There is a major difference in the US compare to how it is understood
and pursued in developing countries for example. In resource poor
countries where I have worked, public health means primary prevention.
That is prevention to avoid sickness before it strike if possible ---
helping healthy people to stay healthy. Here in the US, apart from
immunization, we focus mostly on managing sicknesses. Our concept of
public health implies case management. There is no doubt that we need to
take care of those who are sick. But we also need to understand that, by
the time someone is sick, the train has already left the station. Most
people can avoid becoming sick and they want to if they have
opportunities to make healthy choices. 

To illustrate, during my HIV related work in Sub Saharan African
countries I found that HIV prevention rather than treatment of HIV as
important as it maybe, was at the top of the list in national health
policy. I learned that this focus was due to the fact that treatment was
for the most part out of their means and unsustainable, and unrealistic
given other competing health care needs. Equally importantly for them is
their belief that HIV can and should be preventable. The key question
for research was why is it that some people who are living in similar
conditions are able to take action to reduce their HIV risk while others
cannot. The fact that, most of international research interest and
support is now focusing on treatment not only distract program partners
in the South from their own national priorities but also weakens their
health system. In a way we have been trying to sell our medication
approach to public health to these countries in stead of helping them to
build health care systems that can work for them. 

Lack of interest in primary prevention in the US is quite disturbing to
say the least. Over the years we have talked and discuss evidence about
the growing problem of obesity. It does not require rocket science to
see why we are having problems with obesity here. Yet, a lot of money
has been spent to provide evidence on the nature and extent of the
problem. Even more money is been spent to technical solutions to help
people lose weight. And of course a whole industry is flourishing
selling diet this and diet that. One wonders, what happens to good old
physical exercise, like taking a walk with ones friends, children,
family, a dog etc? Working in the yard or gardening when the weather is
good? It is taking many years to just to improve the quality of food
available to kids in public schools and so far I am still to hear of any
policy decision on this regard. Is it true that a major surgical
operation a better way to deal with the problem? 

My feeling is that, when it comes to public health we know what needs to
be done. Even though some of the determinants of health are complex,
understanding some of the key factors is a matter of common sense. The
real problem is whether an intervention makes money. One does not make
money by educating people on how to organize their lives in ways that
reduces diabetes risks, but rather by treating people who has diabetic.
If a way could be found of turning a good profit through primary
prevention, there will be a lot of interest. This to me is the critical
issue and very depressing indeed. I hope that someone will tell me that
I am wrong.     

Christine.


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