Scandinavia's lessons to the world of public health

Abstract

The Scandinavian Journal of Public Health embarks on a new phase, under the editorship of Professor Stig Wall. It is timely, then, to consider what unique contributions might be made by the journal. Certainly, the Nordic countries, with their highly regarded universities and well-developed research centers, have much to share with the rest of the world across the broad spectrum of basic science, clinical medicine, and population research. However, much of this excellent research is not unique to this part of the world and it is the thesis of this editorial that, in the area of public health, Scandinavia can play a leading role in shaping contemporary thought. The Scandinavian Journal of Public Health should therefore provide a forum for description and discussion of public health issues in the Nordic context, not only for the bene®t of the Nordic community but also to help those of us from other parts of the world who wish to better understand the theory and practice of public health. Epidemiology and public health have recently been criticized for taking an increasingly smaller role in shaping health policy. Reliance by contemporary epidemiology on ``the black box'' (1), ``the web of causation'' (2), ``risk factorology'' (3), and other paradigms has, according to some thinkers, limited the ®eld's ability to meet new challenges to population health. The increasingly individualistic approach within a medical model causes public health in some countries, such as the US, to be subsumed as another medical speciality, rather than as a primary goal of public policy and social values (3). Others worry about the future of epidemiology (4) and believe that public health is in transition (5). If so, then where will we ®nd the science and experience to choose the best course? This increasing insinuation that public health may be irrelevant raises the need for model systems to examine more collectivist and holistic approaches as alternatives to the individualistic, medical approaches. It is possibly safe to say that the Nordic countries have traditionally taken a much more comprehensive and societal approach to health in general, and public health in particular. To illustrate this, let us contrast two recent policy documents outlining national health strategies for the next decade ± one for a Nordic country (Sweden) (6) and the other for the United States (7) (Table I). The ``Green Paper'' describes the public health strategy for Sweden and sets down, possibly for the ®rst time, public health objectives that address the actual determinants of health and disease at the societal level. Objectives 1 ± 4 and 6 ± 13 deal with broad issues of economic disparity and poverty, homelessness, unemployment, non-participation in political decision-making, personal development, workplace environment, segregation, education, and care of the elderly. Only seven objectives deal with speci®c diseases and health-risk behaviors. Nonetheless, all 19 objectives have quanti®able indicators for ful®llment of each objective. In stark contrast are the Healthy People 2010: Health Objectives for the Nation, released in January 2000 by the Department of Health and Human Services of the United States (7). These objectives also have two overall goals: (i) to eliminate health disparities (between groups de®ned by gender, race/ ethnicity, income and education, rural location, disability, and sexual orientation), and (ii) to improve the quality and years of healthy life. While the goals suggest broad societal changes and determinants of health, the focus areas of Healthy People 2010 largely address a biomedical model. Of the 28 objectives, 23 describe health issues that deal with speci®c diseases or risk behaviors, with de®nable indicators, usually entailing reduction in speci®c mortality or prevalence estimates. These two sets of health policy objectives for the ®rst decade of the 21st century suggest a fundamentally different approach to public health operating at different levels of social integration and organization. According to the biopsychosocial model of Engel, health is determined by a series of levels of process (8). According to this model, the Swedish Public Health Plan is operating at the level of society and culture, whereas the American plan is generally operating at