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12.1 Public health—its critical requirements

12.1 Public health—its critical requirements
Oxford Textbook of Public Health

12.1
Public health—its critical requirements

Walter W. Holland

Introduction
Problem definition
Analysis of the problems identified and proposals for their solution
Implementation of proposals and monitoring their effectiveness
Issues of responsibility and accountability

Policy-making

Determination of priorities

Health service organization

Methodology

Dissemination of information
Internal specialty issues

Research

Training and human resources
The changing health environment

The population

Changes in medical and surgical techniques

Changes in social expectations and standards

The changing political environment

Service organization and planning
The future of public health
Further reading
Chapter References

Introduction
An effective health service must identify and be responsive to major public health problems, and be effective in promoting strategies to combat them. If no well-attested solution is available, an effective service ensures that appropriate investigation is mounted in order to develop the body of knowledge and define the means of solving public health problems, and thus to identify appropriate methods of protecting the public’s health. The intelligence system maintained by the service should provide appropriate mechanisms in order to undertake these public health tasks.
The preceding chapters in this book have attempted to outline the present status of public health in terms of both its functions and roles, and its potential. It is the purpose of this chapter to comment on some of the major current issues in the discipline of public health, and to consider how the discipline may require modification, expansion, and revision in order to be able to cope with the problems of the future.
Problem definition
A diagnostic surveillance system is essential to assess the situation and feed back to those involved in public health (particularly at the grassroots level) that a problem exists and requires solution.
The public health system ideally influences all sectors of society, not just those in immediate contact with the health care system. The preceding chapters of this textbook have identified numerous areas in which, given political will and professional freedom, the public’s health can be influenced—for example, housing, the environment, the workplace, recreational facilities, social services support, and alcohol and tobacco policies. The public health service must strive toward this ideal.
Analysis of the problems identified and proposals for their solution
The service must have the ability to initiate action through mobilization of appropriate resources, or the ability to influence those responsible for executive action to undertake corrective or preventive activities. Public health permeates through all the social, environmental, and other activities of populations. It cannot be restricted to the actions of health practitioners. There are environmental and societal, as well as medical, solutions to public health problems. Thus, the activities of farmers in producing food or tobacco, to take two examples, may be as important as the activities of physicians that provide preventive or curative services, depending on the intervention deemed necessary.
Implementation of proposals and monitoring their effectiveness
There is a long-standing misunderstanding that curative medicine is the most important component of the maintenance of the health of the public. Since the middle of the last century, the objectives of the discipline of public health have been considered secondary to those of curative medicine, which is considered to have dramatic and immediate effects on health status. Lay people and politicians, in particular, have been led to believe that the major advances in medicine, and thus in health, are provided through hospital services. Meanwhile, the potential of public health to have long-term influence on health status goes largely unrecognized. Public health, as a discipline, has a responsibility to put pressure on those responsible for implementing health policy to resource adequately the most appropriate public health interventions they have identified. Generally, this will involve a change toward preventive and away from curative (resource-intensive) services. The ambitious primary care programme launched in 1979 by the World Health Organization (WHO) toward ‘Health for All’ is complementary to public health and should be integrated with public health (Mahler 1981).
When the major public health problems in the developed world were due to infectious and nutritional disease, the benefits of public health activity were obvious. In recent times, the need for effective action in public health has perhaps best been demonstrated by the emergence of the HIV infection and AIDS and its public health implications. Despite case-finding and quarantine, that is isolation of the affected, as methods of control, it is generally accepted that prevention has to be directed at effecting behavioural change, particularly among those engaging in high-risk activities.
The difficulties, however, lie in implementation and application. The problems of this infection are indicative of the problems of public health in general. The major emphasis has been placed on the investigation of the virus and the molecular basis of generation of the disease, its treatment, and the development of a vaccine to prevent the disease. Far fewer resources have been, or are being, devoted to the problems of understanding human behaviour, or the modification of human behaviour, and of thus influencing the rate and mode of transmission in Western, African, Asian, and other populations. Thus, once again, emphasis is being placed on the tail-end of the disease process—on treatment—rather than at the beginning, on prevention. Studies of the diffusion, incidence, and prevalence of the disease in various societies are hampered by the ignorance of both the public and governments, which inhibits the activity of those concerned with the implementation of public health (Quinn and Fauci 1998).
Public health, as a discipline, is failing to fulfil its role as outlined at the beginning of this chapter. Public health practitioners do not have the power to implement the policies they have identified. Thus they cannot, without political power, be held responsible for the health of the public. Nor can they, if their advice is ignored, be held to be accountable by politicians for the failure of public health policy.
This chapter sets out to elaborate on the three main issues outlined above, and, in the final part of the chapter, to describe in detail the potential impact of the discipline of public health on health status. Thus, the major issues facing public health in the future are:

