What is “public health?” PUBHLTH 200 – Sept. 13, 2011

What does the public think “public health” means? Disaster response (e.g., post 9/11) Health care for the poor Behavior nannies (e.g., smoke-free laws) Restaurant inspections for cockroaches, etc. I dunno (No idea) Sept. 13, 2011 PUBHLTH 200

How public health professionals think of public health By purpose By groups of professionals who practice PH By methods most identified with PH: epidemiology and biostatistics As governmental health services for the poor As the outcome: health of the public Source: Turnock Sept. 13, 2011 PUBHLTH 200

CEA Winslow’s 1920 definition Public health is “...the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and for the development of the social machinery to insure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his [or her] birthright of health and longevity.” Sept. 13, 2011 PUBHLTH 200

A more concise definition Def’n: Public health is the set of activities a society undertakes to monitor and improve the health of its collective membership. Distinguishing features: Focus on preventing disease & injury “Patient” is entire community, not individuals “Provider” is society, not individual professionals Sept. 13, 2011 PUBHLTH 200

How does public health differ from other health professions? All other health professions (medicine, nursing, dentistry, pharmacy, allied health, social work) typically involve: An individual provider An individual patient Emphasis on treating illness or disability Sept. 13, 2011 PUBHLTH 200

Example of the difference Example of health care: Dentist treats dental caries in an individual patient. Example of public health: Government fluoridates the water supply, making fluoridated water available to all members of the community. Prevents dental caries. Sept. 13, 2011 PUBHLTH 200

Primacy of public health in concept Collective health services Individual health services Medicine Dentistry Nursing Pharmacy Sept. 13, 2011 PUBHLTH 200

Other individual health services Hierarchy in practice Medicine Other individual health services Public health Sept. 13, 2011 PUBHLTH 200

Source: Adapted from CDC, 1979; IOM, 1988; and PHS, 1993 Why is public health so important? Factors that could avoid premature mortality Lifestyle (behavior) 50% Environment 20% Human biology (genetics) 20% Additional medical care 10% Source: Adapted from CDC, 1979; IOM, 1988; and PHS, 1993 Sept. 13, 2011 PUBHLTH 200

Why is public health so important? Contribution to life expectancy gain Of 30-year gain in life expectancy in U.S. during 20th century… 5 years attributable to medical care system 25 years from public health improvements in Sanitation • Nutrition Housing • Job safety Bunker et al., Milbank, 1994 Sept. 13, 2011 PUBHLTH 200

Relationship between public health (PH) and the medical care system (MC): Impact on premature mortality PH MC Sept. 13, 2011 PUBHLTH 200

Relationship between PH and MC: Expenditures Sept. 13, 2011 PUBHLTH 200

Why the PH/MC imbalance? Market systems (economic interests) cater to services for individuals; PH is often a public good (or relevant due to externalities) Interest group politics; often contentious issues (more on this later) What people want (the “Rule of Rescue”) Current trauma vs. abstract future benefit Identifiable vs. “statistical” lives “Invisibility” of PH Sept. 13, 2011 PUBHLTH 200

Benefits and costs of health promotion programs Benefits: abstract, deferred Costs: tangible, immediate Sept. 13, 2011 PUBHLTH 200

Benefits and costs of disease promotion Benefits: tangible, immediate Costs: abstract, deferred Sept. 13, 2011 PUBHLTH 200

Mission of public health “Fulfilling society's interest in assuring conditions in which people can be healthy.” “[The] aim [of public health] is to generate organized community effort to address the public interest in health by applying scientific and technical knowledge to prevent disease and promote health.” Source: IOM, Future of Public Health, 1988 Sept. 13, 2011 PUBHLTH 200

Core functions of public health Assessment of the health of the population Development of public health policies Assurance of the availability of needed services Sept. 13, 2011 PUBHLTH 200

1. Assessment of the public’s health Requires: Data collection Statistical and epidemiologic analysis Dissemination of findings Sept. 13, 2011 PUBHLTH 200

2. Development of public health policies Requires: Use of a scientific knowledge base Appreciation and use of the political process Sept. 13, 2011 PUBHLTH 200

3. Assurance of the availability of needed services Relies on: Encouraging appropriate actions by other entities (public or private) Requiring such actions through law or regulation Directly providing services Sept. 13, 2011 PUBHLTH 200

10 essential public health services 1. Monitor health status to identify community health problems 2. Diagnose and investigate health problems and health hazards in the community 3. Inform, educate, and empower people about health issues 4. Mobilize community partnerships to identify and solve health problems 5. Develop policies and plans that support individual and community health efforts Sept. 13, 2011 PUBHLTH 200

10 essential public health services 6. Enforce laws and regulations that protect health and ensure safety 7. Link people with needed personal health services and assure the provision of health care when otherwise unavailable 8. Ensure a competent public health and personal health care workforce 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services 10. Research for new insights and innovative solutions to health problems Sept. 13, 2011 PUBHLTH 200

Five core areas of public health Epidemiology Biostatistics Environmental Health Sciences Health Behavior & Health Education Health Management & Policy Sept. 13, 2011 PUBHLTH 200

Epidemiology is the core science of the field of public health. Concerned with analyzing and describing patterns of occurrence and determinants of diseases in human populations. Epidemiology is the core science of the field of public health. Sept. 13, 2011 PUBHLTH 200

Biostatistics Focuses on the development and application of statistical and mathematical methods to the design and analysis of public health problems and biomedical research. Sept. 13, 2011 PUBHLTH 200

