Is the 'Wall' Between Medicine and Public Health Crumbling?

    • June 18, 2012

“When I was at the University of North Carolina,” says Desmond Runyan, MD, DrPH, “we used to say that the street that ran between the School of Medicine and the School of Public Health was the widest street in town.” In Runyan’s telling, it wasn’t the distance from curb to curb that was the barrier, it was what he and others have described as the “wall between medicine and public health.”

Runyan found his way around the barrier, earning an advanced degree in public health after finishing medical school. But he said that while pursuing his degree, he felt obliged to leave his “white coat and stethoscope at home, because in public health, one had the clear view that doctors were the problem, not the solution.” Runyan has since spent much of his career helping to deconstruct the metaphorical wall, and from his position as national program director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, he has observed—and contributed to—real progress.

In fact, many alumni of the Clinical Scholars program are doing the same—remaining mindful of friction between the two professions, but finding ways to bring them together in service of improving Americans’ health. By their own descriptions, the effort has a lot to overcome. The professions train in separate schools, have different missions, learn to focus on different aspects of similar problems, have different pay scales that can cause tensions, and more.

In Some Areas, Working ‘Hand-In-Glove’

Donald Schwarz, MD, MPH, from the 1985-1987 cohort of Clinical Scholars, is Philadelphia’s deputy mayor for health and opportunity and the city's health commissioner. He says that the “wall” is real, but that it has ever-widening gaps. “For instance, with infectious disease, there has been a hand-in-glove relationship between the professions for a long time. The history on HIV illustrates that, with the public health infrastructure paying the health care sector to care for people with HIV, while the health care sector works with the public health side on both prevention and outreach.”

“Where the collaborative work has been trickier is with chronic illnesses,” Schwarz explains, because the most severe—and costly—effects of chronic health conditions can come years, even decades later. Philadelphia, for example, has launched an initiative on hypertension. “The challenge is with the funding stream,” Schwarz says. “The bulk of the funding around hypertension has gone to the health care sector, to treat patients with the disease. The vast minority of funding has gone to thought or action to build the hypertension infrastructure on the public health side.” Working with funding from the Centers for Disease Control and Prevention (CDC), however, Philadelphia is beginning to bring the professions together as part of a collaborative effort around hypertension that also involves health insurance companies, nonprofit organizations, the philanthropic community, and government agencies.

Schwarz says the city is also developing an asthma project, in which “the health department is working with an outpatient children's asthma program. The department is doing in-home work,” inspecting homes for mold and other problems, and working to create a healthier environment for children who have asthma.

Chisara N. Asomugha, MD, MSPH, FAAP, from the 2007-2009 cohort of Clinical Scholars, is administrator of the Community Services department in New Haven, Conn. She says, “The wall exists because of the way we're trained. The mission of clinical medicine is to address disease processes at the individual level. And in public health, it’s really about populations and systems that impact health. So as clinicians we're not always thinking in terms of public health.” Still, she says she has always viewed the professions as connected, and is ever on the lookout for ways to bridge gaps. “The fixing is all in the communicating. It's getting the different disciplines to realize that they overlap in significant and important ways,” Asomugha says. “Of course, the professions’ missions are different. For example, a hospital’s mission is to serve people who come to the hospital, not necessarily the physical community that surrounds it or even the systems that impact the health of those they serve. But where the professions find that their missions overlap, that's where we need to have conversations.”

Up the road in Hartford, Mehul Dalal, MD, MSc, of the 2006-2009 cohort of Clinical Scholars, recently joined the Connecticut Department of Public Health, as the state’s chronic disease director. He acknowledges that the barriers between the professions are both “long recognized and lamented,” but says that over the past decade he believes they have begun to crumble. “Medicine and public health are both seeing increased demand for results and accountability, and that has drawn the two fields together. It just doesn’t make sense for us to be working in silos.”

Attacking Underlying Causes

In Dalal’s work on chronic diseases, it is “no longer a question of whether we should work together across professions, but how,” he says. “There are certainly structures that tend to keep the professions apart—different funding mechanisms, different professional pathways, for example. Our chronic disease team is working within the department and with our partners in the health care sector to improve collaborative relationships. We know, for example, that many of the chronic diseases we’re trying to prevent share the same root causes, some that are embedded in the social determinants of health. Many chronic diseases share risk factors too. For example, obesity increases your risk of diabetes, cardiovascular disease, and cancer. So we may be able to move the needle on a number of diseases, if we can effectively address obesity. That’ll require work both in the doctor’s office and in the community.”

Schwarz makes a similar point about obesity. “We've medicalized obesity and the cures for it,” he says, “and yet it's so tied up with environment and genetics. The health care sector gets increasing amounts of money for obesity-related problems, but it's never going to be able to get ahead. We’ll have to collaborate to solve the problem.” The possible solutions go beyond fitness campaigns, he says. “We could build safer streets, with benches for people to sit on, and with better lighting; and we could build appropriate places for kids to play. Those things would probably have substantial impact on people's physical activity level…. We choose instead to invest in health care, paying for stomach stapling, and more and more C-sections for obese women, rather than taking our social investment and putting it into infrastructure in a way that would promote healthier lifestyles.”

In late June of 2012, Raymond Perry, MD, of the 2009-2012 cohort of Clinical Scholars, is set to begin a new job as the medical director for Juvenile Court Health Services, part of the Los Angeles County Department of Health Services (the department is directed by Mitch Katz, MD, of the 1989-1991 cohort). Perry was a Clinical Scholar at UCLA, and he is new enough in the profession that his experience with the divisions between medicine and public health is mostly from word of mouth. “I’ve heard about it more than I’ve experienced it,” he says. “I came along at a time when people were actively trying to break down the wall. Collaboration is certainly a strong part of the program at UCLA, and from the beginning we had a chance to work with the public health services department in Los Angeles on STD screenings in the schools, for example. So I haven’t necessarily seen the wall first-hand, but I’m certainly aware that it has been a challenge for both professions.”

Dalal completed the Clinical Scholars program just three years ago, and brings a similarly optimistic view to the subject. “We have more institutions and people recognizing that we're working on the same team,” he says. “It’s not hard to see where the wall comes from. On the medical side we provide services to individuals, and on the public health side, we serve the broader population. But in reality, of course, those things are linked, and the more clearly we recognize that, the better the results we’ll achieve.”

The RWJF Clinical Scholars Program’s Role

Many of the Clinical Scholars credit the program with shaping their views on the need for collaboration, and with helping break down barriers at the universities participating in the program. Runyan reflects that credit back on the scholars, noting that eight Clinical Scholars have gone on to become deans of schools of public health, and that many who’ve graduated from the program have gone on to teach in public health schools. “To really build the kinds of partnerships we need, it takes people who understand both professions, and who are invested in the collaboration. We’ve tried to find those people for the program, and then to help them grow.”

The RWJF Clinical Scholars program advances the development of physicians who are leaders in transforming health care through positions in academic medicine, public health, and other roles. The program trains clinicians in the program development and research methods that will enable them to find solutions to the many challenges posed by the health care system, community health and health services research.