Personal Views

We need strong public health leadership

BMJ 1997; 314 doi: (Published 01 March 1997) Cite this as: BMJ 1997;314:685
  1. Sian Griffiths,
  2. Klim McPherson
  1. director of public health and health policy in Oxford
  2. professor of public health epidemiology in London

    Over 13 000 people attended the annual conference of the American Public Health Association last November in New York. Packing into the opening ceremony in the Coliseum, the bleak municipal surroundings buzzed with the theme of “Empowering the Disadvantaged.” We learn of the challenges of social injustice and that young men in Harlem have a life expectancy lower than their counterparts in Bangladesh. Many of the themes resonate with those in British public health. The Guardian had run an article the week before which described public health in Britain as being in crisis–“divided by tribal rivalry, the doctors beleaguered and demoralised, there is no clear voice speaking up for the nation's health,” it had said. Was it any better in the United States?

    From an outsider's perspective it was not just the number of people who had gathered at the conference in New York that was impressive–but that they had gathered under one umbrella organisation. The association represents more than 32 000 members from 77 disciplines in public health and related fields. Its main areas of activity include setting public health standards, public health education, scientific debate, and providing professional opportunities. Networking is integral to the association's way of working, which consists of many strong interest groups–for example, in mental health, in epidemiology, in tobacco and other drugs, and in public health nursing.

    Clearly public health in the United States faces many challenges. State departments are still involved in provider activities for deprived groups. For those who are insured managed care does not always include prevention and is increasingly becoming merely a means of insurance companies brokering pay for providers. The gap between health status for rich and poor has never been greater. These themes are not unfamiliar in Britain, in particular the need for strong public health leadership.

    In Britain the 1974 social reforms distanced local government from the NHS, dividing responsibilities for environment, housing, and education from any delivery of health care. Then within the NHS the introduction of managed units and then trusts caused the provider aspects of public health to become increasingly fragmented and distanced from public health departments within health authorities. But health authorities still have responsibility for the health of their population and primary care provides prevention as well as care. The greater availability of equitable health care is fundamental, and the position of public health within the NHS has greater potential levers. The perception, however, that public health departments are linked to purchasing creates ambiguity. While able to promote the broader role of health authorities (argued by some to be public health bodies), by their engagement in issues outside their healthcare contracting culture, the effectiveness can also be compromised by corporate managerial responsibility and by divided allegiances among public health practitioners.

    As currently structured, largely as a medical specialty with medical leadership, a false separation between professional identities can occur to the detriment of public health practice. This exacerbates the dispersion of those engaged in the practice of public health, with fragmentation across the divides of trusts, the primary and secondary interface, local government, and academic institutions. The barriers raised between professional interests committed to public health make working together more difficult.

    With the possibility of a minister of public health, public health in Britain should take a leaf from the American Public Health Association's book. The various organisations should consider coalitions around key issues. We, in a British Public Health Association (whatever it might turn out to be), need to find a way of maintaining professional integrity in our multidisplinary bodies without compromising the appropriate role for public health. The diversity of groups on both sides of the Atlantic are agreed on one thing–the importance of advocacy in promoting the population's health and the urgent need for public health leadership. Public health is more than health authority purchasing, and the specific competencies and contributions of all public health professionals and their education and development needs should be properly defined. Then we might raise the public profile and understanding of public health, develop local networks within our communities, and create a national umbrella organisation capable of influencing the political agenda.

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