Public Health is Everywhere!
Public Health, the lesser known twin of the celebrity Clinical Medicine, has finally come into the limelight. For years people knew little of the contribution public health makes to general health. Instead, people tended to equate health to the state of not being ill and to become healthy, people assumed that this required treatment, a visit to the doctor or to hospital. In other words, they believed in the 'pill for every ill' mentality. However, the climate has changed. Governments, policy makers and directors of health services have slowly realized that medicine costs and that in fact, it is cheaper and more beneficial long term to prevent diseases and illnesses from happening in the first place. They want to stop the risk factors 'upstream' rather than dealing with the aftermath 'downstream'. This can be illustrated with the idea that if a river is likely to get polluted by a chemical plant dumping waste, it would be of greater benefit to the local population to have systems in place to prevent the chemical plant from polluting the waters upstream, rather than waiting until the pollution hits the water supply and spend lots of resources on treating it. That is not to say that medicine should be ignored. Indeed we will always need cures and treatments and public health specialists work alongside clinical medicine in delivering health services. Public health is not an alternative approach to addressing the problems of disease. In reality, public health and clinical medicine are mutually dependent and interactive.
To understand public health, it would probably help to grasp how it differs from clinical medicine. Medicine focuses on individuals, diagnosis, treatment/cure and alleviating pain. Public health looks at populations, prevention of disease, health promotion, protection from hazards, improving quality of life and evaluating health services. Clinical medicine is one-on-one work, the hallmark of public health is community action. It is concerned with the determinants of health. These refer to the causes of disease and illness and comprise of fixed factors (e.g. genetics, age, gender), lifestyle factors (e.g. smoking, drinking), environmental factors (e.g. safe water, clean air, rubbish collection), economic factors (income, housing, economy etc) and social and cultural factors (e.g. links to the community, social class, education, gun control). Together these determinants influence the pattern of illness, disease and health across populations. There are many theories about what causes disease and five main theories are: (1) the germ theory, where germs are responsible for the spread of disease; (2) the theory that disease is the result of genetic abnormality; (3) certain lifestyles dispose to illness or health; (4) diseases have multiple causes, many of which are rooted in the physical or psychosocial environment and (5) health and disease are socially produced. With different public health sections working on the different theories, together public health can tackle the determinants of health.
There have been many successes. Two of the greatest contributions to health are in fact public health interventions. Clean running water has had the most effect on people's health. Second to this is immunisation, which has effectively removed some of the greatest threats of disease such as smallpox, typhus, diphtheria and polio. (As a side note, immunisation along with screening are sometimes referred to as preventive medicine. This is a fairly antiquated term used to separate it from clinical medicine and is incorporated within public health.) Mortality (death) rates were high up until 1850 in western societies, like the UK. However, with improved water supplies, housing standards, working conditions and increased income and food availability, death rates dropped considerably. These interventions were public health, fired up by people like John Snow who studied the cholera outbreak in 1854 in London, mapped the distribution of cases and discovered the source, a water pump. While he was the first epidemiologist, another man, John Bazalgette developed a sewage system following the 'Big Stink' in London in 1858. This successfully pumped sewage away from the resident popluation. Florence Nightingale instigated infection control measures and developed the first system for collecting statistics on health. Interestingly, medicine has had little impact on the lowering of mortality rates. Indeed, the first drugs which can be shown to have influenced mortality rates did not appear until the end of the 1930s. Antibiotics used in the treatment of a wide range of bacterial infections were developed in the 1930s and 1940s. The decline in mortality for most infectious diseases took place before the introduction of antibiotics. (You can read more about the role of medicine in McKeown's seminal thesis, 'The Role of Medicine: Dream, Mirage or Nemesis', published in 1979).
