introduction to public health - m. fleming y e. parker

8/12/2019 Introduction to Public Health - M. Fleming y E. Parker

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introduction to public health

Mary Louise FlemingElizabeth Parker

second edition


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Introduction to

PUBLIC HEALTH

sample proofs only Elsevier Australi


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Introduction toPUBLIC HEALTH

Mary Louise Fleming and Elizabeth Parker

Sydney Edinburgh London New York Philadelphia St Louis oronto



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2011 Elsevier Australia

Tis publication is copyright. Except as expressly provided in the Copyright Act 1968 and the CopyrightAmendment (Digital Agenda) Act 2000, no part o this publication may be reproduced, stored in anyretrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying,recording or otherwise) without prior written permission rom the publisher.

Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been

possible. Te publisher apologises or any accidental in ringement and would welcome any in ormation toredress the situation.

Tis publication has been care ully reviewed and checked to ensure that the content is as accurate andcurrent as possible at time o publication. We would recommend, however, that the reader veri y anyprocedures, treatments, drug dosages or legal content described in this book. Neither the author, thecontributors, nor the publisher assume any liability or injury and/or damage to persons or property arising

rom any error in or omission rom this publication.

National Library o Australia Cataloguing-in-Publication Data

Introduction to public health / editors, Mary Louise Fleming, Elizabeth Parker.

ISBN: 978 0 7295 3890 9 (pbk.)

Includes index.Bibliography.

Public health.

Fleming, Mary LouiseParker, Elizabeth.

Dewey Number: 362.1

Publisher: Heidi AllenDevelopmental Editor: Samantha McCullochPublishing Services Manager: Helena KlijnEditorial Coordinator: Eleanor CantProject Manager: Kiruthiga Kasthuriswamy Edited by Matt DaviesProo read by im LearnerCover and internal design by Avril MakulaIndex by Mei Yen Chua

ypeset by oppan Best-set Premedia LimitedPrinted by Ligare

Churchill Livingstoneis an imprint o Elsevier

Elsevier Australia. ACN 001 002 357(a division o Reed International Books Australia Pty Ltd)

ower 1, 475 Victoria Avenue, Chatswood, NSW 2067



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Contents

Introduction vii Mary Louise Fleming About the Authors xi Acknowledgements xiiiReviewers xiv

Section 1 History and denitions of public health 1Introduction Mary Louise Fleming

1 Dening health and public health 3 Mary Louise Fleming

2 History and development of public health 24 Mary Louise Fleming

3 Contemporary public health policy 46Elizabeth Parker

Section 2 Determinants of health 71Introduction Mary Louise Fleming

4 Epidemiology 75Catherine Bennett

5 Biological and environmental determinants 103 Mary Louise Fleming & Tomas enkate

6 Social and emotional determinants of health 128Elizabeth Parker



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Section 3 Ethics, evidence and practice 149Introduction Mary Louise Fleming

7 Ethics and public health 151rish Gould

8 Evidence-based practice 172 Mary Louise Fleming & Gerry FitzGerald

9 Planning and evaluation 199Elizabeth Parker

Section 4 Health protection and promotion 221Introduction Mary Louise Fleming

10 Disease control and management 224Tomas enkate, Mary Louise Fleming & Gerry FitzGerald

11 Environmental health 250Tomas enkate

12 Disaster preparedness and public health 275Gerry FitzGerald 13 Health promotion 296

Elizabeth Parker

Section 5 Contemporary issues 323Introduction Mary Louise Fleming

14 The impact of globalisation on health 326 Xiang-Yu Hou

15 Aboriginal and Torres Strait Islander health 350Bronwyn Fredericks, Vanessa Lee, Mick Adams & Ray Mahoney

16 The future for public health 373 Mary Louise Fleming

Reection: Public health achievements and challenges inthe twenty-rst century 388 Mary Louise Fleming Glossary 393Index 401



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Introduction

Why is public health important? An Introduction to Public Health is about the discipline o public health, the natureand scope o public health activity and the challenges that ace public health in thetwenty-rst century. Te book is designed as an introductory text to the principlesand practice o public health. Tis is a complex and multi aceted area. What we havetried to do in this book is make public health easy to understand without making itsimplistic. As many authors have stated, public health is essentially about the organ-ised efforts o society to promote, protect and restore the publics health (Last 2001;Lin et al. 2007; Winslow 1920). It is multidisciplinary in nature and it is in uencedby genetic, physical, social, cultural, economic and political determinants o health.

How do we dene public health and what are the disciplines that contribute topublic health? How has the area changed over time? Are there health issues in thetwenty-rst century that change the ocus and activity o public health? Yes, thereare! Tere are many challenges acing public health now and in the uture, just asthere have been over the course o the history o organised public health efforts,dating rom around 1850 (in the Western world).

O what relevance is public health to the many health disciplines that contributeto it? How might an understanding o public health contribute to a range o healthpro essionals who use the principles and practices o public health in their pro es-sional activities? Tese are the questions that this book addresses. An Introduction to

Public Health leads the reader on a journey o discovery that concludes with not onlyan understanding o the nature and scope o public health but also the challengesacing the eld into the uture. In this edition we have included two new chapters,

one on the health o Aboriginal and orres Strait Islander Australians, and a secondon emergency planning and response, two undamentally important issues to advanc-ing public health into the uture.

Te book is designed or a range o students undertaking health courses wheresuch courses include a ocus on advancing the health o the population. While it isimperative that people wanting to be public health pro essionals understand the



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theory and practice o public health, many other health workers contribute to effec-tive public health practice. Te book would also be relevant to a range o undergradu-ate students who want an introductory understanding o public health and itspractice.

Public health is an innately political process. As we discuss in this book, there isa clear relationship between disease and the way in which society is structured.

Income distribution, the allocation o resources to ensure sufficient in rastructure ortransport, housing and education and how much political support there is to provideadequately or these undamental services all impact on our health. Tey particularlyimpact on the health o certain groups within the population who do not have thenancial, social and political resources to advocate or change. Why is it that we stillhave such disparities in health? Indigenous Australians, or example, have a li eexpectancy some 17 years less than the non-Indigenous population (National Pre- ventative Health ask orce 2009). In an egalitarian society such as Australia, thatprides itsel on a air go or all, should this be acceptable? In this book, we discussthe political, social and economic determinants o health as well as the physical andenvironmental issues that impact on population health.

Dening and understanding public healthDening public health is not an easy task. Tis is because not everyone who worksin public health agrees on a single denition. Denitions also vary rom country tocountry. For example, the American Public Health Association (APHA) classiespublic health into prevention, policy development and population health surveillanceactivities. It concludes:

Public health is the practice o preventing disease and promoting good healthwithin groups o people, rom small communities to entire countries. Publichealth pro essionals rely on policy and research strategies to understand

issues such as in ant mortality and chronic disease in particular populations.(American Public Health Association 2008)

It urther comments that public health and the prevention strategies that it promotesorm the oundation or health system re orm. APHA goes on to say that delivering

resources to entire communities has more positive health impacts on people thanindividual interventions alone. Population-based programmes address the maincauses o disease, disability and health disparities or a wide range o people and canhelp achieve increased value or our health dollar. Tese programmes, in conjunctionwith stronger health care coverage and delivery, will lead to a true change in ournations health (American Public Health Association 2011).

In the United Kingdom the Public Health Association believes that public health

deals with a wide range o issues as identied below:[Public health]

is an approach that ocuses on the health and wellbeing o a society andthe most effective means o protecting and improving it

encompasses the science, art and politics o preventing illness and diseaseand promoting health and wellbeing addresses the root causes o illness anddisease, including the interacting social, environmental, biological andpsychological dimensions, as well as the provision o effective health services



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disease, as well as a range o cancers and other disabling conditions. Internationalevidence shows that well- unded, comprehensive tobacco control programmes cansuccess ully reduce tobacco use. Te National Preventative Health ask orce (2009)reported on the substantial reduction in mortality in Australia rom tobacco use.However, the task orce rightly noted that these changes had taken a large number oyears to reach current levels. Te problem is that these improvements are not imme-

diately evident. It is also difficult to measure the individual contributions to changemade by various different interventions.In summary, this book covers the history and contemporary elements o public

health, it includes a conversation about the determinants o health and how theyshape public health practice, it discusses the important role or evidence in underpin-ning public health practice and it looks into the uture to describe the emergingepidemics and the achievements and challenges acing public health in the twenty-rst century.

