The Ever Evolving Concept of a New Public Health : Book Review

In the second edition of The New Public Health, authors Tulchinsky and Varavikova present a comprehensive overview of the evolution of public health and health issues. Their book succeeds in introducing the broad areas of this expanding field as they seek to balance traditional concerns for populations with more modern concerns for individuals and human rights. One of the main strengths of this text is the authors‟ coverage of many contemporary public health topics, such as specialized communities, which include the mentally ill, homosexual men and women, immigrants, and Native Americans. However, the authors provide very limited criticism of prior mishaps in public health and little emphasis on health promotion, a major component of current approaches. Instead, there is an overemphasis on an epidemiological perspective of many public health topics. Admission of failures to address certain issues adequately, a more robust presentation of the premises of health promotion, and more attention to ecological models of disease prevention would have strengthened the second edition of The New Public Health. Perhaps the authors will include these dimensions of the 21st century in subsequent editions of their valuable book. © 2010 Californian Journal of Health Promotion. All rights reserved.

The New Public Health presents an overview of the field of public health and health issues that have made an impact throughout history, on both national and global levels.The authors, Theodore H. Tulchinsky and Elena A. Varavikova, have dedicated years of service in developing countries, experiences that have enriched the subject matter in this comprehensive text.The book provides a broad overview of the essence of public health, describes many concepts and tools used in the discipline, and addresses many challenging contemporary issues.
The book opens by providing an overview of the history of health and medical breakthroughs and continues with the evolution of the discipline of public health to current practices.Public health is a predominantly modern concept; however, its practice dates back to 1000 BCE and the Hebrew Mosaic Law, which emphasizes the prevention of disease through personal and community hygiene.The emphasis of the early years of public health was the study and implementation of measures to control communicable diseases, the primary threats to large populations in European nations in the 19th century.This was achieved through the practices of sanitation and vaccination.
The "new public health" is a common term used throughout the 20th and 21st centuries.This concept, a major element of the book, expands the traditional role of public health to include individual factors and expands the study of public health into many different disciplines that have traditionally been excluded.As defined in this text, "The new public health is not so much a concept as it is a philosophy which endeavors to broaden the older understanding of public health, so that, for example, it includes the health of the individual in addition to the health of populations, and seeks to address such contemporary health issues as are concerned with equitable access to health services, the environment, political governance and social and economic development" (Tulchinsky &Varavikova, 2009, p. 68).The authors (2009) further explain: "The New Public Health incorporates a wide range of interventions in the physical and social environment, health behavior, and biomedical methods along with health care organization and financing" (p.xxiv).At times, the authors seem to be merely revisiting concepts explored in other texts without sufficient adding to or integrating these ideas.
Tulchinsky and Varavikova state how this term is an evolving concept that continues to embody ideas and experiences related to public health.The continuous evolution of this term is a vital factor in comprehending the basis of the concept.They continue to conclude, "The new public health brings together aspects of public health that are community-oriented and personal care that is individual-oriented.One can no longer be separated from the other if we are to address the health needs in the twenty-first century" (p.xxiv).Many of the points declared by both authors are valid.
The concept of a new public health was first introduced by Hibbert Winslow Hill (1916, p. 8).In Hill"s explanation, "The old public health was concerned with the environment; the new is concerned with the individual.The old sought the sources of infectious disease in the surroundings of man; the new finds them in man himself."Hill"s idea of the new public health is reflected in many of the ideas mentioned throughout the Tulchinsky and Varavikova book, particularly the emphasis on individual and population-based public health.The question therefore remains, how new is the "new public health" and have the authors added substantially to our understanding of the subject since its first introduction in 1916?

