Letter to the Editor
The 3 buckets of prevention described by John Auerbach,1 MBA, have the potential to dramatically improve the public health and help fulfill the triple aims related to care, health, and cost.2 However, at a time when local public health departments have lost more than 50 000 staff members since 2008,3 we must be careful not to leave dangerous holes in the Public Health Protective Net.
The Public Health Protective Net includes those individual services that are not for the benefit of the individual but are for the protection of others. The public health agency (state or local if delegated by the state) is the only entity with the legal authority to provide certain vital services.4–8 Many of the public health achievements extending the life spans of almost every human9 , 10 are the result of the Public Health Protective Net. These achievements must not be taken for granted.
The protective net most closely resembles the services in bucket 2, but they are not necessarily clinical in nature. They are people-focused, not patient-focused. These are services that clinical nurses and physicians (bucket 1) often cannot provide and must quietly and confidentially rely upon public health to provide. These services are not the community-wide interventions included in bucket 3, although if not provided, community-wide interventions might be necessary.
Specific examples include but are not limited to the following:
- Communicable disease treatment and isolation refusals: Making sure that someone who is infectious is treated or isolated even if he or she does not want to be. Public health professionals use the least restrictive options available.8 And communicable disease laws alone, although a powerful motivator and an important necessary component, may fail in situations where individuals feel they do not have acceptable options.11 For these reasons, public health professionals often meet people where they are, and help them, protect us, through an offer of timely, compassionate, confidential, and acceptable options to facilitate their cooperation.
- Contact tracing: Reaching out to contacts and contacts of contacts to make sure those individuals do not become infected and do not infect others. Contacts may need prophylactic medication, vaccination, quarantine, and/or testing. In theory, some of these services can be provided as part of bucket 1 for patients with coverage; however, the risk of delays and disincentive of co-pays can poke inadvertent holes in the Public Health Preventive Net.
- Control measures: Visiting restaurants, sewage plants, nursing homes, schools, pools, camps, etc, to make sure that the right procedures are used to keep a single case or exposure from becoming an outbreak.
- Zoonotic diseases: Working with other One Health12,13 professionals to ensure that animal illnesses do not become human illness (eg, arranging for an animal that has exposed humans to be tested or observed for rabies or other zoonotic diseases).
We must be careful not to disrupt this very effective, low-cost protective net even as we develop innovative solutions for the health care system to fulfill the triple aims.
—Virginia M. Dato, MD, MPH, FACPM, FAAP
Department of Biomedical Informatics
University of Pittsburgh School of Medicine
1. Auerbach J. The 3 buckets of prevention. J Public Health Manag Pract. 2016;22(3):215–218.
2. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff. 2008;27(3):759–769.
5. Epstein RA. In defense of the “old” public health: the legal framework for the regulation of public health. SSRN Electron J. 2002. doi:10.2139/ssrn.359281.
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9. Centers for Disease Control and Prevention. Ten great public health achievements—United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(19):619–623.
10. Centers for Disease Control and Prevention. Ten great public health achievements—United States, 1900-1999. MMWR Morb Mortal Wkly Rep. 1999;48(12):241–243. http://www.ncbi.nlm.nih.gov/pubmed/10220250
. Accessed March 10, 2016.
11. Yee Chan K, Reidpath DD. “Typhoid Mary” and “HIV Jane”: responsibility, agency and disease prevention. Reprod Health Matters. 2003;11(22):40–50.
13. Lerner H, Berg C. The concept of health in One Health and some practical implications for research and education: what is One Health? Infect Ecol Epidemiol. 2015;5:25300.