responsibility and accountability—how public health professionals can influence health care provision and become accountable for public health activities

internal issues specific to the discipline of public health (human resources, training, research, centralization, etc.)

the responsiveness of the discipline to a changing health environment

a changing political, organizational, and financial environment.
Thus the major problems which public health needs to address are:

outbreaks of disease caused by infectious toxic agents, for example, smallpox, typhoid, food poisoning, bovine spongiform encephalitis, radiation, etc.

problems arising from social and environmental issues such as inadequate housing, unemployment, poverty, abortion, fluoridation of water, or even global environmental changes including climate change

behavioural concerns such as smoking, excessive consumption of alcohol, drug misuse, and insufficient exercise, which have both individual and societal determinants

health service issues including assessment of health care needs and outcomes, and the effectiveness and efficiency of particular services.
Issues of responsibility and accountability
Policy-making
Public health practitioners cannot act in isolation. They are always dependent on government, at central or local level, for the freedom to practice their discipline effectively. There is implicitly an underlying failure to recognize the nature of professional responsibilities for the public’s health: in consequence, there is a failure to allow the public health professions a sufficient place or the power to determine and execute appropriate health policies. Often, public health knowledge and wisdom is counterintuitive to accepted practice. It is often difficult for the public health practitioner to convince health policy-makers of the most appropriate course of action. After all, Florence Nightingale advocated the miasmatic theory of contagion, whereas the public health practitioners of the day believed in the transmissibility of infection. However, Nightingale and her followers were influential in their views on hospital design, and, as a result, the advice of public health practitioners was neglected. More recently, many politicians believed that cervical cancer screening should be introduced for all women aged 16 to 64 years, thus (given limited resources) neglecting the fact that the major ‘at-risk’ group were those aged over 35 years, and that overdilution of effort would reduce the overall benefits of this service.
Often, financial or bureaucratic responsibilities are given too high a priority, and the public health suffers. Public health professionals are rarely given the necessary responsibility for the public’s health—perhaps because their priorities would not necessarily reflect the priorities of government, and health services would no longer necessarily reflect government policy.
Determination of priorities
Thus, as a result of political interest, often perceived by professionals as interference, the public health practitioner is not free to determine his or her own priorities. In terms of the role of public health given at the beginning of this chapter, practitioners are not permitted to identify the problems freely, nor to devise and implement appropriate solutions. The media, and subsequently, public opinion, may affect the decision-making process, and newsworthy, but from a public health perspective trivial, problems may be given unwarranted attention. For example, recently, much attention focused on measures to reduce lead pollution from motor vehicle emissions in the United Kingdom, but none on the more serious impact of lead contamination of the water supply from lead pipes.
Health service organization
Public health medicine plays a vital role in the management and organization of health services. However, decisions about reorganizations are often beyond the realm of practitioners who, despite their specialized knowledge of health care provision, may later have to enforce inequitable methods of organization. Thus public health professionals are given responsibility for implementing operational decisions without being party to strategic planning. This lack of clearly allocated responsibilities and accountabilities is the paramount problem facing the public health services.
Public health practitioners are needed as part of an independent authority, not beholden to any specific interest group, but with an input into both strategic and operational decision-making in all forms of policy with an impact on health. Only if the public health practitioner is able and willing to provide uncomfortable, unwanted advice (even if later rejected) is it likely that the public health function can retain its integrity and can be adequately performed.
These conditions are now met, at least in theory, in the United Kingdom, by the division into purchaser–provider organizations, with the public health discipline represented in the purchaser domain.
