[The public health profession in Spain: an urgent challenge to strengthen its practice]. / La profesión de la salud pública en España: un reto urgente para fortalecer su práctica.

The recent health crises have highlighted the weakness of public health structures in Spain. The causes are, among others, the scarcity of economic resources and the delay in their institutional modernization. In addition, there is the weakness of the training processes and the employability. The Spanish Society of Public Health and Health Administration (SESPAS) has developed a White paper of the public health profession with the aim of contributing to strengthening professional practice. The sociodemographic characteristics of the associations federated to SESPAS have been described and the discourse of professionals has been analyzed through six focus groups and 19 interviews (72 people). To agree on the conclusions and recommendations, a meeting was organized with the participation of 29 participants. The demographic and employment data of the 3467 people belonging to seven SESPAS societies show that, overall, about 60% are women and 40% were under 50 years of age. Undergraduate degrees were medicine (35.9%), nursing (17.4%) and pharmacy and veterinary medicine (10.4%). Key aspects of the meaning of public health, training, employability and career and institutionalization of public health were collected through interviews and focus groups. The final meeting agreed on 25 conclusions and 24 recommendations that aim to contribute to strengthening professionals and the public health profession in Spain. Some of them, related to training, employability and professional career, have been shared in a workshop at the School of Public Health of Menorca with public health officials from the Ministry of Health and some autonomous communities.

[Inappropriate use of health resources and the trivialisation of medicine]. / El consumo sanitario inapropiado y la trivialización de la medicina.

One of the main problems of our health care system is its excessive use. The most evident results of this misuse are the waste of resources and the iatrogenic consequences that are not justified by any expectations in health improvement. Among the possible causes of this inappropriate use, the trivialization of medical practice should be emphasized. This entails not only a loss of respect and consideration, but facilitates and even stimulates reckless use. Although patients and health care workers are both responsible for this recklessness, politicians and health care managers should be held responsible more so. Without a real emancipation allowing health care users and the population to control the factors that determine their health, it is unlikely that the inappropriate use of health resources and its associated iatrogenic consequences will be reduced.

[Future National Public Health Agency: an opportunity for the public health system in Spain]. / La Agencia Estatal de Salud Pública: una oportunidad para el sistema de Salud Pública en España.

The creation of a national centre for public health, with adequate resources, will make it possible to face the public health challenges of the present and the future in our country. To this end, the proposed state agency, should hold functions based on advanced public health organizational schemes, while linking with the sustainable development goals. The coordination of a national public health strategy built on a collaborative network of networks would also be essential, as developing an innovative, benchmarked and prioritised public health communication strategy, among other tasks. The lack of resources, the current relative disconnection of essential public health functions at the state level, and the inequity in their development of these functions at the regional and municipal levels, favour the development of the agency project as a network of networks. In this paper we give ideas for a process that seems decisive for Spanish public health in the 21st century.

La profesión de la salud pública en España: un reto urgente para fortalecer su práctica / The public health profession in Spain: an urgent challenge to strengthen its practice

Las últimas crisis sanitarias han puesto de manifiesto la debilidad de las estructuras de salud pública en España. Las causas son, entre otras, la escasez de recursos económicos y el retraso en su modernización institucional, junto a la debilidad de los procesos formativos y de la empleabilidad. La Sociedad Española de Salud Pública y Administración Sanitaria (SESPAS) ha impulsado la elaboración del Libro blanco de la profesión de salud pública con el objetivo de contribuir a fortalecer el ejercicio profesional. Para ello se han descrito las características sociodemográficas de las asociaciones federadas a SESPAS y se ha analizado el discurso de los profesionales a través de seis grupos focales y 19 entrevistas en profundidad (72 personas). Con este material se realizó una reunión (29 personas) para consensuar conclusiones y recomendaciones. De las 3467 personas pertenecientes a las siete sociedades de SESPAS que proporcionaron datos, alrededor del 60% son mujeres y el 40% tienen menos de 50 años, siendo los estudios de grado de medicina (35,9%), enfermería (17,4%), farmacia y veterinaria (10,4%) los más frecuentes. En las entrevistas y grupos focales se identificaron como temas centrales la formación, la empleabilidad y la carrera profesional. En la reunión final se acordaron 25 conclusiones y 24 recomendaciones que pretenden contribuir a fortalecer a los/las profesionales y la profesión de la salud pública en España. Las relacionadas con la formación, la empleabilidad y la carrera profesional fueron compartidas en un Encuentro en la Escuela de Salud Pública de Menorca con responsables de salud pública del Ministerio de Sanidad y de algunas comunidades autónomas.(AU)

