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Global health challenges: trends in public health training, research and advocacy.

As we begin the 21st century, public health is at the crossroads in trying to understand the relative importance of health determinants in risk exposures, and the collective susceptibility of our societies. Classically conditioned attitudes of investigation, instruction, and exposition in the management of acute disease breaks down, when disease surveillance becomes virtually useless as in the prevention of chronic conditions. Older populations, new lifestyle changes, environmental hazards and urbanization have converged to make social class and poverty predominant factors in the expression of morbidity and mortality. In the process, the comfort of specific disease eradication is replaced by continuous challenges in dealing with the dynamics of social change--behaviors in diet and exercise--as well as the globalization of poverty, addiction, injury and violence. The consequent dilemma to develop a base for public health intervention, a strategy for training and a platform for advocacy for health improvement shows an eclectic pattern. The traditional clinically oriented perspective has moved towards a comprehensive population-based disease management model. A second trend with a somewhat narrowed vision for public health is the one focused on cost containment limiting preventive care. As technological advances in genetics and medicine and health informatics brings more rational, evidence based management in health care, two major gaps in public health training continues to persist. One is the lack of adequate attention to social class and poverty as a major pervasive factor. The other relates to the inability to address effectively, injury, violence, and mini wars diluting the value perspectives and advocacy in public health.