that will spring to mind. The goal of Bermuda's public health care system however, is to improve the well being of the entire population through preventative, rather than curative measures -- a task easier accomplished with the help of the public. "I think part of our difficulty is that people usually think of the health care system as a separate system from public health,'' explained John Cann, Government's Chief Medical Officer. "Most think of the medical system as the health system and public health is often equated with sanitation and the control of infectious diseases. While these are two of the responsibilities of public health, the role of the public health system has greatly expanded. "It's understandable. For instance, when you look at how much money is put into the health system, Government puts millions of dollars into curative rather than preventative measures. And it's done that way everywhere in the world. But we've come to recognise that the real improvements in health have come about because we've got good housing, clean water and a safe food supply. These have pretty much brought many infectious diseases under control through public health measures and prevention. And so over the past two decades, emphasis has gradually shifted away from institutional and curative care to community-based preventive care.'' According to Dr. Cann, Bermuda's public health care system works to: Prevent epidemics and the spread of disease Protect against environmental hazards Promote and encourage healthful behaviour Respond to disaster and, Assure the quality and accessibility of health services.

Half of all deaths are preventable problems, caused by tobacco use, improper diet, lack of physical activity, alcohol misuse, microbial and toxic agents, unsafe sexual behaviour, motor vehicle accidents and illicit drug use, he added. But the life expectancy for Bermudians has increased from 45 to 75 years old since the year 1900 -- a direct consequence of such health measures as sanitation, immunisation and education.

"Public health has played an important role in improving the health of people and will continue but further improvements can only be in partnership with the people we are trying to serve. To continue to improve health, people must exercise, stop smoking and drink in moderation to lead healthful lives and these things will improve the health of the Lifestyle changes must be made! or having the latest piece of equipment. But unless people become motivated and understand the risks, we are not going to make any more headway. "So part of public health, is that we have to communicate this to the public to help them understand the health threats to them and effectively encourage them to make some changes in their lifestyle. We recognise that we must do more. Our job is to let them know what public health is, what they can do to improve public health and to help them understand the importance of public health.'' The United States' Institute of Medical Health examined the American public health system and concluded there were three core functions which must be addressed -- assessment, policy development and assurance. Assessment involves determining where and when public health threats are occurring; policy development involves considering alternatives for action and deciding which to pursue and assurance involves seeing that such policies are carried out, said Dr. Cann. And like a cycle, each leads to the next. "We put all this information together to determine how healthy a community is,'' he explained.

"From that, we should be able to help the community to say here are the health problems that face Bermuda and here are the problems we should address...We set priorities and even if we can't spend all our money on one problem, we decide how to best divvy up that money to solve which problems.

"But we recognise that we're just a facilitator and we have to provide basic information and help the community solve the problem. Policy is important, but it should come from a lot of people and not be narrowly sought.'' The preventative measures employed by public health, can take one of three forms, explained Dr. Cann: Primary prevention reduces the susceptibility or exposure to health threats through such methods as immunisation, health education and health promotion Secondary prevention most often detects and treats diseases in their early stages. An example is the use of mammography to detect breast cancer Tertiary prevention alleviates some of the effects of disease, injury or disability through measures such as surgery, physical therapy and medication.

"Population-based prevention encompasses an organised community effort to address health. In Bermuda, public health is protected by those people working in the Ministry of Health and its affiliated departments.'' According to the Department, there are certain features which are essential to public health -- conducting Community aid epidemics, providing a safe environment and measuring the performances, effectiveness and outcomes of health services. "In short, public health is about treating individuals, but the reasons for the actions and the goals that are trying to be met are at the level of the community.'' As part of that, he said, Bermuda's public health agency is working to put itself in a position where it is more accountable to the people; where there can be on-going evaluation and measurement of its efforts. As such, understanding those aims of the health department are important. Firstly, all Bermudians are ensured healthy growth and development, with an opportunity to attain an optimum level of physical, mental, emotional and social progression appropriate to their life stage. "Attaining an optimal level of health requires positive influences and choices at all stages life, from prenatal development to old age,'' he explained. "Individuals and their families must be given the opportunity to achieve and maintain health throughout life, taking into consideration the effects of their cultural and social environment, and the principle that health and a healthful life are more than the absence of disease or illness.'' All residents must also have the opportunity to adopt and maintain a healthy lifestyle; promoting such practices for themselves, their family and the community. "Available epidemiological evidence indicates that certain behaviours increase the likelihood of premature death and disability. Behaviours more likely to result in good health include abstaining from the use of tobacco, not abusing drugs, alcohol and other substances, employing sound nutrition practices and regular physical activity.'' Reducing or eliminating all communicable disease is another departmental goal.

"Communicable diseases remain a major cause of morbidity and a significant cause of mortality. Vaccines have significantly reduced the incidence of most infectious childhood diseases, however without continuing immunisation, these diseases would represent an increased potential for illness in the population.

Most communicable diseases have been reduced in incidence, but have not been eliminated.'' A final public health goal is to create an healthy environment for the residents of Bermuda....(so that)... all residents will be protected from adverse health consequences of exposure to toxic, hazardous substances and conditions in homes, public places and the workplace.'' PHOTO Hierarchy of the Department of Health Dr. John Cann HEALTH HTH