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Skip to 0 minutes and 12 seconds Another consideration for public health is its evolutionary nature. If we are to influence and improve population health and well-being and respond effectively to present and future public health challenges, it is important for us to recognise that as a discipline, public health continually evolves. Knowledge of the historical development of public health has importance, for as Theodore Roosevelt, the 26th president of the United States of America is quoted as saying, “the more you know about the past, the better you are prepared for the future”.

Skip to 0 minutes and 52 seconds The ancient history of public health is rich and varied but analysis of contemporary public health activity with its roots embedded in 19th century Europe marks out different phases or eras of public health that can be conceptualised as waves. The conceptualisation metaphorically of public health as a series of waves suggests there is a complex interplay and relationship between health, well-being and social progress. Such an analysis serves to challenge our thinking about how and why in a changing world, current and emerging public health issues and threats to health will require different solutions and new ways of working, if there are to be sustainable improvements to population health and well-being.

Skip to 1 minute and 46 seconds Each wave of public health development depicts a phase of activity that increases in intensity, reaches a peak and then declines. Before each wave reaches it peak of health and social progress, the next wave emerges. Although public health activities cumulative, the impact of each wave on population health and well-being is at its maximum only when it first emerges. The following is a summary of the four waves of public health. The first wave of public health approximately 1830 to 1890, known as the classical period of public health.

Skip to 2 minutes and 31 seconds Classical public health interventions, for example; housing improvements, the supply of clean water, the development of sewerage systems and better working conditions emerged in response to social and civil disorder and the perceived irresponsible health related behaviour of the poor during the 19th century industrial revolution. In the absence of public health professionals and a public health infrastructure, politicians, engineers and many other social reformers came together forming new government structures, legislation and a voluntary and charitable sector. Miasmic theories of health that disease was the result of bad air, was a dominant belief. The second wave of public health approximately 1890 to 1950, the period of scientific rationalism.

Skip to 3 minutes and 32 seconds Scientific rationalism approach based on the application of science provided break throughs in many areas including engineering, transport, communications and medicine. The work of scientists such as Louis Pasteur, Robert Koch and Joseph Lister resulted in the shift to germ-based theories of disease. The concept of the expert health professional, medical specialisation and the medical model of health started to gain dominance. The third wave of public health approximately 1940 to 1980, the emergence of the welfare state and post-war consensus. Following the Second World War, the five giants namely squalor, disease, want, ignorance and idleness had not been overcome and so policy focused on changing material circumstances.

Skip to 4 minutes and 32 seconds While the focus of disease was still on medicine, different models of health and the determinants of health emerged. It was believed that the creation of the welfare state, universal education, various housing acts and the provision of social security and quality health care would improve the health of the population over time to such an extent that the need for health services would gradually diminish. The politicians were the key figures of the third wave of public health development. The fourth wave of public health development 1960 to 2000, effective health care interventions. Premature death in Northern parts of Europe continued to decline throughout the 20th century following the cumulative effects of the first three waves of public health.

Skip to 5 minutes and 29 seconds However, post-industrial challenges to health and well-being slowly emerged associated with the transition to a knowledge economy, the replacement of manufacturing with service industries, the changing structure and dynamics of family life, rising divorce rates, out of marriage childbearing, female control over their fertility, changing work gender roles, weak and social networks and ageing. Societies inevitably change and become more complex. Populations change in size and structure and how we live our lives tends to be viewed through an economic lens. It is said that the cultural values that permeate society are those of individualism, materialism and consumerism. What will the inevitably of change mean for the health and well-being of future populations?

Skip to 6 minutes and 26 seconds What will be the future public health challenges and how should they be addressed? These are difficult questions to answer but they do suggest that we will need to work differently and find new solutions to improve the health of populations.

The future of public health challenge

Another consideration for public health practice is that it is not fixed.

Watch the video in which Pauline describes Hanlon’s concept of ‘waves’ of public health activity and the need for nurses to respond in new ways to current and future challenges

Your task

Identify which wave your country is currently in and the implications of this for your patients or clients.

If you are interested in finding out more about this subject, we recommend you take a look at the further reading below and access a copy of the ‘waves’ timeline in the Downloads section.

Further Reading

Hanlon, P., Carlisle, S., Hannah, M., Reilly, D., and Lyon, A. (2011) ‘Making the Case for a “Fifth Wave” in Public Health’. Public Health [online]. 125 (1), 30-36. available from https://linkinghub.elsevier.com/retrieve/pii/S0033350610003197 [8 August 2018]

Those of you with Open Athens credentials, either you own or via your Coventry University ID and password, can also access the following book.

Hanlon, P., Carlisle, S., Hannah, M., and Lyon, A. (2012) The Future Public Health. [online] Maidenhead: Open University Press. available from https://www.dawsonera.com/readonline/9780335243587 [28 June 2018]

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This video is from the free online course:

Could You Be the Next Florence Nightingale?

Coventry University