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Essential Dental
Public Health
This page intentionally left blank
 Essential Dental
Public Health
Second Edition

Blánaid Daly
Senior Clinical Lecturer/Academic Lead in Special Care Dentistry,
Specialist in Special Care Dentistry and Specialist in Dental Public Health,
King’s College London Dental Institute, London

Paul Batchelor
Hon. Senior Lecturer in Dental Public Health, UCL, and
National Research Facilitator and Course Director,
Dental Health Services Leadership and Management programme,
FGDP(UK), Royal College of Surgeons, London

Elizabeth T. Treasure
Professor of Dental Public Health and Deputy Vice Chancellor,
Cardiff University

Richard G. Watt
Professor and Honorary Consultant in Dental Public Health,
University College London

1
 Great Clarendon Street, Oxford OX2 6DP,
United Kingdom
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© Oxford University Press 2013
The moral rights of the authors have been asserted
First Edition published in 2002
Second Edition published in 2013
Impression: 1
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Foreword

The time is now right for developing a new approach to because there are associations between risk factors for
promote oral health. One that considers oral health as oral disease and major NCDs. This realization led the
an integral part of general health and addresses the WHO to re-orient its Global Oral Health Programme to
needs and demands of populations and includes an foster its integration with chronic disease prevention
integrated public health approach to tackle the social and general health promotion. The World Health
determinats of chronic diseases. Greater recognition Assembly’s resolution on oral health: action plan for
should be placed on effectively promoting oral health promotion and integrated disease prevention urged
as there is a growing body of evidence of the benefits Member States to adopt measures ‘to ensure that oral
and effectiveness of investing in health promotion health is incorporated as appropriate into policies for
programs through an integrated approach. Integrated the integrated prevention and treatment of chronic
health promotion programmes deliver benefits for the non-communicable disease and communicable dis-
community through promoting positive wellbeing, ease, and into maternal and child health policies’
strengthening community capacity as well as minimizing (Peterson 2008). Recently, the declaration of the High-
the burden of serious diseases, such as diabetes and level United Nations Meeting on Prevention and
cardiovascular disease. A health promotion approach Control of Noncommunicable Disease commits gov-
moves health from an individual lifestyle/choice model ernments of the world to significant and sustained
to a broad community issue. Health is created where action to address the rising burden of noncommunica-
people live, love, work and play. Therefore a public health ble diseases (NCDs) such as diabetes, cancer, cardio-
promotion strategy starts from settings of everyday life vascular and respiratory diseases and oral diseases
within which health is promoted, rather than with disease (UN 2011). The Declaration calls for integrated and
categories, and with strengthening the health potential cross-sectoral approaches to tackle noncommunicable
of the respective settings. Because, to change behaviours diseases—an approach highly appropriate for most
one needs to change the environment that predisposed oral diseases. It is appropriate because the risk factors
people to health compromising behaviours. That is for oral diseases are common to other major chronic
why health promotion involving concern for social and diseases. Therefore using the Common Risk Factor
physical environments supportive of health is pivotal to Approach (CRFA) will become mainstream for all health
improving health. A re-orientation from prescription sectors and dentists must be involved in applying that
to health promotion, should redress the balance of approach by incorporating programmes for promotion
influences and make healthier choices easier, facilitate of oral health and prevention of oral diseases into pro-
decision-making skills rather than be prescriptive. He- grammes for the integrated prevention and treatment
alth promotion includes combatting the influences of of chronic diseases such as heart diseases, cancers,
those interests which produce and profit from ill health. hypertension and diabetes.
That involves controls on industry sponsored educational The way forward for oral health policy is that policy
materials in schools, advertising, and campaigns to makers and deans of dental schools need to allocate a
reduce barriers and enable and empower people. higher priority and resources to oral health promotion
There is a growing realization that oral health is an inte- directed at the social determinants of risk factors
gral part of overall health, and shares many common risk common to a number of diseases, the Common Risk
factors with leading non-communicable disease (NCDs) Factor Approach; to behavioural and political factors.
vi Foreword

