Introductory Chapter: Public Health Afflictions and Challenges in the Developing World

1. Conceptualizing public health

The most interesting definition of public health is probably that provided by Sir Donald Acheson and colleagues who in the influential report published in 1998 apprehended it as “the science and art of preventing disease, prolonging life and promoting, protecting and improving health through the organized efforts of society” [1]. Generally, and as the name implies, public health is concerned with the health of a given population or group which is pursued as part and parcel of the agenda of governments and public institutions to improve the lives of the people under their domains. In other words, it is health conceived as a critical element of regulations, policies, and support framework of the government or its agencies. Public health is as well a common domain between individuals, communities, groups, and government and/or its institutions and agencies. Even where there are formal and institutional provision of facilities and services, accessing these services and responding to guidelines and procedures of health are usually at the level of individuals and communities. The above is especially obvious in the area of infectious or contagious diseases where prevention and curtailment are deemed necessary. In other words, a good public health system depends as much on formal provision of facilities and services as it depends on a responsive public.

Therefore, health promotion is a key element and goal of public health. In doing this, public health strives to encourage healthy lifestyles and the prevention of diseases and epidemics through health education and intervention actions. There is no gainsaying the fact that public health interventions that are carefully tailored and conscientiously implemented would lead to reduced mortality in the general population and improved quality of life and life expectancy. These would in turn impact positively on socioeconomic development.

By definition, public health lays emphasis on social and environmental contexts of diseases and health problems. It, from this pedestal aspires to improve health through large-scale societal initiatives like vaccinations, fluoridation of drinking water, easy and affordable access to health facilities, and even such behavior modifying acts like prohibition of smoking and demonizing cigarettes as a way of curbing the spread of tobacco-related diseases in the population. In other words, public health while including the treatment of individuals or communities goes beyond this to focus on health promotion, disease prevention, recovery, rehabilitation, and broad health support for the community or society.

From the perspective of the present volume, the conceptualization of public health as both art and science is very instructive. In this sense, it provides a unique opportunity for a fusion or coming together of science and arts. Therefore, public health is neither all about biomedicine nor about the policies and programs on health from public institutions, communities, and government. It is in reality, comprehensive and demands concerted action from different actors. It is thus how disease is prevented, life prolonged, and health promoted through public instruments and policies systematically driven and coordinated or organized to achieve the goals of good health.

In view of the above, it has been posited that “the mission of public health is therefore to achieve an equitable distribution of health for the total population” ([2] p. 5). Equally of interest is that public health is a multidisciplinary domain and thus involves different professionals and practitioners working in concert. However, a critical skill set is knowledge of the principles of epidemiology which gives one the insights into disease patterns, risk factors, and outcome of treatments and even prevention initiatives. Also, a good social knowledge and environmental awareness are equally recommended. In more recent times, political savvy has equally come in handy in dealing with policy makers and governments that provide much of the funding for public health.

2. Major concerns and approaches

Public health as compared to clinical health approach focuses on the health of the population, i.e., group, community, and society, unlike clinical health that is concerned with the health of the individual alone. In other words, while the clinical health provider assists or helps an individual with her own healthcare issues, the public health approach is more broad-based and encompassing beyond the individual. Therefore, while the clinical health approach may focus on why a given individual confronts a particular health issue, public health would take a look at the given social group (neighborhood, community, society) to identify prevalence of a given health issue, risk factors associated with it, accessibility of healthcare for the issue by the members of the society, measures at prevention, and curtailment among the given group. As a result, “public health seeks to improve the health of the whole community with emphasis on protection, prevention of diseases, and promotion of well-being” ([2] p. 5).

The major areas or concerns of public health include hygiene and sanitation; epidemiology; environmental factors; disease prevention; and policies/regulations that address these concerns. Public health focuses on the prevention of diseases or ailments through health education; focused policies; and research and programmed intervention services. Also, public health in principle seeks to address inequity in health; accessibility of health services especially to the marginal or less privileged members of the society; and ensuring quality health provisioning both in public and private health facilities.

In terms of approach, public health takes the community or society as a whole as its focus rather than the individual. It therefore aims at improving the health of communities and societies through concerted efforts. Some of the prominent functions of public health include surveillance, analysis, and evaluation of the health status of the population; health promotion; development of policies and plans that engender health; disease prevention activities and campaigns; development of effective programs and facilities for health protection; evaluation and monitoring of public health policies; and strategies and facilities, among others.

Public health emphasizes a collective approach to health in the population. It usually privileges preventive efforts and health education of the general public aimed at both improving health and reducing risks to health ailments. This collective approach which nowadays entails systematic and public policy response to health issues is different from the provision of medical treatment to an individual or on the basis of one patient per time.

3. The developing world and public health challenges

The conceptualization of public health is generally very close to the comprehensive view that health goes beyond the mere absence of illness or disease. Thus, public health also mirrors a broad definition of health especially along the lines of the emblematic position of the World Health Organization that in 1946/1948 conceptualized health simply as “state of complete physical, mental and social well-being and not merely the absence of disease” ([3] p. 100). However, the reality of the structural challenges of the developing world has created a unique public health orientation that focuses essentially on the absence of diseases. Apart from a history of proliferating diseases and health challenges, the paucity of technical competence, funds, and good leadership have all made public health systems in these parts of the world overburdened and often inadequate to the needs of the people.

While public health concerns in the developing world are very encompassing and often include long list of health ailments and impediments, the core public health problems include such diseases and ailments with high mortality as malaria, infections, diarrhea, respiratory tract infections, HIV/AIDS, anemia and malnutrition, intestinal worms, and lately Ebola. These diseases are usually more prevalent among poor and marginal members of the population. In an ironic sense, those who are far away from necessary health support or lack the resources to access health services are much more affected and afflicted. The above is a core justification for the enthronement of responsive and expansive public health services and public health provisioning to tackle these diseases.

