Public Health What it is and Why you should care. This lecture provides a fundamental understanding of public health by reviewing the mission of public health, core functions of public health and ten essential services of public health. Readings: The 10 Essential Services of Public Health: http://www.apha.org/ppp/science/10ES.htm The Future of Public Health http://www.nap.edu/books/0309038308/html/index.html Public Health What it is and Why you should care. Virginia M. Dato MD MPH FACPM FAAP President American Association of Public Health Physicians vmdato@aaphp.org

Clinical Medicine Enhancing the Capacity to Function Diagnosing symptoms Treating and preventing diseases Relieving Pain Providing Comfort medicine & public health the power of collaboration

The Public Health Perspective Implementing and evaluating population based strategies to promote health and prevent disease Developing and Enforcing Public Health Laws Assessing and monitoring health problems Assuring the provision of essential health services medicine & public health the power of collaboration

Public Health is the science and art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to 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. C.E.A. 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.”

Public Health The vision of Public Health included defining the Substance of Public Health as organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of Epidemiology. Epidemiology is “the study of the distribution and determinants of diseases and injuries in human populations. (Mausner and Kramer – Epidemiology and Introductory Text, W.B. Saunders Company, 2nd Edition 1985). Organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of Epidemiology (The Future of Public Health)

The Organizational Framework of Public Health The vision of public health included defining the organizational framework of public health. That framework encompasses both activities undertaken within the formal structure of government and the associated efforts of private and voluntary organizations and individuals. Encompasses both activities undertaken within the formal structure of government and the associated efforts of private and voluntary organizations and individuals” (The Future of Public Health) “

Mission of Public Health That vision included the mission of Public Health as fulfilling society’s interest in assuring the conditions in which people can be healthy. Why is this important? Why can we not focus just on an individual’s health? The water we drink, the air we breathe, the food we eat and even the messages we are exposed to via media influence our health. Just as an individual tree does not have much of a chance when the forest around it is burning, human health is very much dependent upon the environment . And why does “society” have an interest. Because many problems can not be solved by individuals alone and others can best be solved on a population or community basis. There is an expression “Can’t see the forest for the trees”. The truth is that individual and population or community medicine are both important perspectives. We must pay attention to the forest as well as the individual trees. The Mission of Public Health is that first perspective - the big picture. The fulfillment of society’s interest in assuring the conditions in which people can be healthy - (The Future of Public Health)

This steering committee also articulated the what of public health This steering committee also articulated the what of public health. They defined the fundamental obligation of agencies responsible for population-based health as being to 1. Prevent epidemics and the spread of disease. 2. Protect against environmental hazards 3. Prevent injuries The fundamental obligation of agencies responsible for population-based health is to: Prevent epidemics and the spread of disease Protect against environmental hazards Prevent injuries

Promote and encourage healthy behaviors and mental health 5. Respond to disasters and assist communities in recovery 6. Assure the quality and accessibility of health services Promote and encourage healthy behaviors and mental health Respond to disasters and assist communities in recovery Assure the quality and accessibility of health services

Healthy People in Healthy Communities Vision That Vision was simple - Healthy People in Healthy Communities. Most of us know what health people are. Healthy communities help people be healthy by providing a safe environment. Healthy People in Healthy Communities

Mission The Mission was also simple: Promote physical and mental health and prevent disease, injury and disability. Promote physical and mental health and prevent disease, injury, and disability.

Old Wine In New Bottles F. Douglas Scutchfield Panacea and Hygeia - the Greek Gods of Healing and Health Hippocrates “urged physicians to pay attention to the environment, social, and behavioral context in which illness occurs” medicine & public health

“When a committee of the Massachusetts legislature confidently asserted, on May 22, 1869 that all governments since the time of Moses had made provision to protect the life and health of their people, the legislators affirmed a tradition of corporate responsibility for the welfare of their people.” From Public Health and the State - Changing Views in Massachusetts, 1842-1936 - Barbara Gutman Rosenkrantz Harvard University Press - 1972

Historical Relationship an early supportive relationship prior to the early 20th century a period of professionalization and practice transformation spurred by the emergence of bacteriology an acceleration of functional separation in the post-World War II era the brave new world of managed care and cost emphasis New understanding of public health in the post 9/11/01 world With the advent of the industrial revolution with the resulting crwoed conditions, and increased potion public healt na d medicine had to cooperate. Neither had effective enough tools to work separately. 6

Why should you care about Public Health? Duty and obligation (codified in law) to report certain conditions and cooperate with authorities. Help get individual patients services they need Help improve the legal, financial and social environment that you work in.

