HCM 574 CSU Education as Social Determinant of Health in Saudi Arabia Brochure

Identify a key social determinant of health in the Kingdom of Saudi Arabia as well as a related public health concern. Next, prepare a public service announcement (PSA) in the form of a two-page brochure to educate the public on this concern. Remember to address the following:

An explanation of the social determinant including a definition;

How the determinant is related to a public health disease with current statistics;

What you want the public to do with the information-suggest behaviors you want to change.

How your agency can address the concern, including measures and surveillance;

Frequently Asked Questions (FAQ) – with specific items; and

Whom to contact for additional details (e.g., WHO, Ministry of Health), including an address and phone number.

To see an example, view the following brochure, “Monitoring is a Critical Tobacco Control Activity,” developed by the World Health Organization.

Your brochure should meet the following structural requirements:

A two-page brochure that includes all the elements detailed above.

Public Health 101
Improving Community Health
THIRD EDITION
Richard Riegelman, MD, MPH, PhD
Professor and Founding Dean
Milken Institute School of Public Health
The George Washington University
Washington, DC
Brenda Kirkwood, MPH, DrPH
Clinical Associate Professor
School of Public Health
University at Albany, State University of New York
Albany, NY
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Title: Public health 101: improving community health / Richard Riegelman,
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22 21 20 19 18 10 9 8 7 6 5 4 3 2 1
5
To Nancy Alfred Persily, whose enthusiasm for teaching public health
to undergraduates inspired Public Health 101: Improving
Community Health
6
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Images/Getty; © Christian Delbert/Shutterstock; © Jovanmandic/iStock/Getty Images Plus/Getty
7
Contents
Acknowledgments
Preface: What Is Public Health 101: Improving Community Health
All About?
About the Authors
SECTION I Principles of Population Health
Chapter 1 Public Health: The Population Health
Approach
What Do We Mean by “Public Health”?
How Has the Approach of Public Health Changed Over Time?
What Is Meant by “Population Health”?
What Are the Implications of Each of the Four Components of Public
Health?
Should We Focus on Everyone or on Vulnerable Groups?
What Do We Mean by Population Health’s Focus on the Life Cycle?
What Are the Approaches Available to Protect and Promote Health?
What Factors Determine the Occurrence of Disease, Disability, and
Death?
What Changes in Populations Over Time Can Affect Health?
Chapter 2 Evidence-Based Public Health
How Can We Describe a Health Problem?
How Can Understanding the Distribution of Disease Help Us Generate
Ideas or Hypotheses About the Cause Of Disease?
How Do Epidemiologists Investigate Whether There Is Another
Explanation for the Difference or Changes in the Distribution of
Disease?
What Is the Implication of a Group Association?
Etiology: How Do We Establish Contributory Cause?
What Can We Do If We Cannot Demonstrate All Three Requirements to
Definitively Establish Contributory Cause?
What Does Contributory Cause Imply?
Recommendations: What Works to Reduce the Health Impact?
Implementation: How Do We Get the Job Done?
Evaluation: How Do We Evaluate Results?
SECTION I Cases and Discussion Questions
8
HIV/AIDS Determinants and Control of the Epidemic
The Aging Society
Smoking and Adolescents—The Continuing Problem
Reye’s Syndrome: A Public Health Success Story
Sudden Infant Death Syndrome (SIDS)
SECTION II Tools of Population Health
Chapter 3 Public Health Data and Communications
What Is the Scope of Health Communications?
Where Does Public Health Data Come From?
How Is Public Health Information Compiled to Measure the Health of a
Population?
How Can We Evaluate the Display and Quality of the Presentation of
Health Information?
What Factors Affect How We Perceive Public Health Information?
What Type of Information Needs to Be Combined to Make Health
Decisions?
What Other Data Needs to Be Included in Decision-Making?
How Do We Utilize Information to Make Health Decisions?
How Can We Use Health Information to Make Healthcare Decisions?
Chapter 4 Social and Behavioral Sciences and
Public Health
How Is Public Health Related to the Social and Behavioral Sciences?
How Are Social Systems Related to Health?
How Do Socioeconomic Status, Culture, and Religion Affect Health?
What Are Social Determinants of Health?
10 Key Categories of Social Determinants of Health
How Do Social Determinants Affect Health?
Can Health Behavior Be Changed?
Why Are Some Individual Health Behaviors Easier to Change Than
Others?
How Can Individual Behavior Be Changed?
How Can Health Behavior Be Explained and Predicted?
What Are Some Key Theories and Models Used to Address Health
Behavior?
How Can Theories Be Applied in Practice?
Chapter 5 Health Law, Policy, and Ethics
What Is the Scope of Health Law, Policy, and Ethics?
9
What Legal Principles Underlie Public Health and Health Care?
What Do We Mean by “Health Policy”?
How Are Public Health Policy Priorities Established?
How Do Philosophies Toward the Role of Government Affect Health
Policies?
Is There a Right to Health Care?
How Does Public Health Attempt to Balance the Rights of Individuals and
the Needs of Society?
What Bioethical Principles Are Used to Address Public Health Issues?
How Can Bioethical Principles Be Applied to Protecting Individuals Who
Participate in Research?
What Can Be Done to Respond to the Threat of Pandemic Diseases?
SECTION II Cases and Discussion Questions
Don’ s Diabetes
A New Disease Called SADS—A Decision Analysis
José and Jorge—Identical Twins Without Identical Lives
The Obesity Epidemic in the United States—The Tip of an Iceberg
Changing Behavior—Cigarette Smoking
The New Era of E-Cigarettes
The Elderly Driver
SECTION III Preventing Disease, Morbidity, and
Mortality
Chapter 6 Noncommunicable Diseases
What Is the Burden of Noncommunicable Disease?
How Can Screening for Disease Address the Burden of
Noncommunicable Diseases?
How Can Identification and Treatment of Multiple Risk Factors Be Used
to Address the Burden of Noncommunicable Disease?
How Can Cost-Effective Interventions Help Us Address the Burden of
Noncommunicable Diseases?
Can Genetic Testing Help Predict Disease and Disease Outcomes and
Allow More Personalized Medicine?
What Can Be Done to Prevent Long-Term Mortality and Morbidity from
Our Treatments?
What Can We Do When Highly Effective Interventions Do Not Exist?
How Can We Combine Strategies to Address Complex Problems of
Noncommunicable Diseases?
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Chapter 7 Communicable Diseases
What Is the Burden of Disease Caused by Communicable Diseases?
How Do We Establish That an Organism Is a Contributory Cause of a
Communicable Disease?
How Do We Measure the Potential Impact of a Communicable Disease?
What Public Health Tools Are Available to Address the Burden of
Communicable Diseases?
How Can Barriers Against Disease Be Used to Address the Burden of
Communicable Diseases?
How Can Immunizations Be Used to Address the Burden of
Communicable Disease?
How Can Screening and Case Finding Be Used to Address the Burden of
Communicable Disease?
How Can Treatment of Those Diagnosed and Their Contacts Help to
Address the Burden of Communicable Disease?
What Is the Human Microbiome and Why Is It Important?
How Can Public Health Strategies Be Used to Eliminate Specific
Communicable Diseases?
What Options Are Available for the Control of HIV/AIDS?
What Options Are Available for the Control of Influenza?
What Options Are Available for the Control of Rabies?
Chapter 8 Environmental Health and Safety
What Is Meant by “Environment”?
What Is the Burden of Disease Due to the Physical Environment?
How Do We Interact with Our Physical Environment?
How Does Risk Assessment Address the Impacts of the Physical
Environment?
What Is a Public Health Assessment?
What Is an Ecological Risk Assessment?
What Is an Interaction Analysis Approach to Environmental Diseases?
What Are the Health Impacts of the Built Environment?
What Do We Mean by “Intentional and Unintentional Injuries”?
What Is Being Done to Keep the Population Safe?
SECTION III Cases and Discussion Questions
High Blood Pressure: A Public Health and Healthcare Success
Testing and Screening
H. pylori and Peptic Ulcers
What to Do About Lyme Disease?
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Sharma’s Village
Type 2 Diabetes—An Epidemic Disease
Legal Drugs That Kill—Death from Prescription Drug Overdoses
SECTION IV Health Professionals, Healthcare
Institutions, and Healthcare Systems
Chapter 9 Health Professionals and the Health
Workforce
What Do We Mean by a “Health Professional”?
How Do Education and Training Serve to Define Health Professions?
What Are the Educational Options Within Public Health?
What Is the Education and Training Process for Physicians?
What Is the Education and Training Process for Nursing?
What Roles Can Physicians, Nurses, and Other Clinical Health
Professions Play in Public Health?
What Is Meant by “Primary, Secondary, and Tertiary Care”?
How Are Clinical Health Professionals Rewarded and Compensated for
Their Services?
How Can We Ensure the System Has the Right Number of Healthcare
Professionals?
Chapter 10 Healthcare Institutions
What Institutions Make Up the Healthcare System?
What Types of Inpatient Facilities Exist in the United States?
What Types of Outpatient Facilities Exist in the United States?