Environmental Health Sciences Aims to protect human health from adverse environmental conditions -- in particular from harmful practices and harmful exposures in air, water, and food in the workplace, home, and ambient environment. Sept. 13, 2011 PUBHLTH 200

Health Behavior & Health Education Addresses the factors associated with health-related behavior and health status, and develops and evaluates educational activities designed to improve individual and community health and quality of life. Sept. 13, 2011 PUBHLTH 200

Health Management & Policy Focuses on improving access to, financing of, and delivery of high quality health services, and on developing and implementing cost-effective public health policies Sept. 13, 2011 PUBHLTH 200

Definition of disease prevention [A]nticipatory action taken to reduce the possibility of an event or condition occurring or developing, or to minimize the damage that may result from the event or condition if it does occur. Source: Pickett and Hanlon, 1990 Sept. 13, 2011 PUBHLTH 200

Levels of Prevention and Effects Prevention Primary Secondary Tertiary strategy Disease status Susceptible Asymptomatic Symptomatic Effects Reduced Reduced Reduced disease prevalence/ complications/ incidence consequence disability Source: Turnock, Fig. 3-4 Sept. 13, 2011 PUBHLTH 200

Example of prevention levels: Motor vehicle injuries Primary Building divided highways Secondary Requiring safer cars (e.g., airbags) or driving practices (e.g., wearing seatbelts) Tertiary EMS system Sept. 13, 2011 PUBHLTH 200

Example of prevention levels: High blood pressure Primary Dietary education and exercise Secondary BP control medications Tertiary Treatment for disease sequelae of HBP Sept. 13, 2011 PUBHLTH 200

Agent, host, environment model of disease Traditionally infectious disease A.k.a. Epidemiological Triangle Host Environment Sept. 13, 2011 PUBHLTH 200

Sept. 13, 2011 PUBHLTH 200

Epi triangle adapted to nicotine addiction & tobacco control Agent Tobacco products Environment Family, friends, culture, media politics, economics, history Host Smoker/chewer Vector Incidental host Tobacco product manufacturers Involuntary smoker Adapted from: Giovino 2002 Sept. 13, 2011 PUBHLTH 200

Why are public health issues often contentious? Restrictions on individual liberty Debate over individual responsibility (“blame the victim”) Economic interests Morality issues in public health measures Politics in science Sept. 13, 2011 PUBHLTH 200

1. Restrictions on individual liberty Why are they imposed? “Tragedy of the commons”: Must restrict individuals’ freedoms to protect the greater good of the entire community (e.g., think pollution control). “Public goods”; “externalities” Paternalism (e.g., seat belt laws) Social norms, morals (e.g., sodomy laws) Sept. 13, 2011 PUBHLTH 200

1. Restrictions on individual liberty (cont’d.) Behavior that directly affects others (examples) Prohibitions against criminal activity (murder; abuse; theft) Speed limits; traffic lights; etc. Prohibiting drunk driving Banning smoking in public places Quarantining people with infectious disease Requiring immunizations for school enrollment Prohibiting various forms of pollution Sept. 13, 2011 PUBHLTH 200

1. Restrictions on individual liberty (cont’d.) Behavior that indirectly affects others (examples) Motorcycle helmet and seat belt laws Bans on illicit drugs Sodomy laws Abortion laws UM campus-wide smoke-free policy (outdoors as well as indoors) Sept. 13, 2011 PUBHLTH 200

2. Debate over individual responsibility (“blame the victim”) Question: Are people suffering from problem X at fault for the problem – and therefore individually responsible for resolving it – or are they victims who need and deserve (public) assistance? Sept. 13, 2011 PUBHLTH 200

2. Debate over individual responsibility (“blame the victim”) (cont’d Examples: Smoking Obesity HIV/AIDS Drug/alcohol addiction Homeless (including result of recent spate of foreclosures) Poverty Sept. 13, 2011 PUBHLTH 200

3. Economic interests Often powerful economic interests hurt by public health regulations (e.g., tobacco, alcohol, food companies; polluting firms; health care insurers, hospitals, providers; local retailers such as restaurants and bars) Powerful economic interest = political lobby Sept. 13, 2011 PUBHLTH 200

3. Economic interests (cont’d.) Cost burden falls on different people than does benefit derived Benefit often to the poor and politically disenfranchised Cost often from wealthy and politically connected Politics of current costs for future (abstract) benefits Political interests Budget balancing Politicians’ discount rate Sept. 13, 2011 PUBHLTH 200

4. Morality issues in public health measures Intensely felt positions deriving from sense of moral or religious right or norms Abortion Sex ed HIV/AIDS prevention (safe sex, clean needles) Gay marriage Stem cell research Sept. 13, 2011 PUBHLTH 200

5. Politics in science Administrations often promote their social/ political agendas by interfering with science Withholding research resources (e.g., early AIDS) Tying resources to compliance with policy positions (e.g., no support through USAID to programs promoting birth control) “Litmus tests” for high-level appointees “Stacking” review bodies with “partisans” (e.g., corporate consultants) Misrepresenting or suppressing scientific findings (e.g., global warming) Sept. 13, 2011 PUBHLTH 200

What is public health? Under-appreciated (“invisible”), under-funded, under-practiced Difficult Politically challenging Requires expert mix of science and politics Last but not least: PH is important Sept. 13, 2011 PUBHLTH 200

Thursday: History of public health Sept. 13, 2011 PUBHLTH 200