From public health to the health of the public

“I have ... been taken to see the worst parts of the worst towns in England ... but never did I see anything which could compare with Merthyr ... one of the most strongly marked cases of the evil so frequently observed, of allowing a village to grow into a town, without providing the means of civic organisation. It is the story of laissez-faire carried out to its legitimate conclusion.”¹ So said P H Holland writing to the General Board of Health on 15 December 1853. The priority was for clean drinking water and sewage disposal “before the cholera returns.” Holland hoped that the yet to be appointed officer of health would agree, since he believed that “the labour of such (an) officer will do much to remove the ignorance which has permitted such evils to arise, to arouse the apathy which allows their continuance and to overcome the opposition which impedes their removal. Such officers would show the fearful amount of suffering disease and death .... They would prove that the losses occasioned by avoidable sickness and its consequences reduce a well paid population to poverty and render it more difficult to live with comfort in Merthyr on high wages than on the low wages of even Dorsetshire.”

Holland was appealing for the application of the permissive powers of the 1848 Public Health Act. The remedy was sanitary engineering by local government; the key, public health advocacy based on locally collected quantitative evidence. It worked, and through the success of sanitary engineering the profession of public health rose to respectability. From sanitation, public health moved into food and housing, tackling malnutrition and tuberculosis, then health care for pregnant women and children.² With the introduction of the NHS, however, public health doctors, left behind in local government, fell into the doldrums.

Social care became the province of social workers, the environment of environmental health officers, and the doctors changed their name. But social medicine, then community medicine, failed to describe a distinctive and convincing role in the minds of the public or medical profession. When public health doctors were directed into administering services, even their traditional function of communicable disease control deteriorated.³ Within the corporate management structure of health authorities frankness with the public was discouraged and advocacy muted.⁴ Public health has now regained its traditional name, but all that that has achieved in many people’s eyes is to narrow down “public health” to a medical subspecialty concerned with health care, not prevention.

The renaissance of public health was announced 10 years ago^3–5—prematurely, but the window of opportunity has now opened.⁶ The issue 150 years on from Chadwick is that relative inequalities in health persist.⁷ Merthyr still has the worst health in Wales.⁸ These inequalities are rooted in the socioeconomic structure of society,⁹ mediated by environmental and social factors. Consequently, there are no simple modern day equivalents to drains and sewers. The answers have to come by coordinating the health impact of housing, transport, urban and rural planning, pollution control, food and water safety, and waste disposal, etc, as well as the NHS.²,⁷

The opportunity now exists to make the structural changes that will sustain the momentum for the new public health initiative.⁷ In his 1997 Rock Carling fellowship lecture Walter Holland concluded that the creation of a National Commission of Public Health, though a neat and appealing option, was untenable.² The realistic option was to strengthen the public health function within existing structures. What, therefore, might be done? Local authorities, health authorities, and other key agencies could be made to work together on health. Chief environmental health officers and directors of public health should each be required to be public health advocates, reporting regularly and systematically on all aspects of the public’s health and the environment. The independence of their roles could once again be protected. Routinely collected data on health and the environment (such as air quality) must be recast in the context of public health surveillance, providing information for action.¹⁰

Yet all this laudable activity still assumes that “public health” is essentially a professional activity, doing things to people’s health. But in the new information age it is the public themselves who will drive the agenda. The one thing that will sustain the momentum is providing open access to individuals to comparative information about their own health, environment, and health care.

Editorial p 549, Recent advances p 584, Education and debate pp 587-98