Elsevier

Public Health

Volume 129, Issue 10, October 2015, Pages 1369-1382
Public Health

Original Research
Beyond the Golden Era of public health: charting a path from sanitarianism to ecological public health

https://doi.org/10.1016/j.puhe.2015.07.042Get rights and content

Abstract

The paper considers the long-term trajectory of public health and whether a ‘Golden Era’ in Public Health might be coming to an end. While successful elements of the 20th century policy approach need still to be applied in the developing world, two significant flaws are now apparent within its core thinking. It assumes that continuing economic growth will generate sufficient wealth to pay for the public health infrastructure and improvement needed in the 21st century when, in reality, externalised costs are spiralling. Secondly, there is evidence of growing mismatch between ecosystems and human progress. While 20th century development has undeniably improved public health, it has also undermined the capacity to maintain life on a sustainable basis and has generated other more negative health consequences. For these and other reasons a rethink about the role, purpose and direction of public health is needed. While health has to be at the heart of any viable notion of progress the dominant policy path offers new versions of the ‘health follows wealth’ position. The paper posits ecological public health as a radical project to reshape the conditions of existence. Both of these broad paths require different functions and purposes from their institutions, professions and politicians. The paper suggests that eco-systems pressures, including climate change, are already adding to pressure for a change of course.

Section snippets

The path to the Golden Era

Public health thinking and action incorporates a theory of progress, rarely discussed and not always evident in practice. At its core is JS Mill's utilitarian notion that the purpose of public policy and of the state is, or should be, the advancement of the conditions of the many, including the most vulnerable. Utilitarian ethics, it has been claimed, remains the lynchpin for good public health policies even today.1 Realistically, not all political systems or political elites have regarded

Is the Golden Era of public health coming to end or just under strain?

The WHO has identified the top ten current causes of death worldwide, with ischaemic heart disease at the top.33 The WHO, however, does not venture into futurology or identify long-term risks. Yet there is increasingly strong evidence of major threats ahead. Rockström and colleagues, for example, have presented a much cited overview from an eco-systems perspective,34 echoing the findings of the UN's 2005 Millennium Ecosystem Assessment.35 At the same time, social analysts of health point to

The crisis of public health thinking: where are the certainties?

All of the above points to the need for a fundamental rethink in public health. It is often taken for granted that the bio-medical model of public health has primacy but in recent decades it has become a truism that an increasing proportion of health problems are found in behavioural patterns with causation linked to culture and about which bio-medicine has little to say; parallel to this is the shocking impact of persistent religious intolerance along with geo-political instabilities, both

The crisis of institutions and powers: what drives change?

Although achieving social progress requires some model of social change, it has been the simple practicality of public health measures in the past, rather than quality of their theorisation, which in large part explains their success. On the other hand public health proponents are also Enlightenment dreamers, seeking a more rational, more just and more responsible world, one achieved through better information and evidence, scientific rationality, public involvement and open debate and the

Is the public health movement addressing the right vectors?

The question of the place of public health goes much further than a pragmatic or ideological or intellectual debate. The models vary in how they conceive of progress and how they fit this new economic, social and cultural landscape. In our view, public health practice and its associated movements have been corralled into too narrow a policy terrain, forced to employ models and institutions inherited from the 20th century, or earlier, which are not fully appropriate today. Indeed, what powers

Ethical approval

None sought.

Funding

None declared.

Competing interests

None declared.

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