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What Is New In The ‘New Public Health’?
The new development in the twenty-first century is actually a return to the basic premise that human action is a crucial factor in the onset, management, and outcome of disease. The history of public health is evidence of this return to basics. Public health in the twenty-first century must certainly (continue to) deal with sanitary and environmental issues, provision of clean and safe water, and immunizations, as well as promotive and preventive services – these are crucial, but essential to what constitutes the New Public Health is also a concern with issues of equity, poverty, social structures, structural violence, and the like. These fundamental factors are responsible for a vast array of mortality, morbidity, and suffering, especially of marginalized people, in both developed and developing countries.
There is more than one definition of the New Public Health. It has been described differently by different writers, ranging from a concern for issues that have long been part of the mainstream of public health to concerns that seem to some to be rather better suited to politics and economics. The work and writings – such as The Pathologies of Power – of the infectious diseases physician and anthropologist Paul Farmer is but one example of this more comprehensive definition of the New Public Health. And so also is the People’s Health Movement.
Several books have been written entitled The New Public Health, including one by the author of this research paper (Ashton and Seymour, 1988; Baum, 1998; Tulchinsky and Varavikova, 2000). Though similar in many ways, these books provide distinct perspectives and definitions and thus demonstrate that there are divergent views about what constitute the New Public Health. However, a shared basic premise is that equity and human action, including the creation of beneficent social structures, are crucial to improving the health of human populations. As stated by Baum (1998):
The new public health strives for a fairer, more just, healthier, kinder world and recognizes that it is human action rather than physical constraint that prevents us from achieving it.
But though seemingly new, such a comprehensive understanding of public health has a long, albeit intermittent, history and it is relevant to ask: Is it ‘The New Public Health,’ or is the New Public Health, just de nouveau? Of course, Hippocrates brought the different perspectives together when considering that the way to attack ill health was through combining the messages of Hygieia and Panacea and restoring balance, not only physically but also mentally and physically (O’Neil, 2006). This was mirrored hundreds of years later, namely by WHO’s proposition that health constitutes the physical, social, and psychological well-being of individuals and not merely the absences of disease – a definition that is inimical to that of the New Public Health.
By the nineteenth century in Northern Europe, other considerations drove the reinvention of public health, increasingly focused on what came to be known as ‘sanitary science.’ For although the Romans had introduced sewers and bathhouses 2000 years before, the Industrial Revolution, rapid urbanization, and massive slum development created environmental conditions under which epidemic disease flourished. The response was an environmentally based public health, which was born in Liverpool, England in 1847 with the appointment of the first fulltime city Medical Officer of Health, Dr. William Henry Duncan, and was driven centrally from London by sanitary reformer Edwin Chadwick. At the end of the eighteenth century, Germany had toyed with the idea of medical police, but in Europe, at least, the then ‘new public health’ emerged as an overwhelmingly medical discipline, with a strong initial environmental focus.
Safe water, effective sanitation, paved streets, trash collection, and improved housing were the tools of the trade for practitioners at this time. In England, medical officers of health worked closely with sanitary inspectors and borough engineers, supported by legalization such as the Liverpool Sanatory [sic] Act of 1846 and national Public Health Acts in 1848 and 1875.
But in nineteenth-century England, France, Germany, and elsewhere, there were additional and somewhat different efforts that may more directly be seen as the precursors of what today many call the New Public Health.
The proponents of these efforts, the so-called ‘social theorists of health,’ were guided by the following principles (Trostle, 1986):
- Health is a social and cultural concern.
- Social, cultural, and economic conditions have an important effect on health and disease.
- Social as well as individual measures must be taken to promote health and prevent disease.
