It is often difficult to explain to people what exactly public health is. Many think it is purely focused on activities such as stopping people smoking or keeping water supplies clean. It is, however, a much broader concept – at least as practised within the UK environment over the last decades. In Cambridge, our Public Health Network of 900 or so researchers across many different disciplines uses this definition, adapted from Sir Donald Acheson’s 1998 definition:
…the science and art of promoting and protecting the health and well-being of whole populations”
Some people have used a river analogy to explain how public health works for the health and wellbeing of whole populations, now and into the future1. It’s not perfect as an analogy but it’s a stab at conveying our approach – something that can be pretty challenging.
In the analogy the river arises as a narrow stream, flows onward and gradually grows and broadens, just as in the classic geographical model you may have seen at school. As it flows onward the river becomes dangerous and often polluted. Things happen to push people into the river or lure them close to the slippery edge. Many people do fall in. Lots of them are struggling and lots are swept downstream, where many are drowning. But some people avoid the slippery banks. Others jump in freely but are able to swim and come out of the river unscathed.
Public health research
Much current health related research looks at how we can drag many drowning people out of the downstream areas of the river, without reference to the wider picture. Often, health related research doesn’t look at why people fall into the river in the first place or how we might enable them to get out earlier before they are in real trouble.
Public Health is about looking at the whole river and the land all around – the topography. We assess the evidence about the forces pushing people into the river and the elements that make them susceptible to being lured to the riverside. We measure the pollution in the river and how many people are going in. We look at whether the people can swim, how we can pull people out, and whether in fact they are pulled out rather than just pulled close to the edge, only to slip back. We look at what to do to support those who cannot be saved, and we explore how any particular action might affect those already in the river, those who may be pushed or lured in and those who seem to be at a safe distance from the river.
To do this requires a range of different types of research. All of it has to be grounded in studies of populations – whether out there in the community or in a clinical or social care setting. Our research is integrated with evidence from basic and clinical research as well as the wider social and behavioural environments. This wider contextual research enables us to translate findings from specific settings into evidence to underpin interventions or actions to improve health. And we need the wider understanding of population health to balance our findings with all the other evidence pouring in from so many sources.
Why is a public health research approach needed?
The world is not infinite and human and global resources are challenged in many ways. The successes of public health, social investment and medical advances have created ageing populations across the globe with massive population increases and persistent and widening inequalities. And problems such as dementia, comorbidity and poor mental health mean a miserable end of life for many. In high income countries, this end is very expensively delivered.
We have to find solutions to sustaining our population in good health for as long as possible, including supporting better deaths. We are dying at older ages, of non communicable diseases such as heart disease, cancer, dementia, all of which need to be handled in an affordable, equitable and sustainable way. Public Health research connects biomedical advances to population health through a range of disciplines – and this is how we are finding solutions. This research has to influence political, economic and social systems in order to get results.
What do we need?
We need to maintain and invest in excellent public health research, with feedback loops telling us what is important in population health to generate new basic research. We also need public health leaders who can understand the complicated messages from ground breaking research and who can translate it in the context of the global picture for population health, in order to influence decision making and how money and resources are allocated.
Making a difference
Epidemiological research has for too long focused on fine details without rolling up its sleeves to look at how we can use our findings to make a much greater difference. Sometimes, we have allowed our findings to become part of a move towards individualised approaches to reduction of risk for individuals and not worked hard enough to promote the knowledge that this widens inequalities and moves efforts for prevention away from societal actions. So, we need more integrated research which includes efforts to challenge and test different approaches and looks at how evidence for whole population health and wellbeing can be used to make the changes that will, in the short and longer term support greater population wellbeing.
That’s why, as well as research across the spectrum, we need a new generation of global public health leaders trained to influence governments and global businesses. Economic and market conditions across the globe are enormously powerful drivers of health and well-being – or harm – and so our public health leaders need to influence the decisions that set market conditions, aiming to contribute to social benefit and lessen harm. They need to be alert to the sustainability and long term health and wellbeing of people across the planet.
The need is urgent
Populations are changing and global wellbeing and health are jeopardised in major ways – migration, conflict, epidemics of non communicable diseases in LMICs are a few of the risks that we face.
We already know a lot about what works to boost health. We can show, for example, that dementia is getting less common in the current older population in the UK. This is probably because of earlier societal investment in education, living environments, health services and the welfare state for the whole population, with specific measures to boost early life health, deliver education, and introduce smoking legislation which delivered dramatic drops in heart disease and stroke.
But these advances are not secure. In many ways, UK society is moving backwards: the persistent inequalities that play out across the lifecourse, the obesity epidemic with fast food outlets targeting poor areas; dangerous patterns of alcohol consumption; and air quality under threat are just a few examples. The UK is not alone in this. As a public health community which could act independently as an advocate for the global population, we must become more effective on the global stage in ways that have greater influence on the ground.
National Collaborating Centre for Determinants of Health: Moving Upstream (2014)