Introduction to Health Care and Public Health in the U.S. Introduction to and History of Modern Health Care in the U.S. Welcome to Introduction to Health Care and Public Health in the U.S.: Introduction to and History of Modern Health Care in the U.S. This is lecture b. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S. Lecture b This material (Comp 1 Unit 1) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/. Health IT Workforce Curriculum Version 4.0

Introduction to and History of Modern Health Care in the U. S Introduction to and History of Modern Health Care in the U.S. Learning Objectives – 1 Define key terms in health care and public health (Lectures a, b, c, d) Describe components of health care delivery and health care systems (Lecture a) Discuss examples of improvements in public health (Lecture b) The learning objectives for Introduction to and History of Modern Health Care in the U.S., are to: Define key terms in health care and public health Describe components of health care delivery and health care systems Discuss examples of improvements in public health

Introduction to and History of Modern Health Care in the U. S Introduction to and History of Modern Health Care in the U.S. Learning Objectives – 2 Define core values and paradigm shifts in U.S. health care (Lecture c) Describe the technology used in the delivery and administration of health care (Lecture d) Define core values and paradigm shifts in U.S. health care And describe the technology used in the delivery and administration of health care

Public Health Charles Edward Winslow Thomas Frieden “Public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.” Thomas Frieden “Public health focuses on denominators — what proportion of all people who can benefit from an intervention actually benefit” This lecture will provide a definition of public health, and detail how public health has improved health care. According to Charles Edward Winslow, a famous American bacteriologist and public health expert in the first half of the 20th century, public health is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations both public and private, communities, and individuals. More recently, Dr. Thomas Frieden, the Director of the Centers for Disease Control and Prevention, or CDC, has noted that public health focuses on denominators, or the entire population, and who can benefit from public health interventions.

10 Great Public Health Achievements – U.S., 1900-1999 Vaccination Motor-vehicle safety Safe 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 So what are the ten great public health achievements in the United States this century? The Centers for Disease Control and Prevention lists them as: vaccination, motor vehicle safety, safe work places, control of infectious diseases, a decline in death from coronary heart disease and stroke, safer and healthier food, healthier mothers and babies, family planning, the fluoridation of drinking water, and the recognition of tobacco use as a health hazard.  It’s interesting that each of these achievements requires large populations to actively shift the way they think about illness and act in a large-scale fashion to make changes in behavior in order to successfully implement public health improvement. It’s also interesting that though scientific advancements have spearheaded many of these achievements, public education remains a primary motivator of public health achievements.

Control of Infectious Diseases Typhoid Spread by ingesting contaminated food or water 1891 Death rate in Chicago was 174 per 100,000 people Now only about 400 cases are seen in the U.S. each year Smallpox Epidemic viral illness Early 1950s About 50 million cases of smallpox each year worldwide 1977 Smallpox eradicated Let’s focus our attention on the control of infectious diseases. A classic example of public health success in this arena is the successful control of typhoid.  Typhoid is caused by bacteria, and is spread by ingesting contaminated food or water. The organism spreads through the body via the bloodstream, and causes a fever and a systemic, sometimes potentially fatal illness. In 1891, the typhoid death rate in Chicago alone was 174 per 100,000 people. Now, thanks to public health measures such as sanitation and improved hygiene, combined with the development of a vaccine, only about 400 cases are seen in the United States each year and most of these cases originate when patients travel in developing countries. Another example of the role of public health in the successful control of infectious disease is smallpox. Smallpox is a devastating disease. It’s an epidemic viral illness and was responsible for hundreds of millions of deaths in the 20th century alone. No effective treatment was ever developed for the disease, and it killed about thirty percent of patients who were infected. Between sixty-five and eighty percent of those who survived the disease were marked with deep scars, most prominently on the face. As late as the 18th century, smallpox was responsible for the death of every tenth child born in France. In the early 1950s, there were about fifty million cases of smallpox each year worldwide. By 1967, this figure fell to ten-to-fifteen million, because of mass vaccination drives. By 1977, smallpox was eradicated. This was predominantly due to an aggressive public health program and the use of an effective vaccine.

