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Annu. Rev. Publ. Health 1993.14:469-90 Quick links to online content
Copyright © 1993 by Annual Reviews Inc. All rights reserved
Julio Frenk
National Institute of Public Health, Mexico; Center for Population and
Development Studies, Harvard University, Cambridge, Massachusetts 02138
Annu. Rev. Public. Health. 1993.14:469-490. Downloaded from www.annualreviews.org
KEY WORDS: definition of public health, conceptual models, health research, human
resource development, utilization of knowledge
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INTRODUCTION
0163-7525/93/0510-0469$02.00
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countries, schools and institutes of public health have become isolated from
scientific progress and from efforts to organize better health systems. This
has relegated them to a secondary role both in academia and in applied areas,
thus generating a vicious circle between isolation and irrelevance.
Today more than ever, public health institutions need to redefine their
mission in light of the increasingly complex environment in which they
operate. Today more than ever, they must ask themselves about their social
role, about the scope of their actions, and about the bases of their knowledge.
In light of the magnitude of the problems, which have even led many to
Annu. Rev. Public. Health. 1993.14:469-490. Downloaded from www.annualreviews.org
Renacimie
abandon the term "public health," we urgently need to propose for ourselves nto !!!
a renaissance that, by assimilating the most valuable aspects of our intellectual
tradition, legitimately enables us to speak of a new public health. What are
the conceptual principles that underlie this renaissance? What are its organi
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1. Conceptual base. This element establishes the limits of the specific area
of research, teaching, and action. Hence, it involves rigorously defining
what constitutes public health, and more specifically-in an effort to
differentiate the previous uses of this term-the new public health.
2. Production base. This element refers to the set of institutions where a
critical mass and a critical density of researchers come together to
generate the body of knowledge that gives substantive content to the
intellectual field.
3. Reproduction base. This element ensures the consolidation and continu
ity of the intellectual field-and thus the construction of an authentic
tradition-through three principal vehicles: educational programs to train
PUBLIC HEALTH 471
In the rest of this article, we examine the challenges to the new public
health by analyzing each of the above elements.
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CONCEPTUAL BASE
Any project to renew public health would be useless if it did not take as its
point of departure a systematic effort to specify its current meaning and to
separate it from obsolete conceptions. In this section, therefore, we attempt
first to define the two faces of public health: as a field of research and as a
form of professional practice. In the case of research, we propose a typology
and reflect on the role of the different scientific disciplines in public health.
We also discuss the reasons why we believe that the term "public health"
should continue to be used. Indeed, when defined rigorously, this term is
better than the alternatives that have been proposed by other reform projects.
The updating that public health requires today should be truly conceptual, not
just a matter of terminology.
However, a complete conceptual development cannot be limited to defini
tions, but must also deal with the models that have guided public health. The
second part of this section briefly reviews such models in order to introduce
a subject that should receive much more attention in the effort to get the new
public health off the ground.
OBJECT OF ANALYSIS
LEVEL OF ANALYSIS
Conditions Responses
.j::o
I
Biomedical Research
(Subindividual level)
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Clinical Research
Health Research
(Individual level)
{
Research by
determinants
Epidemiological
Research
Research by
consecuences
{
Public Health Research
(Population level) Health Services
{
Research on Health Research
Systems Organization
(Micro level) Health Resources
Health Systems
Research
Research
Health Policy Research
(Macro level)
THE ROLE OF THE DISCIPLINES The very definition. of public health research
involves an effort to achieve interdisciplinary integration. An important
obstacle to such integration has been the tendency to identify each level of
analysis with a given discipline. In particular, the resultant confusion suggests
that the biological sciences are applicable only to the individual and
subindividual levels, whereas the population level is the exclusive jurisdiction
of the social sciences.
All human populations are organized in societies, which is why the social
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far from pertaining solely to the study of individual phenomena, the biological
sciences also contribute to understanding human populations. The other side
of the coin is that the biological sciences are just as essential to public health
as are the social sciences.
In addition, there is a second reason why the biological scieces should be
an integral part of public health. To achieve a proper understanding of any
health condition in a population (a particular disease, for example), we must
understand the biological processes that underlie the condition. The rich
research tradition on the so-called tropical diseases offers innumerable
examples of this type of linkage between biological and population phenom
ena.
