1. Modern Public Health: Tools and Functions

2. Objectives
Describe the difference between medical care and public health.
Define epidemiology and give an example.
List the core functions of public health.
Classify examples according to the 10 essential services.
Purpose of Module
Overview of current Public Health practices, tools & functions of modern Public Health, including :
Epidemiology and other tools.
Obligations and essential services of Public Health.

3. How is Public Health Different From Medicine?
Public health is population-based
Medicine is based on the individual
Key Points:
Public Health and Medicine OVERLAP.
The two disciplines must work together to create a truly healthy world community.
Public Health is population-based, while medicine is based on the health of the individual. Public health attempts to prevent the diseases that medicine treats.
Do not overemphasize these points; there is a large overlap between the two.
Use examples that resonate with your audience
For example, recent laws passed in many states ban smoking from restaurants and other indoor areas. This is a public health measure designed to decrease people’s exposure to second-hand smoke and its negative health effects.

4. Goals Medicine Public Health Best outcome for individual
Individual Health
Public Health
Population Health
Best outcome for individual
Healthy community
Balance of individual autonomy vs. limitations on individual
Balance in allocation of resources
Focus on prevention
Points
Medicine tries to maximize the chance of the best outcome for the individual.
Public Health tries maximize the best outcome for populations.
Given limited resources, PH cannot address every risk.
PH must focus on areas considered most important and/or where resources might have maximum impact (e., prevent most damage).
EXAMPLE: Rabies affects few people, but creates fear and is very fatal (worst outcome); prevention maximizes impact.
EXAMPLE: Clean water affects the entire population (“an ounce of prevention is worth a pound of cure”)
While medicine also addresses prevention, Public Health balances what individuals might prefer to do if left unchecked and actions that appear necessary for the good of the whole group.
Background
PH practice is always struggling to find the correct balance between respect for individual autonomy and decision-making and the need for limitations on individuals in order to achieve social justice. This is the heart of the community decision-making that is necessary for promotion of the public’s health.
EXAMPLE: The establishment of environmental regulations.
EXAMPLE: Immunization requirements of all children.
EXAMPLE: The move to limit or eliminate use of tobacco products.
EXAMPLE: The HIV epidemic exemplifies this tension
Disease reporting.
Partner notification.
Syringe and needle exchange.
Access to substance abuse treatment.

5. Spending in 2001 Total national health expenditures:
$1,424.5 billion
Public health activities:
$46.4 billion
Distribution of national health dollars:
86.8% to personal health services/supplies
3.3% to government PH activities
Optional Handout: 2.2 National Health Expenditures Table 115
Source: Table 115, Health, United States, 2003, National Center for Health Statistics at
NOTE:
Total government public health activities include personal care services delivered by government public health agencies.
Ten percent of national health dollars is for investments, construction, etc.

6. Diagnostic Tools Medicine Public Health Thermometer Stethoscope
Individual Health
Public Health
Population Health
Thermometer
Stethoscope
Individual data, medical history
Demographics
Vital statistics
Epidemiology
Tools of Medicine (used to diagnose and treat diseases)
Tools of public health (allows practitioners to look at long and short-term trends across populations)
Epidemiology is the one science unique to public health.

7. What is Epidemiology?
The study of the distribution and determinants of disease in populations, to seek the causes of both health and disease.
Epidemiologist—a medical detective who links observed problems with potential causes, to arrive at a diagnosis and design and implement a mitigating response.
Key Points:
Epidemiology is the one science unique to public health.
Based on two Greek words for epidemic (“epis,” which means ‘on, or akin to’ and “demos,” which means ‘people’).
Used to study infectious diseases and many chronic diseases and conditions such as heart disease, cancer, and birth defects.
The epidemiologist tries to identify causes of disease to limit their spread, provide the correct treatment to those affected, and prevent future occurrences.
The goal of the epidemiological investigation is to:
Identify the source of the infection.
Identify the mode of transmission.
Identify the pattern of spread.
Help identify the responsible agent in the laboratory.
Help treat the ill and prevent further infection.