The WHO Commission on Social Determinants of of oral and general diseases because many of the risks
Health (CSDH 2008) defines social determinants of for disease and poor health functioning are shared by
health (SDH) as ‘the structural determinants and con- large numbers of people. One-to-one chairside inter-
ditions of daily life responsible for a major part of ventions do little to improve the overall oral health of
health inequities between and within countries’. The populations because new people continue to be aff-
determinants of health and health inequalities—the licted even as ’sick’ people are treated or cured. It
‘causes of the causes’, are socially patterned and this therefore is more cost-effective to prevent many chronic
patterning may pass from generation to generation. diseases using a common-risk factor approach at the
However, insufficient attention is given to the causes of community and environmental levels than to address
behaviours, the underlying social and environmental them at the individual level. An important focus for
conditions that influence behaviours. Environmental prevention should therefore relate to policies to control
conditions deserves much more attention. diet and to behaviour change. The environment deter-
Another important reason for changing from the cur- mines behaviour. The most effective way to change
rent approach to one using public health principles behaviour is to change the environment within which
outlined in this book, is that high levels of dental dis- people live. Making healthy choices the easier choices
eases persist despite the availability of a scientific epi- and unhealthy choices more difficult. Such a policy is
demiological basis for preventing them. There is a large enabling and supportive.
gap between what is known and carried out in practice. The future roles of dentists therefore is to advise
Dentistry has not been capable of controlling, nor effec- patients and communities about risks to dental he-
tively or efficiently preventing diseases. In an era of alth, investigating and controlling the risks, influenc-
evidence-based public health medicine and dentistry, ing the health related behaviours of patients and
such approaches are no longer acceptable. The limita- populations by changing their environments, diag-
tions of what conventional dentistry has achieved are nosing oral and dental diseases and assessing
serious. Therefore, on humanitarian grounds alone, a patients’ needs based on a combination of normative
major shift to effective dental public health approaches and perceived needs, providing high quality evidence–
are essential. based dental care—doing the right thing and doing it
Unfortunately relatively little emphasis is currently right, and administration of a dental team. Most den-
placed on effective dental public health and conse- tist involvement in dental public health policy devel-
quently high levels of dental disease and dental pain opment will be as health advocates. Every health
and functional disability are common. The main empha- professional has the potential to act as a powerful
sis remains on replacing artificially tissue lost by dis- advocate for individuals, communities, the health
ease despite the fact that no disease has ever been workforce, the general population and their elected
treated away. The current approach is equivalent to representatives. Since many of the factors that affect
dentists and their teams trying to clean the mess on health lie outside the health sector, dentists may need
the floor with better and more efficient brooms, whilst to use their positions both as experts in health and as
leaving the tap full on. So the mess persists and may respected professionals to investigate or encourage
get worse and affect the underlying structures. Then changes in policies in other sectors. To increase effec-
more costly treatments are needed to remedy the tiveness, advocates build partnerships with the com-
accumulated destruction. A more rational solution is munity, other professional groups, and other sectors.
to try to turn the tap off, tackling the determinants of They place their skills at the disposal of the commu-
health, and cleaning up the smaller mess that remains. nity. Being available, not on top.
That requires dentists to deal with the determinants of Understanding and adopting the principles of dental
the diseases and treating what remains effectively. public health described in this book should be consid-
Greater emphasis must be given to the development ered as essential as knowing the principles of clinical
of interventions that focus on the ‘causes of the causes’ procedures. In order for the oral health workforce to
 Foreword vii

successfully reduce dental diseases and tackle ine- References

qualities in oral health the right education is essential.
CSDH. (2008). Commission on Social Determinants of
Teaching dental public health should form the central
Health. Closing the gap in a generation: health equity
hub of dental education around which its biological,
through action on the social determinants of health. World
clinical, and technological spokes should revolve. In- Health Organization: Geneva, 2008. http://www.who.int/
corporating the principles outlined in this book will social_determinants/thecommission/finalreport/en/
enable dentists to fulfill their professional and civic index.html
roles as altruistic health workers and encourage trust Petersen PE. (2008): World Health Organization global
and personal satisfaction because they have done policy for improvement of oral health – World Health
their best. Assembly 2007, International Dental Journal 58, 115–121.
UN (2011). United Nations General Assembly. Political
declaration of the High-level Meeting of the General
Professor Aubrey Sheiham
Assembly on the Prevention and Control of Non-
Emeritus Professor of Dental Public Health, communicable Diseases. Resolution. A/66/L1. 2011.
Department of Epidemiology and Public Health, http://www.un.org/ga/search/view_doc.
University College London. asp?symbol=A/66/L.1
Preface to the second edition

