Public HealthAn IntroductionRenata
What Is Public Health?
It is often easier to talk about examples of public health initiatives, such as vaccination programs and milk pasteurization, than to describe exactly what public health is.http://www.youtube.com/watch?v=R1aloiSY3dI
What Are You Studying?Suppose your Uncle Joe stops you and asks you what is Public Health?What would you tell him?Uncle Joe
Public Health Accomplishments: A Field That Makes A Difference Technology, science, the arts: Lots of disciplines improve and enrich our lives. But none can match public health in extending the length and improving the quality of life in the United States over the past century.
Increased Years of Life1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000.*
Age of Death
U.S. Life Expectancy, 1900-2000
How did we add 30 years in one century?
Mostly through the accomplishments of public health. Five of the 30 years can be attributed to improvements in medicine and drugs. The other years are due to various public health initiatives.
Contributions to Increase Life Expectancy
Public Health Accomplishments1. Vaccination 2. Motor-vehicle safety 3. Safer workplaces 4. Control of infectious diseases 5. Decline in deaths from coronary heart disease and stroke 6. Safer and healthier foods 7. Healthier mothers and babies 8. Family planning
The Evolving Need for Public Health 1700s-1800sThe Age of IndustrializationPeople moved from the farms to the citiesSmall pox inoculations - Lady Mary Wortley MontaguDevelopment of the smallpox vaccine - Edward JennerIntroduction of epidemiology John SnowThe Germ Theory of Disease - Louis Pasteur The four postulates of infectious disease Robert KochThe unhealthy conditions of New York City tenements Lillian Wald
Lady Mary Wortley MontaguLillian Wald
Snow: The Initial Investigations Snow on Cholera http://www.ph.ucla.edu/epi/snow/Snowpart1_files/frame.htmThe Initial Investigations http://breeze.unc.edu/p60491740/Next Steps http://breeze.unc.edu/p15812471/Snow Takes Action http://breeze.unc.edu/p24403330/Further Investigation http://breeze.unc.edu/p17552645/The Case of the Hampstead Widow http://breeze.unc.edu/p35464436/
The Evolving Need for Public Health 1900s to the Present1918 Influenza PandemicIn 1964, the U.S. Surgeon General report on cigarette smoking and its connection with cancerIn 1981, the HIV-AIDS virus was first recognizedIn 1990, as awareness of the relationship between diet and disease increasedIn 2001, the threat of bioterrorism
Development of the U.S. Public Health Infrastructure 1798. The U.S. Public Health Service
The first marine hospital owned by the Federal Government was purchased from the State of Virginia in 1801 and was located at Washington Point in Norfolk County.
Other Public Health Infrastructure Developments 1798: First local public health board1870s: State boards of health createdLate-1800s: Shift to social reform as strategy for public health1970s 1990s: Public healths responsibilities broaden to include chronic diseases
Lemuel ShattuckNew York, New York. Bread line beside the Brooklyn Bridge approach, 1930s.
What Are the Leading Health Indicators?Will be used to measure the health of the Nation over the next 10 years. Each of the 10 Leading Health Indicators has one or more objectives from Healthy People 2010 associated with it.Each were selected on the basis of their ability to motivate action, the availability of data to measure progress, and their importance as public health issues.
What Are the Leading Health Indicators? (continued)Physical Activity Overweight and Obesity Tobacco Use Substance Abuse Responsible Sexual Behavior Mental Health Injury and Violence Environmental Quality Immunization Access to Health Care
Who is Responsible for the Publics Health?Government agenciesfederal, state and local Non-governmental agencies, such as non-profit organizations.
Overview of Health and Human Services Responsible for protecting the health of Americans and providing essential human services, especially for citizens least able to help themselvesit is charged with most (but not all) public health activities. The Secretary of Health and Human Services serves as a member of the President's Cabinet. is appointed by the President and must be approved by the U.S. Senate.
National Organizations For Public Health Professionals American Public Health AssociationAssociation of State and Territorial Health OfficialsNational Association of City and County Health OfficersHRSA Public Health Training Centers Network
State Authority and Responsibilities The more complete and coordinated structure for public health activities is at the state and local levels.Various states have taken different approaches to organizing and administering public health.Centralized vs. decentralized
Local Health Departments and Boards of Health Each community has its own unique local public health systemGenerally, public health decisions at the local level are made by professionals at regional or county health departments and by their boards of health.Public health practitioners at these departments are responsible for ensuring that all members of the community are served. Generally, a local board of health has primary responsibility and legal authority for public health decisions.
