1. The History of Public Health
Kristine M. Gebbie, DrPH, RN
Columbia University School of Nursing
Center for Health Policy
630 West 168th Street, Mail Box 6
New York, NY
(212)
Kristine Gebbie joined the faculty of Columbia University School of Nursing in 1995, and is the Director of the Center for Health Policy. Her teaching and research are in health policy and health systems, with particular attention to population-focused prevention and public health systems. She currently has research funding from both the Health Resources and Services Administration and the Centers for Disease Control and Prevention.
Prior to coming to New York, Dr. Gebbie served as the nation’s first National AIDS Policy Coordinator, a White House position created by President Clinton to coordinate national efforts in HIV/AIDS prevention, treatment and research. Prior to that she was Secretary of Health for Washington State and head of public health in Oregon. Dr. Gebbie’s earlier career was in academic health centers, as faculty member at UCLA School of Nursing and as faculty member and hospital administrator at St. Louis University School of Nursing and St. Louis University Hospitals. She has served on national committees advisory to the Secretary of the US Department of Energy as well as the Director of the Centers for Disease Control and Prevention.
Dr. Gebbie is an elected member of the Institute of Medicine, the American Academy of Nursing,and the New York Academy of Medicine. She is also an active participant in a wide variety of national and international professional organizations.
Dr. Gebbie’s extensive list of publications includes topics such as community mental health, mental health consultation, public health nursing, public health infrastructure, health policy and HIV/AIDS. In addition to many peer-reviewed journal publications, she has authored or co-authored several texts and book chapters and editorials. She writes a regular health policy column for the journal AIDS Reader, and serves on the editorial boards of the American Journal of Nursing, Journal of Public Health Policy and Journal of Public Health Management and Practice.

2. Developed as part of an Enhanced AHEC Community Partnership for Health Professions Workforce and Educational Reform project funded by the Health Resource and Service Administration (HRSA)

3. OBJECTIVES
Describe mission, responsibilities and core functions of public health systems
Identify essential services
Identify important historical figures
Objectives
The objectives are stated in abbreviated form on this slide; the specifics are that at the end of this module students will be able to:
- Describe the mission, responsibilities and core functions of public health systems within a community
- Identify at least 5 of the essential services of public health
- Identify at least one important historical figure in public health

4. Definition of Health
The state of complete physical, mental and social well-being and not merely the absence of disease or infirmity WHO, 1947
It is significant that we have had such a comprehensive definition of health as our global goal for over half a century, even though we are far from achieving it. This is illustrative of the aspirations of the public health community generally. Newer definitions may explicitly recognize the fact that ‘health’ as a state of mind may exist even in the presence of some diagnosable conditions. This has been brought home most clearly by those with conditions once called crippling or handicapping who ask that they be considered not ill but “differently abled”.
More recent WHO documents identify the need for individuals to experience functional participation in the life of family and community as a part of achieving health.
Resource:

5. Definition of Public Health
Activities that society undertakes to assure the conditions in which people can be healthy, including organized community efforts to prevent, identify and counter threats to the health of the public.
Definitions of health have evolved over the course of this century from the simple absence of diagnosable disease, to a state of well-being to the inclusion of the capacity to live and work in community.
Public health moves the concept of health into the realm of a shared concern, whatever definition of health is understood. While public health can be and is pursued by all sectors of the community in some way, the definition implies that there is an organized and explicit commitment to bring about the desired conditions. Such a commitment is generally acted upon at least in part through governmental action.

6. Public Health System Activities
Health promotion
Disease prevention
Health promotion
- Any intervention that seeks to eliminate or reduce exposure to harmful factors by modifying human behaviors
- Any combination of health education and related organizational, political and economic interventions designed to facilitate behavioral and environmental adaptations that will improve or protect health
Disease prevention
- Any intervention that seeks to reduce or eliminate diagnosable conditions
- May be applied at the individual level, as in immunization, or the community level, as in the chlorination of the water supply

7. Prevention Triangles Tertiary Medical Care Tertiary Prevention
Secondary
Medical Care
Secondary
Prevention
Primary Medical Care
Each of these triangles represents a way that prevention has been illustrated as a part of the whole system that includes all forms of population and personal health care.
The primary, secondary and tertiary prevention pyramid at left is an older model, and may be confusing in its use of the term “tertiary prevention” to mean secondary and tertiary medical interventions such as surgery, chemotherapy and long-term care.
The newer pyramid at right illustrates the mid-place occupied by the clinical preventive services, which can be either population-focused or a part of personal care, and which include both primary prevention (immunization) and secondary prevention (e.g., cancer screening)
The placement of population-oriented prevention at the base is significant in
- its focus on all of the people as recipients
- its broad, long-lasting impact on health
- its role in defining and facilitating the whole system to work
Clinical Preventive Services
Primary
Prevention
Population Oriented Prevention