What Do We Mean by the “Quality of Healthcare Services?”
How Can Health Care Be Coordinated Among the Multiple Institutions
That Provide Healthcare Services?
What Types of Coordination of Care Are Needed and What Purposes Do
They Serve?
What Types of Healthcare Delivery Systems Are Being Developed and
How Can They Help Ensure Coordination of Health Care?
How Can Electronic Medical Records Be Used To Facilitate Coordination
of Care and Improve Quality?
How Is Technology Being Used to Improve the Quality of Care?
What Mechanisms Are Being Used to Monitor and Ensure the Quality of
Health Care in the United States?
Chapter 11 Health Insurance and Healthcare
Systems
How Much Money Does the United States Spend On Health Care?
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What Types of Government-Supported Health Insurance Are Available?
What Types of Employment-Based Health Insurance Are Available?
What Mechanism Is Available to Obtain Insurance for Those Not
Otherwise Eligible for Health Insurance?
What Are the Extent and Consequences of Being Uninsured and
Underinsured in the United States?
Are There Other Programs Available for Those Who are Disabled or
Injured on the Job?
How Does the United States’ Health System Compare with Other
Developed Countries?
How Can We Describe the Healthcare Systems in Canada and the United
Kingdom?
What Conclusions Can We Reach from These Descriptions of the
Healthcare Systems in the United States, Canada, and the United
Kingdom?
How Can a Healthcare System Be Scored?
Using the National Scorecard, How Does the United States’ Healthcare
System Perform Compared to Those of Other Developed Countries?
How Can the Costs of Health Care Be Controlled in the United States?
How Can Population Health Become a Mechanism for Controlling Costs?
SECTION IV Cases and Discussion Questions
When Nursing Meets Medicine
Jack and Continuity of Care
Donna’s Doctor—To Err Is Human
Health Care in the United States—For Better or Worse?
Excess Costs—How Much Can Be Saved?
Navigating the Health System
Influenza in Middleburg and Far Beyond
SECTION V Public Health Institutions and Systems
Chapter 12 Public Health Institutions and Systems
What Are the Goals and Roles of Governmental Public Health Agencies?
What Are the 10 Essential Public Health Services?
What Are the Roles of Local and State Public Health Agencies?
Is There a Process of Accreditation of Health Departments?
What Are the Roles of Federal Public Health Agencies?
What Are the Roles of Global Health Organizations and Agencies?
How Can Public Health Agencies Work Together?
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What Other Government Agencies Are Involved in Health Issues?
What Roles Do Nongovernmental Organizations Play in Public Health?
How Can Public Health Agencies Partner with Health Care to Improve the
Response to Health Problems?
How Can Public Health Take the Lead in Mobilizing Community
Partnerships to Identify and Solve Health Problems?
Chapter 13 Food and Drugs As Public Health Issues
What Are Important Milestones in the History of Food and Drugs As
Public Health Issues in the United States?
Food and Food Safety
Drugs and Drug Safety
Chapter 14 Systems Thinking: From Single
Solutions to One Health
What Makes Systems Thinking Different?
What Is a System?
What Are the Initial Steps in Systems Analysis?
What Additional Steps Are Needed to Complete a Systems Analysis?
How Can We Use a Systems Analysis to Better Understand a Problem
Such As Coronary Artery Disease?
How Can We Use Systems Diagrams to Display the Workings of a
System?
How Can We Apply Systems Thinking to Population Health Issues?
How Can Systems Thinking Help Us Incorporate Interactions Between
Factors to Better Understand the Etiology of Disease?
How Can Systems Thinking Help Take into Account the Interactions
Between Diseases?
How Can Systems Thinking Help Identify Bottlenecks and Leverage
Points That Can Be Used to Improve Population Health?
How Can Systems Thinking Help Us Develop Strategies for Multiple
Simultaneous Interventions?
How Can Systems Thinking Help Us Look at Processes As a Whole To
Plan Short-Term and Long-Term Intervention Strategies?
What Is Meant by One Health?
What Is the One Health Initiative?
What Is the One Health Educational Framework?
Microbiological Influences on Health and Disease
Ecosystem Health/Physical Environment
How Can Global Movements of Populations Affect Health?
How Can Agricultural Practices and Changes in Food Distribution
Influence the Occurrence of Infectious Diseases in Humans?
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How Can Ecological Changes in Land and Resource Use Affect the
Development of Infectious Diseases?
How Can Climate Change Affect Human Health?
Human–Animal Interactions
What Is the Human–Animal Bond and What Are Its Health Benefits?
What Are the Major Risks from Cats and Dogs and How Can They Be
Minimized?
What Is Meant by Exotic Pets and What Risks Do They Pose for
Infectious Disease?
SECTION V Cases and Discussion Questions
Public Health Departments—Getting the Lead Out
Community-Oriented Primary Care (COPC)
Hurricane Karl and the Public Health Success in Old Orleans
Lung Cancer: Old Disease, New Approaches
Restorital—How Do We Establish Safety?
West Nile Virus: What Should We Do?
Antibiotic Resistance: It’s With Us for the Long Run
Glossary
Index
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Images/Getty; © Christian Delbert/Shutterstock; © Jovanmandic/iStock/Getty Images Plus/Getty
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Acknowledgments
Public Health 101: Improving Community Health, 3rd Edition is the culmination
of two decades of effort aimed at introducing public health to undergraduates.
The effort originated with the teaching of an introductory course in public
health in 1998 at the then newly created George Washington University
School of Public Health and Health Services. The new course, organized by
associate dean Nancy Alfred Persily, inspired efforts to teach and to learn from
a new generation. The approach was designed as part of a liberal arts
education, stimulating the movement that came to be called the Educated
Citizen and Public Health.
Efforts to think through the content of an introductory course in public health
have involved a large number of people throughout the United States. Public
health, arts and sciences, and clinical educators all participated in the 2006
Consensus Conference on Public Health Education, which put forward the
framework for Public Health 101 upon which this book is based. Among those
who led and continue to lead this effort is Susan Albertine, whose insights into
the relationship between public health and liberal education have formed the
basis for much of the Educated Citizen and Public Health movement.
I have taught Public Health 101 since 2002, which has provided me with an
opportunity to teach and to learn from well over 500 undergraduate students at
The George Washington University. Their feedback and input has been central
to writing and rewriting this book. I would also like to thank Alan Greenberg
and Heather Young, the chair and vice chair of the Department of
Epidemiology and Biostatistics at The George Washington University Milken
Institute School of Public Health, for their support of my efforts to expand the
audience for undergraduate public health.
I am pleased that Brenda Kirkwood has joined me as a co-author. I first had
the opportunity to work with Brenda while she was a DrPH student at The
George Washington University. Dr. Kirkwood has made extraordinary
contributions to Public Health 101. Her insights and careful reviews and
dedication to getting the details right have been key to the quality of this
edition. Brenda is truly exceptional and a pleasure to work with, as will be
confirmed by all who work with her.
Mike Brown, Director of Product Management of the Public Health and Health
Administration line of products for Jones & Bartlett Learning, has made special
contributions to this book and the Essential Public Health series as a whole.
His vision has helped craft the series, and his publishing expertise made it
happen. The production, marketing, and editorial staff of Jones & Bartlett
Learning deserve special recognition. Their commitment to this book and the
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entire Essential Public Health series has gone well beyond the expectations of
their jobs.
Last, but by no means least, is my wife, Linda Riegelman, who encouraged
this book and the Essential Public Health series from the beginning. She saw
the need to reach out to students and make real the roles that public health
plays in their everyday lives.
Confronting the challenge of putting together Public Health 101 has been one
of the great joys of my professional life. I hope it will bring both joy and
challenge to you as you enter into the important and engaging world of public
health.
Richard Riegelman, MD, MPH, PhD
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Images/Getty; © Christian Delbert/Shutterstock; © Jovanmandic/iStock/Getty Images Plus/Getty
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Preface: What Is Public Health 101:
Improving Community Health All
About?
Public health is more than a profession; it is a way of thinking. Public Health
101: Improving Community Health introduces you to the profession and also
the way of thinking that we will call population health. Population health is an
important way of looking at the world, whether you are going into public health
as a profession, a clinically oriented health profession, business, law,
international affairs, or a range of other professions.
Population health is also a key way of thinking, which prepares you for the
challenges of citizenship in a democracy. Many of the issues that come before
us as a society stem from or benefit from a population health perspective.
Whether we are dealing with AIDS, the impact of aging, climate change, or the
costs of health care, the population perspective can help us frame the issues
and analyze the options to intervene. Population health requires an evidencebased approach to collecting and using the facts to develop and implement
approaches to improve community health.
In addition, the population perspective leads us to look broadly at the way
issues intertwine and interact with each other. We call this systems thinking. In
population health, systems thinking is taking center stage as we increasingly
struggle with complex problems that require us to look beyond the traditional
boundaries of health and disease and the traditional lines between the roles of
the health professions.