Role of Non-Governmental Entities Organizations that are not part of the government also play a vital role in the U.S. public health infrastructure. These organizations include hospitals, health care providers in private practice, and health plans. Private, non-profit organizations, too, contribute to public healths mission. Among them are the United Way, American Red Cross and American Cancer Association.
Summary of Public Health Organizational Structure Primary responsibility and authority for public health in the U.S. is assigned to federal, state and local public health agenciesFederal agencies set policy and standards and provide guidance and funding; State agencies define policies and establish and help fund local or regional public health initiatives; and Local/regional health departments implement public health programs.
*1. Vaccination Resulted in eradication of smallpox, elimination of poliomyelitis in the Americas and control of measles, rubella, tetanus, diphtheria and Haemophilus influenzae type b in the U.S. and other parts of the world.2. Motor-vehicle safety Resulted in large reductions in motor-vehicle-related deaths due to safer vehicles and highways and efforts to change personal behavior (e.g., increased use of safety belts, child safety seats and motorcycle helmets, as well as decreased drinking and driving).3. Safer workplaces Resulted in reduction of approximately 40 percent in the rate of fatal occupational injuries.4. Control of infectious diseases Resulted in dramatic reduction of infections, such as typhoid and cholera, through clean water and improved sanitation, and greater control of infections, such as tuberculosis and sexually transmitted diseases, through the discovery of anti-microbial therapy.5. Decline in deaths from coronary heart disease and stroke Resulted in 51 percent decrease in the death rate from coronary heart disease through efforts to modify behaviors and reduce risk factors, such as smoking and high blood pressure, and to provide better access to early detection and treatment. 6. Safer and healthier foods Resulted in near elimination of major nutritional deficiency diseases, such as rickets, goiter and pellagra, in the U.S. through the identification of essential micronutrients and establishment of food-fortification programs.7. Healthier mothers and babies Resulted in 90 percent decrease in infant mortality and 99 percent decrease in maternal mortality through better hygiene and nutrition, availability of antibiotics, greater access to health care and technologic advances in maternal and neonatal medicine.8. Family planning Resulted in altered social and economic roles of women, made possible by: family planning and contraceptive services; smaller family sizes and longer intervals between the birth of children; increased opportunities for pre-conceptional counseling and screening; fewer infant, child and maternal deaths; and use of barrier contraceptives to prevent pregnancy and spread of sexually. transmitted diseases9. Fluoridation of drinking water Resulted in reductions in tooth decay (40 to 70 percent in children) and of tooth loss in adults (40 to 60 percent); contributed to effectively preventing tooth decay, regardless of socioeconomic status or access to care. 10. Recognition of tobacco use as a health hazard Resulted in prevention of millions of smoking-related deaths, changes in social norms to prevent initiation of tobacco use, promote cessation of use and reduce exposure to environmental tobacco smoke.
*Age of Industrialization In the 1700s, as people left farms and small villages for towns and cities, to make a living in the newly emerging industrial economy, conditions became ripe for the spread of infectious diseases.Crowded, unsanitary conditions and long hours of work in unsafe and often exploitative industries contributed to waves of disease, such as cholera, smallpox, typhoid, tuberculosis and yellow fever. As the diseases took their toll, however, several key discoveries that would eventually lead to the reduction and control of infectious disease occurred. Following are some of the highlights: Lady Mary Wortley Montagu, In 1717, introduced to England the Turkish practice of inoculating children with smallpox. In 1796, Edward Jenner further developed smallpox vaccine. In 1848, Dr. John Snow traced an outbreak of cholera to well water drawn from the pump at Londons Broad Street. Snow found the source by pinpointing on a map where cholera deaths occurred. The evidence led Snow to water drawn from the pump as the disease source. By identifying the source and persuading the city to close the pump, Snow helped prevent hundreds of cholera cases. His use of data was one of the earliest recorded examples of epidemiology (the use of statistics to study disease transmission), a key strategy of population-based public health practice.In the 1850s, Louis Pasteur discovered that most infectious diseases are caused by germs. (His discovery is referred to as the "germ theory of disease.") This discovery is considered among the most important in medical history. Jenners smallpox vaccine and Snows epidemiological discovery of one source of cholera in England were milestones achieved through deductive logic and common sense. But in 1884, Robert Koch developed four postulates that further guided understanding of infectious agents and disease. While Kochs study focused on the etiology (origin) of tuberculosis, his postulates were applied to other diseases as well. They held that:The organism must be found in all animals suffering from the disease, but not in healthy animals. The organism must be isolated from a diseased animal and grown in pure culture. The cultured organism should cause disease when introduced into a healthy animal. The organism must be re-isolated from the experimentally infected animal. In the late 1800s, in the United States, the tenements of New York City, brimming with newly arrived immigrants, led to poor public health conditions similar to those found in European cities earlier. Epidemics of smallpox, yellow fever, cholera, typhoid and typhus were not uncommon. Tuberculosis and malaria killed thousands of people each year. Children worked 12- to 14-hour days in sweatshops. Lillian Wald, viewed as one of the nations early public health nursing pioneers, devoted her life to addressing health needs of tenement populations. Read more about Lillian Wald at the Jewish Womens Archives. As nurses such as Lillian Wald and others sponsored by church and womens groups, hospitals, charitable services and, eventually, cities began caring for the sick in the tenements, the seeds for a more comprehensive government-sponsored public health service were sown. *What became of Snow and his theories?
