The New Public Health and what it means for Albania
Theodore H. Tulchinsky1.
1 Braun School of Public Health and Community Medicine, Hebrew University-Hadassah, Hadassah Ein Karem, Jerusalem, Israel
Corresponding author: Theodore H. Tulchinsky, MD, MPH
Address:The Hebrew University-Hadassah Braun School of Public Health and Community Medicine, P.O. Box 12272, Jerusalem, Israel
Telephone: +97226758516; E-mail: email@example.com
I have had the privilege of helping to train seven Albanians in public health at our International Master of Public Health program at the Braun School of Public Health of the Hebrew University in Jerusalem, including leaders in public health in Albania such as Professors Enver Roshi and Genc Burazeri.
I have visited Albania many times in the past decade working with the Institute of Public Health and the Faculty of Medicine to develop public health professional education in the country. Thus, it is an honor to accept the invitation to write an editorial in your new Albania Medical Journal to address the relevance of the New Public Health for Albania.
Public health has evolved and shown remarkable successes, much like the evolution from the era of the dial to iPhone telephone with many more useful applications during the past half Century (Figure 1).
Figure 1. Classical and New Public Health.
Classical public health is a strong tradition which goes back several centuries with many governmental activities to ensure health protection of the population from many hazards causing premature deaths of uncounted millions in epidemics, food borne disease, poor maternal and child health and unsafe workplaces. Public health systems evolved in keeping with traditions of various societies. In western countries local governmental authorities were the primary agencies for public health including sanitation, food control, business licensing vital records and other facets of public health. State and national governments began to assist and develop services beyond the financial and professional capacities of local authorities. Gradually national governments became the overarching agency responsible to protect the health protection of the nation’s population (1).
Epidemiologic challenges have changed with dramatic success in communicable disease control. Today, non communicable diseases and trauma are the key threats to human life and well-being. Cardiovascular diseases and cancers are leading killers in high and in mid level income countries, and increasingly in low income countries as well. There have been myriad efforts to find ways to control these pandemics, with no single “magic bullets” like a vaccine for their control. Epidemiologic studies have identified key “risk factors” and potential interventions including health promotion and lifestyle measures of have became a major part of the public health endeavors.
The advent of HIV/AIDs and Hepatitis C in the 1980s with no biomedical control capacity led to innovations such as condoms usage for sexual safety, needle exchange programs, and education as the major tools to fight these deadly diseases. In short, we had to learn to work with human behavior because biomedical methods were not available initially. When effective antiretroviral therapy came along in the 1990s, it provided revolutionary tools along with education to control this pandemic; education or treatment alone were not sufficient to bring these diseases under control. As with cardiovascular diseases, the risk factors are many and disease management involves both public health and direct clinical care in a shared set of responsibilities with the patients, their families, the health system and society at large (2).
Figure 2. Life Expectancy at Birth, Albania and Selected Countries 1970-2010
(Source: WHO European Region, Health for All Database, January 2013).
Albania is doing well in improving life expectancy at birth (see Figure 2), but progress with stroke mortality reduction is not progressing as should be expected (Figure 3). Albania would benefit from making control of non communicable diseases a central target of the health system. Moldova, a poor country with lower life expectancy and with a higher stroke mortality rate is placing much effort on education for non communicable disease control and showing early positive effect with a major drop in stroke mortality.
Figure 3. Standardized Mortality Rates from Cerebrovascular Accidents, Albania and Selected Countries 1970-2010.
Emphasis on control of non communicable conditions to improve population health is crucial to public health today. This involves change not only at the policy level, but in integrated organized programs to promote awareness and safe interventions by physicians, patients and their families. It also means food and nutrition security need to change with more vegetable production and consumption, reduced salt (and sugar) consumption. Legislation is needed to ensure fortification of basic goods with essential trace minerals and vitamins in food manufacturing and standards for imported food products (3).