The recent health crises have highlighted the weakness of public health structures in Spain. The causes are, among others, the scarcity of economic resources and the delay in their institutional modernization. In addition, there is the weakness of the training processes and the employability. The Spanish Society of Public Health and Health Administration (SESPAS) has developed a White paper of the public health profession with the aim of contributing to strengthening professional practice. The sociodemographic characteristics of the associations federated to SESPAS have been described and the discourse of professionals has been analyzed through six focus groups and 19 interviews (72 people). To agree on the conclusions and recommendations, a meeting was organized with the participation of 29 participants. The demographic and employment data of the 3467 people belonging to seven SESPAS societies show that, overall, about 60% are women and 40% were under 50 years of age. Undergraduate degrees were medicine (35.9%), nursing (17.4%) and pharmacy and veterinary medicine (10.4%). Key aspects of the meaning of public health, training, employability and career and institutionalization of public health were collected through interviews and focus groups. The final meeting agreed on 25 conclusions and 24 recommendations that aim to contribute to strengthening professionals and the public health profession in Spain. Some of them, related to training, employability and professional career, have been shared in a workshop at the School of Public Health of Menorca with public health officials from the Ministry of Health and some autonomous communities.(AU)

[Hygeia and virtue or remembering Protagoras: dialogue on community health ethics. SESPAS Report 2018]. / Hygea y la virtud o recordando a Protágoras: diálogo sobre ética de la salud comunitaria. Informe SESPAS 2018.

A dialogue between ethics and public health on the moral implications of the promotion of community health in which the importance of respecting autonomy and contributing to the empowerment of the community with which it collaborates is highlighted; in addition to the appropriateness of an explicit commitment that sets out the limits of collaboration and the opportunity for a specific deontology.

[Assets: from maps to territory. SESPAS Report 2018]. / Activos: de los mapas al territorio. Informe SESPAS 2018.

In recent years, health asset maps have become increasingly important tools in the field of health promotion. They are being incorporated into the daily practice of many healthcare workers, in individualized care in consultations (through social prescription), and in groups or community development processes. It is necessary to reflect on how the asset maps are being produced, analyzing how the different stages of the process can be involved in their construction. The formats in which the data is obtained through the identification of health assets are presented, as well as the processes of production of the information, participative and evaluated processes, are crucial for the maps to be useful, for professionals as well as citizens and institutions.

[Who, how and what: community health and local administration]. / Quién, cómo y qué: salud comunitaria y administración local.

The thirteenth SESPAS (Spanish society of public health and health management) report is structured in three blocks Who, How and What about community health and local governance. In the who block the main agents working in community health are described: communities, health care system, and local government; and how their relations and implication in community health have evolved; which concepts are used; what is the current situation and which challenges they have. The How block contains methodological views, oriented towards implementation of community interventions, based upon participatory tools, development of networks and review of evidence and evaluations to build a National Strategy of Health Promotion of the Spanish Ministry of Health, welfare and consumers affairs including suitable deontologic principles. Finally, the what block refers to a wide range of experiences of community health at the local level as well as training in community health, urbanism, gender, neighborhoods, healthy universities. Additionally, besides regular papers, we show dialogs including debates to further develop community health. It contains 18 papers, without taking into account this introduction, authored by 40 men and 49 women.

