What are the drivers of the new paradigm?

David Hunter presents a useful discussion on, and arguments for, shifting our responses on contemporary public health problems from relying predominantly on health care to broad public health policies. The epidemiological basis of the argument is sound and well established: population-based prevention reducing general risk factor levels through changing lifestyles is by far the most cost-effective and sustainable way to reduce the rates of major chronic diseases and to promote population health.¹

It is well realized that influencing people's lifestyles goes far beyond health services. Having said that, I must emphasize that health services can have an important role. Health services, especially primary health care, work continuously in the community close to people. If they systematically assess people's health risks, advise on changes and collaborate with the community, health services can in the long run make a major contribution to the overall preventive work in the society.

But basically the question of disease prevention and health promotion in the population is about our social and physical environments—how harmful or conducive they are for health. This, of course, is not only an issue of health policy, but of decisions in different policy areas. Hunter makes reference to the concept of Health in All Policies (HiAP) that Finland introduced during its EU Presidency and that is, indeed, now in the public health strategy of the European Commission.²

But where Hunter's discussion falls short is on the question what the drivers of the current paradigm are, and how we can promote change in the paradigm. Is it only a question of bad politicians?³

Hunter refers to the problem that politicians operate within the framework of short-term electoral cycles. But we see exactly the same problems for disease prevention and health promotion in countries with no elections, or where elections have less impact on policies than in the Western world.

At the end of the day the question is about social change. In such change, political decisions and actions of the private sector are in a complicated way interrelated with the values, intentions and behaviours of people. Real public health leadership should mobilize the people for social change—helping them to change towards the new public health paradigm that Hunter so well describes.

What I describe above is to a certain extent supported by the Finnish experience where since the 1970s comprehensive work has been carried out to change particularly heart health-related lifestyles: diet, smoking and physical activity. A complex process involving the people, various stakeholders, various sectors, public policies and responses by the private sector have resulted in dramatic changes especially in dietary habits and men's smoking, and in a major reduction in the blood cholesterol and blood pressure levels of the population.⁴ These changes in turn have resulted in some 80% reduction in annual cardiovascular mortality rates and a dramatic improvement in population health. Had the rates remained on the level of the early 1970s, now some 10 000 working-age people more would have died of cardiovascular causes annually. Such numbers of lives could not at any cost have been saved by curative medicine—not to speak of the many other benefits for health and quality of life.

Thus, I strongly support Hunter's wish for a new paradigm: broad social change for improved population health and well-being. For that we should put more scientific and practical efforts in the question as to what could drive such change. Hunter is right, in that health practitioners need to become advocates for change working with the public. But more generally, we need public health leadership on global, national and local levels—combined with good partnership—to mobilize people for health in the way that moves politicians and private sector towards broad and effective change.

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