Until recently, public health was considered a discipline taught only at the
graduate level. Today, undergraduate public health is booming at 4-year
colleges and is beginning to take hold at community colleges as well. Its roots
in general and liberal education go back to the 1980s, when David Fraser, the
president of Swarthmore and an epidemiologist who led the investigation of
Legionnaires’ disease, wrote a now classic article called “Epidemiology as a
Liberal Art.”1
In 2003, the National Academy of Medicine, formerly called the Institute of
Medicine, recommended that “all undergraduates should have access to
education in public health.”2 That recommendation encouraged the
development of the Educated Citizen and Public Health initiative, a
collaboration of undergraduate educators and public health educators to
define and stimulate public health curricula for all undergraduates. Public
Health 101 was written to implement the recommendations that came out of
this initiative and continues to form the basis for undergraduate education in
public health.
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The third edition of Public Health 101 has a new subtitle, Improving
Community Health. Improving Community Health is designed to highlight the
importance of community-wide collaboration to promote and protect health as
well as to prevent disease and disability. The third edition more fully addresses
the work of a wide range of health professionals whose roles are an
indispensable part of improving community health.
This third edition of Public Health 101 has been thoroughly updated and
expanded. Each chapter includes new material designed to expand your
understanding of public health. From e-cigarettes to the opioid epidemic, from
aging as a public health issue to the One Health movement, Public Health 101
aims to make public health relevant to today’s students and today’s world.
Each of the five sections includes new case studies challenging you to apply
what you have learned.
Public Health 101: Improving Community Health will not try to overload your
mind with facts. It is about providing you with frameworks for thinking, and
applying these frameworks to real situations and thought-provoking scenarios.
Each chapter begins and ends with vignettes designed to show you the types
of situations you will confront in public health. After each section, there are
case studies that relate to one or more chapters in the section. They provide
realistic, engaging exercises and open-ended questions to help you think
through the application of the key concepts presented in each section.
Hopefully, you will come away from reading Public Health 101 with an
appreciation of how the health of the public is influenced by and can be
improved by efforts directed at the population level, as well as at the individual
level. Let us begin in Chapter 1 by exploring the ways that public health affects
everyone’s daily life.
▶ References
1. Fraser DW. Epidemiology as a liberal art. N Engl J Med. 1987;
316:309–314.
2. Gebbie K, Rosenstock L, Hernandez LM. Who Will Keep the
Public Healthy? Educating Public Health Professionals for the
21st Century. Washington, DC: National Academy Press; 2003.
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Images/Getty; © Christian Delbert/Shutterstock; © Jovanmandic/iStock/Getty Images Plus/Getty
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About the Authors
Richard Riegelman, MD, MPH, PhD, is professor of epidemiology–
biostatistics, medicine, and health policy, and founding dean of The George
Washington University Milken Institute School of Public Health. His education
includes an MD from the University of Wisconsin, plus an MPH and PhD in
epidemiology from The Johns Hopkins University. Dr. Riegelman practiced
primary care internal medicine for over 20 years.
Dr. Riegelman has over 75 publications, including 6 books for students and
practitioners of medicine and public health. He is editor of the Jones & Bartlett
Learning Essential Public Health series. The series provides books and
ancillary materials for the full spectrum of curricula for undergraduate public
health education.
Dr. Riegelman has spearheaded efforts to fulfill the National Academy of
Medicine’s recommendation that “all undergraduates should have access to
education in public health.” He continues to work with public health and
undergraduate education associations to integrate public health into the
mainstream of undergraduate education at 2-year as well as 4-year colleges
and universities. Richard Riegelman teaches undergraduate and graduate
public health courses, which include Public Health 101 and Epidemiology 101.
Brenda Kirkwood, MPH, DrPH, works in academic administration and is
clinical associate professor at the School of Public Health, University at
Albany, State University of New York. Dr. Kirkwood has experience in higher
education spanning public and private institutions on the associate,
baccalaureate, and graduate levels, including development and teaching of
undergraduate and graduate public health courses, development and
management of public health academic programs, student advisement and
mentorship, and contributing to public health education research. Prior to her
career in higher education, Dr. Kirkwood held positions within the New York
State Department of Health. She received a BS from Ithaca College, MPH
from the University at Albany, State University of New York, and DrPH from
The George Washington University.
Dr. Kirkwood has been actively involved in national efforts to expand public
health education and strengthen the public health workforce. Her numerous
publications and presentations have focused on the roles of, and opportunities
for, public health education in 2-year and 4-year colleges and universities as
well as at the graduate level.
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© Jack Berman/Moment/Getty
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SECTION I
Principles of Population Health
S
ection I of Public Health 101: Improving Community Health introduces
you to the ways that public health affects your every waking moment,
from the food you eat, to the water you drink, to the car you drive. Even sleep
matters. In public health, we use bed nets to prevent malaria, we use beds
that prevent back pain, and put infants to sleep on their backs to prevent
sudden infant death syndrome (SIDS).
In Section I, we will examine a range of approaches to public health that have
been used over the centuries. Then we will focus on a 21st century approach
known as population health. Population health considers the full range of
options for intervention to address health problems, from community control of
communicable disease and environmental health, to healthcare delivery
systems, to public policies such as taxation and laws designed to reduce
cigarette smoking. Population health takes a life cycle approach, considering
how risks to health affect the population throughout the life span. We will also
look at how populations are changing and aging by examining three important
transitions that affect population health today and will continue to do so for
years to come.
In this section, we will also examine an evidence-based approach to
population health that focuses on defining the problem, establishing the
etiology, making evidence-based recommendations, implementing these
recommendations in practice, and evaluating the impacts of interventions. The
population health and evidence-based approaches introduced in Section I
provide an underpinning for all that follows.
At the end of Section I (and at the end of every section), there are cases with
discussion questions that draw on chapters from the section. Each case is
designed as a realistic description of the types of problems we face as we
seek to improve community health.
So with no further ado, let us take a look at how public health can and does
affect all of our daily lives.
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© Jack Berman/Moment/Getty
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CHAPTER 1
Public Health: The Population
Health Approach
LEARNING OBJECTIVES
By the end of this chapter, the student will be able to:
■ identify multiple ways that public health affects daily life.
■ define eras of public health from ancient times to the present.
■ define the meaning of “population health.”
■ illustrate the uses of health care, traditional public health, and social interventions in population
health.
■ identify a range of determinants of disease.
■ identify ways that populations change over time and how this affects health.
I woke up this morning, got out of bed, and went to the bathroom. There I used the toilet, washed
my hands, brushed and flossed my teeth, drank a glass of water, and took my blood pressure
medicine, cholesterol medication, and an aspirin. Then I did my exercises and took a shower.
On the way to the kitchen, I didn’t even notice the smoke detector I passed or the old ashtrays in
the closet. I took a low-fat yogurt out of the refrigerator and prepared hot cereal in the microwave
oven for my breakfast.
Then I walked out my door into the crisp, clean air and got in my car. I put on my seat belt, saw the
light go on for the airbag, and safely drove to work. I got to my office, where I paid little attention to
the new defibrillator at the entrance, the “no smoking” signs, or the absence of asbestos. I arrived
safely in my well-ventilated office and got ready to teach Public Health 101.
It wasn’t a very eventful morning, but then it’s all in a morning’s work when it comes to public health.
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© Champion studio/Shutterstock
T
his rather mundane morning is made possible by a long list of
achievements that reflect the often-ignored history of public health.1 We
take for granted the fact that water chlorination, hand washing, and indoor
plumbing largely eliminated the transmission of common bacterial diseases,
which for centuries killed the young and not so young. Do not overlook the
impact of prevention on our teeth and gums. Teeth brushing, flossing, and
fluoridation of water have made a dramatic impact on the dental health of
children and adults.
The more recent advances in the prevention of heart disease have been a
major public health achievement. Preventive successes include the reduction
of blood pressure and cholesterol, cigarette smoking prevention and cessation
efforts, the use of low-dose aspirin, an understanding of the role of exercise,
and the widespread availability of defibrillators. These can be credited with at
least half of the dramatic reductions in heart disease that have reduced the
death rate from coronary artery disease by approximately 50% in the United
States and most other developed countries in the last half century.
The refrigerator was one of the most important advances in food safety, which
illustrates the impact of social change and innovation not necessarily intended
to improve health. Food and product safety are public health achievements
29
that require continued attention. It was public pressure for food safety that in
large part brought about the creation of the U.S. Food and Drug
Administration. The work of this public health agency continues to affect all of
our lives from the safety of the foods we eat to the drugs and cosmetics we
use.
Radiation safety, like radiation itself, usually goes unnoticed, from the
regulation of microwave ovens to the reduction of radon in buildings. We rarely
notice when disease does not occur.
Highway safety illustrates the wide scope of activities required to protect the
public’s health. From seat belts, child restraints, and airbags to safer cars,
highways, designated driver programs, and enforcement of drunk driving laws,
public health efforts require collaboration with professionals not usually
thought of as having a health focus. New technologies produce new
challenges as our constant communications lead to inattention to the road.
However, technology also offers new opportunities which help compensate for
some of our “blind spots.”
