p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 6 8 1 e6 8 2
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Editorial
Stewardship and Public Health
In November 2007 the UK based Nuffield Council for Bioethics published what some considered to be a landmark report entitled Public Health: ethical issues.1 The report set out to explore the ethical issues that are created when seeking to intervene to improve the health of the population, as opposed to those relating to the health in an individual. It also sought to make recommendations on how, given the complex relationships that exist between individuals, organisations and the sovereign states in which they live and operate, we should seek to respond to the duties and entitlements which are set out in the various health policies which are adopted. To do this, the working group which developed the report, proposed that public health interventions to achieve and maintain the health of populations should be considered in as a form of stewardship: The concept of ‘stewardship’ is intended to convey that liberal states have a duty to look after important needs of people individually and collectively. It emphasises the obligation of states to provide conditions that allow people to be healthy and, in particular, to take measures to reduce health inequalities. The stewardship-guided state recognises that a primary asset of a nation is its health: higher levels of health are associated with greater overall well-being and productivity … Although the state should be guided in its public health policies by the concept of stewardship, this does not absolve other parties, in particular the corporate sector, from their responsibilities.1 The working group went on to define what they described as “The Intervention Ladder”, by which increasing levels of state intervention, which are associated with greater infringements of individual freedoms, require higher levels of justification to be deemed acceptable. The stewardship model proposed also notes the obligation to reduce health inequalities, without creating new ones, and the need for what Michael Marmot has termed “proportionate universalism”2 Clearly, the notion of stewardship in the delivery of health and health care is not unique to the work of the Nuffield working group. Indeed the WHO has long described the responsibilities of national governments for population health in such terms.3 But what was striking in the Nuffield Council on Bio-ethics report was the strongly expressed view that public health was not the sole responsibility of the individual and could not be reduced to encouraging healthier lifestyle choices. In doing so, it reasserted that public health was based
on mutuality e that the responsibilities and benefits of population health were shared between the individual, the community, and the state. As you will have already noted, this issue of Public Health contains three papers which started out as presentations at the 2013 Public Health England conference in Warwick. We are grateful to our Guest Editor e Anthony Kessel, Director of International Public Health at Public Health England e who worked with colleagues to bring this to press. We believe that these papers, together with one other paper selected for this issue, explore this stewardship model of public health intervention in practice. Perhaps the most obvious way in which stewardship is applied in public health relates to the growing problem of drugresistant bacteria and the need for stewardship associated with the use of antibiotics. The NHS in England has been at the cutting edge of this in establishing its Antimicrobial Stewardship Programme, a report from which is included in the mini-symposium.4 This highlights that e whilst progress is being made e much is still left to do: a fact not lost on the UK Government, which recently announced a major review of the issue.5 Vaccination is a topic which the Nuffield Council on Bioethics considered in some depth. This is an area explored by Paul Fine in his plenary presentation which focusses specifically on the societal aspects of vaccination policy and practice.6 Seeking to protect the individual and the community through population vaccination programmes remains the clearest “test-case” for public health stewardship, where the risks posed by individuals who do not consent to vaccination, and so undermine population (“herd”) immunity, may need to be balanced by state encouragement to seek effective vaccination. Stewardship is also a term commonly applied in the context of planetary health; where sound stewardship of our resources and the environment is needed to mitigate the effects of global warming. In a third paper, a team from South Korea describe an approach to modelling future disease burden due to climate change.7 As many of you will have already experienced, there is a growing call from those involved in sustainable development and climate change mitigation and adaptation for public health practitioners to be co-advocates with them in seeking change. Balancing the health of our present population and protecting that of future generations through sustainable use of our current resources is e arguably e the greatest stewardship challenge for public health.
682
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 6 8 1 e6 8 2
For this reason, we have made this paper our Editor's Choice for the month. We have highlighted three papers from this August issue of Public Health which we believe show aspects of stewardship in practice: but actually, it could have been any of them. After all, stewardship is at the heart of what we do as population health practitioners.
references
1. Nuffield Council on Bioethics. Public health: ethical issues. London: Nuffield Council on Bioethics. Available from: http:// www.nuffieldbioethics.org/public-health; 2007 (last accessed 4 July 2014). 2. Fair Society. Health lives: strategic review of health inequalities in England post-2010 (The marmot review). Available from: http:// www.instituteofhealthequity.org/projects/fair-societyhealthy-lives-the-marmot-review/fair-society-healthy-livesfull-report; 2010 (last accessed 4 July 2014). 3. WHO Stewardship. Available from: http://www.who.int/ healthsystems/stewardship/en/ (last accessed 4 July 2014). 4. Cooke J, Stephens P, Ashiru-Oredope D, Johnson AP, Livermore DM, Sharland M. Antibacterial usage in English NHS
hospitals as part of a national Antimicrobial Stewardship Programme. Public Health 2014;128(8):693e7. http://dx.doi.org/ 10.1016/j.puhe.2014.06.023. 5. BBC News. Antibiotic resistance: Cameron warns of medical 'dark ages'. Available at: http://www.bbc.co.uk/news/health28098838; 2014 (last accessed 4 July). 6. Fine P. Science and society: vaccines and public health. Public Health 2014;128(8):686e92. http://dx.doi.org/10.1016/ j.puhe.2014.06.021. 7. Yoon S-J, Oh I-H, Seo H-Y, Kim E-J. Measuring the burden of disease due to climate change and developing a forecast model in South Korea. Public Health 2014;128(8):725e33. http://dx.doi.org/10.1016/j.puhe.2014.06.008.
