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Friday, December 05, 2014

Does a JAMA viewpoint essay by Dr. Harold Sox reveal what population health really means?

Dr. Harold C. Sox writing in the November 13,2013 issue of JAMA in an article entitled  "Resolving the tension between Population Health and individual health care" says:( my bolding ).

"Perhaps the de facto organizing principle for US health care,,approaching each patient strictly as an individual is obsolete.The population health approach is an alternative."

This sentence seems structured to allow for escape mechanisms. He hedges by beginning with "perhaps" and then says that" approaching each patient strictly as an individual " , so he could later claim that, of course ,treat the individual but you also have to consider the interests of society.

The money quote is :

 " Must the Population health approach compromise the needs of the individual to benefit the community?"

It will take several generations to realize the full benefit of investments in disease prevention . In the short run,the investments may draw resources away from tests and treatment for some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment.In the interim, skillful clinical decision making can make the most of limited resources"

He is answering  his introductory question in the affirmative by giving an example of how an individual would suffer for the allegedly benefit of a group  and incredibly does not express any concern about sacrificing the individual to some hypothetical future benefit to the community or society.In fact and amazingly  the only benefit he actually mentions is "reduce the outlay for treatment".

 Sox continues:

 " Are the needs of the individual and the population reconcilable?
Using the same method of value and the same decision making principle for patients and for populations would be an important step toward a system that fairly allocated resources between the healthy many and the sick few"

The traditional role of the physician has been the care of "sick few".Are they now being asked to allocate some of the resources away from the sick to the "healthy many"?

But the principles involved in treating patient who requests help from a physician and  and proposing preventive measures for a population are not the same. The population has not requested help and may have not even authorized the "treatment"  A key principle in treating the individual is to respect his/her values. How can one determine the values of a population? Do all member of the population have to agree.? Is disease prevention is only principle to value, do liberty, and avoidance of coercion not matter? Who is to judge what is the fair allocation? Is disease prevention more important than treating the sick which historically is what physician basically did ?What about the possible harms of a preventive program?Should the population members have to agree to the preventive measures? Is informed consent not to be part of population medicine?

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