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APRIL 07, 2020 -- Clinical medicine at its base is "one patient, one physician, one moment, one decision" — all day, every day. At The Lundberg Institute we add: Let it be a decision shared by patient and physician, informed by the best evidence, and considering cost as a factor, regardless of who is paying the bills.
Public health, on the other hand, is population medicine, caring for the aggregate of individuals, collectively.
Clinical medicine is largely diagnosis and treatment of diseases that already manifest in specific patients. Disease, identified and eradicated in one person, defines best success in clinical medicine.
Public health is largely the effort to understand diseases and prevent any person from becoming a patient with a specific disease. For a disease to never enter a human best defines success in public health. "Nothing" is good.
As a high school student in Lower Alabama in 1947, I first learned about public health by standing in a mandatory line to get my blood drawn. We were told that 1 of 10 Alabamians was infected with syphilis, and that there now was an effective treatment called penicillin. My serologic test for syphilis was negative (I was a virgin at that time and also did not manifest the signs and symptoms of congenital syphilis). Some of my classmates did have positive tests and got treated.
Nine years later (1956), I learned the rudimentary facts of public health as a medical student in Birmingham. Screening, contact tracing, treatment — be it a drug or strict isolation — and thus prevention.
Now, in "the time of COVID," vast unplanned clinical and public health experiments are in progress in all countries, side by side. Real World Experiences are meant to be converted into Real World Evidence. Strict application of public health principles of case finding, aggressive contact tracing, and isolation can save entire communities (too late for most large American cities) from rampant COVID-19 infection on the First Wave (now), the Second Wave (fall-winter), the year 2021, and so forth. We must test as widely as possible, ultimately everyone (see #TESTTESTTEST on Twitter), but obviously not until the testing capacity makes that possible.
Ongoing natural experiments include Norway vs Sweden, Japan vs South Korea, the San Francisco Bay Area vs South Carolina, and Belgium vs the Netherlands. Infection rates confirmed by 100% sensitive and specific COVID-19 testing (a current pipe dream) are being supplemented by surrogates such as death rate (easy to count, hard to categorize definitively), ICU bed use, emergency department patient lines, and positive nasal swab tests, spotty though they be.
There is no known effective treatment for COVID-19, except assisted breathing, when required, until recovery or death. Controlled clinical trials of potential therapeutic agents are ongoing. The burgeoning science of Real World Evidence and internet-based "virtual trials" is maturing in front of our eyes and should be used massively. Internet communication is marvelous, but we must separate signal from noise and that can be problematic.
Maybe this time "the twain" — Public Health and Clinical Medicine — can meet in the common interest of healthy humanity.
That's my opinion. I'm Dr George Lundberg, at large at Medscape.
George Lundberg, MD, is sheltering in place without access to his usual video studio. He is editor-in-chief at Cancer Commons and a clinical professor of pathology at Northwestern University. Previously, Dr Lundberg served as editor-in-chief of JAMA (including 10 specialty journals), AMA News, and Medscape.
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