Sanitarian becomes ecologist: the new environmental health.

Sensitivity to the environment demands new skills and attitudes Once again public health is on the move. After 40 years in which medical thinking has been dominated by the "magic bullet," therapeutic, model of health the pendulum has swung strongly in the direction of health promotion and preventive medicine. The reasons for this shift are complex. They include the prevailing political philosophies, which are antipathetic to publicly funded services and emphasise personal responsibility. But they also include various strands of academic support. These range from Ivan Illich's indictment of the iatrogenic effects of much of medical practice to the abundant evidence that, despite enormous investment in medical care, the health oflarge sections of the population has failed to show commensurate improvement.' Not least is McKeown's demonstration that most of the improvement in mortality in England and Wales between 1840 and 1970 had occurred before the availability of effective treatments.2 McKeown's claim that the main contributions to improved health came from (in order of importance) limitation in family size (a behavioural change), increase in food supplies and a healthier physical environment (environmental influences), and specific preventive and therapeutic measures has had a particularly strong influence around the world. The World Health Organisation's strategy of Health For All by the Year 2000 and its setting of targets for health improvement through initiatives such as the healthy cities project have provided a framework and powerful legitimation for the revived emphasis on public health.3 5 Recently both the Acheson report Public Health in England and the Institute of Medicine's report on the future of public health in the United States have highlighted the extent to which routine public health systems and practice have been neglected since the war.67 In Britain the government white papers Promoting Better Health and Working for Patients have both given much greater emphasis to public health and prevention than before.69 Indeed, under the new arrangements the public health function becomes central to the district health author-ity's role. The separation of the roles of provider and purchaser frees the health authority and its director of public health to take an overview of the population's health and conduct the orchestra of individual, collective, and organisational responses to tackling the problems revealed. The implications of these developments for the traditional partners in public health are considerable, not least for environmental health officers, who were so central to the old public health, with its …