So what's next for public health? Epidemiologists have divided modern western societies into three periods. Before 1850, society had high mortality rates, high infant mortality rates and disease and famine were rampant. Between 1850 and 1918, improvements to the environment meant that mortality rates in England from infectious diseases dropped by 60% for those aged 24 to 40 years. Life expectancy improved and levels of infectious disease also decreased. After 1918, there was a rise in chronic conditions, like cancer and degenerative diseases, as people lived longer. More recently we are seeing an increase in delayed degenerative disorders like Parkinson's Disease and dementia as well as a rise in obesity. Global warming is also of concern. Firstly, the rise in temperatures means more flooding and other adverse weather conditions that have devastating consequences for people's homes and lives. Secondly, as the hot summer of 2003 illustrated in Europe, heat waves can result in excess deaths and severe dehydration amongst older people and other vulnerable groups. Thirdly, changes in climate can mean changes in habitats of vectors (e.g. maleria carrying mosquitos) and disease causing agents. As Europe heats up, we may start to see tropical diseases like Dengue fever in the northern countries. And of course, there is the impact other global issues have on health: improved transport links, population displacement due to wars and other political crises, food production, urbanisation, emigration, consumerism etc. There is a great deal of work that needs to be done and one which public health is quite capable of doing.
Public Health in the Movies
1. Outbreak (1995) - Dustin Hoffman does health protection in a spacesuit!
2. Sahara (2005) - Matthew McConaughey teams up with WHO doctor Penelope Cruz in this Hollywood financial flop but interesting to watch because of the sub-plot involving the poisoning of local water
3. The Invasion (2007) - Nicole Kidman deals with a communicable disease from outer space
4. Voyage of Terror (1998) - a made for TV movie starring Lindsay Wagner as an infectious disease researcher on a cruise with a daughter when a virus breaks out (good laugh at what not to do!)
5. The Insider (1999) - Russell Crowe realises the dangers about smoking
6. Panic in the Streets (1950)
7. The Andromedia Strain (1971) - about alien poisoning!
8. Erin Brockovich (2000) - Julia Roberts tackles environmental toxins for a community
9. Thank you for Smoking(2005)
10. Traffic (2000)
11. Supersize me (2004)
12. An Inconvenient Truth (2006) - Al Gore goes all environmental!
13. Bowling for Columbine (2002) - about gun control in the USA
14. Fast Food Nation (2006)
15. The Constant Gardener (2005) - TB, pharmaceutical companies and Ralph Fiennes
16. China Syndrome (1979) - about a nuclear power plant
17. Chinatown (1974) - about land use, water rights, corruption
18. Silkwood (1983) - about a plutonium processing plant
19. Dr Erhlich's Magic Bullet (1940)
20. Batman Begins (2005) - Christian Bale must stop a toxin being distributed into the water supply
21. The Distinguished Gentleman (1992) - Eddie Murphy tackles power lines and leukemia.
22. The Pelican Brief (1993) - Julia flies the flag again for public health this time involving a bird sanctuary
23. Twelve Monkeys (1995) - Bruce Willis goes back in time to stop a manmade virus from wiping out the world's population
24. Planet Terror (2007) - Bruce Willis saves us again this time from a biological weapon
25. Brief Encounter (1945) - The male lead, Alex Harvey, is a GP but has a passion for preventive medicine, particularly to prevent respiratory disease in miners.
The AIDS movies - Philadelphia (1996), The Band Played on (1993), Parting Glances (1986), - and most James Bond movies. How often has the guy protected us from world war and germ warfare!
Public Health on Television
Programmes that spring to mind - Friends (Season 2 'The one with Chickenpox' and Series 6 when Monica gets the flu), Bones (In series one, her team released a virus from an old skeleton and the unit had to quarantined at Christmas), Medium (Series 3, Alison stops a housing development from occurring near a contaminated site linked with cancer), Scrubs (had two episodes on infection control) and ER has constantly had public health scenarios, for example smallpox outbreak, child dying from measles because she had no vaccination, the character Ray did a rotation at US version of Health Protection Agency. Not forgetting our public health champions: Jamie Oliver for raising the awareness of healthy school dinners, Aggie and Kim for showing people how to clean their homes (infection control!), the Diet Doctors and Gillian McKeith (okay so she wasn't a real dietician but she did get people to tackle their obesity).