Public Health Principles and Practices: A Platform for College Health Edward P. Ehlinger, MD, MSPH...

Public Health Principles and Practices: A Platform for College Health

Edward P. Ehlinger, MD, MSPHDirector and Chief Health Officer

Boynton Health ServiceUniversity of Minnesota

June 4, 2010

[email protected]

Ruth Westheimer born Karola Ruth Siegel on June 4, 1928

• "Talking from morning to

night about sex has helped my

skiing, because I talk about

movement, about looking

good, about taking risks."

http://upload.wikimedia.org/wikipedia/commons/3/3c/DrRuthWestheimerCrop.jpg

Rosalind Russell born on June 4, 1911

• “Flops are a part of life's

menu and I've never been

a girl to miss out on any

of the courses.”

http://en.wikipedia.org/wiki/Image:Rosalind_Russell_in_The_Casino_Murder_Case_trailer.jpg

Ruth Westheimer born Karola Ruth Siegel on June 4, 1928

• “Don't stint on

foreplay -- or

afterplay. Be

inventive!”

http://upload.wikimedia.org/wikipedia/commons/3/3c/DrRuthWestheimerCrop.jpg

Dik Browne American cartoonist died on June 4, 1989He wrote and illustrated Hagar the Horrible and

illustrated Hi and Lois

Examples of strips of his published on June 4th

Dik Browne American cartoonist died on June 4, 1989

Healthcare reform

Financial pressures

The future of College Health is uncertain• Healthcare reform will raise questions that will

threaten the existence of college health– “Everyone will have insurance so why have a health

service?”– “Everyone will have insurance so what is the need

for a health service fee?”• Some entrepreneurs may see healthcare

reform as an opportunity to gain some college health business.

• Some in college health may see healthcare reform as an opportunity to change the model of college health.

Rosalind Russell born on June 4, 1911

• "When something

happens to you, you

either let it defeat you,

or you defeat it.“

http://en.wikipedia.org/wiki/Image:Rosalind_Russell_in_The_Casino_Murder_Case_trailer.jpg

How will you respond to those questions and challenges?

How will you convince your college/university that what you provide is unique and best meets

the needs of students (and others) on your campus and the needs of

your institution?

Health is essential to the mission of Post-Secondary Education

• “When health is absent, wisdom cannot

reveal itself, art cannot become manifest,

strength cannot fight, wealth becomes

useless, and intelligence cannot be

applied.”• Herophilus of Chalcedon, 335-280 BCE

• Physician to Alexander the Great

No one provides the constellation of services offered by college health

• On-campus location• Interest in serving a unique population with

unique needs• Expertise in serving college students• Provides a constellation of services not

provided by any other provider– Services that meet the needs of students and the

campus– Services that help meet the needs of the broader

community

College Health ServicesService – Teaching - Research

• Medical Care/Primary Care (broadly defined)

• Dental Care

• Occupational Health

• Health Promotion/Wellness

• Health Education

• Student Development

• Environmental Health and Safety

• Public Health

Today is a BIG day in Public Health

June 4, 1912June 4, 1919

June 4, 1912• Massachusetts became the first state in the

US to set a minimum wage.

Income

0

2.5

5

7.5

10

12.5

0 1 2 3 4 5

lowest Income Groups highest

Dea

ths

per

1,0

00

June 4, 1919

Thursday, June 5, 1919

Suffrage Wins in Senate; Now Goes to States Constitutional Amendment Is Passed, 56 to 25, or Two More

Than Two-thirds

Women May Vote In 1920

Leaders Start Fight to Get Ratification by Three-fourths of States in Time

Debate Precedes Vote

Wadsworth Explains His Attitude In Opposition - Resolution Signed with Ceremony

19th Amendment

• The right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of sex. Congress shall have power to enforce this article by appropriate legislation.