We therefore postulate that an essential element of the public health
renaissance is to reincorporate fully the teaching and research of the biological
sciences, which many schools of public health have neglected in recent
decades. Together with this reencounter, a broad, rigorous, and pluralist
development of the social sciences is necessary; this has also been absent
from many academic institutions devoted to health. This urgent need for
interdisciplinary integration is one of the reasons why, in defining public
health, we prefer to use the concept of population more than that of
collectivity, which is found in such proposals as that of "collective health" in
Brazil. The terms collectivity and community allude to a form of social
organization. The term "population" is broader, because it includes both the
social and biological dimensions of human groups.
This reasoning also underlies the need to preserve the term public health
over those that have arisen in recent decades to designate certain innovative
projects, such as "social medicine" or "sociomedicine." These terms are
acceptable when studying only the social dimension of health (27), but are
not valid as substitutes for the concept of public health, which, as we have
PUBLIC HEALTH 477
just argued, is broader. Indeed, what defines the essence of the new public
health is not the exclusive use of certain sciences over others. The biological
reductionism of the past should not be replaced by a sociological reductionism.
Rather, we need an effort of integration among scientific disciplines. This is
precisely the conceptual opening that stems from defining public health by
reference to its population level of analysis.
Conceptions about the limits and contents of the universe of public health
have varied throughout history. Likewise, the definitions that we have
proposed for the two dimensions of public health result from a historical
development in which different conceptual models of knowledge and action
in this field have been taking shape. As the history of thought is not a mere
progression of ideas, many of these models persist today. It is thus advisable
to become familiar with them.
Areas of Application
(Populations,
Problems,
Programs)
Cond�ions
Objects of
Analysis
Responses
J
l
y-
Scientific Bases
analyzed from two main perspectives: health and disease. The limits between
the two are not always obvious; in fact, the most comprehensive conceptions
go beyond this dichotomy. However, public health thinking has included
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two main currents that, as Dubos reminds us, go back to the worship of
Hygeia versus Aesculapius (12). One focuses on the study of disease; the
other, while not excluding disease, seeks to understand the determinants of
health in a broad conception that includes human development and well
being.
The social response to health and disease conditions may be directed to
different objects of intervention. Historically, the main objects have been the
individual, including his or her immediate family surroundings, and the
environment, which can be subdivided into the biological and physical
components and the social components.
Crossing these two dimensions produces the typology of models shown in
Figure 4. The names given to the models correspond to the main historical
currents of thinking about health. For example, the "hygienist/preventive"
model was developed considerably in the nineteenth century, when there was
a movement to instruct the family on a series of rules for behavior that defined
a "healthy life," and came to constitute what Foucault has called "a morality
I Ecologist Model I
I
Social Environment Sociomedical Model Social Epidemiologic Model
Figure 4 Main conceptual models on public health. (Adapted from Ref. 17.)
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of the body" (13). This model was displaced by the "biomedical model," which
brought the control of specific diseases to the center of public health concerns
(29), but eventually reappeared in programs aimed at changing individual
behaviors and lifestyles as a basic strategy of health promotion (14).
Not all the conceptual models fit perfectly into the proposed categories.
For example, the "ecologist model," whose principal exponent is Dubos (12),
seeks to transform both the physical and social environments. The "socio
medical model" actually encompasses very diverse conceptions whose single
common denominator is that they all attempt to explain health phenomena in
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PRODUCTION BASE
Streghthering: fortalecimiento
Lack= ausencia
PUBLIC HEALTH 483
reality continuously through a dual effort: on the one hand, the ability to look
outside, at the changing character of their environment; on the other hand,
the introspection required to renew organizational schemes (16). To be
successful, such an effort should harmonize two values: the academic
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Public health requires a new style of leadership. One of the key aspects is
that it must be permanently open to its environment in two directions. First,
public health must establish sensors to detect unmet needs and emerging
opportunities in order to guide the selection of priorities. Second, it must
develop effectors that facilitate the utilization of knowledge in new techno
logical developments and in more rational decision-making processes. In this
section, we focus on the second aspect, which is essential to the renewal of
public health.
