1. Individual
Molecular
Society
Family

3. Measurements of disease factors influencing health

4. Objectives
To understand the importance of parameters measuring healthy conditions; social, cultural and economical.
You students should also be capable to understand the role of human genetics, food and nutrition, infectious agents, environment and education in health status.

5. What is Health? History of the word
The word health first appeared in the English language in 1000 AD and comes from the root word “heal” or “whole”. Traditionally, it has been defined as:
“physical and mental well-being, freedom from defect, pain, or disease.”
Webster’s Dictionary
However, to some, this definition contradicts current thinking, in that many individuals may have varying degrees of pain or discomfort even if it is as small as a blister or a paper cut. In addition, we have come to understand that it is possible to “manage disease” or to be quite healthy even in the presence of a disability. Consider the physical feats of athletes who have cancer or AIDS, for example. The actor Christopher Reeves has raised our awareness about the capacity to contribute as a quadriplegic.
Experts continue to debate how best to define health.

6. Individual
Molecular
Society
Family

7. Health is a state of complete Physical, Mental, and Social well-being and not merely the absence of disease or infirmity. WHO, 1948
The Metaphysical Context of the Universe
Physical
Mental
Social
WHO Definition of Health
In 1948, the World Health Organization defined health in a new way,
“health is the state of complete physical, mental, and social well-being, and not merely the absence of disease.”
This definition acknowledges that health includes the mental aspects of our being and the fact that as human beings, we need social networks in order to thrive as well. It depicts the metaphysical, which some might say is related to the spiritual dimension, and the secular aspects of health. Some have thought this to be a much broader and practical way to think about health.
However, others have argued that using the term “complete well-being” is unrealistic because even at their best, most people still feel there are areas of their health that could use improvement. It is interesting to discuss our thoughts about health and to understand that health is a subjective rather than an objective concept.
The Secular Dimensions of Health

8. Two Major Aspects of Health
Feeling Well
Ability to Function
Defining our own health
Aside from formal definitions, experts are learning that the way we feel about our health is very important. In fact, there is evidence that the way we perceive our level of health may be more important than true measures of health.
Two areas to think about are 1)how we feel and 2) how well we can function.
1) How we feel-Feeling well is related to our attitude as well as true measures of health. As the saying goes “it is all relative”. In other words, individual perceptions of pain and limitations vary widely person to person. People who feel well and have a positive attitude are more likely to actually be healthy as well.
2) Ability to function-The ability to carry out minimal requirements for independent living can be another parameter for defining our health. It may be difficult to feel healthy when we cannot function independently. However, once again, there are many cases of individuals learning to adapt to disabilities and functioning very well over time.

9. Determinants of Health
the complex inter-relationships of
genetics
social environment
physical environment
behavior
health/illness services
that determine the level of health and sense of well-being in an individual
Determinants of Health
Health is really multi-factorial. Synergy between many factors occurs to determine how susceptible we are to disease or, by comparison, how healthy we are day to day. It can be challenging to classify these determinants. We will discuss five categories of factors that each have strong implications for our health. It is important to keep in mind the fact that the categories are not discrete and certainly overlap. The impact of healthy lifestyle behaviors, for example, are strongly influential on all of the other categories of factors.
Lifestyle Factors
In the first half of this century people were too busy trying to survive to worry about health as much we do today, much less about how we might practice healthier habits in order to prevent disease. Progress that did occur was brought about through the organization of unions in the workplace, legislatures, and public health ordinances.
Toward the end of the century, in 1999, the Healthy People 2000 report, made a call to work towards a culture that actively promotes responsible behavior and the "adoption of life-styles that are maximally conducive to good health” (USDHHS, 1990). Since that time, there is more and more concrete evidence indicating that practicing healthy habits can significantly decrease our chances of developing chronic disease. One of our favorite quotes is by Dr. Elliot Joslin, “Genes load the gun. Lifestyle pulls the trigger”. Therefore, of all the health determinants that we have discussed, lifestyle factors are among the most controllable and influential factors influencing our health.

