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

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Presentation on theme: "What is public health? PUBHLTH 200 – Sept. 13, 2011."— Presentation transcript:

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) Sept. 13, 20112PUBHLTH 200

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 Sept. 13, 20113PUBHLTH 200

4 CEA Winslows 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. Sept. 13, 20114PUBHLTH 200

5 A more concise definition Defn: Public health is the set of activities a society undertakes to monitor and improve the health of its collective membership. Distinguishing features: 1.Focus on preventing disease & injury 2.Patient is entire community, not individuals 3.Provider is society, not individual professionals Sept. 13, 20115PUBHLTH 200

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 Sept. 13, 20116PUBHLTH 200

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. Sept. 13, 20117PUBHLTH 200

8 Primacy of public health in concept Public health Collective health servicesIndividual health services Medicine Dentistry Nursing Pharmacy Sept. 13, 20118PUBHLTH 200

9 Hierarchy in practice Medicine Other individual health services Public health Sept. 13, 20119PUBHLTH 200

10 Why is public health so important? Factors that could avoid premature mortality Lifestyle (behavior)50% Environment20% Human biology (genetics)20% Additional medical care10% Source: Adapted from CDC, 1979; IOM, 1988; and PHS, 1993 Sept. 13, 201110PUBHLTH 200

11 Why is public health so important? Contribution to life expectancy gain Of 30-year gain in life expectancy in U.S. during 20 th 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 Sept. 13, 201111PUBHLTH 200

12 Relationship between public health (PH) and the medical care system (MC): Impact on premature mortality PH MC Sept. 13, 201112PUBHLTH 200

13 Relationship between PH and MC: Expenditures MC PH Sept. 13, 201113PUBHLTH 200

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 Sept. 13, 201114PUBHLTH 200

15 Benefits and costs of health promotion programs Benefits: abstract, deferred Costs: tangible, immediate Sept. 13, 201115PUBHLTH 200

16 Benefits and costs of disease promotion Benefits: tangible, immediate Costs: abstract, deferred Sept. 13, 201116PUBHLTH 200

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 Sept. 13, 201117PUBHLTH 200

18 Core functions of public health 1.Assessment of the health of the population 2.Development of public health policies 3.Assurance of the availability of needed services Sept. 13, 201118PUBHLTH 200

19 1. Assessment of the publics health Requires: 1.Data collection 2.Statistical and epidemiologic analysis 3.Dissemination of findings Sept. 13, 201119PUBHLTH 200

20 2. Development of public health policies Requires: 1.Use of a scientific knowledge base 2.Appreciation and use of the political process Sept. 13, 201120PUBHLTH 200

21 3. Assurance of the availability of needed services Relies on: 1.Encouraging appropriate actions by other entities (public or private) 2.Requiring such actions through law or regulation 3.Directly providing services Sept. 13, 201121PUBHLTH 200

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 Sept. 13, 201122PUBHLTH 200

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 Sept. 13, 201123PUBHLTH 200

24 Five core areas of public health Epidemiology Biostatistics Environmental Health Sciences Health Behavior & Health Education Health Management & Policy Sept. 13, 201124PUBHLTH 200

25 Epidemiology 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. Sept. 13, 201125PUBHLTH 200

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. Sept. 13, 201126PUBHLTH 200

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. Sept. 13, 201127PUBHLTH 200

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. Sept. 13, 201128PUBHLTH 200

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 Sept. 13, 201129PUBHLTH 200

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 Sept. 13, 201130PUBHLTH 200

31 31 Levels of Prevention and Effects PreventionPrimary SecondaryTertiary strategy Disease status Susceptible Asymptomatic Symptomatic EffectsReducedReducedReduced diseaseprevalence/complications/ incidence consequence disability Source: Turnock, Fig. 3-4 Sept. 13, 2011

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 Sept. 13, 201132PUBHLTH 200

33 Example of prevention levels: High blood pressure Primary –Dietary education and exercise Secondary –BP control medications Tertiary –Treatment for disease sequelae of HBP Sept. 13, 201133PUBHLTH 200

34 Agent, host, environment model of disease Agent Traditionally infectious disease A.k.a. Epidemiological Triangle Host Environment Sept. 13, 201134PUBHLTH 200

35 Sept. 13, 201135PUBHLTH 200

36 Epi triangle adapted to nicotine addiction & tobacco control Agent Vector Host Tobacco products Tobacco product manufacturers Smoker/chewer Incidental host Environment Family, friends, culture, media politics, economics, history Involuntary smoker Adapted from: Giovino 2002 Sept. 13, 201136PUBHLTH 200

37 Why are public health issues often contentious? 1.Restrictions on individual liberty 2.Debate over individual responsibility (blame the victim) 3.Economic interests 4.Morality issues in public health measures 5.Politics in science Sept. 13, 201137PUBHLTH 200

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) Sept. 13, 201138PUBHLTH 200

39 1. Restrictions on individual liberty (contd.) 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 Sept. 13, 201139PUBHLTH 200

40 1. Restrictions on individual liberty (contd.) 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) Sept. 13, 201140PUBHLTH 200

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? Sept. 13, 201141PUBHLTH 200

42 2. Debate over individual responsibility (blame the victim) (contd.) Examples: –Smoking –Obesity –HIV/AIDS –Drug/alcohol addiction –Homeless (including result of recent spate of foreclosures) –Poverty Sept. 13, 201142PUBHLTH 200

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 Sept. 13, 201143PUBHLTH 200

44 3. Economic interests (contd.) 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 Sept. 13, 201144PUBHLTH 200

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 Sept. 13, 201145PUBHLTH 200

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) Sept. 13, 201146PUBHLTH 200

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 Sept. 13, 201147PUBHLTH 200

48 Thursday: History of public health Sept. 13, 201148PUBHLTH 200

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