How this book is organisedTe book is organised into ve sections. Te ve sections, and the 16 chapters withinthem, are outlined on the books contents page. Each chapter is organised in the ol-lowing way: a list o learning objectives an introduction the content o the chapter review questions.

Te ollowing outlines each section o the book and how each helps you to under-stand the complex relationships that make up contemporary public health.

Section 1 o the book introduces you to denitions o public health, the principlesthat underpin the discipline, and its multidisciplinary and multisectoral nature. Wethen examine the range o health pro essionals working in public health and why theyneed to comprehend the nature and scope o public health and its role in promoting,protecting and restoring the publics health. We brie y explore the interesting historyo public health over the past 160 years since the inception o organised public healthefforts. We paint a picture o the historical issues that have impacted on publichealth over the years and how history has always been a good signpost or what publichealth will be like in the uture. Finally, we examine the impact o public health policyon public health practice. You will have the opportunity to consider how public healthpolicy decisions impact on Aboriginal and orres Strait Islander peoples health, oralhealth and the human immunodeciency virus/acquired immune deciency syn-drome (HIV/AIDS), as examples. You will come to understand the nature and unc-tion o state health departments around Australia and their relationship with the

ederal Department o Health and Ageing. We consider the role o not- or-protorganisations and the contribution o local government to public health.Section 2 covers the range o actors that impact on health and, consequently, the

organised efforts o public health. It lays the oundations or decisions about prioritiesand strategies or public health interventions. It will provide you with evidence uponwhich decisions are made about where to intervene, how to intervene and how totrack population health changes. We give you an understanding o the undamentalprinciples o epidemiology, and how this discipline underpins the activities o publichealth. An understanding o epidemiology will enable you to make in ormed



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decisions about patterns o mortality and morbidity, and where to intervene; and itwill help you track health changes in the population and in subpopulations over time.We analyse the determinants o health genetic, physical, social, emotional, eco-nomic and environmental. Clarity regarding the determinants o health will assistyou, in turn, to understand and apply the principles o public health in yourpractice.

Section 3 examines the use o evidence to in orm the planning and evaluation opublic health activity. We begin this section by considering the ethics o public healthpractice. Undertaking ethical practice is essential or health pro essionals no matterwhat aspect o health they practise in. Using case study examples we provide you witha picture o how evidence can in orm practice. It examines the nature o evidence beingconsidered and it discusses the issues practitioners need to understand in order tomake evidence-based decisions. Te nal chapter in Section 3 provides you with adviceabout public health planning and evaluation models and the nature and extent o theirapplication in practice, using a range o examples in a variety o public health settings.

Tere are our chapters that make up Section 4. Tese chapters ocus on a con-tinuum o public health activity, rom disease control to health protection and healthpromotion. One ocuses on communicable and non-communicable disease control,

monitoring and surveillance. Another examines the development and relevance oenvironmental health to public health. We trace the development and importance oenvironmental health and occupational health and sa ety to population health, andexamine the contemporary notion o ecological public health. Te third chaptercovers issues o importance to contemporary public health emergency planningand response. We dene disaster and examine the principles o disaster manage-ment. In this sections nal chapter, the importance o health advancement and thepromotion o health are discussed. Tis section should give you a good understandingo the scope o public health interventions and their application in practice.

In the nal section o the book, Section 5, we examine the uture or public health inthe twenty-rst century. We consider the globalisation o health. Public health hasbecome a global issue. With travel around the planet easy and accessible to many, healthissues that once might have impacted on the population in a region or country are nowbeing transported around the world. In addition, re ugee health has become an impor-tant part o contemporary public health activity, particularly in the Asia-Pacic region.We introduce the health o Aboriginal and orres Strait Islander peoples, as a chapterin its own right, because o the important role Indigenous and non-Indigenous healthworkers can play in Closing the Gap or Indigenous peoples. In the nal chapter o thisbook we think about the uture o public health and the challenges acing the popula-tion, such as global warming and environmental sustainability. We also talk about thenature and scope o the public health work orce needed to meet these challenges.

Our re ection piece at the end o the book gives you a chance to consider themajor challenges acing public health, where we imagine the discipline might be

heading and what the consequences are or the publics health in the next 50 years.

About the authorsMICK ADAMSMick Adams is an Adjunct Pro essor with the Faculty o Health at the QueenslandUniversity o echnology (QU ). He has previously held a range o positions withAboriginal and orres Strait Islander community organisations, representative



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organisations and government departments including Chairperson o the NationalAboriginal Community Controlled Health Organisation (NACCHO) (20072009).Dr Adams has contributed to the advancement o Aboriginal and orres StraitIslander health or over 30 years

CATHERINE BENNETTPro essor Catherine Bennett is the oundation Chair in Epidemiology at DeakinUniversity, and Head o the School o Health and Social Development. She specialisesin communicable disease epidemiology and teaching research methods. Catherinealso has experience working in the government sector. She is engaged in a numbero large National Health and Medical Research Council unded research programmes.She established and leads a NHMRC unded research programme on the epidemiol-ogy o community-onset Staphylococcus aureus (superbugs, MRSA) in ections withcollaborators in the United States.

GERRY FITZGERALDGerry FitzGerald is Pro essor o Emergency Services in the School o Public Health

at the Queensland University o echnology, and is responsible or developing emer-gency and disaster management education and research programmes. He has a Bach-elor o Medicine/Bachelor o Surgery degree, Bachelor o Health Administration anda Doctor o Medicine.

MARY LOUISE FLEMINGPro essor Mary Louise Fleming is Head o the School o Public Health at the Queens-land University o echnology. She has over 20 years experience in teaching andresearch in higher education as well as public health and health promotion. Herresearch experience is in action research; process, impact and outcome evaluation inhealth promotion; and public health interventions. Mary Louise has worked as aconsultant or the World Health Organization and Commonwealth and state healthdepartments and has sat on National Health and Medical Research Council (NHMRC)public health project grant review panels. She has been widely published in the areao health promotion.

BRONWYN FREDERICKSBronwyn Fredericks is an Associate Pro essor and Senior Research Fellow with theFaculty o Health and the ammend Institute o Health and Biomedical Innovation(IHBI), Queensland University o echnology (QU ). Dr Fredericks has worked inthe health care and human service arena at ederal, state and community sector levelsand has been actively engaged with community-controlled organisations in either a volunteer, elected or paid capacity or over 30 years.

TRISH GOULDrish Gould is a research officer in the School o Public Health at the Queens-

land University o echnology. She has experience in public health and healthpromotion research, project management and coordination, writing, and editing.

rish has a MA in biological anthropology, and her interest areas include ethics,human rights, and the health impacts o migration, acculturation, inequity anddiscrimination.



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XIANG-YU HOUDr Xiang-Yu Hou lectures in international health in the School o Public Health,Queensland University o echnology (QU ). She has been working or QU orover 10 years in a variety o international health projects. Her main research interestsare in social medicine, including child health.

VANESSA LEEVanessa Lee is a Senior Lecturer within the Faculty o Health Sciences, University oSydney (UoS). She is co-chair o the Aboriginal and orres Strait Islander SpecialInterest Group (SIG) or the Public Health Association o Australia (PHAA) and is amember o the National Indigenous Public Health Curriculum. Ms Lees researchinterests are within the Aboriginal and orres Strait Islander community-controlledhealth sector.

RAY MAHONEYRay Mahoney is a Research Fellow in Aboriginal and orres Strait Islander Health,in the School o Public Health, Faculty o Health, Queensland University o echnol-ogy (QU ). He has previously worked in health or the Queensland, NSW and Vic-torian state governments, and with the Aboriginal Community Controlled HealthService Sector in Victoria. Rays career in Aboriginal and orres Strait Islander healthspans almost 20 years.

