Letter to the Editor - Authors’ response to Letters to the Editor re: Clinical public health: harnessing the best of both worlds in sickness and in health

We are pleased that our paper on clinical public health¹ received support from Dr. Shah,² who also provides important historical aspects of clinical public health. Dr. Shah was the inaugural director of a newly created residency program (Community Medicine, now known as Public Health and Preventive Medicine) at the University of Toronto in 1976. Although he claims to have failed to “bring clinicians and public health professionals together to define the common elements and synergy needed,”² we believe he did not fail, because his efforts ignited sparks among his students (including several co-authors of this paper¹). Building on his important legacy, subsequent generations of clinicians and public health professionals have made strides towards effective collaboration of clinical medicine and public health.

Dr. McLaren rejects the formation of clinical public health because it is insufficient “to address complex health problems and improve health for all,” and instead proposes political-economic public health that includes wider intersectoral collaboration.³ We recognize that clinical public health is insufficient to accomplish all health goals, yet humbly assert that the collaboration envisioned through clinical public health will facilitate feasible, principled progress. Sometimes we need to start incrementally, as progressing too ambitiously could result in the best becoming the enemy of the better. Clinical public health is a new starting point that we hope will eventually help leverage broader collaboration across professional and advocacy sectors. Also, while clinical public health cannot address all health problems, we would argue that political-economic public health, per se, will equally not solve all the problems resulting from the shortcomings in current political and economic systems—although it could be an important step along the way.

We concur with Dr. McLaren that “curative and preventive (‘upstream’) activities” are not equal in power.³ We note that public health is often the “poor cousin of clinical medicine”¹ and suggest that adoption of a clinical public health collaborative model is one way to achieve a healthy power balance.

Dr. McLaren suggests that our paper “adopt[s] a narrow version of public health as an arm of the health care/medical system focussed primarily on service delivery and surveillance.”³ On the contrary, we view public health in a broad sense. Our paper¹ is the second in our clinical public health paper series. Our first paper, “Defining clinical public health,”4 surveyed clinicians, researchers and public health professionals. It was apparent that the concept of clinical public health subsumes the broadest understanding of public health, including socially based health issues caused by “shared social and commercial determinants.”⁴,^E75

Our first paper⁴ led to two letters to the editor: one that rejected⁵ and one that supported⁶ the idea of clinical public health. This second paper¹ has also led to two letters: one supporting² and the other questioning³ our idea. We hope that these papers and the resulting letters in response will lead to further discussion and debate on the feasibility and future development of clinical public health, and perhaps a broader understanding of and action on the political and economic determinants of health.