1. Introduction to Healthcare and Public Health in the US
Welcome to Introduction to Healthcare and Public Health in the US, Introduction and History of Modern Healthcare in the US This is Lecture b.
The component, Introduction to Healthcare in the US, is a survey of how healthcare and public health are organized and services are delivered in the US.
Introduction and History of Modern Healthcare in the US
Lecture b
This material (Comp1_Unit1b) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

2. Introduction and History of Modern Healthcare in the US Learning Objectives
Delineate key definitions in the healthcare domain (Lectures a, b, c, d)
Explore components of healthcare delivery and healthcare systems (Lecture a)
Define public health and review examples of improvements in public health (Lecture b)
Discuss core values and paradigm shifts in US healthcare (Lecture c)
Describe in overview terms, the technology used in the delivery and administration of healthcare (Lecture d)
The Objectives for Introduction and History of Modern Healthcare in the US, are to:
Delineate key definitions in the healthcare domain (covered in lectures a, b, c and d)
Explore components of healthcare delivery and healthcare systems (covered in lecture a)
Define public health and review examples of improvements in public health (covered in lecture b)
Discuss core values and paradigm shifts in US healthcare (covered in lecture c), and
Describe in overview terms, the technology used in the delivery and administration of healthcare (covered in lecture d)
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

3. 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.“
(Winslow, C.E.A. 1920)
This lecture will provide a definition of public health and detail how public health has improved healthcare.
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.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

4. 10 Great Public Health Achievements – US, 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 illnesses 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.
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Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

5. Public Health Successes (continued)
Control of infectious diseases
Example: Typhoid
spread by ingesting contaminated food or water
In 1891 the typhoid death rate in Chicago alone was 174 per 100,000 people
Now only about 400 cases are seen in the US each year, most of whom originate when patients travel in developing countries
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 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, the improvement of 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.
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Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

6. Public Health Successes (continued)
Control of infectious diseases
Example: Smallpox
Epidemic viral illness
In the early 1950s there were about 50 million cases of smallpox each year worldwide
By 1977, smallpox was eradicated, thanks to an aggressive public health program and the use of an effective vaccine
Another example of the role of public health in the successful control of infectious disease is the example of small pox. Small pox 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, small pox was responsible for the death of every tenth child born in France. In the early 1950s, there were about fifty million cases of small pox each year worldwide. By 1967, this figure fell to ten-to-fifteen million because of mass vaccination drives. By 1977, small pox was eradicated. This was predominantly due to an aggressive public health program and the use of an effective vaccine.
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Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

7. Public Health Successes (continued)
Control of nutritional deficiencies
Example: Goiter
Lack of iodine in diet leads to impaired thyroid hormone synthesis and an enlargement of the thyroid gland in the neck (a goiter)
Fortification of salt with iodine virtually eradicated nutritional goiter in the US
Interventions dictated by public health have been responsible for the successful control of many nutritional deficiencies. An example is that of goiter. A goiter [GOY-der] is an enlargement of the thyroid gland in the neck due to impaired thyroid hormone synthesis due to the lack of iodine in diet. The solution to the problem of nutritional goiter in the United States was to fortify salt with iodine which virtually eradicated the problem.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

8. Public Health Successes (continued)
Control of nutritional deficiencies
Example: Tooth Decay
Adding fluoride to drinking water substantially reduces the incidence of dental caries (tooth decay) in populations
In 1945 fluoride was added to water in Grand Rapids, Michigan
Now over 10,000 US communities fluoridate their water
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 [CARE-reez], 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 water in Grand Rapids, Michigan, and showed a subsequent reduction in caries. Now, more than 10,000 US communities fluoridate their water.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

9. How Has Public Health Improved Healthcare?
Improvements in understanding disease
Epidemiology is considered the basic science of public health and is
a quantitative basic science
a method of causal reasoning based on developing and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality
a tool for public health action to promote and protect the public’s health
So how has public health improved healthcare? Public health is directly responsible for improvement in understanding disease. Epidemiology [ep-ih-dee-mee-ALL-uh-jee] 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 currents 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.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

10. How Has Public Health Improved Healthcare? (continued)
An example of epidemiology at work:
In 1854: epidemic of cholera 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 a contaminated 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.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

11. How Has Public Health Improved Healthcare? (continued)
Improvements in data collection
Original methods of data collection were crude
progressive improvement in methodology led to the use of sophisticated scientific methods to collect data
cohort studies
randomized controlled trials
Public health successes have been assisted by improvements in the science and processes associated with data collection. Original methods of data collection were somewhat crude. An example of this would be field surveys. Progressive improvements in methodology have lead to the use of sophisticated scientific methods to collect data. One example is cohort studies. This is a form of a longitudinal study that follows two sets of patients. One set has the factor that is being considered, the other does not have the characteristic. Another use of sophisticated scientific methodology is to conduct public health trials as randomized controlled trials. Randomized controlled trials reduce the element of bias in a scientific study. Patients are assigned to one of two pools. One pool receives an intervention and the other does not. This reduces the influence of confounding variables in data analysis.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

12. How Has Public Health Improved Healthcare? (continued)
Improvements in data collection
Example: the Framingham Heart Study
The 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
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 or high blood pressure and dementia.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

13. How Has Public Health Improved Healthcare? (continued)
Improvements in data analysis (use of tools such as multivariate analysis and meta-analysis)
Improvement in disease surveillance
Example: 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 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 [roads] 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.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

14. How has public health improved healthcare? (continued)
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 awarded 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.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

15. Public Health Definition
Introduction and History of Modern Healthcare in the US 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 and History of Modern Healthcare in the US.
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 impacted the control of infectious diseases, such as typhoid, small pox and goiter, and helped identify nutritional deficiencies and contributed to a greater understanding of diseases. It has also supported improvements in data collection, training and infrastructure.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b

16. Introduction and History of Modern Healthcare in the US References – Lecture b
Centers for Disease Control and Prevention - Ten great public health achievements—United States, 1900–1999. (1999, April 2). MMWR, 48(12),
Definition of Epidemiology from Principles of Epidemiology, 2nd edition, CDC Self Study Course 3030-G. (2008). Retrieved December 6, 2011, from Centers for Disease Control and Prevention website:
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
Smallpox. (2001). Retrieved December 6, 2011, from World Health Organization - Media Center website:
Typhoid Fever in the United States - NH Backgrounder. (2001, April 25). Retrieved December 6, 2011, from National Institutes of Health, National Institute of Child Health and Human Development website:
Typhoid Fever, Frequently Asked Questions. (2005, January 10). Retrieved December 6, 2011, from Centers for Disease Control and Prevention - National Center for Emerging and Zoonotic Infectious Diseases website:
Vandenbroucke, J. P. (1998). Clinical investigation in the 20th century: the ascendency of numerical reasoning. Lancet, 352 (suppl 2)(12), 6. Retrieved from
William B. Kannel, MD - Pioneer in Cardiovascular Epidemiology, 1923–2011. (2011, January 10). Retrieved December 6, 2011, from Framingham Heart Study website:
Winslow, C. E. (1920). The Untilled Fields of Public Health. Science, n.s. 51, 23.
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Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture b