Tuesday, January 06, 2009

Why I Chose a Career in Public Health....

When I re-entered University at age 39, my purpose was to get a better job in the health-care field. My top choices were physical therapist, psychological counselor, or acupuncturist. During my first semester I began to see that physical therapy was much like a car mechanic and that the daily work would be fixing people's knees and other parts that were broken and, most importantly, that PTs don't have as much autonomy as I'd like. The doctor diagnoses the injury and prescribes the regime. I was much more interested in the mind's role in healing and prevention. In psychological counseling the therapist works with patients on a number of behavioral issues, not just physical health. I began to research health psychology. Around the same time, I found some studies on acupuncture that questioned its ability to heal any disease, and there was no real emphasis on prevention. After many years of studying Taoist healing practices that focus more on prevention than acute repair, I wanted to help prevent disease from beginning in the first place.

Near the same time, a friend passed on a book entitled The Status Syndrome by Michael Marmott. In it the author explained that diseases manifest themselves in a population differently with regards to social class. People at the top of the social hierarchy live longer than people at the bottom, including the radical discovery that people with PhDs generally live longer than people with a Master's degree and right on down the line. The issues raised in that book caused me to have a spiritual crisis and led me to pursue a career that relies less on religious faith and more on personal empowerment and education. It also sparked a strong desire for discovering an empirical basis to substantiate claims about efficacious healing practices.

In addition, I grew increasingly frustrated about our western health system, which is based on a model designed to combat acute trauma and infectious diseases. Unfortunately, that model is ineffective in preventing non-communicable diseases (NCDs) because they are about lifestyle choices made by the individual, heavily influenced by cultural norms and pressures.

The western medical system approach is top-down, meaning that doctors tell patients what to do. Because of medical advances over things like bacteria—which have been great in reducing infectious diseases and the burden of those on hospitals and communities—doctors and the medical establishment have been given too much power over areas where they are not particularly effective. This kind of power has a tendency to narrow people's vision, so that the current model is excessively preoccupied with physiology and the view that everything is biologically determined. So the focus is on high-ticket items like surgery rather than cost-effective, preventative, lifestyle changes.

For non-communicable diseases such as cardiovascular disease and diabetes, the need is greater than ever to create a system that can raise awareness and motivate people to change high-risk behaviors. This approach aims to keep people out of the hospital for things like heart surgery by keeping them healthy in the first place.

This is why I look to other, decentralized health systems as a model for dealing with education and prevention issues. Systems like those at various times in Bangladesh, Cuba, Pakistan, the state of Kerala in India, China, and the parts of the Philippines have designated roles for ordinary people to become community health educators. These people function as disseminators of information to rural regions where doctors are unable to access. These decentralized systems accomplish two amazing things. First, the distribution of medical knowledge creates a less hierarchical system in which more people can share in the decision making process. Second, and most important, these community educators more easily reach marginalized groups, which often have a heavy burden on healthcare systems. Using education programs between people who are on the same status level is an effective tool alongside a top-down authoritarian approach.

When it comes to many diseases—particularly non-communicable ones—awareness is an essential ingredient in preventing a disease from becoming a major player mortality rates. And so much of maintaining good health is about having access to information. For example, we are seeing a reduction of cigarette smoking in developed countries because more people in those places have become educated about the overwhelming evidence about the dangers of cigarette smoking. In less developed countries, there has been an increase in smoking because those places have not been able to enact effective campaigns about the ills of cigarette smoking. But in due time, we will see a reduction in cigarette smoking in those places, too, as health education systems have time to catch up. As with cigarette smoking, condom usage, diet, exercise, clean water and clean hands, many other preventative behaviors can also be taught and learned.

All these issues combined to lead me to a degree program in public health, with an emphasis on non-communicable diseases. For me, public health can be the “ounce of prevention [that] is worth a pound of cure.”