When we wrote this book 11 years ago, Dental Public inequalities. The International Association of Research
Health (DPH) was a comparatively new specialty, still (IADR) has recently called for this agenda to be moved
defining its role in oral health policy and the delivery of forward and for researchers to focus now on research-
oral health services. That role is now well established ing the implementation of strategies to reduce oral
and DPH is a core topic in undergraduate dental cu- health inequalities.
rricula (GDC 2011, Association of Dental Education in The role of DPH is therefore well established, and
Europe 2010) and is shaping oral health policy and the whilst it focuses on the broader picture at a population
delivery of oral health services. level the practice of dental public health is everybody’s
In England, DPH has informed the development of business, particularly the dental team in primary care
the oral health strategies Choosing Better Oral Health that makes first contact with patients and the public. It
(2005) and Valuing People’s Oral Health (2007) and is essential that the dental team is equipped with the
the evidence based toolkit for prevention of dental appropriate knowledge, skills, and values required to
disease in primary care Delivering Better Oral Health perform its role in society.
(2012). In terms of oral health service delivery, the In the light of all the developments over the last 11
Steele Independent Review of NHS Dentistry evidenced years it is time to update this book. We have retained
a sea change in dental policy by placing public health the format of the first edition and kept it as a basic
at the heart of dental services. introductory text. As with the first edition we have pro-
In Scotland there is the innovative national Ch- vided additional references for those of you who want
ildsmile dental prevention programme which starts in to explore the topic in more depth.
early childhood and aims to improve children’s oral We are very pleased that the first edition of the
health and tackle oral health inequalities. In Wales leg- book has reached such a wide audience. We have
islation has recently been enacted to support devel- enjoyed meeting students both in the UK and abroad
opment and introduction of clinical care pathways for who have used this book and we have incorporated
people with special needs as well as the introduction of their insights and feedback in producing this updated
Designed to Smile also aimed at improving pre-school version.
children’s oral health.
At an international level, there is a growing consen- Blánaid Daly
sus on the need to tackle the social determinants of Paul Batchelor
health and much high quality oral health research is Elizabeth T. Treasure
directed at describing and understanding oral health Richard G. Watt
Contents

Part 1 Principles of dental public health

1 Introduction to the principles of public health 3

2 Determinants of health 14
3 Definitions of health 23
4 Public health approaches to prevention 37

Part 2 Oral epidemiology

5 Overview of epidemiology 51
6 Trends in oral health 68
7 Evidence-based practice 79

Part 3 Prevention and oral health promotion

8 Principles of oral health promotion 99

9 Overview of behaviour change 114
10 Prevention and oral health education in dental practice settings 126
11 Sugars and caries prevention 134
12 Fluoride and fissure sealants 144
13 Prevention of periodontal diseases 151
14 Oral cancer prevention 159
15 Public health approaches to the prevention of traumatic dental injuries 169
16 Prevention for people with disabilities and vulnerable groups 174

Part 4 Health services

17 Overview of health care systems 189

18 The structure of the NHS in the UK 197
19 The structure of dental services in the UK 207
20 The European Union and dentistry 215
21 Planning dental services 218
22 Health economics 231
23 Problems with health care delivery 238

Index 247
This page intentionally left blank
 1 Principles of dental
public health

Chapter 1 Introduction to the principles of public health 3

Chapter 2 Determinants of health 14
Chapter 3 Definitions of health 23
Chapter 4 Public health approaches to prevention 37
This page intentionally left blank
 1 Introduction to the
principles of public
health

CHAPTER CONTENTS

Introduction Ottawa Charter

Definition of dental public health Millennium development goals
Relevance of public health to clinical practice WHO Commission on the Social Determinants
What is a public health problem? of Health