Control of Nutritional Deficiencies Goiter Enlargement of the thyroid gland in the neck Fortification of salt with iodine virtually eradicated nutritional goiter in the U.S. Tooth Decay Adding fluoride to drinking water substantially reduces the incidence of dental caries 1945 Fluoride added to drinking water in Grand Rapids, Michigan Over 10,000 U.S. communities fluoridate their water Interventions dictated by public health have been responsible for the successful control of many nutritional deficiencies. An example is that of goiter. A goiter is an enlargement of the thyroid gland in the neck, due to impaired thyroid hormone synthesis, due to lack of iodine in the diet. The solution to the problem of nutritional goiter in the United States was to fortify salt with iodine, which virtually eradicated the problem. Another example is the reduction of tooth decay in the population. Frederic McKay, in 1891, first described the association between a reduction in the incidence of dental caries, or tooth decay, in populations, and the addition of fluoride to drinking water. In 1945, Dr. H. Trendley Dean and associates at the National Institute of Health, added fluoride to the drinking water in Grand Rapids, Michigan, and showed a subsequent reduction in caries. Now, more than 10,000 U.S. communities fluoridate their water.

How Has Public Health Improved Health Care? - 1 Improvements in understanding disease Epidemiology: The basic science of public health Quantitative basic science Method of causal reasoning based on developing and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality Tool for public health action to promote and protect the public’s health So how has public health improved health care? Public health is directly responsible for improvement in understanding disease. Epidemiology is the basic science of public health. It is a quantitative basic science built on a working knowledge of probability, statistics, and sound research methods. It is a method of causal reasoning based on developing and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality. Epidemiology is also a tool for public health action to promote and protect the public’s health based on science, causal reasoning, and a dose of practical common sense.

How Has Public Health Improved Health Care? - 2 Example of epidemiology at work: 1854 Cholera epidemic in London, England Cholera is a bacterial disease Lack of sanitation and overcrowding led to the spread of disease Dr. John Snow linked the spread of disease to contaminated Broad Street public water pump Snow’s hypothesis: Cholera was spread by contaminated water Here is an example of epidemiology at work: In 1854, an epidemic of cholera ravaged London, England. Cholera is a bacterial disease spread by contamination of food or water. Lack of sanitation and overcrowding were important factors that led to the spread of disease. Dr. John Snow, a physician, linked the spread of disease to a contaminated public water pump on Broad Street. Snow hypothesized that the disease was spread by contaminated water, and he used statistics to connect the quality of water to the number of cases of cholera.

How Has Public Health Improved Health Care? - 3 Improvements in data collection have led to the use of better scientific methods to collect data and carry out experiments Field surveys Cohort studies Randomized controlled trials Public health has also led to improvements in health care resulting from improvements in data collection and methods to carry out experiments. An example of this would be field surveys. In this type of research, data about individuals is collected in the field. Progressive improvements in methodology have led to the use of improved scientific research designs. Cohort studies are one example. This is a form of a longitudinal study that follows two or more sets of patients. One set has the characteristic that is being considered, the other does not have the characteristic. Randomized controlled trials, or RTCs, represent another improved scientific research design. RCTs reduce sampling bias in scientific studies. Patients who are otherwise identical are assigned to one of two groups. The experimental group receives an intervention, and the control group does not. This reduces the influence of confounding variables in data analysis.

How Has Public Health Improved Health Care? - 4 Improvements in data collection Framingham Heart Study Followed patients for a number of years to identify factors that contribute to the development of cardiovascular disease (CVD) Over the years, multiple generations of participants have helped identify major CVD risk factors Helped to understand the effects of CVD on other diseases An example of improvements in data collection leading to better public health is the Framingham heart study. In 1948, the National Heart Institute, which is now the National Heart, Lung, and Blood Institute of the National Institutes of Health, and Boston University began the Framingham Heart Study. The study recruited men and women from the town of Framingham, Massachusetts, and followed them for a substantial number of years to attempt to identify factors that contribute to the development of cardiovascular disease. Over the years, three generations of participants have helped to identify major cardiovascular disease risk factors. With the assistance of these patients, researchers have also attempted to understand the effects of cardiovascular disease risk factors on other diseases such as hypertension, also called high blood pressure, and dementia.

