- Email: [email protected]
The new new public health
CORRESPONDENCE
3
the working group on public health and primary care. London: Department of Health, 1998. Department of Health. The new NHS: modern-dependable. Command Paper Cm3807. London: Stationery Office, 1997.
Sir—Richard Horton’s commentary1 needs to be challenged on several points. He makes sweeping statements about how “marginal public health has been in the life of the nation” and how it “lacks a unity of purpose which has not been seen since World War II”. He claims that “it cannot be doubted that public health has withered in the past quarter century” and that it has “lost not only its direction but also its passion”. I beg to differ. Although I would be the first to admit that not all in the garden is rosy, I think he should be aware of initiatives that have been taken in Wales in which public-health physicians have taken the direct lead or have been very closely involved.2,3 The initiatives are too numerous to detail. They include the unique and innovative Heart Beat Wales campaign, the development of the Strategic Intent and Direction and subsequently Local Strategies for Health, and the production of a series of protocols for the Health Gain and National Demonstration Project in Clinical Effectiveness; more recently still there has been the close involvement in the Calman, Hine, and Cameron reports on cancer services. Although some of these initiatives have had their critics, they have all pointed in the right direction— namely, to improve health, and to provide an effective and efficient service for those who are ill. We all recognise that we still have a long way to go but one most important factor can only be indirectly influenced by public-health doctors or for that matter any doctors or health workers: lifestyle, where changes in smoking, alcohol intake, diet, nutrition, and exercise would greatly improve health. Public-health doctors around the UK are making strenuous efforts to get involved with and influence all these issues, so it is somewhat disheartening to read broad unsubstantiated statements in a leading journal. In the real world of the deprived urban areas of Swansea, Neath, and Port Talbot, and the run down former mining areas of the South Wales valleys, life is that depicted in Bethan’s story the most recent annual report of the director of public health for Morgannwg Health.1 It is one of unemployment, poor selfesteem, heavy smoking, alcohol, drugs, teenage pregnancy, and a highly restricted and uninspiring lifestyle. For many of these people escape from the
904
poverty trap is not realistic, and chronic disease, mental health problems, and shorter life expectations are a reality. Local consultants in public-health medicine are aware of these difficulties and are making some attempts to do something about them. But try as we might, the task is formidable without major social and economic reforms, realistic employment, and a revitalisation of the valleys. Some of my colleagues may well have trouble with the definition of public health, but mine is simple: everything to do with health. It is indeed very wide ranging and it is true that we may have become “immersed in the minutae of management reforms in the NHS”, this is only a temporary setback inflicted on, rather than led by, us. During the various reforms we have often been in the forefront to try and propose far simpler ways of delivering health care than the complex ones we have been saddled with since 1991. May I plead that The Lancet starts campaigning for us, not against us. Help us to achieve the reforms we know we still need. J G Avery Iechyd Morgannwg Health, 41 High Street, Swansea SA1 1LT, UK 1
2
3
Horton R. The new new public health of risk and radical engagement. Lancet 1998; 352: 251–52. Bethan’s story: report of the Director of Public Health. Swansea: Iechyd Morgannwg Health, 1998. Welsh Office. Better health, better Wales. (Green Paper) CM3922. London: Stationery Office, May, 1998.
