attract outside funding, which can be used to support public health programming. Leaders in medicine and public health should offer speaking opportunities to their counterparts at meetings and conferences, and these speaking engagements should be institutionalized. AMA policy H-440.942, resulting from a resolution introduced by ACPM in 1991, “urges each state medical society to extend to their respective state health officer a standing invitation to participate in and report to the annual meeting of their house of delegates upon issues, accomplishments, problems, and needs of public health significance within the state.” Much as a governor delivers a “state of the state” address to the state legislature each year, a state health officer could deliver a “state of the public’s health” address at each annual meeting of the state medical association’s house of delegates. State public health agencies and associations should reciprocate by inviting state medical society leaders to address their major conferences about issues of concern to medicine. Similar exchanges should occur at the national and local levels. Public health and preventive medicine physicians need to join their county and state medical associations and the AMA. Leaders of organized medicine will be more enthusiastic about working with the public health sector if its physicians are members of the medical association. AMA data show that about 4600 physicians in the United States designate their specialty as preventive medicine, but only about one fifth are members of the association. Public health and preventive medicine physicians have every reason to join, given the AMA’s devotion to the principles and practices of public health—a devotion shared by many county and state medical societies. As the AMA’s new slogan states, “together we are stronger.”
An Issue to Rally Around Perhaps the most compelling force to unite medicine and public health is the opportunity to work together to bolster the funding of each sector. Medicine is under financial siege from Medicare and Medicaid cuts in physician payment, skyrocketing medical liability insurance premiums, fee constraints from managed care, the costs of new medical technologies and converting to electronic health records, and the aging of the population with the concomitant burden of chronic disease.
American Journal of Preventive Medicine, Volume 29, Number 2
Public health is under similar pressure—from cuts in federal and state funding in the face of new responsibilities and worsening threats such as bioterrorism and disaster preparedness, emerging infectious diseases, and the growing epidemic of obesity and diabetes. Fifteen states cut their funding for public health in fiscal year 2004, and 31 states and the District of Columbia did so the previous year.11,12 Medicine and public health need to work together to ensure adequate funding for the care of our patients and populations. We must, of course, continue to fight for funding from the traditional sources that pay for these services. But as those sources shrink, we must turn our attention to other wells that are untapped or not fully tapped. Four areas, in my judgment, deserve special attention: tobacco taxes, tobacco settlement funds, alcohol taxes, and taxes on soft drinks sweetened with caloric sugars. Smoking-attributable disease, alcohol abuse, and obesity impose huge burdens on healthcare programs such as Medicare and Medicaid.13–15 Sugar-sweetened soft drinks are the largest single food source of calories in the American diet, and sugar-sweetened beverages have been linked to obesity in children and weight gain and type 2 diabetes in women.16 –19 So it is only fitting to use “sin taxes” to help pay for those burdens and efforts to mitigate them. Many states have increased tobacco taxes in recent years, but the federal cigarette excise tax is still low, and many states have not earmarked tobacco tax revenue to medical and public health programs.20 Huge portions of state tobacco settlement funds have been allocated to deficit reduction and programs that have nothing to do with medicine and public health.21 Most states have not increased alcohol taxes in decades.22 Furthermore, a minority of states impose specific taxes on soft drinks, and among those that do so, very few earmark tax revenues for health purposes.23 In any given state, medicine and public health can target one of these funding sources, develop a proposal for allocating the funds to be captured, form a coalition (or use an existing one), and then plan and carry out a legislative campaign. If unable to overcome political obstacles and special interests, the two health sectors and their allies can wage the next battle by pursuing a ballot initiative—if they reside in one of the 24 states that allow ballot initiatives.24 The challenges to qualify a measure for the ballot and to get it passed are daunting, of course. But the potential payoff is enormous. And nothing will more effectively cement the relationship between medicine and public health than for the two sectors to fight shoulder to shoulder, for a worthy cause, in the trenches of a political campaign.
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