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

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

2. 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) PUBHLTH 200

3. 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 PUBHLTH 200

4. 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.” PUBHLTH 200

5. 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 PUBHLTH 200

6. 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 PUBHLTH 200

7. 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. PUBHLTH 200

8. Primacy of public health in concept Public health Collective health services Individual health services Medicine Dentistry Nursing Pharmacy PUBHLTH 200

9. Hierarchy in practice Medicine Other individual health services Public health PUBHLTH 200

10. 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 PUBHLTH 200

11. 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 PUBHLTH 200

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

13. Relationship between PH and MC: Expenditures MC PH PUBHLTH 200

14. 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 PUBHLTH 200

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

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

17. 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 PUBHLTH 200

18. Core functions of public health • Assessment of the health of the population • Development of public health policies • Assurance of the availability of needed services PUBHLTH 200

19. 1. Assessment of the public’s health Requires: • Data collection • Statistical and epidemiologic analysis • Dissemination of findings PUBHLTH 200

20. 2. Development of public health policies Requires: • Use of a scientific knowledge base • Appreciation and use of the political process PUBHLTH 200

21. 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 PUBHLTH 200

22. 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 PUBHLTH 200

23. 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 PUBHLTH 200

24. Five core areas of public health • Epidemiology • Biostatistics • Environmental Health Sciences • Health Behavior & Health Education • Health Management & Policy PUBHLTH 200

25. Epidemiology 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. PUBHLTH 200

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

27. 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. PUBHLTH 200

28. 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. PUBHLTH 200

29. 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 PUBHLTH 200

30. 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 PUBHLTH 200

31. Levels of Prevention and Effects PreventionPrimarySecondaryTertiary strategy Disease status Susceptible Asymptomatic Symptomatic Effects Reduced Reduced Reduced disease prevalence/ complications/ incidence consequence disability Source: Turnock, Fig. 3-4 PUBHLTH 200

32. 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 PUBHLTH 200

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

34. Agent, host, environment model of disease Agent • Traditionally infectious disease • A.k.a. Epidemiological TriangleHostEnvironment PUBHLTH 200

35. PUBHLTH 200

36. 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 PUBHLTH 200

37. 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 PUBHLTH 200

38. 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) PUBHLTH 200

39. 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 PUBHLTH 200

40. 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) PUBHLTH 200

41. 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? PUBHLTH 200

42. 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 PUBHLTH 200

43. 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 PUBHLTH 200

44. 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 PUBHLTH 200

45. 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 PUBHLTH 200

46. 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) PUBHLTH 200

47. 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 PUBHLTH 200

48. Thursday: History of public health PUBHLTH 200