SECOND OPINION: Prof Ivan Perry believes the concept of public health as a discipline committed to preventing disease and creating the conditions for a healthy society is poorly understood and is not adequately supported
Health is now the dominant political issue in Ireland. In much of the debate, the terms health and health services are used interchangeably on the assumption that health is largely a product of health services.
Well over 90 per cent (perhaps 95 per cent) of our health budget is allocated to the provision of health services. While the health service provides a vital safety net when we are ill, it makes a relatively small contribution to protecting the health of the population, promoting positive health and well-being and preventing premature death.
The work of prevention and health promotion falls within the sphere of public health. Unfortunately, in Ireland most people associate public health with the provision of health services for the poor. The broader concept of public health as a discipline committed to preventing disease and creating the conditions for a healthy society is poorly understood and is not adequately supported.
Indeed, it is suggested that in the history of mankind, few ideas have attracted such support in the abstract and neglect in practice as the primacy of prevention over cure.
Western societies seem almost immune to the simple notion that it is easy to scramble but impossible to unscramble an egg. We prioritise investment in expensive end-stage care in the acute hospital sector and neglect relatively inexpensive measures that would prevent illness and add quality years to life.
To be fair, the public health movement has made some progress in recent years. Ireland is now regarded as a world leader in tobacco control and we have finally acknowledged that the epidemic of obesity is as much a challenge for Government and society as for individuals and families.
The role of poverty and social exclusion as critical determinants of health in Ireland is increasingly recognised, albeit at a theoretical rather than a practical level. However, the dominant concept of health and its determinants focuses on the need for individuals and families to make the right choices about healthcare, lifestyle and behaviour.
Indeed, our approach to prevention largely revolves around the limited concepts of health education, exhorting the public to mend their wicked ways, and "preventive medicine", the idea that all will be well if we can persuade the populus to visit their family doctor for regular check-ups.
The recent Fine Gael health policy document, Future Health: A national health screening policy (in essence a charter for the worried well), represents an example of the latter fallacy.
We focus almost exclusively on narrow biological, behavioural and health service related determinants of health. We are reluctant to accept that while personal choice is important in health as in all aspects of our lives, our health-related choices and behaviours are largely determined by the prevailing social, economic and physical environment.
For example, it will be hard for our children to acquire healthy eating habits and avoid putting on weight if we continue to design our buildings and cities around the elevator and the car and if every time they go to the cinema they are presented with a tub of popcorn and a small bucket of coke.
Similarly, we are worried about mental health, suicide and road traffic accidents in young men but are unwilling to address the relentless targeting of boys and young men in alcohol marketing campaigns, as evidenced by the level of alcohol sponsorship for major sports in Ireland.
Progress on these and related issues depends on investment in our public health research infrastructure and in the education and training of public health professionals with the knowledge and skills to access levers of change in society.
Infectious diseases pose a further threat to the health of the population that we ignore at our peril. Well-developed public health systems will be vital in protecting our population from the global flu pandemic that is now regarded as almost inevitable.
In this context, it is noteworthy that doctors who specialise in public health medicine in Ireland, who will be at the front line in managing a major flu epidemic, are currently not appointed at consultant grade (despite training to consultant level) and do not receive payment for out-of-hours work.
Despite dramatic improvements in life expectancy over the past century, largely attributed to societal level changes in living conditions, we are treated in the media coverage of health issues to homilies on the inevitability of death and the utopian folly of prevention.
Our efforts to combat the scourge of tobacco, responsible for approximately five million deaths worldwide each year, are regarded by some commentators (including clinicians who should know better) as a distraction from the real problems of the health service, a further manifestation of the dreaded "nanny state".
As a society we fret obsessionally over the health of the economy. We monitor growth rates, inflation, unemployment rates and a host of other indices. Amartya Sen, the Nobel prize winning economist, reminds us that economics is about means, not ends.
This is the core challenge for public health as a discipline: to hold our Government accountable for creating the conditions for a healthy society.
• Prof Ivan Perry is head of the Department of Epidemiology and Public Health at University College Cork. He is co-organiser of a summer school on Health Systems and Population Health which will take place this Thursday and Friday (September 1st and 2nd) at UCC.
• The summer school is jointly organised by the Department of Public Health, HSE Southern Area, The Institute of Public Health in Ireland and UCC.
• For information regarding registration, contact Eileen Ryan, HSE at 021-4927601 or email EileenM.Ryan@mailp.hse.ie