Public health movement: history and Core themes of dental public health practice
background Implications of dental public health for practice,
Emergence of the new public health research, and teaching

Alma-Ata declaration References

Further reading

By the end of this chapter you should Introduction

be able to:
Public health is now recognized as being a core
● Define dental public health. component of the undergraduate medical and dental
● Identify the links between clinical practice and curricula in many parts of the world (Association for
dental public health. Dental Education in Europe 2010; General Dental
● Outline the criteria used to determine if a condition Council 2011; General Medical Council 2009). This
is a public health problem. recognition acknowledges that public health is an
● Describe the central arguments presented by the important subject relevant to the practice of medicine
critiques of the biomedical approach to health care and dentistry. This chapter will outline what is meant
delivery. by public health and, in particular, its relevance to
clinical dental practice. The philosophical and histori-
cal background of public health will be reviewed and
the limitations of the traditional system of health care
This chapter links with:
highlighted. Finally, a dental public health framework
● All the other sections in this text by providing the will be outlined to highlight the central importance of
background to dental public health. public health to the future development of dentistry.
4 Part 1 Principles of dental public health

Definition of dental public sciences that collectively enrich the value and rele-
vance of the subject (Box 1.1)
health
Dental public health can be defined as the science and
practice of preventing oral diseases, promoting oral
Relevance of public health to
health, and improving quality of life through the orga-
nized efforts of society.
clinical practice
The science of dental public health is concerned with The practice of dentistry is undergoing a period of
making a diagnosis of a population’s oral health prob- rapid change due to a wide range of factors in society
lems, establishing the causes and effects of those prob- (Box 1.2). The knowledge and skills required for the
lems, and planning effective interventions. The practice
of dental public health is to create and use opportuni-
Box 1.1 Sciences and disciplines underpinning dental
ties to implement effective solutions to population oral public health
health and health care problems (Chappel et al. 1996).
Dental public health is concerned with promoting
● Epidemiology
the health of the population and therefore focuses
● Health promotion
action at a community level. This is in contrast to clini-
● Medical statistics
cal practice which operates at an individual level. How- ● Sociology and psychology
ever, the different stages of clinical and public health ● Health economics
practice are broadly similar (Table 1.1). ● Health services management and planning
Dental public health is a broad subject that seeks to ● Evidence-based practice
expand the focus and understanding of the dental pro- ● Demography
fession on the range of factors that influence oral
health and the most effective means of preventing and
Box 1.2 Changes affecting the practice of dentistry
treating oral health problems. Dental public health
is underpinned by a range of related disciplines and
Epidemiological changes Changing pattern of dis-
ease; for example, dramatic improvements in caries,
Table 1.1 Stages of clinical and public health practice
persistence of oral health inequalities.
Demographic shifts Ageing population, changes in
Individual clinical Public health practice family structures, greater population mobility, increas-
practice ing cultural diversity.
Organizational changes Health service reforms,
Examination Assessment of need greater emphasis on primary care services and pre-
Diagnosis Analysis of data vention, evidence-based medicine/dentistry, corpo-
rate bodies, clinical governance.
Treatment planning Programme planning Professional development Importance of life-long
Informed consent for Ethics and planning learning, team work, interpersonal skills.
treatment approval Social change Consumerism, increasing public
expectations and demands on health services, widen-
An appropriate mix of Programme ing social and economic inequalities.
care, cure, and prevention implementation Political pressures Changes to the welfare state,
Payment for services Types of finance pressures for cost containment on public spending,
rationing care, increasing professional accountability.
Evaluation Appraisal and review Technological change Health informatics, pharmaceu-
tical developments, ‘new genetics’, new dental materials.
Modified from Young and Striffler 1969.
 Chapter 1 Introduction to the principles of public health 5

