All of us here today are public health enthusiasts. If we weren’t we would be somehwere else, maybe helping sick people to get better. That is a worthy calling and thank goodness for all the people who do it. But so too is prevention, so too is keeping society healthy, so too is protecting the environment, so too is keeping food and water safe, so too is attending to immunization and child health.
When we talk about public health these latter things, that focus on the whole community, or groups within society and the things that determine their health, are what we are talking about. This is big picture stuff. This is about asking why some communities are healthy and some are ill. Why do some communities have such high rates of diabetes, like the Pacific Islands, while other countries have no diabetes but lots of HIV and TB? These are the kind of interests and enthusiasms that have led people into public health as a career for as long as it has been around.
These are the kind of questions that were asked ages ago and which are still appropriate to be asked now. So what is this thing called the ‘new’ public health? How has it come about and does it have added value? In brief, the new public health has come about because of growing interest in the subtle interaction of the environment with people living in affluent societies. The old public health remains the public health that most of the world needs, quite frankly, because communicable disease, malnutrition and other scourges are still the major killers worldwide.
These are more or less the same as those that led people in the fifteenth century to look at how things such as the plague and cholera could be controlled through sanitation, clean water and quarantine.
The New Public Health
But the new public health is much more concerned with the interplay between affluence, social well being, education and health, social capital and health. These are not hard and fast things, like having no system for waste water disposal or using contaminated drinking water. They are more subtle, but in societies like ours where the basic public health engineering and mmunization and food safety are well in place and require surveillance but not reinvention, these new factors – the social, economic and community quality factors – are rising in importance as determinants of health and causes of illness. 1 For example, Michael Marmot has done studies with Geoffrey Rose and others in the UK examining coronary disease rates among civil servants, known as the Whitehall studies. They found that things like a sense of social control and cohesiveness were important determinants of whether people develop coronary disease.
Money wasn’t everything. In the Whitehall II study, Marmot (Director of the International Centre for Health and Society at the University College London) and his colleagues examined the psychological characteristic of work termed “low control” – meaning that an individual worker had little control over his or her daily activities in the workplace. The results showed that it was an important predictor of the risk of cardiovascular disease and that it had an important role in accounting for the social gradient in coronary disease.
The Origins of the New Public Health
The Canadians have been very active over many years in promoting our understanding about the interplay between society and social environmental factors and health. This started in 1974 when Marc Lalonde, who was then the Canadian health minister, commissioned a report on the health of Canadians which proposed four sets of factors that were important to keep in mind when thinking about the health of the public. The Lalonde Report2 refers to these four factors collectively as “The Health Field Concept”. The four elements are human biology, environment, lifestyle and health care organization.
The human biology element includes all those aspects of health, both physical and mental, which are developed within the human body as a consequence of the basic biology of man and the organic make-up of the individual. The environment category includes all those matters related to health which are external to the human body and over which the individual has little or no control (for example, foods, water supply, etc). The lifestyle category consists of the aggregation of decisions by individuals which affect their health and over which they more or less have control.
The fourth category in the concept is health care organisation, which consists of the quantity, quality, arrangement, nature and relationships of people and resources in the provision of health care - the health care system. The Lalonde Report was ground breaking in its day and provoked widespread international interest. Implementation proved to be far harder than was expected and the resilience of the health-care system to drain resources away from the first three fields was spectacular.
Nevertheless, Canada has had a more lively interest in the contribution of the first three fields to health and has preserved a degree of control over health care, including rigid enforcement of a restriction on numbers of doctors trained and practicing, ever since. Although perhaps not a direct consequence of the Lalonde Report, Canada has also 2 played a leading role in the evolution of health promotion as a discipline. Several of the leaders in the field, now nearly 30 years on from the Report, are Canadians.
They have had a special sensitivity to the potential for health gain by examining not only what can be done to encourage and sustain changes in individual human behaviour that will contribute to better health, but also those changes that can be effected in the natural and built environment that can assist in achieving this goal. Health promotion and the new public health In Australia, the new public health has been reflected in the steady rise of health promotion, expressed such ways as the formation of the Australian Health Promotion Association.
The Association’s major objectives include providing opportunities for members’ professional development, increasing public and professional awareness of the roles and functions of health promotion practitioners, and contributing to discussion, debate and decision making on health promotion policy and programs. Since its incorporation in 1990, the Health Promotion Association has grown and developed such that it now has an established function and a central place in Australia’s health promotion landscape.
Health promotion is an active form of public health in which an agenda is set with communities and individuals to affirm positively the value of health and push towards high levels of health, seeing it rather as the WHO does as a positive state of well being and not simply the absence of illness. Health promotion uses a range of tactics and methods to achieve its ends, including community participation, development and skill strengthening, advocacy (where health professionals and others lobby for health to be taken seriously at political and commercial levels), and education.
Something of a contrast has come to be drawn between the activist promotion end and the formal epidemiological end of the public health spectrum, the former hoeing in boots and all to effect change and the latter taking careful steps, using rigorous studies and statistics, to establish cause and effect relationships before acting. Both groups tend to drive one another nuts. This is a lively tension and not one that is likely to go away.