The physical environment also has been made safer by the efforts of public
health. Improvement in the quality of the air we breathe both outdoors and
indoors has been an ongoing accomplishment of what we will call “population
health.” Our lives are safer today because of interventions ranging from
installation of smoke detectors to removal of asbestos from buildings.
However, the challenges continue. Globalization increases the potential for the
spread of existing and emerging diseases and raises concerns about the
safety of the products we use. Climate change and ongoing environmental
deterioration continue to produce new territory for “old” diseases, such as
malaria, dengue fever, and, more recently, Zika. Overuse of technologies,
such as antibiotics, has encouraged the emergence of resistant bacteria.
Overprescription of opioids has led to an epidemic of fatal overdoses among
the young and not so young.
The 1900s saw an increase in life expectancy of almost 30 years in most
developed countries, much of it due to the successes of public health
initiatives.2 We cannot assume that these trends will continue indefinitely. The
epidemic of obesity already threatens to slow down or reverse the progress we
have been making. The challenges of 21st century public health include the
protection of health and continued improvement in quality of life, not just the
quantity of years individuals are living.
To understand the role of public health in these achievements and other,
ongoing challenges, let us start at the beginning and ask: What do we mean
by “public health”?
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31
▶ What Do We Mean by “Public Health”?
Ask your parents what “public health” means, and they might say, “Health care
for the poor.” They are right that public health has always been about
providing services for vulnerable populations or those at higher than
average risk of disease and/or bad outcomes of disease, either directly or
through the healthcare system. Public health approaches to vulnerable
populations range from reducing exposure to lead paint in deteriorating
buildings, to food supplementation, to preventing birth defects and goiters.
Addressing the needs of vulnerable populations has always been a
cornerstone of public health. As we will see, however, the definition of
“vulnerable populations” continues to change, as do the challenges of
addressing their needs.
Ask your grandparents what “public health” means, and they might say,
“Washing your hands.” Well, they are right too—public health has always been
about determining risks to health and providing successful interventions that
are applicable to everyone. But hand washing is only the tip of the iceberg.
The types of interventions that apply to everyone and benefit everyone span
an enormous range: from food and drug safety to controlling air pollution, from
measures to prevent the spread of tuberculosis to vaccinating against
childhood diseases, from prevention and response to disasters to detection of
contaminants in our water.
The concerns of society as a whole are always in the forefront of public health
though traditionally the focus of public health has been on prevention among
mothers and children and the working aged population. These concerns keep
changing and the methods for addressing them keep expanding. New
technologies and global, local, and national interventions are becoming a
necessary part of public health. To understand what public health has been
and what it is becoming, let us look at some definitions of “public health.” The
following are two definitions of “public health”—one from the early 1900s and
one from more recent years.
Public health is “the science and art of preventing disease,
prolonging life and promoting health through organized
community effort.”3
The substance of public health is the “organized community
efforts aimed at the prevention of disease and the promotion of
health.”4
These definitions show how little the concept of public health changed
throughout the 1900s; however, the concept of public health in the 21st
32
century is beginning to undergo important changes in a number of ways,
including:
■ The goal of prolonging life is being complemented by an emphasis on the
quality of life. Protection of health when it already exists is becoming a
focus along with promoting health when it is at risk.
■ Use of new technologies, such as the Internet, is redefining “community,” as
well as offering us new ways to communicate.
■ The enormous expansion in the options for intervention, as well as the
increasing awareness of potential harms and costs of intervention
programs, requires a new science of “evidence-based” public health.
■ Public health and clinical care, as well as public and private partnerships,
are coming together in new ways to produce collaborative efforts rarely
seen in the 1900s.
■ Complex public health problems need to be viewed as part of larger health
and social systems, which require efforts to simultaneously examine
multiple problems and multiple solutions rather than one problem or one
solution at a time.
■ Public health increasingly needs to pay attention to the full range of health
issues, not just prevention among mothers and children and the working
aged population but prevention of disability among our growing elderly
populations. A full life cycle approach is now needed to improve community
health.
A new 21st century definition of public health is needed. One such definition
might read as follows:
The totality of all evidence-based public and private efforts
throughout the life cycle that preserve and promote health and
prevent disease, disability, and death.
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© AnnettVauteck/E+/Getty Images
This broad definition recognizes public health as the umbrella for a range of
approaches that need to be viewed as a part of a big picture or population
perspective. Specifically, this definition enlarges the traditional scope of public
health to include an examination of the full range of environmental, social, and
economic determinants of health—not just those traditionally addressed by
public health and clinical health care. An examination of the full range of
interventions to address health issues, including the structure and function of
healthcare delivery systems, plus the role of public policies that affect health
even when health is not their intended effect. This is being called a “health in
all policies” approach.
If your children ask you what public health is, you might respond: “It is about
the big picture issues that affect our own health and the health of our
community every day of our lives. It is about protecting health in the face of
disasters, preventing disease from addictions such as cigarettes and opioids,
controlling infections such as the human immunodeficiency virus (HIV) and
Zika, and developing systems to ensure the safety of the food we eat and the
water we drink.”
A variety of terms have been used to describe this big picture perspective that
takes into account the full range of factors that affect health and considers
their interactions.5 We will use the term population health. Before exploring
what we mean by the population health approach, let us examine how the
a
approaches to public health have changed over time.
34
aTurnock2 has described several meanings of “public health.” These include the system and social
enterprise, the profession, the methods, the government services, and the health of the public. The
population health approach used in this text may be thought of as subsuming all of these different
perspectives on public health.
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▶ How Has the Approach of Public Health Changed Over Time?
Health Protection (Antiquity—1830s)
Organized community efforts to promote health and prevent disease go back
to ancient times.6,7 The earliest human civilizations integrated concepts of
prevention into their culture, their religion, and their laws. Prohibitions against
specific foods—including pork, beef, and seafood—plus customs for food
preparation, including officially designated methods of killing cattle and
methods of cooking, were part of the earliest practices of ancient societies.
Prohibitions against alcohol or its limited use for religious ceremony have long
been part of societies’ efforts to control behavior, as well as prevent disease.
Prohibition of cannibalism, the most universal of food taboos, has strong
b
grounding in the protection of health.
The earliest civilizations have viewed sexual practices as having health
consequences. Male circumcision, premarital abstinence, and marital fidelity
have all been shown to have impacts on health.
Quarantine or isolation of individuals with disease or those exposed to disease
has likewise been practiced for thousands of years. The intuitive notion that
isolating individuals with disease could protect individuals and societies led to
some of the earliest organized efforts to prevent the spread of disease. At
times they were successful but without a solid scientific basis. Efforts to
separate individuals and communities from epidemics sometimes led to
misguided efforts, such as the unsuccessful attempts to control the black
plague by barring outsiders from walled towns while not recognizing that it was
the rats and fleas that transmitted the disease.
During the 1700s and the first half of the 1800s, individuals occasionally
produced important insights into the prevention of disease. In the 1740s,
British naval commander James Lind demonstrated that lemons and other
citrus fruit could prevent and treat scurvy, a then-common disease among
sailors, whose daily nourishment was devoid of citrus fruit, the best source of
vitamin C.
In the last years of the 1700s, English physician Edward Jenner recognized
that cowpox, a common mild ailment among those who milked cows, protected
those who developed it against life-threatening smallpox. He developed what
came to be called a vaccine—derived from the Latin vacca, meaning “cow.”
He placed fluid from cowpox sores under the skin of recipients, including his
son, and exposed them to smallpox. Despite the success of these smallpox
prevention efforts, widespread use of vaccinations was slow to develop,
partially because at that time there was not an adequate scientific basis to
explain the reason for its success.
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Hygiene Movement (1840–1870s)
All of these approaches to disease prevention were known before organized
public health existed. Public health awareness began to emerge in Europe and
the United States in the mid-1800s. The U.S. public health movement has its
origins in Europe, where concepts of disease as the consequence of social
conditions took root in the 1830s and 1840s. This movement, which put forth
the idea that disease emerges from social conditions of inequality, produced
the concept of social justice. Many attribute public health’s focus on
vulnerable populations to this tradition.
While early organized public health efforts paid special attention to vulnerable
members of society, they also focused on the hazards that affected everyone,
such as contamination of the environment. This focus on sanitation and public
health was often called the hygiene movement, which began even before the
development of the germ theory of disease. Despite the absence of an
adequate scientific foundation, the hygiene movement made major strides in
controlling communicable diseases, such as tuberculosis, cholera, and
waterborne diseases, largely through alteration of the physical environment.
The fundamental concepts of epidemiology also developed during this era. In
the 1850s, John Snow, often called the father of epidemiology, helped
establish the importance of careful data collection and documentation of rates
of disease before and after an intervention in order to evaluate effectiveness.
He is known for his efforts to close down the Broad Street pump, which
supplied water contaminated by cholera to a district of London. His actions
quickly helped terminate that epidemic of cholera. John Snow’s approach has
become a symbol of the earliest formal epidemiological thinking.
