Theodore H. Tulchinsky and Elena A. Varavikova. San Diego, California, United States of America: Academic Press; 2000. 882 pp.
ISBN 0-12-703350-5



There is no question that public health activities have made a remarkable contribution to the understanding of the causes and consequences of disease, from the earliest activities in the field in the 17th and 18th centuries to the present time. However, at the beginning of the new millennium many experts in various areas of public health have expressed worries about the future direction of the field, including the limitations of what some have labeled "conventional" public health. Some experts believe that we have placed too much emphasis on biomedicine and the attempt to explain all causes of disease using a biophysiologic model. The other side of the coin might be the perceived separation of traditional public health work from clinical medicine. As medical care absorbs more resources in both developed and developing countries, traditional prevention and health promotion activities are being neglected.

This book is an attempt to expand the definition of public health¾and thus the text's title. One of its purposes appears to be to elucidate the interdependence of all elements of health care. The authors stress the need to balance services that meet the needs of individuals with those that benefit the whole community, and thus use resources effectively. They note the history of reduction of morbidity and mortality through traditional public health measures in the late 19th and early 20th centuries, before the most effective medical treatments were available. However, they believe that as medical care has improved, there has been a widening separation between medical care and public health practices. They argue that it is now apparent that this separation cannot continue, given the shift toward a larger burden of chronic disease, the need for more medical care, and the increasingly evident need to reform health systems. The effectiveness of both prevention and treatment is diminished when they are organized and financed separately.

The book began with the two authors' collaboration on a review of the health situation in Russia in the early 1990s, and the text was initially published in Russian. The authors wrote that book after seeing a need to bring current thinking and an international orientation to students and public health practitioners in Russia, to help shape development of pubic health in the post-Soviet period.

The new, English edition is intended to reach a wider audience in many countries, especially undergraduate and entry-level graduate students. The authors state in their introduction that they also hope the book will be of use to clinicians, policymakers, and managers in helping define a new approach that links the fields of public health and clinical services.

The authors define the new public health as a "comprehensive approach to protecting and promoting the health status of the individual and the society based on a balance of sanitary, environmental, health promotion, personal, and community-oriented preventive services, coordinated with a wide range of curative, rehabilitative, and long-term care services." Their book attempts to give an overview of all the various pieces of this very broad definition. The text has 16 chapters, which together cover nearly 300 subtopics. It begins with a history of public health and continues with issues that are traditionally central to most introductory public health texts: measuring and evaluating health of populations, and communicable diseases. There are also chapters on nutrition and food safety and on environmental and occupational health. Other chapters concentrate on less-traditional issues such as noncommunicable conditions. There's also a chapter on "family health," which essentially describes health problems in individuals at different stages of life and provides information on individual preventive actions and medical care.

A large portion of the book is devoted to organization and management of health systems as well as health economics, human resources, and technology. There is also a long chapter that describes health and medical care systems in a number of countries in all areas of the world.

This book is an interesting attempt to provide a very broad overview of a large number of issues related to public health, medical care, and the organization and financing of health care systems. While perhaps appropriate for beginning public health students, this approach may present a disadvantage to more-experienced professionals. The text attempts to cover so many topics that many have to be given only a very small amount of space. This is especially true, for example, in the chapter on noncommunicable conditions, where a large number of chronic diseases are described in just one or two paragraphs each.

It is also a very difficult undertaking to try to cover all these issues in a way that is relevant in numerous countries, with different levels of development, diverse cultures, and varied political traditions. One of the possible limitations for readers in developing countries is that many examples, especially in the chapters on organization of health systems, come from the United States of America. For example, the organization of county health departments and the development of regulations related to the protection of health in the United States may not be very relevant in other countries.

In general, the book is easy to read, and the language is not likely to be a major problem for those readers whose first language is not English. In addition, there is a good key to abbreviations and an extensive glossary of terminology, which is likely to be helpful both to beginning public health students in English-speaking countries and to those who are not native English speakers or who are unfamiliar with some of the terminology specific to the United States.

Another important plus are the multiple references and recommended readings and other resources at the end of each chapter. Many of these are Internet sites, which may be more readily available than the suggested books and periodicals, at least in some areas of the world.

In summary, this book is a very ambitious attempt to define an expanded concept of public health and to give an overview of all its components. It is likely to be useful for beginning students but may not be very satisfying for practicing public health professionals, given its very brief treatment of many subjects.

Linnea Capps
Harlem Hospital and Columbia University
New York, New York

Organización Panamericana de la Salud Washington - Washington - United States