1. An Introduction to Prevention & the Public Health System A.H. Strelnick, M.D. Professor, Family Medicine Albert Einstein College of Medicine

2. Prevention & Public Health b “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.” –Former U.S. Surgeon General –C. Everett Koop, M.D.

3. Public Health in America b Vision: Healthy People in Healthy Communities b Mission: Promote Physical and Mental Health and Prevent Disease, Injury, and Disability b Public Health –Prevents epidemics & spread of disease –Protects against environmental health hazards –Prevents injuries –Promotes & encourages healthy behaviors –Responds to disasters & assists in recovery –Assures quality & accessibility of health services

4. Essential Public Health Services b 1. Monitor health status to identify community health problems b 2. Diagnose & investigate health problems & health hazards in the community b 3. Inform, educate & empower people about health issues b 4. Mobilize community partnerships to identify & solve health problems

5. Essential Public Health Services b 5. Develop policies & plans that support individual & community health efforts b 6. Enforce laws & regulations that protect health & ensure safety b 7. Link people to needed personal health services & assure the provision of health care when otherwise unavailable

6. Essential Public Health Services b 8. Assure a competent public health & personal health care workforce b 9. Evaluate effectiveness, accessibility & quality of personal & population-based health services b 10. Research for new insights & innovative solutions to health problems

7. Definitions of Public Health C.E.A. Winslow (1923)C.E.A. Winslow (1923) –Public health is the science and the art of (1) preventing disease, (2) prolonging life, and (3) organized community efforts for (a) the sanitation of the environment, (b) the control of communicable diseases, (c) the education of the individual in personal hygiene, (d) the organization of medical and nursing services for the early diagnosis & preventive treatment of disease, and (e) the development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity.

8. Definitions of Public Health b Rene Dubos (1968) Social organization and ways of life that promote & support the survival of the groupSocial organization and ways of life that promote & support the survival of the group b Dan Beauchamp (1976) Means to achieve social justice & protect all human lifeMeans to achieve social justice & protect all human life b Avi Ellencweig & Ruthellen Yoshpe (1984) Protection of the community against the hazards engendered by group lifeProtection of the community against the hazards engendered by group life

9. Definitions of Public Health b Institute of Medicine, The Future of Public Health, 1988 The mission of public health is the fulfillment of society’s interest in assuring the conditions in which people can be healthyThe mission of public health is the fulfillment of society’s interest in assuring the conditions in which people can be healthy Its aim is generating organized community efforts to address the public interest in health by applying scientific & technical knowledge to prevent disease & promote healthIts aim is generating organized community efforts to address the public interest in health by applying scientific & technical knowledge to prevent disease & promote health

10. Core Functions of Public Health Agencies & Organizations b Assessment –Regular & systematic collection, assembly, analysis & distribution of information on health of the community, including statistics on health status, community health needs & epidemiology b Policy Development –Apply scientific knowledge in decision-making about public’s health through democratic process b Assurance –Guarantee necessary services through regulation, incentives, and/or direct provision

11. Public Health vs. Clinical Medicine Traditions b Asclepius Greek hero/god of medicine, concerned as the healer with the individual, the functioning of the body, diseases within the body & treatments to alter the course of disease within the individualGreek hero/god of medicine, concerned as the healer with the individual, the functioning of the body, diseases within the body & treatments to alter the course of disease within the individual b Hygeia Greek goddess of health, daughter of Asclepius, concerned with environment & interaction between societies & their environments (human ecology)

12. Selected History of Public Health b 1348--Venice appoints sanitary council to quarantine ships, goods & people to prevent plague & contagion b 1485--Venetian Council of Health established to regulate all Mediterranean ports & harbors to prevent spread of plague, leprosy, yellow fever & cholera

13. Selected History of Public Health b 1601--English Poor Law enacted, establishing general hospitals for physically ill & asylums for mentally ill b 1701--Massachusetts passed laws to isolate smallpox patients & quarantine ships b 1721--Inoculation for smallpox accepted as effective means to contain disease

14. Selected History of Public Health b 1847--AMA founded b 1848--John Griscom’s “The Sanitary Condition of the Labouring Population in New York” b 1849--John Snow removed handle from Broad Street Pump, London, ending cholera epidemic & founding epidemiology b 1850--Lemuel Shattuck’s “Report of the Massachusetts Sanitary Commission”

