Letters 153
Letter from Glassgow
DON'T FORGET PUBLIC HEALTH
‘Public health’, declared my colleague, ‘is the original
medical specialty. Long, long before cardiology, neonatology,
transplant surgery and the other medical specialties,
sub-specialties and sub-sub-specialties, public health had a
structure and knowledge base.’ I didn’t know at the time what
brought about the rant. Subsequently I got to know that, once
again, at a medical meeting the importance of public health
was being pooh-poohed by some in the medical hierarchy and my
colleague was not impressed.
Public health is crucially important in all
countries, not just in ‘developing’ countries. Of course, the
priorities will vary in different countries so that saving 1.8
million children who die each year from diarrhoea
1
is a priority for ‘developing’ countries. Indeed, Clasen et
al.’s2 conclusions that
interventions to improve the microbiological quality of
drinking water are effective in reducing diarrhoea in children
under 5 years and adults, and that household interventions are
more effective than water source interventions will be of
particular interest to public health workers in ‘developing’
countries.
For Scotland and the UK the challenge is
not of diarrhoea but of chronic diseases such as diabetes and
hypertension, alcohol misuse, tobacco-induced disease, other
diseases related to diet and lifestyle, and the ability to
deal with old age problems such as hip and knee replacement.
Yes, I am aware that these issues are now also affecting
countries such as India—what can be called the ‘double-whammy’
of illness due to poverty and increasing wealth occurring
simultaneously. But my point is that public health is
important no matter which country you live in.
As a public health physician I always have
to explain what it is I do (even to my children), and I have a
sense of always having to justify how public health ‘adds
value’ to the healthcare system within which we operate. Of
course, the parameters of public health vary in
different countries, with public health being closely linked
to primary care in some countries, while in others it is
linked to the state-funded health services. In Scotland public
health is an integral part of the National Health Service (NHS
Scotland) and public health contributes in three main areas:
-
Health improvement:
Improving the health of the population through, for example,
prevention of cervical cancer and thereby adding years to
life, and by increasing the health of the population by
adding life to years;
-
Health protection: Protecting the
population from com-municable diseases and environmental
hazards such as chemical spills;
-
Healthcare: Helping to provide
quality health services to meet the needs of patients and
the population.
I don’t need to spell out that public
health is a ‘Cinderella’ specialty when compared with the more
high-profile specialties such as interventional cardiology or
transplant surgery. Personally, I am not precious about public
health and I don’t think we need to be defensive about it.
However, I do think public health doesn’t always get the
recognition it should from our medical colleagues. Therefore,
I do think that it’s useful to bang our drum a little louder
about public health so that rather than the spin of
professional journalists, here is some drum banging about
public health!
The UK Public Health Association (UKPHA
http://www.ukpha.org.uk) met recently in Edinburgh and
that helped me to appreciate the breadth and depth of the
public health work currently going on within the UK. This was
UKPHA’s 15th Annual Public Health Forum and it is UK’s largest
multidisciplinary conference on public health. The title of
the conference was ‘Generation to generation: Sustainable
directions for public health’. The UKPHA itself is the largest
independent UK-wide voluntary public health organization that
brings together individuals and organizations committed to
promoting public health policy across all levels of government
and sectors. The Chair of UKPHA is David Hunter (http://www.dur.ac.uk/school.health/staff/?username=dhs0djh),
a well respected public health researcher and analyst who is
Professor of Health Policy and Management at the University of
Durham in Northeast England.
The meeting attracted about 700 delegates
and was truly multidisciplinary. It covered the 4 countries of
the UK (Scotland, England, Wales and Northern Ireland) with a
sprinkling of participants from overseas. I found the job
titles of participants fascinating and in addition to the
usual suspects regarding job titles, there were the following:
‘freelance public health practitioner’; ‘family food manager’;
‘specialist domestic violence midwife’; ‘smoke-free public
places project worker’; and ‘tackling teenage pregnancy
coordinator’. For me this underlines the idea of public health
being a broad church with many streams of work and activity
needed to improve the health of people.
At the conference I was impressed by two
presentations I went to which made me question what we do (are
we doing the right thing?) and how we do it (are we doing
things right?). The first was a plenary session from Professor
Ichiro Kawachi of the Harvard School of Public Health, who
spoke on ‘Individual or collective responsibility for health’
(or why some societies make you sick). His premise was that
the linkage between social environment and patterns of illness
and disease is relatively neglected in policy and practice.
Yet there is evidence that issues such as income distribution,
social cohesion and social capital, inequalities in political
participation and residential segregation impact on the health
outcomes of people (in terms of mortality, morbidity and
quality-of-life). There is nothing new in what Professor
Kawachi said, but the way he engaged the audience made me feel
like dragging him off to speak to some of our senior doctors
who are sceptical (to say the least) of public health.
The second session was a debate on drugs
entitled ‘Drugs—is prohibition still the answer in the 21st
century’? In this session Danny Kushlick, Director of the
Transform Drug Policy Foundation arguing against complete
prohibition of illegal drugs, went head-to-head with Professor
Neil McKeganey, Director of the Glasgow University Centre for
Drug Misuse Research arguing for the existing prohibition. My
instinct was to ask ‘What does the evidence say?’ but
unfortunately the evidence is lacking or suggests
contradictory conclusions. I came away thinking that it is
important for the question of prohibition to be posed but that
the evidence, both in terms of clinical effectiveness and
cost-effectiveness, needs to be robust and reliable before
going along the ‘no prohibition’ route. Nonetheless, I was
pleased that public health was debating difficult, even
unpopular, issues and assessing the evidence for them.
So my message to all health workers is—don’t forget public
health. It may not be the most glamorous specialty but it is
asking (and answering) important questions which will improve
the health of people in all countries. And now, suitably
enthused again by the UKPHA Conference, I may even go away and
join the UKPHA…
REFERENCES
-
Luby SP. Quality of drinking water. BMJ 2007;334:755–6.
-
Clasen T, Schmidt WP, Rabie T, Roberts I, Cairncross S.
Interventions to improve water quality for preventing
diarrhoea: Systematic review and meta-analysis.
BMJ 2007;334:782–5.
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