8. Ethical Values of Public Health
Beneficence
Non-malfeasance
Autonomy
Social justice
Truth-telling
These are the basic building blocks of an ethics of health.
Beneficence is the principle of doing good with every action.
Non-malfeasance is the principle of avoiding harm if at all possible
Autonomy is the principle of individual decision-making, respecting the right of each human to make his or her own life choices.
Social justice requires that like cases (of anything) be treated in like manner and that every individual’s right to social justice be respected.
Truth-telling demands that accurate information be available to all participants in any information exchange or decision-making situation.
In the case of health and illness care, these are often seen as being in tension, as it is not always possible to fully act on any one of them without violating another. For example, truth telling may cause harm, and full autonomy for some people leads them to do harm to others.

9. Balancing Ethical Conflicts
Public health practice is always struggling to find the correct balance between respect for individual autonomy and decision-making and the need for limitations on individuals in order to achieve social justice.
This is the heart of the community decision-making that is necessary for promotion of the public’s health. We are long past the parentalistic model under which the state might appoint a health officer who can individually demand that others follow instructions with no recourse. The establishment of environmental regulations, decisions to require immunization of all children, and the move to limit or eliminate use of tobacco products all represent a balance between what individuals might prefer to do if left unchecked and actions that appear necessary for the good of the whole group.
The HIV epidemic has provided us with some of the most vivid examples of this tension, including debates about disease reporting, partner notification, syringe and needle exchange and access to substance abuse treatment.
South Carolina was an early adopter of required HIV reporting and partner notification, seen by many as errors too far on the side of social justice. This would make a good issue for class discussion at this point.

10. Key Events in the History of Public Health

11. Key Events Did you know that . . .
South Carolina had the first provincial health officer in America, in 1712?
South Carolina had its first water protection regulations in 1671?
Public health is not an invention of the 20th century, and the issues we debate today have many parallels in history. For example, nearly 200 years ago English upper classes were protesting laws requiring safer disposal of human sewage, indicating that if the poor really didn’t want to be sick they should just move to the country and get out of the unhealthy slums!!

12. Key Events Snow and Cholera
Epidemiology: mapping cases of cholera and household use of water sources revealed pattern involving a single water pump
Removing the handle from the Broad Street pump ended the epidemic
John Snow and the Broad Street Pump is the classic tale of basic epidemiology, the core science of public health. Prior to identification of Vibrio cholera as the causative agent of cholera, and absent any of the modern laboratory supports or computer analysis, Snow developed a theory of the source of the outbreak. He devised a simple map identifying the number and distribution of cases of the disease in the community and the specific water system serving each house in which disease occurred. On this information (His tables are reproduced on the next slide) he hypothesized that one water pump was responsible for transmission of the disease. Disabling the pump by the simple expedient of removing the handle brought the outbreak of cholera to a close.
Teacher’s Note:
The University of Illinois at Chicago has posted a web site which includes case studies of this outbreak and intervention. This might be used as a homework assignment for your students and can be found at:
and

13. Death Rates From Cholera 1853-54
These two tables were constructed by Dr. Snow in pursuit of his hypothesis that cholera was transmitted by contaminated water through an unknown mechanism. Between 1849 and 1854, the Lambeth Company changed its source to an area of the Thames where the water was “quite free from the sewage of London”; the dramatic difference in cholera rates were the result.
This is an example of testing an hypotheses using a natural experiment. In the first table, the row “both companies” refers to neighborhoods in which the supply was mixed, and door-to-door inquiry was needed to determine exactly which company was the supplier of the water and ultimately the cholera-causing organisms.

14. Did you know that . . .
In an 1881 report the SC Board of Health identified swamp drainage as an important tool in stopping malaria, 10 years before the mosquito was identified as the specific vector of the disease?
While John Snow is the best known of the early users of epidmiology to limit disease, the process was happening elsewhere, including South Carolina.