19th amendment to the U. S. Constitution Dates of Ratification by States

• Illinois, June 10, 1919

• Michigan, June 10, 1919

• Wisconsin, June 10, 1919

• Kansas, June 16, 1919;

• New York, June 16, 1919

• Ohio, June 16, 1919

• Pennsylvania, June 24

• Massachusetts, June 25

• Texas, June 28, 1919

• Iowa, July 2, 1919;

• Missouri, July 3, 1919

• Arkansas, July 28, 1919

• Montana, August 2, 1919

• Nebraska, August 2, 1919

• Minnesota, September 8, 1919

• New Hampshire, September 10

• Utah, October 2, 1919

• California, November 1, 1919

• Maine, November 5, 1919

• North Dakota, December 1, 1919

• South Dakota, December 4, 1919

• Colorado, December 15, 1919

19th amendment to the U. S. Constitution Dates of Ratification by States

• Kentucky, January 6, 1920

• Rhode Island, January 6

• Oregon, January 13, 1920

• Indiana, January 16, 1920

• Wyoming, January 27, 1920

• Nevada, February 7, 1920

• New Jersey, February 9, 1920• Idaho, February 11, 1920

• Arizona, February 12, 1920

• New Mexico, February 21

• Oklahoma, February 28

• West Virginia, March 10

• Washington, March 22, 1920

• Tennessee, August 18, 1920.

• Became National Law August 26, 1920

• November 2, 1920 – Presidential election

– Warren Harding and Calvin Coolidge elected

1921- The Shepherd-Towner Maternity and Infant Protection Act

• Authorized grants for state

programs of maternal and

children's services

Sheppard Towner Act (Maternity and Infancy Care Act)

1921-1929

• First public grants-in-aid program in U.S.• Developed MCH units in state Health Depts• Birth registration (30 - 46 states)• Increased Public Health Nursing• Partnership of federal and state government• Not continued because of fear of socialism • Basis for Title V of Social Security Act

Core Functions of Public Health

• Assessment

• Policy Development

• Assurance– Institute of Medicine, Future of Public Health

John Sundwall, MD, Ph.D. • Director of University of Minnesota Health Service

1918-1921 University of Michigan Division of Hygiene and Public Health 1921-1941

• “Unfortunately, parents, students, and faculty regard a health service as little more than a clinic or hospital concerned only with illness and injuries, their diagnosis and treatment; and regard the health fee paid directly or indirectly by students as sickness insurance.”

John Sundwall, MD, Ph.D.• “Obviously, the best scientific treatment

and care of illness and injuries must be one of the major concerns of the Health Service, but, in addition, a health service must be, as the term signifies, a health service. It bears something of the same relation to the university community that a public health department bears to a municipality or county, however in a more progressive and advanced state, in the vanguard of the public health movement.”

C. E. A. WinslowDean, Yale School of Pubic Health

• “a university health service can

realize its possibilities of

leadership only if it visualizes

public health in the broadest

terms.”

• 1929

Prevailing View of U. S. Health Care System

Health Care System

PublicHealthSystem

MedicalCare

System

Health Care System = Public Health Subsystem + Medical Care Subsystem

College Health/Public Health View of Health System

HEALTH of the PUBLIC

Health CareOther

Influences

Public policies - Education - Economy Scientific advances - Housing

Knowledge - Social normsRecreation - Transportation

Media/Entertainment - Religion Income inequality - Sense of community

Many more

Core FunctionsAssessment

Policy DevelopmentAssurance

ApproachesHealth PromotionHealth Protection

Disease/Injury PreventionTreatment/rehabilitation

Medical Care

Clinical Preventive

Services

Community Health Services

Factors Influencing Health Status

Safer,Healthier

Population BecomingVulnerable

Becoming nolonger vulnerable

VulnerablePopulation Becoming

Afflicted

Afflictedwithout

Complications DevelopingComplications

Afflicted withComplications

Targetedprotection

Primaryprevention

Secondaryprevention

Dying fromComplications

Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

World of Providing…

• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…

Medical and Public Health Policy

DISEASE AND RISK MANAGEMENT

World of Transforming…

• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…

By Strengthening…

• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…

Healthy Public Policy & Public Work

DEMOCRATIC SELF-GOVERNANCE

Centers for Disease Control and Prevention Bobby Milstein

Scope of Public Health

Guiding principles: Prevailing View/College Health View

Medical Care

• Science-based

Public Health/College HealthPublic Health/College Health

Science-basedScience-based Data are important!

Basic and clinical research are important in medical care.

Surveillance, monitoring, and epidemiology are important in college

health/public health.

