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Challenges to public health in the new millennium
  1. JOHN WYN OWEN CB
  1. Nuffield Trust

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    Of all the medical specialties, it is public health that by its very nature is most affected by political, social and economic changes. Therefore the challenge to public health in the new millennium will be deciding how to adapt to the simultaneous changes in all these areas created by the forces of globalisation. Diseases will travel faster than every before, as will the information (and misleading pseudo-information) abut how to treat them. Information and mobility will bring great wealth to some and the troubles of the very poor, especially their health problems, closer to all of us. Existing political power structures will be challenged by the power of big business and, perhaps, small organisations, ranging from legitimate and well meaning pressure groups to terrorist organisations, newly empowered by modern information technology. International organisations such as the European Union, will develop as an attempt by nation states to rescue their power by sharing it.

    The last great paradigm shift in social development was the industrial revolution of the 19th century. The transformation of an agrarian, socially stable society with little political or physical mobility into an urban society on the move in every sense, which was most noticeable in the United Kingdom but was mirrored throughout much of the world, shares many parallels with the impact globalisation will have. Back then the UK's 1848 Public Health Act and its successors were the finest examples anywhere of public health helping to shape a social transformation in a humane direction. The UK can once again take a lead in this by asking “do we need a Health of the People Bill?” Despite the gathering pace of globalisation, nation states still for the moment have the capacity for meaningful action and leadership.

    The approach to public health established by the 1848 Act, as well as by other Acts introduced in the last century, certainly led to dramatic improvements in the health of the people. These Acts have continued to be effective in both preserving and promoting health even though there have been major changes in the structure of central and local government, the introduction of an NHS and the privatisation of such fundamental public health provisions as water supply and sewerage. But with devolution, European law and changes in disease occurrence and demography, the laws governing public health need updating and tidying up. In a democracy it is actually important to know who is responsible for what. No one should be able to avoid blame and no one should be required to accept blame for matters that are beyond their control. We have come close to that on recent occasions.

    The determinants of health have, on the whole, little to do with the health service, and public health has been overmedicalised in many countries. Local authorities in particular play a crucial part. The assessment of the lessons from The Health of the Nation are that local authorities were undervalued and marginalised and it is clear that these lessons have been learned by the present government. A positive health approach with local strategies, locally owned, offers a way of getting local government and local people more actively engaged in a public health agenda.

    To improve and maintain health requires international and national coordination because the factors that influence health know no boundaries and although the needs of different areas, for example, urban and rural, will vary, central coordination and leadership is crucial

    Furthermore, devolution in the United Kingdom—a feature of many other countries—has led to the establishment of a Scottish Parliament and a Welsh Assembly with significant devolved law making powers and in Scotland “including overall responsibility for the NHS in Scotland and public and mental health”. Beef on the bone has already been raised as early business in the Assembly and the Parliament and different practices may be adopted on either side of the English borders. These developments have important public health implications, and Canada and Australia—countries with a federal structure—can provide examples of how to tackle the problems that will certainly arise.

    In his Annual Report for 1998 the CMO for England said “The 1848 Act had a Board of Health, a high-level committee to oversee the changes proposed. Perhaps something similar would be useful now”. Perhaps it would. Those attending the Nuffield Trust Christ Church workshop in July 1998 certainly thought so.

    In the United Kingdom it may also be necessary to strengthen the role of ministers—especially that of the Secretary of State for Health—in relation to those matters for which they do have direct responsibility, such as international negotiation and maintaining a broad policy overview. It is their job to ensure, whether through legislation or otherwise, that the responsibilities of the key players are clearly defined and to satisfy themselves that effective structures are in place for improving the health of the people. The Secretary of State, as the public health minister in the United Kingdom cabinet, will need clarity about their role and that of ministers responsible for public health in the nations of the United Kingdom. A high level advisory council of experts and representatives of countries and regions is needed to provide the necessary authoritative advice to the Secretary of State so that he is able to give the necessary leadership. This Council must have the ability both to devise and collect the appropriate information that is crucial for the execution of policies. It must also have the power to publish and disseminate information, which may be uncomfortable for ministers, to influence public knowledge and behaviour. Recent concerns about, for example, BSE and genetically modified foods demonstrate the need for ministers to have access to public health experts and for the public to be reassured that the advice they receive is sound and independent. None of this is new and much of what we advocate returns us to the position that public health had at the end of the last century.

    It is also important to distance ministers from certain matters, such as the collection and dissemination of information and statistics about the health of the people and the factors that affect it. An independent body—a commission or board acting as the champion for the health of the public and operating at arm's length from central and local government—could do much to meet those two needs, and strengthen public confidence in the public health function.

    The European Union has now firmly put its badge on public health as a subject but there is a lack of overall coordination of public health across the different directorates of the Commission. We also need to sort out how institutions such as the WHO European Regional Office, which possesses significant resources and expertise, can be harnessed successfully to the benefit of Europe as a whole and in a way that would be both helpful and effective. If in the next few years the United Kingdom successfully develops its own public health function, achieving the right balance of harmonisation and subsidiarity in the context of Europe, devolution and the renewal of local government, it would be well placed to take the initiative and provide a lead on public health in Europe as well.

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