Compelling as they are to modern readers who know the end of the story, Snow's exhaustive books, articles, and presentations immediately influenced the opinion of very few scientific or medical authorities of his day in England or in Europe. Snow's work, when it was read, was largely rejected as "untenable" and inconclusive. Those who did value Snow's work thought that contaminated water might predispose persons to cholera, but unlike Snow, they did not believe that it was a sufficient single cause.His now famous 1855 edition of On the Communication of Cholera had sold only 56 copies by the time Snow, a lifelong bachelor, died in 1858 at the age of 45 (Chave, 1958, p. 347). Virtually all authorities continued to hold complex airborne miasma theories of cholera transmission for several more decades. Recognition and acceptance of Snow's work would gradually increase for the next several decades, until the more foundational work of Koch and Pasteur cleared the way for contagion theory and documented the existence and disease-causing abilities of the "animalcules" (bacteria) hypothesized by Snow and others. Snow himself was not widely known in epidemiology or medicine until more than 75 years after his death, when epidemiologist Wade Hampton Frost republished Snow's work in Snow on Cholera in 1936. In short, Snow labored in public health for about ten years for no pay and in relative obscurity. He died unrecognized for having come very close to understanding the nature of cholera and its transmission. What became of the Broad Street Pump?
Astounding as it seems to modern readers, so few people of influence accepted Snow's waterborne theory of cholera that within several weeks after the outbreak, the Broad Street pump was back in service (Chave, 1958). Records show that throughout London, shallow street pumps like that in Broad Street continued to be used for more than twenty years, but their existence was increasingly fought by medical and sanitary reformers who warned of the danger they posed. Even when cholera was present, the pumps often remained in service.
What became of cholera?
In the 20th Century, sanitary improvements have largely eliminated cholera from industrialized countries. Cholera remains endemic in many areas of the world, however. The seventh cholera pandemic that began in Indonesia in 1961 continues. After a Peruvian outbreak in 1991, Central and South America saw more than one million cases and eleven thousand deaths through 1995, and the disease also continues to produce significant morbidity and mortality in Africa and Asia.*1900s to Today In 1918, an influenza pandemic killed an estimated 20 to 40 million people around the world, far more than had died during World War I, which ended the same year. In the world of public health, the pandemic established epidemiology as a key strategy for fighting disease. Read more about the flu pandemic of 1918 at http://www.stanford.edu/group/virus/uda/ *In 1964, the U.S. Surgeon General issued the first (of many) reports on cigarette smoking and its connection with cancer. The report was an early volley in what has grown to be a major public health emphasis: preventing smoking-related cancer deaths through public education, policy and promotion of the negative health impact of smoking and the benefits of not smoking. * In 1981, the HIV-AIDS virus was first recognized. Public health responded with initiatives to educate the public about the disease, its cause, how it is transmitted and how it can be prevented, as well as initiatives to provide treatment to AIDs patients.* In 1990, as awareness of the relationship between diet and disease increased, Congress passed the Nutrition Labeling and Education Act, requiring that all packaged foods have nutritional labeling and that health claims for foods meet standards set by Secretary of Health and Human Services. The goal: provide consumers with information on the nutrients in the foods they buy as a means of reducing the incidence of heart disease, cancer and other illnesses.* In 2001, the threat of bioterrorism in the U.S. became real when mail containing deadly anthrax spores was sent to several members of the U.S. Congress and other individuals. The incident, along with the Sept. 11 terrorist attacks on the U.S., led public health to consider and implement bioterrorism preparedness measures.*
*1798. The U.S. Public Health Service. The first marine hospital owned by the Federal Government was purchased from the State of Virginia in 1801 and was located at Washington Point in Norfolk County.The origins of a government public health infrastructure dates to the nations early days and its reliance on sea merchants, men vital to the transport of goods to and from the country. Seamen, as you can imagine, frequently fell victim to disease and injury. To provide care for sick or injured seamen, the federal government, in 1798, established a Marine Hospital Service, charged with building and administering marine hospitals at a number of port cities. *1798: First local public health board. With each advance in knowledge, from greater understanding of environmental controls for water sanitation and sewage treatment to measures for controlling the spread of diseases (quarantine, isolation and vaccination), some localities began creating health agencies to implement the controls.Baltimore is cited as one of the first to do so, in 1798.1850: Growth of local and state public health activities. Lemuel Shattucks Report of the Sanitary Commission of Massachusetts in 1850 outlined existing and future public health needs for that state. The report became Americas blueprint for development of a public health system. Shattuck called for the establishment of state and local health departments to organize public efforts aimed at sanitary inspections, communicable disease control, food sanitation, vital statistics and services for infants and children. 