From time to time I am asked to explain Public Health to students, colleagues from other disciplines or a more general audience. A traditional approach might be to structure such a session around the three domains of Public Health (health improvement, health protection, quality improvement), building on specific examples:
- Tackling cholera in the Victorian era: John Snow and the Broad Street Pump
- Understanding and reducing health inequalities from the Whitehall Study (1967), Black Report (1980) Whitehall II study (1985) to Fair Society Healthy Lives (2010) and beyond
- Maslow’s hierarchy of need and Dahlgren and Whitehead’s models that summarise the importance of social determinants of health
- Epidemiological studies and the progression through descriptive studies to observational and experimental studies, using Richard Doll and Bradford Hill’s studies on smoking. Doll and Bradford Hill observed a rise in lung cancer cases, then explored potential causes via a case control study with lung cancer patients vs other patients (published 1950), then a cohort study with doctors who smoked or didn’t smoke (1954).(+) It took a further 51 years for the Smoking, Health and Social Care (Scotland) Act (2005) legislation banning smoking in public places and the ban on smoking in cars with children a decade later.
((+) For an excellent clear description of different types of epidemiology studies see Beaglehole et al’s Basic Epidemiology (free download in multiple languages)).
However, this approach perhaps doesn’t highlight the distinction between individual and population health clearly enough for a general audience. After all, one response to the final example above is to talk about uptake of smoking cessation services and other individual approaches to health. A GP may respond that Maslow’s hierarchy applies to an individual as well as a population – a patient is unlikely to be receptive to ideas about health screening or treatment if they are hungry or worried about their home or job.
As I prepare for a session teaching 4th year medical students this week I am keen to try something different, though informed by these and other key Public Health topics. The focus here is on highlighting the differences between approaches to improve individual and population health.
There is a lot of interest to Public Health in the scientific and general press at the moment. For example, over the last few weeks there have been major studies/ stories about the following topics in the world’s top medical journals:
- Air Pollution and Climate Change: Lancet study using data from the Global Burden of Diseases study 2015; BMJ editorial on the role of doctors in the US in Trump/ post-truth era
- Alcohol: Lancet review of alcohol control policies in England, including Minimum Unit Pricing. The paper notes “striking contrast” between alcohol-related mortality in England (increasing) and liver disease in much of the rest of England (decreasing). Understanding variation is an important part of Public Health work, as we shall explore.
- HIV infection: Persisting impact on Public Health in Muirhouse, Edinburgh
- Ebola: Interplay between virology, genetics and Public Health in understanding and ultimately controlling 2013-16 outbreak
- Sugar, salt and self regulation: Editorial in the BMJ
We can learn from commentary around these stubbornly persistent threats to health: eg this individual reflection on diesel fumes and health in the Guardian. Individual response and action is important, and there is clearly a role for behaviour change and medical treatment, but measures to reduce the impact of these global threats to human health will take work at all levels, from individual to supranational and global approaches. In a period of political and economic uncertainty Public Health tools at regional, national and international level (tax, cost, regulation, legislation) are being discussed again, around topics that would have been as familiar Hogarth as to our Public Health predecessors in the Victorian era and first half of the 20th century.
(Image from BMJ 29 October 2016)