In a succinct take on the health system in sub-Saharan Africa, which is typical of the developing world, sometime in the past (a scenario that has hardly changed), it was postulated, “in spite of prolonged efforts in reforms, meetings, declarations, policy rhetoric as well as the massive input of financial and technical resources, the continent records some of the highest rates of infant deaths and maternal mortality in the world. Also, Africa represents about 10 percent of the global population but accounts for 63 percent of individuals living with HIV/AIDS and 90 percent of malaria infections worldwide” ([4] p. 7). The foregoing calls attention not only to the imperative of a robust public health sector in Africa, but the unending spate of health deficiencies challenge innovation and proactive response in different African countries where lessons have neither been learnt from the past nor experiences harnessed for improved health delivery.

Health delivery from the perspective and experience of the developing world goes beyond the orthodox and Western-defined purviews of medicine and science. In other words, indigenous knowledge as philosophy and ethos of practice affect healthcare decisions and choices in these areas.

The call for the exploitation of meaningful ways of integrating traditional medicine into the health system benefits from the undeniable easy availability and accessibility of traditional healers in most parts of the world especially Africa and India. In fact, Chatora [5] contends that the availability of traditional or unorthodox (non-Western) medical practitioners generally far outstrip that of conventional medical doctors in most parts of the African continent. Incidentally, these traditional healers are accessible both in terms of geographical proximity and finance. They also often initiate a one-on-one interaction with their patients in the process of healing that can hardly obtain within the formal health system.

Another fundamental issue in public health in most of the developing world revolves around the role of the private and informal sectors in public health provisioning. Organizations in these sectors especially the faith-based organizations (FBOs), i.e., churches, religious organizations, religious NGOs, etc., have featured prominently in the health decisions and choices of people overtime. In fact, FBOs, for instance, are seen as critical role players in health delivery and choice people make with regard to health [6, 7, 8]. While these private and informal sectors and their roles have been well-studied and even targeted in the guise of public private partnership in health, there is still an overwhelming number of things that happen in these sectors that are neither formally recognized nor regulated. In other words, there is need for not only the formal recognition of these sectors but crucially how synergies can be built to harness what is good in these sectors and expunge what is bad or counterproductive. A big selling point of these alternative health sectors is perhaps their affordability and easy access to a great majority of the people. Therefore, we need to begin conceptualizing public health systems that build also on the good aspects of the private and informal sectors and which also seek to recreate their general appeal within the context of formal health provisioning in the continent.

The three biggest infectious diseases in Africa from both prevalence and resources committed are HIV/AIDS, tuberculosis, and malaria. These are the three giants of public health interventions and efforts in the continent. However, there have been new challenges especially in the form of new and periodic diseases like Ebola which has emerged in the last decade as a major public health concern in some African countries. As has been aptly summarized, “nowhere are global public health challenges more acute than in Sub-Saharan Africa. With just 13 percent of the world population, the region carries 24 percent of the global burden of disease” ([9] p. 1). Even though, globally and continentally, good strides have been made in curtailing the ravages of HIV, there is still a huge disease burden arising from it especially in Africa. Thus, “antiretroviral treatment is being provided to many of those in need in Africa, in numbers greater than was thought possible at the beginning of the decade. Nonetheless, for most Africans living with HIV, such treatment remains out of reach” ([9] p. 4).

The above indicates that in spite of the recent improvements made in curtailing both the spread of HIV/AIDS and the mortality from it, there is still much work to be done in the public health system especially in sustaining the progress made and in scaling up general response. Incidentally, apart from donor/international support, there is a need for committed leadership, good governance, and policies backed by reasonable internal funding in African countries especially those heavily affected in terms of the disease burden. The situation is a little better in India, but acute population growth and dearth of potable water have meant that India confronts a fragile public health situation. Therefore, the need for concerted efforts as well as dynamic and proactive measures against diseases and afflictions cannot be overemphasized.

Without doubt, the most current global public health scourge in the form of the corona virus which caught the whole world by surprise underlines the need for robust public health systems. The fact that such developed nations of the world as the USA, the UK, France, Italy, Spain, Germany, etc. could be caught napping and severely devastated as a result by the new virus with origins in Wuhan, China, calls attention to the inescapable fact that public health delivery and the institutions involved in it are by nature dynamic and confront ever-changing and mutative human environments. That health systems in the developed nations of the world that are well-developed and heavily-resourced could be severely eroded by the corona virus simply underlines the huge challenges of public health in the developing parts of the world, where both structural and environmental forces function as ready impediments to effective health delivery.

There is therefore a need to interrogate prevailing health systems and health delivery in these parts of the world in relation to what appears to be a cyclic incapacity of public health. Perhaps, the contention of Kaseje that “the health system is neither robust nor flexible enough to respond to emerging scenarios that lead to reversal of gains. Traditional, faith, and other informal sources of care are used more because they are more available, accessible, affordable, and acceptable yet they are ignored and therefore unregulated and unsupported” ([4] p. 7) is really instructive. We need to confront the various problems or challenges bedeviling the system and reposition the system for improved quality of life and overall development.

In effect, the chapters in this volume deal with various and complementary issues in public health from the perspective of the developing world. While these chapters have discussed some of the most pressing and prominent issues in public health in the developing world, there is no doubt that some pertinent issues have gone untreated in it. Therefore, while the volume has sought to be comprehensive, it cannot claim to have treated all there is to know about public health in the developing world. However, the volume draws strength and relevance from the deep theoretical insights of some of the chapters and more crucially from the penetrating case studies from different parts of the developing world that some of the other chapters provide.