10. Genetics Body Size Special Abilities Disease Resistance
Disease Susceptibility
Genetic Diseases
General Robustness
Health Determinants
Genetics
Genes carry the informational code that determine everything from the color of our hair and eyes to the structure of chemical components within the body. A disruption in the code or the wrong code can have significant effects on health.
Similarities in appearance and in body structure are some of the most striking examples of the operation of genes. If you look at families walking in a mall, it is easy to see similarities among family members. Body size is very genetically determined. In addition, a weak heart or a propensity for cancer can also be inherited. Nonetheless, it is important to realize that the practice of healthy lifestyle habits can mediate the effect of genes. It is important to counsel individuals about the power of healthy living in preventing disease and injury.

11. Physical Environment Macro-environment Micro-environment
Food and Water
Air Pollution
Micro-environment
Home
Workplace
Physical Environment
There are many ways in which the environment can effect our health. The weather and air are such a normal part of our everyday life that it is easy to forget how they may effect us. However, our environment can affect our health in a variety of ways such as:
Food and Water
Contaminated water is the single greatest contributor to serious illness particularly in third world countries. Diseases such as enteritis, diarrhea, and cholera cause many deaths in underdeveloped countries. Famine, drought, and pests can significantly alter the quantity and quality of the food supply.
Air pollution
Poor air quality poses more challenge than water pollution. Since the Clean Air Act of 1970, lead and carbon monoxide levels have been reduced but more recently these levels have begun to increase due to population growth and industrial expansion. Acid rain and the depletion of the ozone layer are among the most serious air pollution threats.

12. Social Environment Religion Race/Gender Socioeconomic Status Education
Occupation
Family Composition
Social Environment
Social factors have a strong impact on health. Race, income, level of education, gender, location, and occupation are some that have been studied. The way societies are governed affects policy decisions, which have implications for distribution of resources and access to health care.
"Over time… socially designed systems have become more important than the physical environment to individual survival because they control the distribution of and access to those very factors that now determine mortality levels" John Ratcliffe, 1980
Religion- Some religions have guidelines that impact on health. For example, Seventh Day Adventists are encouraged to eat a modified vegetarian diet, not to smoke or to drink alcohol. This religious group has significantly less cancer and heart disease rates than the national average. It is thought that it is the practice of specific health habits, rather than a specific religious belief, that accounts for the better health outcomes.
Gender-Throughout the world, women tend to have lower mortality rates and longer life expectancies than men do. In general, women tend to seek medical advice sooner than men do but all of the reasons for the difference in mortality rates have not yet been identified.

13. Socioeconomic Status, Income and Health
As GDP increases, the health of a nation increases
In times of economic hardship, the incidence of disease increases
Socioeconomic Status- No matter how it is measured, socioeconomic status has been shown to be highly related to health status. Where there are higher levels of income, of education, and of occupations, there usually exists lower rates of mortality. The reverse is also true. It is obvious that where there are more economic resources, there is a higher standard of living which translates into greater access to healthcare and medical resources. By comparison, when a recession or depression occurs, measures of health status show decline.
The relationship between income and health can be seen these ways:
1-Differences in Life Expectancy-The disparity in mortality rates and other health measures between wealthier and poorer countries.
2-As Gross Domestic Product (GDP) increases so does health because wealth is distributed more evenly and the standard of living improves.

14. Health Care Quality Availability
“Health has improved NOT because of steps taken while we are ill, but because we are ill less often.”
Health Care
Experts disagree at times over how much changes in the healthcare system have truly contributed to the improvements in health among Americans. All would agree that quicker access to medical care, improvements in trauma units, and other specialized units such as those for coronary neonatal care have saved and improved the quality of many lives. However, as we have just discussed, for those who live in poverty, or in rural or underserved communities, it is still very difficult for citizens to take advantage of these types of services. Currently, some 16% of Americans are uninsured making it very difficult to obtain needed medical services, which continue to rise in cost.
Thomas McKeown, 1978

