Public Health – the Vision and the Challenge

Dr. Walter W HollandBSc(hons), MB, BS(hons), MD, FRCP, FFPH

LSE Health and Social Care London School of Economics

Sir Ernest Rock Carling lecture 30.10.1997

Learning Objectives

• To examine the development and major issues in public health in the last 100 years

• To consider what we believe needs to be done for the future

• To emphasize our own personal analysis of the issues, and possible solutions

Public Health in the 19th century - overview

• Firm foundations were created for public health in this country by giants such as Chadwick, Simon, Farr, Snow, Duncan, Budd and many others.

• Manifested by1. the Poor Law Institutions2. the Public Health Act of 18753. sanitary issues (control of cholera in urban areas)4. concern with the provision of unadulterated food.

Public Health in the 20th century

• The initial part of this century was dominated by public health – concern with the health and fitness of young men, the health of the school child, introduction of the Lloyd George National scheme for the employed

• First World War – cataclysmic event consuming all energies

• 1918 – creation of the Ministry of Health, also responsible for housing

• Interwar period between the two world wars – use of the MoH’s Annual Report to highlight particular problems of poverty, unemployment and so on.

Public Health in the 20th century - continued

• During the Second World War – Beveridge report led to improvements in health, education, housing, pensions and employment, and rationing of food ensured availability of nutritious diet for all.

• 1948 – NHS introduced• 1948 – 1972 – Social and Environmental services

became independent from public health• 1972 – change in title to community medicine

Public Health in the 20th century - continued

• Past 25 years – Return to the title of public health and numerous reorganizations

• Major landmarks:1. Concerns with management2. Black Report on Inequalities in Health3. Health of the Nation Initiative4. Purchaser-provider split

Major issues in public health that have recurred time and

again

Issues affecting health

• Housing– The move to demolish unsanitary slums– The Garden City Movement– Destruction wreaked by the Second World War, led to a need to rebuild and improve housing.

• Nutrition– Under-nutrition before 1939– M’Gonigle - demonstrated deleterious effects of an inadequate diet

on health, despite improved living conditions– Rationing during World War II was an important impetus to change– Recently there is an increasing tendency towards overweight and

obesity

http://www.tcpa.org.uk/downloads/1899-1999.pdf

Morbidity and Mortality

• 20th century decline of infectious disease mortality - most important cause of increased life expectancy

• Problems of antibiotic resistant organisms, and new conditions such as AIDS and Legionella

• Decline in mortality due to respiratory diseases, and major declines in mortality due to diseases of the digestive, genito-urinary and nervous systems.

• Dramatic reduction in maternal, infant and child mortality.• Increases in mortality for circulatory diseases and cancer

The environment

Source – The London Smog Disaster of 1952. Days of toxic darkness.http://www.portfolio.mvm.ed.ac.uk/studentwebs/session4/27/greatsmog52.htm

The environment

• Dramatic environmental change has been the improvement of air quality.

• Clean Air Act of 1956• Problems of air pollution are still a matter of considerable

concern - in the form of nitrogen dioxide and carbon monoxide

• new issues have arisen - lead in the environment, in paint, in petrol, in food or in the soil; the impact of the use of pesticides in farming; the content of some animal feeds; the sitting of waste dumps, or the building of houses and schools on sites formerly used for industrial waste disposal.

The cons of progress

• Increase is cigarette smoking• Less physical exercise - increase in diseases as

coronary heart disease, stroke and arthritis• Recent advances in reproductive medicine

and treatment of infertility, have vast ethical implications yet to be fully addressed by the profession, politicians and society at large.

The cons of progress - continued

• Mental illnesses have been a continuing concern.

• Life expectancy has increased - issues of long-term care, dementia, arthritis and multiple diseases

• Rise in the side-effects for drugs• Poverty - inequalities in levels of health

between the various social groupings

Organizational issues

• Since Victorian era - friction between the ideas and methods of medical practitioners concerned with public health and those with other qualifications, conflict of state authority and libertarian principles, conflict between the view of public health practitioners who demonstrated the need for sanitary reforms which reduced the profit of landlords and unscrupulous employers

• In the Victorian era - Most public health doctors combined clinical practice with part-time, salaried public health duties.

Organizational issues - continued

• Change from the Poor Law administration of hospitals in 1929-30, to local authority control - first major change

• Major drawback - those involved became more concerned with the problems and minutiae of clinical/hospital administration, became medical superintendents and thus directed clinical care

Organizational issues - continued

• The introduction of the NHS in 1948 changed this picture radically

• PH was separated from clinical practice and remained under Local Authority control

• The 1974 reorganization integrated all health authorities

• One of the most effective tools for the PHP - the public annual report of health

Education, Research, Manpower

• PH over the last 80 years - search for its sense of identity, was perceived both by the profession and by society in general as searching for a role and tending towards bureaucracy and administration

• It is only in recent years that progress has been achieved - academic departments of public health in every medical school, structured post-graduate training

• Research, in general has been neglected

Where Now?

Concerns• Role of PH in the control of communicable diseases -

the law currently lags behind the reforms of both the health service and Local Authorities

• Directors of Public Health now have authority in areas of clinical concern in which they are not expert

• The public health function is now frequently labeled as “health policy”, responsible for contracting for clinical services

• Once again therefore, public health is being seduced into assuming responsibility for large budgets which must be spent on clinical services, and once again public health practitioners believe that they can use this power to improve health

• The Director of Public Health’s position as an Executive Director and budget-holder has tended to become a constraint in freedom to speak freely and deliver if necessary a critical, unpopular or controversial public health message.

Public Health Responsibilities Today

• Major public health problems– Outbreaks of disease caused by infective or toxic

agents– Problems arising from social and environmental

issues– Behavioral concerns– Health service issues

• Public health should not become involved in the management of clinical services

Public Health Responsibilities Today - Continued

• Public health practitioners must develop their skills in handling outbreaks of disease

• Training in epidemiology is crucial to this• It is important for the effective monitoring of health

needs and outcome that data collected about patients are linked to individuals, and not merely based on events

• Appropriate epidemiological and other studies are necessary to determine the factors responsible for ill-health

Health Risks

• A variety of biological, behavioral, social and environmental factors play a part in the development of diseases in individuals or populations

• If public health is to fulfill its proper function - to improve and maintain health - the specialty must secure the necessary means and freedom both to identify and to disseminate knowledge of the factors that lead to ill-health and possible means of solution.

Risk Communication

• Risk perception and communication - extremely complex process , central to any modern public health function and structure

• Ability to communicate with the media, pressure groups and the public on the concept of health has enormous implications for any future public health structure

Possible Solutions

• There remains at present, confusion between the role of public health in the management of clinical services and its primary role in the management of public health services.

• Public health can influence the priorities and distribution of health service resources to improve the health of the population for which it is responsible.

Options for a better structure

• Return of the MOH• National Commission of Public Health• Modification of present structure with re-

creation of Institutes of Public Health - most realistic way forward and the one that is most likely to be both practicable and productive

What Next

• An essential ingredient for progress is clarification of the role of individuals required to perform the public health function and thus has implications for staffing and personnel

• It is essential that the interdisciplinary nature and working of the discipline is established more firmly than at present.

• Public health physicians must accept fully that they must work on equal terms with other qualified health professionals of similar.

Conclusions

• Public health has made massive inroads into diseases within a relatively short period.

• Public health is now at a cross-roads where it can either accept the status quo or confront realistic change and challenge and seek to regain its former independent voice.

• The specialty has a duty to inform the public responsibly on public health matters.

• We perceive public health as the central medical specialty of the future.