Public health theory in Scotland has paid little attention to the enormous changes which have taken place in society. It's time for a radical re-think, say Donald Coid and Desmond Ryan
Theories of public health appear to be carved in tablets of stone rather than adapted to the society that has to apply them. Deindustrialisation confronts Scotland with the need for a basic shift in public health thinking.
An individual who persists in repetitive but unproductive behaviour needs professional help. Similarly, the public health function in Scotland, one of Europe's best educated but least healthy societies, is in line for therapy. The review of the public health function in Scotland, by the Office for Public Health in Scotland, is the fourth in 13 years. Will this finally break through into an understanding of public health medicine appropriate to a society living through a deindustrial revolution?
Scotland needs a public health profession able to make productive sense of what has been going on in its past. And there is a lot to learn from history.
Carlo Cipolla divides the pre-modern era - the millennium-and-a-half from the fall of Rome to the industrial revolution - into three phases.1 In the so-called Dark Ages, there were few cities, and practitioners of the healing arts were either clergymen or quacks. From the 13th to the 17th centuries there was a revival of prosperity and a renaissance of classical learning in European cities. Universities were established, guilds emerged and physicians asserted themselves as a reputable group. They emphasised their authority through reference to classical texts, severing their ties with the clergy, and distancing themselves from the quacks.
In the third period, from the late 17th century to the emergence of modern medicine in the mid-19th century, medical opinion paid progressively less attention to the classical texts and more to reading the book of nature.
Taking Glasgow as his case study, Sydney Checkland divides the modern era - the century- and-a-half of modern medicine's response to industrialisation - into four phases.2 From 1830 to 1900, health intervention was targeted at infectious diseases and took the form of a material infrastructure to secure sanitation through water supply. By 1900 adult mortality had turned downwards, but infant mortality remained high. Adult physique in the deprived areas was so poor that city men were rejected en masse for service in the Boer War.
From 1900 to 1948, prevention became more intrusive, moving into maternity and child care, then into more general dietary concern and on to a concerted attack on TB.
After the Second World War, the state finally took responsibility for all illness, with the establishment of the NHS. At the same time, the medical profession suddenly produced a vast range of bio-medical therapies. This was followed by the loss of performance in the British economy as it dived into deindustrialisation in the 1970s.
Policy in this phase has been more concerned with reducing health costs than securing health gain. Biomedical therapies multiplied further, but general managers were politically promoted to rein in their costs to the NHS. The health divide has widened, and some vital statistics have worsened for the first time in a century.
Public health is an interacting system. Its main factors are: the state of knowledge; the state of the socio-economic organisation and the health environment; and how prepared a political elite is to act on the health environment in the public interest.
The giants of Scottish public health - James Burn Russell, Henry Littlejohn, William MacKenzie, John Boyd Orr - made an impact because they understood that their role in the system was not merely technical and professional, but also political. They saw that people got sick and died because of the circumstances in which they lived. Being an effective spokesman for public health meant persuading people to act in the public interest. The powerful needed to be shown how apparently unconnected things were in fact connected. The relationship of malnourished children to the 1930s system of agricultural prices is a case in point.3
The public health system is a historical system subject to change. Do we need a health theory for each form and stage of society? We think so, and believe that the phase we are entering - deindustrialisation - poses a major challenge for public health medicine.
The public looks to public health professionals to act on relevant knowledge. Public health should be the part of the healthcare system that finds out how people are becoming ill in the first place, rather than trying to improve our capacity to cure them.4
British industrialisation was a health catastrophe. The medical profession was in a primitive state, with little scientific knowledge. Incomes and housing were left to market forces, and effective action had to come through attention to the environment, especially through sanitary improvements. It took a century for the British to develop a public health theory with which to tame the forces of industrialisation.
Now we are in a position analogous to those days. Industry is no longer at the centre of our cities. Increasing numbers of city dwellers find themselves marginalised, where social conditions and life chances are disconnected from macro-economic trends.5
Hammered by 'jobless growth' in the economy and 'social disinvestment' in the welfare state, what used to be known as the working classes are separated from the economic basis for their traditional strategies of survival.
The 'fever nests' of the age of cholera have become today's 'problem estates'; tobacco and alcohol the pathogens. The illnesses may be different, but the mortality and morbidity have similar patterns. Deindustrialisation is a new health catastrophe in the making.
This phase finds the public health profession once again in a primitive state. The reluctance to acknowledge that the first industrial nation has become post-industrial points to an anachronistic view of public health.
Public health still keeps the covenant with the sacred tablets of biomedicine. It has not yet learned to read the new pattern of self-harming health behaviour, where people 'know' but do not act on what they know. It is not asking why Scottish children have such low self-esteem, even though low self-esteem and self-harm are strongly associated.
Britain's apparent loss of the formula for successful family-building has unimaginable societal health implications. But where is the public health work on this?
The declining social role of religion, the most significant source of future orientation, self-discipline and social support in any society, should be of central interest to public health researchers. The simultaneous loss of the economic base, the family and organised religion has huge health implications - but again, where is the evidence of work?
Up the garden path
The public expects the medical profession to fulfil its role as guardian of public health by acting on relevant knowledge. The first indispensable skill is to spot the point of transition between one phase of public health circumstances and another. History teaches us that this change is less likely to be a scientific than a socio-economic phenomenon: the growth of trade, the rise of manufacturing, the needs of nations at war.
The theory of public health has to be an inductive, historical one, more like a theory of gardening than a theory of gravity. Each garden is unique: the gardener has to learn how to exploit its potential and compensate for its weaknesses. Scottish public health needs to study its garden anew; for the post-industrial garden is a wholly new ecological system.
What if self-esteem turned out to be the vitamins of post-industrial public health?
Any review of the public health function must begin from a point of social reality. To do this it may be necessary to take the tablets of yesterday's public health law back up the mountain and have them rewritten.
1 Cipolla C. Public health and the medical profession in the Renaissance. Cambridge University Press, 1976.
2 Checkland S. British urban health in general and in a single city. Health care as social history: the Glasgow case. Checkland O and Lamb M (ed). Aberdeen University Press, 1982.
3 Orr J. Food, health and income. Macmillan, 1936.
4 Lancet Editorial, 1994 343 (8895): 429-30
5 Wacquant L. The rise of advanced marginality: notes on its nature and implications Acta Sociologica 1996 39 (2): 121-40