15. Primary Prevention
Measures taken to prevent the disease from occurring such as:
healthy lifestyle habits
Immunizations
Primary Prevention
Activities known to help prevent disease or illness prior to its occurrence are classified as primary prevention. Practicing healthy habits such as eating a healthy diet, being physically active, and moderating alcohol intake are examples of habits that can help lower one’s risk of disease. Immunizations are among the most successful disease prevention initiatives. Historically, children in the US are vaccinated against a group of diseases prior to entering school. Currently, work is being done to develop vaccines that can be protective later in life such as the flu vaccine and one developed to prevent pneumonia. Specific information on several specific lifestyle factors are included in Part 2 of this presentation.

16. Secondary Prevention Measures undertaken to facilitate early detection
Screenings
Diagnostic tests
Secondary Prevention
Specific action taken to enable early detection of a health problem and to stop or modify the severity or extent of illness are considered secondary preventive measures. For example, when a woman receives a mammogram or has her cholesterol checked, these tests are used to help identify early development of breast cancer or heart disease.

17. Tertiary Prevention
Measures to minimize complications or exacerbation of injury or disease.
Rehabilitation Therapy
Patient counseling
Tertiary Prevention
Rehabilitation, while a treatment modality, can also be considered as tertiary prevention. Strategies to help minimize complications and facilitate optimum recovery from an illness, may include both medical and education approaches.
Successful utilization of such methods can help prevent the recurrence of an illness and improve one’s functional ability. Counseling and practicing healthy eating are examples of tertiary preventive approaches.

18. Rising Life Expectancy
Why should one practice prevention?
The world is healthier than it has ever been, with a 30 year global increase in the past 100 years. The dramatic increase in life expectancy that was observed in the past century in both developing and developed world can be attributed primarily to improved preventive practices, not to advances in clinical medicine. It has been estimated that the majority of the increase in life expectancy was due to prevention.
Slide created by GHN Supercourse group
Source: United Nations (U.N.) Population Division, Demographic Indicators, (The 1996 Revision) (U.N., New York, 1996).

19. Prevention and Religion
Washing Hands
Hands should be washed when one touches something polluted or unclean; likewise, before or after eating.
The Prophet, Peace Be Upon Him, said: “Whoever sleeps and his hands are not clean from fat and thereby gets harmed should blame no one but himself”
“The Prophet, Peace Be Upon Him, used to wash his hands before eating”
Disease prevention and hygiene practices have a very long history. Hygienic practices are inherent in all the major religions such as here with Islam, but also including Christianity, Judaism, and Hinduism. We at the Supercourse can provide our best scientific information via the Internet to the major religions. This prevention information can then be carried on the existing information sharing systems in the local communities, including religion, school friends, colleagues, social groups, etc.
from lecture on Islam and health developed by Sherine Shawky and Abed Husseini, Berzeit University
*Note: Prophet refers to Mohammed, known as the Prophet of Islam

20. Historical Examples of Global Prevention Activities
Eradication of smallpox is the best known example of WHO’s accomplishments. Indeed, the benefits of smallpox eradication for public health are very impressive. In 1967, when WHO started international eradication efforts, smallpox, was estimated to have afflicted up to 15 million people annually, of whom some two million died with millions more left disfigured and sometimes blind. With the amazing global cooperation, in 1980, WHO was able to certify that the disease had been eradicated.
If smallpox were not eradicated, there would have been 350 million new victims in the past 20 years -- roughly the combined population of the USA and Mexico -- and an estimated 40 million deaths -- a figure equal to the entire population of Spain or South Africa.(WHO
Pictures taken from lectures Modeling Potential Response to Smallpox by Martin Meltzer, CDC, USA
And
Microbial threats to health in the US by Joshua Lederberg
*Model for acute infectious agents