next generation of dental professionals will therefore and welfare systems. It is essential that dental profes-
be very different than was previously the case. sionals have a broad understanding of the changing
Studying dental public health provides an ideal structure, organization, and finance of their health care
opportunity to gain an improved understanding of system. This knowledge will enable dentists to plan
many of the factors outlined in Box 1.2. Three key areas and develop their dental practices more effectively.
are most relevant to the practice of clinical dentistry, as
detailed in the following sections.
What is a public health
Epidemiology of oral diseases problem?
It is essential that dental services are developed to It is now widely recognized that demands on health
address and effectively meet the oral health needs of care systems will always be greater than the resources
individuals and the wider community. Knowledge of available to meet these needs. This dilemma is not
the epidemiology of oral disease will facilitate an confined to the developing world where resources are
understanding of the extent, aetiology, natural history, acutely limited. The richest countries in the world, such
and impacts of oral conditions. By applying critical as the USA, Germany, and the UK, are faced with simi-
appraisal skills in their clinical decision-making, den- lar problems of increasing demands and escalating
tal professionals can practise dentistry more effectively health care expenditure. For example, expenditure on
through an evidence-based approach to care. Clinical heath care in the USA rose from 5.1% of gross domes-
epidemiology provides the skills required to undertake tic product in 1960 to 17.6% in 2010 (OECD 2012).
this task by teaching the principles of study design and Across the OECD, the average expenditure on health
evaluation. care is now 9.6%. In the UK, spending on the General
Dental Services has risen steadily over recent decades.
In 1977/78 the figure was £270 million, by 1997/98 it
Prevention and oral health promotion was £1528 million, and in 2012 it was estimated to be
in excess of £3.3 billion.
Prevention is as pivotal to the dentist’s role as treat-
ment of disease. A core aspect of dental public health is
exploring the principles of prevention and oral health DISCUSSION POINTS 1
promotion and identifying opportunities for effective What factors contribute to the increasing demands
preventive interventions. This requires an understand- on health care systems?
ing of the social, political, economic, and environmental Are there any ways in which this demand can be
factors that influence oral health and the capacity of controlled?

dentistry to influence them. Of particular importance to

oral health is a broad understanding of diet and nutri-
One response to increasing demands and limited
tion, body hygiene, tobacco use, and the use of fluo-
resources is to direct resources to particular priority
rides in the prevention of dental caries, periodontal
areas. However, what would be considered an impor-
disease, and oral cancers.
tant problem? This is where core public health princi-
ples have a major contribution to make. Box 1.3 lists
certain public health criteria that can be used to deter-
Planning and management of health
mine the significance of a health problem (Sheiham
services
1996).
Dental services are a part of the health care system The first criterion relates to the prevalence of the
and are affected by many of the complex organizational health problem, in essence is the disease widespread?
and policy developments of the wider health, social, Who has the disease? What percentage of the total
6 Part 1 Principles of dental public health

population is affected? What is the distribution of the presents a summary of the impact of oral conditions on
disease within the community? Is the prevalence of the the individual and society. Finally, it is important to
condition increasing or decreasing? The second aspect consider the potential for prevention and treatment of
relates to the impact of the condition at the individual the disease. Is the natural history of the disease fully
level. How severe are the effects of the disease to the understood? Can the early stages of the condition be
patient? For example, do people die as a result of it? Do recognized? If so, are there interventions that can be
they suffer pain, discomfort, or loss of function? Can implemented to stop the disease progressing? If it does
they perform their normal social roles? Are they pre- progress, are there effective treatments available?
vented from going to school or becoming employed
because of the problem? The third aspect relates to the
effects of the disease across society. What are the costs DISCUSSION POINTS 2
to the health service of treating the condition? How Apply the criteria from Box 1.3 to dental caries,
much time do people take off work to get treatment and periodontal disease, and malocclusion.
care? What effect does the condition have on economic Do you consider these oral health conditions are
performance and productivity of the country? Figure 1.1 dental public health problems?
Explain the basis for your answer.

Box 1.3 Criteria for a public health problem

● Prevalence of the condition.

Public health movement:
● Impact of the condition on an individual level. history and background
● Impact on wider society.
Public health is not a new subject. Indeed, it has a long
● Condition is preventable and effective treatments
and interesting history, which is linked to many of
are available.
the social, economic, and political changes that have

Society

Social
Social isolation Time off work

Individual

Functional limitation Pain/discomfort

Impact of Oral Diseases

Costs Educational
to Sleepless nights Cost of treatment performance
NHS Fear/anxiety
Self esteem Aesthetics
Time attending services

Social attractiveness Time off school

Reduced productivity of workforce

Figure 1.1 The impact of oral disease.

