Public health – the sewer system of health care!

One of the biggest challenges I’ve faced in my 25 years as a public health official has been finding ways to get people to understand the difference between public health and the traditional health care system. I’ve tried statements like, “Public health is focused on prevention and populations, while health care deals with treatment and individuals.” I’ve explained how public health works to keep people well, while most of the emphasis in traditional health care is on illness. I’ve even used graphics showing the spectrum between premature death and disability and high level wellness, emphasizing how public health “sets the floor for the personal health care system.” But nothing has really worked.

Then one day, as I was replacing the concentric float fill valve on my toilet at home, inspiration struck me like a bolt of lightning, “Public health is the sewer system of the American health care structure!”

A number of my colleagues in public health have been less than enthusiastic about this analogy of mine, but let me give you some of the reasons why I think it’s so brilliant.

First of all, it gets attention and is easily remembered. Sewers, and all of the scatological functions of the human body that require them, fit into one of those categories of discussion that polite, civilized people avoid. They transport obscene matter, about which genteel, well-mannered folk just don’t speak. In actual fact, they are full of s#@% and they stink! But precisely because it seems that no one would ever willingly compare their profession to a sewer, the analogy does seem to grab and hold attention!

The second reason I believe this analogy is so appropriate is because sewers are in large part the foundation of the civilized world, and public health is the foundation upon which the health care system is built. That’s why the Patient Protection and Affordable Care Act (PPACA) has so much to say about revitalizing this country’s public health system, and includes funding to do something about it. It makes no sense to try to improve a health care system by rebuilding it on a crumbling foundation! Unfortunately, some in Congress have not yet accepted this analogy, and continue to try to chip away at the funding that was placed there to protect the foundation.

A third reason that this comparison of public health with a sewer system is so inspired is because no one ever thinks about either public health or their sewer unless something has gone terribly wrong. We take both of these systems for granted until there’s an Ebola virus outbreak or influenza epidemic somewhere or until the sewage starts backing up into our basement or kitchen sink. Then suddenly we wonder why we didn’t invest more time and money in the upkeep and support of the system in question!

Fourthly, sewer lines connect private individuals and industries to public sewer lines and utilities. This public-private partnership is mirrored in public health. Public health provides the interface between governmental health departments at the local, state and federal level and private health care providers and health care systems. This collaboration is what has allowed us to build a strong baseline of health in this country, and facilitates rapid action in the health system when emergency responses are needed.

Finally, modern public health and modern sewer systems were born together in mid-19th century London! They were not born as allies, however. Each was the product of a different theory of disease. Public health grew out of the theory that cholera was a disease that was caused by something like germs being carried in the water system. Sewers, on the other hand, were originally developed on the theory that “bad air” caused disease, and there was a need to move the filth that was being collected in basement cesspools and causing a terrible stench, or “bad air,” out of the city and into the rivers. Eventually, the germ theory was shown to be correct, and public health and public sanitation began to work together to produce the greatest level of health that the world had yet seen. And so I believe it is no insult to my colleagues or to our profession to say we are the sewer system of the health care structure of America. But please be sure to remember while we may be like the system, we are in no way similar to that which is transported in the system!