Guiding Principles

Medical Care

• Science-based

• Focus on individual


Science-basedScience-based

Population-basedPopulation-based

NIAAA - College Drinking Prevention 4 Tiers of Effectiveness

• Tier 1: Evidence of Effectiveness Among College Students

• Tier 2: Evidence of Success With General Populations That Could Be Applied to College Environments

• Tier 3: Evidence of Logical and Theoretical Promise, But Require More Comprehensive Evaluation

• Tier 4: Evidence of Ineffectiveness

College Drinking PreventionNIAAA 4 Tiers of Effectiveness

• Tier 1: Evidence of Effectiveness Among College Students– Strategy: Combining cognitive-behavioral skills

with norms clarification and motivational enhancement interventions.

– Strategy: Offering brief motivational enhancement interventions.

– Strategy: Challenging alcohol expectancies.

• We should implement these strategies as part of our clinical role.


• Tier 2: Evidence of Success With General Populations That Could Be Applied to College Environments– Strategy: Implementation, increased publicity, and

enforcement of laws to reduce alcohol-impaired driving.

– Strategy: Restrictions on alcohol retail outlet density – Strategy: Increased prices and excise taxes on

alcoholic beverages. – Strategy: The formation of a campus and community

coalition involving all major stakeholders may be critical to implement these strategies effectively.


• Tier 3: Evidence of Logical and Theoretical Promise, But Require More Comprehensive Evaluation– Strategy: Increasing publicity about and

enforcement of underage drinking laws on campus and eliminating "mixed messages."

– Strategy: Conducting marketing campaigns to correct student misperceptions about alcohol use.

– Strategy: Regulation of happy hours and sales.• We should implement Tier 2 and Tier 3 strategies as

part of our public health role.

Guiding Principles

Medical Care

• Science-based


• Health an individual

responsibility




Health an individual and Health an individual and

societal responsibilitysocietal responsibility

The Ecosystem of an IndividualThe Ecosystem of an Individual

AttitudesAttitudes ValuesValues

CultureCultureNormsNorms

LawsLaws ...isms...isms

SOCIETYSOCIETY

courts

multinationalcorporations

crime

immigrants

violence

government

T.V.

moviesCOMMUNITYCOMMUNITY

FAMILYFAMILYschools

friends

work

police

peers

child care

health care providers

relativessibs

grandparentsparents

IndividualIndividual

Health PromotionHealthy People 2000

• Personal choices have powerful influence over one’s

health. While health behaviors are personal, choices

are made in a broader social context that is difficult

to separate from the psychology of the individual. So

while the choice may be individual, the locus of

intervention needs to be wide enough to incorporate

the environment that will either support or

undermine personal choice.

Guiding Principles

Medical Care

• Science-based



responsibility

• Focus on specific

illnesses or diseases






Broad definition of healthBroad definition of health

College Health View of Health System


Health CareOther

Influences




Many more





Medical Care

Clinical Preventive

Services


Did women’s suffrage affect health?

U of MN Student Health Advisory Committee

• Smoke-free campus• Bicycle trails• Farmers Market• Menu labeling• Year-round fees• Extended hours of operation• Insurance RFP• Late night transportation• FDA blood donation policy

Guiding PrinciplesMedical Care

• Science-based



responsibility



• Specialization







Interdisciplinary/Interdisciplinary/

multidisciplinarymultidisciplinary

Scope of Clinical Specialists, Clinical Generalists, and Public Health

Safer,Healthier

Population

VulnerablePopulation

Becomingvulnerable


Afflictedwithout

ComplicationsBecomingafflicted


Developingcomplications


Centers for Disease Control and Prevention, Bobby Milstein

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Guiding Principles

Medical Care

• Science-based



responsibility



• Specialization

• Competitive









Collaboration/ Collaboration/

Cooperation/IntegrationCooperation/Integration

Public Health

• What we, as a society, do collectively to assure the conditions in which people can be healthy. – Institute of Medicine

College Health View of Health System


Health CareOther

Influences




Many more





Medical Care

Clinical Preventive

Services


Guiding Principles

Medical Care

• Science-based



responsibility



• Specialization

• Competitive

• Treatment









Collaboration/ CooperationCollaboration/ Cooperation

Prevention/Promotion/Prevention/Promotion/

ProtectionProtection

Leading Causes of Death• Heart disease 725,790• Cancer 537,390• Stroke 159,877• Lung diseases 110,637• Injuries 92,191• Pn/influenza 88,383• Diabetes 62,332• Suicide 29,725• Kidney disease25,570• Cirrhosis 24,765

