In November 2007, Australia elected a new federal government. In the 11 years of Coalition rule there was emphasis on individual initiative and responsibility for health. In contrast, Labor governments have traditionally been more sympathetic to centralised control of public medical and health services. We do not know whether this difference in emphasis will be evident in the policy directions of the new government, but it is timely for us to revisit some of the basic tenets of a public health approach and to outline the contribution that this Journal can make to public health knowledge and practice.
As Editors, we have consistently promoted public health as a broad, multidisciplinary field with a variety of approaches to protecting the health of the public. The Journal covers health issues ranging from analysis at the molecular level to analysis of individual behaviour and its determinants, including the social and cultural context in which people live. We include analysis of the economic and political context where decisions are made about public health policy. In addition, our concern is that the analysis of practice and policy should rest on methodologically sound research, underpinned by conceptual discussion of contentious areas of practice or policy.
Papers published in this Journal show a strong emphasis on prevention of disease. If prevention programs are to be cost-effective, they should be focused on areas where there is both a clear need and a good chance of success. The notion of ‘avoidable mortality’ requires that a disease is identifiable, can be treated effectively and that treatment programs are available. Epidemiological study of mortality records in New Zealand1 identified avoidable major causes of death. In the young, injury (including suicide) dominated. Chronic disease increased in importance with age, especially ischaemic heart disease, diabetes and smoking-related cancers. People living under conditions of social deprivation suffered more avoidable deaths, as did men. Recent replication of this study in Victoria showed avoidable mortality rates declined by more than half between 1979 and 2001, largely as a result of decline in cardiovascular mortality. Sex, socio-economic disadvantage and remote locality were sources of resistance to the decline.2 It follows that substantial improvement in a nation's health requires good medical treatment, but this needs to go hand-in-hand with primary prevention programs such as reduction of smoking and better diet and exercise, together with secondary preventive services aimed at controlling high blood pressure and screening for cancer, specifically targeting disadvantaged population groups.
Many Issues of this Journal carry papers that focus on various settings where avoidable mortality is present and where it is possible to implement effective programs for its reduction. In this Issue, there is a focus on a range of aspects of young people's health: child disability and the effect on parents’ mental health (Eric Emerson and Gwynnyth Llewellyn), the health of young offenders (Tony Butler and colleagues), and injury risk of young Asian New Zealanders (Kumanan Rasanathan and colleagues). There is also an historical analysis of the public health advocacy campaign to ban smoking in cars carrying children, benefiting, of course, both children and adults (Becky Freeman and colleagues).
The analysis of avoidable mortality, valuable as it is, does not tell the full story. It excludes infectious diseases, which are rare but could result in devastating epidemics. The aim is to eradicate diseases ranging from poliomyelitis to measles and to limit the spread of diseases such as tuberculosis by constant surveillance and by vaccination. Where infection is associated with stigmatised or private behaviour, as in sexually transmissible infections, ascertaining the risk is difficult3 and a range of strategies are needed to encourage preventive action. Our Journal articles have, for example, documented increased concern about the risk of hepatitis B among injecting drug users4 and the need for culturally appropriate prevention programs for young Indo-Chinese injecting drug users.5 In this Issue, Libby Topp and colleagues show that, in addition to infection, people who inject drugs suffer needle injuries, and Kelly Allen and colleagues argue for urgent prevention programs to deal with the rise of infectious syphilis in Victoria.
Analysis of the ban on smoking in cars by Becky Freeman and colleagues noted that the vulnerability of children makes their protection an important public health issue. This social and cultural significance also makes childbirth and maternal health a high priority. The effectiveness of treatment for postnatal depression has been called into question in this Journal (although this raised considerable debate).6 When maternal and child health concerns are accompanied by social disadvantage the task becomes more complex. In this Issue, Paul Torzillo and colleagues point to the sad lack of basic facilities such as water for washing children in rural and remote Australian Aboriginal communities.
The striking social and health disadvantage of Australian Aboriginal people requires more than improved health care and targeted prevention strategies, essential as these are. Racism affects both their physical and mental health status and it is argued to be widespread in urban areas and even more prevalent in regional settings.7 We need additional programs in schools and health care facilities to change the behaviour of non-Aboriginal people. We also need better ways of enhancing a positive Aboriginal identity. Ideally, we need public health professionals to engage in creating a more compassionate society.8 It is worth noting that this cautious and sensitive approach was lacking in a recent intervention against child abuse in the Northern Territory. As a Letter to the Editor argued: “One of the sad realities of human nature is our propensity to seek immediate solutions that at first glance appear simple and effective yet ignore the complexities of a given situation.”9 This is consistent with the call in this issue by Alice Rumbold and colleagues for better Indigenous health research.
Public health researchers have analysed prevention programs and made relevant recommendations for public health policy. A few examples follow. Extending the excellent work done on tobacco control in Australia, systematic review of the literature showed that non-smokers were at risk of lung cancer from passive smoking leading to a recommendation for a total ban on smoking in public venues.10 Prevention programs can require subtle understanding. Some migrant women with poor English are under-screened for cervical cancer,11 while some women, after a negative Pap test, are rescreened early, thus reducing the cost-effectiveness of the program.12 The challenge is to develop educational programs that encourage the under-screened to attend while discouraging the over-screened. In this issue, Rob Anderson and colleagues analyse the cost-effectiveness of various screening intervals and show the trade-offs involved in a two-year screening interval.
Public health researchers have demonstrated a cautious approach to interventions, requiring them to be carefully justified and properly evaluated. Increased exercise is an important primary prevention strategy and, although a paper in this issue reveals that participation of adults in physical activity shows signs of increasing (Chau and colleagues), it remains an important focus for prevention. Mass media programs to promote physical activity are potentially effective interventions in a whole population. To have a sustained effect, such initiatives need to be integrated into existing community-based public health programs and physical activity services. A recent Australian mass media campaign was seen as not meeting this requirement, nor was it properly evaluated to establish whether it had an impact and on whom.13 Similarly, while there is concern about obesity in Australian children and adolescents, there is a weak evidence base on the effectiveness of interventions. This calls into question over-enthusiastic implementation of expensive obesity control programs. If these are not properly evaluated, using robust evaluation methods, peer-reviewed evidence of cost-effectiveness will not be forthcoming.14
Central to the caution exercised by public health researchers and practitioners is the issue of research method. In one of the most popular sections of the Journal we have covered the rigorous design of methods as varied as qualitative methods and systematic reviews of randomised controlled trials. An important focus of the Journal has been on the use of linked administrative health records. Federal and State privacy legislation requires individual consent and this appeared to preclude linking of data from various databases. Vigorous argument against this interpretation emphasised that it undermined public health research. Three papers in this Issue, by Emma Brook and colleagues, Martin Tobias and colleagues and Sanja Lujic and colleagues, show that public health research benefits substantially from data linkage methods.