Journals
Present Issue
Past Issues
 

THESMANEWS
Present Issue
Past Issues

SMJ Editorial Board

Letters to the Editor

Instructions to Authors

Singapore Med J 1999; Vol 40(12):

Health Without Borders
H P Lee

“Medicine has a changing and unchanging face, and it is as necessary to learn the meaning of the first as it is to recognise and to cherish the second.” Sir FMR Walshe, 1952

Introduction
Just as it is now well accepted that the world of economics and trade is borderless, so will it be with health. While each country continues to focus on local problems, the broader concerns of assessing health needs, surveillance, evidence-based decision making and the social dimensions of health have become truly global(1). The widespread movement of people and disease across boundaries and the universal influence of the Internet only serve to emphasise how small planet Earth really is.

Health in transition Public Health Medicine (PHM), by definition, is concerned with what happens to the ‘publicus’ (the people). It is a dynamic subject that moves with the times, responding to new disease patterns and new strategies in health care(2). Thus, it is always present-and future-oriented, keeping one eye on the here-and-now and the other on what is to come.

Populations are changing, with most facing the demands of ageing - referred to as the Demographic Transition. The challenge of preparing for such a scenario of looking after healthy and frail elderly is taxing the minds of many a government and organisation, not least in Singapore as well. How do we provide for long-term care for chronic disabilities? How do we keep our people healthy, active and productive for as long as it is biologically and socially possible? All the strategies related to health promotion and community-based services constitute a major concern of PHM.

Diseases also change, referred to as the Epidemiologic Transition. Unfortunately, they have become complicated. Not only are we faced with the increase of chronic and non-communicable diseases, there are also the re-emerging and emerging infections such as age-old tuberculosis and the newly discovered Nipah virus, which essentially destroyed the pig farming industry in neighbouring Malaysia.

As a result of the above, there is the Risk Factor Transition - indicating a change in relative importance. The growing dominance of lifestyle-related factors can be seen in both groups of diseases, eg. sexual habits in HIV infection and dietary patterns in some cancers. All such factors are aspects of human and social behaviour which pose major challenges in preventive and promotive strategies. It is far easier to control the physical environment as in sanitary reforms than it is to change behaviour, which is the main thrust of modern-day Health Promotion.

Thus it is essential for PH practitioners of the future to be fully prepared for a wider spectrum of diseases and health concerns; a broader age-range of people from the very young to the very old; and for a more varied demand and expectation of health care services. The increasingly important team concept in health care delivery and research will mean a blurring of boundaries between professional and departmental disciplines.

The burden of providing health care, which should include all rehabilitative and support services, will be a daunting task. With the increasing use and reliance on hightech equipment (as a natural consequence of scientific advancement), health care costs will escalate. What then do we do to enable people to pay for them? If taxes are inadequate, can social insurance do the trick? In Singapore, we have our innovative Medisave and company benefits. At the end of the day, all these financing schemes will not work if we do not ask ourselves: Are we getting value for the money we spend? PHM is about both planning and evaluating health care services, to guide decision-making on what we need and whether we are getting what we need at affordable costs.

Agenda for health
So, PHM’s role in the future will strengthen in two key areas:
(1) Health information
Knowledge has always been the basis of our medical practice, thus the ready acceptance of Continuing Professional Development and Education as a way of life. But methods may change; instead of lectures and the like, we may surf the ‘information superhighway’ for new knowledge in our own homes and clinics. That being the case, the need for skills in assessing the information and applying it would be even greater. To support evidence-based medicine and health-care, there is a vital need for a rigorous approach to the generation and appraisal of information that will collectively add up to the scientific evidence to guide health interventions and decisions.

The foundational sciences of Epidemiology, Biostatistics and their application in quality assurance health care assessment will be much used. Information is costly, and every effort must be made to justify such expenditure by paying attention to the quality of study design, data collection, analysis and interpretation. The advent of computers have facilitated much of these processes, but they are at best ‘dumb tools’. We need trained and creative minds to get the system right and to ensure that informatics serves mankind and not the other way round.

(2) Health promotion
This goes beyond mere disease prevention. It includes having a protective environment (with relevant legislation and services) and a promotive mindset, empowering individuals and families to make decisions in the best interests of their health. The key factors that influence health must be addressed. Strategies to promote healthy lifestyles for health are well summarised in the UK publication “The Nation’s Health”(3).

What then are the global issues of health? As Bernard Turnock expounded, they are the 3 Ps: Pollution, Population and Poverty(4). All other problems stem from these three, and the response would have to be broad-based, going beyond mere medical interventions. For example, tobacco control remains a prime public health objective. But it would be totally inadequate if the approach ignored the broader political, economic and social issues of tobacco production, lifestyle and values.

Conclusion
In the words of Robert Beaglehole: “Public Health is an evolving term... Ideally, (it) should be dynamic and flexible, incorporating the most appropriate elements of earlier public health movements: disease prevention, health promotion, health education, health policy, environmental concern and community empowerment”(5).

“The task of medicine has always been the same: to promote health by preventing illness and curing it.” Henry Sigerist, 1891 - 1957

Department of Community
Occupational and Family Medicine
National University of Singapore
16 Medical Drive
Singapore 11759

H P Lee
Professor and Head