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Public health medicine as a specialty in the UK was established in the nineteenth century with the introduction of medical officer of health posts by local authorities, the first being Dr William Duncan in Liverpool, 18471. In the early development of public health practice, doctors took a prominent part, but public health interventions have never been an exclusively medical prerogative. For example, the first Public Health Act of 1848 was instigated by Edwin Chadwick (1800-1890)2, secretary to the Poor Law Commission and later famous as a sanitarian. Today, many other disciplines are claiming a central role.
The difference between ‘public health medicine’ and ‘public health’ is subtle and the difficulties of defining the medical role are reflected, possibly, in the regular changes of name for the specialty: since 1974 these have included social medicine and community medicine, as well as the current label. Over the past century and a half the specialty has adopted epidemiology and statistics among its core skills and has acknowledged the importance of economics, sociology, psychology and management skills. It has also recognized the contribution of all the professions allied to medicine and, not least, the role of politics. Public health is vulnerable, possibly uniquely so, to political context. The major reorganizations of the National Health Service, and the introduction of innovations such as contracting, have all directly affected public health practice. The effect on its practitioners, in image, morale and the skills needed, has received insufficient attention; an example being the redundancies and early retirement resulting from reorganizations, with an inevitable impact on the skill and experience base of the specialty. Currently, the merging of health authorities, and the plan to abolish them in Wales, has led to questions all too familiar to public health medicine specialists: what do they do; what qualifications and experience is required; how many do we need? Are they doctors, managers, or both? Public health practitioners have been accused in the past of ‘navel gazing’ about the nature of their specialty; but, given the constant re-examination of public health practice, this is understandable, even necessary.
The image of medicine in general has taken some knocks lately, but a poor image is not a new experience for public health doctors. For the first fifty years they were the ‘drains doctors’; for the next period, their image became the bureaucrat characterized by Dr Snoddy in the TV series of Dr Finlay's Casebook, based on the medical stories of AJ Cronin. Strenuous efforts to improve the image, both in the skills and in the scope of practice, have had varied results. For the past fifty years or so, the general image of public health practitioners is of workers in a wide mix of poorly understood specialized areas. The gulf between the academic and service branches of the specialty has widened: few academic public health and epidemiology specialists have a strong NHS service background—a fact that may contribute to the poor image of the specialty. The ‘core skill’ of epidemiology is also in question, since this discipline has evolved into a powerful subspecialty with an increasing emphasis on technique rather than public health practice3. Despite acquiring management skills and training—many public health physicians now have a management qualification of some kind in addition to the management skills required for Membership of the Faculty of Public Health Medicine—the ability of doctors to work as managers within public health medicine remains controversial and much criticized by non-medical managers. Fiction, never kind to public health officers, still portrays the service practitioners as a motley crew of generally negative officials. A recent episode of the BBC drama series Casualty (27 January 2001) showed that the stereotype of unhelpful management lackey persists: during a suspected outbreak of legionellosis the public health consultant, abrupt and officious, was referred to by casualty staff as ‘Dr Death’, and his contribution to the investigations was derided.
There are reasons both for concern and for optimism in the current phase of public health. First, public health is needed but also often resented, with connotations of the ‘nanny state’ and the uneasy relationship between individual and collective responsibility for health behaviours. It could be dubbed the specialty that other specialists love to hate while grudgingly admitting that someone has to do it. Prevention will always be less fashionable than cure, and cure in public health terms is hard to demonstrate, at least in the short term. The multidisciplinary nature of public health practice is a strength, but raises issues of leadership and direction. Successive reorganizations and an emphasis on delivery of care have possibly distracted many public health physicians from the traditional core issues. The contemporary drivers of public health practice can be classified into six main groups: epidemiological, demographic, scientific, social, structural and political. The drive for more standardized evidence-based practice and for closer regulation of physicians rides alongside these main themes, impinging directly on what is expected from public health doctors and the time they have for ‘public health’.
The epidemiological and demographic transition—from pandemics of infection to the higher prevalence of chronic and degenerative disease associated with longevity—has already influenced health priorities, for example in the treatment of cardiovascular and orthopaedic disease. Yet, public-health work in fields such as mental health, disability and the needs of the elderly is still accorded low priority in the NHS. Also, emerging infections5 and the potential health impacts of climate change6 have demonstrated the continuing need for surveillance of communicable disease as a central public health skill. An underemphasized element in the epidemiological transition is the increasing vulnerability of elderly and infirm populations to infection, and the emergence of long-term sequelae of infection, for example with Helicobacter pylori7.
