Six Ps to drive the future of public health

Dear Editor, The SARS-CoV-2 pandemic has stressed the importance of Public Health. Its traditional functions need to be continually reviewed and updated to build on this outcome. Core principles and guiding concepts of all Public Health activities should aim to allocate resources equitably, act on upstream determinants of health, synthesise evidence and provide guidance to health services and professionals and health policy. Furthermore, the role of Public Health is closely linked to the efforts for achieving health equity. As outlined in a recent WHO report,1 health services, income security and social protection, living conditions, social and human capital, and employment and working conditions are key areas of intervention for achieving health equity. In the past, the Public Health domains have included: health Promotion, disease Prevention and health Protection.2 In this paper, we briefly analyse these ‘traditional Ps’ and add three new ones: Prediction, Precision and Participation. The Ottawa Charter was conceived from a paradigm shift3: from health as an outcome of individual choices to a vision closely interwoven with the social environment and collective strategies. The Charter has celebrated its 35th anniversary; yet, achieving universal health coverage remains a largely unmet goal.4 Disease prevention addresses various stages of the health-disease spectrum. Primary and secondary prevention, i.e. preventing the onset of disease and mitigating its effects after diagnosis, have long been established in routine health services. Instead, the opportunities for tertiary and quaternary prevention, i.e. mitigating disease-related harms and complications and preventing overmedicalisation, must be fully exploited. This essential pillar concerns the detection, prevention and mitigation of the effects of infectious diseases and of environmental, chemical and radiological physical threats.5 Health protection requires collaboration with decision makers at local and global levels. Hazardous exposure levels are derived from population studies; however, local context and epidemiology should be considered when implementing community-level interventions. Methodologically, different risk thresholds need to be modelled and analysed in an integrated manner, taking an ‘all-hazards’ approach. Predictability depends on robust surveillance systems with reliable, timely, interoperable and actionable data.6 Digital public health is an emerging field in which data analysis is being facilitated by improved computational capabilities, and data collection is being expanded to include a variety of sources, including user-generated information.7 The public health scientific community can add value by predicting the burden of communicable and noncommunicable diseases. Forecasts provide insightful data on future scenarios that ultimately give policymakers all the elements they need to enforce and implement the most appropriate policies. The contribution of other scientific fields—e.g. climate change, pollution, food safety—enriches the scenario. Preparedness classically involves emergency and response, but also needs to be operationalised as part of routine planning activities. Forecasting health needs guides the targeting of investments and the renewal of health system infrastructures.8 The concept of precision medicine, in which targeted therapeutic approaches are used according to specific patient characteristics, needs to be expanded into a paradigm of “precision public health”. The goal should be to use the best available data to target the most urgent interventions without neglecting traditional public health concerns.9 Such an approach was advocated and pursued during the COVID-19 pandemic by taking containment and mitigation measures according to locally available epidemiologic indicators and developing prevention strategies based on group-specific risk factors.10 Future health policy must incorporate the paradigm of precision public health, deeply rooted in a data-driven approach to patient management and community health. The availability of new tools, such as artificial intelligence and Big Data enables the analysis and aggregation of large amounts of biomedical information at the individual and community level. Healthcare providers and planners need to focus on vulnerable population groups that share similar genetic substrates or common behaviours and lifestyles, or belong to the same socioeconomic groups.11 In clinical care, patient- and person-centred health care is a promising new paradigm. When patients are proactively involved in the decision-making process, their health status improves. Similarly, public health outcomes become tangible only when active citizen participation in the decision-making process is encouraged using scientific communication and behavioural science tools. This form of empowerment can be achieved through tailored messages for different audiences with varying levels of health literacy. Nonetheless, public health communities must be able to understand the political and commercial determinants of health if they are to be able to perform these proposed additional functions. In this sense, addressing infodemic and misinformation in health is key to ending the current syndemic12 and making further progress in critical people’s participation. The G20 Rome Leaders’ Declaration highlighted many of the changes needed in these areas, including adequate investment in fully integrated health and care workforce participation, and strengthening health systems to improve social inclusion and gender equality.13 We know that Public Health is complex, multidimensional and dynamic, and its components have nonlinear interactions that in some cases lead to unintended consequences.14,15 The continuous evolution of Public Health to update its framework and domains is an essential task. In this perspective, we argue that building on these six Ps could facilitate: An awareness of the complexity and implications of Public Health in relation to Planetary and One Health perspective. A shared framework and definition of professional development in capacity building programs. A better understanding of the role of Public Health in the different sectors of our society (i.e. policy makers, public administrators, journalists, volunteer associations, etc.). A mutual support at the national and international levels in developing preparedness plans needed to address global health threats. In addition, the six Ps could be practically declined having in mind that ensuring health system sustainability and resilience, reducing poverty to improve health equity, and viewing health equity as a driver and end result of economic recovery, have the potential to make near-term progress in reducing inequities. By focusing on specifical social and economic barriers and impact dynamics, measurable policy options and actions can be identified and prioritized that have a positive impact on reducing health inequalities and risk factors to achieve sustainable and inclusive recovery and long-term development. To achieve the Sustainable Development Goals, efforts must make up for lost time in such actions and in implementing measurable interventions.16 By virtue of its role, public health activity must be based on the scientific method and be capable of ensuring high standards of independence, impartiality, objectivity and integrity, and thus be perceived by the public. The identification and effective management of potential conflicts of interest among public health professionals and among stakeholders involved in the discussion of policies and strategies at the local, national and international levels is an essential element in ensuring alignment with the common good goal of public health.17 Such potential sources of bias must be identified and declared to improve transparency and accountability of the role in the discussion, and they must be managed accordingly. Furthermore, in this new scenario, attention must be paid to potential undesirable consequences resulting from the ability to predict impending events and illnesses at both individual and community levels, as this awareness may in turn generate divergent social perceptions and consequently promote unexpected and detrimental social behaviours. The complexity18 of social systems and the undoubted fact that humans are emotional being first and thinking seconds lead to the conclusion that even in the most predictable, accurate and participated world, unpredictable outcomes will always come19 and we, as public health professionals must monitor, investigate and manage these emergent phenomena in the most appropriate ways. Nevertheless, current and future technologies, together with the provision of a supranational framework for action can help to pursue the One Health and Planetary Health approach, which involves humans, animals, but also the environment in a unique planetary approach.20 Operationalizing this approach is imperative after the overall experience with the SARS-CoV-2 pandemic,21,22 and the six Ps can support this process. The challenge of this paradigm is the need to implement this vision in a community dimension that embraces the ultimate goals of guaranteeing health and wealth, sustainability, equity and social justice. Indeed, the Public Health perspective cannot focus on the individual level but must always pursue the ultimate goal of the common good through the participation of all the community. S. Brusaferro, MD, Prof. L. Arnoldo, MD L. Brunelli, MD R. Croci, MD A. Mistretta, MD, PhD, Prof.