The director of public health is an executive director, and thus a full responsible member of the body responsible for the health of a defined population. That authority is in the position to purchase services that promote health, including health services. Attempts are being made to develop methods to decide on the relative resources to be used for preventive, curative, and rehabilitative services for individual disease groups, for example coronary heart disease (O’Brien et al. 1997). The director of public health is also responsible for publishing an annual report on the health problems of the population for which he or she has responsibility, identifying both problems and solutions and, over time, recording what progress has been made. Although this report is intended to be independent, there are fears that it may be subject to some degree of censoring. However, the changes in structure, detailed in earlier chapters, enable an authority to take a much broader view and enables expenditure to be directed to, for example, road or housing improvements, rather than only accident and emergency facilities, to reduce the problem of accidents. A start in this direction is being made in some places (Holland 1995).
The public health professional must have an advisory as well as an executive capacity, and must be accountable for the advice he or she gives. The advice of a public health professional may conflict with that of a clinical medical practitioner, since priorities for the health of one individual may differ from priorities for populations. Co-ordination is thus necessary, and reconciliation of differing priorities is needed. The professional structure should allow the combination of executive and advisory functions, plus the necessary reconciliation with other professionals.
As long as public health remains totally enveloped within the current bureaucratic and administrative structure, the conflicts and difficulties are likely to be too great for it to be able to enforce appropriate methods of action and implementation of findings. However, there is danger that, were it removed from this structure, it would become even more remote. In many countries, such as the United Kingdom, public health is divided between two separate authorities: medical public health practitioners are enveloped within the medical hierarchy; non-medical public health practitioners are part of the local government. The conflict within each of these hierarchies, as well as the conflict between them, militates against an appropriate and effective public health function. In the United Kingdom attempts at developing a unified body are currently being made. In the past, public health has been separate from clinical medicine; but even then it aspired to have clinical functions in relation to individuals. Even at the start of public health activity, the subservience of public to bureaucratic domination existed. Thus, it is difficult to develop an entirely independent public health activity capable of influencing authorities at all levels. Only where public health was set to tackle major individual problems, as for example with tuberculosis, smallpox, and diphtheria, has it been able to act effectively. An example is the American Public Health Service (USPHS), which was accountable for overall achievements rather than specific activities.
Methodology
To fulfil the role identified at the beginning of this chapter, public health practitioners must develop an agreed methodology, based on evidence, for tackling public health problems. Methods of investigation and the risks of specific hazards have been set out in previous chapters in this book. Unless public health develops a more thorough, competent, professional methodology it is bound to have relatively small impact on the improvement of public health. The difficulties that practitioners face are numerous, and the development of professional expertise is the only hope so that they can fulfil their expected role and contribute constructively to the improvement of health policies.
No universal model of the detailed responsibilities of public health practitioners exists. Generally, public health practitioners are responsible for the maintenance of the health of populations and the evaluation and assessment of the needs for service of different population groups. This can take many forms. In some countries, for example the United States, The Netherlands, and France, the public health function is also concerned with the delivery of health services to individual population groups, for example indigent children. However, its major tasks should be:

to assess the health status of the population

from this, to evaluate the health care needs

to determine the most appropriate way to satisfy the health care needs of individual population groups and to assess the effectiveness with which those needs are met

