"Health is a Crossroad"--Nature and society,individual and community,in safeguarding public health

Any person actively engaged in the sphere of Public Health who refers to "molecular medicine" is bound to arouse suspicion. Nevertheless, neither Public Health nor public health protection or the health sciences in general can afford to ignore medicine and biology. This fundamental fact is explored in a historical and subsequently in an anthropological context. The connections between molecular medicine and public health are discussed at length. Accordingly, health on an individual as well as on a social level is essentially bound to the knowledge of genetically determined dispositions. We may expect that this molecular-genetic reality will become as "true" in future as the hygienic-bacteriological reality has become "true" today. The medicalisation of all human realities will be continued by their "molecularisation". It is important to fundamentally understand the actual effects of this transformation, which is the subject of a wider public discussion. This is the only way to rationally estimate both the opportunities offered by molecular medicine and the involved risks. It is essential for a debate of this kind within public health care institutions that the public health movement addresses the current developments of molecular medicine in a critical but constructive manner. "Nature", and with it the medicine and biology of public health, is an essential aspect of protecting public health. This is the only way to clarify the sphere of activity of public health protection in general, to appreciate its dynamics and to develop adequate measures: "Health is a crossroad" according to Julio Frenk: "It is where biological and social factors, the individual and the community, and social economic policy all converge".     

Community genetics and community medicine

In the decades to come, molecular genetic insights and techniques will have great influence on prevention and health care. Health care providers should anticipate important new developments rather than just wait and see. For community doctors, who can impossibly oversee all relevant developments in sufficient detail, close communication with the community and clinical genetic specialists is necessary to keep pace with progress. With regard to genetic counselling and reproductive medicine, working agreements between primary care and specialist centres are important. General communication about hereditary issues can be dealt with by well informed GPs, with appropriate computerized decision support, but in order to address specific risks and disorders consultation at a clinical genetic centre is preferred. In clinical medicine, much work is being done on DNA-based 'dia-prognosis' and more targeted interventions. Estimations of when such innovations will really have an impact range from 2005 to beyond 2020, and there are still many uncertainties, especially regarding common multifactorial disorders. Community-based genetic epidemiology has become a basic science in understanding the human genome. Clinical epidemiological methodology can contribute a lot to the quality of molecular clinico-genetic studies. Long-term follow-up to evaluate predictions and interventions needs more attention, and can easily be integrated into primary care medicine. In view of the ambition to develop more tailormade interventions, research methodology will be challenged regarding n = 1 studies. With respect to counselling and clinical practice, many ethical issues, relevant for community medicine, have to be considered in the domains of both reproductive medicine and clinical practice. Doctors, patients and society, traditionally battling to reduce diagnostic and prognostic uncertainties, must now learn to cope with approaching certainties. As for all new technologies, cost-effectiveness is an important topic for genetics. Increased cost-effectiveness because of better targeted interventions may be counterbalanced by the price of the new technologies and an expanding indicated population. In view of current developments, community practitioners must integrate community genetics into their daily routine, and critically anticipate possibly relevant innovations. More efforts in genetic risk assessment and communication are necessary in undergraduate and postgraduate training. A multidisciplinary approach is needed, in collaboration with primary care-oriented genetic specialists. Efforts to educate the public and (potential) patients should start at an early age, and must focus on what (future) health care users need for a balanced appraisal of genetic information and for optimal decision making in health promotion and health care.     

The need for integration in health sciences sets the future direction for public health education

Since the foundation of the People's Republic of China in 1949, there has been remarkable developments in public health in the country. These achievements are primarily attributed to the public health services and patriotic public health campaigns, although the contribution of high-technology medical applications is also recognized. However, along with the recent socio-economic developments and scientific and technological progress, medical disciplines have become more and more specialized, and clinical and preventive medicine have become further separated from each other. Conventional Chinese wisdom says 'when long divided they must unite, when long united they must divide'. At the onset of the new round of reforms of health care in China, it seems important to revisit the discussions on the urgency for integration of health sciences in medicine in China. Several issues and viewpoints on integrating medicine are discussed in this paper. The biopsychosocial model for health calls for broad integration. Primary care development in China requires integration in education and practice, and in treatment and prevention. Control of chronic diseases requires integrated and united action. Integration of traditional Chinese medicine with Western medicine requires creativity. The integration perspective should be instilled in the minds of medical students. Integration also entails integrated practice. After all, integration entails integrated education and practice in public health education. Changing the current public health education system still has a long way to go. True integration requires integration of concepts, policies, resources and measures, as well as changes in the organization of health care including public health, prevention and treatment. This needs to be a systematic process. Finally, success of integration relies on social mobilization, advocacy, promotion and attention of the entire society.     