Included here must be the work of William Farr (1807–83) in the British Registrar General’s office, who noted that different classes of the population had very different rates of mortality. He then became committed to social reforms and to using statistics as a means to advance these reforms. In 1845, George Engels published the Condition of the Working Class in England, in which he clearly analyzed and showed the relationship between social structure and physical illness. John Snow (1813–58), the father of modern epidemiology, must also be mentioned, as he initiated a so-called ‘shoe-leather’ approach to understanding a cholera epidemic in London, noting the cause to be people’s proximity to and need of collecting water from the (contaminated) Broad Street pump – whose handle he broke to stop the epidemic (Trostle, 1986).
In France, we must take note of physician and statistician Louis-Rene´ Villerme´ (1782–1863), who investigated the working conditions for child laborers in the silk mills of Mulhouse, which led to the passing of the law of 1841 establishing increased protection to children in industry.
No doubt the best-known forefather of the New Public Health was the German pathologist Rudolf Virchow (1821–1902), also called the father of social medicine, who stated, ‘‘Medical science is by its very nature social science.’’ He made significant discoveries in medicine, and he also designed and supervised the Berlin sewage system, but he is better known for his report of the typhus epidemic in Upper-Silesia in 1848, in which he blamed the government for the epidemic and famine, and prescribed education, freedom, and prosperity as lasting solutions to the problems rather than the short-term palliatives of food aid or new drugs. He wrote: ‘‘If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life’’ (qtd. in Trostle, 1986). In The Medical Reform (1848), he proposed that medicine should be reformed on the basis of four principles:
- that the health of the people is a matter of direct social concern;
- that social and economic conditions have an important effect on health and disease;
- that these relations must be subjected to scientific investigation; and
- that the measures taken to promote health and to combat disease must be social as well as medical.
This phase (or phases) of the public health movement lasted into the 1870s, when a more individual focus on hygiene and behavior as the interface between biology and the environment emerged. This became possible as a result of the household availability of soap and water on the one hand, and the insights offered by the germ theory of disease on the other – the ushering in of the so-called ‘bacteriological era,’ detracting attention from the sociopolitical and economic factors of public health, which did not resurface until after the middle of the twentieth century.
As the most pressing environmental problems were brought under control, at least in the developed world, action to improve the health of the population moved on, first to personal preventive medical services such as immunization and family planning, and later to the development of community and school-based nursing and prevention services. This phase was marked by the increasing involvement of the state in medical and social welfare in the United Kingdom and elsewhere. In particular, the countries of the British Empire largely adopted the emergent model from the mother country, and, for better or worse, the footprint and fossil layers of this are still evident today in the countries of the British Commonwealth.
By the 1930s, the new factor that came into play was the possibility of effective and reliable treatment with the discoveries of insulin, the sulfonamides, and penicillin. However, Thomas McKeown is the most prominent commentator to have drawn attention to the small contribution made by therapeutic medicine to changes in life expectancy before this time, in comparison to the impact from environmental measures, improvements in the standard of living, and behavior changes (in particular the adoption of birth control and the move toward smaller family size) – the social determinants of disease.
A sense of post hoc ergo proctor hoc (‘after this, therefore because of this,’ or the cause and effect fallacy) began to dominate understanding of the relative contributions of preventive efforts versus treatment over the next 30 years. The apparent demise of infectious diseases in the developed world coincided with the therapeutic revolution in progress. By the end of World War II, health-care systems increasingly became built around the hospital as the centerpiece; departments of public health were progressively weakened as power and resources shifted into the new ‘cathedrals,’ especially the teaching hospitals.
The origins of the ‘new’ New Public Health can be dated to a cascade of writings, arguments, and initiatives that began in the early 1970s (Ashton and Seymour, 1988). By this time, the therapeutic emphasis was being increasingly challenged, both on grounds of absolute cost but also in terms of equity and cost-effectiveness. In the United Kingdom, a dormant research interest in inequalities in health was reawakened by the likes of Townsend and Tudor-Hart, who demonstrated how the contemporary models of health care were failing the most disadvantaged.