8. The Epidemiology Triangle
Host
In investigating disease and injury, epidemiologists identify the agent, host, and environment in order to understand how a disease or injury is caused and how it might be stopped or prevented.
HEALTH is the equilibrium among the Agent-Host-Environment.
Describe examples of disease and injury in this context or use next slide.
Agent
Environment

9. Examples Human Bacteria, Virus Water, Food, Air Energy Automobile Host
Agent
Environment
Human
Bacteria, Virus
Water, Food, Air
Energy
Automobile
Key Point:
Demonstrate how agent host environment triangle works.
Human – host, agent = Polio virus, environment = water, beaches (fecal-oral or person-to-person)
Automobile accidents Agent = transfer of energy

10. Public Health Tools Host Agent Environment Engineering Enforcement
Education
Key Points
To break the spread of injury or disease, intervene on one or more sides of the triangle.
A useful way to categorize public health interventions is the 3 Es:
ENGINEERING can be applied to the agent, host or environment.
Historical examples include chlorination and vaccination.
What are more specific examples? (polio vaccine; air bags & better highways to curb highway fatalities)
ENFORCEMENT
Give examples of when it can be used and when not. Why?
Sewage treatment, public beach regulations
Quarantine
Water supply regulations
Building codes
ATUPA (Adolescent Tobacco Use Prevention Act)
Seatbelt laws
EDUCATION
Give examples of successes and limitations.
Successes: PH Campaigns
Limitations: Changing behavior is more difficult than installing a piece of equipment.

11. Public Health & Life Expectancy
In the next 5 minutes:
Brainstorm a current or historic problem
Identify Agent, Host, Environment
Map interventions that address the problem
Education, Enforcement, Engineering
Host
ACTIVITY
Break into groups.
Give each group a flip chart pad.
Think of a Public Health problem (current or historic)
Map the problem -- Identify Agent-Host-Environment
Map the interventions -- of Education, Enforcement, and Engineering.
Possible topics: Firearms, Salmonella, Domestic Violence, Botulism, West Nile, TB, AIDS, obesity.
Instructor may demonstrate first using an example such as POLIO (fecal-oral transmission)
Draw a triangle
Write HUMAN at top (host)
Write VIRUS at left (agent)
Write WATER at right (environment)
Write interventions:
ENGINEERING: vaccine
EDUCATION: avoid beaches; get vaccine
ENFORCEMENT: require vaccinations for school-aged children
Agent
Environment

12. Core Functions and Essential Services of Public Health

13. A Public Health System Is Complex
Churches
Community Centers
Police
EMS
MCOs
Health Department
Home Health
Hospitals
Schools
Parks
Doctors
Jails
Philanthropist
Elected Officials
Mass Transit
Points
Although governmental departments of health are at the core of public health, many organizations in a community contribute to public health.
A public health system is complex.
Background
Here is a depiction of the complexity of our public health system and examples of organizations and groups that it make up the network. Many partner groups contribute to health and delivery, such as:
Healthcare providers like hospitals, physicians, community health centers, mental health labs, nursing homes and others who provide preventive, curative, and rehabilitative care.
Public safety such as police, fire and EMS. Their work is focused on preventing and coping with injury and other emergency health situations.
Human Service and Charity Organizations such as food banks, public assistance agencies, transportation providers, and others that assist people to access healthcare and receive other health-enhancing services.
Education and Youth Development Organizations like schools, faith institutions, youth centers, and others groups that assist with informing, educating, and preparing children to make informed decisions and act responsively regarding health and other life choices and to be productive contributors in the community.
Recreation and Arts-related Organizations who contribute to the physical and mental well-being of the community and those that live, work and play in it.
Economic and Philanthropic Organizations such as employers, community development and zoning boards, United Way, community and business foundations that provide resources necessary for individuals and organizations to survive and thrive in the community.
CHCs
Environmental Health
Civic Groups
Fire
Tribal Health
Laboratory Facilities
Drug Treatment
Employers
Economic Development
Mental Health