the identification of specific health hazards, and their containment.
Thus the development of strategies for the promotion of health, the containment of ill health, and the deployment of human resources in order that the health hazards in the environment are appropriately investigated and contained are essential responsibilities of the public health service, as is the determination of priorities for health services. This discussion has illustrated some of the reasons why these functions are not presently achieved.
Dissemination of information
Dissemination of information and research findings is an essential function of the public health discipline, if progress is to be made using resources optimally. A number of means of dissemination are available to the public health practitioner, through the media or through the more traditional routes of journals, conferences, and seminars. In terms of the dissemination of information to the general public, there are often difficulties in the relationship between the media and practitioners because the media, despite their potential as a powerful tool in public health information and health-promotion campaigns, often neglect major public health issues.
The difficulties and deficiencies of providing information, both in the assessment of whether health services are performing adequately, determining how priorities can be determined, and how individuals and populations can improve their own health has been reviewed by Holland (1995).
Outbreaks of infectious disease, particularly of rare conditions such as Legionella infection or toxocariasis, are more dramatic than the containment of common diseases causing many more cases, for example influenza or acute respiratory infection. The concern that has been evoked through the AIDS epidemic is an example of the power of dissemination of information through the media. The lack of concern with, for example, road accidents or coronary heart disease mortality is an example of how the media may neglect non-sensational, although important, public health problems, but may report sensational stories which make ‘good copy’, although these may be less important from a public health perspective.
A major obstacle to dissemination is that the agendas of those responsible for public health may vary. The public health professional cannot always rely on governmental support for public health policy, since there are often vested interests at stake. For example, a restriction on smoking may affect employment, the economy, taxation revenue, and the cost of pensions provision—the priorities of a government will determine whether these are politically unacceptable prices to pay. There may also be conflict between clinical practitioners and public health practitioners since their priorities may differ—the former often placing an emphasis on curative activity, the latter on preventive.
Thus to fulfil their role effectively, public health practitioners have to perform certain functions.

They have to be forthright in the advocacy of programmes that improve health and state clearly and openly the dangers and consequences of some actions, clinical, environmental, or political.

They have to be able to influence the budget for public health activities and ensure that long-term public health issues are considered on a separate dimension from short-term clinical and practical issues which would otherwise always take precedence.

