Public health is a set of techniques by which communities can uniquely complement individual efforts to maintain health. Although much of public health practice is carried out by local health departments at the municipal, county and state level, lately large employers, some managed-care groups (HMOs) and some civic organizations have begun to perform public-health functions. Historically public-health efforts were focused primarily on efforts to control contagious diseases. The basic operations still persist as governments maintain standards for environmental safety and sanitation. Regional health departments maintain diseasereporting systems to permit early control of communicable disease outbreaks. Part of communicable disease control has also involved subsidizing personal health services such as immunization, treatment and preventive counseling for potentially contagious community members who are uninsured or not inclined to overcome other social obstacles to care that remain despite insurance. Access to care remains a large problem for the American healthcare system. Many local health departments find that the traditional public health functions can be overwhelmed by the demand for personal health services.

The causes of death and disease have changed in the last hundred years. In 1895 the principal causes of death were tuberculosis and pneumonia. In 1995 the primary causes of death were heart disease, stroke and cancer, while injuries remain the leading cause of premature death. Perhaps more fundamentally the cultural construction of disease has shifted as epidemiological investigations repeatedly implicate personal and social behaviors as modifiable risk factors for disease. The frontier of public health threats now includes violence, unintentional injury substance use, tobacco, unsafe sex, dietary fat and community disempowerment. These factors move the locus of action away from the biomedical concerns of clinical medicine, and require interventional skills quite unlike those historically stressed by medical schools. The medical community drifts piecemeal towards developing behavioral skills that do not resemble the technical aspects of clinical intervention in which it excels. Conflict between medical culture and public-health culture has been slow to resolve.

Because public-health techniques now include social marketing, media techniques and information campaigns, employers and insurers with a natural interest in the health of their populations have begun to engage in public-health practice. Public and private sectors will continue to show a greater confluence of interest and practice in public health.

A natural dilemma arises for public health as it addresses behavioral determinants of disease. There is conflict between eliminating risky behavior (abstinence) and making risky behavior safer (protection). Public-health workers tend to think in practical terms and often consider both goals compatible means to the end of disease reduction. To its chagrin, the public-health community has frequently found the puritan strains of American culture vigorous enough to squelch or temper the battle cry, “Don’t indulge! But…if you do, do it safely.”