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THE NEW PUBLIC HEALTH

Julio Frenk
National Institute of Public Health, Mexico; Center for Population and
Development Studies, Harvard University, Cambridge, Massachusetts 02138
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KEY WORDS: definition of public health, conceptual models, health research, human
resource development, utilization of knowledge
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INTRODUCTION

Health is a crossroad. It is where biological and social factors, the individual


and the community, and social and economic policy all converge. In addition
to its intrinsic value, health is a means for personal and collective advance­
ment. It is, therefore, an indicator of the success achieved by a society and
its institutions of government in promoting well-being, which is the ultimate
meaning of development.
As a field of knowledge and as a social practice, public health has
historically been one of the vital forces that have led to reflection on and
collective action for health and well-being. However, there is a widespread
impression that this leading role has been weakening and that public health
is today experiencing a severe identity crisis, as well as a crisis of organization
and accomplishment. A recent report prepared by a special committee of the
Institute of Medicine opens with the following statement: "In recent years,
there has been a growing sense that public health, as a profession, as a
governmental activity, and as � commitment of society is neither clearly
defined, adequately support)!«,/nor fully understood" (8).
Like the societies of which they are a part, public health institutions all
over the world are experiencing new tensions that have exacerbated problems,
but have also created challenges for innovation. For nearly 80 years, we have
had schools devoted to the teaching of public health. Over time, our schools
have developed a valuable tradition that has made it possible to build a broad
institutional basis. At the same time, departments and programs with other
names have arisen. These departments share a great deal of the vision and
mission of public health. However, problems have been mounting. In many
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countries, schools and institutes of public health have become isolated from
scientific progress and from efforts to organize better health systems. This
has relegated them to a secondary role both in academia and in applied areas,
thus generating a vicious circle between isolation and irrelevance.
Today more than ever, public health institutions need to redefine their
mission in light of the increasingly complex environment in which they
operate. Today more than ever, they must ask themselves about their social
role, about the scope of their actions, and about the bases of their knowledge.
In light of the magnitude of the problems, which have even led many to
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abandon the term "public health," we urgently need to propose for ourselves
a renaissance that, by assimilating the most valuable aspects of our intellectual
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tradition, legitimately enables us to speak of a new public health. What are


the conceptual principles that underlie this renaissance? What are its organi­
zational challenges? What are the characteristics of the epidemiological and
social context that establish the need for change and specify the limits of its
feasibility? This article attempts to offer some preliminary answers to these
questions. The purpose is to contribute to a process that will once again place
public health at the center of the scientific and political debate on the future
course of individual and social well-being.

ELEMENTS OF AN INTELLECTUAL TRADITION

To a large extent, the challenge to public health is to build and consolidate


a vigorous intellectual tradition that both supports its efforts to create
knowledge and guides its practical applications. Many generations of public
health researchers, professors, and workers have made essential contributions
along these lines. Like all living traditions, this one should involve a
continuous process of building and renewal. From this point of view, we can
organize our discussion by considering that the development of an intellectual
field (4) is based on the following four elements (15, 23):

1. Conceptual base. This element establishes the limits of the specific area
of research, teaching, and action. Hence, it involves rigorously defining
what constitutes public health, and more specifically-in an effort to
differentiate the previous uses of this term-the new public health.
2. Production base. This element refers to the set of institutions where a
critical mass and a critical density of researchers come together to
generate the body of knowledge that gives substantive content to the
intellectual field.
3. Reproduction base. This element ensures the consolidation and continu­
ity of the intellectual field-and thus the construction of an authentic
tradition-through three principal vehicles: educational programs to train
PUBLIC HEALTH 471

new professionals and researchers, publications to disseminate results,


and associations for the exchange of ideas and the aggregation of
interests.
4. Utilization base. This element ensures the translation of knowledge into
two types of products: technological developments (including new
organizational schemes) and decision making based on research results.
As we discuss later, the utilization base is of great importance for
providing feedback to the individuals and institutions involved in the
production and reproduction of knowledge.
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In the rest of this article, we examine the challenges to the new public
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health by analyzing each of the above elements.

CONCEPTUAL BASE

Any project to renew public health would be useless if it did not take as its
point of departure a systematic effort to specify its current meaning and to
separate it from obsolete conceptions. In this section, therefore, we attempt
first to define the two faces of public health: as a field of research and as a
form of professional practice. In the case of research, we propose a typology
and reflect on the role of the different scientific disciplines in public health.
We also discuss the reasons why we believe that the term "public health"
should continue to be used. Indeed, when defined rigorously, this term is
better than the alternatives that have been proposed by other reform projects.
The updating that public health requires today should be truly conceptual, not
just a matter of terminology.
However, a complete conceptual development cannot be limited to defini­
tions, but must also deal with the models that have guided public health. The
second part of this section briefly reviews such models in order to introduce
a subject that should receive much more attention in the effort to get the new
public health off the ground.