ELIZABETH PARKERElizabeth Parker is an Adjunct Associate Pro essor, and ormerly Director o Aca-demic Programs, in the School o Public Health at the Queensland University o

echnology. She has teaching and research experience in public health and healthpromotion, and was a member o the Editorial Advisory Committee or the HealthPromotion Journal o Australia. She worked as a senior manager in the oronto

Department o Public Health, and has acted as a consultant on projects or the Aus-tralian Government and Queensland Health. She is co-author, with Pro essor MaryLouise Fleming, o the book,Health Promotion: Principles and Practice in the Austral-ian Context.

THOMAS TENKATEDr Tomas enkate is Director, School o Occupational and Public Health, RyersonUniversity, oronto, Canada. Formally with the School o Public Health, QueenslandUniversity o echnology, he has been an environmental health practitioner since1990. He has also worked or Queensland Health or more than 10 years in a varietyo environmental health investigatory, policy and research roles. His main interests

are in the areas o exposure and risk assessment (particularly relating to humanexposure to UV radiation), ood sa ety and communicable disease epidemiology.

Acknowledgementso Andrew, Lachlan and Annabel thank you or your ongoing support. (When are

you going to be nished that book, Mum?)A special thank you to rish Gould, whose support and assistance with this manu-

script has meant that Elizabeth and I could complete the job. Without rish we would



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still be completing the manuscript. Tank you, rish, or all your help and or thequality o your work.

A special thank you to Emma and other amily, riends and colleagues or theirsupport and encouragement during the writing o this second edition. And aspecial thank you to rish Gould or her humour, endless patience and dedicatedassistance.

Reviewer listDr Rebecca Olson

BA, BA Hons, PhDSchool o biomedical and health sciences, University o Western Sydney

Adriana MilazzoMPHTe Adelaide University

Stephane BouchouchaBSc (Hons); MSc Public Health, Grad Cert eaching and Learning HE

Charles Darwin University REFERENCESAmerican Public Health Association, 2008. What is Public Health? Fact Sheet. Available:

http://www.apha.org/NR/rdonlyres/C57478B8-8682-4347-8DDF-A1E24E82B919/0/what_is_PH_May1_Final.pd 24 Feb 2011.

American Public Health Association, 2011. Healthiest Nation in One Generation. Available:http://www.apha.org/advocacy/healthiestnation/ 15 February 2011.

Last, J.M., 2001. A dictionary o epidemiology, ourth ed. Ox ord University Press,New York.

Lin, V., Smith, J., Fawkes, S., 2007. Public Health Practice in Australia: Te organised effort.Allen & Unwin, Sydney.

National Preventative Health ask orce, 2009. Australia: Te healthiest country by 2020.National Preventative Health Strategy the roadmap or action. Canberra:Commonwealth o Australia. Available: http://www.preventativehealth.org.au/internet/preventativehealth/publishing.ns /Content/CCD7323311E358BECA2575FD000859E1/$File/nphs-roadmap.pd 24 Feb 2011.

United Kingdom Public Health Association, 2011. UKPHA Denition o Public Health.Available: http://www.ukpha.org.uk/about-us.aspx 20 Feb 2011.

Winslow, C.E.A., 1920. Te Untilled Field o Public Health. Science 9, 2333.



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Chapter 1

Defining health andpublic healthMARY LOUISE FLEMING

Learning objectivesAfter reading this chapter you should be able to: dene health and public health discuss how the concept of health means different things to different individuals

and be able to consider the range of factors that inuence these denitions identify and describe the principles of public health recognise and describe how public health is dened and how each denition has

shaped the development and implementation of public health approaches describe the relationship between public health and other disciplines discuss the nature and scope of public health describe the varying roles of the public health workforce.

IntroductionWhat is health? How is it dened and described? What do you mean when youdescribe yoursel as healthy? How is public health dened? What are the undamentalprinciples o public health? How does public health interact with other disciplines?And how do we describe what public health workers do?

Tese are many o the questions that will be considered in this chapter, which isdesigned to help you become amiliar with the principles and practices o public



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health. Tis book is about introductory principles and concepts o public health orstudents. It is also relevant or health workers rom a range o disciplines who wantto understand and incorporate public health principles into their work.

We begin our journey by considering a undamental issue that underpins thenotion o public health, that is, the denition o health, and we consider the rangeand variety o denitions o health, both lay and pro essional.

Dening health and ill-healthComplete the simple exercise below to help you to begin thinking about how you andyour riends dene health.

ACTIVITY

Ask ve of your friends, classmates or familymembers what health means to each of them.

What are the common themes that emergedfrom each of the ve denitions of health?

What was unique about the differentdenitions?

REFLECTIONKeep these ve denitions in mind as you read,and compare them with other ways of deninghealth. How do you think of the term health?Does it mean an absence of illness, or an abilityto do all the things you want or have to do everyday? Does it have more of a religious, cultural orsocial signicance? The term health is difcult todene. How an individual denes his or herhealth is sometimes different, compared witha professionals denition of health.

Most public health workers, or educators whowork in public health, see health as central totheir work, and believe that the majority of peoplealso hold health to be an important part of theirlives. We clearly know that this is not the case.Much research (Baum 2002; Blaxter 1990, 2007;Fleming & Parker 2007) has been undertakenregarding the way in which people dene healthwithin the context of their daily lives.

To understand the nature and scope of publichealth in our society we also need to consider thevariety of ways in which the term health isdened. The section that follows discusses layand professional denitions of health and illness.

Health and illnessIllness is primarily about how an individualexperiences disease, and disease itsel repre-sents a set o signs and symptoms and medi-

cally diagnosed pathological abnormalities.Illness can be culturally specic and mayalso be in uenced by social, spiritual, super-natural and psychological aspects (Maher1999). An individual li estyle perspective hasalso been seen as an important dimension ohealth. Introduced initially by the document A New Perspective on the Health of Canadi-ans (Lalonde 1974) the individual li estyleperspective had as its ocus individualbehaviours. Te World Health Organization(WHO, dened later in this chapter) subse-quently redened li estyle to mean behav-ioural choices made rom alternatives thatare available to people according to theirsocioeconomic circumstances (Kickbusch1986). A social view o health considersissues such as the impact o social and eco-nomic actors on health, but these dimen-sions have ofen been overshadowed bythe biomedical view o health. A biomedicalmodel o health predominately had as its

ocus diagnosing diseases. Te models ocus

does not take into account the role o socialactors and it also overlooks the act thatprevention o disease is not included.

In the 1940s, the WHO dened health asa state o complete physical, social and emo-tional wellbeing and not merely the absenceo disease or inrmity (WHO 1948). Someauthors have argued that a state o healthdelineated by this denition is too difficult



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to achieve (Bircher 2005; Waltner- oews 2000), but it certainly moved the debateabout health away rom an exclusive biomedical perspective.

Health itsel is difficult to measure because it is a dynamic concept rather thansomething that is always the same. [H]ealth cannot be dened without re erenceto some goals (Waltner- oews 2000 p 657) and it is a dynamic state o wellbeingcharacterised by a physical, mental and social potential (Bircher 2005 p 335). It is

much easier to measure disease or an absence o disease than it is to measure healthor wellbeing.

Lay denitions of healthLay concepts o health and illness have been extensively researched and discussed.Blaxter (2007), quoting Kleinman, describes three ways in which health and illnesshave been discussed; these include pro essional, alternative and lay. Contemporaryscholars pre er to consider lay belie s about health and illness to be dened as com-monsense understandings and personal experience, imbued with pro essional ration-alization (Blaxter 2007 p 26). In a seminal study in 1990 Blaxter, while exploring laydenitions o health and illness, ound that people dene health in a variety o di -

erent ways. In her research, she suggests that health is dened by people as not beingill or diseased or as being a reserve against illness. Others dene health as a healthyli e, as physical tness or as having energy or vitality. Still others take health to meansocial relationships, that is, relationships with other people or as a unction o theability to do things. For others health has meaning as psychosocial wellbeing.