21. Koch identified tubercle bacillus Streptomycin introduced Vaccination
Death rate for Tuberculosis, , United States, Source: US Bureau of the Census, Historical Statistics of the United States; Colonial Times to 1970 (Washington, D.C: Government Printing Office, 1975), Part 1 pp58,63.  Note: Data between 1860 and 1900 for Massachusetts only.
Koch
identified
tubercle
bacillus
Streptomycin
introduced
Author: John Last, Canada
Death rate for Tuberculosis, , United States, Source: US Bureau of the Census, Historical Statictics of the United States; Colonial Times to 1970 (Washington, D.C.:Government Printing Office, 1975), Part 1 pp58,63.  Note: Data between 1860 and 1900 for Massachusetts only. Ecological Determinants of Disease
The 19th century change in the pattern of disease was more than a direct cause-effect relationship of improved sanitation to reduced death rates from infections, it was aided by a change in values and behavior. The death rate from tuberculosis began to fall in the early 19th century and continued to fall steadily long before the discovery of effective chemoprophylactic regimens virtually wiped out the disease in the rich nations in the 1950s.
Prosperity led to improved housing conditions and better nutrition. Literacy increased. It became less common for several children in the family to share the same bed. Being well-fed, better housed, well-informed, and separated from others by enough space to reduce the probability of person-to-person transmission of infection, all helped to reduce the burden of premature death. Perhaps there was also a rise in the natural (maternal to infant) level of immunity to some of the infections that had previously carried off huge numbers of infants and children, and a decline in the virulence of some of the most lethal pathogens.
Vaccination
available

22. The Sanitary Revolution and the Ascendancy of Public Health
The sanitary revolution produced the greatest transformation in the pattern of disease that the world had known since nomadic hunter-gatherers settled in permanent villages, and ultimately developed modern urban industrial communities
The 19th century sanitary revolution arose from Snow's discovery, reinforced by the work of others: William Farr, physician and vital statistician, the first Compiler of Abstracts in the newly created office of the English Registrar General; the bacteriologists, Louis Pasteur and Robert Koch; the pathologist-sanitarian Rudolph Virchow; the social reformers and early public health specialists, Edwin Chadwick, Lemuel Shattuck, John Simon, soon battalions of others. Human settlements were the seedbed for civilizations, but in the absence of adequate hygiene and sanitation, they were hotbeds of pestilence and disease too. The 19th century cities were dangerous places, rife with disease and premature death. More than a quarter of all babies born alive were dead within a year, half were dead before they were old enough to have children of their own. They died of gastrointestinal and respiratory infections: cholera, typhoid, infant diarrhea, diphtheria, croup, measles, pneumonia, tuberculosis.
Slide author: John Last, Canada
*Note: sanitary revolution refers to changes in public health practices that took place in North America and Europe at the end of 19th century

23. Death Rates for Measles in Children Under Age 15, England and Wales, 1850-1970
Constructed by GHN Supercourse group
Epidemiologic transition and Health
Today, it is widely assumed that with increasing economic growth, the developing countries will follow the same path as Europe and North America and experience what has become known as the "epidemiologic transition." This term describes the changing patterns of disease that accompanied overall improvements in health in the late 19th and early 20th Century. As mortality rates declined and life expectancy rose, these populations experienced a shift in the pattern of disease, from one dominated by infectious diseases to one dominated by chronic disorders such as heart disease and cancer. The shift to chronic diseases can be partly explained by the fact that many more people were living to the age when chronic diseases strike. Even so, this transition represented not just a simple substitution of one set of problems for another but an overall improvement in health. Elements of this epidemiologic transition are in fact occurring now, to varying degrees, throughout much of the developing world. In some of the middle-income countries of Latin America and Asia, for instance, chronic diseases now take as great or an even greater toll than infectious diseases [1]. But this transition is by no means complete. Many countries, especially the poorest, still have a huge burden of infectious diseases along with a growing problem of chronic diseases. These populations have not traded one set of problems for another; instead, they are suffering from both, in what is known as the "double burden" of disease [2]. Nor is the transition inevitable. As the history of the Sanitary Revolution illustrates, concerted policies and investments are necessary to improve both environmental quality and public health.
1. Christopher J. L. Murray and Alan D. Lopez, eds., The Global Burden of Disease: Volume 1 (World Health Organization, Harvard School of Public Health, and The World Bank, Geneva, 1996), p. 18.
2. A. Rossi-Espagnet, G.B. Goldstein, and I. Tabibzadeh, "Urbanization and Health in Developing Countries: A Challenge for Health for All," World Health Statistics Quarterly, Vol. 44, No. 4 (1991), p. 208.
Source: Thomas McKeown, The Modern Rise of Population (Academic Press, San Francisco, 1976), pp. 93, 96.