La Agencia Estatal de Salud Pública: una oportunidad para el sistema de Salud Pública en España / Future National Public Health Agency: an opportunity for the public health system in Spain

La creación de un centro estatal de salud pública, con una dotación adecuada de recursos, permitirá afrontar los desafíos de la salud pública del presente y del futuro en España. Para ello, las funciones de esta futura institución, que se propone como Agencia Estatal, deben abordar, además de las necesidades habituales de organización de la salud pública, la conexión de estas con los Objetivos de Desarrollo Sostenible, coordinando una estrategia estatal que integre distintos actores de salud en una red generosa y cooperativa, y desarrollando una estrategia de comunicación en salud pública innovadora, referente y priorizada, entre otros aspectos. La falta de recursos, la relativa desconexión actual de las funciones esenciales de salud pública en el ámbito estatal y la inequidad en el desarrollo autonómico y municipal de estas propician el desarrollo del proyecto de la Agencia como una red de redes, tal como se defiende en este trabajo. Aportamos ideas para un proceso que confiamos en que será decisivo para la salud pública española del siglo XXI. (AU)

The creation of a national centre for public health, with adequate resources, will make it possible to face the public health challenges of the present and the future in our country. To this end, the proposed state agency, should hold functions based on advanced public health organizational schemes, while linking with the sustainable development goals. The coordination of a national public health strategy built on a collaborative network of networks would also be essential, as developing an innovative, benchmarked and prioritised public health communication strategy, among other tasks. The lack of resources, the current relative disconnection of essential public health functions at the state level, and the inequity in their development of these functions at the regional and municipal levels, favour the development of the agency project as a network of networks. In this paper we give ideas for a process that seems decisive for Spanish public health in the 21st century. (AU)

[Public health and public health systems sustainability]. / Salud pública y sostenibilidad de los sistemas públicos de salud.

Public health and healthcare originally started out separately from one another in the past, having later further developed taking different paths in modern times. The major development the health systems underwent in the last half of the 20th century entailed a heightening of the individual standpoint and a division of these two approaches despite the attempts made to bring them together as of the WHO Alma-Ata Conference in 1978. The waning of rationalism and other social phenomena had a hand the collective or population-oriented focus being focused on to a lesser degree in Public Health, but these trends also gave rise to a growing problem of rationality in individual healthcare and sustainability in the public health systems. The debate on the current scene stands to set out the sustainability-related problems mediated by internal and external agents and to revise Public Health's possible contribution to the improvement thereof by advocating yet a further attempt at bringing together and integrating these two diverging standpoints.

Ética, Salud Pública y COVID-19: algunas consideraciones (elementales) impopulares / Ethics, Public Health and COVID-19: some unpopular (and elementary) considerations

Desde la mirada de un epidemiólogo jubilado se consideran algunos aspectos de la entidad nosológica COVID-19 particularmente relevantes para la salud pública desde una perspectiva ética, como por ejemplo el papel de los medios de comunicación, de las redes sociales, de los expertos y de la ciudadanía sobre la percepción de la magnitud del problema y la adopción de unas medidas preventivas muy drásticas e intrusivas cuyos efectos adversos pueden superar los atribuibles directamente a la infección. Un resumen de los requisitos que, desde la aplicación de la ética a la salud pública, se recomiendan a la hora de poner en práctica las medidas colectivas de protección de la salud comunitaria, complementa el trabajo (AU)

From the perspective of a retired epidemiologist, some aspects of the COVID-19 disease entity that are particularly relevant for public health from an ethical perspective are considered, such as the role of the media, social networks, experts and citizenship in the perception of the magnitude of the problem, and the adoption of very drastic and intrusive preventive measures whose adverse effects may exceed those directly attributable to the infection. A summary of the requirements that, from the application of ethics to public health, are recommended when implementing collective measures to protect community health complements the work (AU)

Des de la mirada d'un epidemiòleg jubilat es consideren alguns aspectes de l'entitat nosològica COVID-19 particularment rellevants per a la salut pública des d'una perspectiva ètica, com per exemple el paper dels mitjans de comunicació, de les xarxes socials, dels experts i de la ciutadania sobre la percepció de la magnitud del problema i l'adopció d'unes mesures preventives molt dràstiques i intrusives els efectes adversos de les quals poden superar els atribuïbles directament a la infecció. Un resum dels requisits que, des de l'aplicació de l'ètica a la salut pública, es recomanen a l'hora de posar en pràctica les mesures col·lectives de protecció de la salut comunitària complementa el treball (AU)

