Should we redefine the CDC's Ten Essential Public Health Services?

No...there are more important issues that deserve our focus!

Historically, the Ten Essential Public Health Services, promoted by the Centers for Disease Control, [i] have served as a framework to define the scope of the public health profession in the United States, and justify much needed federal funding.[ii] However, while this list of services provides a context for public health as a discipline on many levels (federal, state, county), it provides an incomplete framework for practice. The Ten Essential Services document is a framework that is constrained by the system in which it was developed; one that is primarily oriented towards public health solutions that are focused on the individual. Some public health practitioners have suggested that the Ten Essential Services are outdated - or at best inappropriate - for practical application in the field of public health. At present, a work group of California's public health officers has coalesced to redefine and/or update the existing Ten Essential Services, in the hope that such efforts will engender more relevant public health practice. However, if we believe the fundamental goal of public health practice is to improve population health, it is worth asking whether it necessary for county public health officers to spend their time, energy and resources redefining the Ten Essential Services, or whether there might be a better use of such efforts.

The Ten Essential Services can be relevant to current public health practice, to the extent that this framework reminds practitioners of the fundamentals of the discipline, how broad the scope of work can be, and the importance of a multilateral approach to problem solving at the population level. And yet, the scope of the framework is so broad as to be almost undefined. The first two goals of Healthy People 2010 [iii] offer an example of the applicability (or lack thereof) of the Ten Essential Services. Current California mortality data suggest an overall positive trend - that we are doing better in our efforts to improve years of life (part of HP 2010 goal number one), but illustrates the challenges we face in eliminating health inequities (HP 2010 goal number 2). As public health practitioners, we struggle to describe health inequities beyond their medical definitions, emphasizing that health is attributable in large proportion to environmental, social and economic factors. However, measuring longevity as a proxy for population health may be misguided. Rather than identifying the root cause of a particular health inequity, the use of a mortality rate as a health indicator may in fact limit public health efforts to develop policies that can address this inequity beyond those solutions that are traditionally focused on individuals.

The lack of available morbidity data, the lack of validated measurement tools, and the lack of widespread dissemination of the “place-based” approach to public health solutions suggest that California's county level health officers should shift their focus away from further redefining the Ten Essential Services, and instead focus on development of better measures of population health. Simply measuring longevity, and the use of such data to inform policy decisions, ultimately undermines the community-based approach to public health:

Measurement can, and in this context does, function as a trap. We measure a thing because it can be measured, and then we find our system trying to supply what we measure, not because it is what we want, but because it is what we can measure, and thus disseminate.[iv]

Health policy decisions that allocate resources to address or eliminate a particular health disparity are informed by trends that we can measure. With federal policy that is increasingly focused on measurement as a mechanism to improve quality of care in the US, it may be not only useful but strategic to focus some effort towards developing validated measures of population health. Insofar as public health officers can bring daily practice to bear on health policy discussions, it seems clear that – rather than redefining the Ten Essential Services – their efforts may be better dedicated towards developing measures that reflect more appropriate indicators of “place-based” health, and that will serve to reframe discussions of national health policy.

References:

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[i] Centers for Disease Control and Prevention. The Essential Public Health Services. Office of the Director: National Public Health Performance Standards Program. Available at: http://www.cdc.gov/od/ocphp/nphpsp/EssentialPHServices.htm. Accessed March 18, 2008.

[ii] Institute of Medicine (US). The Future of Public Health. Washington: National Academies Press; 1988.

[iii] Healthy People 2010: Fact Sheet. Department of Health and Human Services: Office of Disease Prevention and Health Promotion. Available at: http://www.healthypeople.gov/About/hpfact.htm. Accessed March 18, 2008.

[iv] Fine, M. The Nature of Health: How America Lost, and Can Regain, A Basic Human Value. Radcliffe Publishing Ltd. Oxon, UK: 2007.

Is it time for gender-specific medicine?

YES...and about time, too!!!

I've just returned from the annual meeting of the American Medical Women's Association, better known as AMWA. This is an organization that exists to develop women physician leaders and advocate for quality women's health at the local, state and national level. (You can find more information about AMWA at their website: www.amwa-doc.org). This year, the conference theme was focused on Women and Aging, and in addition to getting some medical education credits, I also had the privilege of connecting with some amazing women leaders. Enthusiastic discussions ensued for a full two days, focused on everything from the viability of recent California health reform to the relevance of gender-specific medicine. What a great event for someone like me...who is just itching to connect the dots between what we do as clinicians (who provide healthcare services to individuals, in the short term) and what we do as public health professionals or policymakers (who provide or regulate healthcare to populations, with significant health and economic consequence in the long term).

As I mentioned, the theme of the conference was care of elderly women. What I found troubling, as did several of my colleagues, was the lack of educational sessions that emphasized differences in symptoms, and response to treatment, between men and women who are living with the same disease (like diabetes or coronary artery disease). We now have substantial evidence that suggests women and men tend experience the same disease with different clinical manifestations, to the extent that sometimes women have symptoms that are completely different, or completely absent from the typical man's experience. Women may also respond to a different treatment regimen for the same disease! However, throughout the conference, few presenters actually acknowledged these gender differences as a significantly important issue for continuing medical education.

Heart disease is a great example. More women than men die yearly of coronary heart disease (CHD) than from all cancers, AIDS, and violence combined. However, women tend not to come into the emergency room complaining of chest pain when they are experiencing a heart attack (what we in the clinical realm call a myocardial infarction). In fact, most women usually have normal stress test results even if they have significant blockage in their coronary arteries. As a result, different screening tests, and potentially treatments, are needed to adequately address the burden of this disease in women. I was pleased to hear such a thorough presentation of the testing and treatment protocols for women with CHD at the conference, but there are at least two potential barriers to the future development of comprehensive policy that might allow for the implementation of gender-specific curricula nationwide. First, most medical education curricula continue to reflect the diagnosis, management and treatment of a male patient, often fo the purely historical reason that the best evidence we have is often drawn from studies where men were the population of reference, and we generalize these protocols to women. Second, even when strong evidence or best practices exist, this information is poorly disseminated among practicing physicians. Despite these (and other) challenges, more gender-specific training is needed for both newly-trained physicians and experienced practitioners. Nationwide organizations like AMWA are often one of the best ways to distribute new clinical information to practicing clinicians, and are uniquely suited to meet challenges like the ones I have presented here. A push for medical education policies that acknowledge the importance of gender-specific curricula from medical school to continuing education, also seems appropriate given the national emphasis on quality improvement and patient-centered care. It may be a first, albeit incremental, step towards dramatically improving the quality of care that women receive nationwide.

Learn more about gender-specific medicine at: http://partnership.hs.columbia.edu/