Introduction

What is the future for public health in the twenty-first century? Can we glean an idea about the future of public health from its past? As Winston Churchill once said, ‘The further backward you look the further forward you can see’. What can we see in the history of public health that gives us an idea of where public health might be headed in the future? (Fairchild et al. 2010)

In the twentieth century there was substantial progress in public health in Australia. These improvements were brought about through a number of factors. In part, improvements were due to increasing knowledge about the natural history of disease and its treatment. Added to this knowledge was a shifting focus from legislative measures to protect health, to the emergence of improved promotion and prevention strategies and a general improvement in social and economic conditions for people living in countries such as Australia. The same could not, however, be said for second- or third-world countries, many of whom have the most fundamental of sanitary and health protection issues still to deal with. For example, in sub-Saharan Africa and Russia, the decline in life expectancy may be an aberration or it may be related to a range of interconnected factors. In Russia, factors such as alcoholism, violence, suicide, accidents and cardiovascular disease could be contributing to the falling life expectancy (McMichael & Butler 2007). In sub-Saharan Africa, a range of issues such as HIV/AIDS, poverty, malaria, tuberculosis, undernutrition, totally inadequate infrastructure, gender inequality, conflict and violence, political taboos and a complete lack of political will have all contributed to a dramatic drop in life expectancy (McMichael & Butler 2007).

Within Australia, sub-populations still suffer adverse health effects. For Aboriginal and Torres Strait Islander people, mortality rates are higher for almost all causes of death (see Chapter 15). The major risk factors for poor health in this population include low birth weight, obesity, poor nutrition, high levels of alcohol and other drug use, poor housing and living conditions, and inadequate access to health care. These issues have been canvassed extensively in Section 2 of the book and in particular in Chapter 15.

The multidisciplinary nature of contemporary public health has become evident in the range of developments that have advanced public health during the twentieth century. Biomedical scientists have identified many of the disease-causing organisms and have developed control methods to manage them. Epidemiologists have identified the determinants that underpin many chronic diseases, enabling this information to be used to reduce people’s risk of illness. Efforts to improve the environment through clean air and water have resulted in cleaner environments than was the case 50 years ago (Schneider 2006).

Improvements such as these have advanced the health of Australians and meant that life expectancy has also increased substantially; a large part of these improvements have been attributed to public health interventions. The 10 great American public health achievements in the twentieth century are listed in Box 16.1. It is interesting to note that none of these achievements had a focus on the ecosystem or ecological sustainability. However, these issues are now firmly on the world stage, and on the public health agenda, for action in the twenty-first century.

We can clearly see the re-emergence of infectious diseases as a major challenge for public health in the twenty-first century. The challenge of HIV/AIDS has been with the community for more than 20 years, but new diseases such as swine flu, severe acute respiratory syndrome (SARS) and avian influenza (‘bird flu’) have also emerged as major diseases that may affect the public’s health into the future, and this underscores the importance of surveillance and monitoring strategies to control outbreaks of such diseases.

In the late 1990s, the National Public Health Partnership (NPHP 1998) produced an overview of the public health system and its activities. In that document, a section outlined recent key achievements for public health. Many of these achievements are similar to the United States list presented in Box 16.1. Countries such as Australia and the United States have a similar set of public health successes, in which they have demonstrated improvements in mortality and morbidity over the past century. Others on the Australian list have a more contemporary flavour, as shown in Box 16.2.

New health challenges require a changing set of strategies for public health action into the future. This is an ambitious agenda of growing urgency, with daunting challenges. Tang et al. (2005) provided the context, noting that since the 1986 Ottawa Charter for Health Promotion (WHO 1986) new patterns of consumption and communication, urbanisation, environmental changes and public health emergencies – along with accelerating social and demographic changes to work, learning, family and community life – have become critical factors influencing health. Similarly, Baum (2008) argues for public health strategies in the future that have developing supportive societies and communities as their central plank (Baum 2008). She goes on to state:

Public health challenges in the twenty-first century: balancing re-emerging issues and new developments

As we begin the twenty-first century, public health faces new challenges, yet it also needs to remember its roots. While we have discussed some of these issues in Sections 2, 4 and 5, the challenges into the future are more complex and bring together the importance of fundamental public health with the emergence of global issues such as climate change. In some countries, basic sanitation is still a major challenge for public health. There are renewed threats from infectious diseases, such as HIV/AIDS, food-borne pathogens and ecological issues that threaten the planet, such as climate change. An ageing population brings its own issues, including the associated increased costs of health care. While there has been a decline in cigarette smoking, this decline has slowed; and among adolescents, rates of alcohol abuse and illicit drug use have remained largely unchanged for the past decade (Schneider 2006). More recently, the emergence of the problems associated with physical inactivity and unhealthy diets have contributed to increasing levels of overweight and obesity in the Australian population and a range of associated chronic conditions.

In the twenty-first century, one of the major challenges for health systems and governments around the world will be the increasing cost of health and medical care. Advances in the medical model and a focus on curing health problems, rather than preventing them, have meant that more resources have been expended on medical care and treatment. However, as that type of care has become more sophisticated, the costs have also increased.

In 2003, the Institute of Medicine (IOM), in their report titled The Future of the Public’s Health in the 21st Century, noted that the United States was not meeting its potential in the area of population health. It highlighted three important issues: (1) the focus on medical care rather than prevention; (2) the attention to biomedical research rather than prevention research; and (3) the ongoing disparity in health between different population groups by issues such as race and ethnicity, gender and socio-economic status (IOM 2003). A health system for the future needs to shift its attention from funding high-tech infrastructure that supports a small percentage of the population to a continuum of care that enhances health promotion and comprehensive primary care strategies.

In developed countries, there has been a general call for better education and training of the public health workforce to meet the diverse needs of population health in the twenty-first century (Last 2010; Baum 2008; Schneider 2006; Watterson 2003).

Solutions to public health issues

A future orientation for public health is one of the strategies that Lin et al. (2007) argue for in their book on public health. Table 16.1 summarises some of the issues presented by a range of authors (Beaglehole & Bonita 2004; Hancock 2007; Lin et al. 2007; McMichael 2006; McMichael & Butler 2007; Butler & McMichael 2010; Magnusson 2009) who articulate future developments that will impact on public health. It is amazing how similar are the lists from many different authors. The focus is clearly on the big social, environmental and economic issues that have a direct and indirect affect on the health of the population. Consider the range of issues presented and the implications for public health, and complete the following activity and reflection.

TABLE 16.1 Future issues impacting on public health activity in the twenty-first century

Activity

• Consider the health issues raised in Table 16.1. What do you think are the three major challenges for public health in the twenty-first century?

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1. History and development of public health
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