Possibly more significant was the Black Report (1980) of the expert committee on health inequality, chaired by Sir Douglas Black. The establishment of the expert committee on health inequality was stimulated by a 1976 article (‘Dear David Ennals’) by Richard Wilkinson, a central figure in contemporary New Public Health. The Black Report found that the main cause of these inequalities was poverty, and that to attack these inequalities, the gap between the upperclass and lower-class peoples must be narrowed.
Since the initial report was published, material/ structural explanations for health inequalities, operationalized often as education, income, housing, and so on, have largely dominated the literature. The impact of ‘social relations and practices’ on ‘health inequalities’ is being explored by studies concerned with context. Over the last 10 years, this body of research has been largely driven by a search for explanations of the relationship between social inequality and health/disease (Frohlich et al., 2001). The recently (2005) established UN Commission on the Social Determinants of Health, headed by Michael Marmot is a verification that these factors, basic to the concepts inherent in the New Public Health, are being taken seriously.
Illich argued powerfully that, far from being part of the solution, the activities of the medical profession in producing iatrogenic illness were often part of the problem. The growth of feminist ideas and alternative lifestyles in the 1960s led to growing demands to reclaim health as a legitimate area for layand self-help. An excellent example of this was the establishment of the Boston Women’s Health Book Collective in the late 1960s in the United States and its book Our Bodies Ourselves, first published in 1973. A watershed was the publication in 1974 by Canadian Minister of Health Marc Lalonde of a government report, A New Perspective on the Health of Canadians. A community diagnosis for Canada, this report focused attention on the fact that much of the new burden of noncommunicable disease resulting in premature death and disability was preventable, and that a public health approach was as relevant in addressing these issues as it had been with the infectious diseases. The Lalonde Report was a major stake in the ground for the New Public Health. Subsequent building blocks were not long in coming.
The Declaration Of Primary Health Care
In 1978 at a meeting in Alma Ata (in the former Soviet Union) sponsored by the World Health Organization and UNICEF, the Declaration of Primary Health Care (PHC) was passed, in which the development of a public health model of primary health care was seen as being central to effective health development. This Declaration fed into the growing consensus being mobilized by the World Health Organization, and that found its expression in the WHO’s Global Strategy of Health for All By the Year 2000. This was accepted as WHO policy in 1981 by the 34th World Health Assembly. According to the Strategy, the task was to ensure that by the year 2000 all people in all countries should have at least such a level of health that they would be capable of working productively and participating in the social life of the community in which they lived. The means to achieving this that were put forward were:
- promotion of lifestyles conducive to health,
- prevention of preventable conditions, and
- rehabilitation and health services.
The Alma Ata declaration identified eight essential elements of primary health care using a public health model:
- health education,
- food supply and proper nutrition,
- safe water and basic sanitation,
- maternal and child health care,
- prevention and control of the most important and significant causes of ill health locally,
- basic treatment of health problems, and
- provision of essential drugs.
Mental health was added later.
In terms of ushering in the New Public Health, special attention must be given to the five principles of PHC:
- community involvement,
- focus on preventive care,
- appropriate technology,
- intersectoral approaches.
One significance of these principles was that a discussion of equity (and social justice and human rights) was legitimized as an appropriate topic of public health discourse, and thus heralded a New Public Health.
Healthy Public Policy And Health Promotion
The WHO’s work galvanized practitioners around the world, and the outcome was two important, complementary concepts – those of healthy public policy and health promotion. Healthy public policy, which is particularly associated with the work of Milio in the United States, sought to make explicit the health consequences of policies in different domains of public life; health promotion, a concept particularly associated with the work of Kickbusch at WHO in Copenhagen, sought to put flesh on Lalonde’s concept of the health field in terms of how health was to be improved by adopting a ‘whole systems’ approach. The Ottawa Conference on Health Promotion in 1986 identified five major strands for the New Public Health:
- Building public policies that support health. This recognized that health promotion went beyond health care and made health an agenda item for policy makers in all areas of governmental and organizational action. Health promotion required that the obstacles to the adoption of health-promoting policies be identified in nonmedical sectors, together with ways of removing them. The aim was to make the healthier choices the easier choices.