24. Epidemiologic Transition, Mexico Decline in Communicable, Rise of NCDs
Diarrhea
Malaria TB
Typhoid
CHD CA
Epidemiologic transition is not something limited to developed countries. Evidence of epidemiologic transition can also be observed in countries like Mexico.
The epidemiologic transition has been clearly noted in most countries in the last century. Here in Mexico, almost all of the infectious diseases were reduced, as this occurred, life expectancy rose, and CHD and CA were unmasked.  This demonstrates the systems of disease on a population basis.

25. The greatest radiation accident took place in Chernobyl Nuclear Power Plant (near Pripjat, Ukraine) on April 26, More than people participating in clean-up projects, among which constituted Ukrainians. The works were carried out up to Radioactive contamination spread on the territory of Ukraine, Belarus and Russia. The density of contamination is shown on the map to the left. There are contamination deposition levels of Cs-137 around of Chernobyl.
Despite various successes of sanitary revolution, health of our environment is still a major concern. Chernobyl Nuclear Plant accident reminded everyone how important it is to prevent environmental pollution and other man made health threats. Health Effects of Radiation and secondary prevention activities for those who were exposed to it is a major concern for public health professionals in Ukraine and other regions.
Slide author: Boris Ledoshchuk, MD, PhD, Ukraine

26. Example of successful prevention program in Cuba : VACCINATION PROGRAM RESULT
POLIO ELIMINATED SINCE 1962
DIPHTHERIA ELIMINATED SINCE 1969
NEWBORN TETANUS ELIMINATED SINCE 1972
CONGENITAL RUBELLA ELIMINATED SINCE 1989
MENINGITIS POST MUMPS ELIMINATED SINCE 1989
MEASLES ELIMINATED SINCE 1993
WHOOPING COUGH TRANSMISSION INTERRUPTED SINCE 1994
RUBELLA TRANSMISSION INTERRUPTED SINCE 1995
MUMPS TRANSMISSION INTERRUPTED SINCE 1995
MORBIDITY
MENINGOCOCCICAL DISEASE REDUCTION 93%
TYPHOID FEVER REDUCTION 75%
B HEPATITIS REDUCTION 52%
Healthcare system in Cuba is universal, free, and accessible with a great emphasis put on prevention and information sharing. In the past several decades Cuba achieved significant rise in life expectancy and significant reduction in maternal and infant mortality. Almost all of these achievements may be attributed to prevention activities. Presented slide demonstrates the achievements of vaccination programs in Cuba. Similar achievements can be observed in many other countries including Sweden, Finland, and some parts of India. Clearly at the last half of this century prevention is still having a powerful positive impact in most countries
Author: Peter G. Bourne, Cuba
Public health in Cuba

27. Introduction
Cervical cancer is the 2nd most common cancer among women globally
Higher cervical cancer mortality in developing countries due to lack of effective screening programs
More than 471,000 new cases of cervical cancer are diagnosed each year, predominantly in developing countries (1998). There is higher cervical cancer mortality in developing countries due to the lack of effective screening programs that are aimed at detecting precancerous conditions and treating them before they progress to invasive cancer. Effective screening/prevention programs have a great potential to reduce the number of deaths attributed to this chronic disease
Slide author: Naila Baig Ansari, Dept. of Community Health Sciences, The Aga Khan University Karachi, Pakistan ,

