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Healthcare: It Ain't Public Health, But...

Healthcare: It Ain't Public Health, But...

The routes where public health and healthcare travel are an awkwardly engineered – two-way – roundabout, rarely the two shall meet. And whether one is an emergency manager or a public health administrator, it'd be good to know – before things go bad – what the community's healthcare providers can and cannot do in support of a disaster or health emergency. And it'd be good to know that 92% of the Nation's healthcare system is in the private sector with employees that have limited authority to practice outside their facilities.

Oh yeah, and it'd be good to know that if healthcare providers cannot keep their doors open – if they cannot collaborate to surge bed capacity – the job of figuring out how to care for the community's ill and injured will fall squarely on the shoulders of emergency management and public health.

Healthcare may not be public health, but history proves there is a time – in truly catastrophic disasters and public health emergencies – when pubic health may need to do its best impression of a healthcare provider.

"If things have degraded to a point that the public health nurses are scrambling to deliver healthcare services in the street, a tent, or a high school gym, it's likely that emergency management is a bit overwhelmed..."

You see, if things have degraded to a point that public health nurses are scrambling to deliver healthcare services in the street, a tent, or a high school gym, it's also likely that emergency management is a bit overwhelmed. It's also likely that there is pain and suffering beyond what the community ever imagined or prepared for. Maybe the thought of such chaos will give emergency managers and public health administrators reason to pray for the success of their regional healthcare coalitions? 

 Oh, I digress. Today, let's just get a handle on the chasm between healthcare and public health.

A Word About Definitions

Academics will debate nuances between the definitions of healthcare, medicine, behavioral health, and public health. Is 'medicine' the same as 'healthcare' or just a subset within? What about behavioral health? Is it considered a healthcare service? The insurance companies often don't believe it is. What about public health departments, are they providers of medical services?

Such definitions might matter in the classroom, but they mean little to the local emergency manager in the aftermath of an earthquake or a public health administrator who's knee deep trying to figure out how they became the community's Emergency Support Function #8 lead.

"Healthcare is about diagnosing, treating, and caring for individual patients – whether one has difficulty breathing from congestive heart failure during a flood evacuation or has been impaled by a 2x4 during an F-5 tornado.

For our purposes, we'll stick to the popular notion that medicine and behavioral health fall under the umbrella of healthcare, and that public health is a whole different animal. The Harvard T.H. Chan School of Public Health draws a clear distinction between the two in stating that medicine is, "disease diagnosis, treatment, and care for the individual patient [Emphasis Added]," and public health is, "disease prevention and health promotion for the whole community  [Emphasis Added]."

That is not to say that public health departments never provide services that fall in the 'healthcare' realm, but they are not providers of secondary/acute care, tertiary care, respite care, or home care services. Arghhh... more definitions.

Healthcare

Healthcare Description Image

Healthcare is about diagnosing, treating, and caring for individual patients – whether one has difficulty breathing from congestive heart failure during a flood evacuation or has been impaled by a 2x4 during an F-5 tornado. For those in the preparedness realm, both are real possibilities. And both are ideally triaged and treated by healthcare providers rather than public health professionals. But, a healthcare provider is not a healthcare provider is not a healthcare provider.

I know I said that definitions mean little in the context of response, but we're going to look at a few from The Free Dictionary: Medical Dictionary necessary to demonstrate the layered complexity of the healthcare system. Why list them? Because it's important to understand that there is far more to healthcare system preparedness than just hospitals. And it is important to recognize that when other healthcare facilities are ignored in preparedness, the ill and injured will not only wipe out a community's EMS system, but it will blow up even the best hospital's medical surge plan.

The reality is, when the continuum of care breaks down everyone heads for the emergency room.