Biomedical Bias
Once the authors explain the history and development of the concept of public health, the book takes an epidemiological turn and discusses how the practice of assessing statistical trends contributed to gaining a more precise understanding of predicting the movement of certain diseases.According Tulchinsky and Varavikova (2009), "Knowledge of the natural history of disease is fundamental to understanding where and with what means intervention can have the greatest chance for successful interruption or change in the disease process for the patient, family, or community" (p.37).The first area of public health that developed as a discipline was epidemiology, which was officially established as an investigative area for public health action in 1850 by the London Epidemiological Society (Tulchinsky & Varavikova, 2009).
Following this technical description, the book covers a range of communicable and noncommunicable diseases.The authors describe how these diseases differ and the various attempts to control them, different types of deficiencies, family and sexual health, globalization, health technology, health law, healthcare and management of health systems.
The authors attempt to address these issues in a holistic manner by providing different disciplinary perspectives, e.g., psychology and sociology, when discussing each topic.This holistic approach takes a more ecological perspective by also considering the life stages of individuals and further includes the importance of social and psychological well-being, which introduces the humanistic component in public health issues.Science and medicine tend to overlook the social component of illnesses.The authors also delve into issues of specialized communities, such as homosexuals and the mentally ill, which in many textbooks tend to be overlooked.
While the text includes elements of a holistic approach, its focus is on epidemiology with an emphasis on fighting public health problems through the use of science.Tulchinsky & Varavikova (2009) state that, "Interventions to change host, environment, or agent factors are the essence of public health" (p.37).However, this point of view may be problematic, since it narrows the understanding of challenges rather than opening new doors to solving social health issues.The book"s narrow focus has led to only brief mentions of the tenets and practices of health promotion, one of the primary components of the new and old public health.This perspective may be problematic for newcomers to the field, since the text downplays the importance of health promotion and other efforts that address social health issues, such as illnesses that affect impoverished populations.

Health Promotion
The idea that an epidemiological approach is the solution to public health issues is problematic.For example, epidemiological studies have provided evidence that risky sexual behaviors are associated with a higher HIV/AIDS risk; however, epidemiologists are not trained to devise programs to change such behaviors.Descriptive examples of such programs illustrate the importance of health promotion in minimizing diseases around the globe.Such examples would provide a clearer view of how public health practices work and issues that must be dealt with when implementing any type of project.As an example of this oversight, Tulchinsky & Varavikova briefly discuss the importance of health promotion in the control of the spread of the AIDS epidemic by presenting information on how "safer sex" education has been effective.
The authors do not elaborate on the implementation of health promotion initiatives in the area of HIV/AIDS and fail to mention the policy of "AIDS Exceptionalism," which ensured that human rights of vulnerable populations will not be violated by health authorities (Piot, 2008).Instead, Tulchinsky and Varavikova (2009) elaborate on the view that "failure or delay of public health authorities even in the late 1980s to close public bathhouses in New York and other cities in the United States where exposure to multiple same-sex partners promoted transmission of the infection could be interpreted as negligence" (p.593).This statement emphasizes the location where such sexual encounters were taking place as the reason for the rapid transmission of HIV/AIDS, without holding accountable the actual sexual behaviors responsible for the transmission of the virus.The importance of behavior change interventions in reducing the transmission of HIV/AIDS in the homosexual community is not discussed.
Other writers have taken a different stance in their vision of the new public health.The writings of Ashton and Seymour (1988) emphasize health promotion"s integral role in the area of public health and explain how it enables people to take control over their lives and their health.This practice of health promotion is not accentuated throughout the text by Tulchinsky and Varavikova.In order for this book to truly represent the "new" public health, the authors should have more fully discussed health promotion, as well as both the positive and negative outcomes of public health initiatives.This shift would not devalue the area of epidemiology in any way but merely bring forth an argument that challenges the prevailing notion that of science is the key to solving social health issues.As explained by Peterson and Lupton (1996) in their critical analysis of the new public health, "We are not arguing that science as a system of knowledge and action should be rejected wholesale.We are simply challenging its position as the most privileged way of approaching social problems, by showing how science works to construct these problems and by seeking to identify its unintended outcomes" (p.177).

