Chapter 1: Public Health and Preventive Medicine: Trends and Guideposts

INTRODUCTION

There are varied definitions of public health. Recent volumes from the U.S. Institute of Medicine have addressed the definitions and functions of public health^1,2 in a careful and thoughtful way, and described several pathways to healthier communities. The field of preventive medicine, the interface between public health and medical practice, is also critical to the health of populations, but is in a faster transition as the roles traditionally performed by physicians in population medicine are reconsidered and the structure of public health evolves. In the meantime, the health needs of the public are as acute as ever and demand all of the energy, skill, and science that public health and preventive medicine can muster.

Fortunately, there have been rapid and important advancements in public health and preventive medicine. Some have come as a result of inexorable achievements in productive science, and others were prodded by special public health emergencies and problems, or organizational changes in the delivery of preventive and curative health services. Many advancements in both practice and knowledge have been evolutionary, but in a few instances, there have been fundamental enhancements to our knowledge of the universe and their applications to the public health sciences. While there may be disagreements about what these achievements have been, and indeed some may not yet be fully recognized, the past several years have witnessed several striking and rapidly advancing trends. The following are some of the important trends that have shaped public health and preventive medicine, particularly within industrialized countries.

• Increased incorporation of business and administrative practices into prevention and public health service delivery.

While general administrative principles and practices have long been a part of public health education and program delivery, the administrative and business emphasis that has swept through most sectors of Western society has also had a clear impact on public health practice. The further application of “industrial standards,” quality improvement techniques, outcome measures, and complex accounting practices have changed the vocabulary and skills requisite for modern public health practice.^3,4 With this has come more emphasis on outcome measures. The emphases on both practice guidelines and evidence-based practice have yielded a further orientation toward both traditional and new outcome measures as indicators of community health. More sophisticated measures are in development, and more comprehensive attempts at program performance monitoring are occurring. As more sophisticated, detailed, and measurable outcomes are developed, this monitoring may not only evaluate specific public health or community programs, but may also work toward assessing the entire public health, health education, and clinical service structure within a community.

• Changes in the definition of the group or population, the fundamental unit of public health.

In general, “the population” that is both the target of preventive and public health programs and interventions has been historically defined as referring to geographic boundaries, due to their encompassing nature and ...