Healthcare Specialty Areas Image

  • Primary Care: The usual point at which an individual enters the healthcare system. Its major task is the early detection and prevention of disease and the maintenance of health. This level of care also encompasses the routine care of individuals with common health problems and chronic illnesses that can be managed in the home or through periodic visits to an outpatient facility. Providers of care at the primary level include family members, as well as the professionals and paraprofessionals who staff community and neighborhood health centers, hospital outpatient departments, physicians' offices, industrial health units, and school and college health units.
  • Secondary/Acute Care: Concerned with emergency treatment and critical care involving intense and elaborate measures for the diagnosis and treatment of a specified range of illness or pathology. Entry into the system at this level is either by direct admission to a healthcare facility or by referral. Provider groups for secondary care include both acute- and long-term care hospitals and their staffs.
  • Tertiary Care: Includes highly technical services for the treatment of individuals and families with complex or complicated health needs. Providers of tertiary care are health professionals who are specialists in a particular clinical area and are competent to work in such specialty agencies as psychiatric hospitals and clinics, chronic disease centers, and the highly specialized units of general hospitals, for example, a coronary care unit. Entry into the health care system at this level is gained by referral from either the primary or secondary level.
  • Respite Care: Provided by an agency or institution for long-term care patients on a short-term basis to give the primary caretaker(s) at home a period of relief.
  • Restorative/Home Care: Follow-up care and rehabilitation in such facilities as nursing homes, halfway houses, inpatient facilities for alcohol and drug abusers, and in the homes of patients served by home health care units of hospitals or community-based agencies.
  • Continuing Care: Provided on an ongoing basis to support those persons who are physically or mentally handicapped, elderly and suffering from a chronic and incapacitating illness, mentally retarded, or otherwise unable to cope unassisted with daily living. Such care is available in personal care homes, domiciliary homes, inpatient health facilities, nursing homes, geriatric day care centers, and various other types of facilities.

Yep, healthcare is complicated. It does not operate in the neat vertical chain of command that does emergency management and public health. Each facility or service may have a different owner or parent corporation; each may operate in direct competition with the others; each has full liability for omissions and commissions that cause harm to their patients or staff, and as private entities, the jurisdictional boundary is the property line, not the city or county line. 

Also, whether a healthcare facility is for-profit or not-for-profit makes little difference when it comes to the need for revenue. There are rarely government subsidies or bailouts to keep healthcare facilities in the black. So, I guess you could say that even not-for-profits need to make a 'profit' to keep the doors open.

Public Health

Public Health Health Description Image

As we mentioned prior, the Harvard T.H. Chan School of Public Health writes that public health emphasizes "disease prevention and health promotion for the whole community." Now, before we write this off as an off-base definition from some small unknown university, let's check what the World Health Organization (WHO) has to say:

"Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole [Emphasis Added]," says WHO. "Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases [Emphasis Added]. Thus, public health is concerned with the total system and not only the eradication of a particular disease." 

WHO goes on to list the three main public health functions:

Public Health Specialty Image

  • The assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities.
  • The formulation of public policies designed to solve identified local and national health problems and priorities.
  • To assure that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services.

And finally, the Centers for Disease Control and Prevention (CDC), National Public Health Performance Standards (NPHPS), which are intended to provide a framework to assess capacity and performance of public health systems and public health governing bodies, identifies the 10 Essential Public Health Services as:

  1. Monitor health status to identify and solve community health problems.
  2. Diagnose and investigate health problems and health hazards in the community.
  3. Inform, educate, and empower people about health issues.
  4. Mobilize community partnerships and action to identify and solve health problems.
  5. Develop policies and plans that support individual and community health efforts.
  6. Enforce laws and regulations that protect health and ensure safety.
  7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
  8. Assure competent public and personal healthcare workforce.
  9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
  10. Research for new insights and innovative solutions to health problems.

By now, I hope I have sold my argument: healthcare is not public health. The Nation's public health 'system' is actually a series of interconnected public health systems. The 'system' is government operated at all levels and is vertical in nature. 

The federal public health system is lead by the United States Public Health Service and the CDC (We'll let them fight about who's more important.), which are responsible for coordinating with each state's public health system. And each state has the autonomy to structure their local public health system as they see fit. We'll spare the details, and let those who love that stuff read our article, Balancing Individual Rights and National Health Security.

The takeaway for the emergency manger is that the public health department does not have the staff, expertise, or equipment to treat acutely ill patients with congestive heart failure, asthma, or a severed right leg. Regardless, they possess the highest level of medical expertise of any agency in state and local government.

Yeah, we have a private healthcare system that can perform miracles for the ill and injured, but only if providers can keep their doors open. If not – like it or not – helloooo.. public health.

And this is the very reason healthcare coalitions should matter to every emergency manager and public health administrator.

Stay tuned. That is a story that deserves its own space.

 

infoGraphic: Public Health vs. Healthcare

 

 

Karl Schmitt, MPA

Karl Schmitt, MPA


Karl is the Passionate Founder & CEO of bParati. He is on a mission to build a national network of effective, sustainable healthcare coalitions. More...

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In all we do, we seek to reduce human suffering and loss of life caused by disasters.

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Karl Schmitt, Passionate Founder & CEO, bParati

Karl SchmittPassionate Founder & CEO

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