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But for “public health,” you would not be reading these words. What follows starts with the personal and moves to the public, writ large. None of this should be controversial, as we all kind of know, or knew before the latest political gambit blasted through our collective memories and quickly polarized information into take it all for what it is worth.
The personal: But for public health, you would not be reading these words. My mother graduated from college with her BN in the late 1950s and went to work for the city of Philadelphia as a public health nurse. They called themselves “streetwalkers for the city of Philadelphia” because they walked a beat, bringing front-line medical care to poor sections of town. Mom was very tall for her era, a lean 5’11” white woman perfectly safe in an all-black neighborhood because the drug gangs had not yet arisen and driven off the old men who sat on every stoop keeping a watchful eye over “their nurse.”
The pay was not great, so a number of nurses roomed together and threw a spaghetti dinner almost every weekend, designed to attract young men from the medical schools and such. That, and 10th Presbyterian Church, is why my parents met, married, had me and three girls, and are wonderfully still married to this very day.
The personal, at second hand: As a nursing student, or perhaps a new nurse, my mother was in attendance at one of the first large medical presentations in Philadelphia on the link between smoking cigarettes and lung cancer. A number of medical luminaries, the Dr. Faucis of the 1950s, were present and seated on a dais, facing the audience. At the conclusion of the presentation, concluding cigarette smoking causes lung cancer, one of the premier surgeons of the day elaborately drew his cigarette case from his breast pocket, carefully lit up, and slowly exhaled a large cloud of cigarette smoke. Then, as now, experts can come to believe too much in their own expertise well beyond their actual credentialed specialty.
What, then is “public health?” Let us take the government’s words for it. Start with the Center for Disease Control introduction to public health:
Public Health Defined
“The science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.”
—CEA Winslow. The untilled field of public health. Mod Med 1920;2:183–91.
“Fulfilling society’s interest in assuring conditions in which people can be healthy.”
—Institute of Medicine
“Public health aims to provide maximum benefit for the largest number of people.”
—World Health Organization
What might the field of public health actually encompass? The American Public Health Association explains:
Some examples of the many fields of public health:
- First responders
- Restaurant inspectors
- Health educators
- Scientists and researchers
- Community planners
- Social workers
- Public health physicians
- Public health nurses
- Occupational health and safety professionals
- Public policymakers
You are sharp-eyed enough to pick out that epidemiology, which still is not limited to the infectious diseases or immunology, is but a piece of the puzzle. My mother and her sisters-in-uniform were public health nurses. A public health physician is a medical doctor with additional training beyond clinical medicine.
A public health physician is a highly trained physician who focuses their efforts on improving the health of an entire population instead of solely on one-on-one patient treatment. The primary focus is on the prevention of disease within a community, and there are numerous responsibilities that you may have within the position.
…You’ll need a solid medical degree in order to enter this field. Usually, physicians working in the public health field start by providing primary care and gradually move into the field by earning a Master of Public Health degree. Others begin their training early with the specific goal of becoming a public health physician. In either case, a Master of Public Health will be needed, along with the training needed to become an MD or other similar physician’s training. It can take several years to complete the training, but for many the rewards are well worth it.
Public health includes, according to the CDC, “clinical care” or “health care”:
clinical care: prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by medical and allied health professions; also known as health care.
That is quite a bit more than researching and treating infectious diseases. What are some of the known public health side-effects of the Fauci prescription?
Try domestic violence for starters, again from an official government source, connecting social distancing with domestic violence:
As the COVID-19 pandemic continues, Americans are required to stay home to protect themselves and their communities. However, the home may not be safe for many families who experience domestic violence, which may include both intimate partners and children. COVID-19 has caused major economic devastation, disconnected many from community resources and support systems, and created widespread uncertainty and panic. Such conditions may stimulate violence in families where it didn’t exist before and worsen situations in homes where mistreatment and violence has been a problem. Violence in the home has an overall cost to society, leading to potentially adverse physical and mental health outcomes, including a higher risk of chronic disease, substance use, depression, post-traumatic stress disorder, and risky sexual behaviors.1 Further, victims of domestic violence including intimate partner abuse and child abuse are at great risk for injuries including death.
Let us move on to suicide. The Surgeon General calls suicide prevention a public health issue, in part:
Suicide is a problem that touches the lives of many Americans. Suicide is among the leading causes of death for adults under age 45 in the United States, and it exacts a huge emotional and economic toll on those left behind.
Reducing the number of suicides requires the engagement and commitment of people in many sectors in and outside of government, including public health, mental health, health care, the armed forces, business, entertainment, media, and education. Learn how the Surgeon General is drawing on suicide prevention experts across the nation to help make Americans aware of the heavy burden suicide imposes on our nation and to facilitate the prevention of suicide and related problems.
There is a robust public health literature on suicide increasing with economic downturns and mass layoffs. These, along with fatal overdoses, have become labeled “deaths of despair.” A 1992 study of suicide and unemployment between 1940 and 1984 found “the higher the unemployment rate the higher the suicide rate and the lower the female participation in the labor force the higher the suicide rate.” A 2013 study of long-term unemployment noted past studies on the link between unemployment and suicide, and shifted the focus to the effect of length of unemployment, concluding that “the long-term unemployed have a greater risk of suicide and attempted suicide compared to those unemployed in the short term, or compared to the general employed population.” A 2019 VA factsheet summarized multiple studies and multiple effects of unemployment on suicide rates, noting that some studies seem contradictory. The issue has been raised in publications aimed at the general public. See, for example, Chicago Magazine in 2011.*
Addiction deaths were the subject of a short 2017 article in The Atlantic linking joblessness and opioid deaths:
A new study suggests unemployment might be one of the factors behind that dramatic rise [in drug overdose deaths]. The paper, published by NBER last week, finds that as the unemployment rate increases by one percentage point in a given county, the opioid-death-rate rises by 3.6 percent, and emergency-room visits rise by 7 percent.