Tink back to your earlier activity. How do the denitions o health collected romthe ve people you have spoken with t in with the different lay denitions o healthand illness discussed above?

Read on and consider how others have characterised health. Te ollowing discus-sion introduces you to other dimensions o health that may assist you to understandhow complex dening health can be, and how difficult it is to hold a single denitiono health that ts with everyones idea o the dimensions o health.

Collectively, health can be seen to represent the social, cultural and economiccontext o peoples lives a status, socially recognised and admired. Others believetheir health is dominated by religious or supernatural orces (Durie 2004). For some,the centrality o peoples relationships to the land, amily and community are thecentral oci or health and wellbeing (Durie 2004; Tompson & Gifford 2000). ForAboriginal and orres Strait Islander Australians health is about the totality o theirenvironment.

Health to Aboriginal peoples is a matter o determining all aspects o their li e,including control over their physical environment, o dignity, o community sel -esteem, and o justice. It is not merely a matter o the provision o doctors, hospitals,medicines or the absence o disease and incapacity (National Aboriginal HealthStrategy Working Party 1989 p ix). Tese issues are discussed urther in Chapter 15.

A critical perspectiveWhile lay denitions o health have ocused on the ways in which health is denedin the day-to-day lives o people, Baum (2008), or example, examines how health isdened by looking at the purposes that are achieved through particular ways o den-ing health. able 1.1 summarises some o the ways in which a number o authors sayhealth is dened (Baum 2008; Brown et al. 2005; Morris 2010), according to how theterm might be used by different people.



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As an educated person, you need to think about the ways in which health is denedand the limitations o a variety o denitions so that you reach your own denition onthe basis o your reading o the literature. Health as a term can then be considered in a variety o different ways and can be challenged, because sometimes denitions avoidthe wide-ranging social, economic and political actors that have a real and sustainedimpact on the health o the population, as we see in some o the denitions above.

We now turn our attention to consider denitions o public health. Te two dis-tinguishing eatures o almost all denitions o public health are (1) its ocus onpopulations rather than on individuals and (2) efforts to promote health are organisedand deliberate, with a ocus on collective action.

Dening public health: an art and a science?Public health is based on scientic principles and it uses a range o disciplines such

as epidemiology, biostatistics, biology and biomedical sciences in its analysis o publichealth problems (Lawson & Bauman 2001; Lin et al. 2007; Schneider 2006). Publichealth relies heavily on environmental sciences and the social and behavioural sci-ences. Public health is also an art in that it involves applying this scientic knowledgeto a range o practical settings that require attention to issues such as selecting intervention strategies and approaches that communities need. Furthermore, public healthdeals with social, cultural, political and economic issues, as well as health issues.

Winslow (1920), an American public health leader in the early twentieth century,dened public health as a science and an art:

(Summarised from Baum 2008; Brown et al. 2005; Morris 2010)

TABLE 1.1 Contemporary denitions of health

Denitional focus Application

Health dened by capitalistsociety

Dening and controlling mechanism where apersons health is dened primarily throughillness.

Health maintenance Being a good citizen because becoming ill maymean a person becomes an economic burden onsociety.

Health as a collective perspective:

A political perspective

Health outcomes

Health is dened by inequities in health statusand inuenced by environment, housing andoccupational conditions.

Dened as a change in the health of anindividual, a group of people or population whichis attributable to an intervention or series ofinterventions (Baum 2002 p. 12). Often neglects

the notion that the demonstration of healthoutcomes is complex.

Ecosystem health (Baum 2008,Brown et al. 2005)

Consideration of the environment and theinterdependence of systems within the overallecosystem in order to achieve long-termsustainability of our planet.



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o preventing disease, prolonging li e, and promoting physical health andefficiency through organised community efforts or the sanitation o theenvironment, the control o community in ections, the education o theindividual in principles o personal hygiene, the organization o medical andnursing services or the early diagnosis and preventive treatment o disease,and the development o the social machinery which will ensure to every

individual in the community a standard o living adequate or themaintenance o health. (Winslow 1920 p 24)

In its time, this denition was very orward thinking because it identied anumber o public health elements that are still considered important. For example, itre ers to organised efforts, it considers environmental issues and in ectious diseases,personal wellbeing, early diagnosis and prevention and the social dimensions ohealth. Little did Winslow know that many o the issues that the public health com-munity had controlled or eliminated have re-emerged in the twenty-rst century asmajor challenges.

A denition o public health that is ofen quoted is that o the Institute o Medicine(1988). In that denition, public health is described as what society does to assure

the conditions or people to be healthy. o do this, the denition goes on to suggest,there needs to be a countering o continuing and emerging threats to the health othe public.

What are some o these emerging threats? Environmental actors such as theeffects o greenhouse gases and global warming, HIV/AIDS, avian in uenza, SARS(severe acute respiratory syndrome) and H1N1 (swine u) are signicant publichealth issues (McMichael & Butler 2007; US Department o Health and HumanServices website 2011). Tese twenty-rst-century challenges require public health toreturn to its roots to control in ectious diseases, as well as be a part o a global effortto sustain the planet and its environment or generations to come (Gostin 2010;McMichael & Butler 2007).

Public health today is recognised as being integral to promoting and sustaining

the health o the population. Te ollowing denition o public health by Last (2001)supports this approach:

the efforts organised by society to protect, promote, and restore thepeoples health. It is the combination o sciences, skills and belie s that isdirected to the maintenance and improvement o the health o all the peoplethrough collective or social actions. (Last 2001 p 145)

Tis denition o public health provides us with a ramework rom which we cangain a better understanding o the role o public health in our society. It dispels thenotion that health is only concerned with curing illness and disease.

Public health is about preventing disease, illness and injury, together with promot-

ing the quality o li e o human populations. Tis is a very complex processand requires the committed skills and expertise o many different pro essionaldisciplines.

In Australia, similar denitions are used to describe the art and the science opublic health. Te Public Health Association o Australia (PHAA) denes publichealth as a combination o science, practical skills and belie s that is directed to themaintenance and improvement o the health o all people. It is one o the effortsorganised by society to protect, promote and restore the peoples health through col-lective or social actions (PHAA website). Recent debates in the literature (Goldberg



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2009; Rothstein 2009) about denitions o public health have ocused on how broadand all encompassing, or narrow, denitions o public health should be. What iscommon about most o these denitions is the notion that there is an organised desireto improve the health o the population as a whole, a sense o general public interestand a ocus on the broader determinants o health (Beaglehole et al. 2004). It isworthwhile stopping here to consider the meaning o the term determinant. Deter-

minants are discussed in Section wo (Chapters 4, 5 & 6) as both the causes o andrisk actors or health events. A wide range o determinants, including physiological,psychosocial, behavioural and risk conditions, can work together to in uence qualityo li e, wellbeing, illness and disability. However, the ways in which these determi-nants mani est themselves in each society would depend on history, culture and poli-tics (Lin et al. 2007 p 76).

As health workers, your knowledge and understanding o the art and scienceo public health will be an important element o your pro essional development.Tis knowledge and understanding will enable you to rst identi y the trendsin the health o the population and, second, demonstrate the skills to appropri-ately respond to these in restoring, promoting and maintaining the health o thepopulation.

Te concepts o public health should become a little clearer to you as we urtherdiscuss its vital role in our day-to-day lives. Consider the ollowing scenario to helpyou think about the contribution o public health to daily li e and to enable you tobegin to broaden your understanding o public health (Case Study 1.1).

Tere are a number o activities that we take part in every day that affect our healthand the publics health collectively. Public health has developed systematic ways othinking about health issues (Schneider 2006). Tis systematic approach enablespublic health workers to tackle a health issue in a considered and deliberate ashion.However, unless public health has a collective action domain it will lack a ocus onsocial and economic issues that are so central to supporting and maintaining changesthat enhance the publics health.

