1. Public Health and Clinical Medicine Natural Partners Paul Jarris, MD, MBA Executive Director Association of State and Territorial Health Officials

2. ASTHO – From Micronesia to Alaska and Across the U.S. to the Virgin Islands

3. ASTHO – From Micronesia to Alaska and Across the U.S. to the Virgin islands

4. 10 Essential Public Health Services Monitor health status to identify community problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate, and empower people about health issues. Mobilize community partnerships and action to identify and solve health problems. Develop policies and plans that support individual and community health efforts.

5. 10 Essential Public Health Services, Cont’d Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assure a competent public health and personal health care workforce. Evaluate effectiveness, accessibility, and quality of personal and population- based health services. Research for new insights and innovative solutions to health problems.

6. MCH Pyramid Medical Visit Transportation Newborn Screening Systems of Care

7. Ten Great Public Health Achievements -- United States, 1900-1999 Vaccination Motor-vehicle safety Safer 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

8. Determinants of Health  Debisette, et. al., 2005

9. Determinants of Health (by percent contribution) McGinnis et. al., 2002

10. US Spending on Health Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce, Bureau of Economic Analysis, and U.S. Bureau of the Census.

11. Clinical Interactions Year one and two: 13 visits All ages: 3.1 visits Typical patient with a Chronic illness  4 visits/year X 30 minutes = 120 minutes  365 X 24 X 60 = 525,600 minutes per year  120/525,600 = 0.02% of time

12. The Real Threats to Our Health

13. Prevention Primary prevention/Universal  Reduction or control of causative factors for a health problem and includes reducing risk and environmental exposures Secondary prevention/Selective  Early detection and treatment Tertiary prevention/Indicated  Appropriate supportive and rehabilitative services to minimize morbidity and maximize quality of life  CDC, 1992

14. Prevention in the Clinical Setting Primary Prevention: services provided to individuals to prevent the onset of a targeted condition  routine immunization of healthy children and adults  Anticipatory guidance Secondary Prevention: services to identify and treat asymptomatic persons who have already developed risk factors or preclinical disease but in whom the condition has not become clinically apparent.  Pap smear to detect cervical dysplasia before the development of cancer  mamography  Screening for high blood pressure Tertiary Prevention: treatment and management of persons with clinical illnesses  cholesterol reduction in patients with coronary heart disease  insulin therapy to prevent the complications of diabetes mellitus US Preventive Services Task Force, 1996

15. Prevention in Public Health Policy Development and Implementation Population-based Services Direct Services

16. Example: Smoking Interventions* Clean Indoor Air Legislation Tobacco Price Increases Mass Media Campaigns Telephone Quitlines Provider reminders with Provider education *Recommended with Strong Evidence by the Guide to Community Preventive Services

17. Smoke-Free Laws March 2007 * The Montana and Utah laws extend to bars in 2009. * Arizona law effective 5/1/07; New Mexico law effective 6/15/07 Restaurants Restaurants & Bars

18. Effects of a 10% Increase in Tobacco Price Nearly 7% decline in youth prevalence A 2% decline in adult prevalence A 4% decline in overall consumption

19. Mass media campaigns when combined with other interventions Median decrease in tobacco use initiation in youth exposed to mass media campaigns was eight percentage points. Studies evaluating the impact of mass media campaigns on statewide tobacco consumption found a median decrease of 15 packs per capita per year.

20. Patient telephone quitlines Median improvement in quit rates among smokers who used telephone support when compared with smokers who did not was 41 percent. When combined with other interventions such as medical therapies, telephone quitlines were found effective in helping smokers quit in both community and clinical settings.