HHS recognized the danger of addicts falling back into using without recovery groups, and started promoting virtual recovery programs as a temporary solution through the COVID-19 shutdowns.
Public health importantly includes prevention and early detection for cancer, heart disease, and diabetes, among others. We have all been raised with the public health admonition that we should get our regular check-ups, both medical and dental, for the sake of our very lives. Dental disease is linked to heart disease, brought on by harmful bacteria that started in the mouth. It is also linked to worsening nutrition, which makes you more vulnerable to disease. Everyone reading this has had the public health messages beating into their brains for much of their lives. We all understand why professional athletes wear pink gear in October. The Irish Examiner was early in publishing warnings by cancer doctors in Europe:
Focusing solely on the current Covid-19 pandemic could “precipitate a future cancer epidemic”, researchers from Ireland and Europe have warned.
Research from Queen’s University Belfast, the University of Split in Croatia and King’s College London has shown that the response to the outbreak of Covid-19 is “significantly affecting the treatment and care of patients with cancer”.
The research, published in the European Journal of Cancer, found delays in urgent referrals and patients having their cancer treatment, such as chemotherapy postponed, or surgery being delayed.
White House Press Secretary Kayleigh McEnany made it personal in one of her first press briefings:
Press Briefing by Press Secretary Kayleigh McEnany
HEALTHCARE | Issued on: May 12, 2020
MS. MCENANY: Well, he has encouraged states to follow the guidelines. That’s still consistently our recommendation today, that you should follow the phased approach to reopening as outlined in the data.
I do want to stress, as the President has stressed, that we do want to reopen this country because there are consequences that run the other way when we stay closed down as a country, and I want to run through a few of those with you.
A hotline run by the Substance Abuse and Mental Health Services saw a 1,000 percent increase in responses during April, as we kept this country closed. Epic’s data said appointments for screening for cancer of the cervix, colon, and breast were down 86 percent and 94 percent in March. There are real consequences for that.
I’m a BRCA2 — I carry a BRCA2 mutation, so I was someone who was regularly screened for breast cancer until I got my mastectomy. And when I went to my cancer hospital for screening, I didn’t see as many people in the halls.
And that is quite frightening because the consequence of that is this: According to the IQVIA Institute for Human Data Science, a total of 80,000-plus diagnoses of five common cancers in the United States are protected — are projected to be missed or delayed during the three-month period of early March to early June, which is why this President has always said, “Go to your doctor. Do your screenings.” There’s a way to safely do this. If you feel chest pain, go to your doctor. We can’t scare people from going to hospitals. It’s a consequence of staying closed, though, when people are scared. They’re scared to even go to their doctor, and there are consequences for that.
And finally, I would just point out a recent CNN article from Friday noted a national public health group that warned as many as 75,000 Americans could die because of drug or alcohol misuse and suicide as a result of the coronavirus pandemic.
So there are consequences to us staying closed. And it’s why I believe it was eight medical groups came out with a statement — eight medical groups noted concerns that some people with symptoms of heart attack, stroke, and cardiac arrest are avoiding hospitals.
So it’s why I’ve said from this podium, I think at least two times — today is the second or third — you’ve got to go to your doctor. We’ve got to encourage this country to safely reopen.
These are all first-world problems, that is, problems not masked by more elementary threats to public health. Let us end this brief exploration at the global level. Move from mere malnutrition to starvation. With most documented and illegal immigrants in jobs deemed “nonessential,” the remittances their families and villages depend upon are gone. The global economic expansion that had finally pulled so many out of generational destitution has been deliberately crashed by the richest nations in the world. The United Nations has already warned that 130 million are on the brink of starvation. This should come as no surprise, if you’ve been conscious for any significant portion of the past decades.
Let us hear from the real medical experts offering real public health advice. Real public health advice is full public health advice, however messy and unpleasant the apparent trade-offs that then appear in this imperfect world. This should start with “America’s doctor,” the Surgeon General, in his leadership capacity in the US Public Health Service, backed up by the other fellow wearing a USPHS admiral’s uniform.
* Chicago Magazine, August 2011
Dunn and Classen, who have previously studied the link between suicides and presidential elections, released an early version of the paper in 2009 (PDF); it was published earlier this year in Health Economics. Their findings, covering 1996 through 2005, aren’t surprising: “mass layoffs and long spells of unemployment specifically were associated with increased suicide risk.” This should be of particular concern since unemployment duration is at unprecedented levels, and since concerns are rising about the unwillingness of employers to even consider hiring the unemployed:
“We may be seeing what’s called statistical discrimination,” said Robert Shimer, a labor economist at the University of Chicago. “On average, these workers might be less attractive, and employers don’t bother to look more closely to pick out the good ones.”
And the data is getting less thin. The research by Dunn and Classen tracks with a CDC study published shortly thereafter about suicide rates from 1928 through 2007—i.e. from the Great Depression to the Great Recession:
The study found the strongest association between business cycles and suicide among people in prime working ages, 25-64 years old.
…The overall suicide rate generally rose in recessions like the Great Depression (1929-1933), the end of the New Deal (1937-1938), the Oil Crisis (1973-1975), and the Double-Dip Recession (1980-1982) and fell in expansions like the WWII period (1939-1945) and the longest expansion period (1991-2001) in which the economy experienced fast growth and low unemployment.