Public health institutions in the second republic of Poland--the organization, its aims and tasks

The author discusses the organizations, the aims and the tasks of the selected public health care institutions in the Second Republic of Poland which realized particular health policy of the state. The policy included all matters concerning the public health care solved by the state through the assignment of the aims and tasks as well as the organization of the infrastructure for its realization. In order to determine the tasks of public health care one should ask how the medicine, as a branch of science, influenced off the health policy, what way it was connected with policy and economy as well as how it determined the creation of such a policy? The answers to these questions were provided by the health policy of the state expressed, among others, by health care addressed to an individual, a social group and the whole society. The range of health care corresponds to the assumed objectives aimed at by the state through plans and actions ensuring (at least theoretically) the best solutions. Generally its attempt to provide care and to maintain the health of an individual and the whole society. The tasks of public health care can be grouped in three domains: therapy, prophylaxis and rehabilitation.     

Medical ethics and the public health.

The development of preventive medicine is reviewed from an historical perspective. In its third and current stage of development preventive medicine has become involved in the life cycle of individual diseases and this presents a number of ethical difficulties for doctors and not least those concerned with the public health. Some proposed responses are considered and rejected. It is concluded that participants should be given more detailed information about screening tests and that doctors are under an ethical obligation to consider with the utmost care any contra-indications to a particular vaccination or a screening procedure in an individual patient. Serious reservations are expressed about the ethics and scientific justification of some government preventive medicine programmes currently in operation or projected.     

Alzheimer,dementia and the living will: a proposal

The world population aged significantly over the twentieth century, leading to an increase in the number of individuals presenting progressive, incapacitating, incurable chronic-degenerative diseases. Advances in medicine to prolong life prompted the establishment of instruments to ensure their self-determination, namely the living will, which allows for an informed person to refuse a type of treatment considered unacceptable according to their set of values. From the knowledge on the progression of Alzheimer disease, it is possible to plan the medical care, even though there is still no treatment available. Irreversible cognitive incapacity underlines the unrelenting loss of autonomy of the demented individual. Such a loss requires the provision of specific and permanent care. Major ethical issues are at stake in the physician–patient–family relationship, even when dementia is still at an early stage. The authors suggest that for an adequate health care planning in Alzheimer disease the living will can be presented to the patient in the early days of their geriatric care, as soon as the clinical, metabolic or even genetic diagnosis is accomplished. They also suggest that the appointment of a health care proxy should be done when the person is still in full enjoyment of his cognitive ability, and that the existence and scope of advance directives should be conveyed to any patient in the early stages of the disease. It follows that ethical guidelines should exist so that neurologists as well as other physicians that deal with these patients should discuss these issues as soon as possible after a diagnosis is reached.     

Family history of diabetes as a potential public health tool

Given the substantial morbidity and mortality associated with type 2 diabetes, it is important that public health seek ways to delay or prevent the onset of this condition. Risk factors for type 2 diabetes are well established and include underlying genetic susceptibility. Despite this knowledge, as well as significant advances in understanding the human genome, the prevalence of type 2 diabetes continues to rise at an alarming rate. Because type 2 diabetes is a complex condition involving a combination of genetic and environmental factors, DNA testing for susceptibility genes is not yet warranted. However, because family history reflects genetic susceptibility in addition to other factors, it may be a useful public health tool for disease prevention. When evaluating family history as a public health tool, several important issues need to be considered, including the analytic and clinical validity and the clinical utility of using family history as a screening tool. These issues as well as a review of the epidemiologic evidence evaluating family history as a risk factor will be reviewed.Overall, a family history approach appears to be a promising new public health tool to fight the growing epidemic of diabetes in the United States. Adequate levels of funding to further evaluate this approach and to develop appropriate tools should be made available for research activities focused on this important area.     

The definition and identification of need for health care.

Some definitions of need for health care as a basis of planning health services are discussed. A model proposed by Donabedian (1974) relating need to resources is used to consider the problems faced by the Resource Allocation Working Party (RAWP) (Department of Health and Social Security, 1976). The paper concludes that need should be defined in relation to the procedures available to meet it and the resources that permit those procedures to be used. The procedures include the whole gamut of prevention and screening, cure and care, research and development. This necessarily raises moral and ethical issues which stretch beyond the limits of medicine and concern patients, their relatives, and the public in general. Neither the medical profession nor the lay public can be expected to help define need for health care unless they understand the underlying issues. This is a challenge to those responsible for professional and public education.     

Economic considerations in technology assessment: the case of genetic disease.

This paper describes economic issues pertinent to health care technology assessment. Of interest are the allocation of resources between health and other sectors of the economy, between alternative services within the health sectors, and the costs of producing the services that are selected. These issues are discussed and then illustrated by reference to a specific area of health care technology: screening for and intervention against genetic diseases. It is concluded that investments in screening programs for Tay Sachs disease and Down Syndrome are allocatively efficient. Indications are that such investments are also efficient for interventions against Neural Tube Defects; however, there are complex ethical issues involved. There are many genetic diseases for which screening tests have yet to be developed. As such tests become available, each will have to be evaluated on its own merits relative to alternative health sector investments.     