The creation of a solid utilization base requires differentiated structures in
public health organizations, especially those responsible for generating new
knowledge. Indeed, most of the barriers between decision-makers and
researchers correspond to structural circumstances, not to mere differences in
training or personality. Those barriers are rooted in the different kinds of logic
Tomador
and demands that researchers and decision-makers face in their respective
areas of activity (19). The main barriers are summarized in Figure 5, together
de
with some possible solutions for overcoming them. Before analyzing these decisiones
barriers, certain concepts should be clarified. By "decision-maker" we mean
any person who makes a decision to determine a course of action in response
to a given health problem. Although a high proportion of decision-makers are
public officials, these two terms should not be used interchangeably, as
decision-makers include a broader range of people, such as leaders of
community organizations and service providers. In all cases, they face
problems whose solutions require decisions to be made on the basis of a
diversity of factors. To ensure that research is relevant to decision-making,
Rooted: arraigado
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stage: planificar
4. Perceptions about the final product of Explicit utilization objectives together with
research: discovery vs. decision production-of-knowledge objectives
Figure 5 Sources and solutions of possible barriers between researchers and decision makers.
(Adapted from Ref. 19.)
Uncertainty: incertidumbre
there should be more than one solution, each with different effectiveness (1).
In addition, there should be uncertainty as to the nature and effectiveness of
the solutions. Research can then produce knowledge that reduces the
uncertainty. Unfortunately, there are several circumstances that prevent this
application of knowledge and result in decision-making that responds more
to immediate pressures or to ideological preferences than to scientific
evidence.
As shown in Figure 5, the first potential conflict revolves around the
definition of priorities. The perception that decision-makers have of the most
pressing problems may not coincide with the topics that researchers consider
to be of greatest scientific interest. A possible solution to this barrier involves
ensuring the presence of decision-makers in the governing or consultative
bodies of research institutions, so that they can express their needs and identify
opportunities in current projects.
Sometimes, the discrepancy reflects a distorted perception by decision-mak
ers of the value of research. This distortion may take two forms: undervaluing
the potential of research to help in decision-making or overestimating its
potential, thereby generating unrealistic expectations. To overcome this
barrier, decision-makers must be "informed consumers" of research products,
which requires an educational effort that, to date, has been neglected. This
effort involves introducing research topics in the educational programs for
Overcome: superar // neglected: descuidado
PUBLIC HEALTH 485
those who are not going to be researchers, but users of research. Such topics
would have two essential purposes: to learn to value the contribution of
research to decision-making and to gain a mastery of the minimum criteria
for judging the quality of results. A strategy is needed to induce a greater and
more informed demand for research products. Cronofóbico
A second barrier reflects the real differences between political time and
scientific time. In general, decision-makers are chronophobic, because time
is one of the principal enemies to overcome; researchers, on the other hand,
tend to be chronophilic, because time is one of the main ingredients of their
Annu. Rev. Public. Health. 1993.14:469-490. Downloaded from www.annualreviews.org
research, allowing for the full expression of the processes under study. One
way of overcoming this barrier is to ensure the collaboration between
researchers and decision-makers from the earliest planning stages of the
proposed research. This would open a space for negotiation and agreement
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on the time frames required for producing useful results. Differences in time
management may also be addressed if researchers offer intermediate products,
such as bibliographic reviews and progress reports, which are useful for
decision-making even before the project has been completed.
Another set of important differences has to do with the language and
accessibility of results. For the researcher, results must be communicated in
precise terms, so that they enrich the paradigms of his or her own discipline.
This means that language is often esoteric and that communication occurs in
specialized publications, which often can only be retrieved through a
bibliographic search. For the decision-maker, results must be expressed in an
understandable language and be readily available.
Communication barriers can be reduced if, in addition to specialized
articles, research projects also produce "executive summaries," which com
municate in a nontechnical language the results most pertinent to decision
making. This would imply developing a dual system for presenting results:
academic articles for peer scientists and executive summaries for decision
makers. The summaries could be complemented with joint seminars where
decision-makers and researchers analyze results. To facilitate such an ex
change between the two groups, "translators" could be trained who would
consider the needs, values, and priorities of each (26). Such translators already
exist for the general public, in the form of writers who are professionally
devoted to the dissemination of scientific information. Equal importance
should be accorded to professionals who facilitate communication between
researchers and decision-makers, by translating the findings into recommen
dations for policy and action.
