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EDITORIAL
Year : 2020  |  Volume : 64  |  Issue : 2  |  Page : 97-98  

Redefining and redesigning public health for the future


Advisory Board Member of Indian Journal of Public Health; Indian Council of Medical Research, New Delhi, India; Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia

Date of Submission23-Feb-2020
Date of Decision09-Mar-2020
Date of Acceptance16-Mar-2020
Date of Web Publication16-Jun-2020

Correspondence Address:
Rajesh Kumar
Advisory Board Member of Indian Journal of Public Health; Indian Council of Medical Research, New Delhi; Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London; School of Public Health and Community Medicine, University of New South Wales, Sydney

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_185_20

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How to cite this article:
Kumar R. Redefining and redesigning public health for the future. Indian J Public Health 2020;64:97-8

How to cite this URL:
Kumar R. Redefining and redesigning public health for the future. Indian J Public Health [serial online] 2020 [cited 2020 Dec 5];64:97-8. Available from: https://www.ijph.in/text.asp?2020/64/2/97/286812



Public health is now recognized as a distinct discipline globally. However, opportunities of learning, research, and practice in this field are limited in India. Public health practice, initiated about two centuries ago, has undergone some changes with the changing needs of the societies around the world. To address the social needs of the present time and to serve the demands that may emerge in future, a critical review of the principles, core values, and approaches of public health is required keeping in view the historical perspective which led to the birth of this unique field of study and practice by incorporating relevant aspects of humanities and technical innovations of the natural sciences, especially from the engineering and biomedical sciences.

The understanding of public measures to prevent epidemics rendered health protection as a responsibility of the state and public authorities were appointed to enforce these regulations.[1] Social protection laws were also enacted to alleviate the sufferings of the fellow human beings. Social values about the worthiness of this goal made public measures possible such as the establishment of government hospitals and workhouses which provided free services to the needy. Frederick Engels, Edwin Chadwick, Lemuel Shattuck, and many others showed that industrial societies are breeding large health inequalities.[2],[3],[4] This body of knowledge and values were brought together in the political arena by social activists to shape a political approach to address the social injustice as a primary determinant of ill-health among the masses.

Consequently, sociopolitical structures did change in some parts of the world in favor of public health, but these changes could not be sustained for long. Biomedical approach gained prominence leading to techno-managerial solutions rather than addressing the social, political, and commercial causes of ill-health. Growth in gross domestic product has been hailed as a goal worthy of pursuit rather than the health and well-being of the people. Although in British India, some provinces enacted Public Health Laws, and Sanitary Commissioners were appointed for implementation and monitoring of the regulations, but on recommendations of the Health Survey and Development Committee[5] under the chairmanship of JW Bhore in 1946, government of India merged public health with medical care at all levels of health services. Public health has been placed under the preview of medical doctors who have limited understanding of the political economy and hardly play any role in addressing the social determinants of health.

Globally, public health thinking has been influenced by CEA Winslow who defined Public Health in 1920 as “the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health; organizing these benefits in such fashion as to enable every citizen to realize his birth right of health and longevity.”[6] Although a standard of living adequate for maintenance of health was emphasized but it has hardly received desired attention; public health has mainly focused on sanitation, infection control, education of individuals, and medical and nursing care.

In India, the first institute of public health designed separate courses for medical, engineering and social science students with a heavy emphasis on biomedical approach. Medical colleges also have continued training only medical graduates in preventive medicine/social medicine/community medicine relying heavily on the principles of medical sciences with a perfunctory addition of some public health concepts. Only in one central university Social Science Faculty has viewed public health in a broader socio-political framework. In other countries, such as the USA, though schools of public health, established separately from the medical schools, incorporated some aspects of behavioral and environmental sciences, and accepted faculty and students from nonmedical streams but the curricula continued to be heavily influenced by biomedical approaches. Hence, the issues related to “social machinery” to ensure “a standard of living adequate for the maintenance of health” continues to be neglected in conventional public health approach.

Even today the socio-economic model of health production hardly finds a prominent place in public health schools and “Right to Health” has remained elusive. In practice, health continues to be viewed in medical terms as “absence of disease,” despite the World Health Organization (WHO) proclaiming that “health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.”[7] The WHO tried to broaden its approach by designing primary health-care strategy,[8] but in practice, the application of primary health-care continues to be selective medical oriented approach which could prevent some diseases and prolong life expectancy to some extent but failed to empower people for having access to resources and power that is necessary for bringing about desired changes. Although the role of public policy for promoting health has been advocated by the WHO as recommended by its Commission on Social Determinants of Health chaired by Michael Marmot but it has also not made much headway in the countries.[9]