Cómo conseguir dejar de hacer: la asignatura pendiente / How to get out of the way: The unfinished subject

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La ètica de la ignorància (i de la incertesa) i la iatrogènia, un problema de salut pública / La ética de la ignorancia (y de la incertidumbre) y la iatrogenia, un problema de salud pública / The Ethics of Ignorance (and Uncertainty) and Iatrogenesis, a Public Health Problem

La iatrogènia és, actualment, un dels principals problemes de salut pública, que acostumem a atribuir exclusivament a errors i negligències, menyspreant l'exagerat intervencionisme sanitari a causa del consumisme i també negant la ignorància i amb poca tolerància de la incertesa. La consideració dels dubtes i de les equivocacions des d'una perspectiva ètica pot contribuir a la millor comprensió i prevenció dels danys associats a la pràctica mèdica i sanitària mitjançant la promoció de la prudència com a valor essencial de qui ha de prendre decisions sobre la salut i les malalties de les persones i les comunitats

La iatrogenia es actualmente uno de los principales problemas de salud pública, que acostumbramos a atribuir exclusivamente a errores y negligencias, menospreciando el exagerado intervencionismo sanitario promovido por el consumismo y también debido a la negación de la ignorancia y a la intolerancia de la incertidumbre. La consideración de las dudas y de las equivocaciones desde una perspectiva ética puede contribuir a la mejor comprensión y prevención de los daños asociados a la práctica médica y sanitaria mediante la promoción de la prudencia como valor esencial de quienes que han de tomar decisiones sobre la salud y las enfermedades de las personas y las comunidades

Iatrogenesis is now, one of the main public health problems, which we tend to attribute exclusively to errors and negligence, belittling the exaggerated health interventionism promoted by consumerism and also due to the denial of ignorance and the intolerance of uncertainty. The consideration of doubts and mistakes from an ethical perspective can contribute to the better understanding and prevention of the damages associated with medical and public health practice by promoting prudence as an essential value of those who have to make decisions on people's health

[Cuts, austerity and health. SESPAS report 2014]. / Recortes, austeridad y salud. Informe SESPAS 2014.

Since 2009, the economic recession has led to cuts in spending on social welfare policy and in health care. The most important risks to health depend on negative changes in social determinants. Notable among these determinants are unemployment and the large proportion of people at risk of poverty, which affects 30% of children younger than 14 years. Social inequalities have increased significantly, much more than health inequalities, probably because the value of retirement pensions has been maintained until now. Most of the population is fairly satisfied with the public health system, although it is under considerable pressure. Mortality statistics have not been affected so far, but there has been an increase in mood disorders and mental health problems. Health services utilization has decreased and the number of publicly prescribed drugs has fallen dramatically. This restriction accounts for much of the decrease in public spending on health, since the hospital care budget has not decreased, despite the fall in primary care and public health spending. The crisis could encourage community health and the inclusion of health in all policies. It is the responsibility of professionals and public health institutions monitoring the trend in health problems and their determinants to avoid irreversible situations as far as possible.

Hygea y la virtud o recordando a Protágoras: diálogo sobre ética de la salud comunitaria. Informe SESPAS 2018 / Hygeia and virtue or remembering Protagoras: dialogue on community health ethics. SESPAS Report 2018

Conversación entre la ética y la salud pública sobre las implicaciones morales de la promoción de la salud comunitaria, en la que se destaca la importancia de respetar la autonomía y de contribuir al empoderamiento de la comunidad con la que se colabora, además de la conveniencia de establecer un compromiso explícito en el que consten los límites de la colaboración y de la oportunidad de una deontología específica

A dialogue between ethics and public health on the moral implications of the promotion of community health in which the importance of respecting autonomy and contributing to the empowerment of the community with which it collaborates is highlighted; in addition to the appropriateness of an explicit commitment that sets out the limits of collaboration and the opportunity for a specific deontology