Las Vegas Sun

September 20, 2021

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Guest column: Time to reunite public health, clinical medicine

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Wade Vandervort

Theresa Nolan, Executive Director of Clinical Operations for UNLV Medicine, fills syringes with the Moderna COVID-19 vaccine at UNLV, Monday, April 5, 2021.

Editor’s note: As our nation continues to overcome the coronavirus pandemic, we cannot simply put the crisis behind us and move on. It’s vital that we reflect on our mistakes and use the hard lessons we learned over these many grueling months to build in protections against the next global outbreak of disease. Because let’s not delude ourselves, this won’t be the last pandemic the world will face.

Today, we offer a guest column from medical experts Marc Kahn and Benjamin Sachs that offers a framework for moving forward.

Kahn is the dean of the Kirk Kerkorian School of Medicine and vice president for health affairs at UNLV; Sachs a professor at the University of South Florida Morsani College of Medicine and the UCF College of Medicine.

As you’ll see, the two offer a clear-eyed assessment of the problems that exacerbated the crisis, along with a pragmatic set of solutions. We encourage Southern Nevadans to read their commentary and contact policymakers about it.

One more remark before we present the column. We thank Kahn, a frequent contributor of commentary to the Sun, for sharing his perspective on health care policy in our region. His leadership speaks to one of the many reasons the UNLV medical school is such a valuable asset to our community — it’s a source of trustworthy voices delivering important messages to Nevadans about health care here in our backyard.

With that, we turn it over to Drs. Kahn and Sachs.

Marc Kahn and Benjamin Sachs

The U.S. has experienced over 600,000 deaths from 33 million-plus cases of COVID-19. Nevada has experienced over 5,500 deaths and 320,000 cases. The pandemic has also had a disastrous effect on K-12 education, mental health and food security, and has disproportionately affected minority communities. The cumulative financial costs of the COVID-19 pandemic are estimated at more than $16 trillion, or approximately 90% of the annual gross domestic product of the U.S.

From all of this, there are lessons to be learned.

The timeline of the pandemic provides numerous examples of the consequences of the separation of public health, that being the care of populations, and clinical medicine, that being the care of individual patients.

First, there was a failure of communication between public health officials and physicians to recognize and respond to the early warning signs even after the Wuhan lockdown on Jan. 23, 2020.

In the fall of 2019, the federal government was unaware of an emerging disease in China, in part because in 2018, it withdrew key U.S. experts from China, including members of an organization that helped to monitor and respond to outbreaks and the manager of an animal disease monitoring program from the U.S. Department of Agriculture. We now have some evidence that the COVID-19 virus was circulating in China in the fall of 2019, and certainly in China and Europe by October or early November. But not until late December did the Wuhan Central Hospital and the local Centers for Disease Control and Prevention issue a warning regarding a pneumonia outbreak in the city. Hong Kong and Taiwan acted on this advisory by screening in-bound passengers from Wuhan.

Despite these reports, the CDC stated that Dec. 31 was the first time it learned about a cluster of 27 cases of pneumonia in Wuhan. The CDC tried but failed to develop an in-house test and required all tests to be performed at the CDC. Instead, the CDC should have “outsourced” the development and procurement of COVID-19 PCR tests. These steps led to significant delays in national viral testing. As the pandemic wore on, the CDC failed to aggressively monitor viral mutations and contain their spread.

The U.S. health care delivery system was unprepared. In January 2020, an integrated health care and public health system would have acted sooner to prepare staff and facilities, and stockpile essential supplies. Many hospital systems use “just in time” inventory management as a cost-control measure where inventory is provided when needed but not stockpiled. Most PPE and ventilators are manufactured in China. As the pandemic spread, China and the developed world competed for PPE and ventilators, resulting in major shortages. By January or February, the federal government should have assumed responsibility for procurement of PPE, because many states did not have the infrastructure to respond to the growing crisis. Inadequate PPE contributed to the deaths of more than 2,900 health care workers needed to care for sick patients.

There is poor long-term funding of public health at the federal, state and city levels.

In 2019, health care spending in the U.S. was $3.8 trillion. In contrast, public health spending was estimated to be $93.5 billion in 2018, but probably only 34% to 61% was truly spent on public health. More than three-quarters of Americans live in states that spend less than $100 per person annually. Clearly, we have funded clinical medicine at the expense of public health.

The U.S. response to the pandemic became heavily politicized early in its course. Throughout the course of the pandemic, experts downplayed its deadliness and questioned the need for face masks, social distancing and lockdowns. Furthermore, public distrust only grew as conspiracy theories and medical quackery flooded social media, further driving a wedge between public health and clinical medicine.

How can the U.S. prepare for the next pandemic and improve the health of the public?

We need to dramatically increase the federal, state and local public health budgets. Recognizing that the U.S. spends nearly twice as much as the average of 11 Organization for Economic Co-operation and Development (OECD) countries on health care — yet has the lowest life expectancy, highest suicide rates, highest chronic disease burden and an obesity rate that is two times higher than the OECD average — we are not getting good value. Clearly, with the help of public health expertise, we need to train and incentivize physicians to change their mindset from a disease model to a wellness model.

Medical schools are required to educate students in the health of individuals and populations, and are required to provide curricular content on societal problems, cultural competence and health care disparities. However, the details are left to the discretion of individual schools. We need to redesign medical education to emphasize disease prevention and promotion of health — objectives that are essential for both clinicians and public health professionals. We also need to encourage more physicians to work in public health.

Research funding should encourage collaboration between clinical medicine and public health. The frontline medical community have been true heroes. However, in response to treating this new disease, instead of conducting randomized clinical trials, clinicians have too often resorted to anecdotal reports of small clinical trials and observational studies with little regard to confounders. The input of trained epidemiologists and biostatisticians would have made a big difference. To help, we urge medical schools and schools of public health to expand their joint faculty appointments.

Our society faces many challenges including, bioterrorism, health care quality, population aging, chronic diseases such as diabetes and health care financing. We can only address these complex issues through close collaboration between public health and clinical medicine.

Marc Kahn is dean of the Kirk Kerkorian School of Medicine vice president for health affairs at UNLV. Benjamin Sachs is a professor at the University of South Florida Morsani College of Medicine and the UCF College of Medicine.