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In 2001 I gave the Harben Lecture of the Royal Institute of Public Health taking as my title 'Knowing is not enough'. My theme was the gap between the science of public health (especially epidemiology) and its national and global application, and the phrase, already borrowed by the US Institute of Medicine for its report Crossing the Quality Chasm, came from Goethe:
'Knowing is not enough, we must apply,
Willing is not enough, we must act.'
These sentiments would make an equally appropriate preface to Beaglehole and Bonita's Public Health at the Crossroads—an ambitious and provocative work now in its second edition.1 The work is ambitious in offering an account of public health science, policy and practice from both longitudinal (historical) and latitudinal (global) perspectives and at the same time attempting to see a way forward for the discipline. It is provocative in arguing that much of the failure of both epidemiology and public health to fulfil their potential can be blamed on the public health professions, who have become too narrowly focused on the medical aspects of public health and especially the organization and cost containment of medical services.
Public health practitioners in the UK may well smile wrily at the idea that their discipline is at the crossroads. Many must feel that, at least in terms of structure, a crossroads was reached some time ago and that different parts of our 'United' Kingdom chose different paths. Most, however, will acknowledge that the route that takes us eventually to the sunny uplands of full effectiveness will be punctuated by further crossroads—more, indeed, than are comfortable for those who wish to see a certain way ahead. In their masterly and intensively referenced sweep of the history of public health, Beaglehole and Bonita themselves document periods of epidemiological transition that have provided major crossroads for public health policy and practice—an era of pestilence and famine; giving way to an era of receding pandemics; followed by an era of non-communicable diseases; and now the beginning of an era in which old infectious diseases make a come-back, new ones emerge and non-communicable diseases stubbornly persist.
A question that recurs almost as a motif in Public Health at the Crossroads is whether, in its current preoccupation with the application of knowledge to individual patients, public health is failing society by neglecting the social and economic influences upon health and disease. Admittedly this second route for the discipline is thick with political and commercial brambles. Taking a global perspective and acknowledging that different countries are at different stages in their epidemiological transition, Beaglehole and Bonita see the need for a short and succinct definition of public health that is 'broad in scope and wide in appeal'. The definition they propose is 'Collective action for sustained population wide health improvement'. Certainly it meets their criteria, but am I alone in finding Acheson's version—'The art and science of preventing disease, promoting health and prolonging life through the organised efforts of society'—more comprehensive, more appealing and very much more elegant (as well as lacking the stalinist overtones)?
How does all this fit with the matters that will be uppermost in the minds of most British readers of the new edition. Sir William Stewart has advised that 'we have to look on things globally but not get lost in global issues'. I have referred already to the crossroads recently passed in terms of structural change. Will the differing paths taken at devolution in England, Scotland, Wales and Northern Ireland mean that public health practitioners in one or more of those countries will find themselves wandering in the wilderness? Or will they prove to be merely short parallel roads that come together as the map becomes clearer? Still more to the point, does the recent awakening of interest by both public and policy makers in public health, stimulated by epidemiology in the form of authoritative reports on obesity and smoking and evidenced by the production of the Wanless reports (commissioned, interestingly, by the Treasury rather than the Health Department) offer a new broad highway for colleagues in the UK to follow? Is Sir Derek Wanless right in his view that 'the real knowledge and skill to take forward the public health agenda lies at local level'? To respond to his report Securing Good Health for the Whole Population will be a complex task, but he warns that a failure of the public health movement to rise to the opportunity will lead to lasting regret. Moreover, by reiterating the message of his first report, that 'public health is good economics,' he provides the discipline with a scythe to cut a path through the brambles referred to previously.
But has the dispersal of expertise (likely to be accentuated in England by the abolition of health authorities, though averted in Wales by the creation of a Wales-wide Public Health Service) weakened the ability of the discipline to wield this weapon effectively? And does not Wanless's emphasis on the need for the population to be 'fully engaged in the pursuit of good health' somewhat smack of the victim-blaming that Beaglehole and Bonita castigate as a governmental excuse for inaction? It is a disappointment that neither Beaglehole and Bonita in the book nor Wanless in his report tackle the means by which government departments other than Health might be held to account for the effects of their policies on population health. Without such accountability the efforts, however valiant, of the public health community at local level will prove too puny to be fully effective. What a pity that Wanless failed to tackle the glaring anomaly whereby the Secretary of State for Health in Whitehall is almost exclusively concerned with the Health Service whereas a junior Minister holds the public health portfolio. If it were the other way round (i.e. acknowledging that the NHS is essentially a tool of public health) such accountability might come closer to reality—though admittedly it is hard to imagine any Health Secretary becoming sufficiently powerful within Cabinet to demand real accountability from the likes of the Chancellor, the Environment Secretary or the Employment Secretary. The belated recognition that good public health is good economics cries out, therefore, for the establishment of a body on the lines of and with similar powers to the National Audit Office and the Parliamentary Accounts Committee. A National Office of Audit of Health (with the not inappropriate acronym NOAH) would symbolize the UK Government's understanding that the population's health is at least as precious a resource as its finances. And the same may be even more true of countries with less abundant resources.
Having provided a wide-ranging, admirably evidence-based and often daunting and gloomy account of public health status and public health endeavours globally, Public Health at the Crossroads ends on a cautiously optimistic note. This optimism is based on Beaglehole and Bonita's assessment that the economic pendulum will swing back towards a more collectivist approach as the ill-effects of the free market are recognized, and that the public health movement will then find more opportunities to exert a central role in human affairs. One does not have to embrace whole-heartedly their political philosophy to hope that their optimism is justified.