Definition of Public Health


The term public health is charged with ambiguous meanings. Throughout its
history, five connotations have been particularly prominent. The first equates
the adjective "public" to governmental action, that is, the public sector. The
second meaning is somewhat broader, as it includes not only government
programs, but also participation of the organized community, i.e. the public.
The third use identifies public health with "nonpersonal health services," that
is, services that cannot be appropiated by a specific individual, because they
are targeted at the environment (e.g. sanitation) or the community (e.g.
massive health education). The next usage is slightly broader, because it adds
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a series of personal preventive services for vulnerable groups (e.g. maternal


and child care programs). Finally, the expression "public health problem" is
often used, especially in nontechnical language, to refer to diseases that are
particularly frequent or dangerous.
There are also associations among these different meanings. In some
industrialized countries, for example, the private sector has tended to provide
most personal therapeutic services, whereas the public sector has assumed
responsibility for preventive and nonpersonal services, which tend to deal
with high-frequency problems. This has reinforced the notion of public health
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as a separate subsystem of services, provided by the state and parallel to the


mainstream of high-technology curative medicine. This perspective largely
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permeates the aforementioned report by the special committee of the Institute


of Medicine. Thus, its definition of the "substance" of public health limits it
to "organized community efforts aimed at the prevention of disease and
promotion of health" (10).
Recently, a more comprehensive conception of public health has emerged.
According to this view, the adjective public does not designate a particular
set of services, a form of property, or a type of problem, but rather a
specific level of analysis: the population level. In contrast to clinical
medicine, which operates at an individual level, and biomedical research,
which analyzes the subindividual level, the essence of public health is that
it adopts a perspective based on groups of people or populations. This
population perspective inspires the two facets of public health: as a field
of inquiry and as an arena for action (17).

PUBLIC HEALTH RESEARCH As a multidisciplinary field of research, the new


public health can be defined as the application of the biological, social, and
behavioral sciences to the study of health phenomena in human popUlations.
This is why it encompasses two main objects of analysis: first, the epidemi­
ological study of the health conditions of populations; second, the study of
the organized social response to those conditions, in particular, the way in
which such response is structured through the health care system.
To visualize the role of public health within the more general field of health
research, we can relate the levels with the objects of analysis. This produces
the typology shown in Figure 1 (21). For the first dimension of the
typology-the objects of analysis-we define conditions as the biological,
psychological, and social processes that constitute the levels of health in a
given individual or population. By response we are not referring to the inter­
nal physiopathological reaction to a given disease process, but to the exter­
nal response that society organizes for improving health conditions. For the
second dimension, we recognize two levels of analysis: the first level ad-
PUBLIC HEALTH 473

OBJECT OF ANALYSIS
LEVEL OF ANALYSIS

Conditions Responses

Individual and Subindividual Biomedical Research Clinical Research

(Basic biological processes; structure (Efficacy of preventive, diagnostic.


and function of the hUm:1n body; and therapeutic procedures; natural
pathological mechanisms) history of diseases)

Population Epidemiological Research Health Systems Research


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(Frequency, distribution, and detenni- (Effectiveness, quality, and costs of


nants of health needs) services; development and distribu-
tion of resources for care)
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Figure 1 Typology of health research, with examples of phenomena to be studied. (Adapted


from Ref. 21.)

dresses individuals or parts of individuals (i.e. organs, cells, or subcellular


elements); the other is the aggregate level of groups or popUlations.
Crossing these two dimensions yields the three principal types of research
that characterize the field of health: biomedical, clinical, and public health
research. Thus, most biomedical research is concerned with the conditions,
processes, and mechanisms of health and illness, especially at the sub­
individual level. Clinical research focuses primarily on studying the efficacy
of the preventive, diagnostic, and therapeutic responses applied to the
individual. The objects indicated above can also be analyzed at the population
level. As shown in Figure 1 , this is precisely what constitutes public health
research, which is subdivided into two principal types: epidemiological
research, which studies the frequency, distribution, and determinants of health
needs, defined as those conditions that require care (11), and health systems
research (HSR), which can be defined as "the scientific study of the organized
social response to health and disease conditions in populations" (23).
To extend the typology, Figure 2 shows that epidemiological research may,
in tum, be classified according to the point of departure for analysis. On the
one hand, it is possible to start with a set of determinants to study their various
consequences; this is the case of environmental, occupational, genetic, and
social epidemiology. On the other hand, research may begin by examining
some specific health condition (for example, positive health, infectious
diseases, chronic and degenerative ailments, injury) to investigate its multiple
determinants.
Health systems research also includes two major categories. The first can
be called "research on health systems organization," which is focused on the
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.j::o


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I
Biomedical Research
(Subindividual level)

Clinical Research
Health Research
(Individual level)

{
Research by
determinants
Epidemiological
Research
Research by
consecuences

{
Public Health Research
(Population level) Health Services

{
Research on Health Research
Systems Organization
(Micro level) Health Resources
Health Systems
Research
Research
Health Policy Research
(Macro level)

Figure 2 Classification of health research. (Adapted from Ref. 23.)