CASE STUDY 1.1A typical morningYou get up in the morning, woken earlier than expected by the waste-disposaltruck collecting outside in your street. Having completed the morning routine(shower, toilet, teeth etc.) you dress and turn on the radio for the news report.Throughout the broadcast you hear that it is Breast Cancer Awareness Week.Having realised that you are running late for the rst lecture at university, youquickly rush out the door and into the car. Seat belt on, and out into the usualtrafc chaos. As you drive past McDonalds the sign is too enticing, and,remembering you didnt have breakfast at home, you drive through and pick up amufn and coffee. Across the road in the local state school you notice theambulance service has two ambulances on the oval and school students areclimbing in and out of them. Finally arriving at university, you park your car asnear as possible to the lecture theatre and walk the short distance to your lecture.



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ACTIVITY Daily life and public health From the scenario above, list the issues that

you feel are relevant to public health.

REFLECTIONReect on the issues you have listed above. Didyou consider any of the following issues:

your access to clean water, sewerage andrubbish removal and disposal

the radio broadcast of a media campaign,which raises your awareness of breast cancerand screening

your safety on the road, which is enhanced bylegislation such as that of seat-belt wearing,trafc lights and construction of road ways tomaximise safety

your ability to drive on roads that aremaintained for safe use

your purchase of food, which has beenprepared with standards of hygiene thatprotect your health

the quality of the food you consumed forbreakfast

the ambulance service visiting a school todiscuss their role

the fact that you parked your car close to thelecture theatre and walked for a short distanceto your lecture?

I you were asked to think about how youmight tackle a public health problem, youmight think about it in terms o levels oprevention primary, secondary and terti-ary (see Chapter 13 or more detail on theseconcepts). Primary prevention ocuses on

maintaining health, or example, schoolhealth programmes, seat belts in motor vehicles, anti-smoking campaigns, andphysical activity and nutrition programmes.Secondary prevention aims to minimise theextent o a health problem by ocusing onearly intervention, such as, prostate, boweland breast screening. ertiary interventionaims to minimise disability and providerehabilitation services, such as cardiacrehabilitation.

Another way o dealing with a public

health problem is to consider a chain o cau-sation (see Chapter 10 or urther considera-tion o this concept) involving an agent, ahost and the environment. In this case, prevention is accomplished by interrupting thechain o causation, or example, by provid-ing immunisation, using antibiotics or puri-

ying water.For you to gain a more comprehensive

understanding o public health it is vitalthat you appreciate the underlying vision, values and core components o publichealth, as they provide the oundationsupon which strategies are developed andimplemented.

Public health visionand valuesHaving a vision o where you think public health might be placed in the next5 to 10 years is important or the discipline and or you in your practice. Tere

are a range o actors that impact on health and public health that will have apro ound effect on the nature and scope o the discipline in the next decade.Globalisation is one o those issues (as discussed in Chapter 14); other issuesinclude the emergence o new virulent in ectious diseases, an increase in chronicdisease such as diabetes, the ageing population and the ever-increasing cost andthe expanding technological sophistication o health care. In Chapters 10 to 13 weexamine the role o health protection and health promotion in advancing the healtho the population, and in Chapter 14 we explore the notion o globalisation andits impact on health.



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ACTIVITY

Write a sentence on where you think the focusof public health will be in 10 years time.

What steps did you take to arrive at thatdecision?

What are the implications of your decision onresources and the workforce in public health?

REFLECTIONWhat factors might inuence what you thinkpublic health will be focused on in 10 years time?You might use projected data about patterns ofmortality and morbidity to begin. What othersources of data or reports from places such asthe WHO or the Australian Government mightthere be that you could consider? Think about thehealth issues that might be important in 10 yearstime; how do these health issues impact on theresources needed to manage them? What mightthe workforce look like in 10 years time to meetchanging public health needs?

Te traditional values o public healthare described by Lawson and Bauman (2001)as consistent public health principles. Teauthors re er to three major principles: using scientic evidence as a basis or

action ocusing on the health o all sections othe population

emphasising a collective actiondimension (Lawson & Bauman 2001p 5).

Addressing health issues across popula-tion subgroups is also very important topublic health. It affirms the principle oequity, which is central to public healthactivity. Achieving the publics health insome subpopulations is a very difficult taskthat constantly challenges the skills andexpertise o health workers. Tis is becausepeoples lives are complex and their ocus onaffordable housing, transport and accessto ood may mean that health is not apriority.

A collective action dimension tends tobe contextualised differently according tothe social and cultural aspects o the society

in which we live. For example, in the United States there is still a very strongemphasis on individual rights and reedom; in contrast, in Australia, there is anotion o the collective good. Applied to public health, this means that the

community accepts laws and regulations that limit the individuals reedom, i itmeans that the health o the population is protected.

Core functions of public healthTere are a number o different ways in which the core unctions or the ocus opublic health have been described and dened. For example, Lawson and Bauman(2001) describe our major task categories that include health promotion and diseaseprevention; traditional public health unctions; monitoring and surveillance; andpublic health policy. By contrast, urnock (2001) describes seven key principles o

public health practice that involve social justice; equity o access and equity in healthoutcomes; links with government; an expanding and evolving agenda; a preventiveocus; a balance between science and societal needs; and an appreciation o the poli-

tics o public health.A similar perspective is taken by Beaglehole et al. (2004), who talk about

the ve key themes o modern public health theory and practice. Tese themesinclude leadership o the health system; collaborative action across sectors; multi-disciplinary approaches to all determinants o health; political engagement in thedevelopment o public health policy; and partnerships with the populations served



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(Beaglehole et al. 2004). Beaglehole et al. (2004) suggest that in order to strengthenpublic health these main themes should be acknowledged and acted on. A sup-portive ramework or public health requires strong and responsive governmentleadership and adequate resources or personnel and in rastructure, completedby public health research, teaching and services that use the ull range o public-health sciences (Beaglehole et al. 2004 p 2086). Other authors have presented a

different ocus. For example, Griffiths et al. (2005) discuss three key domains opublic health. In the three key domains o health improvement, health protec-tion, health service delivery and quality there is an intersecting and overlappingo activity. Health improvement includes a ocus on reducing inequalities andworking with partners outside the health sector. Health protection encompassespreventing and controlling in ectious diseases, responding to emergencies andprotecting rom and dealing with environmental health hazards. Health servicedelivery and quality ocuses on service delivery, evidence-based practice, planningand prioritising and appropriate research, audit and evaluation activities (Griffithset al. 2005).

Gostin et al. (2004 pp 98103) discuss three effective core strategies o publichealth. Te authors provide examples o how each strategy can be implemented. Tey

talk about strengthening the governmental public health in rastructure, engagingnon-governmental actors in partnerships or public health and trans orming nationalhealth policy so that traditional dominant investments in personal health care andbiomedical research are balanced against investments in the multiple determinantso societal health.

For at least the last 10 years, efforts to dene core public health competencies haveoccurred around the world. In the USA, the UK and Australia, pro essional bodiesand government instrumentalities have attempted to dene the roles and responsibili-ties o public health workers. In 2000, the National Public Health Partnership (NPHP)(2000) dened core public health unctions in Australia.

Te Public Health and Education Research Program (2007), unded by the Austral-ian Government Department o Health and Ageing, dened public health practice asinvolving ve areas. Tese are: health monitoring and surveillance; disease preventionand control; health protection; health promotion; and health policy, planning andmanagement. Te application o research methods and pro essional practice orm thetwo underpinning competency groups.

More recently, the then Australian Network o Academic Public Health Institu-tions (ANAPHI) produced Foundation Competencies or Master o Public HealthGraduates in Australia (Genat et al. 2009). Te oundation competencies weredesigned around six areas o practice including health monitoring and surveillance;disease prevention and control; health protection; health promotion; health policy,planning and management and evidence-based pro essional population healthpractice.

Tere is a set o common themes that go to the heart o public health practice.Tese include collaborative action across sectors, multidisciplinary approaches,establishing partnerships, reducing inequality, and enhancing political support orpublic health policy. Public health pro essionals need to work with many other pro es-sionals outside as well as inside the health sector and to approach public health issues

rom a multisector perspective. What we mean by multisector in the public healthcontext is that, or example, public health needs to work with government education,housing and transport departments to ensure that these services are available to thewhole population in an equitable manner.