Ignaz Semmelweis, an Austrian physician, used much the same approach in
the mid-1800s to control puerperal fever—or fever of childbirth—then a major
cause of maternal mortality. Noting that physicians frequently went from the
autopsy room to the delivery room without washing their hands, he instituted a
handwashing procedure and was able to document a dramatic reduction in the
frequency of puerperal fever. Unfortunately, he was unable to convince many
of his contemporaries to accept this intervention without a clear mechanism of
action. Until the acceptance of the germ theory of disease, puerperal fever
continued to be the major cause of maternal deaths in Europe and North
America.
The mid-1800s in England also saw the development of birth and death
records, or vital statistics, which formed the basis of population-wide
assessment of health status. From the beginning of this type of data collection,
there was controversy over how to define the cause of death. Two key figures
in the early history of organized public health took opposing positions that
reflect this continuing controversy. Edwin Chadwick argued that specific
pathological conditions or diseases should be the basis for the cause of death.
37
William Farr argued that underlying factors, including what we would today call
social determinants of health, should be seen as the actual causes of death.
Contagion Control (1880–1940s)
The methods of public health were already being established before the
development of the germ theory of disease by Louis Pasteur and his European
colleagues in the second half of the 1800s. The revolutions in biology that they
ignited ushered in a new era in public health. U.S. physicians and public health
leaders often went to Europe to study new techniques and approaches and
brought them back to the United States to use at home.
After the Civil War, U.S. public health began to produce its own advances and
organizations. In 1872, the American Public Health Association (APHA) was
formed. According to its own historical account, the APHA’s “founders
recognized that two of the association’s most important functions were
advocacy for adoption by the government of the most current scientific
advances relevant to public health, and public education on how to improve
community health.”8
The biological revolution of the late 1800s and early 1900s that resulted from
the germ theory of disease laid the groundwork for the modern era of public
health. An understanding of the contributions of bacteria and other organisms
to disease produced novel diagnostic testing capabilities. For example,
scientists could now identify tuberculosis cases through skin testing, bacterial
culture, and the newly discovered chest X-ray. Concepts of vaccination
advanced with the development of new vaccines against toxins produced by
tetanus- and diphtheria-causing bacteria. Without antibiotics or other effective
cures, much of public health in this era relied on prevention, isolation of those
with disease, and case-finding methods to prevent further exposure.
In the early years of the 1900s, epidemiology methods continued to contribute
to the understanding of disease. The investigations of pellagra by Goldberger
and the United States Public Health Service overthrew the assumption of the
day that pellagra was an infectious disease and established that it was a
nutritional deficiency that could be prevented or easily cured with vitamin B-6
(niacin) or a balanced diet. Understanding the role of nutrition was central to
public health’s emerging focus on prenatal care and childhood growth and
development. Incorporating key scientific advances, these efforts matured in
the 1920s and 1930s and introduced a growing alphabet of vitamins and
nutrients to the U.S. vocabulary.
Filling Holes in the Medical Care System (1950s–
mid-1980s)
A new era of effective medical intervention against active disease began in
force after World War II. The discovery of penicillin and its often miraculous
38
early successes convinced scientists, public health practitioners, and the
general public that a new era in medicine and public health had arrived.
During this era, public health’s focus was on filling the holes in the healthcare
system. In this period, the role of public health was often seen as assisting
clinicians to effectively deliver clinical services to those without the benefits of
private medical care and helping to integrate preventive efforts into the
practice of medicine. Thus, the great public health success of organized
campaigns for the eradication of polio was mistakenly seen solely as a victory
for medicine. Likewise, the successful passage of Medicaid and Medicare,
outgrowths of public health’s commitment to social justice, was simply viewed
as efforts to expand the private practice of medicine.
This period, however, did lay the foundations for the emergence of a new era
in public health. Epidemiological methods designed for the study of
noncommunicable diseases demonstrated the major role that cigarette
smoking plays in lung cancer and a variety of other diseases. The emergence
of the randomized controlled trial and the regulation of drugs, vaccines, and
other interventions by the Food and Drug Administration developed the
foundations for what we now call evidence-based public health and evidencebased medicine.
Health Promotion/Disease Prevention (Mid-1980s–
2000)
The 1980s and much of the 1990s were characterized by a focus on individual
responsibility for health and interventions at the individual level. Often referred
to as health promotion and disease prevention, these interventions targeted
individuals to effect behavioral change and combat the risk factors for
diseases. As an example, to help prevent coronary artery disease, efforts were
made to help individuals address high blood pressure and cholesterol,
cigarette smoking, and obesity. Behavioral change strategies were also used
to help prevent the spread of the newly emerging HIV/AIDS epidemic. Efforts
aimed at individual prevention and early detection as part of medical practice
began to bear some fruit with the widespread introduction of mammography
for detection of breast cancer and the worldwide use of Pap smears for the
detection of cervical cancer. Newborn screening for genetic disease became a
widespread and often legally mandated program, combining individual and
community components.
Major public health advances during this era resulted from the environmental
movement, which brought public awareness of the health dangers of lead in
gasoline and paint. The environmental movement also focused on reducing
cancer by controlling radiation exposure from a range of sources, including
sunlight and radon, both naturally occurring radiation sources. In a triumph of
global cooperation, governments worked together to address the newly
discovered hole in the ozone layer. In the United States, reductions in air
39
pollution levels and smoking rates during this era had an impact on the
frequency of chronic lung disease, asthma, and most likely coronary artery
disease.
Population Health (2000s)
The heavy reliance on individual interventions that characterized much of the
last half of the 1900s changed rapidly in the beginning of the 21st century. The
current era in public health that is often called “population health” has begun to
transform professional and public thought about health and the relationship
between traditional public health and the healthcare system. From the
potential for bioterrorism, to the high costs of health care, to the control of
pandemic influenza, AIDS, and Ebola, the need for community-wide or
population-wide public health efforts has become increasingly evident. This
new era is characterized by a global perspective and the need to address
international health issues. The concept of One Health, which focuses on the
connections between human health, animal health, and ecosystem health, is
providing a framework for understanding the global health impacts that affect
all of us. One Health includes a focus on the potential impacts of climate
change, emerging and reemerging infectious diseases, and the consequences
of trade in potentially contaminated or dangerous products, ranging from food
to toys.
TABLE 1.1 outlines these eras of public health, identifies their key defining
elements, and highlights important events that symbolize each era.9
TABLE 1.1 Eras of Public Health
Eras of
public
health
Focus of
attention/paradigm
Action framework
Notable events and
movements in public health
and epidemiology
Health
Authority-based
Religious and cultural
Quarantine for epidemics;
protection
control of individual
practices and prohibited
sexual prohibitions to reduce
(Antiquity–
and community
behaviors
disease transmission; dietary
1830s)
behaviors
restrictions to reduce foodborne disease
Hygiene
Sanitary conditions
Environmental action on a
Snow on cholera; Semmelweis
movement
as basis for
community-wide basis
and puerperal fever; collection
(1840–
improved health
distinct from health care
of vital statistics as empirical
1870s)
foundation for public health and
epidemiology
Contagion
Germ theory:
Communicable disease
Linkage of epidemiology,
control
demonstration of
control through
bacteriology, and immunology
(1880–
infectious origins of
environmental control,
to form tuberculosis (TB)
1940s)
disease
vaccination, sanatoriums,
sanatoriums; outbreak
and outbreak investigation
investigation, e.g., Goldberger
in general population
and pellagra
40
Filling
Integration of
Public system for control
Antibiotics; randomized
holes in
control of
of specific communicable
controlled trials; concept of risk
the
communicable
diseases and care for
factors; surgeon general
medical
diseases,
vulnerable populations
reports on cigarette smoking;
care
modification of risk
distinct from general
Framingham study on
system
factors, and care of
healthcare system,
cardiovascular risks; health
(1950s–
high-risk
beginning of integrated
maintenance organizations and
mid-
populations as part
healthcare systems with
community health centers with
1980s)
of medical care
integration of preventive
integration of preventive
services into general
services into general
healthcare system
healthcare system
Health
Focus on individual
Clinical and population-
AIDS epidemic and need for
promotion/
behavior and
oriented prevention with
multiple interventions to reduce
Disease
disease detection in
focus on individual control
risk; reductions in coronary
prevention
vulnerable and
of decision-making and
heart disease through multiple
(Mid-
general populations
multiple interventions
interventions
Population
Coordination of
Evidence-based
Evidence-based medicine and
health
public health and
recommendations and
public health; information
(2000s)
healthcare delivery
information management,
technology; antibiotic
based upon shared
focus on harms and costs
resistance; global collaboration,
evidence-based
as well as benefits of
e.g., one health; tobacco
systems thinking
interventions, globalization
control; climate change, and a
1980s–
2000)
full life cycle approach to
improving community health
Data from Awofeso N. What’s New About the “New Public Health”? American Journal of Public Health. 2004;94(5):705–709.
Today we have entered an era in which a focus on the individual is
increasingly coupled with a focus on what needs to be done at the community
and population level. This era of public health can be viewed as “the era of
population health.”
b In recent years, this prohibition has been indirectly violated by feeding beef products containing bones
and brain matter to other cattle. The development of “mad cow” disease and its transmission to
humans has been traced to this practice, which can be viewed as analogous to human cannibalism.