PUBLIC HEALTH 475

micro- and intra-organizational level of the health system. It studies the


combination of various resources for producing health services of a given
quality and technological content. Thus, it includes research on health
resources and health services. As can be seen, health services research is part
of HSR, as it seeks to analyze the primary products of the system, which are
precisely the services. However, the literature still commonly uses the terms
"health systems research" and "health services research" interchangeably.
The second category of HSR is called "health policy research. " It focuses
on the macro- and interorganizational level of the health system. Its purpose
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is to investigate the social, political, and economic processes that determine


the specific forms adopted by the organized social response. Therefore, it
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studies the determinants, design, implementation, and consequences of health


poliCies.
Naturally, the typologies proposed here represent mere abstractions for
synthesizing distinctions that are never so clear-cut in real life. In particular,
the four boxes in Figure 1 should not be seen as mutually exclusive
compartments. On the contrary, there are numerous connections among the
major types of health research. Thus, for example, various emerging fields,
such as bioepidemiology, clinical epidemiology, decision analysis, and
technology assessment, deal with interfaces among the four types. Indeed,
the principal message of Figure 1 is integration: The essential difference
between public health research, on the one hand, and biomedical and clinical
research, on the other, is not in the objects but in the levels of analysis. A
great part of the isolation of traditional public health might have resulted from
a conception that postulated that it should study objects other than those
examined by the biomedical and clinical sciences, thus erecting an insur­
mountable barrier. As we attempt to demonstrate further on, the future of
public health will depend on its ability to build bridges with the other types
of health research and to make its specific and irreplaceable contribution to
this undertaking, namely, analysis at the population level. Thus, the challenge
is to integrate levels and objects of analysis so as to achieve a full
understanding of the broad health field. In the case of public health, this also
requires integration among scientific disciplines.

THE ROLE OF THE DISCIPLINES The very definition. of public health research
involves an effort to achieve interdisciplinary integration. An important
obstacle to such integration has been the tendency to identify each level of
analysis with a given discipline. In particular, the resultant confusion suggests
that the biological sciences are applicable only to the individual and
subindividual levels, whereas the population level is the exclusive jurisdiction
of the social sciences.
All human populations are organized in societies, which is why the social
476 FRENK

sciences are indispensable for fully understanding health in populations, i.e.


public health. However, there is also a biological dimension of human
populations, which is expressed, among other phenomena, in the distribution
of genetic characteristics, herd immunity, and the interaction of humans with
other populations, such as microorganisms. In particular, there is a broad field
that could be called "bioepidemiology," which encompasses the study of the
biological determinants, risk factors, and consequences of health processes in
populations, as well as the use of methods and techniques derived from the
biological sciences to characterize such phenomena. The examples of such
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applications include seroepidemiology and health surveys that require labo­


ratory tests to measure the prevalence or incidence of a given condition;
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bromatological and somatometric studies, which are a key part of nutritional


epidemiology; and the toxicological analysis of environmental risks. Thus,
far from pertaining solely to the study of individual phenomena, the biological
sciences also contribute to understanding human populations. The other side
of the coin is that the biological sciences are just as essential to public health
as are the social sciences.
In addition, there is a second reason why the biological scieces should be
an integral part of public health. To achieve a proper understanding of any
health condition in a population (a particular disease, for example), we must
understand the biological processes that underlie the condition. The rich
research tradition on the so-called tropical diseases offers innumerable
examples of this type of linkage between biological and population phenom­
ena.
We therefore postulate that an essential element of the public health
renaissance is to reincorporate fully the teaching and research of the biological
sciences, which many schools of public health have neglected in recent
decades. Together with this reencounter, a broad, rigorous, and pluralist
development of the social sciences is necessary; this has also been absent
from many academic institutions devoted to health. This urgent need for
interdisciplinary integration is one of the reasons why, in defining public
health, we prefer to use the concept of population more than that of
collectivity, which is found in such proposals as that of "collective health" in
Brazil. The terms collectivity and community allude to a form of social
organization. The term "population" is broader, because it includes both the
social and biological dimensions of human groups.
This reasoning also underlies the need to preserve the term public health
over those that have arisen in recent decades to designate certain innovative
projects, such as "social medicine" or "sociomedicine." These terms are
acceptable when studying only the social dimension of health (27), but are
not valid as substitutes for the concept of public health, which, as we have
PUBLIC HEALTH 477

just argued, is broader. Indeed, what defines the essence of the new public
health is not the exclusive use of certain sciences over others. The biological
reductionism of the past should not be replaced by a sociological reductionism.
Rather, we need an effort of integration among scientific disciplines. This is
precisely the conceptual opening that stems from defining public health by
reference to its population level of analysis.

