Saturday, April 3, 2010

The Girl in the Well

While this blog takes every opportunity to champion the essential role of family physicians in reforming our broken health system, I readily admit that the ability of primary care to affect the most important health problems in the U.S. pales in comparison to the impact of public policies. Restricting tobacco advertisements, raising cigarette taxes, and banning smoking in public places has done more for the health of Americans than thousands of clinicians advising their patients to quit. Laws that encourage the construction of sidewalks, parks, and supermarkets in low-income neighborhoods are more effective at increasing physical activity and healthful eating than armies of dedicated health counselors. Reducing highway speed limits and enacting seat belt and bicycle helmet laws has saved far more lives than injury prevention counseling from thousands of well-meaning pediatricians.

Why is it, then, that so much of our national conversation on improving health has focused on health care rather than public health measures? Why are we captivated by the interaction between a single clinician and his or her patient (the inviolate "doctor-patient relationship") rather than overwhelming evidence about interventions that could better the health of communities? The answer is that statistics are, by themselves, underwhelming. Most people are moved to action by anecdotes, a fact that politicians know very well. This is why there are always a few "special guests" sitting with the First Lady at every State of the Union Address for the President to use as props, and why speaker after speaker at February's health reform summit began their long-winded addresses with stories about individual citizens whose lives would be (depending on their political perspective) improved or worsened by the proposed legislation.

Dr. Alfred Somner, former dean of the Johns Hopkins Bloomberg School of Public Health, calls this the "girl in the well" phenomenon:

The world will watch with bated breath through a four-day rescue ordeal, while at the same time hundreds of millions of people go to bed hungry each night ... We accept the problems of the masses as just so much background noise; but it is background noise that causes immense, entirely unnecessary misery the world over and contributes in our own country to spiraling health-care costs.

For primary care to be most effective at improving health, it must work hand-in-hand with public health departments and community organizations, which themselves must be adequately resourced and funded. A case in point: the Communities Putting Prevention to Work Initiative, launched by the U.S. Department of Health and Human Services last September to target physical inactivity, nutrition, obesity, and smoking, takes the critical step of looking beyond the girl in the well, and in doing so, promises to make the one-on-one work of family doctors just a little bit easier.


Disclosure: I am employed by the U.S. Department of Health and Human Services.