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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
470 FRENK
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
abandon the term "public health," we urgently need to propose for ourselves
a renaissance that, by assimilating the most valuable aspects of our intellectual
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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
�
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I
Biomedical Research
(Subindividual level)
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)
poliCies.
Naturally, the typologies proposed here represent mere abstractions for
synthesizing distinctions that are never so clear-cut in real life. In particular,
the four boxes in Figure 1 should not be seen as mutually exclusive
compartments. On the contrary, there are numerous connections among the
major types of health research. Thus, for example, various emerging fields,
such as bioepidemiology, clinical epidemiology, decision analysis, and
technology assessment, deal with interfaces among the four types. Indeed,
the principal message of Figure 1 is integration: The essential difference
between public health research, on the one hand, and biomedical and clinical
research, on the other, is not in the objects but in the levels of analysis. A
great part of the isolation of traditional public health might have resulted from
a conception that postulated that it should study objects other than those
examined by the biomedical and clinical sciences, thus erecting an insur
mountable barrier. As we attempt to demonstrate further on, the future of
public health will depend on its ability to build bridges with the other types
of health research and to make its specific and irreplaceable contribution to
this undertaking, namely, analysis at the population level. Thus, the challenge
is to integrate levels and objects of analysis so as to achieve a full
understanding of the broad health field. In the case of public health, this also
requires integration among scientific disciplines.
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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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.
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
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I Ecologist Model I
I
Social Environment Sociomedical Model Social Epidemiologic Model
Figure 4 Main conceptual models on public health. (Adapted from Ref. 17.)
480 FRENK
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
Annu. Rev. Public Health 1993.14:469-490. Downloaded from www.annualreviews.org
each of the models proposed in Figure 4. Our purpose has simply been to
show the wealth of intellectual traditions that have characterized public health.
Each of them has implied a particular program of development for acquisition
of knowledge and for action in public health (2). Therefore, they are an
essential element for placing the bases of production, reproduction, and
utilization of knowledge in their conceptual context.
PRODUCTION BASE
All these advantages also pose an enormous challenge to the new public
health: to break with isolation so as to open the way to creative interaction
with biomedical research, clinical medicine, and the social sciences. In
addition to this opening, the development of a solid basis for the production
of knowledge requires an effort to create and consolidate institutions that
include research among their essential missions. In this regard, the world
consensus that appears to be emerging on the need to promote health research
in underdeveloped countries is encouraging. This consensus is reflected in the
report of the Commission on Health Research for Development (7). One of
the Commission's main recommendations is to promote "essential national
health research," i.e. research that every country, regardless of its level of
development, must carry out if it aspires to advance independently in acquiring
new knowledge of its own health problems and in closing the gap between
current knowledge and action. Although the precise mix of projects will vary
from country to country, mission-oriented research is especially relevant for
carrying out this recommendation. The public health community must take
advantage of the emerging consensus that the kind of research it promotes is
precisely what the world requires today.
REPRODUCTION BASE
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,
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UTILIZATION BASE
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
and demands that researchers and decision-makers face in their respective
areas of activity (19). The main barriers are summarized in Figure 5, together
with some possible solutions for overcoming them. Before analyzing these
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,
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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.)
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
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.
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
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standards of research and education, but also as the undertaking of all possible
efforts to translate knowledge into action.
Finally, there is the problem of integrating different results on the same
research question. The decision-maker requires integrated information that
enables him or her to assess all the dimensions of a question so as to make
a decision. In contrast, the way in which scientific work is usually organized
leads to disaggregation of the objects of study. This problem has two aspects.
The first has to do with those situations in which various research projects on
a single topic do not yield conclusive results, or the results may even be
mutually contradictory. In this case, one solution could be a detailed review
of evidence and meta-analysis, which uses quantitative techniques for
synthesizing data from several projects (24, 25, 33). The second aspect of
the problem of integration has to do with those situations in which the
decision-maker has results from several projects that have dealt with a single
topic but at different levels of analysis. In this case, the solution is to carry
out mission-oriented research, which has the advantages discussed earlier.
Much of the discussion on the utilization of knowledge leaves the
implementation of solutions in the hands of individual actors. However, the
current complexity in the production of knowledge requires organized
solutions. Research institutions must have differentiated structures that make
it possible to establish dynamic and creative linkages with their environment,
especially the capacity for projecting scientific knowledge toward decision
making.
Otherwise, the barriers indicated in Figure 5 will continue to impoverish
not only the utilization of knowledge, but also its production and reproduction.
The failure to use results leads to inadequate public support for research. This,
in tum, generates a decline of scientific production, which ends up reinforcing
the vicious downward spiral in the use of research (34). Impoverished
research, in tum, undermines the intellectual vitality of educational endeavors
to reproduce knowledge.
This problem evidently affects all research. However, given its proximity
PUBLIC HEALTH 487
CONCLUSIONS
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
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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
Annu. Rev. Public Health 1993.14:469-490. Downloaded from www.annualreviews.org
should be guided by the essential opening process that gives meaning to public
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.
ACKNOWLEDGMENTS
Literature Cited
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32. Terris, M. 1985. Editorial: the distinc 34. World Health Org. 1986. Improving
tion between public health and com Health Care Through Decision-linked
munity/social preventive medicine. J. Research: Application in Health Sys
Public Health Policy 6:435-39 tems and Manpower Development. Part
33. Thacker, S. B . 1988. Meta-analysis: II: options for implementation. Doc.
a quantitative approach to research in- No. HMD/86.4.2. Geneva: WHO
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