It is generally agreed that there is a great divide between public health and medical care. Some feel it is akin to a wall rather like the historical Berlin Wall. However, while the Berlin Wall has crumbled, the wall between   public health and medical care stands firm. While the focus of medical care is the individual patient, public health’s patient is the community, it focus its efforts on trying to improve the health of the community. Medical care thus is all about healing patients who are sick while public health concentrates on preventing illness. The object of medical care is to modify, reduce or totally eliminate the signs and symptoms of disease. It has been pointed out that the classification of diseases into acute and chronic from the medical care point of view is a reflection on the potential degrees of success in treating the disease. From the standpoint of public health, the differences between the two are related to onset, cause, and duration, acute disease often being linked to causative organisms while chronic disease is related to lifestyle factors.

 
It is postulated that the barriers between public health and medical care have been erected principally because there are indeed structures to keep these professions apart.    For example, these are regarded as distinct professions with clear, divergent career pathways. Medical care is usually associated with all the glamour, while public health is the poor cousin, the Cinderella yearning for a Prince Charming. There are other distinct differences like in funding mechanisms, where public health is usually publicly funded whereas medical care could be either public or privately funded.

 
While there is general agreement that it is much more cost effective to prevent rather than treat disease, health systems faces a huge problem when it comes to making decisions on apportioning funds.  Hospitals have been described as bottomless wells, where no amount of funding will ever be sufficient – there are always new drugs that are desperately needed, the latest medical equipment to acquire, and specialized personnel to be employed.  For example, in an area like HIV, patients who are HIV positive need to be treated with expensive drugs, but at the same time prevention and health promotion activities need funding. The situation is more obvious with diseases like dengue fever where only supportive therapy can be provided to patients with the disease, where it makes more sense to concentrate on efforts to eradicate the mosquitoes that transmit the virus. So while there is an intention to increase funding for public health, the hugely expensive demands of medical care in hospitals make it next to impossible to do so.

So what can we do? The only workable solution is for doctors involved in medical care to also involve themselves in aspects of public health like prevention and health promotion. This begs the question as to why doctors are not doing this as part of caring for their patients. A major reason is time constraints.  Many doctors are hard pressed for time so that consultations are often hurried, leaving them no time beyond treating the ailment for which the patient came to see the doctor. Another reason is the mind-set of those involved in medical care being geared towards treatment. For example, it is an accepted fact that obesity is a major risk factor for diabetes, heart disease and cancer. Unfortunately, obesity and its cures have been musicalized so that instead of focusing on healthy nutrition and promoting physical activity, the move is towards stomach stapling, increased Caesarian sections for pregnant obese women and the like.  The doctor is oriented towards treatment to relieve a patient of his/her symptoms. It may also be prompted by the fact that many health insurance plans specifically exclude payment for health screening or preventive services.  In addition, the average doctor tends to regard prevention as the government’s role in public health associating it with campaigns and other actions directed towards the community.   Thus, the doctor’s role is perceived to be purely personal and curative.

 
This would then mean there has to be a change in the mindset and thinking of doctors involved in the provision of medical are. This is not to say doctors are not involved in aspects of public health like health promotion, but a lot more needs to be done in a systematic fashion. It may be worthwhile recalling the four levels of prevention mooted many years ago (Leavell & Clark, 1953) – health promotion, protection against specific disorders [1], early disease detection with prompt treatment and limitation of disability.  For example, when a doctors is treating a patient with chest pain who turns out to have ischemic heart disease, apart from treatment for the condition, advice needs to be provided on managing stress, losing weight, exercising moderately, stopping smoking, eating healthy and the like.

 
It needs to be realized that merely educating the patient by increasing his/her awareness on prevention of disease or promoting health may not be sufficient. Doctors tend to assume that merely providing advice suffices.   However, there has to be a change in attitude and a subsequent change in behavior of the person concerned. For example, discouraging smoking by telling the person that this would reduce the risk of lung disease, heart disease, cancers, heart and the like may not be sufficient motivation for that person to reduce his/her smoking or case to smoke. Instead of using a blunderbuss approach, just as medical are is personalized targeting the specific ailment, health promotion too has to be personalized.  The first step would be to analyze the altitude of the person with respect to the behavior that is being addressed. Only if that person agrees that that particular habit or practice is detrimental to his/her health, will any intervention work. Subsequently, there is a need to work with the person to help change the harmful behavior or habit.  This can be done for example, by setting target for that person to achieve, and then assisting the person to identify practical strategies to work towards achieving this goal.

 
Only if doctors involved in the provision of medical care are prepared and willing to take on aspects of public health like prevention and health promotion on an individual level can we work towards chipping away at this wall between public health and medical care.        

1. Leavell HR, Clark EG (1953) Textbook of Preventive Medicine. New York, McGraw Hill 7-27.