CLASSIFICATION TALK:
Rudy Fedrizzi
Picture from Keene Sentinel
Rudy Fedrizzi, accompanied by his colleague, Epidemiologist Lyrica Stelle, operating the laptop, gave a classification talk that focused on the importance of Public Health and his own reason for moving from private practice as an obstetrician to his present administrative role in the Vermont Department of Health. Rudy served as a physician in the Air Force for four years and then as an obstetrician for seventeen years. He became tired of practicing medicine as a “lifeguard,” always coming to the rescue rather than actually improving the health of people in his care. He felt constantly reactive—responding to his beeper. Public health, in contrast, focuses on the prevention of diseases. Rather than a focus on end-stage disease, public health intends to move upstream to explore more root causes that can be modified.
Rudy finds the best definition of public health to have been crafted by Charles-Edward Winslow in 1920 at the inauguration of the Yale School of Public Health in 1920:
“… the science and art of preventing disease, prolonging life, and promoting physical (and mental) health through organized efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.”
The focus of this definition is on the social determinants of disease, such as the use of tobacco products. In contrast, when Rudy was educated in the 1980s and 90s, there was no training in nutrition and there was a lack of recognition of the overwhelming impact of the social factors of health. Medical care accounts for only 10-15% of the direct impact various factors have on the health of our nation’s population, yet over 90% of our health care dollars are spent on medical care. Other advanced nations spend only 50% of their health care dollars on direct medical care.
Rudy outlined a brief history of the evolution of public health action in Western culture—from the imposition of the quarantine in Italy in 1347 during the Black Plague, through the visual identification of bacteria using the microscope in 1674, through the verification of the benefits of lemons and oranges to prevent scurvy among the British Navy in 1754, through the identification of public water supplies as a carrier of cholera in 1854, through the passing of federal legislation for meat-packing inspection in 1906, through the establishment of the Federal Department of Health, Education, and Welfare under Eisenhower in 1953, up to the official eradication of smallpox in 1979. Over the past 160 years, life expectancy in the United States rose from 40 years to 78 years largely because of the progress in public health efforts. Because of an increased control of infectious diseases through public health measures, deaths from infectious diseases dropped from 800 persons per 100,0000 to less than 50 persons in 2020—a decrease precipitated through public sanitation efforts, vaccinations, antibiotics, federal food regulations, food fortification (folates, for example), and the reduction of chemical contaminants.
The use of vaccines has wiped out many infectious diseases, although vaccine hesitancy has grown recently. Maternal mortality rate dropped precipitously from over 800 instances per 100,000 live births in 1900 to around 20 today—still placing the United States only 50th among the world’s nations. One of the reasons for the decline that has taken place was the recognition earlier in the 20th century of fewer deaths among midwife-assisted births compared to physician-assisted births because of better sanitary procedures adhered to by midwives! There still remains significant disparity in infant mortality rates in the United States between White and Black populations—a probable result of unaddressed social factors. A dramatic example of the effectiveness of public health measures is the dramatic drop in deaths caused by the use of tobacco products since the surgeon general’s report on smoking and health in 1964.
The future success of Public Health depends upon
- Re-establishing its reputation;
- Integrating its efforts with clinical care;
- Addressing the deleterious effects of climate change (tick-borne illnesses, for example);
- Identifying and addressing the social and structural determinants of health;
- Addressing social inequality.
QUESTION:
Paul Tierney asked why there are so few doctors per capita. Rudy replied because the education and training of physicians is expensive. We can adjust our reliance upon physicians by such means as relying more on midwives. Eighty-five percent of births move smoothly; only fifteen percent have problems—so we should make more use of midwives.