A story in the Minneapolis Star-Tribune caught my attention today, not only because it was an interesting article but because it may indicate a shift in our country’s approach to health care. As we all know, the number of people with diseases and conditions that are preventable is growing in America (and globally).

 One way to deal with this is on an individual level, treating the symptoms or curing the disease after the fact. In this model, the focus is on individual treatment, or downstream of the event. Another way to deal with this problem is at the community level, working to prevent the disease or condition from ever occurring. In this model, the focus is on prevention, or upstream of the event. (I’ve greatly oversimplified the issues – there are accidents, genetic predispositions, etc that we can’t prevent – but you get the general idea.)

Health care costs are skyrocketing, competing with gas, food and mortgages. Perhaps at an individual, day-to-day level, we can’t control gas, food or the housing crisis. But we can do something about our health. If we take steps to prevent something from occurring, we can dramatically increase the health of our nation (and ourselves) while reducing the money spent on treating health issues.

The Broad Street Pump

Every public health student knows the story of the Broad Street Pump.

A cholera epidemic was decimating England in the 19th century, and current medical knowledge suggested the disease was transferred by the “effluvia” in the atmosphere (the miasma theory). Dr. John Snow, a British physician, is considered the father of modern epidemiology for his role in the cholera epidemic. Snow had his doubts about the miasma theory as the mode of communication for cholera, as he states in his famous treatise, On the Mode of Communication of Cholera:

“Besides the facts above mentioned, which prove that cholera is communicated from person to person, there are others which show, first, that being present in the same room with a patient, and attending on him, do not necessarily expose a person to the morbid poison; and, secondly, that it is not always requisite that a person should be very near a cholera patient in order to take the disease, as the morbid matter producing it may be transmitted to a distance. It used to be generally assumed, that if cholera were a catching or communicable disease, it must spread by effluvia given off from the patient into the surrounding air, and inhaled by others into the lungs. This assumption led to very conflicting opinions respecting the disease. A little reflection shows, however, that we have no right thus to limit the way in which a disease may be propagated, for the communicable diseases of which we have a correct knowledge spread in very different manners. The itch, and certain other diseases of the skin, are propagated in one way; syphilis, in another way; and intestinal worms in a third way, quite distinct from either of the others.”

Snow and the Reverend Henry Whitehead interviewed residents in the area, and Snow plotted the outbreak on London maps. He noticed that people who consumed water from two companies taking water from the Thames, which was polluted with sewage, had a much greater incidence of cholera. In particular, cases seemed to center around a water pump on Broad Street:

“The mortality in the houses supplied by the Southwark and Vauxhall Company was therefore between eight and nine times as great as in the houses supplied by the Lambeth Company; and it will be remarked that the customers of the Lambeth Company continued to enjoy an immunity from cholera greater than the rest of London which is not mixed up as they are with the houses supplied by the Southwark and Vauxhall Company. … The result of the inquiry then was that there had been no particular outbreak or increase of cholera, in this part of London, except among the persons who were in the habit of drinking the water of the above-mentioned pump-well.”

Snow recommended the pump handle be removed, and that, along with a mass exodus by the neighborhood population, helped to quell the cholera epidemic. Snow recommended a number of methods to prevent cholera, focusing on hygiene.

Apparently we learned our lesson: a number of public health initiatives contribute to our well-being, such as ensuring the safety of our food and water supply (recent tomato issues excluded).

A town with heart (problems)

New Ulm is a small town in Minnesota, roughly 95 miles southwest of Minneapolis. According to the Star Tribune story, more than 90 percent of the 15,000 residents get their health care from the Minneapolis-based Allina Hospitals & Clinics health care network. The town also has an easy way of monitoring the health of its residents – most patients go to the Allina-owned New Ulm Medical Center, allowing Allina to access the electronic medical records system. This allows doctors to identify people at risk for heart attack and figure out which treatments are effective, Allina says in a press release.

Allina is creating a new $100 million Center for Healthcare Innovation – the not-for-profit network is investing $50 million over the next five years and hopes to raise an additional $50 million over five years through partnerships. In addition to New Ulm, the Center will work in the Phillips and Powderhorn Park neighborhoods of Minneapolis. Phillips and Powderhorn Park are adjacent neighborhoods about one mile south of downtown, and have a reputation for being high-crime, high-poverty areas. There are over 100 ethnic groups represented in the neighborhood, and the residents have a disproportionate number of chronic social and health problems (obesity, asthma, teen pregnancies and HIV infections). Allina wants to bring together “residents, researchers, policy makers, community leaders and others [to] forge new models for improving residents' health status and understanding how medical, social, educational and economic factors are interdependent and impact health.”

“It’s working on the things that cause illness upstream rather than waiting for something to go wrong and fixing it later,” Donald Berwick, head of the Institute for Healthcare Improvement in Cambridge, Mass., says in the Star Tribune article. Berwick said the Center is at the start of “a trend of community interventions because ‘in the end it's the only way we can get at the big burden of the cost of care.’” A University of Minnesota epidemiologist Michael Oakes said that chronic diseases are often rooted in social problems, such as bad diets, broken families, smoking and dropping out of school. In this instance, the upstream prevention model could alleviate a number of future problems that would fall into the downstream treatment model.

Uganda’s malaria policy and public health

Even something as simple as a shift in policy can make a difference. (I’m not saying changing policy is easy, but that prevention doesn’t have to be a complex system of guidelines to follow.)

A research article published in today’s Public Library of Science evaluated two malaria treatments and resulting implications in Uganda. Recommended first-line treatment for uncomplicated malaria in Uganda is artemether-lumefantrine (AL), the authors say. “With the emergence of widespread resistance to chloroquine (CQ) and sulfadoxine-pyrimethamine (SP), most African countries have adopted artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated malaria.” Yet the limitations of AL, an ACT – twice-daily dosing regimen, administration with fatty food, high risk of reinfection in high transmission areas – led the authors to investigate a new alternative, dihydroartemisinin-piperaquine (DP). DP is dosed once daily and has a long post-treatment effect, according to the authors.

While both drugs were effective, DP “significantly reduced risk of treatment failure due to recurrent parasitaemia and a lower risk of recurrent parasitaemia due to recrudescence.” “This raises the question of what role DP should play in Uganda's antimalarial treatment policy,” the authors write. Apparently a plan is underway to include AL in a home-based management of fever program. The authors suggest that, recognizing the challenges of changing drug policy, “it is possible that DP could be introduced into HBMF instead of AL as planned.”

“Additionally,” they say, DP could be the “official first-line alternative in Uganda, and possibly other countries in Africa.”

Whether there is a general shift toward community intervention, as Berwick suggests, remains to be seen. For now, I’ll hope public health officials are doing what they can to keep me healthy – and hope that a doctor can treat me if they can’t.