Public health programmes: you don't know what you've got till it's gone

Editor—In 2005 a new inspection regimen will be launched in the British NHS: public health programmes will have to prove that they are providing good value for taxpayers' money.¹ The Swedish Institute for Infectious Disease Control was recently publicly criticised by the National Board of Health and Welfare because nearly 70 African immigrants became infected with Mycobacterium tuberculosis.² Similar events are occurring in many countries around the world.

All governmental institutions should document their efficiency, but most Western countries have observed a dramatic decline in infectious diseases, increase in life expectancy, and improved health services in the past decades. These data should provide such documentation. When a disease is practically eradicated from a society it is easy to forget that efforts are also needed to prevent its re-emergence. To prove that public health programmes are the reason why people did not become ill in the previous year is difficult. However, neglect of well-known public health principles fuelled the global tuberculosis epidemic and is why WHO declared tuberculosis a global health emergency in 1993.³ Dengue viruses were seen again in Brazil because the programme that had eradicated the vector in the 1960s could not be sustained.⁴ Tuberculosis, malaria, cholera, meningococcal disease, Ebola, yellow fever etc, are endemic in countries unable to sustain public health programmes such as are established in industrialised countries.⁵

An ideal public health programme should not allow for any diseases to occur within a society. The cost effectiveness of such a hypothetical programme cannot be proved in traditional ways because improvement can no longer be obtained. There are, however, numerous examples where financial cutbacks in national health systems have led to re-emergence of different diseases.