Guest column: Time to reunite public health, clinical medicine

Wade Vandervort

Theresa Nolan, Executive Director of Clinical Operations for UNLV Medicine, will fill syringes with the Moderna COVID-19 vaccine at UNLV on Monday, April 5, 2021.

By Marc Kahn and Benjamin Sachs

Sunday, June 20, 2021 | 2 a.m

Editor’s note: As our nation continues to weather the coronavirus pandemic, we cannot just leave the crisis behind and move on. It is important that we reflect on our mistakes and use the hard lessons we have learned over these many busy months to build protective measures against the next global disease outbreak. Because let’s not be mistaken, this won’t be the last pandemic the world will face.

Today we offer a guest column by the medical experts Marc Kahn and Benjamin Sachs, which provides a framework for the further procedure.

Kahn is Dean of the Kirk Kerkorian School of Medicine and Vice President of Health Affairs for the UNLV; Sachs is a professor at the University of South Florida’s Morsani College of Medicine and the UCF College of Medicine.

As you will see, the two offer a clear assessment of the problems that exacerbated the crisis, along with pragmatic solutions. We encourage southern Nevada residents to read their comments and contact policy makers about them.

One more remark before we present the column. We thank Kahn, a frequent commentator on the Sun, for sharing his view of health policy in our area. His leadership speaks for one of the many reasons the UNLV Medical School is such a valuable addition to our community – it is a source of trustworthy voices delivering vital messages to Nevadaers about health care here in our backyard.

With that we hand it over to Drs. Kahn and Sachs.

Marc Kahn and Benjamin Sachs

There have been over 600,000 deaths in over 33 million cases of COVID-19 in the United States. Nevada has seen over 5,500 deaths and 320,000 cases. The pandemic is also having catastrophic effects on K-12 education, mental health and food security, and has disproportionately affected minority communities. The cumulative financial cost of the COVID-19 pandemic is estimated at more than $ 16 trillion, or about 90% of the U.S. annual gross domestic product

Lessons can be drawn from all of this.

The timeline of the pandemic offers numerous examples of the consequences of the separation of public health, i.e. the care of the population, and clinical medicine, i.e. the care of individual patients.

First, even after the Wuhan lockdown on January 23, 2020, there has been no communication between public health officials and doctors to identify and act on the early warning signs.

In the fall of 2019, the federal government was unaware of a newly emerging disease in China, also because key US experts were withdrawn from China in 2018, including members of an organization that helped monitor and respond to outbreaks and the manager of a US animal disease surveillance program – Ministry of Agriculture. We now have some evidence that the COVID-19 virus was circulating in China in the fall of 2019, and certainly in China and Europe in October or early November. But it wasn’t until late December that Wuhan Central Hospital and the local Centers for Disease Control and Prevention issued a warning of an outbreak of pneumonia in the city. Hong Kong and Taiwan followed suit by screening incoming passengers from Wuhan.

Despite these reports, the CDC said it first learned of a cluster of 27 cases of pneumonia in Wuhan on December 31. The CDC tried, but failed, to develop an internal test and requested that all testing be done at the CDC. Instead, the CDC would have “outsourced” the development and procurement of COVID-19 PCR tests. These steps resulted in significant delays in national virus testing. As the pandemic progressed, the CDC was unable to aggressively monitor viral mutations and contain their spread.

The US health care system was unprepared. In January 2020, an integrated health and public health system would have acted earlier to prepare staff and facilities and to stockpile vital supplies. Many hospital systems use just-in-time inventory management as a cost control measure in which inventory is made available when needed, but not stored. Most of the PPE and ventilators are made in China. As the pandemic spread, China and the developed world competed for PPE and ventilators, creating major shortages. The federal government is said to have taken over the procurement of PPE by January or February, as many federal states did not have the infrastructure to react to the growing crisis. Inadequate PPE contributed to the deaths of more than 2,900 healthcare workers who were needed to care for sick patients.

Public health at the federal, state and city levels is poorly funded in the long term.

In 2019, US health care spending was $ 3.8 trillion. In contrast, public health spending was estimated at $ 93.5 billion in 2018, but probably only 34 to 61% was actually spent on public health. More than three-quarters of Americans live in states that spend less than $ 100 per person annually. We have clearly funded clinical medicine at the expense of public health.

The US response to the pandemic has been heavily politicized at the beginning of its course. As the pandemic progressed, experts downplayed the deadline and questioned the need for face masks, social distancing and bans. Furthermore, public distrust only grew as conspiracy theories and medical quackery flooded social media, driving a wedge between public health and clinical medicine.

How can the US prepare for the next pandemic and improve population health?

We have to drastically increase the public health budgets of the federal, state and local governments. Recognizing that the United States spends almost twice as much as the Organization for Economic Cooperation and Development (OECD) average of 11 countries on health care – yet has the lowest life expectancy, highest suicide rates, highest exposure to chronic diseases and have an obesity rate twice the OECD average – we are not getting good value for money. It is clear that we need to use public health expertise to train and encourage doctors to change the way they think from a disease model to a wellness model.

Medical schools must educate students about the health of individuals and populations, and provide curricula on societal issues, cultural literacy, and health inequalities. However, the details remain at the discretion of the individual schools. We need to reshape medical education to highlight disease prevention and health promotion – goals that are essential for both clinicians and public health professionals. We also need to encourage more doctors to work in public health.

Research funding should encourage collaboration between clinical medicine and the public health system. The front line medical community were true heroes. Too often, however, in response to treating this new disease, clinicians have resorted to anecdotal reports from small clinical trials and observational studies rather than conducting randomized clinical trials without looking for confounders. The contribution of trained epidemiologists and biostatisticians would have made a huge difference. To help, we urge medical schools and public health schools to expand their joint teaching positions.

Our society faces many challenges, including bio-terrorism, quality of health care, aging populations, chronic diseases such as diabetes, and health care financing. We can only address these complex issues through close collaboration between public health and clinical medicine.

Marc Kahn is Dean of the Kirk Kerkorian School of Medicine and Vice President for Health at UNLV. Benjamin Sachs is a professor at the Morsani College of Medicine at the University of South Florida and at the UCF College of Medicine.