Real Leading Causes of Death• Tobacco 400,000• Diet/inactivity 300,000• Alcohol 100,000• Microbial agents 90,000• Toxic agents 60,000• Firearms 35,000• Sexual behavior 30,000• Motor vehicles 25,000• Illicit drug use 20,000


Guiding Principles

Medical Care

• Science-based



responsibility



• Specialization

• Competitive

• Treatment

• Short term responsibility












Long-term responsibilityLong-term responsibility

Adoption of Health-risk Behaviors

Social, Emotional, & Cognitive Impairment

EarlyDeath

Adverse Childhood Experiences

Death

Disease, Disabilityand Social Problems

ConceptionAdverse Childhood Experiences: childhood abuse and neglect growing up with domestic violence, substance abuse or mental illness in the home, parental discord, crime

ACE Score and Alcoholism, Suicide Attempts, or Sexual

Assault

0

5

10

15

20

25

30

35

Per

cen

t W

ith

Hea

lth

Pro

ble

m

(%)

0 1 2 3 4 or more

Number of adverse factors:

Considers selfan alcoholic

Ever attemptedsuicide

Sexually assaultedas an adult (women)

College Students Should Be A Long-term Public Health Priority Group

• Numbers are large and increasing

– Can be targeted

– Last time we have relatively easy access to them

• Establishing lifestyle and behaviors

• Role models for younger individuals

• Set norms of behavior

• Leaders of the future

Robert Fulgumborn June 4, 1937

• “Don't worry that

children never listen to

you; worry that they

are always watching

you.”


• Science-based



responsibility



• Specialization

• Competitive

• Treatment


• Reimbursement driven













Social responsibilitySocial responsibility

How our healthcare money is spent

5%

95%

Medical CarePublic Health


• Science-based



responsibility



• Specialization

• Competitive

• Treatment



• Market justice














Social justiceSocial justice

Market Justice and US Health Care• In the United States, health care competes for consumers with

other items in the marketplace. Individual resources and choices determine the distribution of health care, with little sense of collective obligation or a role for government. Known as market justice, this approach derives from principles of individualism, self-interest, personal effort, and voluntary behavior.

• The contrasting approach, social justice, allocates goods and services according to the individual's needs. It stems from principles of shared responsibility and concern for the communal well-being, with government as the vehicle for ensuring equity.

• Peter P. Budetti, MD, JD, JAMA. 2008;299(1):92-94.

• Market Justice: You get what you want and what you can pay for.

• Social Justice: Everyone gets basic needs met and no one benefits at the expense of someone else.

Public HealthGeoffrey Vickers - 1957

• The constant redefinition of the unacceptable.

“The philosophy of science is to discover truth.

The philosophy of medicine is to use truth to treat individuals.

The philosophy of public health is social justice.”

William Foege, M.D.


• Science-based



responsibility



• Specialization

• Competitive

• Treatment



• Market justice














Social justiceSocial justice

C.E. A. WinslowDean, Yale School of Pubic Health

• “a university health service

can realize its possibilities of

leadership only if it visualizes

public health in the broadest

terms.” • 1929

Public Health on College Campuses

The Role of College Health in Shaping the Future of Health Care

Evolving View of Health and Health Care

• From disease to risk factors

Leading Causes of Death• Heart disease 725,790• Cancer 537,390• Stroke 159,877• Lung diseases 110,637• Injuries 92,191• Pn/influenza 88,383• Diabetes 62,332• Suicide 29,725• Kidney disease25,570• Cirrhosis 24,765

Real Leading Causes of Death• Tobacco 400,000• Diet/inactivity 300,000• Alcohol 100,000• Microbial agents 90,000• Toxic agents 60,000• Firearms 35,000• Sexual behavior 30,000• Motor vehicles 25,000• Illicit drug use 20,000



– Particularly important for young adults

• From treatment to prevention


Need for treatment and preventionIn tobacco control




– From a population perspective, the younger the

population, the more important the prevention

efforts.