- Creating supportive environments. Health promotion recognized that both at the global level and at the local level, human health was bound up with the way in which we treat nature and the environment and cross-linked to the increasingly important agenda of sustainability. Societies that exploit their environments without attention to ecology reap the effects of that exploitation in ill health and social problems. Health cannot be separated from other goals and changing patterns of life. Work and leisure have a definite impact on health. Health promotion must therefore create living and working conditions that are safe, stimulating, satisfying, and enjoyable.
- Strengthening community action. Health promotion works through effective community action. At the heart of this process are communities having their own power and having control of their own initiatives and activities. This means that professionals must learn new ways of working with individuals and communities – working for and with them, rather than on them. In the words of one Liverpool community member: ‘‘Professionals being on tap, not on top.’’
- Developing personal skills. Health promotion supports personal and social development through providing information, education for health, and helping people to develop the skills that they need to make healthy choices. By doing so, it enables people to exercise more control over their own health and over their environments, making it possible for people to learn throughout life to prepare themselves for all of its stages and to cope with chronic illness and injuries. This has to be assisted in the school, at home, at work, and in community settings.
- Reorientation of health services. The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, medical care workers, bureaucracies, and governments as coproducers of health. They must work together to reorient health care toward a system that begins with a population orientation, tackles issues of inequalities, and provides care in the most appropriate ways depending on the local health issues.
Healthy Cities Initiative
One of the most productive spin-offs of work on the New Public Health has been the World Health Organization’s Healthy Cities Initiative. Despite its important role of mobilizing and galvanizing public health globally during the half-century of its existence, WHO has struggled to claim major successes apart from the eradication of smallpox, not least in the more developed parts of the world. Translating the rhetoric of ‘health for all’ into action was proving challenging. It was in Toronto in 1984 that the idea of a ‘Healthy Cities Project’ first surfaced at a conference titled ‘Beyond Health Care.’ The original intention behind the Healthy Cities Project was that, by bringing together a small number of European cities to collaborate in the development of urban health promotion initiatives, it would be possible to promote models of good practice that were seen as relevant by other municipal administrations and would be picked up and copied or developed.
By concentrating on concrete examples of health promotion based on a commitment to equity, community participation, and intersectoral action, the Healthy Cities Project was seen as marking the point at which the Health For All Strategy was taken ‘off the shelves and into the streets of European cities’ (Ashton, 1986; personal quote). The demographic justification for the urban focus was that within a few years a majority of the world’s population would be living in cities.
The first formal activity of the Healthy Cities Project took place in Lisbon in April 1986, when participants from 21 cities met to explore ideas about the healthy city and ways in which the project might usefully develop. The initially modest intentions for a project of four to six cities had to be changed to accommodate the enormous interest in the project, and by 1988, 24 European project cities were involved, together with as many as 100 other European cities in national networks and networks of cities in Canada, Australia, and New Zealand. Subsequently, this engagement spread throughout the world (Figures 1a, b, 2, and 3).
The idea of a healthy city incorporated the belief that the city as a place that shapes human possibility has a crucial role to play in determining the health of those living in it, in essence, an ecological concept. According to Hancock and Duhl, two of the founders of Healthy Cities:
a healthy city is one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to support each other in performing all the functions of life and in developing themselves to their maximum potential (Ashton, 1986).
At its most fundamental, a city is unhealthy if it cannot provide its citizens with the basic necessities for life:
- safe and adequate food,
- a safe water supply,
- sanitation, and
- freedom from poverty and fear.
However, these alone are insufficient, and most people expect much more – a range of environmental prerequisites, economic, physical, social, and cultural. In the spirit of Alma Ata, cities should be able to address the common health problems affecting their inhabitants. Today these include many behaviorally related issues, such as alcohol, drugs, tobacco, HIV and other sexually transmitted infections, obesity, violence, and death and injuries from external causes, including road traffic accidents.
