- Small is Beautiful, but Universals are Equitable
To see a World in a Grain of Sand
And a Heaven in a Wild Flower
Hold Infinity in the palm of your hand
And Eternity in an hour—William Blake, Auguries of Innocence
Practitioners of the healing arts work in the medium of individuals—one person at a time. A physician, a social worker, a teacher, a nurse, a nutritionist, a therapist works with individuals to transform disease into health, chaos into order, rot into verdant growth, and helps maintain the individual in the state of well-being s/he enjoys.
Policymakers, in contrast, work for the greatest good for the greatest number of individuals, an objective most contemporaries would endorse but the details of which come in for heated debate.
In between lie particular populations, whose members share characteristics relevant for health and health care—for example,
• dialysis patients in Puerto Rico (even before Hurricane Maria hit at the end of summer 2017) bear a risk of mortality 50% higher than the national average for dialysis patients [see Harford et al., this issue];
• in Middle Tennessee, members of the Laotian community who do not speak English are as likely to seek health care as those who do—a fact that loses its surprise value when one learns that this community has access to a Laotian-speaking physician [see Saenphansiri et al., this issue];
• in some areas of Appalachia, neonatal abstinence syndrome is epidemic, as the numbers of opiate-addicted mothers and newborns skyrockets in rural areas around the U.S. [see Erwin et al., this issue];
• in Haiti, HIV- positive mothers are now approximately twice as likely as non-HIV-infected mothers to have prenatal care and to have medical personnel at delivery, the result of concerted efforts to get HIV-positive, pregnant women in Haiti into care for themselves and to prevent transmission of the virus to their infants [see Hearld and Budhwani, this issue].
Reflecting on the papers in the present issue, one may freshly recognize how beneficial it is to shuttle between the clinic and the conference room with such intermediate generalizations. Indeed, this is the great work of public health, a field that has evolved since the 17th century through its maturation in the 19th century in England and France in response to widespread health problems spawned by the Industrial Revolution, right up until the current era (1970s-present) in which attention has fitfully turned to [End Page vii] societal/cultural inequities along demographic (gender, race, ethnicity, socioeconomic status, region, sexual identity) lines.
Population-sized generalizations can clarify the best clinical practices (e.g., heightened attentiveness to addiction during prenatal care when working in areas where neonatal abstinence syndrome is epidemic) and can also directly shape policy (e.g., Medicare regulations causing Puerto Rican dialysis patients to endure a "doughnut hole" gap in coverage—and a resulting heightened risk of death—should be corrected).
What follows is an summary of the other papers in the present issue organized into the categories Clinical Practice, Health Policy, and Medical Education. I recommend them all to you.
In addition to the paper on neonatal abstinence syndrome in Appalachia mentioned above, this issue includes a host of papers concerning clinical practice with particular populations:
• New treatments for Hepatitis C Virus (HCV) are effective in an urban safety-net hospital, as they are in clinical trials [Assoumou et al.].
• Children served at Health Care for the Homeless Program sites benefit from care largely meeting American Academy of Pediatrics recommendations, although integrating comprehensive care into clinic visits made for acute care remains challenging [Chatterjee et al.].
• Telemedicine for patient education is feasible for American Indian patients with diabetes, as most appear to have access to the relevant technology [Mathieson et al.].
• Routine screening for pregnancy intention during primary care visits is an important step in meeting persistently unmet reproductive health care needs, according to Kvach et al.'s study of a quality improvement project at two urban federally qualified health centers [Kvach et al.].
• Measurably elevated rates of frailty—a state associated with aging—occur in patients 40-64 years who use the services of...