• From short-term to long-term perspective

AdultPreconception

Prenatal

Intrapartum

Infant

Child

Adolescent

Non-child bearingParenting

HealthCare Influences

Environmental and Social Influences:

Parents/extended familyCulture/MediaRoles of men/women/childrenNorms/PoliciesEconomyCommunityEducationMultiple other influences

Health Care Influences:

Health PromotionDisease PreventionHealth ProtectionMedical Care ( 10, 20 , 30)Surveillance and data Environmental and Social Influences

Cycle of Development





– Modifying risk-factors and seeing effects of

prevention require long-term perspective

• From individual to population






– College health is one of few fields responsible for

both individual and population-based outcomes

• From population to context

The Ecosystem of a PopulationThe Ecosystem of a PopulationCollege Health Focuses on ContextCollege Health Focuses on Context

AttitudesAttitudes ValuesValues

CultureCultureNormsNorms

LawsLaws ...isms...isms

SOCIETYSOCIETY

courts

multinationalcorporations

crime

immigration

violence

government

T.V.

moviesCOMMUNITYCOMMUNITY

FAMILIESFAMILIESschools

friends

work

police

peers

health care providers

relativessibs

parents

STUDENTSSTUDENTS






• From population to context

• From individual population problems to syndemic

context

Context is the Community

• Whereas the usual public health

approach begins by defining the

disease and the population in

question, a syndemic orientation first

defines the community in question.

Syndemic Contextual View of Health• A syndemic is two or more

afflictions, interacting synergistically, contributing to excess burden of disease in a population.– Synergistic epidemics– Syndrome of epidemics

• Syndemics occur when health-related problems cluster by person, place, or time

Bobby Milstein

Syndemics

• The word syndemic was coined by anthropologist Merrill Singer and first published in 1992 to convey what he saw as inextricable and mutually reinforcing connections between health problems such as substance abuse, violence, and AIDS among urban women in the US.

• Singer, 1994; 1996; Singer M and Snipes C, 1992; Singer M and Romero-Daza N, 1997

SAVA Syndemic

** Adapted from Singer M, 1996

SAVA Syndemic• "Commonly, violence, substance abuse, and AIDS have

been described as concurrent epidemics among inner-city populations. However, the term epidemic fails to adequately describe the true nature of the contemporary inner city health crisis, which is characterized by a set of closely interrelated, endemic and epidemic conditions, all of which are strongly influenced by a broader array of political-economic and social factors, including high rates of unemployment, poverty, homelessness and residential overcrowding, substandard nutrition, infrastructural deterioration and loss of quality housing stock, forced geographic mobility, family breakup and disruption of social support networks, youth gang formation, and health care inequality

• (Wallace R, 1988; 1990; Wallace D, 1990).

DAT Syndemic

Tobacco

DATSyndemi

c

Alcohol

Depression

Syndemic Contextual View of Health

Problems are important but the ties between them are often even more important. Pay attention to confounding factors – that’s where the issues are most intense.

To Understand Syndemics…

•"You think that if you understand

one, you understand two-because

one and one are two. But you must

also understand 'and'."

Sufi saying

Contextual/Syndemic View of Health among College Students

Alcohol

Tobacco

Depression

ObesityStress

Violence

Health System Dynamics

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Centers for Disease Control and Prevention, Bobby Milstein

Safer,Healthier

Population BecomingVulnerable


VulnerablePopulation Becoming

Afflicted

Afflictedwithout

Complications DevelopingComplications


Targetedprotection

Primaryprevention

Secondaryprevention


Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

World of Providing…

• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…

Medical and Public Health Policy

DISEASE AND RISK MANAGEMENT

World of Transforming…

• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…

By Strengthening…

• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…

Healthy Public Policy & Public Work

DEMOCRATIC SELF-GOVERNANCE

Centers for Disease Control and Prevention Bobby Milstein

Syndemic Context

An involved population

Change is coming!

• “Willed change” the Sufi say, “is not real. Only unwilled change is real.” Only unwilled change catapults us into what we did not plan to do. Only unwilled change really matters to the molding of the soul, to the stretching of the self beyond the self, in other words. And matter it does. Deeply. Willed change is what I seek and shape. Unwilled change is what seeks and reshapes me.”

– From “The Story of Ruth” by Joan Chittester

Robert Fulgumborn June 4, 1937

• Author of “All I Really Need to Know, I Learned in Kindergarten.”

• “The world does not need tourists who ride by in a bus clucking their tongues. The world as it is needs those who will love it enough to change it, with what they have, where they are.”

C. E. A. Winslowat the 1929 dedication of University Health Service

University of Minnesota

“…a university health service …can realize its possibilities of leadership only if it visualizes public health in the broadest terms. Public health is concerned with the prevention of disease and the promotion of health in the widest sense…”

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Public Health Principles and Practices: A Platform for College Health Edward P. Ehlinger, MD, MSPH...

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