Feature

Public health: a giant awakes?

There has been a recent reawakening of support for the ideals of public health, but the government remains, as yet, unmoved, says Daloni Carlisle

More than a year ago the government received a report from Sir Donald Acheson, its chief medical officer, calling for the creation of regional and district directors of public health. The report was widely welcomed by organisations such as the Royal College of Nursing and the Health Visitors Association. Urgent action was promised by John Moore, the then secretary of state for health and social security.

It took a full year for the reformed Department of Health to act on the report: in December it issued a health circular — an advisory document — which broadly accepted the recommendations in the Acheson report and called on districts and regions to appoint directors of public health. These directors would have consultant status, and reports should be with the Department by the end of this year.

This announcement was timely, if disappointing. Timely because 1988 saw a massive reawakening of the ideals of public health in a spate of conferences and the founding of at least two new public health organisations. Disappointing in that it seemed to be based firmly in the medical model, ignoring the skills of those health workers and others whose expertise lies in health rather than illness.

For those who are unfamiliar with public health and what it means, consider the plight of a community living on a housing estate that was badly built or designed and which is, as a result, damp. Damp housing is associated with high levels of respiratory diseases. It is reasonable or effective to treat this respiratory disease with antibiotics and other drugs and leave it at that? Or do health workers have a duty to look not only at the symptoms of illness but also at the reasons why a community might be affected by high levels of illness? Should professionals such as local authority employees become involved in dealing with community health issues?

There is now a massive ground-swell that says treating the symptoms is not enough. It includes doctors, nurses, health visitors, trade unions, environmental health officers, Friends of the Earth, local authority workers and many others. The World Health Organisation is looking closely at public health around the world as part of its Health for All by the year 2000 initiative.

The movement argues that individuals can be responsible for their health only to a limited degree. A community cannot solve its damp housing as long as the individuals are treated as individuals. The effects of homelessness on the health of the estimated 370,000 homeless people cannot be solved until they are housed. Two million unemployed people cannot solve their physical and mental health problems until they are found work. And the third world cannot solve its health problems until the developed world ensures more equal sharing of resources.

Two new public health organisations within the UK are trying to address these issues. The first is the Rethinking Public Health Forum, founded by Health Rights, which brings together organisations with an interest in public health, including national networks of local authorities, the Health Education Authority, campaigns, professional groups and trade unions. It has 30 member organisations and meets to discuss initiatives and share ideas.

The second is the Public Health Alliance, launched in Parliament in October last year. David Player, former director of the Health Education Council, is a key figure and the alliance has the backing of the NHS Consultants Association, among others. Its aim is to prepare papers and reports on public health issues such as air pollution.

So the health circular on public health is indeed timely. But it comes at a time when health authorities also being asked to consider the appointment of consultants in accident and emergency medicine. Given the choice and the limited resources, the feeling is that accident and emergency may win the day, regardless of the potential savings that public health could make.

This is a revised version of an article that first appeared in Nursing Standard on 14 January.