They have to assume a clearly identifiable role in helping to influence and guide the policies, not only of health authorities but also of schools, environmental agencies, welfare agencies, housing departments, microbiological laboratories, and practising clinicians in hospital and general practice.
Internal specialty issues
Research
With the burden of death and disability from non-communicable disease increasing, research into the prevention of these conditions is receiving increased emphasis.
In many countries there is no coherent strategy for the maintenance of a stable research base. In the United Kingdom, for example, the National Health Service devotes far too small a part of its budget to seeking how to improve its own operations, and the pharmaceutical industry finances by far the largest part of funding for medical research. Inevitably, research priorities will be largely determined by the pharmaceutical market-place (House of Lords 1988; Secretaries of State for Health 1989b).
A second major problem stemming from this situation is the lack of human resources because of the absence of a stable career structure for those in research. Research standards can only be maintained by the development of a strong infrastructure for research in well-funded establishments, and through maintaining the supply of a well-trained and strongly motivated research community.
Public health research, by its very nature, can propose an alternative to traditional research priorities (for example, by concentrating on conditions such as influenza, which affect the population widely, as compared with more ‘interesting’ problems, such as rare metabolic disorders which, although serious, affect only small numbers of individuals). Thus it is in some ways in conflict with research supporting clinical activities. Since such research is allied to operational research, which is concerned with evaluating the effectiveness of new or existing treatments or technology, it may often arouse resentment among the medical professions, which may have a vested interest in those treatments or techniques. Public health research more often promotes prevention against cure.
For the development of appropriate public health research, a research strategy must be developed. This must include the gathering of intelligence on a broad front to determine main national priorities. These can be chosen by reference to alternative methodologies such as cost–benefit and cost-effectiveness analyses in the light of overall goals. Political and social values clearly enter into the determination of benefits and costs; but analytical tools must be used for more systematic and rational decisions to be made. Science is an aid to the art of policy-making, not an alternative.
An appropriate research structure is necessary in order that the tasks can be appropriately tackled. This implies a proper human resource development structure, with the involvement of educational institutions and government, and provision of adequate resources for such research.
Funding for health research is generally inadequate, and good research proposals are not always supported. Career prospects in research are often dismal, and the demands of patient care inhibit research activity. There is a lack of awareness of the importance of research and of the time and resources required to promote it. Findings of research are not always properly disseminated, and therefore duplication of research efforts cannot always be avoided.
Training and human resources
In order for public health to be generally accepted and developed as a valid influence on health status, appropriate training facilities are of vital importance. This implies specific skills in the application of public health, as well as an appreciation of the requirements for the subject. In the United Kingdom, the Faculty of Public Health Medicine has stressed the importance of a multidisciplinary approach to training in public health (Peach and Lakhani 1985; Faculty of Public Health Medicine 1992).
For an adequate education of medical graduates in public health, the subject must be given appropriate prominence in all parts of the undergraduate curriculum. Public health is a bridging subject which can integrate the various aspects of medical education. It is essential that future medical graduates have the ability to see common community problems, and they are able to appreciate the methods used by public health practitioners in the determination and evaluation of health care needs in order that they may see the relevance of individual components of the medical curriculum from a better perspective. They require a grounding in numerical and statistical concepts, as well as in social science theory and methods so they can understand both the need for and the applications of a variety of different techniques to the promotion of health. They should also have an understanding of the ways in which society changes in relation to the environment and other factors that are important in the determination of health and disease. Through a more realistic exposure to public health as a discipline, they should also be better able to understand the relative importance and place of diagnostic and therapeutic techniques in medicine, and the importance of preventing ill health rather than being concerned purely with its treatment.
Nurses, too, are a vital part of the public health team, and collaborate with the other professions in the provision of a service. Training in public health nursing covers basic nursing sciences and public health science. Nursing education has progressed in recent years, and nurses are increasingly achieving higher professional status. However, the nursing profession is still largely fighting for recognition of its potential for diagnoses and treatment, in addition to its traditional caring role, particularly in developed countries, where many aspects of health care have become highly medicalized.