In the current scenario, when climate emergency, expanding conflicts, and increasing inequalities have placed our planet and its people in a peril, a new approach is required to place public health development as a central focus of the society. Public health discipline, therefore, should rediscover its sociopolitical-ecological moorings and design a strategy to combat the emerging challenges. Instead of narrow focus only on biomedical approaches, it should embrace the framework of political-economy to “ensure healthy lives and well-being for all at all ages” which is specified as the 3rd goal among the United Nation's sustainable development goals (SDGs).[10] It is imperative that public health should spearhead actions for achievement of all the SDGs as most of the goals, directly or indirectly, have a bearing on the health and well-being of the people. A narrow focus on universal health coverage, an idea espoused by the WHO which largely measures its success in terms of reduction in out-of-pocket health expenditures or catastrophic health expenditures,[11] encourages large investments in medical care interventions rather than the public health-oriented actions to address social determinants of health.

The contribution of social determinants of health is ignored partly due to the lack of scholarship in this field in medical institutions as most of the scholars with medical background do not have capacity to dwell into this field and usually attribute gains in health to medical interventions only. Therefore, it is important to redesign public health education system to develop this capacity which is possible only by situating public health schools in multi-faculty universities with strong track record in social sciences to develop courses at undergraduate, postgraduate, doctoral, and postdoctoral level with prominence on social determinants of health so that capacity is built for enabling multisectoral public policies and programs. The public health should focus on social system to address the real threats to health rather than on the individual's illnesses which should be taken care by the medical system.

Public health should find solutions to target eradication of root causes that are common to all illnesses rather than directing all its energies for eradication of specific diseases. Achieving these goals will require transcending the individual and challenging the social system to ensure fair wage and fair trade to raise the standard of living so that people can meet their minimum needs (shelter, food, clean air, and potable water). Taking public health actions in multiple sectors would require political will to take on vested commercial interests which produce and propagate health damaging products and behaviors. Therefore, public health practitioners should have capacity for developing strategies to establish the worth of public health actions to legislators, civil servants, and general public to build up the constituents in support of these actions. Public health should be considered as the science and art of deployment of all resources of the society efficiently for the health and well-being of all the people.

A constitutional guarantee on right to health should ensure that any policy or activity which is harmful to health can be made justiciable. Adequately staffed public health departments should be established at each level of administration, i.e., central, state, district, cities, and villages to ensure multisectoral action for promoting public health. Above all, a Public Health Commission should be established to oversee that adequately funded public health education system is established in all higher education institutions, audit of all public policies is conducted periodically and only policies that promote health are advocated, formulated, implemented, monitored, and evaluated so that health and wellbeing of people can occupy central stage in all the socio-economic policies and programs which are necessary for ushering in the era of sustainable development.



 
   References Top

1.
Mackowiak PA, Sehdev PS. The origin of quarantine. Clin Infect Dis2002;35:1071-2.  Back to cited text no. 1
    
2.
Engels F. The Condition of the Working Class in England. Leipzig: Otto Wigand; 1845. Available from: https://www.marxists.org/archive/marx/works/1845/condition-working-class/index.htm. [Last accessed on 2020 Mar 08].  Back to cited text no. 2
    
3.
Report on the Sanitary Conditions of the Labouring Population of Great Britain. London: Poor Law Commission; 1842.  Back to cited text no. 3
    
4.
The Report of the Sanitary Commission of Massachusetts 1850. Boston: Dutton and Wentworth, State printers; 1850.  Back to cited text no. 4
    
5.
Government of India. Report of the Health Survey and Development Committee. Vol. 1, 2, 3. Delhi: Manager of Publications; 1946.  Back to cited text no. 5
    
6.
Winslow CEA. The untitled fields of public health. Science 1920;51:23-33.  Back to cited text no. 6
    
7.
Constitution of World Health Organization; 1948. Available from: https://www.who.int/about/who-we-are/constitution. [Last accessed on 2020 Mar 08].  Back to cited text no. 7
    
8.
Report of the International Conference on Primary Health Care Alma-Ata, USSR, 6-12 September 1978 Jointly Sponsored by the World Health Organization and the United Nations Children's Fund. Available from: https://www.unicef.org/about/history/files/Alma_Ata_conference_1978_report.pdf. [Last accessed on 2020 Mar 08].  Back to cited text no. 8
    
9.
Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Social Determinant of Health. Geneva: World Health Organization; 2008.  Back to cited text no. 9
    
10.
United Nations. Sustainable Development Goals. Available from: https://www.un.org/sustainabledevelopment/sustainable-development-goals/. [Last accessed on 2020 Mar 08].  Back to cited text no. 10
    
11.
Tracking Universal Health Coverage. Tracking Universal Health Coverage: 2017 Global Monitoring Report. Joint WHO/World Bank Group Report; December, 2017. Available from: https://www.who.int/healthinfo/universal_health_coverage/report/2017/en/. [Last accessed on 2020 Mar 16].  Back to cited text no. 11
    




 

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