1. A Brief History of Public Health

2. What is Public Health?
“To promote health and quality of life by preventing and controlling disease, injury, and disability.”
—CDC Mission Statement
How did we get to this point?
Follow up from the Introductions exercise and HANDOUT 0.2 What is Public Health?

3. Objectives Define public health.
Describe conditions that existed before the advent of modern public health.
Describe three public health interventions since 1900 that have increased life expectancy in the U.S.
Purpose of this module:
To understand roots of public health – a very fast run-through of history

4. Survive the Tribe
Public health = the most ancient of human activities.
From the beginning of human history, human beings have needed to ensure the survival of the larger community or the tribe.
Focus has been beyond the individual to the whole population.
EXAMPLE, early tribes understood the need to protect mothers and infants. Ensuring maternal and child health continues to be a major focus of Public Health today.
Societies that survive develop “public health measures” -- strong rules/regulations/taboos/powers to protect the community’s health:
Imbedded in the belief system (religion, superstitions, and in the case of modern public health, science).
Imposed by the political system.

5. Requirements for Survival
Care
Shelter
Populations must protect conditions related to these requirements for survival:
Air – poor quality can cause sickness or death, often in minutes.
Water – poor quality or lack of water can cause sickness or death in days.
Food – can sustain or injure; poor quality or lack of food can cause sickness or death in days or weeks.
Shelter – must have, at least on a seasonal basis.
Care and mutual support – especially around birthing and protecting the new generation.
All these requirements continue to be essential for group survival and success.
Food
Water
Air

6. Public Health Codes Tribal Rules Hieroglyphs Chinese Empire
Bible (Leviticus)
Koran
Roman Senate
Salus populi: suprema lex esta
Powerful codes and regulations have existed in multiple cultures, in virtually all civilizations, Eastern and Western
Health codes are based on the society’s belief system and the society’s understanding of health/disease
Salus populi: suprema lex esta = “Let the welfare of the people be the supreme law”
Requirements and prohibitions (tribal rules) are passed on through oral traditions
EXAMPLES
Don’t camp in damp, swampy places
Don’t use still or unclear water
Don’t allow animal waste inside shelters
Avoid certain foods, plants or animals
Assist with feeding of infants
Oral traditions eventually become part of written codes (e.g., in China, Middle East, North Africa, South and Central America)
EXAMPLE: The Bible, the book of Leviticus spells out the rabbi’s power to evict lepers and demolish their housing (based on fear of the disease and the misperception that it was communicable).
EXAMPLE: Both the Koran and the Bible have detailed food codes.

7. Timeline Ancient Greece Roman Empire Middle Ages
Birth of Modern Medicine
“Great Sanitary Awakening”
Modern Public Health
Very quick overview of major historical developments related to PH
Focus on/bias toward Western History
NOTE: This slide is an advanced organizer; a preview of the time periods examined in this section.

8. Ancient Greeks (500-323 BC) Personal hygiene Physical fitness
Olympics
Naturalistic concept
Disease caused by imbalance between man and his environment
Hippocrates
The public health messages haven’t changed all that much.
The Greeks understood the importance of washing hands, taking a bath, exercising and eating good food.
Naturalistic concept – ill health was caused by an imbalance between man and environment.

9. Hippocrates (b. 460 BC) Father of Western medicine
Causal relationships
Disease and climate, water, lifestyle, and nutrition
Coined the term epidemic
Epis (“on” or “akin to”)
Demos (“people”)
Hippocrates – father of Western medicine
Believed that illness had a physical and rational explanation.
Looked for and described causal relationship between disease and factors such as climate, soil, water, lifestyle and nutrition.

10. Roman Empire (23 BC – 476 AD) Adopted Greek health values
Great engineers
Sewage systems
Aqueducts
Administration
Public baths
Water supply
Markets
Romans
Built aqueducts to bring water into the city.
Plumbing technology was very advanced.
Replaced leaky clay pipes with lead pipes (unfortunately, Romans suffered from lead poisoning).
Collected taxes to support public services such as:
Public baths.
Water and sewage systems.
Restaurant inspection.