Special Populations
An interesting portion of "The New Public Health" is Chapter 7, "Special Community Health Needs," which sheds some light on marginalized and vulnerable communities that need special public health attention.These communities include those who are unemployed, uninsured, homeless, mentally ill, substance abusers, migrant workers, refugees, and homosexuals, among others.The new public health is supposed to address issues in such vulnerable populations.The authors are commended for their efforts to ensure that attention is given to such underprivileged communities.
The authors note that there has been a rapid spread of many communicable and noncommunicable diseases in these communities without proper initiatives to reduce the incidence and prevalence of such health problems.However, a framework or blueprint of what improvements are needed to solve these problems, which will ultimately affect society as a whole, are lightly touched upon without any real guidance from the authors.The limited knowledge that Tulchinsky and Varavikova have of the health promotion planning models, such as PRECEED-PROCEED (Green and Krueter, 2005), is more apparent when they fail to offer suggestions for more effectively working with special populations.
The sociological context of many issues, especially those concerning minority groups and specialized communities in the U.S. or abroad, should be dealt with in a culturally sensitive manner in order for a study or intervention to be effective.An important point mentioned in the publication "The New Public Health: Health and Self in the Age of Risk" written by Peterson and Lupton (1988) is the lack of training for public health students in the areas of sociology and cultural competence (p.x-xi).These elements are important in the development of effective research strategies; however, they are often dismissed with little regard for how essential they are to the success of any public health endeavor.This multidisciplinary approach to public health, which is increasingly important as the U.S. and world become more multicultural, was one of the major points prescribed by the Institute of Medicine (2003) report, "Who Will Keep the Public Healthy?" This book provides good coverage of the issues faced by the mentally ill, explaining in depth how they have been deprived of proper care and medical attention.The authors illustrate the disheartening situation of this vulnerable population from a global standpoint while addressing possible solutions.They also provide suggestions on ways to prevent mental disability.These suggestions are divided into three areas: before conception, during fetal life, and after birth.The authors conclude this section with how the community can be involved in helping this vulnerable population.

Strengths and Weaknesses
This text will be extremely useful as a textbook and reference for public heath students and practitioners alike.It is reader-friendly, and the topics are presented in a well-organized fashion.The authors offer clarification and explanation of important topics through the use of text boxes, which offer the reader additional information through detailed stories, and clear illustrations of statistical rates through graphs.Additionally, precise definitions of confusing concepts are featured within the text boxes.
However, several areas could be revised or enhanced to make coverage more up to date.One of the weaker points of this publication is the manner in which the authors avoid mentioning failures in attaining public health goals or mistakes made in previous initiatives.An example of this is the manner in which the authors report the national Healthy People 2010 targets.These targets have not been attained in the time allotted, which may be because of poorly designed programs or properly conceived programs poorly run.The authors touch on this topic lightly without explaining it in depth.Public health practitioners and students alike need to be aware of the failures in public health in order to adequately and successfully correct and limit their reoccurrence.It is crucial to explain and provide ideas to resolve many of the health issues to the reader.This example brings back the lack of emphasis on health promotion that is evident throughout this publication.It is important to mention that the Healthy People 2010 targets were created with a health promotion perspective in mind.

Conclusion
"The New Public Health" by Theodore H. Tulchinsky and Elena A. Varavikova is a comprehensive publication that educates and inspires readers in the area of public health.The book touches on a wide range of disciplinary perspectives and public health topics.It is an asset to the field and can be used as a reliable reference to many topics, from major public health breakthroughs to major illnesses affecting the global population.It provides a framework that illustrates the foundation of public health through explaining the history of its evolution.The major concepts and health problems that have shaped the discipline of public health are included in this publication.However, there is an over-reliance on medicine and epidemiology to resolve many social health issues without a discussion of the concrete benefits that health promotion has to offer.Health promotion deserves more attention in The New Public Health as a viable strategy for eliminating health disparities, bringing together diverse global communities, and producing the social, cultural, and behavioral changes necessary to further reduce disease, disability, and premature death.
Tulchinsky and Varavikova address many different topics without real life examples.