What price community medicine?: the philosophy, practice and politics of public health since 1919

Abstract

that AIDS is a "racial poison", compared to which the threats to the health of the population identified by the earlier social hygiene movement pale into insignificance! But even to raise such issues is to draw attention to the enormous changes that have occurred in the social framework of discussion on public health since the period that Greta Jones has skilfully anaylsed in this book. As Jane Lewis points out, few histories of the National Health Service, prior to the work of Charles Webster, have paid much attention to the role of public health departments in the State system of health care in Britain. Lewis's book admirably corrects this deficiency and documents the complex historical price that has been paid for community medicine, involving the internal failures of preventive medicine and the external constraints that it has persistently encountered both from government and clinicians. Dr Lewis outlines how the concept of public health, which enjoyed a broad political mandate in the nineteenth century, became much narrower during the twentieth century, concentrating on the delivery of personal health services and municipal hospital management. This development has resulted in the ill-defined realm of community medicine, created as a new specialism in 1974. But community medicine is a sort of no-man's land for doctors who are specialized in health planning, epidemiology, disease prevention, and environmental analysis. They are caught somewhere between the cost-cutting requirements of local government management and the priorities of a clinical medicine that regards its own professional independence as a divine right. The decline of public health, according to Lewis, has largely been the result of the profession's failure to establish a coherent philosophy and to function as a watchdog service, relating poverty and ill health to political decisions concerning the allocation ofeconomic resources for the health of populations. The salaried officers of the public service allowed themselves to be sidetracked into focusing their attention on the management of personal health services. This left the public health service ill-equipped to counter the criticisms made by political pressure groups and social investigators of poverty and ill health during the second world war. The rise of the academic concept of social medicine replaced old-style public health with new analyses of social pathology. This, together with the power ofthe clinical profession, eliminated the role ofmedical officers of health from the centre stage of the National Health Service when it was established in 1948. …