41
▶ What Is Meant by “Population Health”?
The concept of population health has emerged in recent years as a broader
concept that stresses collaboration between traditional public health
professions, healthcare delivery professionals, and a range of other
professions that affect health. Population health provides an intellectual
umbrella for thinking about the wide spectrum of factors that can and do affect
the health of individuals and the population as a whole. FIGURE 1.1 provides
an overview of what falls under the umbrella of population health.
FIGURE 1.1 The Full Spectrum of Population Health
Population health also provides strategies for considering the broad range of
potential interventions to address these issues. By “intervention” we mean
the full range of strategies designed to protect health and prevent disease,
disability, and death. Interventions include preventive efforts, such as nutrition
and vaccination; curative efforts, such as antibiotics and cancer surgery; and
efforts to prevent complications and restore function, from chemotherapy to
physical therapy. Thus, population health is about improving community
health.
The concept of population health can be seen as a comprehensive way of
thinking about the modern scope of public health. It utilizes an evidence-based
approach to analyze the determinants of health and disease and the options
for intervention to preserve and improve health throughout the life cycle.
Population health requires us to define what we mean by “health issues” and
what we mean by “population(s).” It also requires us to define what we mean
by “society’s shared health concerns,” as well as “society’s vulnerable groups.”
To understand population health, we therefore need to define what we mean
by each of these four components:
■ Health issues
■ Population(s)
■ Society’s shared health concerns
■ Society’s vulnerable groups
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43
▶ What Are the Implications of Each of the Four Components of Public
Health?
All four of the key components of public health have changed in recent years.
Let us take a look at the historical, current, and emerging scopes of each
component and consider their implications.
For most of the history of public health, the term “health” focused solely on
physical health. Mental health has now been recognized as an important part
of the definition; conditions such as depression and substance abuse make
enormous contributions to disability in populations throughout the world. The
boundaries of what we mean by “health” continue to expand, and the limits of
health are not clear. Many novel medical interventions—including modification
of genes and treatments to increase height, improve cosmetic appearance,
and improve sexual performance—confront us with the question: Are these
health issues?
© rtguest/Shutterstock
The definition of “population,” likewise, is undergoing fundamental change. For
most of recorded history, a population was defined geographically. Geographic
communities, such as cities, states, and countries, defined the structure and
functions of public health. The current definition of “population” has expanded
to include the idea of a global community, recognizing the increasingly
44
interconnected issues of global health. The definition of “population” is also
focusing more on nongeographic communities. Universities now speak of an
online-learning community, health care is delivered to members of a health
plan community, and the Internet is constantly creating new social media
communities. All of these new definitions of “population” are affecting the
thinking and approaches needed to address public health issues.
What about the meaning of society-wide concerns—have they changed as
well? Historically, public health and communicable disease were nearly
synonymous, as symbolized by the field of epidemiology, which actually
derives its name from the study of communicable disease epidemics. In recent
decades, the focus of society-wide concerns has greatly expanded to include
toxic exposures from the physical environment, transportation safety, and the
costs of health care. However, communicable disease never went away as a
focus of public health, and there is a recent resurgence in concern over
emerging infectious diseases, including HIV/AIDS, pandemic flu, Ebola, and
Zika as well as newly drug-resistant diseases, such as staph infections and
tuberculosis. Additional concerns, ranging from the impact of climate change
to the harms and benefits of new technologies, are altering the meaning of
society-wide concerns.
Finally, the meaning of “vulnerable populations” continues to transform. For
most of the 1900s, public health focused on maternal and child health and
high-risk occupations as the operational definition of “vulnerable populations.”
While these groups remain important to public health, additional groups now
receive more attention, including the disabled, the frail elderly, and those
without health insurance. Attention is also beginning to focus on the
immunosuppressed among those living with HIV/AIDS, who are at higher risk
of infection and illness, and those whose genetic code documents their special
vulnerability to disease and reactions to medications.
Public health has always been about our shared health concerns as a society
and our concerns about vulnerable populations. These concerns have
changed over time, and new concerns continue to emerge. TABLE 1.2
outlines historical, current, and emerging components of the population health
approach to public health. As illustrated by communicable diseases, past
concerns cannot be relegated to history.
TABLE 1.2 Components of Population Health
Historical
Health
Population
Examples of society-wide
concerns
Examples of
vulnerable groups
Physical
Geographically
Communicable disease
High-risk maternal
limited
and child, high-risk
occupations
Current
Physical
Local, state,
Toxic substances, product
45
Disabled, frail
Emerging
and
national, global,
and transportation safety,
elderly, individuals
mental
governmentally
communicable diseases,
with pain, uninsured
defined
costs of health care
Cosmetic,
Defined by
Disasters, climate change,
Immunosuppressed,
genetic,
local, national,
technology hazards,
genetic vulnerability
social
and global
emerging infectious
functioning
communications
diseases
46
▶ Should We Focus on Everyone or on Vulnerable Groups?
Public health is often confronted with the potential conflict of focusing on
everyone and addressing society-wide concerns versus focusing on the needs
of vulnerable populations.10 This conflict is reflected in the two different
approaches to addressing public health problems. We will call them the highrisk approach and the improving-the-average approach.
The high-risk approach focuses on those with the highest probability of
developing disease and aims to bring their risk close to the levels experienced
by the rest of the population. FIGURE 1.2A illustrates the high-risk approach.
The success of the high-risk approach, as shown in FIGURE 1.2B, assumes
that those with a high probability of developing disease are heavily
concentrated among those with exposure to what we call risk factors. Risk
factors include a wide range of exposures, from cigarette smoke and other
toxic substances to high-risk sexual behaviors.
FIGURE 1.2 (A) High Risk and (B) Reducing High Risk
The improving-the-average approach focuses on the entire population and
aims to reduce the risk for everyone. FIGURE 1.3 illustrates this approach.
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FIGURE 1.3 Improving the Average
The improving-the-average approach assumes that everyone is at some
degree of risk and the risk increases with the extent of exposure. In this
situation, most of the disease occurs among the large number of people who
have only modestly increased exposure. The successful reduction in average
cholesterol levels through changes in the U.S. diet and the anticipated
reduction in diabetes via a focus on weight reduction among children illustrate
this approach.
One approach may work better than the other in specific circumstances, but in
general, both approaches are needed if we are going to successfully address
today’s and tomorrow’s health issues. These two approaches parallel public
health’s long-standing focus on both the health of vulnerable populations and
c
society-wide health concerns.
d
Now that we understand what we mean by “population health,” let us take a
look at the range of approaches that may be used to promote and protect
health.
c An additional approach includes reducing disparities by narrowing the curve so that the gap is reduced
between the lowest of the low-risk and the highest of the high-risk. For instance, this might be
accomplished by transferring financial resources and/or health services from the low-risk to the highrisk category through taxation or other methods. Depending on the distribution of the factors affecting
health, this approach may or may not reduce the overall frequency of disease more than the other
approaches. The distribution of risk in Figures 1.2 and 1.3 assumes a bell-shaped or normal
distribution. The actual distribution of factors affecting health may not follow this distribution.
d The term population health is increasingly begin used by a wide range of health professionals and now
carries a range of meanings. It may be used to refer to the health of a clinical population served by a
hospital, a group practice, or a health plan. It may also be used to refer to a high-risk group or those
who already have a specific disease. All these uses of the term population health share a focus on a
defined population. Whenever the term population health is used it is important to ask “which
population“?
48
49
▶ What Do We Mean by Population Health’s Focus on the Life Cycle?
To improve community health, population health approaches need to consider
the impacts on health throughout the life cycle. Issues of health risks actually
extend from prenatal to postmortem. The prenatal in utero environment has
long been known to affect health after birth, while the Ebola epidemic
reminded us that direct contact with the recently deceased can be a major
source of spread of disease.
Age is the single most important factor influencing the causes of death and
disability. To allow us to focus on age, public health has long divided age into
groups. These age groups may be defined by biological impact such as the
different impacts which occur among the very young and the very old. They
may also be defined by changing social issues, the most common of which is
the age for entering and leaving the workforce.
The way we divide populations by age has changed over time and continues
to change. The category we call adolescents and youth is evolving as the
transition to the workforce is occurring at an older age. As the healthy life span
increases, a new age category, sometimes called the young elderly, is
emerging between the traditional end of full-time work and the onset of the
stage we will call the old elderly.
TABLE 1.3 presents one way of dividing the age groups in the United States
and describing leading causes of death and disability.
TABLE 1.3 Leading Causes of Death and Disability by Age Groups
in the United States11–13
Age
Group
(Age)
Age Group
Name
Unique features of
the age group and
death rates per 1,000
in the United States
Major causes of death and disability in
the United States
Birth to
Neonatal
Highest death rate of
Most deaths due to conditions present at
any age group until
birth including premature birth, low
over 50.
birthweight, and birth defects.