 Chapter 1 Introduction to the principles of public health 7

occurred in history in the last 150 years. The public pump in Broad Street. By removing the pump handle,
health movement originally arose in response to the the epidemic was controlled as no one could then
appalling living and working conditions that affected a access the infected water source (Figure 1.2). This is an
high proportion of the working classes in the industri- example of public health practice in action: an epide-
alized world in the 19th century. Rapid industrialization miological assessment of the problem, identification of
and urban growth created industrial towns and cities in the environmental cause of the infection, and imple-
which overcrowding, extreme poverty, squalor, and dis- mentation of effective action, cheaply and quickly.
ease were commonplace. Pioneering social reformers
such as Southwood Smith, Edwin Chadwick, and John
DISCUSSION POINTS 3
Snow identified the need to improve the living and
● If John Snow had not been in Soho, how would
working conditions of the poor to promote the public
this cholera outbreak have been dealt with by his
health. In the UK, municipal reforms and improvements
less enlightened colleagues?
in the environment then resulted from passing legisla-
● What would have been the obvious limitations of
tion such as the Public Health Act 1875.
this approach?
One example of this early public health approach to
dealing with disease is the response to a cholera out-
break in Soho, London, in 1875. John Snow, a local doc- Public health reforms that focused upon improving
tor, identified that cholera was a waterborne disease by environmental conditions which significantly boosted the
mapping the outbreak to a single water source, a water health of the poor in Victorian and Edwardian Europe

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Figure 1.2 Snow’s map of cholera cases in Soho, 1854.

Reproduced from Naidoo and Wills (2000) Health Promotion: foundations for practice, with permission from London, Baillière-Tindall.
8 Part 1 Principles of dental public health

were not simply driven by altruistic motives. The need Emergence of the new public
for a fit and healthy workforce and armed services was
the main pressure for reform. A significant proportion
health
of British army recruits for the Boer War were rejected In the UK, following the creation of the NHS in 1948,
on health grounds, many of them because of dental the health service steadily expanded in size and influ-
problems. It was reported that 6% of potential recruits ence. Indeed, in most developed countries, health ser-
were rejected because of missing or decayed teeth, vices expanded considerably in the second half of the
and within 3 months of enlisting, 3 in every 1,000 sol- 20th century. However, by the 1970s and 1980s the
diers were declared unfit because of dental problems limitations of modern medicine were becoming
(Gelbier 1994). increasingly evident. Medicine continued to adopt a
The industrial revolution and the development of treatment-orientated approach, but a number of other
mechanization influenced emerging ideas about health problems also emerged: health services did not appear
and disease. The lessons of the public health movement to have any clear goals and were poorly evaluated,
were overtaken by the growth of knowledge about the accountability was poor, and there was maldistribution
functioning of the body and the analogy of the body with of resources and inequality in the access and quality of
machines. The engineering concept was easy to explain health care. (The problems with health care systems
to lay people, but it focused health interventions on the will be covered in more detail in Chapter 23.)
individual rather than the population level. This approach
became known as the biomedical model of health. Fea-
tures of the biomedical model are presented in Box 1.4. DISCUSSION POINTS 4
By the turn of the 20th century the focus of public Do you think these problems of health care delivery
health had shifted away from social and environmental are applicable to the current health system?
causes of disease to a more biomedical approach, Can you give some examples?
which instead emphasized behavioural lifestyle and
biological influences on health. This approach there-
fore became dominated by a more medicalized form of The limitations of modern medicine were highlighted
practice in which immunization and screening pro- by a selection of influential philosophers and academ-
grammes had the highest priority and were the major ics whose criticisms of the current system of health
focus for prevention. care were very important in establishing the new public
health movement. A synthesis of their main arguments
Box 1.4 Features of the biomedical model is presented in Box 1.5.
The new public health movement has refocused
● Disease orientated, with a focus on pathological attention on to the political, economic, and environ-
change. mental influences on health within contemporary soci-
● Explanations for ill health concentrate on ety. More emphasis is therefore placed upon developing
biological factors, operating at an individual level. a range of policy options to create a more health-
● Knowledge and expertise controlled by the promoting environment. This development requires
medical profession. health professionals to work collaboratively with a
● Compartmentalized and mechanistic approach to wide range of sectors and agencies. The improvement
diagnosis and treatment. in health is largely dependent upon activities outside
● Interventionist and high-technology approach to
of the health services. This presents a major challenge
treatment—belief in ‘magic bullets’.
to traditional beliefs of the role of medicine in society.
● ‘Top-down’ approach—hierarchical structure.
A number of international reports and WHO declara-
● Centralized institutional centres of excellence—
tions embodied the new public health approach and
teaching hospitals.
the refocusing on primary health care.
 Chapter 1 Introduction to the principles of public health 9

