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Clinical Review Recent advances

Public health

BMJ 1998; 317 doi: (Published 29 August 1998) Cite this as: BMJ 1998;317:584
  1. Gabriel Scally, regional director of public health (
  1. NHS Executive South and West, Bristol BS12 6SR
  • Accepted 6 May 1998

Editorials by Alderslade, Palmer Education and debate pp 587, 592, 596

Identifying particular advances in public health is difficult because, in the final analysis, success can be judged only by improvement in the health of a population. Progress is rarely, if ever, a matter of developing a technical intervention and applying it. Population health is determined by a complex mixture of genetic, environmental, and social factors, as well as individual behaviour. Achieving progress not only relies on altering a complex situation but is often something that can be judged only over a period of years (or decades)rather than months. Clearer understanding of the determinants of health and ill health, better control of hazards to health, and earlier detection or improved treatment of established disease are the building blocks of gains in public health. In keeping with the broadening scope of public health practice, the skill base of the workforce is developing beyond medicine, particularly in the applied social sciences.


This paper was based on personal experience in public health, the contemporary public health literature, and the comments of respected colleagues. The literature search had been undertaken during the preparation of a recent book.1

Life course epidemiology

The prime targets for preventive action in recent decades have been the chronic diseases that are the major causes of mortality in developed countries. The approach adopted has largely been based on the understanding of risk factors for these diseases and has focused on changing the behaviour of adults, particularly in the areas of smoking, exercise, and nutrition. A major challenge to this approach has come from the work of David Barker and colleagues who have postulated that the development of chronic disease in adulthood is programmed before or shortly after birth.2As supporting evidence has emerged, the initially sceptical response to this …

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