Public health in Norway

The Sanitation Act of 1860 is to Norwegians what the 1848 Public Health Act is to Britons. It can be regarded as the beginning of public health as a profession and a movement. Social changes and the industrial revolution created a need for public intervention on fighting epidemics, improving sanitary conditions, water supply, sewerage and other health related issues. The idea behind this has been characterised as «a vision of social justice» (4). From the very beginning the ties to politics were strong and public health has been described as» … the only discipline that has the tradition to defend the population’s health in political debate» (5).

Primary care doctors became public health officers and in 1912 a new Act on the execution of public health issues formalised the role and authority of the medical profession in public health. Norwegian public health has been strongly related to primary care for at least two reasons:

• When the public health movement was created there were hardly any hospital specialists and the municipality based doctors were the obvious leaders in the field. Specialisation and development of secondary care during the 20th century did not change this and the public health movement became more or less separated from modern hospitals.

• Close ties to local communities have shown fruitful as a source for knowledge and inspiration, have given a short way from decision to acting and have been in accordance with the Norwegian ideology of decentralised politics.

The medical part of the organised efforts of society to improve public health has been known by various names among Norwegian doctors over the years. «Public duties» (offentlige gjøremaal) was the designation used during the last part of the 19th century. Later on «public medical issues» (offentlige legeforretninger) became the common term, related to the Act on the execution of public health issues of 1912. From the late 1940ies «public medical work» (offentlig legearbeid) was used reflecting the medical doctors’ participation in rebuilding the country after The Second World War. In the mid 1970ies «community medicine» (samfunnsmedisin) was introduced and in 1984 a formal speciality in community medicine was established.

The mandate of public health medicine

The change from «public medical work» to «community medicine» can be regarded as a conceptual as well as a linguistic modification. It was related to and came at the same time as the shift from the «old» to the «new» public health on an international scene. This shift was mainly due to a renewed view of lifestyle and its impact on health. The political climate of the 1970ies following the wake of the 1968 turmoil should also be kept in mind. The new public health focused more on social support and behaviour and less on physical infrastructure. Intersectoral and interdisciplinary action became crucial and there was a growing concern with sustainability and health promotion (6).

The change may also be seen as step towards a stronger identity and independence of community medicine as a medical speciality. Traditionally public health officers have been civil servants administering governmental laws and regulations. Typically, the milestones of public health in Norway (and other countries) have been new legislation (like 1860, 1912 and 1984 when an Act on municipality health services was introduced), rather than scientific breakthroughs.

Clinicians get their mandate «from below», in the way that the premises for their action are symptoms and signs presented to them by patients. Public health doctors to a much higher degree get their mandate «from above» in the sense that they inspect, oversee and regulate according to directives from the authorities. Public health doctors may of course also act on the basis of local findings and observations, but still there is a difference in the way they perceive their role. The new public health and the formal speciality of community medicine represented a slight shift in the balance «from above» to «from below». Though most community medicine doctors administer public regulations in one way or another, it should be possible to observe and analyse health problems on a community level, like clinicians do on an individual level. This is a way of defending their professional autonomy based on scientific evidence like other specialities and branches of medicine.

Community medicine as a medical speciality

The classification of medical specialities is arbitrary and unsystematic. Specialisation is partly based on organ systems (neurology, dermatology), partly on mechanisms of disease (oncology, infection diseases), partly on the age of patients (paediatrics, geriatrics), and partly on the technology or method of treatment (radiology, surgery). Some specialities are characterised by the context they work in (general practice, occupational health) and community medicine belongs to this category.

The first years after the speciality was formally established in Norway it seemed attractive and scores of doctors were certified as specialists every year. From the late 1990s there has been a dramatic drop. In 1997 and 1998 respectively 50 and 31 new specialists were certified. In 1999 the number fell to 5 and over the last years less than a handful specialists have been certified per year. The reason for this change is partly unclear, but is seems like the demand for specialists, especially in the municipalities, has fallen sharply.

There is an important discrepancy between being a certified specialist and working in the field of public health. Only one third of the specialists in community medicine work in this sector. On the other hand, less than half of the medical administrators and public health officers in the Norwegian municipalities are certified specialists in community medicine (7). Income and prestige are lower than for most other specialities and it is hard to recruit young doctors into the field of public health. A proposal to overhaul the education programme for training of community medicine specialist has recently been produced (8). There is broad agreement that community medicine as a speciality should be more independent of primary care and that specialist candidates should be trained for working at all levels within the health care system.

It might, however, be that today’s concept of medical specialisation is unsuitable for community medicine. The variety of work among doctors in this field is wider than for other specialities. The professional common ground for municipality health practitioners, public health officers, health administrators, health promotion actionists, nutritional advisers, epidemiologists, health economists and other doctors working in group oriented areas of medicine may be insufficient for a joint speciality. A tailor-suited education for individual competence building may be more effective than a standardised specialist training programme.