11. Roman Aqueducts Le Pont du Gard
This is the magnificent Pont du Gard in southern France The Romans constructed it between 500 and 523 B.C. as an aqueduct to carry fresh water to the city of Nimes.
Le Pont du Gard

12. Middle Ages (476-1450 AD) Shift away from Greek and Roman values
Physical body less important than spiritual self
Decline of hygiene and sanitation
Beginnings of PH tools
Quarantine of ships
Isolation of diseased individuals
In Europe during the Middle Ages (also called the “Dark Ages”)
Decline of hygiene and sanitation -- general abandonment of the Greek and Roman values of hygiene and sanitation.
Faith and prayer were the accepted treatment for illness.
Even during the middle ages, some important public health tools developed:
An understanding that isolating ships and diseased individuals could help prevent the spread of disease.
Quarantine of ships and travelers for 40 days.
Persons denied entry to infected ships.
Background

13. The Plague Death of 25% to 50% of population
Epidemic disease in Western Europe between 1348 and AD (the end of the Middle Ages through the Renaissance)
The Plague (The Black Death)
Worst from
Killed at least 25 million people in Europe (1/3 of the population).
Killed more than 60 million worldwide.
Boccaccio said that the victims, "ate lunch with their friend and dinner with their ancestors in paradise."
Map graphic courtesy of “The Black Death, 1348," EyeWitness to History, (2001)
Background
The plague spread when people fled to other cities. It is believed the plague originated in Asia, and moved west with Mongol armies and traders. The plague traveled on trade routes and caravans. In 1348 a ship docked at in Dorset, England. On this ship were flea-infested black rats that carried a disease, which was to wipe out almost 33% of the British population. The disease would plague Britain's shores for 300 years, triggering repeated epidemics.
Two main types of fatal plague in this period: pneumonic and bubonic. Pneumonic plague was spread by sneezing and bubonic plague by flea bites. The fleas that delivered the deadly bite would leap from dead rats to humans and could survive in any warm place. Pneumonic fever was more contagious because it was air-based. Symptoms of bubonic plague would start with a high temperature, headaches and vomiting, followed by lumps appearing in the groin and armpits. Eventually the victim would be covered all over with black bruises; death would shortly follow.
Such a devastating disease was bound to bring huge changes to medieval society. Some writers complained the disease had brought out the worst in people. In other cases, because so many had died, labor was in short supply.

14. Renaissance (1400-1600 AD) Global Exploration
Disease, spread by traders and explorers
Killed 90% of indigenous people in New World
Into the Renaissance:
Arts and literature and exploration flourished.
Explorers and traders unknowingly spread diseases like smallpox, measles, and typhoid.
This method of the spread of disease still exists today (e.g., spread of SARS across countries, albeit in a very accelerated form).
Background (global disease spread)
“The Spanish inadvertently owe much of their success in conquering the Aztecs and Incas in Mexico in the 16th century to smallpox. Unlike the Spanish, the native Indians had no immunity to the disease, having never encountered it before. It wiped out huge numbers of them. A century later the North American Indians suffered a similar devastation. In the 18th century smallpox decimated the aborigines when it reached Australia, the last corner of the world to have escaped its ravages.”
Source:
Born to Die : Disease and New World Conquest, by Noble David Cook (1998)
Explains how the conquest of the New World was achieved by a handful of Europeans--not by the sword, but by deadly disease. The Aztec and Inca empires were destroyed by a few hundred Europeans whose most important weapons, though the conquerors did not realize it at the time, were diseases previously unknown in the Americas. The end result of the colonizing experience in the Americas, whether of the Portuguese, Dutch, Spanish, English, or French, was the collapse of native society.
Background (Age of Exploration)
Latter half of the fifteenth through the sixteenth centuries
Genoese navigator, Christopher Columbus (1451–1506)
First English voyage around the world by Sir Francis Drake (ca. 1540–1596)
Vasco da Gama's (ca. 1460–1524) voyage to India, making the Portuguese the first Europeans to sail to that country and leading to the exploration of the west coast of Africa
Bartolomeu Dias' (ca. 1450–1500) discovery of the Cape of Good Hope
Ferdinand Magellan's (1480–1521) voyage to find a route through the Americas to the East, which ultimately led to discovery of the passage known today as the Strait of Magellan
Source:

15. Age of Reason and Enlightenment (1650-1800 AD)
Birth of Modern Medicine
William Harvey
1628 theories of circulation
Edward Jenner
1796 cowpox experiment
Coined the term vaccine (vacca, Latin for “cow”)
A renewed interest in Reason & Enlightenment laid foundation for more scientific explorations
Graphic: statue of Edward Jenner vaccinating eight-year-old James Phipps
Background
William Harvey (English physician, )
Demonstrated function of the heart and circulatory system
1628 publication of his theories in “An Anatomical Study of the Motion of the Heart and of the Blood in Animals”
First to suggest that humans and other mammals reproduced via the fertilization of an egg by sperm.
Used dissection (no microscope) to create theories
Edward Jenner (English physician, )
1796 vaccination of eight-year-old James Phipps proved that cowpox or swinepox provided immunity against smallpox (age-old tradition that people who had earlier caught the mild disease of cowpox did not catch the normally fatal disease of smallpox – on May 14, 1796 Jenner inoculated Phipps with swinepox and on July 1 he inoculated Phipps with smallpox)
Coined the word vaccine from the Latin vacca for cow,
Laid the foundation of modern immunology as a science

16. Industrialization Urbanization (1800s)
Industrialization and urbanization in the 19th Century produced a new set of public health problems:
Slums
Poverty
Disease
Worse than 1000 years before!
At this time, English working class had a life expectancy of 7 years!
Background:
Lower East Side Tenement Museum, New York City
Virtual Tour: “It was easy to overlook 97 Orchard Street. The building was but one of the thousands of tenements that sprouted up on the Lower East Side during the nineteenth century. However, for Lukas Glockner, 97 Orchard Street wasn't just another tenement; it was a ticket to prosperity. When the German immigrant opened his tenement in 1863, he was hoping to turn a profit by providing cheap homes to the immigrants who were flooding into Manhattan. The tenement fulfilled Glockner's dreams: people filled the building and swelled his pocketbook. Indeed, between 1863 and 1935, 7000 tenants lived in 97 Orchard Street. The lives of some of these residents are the basis of our Virtual Tour.”

17. Great Sanitary Awakening (1800s-1900s)
Growth in scientific knowledge
Humanitarian ideals
Connection between poverty and disease
Water supply and sewage removal
Monitor community health status
The great sanitary awakening is the birth of modern public health:
Great strides in scientific knowledge to help understand the origin and treatment of disease.
Interest in humanitarian ideals
Acknowledgement of the connection between poverty and disease.
Even today, poverty is the single best predictor of poor health.
Returning to what the Romans had figured out, new infrastructure for clean water and sewage removal
Birth of a system to monitor the health status of communities
Background
Ashton (1990) describes four phases of the development of modern-day public health:
An initial environmentally-focused phase which addressed infectious diseases related to “urbanization, poverty and squalor”. This phase lasted from the 1840s to the late 19th century.
A second phase of personal preventive medical services related to immunization, family hygiene, health education and family planning which began with the development of vaccines in the late 19th century and lasted until the 1930s.
A therapeutic era that began with the development of insulin and antibiotics in the 1930s and persists until today. Its focus is on improving population health through the provision of organized medical services deploying effective therapeutic technologies.
A recognition that the ‘environment’ is also social, economic and psychological and that ‘healthy public policy’ (Hancock, 1982) is an appropriate part of this new public health.

18. Dr. John Snow (1813-1858) John Snow
The “George Washington” of public health.
Well-educated despite being raised in a working class family.
Man of many interests, a physician to Queen Victoria, and a mathematician.
Became very concerned about the cholera outbreaks in London that were devastating the population. He made careful observations of the disease, who caught it, where the deaths occurred.
John Snow and the Broad Street Pump
Classic tale of basic epidemiology, the core science of public health.
Before people understood the role of bacteria in causing disease and without any of the modern laboratory supports or computer analysis, Snow developed a theory of the source of the outbreak.
More information:

19. Epidemiology (1854) EPIDEMIOLOGY
The study of the distribution and determinants of disease in populations, to seek the causes of both health and disease.
(see Module 2: Modern Mission of Public Health)
John Snow and the Broad Street Pump
Dr. Snow devised a simple map identifying the number and distribution of cases of the disease in the community and the specific water company serving each house in which disease occurred.
With close observation and mathematical calculations, he hypothesized that one water pump (on Broad Street) was responsible for transmission of much of the disease.