28 days
Approximately
4/1,000. Nearly twothirds of deaths during
first year of life occur
in this period
Birth to 1
year
Infancy
Infant mortality rates
Sudden infant death syndrome and
approximately 6/1,000
infectious diseases are important causes of
live births with
death after 1 month.
approximately 2/1,000
after 1 month
50
1–5
Early
Death rates fall
Unintentional injuries are the leading cause
years
childhood
dramatically in the
of death and disability.
United States and
developed countries
where infectious
disease and
malnutrition deaths
are low. Rates
approximately
0.2–0.4/1,000 per year
5–14
Childhood
years
Lowest death rates of
Unintentional injury remains the leading
any period with most
cause of death and disability, with cancer
years approximately
being the second leading cause of death.
0.1/10,000
Suicide is the third leading cause of death
among those 10–14.
15–24
Adolescents
Increasing death rates
Dramatic increase in unintentional injuries
years
and Youth
with nearly 1/1,000
and intentional injuries with homicide and
deaths per year by
suicide as the second and third leading
age 24
causes of death. Behavior and mental
disorders are the single largest cause of
disability, and remain so until after age 65.
25–65
Working age
years
Rates gradually
Causes of death change with increases in
increase from
cancer and heart disease as the first and
approximately 1/1,000
second leading causes of death by age 45
at age 30 to 1.5/1,000
and remaining so through age 65. Chronic
at age 40 to 3/1,000 at
obstructive pulmonary disease is the third
age 50 to 8/1,000 at
leading cause of death by age 55 and
age 60 to 12/10,000 at
remains so until age 85.
age 65
Muscular-skeletal diseases are the
greatest cause of disability during this
period.
66–85
Young
Rates gradually
Cancer remains the leading cause of death
years
elderly/Senior
increase from
until age 80 when it is exceeded by heart
citizens
approximately
disease. Strokes and Alzheimer’s increase
20/10,000 at age 70 to
as cause of death and disability after age
30/1,000 at age 75 to
75.
50/1,000 at age 80
85+years
Old
Rates rapidly increase
Heart disease and cancer remain the first
elderly/Frail
from approximately
and second leading causes of death
elderly
80/1,000 at age 85 to
followed by Alzheimer’s and strokes until
140/1,000 at age 90 to
age 95 when Alzheimer’s becomes the
225/1,000 at age 95 to
second leading cause of death.
300 per 1,000 at age
Alzheimer’s becomes the leading cause of
100
disability in this age group.
Data from Centers for Disease Control and Prevention. National Center for Health Statistics. Deaths, percent of total deaths,
and death rates for the 15 leading causes of death in 5-year age groups, by race and sex: United States, 2014. Available at
https://www.cdc.gov/nchs/nvss/mortality/lcwk2.htm. Accessed July 23, 2017; Centers for Disease Control and
Prevention. National Center for Injury Prevention and Control. 10 Leading Causes of Death by Age Group, United States—
2010. Available at https://www.cdc.gov/injury/wisqars/pdf/10lcid_all_deaths_by_age_group_2010-a.pdf. Accessed July
23, 2017; National Institute of Mental Health. Cumulative U.S. DALYs for the Leading Disease/Disorder Categories by Age
51
(2010). Available at https://www.nimh.nih.gov/health/statistics/disability/us-leading-disease-disorder-categories-byage.shtml. Accessed July 23, 2017.
52
▶ What Are the Approaches Available to Protect and Promote Health?
The wide range of strategies that have been, are being, and will be used to
address health issues can be divided into three general categories: health
care, traditional public health, and social interventions.
Health care includes the delivery of services to individuals on a one-on-one
basis. It includes services for those who are sick or disabled with illness or
diseases, as well as for those who are asymptomatic. Services delivered as
part of clinical prevention have been categorized as vaccinations, behavioral
counseling, screening for disease, and preventive medications.14
Traditional public health efforts have a population-based preventive
perspective utilizing interventions targeting communities or populations, as
well as defined high-risk or vulnerable groups. Communicable disease control,
reduction of environmental hazards, food and drug safety, and nutritional and
behavioral risk factors have been key areas of focus of traditional public health
approaches.
Both health care and traditional public health approaches share a goal to
directly affect the health of those they reach. In contrast, social interventions
are primarily aimed at achieving other nonhealth goals, such as increasing
convenience, pleasure, economic growth, and social justice. Social
interventions range from improving housing, to improving education and
services for the poor, to increasing global trade. These interventions may have
dramatic and sometimes unanticipated positive or negative health
consequences. Social interventions, like increased availability of high-quality
food, may improve health, while the availability of convenient high-fat or highcalorie foods may pose a risk to health.
TABLE 1.4 describes the characteristics of health care, traditional public
health, and social approaches to population health and provides examples of
each approach.
TABLE 1.4 Approaches to Population Health
Health care
Characteristics
Examples
Systems for delivering one-on-
Clinical preventive services, including
one individual health services,
vaccinations, behavioral counseling, screening
including those aimed at
for disease, and preventive medications
prevention, cure, palliation,
and rehabilitation
Traditional
Group- and community-based
Communicable disease control, control of
public health
interventions directed at health
environmental hazards, food and drug safety,
53
promotion and disease
reduction in risk factors for disease
prevention
Social
Interventions with another
Interventions that improve the built environment,
interventions
non-health-related purpose,
increase education, alter nutrition, or address
which have secondary impacts
socioeconomic disparities through changes in tax
on health
laws; globalization and mobility of goods and
populations
None of these approaches is new. However, they have traditionally been
separated or put into silos in our thinking process, with the connections
between them often ignored. Thinking in systems and connecting the pieces is
an important part of the 21st century challenge of defining public health.
Now that we have explained what we mean by “public health” and seen the
scope and methods that we call “population health,” let us continue our big
picture approach by taking a look at what we mean by the “determinants of
health and disease.”
54
▶ What Factors Determine the Occurrence of Disease, Disability, and Death?
To complete our look at the big picture issues in public health, we need to gain
an understanding of the forces that determine disease and the outcome of
disease, including what in public health has been called morbidity (disability)
e
and mortality (death).
We need to establish what are called contributory causes based on evidence.
Contributory causes can be thought of as immediate causes of disease. For
instance, the HIV virus and cigarette smoking are two well-established
contributory causes of disease, disability, and death. They directly produce
disease, as well as disability and death. However, knowing these contributory
causes of disease is often not enough. We need to ask: What determines
whether people will smoke or come in contact with the HIV virus? What
determines their course once exposed to cigarettes or HIV? In public health,
we use the term determinants to identify these underlying factors, or “causes
of causes” that ultimately bring about disease.
Determinants look beyond the known contributory causes of disease to factors
that are at work often years before a disease develops.15,16 These underlying
factors may be thought of as “upstream” forces. Like great storms, we know
the water will flow downstream, often producing flooding and destruction along
the way. We just do not know exactly when and where the destruction will
occur.
© Cherngchay Donkhuntod/Shutterstock
55
There is no official list or agreed-upon definition of what is included in
f
determinants of disease. Nonetheless, there is wide agreement that the
following factors are among those that can be described as determinants in
that they increase or at times decrease the chances of developing conditions
that threaten the quantity and/or quality of life. Some but not all of these
factors are related to socioeconomic status and are categorized as social
determinants of health.
Behavior
Infection
Genetics
Geography
Environment
Medical care
Socioeconomic-cultural
BIG GEMS provides a convenient device for remembering these determinants
of disease. Let us see what we mean by each of the determinants.
Behavior—Behavior implies actions that increase exposure to the factors that
produce disease or protect individuals from disease. Actions such as smoking
cigarettes, exercising, eating a particular diet, consuming alcohol, having
unprotected intercourse, and using seat belts are all examples of the ways that
behaviors help determine the development of disease.
Infection—Infections are often the direct cause of disease. In addition, we are
increasingly recognizing that early or long-standing exposures to infections
may contribute to the development of disease or even protection against
disease. Diseases as diverse as gastric and duodenal ulcers, gallstones, and
hepatoma or cancer originating in the liver are increasingly thought to have
infection as an important determinant. Early exposure to infections may
actually reduce diseases ranging from polio to asthma through their impact on
the microbial environment in our gastrointestinal track, increasingly referred to
as our microbiome.
Genetics—The revolution in genetics has focused our attention on roles that
genetic factors play in the development and outcome of disease. Even when
contributory causes, such as cigarettes, have been clearly established as
producing lung cancer, genetic factors also play a role in the development and
progression of the disease. While genetic factors play a role in many diseases,
they are only occasionally the most important determinant of disease.
Geography—Geographic location influences the frequency and even the
presence of disease. Infectious diseases such as malaria, Chagas disease,
56
schistosomiasis, and Lyme disease occur only in defined geographic areas.
Geography may also imply local geological conditions, such as those that
produce high levels of radon—a naturally occurring radiation that contributes
to the development of lung cancer. Geography implies that special locations
are required to produce disease, such as altitude sickness, frostbite in cold
climates, or certain types of snake bites in the tropics.