THE PRACTICE OF PUBLIC HEALTH As indicated above, public health is not


only a field of inquiry, but also a space for professional practice. This
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dimension also requires conceptual clarification.


As an arena for action, the modem conception of public health goes
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beyond fragmentary dichotomies, such as personal versus environmental


services, preventive versus curative activities, and public versus private
responsibilities. Instead of lending itself to these dichotomies, the new public
health addresses the systematic efforts to identify health needs and organize
comprehensive services with a well-defined population base. It thus encom­
passes the information required for characterizing the conditions of the
population and the mobilization of resources necessary for responding to
such conditions. In this sense, the essence of public health is the health of
the public. Therefore, it includes "the organization of personnel and facilities
to provide all health services required for the promotion of health, prevention
of disease, diagnosis and treatment of illnesses, and physical, social, and
vocational rehabilitation" (32). Public health encompasses the more narrow
concept of medical care, but not in its technical and interpersonal aspects
as applied to individuals in clinical situations, but rather in its organizational
dimension as related to well-defined groups of providers and users. In
addition, public health includes coordination of those actions that have an
impact on the health of the population, although they go beyond health
services strictly speaking. This is the meaning of the definition offered by
the special committee of the Institute of Medicine about the mission of
public health: "The fulfillment of society's interest in assuring the conditions
in which people can be healthy" (9).
An important factor in the emergence of this broad perspective on the
practice of public health has been the growing involvement of the state in
financing and providing all types of health services. Indeed, any original
limitation placed on the public sector to organize only environmental or
preventive services has been invalidated practically worldwide, as the state
has assumed a dominant role in the health system, including personal medical
care. Indeed, the largest share of resources currently spent by the public sector
in almost all countries is earmarked for personal curative services, whether
provided by private contractors or salaried government personnel (22).
478 FRENK

THE UNIVERSE OF PUBLIC HEALTH Although we have defined research and


practice separately, both refer to the same universe, which delimits the space
for integrating the two faces of public health. This universe can be represented
graphically as a three-dimensional matrix, as shown in Figure 3. Thus, the
efforts to generate knowledge about health and then to act upon it can be
expressed in various areas of application, which may be specific populations,
such as children, pregnant women, the elderly, and migrants; particular
problems, such as mental or dental health; or specific programs, such as
environmental, occupational, and international health. Referring to the
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previous discussion on the objects of analysis, in each one of these areas of


application, it is possible to do research and to act on health conditions or on
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the responses to them. In tum, the knowledge of such objects is based on


applying the biological, social, and behavioral sciences.
Conceptions about the limits and contents of the universe of public health
have varied throughout history. Likewise, the definitions that we have
proposed for the two dimensions of public health result from a historical
development in which different conceptual models of knowledge and action
in this field have been taking shape. As the history of thought is not a mere
progression of ideas, many of these models persist today. It is thus advisable
to become familiar with them.

Areas of Application
(Populations,
Problems,
Programs)

Cond�ions

Objects of
Analysis
Responses

Biological Social Behavioral


Sciences Sciences Sciences

J
l
y-
Scientific Bases

Figure 3 The universe of public health.


PUBLIC HEALTH 479

Conceptual Models in Public Health


Because the boundaries among fields of knowledge do not come from an
intrinsic or predetermined division of reality, the first step in the development
of a discipline or profession is, to quote Bourdieu et al (5), "to construct the
object." As noted above, the health field includes two major objects of
analysis: conditions and responses. This distinction is useful for identifying
the principal conceptual models that have guided public health, as depicted
schematically in Figure 4.
In simplified form, we suggest that conditions have historically been
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analyzed from two main perspectives: health and disease. The limits between
the two are not always obvious; in fact, the most comprehensive conceptions
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go beyond this dichotomy. However, public health thinking has included


two main currents that, as Dubos reminds us, go back to the worship of
Hygeia versus Aesculapius (12). One focuses on the study of disease; the
other, while not excluding disease, seeks to understand the determinants of
health in a broad conception that includes human development and well­
being.
The social response to health and disease conditions may be directed to
different objects of intervention. Historically, the main objects have been the
individual, including his or her immediate family surroundings, and the
environment, which can be subdivided into the biological and physical
components and the social components.
Crossing these two dimensions produces the typology of models shown in
Figure 4. The names given to the models correspond to the main historical
currents of thinking about health. For example, the "hygienist/preventive"
model was developed considerably in the nineteenth century, when there was
a movement to instruct the family on a series of rules for behavior that defined
a "healthy life," and came to constitute what Foucault has called "a morality

SOCIAL RESPONSE: CONDITIONS: ANALYTICAL PERSPECTIVES


OBJECTS OF INTERVENTION
Health Disease

IndividuaVFamily Hygienist/Preventive Model Biomedical Model

Biophysical Environment Sanitarist Model Classical


Epidemiologic Model

I Ecologist Model I
I
Social Environment Sociomedical Model Social Epidemiologic Model

