Public Health

1
Public Health the Vision and the Challenge
Sir Ernest Rock Carling lecture 30.10.1997
Dr. Walter W HollandBSc(hons), MB, BS(hons), MD,
FRCP, FFPHLSE Health and Social Care London
School of Economics
2
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

3
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 by
• the Poor Law Institutions
• the Public Health Act of 1875
• sanitary issues (control of cholera in urban
  areas)
• concern with the provision of unadulterated food.

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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 MoHs Annual Report to highlight
  particular problems of poverty, unemployment and
  so on.

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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

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Public Health in the 20th century - continued

• Past 25 years Return to the title of public
  health and numerous reorganizations
• Major landmarks
• Concerns with management
• Black Report on Inequalities in Health
• Health of the Nation Initiative
• Purchaser-provider split

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Major issues in public health that have recurred
time and again
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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
• MGonigle - 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
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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

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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
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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.

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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.

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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

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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.

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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

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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

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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

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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

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• 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 Healths 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.

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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

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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

22
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.

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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

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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.

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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

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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.

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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.