Public health physicians: here to help.
Not long ago the Australasian Faculty of Public Health Medicine (AFPHM) celebrated its 20th anniversary. The Faculty was formed in 1990 after a group led by then NSW Chief Health Officer Sue Morey had advocated for physicians, whose primary interest and responsibility was the health of populations, to have access to both a training programme and a professional network. Successful negotiations were entered into with Royal Australasian College of Physicians’ president Priscilla Kincaid-Smith for a faculty to be formed within the organization of the College (S. Morey, pers. comm., 25 September 2009). The medical tradition in public health has its origins in the sanitary reform movement which swept Britain in the middle of the 19th century. Chadwick’s landmark report highlighted the dire sanitation in the overcrowded, working class districts of Britain’s rapidly industrializing cities. The political will to respond was not entirely clear, and it was the arrival of the second cholera pandemic which finally forced the passage of the Public Health Act 1848 by the British parliament. This legislation required local government authorities to employ medical officers of health. These ideas were transferred to the Australian colonies, delayed to greater or lesser degrees; by way of example, legislation which established local boards of health employing registered medical practitioners was introduced first into Victoria in 1854 and by the NSW parliament in 1896. In this period, characterized by the elucidation and eventual acceptance of the germ theory of infectious diseases and the rise of laboratory medicine, the public health responsibilities of medical officers and their partners, the health inspectors (now generally referred to as environmental health officers), focussed on health protection. Typical public health legislation of 100 years ago provided for the safety and purity of drinking water, foods and drugs, the control of nuisances, noxious trades and unhealthy buildings, and prevention of the spread of infectious diseases through notification of, and response to, individual cases. By the second half of the 20th century, it was becoming clear that, at least in affluent industrialized communities, many of the sanitary and infectious disease problems had declined considerably. Concern about these traditional public health challenges was replaced to some extent by recognition of a growing burden of preventable chronic disease and injury. These were also amenable to population approaches – improved awareness among the general public and health providers of behavioural risk factors, the role of public policy in making it easier for individuals to pursue healthy behaviours, and the continuation of legislation with health protection goals, such as tobacco control and injury prevention. The need to embrace new approaches to improving the health of populations was typified by Dr Roderick McEwin, chairman of the NSW Health Commission, in an address to the 1974 annual meeting of the College, when he referred to the state’s woeful performance in preventive medicine and health education, citing as evidence the low immunization coverage among NSW children. Where does this long evolution of roles and priorities leave the Australian public health physician of the 21st century? Health protection remains an important professional niche for the public health physician, because a clinical understanding is important to the management of individuals who either pose a public health risk, for example by being infectious, or have been exposed to one. Many physicians and paediatricians will have had contact with those public health physicians who are associated with public health units and disease control centres located in all Australian states and territories. Public health physicians aim to nurture these contacts as their training and inclination fits them to be the bridge between clinicians and the public health workforce. Public health physicians occupy a range of other positions. A report commissioned in 2009 by the AFPHM sought to define the role and place of public health physicians in the Australian health setting. Samples of Fellows and of their managers were interviewed, and the authors analysed 104 position descriptions, or about one-quarter of the number considered ‘active Fellows’ in the College database. Not surprisingly, the major employers were state health services (79%), and academic institutions (17%). In addition to the health protection functions of disease control, environmental health and emergency management, Fellows worked across a range of activities: health monitoring and surveillance; health promotion; healthpolicy, planning and management; research design and implementation; and education and training. Governments, faced with the financial necessity of containing healthcare costs, if not with an ideological desire to improve the well-being of their people, must increase their organized efforts to increase health and prevent disease – a good working definition of ‘public health’. In the Australian context, the continuing evolution of primary healthcare organizations will give them an increased share of responsibility for improving the health Internal Medicine Journal 41 (2011)