Journal of Public Health Advance Access originally published online on October 31, 2006
Journal of Public Health 2006 28(4):297-298; doi:10.1093/pubmed/fdl073
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Editorial |
Another public health triumph
E. G. Jessop
Editor, Journal of Public Health
There was another public health triumph recently, but one little remarked in the United Kingdom. Brazil was certified as having eliminated the transmission of Chagas’ disease. This is a tremendous achievement, justly celebrated by an editorial in Brazil’s main public health journal.1 Chagas’ disease is an extremely unpleasant illness. Dias records that ‘in the 1970s there were still more than five million Brazilians infected with Trypanosoma cruzi, with an estimated 100,000-plus new cases per year and more than 10 thousand deaths’. Control was achieved by eradicating the main insect vector with a spraying programme and eliminating transmission by infected blood transfusion. Although Dias warns against ‘inconsequential triumphalism’, this surely is success on a massive scale.
The necessary ingredients for such success are 2-fold—(i) a technical solution and (ii) the political will to implement the solution systematically and relentlessly. Implementation must be systematic because partial implementation is unjust: and relentless because, as we have seen all too often, stop-go just lets the problem recur (or worse).
Sometimes, we have one ingredient without the other. Failures of political will spring readily to mind (‘If preventable, why not prevented?’), but lack of a technical solution is equally disastrous. If we do not know what to do, political urgency merely generates meetings, monitoring and bureaucracy. There is plenty of political will to tackle domestic violence, drug abuse and teenage pregnancy, but we do not yet know with certainty what programmes to implement. Some of the most interesting programmes in child and adolescent public health are detailed on a website for ‘Promising practices’ run by the RAND organization,2 and of course, NICE will be publishing public health programme guidance for England and Wales.3 The evidence is somewhat frustrating—some of the best programmes are well researched but have rather modest effects,4 whereas others show dramatic effect but in single small studies.5 Either way, it would be a courageous judgement to commit to systematic and relentless implementation (but perhaps courage is what we need for success in public health?).
We may be tempted to think that communicable disease is easy—a simple linear chain of causation—compared to the multicause socially embedded problems we face in the developed world. But ‘insecticide spray’ does not equal ‘job done’. Tackling Chagas’ disease in a country as vast as Brazil, with its geographical diversity, poverty and poor social capital (as judged by income inequality), requires plenty of social engagement and political sophistication, not to mention international co-operation with other countries of the South American Cone.
And this is the other great achievement of the Chagas’ disease control programme: its benefits will chiefly accrue to poor people. Chagas’ disease is largely a disease of poverty. Securing the resources for an illness, which rarely touches the rich and powerful, is in itself a success and reflects great credit on our public health colleagues in Brazil. In England, Sure Start is a bold attempt to reduce social inequality in health through pre-school programmes. The technical solution is based on sound science such as the Perry Pre-school and Head Start programmes,6,7 but these are local initiatives, and nationwide implementation of Sure Start has proved problematical.8 According to the Times newspaper,9 ‘Tony Blair has been warned by advisers in Downing Street that the programme has been "captured" by the middle-class... . The evaluation spoke of disadvantaged mothers being "overwhelmed or turned off’’ by the service. Ministers concluded that Sure Start was failing to attract the very families it was designed to help’. One crumb of comfort—it is good that implementation is monitored closely enough to reveal this problem and hence allow us to tackle it.
We have much to learn from our colleagues in South America. For now, we give them our respect and send them our congratulations.
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References |
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- Dias JCP. Chagas disease: successes and challenges. Cad Saude Publica 2006;22:2021.
- http://www.promisingpractices.net/about_ppn.asp (6 October 2006, date last accessed).
- http://www.publichealth.nice.org.uk/page.aspx?o=512516 (6 October 2006, date last accessed).
- http://www.modelprograms.samhsa.gov/template_cf.cfm?page=model&pkProgramID=10 (6 October 2006, date last accessed).
- Patton GC, Bond L, Carlin JB et al. Promoting social inclusion in schools. A group-randomized trial of effects on student health risk behavior and well-being. Am J Public Health 2006;96:1582–7.
[Abstract/Free Full Text] - Perry pre-school project. http://www.ncjrs.gov/html/ojjdp/2000_10_1/contents.html (6 October 2006, date last accessed).
- Early Head Start. http://ehsnrc.org/AboutUs/ehs.htm (6 October 2006, date last accessed).
- Belsky J, Melhuish E, Barnes J et al. Effects of Sure Start local programmes on children and families: early findings from a quasi-experimental, cross sectional study. BMJ 2006;32:1476.
- http://www.timesonline.co.uk/article/0,,2-2391506.html (6 October 2006, date last accessed).
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