P. Mackie F. Sim The Royal Society for Public Health, John Snow House, 59 Mansell Street, London, E1 8AN, UK E-mail address: [email protected] (P. Mackie)
http://dx.doi.org/10.1016/j.puhe.2014.08.013 0033-3506/© 2014 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
In this issue This August issue of Public Health is something a little more special than usual. This is because, this issue has a minisymposium based on papers presented at the 2013 annual conference of Public Health England (PHE). With a guest editorial from colleagues in PHE and papers on: the evolution of vaccination and its role in public health; the use of, and stewardship for, antibacterial agents in hospitals; and the prevention of stillbirths, we hope that they provide a useful “taster” for the 2014 conference. Health protection is well represented in this issue of the journal. Two papers consider differing aspects of pandemic influenza response. The first is concerned with the views of healthcare managers on the factors which affect preparedness and the second on the effects of social capital on immunisation uptake. We also have two short communications on VTEC as a reason for exclusion from daycare and on the prevalence of hepatitis B in a multi-ethnic UK community. Chronic disease management also features with a paper from Canada looking at the approaches to prevention in Canada up to 2010. We also are publishing two workplace based studies from southeast Asia, one which looks at depression and chronic disease in China and the second on musculoskeletal pain in migrant workers in Malaysia. Finally on this topic e in another paper from the region e we publish a study which models the impacts of climate change on future disease burden. In the area of health improvement we consider studies on low income households and their vulnerability to food insecurity, barriers to leisure-time physical activity in Asian Indian men, and the emerging problem of Dokha smoking. Add into the mix papers on mental health symptoms amongst Greeks in the current economic crisis and the barriers to implementing new clinical practices and you have your e very special e August issue of Public Health. We hope you find it a stimulating read.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Editorial
Stewardship and Public Health
In November 2007 the UK based Nuffield Council for Bioethics published what some considered to be a landmark report entitled Public Health: ethical issues.1 The report set out to explore the ethical issues that are created when seeking to intervene to improve the health of the population, as opposed to those relating to the health in an individual. It also sought to make recommendations on how, given the complex relationships that exist between individuals, organisations and the sovereign states in which they live and operate, we should seek to respond to the duties and entitlements which are set out in the various health policies which are adopted. To do this, the working group which developed the report, proposed that public health interventions to achieve and maintain the health of populations should be considered in as a form of stewardship: The concept of ‘stewardship’ is intended to convey that liberal states have a duty to look after important needs of people individually and collectively. It emphasises the obligation of states to provide conditions that allow people to be healthy and, in particular, to take measures to reduce health inequalities. The stewardship-guided state recognises that a primary asset of a nation is its health: higher levels of health are associated with greater overall well-being and productivity … Although the state should be guided in its public health policies by the concept of stewardship, this does not absolve other parties, in particular the corporate sector, from their responsibilities.1 The working group went on to define what they described as “The Intervention Ladder”, by which increasing levels of state intervention, which are associated with greater infringements of individual freedoms, require higher levels of justification to be deemed acceptable. The stewardship model proposed also notes the obligation to reduce health inequalities, without creating new ones, and the need for what Michael Marmot has termed “proportionate universalism”2 Clearly, the notion of stewardship in the delivery of health and health care is not unique to the work of the Nuffield working group. Indeed the WHO has long described the responsibilities of national governments for population health in such terms.3 But what was striking in the Nuffield Council on Bio-ethics report was the strongly expressed view that public health was not the sole responsibility of the individual and could not be reduced to encouraging healthier lifestyle choices. In doing so, it reasserted that public health was based
on mutuality e that the responsibilities and benefits of population health were shared between the individual, the community, and the state. As you will have already noted, this issue of Public Health contains three papers which started out as presentations at the 2013 Public Health England conference in Warwick. We are grateful to our Guest Editor e Anthony Kessel, Director of International Public Health at Public Health England e who worked with colleagues to bring this to press. We believe that these papers, together with one other paper selected for this issue, explore this stewardship model of public health intervention in practice. Perhaps the most obvious way in which stewardship is applied in public health relates to the growing problem of drugresistant bacteria and the need for stewardship associated with the use of antibiotics. The NHS in England has been at the cutting edge of this in establishing its Antimicrobial Stewardship Programme, a report from which is included in the mini-symposium.4 This highlights that e whilst progress is being made e much is still left to do: a fact not lost on the UK Government, which recently announced a major review of the issue.5 Vaccination is a topic which the Nuffield Council on Bioethics considered in some depth. This is an area explored by Paul Fine in his plenary presentation which focusses specifically on the societal aspects of vaccination policy and practice.6 Seeking to protect the individual and the community through population vaccination programmes remains the clearest “test-case” for public health stewardship, where the risks posed by individuals who do not consent to vaccination, and so undermine population (“herd”) immunity, may need to be balanced by state encouragement to seek effective vaccination. Stewardship is also a term commonly applied in the context of planetary health; where sound stewardship of our resources and the environment is needed to mitigate the effects of global warming. In a third paper, a team from South Korea describe an approach to modelling future disease burden due to climate change.7 As many of you will have already experienced, there is a growing call from those involved in sustainable development and climate change mitigation and adaptation for public health practitioners to be co-advocates with them in seeking change. Balancing the health of our present population and protecting that of future generations through sustainable use of our current resources is e arguably e the greatest stewardship challenge for public health.
