Bravely Aligning Health and Healthcare
Betty Bekemeier, PhD, MPH, RN, FAAN, is the Director of the Northwest Center for Public Health Practice. She is also the Kirby & Ellery Cramer Endowed Professor at the University of Washington School of Nursing and Adjunct Professor in the School of Public Health. In this commentary, she discusses collaboration and alignment of health care and public health. This piece is part of a series of commentaries focused on transforming public health that will be released throughout this week. The first commentary is available here.
For decades we have talked about aligning “medicine and public health” and now “healthcare and public health.” In Washington, the Accountable Communities of Health are meant to bring us together to (finally) make this happen—despite differing incentives, silo’d systems, and serving some of the same populations. Yet, even in 2020 we still arguably experience chronic disease management making up the majority of the effort of the healthcare delivery services (provided largely by primary care systems) and we see infectious disease control as the ‘bread and butter’ of public health systems (provided largely by state, local, and tribal government.)
The novel coronavirus pandemic, embedded within the racism of our nation’s larger, deeper, and more complex pandemic of racist structures and systems; requires something very different of all of us committed to health equity and healthier communities. It demands that we be willing to rethink, restructure, and reinvest our resources into one integrated system that is truly health promoting for all. Such a system focuses on creating healthy living conditions for marginalized populations and prioritizing the protection of health and safety before the treatment of disease and disability. Granted, this is easier said than done.
Even as chronic diseases keep patients revolving through the doors of their primary care providers (if they have one); exhausted providers know their patients struggle to pay for medications, to have access to healthy eating options, and remain unprotected from the stressors and exposures that underlie and exacerbate their illness. These issues are critical to the health of their patients, but generally outside the scope of typical medical practices. At the same time, public health practice professionals in state and local health departments are expected to play key roles in ensuring the conditions in which all people can be healthy in a community.
One would think these health cousins—health care providers and public health practitioners—would work closely together to slow that revolving door for patients and providers, to inform one another of what ill community members experience and which communities are underserved, and to collaboratively address those underlying structures that create barriers to health and safety. But it rarely happens and never widely and deeply enough. Very differing incentives regarding cost, payment, prevention, savings, and more get in the way of true prevention and health promotion. Despite the population-focused, prevention promises that came out of the Affordable Care Act; the success of one cousin undermines the success of the other. Hard won public health prevention successes, for example, create healthcare savings that do not go back into under-resourced public health systems and, in fact, can undermine future funding, as attention to an issue fades.
Data and technology are also extreme hurdles for these cousins to get around. Public health systems are expected to collect, compile, and provide the data for community partners to use for identifying health threats and addressing underlying problems. Yet the technology and data systems that public health departments have at their disposal are often too old, inadequate, and slow to guide practice and lead timely community planning. Meanwhile healthcare delivery data are difficult to share with public health practice leaders, undermining opportunities for detecting emerging threats early or identifying populations that have been marginalized from service—populations at high risk if infected with COVID-19. Better and shared information technology and data systems could, for example, support data sharing that could identify communities at high risk for COVID-19 or help to better understand the specific health needs of underserved populations.
The barriers that stand between a collaborative, effective, familial alliance between healthcare and public health are numerous and incentives and data are just two. COVID-19 should be the family crisis that brings us (finally) together. COVID-19 throws chronic disease, infectious disease, and our broken systems together into one rather ineffectual mess that we need to come to terms with. Public health practice personnel have worked valiantly to stand up prevention, detection, contact tracing, communication, and community guidance systems. Their efforts will show to have saved countless 1,000s of lives. Healthcare personnel have worked tirelessly, and put themselves at great risk, to test and treat the many 1,000s of those exposed and infected. Yet we were all late, under-resourced, and inadequately collaborating around something that we have known for years would arrive.
While we all pay the price for this under preparation, people of color are particularly paying for this with their lives and families. Let’s not waste a good crisis. Let’s together assure the conditions in which people can be healthy and make 2020 the year that healthcare and public health systems took joint responsibility for creating a health system focused on health—not illness. Rethinking, restructuring, and reinvesting our resources into one integrated system will be enormously difficult. But COVID-19 has made the need for this integration more apparent than ever and created an opportunity (indeed, a responsibility) for us to think and act differently together.