Box 1.5 Influential figures in the new public health movement

Rene Dubos (1979) Argued that modern society’s due to decline of infectious diseases. Main reasons for
obsession with the attainment of ‘perfect health’ was decline were improvements in nutrition, sanitation,
a ‘mirage’, an impossible dream. Instead proposed water supply, and reduction in family size. Medical
concept of holistic health as being a state of balance, services and discoveries had relatively small effect.
equilibrium, and harmony with nature. Stressed the Stressed that if medicine is to be effective it should
limitations of the doctrine of specific aetiology which be concerned with prevention as well as treatment,
dominates biomedical practice. with care as well as cure, and with the context of sick-
Archie Cochrane (1972) Founder of the Evidence-Based ness as well as intervention.
Medicine movement. Identified lack of scientific evi- Nancy Milio (1986) A key figure in the field of
dence for large amount of clinical practice. Stressed health promotion. Coined the expression ‘making the
need to evaluate all forms of medical care with ran- healthier choices the easier choices’. Reviewed the
domized controlled trial. Also stressed the importance importance of healthy public policy and the impor-
of the caring role in medicine. tance of developing health alliances to promote
Ivan Illich (1976) Major critique of modern medicine and health.
medicalization of life. Stressed iatrogenic ‘threat to David Locker (1988) Highly prolific and distinguished
health’ of medical care. Concerned by power and control dental researcher. Particular areas of interest included
of medical profession in modern society and peoples’ development of measures to assess oral health-related
lack of autonomy in coping with life, illness, and death. quality of life, effectiveness of oral health promotion
Vincente Navarro (1976) Critical of the commercializa- interventions, dental pain and anxiety, and oral health
tion of health and the emphasis placed upon profit and inequalities.
financial gain. Stressed how the capitalist system has Michael Marmot (2005) An internationally renowned
taken over health care as a commodity to be bought public health academic and policy advocate. High-
and sold. Also identified how the system defines dis- lighted the universal nature of the social gradient in
eases and formulates politically driven solutions that health and identified the broader social determinants
fail to challenge the underlying factors that create as the key causes of health inequalities. Very influen-
disease. tial as policy advocate on health inequalities at the
Aubrey Sheiham (1977) A leading dental public health WHO, European Union, and with various national
academic. Highly critical of clinical dentistry and the governments.
limited use of scientific evidence in clinical decision- Geoffery Rose (2008) A leading figure influencing
making. Very influential in dental policy and impor- the development of modern public health and preven-
tance of adopting a common risk approach in oral tive medicine. Outlined the limitations of the tradi-
health promotion. tional high-risk strategy in preventive medicine and
Thomas McKeown (1979) Demonstrated that the the potential advantages of the whole-population
major reductions in mortality in the 19th century were approach in disease prevention.

Alma-Ata declaration Focus on prevention A shift in focus and

resources is required, away from the
In 1978, the World Health Organization organized an dominant concentration on treatment towards
international conference in Alma-Ata in the then Soviet prevention and what we now term as health
Republic of Kazakhstan to review the future develop- promotion.
ment of health care internationally (WHO 1978). The Multi-sectoral approach The promotion of
conference agreed an important declaration that has health requires action in a wide range of sectors
since set an agenda for the new public health: beyond the health sector. Education, agriculture,
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