682
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 6 8 1 e6 8 2
For this reason, we have made this paper our Editor's Choice for the month. We have highlighted three papers from this August issue of Public Health which we believe show aspects of stewardship in practice: but actually, it could have been any of them. After all, stewardship is at the heart of what we do as population health practitioners.
references
1. Nuffield Council on Bioethics. Public health: ethical issues. London: Nuffield Council on Bioethics. Available from: http:// www.nuffieldbioethics.org/public-health; 2007 (last accessed 4 July 2014). 2. Fair Society. Health lives: strategic review of health inequalities in England post-2010 (The marmot review). Available from: http:// www.instituteofhealthequity.org/projects/fair-societyhealthy-lives-the-marmot-review/fair-society-healthy-livesfull-report; 2010 (last accessed 4 July 2014). 3. WHO Stewardship. Available from: http://www.who.int/ healthsystems/stewardship/en/ (last accessed 4 July 2014). 4. Cooke J, Stephens P, Ashiru-Oredope D, Johnson AP, Livermore DM, Sharland M. Antibacterial usage in English NHS
hospitals as part of a national Antimicrobial Stewardship Programme. Public Health 2014;128(8):693e7. http://dx.doi.org/ 10.1016/j.puhe.2014.06.023. 5. BBC News. Antibiotic resistance: Cameron warns of medical 'dark ages'. Available at: http://www.bbc.co.uk/news/health28098838; 2014 (last accessed 4 July). 6. Fine P. Science and society: vaccines and public health. Public Health 2014;128(8):686e92. http://dx.doi.org/10.1016/ j.puhe.2014.06.021. 7. Yoon S-J, Oh I-H, Seo H-Y, Kim E-J. Measuring the burden of disease due to climate change and developing a forecast model in South Korea. Public Health 2014;128(8):725e33. http://dx.doi.org/10.1016/j.puhe.2014.06.008.
P. Mackie F. Sim The Royal Society for Public Health, John Snow House, 59 Mansell Street, London, E1 8AN, UK E-mail address: [email protected] (P. Mackie)
http://dx.doi.org/10.1016/j.puhe.2014.08.013 0033-3506/© 2014 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
In this issue This August issue of Public Health is something a little more special than usual. This is because, this issue has a minisymposium based on papers presented at the 2013 annual conference of Public Health England (PHE). With a guest editorial from colleagues in PHE and papers on: the evolution of vaccination and its role in public health; the use of, and stewardship for, antibacterial agents in hospitals; and the prevention of stillbirths, we hope that they provide a useful “taster” for the 2014 conference. Health protection is well represented in this issue of the journal. Two papers consider differing aspects of pandemic influenza response. The first is concerned with the views of healthcare managers on the factors which affect preparedness and the second on the effects of social capital on immunisation uptake. We also have two short communications on VTEC as a reason for exclusion from daycare and on the prevalence of hepatitis B in a multi-ethnic UK community. Chronic disease management also features with a paper from Canada looking at the approaches to prevention in Canada up to 2010. We also are publishing two workplace based studies from southeast Asia, one which looks at depression and chronic disease in China and the second on musculoskeletal pain in migrant workers in Malaysia. Finally on this topic e in another paper from the region e we publish a study which models the impacts of climate change on future disease burden. In the area of health improvement we consider studies on low income households and their vulnerability to food insecurity, barriers to leisure-time physical activity in Asian Indian men, and the emerging problem of Dokha smoking. Add into the mix papers on mental health symptoms amongst Greeks in the current economic crisis and the barriers to implementing new clinical practices and you have your e very special e August issue of Public Health. We hope you find it a stimulating read.