For the non-medical graduate, public health as a discipline is particularly important to those students who are likely to become involved in environmental health, medical statistics, and the management of health and social services. Students of education and future teachers should also have some appreciation of the various ways in which their discipline can promote health and can contribute to improvement in health status.
It is vital that Schools of Public Health are multidisciplinary, since the nature of the public’s health is determined by numerous factors which require input from a variety of disciplines. Only by the interaction of these is it possible that any improvement will occur in the future in the practice of public health (Omenn 1994).
There may also be a role for linking modern medical training to traditional practices in some developing countries. In this way modern and traditional methods can form a partnership, and thus increase the acceptability of newer practices.
Rapid changes in the public health sector warrant continuing training opportunities to confront the changing disease problems. Training opportunities are poor for non-medical staff in the public health sector in developed countries, and there may be skills shortages because of poor working conditions, poor pay, and poor professional status. These problems must be remedied to ensure the adequate skilled human resources to provide an adequate service.
In those countries that have a clear organizational structure in the health service and in local government, like the United Kingdom, it is important that the public health function is exercised by an appropriately trained workforce at each level, that is, at the centre (the government department or ministry of health), and in each district (the district health authority). An individual is unlikely to be effective alone, and there should be a team of individuals, having competence in the appropriate medical and non-medical disciplines, such as statistics, social science, and environmental science, in order for the public health professionals at all levels to fulfil their appropriate responsibilities.
In a less unified system, such as that existing in the United States, the public health service should be organized at each level or geographical area of government, for example at state and at county level. Although the public health service may not be involved in the provision of clinical services, it should be concerned with environmental control and the assessment of health care needs, so that it can advise national or local government on the provision of adequate services.
The workforce structure should be appropriately organized so that there are adequate training posts for both service and academics, in order that an appropriate cadre of well-trained individuals is available, both at present and in the future (IOM 1988).
The changing health environment
The population
The proportion of elderly people in the population is increasing, particularly those aged over 75 years. The elderly make greater and different demands on health services than the young. Demographic changes present new public health problems. In terms of the care of the elderly, the increasing dependence in society that accompanies care of the elderly, geographical variations in employment, skills shortages, unemployment, and poverty are all important determinants of health according to the WHO’s Health for All indicators (WHO 1978).
Changes in medical and surgical techniques
The range of treatments available has increased significantly since the 1950s. Now there are effective drugs, such as antibiotics, which have revolutionized the treatment of infectious disease, and effective treatments are available for serious conditions, such as cardiac bypass operations for the treatment of coronary heart disease. However, many new treatments have not been properly evaluated. These treatments have increased patient expectations of the length and quality of life. Patients have become better informed, and expect a higher standard of care, which is often equated in the mind of the patient with highly medicalized care. Consequently, the public health practitioner finds himself evaluating technology which is already widely implemented. Difficulties exist in attempting to withdraw ineffectual technology once it has become accepted by physicians and patients.
Changes in social expectations and standards
There are still very major differences in access to health services within and between countries. There are sixfold or greater differences in case-fatality rates for conditions such as hernias, acute appendicitis, tuberculosis, and hip fractures in different parts of the United Kingdom alone (Holland 1997). This factor, together with changing demography, results in the emergence of a number of new public health problems (such as equity in health care provision, or the determination of national health priorities) which now have to be tackled.
The changing political environment
It is generally agreed that some level of public intervention is necessary to protect the health of the population. The chief factor which varies between countries of different political ideologies is the extent of this public intervention, often argued in terms of the extent of government intervention in public health.
Service organization and planning
There must be a public health presence at the centre in a planning role, as well as at the periphery. Public health practitioners are required at all levels of a health system, both in strategic planning and in an operational capacity to implement policies. All health systems are concerned with the promotion and maintenance of health, but many interpret this as a disease-treatment service, implying the provision of services only for the chronic sick. But the treatment of public health as a disease service implies its failure in its principal role—that of prevention and health promotion.