How Has Public Health Improved Health Care? - 5 Improvements in data analysis Use of tools such as multivariate analysis and meta-analysis Improvement in disease surveillance The Real-Time Outbreak and Disease Surveillance (RODS) Laboratory at the University of Pittsburgh, Department of Biomedical Informatics In addition to improvements in data collection, public health has also benefitted from improvements in data analysis. For example, use of tools such as multi-variate analysis and meta-analysis offer specialized options to analyze collective data. There has also been an improvement in disease surveillance. One example is the Real-time Outbreak and Disease Surveillance, or RODS Laboratory, which is a bio-surveillance research laboratory at the University of Pittsburgh in Pennsylvania. This laboratory uses software and algorithms to monitor emergency rooms and retail stores to detect and assess disease outbreaks. As you can imagine, this is of immense use in the public health arena.

How Has Public Health Improved Health Care? - 6 Improvement in training Establishment of many schools of public health in the early 20th century Professional degrees such as Master of Public Health (M.P.H.) Improvements in infrastructure Federal State Local health departments Public health has also benefitted from improvement in training. In the early twentieth century, in part due to the Welch-Rose report of 1915, and also partially because of the support of the Rockefeller Foundation, many schools of public health were established and began awarding professional degrees such as the Master of Public Health. And finally, public health has also benefitted from improvement in infrastructure at the federal, state, and local health department levels.

Introduction to and History of Modern Health Care in the U. S Introduction to and History of Modern Health Care in the U.S. Summary – Lecture b Public Health Definition Public Health Successes include the control of: Infectious diseases Nutritional deficiencies Understanding disease Public Health has improved Data collection Training and infrastructure This concludes lecture b of Introduction to and History of Modern Health Care in the U.S. In summary, Public Health is the science and art of preventing disease, prolonging life, and promoting health, and involves various organizations within society. Public education remains a primary motivator of public health achievements. Public Health has significantly affected the control of infectious diseases, helped identify nutritional deficiencies, and contributed to a greater understanding of diseases. It has also supported improvements in data collection, training, and infrastructure.

Introduction to and History of Modern Health Care in the U. S Introduction to and History of Modern Health Care in the U.S. References – 1 – Lecture b References Centers for Disease Control and Prevention - Ten great public health achievements—United States, 1900–1999. (1999, April 2). MMWR, 48(12), 241-243. Definition of Epidemiology from Principles of Epidemiology in Public Health Practice, 3rd edition, CDC Self Study Course SS1978. Retrieved January 19, 2017, from Centers for Disease Control and Prevention: https://www.cdc.gov/ophss/csels/dsepd/ss1978/ss1978.pdf. Frieden, TR (2015). Shattuck Lecture: The Future of Public Health. New England Journal of Medicine. 373: 1748-1754. Ripa, L. W. (1993). A Half-century of Community Water Fluoridation in the United States: Review and Commentary. Dept. of Children’s Dentistry; SUNY Stony Brook, 53(1), Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8474047. Smallpox. (n.d.). Retrieved January 19, 2017, from http://www.who.int/csr/disease/smallpox/en/ No Audio.

Introduction to and History of Modern Health Care in the U. S Introduction to and History of Modern Health Care in the U.S. References – 2 – Lecture b References Typhoid Fever in the United States. (2001, April 25). Retrieved January 19, 2017, from https://www.nichd.nih.gov/news/releases/pages/typhoid_background.aspx Typhoid Fever. (2013, May 14). Retrieved January 19, 2017, from https://www.cdc.gov/typhoid-fever/index.html Vandenbroucke, J. P. (1998). Clinical investigation in the 20th century: the ascendency of numerical reasoning. Lancet, 352 (suppl 2)(12), 6. https://www.ncbi.nlm.nih.gov/labs/articles/9798639/ Framingham Heart Study. (n.d.). Retrieved January 19, 2017, from http://www.framinghamheartstudy.org/ Winslow, C. E. (1920). The Untilled Fields of Public Health. Science, n.s. 51, 23. No Audio.

Introduction to Health Care and Public Health in the U. S Introduction to Health Care and Public Health in the U.S. Introduction to and History of Modern Health Care in the U.S. Lecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. No Audio.