One of the most attractive aspects of a career in the health sciences is the reward of giving individual and personal care to our patients. Helping an individual patient to recover their health is very gratifying. However, many health professionals enjoy working on a much broader scale, bringing good health to the population at large. This is the practice of public health. Public health gives us the opportunity to help many more people than we could otherwise help by giving individual care. Public health is therefore rewarding personally, but is also very important in terms of the number of people helped, and the economy of care.

It is well known that people in Japan have one of the longest life-expectancies in the world. Furthermore, in many respects, Japanese people suffer from less disease and disability than people in most other nations. These health benefits come principally from public health, not from the care that individual health professionals give to individual patients. This importance of public health is often underestimated because the methods of public health are not dramatic, and the effects may not be immediately obvious.

Much of the effort of public health is directed towards the prevention of disease. In the past, this particularly meant the prevention of infectious diseases. A good example of early and successful public health projects was the construction of sewers in ancient Rome. Similarly, the construction of an aqueduct to bring water from Lake Biwa into Kyoto, was an important step in promoting the health of citizens in the city. These public health projects involved engineers, rather than doctors and nurses, but they were just as important, or more important to people's health than medicine.

More obvious methods of fighting disease include vaccination against infection. Vaccination has eliminated or greatly reduced the incidence of many serious infections, such as smallpox. Because of this effectiveness, in most developed countries the vaccination of children is compulsory. Public health workers also fight infectious diseases through education. An early example of this was Semmelweis encouraging medical doctors to wash their hands! An important modern example is educating the public about methods to prevent the spread of HIV. Both of these examples have had successful outcomes, and both demonstrate the importance of changing people's behaviours in order to fight disease.

Not just the behaviours of individuals, but the behaviours of governments must be changed to improve public health. The importance of government policy was recognized by the "Healthy Cities" project which used the motto "All public policy is health policy." This encouraged politicians and bureaucrats to think about the health implications of all of their decisions. In many countries, public health workers, including nurses, therapists and technologists, have formed public health associations to try to influence the policies that governments form. Therefore, public health does not just include the direct provision of health care to individuals, it also includes public works, education and political activity.

Situation 1: A group of public health nurses is discussing a programme to reduce smoking among school children.

Ikeda-san: This year we are going to begin working with all of the junior high schools in the city to reduce smoking among children. Fujimoto-san, do you want to explain to everyone the plan that we have discussed?

Fujimoto-san: Certainly. We thought that an important first step would be to gain the support of the teachers and parents. If they support the programme, then we are much more likely to be able to influence the children.

Sakai-san: How many middle schools will we be dealing with?

Ikeda-san: Fourteen altogether. Most of them already have programmes in place, but they are not well coordinated. They mostly depend on PTA members who change every year.

Fujimoto-san: With the public health department coordinating their efforts, we are more likely to have consistency from year to year, and the schools can share resources.

Ikeda-san: Most of the PTA's already support the idea of reducing smoking. I think that it should be easy to work with them.

Sakai-san: What do you think about the schools themselves?

Fujimoto-san: That's a different matter. Most of the teachers smoke themselves and I think that they might be a little threatened by this programme. Also most of the schools are already busy and don't want to take on any new projects. We are not likely to get a lot of help from them.

Ikeda-san: You can't blame them. The schools mostly want to teach what is on the curriculum. They don't have a lot of time or resources for public health. We have to depend on the parents. However, there is still a lot that we want to try with the teachers.

Sakai-san: What are you thinking about?

Fujimoto-san: The school board is letting us publish some articles in their monthly newsletter. Most of the teachers read that, and it will let us introduce them to the new programme. We are more likely to get their support by giving them some information before we go into the schools.

Sakai-san: What do you think about doing some presentations at teachers' conferences?

Fujimoto-san: Most of the teachers have to attend educational conferences during the school holidays. We are likely to reach a lot of them that way.

Patterns:

*we are much more likely
... to be able to influence the children
* we are more likely
... to have consistency from year to year
* we are likely
... to reach a lot of them that way
* we are more likely
... to get their support by giving them some information before we go into the schools
* we are not likely
... to get a lot of help from them

* Most of
... them already have programmes in place
... the PTA's already support the idea of reducing smoking@
... the teachers smoke themselves
... the schools are already busy
... the teachers read that
... the teachers have to attend educational conferences during the school holidays

* They mostly
... depend on PTA members who change every year@
* The schools mostly
... want to teach what is on the curriculum

* What do you think about
... the schools themselves
... doing some presentations at teachers' conferences?

* What are you thinking about

1. What are some important public health problems that you would like to study? Why?

2. Public health workers sometimes have to be teachers. How would you feel about teaching people about improving their health?

3. Some people think that compulsory vaccination of children is a bad thing. What do you think? Why?

4. Why is all public policy health policy?

5. Whose responsibility is it to stop children from smoking? Why?