[originally published in The Lancet, vol. 375, February 13, 2010, 535-537]
Last year, in The Lancet, Jeffrey Koplan and colleagues1 provided a new definition for global health and proposed several distinctions between global health,international health, and public health. This attempt to distinguish differences between global health and public health conflicts with the key tenets of a global public health strategy (panel). These tenets offer the foundation of a redesigned global health system that could accomplish the optimum level of health for populations. This approach has profound implications for training, scholarship, and practice necessary to improve human health.
Global health and public health are indistinguishable. Both view health in terms of physical, mental, and social wellbeing, rather than merely the absence of disease. Both emphasise population-level policies, as well as individual approaches to health promotion. And both address the root causes of ill-health through a broad array of scientific, social, cultural, and economic strategies.
In 1915, the Welch–Rose report established a blueprint for US public health schools that emphasised training in discrete interventions, targeted at reducing infectious diseases.2 Since then, the world’s health needs have grown more complex, the scientific opportunities for prevention and treatment more sophisticated, and the need for coordinated approaches more urgent. In 2003, the US Institute of Medicine laid out a much broader vision that recognised the need for a multisectoral systems-based approach to sustainable population health.3
Panel: Key tenets of global public health
- Belief that global health is public health. Public health is global health for the public good.
- Dedication to better health for all, with particular attention to the needs of the most vulnerable populations, and a basic commitment to health as a human right.
- Belief in a global perspective on scientific inquiry and on the translation of knowledge into practice, not limited by political boundaries, but sensitive to contextual issues that might influence illness, the design or choice of interventions, or health systems.
- A scientific approach to health promotion and disease prevention that examines broad determinants of health including, but not limited to, delivery of medical care, and creates integrated approaches in clinic, community, and government.
- Commitment to an interdisciplinary approach and collaborative team work to analyse problems of populations. Global concerns, such as climate change, and cross-disciplinary issues, such as zoonotic diseases and human health, involve close collaborations between medicine, public health, veterinary medicine, and many other disciplines.
- Multilevel systems-based interventions deployed to address the interactive contributions of societal and health-governance issues, corporate responsibility, and environmental, behavioural, and biological risk factors are key.
- Comprehensive frameworks for financing and structuring health policies and services that support community-based and clinical prevention integrated with health-care delivery and deployment of a balanced workforce of physicians, nurses, and other providers.
Yet global health is still often perceived as international aid, technologies, and interventions flowing from the wealthier countries of the global north to the poorer countries of the global south. A more nuanced and contemporary perspective emphasises interdependence and recognises the many contributions of both resource-rich and resource-scarce nations.4 With the new understanding that many health problems have a linked aetiology and a common impact, and that innovative solutions can come from all sectors, collaborative relationships become, at a minimum, bidirectional—and optimally, multilateral.
The importance of a global perspective is highlighted by these observations. First, pandemic infectious diseases, such as AIDS and influenza, and the health challenges associated with climate change, are not confined by sovereignty or the extent of nations’ resources. Second, chronic diseases, which already contribute a major share of the global burden of disease, will grow with our ageing population. Increasing evidence suggests that the diet and lifestyle of high-income nations have “communicable” characteristics. In China, 20% of men are hypertensive, while nearly 80 million people in India will have diabetes by 2030.5 Similarly, tobacco-related diseases began in the global north but have become commonplace in the global south.
Third, cross-national comparisons of health systems can yield useful insights. For example, the US health-care system has higher costs yet unimpressive populationhealth outcomes compared with many other nations, suggesting that the US system might be an inappropriate export to developing countries. Fourth, the health workforce is becoming globalised. The traditional model of health professionals from the wealthy north providing care in the poor south is outmoded. Instead, the dominant model is the migration of the health workforce from south to north, with major resource implications worldwide.
The tenets of global public health (panel) highlight public health as a public good, benefiting all members of every society. While local applications must be contextually appropriate, a domestic focus on population health need not compete for attention with an international focus—in a global health system, strengthening one strengthens the other.
Medicine and clinical care remain essential pillars of that system, but the greater payoff comes with an integrated, multidisciplinary, prevention-oriented approach in the community as well as in the clinic. In the USA, human behaviour accounts for 40% of the risk of premature death, while the social and working environments account for 20%. Health care, by contrast, contributes 10% of health outcomes (with genetics explaining the rest).6 At the same time, every dollar invested in prevention produces a sixfold return on investment.7
Public health schools remain at the forefront of efforts to educate global health experts who are prepared to confront the global burden of disease. They bring systems approaches and a focus on prevention science and evidence-based interventions to that effort, along with a multidisciplinary faculty and ties to communities, public sector agencies, non-governmental organisations, and government ministries.
New university structures to support synergies in global health education, research, and service are welcome. Links with graduate programmes in medicine, law, international affairs, and a host of bench and social science programmes can only strengthen the capacity of future global public health leaders. Opportunities abound for research collaborations, dual degrees, and jointly designed interventions at the clinical, community, and population levels.
The foundation of those partnerships, however, recognises that global health and public health represent a single field with a long tradition of bringing scientifically validated approaches, technologies, and systems to bear on the world’s most pressing health needs. Improving the lives of vulnerable populations depends on continuing advances in this field.
Linda P Fried, Margaret E Bentley, Pierre Buekens, Donald S Burke, Julio J Frenk, Michael J Klag,*Harrison C Spencer
We represent a working group of the Association of Schools of Public Health Global Health Committee. We thank Karen L Helsing for her contributions to this Comment. We declare that we have no conflicts of interest.
1Koplan JP, Bond TC, Merson MH, et al, for the Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet 2009; 373: 1993–95.
2 Rockefeller Foundation. Welch-Rose report on schools of public health. 1915. http://www.deltaomega.org/WelchRose.pdf (accessed Jan 28, 2010).
3 Institute of Medicine. The future of public health. 1988. http://books.nap.edu/openbook.php?record_id=10548 (accessed Feb 3, 2010).
4 Colgrove J, Fried, LP, Northridge, ME, Rosner, D. Schools of public health: essential infrastructure of a responsibly society and a 21st-century health system. Public Health Rep 2010; 125: 8–14.
5 WHO. WHO global infobase. https://apps.who.int/infobase/report.aspx (accessed Sept 17, 2009).
6 Schroeder SA. We can do better—improving the health of the American people. N Engl J Med 2007; 357: 1221–28.
7 Trust for America’s Health. Prevention for a healthier America: Investments in disease prevention yield significant savings, stronger communities. July, 2008. http://healthyamericans.org/reports/prevention08 (accessed Feb 3, 2010).