However, one of the main problems is the squeeze on the resources devoted to public health services. This has been clearly demonstrated in the United Kingdom, where in 1989 the government produced a White Paper which suggested major reorganization of the health service (Secretaries of State 1989a). The proposals outlined in this document affect all the essential aspects of a ‘good’ service which have already been described—the levels of responsibility of professionals, accountability, the ability of the service to respond to changing needs, degrees of political influence, and many issues internal to the specialty of public health. Resources available to promote public health must be allocated between all the disciplines necessary for the operation of the public health system. That is, in order for an appropriate public health function to be performed, support is required in terms of numerical, biological, bacteriological, and chemical services, which can be provided from appropriately staffed and equipped establishments. This has implications in terms of organization, for example of the provision of microbiological laboratories to investigate outbreaks of disease. The facilities required are different from those needed in a clinical laboratory dealing only with specimens from individual patients.
The future of public health
Public health is neither adequately funded nor suitably organized to confront the health problems facing the developed world in the twenty-first century. The public health system was designed to combat infectious disease and problems of undernutrition, hygiene, etc. The problems facing the developed world are now very different. We are faced with problems of plenty: inappropriate nutrition leading to heart disease; alcohol- and smoking-related illness reaching almost epidemic proportions; and a range of new occupational illnesses to replace the old. The problems are challenging in terms of preventive, therapeutic, and rehabilitative care.
Effective public health activities are essential to the general well being of the population, to ensure that the conditions in which people live and work are healthy. Public health activities can be undertaken by individuals, agencies, or governments; but governments, regardless of their political ideology, have a central role in ensuring that services are adequate (either by monitoring private services or by funding public services), and in collecting, analysing, and producing data. They have a responsibility to review regularly the status of the public health, to delineate clearly public health responsibilities, to ensure a unified service, and to bring public health services into line with the changing pattern of disease in the population. However, beyond this, it is the responsibility of the professionals to assist in the assessment of priorities and approaches to public health and solutions to its problems. Professionals must ensure that governments are aware of changing global disease patterns, and changing environmental problems.
It is often difficult to understand the resistance to public health and its practice. Part of this problem is that the activities of public health are difficult to comprehend in some instances, or in others appear so obvious that they are considered an extension of common sense. However, it must be recognized that public health permeates all human activity. The recent developments towards more appropriate nutrition and housing, and greater consciousness of environmental issues, have largely emerged as a response of communities to new environmental hazards and as a result of increased awareness of methods for preventing harm to individuals and communities.
It is easier to understand the functions of public health in areas of deprivation: the identification of major problems, the identification of methods for solving those problems, and then implementing those solutions. For example, where an outbreak of diphtheria occurs, it is essential to identify the source, to identify the means of containment, and then to set up the means of prevention. This is essentially what guided the activities of the WHO in eliminating smallpox. In developed countries this activity is more difficult to define. The sources of illness are more complex and multifactorial. Thus, public health has identified smoking as one of the major hazards for disease in the developed world. To implement appropriate antismoking activities involves all sectors of society, from those growing tobacco plants, to those selling the product, to those reaping the benefits from the sale of the product.
The role of public health in planning activities has often been confused. Public health practitioners perform a crucial role in this field in identifying major causes of illness and disease, and then devising appropriate methods of treatment or care, and thus identifying priorities.
The problem arises that many of their proposed solutions are difficult to implement, and often attack the current citadels of power. The results do not occur immediately, and are not as dramatic as those of curative medicine. It is only if the public health practitioner can deploy the resources of those in other sectors of society that truly effective activities can be developed. It is, however, important to appreciate that the risk of dying is but one concern of the practitioner. Thus, public health ought not only be concerned with the prevention of death, but must also be more concerned with the prevention of early death, and with the preservation of the quality of life of those who survive.
