Photo by Alex Mecl | Unsplash
When an eight-year-old with a history of asthma presents to the emergency department (ED) with wheezing, some ED clinicians just see a child with an exacerbation of their condition. When Nana Twum-Danso, MD, MPH, FACPM, saw such a patient as an ED physician — in addition to addressing the clinical diagnosis and treatment — she would also wonder about where the child lived, about their family and neighborhood, and whether there was mold or smokers in their household.
“In this day and age, a child with asthma should not need to be seen in the ED,” explained Twum-Danso, Institute for Healthcare Improvement (IHI) Senior Vice President, Global. “We have good treatments to control the inflammation and rescue inhalers. We’ve done lots of education about how to prevent an asthma attack.”
In other words, social context matters. As a practicing physician, Twum-Danso wondered about health care’s role in addressing the underlying issues influencing her patients’ lives. “We treat the asthma, but then we send the child back home and maybe within a month they might come back [to the ED],” she continued. “Those types of cases used to wear on me. Are we doing enough? Could we be doing more?”
Twum-Danso’s interest in tackling the social determinants of health and being born and raised in Ghana — where she saw many deaths due to preventable diseases — eventually compelled her to pursue specialty training in preventive medicine and public health. “I decided to follow my passion and try to address the systemic reasons some people are more likely to get sick than others,” she recalled. “I loved the one-on-one interaction of individual patient care and the immediacy of diagnosis and treatment in the ED, but there was another part of me that was even more interested in thinking about population-level health and the preventive things we needed to do more of as a society.” She added, “Improving air quality, water quality, sanitation, nutrition, the safety of people’s homes, roads, transportation, etc., can have a huge impact on millions of people’s lives. I was excited about the potential to work at that scale.”
In the following interview, Twum-Danso draws upon her experience in both medicine and public health to describe COVID-19’s influence on the relationship between health care and public health and what it could mean for the future.
On making good use of data
In countries where clinical care is primarily provided by the public system, you’re going to see fairly good data-sharing between clinical care and public health because it’s one system. In countries where health care is primarily private, there hadn’t been as much of an effort to integrate data systems before the COVID-19 pandemic, and that makes sharing data harder. In the US, during the first few months of the pandemic, it was hard to keep track of what was happening clinically and to integrate the data with the public health data systems. I think the pandemic has created bridges — or in many ways, forced [the creation of] bridges — between clinical care and public health in settings where it wasn’t already happening.
Now that we’re in the third year of the pandemic, many countries are using the more timely data collections systems to track the number of cases, deaths, and hospitalizations developed because of COVID. I’m hopeful that we can learn from how they built the muscle for frequent data collection and analysis and apply it to other areas of public health and health care.
On the pandemic as both a clinical and public health issue
Those of us in health care and public health need to row in the same direction to improve the quality of health, not just health care. In the first year of the pandemic, as we were learning about COVID-19, it became clear that people who were obese, had high blood pressure, and diabetes were more likely to get very sick from COVID and to die from it. Those are clinical conditions, of course, but in the US, for example, more than 40 percent of the population is obese. That means it’s no longer just a clinical problem when someone morbidly obese has COVID in the ICU on a ventilator. It’s also a public health problem. And, when you dig deeper into this problem, you find that these chronic diseases are more common in lower-income populations. These are the same populations that are most likely to be in customer-facing, in-person jobs — such as grocery workers and bus drivers. They couldn’t work from home when the pandemic started. And as we saw in the US, these populations were disproportionately people of color. So, when we expand our lens from the individual COVID-19 patient in the ICU struggling to breathe, we start to see the confluence of macro issues such as socioeconomic status, job opportunities, and institutional racism determining who is likely to be exposed to the virus due to work and get sick enough to be hospitalized due to chronic diseases such as diabetes and obesity. That’s the kind of bridge between clinical medicine and public health that I am talking about.
On addressing chronic illnesses as both clinical and public health issues
We knew how devastating diabetes, high blood pressure, and obesity can be to one’s health long before COVID. Think about people who end up on dialysis because of poorly managed diabetes or middle-aged people suffering a stroke because of untreated hypertension. These situations are devastating for individuals and families, but they are also tragic for society because they are preventable. Just as there have been benefits to viewing COVID from both public health and clinical perspectives, shouldn’t we address contributors to diabetes, hypertension, and obesity in a population in a preventive way? Shouldn’t we, for example, look at the structural designs of people’s neighborhoods, public transport, and the affordability of the food available on local store shelves and whether people have healthy options?
On the risks of prioritizing clinical care while neglecting public health
As a public health professional, I found the discussions about “non-pharmaceutical interventions” during the first year of the pandemic very concerning. The phrase rankled me a lot because it essentially pits clinical medicine against public health. Calling interventions [like masks and social distancing] non-pharmaceutical suggested that the default is clinical medicines or other pharmaceutical products, and that these other things are less of a priority while we waited for the medicines to come along. But since it’s only a very small proportion of the population that will need clinical care for COVID, fortunately, non-pharmaceutical interventions are important for all of us. Of course, vaccines fit into the category of pharmaceutical interventions but as we see now, in the third year of the pandemic, vaccines do not necessarily eliminate the need for the basic preventive strategies of masking, hand hygiene and respiratory hygiene.
To value public health as much as we value clinical care, words do matter. Research dollars matter. Investments in data systems matter. If we have good data systems in hospitals, for example, but poor data systems in the public health systems, or inadequate connections between our various data systems, how can we expect good outcomes? We can’t improve what we can’t see, right? We have to make the public health data just as visible as the clinical data if we want to improve the health of populations, not just individuals.
Another thing that concerns me is how a lot of public officials appear to be titrating the public health restrictions to what goes on in the hospitals. Our health system is being crushed. The hospitals are getting full. So, let’s institute mask mandates. Once the hospital volumes ease, you can take off your mask. It feels like such an arbitrary way to manage a public health problem that is so big and pervasive. We need to do both. We cannot de-emphasize public health just because the hospitals are not full. There has to be a better balance.
On the need for a more holistic approach to health and health care
A public health person in charge of a district, state, or country is very clear about who is included in the population they serve. Health care, on the other hand, for the most part sees the people who come through the doors as their population. We need to find ways to bridge those gaps. Because, if health care is thinking only about those who walk through their doors, and public health is thinking only about prevention and health promotion in communities and not enough of about the whole spectrum of care, we won’t achieve our collective goal of improving people’s health. Each of us may need clinical care every so often to cure an illness or screen for a preventable disease, but health care is only a small subset of what contributes to overall health. So, the more bridges we can build between clinical medicine and population health, the better we will be able to serve the public.
We need to create a systems view of the population. We need to make sure incentives are aligned to achieve that population-level view. This would require a complete paradigm shift on how we think about health care and public health, what people are willing to pay for, and how we find the balance between prevention and promotion of health and clinical care. It can be done. It requires bold thinking and rigorous measures to hold ourselves accountable. If we monitor the data and keep adapting and learning as the data come in, we can achieve population-level aims.
Editor’s note: This interview has been edited for length and clarity.
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