21. Provider reminders with provider education Studies that evaluated healthcare systems interventions to encourage provider efforts to advise patients on tobacco use cessation showed that:  Median absolute percentage increase in the number of patients who received provider advice on cessation was 20 points  the median absolute percentage increase in the number of patients who quit was 4.7 points. Provider reminders alone were only found to be recommended with sufficient evidence

22. Poor Diet and Physical Activity

23. Obesity Is Linked To A Significant Increase In Chronic Conditions Baseline – comparable normal weight individuals with no history of smoking or heavy drinking Sturm R. Health Affairs. 2002; 21 (2): 245-253 Public Health. 2001; 115:229-295

24. Increased Risk of Obesity-Related Diseases with Higher BMI Disease BMI of 25 or less BMI between 25 and 30 BMI between 30 and 35 BMI of 35 or more Arthritis1.001.561.872.39 Heart Disease1.001.391.861.67 Diabetes (Type 2) 1.002.423.356.16 Gallstones1.001.973.305.48 Hypertension1.001.922.823.77 Stroke1.001.531.591.75 Centers for Disease Control. Third National Health and Nutrition Examination Survey. Analysis by The Lewin Group, 1999.

25. Deaths Per Thousand Adults 2.50 2.25 2.00 1.75 1.50 1.25 19801990200020102020203020402050 Time (Year) No Change Obesity Prevention Better Care Reducing diabetes deaths: options Systems Dynamic Change Model

26. Deaths from comp per thousand Adults No major changes – status quo Care and reduction in caloric intake 2.50 2.25 2.00 1.75 1.50 1.25 19801990200020102020203020402050 Time (Year) Obesity Prevention and Better Care No Change Reducing diabetes deaths: The Vermont Blueprint Approach!

27. America’s Obesity Epidemic Overweight adolescents have a 70% chance of becoming overweight or obese adults. The percentage of overweight children has more than doubled in the past 20 years. 65% of U.S. adults are overweight. 30% are obese.

28. Connecting Health & the Environment Modern American communities are designed for cars, not walking, recreation, or physical activity.

29. Kids Don’t Walk Anymore! Only 13% of kids walk to school today  Up to 90% who lived a mile away walked to school in the ‘70s Fear of crime and safety concerns are top reasons parents don’t allow kids to walk to school – each year 5,000 pedestrians die

30. The Built Environment Influences Health ASTHO’s Policy Statement State and local governments, private developers, and community groups can promote physical activity by increasing access to :  Sidewalks, playgrounds, parks, bike paths, and safe streets & neighborhoods. Community groups and local governments can work together to increase capital improvement projects that promote physical activity.

31. Public Health Focus School-based interventions Worksite interventions Healthcare system interventions Community-wide interventions

32. New York’s Healthy Heart Program Comprehensive Approaches to Promote Activity  Developed toolkit to promote walking and biking trails.  Conducted over 15 Walkable Community workshops in the state With NY DOT and law enforcement.  Convenes local decision makers, health and planning professionals, to learn how to make communities more pedestrian friendly and safer Goals Create walking and bicycle trails Increase physical activity options in after-school programs Open schools for physical activity use by residents before and after school hours

33. Arkansas Addresses Childhood Obesity Three years of statewide assessments of student BMIs reveals that the progression of the childhood obesity epidemic has been halted in Arkansas.

35. Linking Public Health and Clinical Medicine Vermont Blueprint for Health Source: Vermont Department of Health, Agency of Human Services, 2007

36. Self Management 99.98%

37. Healthier Living Workshop Stanford University Stanford Patient Education Research Center Kate Lorig http://patienteducation.stanford.edu/programs/cdsmp.html

38. 11 Hospital Service Areas 80 Certified Professional and Lay leaders Over 300 Vermonters

39. Self Management Participants

40. Linking Public Health and Clinical Medicine Vermont Blueprint for Health Source: Vermont Department of Health, Agency of Human Services, 2007

41. Tobacco Obesity Substance Abuse DiabetesCAD Depression Public Policy Community Self- Management Information Systems Health Care Practice Health Systems Chronic Condition Risk Factors Core System Competencies The Vermont Blueprint for Health Paul E. Jarris, MD, MBA Vermont Department of Health