Figure 4 Main conceptual models on public health. (Adapted from Ref. 17.)
480 FRENK

of the body" (13). This model was displaced by the "biomedical model," which
brought the control of specific diseases to the center of public health concerns
(29), but eventually reappeared in programs aimed at changing individual
behaviors and lifestyles as a basic strategy of health promotion (14).
Not all the conceptual models fit perfectly into the proposed categories.
For example, the "ecologist model," whose principal exponent is Dubos (12),
seeks to transform both the physical and social environments. The "socio­
medical model" actually encompasses very diverse conceptions whose single
common denominator is that they all attempt to explain health phenomena in
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society (6, 27, 30, 31).


It is beyond the scope of this paper to undertake an exhaustive analysis of
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each of the models proposed in Figure 4. Our purpose has simply been to
show the wealth of intellectual traditions that have characterized public health.
Each of them has implied a particular program of development for acquisition
of knowledge and for action in public health (2). Therefore, they are an
essential element for placing the bases of production, reproduction, and
utilization of knowledge in their conceptual context.

PRODUCTION BASE

In this section, we analyze the generation of knowledge through public health


research. The problem of translating research results into actions is discussed
when we examine the utilization base.
A large part of the current crisis in public health is due to the weak basis
of its scientific production. Indeed, public health research has taken a back
seat to biomedical and clinical research (7). In addition to economic factors
and the ways in which public health has been institutionalized, this lag may
be due to the dominant mode of scientific production, which clashes with the
spirit of integration that should characterize public health.
There is a conventional image that scientific progress necessarily implies
a growing fragmentation of the objects of study and the consolidation of
independent disciplines. No doubt the construction of specialized paradigms
has made possible major progress in scientific knowledge by facilitating the
identification of clear frontiers where the efforts of leading researchers are
focused. Thus, the subspecialization of knowledge produces economies of
scale by avoiding the dispersion of the limited human, material, and financial
resources devoted to research. Moreover, working on narrow questions, while
sacrificing breadth, attains greater depth. This process also facilitates the
development of academic institutions, because it makes the consolidation of
cohesive scientific communities possible in very specific fields.
Its advantages notwithstanding, the fragmentation of knowledge as a basis
for organizing research has several limitations. The most important is that
PUBLIC HEALTH 481

integrating knowledge becomes a no-man's land. Obviously, nature is not


divided into the same categories as those through which researchers frame
their questions. To the contrary, real phenomena have a comprehensive
character that poses an essential challenge to scientific knowledge. Most of
the development of science in the West has been based on a movement to
fragment that comprehensive character analytically. But, we have lacked a
parallel movement of synthesis. Therein lies perhaps the principal reason why
science is often attacked as reductionist.
Fragmentation of knowledge poses severe obstacles to the potential users
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of research, who often have to provide a response to problems that do not


recognize the arbitrary borders imposed by scientific subspecialization. This
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is manifested with particular clarity in a field like public health, which is


closely associated with the problems of the population and with the institutions
created to solve them. In applied fields, decision-makers face complex
problems on which they demand comprehensive information, but scientific
knowledge is provided to them in small parcels that are very difficult to
aggregate. Thus, the gap between decision-making and research widens to
the detriment of both.
One way to counteract the trend toward knowledge fragmentation in the
health field is through "mission-oriented research" (3, 18). This concept refers
to a research effort that attempts to modify some aspect of reality through the
production of knowledge and technology. That modification of reality is
precisely what defines the mission of research. Mission-oriented research is
based on integration along three dimensions: levels of analysis, objects of
analysis, and disciplines.
Integration among levels is possible because, as we saw when explaining
the typology of health research (Figure 1), there is an essential unity of the
objects. Indeed, the only difference between public health research and
biomedical and clinical research is the level of analysis. This makes it possible
to design comprehensive research programs that deal with specific problems
from the subindividual level to the population level. In addition, it is necessary
to integrate objects, so that both conditions and responses are studied. The
challenge, then, is to select some areas of application among those that form
the universe of public health (Figure 3) in order to develop research that
combines biomedical aspects, technological developments, clinical trials,
epidemiological field studies, and social and economic analyses of services.
Naturally, neither of these two types of integration is possible without the
third, integration of disciplines. Indeed, the richness of public health is that
it lends itself to the conjunction of the biological, social, and behavioral
sciences around a common problem.
Mission-oriented research has many advantages over the fragmentary
model. Complete information on the problem is generated more rapidly and
482 FRENK

