The Roles of the State in Disease Control: Public Health

1. The Roles of the State in Disease Control: Public Health Thomas E. Novotny, M.D., M.P.H.

2. Definitions • Public Health: “the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort” • Mission of public health: “fulfilling society’s interest in assuring conditions in which people can be healthy” • Core Function No. 1: Prevent epidemics and the spread of disease Source: Institute of Medicine, The Future of Public Health

3. Dimensions of the Public Health System: Role of Government • Capacity (inputs): resources, relationships, information and evidence • Processes (practices and outputs): core functions and essential service provision • Outcomes (results): health indicators, risk factor prevalence, quality-of-life

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

5. Essential Public Health Practices, continued • Enforce laws and regulations that protect health and ensure safety; • Link people with needed health services and assure the provision of care; • Assure a competent health workforce; • Evaluate effectiveness, access, and quality of health services; • Research for new insights and solutions to health problems.

6. Unique Features of Public Health • Basis in social justice philosophy • Inherently political nature • Dynamic, ever-expanding agenda • Grounding in the sciences • Prevention is prime strategy • Link with government

7. Link with Government • Assessment, assurance, and policy development to support public health mission; • Enforcing provisions of policy that may limit personal and property rights for the greater public good; • Convening partners and facilitating planning to identify and solve population health problems.

8. Underlying Principle of Government Role • Beneficence: government exists to improve the well-being of it members; • Beneficence involves a balance between maximizing benefits and minimizing harms; • Beneficence also involves principle of primum non nocere (doing no harm).

9. The Public Health Prevention Continuum Government Roles Pure private goods Mixed public and private goods Pure public goods Population Health Secondary prevention Tertiary prevention Primary prevention

10. General Government Strategies to Influence Public Health • Policy development to influence social and environmental conditions: • Education • Employment and workplace safety • Housing regulations • Public safety • Pollution control and sanitation • Direct provision of services

11. Historical Process • Conflicting value systems of public health and wider community; • Often takes outbreak, disaster, or other tragedy to implement public health strategies; • Little attention paid to financing core public health functions (pure public goods).

13. Public Health is Firmly Grounded in Law • Success of health education, infection control, or non-compulsory actions depends on ultimate availability of legal sanctions such as fines, injunctions, license revocation; • Police power of the State (power to provide health, safety, and welfare); • Balance of regulation and service provision.

14. Example: SARS • Since November 1, 2002, reported 3,547 cases with 182 deaths; • Affecting 27 countries (including Hong Kong); • New disease or recurrent pattern of emerging infectious diseases? • Government response??

15. Example: SARS

16. SARS in Hong Kong

17. Example: SARSCritical Government Response • Political leadership • Communications strategy (info and education) • Surveillance and contact tracing • Diagnostics • Quarantine and isolation • Treatment, including RCT • Hospital infection control • Environmental investigation and control

18. Example: SARS EXECUTIVE ORDER 13295: REVISED LIST OF QUARANTINABLE COMMUNICABLE DISEASES (April 9, 2003) By the authority vested in me as President by the Constitution and the laws of the United States of America, including section 361(b) of the Public Health Service Act (42 U.S.C. 264(b)), it is hereby ordered as follows: Section 1. Based upon the recommendation of the Secretary of Health and Human Services, in consultation with the Surgeon General, and for the purpose of specifying certain communicable diseases for regulations providing for the apprehension, detention, or conditional release of individuals to prevent the introduction, transmission, or spread of suspected communicable diseases, the following communicable diseases are hereby specified pursuant to section 361(b) of the Public Health Service Act: Severe Acute Respiratory Syndrome (SARS), which is a disease associated with fever and signs and symptoms of pneumonia or other respiratory illness, is transmitted from person to person predominantly by the aerosolized or droplet route, and, if spread in the population, would have severe public health consequences.

19. Global Dimension of Infectious Diseases • Need for international cooperation • Common interests and values • International law: International Health Regulations (WHO) • Now under revision • Currently cover cholera, plague, yellow fever • Externalities of infectious diseases such as HIV/AIDS, MRTB, etc., require global efforts.

20. Globalization of Public Health • Travel and trade across borders; • Inadequate public health and sanitation systems; declining effectiveness of drugs • Socioeconomic disparities: urbanization, poverty, environmental degradation; • Global economic interdependence and integration (loss of State control over economy)

21. International Health Regulations • Established under WHO in 1951: ‘Sanitary and quarantine requirements and otheer procedures designed to prevent the international spread of disease;’ • Lack of compliance almost universal; • Epidemiologic networks will help (public good) • Revisions (1995): Surveillance, response, increased number of diseases covered.

22. Disease Control Priorities:Infrastructure Development • Political commitment • Financing of public health infrastructure • Surveillance • Scientific investigation • Communications • Therapeutics (policy and development) • Critical evaluation of interventions

23. Shaping Public Health Policy:Roles of Society AND the State • Highly credible scientific evidence (especially surveillance); • Public health advocacy (civil society); • Media advocacy; • Enforceable and enforced sensible public health laws.

24. Closing Thought • Life is filled with golden opportunities, carefully disguised is irresolvable problems. • -- John Gardner • former Secretary of Health, Education, & Welfare

25. References • Institute of Medicine. The Future of Public Health. Washington DC: National Academy Press, 1988. • Fidler DP. International Law and Infectious Diseases. New York: Oxfod University Press, 1999. • Grad FP. The Public Health Law Manual, 2nd Edition. Washington DC: American Public Health Association, 1990. • Hong Kong Department of Health. A Briefing on SARS in Hong Kong, 16 April 2003. • Isaacs SL, Schroeder SA. Where the public good prevailed—lessons from success stories in health. The American Prospect, June 4, 2001. • Turnock BJ. Public Health: What It is and How It Works. Gaithersburg, Maryland: Aspen Publishers, Inc., 2001. • World Bank. Public Health In Eastern Europe and Central Asia—A Decade of Experience In Transition. (In Press), April 15, 2003