1. What is “public health?” PUBHLTH 200 – Sept. 13, 2011

2. What does the public think “public health” means?
Disaster response (e.g., post 9/11)
Health care for the poor
Behavior nannies (e.g., smoke-free laws)
Restaurant inspections for cockroaches, etc.
I dunno (No idea)
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3. How public health professionals think of public health
By purpose
By groups of professionals who practice PH
By methods most identified with PH: epidemiology and biostatistics
As governmental health services for the poor
As the outcome: health of the public
Source: Turnock
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4. CEA Winslow’s 1920 definition
Public health is “...the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and for the development of the social machinery to insure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his [or her] birthright of health and longevity.”
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5. A more concise definition
Def’n:
Public health is the set of activities a society undertakes to monitor and improve the health of its collective membership.
Distinguishing features:
Focus on preventing disease & injury
“Patient” is entire community, not individuals
“Provider” is society, not individual professionals
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6. How does public health differ from other health professions?
All other health professions (medicine, nursing, dentistry, pharmacy, allied health, social work) typically involve:
An individual provider
An individual patient
Emphasis on treating illness or disability
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7. Example of the difference
Example of health care:
Dentist treats dental caries in an individual patient.
Example of public health:
Government fluoridates the water supply, making fluoridated water available to all members of the community. Prevents dental caries.
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8. Primacy of public health in concept
Collective health services Individual health services
Medicine Dentistry Nursing Pharmacy
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9. Other individual health services
Hierarchy in practice
Medicine
Other individual health services
Public health
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10. Source: Adapted from CDC, 1979; IOM, 1988; and PHS, 1993
Why is public health so important? Factors that could avoid premature mortality
Lifestyle (behavior) 50%
Environment 20%
Human biology (genetics) 20%
Additional medical care 10%
Source: Adapted from CDC, 1979; IOM, 1988; and PHS, 1993
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11. Why is public health so important? Contribution to life expectancy gain
Of 30-year gain in life expectancy in U.S. during 20th century…
5 years attributable to medical care system
25 years from public health improvements in
Sanitation • Nutrition
Housing • Job safety
Bunker et al., Milbank, 1994
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12. Relationship between public health (PH) and the medical care system (MC): Impact on premature mortality PH MC
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13. Relationship between PH and MC: Expenditures
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14. Why the PH/MC imbalance?
Market systems (economic interests) cater to services for individuals; PH is often a public good (or relevant due to externalities)
Interest group politics; often contentious issues (more on this later)
What people want (the “Rule of Rescue”)
Current trauma vs. abstract future benefit
Identifiable vs. “statistical” lives
“Invisibility” of PH
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15. Benefits and costs of health promotion programs
Benefits: abstract, deferred
Costs: tangible, immediate
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16. Benefits and costs of disease promotion
Benefits: tangible, immediate
Costs: abstract, deferred
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17. Mission of public health
“Fulfilling society's interest in assuring conditions in which people can be healthy.”
“[The] aim [of public health] is to generate organized community effort to address the public interest in health by applying scientific and technical knowledge to prevent disease and promote health.”
Source: IOM, Future of Public Health, 1988
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18. Core functions of public health
Assessment of the health of the population
Development of public health policies
Assurance of the availability of needed services
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19. 1. Assessment of the public’s health
Requires:
Data collection
Statistical and epidemiologic analysis
Dissemination of findings
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20. 2. Development of public health policies
Requires:
Use of a scientific knowledge base
Appreciation and use of the political process
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21. 3. Assurance of the availability of needed services
Relies on:
Encouraging appropriate actions by other entities (public or private)
Requiring such actions through law or regulation
Directly providing services
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22. 10 essential public health services
1. Monitor health status to identify community health problems
2. Diagnose and investigate health problems and health hazards in the community
3. Inform, educate, and empower people about health issues
4. Mobilize community partnerships to identify and solve health problems
5. Develop policies and plans that support individual and community health efforts
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23. 10 essential public health services
6. Enforce laws and regulations that protect health and ensure safety
7. Link people with needed personal health services and assure the provision of health care when otherwise unavailable
8. Ensure a competent public health and personal health care workforce
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services
10. Research for new insights and innovative solutions to health problems
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24. Five core areas of public health
Epidemiology
Biostatistics
Environmental Health Sciences
Health Behavior & Health Education
Health Management & Policy
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25. Epidemiology is the core science of the field of public health.
Concerned with analyzing and describing patterns of occurrence and determinants of diseases in human populations.
Epidemiology is the core science of the field of public health.
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26. Biostatistics
Focuses on the development and application of statistical and mathematical methods to the design and analysis of public health problems and biomedical research.
