What Is Public Health?1 YORK DISTRICT PUBLIC HEALTH COUNCIL QUARTERLY MEETING January 21, 2009 Marc D. Hiller, DrPH College of Health and Human Services, University of New Hampshire 1 Sources: Bernard J. Turnock. 2009. Public Health – What It Is and How It Works, Fourth Edition. (chapter 1, pp. 1-28, “What is Public Health?”) and Institute of Medicine, National Academy of Sciences. 1988. The Future of Public Health. (“Summary and Recommendations”).

Public Perceptions of Public Health (or, What the Person in the Street Thinks Public Health Is?) General ignorance (no clue); “I don’t know, I never thought about it.” “Abstract;” hard to pin down or define Surrounded by uncertainty and confusion (“well….ummmm, I’m not sure”) Vague/obtuse understanding (oh, well, “it’s the health of the public”) Considered simply another branch of medicine

When Does Public Health Come to the Forefront? Seldom, when it is working or doing what is supposed to; typically, it is simply assumed; going unnoticed or appearing to be “invisible” most of the time... EXCEPT When its absence is recognized when there is a problem When a crisis is at hand When “the system” seems to fail

Health Care (Medicine) and Public Health “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.” Source: Former U.S. Surgeon General C. Everett Koop, MD

Public Health vs. Medicine Individual Diagnosis Treatment Intervention Medical care Private (Some public) Public Health Population Disease Prevention Health Promotion Interventions Environment Human behavior Government (Some private) Source: Brandt, AM and Gardner, M. 2000. American Journal Public Health. 90:707-715 .

A Dictionary’s Definition of Public Health “the science and practice of protecting and improving the health of the community, as by preventive medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of environmental hazards.” Source: The American Heritage Dictionary, Public Health Institute. Public Health 101.

CEA Winslow’s Definition of Public Health, 1920 (short version) “the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort.” Source: CEA Winslow, 1920.

CEA Winslow’s “Classic” Definition of Public Health, 1920 (expanded version) “… 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 ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity.”

John Last’s Definition of Public Health, 1980 “… efforts organized by society to protect, promote, and restore the people’s health … combination of sciences, skills, and beliefs directed to maintenance and improvement of health of all people through collective or social actions … emphasis on prevention of disease … activities change with changing technology & social values, but goals remain the same.” Source: John Last, 1980

Public Health Defined, 1988 “Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy.” Source: Institute of Medicine Report (IOM). The Future of Public Health. Washington DC: National Academy Press. 1988.

Characteristics of Public Health “A broad social enterprise or system.” “A body of knowledge and techniques that can be applied to health-related problems.” “Public health is literally the health of the public as measured in terms of health and illness.” “Social justice is said to be the cornerstone of public health.” Source: Turnock B. Public Health – What It Is and How It Works, Fourth Edition. 2009. Sudbury MA: Jones and Bartlett Publishers.

Images of Public Health The System and Social Enterprise (Including the Nation’s Public Health Infrastructure) The Profession (Professionals and the Workforce) The Methods (Knowledge and Techniques Applied to Health-related Problems) Governmental Services (Especially Medical Care for the Poor) The Health of the Public (the Intended Results of Public Health Endeavors, as Measured by the Levels of Health and Illness in the Population) Source: Turnock B. Public Health – What It Is and How It Works, Fourth Edition. 2009. Sudbury MA: Jones and Bartlett Publishers.

Selected Unique Features of Public Health Basis in social justice philosophy Inherently political nature Dynamic, ever-expanding agenda Link with government Grounding in the sciences Use of prevention as a prime strategy Uncommon culture and bond Source: Turnock B. Public Health – What It Is and How It Works, Fourth Edition. 2009. Sudbury MA: Jones and Bartlett Publishers.

20th Century’s Top Ten Achievements in Public Health Fluoridation of drinking water Control of infectious diseases Motor vehicle safety Safer workplaces Safer and healthier foods Healthier mothers and babies Recognition of tobacco use as a health hazard Family planning Decline in deaths from coronary heart disease and stroke Immunizations

Identified “Themes” Associated with Public Health Issues Uneasy tension between science and politics, and practice? What should the role of government be in public health? Newly emerging concern: preparedness The role (and use) of incentives in public health Integral connection between environmental issues and public health Public health is global in nature (e.g., communicable disease transmission/travel; global warming), and broad in scope Ethical issues arise in conducting public health research – do the subjects of research also reap the benefits/rewards; should U.S. standards (protections) apply universally in other (developing) nations Risks? Risks associated with pandemic flu; avian flu Risks associated with HIV/AIDS Vaccinations/immunizations The “Tragedy of the Commons”

Public Health Fundamentals 5 Ps of Public Health (expansion from the 3 Ps) Prevention (individual and community-focused) Promotion (voluntary, education, advocacy) Protection (policies/regulations; enforcement) Population-based (communities, groups) New 5th P: Preparedness (e.g., bioterrorism, natural disasters, pandemics) Closely linked to Environmental Health

