Articles of interest
03rd June 2021
Book in Focus
The Promising Future of Public Health
By Irving I. Kessler
Medicine and public health arose in ancient times when diseases occurred, treatments were initiated and outcomes observed. Epidemiological conclusions were then inferred, based on scientific interpretations of the clinical signs and symptoms. With the passage of time, medical science gradually became systematically organized, far more meticulous and continually advancing through the research of individual investigators and teams of university-based scholars.
For many centuries, infectious diseases were the principal threats to life, and the main concern of medical practitioners. As recently as a century ago, pneumonia, tuberculosis, diphtheria and enteritis were causing one-third of all deaths worldwide, and the great European laboratories of Marie Curie and Robert Koch, inter alia, were continually gaining ground in understanding their etiology, treatment and prevention. Little attention was paid to heart disease, cancer, stroke and diabetes, which account for most of today’s mortality.
In 1910, the Carnegie Foundation, responding to a request by the American Medical Association, sponsored a comprehensive analysis of medical education in the United States and Canada by Abraham Flexner. The results were shocking. Many of the schools were proprietary trade schools owned by physicians, operated for profit, and unaffiliated with hospitals. Students were admitted for two-year programs, with little or no relevant educational background. Many were offered no formal classroom or laboratory education by instructors who were often local practitioners. There was no regulation by federal or state agencies.
The widely publicized Flexner Report had an unexpectedly successful outcome, with the proprietary schools eliminated and many of its recommendations accepted. Several years later, the Rockefeller Foundation decided to strengthen its long-time interest in controlling hookworm disease by establishing the first public health schools at Johns Hopkins and Harvard universities. These two remarkable events led to a golden age in medicine and public health, with many thousands of papers on human health and disease being published, the curricula of medical schools thoroughly upgraded, and minimal government interference with educational and research undertakings.
Beginning in the 1970s, a series of unfortunate circumstances ultimately brought this golden age to an end, however. A massive increase in federal and state rules and regulations governing human health research was enacted, ostensibly to protect the lives of patients being investigated. This greatly reduced the incentives for clinically trained physicians to undertake risk factor studies on human subjects, and enhanced the popularity of animal-based investigations which are simpler to design, much less expensive, unlikely to stimulate governmental regulation, and more rapidly completed.
A second, and ironic, circumstance leading to the doldrums was the computer revolution which has affected the personal and professional lives of much of humankind. Computers have greatly simplified a host of activities underlying health research, but not all of them. The professoriate is now teaching that epidemiological studies need not be based on testable hypotheses, and that careful selection of human subjects for study and laborious literature reviews are too complicated and time-consuming. Instead, there is a shift towards “Big Data” methodologies which are heavily dependent on computers, rather than investigation of agents, hosts and environments of susceptible patients. The most frequent research target today seems to be the role of genes in disease, a simplistic view that is employed by many hospitals to attract patients with genetic diseases.
Another contributor to the current doldrums is the remarkable growth of multi-center studies funded by government agencies and commercial enterprises. Instead of a single or small group of experts in a medical or public health school meeting to develop, conduct and analyze a study, applicants are assembled from multiple institutions, nationwide or even worldwide, to create a project. Such enterprises offer their staff an array of attractive benefits including job security, good salaries, absence of tenure regulations and minimal responsibility for study design or implementation. The political influence of these multi-center groups is far greater than that of individual investigators, but it is rare to find brilliant studies originating from their efforts. However, many of their staff members could have become outstanding researchers in a medical or public health school which supported their indivisible efforts in a non-political setting.
Because of the circumstances described above, the public health programs in medical and public health schools have been deteriorating for several decades. Admission standards were lowered or eliminated, medicine-based curricula were watered down and departmental undertakings of epidemiologically controlled clinical studies of human disease have been markedly reduced. Far fewer clinicians are being recruited by public health faculties or admitted as graduate students, while selection of students lacking any health background has sky-rocketed.
Public health research has become more concerned with counting and tabulating diseases rather than investigating their etiology and means of prevention. The Hippocratic Oath and the Prayer of Maimonides, which were recited at medical and public health school graduations in the past, are now long forgotten. Both would have regarded the current practice of paying monetary rewards to patients for participating in disease studies as a corrupt practice. During the golden age, study subjects were carefully chosen—never self-selected in coffee shops—to ensure that they truly represented the actual target population being investigated. Previously professors universally taught that subjects for study must be carefully selected, in order that they truly represent the target population. Nowadays, no discussion of this critical issue is ever discussed by faculty or students. The abrogation of this epidemiological and moral principle has also begun to affect the nation’s convictions about how well the government is managing its health and disease crises.
What can be done to rectify and revitalize our educational, research and clinical practice of public health? The Promising Future of Public Health recommends a sequence of actions that would, in a few years’ time, produce a cluster of medical and public health school departments with this potential. The initial critical step would be adding a Clinical Public Health (CPH) Department to each participating school, and taking steps to assure its immediate survival. These departments would have a faculty of clinically trained physicians and nurses, statisticians and ancillary personnel, all devoted to human epidemiological research, training students, and analyzing health data for government agencies on a fee-for-service basis. The regular student body would be limited to clinically trained physicians and nurses preparing for public health careers, while short-term non-degree students would include journalists, lawyers and business professionals needing to strengthen their knowledge of health and disease.