A fourth potential barrier is represented by the different perceptions about
the nature of the final product of research. For the scientific community, the
product is the published article and its potential impact on the ideas of others
(as measured, for example, by the number of bibliographic citations). For the
486 FRENK
guide its future. The success of the new public health will require actions on
the organizational front. In this respect, there is a need to pay attention to the
three cardinal points of organization: design, development, and performance.
Our discussion on the bases of production, reproduction, and utilization of
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knowledge has suggested new paths in this direction. After all, social
development is based on the patient and thorough effort to establish solid
institutions. Organizations are the vehicles for bringing together individual
wills in order to attain a level that is higher than the simple sum of these
wills. Following the metaphor taken from physics, what is most important is
not only to form a critical mass of talent, but also to reach a critical density
through which such talent can be mutually enriched within a shared institu
tional space. No doubt the future of public health will depend to a great extent
on our ability to design and develop institutions and to assure their sound
performance. Improving: mejorar//regard: considerar
But, the internal organization of public health itself is not enough. A broad
effort of linkage is needed, a commitment to the population's health and the
services for improving it. The basic challenge in this regard is to modernize
public health. Beyond the several meanings that changing political circum
stances can attribute to this term, modernization should be understood above
all as a process of opening. It is not a question of an irreflexive permeability
that overlooks the advances of the past, but rather an effort to integrate
tradition and progress. This is the meaning of the words spoken by the Mexican
poet Octavio Paz (28) in his address to the Royal Swedish Academy the day
before receiving the 1990 Nobel Prize for Literature:
... between tradition and modernity lies a bridge. Isolated, traditions are petrified
and modernities are rendered volatile; together, each inspires the other, each
responds to the other by giving it weight and gravity.
education in public health should promote excellence. For this purpose, close
links should be established with the broader university milieu. Third, public
health should open up to the other fields of health, so that its population
approach may find support in individual and subindividual phenomena. This
effort to integrate levels of analysis should be accompanied by a parallel effort
to link disciplines. Hence, the fourth opening is to the social, biological, and
behavioral sciences. The specificity in time and space of many health
phenomena requires a comparative approach that can only be attained through
the following two openings: to the international sphere and to the future in
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health: the permanent concern to understand the health needs of the population
and to learn from them.
It is too soon to determine whether public health will prove capable of
responding to the challenges of our time. What is certain is that the possibility
of bringing about a renewal of health systems will depend, to a great extent,
on the modernization of public health. Although their ultimate fate is
associated with the broader social and economic development, health actions
also have their own dynamics, whereby they can contribute to the general
progress of nations. Because it is a crossroad, health makes it possible for
the population to give a specific and daily meaning to the goals of reducing
inequality and promoting social well-being. Therein lies the commitment that,
if fulfilled, will make the new public health flourish.
whereby: por lo cual // therein: en esto
ACKNOWLEDGMENTS Commitment: compromiso
This paper attempts to integrate various elements from my previous work.
Therefore, the first debt of gratitude is to my coauthors of the articles cited
in this text, especially Jose-Luis Bobadilla, Jaime Sepulveda, Enrique Ruelas,
and Lilia Duran. In addition, many ideas expressed in this document have
benefited from exchanges with many people, most importantly Guillermo
Sober6n, Jose Laguna, Jaime Martuscelli, Avedis Donabedian, Harvey
Fineberg, Carlos Santos-Burgoa, and Miguel Angel Gonzalez-Block, as well
as many researchers and students from the National Institute of Public Health
of Mexico. Such gratitude notwithstanding, the responsibility for the content
of this paper lies with the author alone.
An initial version was prepared at the request of the Pan American Health
Organization (PAHO) and presented at the meeting on Development of the
Theory and Practice of Public Health in the Americas, organized by PAHO
together with the US and Latin American Associations of Schools of Public
Health, New Orleans, October 21-24, 1991.
PUBLIC HEALTH 489
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