Thus public health is about the promotion of the health of the whole community. It is concerned with the prevention of disease, the prolongation of life, and the promotion of the quality of life of human populations, and aims to reduce the burden of ill health and disability.
This book has clearly shown the importance of various social, environmental, and industrial factors in the development of disease as well as in the promotion of health. That public health should straddle all of these aspects is essential, and its continued ability to influence all of them is the only way in which appropriate worldwide health policies can be maintained and developed.
Further reading
Beaglehole, R. and Bonita, R. (1997). Public health at the crossroads. Cambridge University Press.
Ciba Foundation (1973). Medical research systems in Europe. Wellcome Trust–Ciba Foundation Joint Symposium. Ciba Foundation Symposium 21. Associated Scientific Publishers, Amsterdam.
Council for Science and Society (1982). Expensive medical techniques. Council for Science and Society, London.
Holland, W.W. and Stewart, S. (1998) Public health: the vision and the challenge. Nuffield Trust, London.
Flook, E.E. and Sanazaro, P.J. (ed.) (1973). Health services research and R & D in perspective. Health Administration Press, Ann Arbor, MI.
IOM (Institute of Medicine) (1988). The future of public health. National Academy Press, Washington, DC.
Knox, E.G. (ed.) (1987). Health-care information. Report of a Joint Working Group of the Körner Committee on Health Services Information and the Faculty of Community Medicine. Nuffield Provincial Hospitals Trust Occasional Papers 8, Nuffield Provincial Hospitals Trust, London.
McGinnis, J.M. and Foege, W.H. (1993). Actual causes of death in the United States. Journal of the American Medical Association, 270, 2207–12.
McLachlan, G. (ed.) (1971). Portfolio for health. The role and programme of the DHSS in Health service research. Nuffield Provincial Hospitals Trust/Oxford University Press.
McLachlan, G. (ed.) (1973). Portfolio for health 2. Nuffield Provincial Hospitals Trust/Oxford University Press.
McLachlan, G. (ed.) (1974). Positions, movements and directions in health services research. Nuffield Provincial Hospitals Trust/Oxford University Press.
McLachlan, G. (ed.) (1978). Five years after. A review of health care research management after Rothschild. Nuffield Provincial Hospitals Trust/Oxford University Press.
McLachlan, G. (ed.) (1985). Data information and intelligence. A statement of needs and opportunities of relevance to the new NHS management procedures. Report of a Nuffield Provincial Hospitals Trust Working Party. Nuffield Provincial Hospitals Trust Occasional Papers 4. Nuffield Provincial Hospital Trust, London.
Sheps, C.G. (Chairman) (1976). Higher education for public health. Prodist, New York.
US Department of Health and Human Services, Public Health Service (DHHS) (1994). For a healthy nation. Returns on investment in public health. Department of Health and Human Services, Washington, DC.
Chapter References
Faculty of Public Health Medicine of the Royal Colleges of Physicians of the United Kingdom (1992). Handbook on training and the examination for membership. Faculty of Public Health Medicine, London.
Holland, W.W. (1995). Achieving an ethical health service. What information do we need. Journal of the Royal College of Physicians of London, 29, 325–34.
Holland, W.W. (ed.) (1997). The European Community atlas of ‘avoidable death’. Commission of the European Communities Health Services Research Series No. 9, Oxford University Press.
House of Lords Select Committee on Science and Technology (1988). Priorities in medical research. Vol. 1: Report. HMSO, London.
IOM (Institute of Medicine) (1988). The future of public health. National Academy Press, Washington, DC.
Mahler, H. (1981). The meaning of ‘health for all by year 2000′. World Health Forum, 2, 5.
O’Brien, M., Halpin, J., Hicks, N., Pearson, S., Warren, V., and Holland, W.W. (1997), Health Care Commissioning Development Project. Journal of Epidemiology, 6 (Supplement), 589–92.
Omenn, G.S. (1994). The context for a future school of public health committed to urban health needs. Sun Valley Forum.
Peach, H. and Lakhani, A. (1985). Organization, training and staffing aspects of public health services in the United Kingdom. In Oxford textbook of public health. Vol. 2, Processes for public health promotion (ed. W.W. Holland, R. Detels, and E.G. Knox), p. 150. Oxford University Press.
Quinn, T.C. and Fauci, A.S. (1998). The AIDS epidemic and demographic aspects, population biology and virus evolution in emerging infections. In Emerging infections (ed. R.M. Krause), pp. 327–63. Academic Press, San Diego, CA.
Secretaries of State for Health, Scotland, Wales, and Northern Ireland (1989a). White Paper. Working for patients’. Cm. 555, HMSO, London,
Secretaries of State for Health, Education and Science, Scotland, Wales and Northern Ireland (1989b). Priorities in medical research. Cm. 902, HMSO, London.
Secretaries of State for Health, Social Security, Treasury, Home Office, Education and Employment, Trade and Industry, Agriculture, Fisheries and Food, Environment, Transport and the Regions, International Development (1999). White Paper. Saving lives: our healthier nation. Cm. 4386, HMSO, London.
WHO (World Health Organization) (1978). Primary health care. Report of the International Conference on Primary Health Care, Alma Ata, 6–12 September. WHO, Geneva.

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2 comments on “12.1 Public health—its critical requirements

  1. […] and strategies for public health interventionFinding Health Insurance Texas- What Do You Need?12.1 Public health—its critical requirements // 0) { //0==expires on browser close var cdate = new Date(); […]

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