摘要：Multiple promising but unsustainable attempts have been made to maintain programs integrating primary care and public health since the middle of the last century. During the 1960s, social justice movements expanded access to primary care and began to integrate primary care with public health concepts both to meet community needs for medical care and to begin to address the social determinants of health. Two decades later, the managed care movement offered opportunities for integration of primary care and public health as many employers and government payers attempted to control health costs and bring disease prevention strategies in line with payment mechanisms. Today, we again have the opportunity to align primary care with public health to improve the community's health. For scientific progress has greatly modified his ethical responsibility. His relation was formerly to his patient—at most to his patient's family; and it was almost altogether remedial… . But the physician's function is fast becoming social and preventive rather than individual and curative. Upon him society relies to ascertain … the conditions that prevent disease and make positively for physical and moral well-being. — Abraham Flexner 1 (p26) Although the American educator Abraham Flexner (1866–1959) made this observation more than a century ago in his assessment of the state of US medical schools, the United States remains one of the few developed economies in which public health and medical care exist in isolation from each other. It was not always this way; physicians and their organizations once nurtured and developed the public health system. The divergence in the two disciplines, according to Starr, occurred at the turn of the 20th century, when the direct care of mothers and children by public health clinics prompted concerns that public health would begin to compete with physicians for the direct provision of medical care services. 2 This divergence continued with medical specialization and was likely further enhanced by the Rockefeller Foundation's 1916 decision to create schools of public health that are separate from schools of medicine. 3 The ultimate consequences of this schism were the failure to attract physicians to public health, with a concomitant decline in the numbers of preventive medicine physicians, and the failure of most other physicians to understand or appreciate the population (or public health) perspective. 4 Multiple attempts have been made since the 1916 decision to reconnect primary care and public health; however, these innovations never expanded far beyond the site where they began, and even fewer were sustained. Today, new opportunities, needs, and tools offer us another opportunity to reintegrate public health and medicine—specifically primary care—in a way that improves population health outcomes and enhances quality of life in the United States. By integration of primary care and public health we mean “the linkage of programs and activities to promote overall efficiency and effectiveness and achieve gains in population health.” 5 (p1) However, if we are to seize the opportunity to bring primary care and public health together successfully, we must learn the lessons of past attempts.