1870s: State boards of health created. Recognizing that infectious and environmental hazards do not respect local boundaries, the states began to develop their own public health boards and agencies after 1870. These agencies often had broad powers to protect the health and lives of state residents, although the clear intent at the time was that these powers be used to battle epidemics of infectious diseases.Late-1800s: Shift to social reform as strategy for public health. During the late 1800s, the focus of public health shifted from problems related to individuals, such as poor hygiene, to broad social reform. Poverty and disease came to be recognized as consequences of industrialization. Thus, it was believed that public health problems could be addressed through social reform in such areas as labor, employment, housing, education and the environment. 1930s-1960s: Shift from personal responsibility to social responsibility. The Great Depression of the 1930s created vast social insecurity that was beyond the capacity of individuals or local communities to adequately address.The federal government was permitted indeed, expected to intervene. This led to a shift from a non-interventionist federal government approach to a more active federal government role in the nations public health. This shift increased the influence of the federal government over public health in general and public health activities of state and local governments in particular. Later, in the 1940s and 1950s, polio epidemics led to federal funding for polio vaccine development and delivery. A nationwide program of vaccination was coordinated by federal, state and local agencies. Beginning in the 1960s, federal grant-in-aid programs designed to fill gaps in the medical care system nudged state and local governments further into providing public health services.The 1965 enactment of Medicare legislation under the Social Security Act marked a significant public health milestone. For the first time, people ages 65 and older were provided a publicly financed health insurance program. 1970s 1990s: Public healths responsibilities broaden. With infectious diseases largely abated through improved social conditions and disease prevention programs, public health increasingly began to focus on preventing chronic diseases, such as cancer, diabetes, stroke, heart disease and emphysema. Also, public health increasingly promoted healthy lifestyles, including improved diets, more exercise and reduced tobacco use.During this time, public health agencies provided a vast array of services, including early periodic screening, school nursing, immunization clinics, tuberculosis follow-up, prenatal and postnatal assessments and education, child development instructions, cardiovascular disease prevention and vision and hearing screenings. Home care services increased as payment sources grew through Medicare, Medicaid and veterans health services, insurance reimbursement and sliding fee charges. *What Are the Leading Health Indicators?The Leading Health Indicators will be used to measure the health of the Nation over the next 10 years. Each of the 10 Leading Health Indicators has one or more objectives from Healthy People 2010 associated with it. As a group, the Leading Health Indicators reflect the major health concerns in the United States at the beginning of the 21st century. The Leading Health Indicators were selected on the basis of their ability to motivate action, the availability of data to measure progress, and their importance as public health issues.The Leading Health Indicators are
*A description of how public health is structured in the U.S. is found in the introduction to Public Health: What It Is and How it Works, 3rd Ed. (2004), by B. J. Turnock. It reads: The public health infrastructure may be described as a complex network of people, systems, and organizations working at local, state, and national levels to protect the health of populations Promoting the health and safety of the local community requires the interaction of many health agencies and organizations in the private and public sectors. It has been estimated that the U.S. currently has more than 3,000 health departments in cities and counties and at least 3,000 Local Boards of Health. In addition, there are 59 state and territorial health departments that have varying interactions with local health authorities. The public health infrastructure also includes a number of other organizations, such as tribal health departments, laboratories, and community health organizations.*Within the federal government, the Department of Health and Human Services (HHS) is responsible for protecting the health of Americans and providing essential human services, especially for citizens least able to help themselves. As such, it is charged with most (but not all) public health activities. The Secretary of Health and Human Services serves as a member of the President's Cabinet. The Secretary is appointed by the President and must be approved by the U.S. Senate.
