Editorials |
Wither? Public health in a changing Europe
R. Horst Noack** Institute of Social Medicine and Epidemiology, Medical University Graz, Graz, Austria, e-mail: horst.noack{at}meduni-graz.at
Large parts of the population of the wealthier countries have not enjoyed the health benefits of their more fortunate citizens. We have not reached the limits of what we can achieve in health by any means.1
The conditions and determinants of population health have changed markedly over the last decades, and so has the context of public health. We are living in a globalized world. Health is seen as a major driving force for economic and social development. The public health community is expected to inform and guide the public about the options the society has to achieve health for all and to build capacities for making that happen. Yet the public health community is insufficiently prepared to take up this challenge, it lacks a coherent sense of direction and sufficient problem-solving capacities.2 A well-informed and thorough debate is needed on the directions, policies, and actions for a post-modern public health.
The 2005 EUPHA conference ‘Promoting the Public's Health—reorienting health policies, linking health promotion and health care’ to be held from 10 to 12 November in Graz will provide a platform for the analysis and debate to researchers, practitioners, and policy-makers.3 The conference is organized by the Austrian Public Health Association in cooperation with the Croatian Public Health Association and the Slovenian Preventive Medicine Society. The three organizing countries have lived through unique political, social, and public health histories, which may offer valuable lessons for the future.
The majority of Europeans lives longer and is healthier than ever before. Yet, health inequalities within and between countries have been growing, and so have the costs of health care. Governments were not particularly concerned about the steepening social gradient in health, but have taken ambitious actions to slow down the rise of health care expenditure, generally with short-lived success.
Analysis of the development of European health care systems reveals two distinct directions: public health medicine and comprehensive public health.2
- Public Health Medicine functions on the basis of an exclusive negative notion of individual health—or rather disease. It is driven by powerful health professions and aims at improving the quality or efficiency of care and the coordination of fragmented services. Managed care policies represent the mainstream of European health care reforms. They tend to show immediate effects on solving acute problems, but miss to address the most powerful health determinants.
- Comprehensive public health functions on the basis of an inclusive positive notion of collective health and disease. Governed by an inter-ministerial agency, many stakeholders and partners co-operate in long-term health promotion and health care strategies addressing the main economic, social, medical, and environmental determinants of health. To my knowledge, so far only Sweden, a country with one of the healthiest population in the world, has fully adopted a comprehensive public health policy. Other countries may have implemented certain elements of such a policy.4
Linking medical and health promotion strategies in preventive care, chronic disease care, or rehabilitation may render valuable synergies between the two approaches. It will, however, still have a limited impact on population health because it does not systematically address the main health determinants as the underlying causes of good health. It was exactly this kind of thinking that led me to search for a comprehensive rationale of health when, in the early days, I became involved in research on primary health care and workplace prevention.
I was then fortunate to be invited to the first WHO Global Conferences on Health Promotion held in Ottawa in November 1986. On the frosty winter day before the Ottawa Charter for Health Promotion was adopted, the German-speaking participants gathered to discuss the implications of the new public health policy for Germany, Switzerland, and Austria. I suspect that none of us was aware that this conference would later be seen as a milestone in the ‘new history’ of public health. The most recent 6th Global Conference on Health Promotion held in August 2005 in Bangkok reaffirmed that health promotion is a core function of public health as well as an essential public health strategy in a globalized world.5
While huge investments are being made in the fields of molecular biology, genetics, and high-tech medicine, there is a gross and growing imbalance between infrastructures and problem-solving capacities of the health care and the health promotion fields. As shown by the new Swedish health policy, capacity building for a comprehensive health approach is yet another key function of post-modern public health.
Capacity building is seen as an innovative concept embracing complex processes of developing political will, leadership, infrastructures, as well as knowledge, skills, and commitment for enabling the society to achieve population-wide health improvement and a more equitable distribution of good health.2 The forthcoming EUPHA conference in Graz will be an excellent opportunity to analyse and discuss the strengths and weaknesses of capacity building for public health in a changing Europe.
References
1 Marmot M. The status syndrom. New York: Times Books, 2004.
2 Beagelhole R, Bonita R, Horton R, et al. Public health in the new era: improving health through collective action. Lancet 2004;363:2084–6.[CrossRef][Web of Science][Medline]
3 Noack RH. Building the Modern public Health: ‘Perspectives, Theory and Practice’. In Tellnes G (ed), Urbanisation and Health, Oslo 2005 (in press).
4 Hogstedt C, Lundgren H, Moberg H, et al. (eds) The Swedish Public Health Policy and the National Institute of Public Health. Scand J Public Health 2004; (Suppl. 64).
5 Bangkok Charter for Health Promotion, World Health Organization, Ministry of Public Health, Thailand, 11 August 2005.
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