Most of us take public health for granted. Two recent health events still vivid in the minds of Americans remind us of the underappreciated role of public health. The brutal tsunami occurring in late December in South Asia and the scandalous removal of Vioxx from the drug market together will be responsible for more than 150,000 deaths. By any standards, these events represent public health tragedies of historical proportions. While having very different origins, they also remind us of the importance of public health and why public health systems remain a vital albeit underappreciated element in modern society.

Clinicians who are involved in the day-to-day treatment of patients are among the many of us who lose sight of the importance of public health. It is easy to see why this is the case. Public health is neither high-tech nor dramatic in its outcomes. Few get particularly excited when a disease is prevented-nothing dramatic happens. Equally unexciting are such things as the assurance of clean water, adequate sewage disposal, decent shelter, proper nutrition and appropriate immunization. These aspects of human living become problematic only when they are not provided.

Learning From the Tsunami

We saw this vividly in the news reports from South Asia, where it became clear that the provision of basic public health services was one of the major forms of assistance that other countries and organizations could provide to the victims of this catastrophe. Sadly, all of the advanced high-technology wonders of modern medicine could do little to assist the unfortunate individuals affected by this disaster. Instead, simple and basic forms of care were needed the most. We clearly saw how important it was and is for communities to have clean and safe water, adequate shelter, decent nutrition and protection from communicable diseases. Public health services in this natural disaster were vital.

This is not to diminish the importance of medical care services, particularly care for traumatic injuries. After the rescue of survivors, and after the primary public health concerns-provision of clean drinking water, food and shelter-were assured, medical care for injuries takes on equal importance. The majority of deaths associated with tsunamis are related to drownings, but traumatic injuries are also a concern. Injuries such as broken limbs and head injuries are caused by the physical impact of people being washed into debris such as houses, trees and other stationary items. Without question, medical care is critical in areas where little medical care exists.¹

Lessons From Vioxx

A very different threat to the public's health was seen in the tragic episode of rofecoxib (Vioxx). In this circumstance, the basis of the problem was not a naturally occurring phenomenon but rather was man-made. Sadly, by the fall of 2004, it became clear that this anti-inflammatory drug manufactured by Merck posed an increased risk of cardiovascular disease. As events unfolded, it became clear that Merck knew of the risks well before the company finally pulled the drug off the market. The Food and Drug Administration was accused of being concerned more with maintaining a cozy relationship with Merck than with assuring the safety of this medication.²

Eric J. Topol, MD, is a cardiologist at the Cleveland Clinic who was one of the earliest and most outspoken critics of the FDA in the Vioxx episode and who recognized early the enormity of the circumstance. "Considering the tens of millions of patients who were taking rofecoxib, we are dealing with an enormous public health issue," Dr. Topol wrote in the New England Journal of Medicine.² "Even a fraction of a percent excess in the rate of serious cardiovascular events would translate into thousands of affected people. Given the finding in the colon-polyp trial in low-risk patients without known cardiovascular disease - there may be tens of thousands of patients who have had major adverse events attributable to rofecoxib."

We depend upon governmental agencies like the FDA (part of the U.S. Public Health Service) to protect the public from dangerous and/or ineffective drugs and substances. At its core, this trust represents the basic structure of public health in a society. This structure is a balanced tradeoff of ceding authority to a governmental body, essentially foregoing certain freedoms, in return for certain protections and assurances from harm. We as citizens hand over this authority, in this instance the authority to regulate medications, in return for the assurance that the medications that are approved for use meet specified standards of safety and efficacy. In this instance, there is clear evidence that this authority was misused in the approval of this medication, which as it turned out, posed significant risk to the health of the public.

Public health threats, as we have seen, may take many forms. In addition to the aforementioned tragedies, we also think of familiar threats to the health of the public such as infectious diseases, bioterrorism, nuclear accidents and environmental contamination. But just as menacing to the public's health are those that emanate from improper medical intervention, sloppy regulation, and corruption of oversight. Although recent events have brought it closer to the fore, we barely think about public health until it fails us.

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.

References

1. Health Effects of Tsunamis. Centers for Disease Control and Prevention Web site. Available at: http://www.bt.cdc.gov/disasters/tsunamis/healtheff.asp. Accessed January 6, 2005.

2. Topol EJ. Failing the public healthrofecoxib, Merck, and the FDA. N Engl J Med. 2004;351:1707-1709.