TURNOCK READING ROOM

Preface to: Public Health: What It Is and How It Works

Turnock BJ---Division of Community Health Sciences, University of Illinois at Chicago School of Public Health

Aspen Publishers, Gaithersburg MD, 1997

Public health remains a generally familiar though somewhat unclear concept both to the general public and to those dedicated to its improvement. This book is written as an attempt to describe simply and clearly what it is, what it does, how it works, and why it is important to all of us.

As someone who has spent 15 years in public health practice and another half-dozen in teaching and researching the field, I have been concerned why something so important and useful is not better understood by those who work in the field and those who benefit from its work. Throughout my career as a public health physician, I have developed a profound respect for the field, the work, and the workers. But I must admit that even while serving as director of a large state health department, I lacked a full understanding and appreciation of this unique enterprise.

What has become clear to me is that the story of public health is not simple to tell. There is no one official at the helm, guiding it through the turbulence that is constantly encountered. There is no clear view of its intended destination and of what work needs to be done by whom to get there. We cannot turn to the deans of our schools of public health, the CEOs of managed-care organizations, or even our federal officials, such as our Surgeon General, for vision and direction. Surely, these people play important roles, but public health is so broadly involved with the biological, environmental, social, cultural, behavioral, and service utilization factors associated with health that no one is accountable for addressing everything. Still, w all share in the successes and failures of our collective decisions and actions, making us all accountable to each other for the results of our efforts. Hopefully, this book will present a broad view of the public health system and deter current and future public health workers from narrowly defining public health in terms of only what they do.

While there is no dearth of fine books in this field, there is most certainly a shortage of understanding, appreciation, and support for public health and its various manifestations. Many of the current texts on public health attempt to be comprehensive in covering the field without the benefit of a conceptual framework understandable to insiders and outsiders alike. The dynamism and complexity of the field suggest that public health texts are likely to become even larger and more comprehensive as the field advances. In contrast, this book aims to present the essentials of public health, with an emphasis on comprehensibility rather than comprehensiveness. It presents fundamental concepts but links those concepts to practice in the real world.

These are essential topics for public health students early in their academic careers, and they are increasingly important for students in the social and political sciences and other health professions as well. But this book is intended as much for public health practitioners as it is for students. It represents the belief that public health cannot be adequately taught through a text, that it needs to be learned through exploration and practice of its concepts and methods. In that light, this book should be viewed as a framework for learning and understanding public health rather than the definitive catalog of its principles and practices.

The first four chapters of the book cover topics of interest to general audiences. Basic concepts underlying public health are presented in Chapter 1; included are definitions, historical highlights, and unique features of public health. This and subsequent chapters focus largely on public health in the US although information on public health globally and comparisons among nations appear in Chapters 2 and 3. Health and illness and the various factors that influence health status are discussed in Chapter 2. This chapter also presents data and information on health status and risk factors in the US and introduces a method for analyzing health problems in order to identify their precursors. The third chapter addresses the overall health system, with a special emphasis on trends and developments that are important to public health. Interfaces between public health and a rapidly changing health system are highlighted. Chapter 4 examines the organization of public health responsibilities in the US by reviewing its legal basis and the current structure of public health agencies at the federal, state, and local levels. Together, these four chapters serve as a primer on what public health is and how it relates to health interests in modern America.

The final four chapters flesh out the skeleton of public health introduced in the first half of the book. They examine how public health does what it does, addressing issues of the inner workings of public health that are designed for the more serious students of the field. Chapter 5 reviews the core functions of public health and both how and how well these are being addressed in the mid-1990s. This chapter identifies key processes or practices that operationalize public health’s core functions and tools that have been developed to improve public health practice. Chapter 6 builds on the governmental structure of American public health (from Chapter 4) and examines other inputs of the public health system, including human, informational, and fiscal resources. Outputs of the public health system, in the form of programs and services, are the subject of Chapter 7. Population-based community prevention services and clinical preventive services are examined, and an approach to program planning and evaluation for public health interventions is presented. The final chapter looks to the future of public health at the turn of the century. Emerging problems, opportunities afforded by the expansion of managed care, and improving local public health practice are discussed, along with obstacles impeding effective public health responses.

Each chapter includes a variety of figures, tables, and exhibits to illustrate the concepts and provide useful resources for public health practitioners. A glossary of public health terminology is provided for the benefit of those unfamiliar with some of the commonly-used terms, as well as to convey the intended meaning for terms that may have several different connotations in practice. At the end of each chapter are discussion questions and exercises that complement the topics presented and provide a framework for thought and discussion. These allow the text to be used more flexibly in public health courses at various levels and with learners at different levels of their training and careers.

Together, the chapters represent a systems approach to public health grounded in a conceptual model that characterizes public health by its mission, functions, inputs, practices, outputs, and outcomes. This model is the unifying construct for this text. It provides a framework for examining and questioning the wisdom of our current investment strategy that directs 100 times more resources toward medical services than it spends for population-based prevention strategies even though medical services can account for only 5 of the 30 years of increased life expectancy at birth that have been achieved in the United States since 1900.

Whatever wisdom might be found in this book has filtered through to me as a result of my mentors, colleagues, and friends. For those who follow us into this vineyard of challenge and opportunity, this is meant to be a primer on public health in the US. It is a book that seeks to reduce the vast scope, endless complexities, and ever-expanding agenda to a format simple enough to be understood by first-year students and state health commissioners alike.