15. Massachusetts and the Shattuck Report
1850 review of sanitation practices and the potential for improving health status by enforcement of a sanitary code led to creation of local board of health in Massachusetts. This movement spread to other localities.
SC State Board of Health
Established in 1898.
Lemuel Shattuck conducted a comprehensive survey of sanitation conditions and practices, and outlined the potential for improving health status by enforcing a sanitary code. His report led to early communal action to protect the public health and created the political support necessary to create a local board of health in Massachusetts. This movement spread to other localities.
The strong role of sanitary engineers such as C. E-A Winslow in the early decades of public health in this country is often overlooked in our current attention to individual health improvement efforts. Winslow was an early leader in public health and a prolific writer on the need for community-wide action to improve health.
South Carolina established its first State Board of Health in 1898, a period of active public health law reform around the nation.

16. US Public Health Service
Marine Hospital Service
Created from concern for protection against imported infectious diseases and need to care for sick seamen
US Public Health Service
Uniformed service on call for local, national or international service in the protection of the public’s health
At the outset of our nation, concern for protection against imported infectious diseases and the need to care for sick seamen led to the creation of the Marine Hospital Service (MHS). The MHS was the predecessor of today’s US Public Health Service (USPHS), a uniformed service of health professionals on call for local, national or international service in the protection of the public’s health.
The U.S. Public Health Service Commissioned Corps continues to provide a wide range of services, from staffing Indian Health Service facilities to international epidemic response teams.
The chief of the USPHS is the Surgeon General and Assistant Secretary for Health of the Department of Health & Human Services (DHHS), currently Dr. David Satcher. Students may remember one or more of his recent predecessors:
C. Everett Koop (Reagan Presidency)
Antonio Novello (Bush Presidency)
Joycelen Elders (beginning of Clinton presidency)
The Surgeon General does not run any agency, and has no line authority, however, there is enormous authority in the ‘presence’ of the office, and in the access to the Secretary and to the President.
Activity: Discuss the use of a “bully pulpit” to promote health.

17. The Muckrakers and New Agencies
Food and Drug Administration created to administer Pure Food, Drug and Cosmetic Act
Superfund administered by the Environmental Protection Agency
U.S. Department of Agriculture
Occupational Safety & Health Act
The early part of the 20th century saw a dramatic increase in industrialization and urbanization, which, in turn, increased threats to health in the form of the sale of adulterated and contaminated food products and pharmaceuticals. The Food and Drug Administration was created to administer the Pure Food, Drug and Cosmetic Act. Additional concerns and legislative action continue to this day.
Later acts that continue to respond to this sort of threat include:
- The Superfund Act administered by the Environmental Protection Agency to deal with long abandoned industrial hazards.
- The US Department of Agriculture recently overhauled the meat inspection program to include modern laboratory methods for detecting bacteria in meat.
- The Occupational Safety and Health Act is enforced by the Department of Labor and addresses occupational threats to health.
- A debate that illustrates the tension in public health decision-making is the current one about whether the FDA authority extends to tobacco. The agency proposed regulations, the industry took it to court, and the Supreme Court ruled (March, 2000) that because Congress has declined to pass specific authorization, the FDA was overstepping its bounds.

18. Great Public Health Achievements of This Century
Vaccination
Motor vehicle safety
Safer workplaces
Control of infectious diseases
Decline in deaths from coronary heart disease and stroke
Safer, healthier food
Healthier mothers and babies
Family planning
Flouridation of drinking water
Recognition of tobacco as a hazard
A summary article on these achievements appeared in the Morbidity & Mortality Weekly Report (MMWR) and may be found at:
Subsequent articles (locate through the MMWR index at
provide more details on each.
Activity: Select one or more of these topics that are particularly pertinent to your students for more detailed discussion at this point. Or, as an out-of-class activity, have each student select one of these topics, locate the detailed article, and be prepared to discuss current/future implications in the area specific to the students profession or experience.
Each one illustrates both disease prevention and health promotion, and the involvement of private and voluntary health groups with official agencies and policy-making bodies to achieve the progress that we have experienced.

19. Discussion Time
What has been your personal awareness of public health?
Have you ever visited a public health program? Used a public health service?
What are current public health issues in your community?
Most have used a public health service or program, but are unaware of it. The discussion time should help students to identify the public health services with which they have interacted, either personally or professionally. If students claim absolutely no involvement with public health you may have to remind them about the water they drink, the way sewage is supervised, mandatory school immunizations, or the simple registration of their births!!

20. Summary Public Health:
Services were developed to address the health needs of communities.
Has developed a world view of health.
Focuses on populations rather than individuals.