See Locally, Act Globally

By Theresa Watts

Growing up, my mother always told me to channel my strong energy and passion into helping those around me. So, when was time to decide what to study in college, choosing to study nursing was a no-brainer. But, in college, nursing evolved from something I was really excited about into a love-hate relationship as I began to feel there was something missing. All of my patients had been diagnosed with various and multiple diseases, but I couldn’t tell what was being done to prevent these diseases in the first place. I never understood why most of my patients’ chronic and infectious diseases could have been prevented — but hadn’t. As a result, understanding the underlying problems behind diagnosed diseases and how they could be prevented became the center of my attention.

I completed my public health nursing clinical rotation during the first semester of the senior year of my four-year nursing program at a university in rural, upstate New York where, in the winter, it is too cold even to snow. A public health nurse and I were working with women of reproductive age and children under age four. We made house calls to these families to provide education, services, case management, and care on issues that included family planning, pre- and post-natal care, breastfeeding, early childhood development, and immunizations. We also helped connect women and their families with community outreach and support. In house after house, we saw the same health diagnoses: children who were autistic, malnourished, and/or otherwise failing to thrive, and women with anemia and/or reproductive problems.

For example, one woman I visited had a child with failure to thrive, meaning that the child’s weight (or rate of weight gain) was significantly less than the average for his age and gender. Failure to thrive is an important sign that something is wrong. Unless the cause is found and corrected, these children develop permanent mental, emotional, and/or physical health problems. The mother hadn’t received care during her pregnancy, and now had iron deficiency anemia (which decreases the body’s ability to delivery oxygen to the cells and has detrimental health effects). She wasn’t taking care of either herself or her newborn. She told me that, if she had been educated about the importance of taking care of herself and newborn prior to conception, she would have actively changed her lifestyle and parenting. Visiting every week allowed the public health nurse and me to develop a strong, trusting relationship with the family and to help improve the child and family’s future well-being.

Recognizing and understanding what was happening locally was important, and I became interested in exploring health discrepancies that exist in other parts of the world, as well. I quickly realized that the health problems I was seeing in rural New York exist in many other parts of the globe, as well. For instance, Nicaraguan women often exhibit the same health conditions I saw in New York, including iron deficiency anemia and reproductive problems. I began to recognize the frequency of health conditions across the globe and to learn about various health care systems and efforts worldwide. It became more and more clear to me that a health care model that focuses on primary prevention is the only effective way to avert the recurrence of infectious and chronic diseases and foster good public health.

There are three different types of preventive care: primary, secondary, and tertiary. The founder of modern U.S. public health, Charles-Edward A. Winslow, defined primary care as: “the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of a standard of living adequate for the maintenance of health; organizing these benefits in such a fashion as to enable every citizen to realize his birthright of health and longevity.” ¹

Public health or primary preventive care focuses on the protecting people’s health before they get sick. Primary health can typically be distinguished from secondary and tertiary care because it offers a preventive and/or community-based approach, compared to secondary and tertiary care’s clinical and/or individual approaches. Examples of primary care activities include using contraception, brushing one’s teeth, exercising, or drinking clean water — all of which help avert poor health outcomes (unintended pregnancy, cavities, obesity, gastrointestinal diseases). Vaccines are an example of primary care, like the relatively new human papillomavirus (HPV) vaccine. The HPV vaccine prevents infection with various strains of the HPV virus, including those that cause most cases of cervical cancer, and thereby reduces cervical cancer rates.

Secondary prevention involves detecting and treating existing health problems at the earliest possible stages after the disease or health problem begins. The recommendation that women have annual Pap tests is an example of secondary prevention: the Pap test identifies cell abnormalities that might indicate early cervical cancer so the disease can be treated at its earliest stage. Many secondary preventative measures are monitored on a routine basis and require individuals to return to their health care provider or do some other form of follow-up. Tertiary prevention attempts to reduce the extent and severity of a health problem to its lowest possible level, in order to minimize disability and restore or preserve function.²  Radiation and/or chemotherapy to treat cervical cancer are examples of tertiary prevention.

Most health care systems worldwide, including the United States’, primarily focus on providing secondary and tertiary preventive care. This is because it’s hard to encourage people and communities to engage in primary preventive behaviors, and scientific advances often focus on treatment rather than prevention. The main problem with this approach, however, is the enormous costs and suffering that result from un-prevented epidemics, including obesity, diabetes, and HIV/AIDS. It is expensive and complicated for society to treat these diseases once they occur and, for those who lack health insurance (like 45 million Americans do today), it may be impossible to get any treatment at all.

A greater focus on primary prevention would help both individuals and societies. I believe we all must become responsible global community members and focus on primary preventive health efforts in order to ensure the survival of future generations. The world’s population is projected to explode from 6 billion to over 9 billion people by 2050. We cannot afford to wait until diseases present themselves — for the good of the planet, we have to do a better job at preventing them. Just as one example, over 120 million women lack access to contraception, a key primary preventive health tool. Many experience pregnancies they would have prevented, if they had the means. And, each year, 600,000 women die from complications of pregnancy and/or childbirth, and another 30 million suffer from permanently disabling pregnancy-related health problems. ³

The need for global primary preventive health care is greater than ever. Poor health on an individual level (particularly poor maternal health) often leads to the poor health of the family, community, and society. Many preventable diseases could be diverted if there was a change in focus from tertiary health systems to a primary health system. When we act as globally conscious citizens, with the main goal of promoting public health, we have a greater chance of preventing various health diseases and fostering health on a national and individual level as well. Demanding changes to health systems so they are better adapted to the global threats and better able to prevent disease is critical for the future health of the plant.

Theresa Watts is a Registered Nurse, Masters of Public Health candidate and a NWHN volunteer.

References:

1. Mersn, M.H., Black, R.E., Mills, A.J., International Public Health: Diseases, Programs, Systems, and Policies (2nd Ed.), Sudbury, MA: Jones and Bartlett Publications, 2006, pp. xiii.

2. Allender, JA and Spradley BW, Community Health Nursing: Promoting and Protecting the Public’s Health (6th Ed.), Philadelphia, PA: Lippincott Williams & Wilkins, 2005, pp. 13-16.

3. Mersn, M.H., Black, R.E., Mills, A.J.,International Public Health: Diseases, Programs, Systems, and Policies (2nd Ed.), Sudbury, MA: Jones and Bartlett Publications, 2006, pp. xiii.