14. Six Obligations Prevent epidemics and the spread of disease.
Protect against environmental hazards.
Prevent injuries.
Promote and encourage healthy behaviors.
Respond to disasters and assist communities in recovery.
Assure the quality and accessibility of health services.
Points
These are the fundamental obligation of agencies responsible for population-based health.
These responsibilities describe and define the function of public health in assuring the availability of quality health services. Both distinct from and encompassing clinical services, public health’s role is to assure the conditions necessary for people to live healthy lives, through community-wide prevention and protection programs.
Background
The American Public Health Association

15. Three Functions
How Public Health Serves (The Practice of Public Health)
Public health serves communities and individuals within them by providing an array of essential services. Many of these services are invisible to the public. Typically, the public only becomes aware of the need for public health services when a problem develops (e.g., an epidemic occurs). The practice of public health becomes the list of "essential services."
Background
The American Public Health Association

16. Ten Essential Services
Background
The American Public Health Association
ASSURANCE
Enforce laws and regulations that protect health and ensure safety: This service involves full enforcement of sanitary codes, especially in the food industry; full protection of drinking water supplies; enforcement of clean air standards; timely follow-up of hazards, preventable injuries, and exposure-related diseases identified in occupational and community settings; monitoring quality of medical services (e.g. laboratory, nursing homes, and home health care); and timely review of new drug, biologic, and medical device applications.
Link people to needed personal health services and assure the provision of health care when otherwise unavailable: This service (often referred to as "outreach" or "enabling" services) includes assuring effective entry for socially disadvantaged people into a coordinated system of clinical care; culturally and linguistically appropriate materials and staff to assure linkage to services for special population groups; ongoing "care management"; transportation services; targeted health information to high risk population groups; and technical assistance for effective worksite health promotion/disease prevention programs.
Assure a competent public and personal health care workforce: This service includes education and training for personnel to meet the needs for public and personal health service; efficient processes for licensure of professionals and certification of facilities with regular verification and inspection follow-up; adoption of continuous quality improvement and life-long learning within all licensure and certification programs; active partnerships with professional training programs to assure community-relevant learning experiences for all students; and continuing education in management and leadership development programs for those charged with administrative/executive roles.
Evaluate effectiveness, accessibility, and quality of personal and population-based health services: This service calls for ongoing evaluation of health programs, based on analysis of health status and service utilization data, to assess program effectiveness and to provide information necessary for allocating resources and reshaping programs.
Research for new insights and innovative solutions to health problems: This service includes continuous linkage with appropriate institutions of higher learning and research and an internal capacity to mount timely epidemiologic and economic analyses and conduct needed health services research.
ASSESSMENT
Monitor health status to identify and solve community health problems: This service includes accurate diagnosis of the community’s health status; identification of threats to health and assessment of health service needs; timely collection, analysis, and publication of information on access, utilization, costs, and outcomes of personal health services; attention to the vital statistics and health status of specific-groups that are at higher risk than the total population; and collaboration to manage integrated information systems with private providers and health benefit plans.
Diagnose and investigate health problems and health hazards in the community: This service includes epidemiologic identification of emerging health threats; public health laboratory capability using modern technology to conduct rapid screening and high volume testing; active infectious disease epidemiology programs; and technical capacity for epidemiologic investigation of disease outbreaks and patterns of chronic disease and injury.
POLICY DEVELOPMENT
Inform, educate, and empower people about health issues: This service involves social marketing and targeted media public communication; providing accessible health information resources at community levels; active collaboration with personal health care providers to reinforce health promotion messages and programs; and joint health education programs with schools, churches, and worksites.
Mobilize community partnerships and action to identify and solve health problems: This service involves convening and facilitating community groups and associations, including those not typically considered to be health-related, in undertaking defined preventive, screening, rehabilitation, and support programs; and skilled coalition-building ability in order to draw upon the full range of potential human and material resources in the cause of community health.
Develop policies and plans that support individual and community health efforts: This service requires leadership development at all levels of public health; systematic community-level and state-level planning for health improvement in all jurisdictions; development and tracking of measurable health objectives as a part of continuous quality improvement strategies; joint evaluation with the medical health care system to define consistent policy regarding prevention and treatment services; and development of codes, regulations and legislation to guide the practice of public health.

