Intended for healthcare professionals

Editor's Choice

Public health: what’s the big idea?

BMJ 2012; 345 doi: (Published 29 August 2012) Cite this as: BMJ 2012;345:e5808
  1. Trevor Jackson, deputy editor, BMJ
  1. tjackson{at}

It is refreshing, in an age of managerialist tinkering, to come across a grand vision, the rejection of the narrow language of individualism and choice in favour of the big picture. This is what Tim Lang and Geof Rayner offer in their invited essay (doi:10.1136/bmj.e5466), in which they argue that public health thinking needs an overhaul and a new model that is fit for the 21st century. Tracing the public health project back to its 18th century origins, they examine the shifting definition of the term. What, they ask, can a model that focused on sanitation, medical infrastructure, and education in personal hygiene say about the public health challenges of today? The challenges they cite include escalating climate change, a world population of nine billion, “mass consumerism shaped by globalised media,” and “the global co-incidence of mass hunger and mass obesity and non-communicable disease.”

Public health, say Lang and Rayner, needs the vision of a Darwin, a Beveridge, or a Roosevelt: “big thinking about the nature of life, good societies, order, and change.” The model they propose is ecological public health, which demands “a new mix of interventions and actions to alter and ameliorate the determinants of health.” This model seeks to achieve “sustainable planetary, economic, societal, and human health; and the active participation of movements to that end.”

But what exactly does this big idea mean? “Telling families who live in poverty that they should make healthy choices ignores the conditions that prevent them doing so,” say Lang and Rayner, in one example. “What is needed is a world in which fitness and sustainable diets are built into daily lives.”

How do we get there? Facing up to corporate power and cracking down on the food and drink industries—instead of inviting them to enter into partnership with public health in ill thought out responsibility deals—might be one way, as Gerald Hasting argues in a related article on (BMJ 2012;345:e5124). “Far from tackling and challenging the corporate marketers, we seem set on doing their bidding,” says Hastings. “We work with them on the Drinkaware Trust, in full knowledge that this makes us no more than junior executives in a textbook example of stakeholder marketing.” Instead, say Lang and Rayner, “Public health must regain the capacity and will to . . . dare to confront power.”

The need to confront power comes across strongly elsewhere in this week’s BMJ. Gerry Rayman and Anne Kilvert describe the crisis in diabetes care in England (doi:10.1136/bmj.e5446), where we are far from achieving a world class diabetes service by the 2013 target. What has gone wrong? With type 2 diabetes rising dramatically, say Rayman and Kilvert, “the responsibility for providing care for most patients with diabetes has fallen to general practitioners and practice nurses. However, in many areas the infrastructure to deal with the load is inadequate.” And in their editorial on the latest report from the Commission on the Social Determinants of Health (doi:10.1136/bmj.e4881), David Hunter and James Wilson confront the difficulties of tackling avoidable health inequalities and giving all people “the freedom to live lives they can value.” How should doctors seeking to make progress in these spheres act? Lang and Rayner have a suggestion: “Specialists need to be noisy and to build alliances.”


Cite this as: BMJ 2012;345:e5808


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