efficiently, because knowledge is integrated from the moment that research


is planned, rather than at the end. The practical implications of research can
be identified and translated into action more easily. Thus, the relationship
between decision-makers and researchers is more a matter of agreement on a
shared mission than confrontation based on differences in training and
expectations. Setting priorities and forming groups are also easier when there
is a well-defined focus of attention. Financing research is also facilitated when
it is associated with a clear mission. Interinstitutional and multicentric
collaboration becomes essential. Finally, knowledge advances more rapidly
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when approaches and disciplines are integrated around comprehensive prob­


lems.
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All these advantages also pose an enormous challenge to the new public
health: to break with isolation so as to open the way to creative interaction
with biomedical research, clinical medicine, and the social sciences. In
addition to this opening, the development of a solid basis for the production
of knowledge requires an effort to create and consolidate institutions that
include research among their essential missions. In this regard, the world
consensus that appears to be emerging on the need to promote health research
in underdeveloped countries is encouraging. This consensus is reflected in the
report of the Commission on Health Research for Development (7). One of
the Commission's main recommendations is to promote "essential national
health research," i.e. research that every country, regardless of its level of
development, must carry out if it aspires to advance independently in acquiring
new knowledge of its own health problems and in closing the gap between
current knowledge and action. Although the precise mix of projects will vary
from country to country, mission-oriented research is especially relevant for
carrying out this recommendation. The public health community must take
advantage of the emerging consensus that the kind of research it promotes is
precisely what the world requires today.

REPRODUCTION BASE

As noted above, intellectual traditions are reproduced through education,


publications, and scientific and professional associations. The strengthening
of the new public health requires a sustained effort to build better publications
and more pluralistic and representative associations than we currently have.
Of special concern are the problems affecting the development of human
resources. In many countries of the world, public health education is
experiencing a crisis that is manifested in a variety of ways: low quality,
obsolescence of its organizational structures, separation from research and
practice, limited relevance to the definition of health policies and decision­
making, lack of standards that could provide guidance in defining new
PUBLIC HEALTH 483

programs, limited sense of identity reflected in the disparate nomenclatures


of programs and degrees, and lack of integrated systems for manpower
development.
One of the roots of this crisis is that many schools of public health have
not proved capable of changing at the same speed at which the reality of
health has evolved in almost all countries. Indeed, both health conditions and
the forms of social response have become much more complex in recent years
(20). The challenge facing the schools is to learn to respond to this new
complexity. To do so, schools should develop the capacity to assess their
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reality continuously through a dual effort: on the one hand, the ability to look
outside, at the changing character of their environment; on the other hand,
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the introspection required to renew organizational schemes (16). To be


successful, such an effort should harmonize two values: the academic
excellence of programs and their relevance to decision-making. The balance
between these two values is the key to a successful utilization of knowledge.

UTILIZATION BASE

Public health requires a new style of leadership. One of the key aspects is
that it must be permanently open to its environment in two directions. First,
public health must establish sensors to detect unmet needs and emerging
opportunities in order to guide the selection of priorities. Second, it must
develop effectors that facilitate the utilization of knowledge in new techno­
logical developments and in more rational decision-making processes. In this
section, we focus on the second aspect, which is essential to the renewal of
public health.
The creation of a solid utilization base requires differentiated structures in
public health organizations, especially those responsible for generating new
knowledge. Indeed, most of the barriers between decision-makers and
researchers correspond to structural circumstances, not to mere differences in
training or personality. Those barriers are rooted in the different kinds of logic
and demands that researchers and decision-makers face in their respective
areas of activity (19). The main barriers are summarized in Figure 5, together
with some possible solutions for overcoming them. Before analyzing these
barriers, certain concepts should be clarified. By "decision-maker" we mean
any person who makes a decision to determine a course of action in response
to a given health problem. Although a high proportion of decision-makers are
public officials, these two terms should not be used interchangeably, as
decision-makers include a broader range of people, such as leaders of
community organizations and service providers. In all cases, they face
problems whose solutions require decisions to be made on the basis of a
diversity of factors. To ensure that research is relevant to decision-making,
484 FRENK

POTENTIAL BARRIERS BETWEEN MEANS OF OVERCOMING


RESEARCHERS AND DECISION MAKERS THE BARRIERS

1. Priorities Education of "informed consumers" of research


Presence of decision makers in the governing or
advisory bodies of research institutions

2. Time management Collaboration between researchers and decision


makers since the planning stage of projects
-
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Identification of intcnnediate products of research

3. Language and accessibility of results Executive summaries


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"Translators" of research to policy


Joint seminars for discussing results

4. Perceptions about the final product of Explicit utilization objectives together with
research: discovery vs. decision production-of-knowledge objectives

5. Integration of different findings - Meta-analysis


on the same problem Mission-oriented research

Figure 5 Sources and solutions of possible barriers between researchers and decision makers.
(Adapted from Ref. 19.)

