From nucleus - January 2016 - Our values: public health [p16-18]
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Laurence Crutchlow encourages us to see the bigger picture.
'To put our patients first whilst fully accepting our duty to promote preventive medicine and public health.'
'Make the care of the patient your first concern'. If there is only one line of the GMC's Good Medical Practice that you have memorised, it is probably this one.
Everything seems to be about the patient in front of you, in the here and now. When a patient arrives in resus after a cycle accident, your first thought is to resuscitate them, to determine what trauma they've suffered, and to get the appropriate help from orthopaedic, surgical and intensivist colleagues. All this will help them. But better cycle paths might have reduced their injuries; if they weren't a heavy smoker they might not have suffered so badly from the chest infection they will later develop on ITU.
Yes, the patient in front of us is our main concern. But to really care for that patient, we must have wider concerns. For this cyclist, their helmet probably saved their life; without it there would have been little chance of resuscitating them. To really care holistically, we have to look at factors beyond the immediate clinical world. This is why public health and preventive medicine are important parts of our practice as Christian doctors.
All our patients, Christian or not, are created in God's image (Genesis 1:27). Even though they are not the perfect representation of God's being we see in Jesus (Hebrews 1:1-4), they show something of God. Humans are made 'a little lower than the angels' (Psalm 8:5), and are 'fearfully and wonderfully made' (Psalm 139:14). Treating them as we would want to be treated (Matthew 7:12) should be central to our medical work, as we restore their broken minds, bodies and spirits to be as God created them.
When there are a limited number of doctors and many patients, there will always be tension between caring for one over another. Jesus certainly saw the value of individuals (Luke 15:7); one of my friends says that the pivotal thing that brought him to faith was realising that Jesus would have died on the cross just for him, even if there had been no-one else in the world needing to be saved. It is reasonable for us to primarilyfocus on the patient in front of us.
But there is more to medicine than immediate and necessary clinical care. Much illness can be prevented, with vaccination the most obvious example. Many diseases are increasingly thought to have at least some link to lifestyle. A lot of general practice work involves 'primary prevention', aiming to reduce the risk of cerebrovascular events or myocardial damage by modifying blood pressure or lipid levels.
Christians need to take a properly considered view of preventive medicine. There can be two traps. We can 'overuse' the Bible to guilt trip people over their lifestyle, or make the opposite error and overestimate what prevention can ultimately do.
Firstly, it is often said that 'the body is a temple of the Holy Spirit' (derived from 1 Corinthians 6:19). This is widely used in some circles to explain why Christians should not engage in behaviours obviously damaging to health, such as smoking. Some take this much further, using this verse as a motivation for weight loss, (1) or even 'organic mothering'. (2) While we can certainly learn from this verse that we should respect the human body as a temple of the Holy Spirit, we need to take care not to make the verse say more than it really does. The context of 1 Corinthians 6:12-20 is quite narrow, dealing with sexual immorality among believers. Only sexual sin is specified as a sin against the body. This needn't stop us thinking about whether the principle may apply more widely (which it might well do), but does mean we shouldn't be dogmatic. As Paul clearly addresses believers here, we also can't use this justification to persuade our non-Christian patients to take care of themselves.
At the other extreme, the Christian doctor must also be aware of the ultimate limits of preventive medicine. We can and do prevent various diseases. But we cannot prevent physical death. Our work postpones death; it does not stop it. The cyclist we resuscitate may live for fifty more years, but will eventually die. When Jesus raised Lazarus, he promised only that this illness would not lead to his death (John 11:4). We have no evidence that Lazarus didn't die in the normal way later in life. Before Lazarus is raised, Martha tells Jesus 'I know he will rise again in the resurrection at the last day' (John 11:24). Although in this case she sets the scene for Jesus to perform a dramatic miracle, her comments should be a reminder to us; it is only in resurrection at the last day that our patients will ultimately avoid death. Purely medical care cannot do this - after all Jesus came to empty the graveyards, not the hospitals!
Public health is 'the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society'. (3) Good public health work is effectively preventive medicine on a mass scale. Perhaps one of the best examples is that of John Snow. He is commemorated not only with a blue plaque over his home on Frith Street, but also with a pub on Broadwick Street, Soho. During a cholera outbreak in 1854 Snow produced a map (4) detailing the location of cases. Prevailing opinion suggested that cholera was spread via the air, but Snow believed that water spread the disease. His map clearly linked cases to a particular public well that had become contaminated. Interestingly a workhouse nearby was unaffected - it drew from its own well. Not everyone agreed with Snow at the time; indeed in 2013 the Lancet published a correction to its 1858 obituary, which failed to even mention cholera. (5)
It might seem a distraction from the patient in front of us to do this kind of work; but going back to our cyclist, how many accidents might we prevent if we realise that in the last year, 80% of cycle crashes on a particular road have been at the same junction? Most colleagues will agree with road improvements, but seeing the bigger picture may lead to more controversial concerns.
A one night stand may be safer if a condom is used. But does broad promotion of 'safe-sex' ignore the emotional harm that might result if people believe that any sex that uses a condom is 'safe'?
Public health can offer particular opportunities to speak for those who cannot speak for themselves; it may be very difficult for a single injured rider to argue for road changes, but a set of accident statistics over several years may well get changes made. It is statistical analysis that proves poor physical health outcomes in those with mental health problems - an often voiceless group who need our advocacy.
Public health measures may be controversial. Some currently support a 'sugar tax', thinking it will reduce obesity; but is price the only factor in what we eat? What other measures can we take? Or we may be convinced that there is good evidence for recommending statins in primary prevention of cardiovascular disease, (6) but if numbers needed to treat are very high, we might be exposing large numbers to the risk of side effects to prevent a single adverse event.
It is interesting that parts of the Old Testament (Leviticus 12-15 particularly) focus on apparently health related issues, around skin diseases and discharge. Some have used these to suggest that the Bible gave clear public health instructions to Israel. Although there are some very sensible measures suggested (for example clearing mouldy houses in Leviticus 14:39-41), it is important to remember that the overarching message of these passages is to emphasise the purity of God's people, rather than to give prescriptive public health guidance. However we can surely assume that God gave laws that were ultimately beneficial, so it shouldn't surprise us his law contains measures that should improve the health of the community, even if that wasn't their main purpose. A previous CMF File looks at links between Christian faith and health. (7)
The main message is that we must think about wider issues when we see patients. Of course we must understand and treat the complaints they present with. But we may be able to make a lasting difference to their health by helping to prevent illness, whether through prevention at an individual level, or public health measures which reduce disease in the population.
It is not only Christians who will share these aims. But in an over-individualised society, the Christian may need to hold fast to these things under pressure. In those situations we need to remember that public health is not just about reducing disease, but is about giving the best possible chance to the vulnerable. Prevention is not given another lecture about smoking cessation, but a genuine attempt to care for the whole person.
If we keep Jesus' wider perspective on health, we will be well-equipped to strike the delicate balance between dealing with the patient at hand, and the wider context.
1. takebackyourtemple.com was one example I found online.
2. The Body, Temple of the Spirit. Organic Mothering Blog
5. Obituary: John Snow. Lancet, 2013(381);9874:1269-1270
6. Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2013(1)
7. Bunn A, Randall D. Health Benefits of Christian Faith. CMF File 44, 2011.