17. As we cycle through the following slides: Break into groups
As we cycle through the following slides: Break into groups. Select a leader/reporter. List examples of the essential service.
Activity
Cycle through each of the next 10 slides and ask what examples can be given. The number of examples you can accept will be based on the time you allot per service.
Alternatively, assign each group 1-3 services and ask them to explain each service and give examples to the group.
Select a group leader and a reporter.
Group leader: Your job is to see that the group completes its task on time and that everyone participates.
Reporter: Your job is to record the group’s examples of essential services and to give a brief summary of the examples to the larger group.
Study up on the essential service(s) assigned to your group.
Think about your own agency’s work, and look for examples of the essential service(s) assigned to your table.
As a group, develop a list of examples of the above public health essential service.

18. Monitor Health Status to Identify and Solve Community Health Problems
Diagnose community’s health status.
Identify threats to health & assess needs.
Collect, analyze, and publish information on access, utilization, costs, and outcomes of personal health services.
Collect and analyze vital statistics and health status of higher risk groups.
Integrate information systems with private providers and health benefit plans.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service includes
accurate diagnosis of the community’s health status
identification of threats to health and assessment of health service needs
timely collection, analysis, and publication of information on access, utilization, costs, and outcomes of personal health services
attention to the vital statistics and health status of specific-groups that are at higher risk than the total population
collaboration to manage integrated information systems with private providers and health benefit plans
Example: Ask students if they have ever seen a complete birth record. Public Health analyzes birth records to monitor general trends in newborn health.
Idea: Obtain a birth record and share with the class.

19. Diagnose and Investigate Health Problems and Health Hazards in the Community
Epidemiologically identify emerging health threats.
Use modern laboratory technology to conduct rapid screening and high volume testing.
Use active surveillance programs to epidemiologically address infectious diseases.
Maintain technical capacities to undertake epidemiologic investigations of disease outbreaks and to examine patterns of chronic disease and injury.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service includes
epidemiologic identification of emerging health threats
public health laboratory capability using modern technology to conduct rapid screening and high volume testing
active infectious disease epidemiology programs
technical capacity for epidemiologic investigation of disease outbreaks and patterns of chronic disease and injury

20. Inform, Educate and Empower People About Health Issues
Market community health issues; communicate to targeted media.
Provide access to health information resources at community levels.
Collaborate with personal health care providers to reinforce health promotion messages and programs.
Participate in joint health education programs; collaborate with schools, churches, and worksites.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service involves
social marketing and targeted media public communication
providing accessible health information resources at community levels
active collaboration with personal health care providers to reinforce health promotion messages and programs
joint health education programs with schools, churches, and worksites.

21. Mobilize Community Partnerships to Identify and Solve Health Problems
Undertake inclusive prevention, screening, rehabilitation, and support programs by convening and facilitating community groups and associations; include groups not typically considered health-related.
Build community health coalitions, drawing upon the full range of potential human resources and material resources.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service involves:
convening and facilitating community groups and associations, including those not typically considered to be health-related, in undertaking defined preventive, screening, rehabilitation, and support programs
skilled coalition-building ability in order to draw upon the full range of potential human and material resources in the cause of community health

22. Develop Policies and Plans That Support Individual and Community Health Efforts
Develop leadership at all levels of public health.
Plan community-level and state-level health improvement in all jurisdictions.
Develop and track health objectives to measure quality improvement.
Collaborate with medical communities to create policies on prevention and treatment services.
Develop codes, regulations, and legislation to guide the practice of public health.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service requires
leadership development at all levels of public health
systematic community-level and state-level planning for health improvement in all jurisdictions
development and tracking of measurable health objectives as a part of continuous quality improvement strategies
joint evaluation with the medical health care system to define consistent policy regarding prevention and treatment services
development of codes, regulations and legislation to guide the practice of public health.