The Future of Public Health - 1988 There is a public health saying that the federal government has the money, the state has the authority and the local government has the problem. Because public health is under the authority of the states, there are 50 different ways that the public health is carried out in the United States. The Future of Public Health written by the Institute of Medicine (U.S.) Committee for the Study of the Future of Public Health, (The Future of Public Health, National Academy of Sciences 1988.) reviewed the status of public health in America and found it in disarray. Although it has been over 10 years since the Future of Public Health was published, it remains the most comprehensive, in depth look at public health and began a process of systematic change and improvement in the public health infrastructure.(See .http://books.nap.edu/books/0309038308/html/1.html#pagetop) This work by a committee of distinguished public health leaders provides a vision for Public Health. http://books.nap.edu/books/0309038308/html/35.html The Committee for the Study of the Future of Public Health Reviewed the Status of Public Health in America Determined that Public Health was in disarray Articulated the Mission, Substance, Organizational Framework and the Three Core Functions of Public Health

Medicine and Public Health Synergies - Models of Collaboration Medicine & Public Health, The Power of Collaboration I. Improving health care by coordinating services for individuals II. Improving access to care by establishing frameworks to provide care for the uninsured III. Improving the quality and cost-effectiveness of care by applying a population perspective

IV Using clinical practice to identify and address community health problems V Strengthening health promotion and health protection by mobilizing community campaigns VI Shaping the future direction of the health system by collaborating around policy, training and research.

Amendment 10 The powers not delgated to the United States by the Consitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.

The “police power” Sovereign power of states To provide for health, safety, & welfare Delegated to local governments Delegated to the federal government

Formal Structure of Government in the US Government includes the federal government, state government and local government. Although public health is not a role specifically assigned to the federal government by the constitution, the federal government plays a role through powers related to commerce, defense (the public health service), leadership and funding. The role of the States can be very different depending upon the state constitutions and state laws. (See State Public Health Laws: An Expression of Constituency Expectations by Kristine M. Gebbie – J. Public Health Management Practice, 2000, 6(2), 46-54. ) Likewise the local role is dependent upon the state constitution since all powers of local government are delegated by the state government. Federal Government commerce funding national security State Government primary responsibility Local Government as delegated by the state

Pennsylvania "communicable disease declared reportable by regulation" or " any unusual or group expression of illness which in the opinion of the Secretary, may be a public health emergency" is covered under Chapter 3 of the Consolidated Statues - Prevention of Spread of Diseases - Communicable Diseases. Reports are covered under 521.4 of the Diseases Prevention and Control Law of 1955.

How Does Public Health Work?

Core Functions Assessment Policy Development Assurance The vision of the committee was that government would be responsible for the core functions of public health. Those core functions were assessment, policy development and assurance. Although well thought out and justified, most members of the public had a difficult time understanding what these core functions meant. Beginning in 1993, efforts were made to make these functions more understandable. The result of that process which included a number of committees and iterations over time and concluded when the Core Functions of Public Health Steering Committee articulated a simpler mission, and vision as well as the what and how of public health. (See http://www.apha.org/ppp/science/10ES.htm for an excellent description of this process.) Assessment Policy Development Assurance

The Ten Essential Services of Public Health This steering committee then defined the how of public health. The steering committee articulated 10 services that are known as the 10 Essential Services of Public Health. The Ten Essential Services of Public Health

Assessment Although we now have the much simpler language of the newer steering committee, I believe that the original core functions are still relevant. I am providing for you the original text from the Future of Public Health on each core function followed by the Essential Services that I believe grew from and are related to the core function. Here we have the actual text from the Future of Public Health on the topic of assessment The assessment function is the collection, assemble, analysis and distribution of information on the community's health

The Ten Essential Services - Assessment I believe that the Essential Services related to the core function of assessment are : Monitor health status to identify community health problems Diagnose and investigate health problems and health hazards in the community Evaluate effectiveness, accessibility, and quality of personal and population-based health services Monitor health status to identify community health problems Diagnose and investigate health problems and health hazards in the community Evaluate effectiveness, accessibility, and quality of personal and population-based health services

Policy Development Here we have the text on policy development: This core function involves the development of comprehensive policies based upon scientific knowledge and decision making.

