Some aspects of the health enterprise are purely related to clinical care for existing medical conditions. Other activities are obviously traditional disease prevention and health promotion. In between is a grey area where activities have roots in both clinical care and public health. This trichotomy is related to the concept of prevention.
There is a hierarchy of prevention that presents the levels of primary, secondary, and tertiary. Primary includes measures we take as individuals or as a community to avoid sickness or injury. Careful hand washing in flu season and fluoridating drinking water are two examples. Tertiary prevention is clinical care – not really prevention at all, except to the extent it prevents serious consequences if clinical care is not provided. Surgically removing intestinal polyps or skin lesions is often effective in preventing life- threatening cancers.
Secondary prevention bridges the gap between medicine and public health. It consists mostly of early diagnosis through screening. This is prevention because it seeks to find health problems at the earliest stage possible in order to block progression and additional damage. It is public health because screening tends to be made available to all, not as indicated by diagnostic processes. It is public health because it uses public media and marketing to proactively recruit people, in contrast to clinical care initiated by people feeling sick. On the other hand, screening is often done by clinicians, and positive test results should be brought to the attention of an appropriate health care provider for further evaluation. This activity then is based on an important partnership between public health and medicine.
Another dimension of the partnership is trying to deal with health professional shortage areas. A federal agency with jurisdiction has recognized and inventoried shortage areas for physicians, dentists, and psychologists/mental health therapists. Shortage is based on the ratio between the number of professionals in each category per population, using criteria of the estimated maximum number of people who can be served by one professional. It is possible for a community to be defined as a shortage area for one of the health professions while having adequate numbers of one of the others. Shortage areas are usually rural, but can also be inner city neighborhoods with a lack of services.
There is an infrastructure to deal with this problem in most U.S. states. The federal government funds agencies called Area Health Education Centers. Their purpose is to 1) persuade and support youth from underserved areas to get training and return to serve their home communities; 2) recruit health professional students to consider practicing in an underserved area: 3) provide various types of technical and administrative support to make practice in shortage areas more viable and attractive. These efforts, which have been going on for over 20 years, have found no easy fixes.
There are many barriers to this work. Areas with shortages of professional health workers often have other deficiencies, such as low educational quality, so that the talent pool may be smaller than in more advantaged communities. In addition, recruiting someone to a rural community is challenging. In the words of the WWI song, “How you gonna keep them down on the farm, after they’ve seen Paree?” Practitioners trained with an abundance of resources don’t relish no-frills practice in rural communities. In addition, most people train in urban institutions and come to appreciate the social, recreational and cultural advantages that will largely be absent in a rural community.
Rural areas often have death rates higher than for comparable conditions in more resource-rich communities. Health problems that don’t come to anyone’s attention except by pain and severe symptoms often will have a much poorer outcome. The Area Health Education Centers are important parts of the public health system, trying to strengthen the infrastructure so that secondary prevention can take place.
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