Public Health is a Treasonable Liberal Plot

I was wondering what it would take to lure me back from self-imposed exile to the blog playground. It wasn’t the raging warbloggers reinventing themselves as epidemiologists to issue indignant howls over the Johns Hopkins study of war-related mortality in Iraq (I don’t feel like playing that game right now, but you can look elsewhere for the fun – here, here, here, here and here). What did attract my attention though was the claim that:

The American public health community has a decidedly left leaning cast to it. It is more politically homogenous than any other medical specialty. How homogenous are they? Well, you won't find statements like this on the website of any other medical speciality. One is obliged to assume that the researchers started with a bias.

Well, you have to consider the source. It did come from MedPundit, a physician.

With authoritative statements from any specialist such as a physician, lawyer, academic, engineer, etc., you have to judge carefully whether or not they know anything about the topic. For example, it’s been a favorite tactic of creationist or intelligent design advocates to have someone, with a PhD in something scientific or technical-sounding such as chemical engineering, criticize the teaching of evolutionary biology in schools. The fact that Francisco Ayala or Ernst Mayr might not agree with this PhD scarcely matters. Someone with a credential criticized evolutionary theory, and that’s enough to for some people to discredit it.

I think the same issue arises when I see a physician rendering an opinion about a public health topic, say epidemiological studies of mortality from violence in Iraq. In judging the basis for their opinion, the first question that comes to mind is what is their experience in public health work? One of my first jobs 25 years ago was working in the state of California’s pesticide illness surveillance program, then under the California Department of Food and Agriculture (later moved to Cal-EPA). We would receive pesticide illness reports from physicians, and attempt to categorize them in terms of types of effects, pesticide associated with the effect, and exposure/effect relationship with additional investigation information provided by county agricultural commissioners. Through this experience, I received a good dose of what physicians did and didn’t know about public health surveillance, after observing inanities such as blood tests for chlolinesterase inhibition being administered to patients who had been exposed to paraquat, heat rashes being diagnosed as sulfur burns, cholinesterase test results from workers without any pre-exposure baselines, patients complaining of non-specific nausea, vomiting or dizziness being diagnosed as organosphosphate exposure, and on and on. We saw that some physicians in the state got pretty savvy with diagnosing and treating pesticide exposures. They had to – they were seeing a couple of farmworkers or pesticide applicators each week with exposure. But, they seemed to be the exception rather than the rule. We observed that more veterinarians appeared to be better at diagnosing pesticide exposures than physicians (we also used to compile poison control center statistics – the PCCs also received animal poisoning calls from vets).

I found out some interesting things by taking this allegation that the public health community “leaned left” and analyzing it. The Institute of Medicine (IOM) describes public health as what we do collectively to assure the conditions for people to be healthy. This formulation of public health includes societal activities beyond those performed by government. The constitution of the World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (yeah, I know, the UN is another leftish plot).

A distinction has been made between clinical practice and public health practice as methods for protecting and improving health:

Clinical practice is commonly thought to include “interventions that are designed solely to enhance the well-being of an individual patient or client and that have reasonable expectation of success.” The analogy to public health practice is that the “patient” in public health is the community. Under this approach, those activities performed to improve the health of the community are deemed public health practice. Though a helpful comparison, the analogy falls short of distinguishing public health practice and research where both activities may be motivated by the need to improve the population's health and may involve the practice of medicine or allied health professions under the standards of professional practice.

Taken at face value, MedPundit’s comments could imply that being a physician doesn’t automatically confer a sense of concern about the health of a community. However, some have argued that being an epidemiologist should:

Responsible professionals reliably perform the tasks they set for themselves as well as the tasks society expects them to undertake. The defining axiom for our approach is that the health of the public is a social good we commit ourselves to pursue, thus assuming an obligation to contribute to its achievement. Epidemiologists cannot claim to be committed to public health as a social good and not accept the responsibility of ensuring that the knowledge gained in their roles as scientists is used to achieve that good.

The ethics guidelines published by the American College of Epidemiology also mentions the obligation of epidemiologists to show how their studies provide public health benefits to the community. It’s a shame that similar guidelines haven’t been developed for politicians. In an article titled “Pursuing the Impossible”, published last year in the Harvard International Review, Dr. Ronald Waldman of Columbia University said:

Preventing the unnecessary loss of civilian life is the job of politicians, who have failed all too often. The world has stood by and watched as one genocide after another has unfolded. Although there is always great sympathy for the survivors, and although humanitarian assistance is frequently, but not always, forthcoming, the effect is, at best, that of applying a bandage to a gaping wound. The most important lesson to learn for the future—one that has already been learned but forgotten many times in the past—is that war and public health are fundamentally incompatible pursuits.

War and public health being fundamentally incompatible pursuits is a point that is obviously lost on the warbloggers, though it’s a bit surprising that some physicians apparently don’t understand it either. Concern about preserving and improving public health isn’t a left-leaning or right-leaning virtue, it’s a societal virtue. Epidemiologists aren’t performing their studies to further a leftist political agenda, they’re just doing their jobs. Alleging that public health professionals are harboring a liberal agenda is no more correct than the corollary that conservatives are the party of death and disease. Right?