Public health is supposed to focus on the big picture. A cancer doctor will spend an afternoon slogging away in clinic with the hope of adding 1 month of survival for one patient, or 3 months of PFS for another. A heart failure doctor might want to add a year if they do everything right. But a public health doctor should be thinking about doing the most for the greatest number of people.
Three of the biggest public health issues right now that are not discussed:
Who will be screened imminently with multi-cancer early detection tests— will they experience net benefit or net harm— when Grail is approved and later covered by Medicare (Congress already authorized the payment)— what will happen?. What about when imaging is added— like midjourney or prenuvo? What about all the downstream investigations?
Which GLP-1 will save the most lives? Are some dangerous? Will the increased HR of retratrutide mean that it is worse than tirezepatide? Running a head to head trial of these agents powered for hard endpoints would be a boon— and will soon be a vital question. Raising HR is generally not a good idea with weight loss products.
What if: a widely used prescription medicine that is supported by disease specific regulatory endpoints increases mortality. This could be catastrophic. How could public health detect and stop this?
These three questions will soon account for a trillion dollars in health care spending, and many millions of disability adjusted life years. The importance of them is staggering.
But public health doesn’t talk about these things.
Instead, I hear endlessly about a measles outbreak in Pennsylvania, and some contaminated lettuce from Mexico. I hear panic then silence about Hantavirus on a cruise ship, and that I should take an annual flu shot. I hear about the importance of pregnant women taking SSRIs and tylenol.
In some cases, I don’t disagree. MMR is important, contaminated lettuce is bad, and pregnant women should minimize medications (like SSRIs), but the evidence linking Tylenol to autism is weak. At the same time, taking Tylenol for no good reason is silly.
But none of these are the most important public health questions of our times. Public health is so nakedly liberal and reactionary that it only talks about issues in response to what the Rs are doing, and can’t seem to formulate ideas on its own.
Measles: Sorry to break the obvious news, but the die was cast for vaccine hesitancy. Forcing people (many who already had the disease ) and those at low risk to take a extremely reactogenic, novel product that didn’t help third parties (whoops!) was a public health error. It undermined trust. You can’t walk that back. A CNN news article or Josh Shapiro presser— won’t change the arc of hesitancy. In the next decade, many will get measles and other preventable illnesses, a fraction will have bad outcomes, and then the arc will bend towards vaccines. Nasty lettuce is a perenial problem, and hanta virus on the cruise ship was a hysteria.
Public health is obsessed with these things but the delta public health (ability for anyone to change the future) is limited. Instead, multi-cancer screening, optimal therapies for weight loss, drug safety— these are massive under-explored topics.
People forget that public health being synonymous with extreme liberal politics— doesn’t just mean that it makes frequent cognitive errors to sate short term political preferences— but also that it is incapable of scanning the horizon and deciding which issues are worth exploring in the first place. Instead, it craves the daily political news cycle.
Vinay, Inspired piece. The two things about public health is that vanishingly little of it serves the public and even less serves health. It should all be shut down and rebuilt from scratch -- or just left shut down if they cannot get there.
Health care is an n of 1 endeavor. Attempting to get beyond that is a difficult endeavor prima facie. Lying about it all (either by omission of important topics) or by actually lying "it will protect you and your grandmother" is an utterly irresponsible failure of morality and any underlying pretension that anything in public health is about health or the public.
You are right. It has become a political (and only a political) roadshow that serves one party and none of the public.
As Dr. K knows, I watched “public health” fuel the opiate epidemic. Then add the political edge. I also agree. Public health just needs to be completely shut down. I’ll stick with my PCP who helps design my care WITH me. And since my grandmothers are dead, I don’t much care for emotion baiting. They know that FEAR sells. That’s why I truly loathe the faction.