28. Estimated impact of AIDS on under-5 child mortality rates – Selected African countries, 2010
250
200
150
100 50
per 1000 live births
with AIDS
Botswana
Kenya
Malawi
Tanzania
Zambia
Zimbabwe
without AIDS
In the past 2 decades, prevention of HIV/AIDS epidemic became a real challenge for the field of public health. Since there is no effective cure for this condition and current treatments are not accessible to everybody, preventing the infection in the first place is the best way to avoid excessive morbidity and mortality due to AIDS.
Countries that had achieved low infant mortality <50/1000 such as Zimbabwe and Botswana related to antenatal care services, oral rehydration, safe water and immunization programs are seeing the most negative impact with 4-7 fold increases in under 5 mortality ;
other countries with higher background child mortality due to other causes are seeing near doubling in under 5 mortality related to AIDS
Slide author: Marc Bulterys, MD, PhD Mother-Child Transmission & Pediatric and Adolescent Studies Section Epidemiology Branch, Division of HIV/AIDS Prevention National Center for HIV/STD/TB Prevention, CDC
Source: US Bureau of the Census

29. 750 AUST SCOT NZ CAN 500 SING USSR 250 ITY FRAN HK CHN USA SPN
Death Rates for Coronary Heart Disease by Country Men Ages 35-74, 1970 and 1993 (Rate/100,000)
750
FIN
AUST
USA
SCOT NZ
CAN
500
SING
USSR
250
ITY
Death Rates for Coronary Heart Disease by Country Men Ages 35-74, 1970 and 1993 (Rate/100,000)
Presented slide shows that FSU countries, unlike many others, experience rise in the coronary heart disease death rates. The major reason for this tendency is the breakdown of public health system in the Former Soviet Union.
Source:NIH,
USAAUST: Australia, CAN: Canada, CHN: China, E&W: England and Wales, FIN: Finland, FRAN: France, HK: Hong Kong, NZ: ITY: Italy, JPN: Japan, New Zealand, SING: Singapore, SCOT: Scotland, SPN: Spain
Dr. Ueshima, Professor and Chairman, Department of Health Science, Shiga University Medical Science, Japan
SPN
FRAN
JPN HK
CHN

30. “Genes load the gun. Lifestyle pulls the trigger”
Lifestyle Factors
“Genes load the gun. Lifestyle pulls the trigger”
Dr. Elliot Joslin
Lifestyle Factors In the first half of the last century people were too busy trying to survive to worry about health as much we do today, much less about how we might practice healthier habits in order to prevent disease. Progress that did occur was brought about through the organization of unions in the workplace, legislatures, and public health ordinances. Toward the end of the century, in 1990, the Healthy People 2000 report made a call to work toward a culture that actively promotes responsible behavior and the "adoption of life-styles that are maximally conducive to good health■ (USDHHS, 1990). Since that time, there is more and more concrete evidence indicating that practicing healthy habits can significantly decrease our chances of developing chronic disease. Therefore, of all the health determinants that we have discussed, lifestyle factors are among the most controllable and influential factors influencing our health.
Author: Diane Wilson, USA
From “Lifestyle Factors and the Prevention Movement”
Additionally, prevention of injuries with safer products, use of seat belts and child seats, awareness of safety in the home, smoke detectors, etc. have saved many lives and much injury over the course of the 20th century.

31. Molecular epidemiology is one of the most exciting and important areas of research leading into the 21st century. It represents a critical link between the Human Genome Project and medicine/public health. Without well-designed population-based molecular epidemiology studies, it will be impossible to interpret the risk of disease associated with the presence of newly identified susceptibility genes. As a result, molecular epidemiology is essential for the development of medical diagnostics, public health prevention strategies and discussions of the ethical, legal and social issues related to the evolution of the Human Genome Project.
Note: human genome project was recently completed
Author: Jan Dorman, PhD University of Pittsburgh Department of Epidemiology

32. What is the future of prevention?
Globalization of Prevention
Networking of people in prevention
Sharing of data, knowledge and wisdom

36. Objectives
To understand the importance of parameters measuring healthy conditions; social, cultural and economical.
You students should also be capable to understand the role of human genetics, food and nutrition, infectious agents, environment and education in health status.