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Alumni Dispatches

Richard Evan (Rick) Steele


Clinical Public Health: the Next Challenge

richard steele What is public health if not bettering the health of the public? In many programs, thrusts and projects, this critical parameter is often lost in the name of evidence-based, randomised controlled trials (EB/RCT). A parameter as nebulous as improved health, however obvious to the individual, makes no sense in an RCT. A much clearer, narrower parameter is required.

The DRG EB/RCT express train left the station years ago and it is hurtling down the tracks, hugely successful in uncovering better and better treatment modalities for specified, medically clear entities that have delineable treatment schemes and probable time lines. Typical examples are trauma, “simple” medical conditions, straightforward surgical procedures, and so on.

Meanwhile, these delineable diagnosis and treatment areas do not cover the whole of what causes poor health and indeed, the interface between the express train and those with more complex diagnoses is most often detrimental to the health status of the disabled persons. This may sound silly, but consider the patient with medically unexplained symptoms that the busy clinician does not understand, does not have time for and tells the patient, “There is nothing we can do for you.”  For the patient with symptoms variably called psychosomatic, functional, imagined or stress-related, such a meeting only cements their perception that their condition is not treatable and they must learn to cope with it without help from the health system. “Just pull yourself together,” is common advice. The more often these patients experience such a meeting with the express train, the worse they feel.

The resulting syndromes go under various names such as whiplash, chronic stress, depression, chronic headache, chronic lower back pain, Gulf war syndrome, multiple chemical sensitivity, electrical sensitivity and so on. The common endpoint for these syndromes is a disability pension. The enormity of this problem boggles the mind. Merely supporting this group of patients financially rivals half of the public outlays for health care or social benefits in northern European countries, and although similar figures are not available in North America, there is no reason to doubt that supporting this group is enormously expensive, and that an effective treatment modality should be enormously popular. The prevalence of these syndromes is not at all clear, since no reliable statistics or data gathering systems exist, but my estimate, based on many years experience in the field, is from 3 to 5 percent of the population.

So what has all this to do with public health? Devising a treatment modality that can bring such patients back to the work force requires a breadth of knowledge and skills that only a highly trained clinician with public health training has (especially epidemiological thinking, organizational skills, management skills and service planning skills). Delivering this modality requires the same. Selling it requires something that no one knows to date, for even though I have devised such a modality and proven that it works (please see Steele RE, de Leeuw E, Carpenter DO, A Novel and Effective Treatment Modality for Medically Unexplained Symptoms, J Pain Management 1:4; 401-12 for details), no funding authority has yet to give this modality a fair shake at the money bin. Instead, much less effective modalities with RCT based treatment schemes get funded, because that is the way the express train works.

This is a battle that requires balance, wit and prowess, and even more, a dogged conviction that you are right even though you are often attacked as the unknowing party in the discussion. Indeed, at meetings in the field, critics of the express train are lambasted much as the heretics of old, and it takes stamina to continue the fight. But fight on we will, and we will prevail. The patients we fight for are not able, so less will not do.

While at Hopkins (1989 to 1991), Dr. Steele convinced then associate dean Andrew Sorensen to convene an interdepartmental day retreat for the MPH faculty, the first of its kind at Hopkins. He was the prime planner and executor of the day, which was the seed that got the now famous interdepartmental MPH introductory course going. Dr. Steele also assisted the CDC/HRSA Public Health Faculty/Agency Forum, working with then Public Health Practice office director Ron Bialek, that set the agenda for the Council on Linkages. He is credited with coining the term competency-based education. During his postdoc year, he was head-hunted by Neil Sampson, HRSA, to be their lightning rod at PHPPHO. During this period he was plugged to be the shadow director (curriculum planner) of the new SPH in Krakow, Poland, under Project Hope. Since then Dr. Steele has amassed massive clinical experience and has become a leading expert in rehabilitation of disabled persons.

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  • Gary Goldberg

    Richmon, VA 03/08/2010 12:44:08 AM

    Extremely important observations. The recognition of the prevalence of MUPS in primary care as well as in PM&R practice and in post-deployment medicine in soldiers is extremely important in order to have a plan to best manage these symptoms.

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