15. Selected History of Public Health b 1906--Federal Pure Food & Drug Act restricts narcotics & patent medicines b 1907--First reportable disease law (Massachusetts) b 1908--First Children’s Bureau in NYCDOH b 1912--Marine Hospital Service becomes U.S. Public Health Service; federal Children’s Bureau

16. Selected History of Public Health b 1922--Sheppard-Towner Act creates Federal Board of Maternity & Infant Hygiene & makes grants to state for maternal & child health; first federal funds for personal health services & federal guidelines for state implementation b 1930--Hygienic Laboratory moves from Staten Island to Washington, D.C., to become the National Institute of Health

17. Selected History of Public Health b 1960--Kerr-Mills Amendments to Social Security Act provides state grants for care of elderly b 1962--Kefauver-Harris Amendments to FDA establishes drug efficacy standards; first Vaccination Assistance Act b 1964--U.S. Surgeon General’s “Report on Smoking and Health”

18. Selected History of Public Health b 1965--Medicare (Title XVIII) & Medicaid (Title XIX) Amendments to Social Security Act b 1969--Coal Mine Safety & Health Act b 1970--Occupational Safety & Health Act

19. Public Health by the Numbers b Schools of Public Health = 35 b Public Health Disciplines > 50 b Public Health Professionals > 50,000 b State & Territorial Departments of Health=55 b County & Local Departments of Health=3000

20. Public Health by the Numbers b Expenditures for Essential Public Health Services (1995) U.S Public Health Service = $7.1 billionU.S Public Health Service = $7.1 billion –Research = $2.4 billion (34%) –Personal health services = $2.0 billion (29%) States = $8.8 billionStates = $8.8 billion –Personal health services = $6.1 billion (69%) Per capita health care costs = $3,342Per capita health care costs = $3,342 Per capita population-based services=$36Per capita population-based services=$36 »Source: Public Health Foundation, 1996

21. State Public Health Workforce b Nurses (20%); Engineers & Sanitarians (7%) b Laboratory Technicians (6%) b Administrators (5%); Physicians (3%) b Planners & Program Analysts (2%) b Social Workers (2%); Nutritionists (1%) b Dentists (0.5%); Health Educators (0.5%) b Clerical & Support Staff (41%); Other (12%) »IOM Report, 1988

22. State Public Health Assessment Activities b Data Collection Vital Records & Statistics (96%)Vital Records & Statistics (96%) Health Facilities (85%)Health Facilities (85%) Health Manpower (83%)Health Manpower (83%) Health Trends Analysis (76%)Health Trends Analysis (76%) Hospital Care (70%)Hospital Care (70%) Population Forecast (67%)Population Forecast (67%) Long Term Care (61%)Long Term Care (61%) Morbidity (54%)Morbidity (54%)

23. State Public Health Assessment Activities b Epidemiology Communicable Disease Control (100%)Communicable Disease Control (100%) Health Screening (100%)Health Screening (100%) Laboratory Analyses (98%)Laboratory Analyses (98%) b Research Collaborative Projects (91%)Collaborative Projects (91%) Laboratory Research (28%)Laboratory Research (28%)

24. State Public Health Policy Development Activities b Health Planning (65%) b Categorical Plans (98%) Emergency Medical Services (89%)Emergency Medical Services (89%) Health Facilities (52%)Health Facilities (52%) Health Services (46%)Health Services (46%) Health Manpower (33%)Health Manpower (33%) Environmental Health (9%)Environmental Health (9%) b Standards for Local Health Agencies (80%) b Population-Based Health Goals (35%)

25. State Public Health Assurance Activities b Inspection Food & Milk Control (93%), Housing Safety (91%), Health Facility Safety (89%), Institutional Safety (80%) & Product Safety (63%)Food & Milk Control (93%), Housing Safety (91%), Health Facility Safety (89%), Institutional Safety (80%) & Product Safety (63%) b Licensing Health Services (93%), Health Facilities (89%) & Health Manpower (87%)Health Services (93%), Health Facilities (89%) & Health Manpower (87%) b Health Education Health Education (100%) & Health Promotion/Disease Prevention (67%)Health Education (100%) & Health Promotion/Disease Prevention (67%)

26. State Public Health Assurance Activities b Environmental Services Sewage Disposal Systems (83%)Sewage Disposal Systems (83%) Public & Individual Water Supply Safety (80%)Public & Individual Water Supply Safety (80%) Radiation Control (78%)Radiation Control (78%) Hazardous Waste Management (54%)Hazardous Waste Management (54%) Water Pollution (54%)Water Pollution (54%) Occupational Safety & Health (50%)Occupational Safety & Health (50%) Solid Waste Management (48%)Solid Waste Management (48%) Air Quality (46%) & Noise Pollution (33%)Air Quality (46%) & Noise Pollution (33%)