20. Broad Street Pump
Snow took the handle off the Broad Street pump, and the cholera outbreak subsided.
Using epidemiologic practices, he identified (and stopped) the source of the disease.

21. Map of Diphtheria Deaths New York City May 1, 1874 to December 31, 1875
Early Epidemiology
Example of early Geographic Information Systems (or GIS)
Like J. Snow, trying to understand a disease by studying the location of its spread.
Picture caption: map showing deaths from Diphtheria in the City Of New York from May 1st 1874 to December 31st Made under the direction of W. De F. Day, M.D., sanitary superintendent, Health Dept.
Made under the direction of
W. De F. Day, M.D., Sanitary Superintendent, NYC Health Dept.

22. Growth in Scientific Knowledge
Louis Pasteur
1862 germs caused many diseases
1888 first public health lab
Robert Koch
1883 identified the vibrio that causes cholera, 20 years after Snow’s discovery
Discovered the tuberculosis bacterium
Tremendous growth in scientific knowledge made modern public health possible:
Relationship between germs and disease:
Until the late 1800s, NO CONCEPT of bacteria and germs.
Theories of “miasma” or bad air were thought to cause disease.
Use of disinfectants
Improved obstetrical care
Use of inoculation
Introduction of anesthetics in surgery
Revival of sanitary measures
Decline in maternal and infant mortality.
NOTE: A vibrio is a type of bacteria whose natural environment is water.
Background
Louis Pasteur, 1822–95.
French chemist.
His early research consisted of chemical studies of the tartrates, in which he discovered (1848) molecular dissymmetry.
His experiments with bacteria (1862) conclusively disproved the theory of spontaneous generation and led to the germ theory of infection.
His work on wine, vinegar, and beer resulted in the development of the process of pasteurization.
Of great economic value also was his solution for the control of silkworm disease, his study of chicken cholera, and his technique of vaccination against anthrax, which was successfully administered against rabies in 1885.
In 1888 the Pasteur Institute was founded in Paris, with Pasteur as its director, to continue work on rabies and to provide a teaching and research center on virulent and contagious diseases.
From The Columbia Encyclopedia, Sixth Edition.  2001
Robert Koch,
showed that anthrax is caused by a specific organism.
Koch's postulates for proving that a particular micro-organism is the cause of a particular disease greatly advance the Germ Theory of Disease. They are still used today in a slightly modified form.
Biography available at:

23. Sanitary Reform England
1842 Edwin Chadwick’s “Survey into the Sanitary Condition of the Labouring Classes in Great Britain”
Landmark research
Graphic descriptions of filth and disease spread in urban areas
1848 General Board of Health
During the 1800s changes occurred after the rise of industrialization and nationalism.
1837 first modern sanitation legislation was enacted.
1842 Chadwick Report
Pauper children
Child labor (indentured workers in mines and factories)
More than half of working class children died before their fifth birthday
Average age of death for common laborers was 16
Chadwick’s Report led to reforms in sanitation, health care, and treatment of poor and working classes
Charles Dickens’ novels brought public attention to the desperate position of the poor and the squalid conditions in which they were living.
Background
Edwin Chadwick,
Researched and published three-volume "Survey into the Sanitary Condition of the Labouring Classes in Great Britain,“ which was a landmark in social history, with graphic descriptions of how the filth in air, water, soil and surroundings was a major factor in the spread of disease, especially in urban areas.
This led to reforms in sanitation, health care and treatment of poor and working classes.
Chadwick, who was appointed Sanitation Commissioner, had several ideas on how public health could be improved. This included a constant supply of fresh clean water, water closets in every house, and a system of carrying sewage to outlying farms, where it would provide a cheap source of fertilizer.
Attempts to introduce public health reforms were resisted successfully by people with vested interests, for example, landlords and water companies, in maintaining the present system.
Source:
Charles Dickens ( )
Oliver Twist (1838)
A Christmas Carol (1843)
Bleak House (1853)
Hard Times (1854)
DICKENS: “Jo lives - that is to say, Jo has not yet died - in a ruinous place, known to the likes of him by the name of Tom-all-Alone's. It is a black, dilapidated street, avoided by all decent people; where the crazy houses were seized upon, when their decay was far advanced, by some bold vagrants, who, after establishing their own possession, took to letting them out in lodgings. Now, these tumbling tenements contain, by night, a swarm of misery. As, on the ruined human wretch, vermin parasites appear, so, these ruined shelters have bred a crowd of foul existence that crawls in and out of gaps in walls and boards; and coils itself to sleep, in maggot numbers, where the rain drips in; and comes and goes, fetching and carrying fever, and sowing more evil in its every footprint than Lord Coddle, and Sir Thomas Doddle, and the Duke of Foddle, and all the fine gentlemen in office, down to Zoddle, shall set right in 500 years - though born expressly to do it.” (from Bleak House)
Source:

24. Sanitary Reform
U.S.
1850 Lemuel Shattuck’s “Report of the Sanitary Commission of Massachusetts”
1869 State Board of Health
Lemuel Shattuck (Teacher, historian, statistician, publisher, and visionary)
Developed the original plan that led to the establishment in 1869 of the nation’s first Board of Health in Massachusetts. First local health department in the U.S. were along the East Coast in the late 1700s.
First to identify major MA public health issues that could be applied to the entire nation, including the recommendation to:
Establish the accurate keeping of health records and vital public health statistics to use as tools to fight disease.
Improvement of public sanitary conditions by developing a system of sanitary inspection.
The development of a vaccination program.
The study of tuberculosis.
The dissemination of public health information to all citizens.
The control of potentially dangerous products; control food adulteration.
The establishment of nursing schools all to be used to promote better health.
Mental disease supervision.
Control alcoholism.
Offer medical school courses in sanitary science.
Educate immigrants about sanitation.
Introduce preventive medicine in clinical practice and offer routine physical examinations.
Source: Photograph from Lemuel Shattuck Hospital, Boston, MA at
Background

25. Redefining the Unacceptable
“The landmarks of political, economic and social history are the moments when some condition passed from the category of the given into the category of the intolerable…The history of public health might well be written as a record of successive redefinings of the unacceptable.”
- Geoffrey Vickers, Secretary, Medical Research Council, Great Britain, 1958
The Sanitary Reform Movement
Example of a society no longer accepting the squalid living conditions such as found in tenements.

26. Redefining the Unacceptable
In the next 5 minutes:
Brainstorm and record a list of “things” affecting the public’s health that have passed from tolerable (accepted) to intolerable (unaccepted).
Include items that you wish would become unacceptable.
Group Activity
May be done in small groups or 2-person teams – ask each team to report one item.
If class is small, accept answers from individuals and write list on a blackboard or flip chart.
“Things” can be conditions, behaviors, diseases, physical states, maladies, circumstances, etc.
Some answers include:
Child labor
Smoking in the workplace, restaurants, etc.
AIDS in Africa – Is just starting to be unacceptable?

27. Sanitation Revolution
Clean water; water treatment
Food inspection
Soaps, disinfectants, and pharmaceuticals
Personal hygiene (bathing)
Public works departments; garbage collection, landfills, and street cleaning
Public health departments and regulation
The death rate in children drops and the average life span increases over the years from less than 40 to 74.
By Greater acceptance of the germ theory of disease begins to shift the job of garbage removal from health departments to public works departments. Health officers, it is felt, should spend their time battling infectious diseases, not cleaning up "public nuisances" such as garbage.
Background

28. Twentieth Century U.S. Mortality Rate: 1900-2001
Look at the BIG PICTURE to summarize accomplishments of PH in the 20th Century
Ask this question:
WHAT DO YOU THINK IS THE REASON FOR THE GREAT DROP IN MORTALITY FROM ?
Answer: clean water is the primary contributor to people living longer. American life expectancy has increased from 45 to 75 years over the past century. Only 5 of those additional years can be attributed to the medical care system. (M.J. Schneider, Intro to Public Health, p. 7) Life expectancy data from J.P. Bunker et al., “Improving Health: Measuring Effects of Medical Care,” Milbank Quarterly 72(1994):

29. Public Health Nursing Nursing
Nurses are the single largest group employed in PH
Public health nurses visited families to help them understand how to promote good health and prevent disease.
Informing, educating, and empowering people about health issues is one of the 10 essential services of public health.
Credits: DHEW book. Department of Health, City of New York
Pictures in this slide:
Photos show nurses boiling milk for babies, showing mothers how to care for their babies
Bottom left: Visiting nurse shows mother how to sterilize bottles. Courtesy of the National Library of Medicine.
Top right: Photograph of Philadelphia’s Visiting Nurses. (calendar from Visiting Nurse Association of Greater Philadelphia). Philadelphia’s Visiting nurses of 1909 prepare to leave their headquarters at 1340 Lombard Street to begin their daily rounds.

