That Friday feeling

Nathan Lawrence, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

We’ve all been there, all looked at the timetable and seen those two dreaded words filling our Friday afternoon and felt our hearts sink as we resign ourselves to a stultifying 3 hour diatribe on numbers needed to treat and the role of a public health doctor.

But it shouldn’t be like that, because I want to argue today that public health is actually both more important and more valuable than clinical medicine in improving people’s health. And to do so, I’d like you to come with me to Sierra Leone (or Sweet Salone as the locals call her).

Over 7 weeks on elective this summer I saw a change in my own thinking that really surprised me. A question I got asked a lot was “Will you come back?” and to start with as I answered I would imagine myself on the wards and doing my bit on the frontline. As time went on however I realised that the vast majority of ex-pats out in Salone are not doctors working in the hospitals, but rather a whole variety of professionals of one sort or another working in the ministry of health or for various charities, all working towards macroscopic improvements in the healthcare of this poor country instead.

And it really matters. There are places in Sierra Leone where yes, there simply are not doctors and going out to be a member of frontline staff would mean one more gap being filled. But when you watch children die of hookworm/malaria on a weekly basis because they’ve reached hospital with an Hb of 2 and there’s nothing which can be done; or you find out that the maternal mortality rate is 1 in 8 (1 in 8! that’s literally crazy) because most women give birth in their village where there is no-one medically trained to supervise them and get them to hospital when necessary; well then you realise that the real intervention needed is not another doctor to desperately try and transfuse this anaemic toddler and then curse the futility of it all, but an education programme and distribution of mosquito nets so that the malaria burden might be halved [1] and the sound of parents weeping on the paediatric ward becomes a rarity instead of a regular occurrence.

But would I do it? Would I practise what I preach and give up clinical medicine to become a public health doctor? I’m not sure: although I would maintain I’d have a bigger impact on people’s health I have to acknowledge the other side of the argument. There is more to life than health and there is a sense in which the most valuable thing we can do as doctors is to be there on the frontline, so that when people fall ill, as we all inevitably must (the certainty that death represents will after all never ultimately be overcome by public health measures) we are there to be kind, competent and compassionate and to make people’s experience of their illness as un-frightening and bearable as possible; above all to treat them as a person and not just another statistic in our fight against lung cancer.

For my part I know I would miss the daily interaction with patients that clinical medicine involves and that career move would undoubtedly be a sacrifice. Equally, I think part of the reason why the public health teaching often fails so spectacularly to capture our imaginations is that the goals in the developed world are often that much less inspiring and I think reducing the incidence of heart disease by 2% would be a much harder objective to care about and spend my career working towards.

But whichever side of this argument you ultimately come down on, if you think public health is boring or wonder why we’re taught it, then please: do your elective in the developing world, because for me at least it was only when we’d run out of antibiotics and I watched a woman die in front of us from her septic abortion that I began to realise the limits of clinical medicine; and the desperate importance of boring old public health.

References: 

1. Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database of Systematic Reviews. 2004; 2:CD000363. http://dx.doi.org/10.1002/14651858.CD000363.pub2