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Public Health in the 21st Century 

Professor Neil Thompsom 

Public health, 'organised community efforts aimed at the prevention of disease and promotion of health' or 'the art and science of preventing disease, promoting health, and prolonging life through organised efforts of society', faces new challenges in the 21st Century. 

The specific challenges may be new, but the need to address new challenges isn't - the challenges and actual subject matter of public health have changed continually ever since human communities first addressed health issues. 

Such  change has been dramatic over the past 100 years or so, with the decline of communicable diseases and the rise in non-communicable diseases, particularly in developed countries. The challenges and subject matter differ between communities and countries, as well' as  over time. As a result, local issues facing poor countries can be quite different to those facing developed countries. Global issues are, of  course, challenges for all countries in the world. 

The organised efforts of society to prevent disease, promote health, and pro- long life could, of course, include all aspects of the health sector. In practice,  however, public health has a population, rather than an individual focus, with the other essential elements being:  

  • emphasis on collective responsibility for health with an important role  for the state; . 
  • emphasis on prevention, especially  primary prevention; .
  • attention to underlying socio economic  determinants of health, as well as more proximal risk factors; . 
  • concern for global a  local environmental health issues; .
  •  multi-disciplinary basis; . 
  • partnership with  population served.

In attempting to reach some consensus on the nature of public health activities, the World Health Organization established a group of 145 public health experts from all over the world. The  group developed a preliminary list of specific public health functions: . 

  • Prevention, surveillance, and control of communicable and non-communicable diseases - immunisation coverage, disease  outbreak control, disease surveillance and prevention of injury; .
  •  Monitoring health - morbidity, mortality, determinants of health, effective-ness of programs and public health functions, health needs assessment;  . 
  • Health promotion - including community involvement, provision of relevant information and education, advocacy; . 
  • Protecting the environment ~ safe water; food quality; sewerage and or solid waste disposal; control of hazardous materials, vectors and atmospheric pollution; . 
  • Public health  legislation - ensuring currency of administrative procedures, health inspection, licensing and enforcement; . 
  • Occupational health - health safety standards; . 
  • Specific services- school health,  health laboratory and emergency disaster services; . 
  • Personal health care to high-risk populations, particularly maternal and reproductive health care, family planning, and infant and child care. 

Addressing the essential elements identified above requires a broad approach, well beyond the direct responsibility of the health sector. This means that virtually no attention is directed to the underlying socioeconomic determinants of health by the health ministries in many countries. The focus on the acute care of specific i health conditions also means that much more attention is directed to disease prevention that health promotion. ; 

A view of public health 'based on a strong commitment to collective endeavour and a broad view of health' will lead to public health activities quite "distinct from those emphasising an individualistic approach to health.3 Individualistic approaches to health are consistent with the economic rationalist policies common in many developed countries today. Such policies are a major challenge for public health, as they favour free markets and reduce state involvement in issues like education, employment, health and welfare  Often, this results in a widening of income and consequent health inequalities.4 The policies tend also to compartmentalise education, employment, health and welfare issues. 

Extending beyond national boundaries, the globalisation of the economy has an effect between countries similar to that seen within countries - widening wealth inequality based on a favouring of the rich at the expense of the poor. 'The extent of global poverty, poor nutrition, the debt crisis and the deterioration of the environment' are all major public health challenges, as is 'population growth, which interacts with  poverty to aggravate environmental pressures'.3 

The almost exponential use of resources by the rich countries has resulted in major impacts of the environment globally.s,6,7 National and global public health poses specific challenges for public health education, of which the major focus has been on general public health training through Master of Public Health (MPH) programs. The focus on MPH programs, particularly by universities supported by the PHERP, has meant that more specialised areas of public health training have received less attention than they warrant, at least at Masters level. There is a need to address: . 

  • public health training of a less intensive nature than provided by Masters level courses; . 
  • emerging public health issues, including national and global economic and environmental aspects; . 
  • training in public health leadership, advocacy and policy development; .
  • the requirements of people living away from the major urban areas in which most tertiary institutions are located. 

It is beyond any tertiary institution to meet all of these requirements. No doubt there is room for some rationalisation, and also a need for greater cooperation between institutions, possibly through the use of cross-institutional enrolments. In this way, the various institutions in Australia offering public health training can more adequately address the public health challenges of the 21st Century. References: 

1. Committee of Inquiry into the Future Development of the Public Health Function. (1988) Public health in England. 

2. Institute of Medicine, National Academy of Sciences, Committee for the study of the future of public health. (1988) The future of public health. 

3. Beaglehole, R, Bonita, R (1997) Public health at the crossroads: achievements and prospects.

 4. Marmot, M, Wilkinson, RG (eds) (1999) Social determinants of health. 

5. McMichael, AJ (1993) Planetary over- load: global environmental change and the health of the human species. 

6. McMichael, AJ (ed.) (1996) Climate change and human health. 

7. Last, J (1998) Public health and human ecology.

Edith Cowan University
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Joondalup, Western Australia 6027


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+61 8 9400 5053

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