…Exploring the Public Health Approach
This article was written by one of our contributors; Ireland-based medical doctor – Ciara Kelly
With the rapid rise in health and wellness trends over the last few years, the phrase ‘Prevention is better than cure’ has been used many times across mass and social media. But in the real world off – line, what does that mean, and how is it applied in day to day clinical practice? Good question. As a medical doctor working in Ireland, I’ve spent the last three years of my training in hospital-based medicine, and I’ve seen it save lives every single day. It’s what happens at the front line of our healthcare services, and is predominantly based on a reactive, or cure-focused, approach. Patients attend for in- and out-patient care with various symptoms, signs, medical and/or surgical conditions, and their hospital team formulates a differential diagnosis and a plan of management and/or treatment. It’s fast-paced and exciting and in that reactive context at the individual level, it works. So where does the concept of prevention come into play? This is the question I began to ask myself during my hospital training, and what led me to pursue public health as a career speciality.
What is public health, and what does it do?
My favourite definition of public health medicine is from Sir Donald Acheson – ‘the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society’. It is based on an upstream, population – level approach to health in society. From a doctor’s perspective, it’s less about using your stethoscope and prescription pad day to day – instead, it involves the day to day use of a variety of skills – leadership, advocacy, data analysis, research interpretation, communication with the public, teamwork and collaboration, presentation, infectious disease surveillance, prevention and control and quality improvement – and that’s not an exhaustive list! No two days are the same. The work of public health professionals spans many domains of healthcare – health protection from infectious (communicable) diseases at national and international levels, monitoring and improvement the health of the population, health service improvement and health intelligence.
It is a ‘bigger picture’ approach to the health and well-being of our patients as healthcare professionals. A major role of public health professionals is to try to create an environment where the healthy choice is the easier choice, through addressing the fundamentally important societal determinants of health, which don’t get a lot of air-time on social media! These include, for example, your income, level of educational reached, socio-economic status, home and community environment, occupation and access to healthcare services. Healthcare professionals, medics and non-medics alike, should know about the role of public health professionals. Why? Well, there are many reasons, but let’s look at the big two.
First, in Ireland and the U.K., our populations are changing – getting bigger yes, but more importantly, older, and while we might be living longer, we don’t seem to be living better. In Ireland, 65% of persons over 65 have two or more chronic illnesses 1 (also known as non-communicable diseases (NCDs), such as type 2 diabetes, cardiovascular disease, cancer and dementia), and in the U.K. NCDs affect 58% of those over the age of 60 2 . The World Health Organisation estimates almost 70% of deaths worldwide are due to these diseases 3 , the rise of which is driven by four major risk
factors – tobacco use, physical inactivity, excessive consumption of alcohol and unhealthy diets. All four of these risk factors are lifestyle behaviours which can be modified and optimised for the better to prevent or at least reduce this rise in chronic disease and improve our healthy life expectancy so that we live both longer and better.
The second major reason we should all know about and promote a public health approach is that the rise in technology and social media has led to widespread dissemination of many health-related myths. These have spanned from those around what foods we ‘should or shouldn’t’ eat as part of a healthy diet to scare-mongering social media campaigns about vaccination side effects. Despite all the information technology leaves at our fingertips, it can seem more confusing that ever to know what sources and who to trust for health advice. Unfortunately, these myths have and continue to lead to real-world harm – for example, over the last year we have seen ongoing measles outbreaks in Ireland, the U.K. and mainland Europe as a result of suboptimal MMR (Measles-Mumps-Rubella) vaccine uptakes among young children as part of their childhood immunisation schedule. In Ireland, social media myths about the Human Papilloma Virus vaccine for cervical cancer prevention led to a crisis being declared regarding low vaccine uptake rates among school girls eligible for the vaccine programme in 2016-2017, despite robust and consistent safety and efficacy assessments of the vaccine, nationally and internationally 4 . Public health professionals should be a trusted voice in society, one you can turn to for evidence-based advice (alongside your primary care physician/general practitioner) when media myths have your head spinning. In the U.K., Public Health England are the main public health voice that communicates with the population, while in Ireland, this is mostly through our Health Service Executive and it’s associated public health bodies such as safe food and the Health Protection Surveillance Centre.
To give you a more rounded insight into what the work within each domain of public health involves, let’s look at a little summary for each of the four – health protection, health improvement, health service improvement and health intelligence (5).