Where to go?

Public health can be defined as all activities that society does collectively to assure the conditions in which people can be healthy. This includes organised efforts to prevent, identify and counter threats to health on a group oriented or community level. The key words are «collective action» and «group orientation».

In an era of individualism it is difficult to introduce and enforce collective programmes on health as well as in other fields of society. One of the many paradoxes of our time is the pursuit of better health through individual lifestyle changes on the one hand and the resistance to governmental interventions to improve health in groups on the other hand. Government legislation that restricts personal choice is the most effective way to get preventive interventions to the whole population, but many barriers to population- wide implementation exist (9). Individual rights and responsibilities are some of the most distinctive features of Western societies today and people are better informed about and more accountable for their own health now than ever before (10). The «freedom to be foolish» must be balanced against society’s responsibility for protection and improvement of the health of all citizens. This is a difficult balance.

Five key themes of modern public health have been defined (11):

• Health systems leadership

• Collaborative actions

• Multidisciplinary approach

• Political engagement

• Community partnerships

In addition public health should aim at changing the goals and priorities within medicine and health care. The goals of medicine can be defined as (12):

• The prevention of disease and injury and the promotion and maintenance of health

• The relief of pain and suffering caused by maladies

• The care and cure of those with a malady, and the care of those who cannot be cured

• The avoidance of premature death and the pursuit of a peaceful death.

Prevention of disease and promotion of health have never had the same priority as the other goals among doctors, even though reducing the need for medical services through target oriented programmes have shown to be effective (13). Advising politicians and decisions makers on priorities with health consequences is one of the main issues in public health.

What to do?

In a series of articles in this issue of Michael the concept of public health is analysed and efforts to revitalise public health and improve research and practice in public health are discussed. The papers were presented at a oneday seminar at The Norwegian Academy for Science and Letters in Oslo 15 September, 2004.

Maurice Mittelmark describes the advent of the «new public health» from the 1970s expanding the field to include social science approaches and research methods (14). He emphasizes the importance of innovative thinking in public health research and the need for interdisciplinary research centres (14). Øivind Larsen joins this quest for broad institutions able to integrate the sum of knowledge that makes up modern public health and he adds teaching and serving the public to their responsibilities (15). Larsen reminds us about the framework of time and space that surround all health issues and he asks for a training program in public health separated from the individualistic oriented medicine.

Nils Aarsæther (16) refers to Robert D. Putman’s concept of «social capital» and the importance of «togetherness» (17). Participating in social activities improves the quality of social life and the welfare of individuals and should be more strongly supported. This is a part of public health activities seldom noticed by medical doctors.

Gunnar Tellnes emphasizes the consequences of urbanisation and suggests health promotion through partnerships for health and social development between the different sectors at all levels of society (18). Hans Ånstad presents health impact assessment as a tool for assisting decision makers (19).

The debate was lively and three commentaries are published with the original presentations (20–22).

Common for all contributions is a wide approach to public health focused on social systems and structures rather than on individual behaviour, and an optimistic attitude as regards future opportunities for improving the health of the public.

Strategies and recommendations

Public health must be redefined and should cover all collective action to improve health on a population-wide scale. Community medicine (samfunnsmedisin) is the medical part of public health including priorities in and management of health care systems as well as efforts to prevent disease and promote health on a population-oriented basis. The strong ties between public health and primary care should be loosened. Hospitals and secondary care should become major targets for public health action (23). The traditional contents of public health, like fighting epidemics and improving sanitary conditions must be retained even when the scope is broadened to include social sciences and health politics. As shown by the recent SARS epidemic and the international preparedness for bioterrorism, the threat of serious and potentially lethal communicable diseases is still the most obvious reason for a public health infrastructure in most societies.

Public health activities among doctors should not be limited to specialists in community medicine. Just like a psychiatrist must have a basic knowledge of surgery and vice versa, every doctor in all specialities must have a basic understanding of public health strategies. The difference between individual-oriented and group-oriented medicine must be more clearly presented from the first year in medical school. The current programme for specialist training in community medicine should be reconsidered and a more flexible and individual structure for training introduced.

The interdisciplinary approach to public health should be advanced but doctors have to develop their own culture and identity within this field. Medical doctors are crucial to public health work and the recruitment can be stimulated by wages and working conditions comparable to clinical medicine.

The bridge between research and practice should be strengthened. The model in clinical medicine where many practitioners are part time researchers and many academics are part time practitioners is also applicable to public health. A more systematic academic support of daily life public health activities is recommended.

Last, but not least: Public health activities must be based on scientific evidence (24). An evidence-based public health strategy for the future is strongly needed.