there should be more than one solution, each with different effectiveness (1).
In addition, there should be uncertainty as to the nature and effectiveness of
the solutions. Research can then produce knowledge that reduces the
uncertainty. Unfortunately, there are several circumstances that prevent this
application of knowledge and result in decision-making that responds more
to immediate pressures or to ideological preferences than to scientific
evidence.
As shown in Figure 5, the first potential conflict revolves around the
definition of priorities. The perception that decision-makers have of the most
pressing problems may not coincide with the topics that researchers consider
to be of greatest scientific interest. A possible solution to this barrier involves
ensuring the presence of decision-makers in the governing or consultative
bodies of research institutions, so that they can express their needs and identify
opportunities in current projects.
Sometimes, the discrepancy reflects a distorted perception by decision-mak­
ers of the value of research. This distortion may take two forms: undervaluing
the potential of research to help in decision-making or overestimating its
potential, thereby generating unrealistic expectations. To overcome this
barrier, decision-makers must be "informed consumers" of research products,
which requires an educational effort that, to date, has been neglected. This
effort involves introducing research topics in the educational programs for
PUBLIC HEALTH 485

those who are not going to be researchers, but users of research. Such topics
would have two essential purposes: to learn to value the contribution of
research to decision-making and to gain a mastery of the minimum criteria
for judging the quality of results. A strategy is needed to induce a greater and
more informed demand for research products.
A second barrier reflects the real differences between political time and
scientific time. In general, decision-makers are chronophobic, because time
is one of the principal enemies to overcome; researchers, on the other hand,
tend to be chronophilic, because time is one of the main ingredients of their
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research, allowing for the full expression of the processes under study. One
way of overcoming this barrier is to ensure the collaboration between
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researchers and decision-makers from the earliest planning stages of the


proposed research. This would open a space for negotiation and agreement
on the time frames required for producing useful results. Differences in time
management may also be addressed if researchers offer intermediate products,
such as bibliographic reviews and progress reports, which are useful for
decision-making even before the project has been completed.
Another set of important differences has to do with the language and
accessibility of results. For the researcher, results must be communicated in
precise terms, so that they enrich the paradigms of his or her own discipline.
This means that language is often esoteric and that communication occurs in
specialized publications, which often can only be retrieved through a
bibliographic search. For the decision-maker, results must be expressed in an
understandable language and be readily available.
Communication barriers can be reduced if, in addition to specialized
articles, research projects also produce "executive summaries," which com­
municate in a nontechnical language the results most pertinent to decision­
making. This would imply developing a dual system for presenting results:
academic articles for peer scientists and executive summaries for decision­
makers. The summaries could be complemented with joint seminars where
decision-makers and researchers analyze results. To facilitate such an ex­
change between the two groups, "translators" could be trained who would
consider the needs, values, and priorities of each (26). Such translators already
exist for the general public, in the form of writers who are professionally
devoted to the dissemination of scientific information. Equal importance
should be accorded to professionals who facilitate communication between
researchers and decision-makers, by translating the findings into recommen­
dations for policy and action.
A fourth potential barrier is represented by the different perceptions about
the nature of the final product of research. For the scientific community, the
product is the published article and its potential impact on the ideas of others
(as measured, for example, by the number of bibliographic citations). For the
486 FRENK

decision-maker, research has not come to a proper conclusion until it


influences a decision. One means for overcoming this barrier is to specify,
from the initial formulation of research proposals, a series of precise objectives
for applying the results, alongside the strictly scientific objectives (D. Yach
and 1. Dick, Implementation of Research: The Key to Closing the Gap
Between Public Health Knowledge and Action, unpublished document). The
purpose is to ensure that utilization of knowledge stops being a random event
and becomes instead a programmed phase of the research process. This would
require that the scientific community give a specific weight to application
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efforts in its schemes for evaluating researchers' performance. Academic


excellence should be defined not only as strict adherence to the highest
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standards of research and education, but also as the undertaking of all possible
efforts to translate knowledge into action.
Finally, there is the problem of integrating different results on the same
research question. The decision-maker requires integrated information that
enables him or her to assess all the dimensions of a question so as to make
a decision. In contrast, the way in which scientific work is usually organized
leads to disaggregation of the objects of study. This problem has two aspects.
The first has to do with those situations in which various research projects on
a single topic do not yield conclusive results, or the results may even be
mutually contradictory. In this case, one solution could be a detailed review
of evidence and meta-analysis, which uses quantitative techniques for
synthesizing data from several projects (24, 25, 33). The second aspect of
the problem of integration has to do with those situations in which the
decision-maker has results from several projects that have dealt with a single
topic but at different levels of analysis. In this case, the solution is to carry
out mission-oriented research, which has the advantages discussed earlier.
Much of the discussion on the utilization of knowledge leaves the
implementation of solutions in the hands of individual actors. However, the
current complexity in the production of knowledge requires organized
solutions. Research institutions must have differentiated structures that make
it possible to establish dynamic and creative linkages with their environment,
especially the capacity for projecting scientific knowledge toward decision­
making.
Otherwise, the barriers indicated in Figure 5 will continue to impoverish
not only the utilization of knowledge, but also its production and reproduction.
The failure to use results leads to inadequate public support for research. This,
in tum, generates a decline of scientific production, which ends up reinforcing
the vicious downward spiral in the use of research (34). Impoverished
research, in tum, undermines the intellectual vitality of educational endeavors
to reproduce knowledge.
This problem evidently affects all research. However, given its proximity
PUBLIC HEALTH 487

to the decision-making process, the field of public health manifests in a


particularly clear way the contradictions analyzed above and the need to come
up with creative solutions.

