Via The Nation, Eric Reinhart writes: Want to Fix Public Health? Stop Thinking Like a Doctor. Excerpt:
A changing of the guard in US public health is impending—and, with it, a chance to rejuvenate a flailing field. Anthony Fauci has retired in the shadow of one of the worst preventable disasters in history, and President Biden is moving to make new appointments while establishing a permanent White House Office for Pandemic Preparedness and Response Policy.
In doing so, Biden and his advisers must confront the fact that the rot in public health is structural: It cannot be cured by simply rotating the figureheads who preside over it. Building effective national health infrastructure will require confronting pervasive distortions of public health and remaking the leadership appointment systems that have left US public health agencies captive to partisan interests.
Part of what has made public health vulnerable and a plaything of partisan politicking is the field’s gradual medicalization. Consider, for example, the history of the nation’s most important public health agency. Since 1953, every director of the Centers for Disease Control and Prevention (CDC) has had a doctor of medicine, or MD, degree as their primary credential, with secondary degrees serving mostly as résumé decor.
Given that medical interventions constitute only 10–20 percent of modifiable factors affecting health, the backgrounds reflected in CDC leadership—and, likewise, at most state and local public health agencies—are notable for their consistent prioritization of narrow biomedical expertise at the expense of other fields that represent the remaining 80–90 percent of pertinent knowledge for making public health policy.
Physician and public health scholar Milton Roemer once observed that for the work of public health, “most of medical education is irrelevant.” But neither doctors’ irrelevant medical knowledge nor relative ignorance of essential fields—labor history, social anthropology, political economy, epidemiology, environmental sciences—is the most troubling aspect of physician control of public health. Rather, it’s the lack of epistemic humility, conferring an inability to recognize the limits and hazards of clinical reasoning, with which medical training often imbues them. Clinical reasoning is not only not the population-level logic of public health; it is frequently antithetical to it.
When we treat patients, doctors are appropriately oriented around taking care of the individual in front of us. We recognize that we typically cannot change their life circumstances—such as economic and housing conditions, employers’ demands, student and medical debt, neighborhood violence, or social isolation—and so we focus our clinical attention on helping them live as well as possible within existing constraints.
Public health, by contrast, is about treating populations. As with medicine, the goal of public health is to enable individuals to be free of health limitations that curtail their ability to live as they please. But public health pursues this by very different means. The task is not to help individuals accommodate to oppressive social or labor contexts. It is instead to use the power of government to change conditions that are constraining people’s freedom. The core tools of public health, then, are not just vaccines or lab tests but also policies pertaining to corporate regulation and consumer safety standards; labor protections; public jobs and housing programs; investments in community health workers, decriminalization, and decarceration; and civil rights lawsuits.