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27. Environmental Health Sciences
Aims to protect human health from adverse environmental conditions -- in particular from harmful practices and harmful exposures in air, water, and food in the workplace, home, and ambient environment.
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28. Health Behavior & Health Education
Addresses the factors associated with health-related behavior and health status, and develops and evaluates educational activities designed to improve individual and community health and quality of life.
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29. Health Management & Policy
Focuses on improving access to, financing of, and delivery of high quality health services, and on developing and implementing cost-effective public health policies
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30. Definition of disease prevention
[A]nticipatory action taken to reduce the possibility of an event or condition occurring or developing, or to minimize the damage that may result from the event or condition if it does occur.
Source: Pickett and Hanlon, 1990
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31. Levels of Prevention and Effects
Prevention Primary Secondary Tertiary
strategy
Disease status Susceptible Asymptomatic Symptomatic
Effects Reduced Reduced Reduced
disease prevalence/ complications/
incidence consequence disability
Source: Turnock, Fig. 3-4
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32. Example of prevention levels: Motor vehicle injuries
Primary
Building divided highways
Secondary
Requiring safer cars (e.g., airbags) or driving practices (e.g., wearing seatbelts)
Tertiary
EMS system
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33. Example of prevention levels: High blood pressure
Primary
Dietary education and exercise
Secondary
BP control medications
Tertiary
Treatment for disease sequelae of HBP
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34. Agent, host, environment model of disease
Traditionally infectious
disease
A.k.a. Epidemiological
Triangle Host Environment
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35. Sept. 13, 2011
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36. Epi triangle adapted to nicotine addiction & tobacco control
Agent
Tobacco products
Environment
Family, friends, culture, media politics, economics, history
Host
Smoker/chewer
Vector
Incidental host
Tobacco product manufacturers
Involuntary smoker
Adapted from: Giovino 2002
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37. Why are public health issues often contentious?
Restrictions on individual liberty
Debate over individual responsibility (“blame the victim”)
Economic interests
Morality issues in public health measures
Politics in science
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38. 1. Restrictions on individual liberty
Why are they imposed?
“Tragedy of the commons”: Must restrict individuals’ freedoms to protect the greater good of the entire community (e.g., think pollution control).
“Public goods”; “externalities”
Paternalism (e.g., seat belt laws)
Social norms, morals (e.g., sodomy laws)
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39. 1. Restrictions on individual liberty (cont’d.)
Behavior that directly affects others (examples)
Prohibitions against criminal activity (murder; abuse; theft)
Speed limits; traffic lights; etc.
Prohibiting drunk driving
Banning smoking in public places
Quarantining people with infectious disease
Requiring immunizations for school enrollment
Prohibiting various forms of pollution
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40. 1. Restrictions on individual liberty (cont’d.)
Behavior that indirectly affects others (examples)
Motorcycle helmet and seat belt laws
Bans on illicit drugs
Sodomy laws
Abortion laws
UM campus-wide smoke-free policy (outdoors as well as indoors)
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41. 2. Debate over individual responsibility (“blame the victim”)
Question: Are people suffering from problem X at fault for the problem – and therefore individually responsible for resolving it – or are they victims who need and deserve (public) assistance?
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42. 2. Debate over individual responsibility (“blame the victim”) (cont’d
Examples:
Smoking
Obesity
HIV/AIDS
Drug/alcohol addiction
Homeless (including result of recent spate of foreclosures)
Poverty
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43. 3. Economic interests
Often powerful economic interests hurt by public health regulations (e.g., tobacco, alcohol, food companies; polluting firms; health care insurers, hospitals, providers; local retailers such as restaurants and bars)
Powerful economic interest = political lobby
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44. 3. Economic interests (cont’d.)
Cost burden falls on different people than does benefit derived
Benefit often to the poor and politically disenfranchised
Cost often from wealthy and politically connected
Politics of current costs for future (abstract) benefits
Political interests
Budget balancing
Politicians’ discount rate
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45. 4. Morality issues in public health measures
Intensely felt positions deriving from sense of moral or religious right or norms
Abortion
Sex ed
HIV/AIDS prevention (safe sex, clean needles)
Gay marriage
Stem cell research
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46. 5. Politics in science
Administrations often promote their social/ political agendas by interfering with science
Withholding research resources (e.g., early AIDS)
Tying resources to compliance with policy positions (e.g., no support through USAID to programs promoting birth control)
“Litmus tests” for high-level appointees
“Stacking” review bodies with “partisans” (e.g., corporate consultants)
Misrepresenting or suppressing scientific findings (e.g., global warming)
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47. What is public health?
Under-appreciated (“invisible”), under-funded, under-practiced
Difficult
Politically challenging
Requires expert mix of science and politics
Last but not least: PH is important
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48. Thursday: History of public health
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