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What do public health practitioners do?Tis is an interesting question that we will consider in two parts. First we will discusswho makes up the public health work orce. Second, we will consider the role o thepublic health worker, now and in the uture.

Who is the public health work orce? Is it anyone rom a health discipline who is

involved in some orm o public health activity, or is it much narrower, such as acommunity primary care worker or a public health specialist? Rotem et al. (1995)conducted a study o the public health work orce and described this work orce as:

[p]eople who are involved in protecting, promoting and/or restoring thecollective health o whole or specic populations (as distinct rom activitiesdirected to the care o individuals). (Rotem et al. 1995 p 437)

Tey ound that personnel come rom a wide range o pro essional and occupa-tional backgrounds and that characteristically they are described as having a highdegree o versatility and exibility (Rotem et al. 1995). Te study suggested that thework orce is made up o mature, highly qualied, multiskilled individuals rom a variety o backgrounds, who have multiple unctions to per orm that are not always

related to their primary training or occupation.In a NSW state-wide consultation by Madden and Salmon (1999) the authorsincluded a third category o health worker as one with public health componentsincluded in their pro essional practice, such as general practitioners and communityhealth nurses who need an understanding o population health.

ACTIVITY What do you think publichealth workers do? How would you dene the public health

workforce? Would your denition be broadand encompassing or narrow and restrictive?Think back to our discussion of denitions ofpublic health.

Make a list of the range and scope of activityfor the public health worker.

Select a public health worker this might bean environmental health ofcer, a communityhealth nurse, a diabetes educator or a healthpromotion practitioner for the National Heart

Foundation (NHF). Write down what you thinka typical day might be for such a worker.Make a list of the roles and responsibilitiesthey might have.

How does this list relate back to thecompetencies we discussed earlier in thechapter?

Public health will increasingly becomethe ocus o a range o different healthworkers as the notion o an expanding scopeo practice becomes articulated urther. Inrural and remote areas where it is difficult toattract health workers the potential inclu-sion o a primary health care role or nurses

and paramedics will involve a ocus on prevention and promotion.Chapters 10, 11, 12 and 13 look at the

application o many o the principles dis-cussed above in a range o settings using a variety o different public health strategies.What does the public health worker do? Tisis the second question. Te role o the publichealth practitioner according to van derMaesen and Nijhuis (2000 p 136) involvesthree important elements:1. improving social conditions that

stimulate health2. preventing social conditions that

threaten health3. neutralising existing social conditions

that cause ill health.How do you think the three elements listedabove relate to the questions in the activitythat ollows?



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BOX 1.1 ROLES AND FUNCTIONS FOR THE PUBLICHEALTH WORKFORCE

Understanding the context for public health activity and its role and functions Clarity around political impacts on public health

Ability to apply a range of methodological approaches to understand data

A theoretical understanding of the disciplines that underpin public health andtheir contribute to strategy selection Understanding a range of skills around surveillance, prevention, promotion and

restoration of the populations health

Developing and analysing policy Planning, implementation and evaluation Evidence-based practice Advocacy, communication and negotiation skills Working intersectorally and with multidisciplinary groups Ethical practice

While there are core unctions or public health workers, the diversity o publichealth practice is still enormous. Te organisation that employs you, the nature othe position, the organisational philosophy, the governance structure o the organisa-tion, whether it is or prot or not- or-prot, state-based or non-government, allimpact on the nature and scope o the public health work you might be asked to do.

Even though the public health worker may have different roles and unctionsaccording to the setting in which he or she works, there are common aspects opractice that all workers need to be able to per orm and to understand. Tese unc-tions are outlined in Box 1.1.

Re ecting on the content covered so ar, you should now be eeling condentabout your understanding o what public health is, and its role and value in todayssociety. Te complexity o public health processes should also be obvious. For publichealth to be effective, it cannot be undertaken on an ad hoc basis and must adopt amultidisciplinary approach across a range o pro essions. Collaborative efforts shouldengage a number o organisations, both government and non-government, in attemptsto strive towards positive health outcomes throughout the population. It is alsoimportant to include ethics at the ore ront o our practice. Chapter 7 examines theissue o ethics in public health practice in more detail.

The World Health Organization agenda forpublic healthWe now turn our attention to public health developments and events that haveoccurred at an international level. Tese, to a large extent, have in uenced the publichealth agenda and given direction to initiatives that have been implemented in Aus-tralia with the aims o achieving the goals o public health.

Te WHO has played a signicant role in articulating and promoting publichealth, particularly in promoting the concept o health or all, which has been



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embraced by countries throughout the world, underpinning their respective healthpolicies. For the WHO, the extent o public health action has become more difficultto dene and has merged with other sectors that in uence health opportunities andoutcomes. Consequently, the WHO (2008) has a six-point action plan or health thatassists in shaping activity and ocus. Tis six-point plan is outlined in Box 1.2.

Since the 1970s the WHO and other substantial international players have had aocus on primary health care, prevention and promotion. Tis has been evident inpolicy that supports the advancement o promotion and prevention. For example, theWHO Alma Ata Declaration stressed the importance o a slogan that said Health orall by the year 2000. Tis primary health care philosophy spoke about the principleso equity, social justice, intersectoral collaboration, community participation andempowerment. It had as its ocus the important role o health promotion and diseaseprevention (See Chapter 13 or a detailed analysis o the nature and scope o healthpromotion.).

In the 1980s the li estyle phase became prominent. At this stage o public healthdevelopment, Canada was at the ore ront o initiatives to ocus on the li estyles oindividuals but also to stress the importance o a contribution to peoples health thatincluded social issues. Issues considered important included li estyle, environment,socioeconomic actors and health care system re orm.

In more recent times, the global concern or ecosystem sustainability, known inpublic health circles as ecological public health, has emerged as the predominanttheme or public health action in the twenty-rst century. Te Jakarta Declaration (1997) went some way towards a ocus on sustainability and globalisation. However,in 2005 the Bangkok Charter for Health Promotion identied globalisation as a centralissue or health promotion endeavours. Participants at the Sixth Global Conference onHealth Promotion, co-hosted by the WHO and Tailands Ministry o Public Health,adopted the charter. It identies major challenges, actions and commitments neededto address the determinants o health in a globalised world by engaging the many

actors and stakeholders critical to achieving health or all (See Chapter 13 or a morecomprehensive account o the Ottawa Charter , the Jakarta Declaration and theBangkok Declaration in the evolution o health promotion policy and practice.).

Health or all by the year 2000 has not been achieved. Te WHO re orecast itsendeavours in this regard with the production o Health or all by 2010, althoughsome regional areas have targets dated to 2020. Te emphasis in public health in thisrevised ocus includes sustainable development, collaboration, protection, preven-tion, resilience, adaptation, the emergence o chronic diseases and the re-emergenceo in ectious diseases.

BOX 1.2 WHOS SIX-POINT ACTION PLAN1. Promoting development2. Fostering health security3. Strengthening health systems4. Harnessing research, information and evidence5. Enhancing partnerships6. Improving performance

(Source: WHO 2008)



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In 2000, United Nations member states agreed on eight Millennium Development

Goals (MDGs) with targets to be achieved by 2015. Four o these goals relate to healthoutcomes: eradicating extreme poverty and hunger; improving maternal health;reducing child mortality; and dealing with HIV/AIDS, malaria and other in ectiousdiseases (McMichael & Butler 2007). o achieve any one o these our goals withinthe designated time rame seems almost impossible in the context o the overwhelm-ing range o issues impacting on population health.

In March 2005, the WHO created the Commission on Social Determinants oHealth (CSDH (WHO 2005)). Te commission operated until May 2008. Te compo-nents o the CSDH included the commissioners, partner countries, evidence-gatheringknowledge networks, civil society organisations and global institutions (Irwin et al.2006 p 0749). Te CSDH developed ve action areas as outlined in Box 1.3.

