Does the Era of Globalization Dictate a change in the Definition of Public Health?

Globalization, which is spreading into every part of our lives, has a strong impact on public health. Unfortunately, in the era of globalization, the process of destroying the meaning of public health (PH) in the current sense began. This process is tending towards narrowing the meaning of the concept of PH down to merely its function within national frameworks, while the concept of global health (GH) should assume a unifying role in terms of solving health problems that spread beyond national frameworks. Today we can read this in the description of what GH is, for example on some websites (1) or in the presentation of some textbooks (2). On the other hand, we can also perceive the process of extension of the concept of PH in the sense of globalization. For example, today one of the world’s most important textbooks in the field of PH no longer has PH in its title, but global PH (GPH) (3). It could be said that there is actually a kind of rivalry for position between the concept of PH which also includes GH, and the concept of GH which excludes PH. Thus, one of the most important challenges for PH today should be how to convince the world that the concept of PH with GH makes more sense than the concept of GH without PH.

Interestingly, PH was present throughout the development of GH, directly or indirectly. If we go back historically, the concept of GH superseded the concept of international public health (IPH), which in turn superseded the concept of tropical medicine (TM). Throughout the history of IPH and GH, activities took place mainly in former European colonies in the form of direct or indirect PH measures, and financial and material aid from developed countries.

For a long time, infectious diseases were the biggest health problem of populations all over the world, but at the end of the 19th and in the first third of the 20th century, the situation in the more developed countries of the world improved with vaccination and good sanitation as the strongest public health measures, and then with the accelerated establishment of public schools of health and international foundations and intergovernmental agencies interested in public health it began to slowly change. As a result, the burden of infectious diseases began to decline significantly in these countries, but not in developing countries. People travelling to and from these countries thus posed the threat of reintroducing infectious diseases to more developed parts of the world. This was especially true for countries that had their colonies in less developed parts of the world. This led to the development of a special branch of medicine dealing with the control of infectious diseases in these parts of the world. Since they were largely located in tropical regions of the world, the branch was called tropical medicine (TM) – an interdisciplinary branch of medicine that prevents the spread of infectious tropical diseases. It covers all infectious diseases that thrive in humid or hot conditions (4, 5). TM experienced a major development step in the late 1970s at the WHO conference in Alma Ata, which called for international efforts to expand and strengthen the capacity of health services in low- and middle-income countries. TM’s concern, which was focused on the control of infectious diseases of warm climates, extended to the provision of health services and thus to the reduction of morbidity among the inhabitants in the most depressed environments. This laid the foundation for IPH.

The field of IPH developed on the basis of the fact that towards the end of the 20th century, other health problems that required international treatment, such as non-communicable diseases and their determinants, began to come to the forefront, and the need for a new PH branch – IPH – arose, a branch whose important feature was the application of PH principles to the management of the health problems of less developed countries and their local and global determinants (6).

However, development did not stop. As the world increasingly began to face the fact that the negative impacts of both the social and physical environment on human health are not limited only to less developed countries, but also occur within developed countries, the IPH concept slowly transformed into the GH concept, maintaining a similar focus to IPH, but placing much greater emphasis on health problems that affect many countries at different levels of development and health problems that are strongly influenced by transnational determinants such as climate change (6, 2). The expanded concept offers an opportunity to address cross-border issues and differences in health and access to health also in developed countries, not only in less developed ones. In this process, the application of PH principles is continuously present, which means that the two concepts, PH and GH, are difficult to separate.

Another challenge for both PH and GH is that within both concepts there still persist remnants of the historical development, which somewhat depends on the part of the world. In some European countries, for example, the process of transformation from classical PH to modern PH has not yet come to an end, which means that they cling to the old entities of PH, social medicine, hygiene and epidemiology of infectious diseases. On the other hand, one section of GH advocates claims that the problem of GH is only infectious diseases, which brings the concept back to the beginnings of its development.

Thus, an important modern challenge for PH is to try to communicate that PH and GH concepts are fundamentally a single concept, but that some PH problems need to be solved at the global level, some at the regional level, and some only at the national level. But this does not mean that the working methods are different. On the contrary – they are very similar, only the levers for resolving them are different. So it is actually just different PH levels.

If we take Slovenia as an example, the PH of the country is always placed in the context of the environment – social and physical – in which it is embedded. But it is not only the context of the national environment. As a member of the European Union (EU), Slovenia is obliged to comply with EU PH guidelines and to report to the EU on risks relating to the entire EU, which means the regional level of PH. The PH of the EU, and thus also the PH of Slovenia, on the other hand, must face global public health problems and not just regional ones. This means that the PH of Slovenia must focus both on solving national PH problems, as well as participating in solving regional and global PH problems. Since PH professionals have to deal with all three levels, how can we even talk about separation between PH and GH?

The unity of the two concepts is also indicated by the fact that the challenges which PH and GH must address are the same. Let us mention just some of them, such as global drug routes, hunger and food security coming from all corners of the world, the warming of the planet and the climate changes associated with it, natural disasters of large proportions and migration, not to mention the globalization of social crises such as are wars. These conditions have a significant impact on the entire world. We are facing steadily growing health inequalities at all three levels. Thus, the problems are the same, only the scale and involvement of actors are different.

Due to cultural and socio-economic characteristics, it is necessary to adapt the field and the way of work to a specific local environment, but nevertheless, these are challenges that are present everywhere. That is why it is crucial that we act decisively, in a united and connected approach - regardless of where we live and at what level of social development we are. The world has become one, so the division into public health and global public health has become meaningless.