New discoveries open new opportunities. Managing hypertension and reducing salt intake reduces strokes and related mortality. Routine aspirin, statins and anti hypertensives act to prevent strokes, coronary heart events and mortality. Stopping smoking, improved diet and moderate exercise reduce cardiovascular disease and cancers. Folic acid in flour reduces neural tube birth defects by 60-70 percent. Finding Helicobacter pylori bacteria as the cause of chronic peptic ulcer disease and gastric cancer, an easily and cheaply treatable has reduced much suffering from these common conditions. Surgical wards are emptied of many forms of surgery common even a decade ago. Cancer of colon can be controlled by colonoscopy screening. Cervical cancer is controllable by Pap smear screening and management, but the finding the cause in the Human Papilloma Virus and effective vaccines opened a more complex potential to control this disease. These are life saving public health interventions, and with other similar applications improve individual and population health. But they require strong leadership, policies, education, resources, training and persistence for implementation.
The New Public Health incorporates many more professions, scientific findings, skills, and applications than were available a generation ago. Training and standards for public health practitioners, academics and policy makers are needed for the rapidly evolving capacity of public health. Defining health targets and revision of health funding priorities are vital to promote prevention, health promotion and rapid adoption of the new standards of protecting population health. Legislation and education are essential to protect the public’s health, and to raise the level of involvement of people in their own health status.
Albania is moving in a good direction by developing training capacity in public health (4). This should help to gain political support and perhaps financial help from donor agencies such as is being done in Moldova to tackle the complex but straight forward issue of cardiovascular disease and other non communicable disease prevention. Controlling avoidable disease and death has innumerable societal benefits. Development of education for the New Public Health in Albania with strong international cooperation will help prepare the next generation of health system leadership to face new and old health challenges. Collaboration with the Braun School of Public health has not only led to training of key leaders in public health in Albania and published research in international peer reviewed journals (5-7).
Public Health Reviews is a European based journal is focused on review of health theme topics in the European and global context. It tries to bring best practices and science in high quality review articles to students, teachers and policy makers in usable forms to bring science to practice in countries with many social, economic and health challenges. It is available free of charge at www.publichealthreviews.eu readily accessible to read and download articles, including an article on Albania (8). Albania is represented by a founding member (Dr. Silvia Bino) of the Editorial Board.
I wish your new Albanian Medical Journal all success in working toward the same goals.
1. Tulchinsky TH, Varavaikova EA. What is “The New Public Health?” Public Health Reviews 2010;3:25-53. Available at: www.publichealthreviews.eu (Accessed 8 May 2013).
2. World Health Organization. Global Status Report on Non Communicable Diseases 2010. WHO, Geneva, 2010. Available at: http://www.who.int/chp/ncd_global_status_report/en/ (Accessed 8 May 2013).
3. Allen L, de Benoist B, Dary O, Hurrell R. Guidelines on food fortification with micronutrients. Geneva: World Health Organization, Food and Agricultural Organization of the United Nations; 2006. Available at: http://www.who.int/nutrition/publications/guide_food_fortification_micronutrients.pdf (Accessed 2 April 2013).
4. Roshi E, Bino S, Burazeri G, Ylli A, Laaser U, Tulchinsky T, Goodman J. Development of a Master of Public Health programme in Tirana, Albania. Journal of Public Health (Springer) 2006;14:229-232.
6. Burazeri G, Kark JD. Hostility and acute coronary syndrome in a transitional post-communist Muslim country: a population-based study in Tirana, Albania. The European Journal of Public Health 2011;21:469-476.
7. Zaletel-Kragelj L, Kovacic L, Bjegovic V, Bozikov J, Burazeri G, Donev D, Galan A, Georgieva L, Pavlekovic G, Scintee SG, Bardehle D, Laaser U. The use and exchange of teaching modules published in the series of handbooks prepared within the frame of the “Forum for Public Health in South-Eastern Europe Network. Zdravstveno Varstvo 2012;51:237-250.
8. Ylli A. Health and Social Conditions of Older People in Albania: Baseline Data from a National Survey. Public Health Reviews. 2010;32:549-560.