Global public health: a new era



John Powles

Institute of Public Health, University of Cambridge, Cambridge CB2 2SR, England (email:



Editor: Robert Beaglehole
Publisher: Oxford University Press, Oxford, England; 2003
ISBN: 0-19-851529-4; 304 pages;
price: £27.50 (paperback)

The contributions published in the most sizeable section (part II) of this useful global survey of public health (chapters 3–11) range between two poles. Some, such as those covering the United Kingdom and North America, equate public health with the activities of formally designated and established public health professions and organizations. They don't make particularly gripping reading. More engaging are those that deal with avoidable human suffering, the institutions that generate and sustain it, and about the strategies whereby it might be reduced. The chapter on Latin America, for example, traces the contours of economic advance before the serious slowdown of the "lost decade" of the 1980s, and sets out the demographic and health parameters for sub-regional groupings of countries. Interestingly, in the low- and middle-income countries of Latin America, road traffic crashes and interpersonal violence are estimated, respectively, to make the third- and fifth-largest contributions to the burden of disease and injury. The authors seek guidance from the Pan American Health Association's list of 11 "essential public health functions" and go on to note that the effective practice of public health requires "many civil servants". However, "due to the current structural adjustment policies, there is instability and high turnover among public health administrators". Latin America "faces a decrease in the incentives for working in governmental institutions and the labour conditions in the field are deteriorating" (p. 128).

Other contributors to the book see in the Global Fund to Fight AIDS, Tuberculosis and Malaria a new push towards vertical programmes. The chapter on public health in Africa concludes that, unless the resources for such programmes "contribute to the development of infra-structure, human capacity and management processes", they are likely to have only a short term impact (p. 149).

The unravelling of economic and political institutions in the former Soviet Union, under external pressure and in the absence of adequate arrangements for institutional transition, has so far been associated with 2.5-3.0 million excess deaths (taking the already elevated mortality levels of 1991 as baseline).a The widespread indifference to this public health tragedy, both within the Russian Federation and elsewhere, makes it seem that the dictum that one can't "make omelettes without breaking eggs" has acquired a new life — this time to excuse the combination of Soviet legacies and foreign meddling that has made such a mess of the "transition" to liberal democracy. The excellent and comprehensive chapter on Eastern Europe and the former Soviet Union provides a few precious insights on why the Soviet public health system, which had dealt successfully with communicable disease, failed so disastrously in tackling chronic disease and injuries. This failure is traced to the low status of public health as a professional activity, to the vertical nature of the disease control programmes, to the stifling effects of authoritarianism in Soviet academia and to the closing of communication with western science. The idea that chronic diseases were "transitional" phenomena that did not require a concerted institutional response provided a further escape hole.

Although the lack of investment in the appropriate public health science contributed powerfully to Soviet failure, there is curiously little acknowledgement in the book of the extent to which success elsewhere has depended on advances in the sciences relevant to public health.

Soviet failures also sharpen appreciation of the importance of public trust in state institutions and public engagement to disease control efforts. The chapter on North America laments the weakening of governmental public health organizations by the anti-state policies of economic liberalism but fails to pay tribute to the vigorous engagement of the public with health and its determinants. The Californian Tobacco Control Programme, for example, which stands as a global beacon in the fight against this most deadly of enemies, receives no mention. The institutions that have enabled North America to add so substantially to the global stock of public health science receive no recognition.

Other chapters in part II cover Sweden (but not, curiously, the star public health performer, Finland), China, South Asia, and Australia and New Zealand. Part I consists of two useful introductory chapters (on the global context of public health and on global health status), while and four concluding chapters (ranging from bioterrorism to ethics and public engagement before a concluding overview chapter) make up part III.

All this in around 300 pages makes for thought-provoking reading. The incoherencies and oversights reflect the state of the field. If the editor's dream of a new "golden age" of public health is to be realized, a lot more work will need to be done.



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a Men T, Brennan P, Boffetta P, Zaridze D. Russian mortality trends for 1991-2001: analysis by cause and region. BMJ 2003;327:964.

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