Health care policy issues as a result of the genetic revolution: implications for public health

The genetic revolution has spawned 4 distinct issues of universal importance to health care policy and society: genetic privacy, regulation and standardization of genetic tests, gene patenting, and education.

Adequate policy advancements for these 4 areas are lacking. Stringent controls must be placed on individual health records to prevent their misuse. Genetic testing within the clinical setting should undergo thorough evaluation before it is implemented. Regulations are needed to prevent the monopolization of DNA sequences.

Society and health care professionals must be educated about the scope of genetic testing because current trends indicate that genetic and molecular assessments are destined to become a routine component of health care.

     

Der HUS-Ausbruch 2011 in Deutschland

From May to July 2012 the world’s largest outbreak of hemolytic uremic syndrome (HUS) occurred in northern Germany with dramatic consequences for the population, the health care system and the food industry. In the following we examine the detection of the outbreak, epidemic management and related public communication aspects based on scientific publications, media reports as well as own and new data analyses. The subsequent 17 recommendations concern issues such as participation in and implementation of existing and new surveillance systems particularly with respect to physicians, broad application of finely tuned microbiological typing, improved personnel capacity and crisis management structures within the public health service and evidence-based communication by administrations and scientific associations. Outbreaks of similar dimensions can inevitably occur again and result in costs which will far exceed investments needed for early detection and control. This societal balance should be taken into account in spite of limited resources in the public health sector.     

Predictive genetic testing - change in paradigms for prevention and health care?

The post-genomic era promises to offer new insights into the nature of disease, its prevention, and treatment. But now that there is a draft code of the human genome, what does this knowledge mean and how might it be applied? How to use genetic information to promote health and prevent disease - the fundamental mission of public health - will be one of the most challenging tasks in future. Assessing the benefits and risks of predictive genetic testing and the efficacy of early interventions as well as exploring complex issues that have emerged (e. g., rapid commercialization of genetic tests, availability of and access to interventions, and potencial discrimination) call for public health leadership.     

Public health in the new millennium

In the new millennium the world has become a ?global village?. Urbanization, economical imbalance, changing social structures and globalization resulting in ever-increasing interpenetration and interdependence between local, national and transnational events constitute the new operational field of public health. This article discusses the challenges and constraints faced by developing countries in its efforts to improve equity in health care. It is noted that the challenges include globalization; emergence of diseases and epidemics; privatization of health care; improving the quality of care; developing Healthy Public Policy; effective decentralization; and a focus on the poor, vulnerable and marginalized groups. In terms of the constraints, most notable is the disagreement between providers of individual care and practitioners of population-based medicine, and the noncontribution of public health research to public policy. In view of such, several recommendations are cited in order to overcome these challenges and constraints and in turn, achieve the goal of improving equity in health care. In this regard, the importance of health systems development including health sector reform in shaping the system and practice of public health in the new millennium is emphasized.     

The Human Genome Project and health behavior and health education research

The Human Genome Project (HGP) is a multinational initiative to map and sequence the human genome. This major biological research effort, estimated to take 15 years and cost $3 billion, should have significant implications for public health generally, and for health behavior and health education research in particular. It is anticipated that the HGP research will lead to expanded (1) newborn genetic disease screening, (2) prenatal diagnoses and (3) trait carrier screening. The HGP also is likely to lead to presymptomatic screening of people with late onset genetic diseases, as well as screening for genetic-based susceptibility for common disease morbidity and mortality mediated by either or both life style and environmental factors. These potential developments have raised ethical, legal and social questions, and have highlighted the fact that research is needed on individual, organizational, population and governmental use of and response to these developments. Central to the expanding role of genetics in public health will be health behavior and education research. Such research could contribute to an effective and humane applied human genetics.     

The concept of screening medicine in oncology

Screening medicine is a basis of a suggested new concept; it comprises: an evaluation of the basic health fund within the terms of real time; continuity of the medical, ecological, epidemical, congenital and genetic information collected within the medical passport; as well as synthesis of the obtained data and monitoring of patients. The above concept enables a qualitatively new approach to coping with issues of individual health and to rendering a high-quality medical care in oncology.     