The Healthy Cities Project, as defined by WHO, contained five major elements:
- The formulation of concepts leading to the adoption of city plans for health that are action-based, and that use Health For All health promotion principles and the 38 European targets as a framework.
- The development of models of good practice that represent a variety of different entry points to action depending on cities’ own perceived priorities. These could range from major environmental action to programs designed to support individual lifestyle change, but illustrating the key principles of health promotion.
- Monitoring and research into the effectiveness of models of good practice on health in cities.
- Dissemination of ideas and experiences between collaborating cities and other interested cities.
- Mutual support, collaboration and learning, and cultural exchange between towns and cities.
The program that was built identified seven specific tasks for participating cities:
- The establishment of a high-level, intersectoral group bringing together the executive decision makers from the main agencies and organizations within the city. The purpose of this group was to take a strategic overview of health in the city and free their organizations to work with each other at every level.
- To establish an intersectoral officer or technical group as a shadow for the executive group to work on collaborative analysis and planning for health in the city.
- To carry out a community diagnosis for the city down to the small-area level, with an emphasis on inequalities in health and the integration of data from a variety of sources, including the assessment of public perceptions of their communities and their personal health.
- The establishment of sound working links between the city and the local institutions of education at school and higher education levels. Part of this work involved the identification of appropriate urban health indicators and targets based on the Barcelona criteria:
- that they should stimulate change by the nature of their political visibility and impact through being sensitive to change in the short term and being comparable between cities;
- that they should be simple to collect, use, and understand, and be either directly available now or available in a reasonable time at an acceptable cost; and
- that they should be related to health promotion.
- That all involved agencies should conduct a review of the health promotion potential of their activities and organizations, and develop the application of health impact statements as a way to make health promotion potential in different policy areas explicit. This includes the recognition that within a city there are many untapped resources for health, both human and material.
- That each city would generate a great debate about health within the city that involved the public in an open way and worked actively with the local media. This could include the generation of debate and dialogue using, for example, the interfaces that exist with the public, such as schools, community centers, museums, libraries, and art galleries. A city’s own public health history was often seen itself as being a powerful focus for debate and learning, and the development of effective health advocacy was also seen as a priority.
- The adoption of specific interventions aimed at improving health, based on Health For All principles and the monitoring and evaluation of these interventions. The sharing of experience between cities and the development of multiple cultural links and exchanges was seen as promoting one fundamental goal of the World Health Organization: the promotion of world peace and understanding, without which all health is threatened. The core values of a commitment to reducing health inequalities and working toward global sustainability pervaded the thinking of the Healthy Cities Planning Group.
Healthy Cities work has since spawned public health action in many other settings, such as schools, hospitals, workplaces, prisons, marketplaces, and sports stadiums. The power of the approach has been seen to lie in providing an integrating context that is both social and environmental in which public health practice may be taken forward in a holistic way.
Since 1988, the importance of tackling the root causes of international tension and supporting international solidarity has become obvious to most people. The destabilization of the world’s political forces, which was symbolized by the terrorist attacks on the World Trade Center in New York in 2001, has highlighted how small the planet is and how important it is to find ways of coexisting. Healthy Cities may still provide a policy option for the way forward. In 1848 in Europe, rapid urbanization had produced a crisis. In that year of revolution, public health reforms at the city level – galvanized in the British case by the work of the Health of Towns Association – diffused a situation that was on the brink. Faced today with megacities in the developing world, often with 50% of their populations under the age of 20, and disaffected youth giving rise to new types of political movement, the second wave of urban public health reform may well provide the key to the planet’s future.
The historical review presented in this research paper verifies that the contemporary embrace of the New Public Health is evidence of the return to the fundamental idea of the impact of social action and social context proposed by the pioneers in the field of public health. And in this era of growing disparity, such an embrace, the embrace of the ‘New’ Public Health, is more important than ever.
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