I don't think that clinical practice and public health should be entirely separate entities. I'm not sure that anyone truly thinks this, or at least I've yet to meet anyone that has said this outright, because it seems like a rather counter-intuitive stance to take on health. After all, while it's true that clinicians and public health workers have different job responsibilities, the ways they work with their populations affect the work of the other group. For example, in class we briefly discussed which approach is the better approach to the problem of obstetric fistula* - the clinical approach or the public health approach? I felt that the class was leaning towards the idea that the public health approach is better. As in, identify the risk factors and/or causes of obstetric fistula - long labor times and malnutrition are two - and then work to reduce the exposure to those risk factors. Create programs to train women to be birth assistants or midwives or study the diets of the women generally affected and determine how to supplement those diets. However, I think this approach leaves out an essential part of the work. Without surgeons to repair the fistulas, until incidence of obstetric fistula reaches zero, the current cases don't go away. There would still be people affected by obstetric fistula, and saying that the public health approach is the best approach, or even that it's the better approach, downplays the work done by clinicians.

I'm a big fan of metaphors, and I think the public health vs. clinical practice issue could be explained relatively well with a metaphor. Imagine any particular issue associated with negative health outcomes (gun violence, malaria, lung cancer). Let's say that issue is like a leg wound caused by a plant with poisonous thorns. The public health approach would be to say "Ok, what caused this person to come into contact with this plant? What could we have done to prevent this?" and then finding out the story behind the leg wound. The person was walking to her grandmother's house and strayed from the path, walking into a poisonous bush. Public health workers would then look at the incidence of straying-from-the-path leg wounds, then determine what methods would be best to prevent this from happening in the future. Maybe more signage would be put on the path, so that people are less likely to stray, or maybe an alternate route could be designed to avoid the poisonous bush area in its entirety. The public health approach is to prevent the wound from happening in the first place. However this still leaves that little girl with a poisoned leg wound.

The clinical approach would be to treat with antidote and close the leg wound, and maybe treat with antibiotics to prevent infection. This, of course, does not address the issue of other little girls straying off the path and also walking into bushes with poisonous thorns, or the potential consequences of only treating the leg wound without investigating the particular causes of that wound. The clinical approach is to, in this metaphor, put a bandaid on the wound.



Whatever the approach is, taking only one of the two leaves people hurt. Either the wound of one person is treated, leaving others at risk, or a lot of wounds are prevented but the wounded aren't treated. Of course, I can't say that either approach is solely taken, but if that were the case then it would clearly not be a good thing. Understanding the importance of both approaches, however, is something that I'm not sure that public health workers and clinicians do. Both public health and clinical care are important to promote and maintain positive health outcomes, and that's why I care so much about working in both fields. I don't want to work only as an epidemiologist or only as a doctor, even though both of those careers are brilliant careers through which a lot of change can be made. I want to be someone who can serve as a bridge between the two silos, and work from both perspectives to enact change.

* Obstetric fistula is a hole in the birth canal, usually between the canal and the bladder or rectum. It can cause incontinence.