Stephen R Leeder
7 March 2005
James Cook University, Townsville
All of us here today are public health enthusiasts. If we weren’t we would be somehwere else, maybe helping sick people to get better. That is a worthy calling and thank goodness for all the people who do it. But so too is prevention, so too is keeping society healthy, so too is protecting the environment, so too is keeping food and water safe, so too is attending to immunization and child health. When we talk about public health these latter things, that focus on the whole community, or groups within society and the things that determine their health, are what we are talking about. This is big picture stuff. This is about asking why some communities are healthy and some are ill. Why do some communities have such high rates of diabetes, like the Pacific Islands, while other countries have no diabetes but lots of HIV and TB? These are the kind of interests and enthusiasms that have led people into public health as a career for as long as it has been around. These are the kind of questions that were asked ages ago and which are still appropriate to be asked now. So what is this thing called the ‘new’ public health? How has it come about and does it have added value? In brief, the new public health has come about because of growing interest in the subtle interaction of the environment with people living in affluent societies. The old public health remains the public health that most of the world needs, quite frankly, because communicable disease, malnutrition and other scourges are still the major killers worldwide. These are more or less the same as those that led people in the fifteenth century to look at how things such as the plague and cholera could be controlled through sanitation, clean water and quarantine. The new public health
But the new public health is much more concerned with the interplay between affluence, social well being, education and health, social capital and health. These are not hard and fast things, like having no system for waste water disposal or using contaminated drinking water. They are more subtle, but in societies like ours where the basic public health engineering and immunization and food safety are well in place and require surveillance but not reinvention, these new factors – the social, economic and community quality factors – are rising in importance as determinants of health and causes of illness. 1
For example, Michael Marmot has done studies with Geoffrey Rose and others in the UK examining coronary disease rates among civil servants, known as the Whitehall studies. They found that things like a sense of social control and cohesiveness were important determinants of whether people develop coronary disease. Money wasn’t everything. In the Whitehall II study, Marmot (Director of the International Centre for Health and Society at the University College London) and his colleagues examined the psychological characteristic of work termed “low control” – meaning that an individual worker had little control over his or her daily activities in the workplace. The results showed that it was an important predictor of the risk of cardiovascular disease and that it had an important role in accounting for the social gradient in coronary disease.1 The origins of the new public health
The Canadians have been very active over many years in promoting our understanding about the interplay between society and social environmental factors and health. This started in 1974 when Marc Lalonde, who was then the Canadian health minister, commissioned a report on the health of Canadians which proposed four sets of factors that were important to keep in mind when thinking about the health of the public. The Lalonde Report2 refers to these four factors collectively as “The Health Field Concept”. The four elements are human biology, environment, lifestyle and health care organization. The human biology element...