The Foundational Principles of Public Health Practice in the United States Anbesaw W. Selassie, MPH, DrPH Associate Professor Biostatistics and Epidemiology Department of Medicine Medical University of South Carolina

Learning Objectives By the end of the session, class participants will be able to: Define public health Define the core functions of public health Provide examples for key public health activities Describe the components of public health system

Prologue to Public Health Always in the news but not labeled as “public health news” Example of four major public health stories in the news The AIDS epidemic H1N1 (Swine Flu) Outbreak of water-borne disease in Milwaukee with 403,000 sick, WI 1993 (C. parvum) Collapse of Public Health in Russia The 9/11 terrorist attack

What is Public Health? Public health is the science and art of: (C-E A. Winslow, 1923) http://www.youtube.com/aphadc#p/c/DB2DEA0AD7122154/1/ABMSfiozfjg Public health is the science and art of: Preventing diseases Promoting health and efficiency Prolonging life

What is Public Health? (Continued…) The processes by which the objectives of Public Health are attained: Creation/maintenance of clean environment Control of infectious diseases Education and promotion of personal health Organization of medical and nursing services for early diagnosis and treatment Promotion of the social system which will ensure every individual a standard of living adequate for maintenance of health.

Mission of Public Health in the US To promote physical and mental health and prevent disease, injury, and disability The US Public Health System comprises a wide array of governmental and non-governmental entities

Entities of the US PH System 59 state and territorial health departments 3,000 county and city health departments >160,000 public and private laboratories Parts of multiple federal dept and agencies Tribal health departments Hospitals and other healthcare providers Volunteer organizations (E.g., Red Cross)

The Substance of Public Health The substance of public health is “organized community efforts aimed at the prevention of disease and promotion of health”

Organizational Framework of Public Health System in the US Partnerships of: Public Organizations (DHEC, DHHS, DDSN, etc.) Private and Voluntary Organizations (United Way, Salvation Army, Ryan White Clinic, etc.) Individuals

The Foundations of Public Health The philosophical base Social Justice- for defining disparities and inequity in health (extension of Herbert Spencer’s Social Darwinism) The science base Epidemiology- for defining problems, developing interventions, and measuring results William H. Foege, MD, MPH JAMA, 1993; 270:251

Core Functions of the US PH System The Institute of Medicine Report on the “Future of Public Health” in 1988, identified the core functions of Public Health as, Assessment Policy development Assurance Assessment Assurance Policy Development Public Health Practice

Medical Care vs. Public Health Medical Care Public Health Focuses on healing 1. Focuses on preventing Individual patient 2. Community as patient Patient assessment 3. Community assessment Rx plan to cure sick 4. Relies on policy development Assures Rx is taken 5. Assures service is available Outcome recognizable 6. Outcome hard to recognize Rewarded/well-funded 7. Under-funded/unappreciated 84% of health-care cost 8. 3% of health-care cost Cost-prohibitive 9. Cost-effective Knowledge intensive 10. Effort intensive

US National Health Expenditure, 2008 $2.339 trillion Where it came from Where it went

National Health Care Expenditure, 1999-2008 83.47 83.33 83.45 83.49 83.53 83.42 83.64 84.28 84.21 84.40 % of Total Exp 3.22 3.18 3.21 3.27 3.09 2.90 2.84 2.87 2.89 2.97 53.6B 69.4B 40.7B

Changes in life expectancy Life expectancy of Americans increased from 48 to 78 between 1900 and 2000. Only 5 of the 30 years are accounted by improvement in medical care (JAMA. 1999;281(16):1481-1484) Medical care Public Health

The Science of Public Health Relies on the various disciplines that provide the basis for public health practice Epidemiology Biostatistics Environmental health Microbiology (Public Health Laboratory) Public health education/Health Promotion Health Policy and Management

The Public Health Approach to Prevention Implementation How do you do it? Intervention Evaluation What works? Risk Factors What is the cause? Surveillance What is the problem? Problem Response

Prioritization of Healthcare Issues in the US Public Health Planning Morbidity: Incidence/Prevalence (E.g. Flu) Mortality:  Death Rate (E.g. AIDS) Case Fatality Rate:  Recovery (E.g. Rabies) Lost Productivity:  Loss (E.g. CNS Injuries) Preventability:  Preventable (E.g. Polio) Medical Cost :  Cost (E.g. TSCI) Premature Mortality:  YPLL (E.g. Firearm) Wide Disparity: Prostate Ca in AA

Epidemiology Epidemiology is the study of the distribution and determinants of health, disease, injuries, and disability in populations. John Last, A Dictionary of Epidemiology, 1995 The goal of epidemiological research is to provide the scientific basis for developing rational measures of prevention and control

Public Health Statistics In the context of public health, statistics is the collection, summarizing, and analyzing of data that are subject to random variation and uncertainties. Public health data are collected on vital events such as births, deaths, marriages, divorces, fetal deaths, and causes of death and diseases. The science of statistics is used to calculate risks from exposure and determine the degree to which rates vary in population groups.

Environmental Health The study of the effect on human health of physical, chemical, and biological factors in the external environment. It is mainly concerned with preventing the spread of disease through water, air, and food Modern day challenges, however, include chemicals, radiations, environmental pollution, and global warming.

Microbiology In the context of public health practice, microbiology refers to the investigation of the spread of infectious agents, their toxins, and how they affect the human body. It is mainly concerned with establishing the diagnosis of an outbreak and tracking the sources of the agents It is an integral part of infectious disease epidemiology

Health Education/Health Promotion Health Education refers to the process by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance, and restoration of good health. Health Promotion refers to the process of enabling people to increase control over and improve their health. It involves the population as a whole in the context of their everyday lives to improve their health.

Health Policy/Health Management The study of the healthcare and medical care systems concerning runaway costs, access to care, and quality of services provided by an organized health delivery system. Health services research is primarily involved in assessing the effectiveness, efficiency, and equity of a healthcare system. It uses epidemiologic, sociological, economic, and analytic sciences in the study of health services.

Source/Reference Schneider MJ. The Sciences of Public Health. In: Introduction to Public Health. Ch.1, pp 1-15, Jones & Bartlett, Boston, 2006. Last JM (ed). A dictionary of epidemiology, 3rd ed. Oxford Publication, 1995 Wallace RB (ed). Public Health Methods. In: Maxcy-Rosenau-Last Public Health & Preventive Medicine. Section 1, Appleton & Lange Publication. 14th ed., 1998