Editor’s reply In Healing the Schism, Kerr White1 notes that “the two cultures ‘medicine’ and ‘public health’ seem to live in different, often unfriendly, worlds”. This division is not surprising. Advocates of a population approach to health have frequently had to struggle against academic colleagues more sympathetic to traditional laboratory-based sciences. The inclination among public-health specialists has been to retreat into separate departments and scientific meetings in which their ideas can flourish free from sceptics. The benefit from this insularity is that the position of public health as a specialty within the academy has been secured—but at a severe cost. For, in the day-to-day world of medical practice, neither public-health practitioners nor their philosophy have much influence. Surely this marginalisation is a cause for anxiety not satisfaction. Jim McEwen believes that public health should continue to root itself
in health-service management. Will Patterson and Barbara Hanratty argue that the stifling atmosphere of the management ethos has done much to choke off passionate voices in public health. The burden of proof rests with McEwen, I think, to explain why public health should dilute its academic and campaigning remit with a substantial role in service planning. J G Avery points out important work to improve the health of people living in Wales. But at a crucial point in his argument he falters. Rather than lead public health into the social and political arena, Avery stops short and focuses instead on the far more limited goal of lifestyle improvement. The new new public health could prosper by looking again at three ideas that underpinned much of the work of John Ryle, the UK’s first professor of social medicine. First, public health must be vigorously reintegrated back into clinical medicine. Ryle believed that the two disciplines of public health and clinical medicine had to be woven closely together and he wrote that “the medicine of the hospital ward and the research unit has been contracting its field and becoming by degrees an exercise in bedside pathology, pharmacology, and therapeutic detail. The broader natural history of disease in man has been too little considered.2 Departments of medicine need clinical epidemiologists in their academic faculty, together with clinicians who have epidemiological training. White argues that epidemiology units might be set up in all major clinical departments.1 Second, public-health teaching in the medical curriculum needs to be strengthened. Ryle saw that “social pathology has not notably influenced clinical teachers and the regular instruction of the medical student”. The model of Thomas McKeown still holds good.3 Finally, public health cannot escape its political intent. Again from Ryle: social medicine has “as its main purpose the education of scientific and lay thought and the direction of legislation on behalf of the national health”. Public health may have won some local skirmishes but the larger fight, as mapped out by Ryle and White, is in danger of being lost. Richard Horton The Lancet, 42 Bedford Square, London WC1B 3SL, UK 1
2 3
White K. Healing the schism: epidemiology, medicine, and the public health. New York: Springer-Verlag, 1991. Ryle JA. Changing disciplines. London: Oxford, 1948. Arnott WM, McEwen T, Stammers FAR. Social medicine teaching. Lancet 1947; ii: 307–08.
THE LANCET • Vol 352 • September 12, 1998
3
the working group on public health and primary care. London: Department of Health, 1998. Department of Health. The new NHS: modern-dependable. Command Paper Cm3807. London: Stationery Office, 1997.
Sir—Richard Horton’s commentary1 needs to be challenged on several points. He makes sweeping statements about how “marginal public health has been in the life of the nation” and how it “lacks a unity of purpose which has not been seen since World War II”. He claims that “it cannot be doubted that public health has withered in the past quarter century” and that it has “lost not only its direction but also its passion”. I beg to differ. Although I would be the first to admit that not all in the garden is rosy, I think he should be aware of initiatives that have been taken in Wales in which public-health physicians have taken the direct lead or have been very closely involved.2,3 The initiatives are too numerous to detail. They include the unique and innovative Heart Beat Wales campaign, the development of the Strategic Intent and Direction and subsequently Local Strategies for Health, and the production of a series of protocols for the Health Gain and National Demonstration Project in Clinical Effectiveness; more recently still there has been the close involvement in the Calman, Hine, and Cameron reports on cancer services. Although some of these initiatives have had their critics, they have all pointed in the right direction— namely, to improve health, and to provide an effective and efficient service for those who are ill. We all recognise that we still have a long way to go but one most important factor can only be indirectly influenced by public-health doctors or for that matter any doctors or health workers: lifestyle, where changes in smoking, alcohol intake, diet, nutrition, and exercise would greatly improve health. Public-health doctors around the UK are making strenuous efforts to get involved with and influence all these issues, so it is somewhat disheartening to read broad unsubstantiated statements in a leading journal. In the real world of the deprived urban areas of Swansea, Neath, and Port Talbot, and the run down former mining areas of the South Wales valleys, life is that depicted in Bethan’s story the most recent annual report of the director of public health for Morgannwg Health.1 It is one of unemployment, poor selfesteem, heavy smoking, alcohol, drugs, teenage pregnancy, and a highly restricted and uninspiring lifestyle. For many of these people escape from the