Major Eras in U.S. Public Health History Prior to 1850 Influence of superstition, religion, miasma theory; battling epidemics/pandemics: avoidance and acceptance; advent of bacteriological era 1850-1949 Sanitary reform through state and local infrastructure (state and local health departments); development of public health infrastructure 1950-1999 Filling gaps in medical care and expanding the health agenda; Major advances in medicine; AIDS; control of infectious disease, growth of chronic disease (largely behaviorally-related) 2000- Community public health practice; evolving public health infrastructure development; preparing for and responding to community health threats

The Future of Public Health – IOM Selected Findings “The current state of our abilities for effective public health action… is cause for national concern and for the development of a plan of action for needed improvement … we have slackened our public health vigilance nationally, and the health of the public is unnecessarily threatened as a result.” Clearly defined public health is basic terms Stated that neither the general public or policymakers understood public health or its importance Urged those working in public health to reach out to educate the public about what public health is _______________ Source: Institute of Medicine (IOM), National Academy of Sciences. 1988.

IOM Selected Findings - 2 Throughout the history of public health, two major factors have determined how problems were solved: 1. The level of scientific and technical knowledge 2. The content of public values and popular opinions (and ultimately political will) Overtime, public health measures have changed with important advances in understanding the causes and control of disease (i.e., epidemiology) Public health practices have been affected by: 1. popular beliefs about illness and 2. by public views of appropriate governmental action

IOM Selected Findings - 3 As poverty and disease came to be seen as both a societal as well as a personal problem, and as governmental involvement in societal concerns increased, collective action against disease became gradually accepted… Health became a social as well as an individual responsibility.

Selected Findings - 4 Knowledge and values today remain decisive elements in the shaping of public health practice… but they blend less harmoniously than they once did. On the surface, there appears to be widespread agreement on the overall mission of public health, as reflected in comments heard by the Committee… Public health does things that benefit everybody Public health prevents illness and educates the population

Selected Findings - 5 But, when it comes to translating broad statements into effective action, little consensus can be found… There is little agreement as to what services should be provided or to what intensity they should be provided (in some states the state health department was a major provider of prenatal care for poor women; in another, women who could not pay got no care). Some state health departments are active and well equipped and funded; others perform minimal functions and have little support In some states, there are large and sophisticated local health departments; in many localities, there is no health department

IOM’s Three Basic Recommendations The mission of public health The government role in fulfilling the mission The responsibilities unique to each level of government Other recommendations made by the committee were instrumental in implementing the basic recommendations for the future of public health, e.g., statutory frameworks, structural and organization steps, strategies to build the fundamental capacities of public health agencies – technical, political, managerial, programmatic, fiscal, educational

1. The Mission of Public Health Fulfilling society’s interest in assuring conditions in which people can be healthy. Generate organized community effort to address the public interest in health by applying scientific and technical knowledge to prevent disease and promote health The mission is addressed by both private organizations and individuals as well as by public agencies Unique function of the governmental public health agency: to see that vital elements are in place and that the mission is adequately addressed

2. The Governmental Role in Public Health The “core functions” of governmental agencies at ALL levels of government are (a) assessment, (b) policy development, and (c) assurance. a. What is Assessment? Every public health agency regularly and systematically collect, assemble, analyze, and make sensible information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems

2. The Governmental Role in Public Health (continued) b. What is Policy Development? Every public health agency has the responsibility t oserve the public interest in the development of comprehensive public health policies (a) by promoting use of its scientific knowledge base in decision making about public health and (b) by leading in the development of public health policy. Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process. c. What is Assurance? Public health agencies must assure their constituents that services necessary to achieve agreed upon goals are provided, either by encouraging actions by other entities (private or public), by requiring such action through regulation, or by providing services directly.

3. Levels of Responsibility Each level of government bears its unique set of responsibilities. a. States Must be the central force in public health, playing the primary public sector responsibility for health. State duties should include: Assessing state health needs; statewide data collection Assuring an adequate state statutory base for health activities Establishing statewide health objectives, delegating power to localities as appropriate and hold them accountable Assuring an organized statewide effort to develop and maintain essential personnel, educational, and environmental health services, provision of access to necessary services, and solving health-related problems Guaranteeing a minimum set of essential health services Supporting local service capacity, particularly when disparities exist

3. Levels of Responsibility (continued) b. Federal The following were viewed as federal public health obligations. Support of knowledge development and dissemination through data gathering, research, and information exchange Establishing nationwide health objectives and priorities, and stimulating debate on interstate and national public health issues Providing technical assistance to help states and localities determine their own objectives and to carry out action on national and regional objectives Providing funds to states to strengthen state capacity for service, especially to achieve an adequate minimum capacity, and to achieve national objectives Assurance of actions and services that are in the public interest of the entire nation such as control of AIDS and similar communicable diseases, interstate environmental actions, and food and drug inspection