Professor Fran Baum who is head of the Department of Public Health at Flinders University in Adelaide has written a book entitled The new public health: an Australian perspective, that I commend to you. In it the idea of the new public health is given extensive coverage. The new public health overlaps and interacts with other health movements of the past decade – particularly health promotion, primary health care, community health, women’s health, Aboriginal health, workers’ health and health education.
History of the New Public Health
The new public health started to develop in the 1980s. It was in the mid-1980s that there was a significant shift in public health when the WHO’s first international conference on health promotion was held in Ottawa, Canada. There were two driving forces behind the Ottawa Charter. It was clear that the Health for All by the Year 2000 strategy was not being adopted by industrialised countries, and the limitations of the lifestyle and behavioural approaches were increasingly being seen as requiring a new conceptualization for health promotion.
Also the time was opportune for a more health promotion statement. The Ottawa Charter managed to integrate many of the different perspectives of health promotion. While being seen as the foundation of the new public health, it did not reject behavioural and lifestyle approaches, but saw them as part of the acquisition of personal skills for health. The Charter is based on the belief that health requires peace, shelter, education, food, income, a stable ecosystem, social justice and equity as prerequisites.
The Development of healthy public policy, which recognises that most of the private and public sector policies that affect health lie outside the conventional concerns of health agencies. Rather they are in policies such as environmental protection legislation, progressive taxation, welfare, occupational health and safety legislation and enforcement, land rights legislation and control of the sale and distribution of substances such as alcohol and tobacco. Health becomes, therefore, a concern and responsibility of each sector of government. The creation of supportive environments in which people can realise their full potential as healthy individuals. The Charter recognises the importance of social, economic and physical environmental factors in shaping people’s experiences of health.
Strengthening community action refers to those activities that increase the ability of communities to achieve change in their physical environmental factors in shaping people’s experience of health.
The development of personal skills acknowledges the role that behaviour and lifestyles plays in promoting health. The skills called for are those that enable people to make healthy choices. It also extends the skills base for health to those associated with community organisation, lobbying and advocacy, and the ability to analyse individual problems within a structural framework.
Reorientation of health services is a call for health systems to shift their emphasis from (in most industrialised countries) an almost total concentration on hospital-based care and extensive technological diagnostic and intervention to a system that is community-based, more user-friendly and controlled, which focuses on health.
The Ottawa Charter stresses the importance of, and recommends:
Advocacy for health
Enabling people to achieve their full health potential
Mediation between different interests in society for the pursuit of health
Following in the spirit of the Ottawa Charter, in 1986 the Better Health Commission (BHC), a group established by the then Commonwealth Minister for Health, Neal Blewett, published Looking Forward to Better Health. Its brief was to recommend ways in which health in Australia might be promoted, especially though ways that were 5 nconventional for the medical and public health professions. It was part of Australia’s response to the World Health Organization’s commitment to achieve equitable levels of health for all people, according tot the political and economic possibilities of each country, by 2000. This report contained proposals for achieving greater equity in health in Australia together with strategies to address several major preventable contributors to death and disease. Task forces established goals and targets for three priority health topics: cardiovascular disease, nutrition and injury. In making these choices the Commission was concerned to identify not only big problems, but also problems potentially amenable to prevention. Heart disease, the principal cause of death, was also chosen because of its multiple modifiable causes (e. g. diet, smoking an sedentary living), nutrition because of its multiple consequences (e. g. diabetes, heart disease and cancer) and injury because it cannot be dealt with preventively by efforts confined to health care but must involve industry, transport, law enforcement and industrial relations.
These three major health problems in contemporary Australian society are priorities for health promotion by virtually any criterion. The work of the BHC was taken further in the National Better Health Program and led to the formulation of national health goals and then national health priorities which remain in place today. By the end of the 1980s, despite success, there was some Australian scepticism about the new directions in public health. Some questioned whether the new public health was really ‘new’ or simply old ideas in new clothing.
This criticism is somewhat harsh as one of the features of the Ottawa Charter is that it does not ignore public health history but rather builds on it. The Ottawa Charter reflected numerous social and health movements of the previous 120 or so years. Its claims to be ‘new’ derives from how it pulled together numerous and diverse movements to present a package which gave public health a more radical and cohesive direction than had been the case for some time.
Today, public health is alive and well and confronting in this country the challenges that it can assist ameliorate. We are an astonishingly healthy nation – on average. We have the second longest healthy life expectancy of all nations, a fraction behind Japan. But within our country we have communities including those of some of our Indigenous people where these privileged are far from being available. It is here that a combination of old and new public health measures is required.
Good work is being done and more is needed. This is the mission of public health.
Marmot, M ‘Inequalities in Health’, The New England Journal of Medicine 2001;345(2):134-136
Lalonde, M (1974) A New Perspective on the Health of Canadians. Ottawa: National Ministry of Health and Welfare
Baume, F (1998) The new public health: an Australian perspective Publisher: Oxford University Press
Leeder S R (1999) Healthy Medicine, Challenges facing Australia’s health services Publisher: Allen & Unwin 7