23. Enforce Laws and Regulations That Protect Health and Ensure Safety
Enforce sanitary codes, especially in the food industry. Enforce clean air standards.
Protect drinking water supplies.
Follow up on hazards, preventable injuries, and exposure-related diseases identified in occupational and community settings.
Monitor quality of medical services (e.g., laboratory, nursing homes, and home health care).
Review new drug, biologic, and medical device applications.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service involves:
full enforcement of sanitary codes, especially in the food industry
full protection of drinking water supplies
enforcement of clean air standards
timely follow-up of hazards, preventable injuries, and exposure-related diseases identified in occupational and community settings
monitoring quality of medical services (e.g. laboratory, nursing homes, and home health care)
and timely review of new drug, biologic, and medical device applications

24. Link People to Needed Personal Health Services and Assure Health Care When Otherwise Unavailable
Assure clinical care for disadvantaged people.
Link populations with services by ensuring culturally/linguistically appropriate materials/staff.
Provide ongoing "care management“ and transportation services.
Target information to high risk population groups.
Provide technical assistance for worksite health promotion/disease prevention programs.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service (often referred to as "outreach" or "enabling" services) includes:
assuring effective entry for socially disadvantaged people into a coordinated system of clinical care
culturally and linguistically appropriate materials and staff to assure linkage to services for special population groups
ongoing "care management“
transportation services
targeted health information to high risk population groups
technical assistance for effective worksite health promotion/disease prevention programs

25. Assure a Competent Public Health and Personal Health Care Workforce
Provide education and training for personnel.
License professionals and certify facilities; regular verification and inspection follow-ups.
Continue quality improvement and life-long learning within all licensure/certification programs.
Partner with professional training programs to assure community-relevant learning experiences.
Assure continuing education in management and leadership for administrators and executives.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service includes:
education and training for personnel to meet the needs for public and personal health service
efficient processes for licensure of professionals and certification of facilities with regular verification and inspection follow-up
adoption of continuous quality improvement and life-long learning within all licensure and certification programs
active partnerships with professional training programs to assure community-relevant learning experiences for all students
continuing education in management and leadership development programs for those charged with administrative/executive roles

26. Evaluate Effectiveness, Accessibility, and Quality of Personal and Population- Based Health Services
Evaluate health programs based on analysis of health status and service utilization data—assess program effectiveness and provide information necessary for allocating resources and reshaping programs.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service calls for:
ongoing evaluation of health programs, based on analysis of health status and service utilization data, to assess program effectiveness and to provide information necessary for allocating resources and reshaping programs.

27. Research for New Insights and Innovative Solutions to Health Problems
Link with appropriate institutions of higher learning and research.
Maintain internal capacity to mount timely epidemiologic and economic analyses.
Conduct needed health services research.
Group Activity (Continued)
Think about your own agency’s work.
As a group, develop a list of examples for this public health essential service.
This service includes:
continuous linkage with appropriate institutions of higher learning and research
internal capacity to mount timely epidemiologic and economic analyses
conduct needed health services research.

28. Which services does your job cover?
In the next 3-5 minutes:
Think about your job and list the essential services covered in your current position.
Point
Some public health jobs cover SEVERAL services, while others are entirely devoted to one service.
Individual Activity
Ask students to think about their job and list the services that they perform.
Wait 3 minutes and then ask individual students to contribute.
If any services don’t quite match, ask the class for verification.
Optional handout to use for this activity:
Handout 2.1 Your Job and the Ten Essential Services