Health policy issues and applications for evidence-based medicine and clinical practice guidelines

Evidence-based medicine and clinical practice guidelines have become increasingly salient to the international health care community in the 1990s. Key issues in health policy in this period can be categorised as costs and access to care, quality of and satisfaction with care, accountability for value in health care, and public health and education. This paper presents a brief overview of evidence-based medicine and clinical practice guidelines and describes how they are likely to influence health policy. Evidence-based medicine focuses on the use of the best available clinical (efficacy) evidence to inform decisions about patient care; guidelines are statements systematically developed from efficacy and effectiveness research and clinical consensus for practitioners and patients to use in making decisions about appropriate care under different clinical circumstances. Both fields have developed methods for evaluating and synthesising available evidence about the outcomes of alternative health care interventions. They have clear implications for health policy analysts: greater reliance should be placed on scientific evidence, policy decisions should be derived systematically, and health care decisionmaking must allow for the active participation of health care providers, policy makers, and patients or their advocates. The methods and information generated from evidence-based guidelines efforts are critical inputs into health policy analysis and decision-making.     

An agenda for future debate on concepts of health and disease

The traditional contrast between naturalist and normativist disease concepts fails to capture the most salient features of the health concepts debate. By using health concepts as a window on background notions of medical science and ethics, I show how Christopher Boorse (an influential naturalist) and Lennart Nordenfelt (an influential normativist) actually share deep assumptions about the character of medicine. Their disease concepts attempt, in different ways, to shore up the same medical model. For both, health concepts function like demarcation criteria in the philosophy of science: they mark off the jurisdiction of medical science, and protect it from an inappropriate intrusion of socioeconomic factors, which threaten the integrity of modern medicine. These views are challenged by new developments in healthcare such as managed care and total quality review. To frame the health concepts debate in a way that better captures the issues integral to these new developments, I advance a new way of reading the distinction between weak and strong normativists. Strong normativists are skeptical of the demarcation project, think facts and values cannot be disentangled, and hold that socioeconomic conditions unavoidably influence how pathology is understood. The new health concepts debate should be framed as one between weak and strong normativists, and it concerns how we should respond to the current developments in health care.     

International cooperation and health. Part I: Issues and concepts

The world is increasingly shaped by powerful global forces, many of which have consequences for human health and the social, economic, and environmental factors that influence health are increasingly determined at a supranational level. As a result, local or national level efforts to influence health determinants can have only a limited impact and it is all too easy for the individual public health practitioner to feel powerless. Yet while public health practitioners, on their own, may indeed be comparatively powerless, together they can achieve a great deal. Part I of this glossary explores a range of issues that arise as they seek to make a difference.     

Perspectives on advancing preventative medicine through vaccinology at the comparative veterinary, human and conservation medicine interface: not missing the opportunities

Vaccination has historically and remains one of the most cost-effective and safest forms of medicine today. Along with basic understanding of germ theory and sanitation, vaccination, over the past 50 years, has transformed lives and economies in both rich and poor countries by its direct impact on human and animal life--resulting in the eradication of small pox, huge reductions in the burden of previously common human and animal diseases such as polio, typhoid, measles in human medicine and contagious bovine pleuropneumonia, foot-and-mouth disease, screwworm and hog cholera and the verge of eradicating brucellosis, tuberculosis, and pseudorabies in veterinary medicine. In addition vaccination along with other animal production changes has provided the ability to produce otherwise unaffordable animal protein and animal health worldwide. The landscape however on which vaccinology was discovered and applied over the past 200 years, even in the past 10 years has and is undergoing continuous change. For vaccination as a public health tool to have its greatest impacts in human and veterinary medicine, these great medical sciences will have to come together, policy-relevant science for sustainable conservation in developing and developed countries needs to become the norm and address poverty (including lack of basic health care) in communities affected by conservation, and to consider costs and benefits (perceived or not) affecting the well-being of all stakeholders, from the local to the multinational. The need to return to and/or develop new education-based models for turning the tide from the heavily return-on-investment therapeutic era of the last century into one where the investment into the preventative sciences and medicine lead to sustainable cultural and cost-effective public health and economic changes of the future is never more evident than today. The new complex problems of the new millennium will require new educational models that train para- and professional people for thinking and solving complex inter-related biological, ecological, public-, political/economic problems. The single profession that is best positioned to impact vaccinology is Veterinary Medicine. It's melding with human medicine and their role in future comparative and conservation-based programs will be critical to the successful application of vaccines into the 21st century.     

Methodische Ansätze in der Versorgungsforschung

According to the established definition of Pfaff, health services research analyses patients' path through the institutions of the health care system. The focus is on development, evaluation and implementation of innovative measures of health care. By increasing its quality health services research strives for an improvement of efficacy and efficiency of the health care system. In order to allow for an appropriate evaluation it is essential to differentiate between structure, process and outcome quality referring to (1) the health care system in its entirety, (2) specific health care units as well as (3) processes of communication in different settings. Health services research comprises a large array of scientific disciplines like public health, medicine, social sciences and social care. For the purpose of managing its tasks adequately a special combination of instruments and methodological procedures is needed. Thus, diverse techniques of evaluation research as well as special requirements for study designs and assessment procedures are of vital importance. The example of the German disease management programmes illustrates the methodical requirements for a scientific evaluation.