3. Levels of Responsibility (continued) c. Localities Because of the great diversity in size, powers, and capacities of local governments, generalizations must be made with caution. Nevertheless, no citizen from any community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system Assessment, monitoring, and surveillance of local health problems and needs and of resources for dealing with them Policy development and leadership that foster local involvement and a sense of ownership, that emphasize local needs, and that advocate equitable distribution of public resources and complementary private activities Assurance that high quality services, including personal health services, needed for the protection of public health in the community are available ans accessible to all persons; that the community receives proper consideration in the allocation of federal and state public health funds, and that the community is informed about how to obtain public health services or to comply with public heath requirements

What (Who) Comprise Public Health? Broad and interdisciplinary in nature Epidemiologists and biostatisticians Biomedical scientists (e.g., biologists, microbiologists, bacteriologists, virologists, chemists, physicians) Environmental health specialists (including environmental health specialists, toxicologists, sanitarians) Social and behavioral scientists (e.g., health educators, psychologists, social workers) Health policy makers and administrators (e.g., administrators, elected officials, program managers) “Non-public health” professionals who are involved in public health activities and programs (e.g., engineers, lawyers, nutritionists, teachers) Other workers and occupations whose “work” constitutes activities that protect and promote the public health, but who never think of themselves as playing a role in public health (e.g., plumbers, rubbish collectors, contractors) In sum, people practicing skills aimed at protecting and promoting the health of the public

The Public Health System MCOs Home Health Parks Economic Development Mass Transit Employers Nursing Homes Mental Health Drug Treatment Civic Groups CHCs Laboratory Facilities Hospitals EMS Community Centers Doctors Health Department Churches Philanthropist Elected Officials Tribal Health Schools Police Fire Corrections Environmental Health Source: Centers for Disease Control and Prevention

Dimensions of the Public Health System Capacity (Inputs): the resources and relationships necessary to carry out the core functions and essential services of public health (e.g., human resources, information resources, fiscal and physical resources, and appropriate relationships among system components). Processes (Practices and Outputs): those collective practices or processes that are necessary and sufficient to assure that the core functions and essential services of public health are being carried out effectively (including the key processes that identify and address health problems and their causative factors and the interventions intended to prevent death, disease, disability, and to promote quality of life). Outcomes (Results): indicators of health status, risk reduction, and quality of life enhancement outcomes are long-term objectives that define optimal, measurable future levels of health status; maximum acceptable levels of disease, injury, or dysfunction; or prevalence of risk factors. Source: Adapted from Public Health Practice Program Office. 1990. the Centers for Disease Control and Prevention.

Public Health Prevents epidemics and the spread of disease Protects against environmental hazards Prevents injuries Promotes and encourages healthy behaviors Responds to disasters and assists communities in recoveries Assures the quality and accessibility of health services

The 10 Essential (Public Health) Services1 Monitor health status to identify community health problems Diagnose and investigate health problems and health hazards in the community Inform, educate, and empower people about health issues Mobilize community partnerships to identify and solve health problems Develop policies and plans that support individual and community health efforts Enforce laws and regulations that protect health and ensure safety Link people with needed personal health services and assure the provision of health care when otherwise unavailable Assure a competent public health and personal health care work force Evaluate effectiveness, accessibility, and quality of personal and population-based health services Research for new insights and innovative solutions to health problems ________ 1 Source: U.S. Public Health Service, 1994.

Ten Essential Services of Public Health Source: Centers for Disease Control and Prevention

Levels of Disease Prevention Primary Prevention: activities intended to prevent future onset of disease, e.g., immunizations, seatbelt use, avoidance of tobacco, reduced alcohol consumption, “safe sex,” exercise, air pollution control, restaurant inspections, health education programs Secondary Prevention: early detection of health problems/disease, to promote further recommended testing and the early intervention of treatment or the risk that communicable diseases transmission to others, e.g., hypertension screening, cholesterol screening, HIV/STD testing, mammograms, pap smears, colonoscopies. Tertiary Prevention: rehabilitation activities designed to prevent subsequent worsening or reoccurrence of disease, disability, or injury, e.g., cardiac rehab, adhering to strict dietary restrictions, re-learning to walk after an orthopedic injury or stroke.

Health Promotion and Disease Prevention Encompasses a Broad Array of Functions and Expertise Assess and monitor the health of communities and populations at risk to identify health problems and priorities In collaboration with community and government leaders, formulate public policies to solve identified local, state, and national problems and priorities Assure that all populations have access to appropriate, effective, and cost-effective health promotion and disease prevention services

A Day in Your Life with Public Health An Exercise In thinking about your activities that typically occur on a daily basis, let’s try to make a list of how public health touches or impacts you (i.e., the ways in which you interface with public health)... Let’s add to the list events or activities that you periodically encounter but not necessarily on a daily, or even weekly, basis … Think practically and creatively … From the moment you arise in the morning, e.g., 6:30am Going to work or to school, e.g., 8:00am Mid-day, e.g., noon End of the work day or school day, e.g., 4:30pm Evening, e.g., 6:00pm Retiring for the night, 11:00pm

A Day in Your Life with Public Health In reviewing the above list(s), what do you realize? What does this illustrate to you?

Public Health At Work in Maine