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A ‘Fifth Wave’ in Public Health: Where Do We Start?

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A ‘Fifth Wave’ in Public Health: Where Do We Start?

By Camilla Baba:

A debate in the Lancet co-authored by Dame Sally Davies, which addresses the ‘fifth wave’ in public health, recently caught my attention. Hanlon et al first discussed the concept of a ‘fifth wave’ in public health in 2011, suggesting that current challenges in public health require a delivery approach where a culture of healthy choices and behaviours is the norm. In their recent piece, Davies and colleagues (2014) consider practical approaches for the fifth wave.  They preface this by charting the history of the various ‘waves’ of public health, suggesting that each links to a major shift in thinking about the nature of society and health. If we think back to the period of the late 19th – early 20th century, social medicine identified the link between unsanitary living conditions and the spread of disease (see Chadwick’s report). In this first wave, structural works such as the provision of clean water to urban areas became a priority. Wave two spanned the late 19th to the mid- 20th century. Modern technology gave rise to hospitals and the concept of an ‘expert’ was born. This led to theories of disease that are still applied today. The end of WWII saw great social change, as the welfare state was first conceived. The role of our everyday life and lifestyles on our health was explored. This was wave three (1940-1980) in action! Mid-20th century onwards has been dominated by efforts to combat disease risk and by the emergence of systems thinking. Health has an agenda item for policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health.

Why a fifth wave?

Hanlon et al suggest that a ‘fifth wave’ in public health is necessary as a means to address serious issues such as social inequalities, loss of wellbeing (rise in depression and anxiety) and obesity, which are occurring in a context where society is also facing challenges due to “the broader problems of exponential growth in population, money creation and energy usage” (2011). Simply put, something has to give and necessity requires a new approach to public health.

The authors suggest a health-promoting societal context where healthy behaviours are the norm and a multi-sector (holistic) approach is taken to ensure this is promoted by our physical, social and economic environments. They argue that 3 practical mechanisms could be used:

  • Value of health – reward healthy behaviours and create social and institutional environments to encourage healthy choices;
  • Healthy choices as default – at the point of decision-making, address health consequences of choices;
  • Minimise influences to unhealthy behaviour – eradicate factors that can encourage unhealthy behaviours (e.g. the Public Health Responsibility Deal)

The importance of marketing and financial incentives in the new drive for public health is stressed. Yet, with the current economic climate I am not convinced. Can we truly tackle these challenges by relying on manufacturers/corporate bodies and their commitment to the ‘common good’? Would that be financially feasible for them and a profitable business model? As a budding health economist I hear myself asking how much profit would they trade for these non –monetary gains? With an increasing percentage of the population living below the poverty line, is a more radical approach needed? As demonstrated by the recent television show ‘The Great British Budget Menu’, healthier choices are often a luxury for those facing food poverty. Perhaps we can go further and make public health the sole priority in the UK. Rather than the’ easier’ option, why not the ‘only’ option? After all, looking back, previous waves have all included a radical aspect in their approaches.

What do you think? Are we in need of a new wave in public health? Have Davies et al got it right? Leave your comments below and continue the debate!


BBC. (2013). The Great British Budget Menu http://www.bbc.co.uk/programmes/b036x3pv aired 02/08/2013

Davies, S.C., Winpenny, E., Ball, S., et al. (2014). For debate: a new wave in public health improvement. The Lancet. E-pub: 03/04/2014.

Hanlon P, Carlisle S et al. (2011). Making the case for a ‘fifth wave’ in public health. Public Health 125,1:30-36.

The Victorian Web. (2002). Chadwick’s Report on Sanitary Conditions. http://www.victorianweb.org/history/chadwick2.html


  1. David Blane

    Hi Camilla, thanks for this interesting piece.

    My take-home message from Hanlon et al’s ‘fifth wave’ writing is the importance of empathy. We need – somehow – to foster a greater sense of empathy and compassion in society, so that the “dis-eases” of modernity (depression, obesity, addictions, inequalities, etc) are framed not as the wayward choices/weaknesses of individuals, but as collective issues, requiring collective responses.

    A similar message has emerged from Scotland’s pioneering Poverty Truth Commission (http://povertytruthcommission.blogspot.co.uk/). Alastair Macintosh, one of the commissioners, puts a lack of empathy at the root of both poverty and violence:

    “I think that poverty is a form of violence. When you live in a world where some people are very poor and other people are very rich, it’s only possible to sustain that situation if the rich are cutting themselves off from seeing and feeling what it is like for the other half. And that cutting off, that deficit of empathy, would be one of my definitions of both violence and poverty.”

    In the healthcare context, colleagues in General Practice & Primary care have found that empathy is a pre-requisite for patient enablement and empowerment – you can have empathy without enablement but you can’t have enablement without empathy (http://www.biomedcentral.com/1471-2296/13/6).

    One question – perhaps for a future blog (?!) – is, how DO we, collectively, increase empathy in society? How might we imagine the role of health professionals, politicians, and multi-national corporations, in such a mission?? If we can achieve greater empathy, then seemingly radical policies like meaningful redistribution of resources may not seem so fanciful…


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