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Effectively addressing infectious diseases requires a broad multifaceted approach. Public health efforts in the 19 th century emphaasized cleanliness and good living conditions. The germ theory of disease that subsequently prevailed led to some important breakthroughs in vaccines and antimicrobials-but also bred complacency. Now, in light of emerging and re-emerging infections and antimicrobial resistance, we know that a unidisciplinary approach to infectious disease control is no longer sufficient and that it is through working with others that we can identify practical ways to address all the factors at play in the emergence and persistence of infectious diseases. When working across sectors, inter-professionally or with intergovernmental or coalition activities, there are four important principles to apply: respect, practicality, the rule of three and having something to offer.

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The Saskatchewan Heart Health Program (SHHP) Dissemination Phase "Building Health Promotion Capacity" is a five-year program funded by Health Canada, Saskatchewan Health and the Heart and Stroke Foundation of Saskatchewan. This phase began in July 1998 and builds on two previous SHHP phases: the provincial heart health survey (Saskatchewan Health, 1990), and the community demonstration projects (SHHP, 1998a, b, c, d). The evolution of the SHHP has occurred in a dynamic provincial context. Saskatchewan is a Canadian prairie province of one million people with most living in the southern and central parts of the province. The population is ageing and urbanizing, and the economy is shifting away from agricultural production toward a diversified service sector. In 1993, health reform created 30 Districts in southern and central Saskatchewan; the formation of three northern Districts followed five years later. All but two Districts are rural-based. Population served ranges from 2,261 to 237,274; total area ranges from 4,019 to 133,900 square kilometers.

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OBJECTIVE: The purpose of this study was to determine the incidence of lactic acidosis in a geographically defined population of metformin users. RESEARCH DESIGN AND METHODS: The study was based on a historical cohort from the Saskatchewan Health administrative databases. Individuals with a metformin prescription dispensed between 1980 and 1995 inclusive were eligible for the cohort. Person-years of exposure were calculated. Cases were defined by hospital discharge with a diagnosis of acidosis (International Classification of Diseases, Ninth Revision code: 276.2) and confirmation by chart review of a blood lactate level > or = 5 mmol/l. Death registrations of individuals dying within 120 days of a metformin prescription were also reviewed. RESULTS: During the study period, 11,797 residents received one or more metformin prescriptions, resulting in 22,296 person-years of exposure. There were 10 subjects who had hospital discharges with a diagnosis of acidosis. However, primary record review revealed only two cases with laboratory findings of elevated blood lactate levels, for an incidence rate of 9 cases per 100,000 person-years of metformin exposure. In both cases, other factors besides metformin could have contributed to the lactic acidosis. No additional cases were found on review of death registrations. CONCLUSIONS: From 1980 through 1995, the incidence rate of lactic acidosis was 9 per 100,000 person-years (95% CI 0-21) in patients dispensed metformin in Saskatchewan, Canada. This incidence rate was derived from a population with complete ascertainment of hospitalizations and deaths associated with lactic acidosis in metformin users. It is similar to previously published rates based on passive reporting of cases, and it is well below the lactic acidosis rate of 40-64 per 100,000 patient-years in patients prescribed phenformin.

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While concepts that underlie good public health and population approaches to health go back a long way, renewed recognition that health is dependent on more than the ability to treat has given new impetus to a more comprehensive approach to thinking about and planning for health and human services. This paper offers a reflection on how we conceptualize population approaches to health. Recognizing our current understanding of health determinants and dynamics, the paper explores moving from "avoiding disease" to to "pursuing health." It then examines the pragmatic balancing act of science, art, beliefs and politics, with attendant traps. It concludes with a way of framing action on population health and translating theory into practice.

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The National Enhancing Prevention Steering Committee is a partnership of eleven national health professional associations and Health Canada. Their joint mission reflects the view that "to ensure the health of Canadians and to ensure an effective health care system, all health professionals have a key role in assisting individuals and communities to increase control over and improve their health." This paper describes the development of the National Strategy for Enhancing Prevention in the Practice of Health Professionals and the learning from that five-year process.

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The Canadian health system is at a crossroads. Significant health services restructuring is occurring across the country. This restructuring process provides a unique opportunity for Public Health and others to reorient the system away from illness to a focus on health--the health of individuals and communities. The purpose of this paper is to motivate and equip Public Health workers to take leadership in the restructuring, to outline key responses and strategies for Public Health associations, to raise public awareness about restructuring, and to challenge decision makers to integrate the Public Health perspective into the restructured health system. This Issue Paper describes the unique contributions Public Health has to offer health services restructuring, outlines the Public Health response to specific restructuring issues, and identifies some successful strategies for influencing change. Two key messages are explored in the paper: 1. Restructuring will be successful if it is based on an investment in health. The health of the public can be maintained and improved through changes to the institutional sector and support for health promotion, disease prevention and health protection services. 2. Public Health must be a full partner in the restructuring of health services. The Public Health perspective includes a broad understanding of the issues that are relevant to the health of individuals and communities. The skills and knowledge base offered through Public Health provide balance and equity in decision making, by ensuring full and representative involvement of community workers and the public. The uniqueness of Public Health is manifested in three distinct ways: its approach within an organized system of practice; its historical contribution; and its purposeful combination of perspectives, skills and knowledge. In partnership with communities, other health professionals and other health-determining sectors, Public Health works to protect, maintain and improve the health of Canadians. While other sectors undertake some of the functions outlined below, what makes Public Health unique is that these contributions are offered collectively through an organized system of practitioners to create a synergistic effect. Eight contributions of Public Health are identified in this paper. Specifically Public Health: Focuses on individuals and communities in a societal and global context. Builds capacity in individuals and communities to improve health. Facilitates community mobilization through community participation. Embraces promotion, prevention, protection. Influences the orientation of the health system toward health outcomes. Provides disease surveillance and control. Builds partnerships among sectors at the local level. Advocates for the health of the public. In addition to describing these contributions, the Issue Paper addresses the major trends in health services restructuring by providing an overview of the issues and outlining the Public Health response. While there is no one single model of restructuring occurring in the provinces and territories, many common themes exist. This paper highlights four categories of restructuring issues: I. Making a Difference in Health II. Skills and Knowledge Base III. Allocation of Financial Resources IV. Governance and Management.(ABSTRACT TRUNCATED AT 400 WORDS)

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THE AUTHOR REPORTS ON A TYPICAL PROBLEM WITHIN THE PUBLIC HEALTH FIELD: the public opposition, based on bias and on unscientific views, of measures that would promote general health. He cautions readers concerning the negative possibilities of slackness in practising public health measures and emphasizes the need for doctors to communicate, widely and on a scientific basis, the facts of good public health practice.

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