Public health in the new era: improving health through collective action

are taking place in a context in which the global public-health workforce is unprepared to confront these challenges. This lack of preparation is partly because the challenges are large and complex, 3 the public-health workforce and infrastructure have been neglected, and training programmes are inadequate. These problems are exacerbated by the concentration of funding on biomedical research and the failure to confront and work with vested interests, which promote and sustain unhealthy behaviour patterns. If public-health practitioners are to address national and global health challenges effectively, the way they work and make their work relevant to these challenges 4 will require a major reorientation. A clear vision of what public health is, and what it can offer, is required. To be achievable, the vision must then be communicated not only to its practitioners, but also to the wider policy community, whose actions are necessary to improve the health of the public. Here, we propose a reformulation of public health appropriate for the global and national health challenges in this new era. The practice of public health Approaches to the practice of public health are contingent on time and place. They are distinguished mainly by the amount of authority vested in the state and their main disciplinary base. In terms of state involvement and responsibility, there are two extreme approaches: the state medicine model and the market model. The practice of public health in the USA is an example of the market approach. The aim of this model is to limit government responsibility for public health and to encourage individual responsibility for health improvement, on the assumption that the market will respond to individuals’ demands for goods that promote health. 5 The state medicine model, by contrast, envisages a strong role for the state, encroaching in many areas that some might consider private life. A particular version was transposed to the Soviet Union, where public health became a central part of state policy, summarised by Lenin’s comment that “if communism does not destroy the louse, the louse will destroy communism”. 6