For personal use. Only reproduce with permission from The Lancet Publishing Group.
• Vol 363 • June 19, 2004 • www.thelancet.com
The world is entering a new era in which, paradoxically,
improvements in some health indicators and major
reversals in other indicators are occurring simultaneously.
Rapid changes in an already complex global health
are taking place in a context in which the
global public-health workforce is unprepared to confront
these challenges. This lack of preparation is partly because
the challenges are large and complex,
workforce and infrastructure have been neglected, and
training programmes are inadequate. These problems are
biomedical research and the failure to confront and work
unhealthy behaviour patterns.
If public-health practitioners are to address national
and global health challenges effectively, the way they work
and make their work relevant to these challenges
require a major reorientation. A clear vision of what
public health is, and what it can offer, is required. To be
achievable, the vision must then be communicated not
only to its practitioners, but also to the wider policy
community, whose actions are necessary to improve the
health of the public. Here, we propose a reformulation of
public health appropriate for the global and national
health challenges in this new era.
The practice of public health
Approaches to the practice of public health are contingent
on time and place. They are distinguished mainly by
the amount of authority vested in the state and their
main disciplinary base. In terms of state involvement and
responsibility, there are two extreme approaches: the state
medicine model and the market model. The practice of
public health in the USA is an example of the market
approach. The aim of this model is to limit government
responsibility for public health and to encourage individual
responsibility for health improvement, on the assumption
that the market will respond to individuals’ demands for
goods that promote health.
The state medicine model, by
contrast, envisages a strong role for the state, encroaching in
many areas that some might consider private life. A
particular version was transposed to the Soviet Union,
where public health became a central part of state policy,
summarised by Lenin’s comment that “if communism does
not destroy the louse, the louse will destroy communism”.
Another version was seen in China for several decades after
the revolution of 1949.
WHO, Geneva, Switzerland
DSc, R Bonita PhD,
; The Lancet, London, UK
of Hygiene and Tropical Medicine
(Prof M McKee
Dr R Beaglehole, Evidence for Information and
Policy, WHO, 1211 Geneva 27, Switzerland