CONCLUSIONS

As we approach the twenty-first century, our capacity to face the challenges


of public health will depend on our ability to derive, from the rich intellectual
traditions that nourish it, the definitions and comprehensive proj ects that will
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guide its future. The success of the new public health will require actions on
the organizational front. In this respect, there is a need to pay attention to the
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three cardinal points of organization: design, development, and performance.


Our discussion on the bases of production, reproduction, and utilization of
knowledge has suggested new paths in this direction. After all, social
development is based on the patient and thorough effort to establish solid
institutions. Organizations are the vehicles for bringing together individual
wills in order to attain a level that is higher than the simple sum of these
wills. Following the metaphor taken from physics, what is most important is
not only to form a critical mass of talent, but also to reach a critical density
through which such talent can be mutually enriched within a shared institu­
tional space. No doubt the future of public health will depend to a great extent
on our ability to design and develop institutions and to assure their sound
performance.
But, the internal organization of public health itself is not enough. A broad
effort of linkage is needed, a commitment to the population's health and the
services for improving it. The basic challenge in this regard is to modernize
public health. Beyond the several meanings that changing political circum­
stances can attribute to this term, modernization should be understood above
all as a process of opening. It is not a question of an irreflexive permeability
that overlooks the advances of the past, but rather an effort to integrate
tradition and progress. This is the meaning of the words spoken by the Mexican
poet Octavio Paz (28) in his address to the Royal Swedish Academy the day
before receiving the 1990 Nobel Prize for Literature:
... between tradition and modernity lies a bridge. Isolated, traditions are petrified
and modernities are rendered volatile; together, each inspires the other, each
responds to the other by giving it weight and gravity.

In the case of public health, modernization must be understood as a process


of opening in at least seven directions. First, as we have emphasized, is
decision-making. Research should provide scientifically validated information
that is relevant to the problems of decision-makers at all levels. The second
opening is toward the university. Together with relevance, research and higher
488 FRENK

education in public health should promote excellence. For this purpose, close
links should be established with the broader university milieu. Third, public
health should open up to the other fields of health, so that its population
approach may find support in individual and subindividual phenomena. This
effort to integrate levels of analysis should be accompanied by a parallel effort
to link disciplines. Hence, the fourth opening is to the social, biological, and
behavioral sciences. The specificity in time and space of many health
phenomena requires a comparative approach that can only be attained through
the following two openings: to the international sphere and to the future in
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order to adopt a strategic vision that enables us to anticipate problems and


not just react when they have already occurred. Finally, all of the above
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should be guided by the essential opening process that gives meaning to public
health: the permanent concern to understand the health needs of the population
and to learn from them.
It is too soon to determine whether public health will prove capable of
responding to the challenges of our time. What is certain is that the possibility
of bringing about a renewal of health systems will depend, to a great extent,
on the modernization of public health. Although their ultimate fate is
associated with the broader social and economic development, health actions
also have their own dynamics, whereby they can contribute to the general
progress of nations. Because it is a crossroad, health makes it possible for
the population to give a specific and daily meaning to the goals of reducing
inequality and promoting social well-being. Therein lies the commitment that,
if fulfilled, will make the new public health flourish.

ACKNOWLEDGMENTS

This paper attempts to integrate various elements from my previous work.


Therefore, the first debt of gratitude is to my coauthors of the articles cited
in this text, especially Jose-Luis Bobadilla, Jaime Sepulveda, Enrique Ruelas,
and Lilia Duran. In addition, many ideas expressed in this document have
benefited from exchanges with many people, most importantly Guillermo
Sober6n, Jose Laguna, Jaime Martuscelli, Avedis Donabedian, Harvey
Fineberg, Carlos Santos-Burgoa, and Miguel Angel Gonzalez-Block, as well
as many researchers and students from the National Institute of Public Health
of Mexico. Such gratitude notwithstanding, the responsibility for the content
of this paper lies with the author alone.
An initial version was prepared at the request of the Pan American Health
Organization (PAHO) and presented at the meeting on Development of the
Theory and Practice of Public Health in the Americas, organized by PAHO
together with the US and Latin American Associations of Schools of Public
Health, New Orleans, October 21-24, 1991.
PUBLIC HEALTH 489

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