Healing the schism: epidemiology,medicine and the public’s health

Thirty years ago, Kerr White, the former Deputy Director for Health Sciences at the Rockefeller Foundation, published a book entitled Healing the Schism: Epidemiology, Medicine and the Public’s Health in which he argued that the two cultures of ‘medicine’ and ‘public health’ seemed to live in different, unfriendly worlds and that this had not always been the case. ¹

In making the argument that the continued separation of the two enterprises greatly diminished their combined scientific, organisational and institutional potentials in the face of the contemporary domination of medical education, research and services by the enormously productive biomedical sciences, Kerr White maintained that epidemiology, among the population-based disciplines, might have the greatest leverage for effecting badly needed change.

In his analysis, White attributed the cleavage to the Rockefeller Foundation decision, in 1916, to support the creation of schools of public health, separate from schools of medicine, resulting in substantial endowments, initially at Johns Hopkins and later at Harvard and widely elsewhere. The solution he proposed included a unified curriculum within medical schools with remedial action based on the post-graduate training of clinicians in epidemiology followed by their return to clinical practice but with a population health orientation.

This latter proposal found its form in the Rockefeller-funded International Clinical Epidemiology Network (INCLEN) that went on to train over 1400 young medical school faculty members in over 80 medical schools in 33 countries. In the aftermath of the COVID-19 pandemic, which has severely tested clinical and public health systems worldwide, it is timely to reflect on whether Kerr White’s vision of integration in research and practice has proved fit for purpose. The experience of the United Kingdom is not encouraging.

As the national enquiry into the handling of the pandemic begins, several things are already clear: the public health system itself had been neglected and under-resourced and the links between public health teams in local government and the National Health Service (NHS) weakened, especially those concerning clinical laboratory capacity and expertise, and the ability to bring a wider multi- and inter-disciplinary perspective to bear. The failings of government to respond promptly and robustly have been well rehearsed and will hopefully be laid bare in the Enquiry findings. However, one aspect of the response, that of the arrangements for securing professional advice to government ministers is something that expediency requires should be of more immediate concern. ²

It is now clear that the pool from which such advice was drawn was far too narrow, being top heavy with laboratory and clinical science including clinical epidemiology. Advice given was also ultra light on some of the other population health sciences that Kerr White identified as included in the six fundamental disciplines of epidemiology: biology, psychology, sociology, demography, economics and statistics, to which one might add in elaboration, social as well as individual psychology, anthropology and lived experience, political science and communications theory.

Thirty years on from INCLEN, it would appear that not much has changed when it comes to the test, except that clinical epidemiology has become a new orthodoxy to the marginalisation of equally important disciplinary perspectives. While public health without the biological and clinical, as bemoaned by Kerr White, with regard to schools of public health, may be one category of error, population health narrowly drawn around the biological and clinical is an equal problem.

As the NHS in England embarks on its latest large-scale reorganisation in pursuit of the holy grail of integrated care, with the creation of Integrated Care Organisations, the latest tension to emerge is one in which public health teams in local government are charged with addressing the upstream determinants of health and health inequalities, while the NHS, through its Integrated Care Boards, is required to tackle those inequalities through the other end of the lens with its clinical prism.

In this potential dialogue of the deaf there is a danger of re-medicalising public health by creating two parallel public health systems, one multi-disciplinary in local government, sparsely resourced and lacking clinical input, the other clinical and epidemiological, narrowly drawn, but backed up by the gargantuan resources of the NHS.

In a companion book, The Medical School’s Mission and the Population’s Health, published at the same time as Healing the Schism, Kerr White and Julia Connolly argued that for medical schools to play their full part in the tasks of protecting population health, not only should the curriculum be one that is community orientated but that it should be a dynamic curriculum able to adapt to changing public health challenges, informed in real time by a health intelligence unit allied to the Dean’s Office. ³

Examples of such an approach to practical intelligence units in the form of the network of Public Health Observatories established in England during the Blair government years exist. ⁴ As we learn the lessons of the COVID-19 pandemic, Kerr White and his colleagues can still teach us what is needed. However, we need the full story, rather than a cherry-picked bio-medical version, and now grounded in multi- and inter-disciplinary Schools of Public Health and Medicine.