30. Ten Great Achievements in Public Health, 1900-1999
Vaccination.
Motor-vehicle safety.
Safer workplaces.
Control of infectious diseases.
Decline in deaths from coronary heart disease and stroke.
Safer and healthier foods.
Healthier mothers and babies.
Family planning.
Fluoridation of drinking water.
Recognition of tobacco use as a health hazard.
OPTIONAL
This is the CDC’s list of the 10 great achievements in public health of the last century.
Can be debated / discussed (EXAMPLE: clean water not included? fluoridation included?)
CDC, Morbidity and Mortality Weekly Report, December 24, 1999 / 48(50); Available at:

31. Challenges Ahead New and Persistent Problems in Public Health

32. Cause of Death (U.S. 1990) Tobacco 19% Diet/Activity 14% Alcohol 5%
Microbial agents 4%
Toxic Agents 3%
Firearms 2%
Sexual Behavior 1%
Motor Vehicles 1%
Illicit Drug Use <1%
Actual causes behind the diseases
Half of all 1990 deaths are due to these 10 factors
Total of 38% from tobacco, diet, and exercise (still on the list, centuries after the Greeks recognized the importance) and alcohol. These are facets of lifestyle.
Top 3 causes are self-inflicted.
What kills people has changed – shift from infectious diseases to behavior-related deaths and chronic disease. What are the ramifications?
Science for 21st century may be behavioral and political. (social sciences)
The social and behavioral sciences, working with communities for change, have become as important tools as the “hard” sciences (chemistry, biology).
CHALLENGE: Acknowledge that behavior (lifestyle) affects health. (e.g., tobacco causes heart disease).
Tobacco
Diet/Activity
McGinnis & Foege, JAMA, 1993

33. World Population Growth
2010
Population (in millions)
CHALLENGE
In public health, we stand back to look at aggregate numbers to understand trends that are not immediately apparent. This big picture look at the population of our planet has implications for every aspect of public health – environmental health, communicable disease, safe and adequate food and water etc.
1850
Year

34. Health Disparities Access and Outcomes Infant Mortality
Cancer Screening and Management
Cardiovascular Disease
Diabetes
HIV Infection/ AIDS
Immunizations
CHALLENGE “Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.”
DHHS selected six focus areas in which racial and ethnic minorities experience serious disparities in health access and outcomes:
1. Infant Mortality
U.S. national average deaths per 1,000 live births (1996 data) -- U.S. ranks 24th compared with other industrialized nations
Rate for white infants per 1,000 (1996)
Rate for black infants per 1,000 (1996) -- nearly 2.5 that of white infants
Rate for American Indian infants per 1,000 (1995) -- some Indian communities approach rates that are twice the national rate
Rate for Hispanic infants per 1,000 (1995) per 1,000 among Puerto Rican subgroup (1995)
2. Cancer Screening and Management
Second leading cause of death in the U.S. (accounts for more than 544,000 deaths each year)
The chances of developing cancer in a lifetime are nearly 50 percent for men and nearly 40 percent for women
About half of those who develop the disease will die from it.
Many minority groups suffer disproportionately from cancer:
For men and women combined, blacks have a cancer death rate about 35 percent higher than that for whites (171.6 vs per 100,000).
The death rate for cancer for black men is about 50 percent higher than it is for white men (226.8 vs per 100,000).
The death rate for lung cancer is about 27 percent higher for blacks than for whites (49.9 vs per 100,000).
The prostate cancer mortality rate for black men is more than twice that of white men (55.5 vs 23.8 per 100,000).
The incidence rate for lung cancer in black men is about 50 percent higher than in white men (110.7 vs per 100,000).
Native Hawaiian men have elevated rates of lung cancer compared with white men.
Alaska Native men and women suffer disproportionately higher rates of cancers of the colon and rectum than do whites.
Vietnamese women in the U.S. have a cervical cancer incidence rate more than five times greater than white women (47.3 vs. 8.7 per 100,000). Hispanic women also suffer elevated rates of cervical cancer.
3. Cardiovascular Disease
4. Diabetes
5. HIV Infection/AIDS
6. Immunizations
Background