Tree years later the WHO ocused on a global strategy or the prevention andmanagement o non-communicable diseases (WHO 2008). Tis strategy is a partner-ship or action to control our diseases cardiovascular disease, diabetes, cancers andchronic respiratory diseases, and our shared risk actors tobacco use, physicalinactivity, unhealthy diets and alcohol misuse.

Tese developments on the international stage are now clearly ocused on healthinequalities and ecological sustainability. Tis recognises that inequalities in healthare seeded in the structures o society economically, politically and culturally andit will take collaborative efforts across sectors to bring good health within the reacho everyone. Chapter 14 covers many o these issues in more detail. Ecologicalsustainability is considered in Chapters 11 and 16.

You will see the term intersectoral approach used ofen in this book. It is very

relevant in developing healthy public policies as it recognises the need or cooperationbetween governments, government departments, the private sector and non-government organisations (NGOs), i policies are going to be effective in achievingthe maximum positive impact on the health o the population.

In concluding this section o the chapter, it is important to remember that ecologi-cal sustainability recognises all components o peoples lives and takes into accountthe impact that these actors have on the health o populations or subgroups o popu-lations. For example, individuals alone are not totally responsible or their healthstatus. Although they need to adopt positive behaviours in regard to their health,

BOX 1.3 FIVE KEY ACTION AREAS FOR THE CSDH1. Improving living and learning conditions in early childhood2. Strengthening social programmes to provide fairer employment conditions and

access to labour markets, particularly for vulnerable social groups3. Policies and interventions to protect people in informal employment that is,

those who work without formal contracts or social protections, often in sectorsoutside government regulation, such as subsistence farming, household-basedenterprises, and street vending

4. Policies across sectors to improve living conditions in urban slums5. Programmes to address key determinants of womens health, such as access to

education and economic opportunities

(Source: Irwin et al. 2006, p 0750)



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actors such as the environment in which they live, their economic status, and theirculture are some o the things which, although they have little or no control overthem, can have a signicant impact on their health. Ecological public health, with its

ocus on sustainable environments or health, has evolved as the main ocus o publichealth in the twenty-rst century.

Public health in the Australian contextIn Australia, managing public health activity is multilayered and is in uenced by theprevailing political thinking. In this chapter, we introduce you to the systems andorganisational arrangements or public health activity. In Chapter 3 we provide youwith more specic in ormation about the health care system and its relationship topublic health and the range o policy initiatives supporting public health.

Te division o responsibility or public health includes the Australian Govern-ment Department o Health and Ageing, state and territory health departments,local government departments, non-government organisations, pro essional associa-tions and a range o advocacy groups. In addition, individuals, such as general prac-

titioners and health workers in community health centres, also undertake healthprotection and health promotion roles and responsibilities.A number o other organisations also play a role. Te National Health and Medical

Research Council (NHMRC) und public health research and make policy statementson health issues; the Australian Institute o Health and Wel are (AIHW) and theAustralian Bureau o Statistics (ABS) monitor and report on health data; and universi-ties educate public health, allied health, medical and nursing pro essionals, andundertake research and consultancy activity in public health. Divisions o generalpractice also play an important role in advancing population health.

Australian Government Department of

Health and AgeingTe Population Health Division (DOHA 2011) and the Office or Aboriginal andorres Strait Islander Health, within the Australian Government Department o

Health and Ageing, both play a national leadership role in public health matters, suchas communicable diseases, immunisation, nutrition and obesity, physical activity,

ood policy, smoking, and alcohol and drug abuse. In addition, the Office o HealthProtection and the Mental Health and Chronic Disease Division play an importantrole in prevention. Te division identies itsel as playing a number o roles in creat-ing and supporting national endeavours in public health. Tese activities are listed inBox 1.4.

Te division has identied a number o broad priorities or public health that

ocus on identi ying and responding to emerging threats and health emergencies, anda ocus on prevention, particularly in areas such as nutrition, physical activity, over-weight and obesity (see the DoHA, Population Health Division website or a reviewo current program involvement). Te Division has an emphasis on responding tohealth issues throughout the li ecourse. In 1996, it established the National PublicHealth Partnership (NPHP), creating a ramework or public health leadership andto strengthen collaboration between stakeholders. Te NPHP was disbanded in 2006.More recently, the Population Health Division has been involved in the NationalPreventative Health Strategy, the National Partnership Agreement on Preventive



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BOX 1.4 ROLE OF THE POPULATION HEALTH DIVISION, AUSTRALIAN GOVERNMENT DEPARTMENT OFHEALTH AND AGEING

Leadership and coordination of a range of national initiatives Supporting activities aimed at understanding and controlling the determinantsof disease Informed decision-making based on effective use of health information, and on

the application of research evidence in the design of programmes to improvehealth

Relationship building between staff of the department and a range ofstakeholders, from states and territories through to academic institutions andnon-government organisations

Working with these stakeholders to expand their knowledge of factors affectingthe health of the population and specic at-risk groups such as Aboriginal andTorres Strait Islander communities and populations located in rural and remoteAustralia.

Health, the Australian Health Survey, and the establishment o the Australian NationalPreventive Health Agency, all important steps orward in prevention and publichealth in Australia. Te Population Health Division has links to advisory bodies sup-ported by the Population Health Strategy Unit, including the Preventative Health

ask orce (National Preventative Health ask orce Website 2011) and the AustralianPopulation Health Development Principal Committee (APHDPC).

In 2010, the Rudd Labor Government proposed sweeping re orms to the Healthand Hospital System in Australia. However, in early 2011, the Gillard Labor Govern-ment substantially modied this proposal and recommended a Federal, States and

erritories system, where money will be pooled and paid directly to hospitals. Teseinitiatives are still to be worked through at the time o writing (see Chapter 3 ormore details).

Tere are a number o ederally supported organisations and legislation thatprotect and enhance the health o the population. Tese include the TerapeuticGoods Administration, Food Standards Australia New Zealand, Australian RadiationProtection and Nuclear Sa ety Agency, and the Australian Sa ety and CompensationCouncil.

o build a prevention agenda in a health system that currently expends the major-ity o its unds on treatment is an ongoing challenge. As the costs o treatment con-tinue to rise, and health technology becomes more sophisticated and expensive, a

ocus on prevention has gained greater traction in the health system. In addition, theemergence o chronic diseases, such as diabetes, means that people will be living alarge part o their lives managing such conditions. Te Australian Government isattempting to make prevention a undamental pillar o the health system. Tis willbe a difficult task, given the strength o some health interest groups that have managedto lobby effectively with a succession o governments around their own ocus andneeds.

Another very important aspect o the leadership role at the ederal level is to havein place in ormation systems that can alert us to emerging health issues. Australia



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ACTIVITY Advancing public health the Australian perspective

In the past 10 years, what have been themajor foci of national developments in publichealth in Australia?

What factors may have inuenced nationaldevelopments? For example, change inpolitical party, health crises, changing patternsof health.

What role can non-government organisationsplay in public health?

What role do you think the ecological publichealth movement has had in advancing theactivities of public health in the public mind?

How do we balance health care needs withpopulation health needs in order to be able tofund the health system in the future?

REFLECTIONThe federal government, in the past 20 or soyears, has played a policy and strategic role inadvancing population health. This strategic rolehas meant an emphasis on the policy and theidentication of major areas for nationaldevelopment, the detail of which is often

translated at state/territory and local governmentlevels. For example, the Population HealthDivision has set a national agenda for healthyeating and increased physical activity. At thestate/territory level that national agenda has beentranslated into actions that more clearly meet theneeds of the population. Do you think thatnon-government agencies such as the CancerFund or the National Heart Foundation (NHF)have been included in policy initiatives at thefederal level? How might you determine if theyhave been given a role? How is ecological public

health dened? Ask ve of your friends if theyunderstand what ecological public health is allabout. In Chapter 3 there will be more detailabout funding for public health in a health caresystem where the majority of current funds areexpended on care and treatment. Can you thinkof any health professionals who might wantfunding levels to remain as they are?

has made considerable investments inin ormation systems development and hasmade signicant progress in the alignmentand coordination o health in ormation.However, one o the common criticisms othe system is that the data collection is not

sufficiently timely nor is it related to particu-lar communities o interest. Also seen as aweakness is a lack o data that track healthpatterns over time, and insufficient com-parative data (Lin et al. 2007 p 216). Tepaucity o data around these issues makes itmore difficult or public health pro essionalsto gain access to and use appropriate in or-mation or decision-making. Te activitybelow asks you to stop and think about therole o the ederal government in publichealth and a number o important issues

that ace the government in the comingyears such as health care costs and unding.