The scientific issues for public health medicine include the future impact of discoveries in genomics and proteonomics. An increasing emphasis on the way environment influences phenotypic expression should, theoretically, be a large boost for public health. Experience of the increasing separation of epidemiology from public health suggests otherwise: there is little evidence that the practitioners in genomics are working closely with those in public health, or even that they recognize the potential contribution of the specialty. There is a good deal of wheel reinvention in the ‘discovery’ by other specialties of the importance of social, economic and environmental influences on disease.
The social influences on public health include the current paradigm of individual responsibility and independence, as opposed to community-based values. For example, the role of public health in curbing the increase in teenage pregnancies is harder to define as well as less acceptable to a generation more accustomed to free will than to collective responsibility. The social aspects of the need for information about trends and patterns of diseases, and about environmental exposures, are in conflict with concerns about confidentiality and retention of information about individuals. The increasingly mobile national and international populations of the world also make information collection more difficult, or in some cases less pertinent: the causes of the disease under study may be many miles away from the information available from small-area statistics based on the residential data to hand.
A key structural issue for modern public health in the UK is the impact of devolution. Diseases do not observe political boundaries, and the economy of scale for some public health interventions is threatened by a trend towards independence in these matters, both for devolved administrations within the UK and for regions within England. The positive side of such trends is the opportunity to focus on local health issues, but some duplication of effort and resources is inevitable.
The political influences on public health are perhaps the hardest of all to apply to the core practice of this specialty. The Labour Government, to its credit, has explicitly recognized the determinants of health. This recognition has not yet been matched by comprehensive or radical action in tackling factors such as poverty, the old and other vulnerable population groups, diet, behaviours that increase ill-health and education about health. The tentativeness apparent in governmental public health interventions contrasts with the rhetoric. Despite a comprehensive review of the need to reform public health legislation on infectious disease over a decade ago8, successive governments have not been able to make this a priority or to find time for it on the legislation agenda. The media take up these themes from time to time, but since the issues are neither dramatic nor glamorous, progress is slow and the role of public health is unclear. There is a striking contrast between the attention given to large incidents and crises (for example the bovine spongiform encephalitis epidemic or the recent trail of medical mishaps) and that given to the longstanding problems of the poor, the chronically ill and other disadvantaged groups.
It is time for public health medicine to reassert its central importance in tackling the drivers of ill-health in our society; and time, too, for others to acknowledge this importance. The welcome spread of epidemiology and public health far beyond the accredited specialty of public health medicine should be matched by recognition of the need to pool skills and to share both knowledge and responsibility for action. Recruitment and selection in the specialty should be based on the core skills and training needed—not least the ability to communicate. Public health medicine, at its best, represents a combination of science and art, particularly the art of communication. The specialty has a role in bridging other specialties and disciplines. One strength of the medical practitioner in public health is the common training and early experience of medicine with fellow doctors; another is the ability to work outside the health structure, for example with local authorities and other agencies. The bridging skills, and the associated communication skills, are hard to acquire. We shall never have enough good public health physicians, just as we constantly strive to increase the number of good specialists in other branches of medicine and surgery. The danger is that we could lose the unique skills of public health physicians in the debate about roles and responsibilities.
Although interest in public health medicine ebbs and flows, the underlying causes of ill-health will ensure the survival of the discipline. Ironically, the now ageing systems for water and sanitation need the ‘drain doctors’ again, with floods and emerging diseases highlighting the need for surveillance and advice on priorities for intervention. The complexity and multidisciplinary nature of health care requires a specialty dedicated to bridging the issues and focusing policy. Public health ‘crises’ are now more widely publicized than the reformers of the nineteenth century could have imagined, although they might have hoped for more progress a century after their era. The role of the public health practitioner as spokesperson, and as the authority figure during a crisis, has even more relevance in our media-driven age. Alphonse Karr remarked in 1849 about revolutions, Plus ça change, plus c'est la même chose. Public health medicine has proved itself capable of adapting to the changing tides of fashion, emerging diseases and political influence. Respect coupled with disparagement is one of the enduring aspects of practice in this specialty. Let us not forget that progress is made by ‘difficult’ people, not those who pretend there are no problems to solve9. Perhaps another change of name will emerge in the coming decades, but the core values, and the core need, will remain unaltered: and politicians will ignore the importance of the specialty at their peril.
‘It is a poor government that does not realise that the prolonged life, health and happiness of its people are its greatest asset.’ (Charles H Mayo, JAMA 1919;73:411)