The Ten Essential Services - Policy And the related essential services are: 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 The Ten Essential Services - Policy 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

Assurance I am including two sections on assurances. This first section demonstrates the concept of government acting either by encouraging actions by other entities or by providing the services directly. The committee recommended that a set of personal and community-wide services be determined by involving key policy makers and the general public. Once identified, the committee recommended that these services be provided to all members of the community either though encouraging actions by others, by requiring action by others or by direct provision. '

The Ten Essential Services - Assurance The Ten Essential Services that I believe are related to assurance are: Assure a competent public health and personal health care workforce Enforce laws and regulations that protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailable The Ten Essential Services - Assurance Assure a competent public health and personal health care workforce Enforce laws and regulations that protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailable

The Tenth Essential Service If you have been counting you know that I have only mentioned nine Essential Services. I believe that the 10th Essential Service impacts assessment, policy and assurance. That Essential Service is Research for New Insights and Innovative Solutions to Health Problems. Public Health never sits still but must be always innovating and developing. The Tenth Essential Service Impacts Assessment, Policy and Assurance Research for new insights and innovative solutions to health problems

Examples of the 10 Essential Services in Action Now lets look at concrete examples of each of the 10 Essential Services of Public Health Examples of the 10 Essential Services in Action

Monitor health status to identify community health problems Examples of monitoring health status to identify community health problems include the many surveillance systems in place through the nation. When used correctly death certificates, birth certificates and immunization registries all tell us about the health of our communities and allow us to take action based upon solid information. Monitor health status to identify community health problems Examples: Death Certificates, Birth Certificates, Immunizations Registries, Surveillance

When problems are identified either by surveillance systems, alert citizens or other means, they need to be investigated. Examples of the essential services “Diagnose and investigate health problems and health hazards in the community” are outbreak investigations done when foodborne illness is reported and child death review boards which examine why children die in a community and how future child deaths can be prevented. Diagnose and investigate health problems and health hazards in the community Examples: Outbreak Investigations, Child Death Review Boards

Inform, educate, and empower people about health issues Governments must inform, educate and empower people about health issues for many reasons. First many health issues require behavioral change by informed citizens. For others non-profit organizations and business can influence health. Finally for some health issues, laws are needed to protect citizens and money is needed to fund programs. Citizens and elected officials need to be informed of the options so they can make good decisions about government services and about their own behavior. Inform, educate, and empower people about health issues Example:Lead Paint displays in hardware stores, New Releases on Rabies and West Nile Virus

Mobilize community partnerships to identify and solve health problems Government can’t work alone. Many of the problems such as poor diets, inadequate wages and lack of physical exercise require community partnership. Hence one of the Essential Services is to mobilize community partnerships to identify and solve health problems. One example is the Allegheny County Health Department's Tobacco Stakeholders group which met to come up with the best ways to limit sales of tobacco to minors. Mobilize community partnerships to identify and solve health problems Example: ACHD Tobacco Stakeholders Group, Advisory Boards, Collaborative Activities

As mentioned previously Government agencies must also develop policies and plans that support individual and community health efforts. Something as simple as sidewalks and crime can have a large impact upon whether people can exercise. Government policies can influence both. Other examples include smoke free restaurants and helmet laws. Develop policies and plans that support individual and community health efforts Example: Smoking Bans, Helmet Laws, Restaurant Inspection Laws

Enforce laws and regulations that protect health and ensure safety Writing good laws and policies is not enough. Governments must enforce laws and regulations that protect health and ensure safety. Citizens in communities with good restaurant inspection programs can eat out with confidence knowing that refrigeration has been tested and food handling has been observed to make sure good practices are in place. Enforce laws and regulations that protect health and ensure safety Example: Food Inspection Certificates, Enforcement of Smoking Regulations