- Surveillance – This involves the collecting, analysis and monitoring of data specific to many infectious diseases both in Ireland, the U.K. and abroad. National public health organisations are responsible for this and liaise with global organisations such as the World Health Organisation and the European and American Centres for Disease Prevention and Control. Using these data activities can be organised to protect population health, including the identification, investigation and control of infectious disease outbreaks and the co-ordination of a rapid response to international infectious disease threats. This involves response at a national level (e.g. to measles and mumps outbreaks, outbreaks of infections in hospitals, and managing the influenza season each year) and internationally (e.g. at the peak of the Ebola and Zika emergencies, public health officials were actively involved in the Irish and U.K. responses and advised on appropriate protection measures at borders and regarding hospital protocols).
- Prevention – This is largely through national immunisation and vaccination programmes such as those for infants and children in Ireland and the U.K., as well as raising awareness about specific issues, such as confusion among parents regarding vaccination side effects, as has been the case with the MMR and HPV vaccines.
- Monitoring the health status of the population – This involves again, using data and statistics to monitor how healthy (or unhealthy!) the population is and the prevalence of the different chronic diseases which are on the rise around the world such as cancer, heart disease and type 2 diabetes. These insights can be used to formulate, plan and implement intervention and prevention measures.
- Health promotion – This is all about promoting healthy lifestyle behaviours and making the healthy choice the easier choice in the environment. This might include, for example, nudges introduced through policy and legislative measures to encourage and direct our actions towards the ‘healthier choice’. Examples of such measures you might be familiar with include regulations around tobacco availability (such as introducing mandatory health warnings on cigarette packets and workplace smoking bans), the regulation of pricing and marketing of alcohol to reduce overconsumption, and taxation on sugar-sweetened and soft drinks beverages and regulation of junk-food marketing to protect children.
Health Service Improvement
- This pillar of public health is all about assessing the quality of the healthcare services available to the population from many perspectives, such as their accessibility, affordability, efficiency and effectiveness. There is a major focus on ensuring that these services are reaching those who need them the most, such as those in migrant or minority communities, and those of lower socio-economic status.
- This pillar is also focused on ensuring our services are up to date in terms of how they are delivered and the evidence that informs them. For example, technology becomes more and more advanced every single day, and we know that we need to figure out the best ways to integrate it into our healthcare services to improve efficiency, such as through shifting to online prescribing of medicines in hospitals, online patient documentation and integration of patient records between hospital and community care.
- Health intelligence is all about healthcare-related data – how we record it, how we use it, and how best to use it to inform our healthcare services, from metrics such as length of in-patient stay in hospital to waiting times for out-patient services to surveillance systems used to monitor the health status of the population, and doing so in a confidential, protected, GDPR-friendly manner too.
How Can I Work in Public Health?
Public health training and specialisation for medical doctors is slightly different in Ireland and the U.K., in terms of training programme length, entry requirements and competitiveness. For those reading this who are keen to know more, and perhaps explore this area as a potential career avenue, below you’ll find links to the U.K. Faculty of Public Health Medicine website and the Irish Royal College of Physicians website for more information! Feel free to drop me a line through email or Instagram if you have any queries on the Irish training scheme application – I start my first year of four in July and I’m very excited!
For U.K. Medics/Healthcare Professionals: https://www.fph.org.uk/
For Irish Medics: https://www.rcpi.ie/faculties/faculty-of-public-health-medicine/
(1) Department of Health (2017) ‘Healthy Eating and Active Living: National Implementation Plan 2017-
2020’. Available at: https://www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/heal/heal-docs/heal-programme-national-implementation-plan-2017-2020.pdf [Accessed 17 April 2019]
(2) The King’s Fund (2019) ‘Long-term conditions and multi-morbidity.’ Available at: https://www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and-disability-long-term-conditions-multi-morbidity [Accessed 14 April 2019]
(3) World Health Organisation (2019) ‘Major NCDs and their risks.’ Available at: https://www.who.int/ncds/introduction/en/ [Accessed 14 April 2019]
(4) Corcoran, B., Clarke, A. and Barrett, T. (2018) ‘Rapid response to HPV vaccination crisis in Ireland’, The Lancet, 391(10135), pp. 2103.
(5) Health Service Executive (2019) ‘About us – Departments of Public Health.’ Available at: https://www.hse.ie/eng/services/list/5/publichealth/publichealthdepts/about/aboutus.html [Accessed 14 April 2019]