The many and the individuals

The thing about public health and public health workers is that we are not healthcare providers in the strictest sense. While some of us may be nurses, physicians, or physician assistants, most of us never even come into direct contact with the people we’re serving. Even those who do “treat” people, e.g. give a vaccine or administer post-exposure antibiotics, are not in charge of the continuing care of the individuals. On the one hand, we’re protecting the health of the people. On the other, it’s not entirely up to us.

This causes some friction, especially when a provider thinks that he or she should be the final arbiter of what to do with their patients. Take, for example, a certain pediatrician to the stars. This pediatrician has said over and over that his decades of experience in medicine and his gut feelings dictate his approach to immunizations. He believes that some vaccines undoubtedly cause bad things, and that vaccines should be spaced out as much as possible, if they are to be given at all.

For his individual patients, that’s fine. It’s really between he and his patients how he is to tend to their healthcare needs, so long as he practices a standard of care that is not negligent and does so in the best interest of his patients. However, for the population at large, this is not a good thing. It’s not good to erode herd immunity against things like measles or mumps. It’s not good under any circumstance.

There was once a kid in a very large university who came down with bacterial meningitis. He had been at a party and allegedly “hooked up” with several young women that night. We did our best to track down those contacts, and everyone else at the party. When we did, we notified them of a possible exposure to bacterial meningitis, and we advices them to go into their local health department to be given antibiotics or to go see the university’s health providers, or to go see their own physician. Well, there was one physician who saw one of the young ladies in question and refused to give her antibiotics. He said that she said that the case and her never really hooked up. They just sat on a bed in a room at the house where the party happened and talked, nothing more. So the physician took her word for it.

This triggered a huge discussion on what to do with her. Would we ask the physician at the local health department to give her the antibiotics anyway? Would we respect her physician’s decision, albeit a questionable decision? What to do?

In the end, the local health department staff reached out to her and explained to her the situation. She was told that she could be in danger if there was any chance that she and the case shared any spit, even incidentally, at the party. (He had fallen most ill about a day after that party, so he was very infectious when he went to it.) She opted not to chance it. Days later, her physician apparently complained about being overruled.

And that’s not the only example I’ve seen or heard of where private practice providers clash with public health practitioners and workers. It seems to be a constant struggle. I don’t see it as a bad thing, though. There must be an interest in providers to take care of their patients, even if jealously so. And the must be a willingness of public health workers to do their due diligence, even if that means stepping on the toes of private practitioners. All as long as we’re all doing it in the best interest of the patient.

So how do we deal with people who refuse vaccines even though they’re licensed healthcare providers who should know better? Or those who refuse to give vaccines and whose action, or inaction, may lead to an outbreak of a serious disease in the community?

I don’t know. It’s above my paygrade to figure out those things. But I have passed this discussion on to a friend who is about to enter a Doctor of Public Health program. I hope his education in that program covers these issues because we need answers. We need guidance. We need to figure out who supersedes whom when it comes to serious disagreements like vaccines, fluoridation, or even antibiotic use.

I’d like to say that evidence supersedes all personal or professional opinions, but the world doesn’t work that way, sadly. In this world, we need to deal with each other, work with each other, and do it all in the best interest of the public and their health.

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3 thoughts on “The many and the individuals

  1. WTF indeed, Reuben. The pediatrician has been posting at that "notorious anti-vaccine site" and trying to "engage" the *Stoned* U.K. editor.

  2. Some public health nurses do have contact with the public in public health clinics and through answering questions about immunizations when parents call in. I'm willing to bet that some of those questions are prompted by what parents read on that pediatrician's website.Recently, that pediatrician has been quite active on various parenting blogs (he's got a new book, which will be released next month, about "autism prevention").He was briefly mentioned on that notorious anti-vaccine website because he removed his support of Andy's "study" published/retracted by The Lancet and provided a very tepid compliment about a science blog. (Paraphrasing Here) "Good information about a variety of medical topics posted by Orac and commenters…but also snide and nasty".Whenever that pediatrician comes to post on that science blog, *some posters* use his own comments about individual childhood vaccines from his website to question him…e.g. Prevnar Vaccine "is too new for me to comment about it". Too new? Prevnar 7 was licensed 2001 and Prevnar 13 licensed 2010. I keep asking him when he will revise his website and he is not too pleased that I use the information on his own website. P.S. Take a look at his comments about Hib vaccine and the MMR vaccine…they're *gems*.

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