35. Multiple Determinants of Health
Policies and Interventions
Behavior
Physical Environment
Social Environment
Individual
CHALLENGE: Who will keep the public healthy?
Public health education is now based on
Ecological Model for understanding health outcomes – EMPHASIZE THE LINKAGES & INTERRELATEDNESS OF THESE FACTORS
Emerging areas such as informatics, genomics, communication, competence and sensitivity to cultural differences, community-based learning and research, global health, policy and law, and ethics.
Collaborations that link public health and medicine in disease prevention and chronic care.
Describe the PH model in the slide
Background: Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century on the NAP website <
Handout 1.1 Determinants (gives another point of view)
PUBLIC HEALTH ADDRESSES ALL FACTORS
Individual behaviors and environmental factors are responsible for about 70 percent of all premature deaths in the United States
Developing and implementing policies and preventive interventions that effectively address these determinants of health can reduce the burden of illness, enhance quality of life, and increase longevity.
Individual biology and behaviors influence health through their interaction with each other and with the individual’s social and physical environments.
In addition, policies and interventions can improve health by targeting factors related to individuals and their environments, including access to quality health care.
Social environment includes interactions with family, friends, coworkers, and others in the community. It also encompasses social institutions, such as law enforcement, the workplace, places of worship, and schools.
Policies and interventions can have a powerful and positive effect on the health of individuals and the community. Examples include health promotion campaigns to prevent smoking; policies mandating child restraints and safety belt use in automobiles; disease prevention services, such as immunization of children, adolescents, and adults; and clinical services, such as enhanced mental health care.
Poverty is one of the greatest threats to health. It frustrates people's ambitions for building a better future, undermines their self-care actions and creates a sense of powerlessness and loss of control over their lives and the determinants of health. Measures that reduce poverty and build capacity are effective in creating an enabling environment for promoting health. Health promotion uses different strategies and approaches to develop capacity and change people’s social circumstances and health behaviors. These interrelated strategies aim to:
Build healthy public policy.
Create a supportive environment for health.
Strengthen community action.
Develop personal skills.
Reorient health services.
Source:
Biology
Access to Quality Health Care
Source: U.S. Department of Health and Human Services, Health People 2010

36. Globalization Emerging infectious diseases
Reemerging infectious diseases
Health disparities between industrial and nonindustrial countries
GLOBAL CHALLENGES
What are examples of "emerging" infectious diseases?
New infections resulting from changes or evolution of existing organisms.
Previously unrecognized infections appearing in areas undergoing ecologic transformation
Answer: HIV/AIDS, Lyme disease and hepatitis C.
What are examples of “re-emerging" infectious diseases?
Known infections spreading to new geographic areas or populations
Old infections reemerging as a result of antimicrobial resistance in known agents or breakdowns in public health measures
Answer: Cholera, Dengue fever, Diphtheria: Meningococcal meningitis, Yellow fever
What are examples of international health disparities?
Mortality rate of children under five
Percentage of children who are moderately or severely underweight
Access to primary schooling
Risks from armed conflict
Risks from HIV/AIDS
Total health care expenditure
Vaccination programs
Background
What causes emergence or re-emergence of infectious diseases?
Several factors contribute to the emergence and re-emergence of infectious diseases, but most can be linked with the increasing number of people living and moving in the world: rapid and intense international travel; overcrowding in cities with poor sanitation; substantially increased international trade in food, mass distribution of food and unhygienic food preparation practices; increased exposure of humans to disease vectors and reservoirs in nature; and alteration of the environment and climatic changes which have a direct impact on the composition and size of the population of insect vectors and animal reservoirs. Other factors include a deteriorating public health infrastructure which is unable to cope with the needs of the population.
What new technologies combat emerging diseases?
Genetic immunization, which involves injecting DNA encoding a pathogen protein directly into muscle tissue, is a new approach that may have important implications for controlling emerging disease outbreaks. DNA vaccines, as they are known, have shown promise in several disease models.