State and territorygovernmentsAt the state/territory level o public healthactivity, responsibilities have included: man-aging public hospitals and communityhealth services; leadership and planning opublic health; health surveillance; local gov-ernment regulation and health promotion,including working with non-governmentand other organisations (Baum 2008). Asummary o these unctions is provided inBox 1.5.

Other roles and responsibilities includethat o the chie health officer, under whoseauthority many health activities are locatedand who exercises statutory responsibilities.Tese include environmental protection,occupational health and sa ety, road andtraffic authority, sport and recreation, and

consumer affairs. Education departments ineach state have a major role to play in pro-motion and prevention through the healthcurriculum, health promoting in schoolsand a range o other activities including SunSmart, Healthy uckshops, drug and alcoholprogrammes such as PROMAS ( Promoting Adjustment in Schools) and driver educa-tion. Emergency services departments in



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each state also play a role in promotion and prevention. For example, with the chang-ing scope o practice, health workers such as ambulance officers play an importantrole in providing in ormation and education to the general public, and in rural andremote communities as primary health care workers.

In Queensland, like many other states, a whole-o -government approach is takenwhere public health and many other services orm part o a more integrated approachto promotion and prevention, and the multisectoral nature o public health is recog-nised and supported. Te success o such approaches o course depends upon politicalwill, interdepartmental collaboration and positive interaction between all tiers ogovernment.

Local governmentLocal government has a critical role to play in public health, especially in the area olegislation and creating healthy communities. Local governments roles in publichealth activity vary across Australia, but more ofen than not still include such unc-tions as well baby clinics, immunisation, ood sa ety, environmental protection,a strong role in cultural and recreational activities and community development, and,importantly, local economic development.

Non-government organisations, communityorganisations, professional associations andpublic health advocacy groupsTere is a broad range o organisations and associations that support public healthendeavours in Australia. Tat support comes in a variety o different ways. Forexample, large well- unded non-government organisations (NGOs) such as the cancer

councils, the National Heart Foundation and Diabetes Australia have a range o roles,including in ormation and education, undraising, advocacy, lobbying and research,in the promotion o health and the detection and treatment o specic health issues.

Other organisations, such as pro essional associations, play an important role inlobbying, advocacy and policy development as well as work orce education throughcon erences and pro essional development activities. Tese associations include thePublic Health Association o Australia, the Australian Health Promotion Association,the Australasian Epidemiology Association and the Australian Institute o Environ-mental Health.

BOX 1.5 STATE/TERRITORY GOVERNMENT FUNCTIONS Health protection such as environmental health, drugs and poisons Disease prevention examples include surveillance, health education,

immunisation, STI (sexually transmitted infection) and cancer screening

Health promotion including a focus on physical activity, nutrition, maternal

and child health, tobacco, drugs and alcohol and injury prevention

Policy and programme support epidemiology, evaluation, research, workforcedevelopment, policy development within and outside the sector impacting onhealth, and clinical service guidelines

(Adapted rom Lin et al. 2007)



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ACTIVITY Health in the public arena On a regular basis, the media will report on

public health issues, initiatives, developments,etc. The newspaper is an effectivecommunication vehicle by which the publicsawareness may be raised about an issue oran event that directly, or indirectly, impacts onthe publics health. What are examples ofrecent newspaper articles that you can ndthat deal with a public health issue?

Public health issues inthe daily pressIdentify and source two articles that comment orreport on a current public health issue. Write abrief review of each newspaper article. Use thefollowing questions to frame your comments:

Why is it a public health issue? Think aboutour discussion of denitions of public health.

Use evidence to decide if this is an importantpublic health issue. Where should thisevidence come from?

What population or subpopulation isinvolved?

What strategies, if any, are being

implemented to address the issue or concern?

What component or components of the publichealth system would take responsibility, forexample, the state health department or anon-government organisation?

What are the future ramications if the issueor concern is not addressed?

A third group o organisations are thoseocused on advocacy and lobbying, includ-

ing the Womens Health Network, the Con-sumer Health Forum and the NationalAssociation o Aboriginal Community-Controlled Health Organisations (Baum

2008).Health promotion oundations are vari-ously integrated into state health depart-ments or have been set up to standindependently o a departmental structure.Tey have an important role in undingresearch activities and their application and,in some jurisdictions, an advocacy and lob-bying role.

o the above list, Baum (2008) addsprimary health care providers, and universi-ties and research institutions. Primary health

care providers include general practitioners,who play a role in screening, immunisationand the health education o patients. Uni- versities and research institutes both have aneducation and research unction.

The future forpublic health?Tere are a number o emerging challenges

that public health aces in the twenty-rst century. Tese challenges include theemergence o new in ectious diseases, theongoing presence o HIV/AIDS (particularlyin developing countries) and the impact thatoverweight and obesity have on a range ohealth issues that in uence the populationshealth. Add to these issues the in uence oglobal climate change and ecological sustain-ability and you have a public health systemstretched to capacity across a range o ronts.

Troughout the book, we continually return to these themes and issues as we

explore the nature and scope o public health.

A nal wordIn this chapter, we have covered a broad range o issues that are re ective o elementso public health. We have examined denitions o health, both lay and pro essional;we have considered the denition, vision and values o public health; and the role oa wide range o health workers who play an important role in public health.



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We have discussed the role o the WHO in setting a global agenda or public healthand the specic role o governments at three levels in Australia rom ederal to stateand local government. We introduced you to the range o other associations, com-munity organisations and advocacy groups who all play important roles in improvingthe health o the population.

In conclusion, we brie y introduced you to public health issues emerging in the

twenty-rst century and the challenges that ace pro essionals working in the publichealth eld i they are to deal with these issues. We return to these issues in the lastchapter o the book.

In the chapter that ollows, we look at the history o public health and see howhistory is a good window to the uture.

REVIEW QUESTIONS1. What do you understand by the terms health, illness, disease and public health?2. Why should public health have a vision and what values should public health

workers espouse and practise?3. Write down the core tasks of public health, and think about how these might differ

in the future.4. Who is the public health practitioner and what do you believe to be the core

functions of a public health worker?5. Make up a table of the three levels of government in Australia and in each column

describe the public health roles and responsibilities.6. What role do NGOs play in public health?7. List and briey comment on the issues you believe will be facing public health in

the twenty-rst century.

REFERENCESAustralian Government Department o Health and Ageing, 2011. Population Health

Division http://www.health.gov.au/internet/main/publishing.ns /Content/phd-what21 February 2011.

Australian Population Health Development Principal Committee (APHDPC), Available:http://www.ahmac.gov.au/site/membership.aspx#other 25 Feb 2010.

Baum, F., 2002. Te new public health, second ed. Ox ord University Press, SouthMelbourne.

Baum, F., 2008. Te new public health, third ed. Ox ord University Press, South Melbourne.Beaglehole, R., Bonita, R., Horton, R., et al., 2004. Public Health in the New Era: improving

health through collaborative action. Lancet 363, 20842086.Bircher, J., 2005. owards a dynamic denition o health and disease. Medicine, Health Care

and Philosophy 8, 335341.Blaxter, M., 1990. Health and li estyles. avistock/Routledge, London, New York.Blaxter, M., 2007. How is Health Experienced. In: Douglas, J., Earle, S., Handsley, S., et al.

(Eds.), A reader in promoting public health. Sage Publications, London.Brown, V.A., Grootjans, J., Ritchie, J., et al. (Eds.), 2005. Sustainability and Health:

Supporting global ecological integrity in public health. Allen and Unwin, Crows Nest.Durie, M., 2004. Understanding health and illness. International Journal o Epidemio

introduction to public health - m. fleming y e. parker

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