Friday, October 7, 2011

"Salus Populi Suprema Lex" -- The health of the people is the supreme law.

Salus Populi Suprema Lex.” The health of the people is the supreme law[1]

The responsibilities of the physician extend not only to the individual but also to society and demand his cooperation and participation in activities which have as their objective the improvement of the health and welfare of the individual and the community... As good citizens it is the duty of physicians to be ever vigilant for the welfare of the community.”[2]

Doctor Rudolph Virchow, considered to be the father of Cell Pathology, was a contemporary of Otto Bismarck. Virchow was very involved in public health, which irritated Bismarck to no end. When Virchow opposed him on the issue of Employer-Based Health Insurance, Bismarck challenged the good doctor to a duel. As tradition would have it, Virchow had the questionable honor of choosing the weapons: sausages. At that time, and perhaps to this day, sausages were widely felt to be the reason many fell ill, no doubt due to the conditions under which they were made. Bismarck, on viewing the “weapons” relented, amused, and perhaps fearful that handling the wieners could make him ill. He famously declared that “Laws are like sausages; it is better not to see them
being made
.”

Today, doctors face the same dilemma: community involvement versus politics that would absolve physicians of that noble obligation as described in the AMA code of ethics.

Virchow was a man ahead of his time. He determined over 150 years ago that practically all diseases are inflammatory conditions, a fact not fully understood until the 21st century. But, in my opinion, his skills as an Anthropologist sealed his place in medicine by stating that “Medicine is a social science, and politics nothing but medicine on a large scale. Physicians are the natural attorneys of the poor.” Many doctors have followed his example and thus laid the foundations of modern Public Health and Medicine. By taking care of community issues such as clean water and food, garbage disposal, sewage, etc. illnesses were dramatically reduced and in many cases prevented. Leaps forward in longevity were thus achieved.

Much of the subsequent spectacular progress in public health in the 19th and early 20th centuries was due to a better understanding of microbiology and the transmission of infectious diseases, together with the recognition of the importance of clean water, hygiene and sanitation.”

But what are public health physicians and government policy makers doing about this state of affairs? There is no coordinated strategy, and there is a very poor information base on effectiveness and cost-effectiveness... Properly thought out prevention, especially targeting young adults and children will save the resources necessary for treatment of chronic diseases later. But where are the zealous physicians and public health advocates of the 19th and 20th centuries?”[3]

Doctors like Virchow are struggling to be heard over the chorus of voices who feels physicians should not be involved in the community.[4] No doubt economic pressures and the inherent arduous nature of practicing medicine make community involvement difficult if not impossible. After all, attending to patients in our clinics is our main obligation. By maximizing effectiveness, quality and savings in our clinics we also benefit the patients we serve.

One group of doctors in Salt Lake City (IHC) has made national news by computerizing practice protocols for maximum efficiency in their pharmaceutical/surgical approach. Why not do the same with community/environmental issues?

If doctors were to study similar protocols designed to track public health issues like polluted air, processed foods, and other community issues that impact our patients’ health, how much more efficiently could we serve our patients? These protocols already exist, but they tend to be ignored as not “hard” enough evidence[5] or as “a socialist agenda.”

The new baseball movie “MoneyBall” chronicles how teams are now using the same computerized approach; by crunching player stats teams rank the best players available. Mr. Beane struggled to convince baseball higher ups to adopt this approach for years. He finally succeeded with the Boston RedSox who went on to win the World Series in 2004 and 2007. There is no argument that money and profits are powerful motivators. Even the most idealistic physicians would agree. In a sense we now have “MoneyHealth.”If ALL issues pertaining to our patients’ health were plugged into the computer, we would certainly save a lot of money[6] and keep our communities healthier.[7]

Capitalist innovators like Schumacher[8] have pleaded for years that the bottom line of Capitalism be expanded beyond profits to include social and environmental responsibility.[9]

It is tempting to retreat away from public health issues in today’s present economic/political situation. But, strong ideologies may not be conducive to putting patients’ welfare first, which is bound to deteriorate, especially for the poor.[10] If physicians do not live up to Virchow’s legacy, our communities may be at a higher risk of “Collapse.”[11]

Should medicine ever fulfill its great ends it must enter into the larger political and social life of our times. It must indicate the barriers which obstruct the normal completion of the life cycle and remove them. Should this ever come to pass, medicine whatever it may then be will become the good of all.”[12] Virchow



[1] American J. Public Health 2001;91:689

[2] AMA statement quoted in “Social and Political Responsibilities of Physicians,” J. Med Philos 1977;2: 376

[3]The Catastrophic Failures of Public Health,” J. Lancet 2004;363:745

[4]Medicine Is a Social Science in Its Very Bone and Marrow,” J. Mayo Clin Proc October 2011;86(10):930

[5]Medicine Is a Social Science in Its Very Bone and Marrow,” J. Mayo Clin Proc October 2011;86(10):930

[6]The future of Public Health,” Special issue, J. Managed Care, September 2005;14#9

[7] Structural Interventions for Addressing Chronic Health Problems,” JAMA 2009;302(6):683

[8] Book “Small is Beautiful: economics as if people mattered,” E.F. Shumacker; Hartley & Marks 1973

[9] Book “The Politics of Fortune; a new agenda for business leaders,” Jeffrey Garten; Harvard Business School Press, 2002

[10]Facing the New Reality: preparing poor America for harder times.” Report by Community Action Agencies, 2011

[11] Book “Collapse: how societies choose to fail or succeed” by award-winning anthropologist Jared Diamond; Viking Press, 2005

[12]Rudolf Virchow, Public Health and the Built Environment,” J. of Urban Health 2003;80:523

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