904
poverty trap is not realistic, and chronic disease, mental health problems, and shorter life expectations are a reality. Local consultants in public-health medicine are aware of these difficulties and are making some attempts to do something about them. But try as we might, the task is formidable without major social and economic reforms, realistic employment, and a revitalisation of the valleys. Some of my colleagues may well have trouble with the definition of public health, but mine is simple: everything to do with health. It is indeed very wide ranging and it is true that we may have become “immersed in the minutae of management reforms in the NHS”, this is only a temporary setback inflicted on, rather than led by, us. During the various reforms we have often been in the forefront to try and propose far simpler ways of delivering health care than the complex ones we have been saddled with since 1991. May I plead that The Lancet starts campaigning for us, not against us. Help us to achieve the reforms we know we still need. J G Avery Iechyd Morgannwg Health, 41 High Street, Swansea SA1 1LT, UK 1
2
3
Horton R. The new new public health of risk and radical engagement. Lancet 1998; 352: 251–52. Bethan’s story: report of the Director of Public Health. Swansea: Iechyd Morgannwg Health, 1998. Welsh Office. Better health, better Wales. (Green Paper) CM3922. London: Stationery Office, May, 1998.
Editor’s reply In Healing the Schism, Kerr White1 notes that “the two cultures ‘medicine’ and ‘public health’ seem to live in different, often unfriendly, worlds”. This division is not surprising. Advocates of a population approach to health have frequently had to struggle against academic colleagues more sympathetic to traditional laboratory-based sciences. The inclination among public-health specialists has been to retreat into separate departments and scientific meetings in which their ideas can flourish free from sceptics. The benefit from this insularity is that the position of public health as a specialty within the academy has been secured—but at a severe cost. For, in the day-to-day world of medical practice, neither public-health practitioners nor their philosophy have much influence. Surely this marginalisation is a cause for anxiety not satisfaction. Jim McEwen believes that public health should continue to root itself
in health-service management. Will Patterson and Barbara Hanratty argue that the stifling atmosphere of the management ethos has done much to choke off passionate voices in public health. The burden of proof rests with McEwen, I think, to explain why public health should dilute its academic and campaigning remit with a substantial role in service planning. J G Avery points out important work to improve the health of people living in Wales. But at a crucial point in his argument he falters. Rather than lead public health into the social and political arena, Avery stops short and focuses instead on the far more limited goal of lifestyle improvement. The new new public health could prosper by looking again at three ideas that underpinned much of the work of John Ryle, the UK’s first professor of social medicine. First, public health must be vigorously reintegrated back into clinical medicine. Ryle believed that the two disciplines of public health and clinical medicine had to be woven closely together and he wrote that “the medicine of the hospital ward and the research unit has been contracting its field and becoming by degrees an exercise in bedside pathology, pharmacology, and therapeutic detail. The broader natural history of disease in man has been too little considered.2 Departments of medicine need clinical epidemiologists in their academic faculty, together with clinicians who have epidemiological training. White argues that epidemiology units might be set up in all major clinical departments.1 Second, public-health teaching in the medical curriculum needs to be strengthened. Ryle saw that “social pathology has not notably influenced clinical teachers and the regular instruction of the medical student”. The model of Thomas McKeown still holds good.3 Finally, public health cannot escape its political intent. Again from Ryle: social medicine has “as its main purpose the education of scientific and lay thought and the direction of legislation on behalf of the national health”. Public health may have won some local skirmishes but the larger fight, as mapped out by Ryle and White, is in danger of being lost. Richard Horton The Lancet, 42 Bedford Square, London WC1B 3SL, UK 1
2 3
White K. Healing the schism: epidemiology, medicine, and the public health. New York: Springer-Verlag, 1991. Ryle JA. Changing disciplines. London: Oxford, 1948. Arnott WM, McEwen T, Stammers FAR. Social medicine teaching. Lancet 1947; ii: 307–08.
THE LANCET • Vol 352 • September 12, 1998