27. State Public Health Assurance Activities b Personal Health Services Maternal & Child Health (100%), Prenatal Care (100%), Family Planning (100%) & Obstetrics (61%)Maternal & Child Health (100%), Prenatal Care (100%), Family Planning (100%) & Obstetrics (61%) Immunizations (100%) & Dental Health (100%)Immunizations (100%) & Dental Health (100%) Chronic Disease (98%), Inpatient Services (91%) & Facilities (41%) & Home Care (83%)Chronic Disease (98%), Inpatient Services (91%) & Facilities (41%) & Home Care (83%) Handicapped Children (78%)Handicapped Children (78%) Mental Health (63%) & Retardation (59%), Alcoholism (52%) & Drug Abuse (43%)Mental Health (63%) & Retardation (59%), Alcoholism (52%) & Drug Abuse (43%)

28. Responding to Leading Health Indicators--Healthy People 2010 b Tobacco Use Department of JusticeDepartment of Justice –Alcohol, Tobacco & Firearms Agency Department of Health & Human ServicesDepartment of Health & Human Services –Food & Drug Administration –Office of Smoking & Health –National Institutes of Health –National Cancer Institute –National Heart, Lung & Blood Institute

29. Responding to Leading Health Indicators--Healthy People 2010 b Substance Abuse Department of JusticeDepartment of Justice –Drug Enforcement Administration –Alcohol, Tobacco & Firearms Agency Department of Health & Human ServicesDepartment of Health & Human Services –Alcohol, Drug Abuse & Mental Health Administration –National Institute of Alcoholism & Alcohol Abuse –National Institute of Drug Abuse

30. Responding to Leading Health Indicators--Healthy People 2010 b Responsible Sexual Behavior Department of Health & Human ServicesDepartment of Health & Human Services –Centers for Disease Control & Prevention –Office of Adolescent Pregnancy Program –Administration for Children, Youth & Families –Health Resources & Services Administration –Bureau of Community Health Services –Office of AIDS Services (Ryan White CARE Program) –National Institute of Allergy & Infectious Diseases Department of EducationDepartment of Education –Office of Comprehensive School Health

31. Responding to Leading Health Indicators--Healthy People 2010 b Mental Health Department of Health & Human ServicesDepartment of Health & Human Services –Alcoholism, Drug Abuse & Mental Health Administration –National Institute of Mental Health –Health Resources & Services Administration –Bureau of Community Health Services Department of EducationDepartment of Education –Office of Comprehensive School Health

32. Responding to Leading Health Indicators--Healthy People 2010 b Injury & Violence Department of JusticeDepartment of Justice –Alcohol, Tobacco & Firearms Agency –Drug Enforcement Administration Department of CommerceDepartment of Commerce –Consumer Product Safety Commission Department of Health & Human ServicesDepartment of Health & Human Services –Centers for Disease Control & Prevention Department of TransportationDepartment of Transportation –National Traffic Safety Commission

33. Responding to Leading Health Indicators--Healthy People 2010 b Environmental Quality Environmental Protection AgencyEnvironmental Protection Agency Department of Health & Human ServicesDepartment of Health & Human Services –National Institute of Environmental Health Sciences –Food & Drug Administration –National Center for Toxicology Research –Centers for Disease Control & Prevention –National Institute of Occupational Safety & Health Department of Labor (also Injury Prevention)Department of Labor (also Injury Prevention) –Occupational Safety & Health Administration –Mine Safety & Health Administration

34. Responding to Leading Health Indicators--Healthy People 2010 b Immunization Department of EducationDepartment of Education –Office of Comprehensive School Health Department of Health & Human ServicesDepartment of Health & Human Services –Centers for Disease Control & Prevention –Health Care Finance Administration –Office of Disease Prevention & Health Promotion –Health Resources & Services Administration –Bureau of Community Health Services –Administration for Children, Youth & Families

35. Responding to Leading Health Indicators--Healthy People 2010 b Access to Health Care Department of Health & Human ServicesDepartment of Health & Human Services –Health Care Finance Administration –Medicaid –Medicare –Office of Special Programs (Early Periodic Screening, Diagnosis & Treatment Program) –Health Resources & Services Administration –Bureau of Community Health Services –Bureau of Medical Services (Indian Health Service) –Agency for Healthcare Research & Quality