The faculties and students in the CPH departments will quickly sense the camaraderie of an environment in which everyone shares an abiding interest in public health and clinical medicine. For this reason, it is essential that they be physically separate, and operationally independent, of the other departments, especially those catering to the needs of students lacking clinical training or knowledge. The bulk of each student’s day must be spent in the company of CPH faculty and students, in order to create an optimal learning and research environment for students singularly devoted to human health and clinical research on their diseases of interest.
The fact that the CPH Departments will contribute annually to their school’s finances, rather than depending on school funding, will render their programs more comparable to those of the clinical departments, and thereby elevate the prestige and receptivity of their programs in the school and university as a whole. The deans of the medical and public health schools should also be attracted by the depth and variety of innovative educational and research opportunities to be offered matriculating physicians and nurses, as well as the fee-for-service income pathways built into the system. By adopting this program, the stagnation of public health will end, and the promising future of public health will finally be realized. The new CPH departments will steadily and gradually build up their capacities through new recruitments in order to offer more and more services that yield funds to their budgets from short courses for professional groups to analytical services for health departments and government agencies.
An additional major facility of the CPH department would be a Health Statistics Center, serving faculty and students as their statistical center and operating as a fee-based agency for informing the public about current diseases affecting their regional population. A major objective would be to avoid recurrence of the statistical chaos associated with the COVID-19 pandemic, with its heavily political overtones.
Public health research became far more interested in counting and tabulating diseases around the world, rather than investigating their etiology and means of prevention. One may conclude that medical and public health schools today are more interested in attracting new sources of tuition from youngsters seeking jobs, than addressing the decline in meaningful research on human disease.
The mentoring of graduate students and younger faculty in public health schools has also become problematic. During the golden age, faculty mentors were the students’ principal advisers. When assigned a student developing a research project or preparing a doctoral thesis, it was the student who made most of the ultimate decisions on the project. At present, most mentors are members of a clinical department, serve part-time in the public health school, and are only marginally interested in public health. Their prime interest in mentoring is for them to benefit from the student’s research or to convince the student to undertake one of the mentor’s projects as if it were their own.
The situation described in the previous paragraph has witnessed the creation of a new industry devoted to providing ‘mentoring services’ for these students, in order to educate them in those areas of the project neglected by most mentors, including preparing a grant or thesis, applying for grant funding, and improving their English-based literary style. The services are now provided by commercial firms, government agencies and universities in oral courses, instructional manuals and Zoom-style computing accompanied by substantial fees. Most of the course-givers lack medical or public health training.
The present mentoring system has created more problems for graduate education including: Who owns the largely mentor-created projects: the mentor or the student? When conflicts arise between mentor and student, can the student ever win? In today’s environment, most mentors are not based in public health departments, thus permitting much less oversight and academic supervision by the public health faculty. Students are also heavily discouraged from seeking to replace their mentors, thus creating groups of dissatisfied students.
Careers in epidemiology-based education and research are no longer viewed as attractive career options for many young physicians with strong interests in academic medicine or public service. Recreating an appropriate setting for such learning should begin by selecting a student body capable of mastering the epidemiologic principles underlying public health, addressing the array of health and disease issues of consequence and maintaining a pleasant and effective environment for teaching, research and public health practice programs.
The diversity existing in the educational backgrounds of today’s public health students renders it almost impossible for academic programs to develop appropriate programs. A year or two spent in such environments rarely boosts student enthusiasm or competence in preparing for lifetime careers in public health.
Harvard University recently announced plans to develop a university-wide data science program with degree programs in medicine, public health and arts and sciences. The heads of the program are professors of statistics and computer science who believe that a fundamental target of the program is to utilize Big Data methodology to understand how six billion base pairs of the human genome affect human health and disease.
The recommendations offered in this volume will benefit epidemiological research and public health programs in both medical and public schools. They have the potential to lead to a revival of departmental programs that have remained in the academic doldrums for years. The deans at these schools should be attracted by the depth and variety of innovative educational and research opportunities to be offered when matriculating physicians and nurses, as well as the fee-for-service income pathways built into the system.
Newly enrolled medical and nursing students will quickly sense the camaraderie of an environment in which everyone shares an abiding interest and a substantial background in clinical medicine and public health. Rather than interacting with classmates who are just beginning to explore careers in vaguely defined aspects of health, they will be relating to colleagues who are fully committed to lifetime service in human health and disease. Such relationships will greatly enrich the learning environment without negatively impacting existing programs for students lacking any prior experience with clinical disease.
Dr Irving I. Kessler, an internationally recognized epidemiologist, served as Tenured Professor at Johns Hopkins University, and as Chairman of the Department of Epidemiology and Preventive Medicine at the University of Maryland. His studies include the first assessment of artificial sweeteners in humans, the effect of coffee on the pancreas, the herpes virus’ role in cervical cancer, the biochemical basis of Parkinsonism and the promising role of nicotine in its control. He was the first to demonstrate the failure of oral hypoglycemic drugs to improve the longevity of diabetics. A founder and past president of the Maryland Gerontological Association, Dr Kessler served as Director of the Maryland Medical Research Institute and as a Premier Member of the Governor’s Council on Toxic Substances in Maryland. He was a consultant to the National Institutes of Health, the National Academy of Sciences and the American Medical Association, and was honored by the American Cancer Society, Phi Beta Kappa, and the Society of Sigma Chi.
The Promising Future of Public Health is available now in Hardback. Enter the code PROMO25 at the checkout for a 25% discount.