Most of the public is familiar with this Essential Services -” Link people to needed personal health services and assure the provision of health care when otherwise unavailable” because of Medicaid , Medicare and the Children’s Health Insurance Programs. However may people are not covered by either employer or government insurance programs. The direct provision of services by government clinics or federally qualified centers is another way that government helps to assure the provision of services when unavailable from the private sector. Link people to needed personal health services and assure the provision of health care when otherwise unavailable Example: Children’s Health Insurance Programs, Federally Qualified Centers.

Assure a competent public health and personal health care workforce. The Essential Services of Public Health are not much good if the the public health workforce is not capable of carrying out them. Educating the public health workforce is just one example of the essential service” Assure a competent public health and personal health care workforce”. Assure a competent public health and personal health care workforce. Example:Conferences, Training programs, journals, School of Public Health, Satellite Programs, Certifications

Quality improvement is part of the American Way and public health takes this responsibility very seriously. Economic analysis, and outcome evaluations are just two of the ways that public health evaluates effectiveness, accessibility, and quality of personal and population-based health services. Evaluate effectiveness, accessibility, and quality of personal and population-based health services Example: Outcome evaluation and Economic Analyses

Research for new insights and innovative solutions to health problems Finally, public health is faced with new problems every day. Research for new insights and innovative solutions to health problems are therefore essential for maintaining the health of the community. Innovative ideas such as needle exchange programs need to be tested before being used population wide. Research for new insights and innovative solutions to health problems Example: Needle Exchange Programs

Example: Heart Disease At the end of this lecture you will be asked to think about ways the 10 Essential Services of Public Health can be used to solve a problem in your community. As an example let’s look at heart disease. For the first essential service- Monitor health status to identify community health problems. -Typically death certificate files are used to monitor deaths from heart disease For the second service - Diagnose and investigate health problems and health hazards in the community Investigations are need to determine which factors (smoking , lack of exercise, weight, blood pressure problems, racial and ethnic disparities) are contributing most to heart disease deaths in a community. 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 For the third essential service, Inform educate, and empower people about health issues - The local public health agency can work with news agencies to provide information to its citizens about ways to improve cardiovascular health such as walking. An example of the 4th essential service, mobilize community partnerships to identify and solve health problems would be working with a local block watch group to make it safer for residents to walk at night or providing instruction in CPR and other rescue techniques. Inform, educate, and empower people about health issues Mobilize community partnerships to identify and solve health problems

Assure a competent public health and personal health care workforce Policies and plans that support individual and community health efforts include laws which require that food be labeled as to its fat and calorie content and schools that include physical activity in the curriculum. Instruction of local health care professionals about ways to help people stop smoking can help assure a competent public health and personal health care workforce. Develop policies and plans that support individual and community health efforts Assure a competent public health and personal health care workforce

Enforce laws and regulations that protect health and ensure safety Laws and regulations that improve cardiovascular health include bans on smoking at work sites. Public Health can link people to needed health services by providing blood pressure screening and cholesterol testing. Enforce laws and regulations that protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailable

Research for new insights and innovative solutions to health problems An example of the essential service to evaluate effectiveness, accessibility and quality of personal and population-based health services is to monitor and publish cardiovascular surgery outcomes by hospital. Research for new insights and innovative solutions to health problems includes trying to find better ways to help individuals alter their behaviors. Evaluate effectiveness, accessibility, and quality of personal and population-based health services Research for new insights and innovative solutions to health problems

Now think about a current public health problem faced by you or your institution. Take that public health problem or issue and think about how you can provide the 10 essential services. It is my hope that by doing this you will think of approaches you might not have other wise considered. I also hope that you now have an appreciation of the many facets of public health and your role in them. Thank you. Exercise: Think about a current public health problem faced by you or your institution. Take that public health problem or issue and think about how the 10 essential services of public health can solve that problem.

“Never doubt that a small group of throughtful, committed citizens can change the world; indeed, it is the only think that ever has” Margaret Mead