Office of the Surgeon General, one of the most visible positions in government from which to advocate healthy behaviors. National Institutes of Health (NIH). NIH is the steward of medical and behavioral research for the nation. Health Resources and Services Administration, the mission of which is to improve and expand access to quality health care for all. Centers of Disease Control and Prevention (CDC). The CDC is recognized as the lead federal agency for protecting the health and safety of people at home and abroad, providing credible information to enhance health decisions and promoting health through strong partnerships. The CDC serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. Indian Health Service (IHS) provides comprehensive health services (medical, dental and environmental health programs) through IHS and tribally contracted hospitals, health centers, school health centers and health stations. Special program concentrations are in disease prevention and health promotion, alcoholism, substance abuse, suicide, accidents, maternal and child health, nutrition and public health services. Substance Abuse and Mental Health Services Administration. SAMHSA works to build resilience and facilitate recovery for people with or at risk for substance abuse and mental illness. Agency for Health Policy Research and Analysis, which conducts research on health care systems; Agency for Healthcare Research and Quality Food and Drug Administration assures safety of food, drugs and medical devices.
*American Public Health Association. The American Public Health Association (APHA) is the oldest and largest organization of public health professionals in the world, representing more than 50,000 members from over 50 occupations of public health. Association of State and Territorial Health Officials. The Association of State and Territorial Health Officials (ASTHO) is the national nonprofit organization representing the state and territorial public health agencies of the United States, the U.S. Territories, and the District of Columbia. ASTHO's members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy, and to assuring excellence in state-based public health practice. National Association of City and County Health Officers. NACCHO is the national organization representing local public health agencies. NACCHO works to support efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity and supporting effective local public health practice and systems. HRSA Public Health Training Centers Network. This national network of centers funded by the Health Resources and Services Administration develops a range of academic and continuing education programming in core public health competencies.
*Most states recognized their responsibility for the welfare of citizens. Thus, the more complete and coordinated structure for public health activities is at the state and local levels.The various states have taken different approaches to organizing and administering public health. Some have a centralized public health structure; others have a de-centralized approach. For example, if your state has a centralized approach, you and other public health employees are state (not county) employees and the funding for programs and program direction comes from the state. If your state takes a decentralized approach, you and your fellow public health co-workers are probably employees of a county or region. Under a de-centralized approach, funding may come from the state, but decision-making is local. *Each community has its own unique local public health system made up of multiple and diverse public and private entities (such as non-profit organizations). Generally, however, public health decisions at the local level are made by professionals at regional or county health departments and by their boards of health.Public health practitioners at these departments are responsible for ensuring that all members of the community are served. Generally, a local board of health has primary responsibility and legal authority for public health decisions. (In contrast, some boards may serve an advisory role to the ultimate local public health governing body.) Implementation of local public health policy decisions is the responsibility of the local public health department staff. *In addition to federal, state and local public health agencies, organizations that are not part of the government also play a vital role in the U.S. public health infrastructure. These organizations include hospitals, health care providers in private practice, health plans and others that work independently of but alongside public agencies, to promote population health and prevent disease. Private, non-profit organizations, too, contribute to public healths mission. Among them are the United Way, American Red Cross and American Cancer Association.*Primary responsibility and authority for public health in the U.S. is assigned to federal, state and local public health agencies, each of which has distinct roles and responsibilities. Generally,Federal agencies set policy and standards and provide guidance and funding; State agencies define policies and establish and help fund local or regional public health initiatives; and Local/regional health departments implement public health programs. Responsibility for public health is shared broadly among governmental agencies and non-governmental organizations, such as hospitals, private clinics and health plans. Such non-governmental organizations, which also include private, non-profit agencies dedicated to addressing community health issues, play an important role in helping build healthy communities. Although the authorities, responsibilities and activities may vary across the various public health agencies, they have in common the core functions of public health: assessment, policy development and assurance. Youll learn about these in Unit 2: Principles and Practices.