Environment—Environmental factors determine disease and the course of
disease in a number of ways. The unaltered or “natural” physical world around
us may produce disability and death from sudden natural disasters, such as
earthquakes and volcanic eruptions, to iodine deficiencies due to low iodine
content in the food-producing soil. The altered physical environment produced
by human intervention includes exposures to toxic substances in occupational
or nonoccupational settings. The physical environment built for use by humans
—the built environment—produces determinants ranging from indoor air
pollution, to “infant-proofed” homes, to hazards on the highway.
Medical care—Access to and the quality of medical care can be a determinant
of disease. When a high percentage of individuals are protected by
vaccination, nonvaccinated individuals in the population may be protected as
well. Cigarette smoking cessation efforts may help smokers to quit, and
treatment of infectious disease may reduce the spread to others. Medical care,
however, often has its major impact on the course of disease by attempting to
prevent or minimize disability and death once disease develops.
© MAGNIFIER/Shutterstock
57
Socioeconomic-cultural—In the United States, socioeconomic factors have
been defined as education, income, and occupational status. These measures
have all been shown to be determinants of diseases as varied as breast
cancer, tuberculosis, and occupational injuries. Cultural and religious factors
are increasingly being recognized as determinants of diseases because
beliefs sometimes influence decisions about treatments, in turn affecting the
outcome of the disease. While most diseases are more frequent in lower
socioeconomic groups, others, such as breast cancer, may be more common
in higher socioeconomic groups.
Determinants of disease come up again and again as we explore the work of
population health. Historically, understanding determinants has often allowed
us to prevent diseases and their consequences even when we did not fully
understand the mechanism by which the determinants produced their impact.
For instance:
■ Scurvy was controlled by citrus fruits well before vitamin C was identified.
■ Malaria was partially controlled by clearing swamps before the relationship
to mosquito transmission was appreciated.
■ Hepatitis B and HIV infections were partially controlled even before the
organisms were identified through the reduction in use of contaminated
needles and the establishment of standards for blood transfusions.
■ Tuberculosis death rates were greatly reduced through less crowded
housing, the use of TB sanitariums, and better nutrition.
Using asthma as an example, BOX 1.1 illustrates the many ways that
determinants can affect the development and course of a disease.
BOX 1.1 Asthma and the Determinants of Disease
Jennifer, a teenager living in a rundown urban apartment in a city with high levels of air pollution,
develops severe asthma. Her mother also has severe asthma, yet both of them smoke cigarettes.
Her clinician prescribed medications to prevent asthma attacks, but she takes them only when she
experiences severe symptoms. Jennifer is hospitalized twice with pneumonia due to common
bacterial infections. She then develops an antibiotic-resistant infection. During this hospitalization,
she requires intensive care on a respirator. After several weeks of intensive care and every known
treatment to save her life, she dies suddenly.
Asthma is an inflammatory disease of the lung coupled with an increased reactivity of the airways,
which together produce a narrowing of the airways of the lungs. When the airways become swollen
and inflamed, they become narrower, allowing less air through to the lung tissue and causing
symptoms such as wheezing, coughing, chest tightness, breathing difficulty, and predisposition to
infection. Once considered a minor ailment, asthma is now the most common chronic disorder of
childhood. It affects over 6 million children under the age of 18 in the United States alone.
Jennifer’s tragic history illustrates how a wide range of determinants of disease may affect the
occurrence, severity, and development of complications of a disease. Let us walk through the BIG
GEMS framework and see how each determinant had impacts on Jennifer.
Behavior—Behavioral factors play an important role in the development of asthma attacks and in
their complications. Cigarette smoking makes asthma attacks more frequent and more severe. It
58
also predisposes individuals to developing infections such as pneumonia. Treatment for severe
asthma requires regular treatments along with more intensive treatment when an attack occurs. It is
difficult for many people, especially teenagers, to take medication regularly, yet failure to adhere to
treatment greatly complicates the disease.
Infection—Infection is a frequent precipitant of asthma, and asthma increases the frequency and
severity of infections. Infectious diseases, especially pneumonia, can be life-threatening in
asthmatics, requiring prompt and high-quality medical care. The increasing development of
antibiotic-resistant infections poses special risks to those with asthma.
Genetics—Genetic factors predispose people to childhood asthma. However, many children and
adults without a family history develop asthma.
Geography—Asthma is more common in geographic areas with high levels of naturally occurring
allergens due to flowering plants. However, today even populations in desert climates in the United
States are often affected by asthma, as irrigation results in the planting of allergen-producing trees
and other plants.
Environment—The physical environment, including that built for use by humans, has increasingly
been recognized as a major factor affecting the development of asthma and asthma attacks. Indoor
air pollution due to wood burning is the most common form of air pollution in many developing
countries. Along with cigarette smoke, air pollution inflames the lungs acutely and chronically.
Cockroaches often found in rundown buildings have been found to be highly allergenic and
predisposing to asthma. Other factors in the built environment, including mold and exposure to pet
dander, can also trigger wheezing in susceptible individuals.
Medical care—The course of asthma can be greatly affected by medical care. Management of the
acute and chronic effects of asthma can be positively affected by efforts to understand an
individual’s exposures, reducing the chronic inflammation with medications, managing the acute
symptoms, and avoiding life-threatening complications.
Socioeconomic-cultural—Disease and disease progression are often influenced by an individual’s
socioeconomic status. Air pollution is often greater in lower socioeconomic neighborhoods of urban
areas. Mold and cockroach infestations may be greater in poor neighborhoods. Access to and the
quality of medical care may be affected by social, economic, and cultural factors.
Asthma is a condition that demonstrates the contributions made by the full range of determinants
included in the BIG GEMS framework. No one determinant alone explains the bulk of the disease.
The large number of determinants and their interactions provide opportunities for a range of health
care, traditional public health, and social interventions.
Determinants of health may change over time, and the composition of
populations may change in ways that affect health. Let us take a look at some
of the ways that populations have changed and are changing that affect
population health.
e We will use the term “disease” as shorthand for the broad range of outcomes that includes injuries and
exposures that result in death and disability.
f Health Canada15 has identified 12 determinants of health, which are: (1) income and social status, (2)
employment, (3) education, (4) social environments, (5) physical environments, (6) healthy child
development, (7) personal health practices and coping skills, (8) health services, (9) social support
networks, (10) biology and genetic endowment, (11) gender, and (12) culture. Many of these are
subsumed under socioeconomic-cultural determinants in the BIG GEMS framework. The World Health
59
Organization’s Commission on Social Determinants of Health has also produced a list of determinants
that is consistent with the BIG GEMS framework.16
60
▶ What Changes in Populations Over Time Can Affect Health?
A number of important trends or transitions in the composition of populations
that affect the pattern of disease have been described in recent years. These
transitions have implications for what we can expect to happen throughout the
21st century. We will call these the demographic, epidemiological, and
nutritional transitions.
The demographic transition describes the impact of falling childhood death
rates and extended life spans on the size and the age distribution of
populations.17 During the first half of the 20th century, death rates among the
young fell dramatically in today’s developed countries. Death rates continued
their dramatic decline in most parts of the developing world during the second
half of the 20th century.
Birth rates tend to remain high for years or decades after the decline in deaths.
High birth rates paired with lower death rates lead to rapid growth in
population size, as we have seen in much of the developing world. This trend
continues today and is expected to go on in many parts of the world well into
the 21st century. Population pyramids are often useful for displaying the
changes in the age distribution that occur over time. Population pyramids
display the number of males and females that are present or expected to be
present for each age group in a particular year. The population pyramids in
FIGURE 1.4 illustrate how the population of Nigeria is expected to grow
through 2050 due to a high birth rate and a lowered death rate.
61
62
FIGURE 1.4 Population Pyramid Expected for Nigeria
Reproduced from U.S. Census Bureau. International Database. Available at
http://www.census.gov/population/international/data/idb/informationGateway.php. Accessed
July 14, 2017
Despite the delay, a decline in birth rates reliably occurs following the decline
in childhood deaths. This decline in births gradually leads to aging of the
population and can eventually lead to declining population numbers in the
absence of large-scale immigration. We are now seeing societies in much of
Europe and Japan as well as the United States with rapidly growing elderly
populations. Over 25% of the population of Japan is currently over 65
compared to approximately 15% in the United States.
Take a look at the population pyramids in FIGURE 1.5, which show what is
expected to occur in the coming years in much of Europe and Japan. Japan is
used as an example of the emergence of an inverted population pyramid, with
a smaller young population and a larger older population. Populations with a
large number of the elderly relative to the number of younger individuals have
a heavier burden of disease and create the conditions for aging to become a
public health issue.
63
64
FIGURE 1.5 Population Pyramid Expected for Japan
Reproduced from U.S. Census Bureau. International Database. Available at
http://www.census.gov/population/international/data/idb/informationGateway.php. Accessed
July 14, 2017
The large number of immigrants to the United States and their generally higher
birth rates have slowed this process in the United States, but the basic trend of
a growing elderly population continues. The population pyramids for the United
States are displayed in FIGURE 1.6.
65
66
FIGURE 1.6 Population Pyramid Expected for the United States
Reproduced from U.S. Census Bureau. International Database. Available at
http://www.census.gov/population/international/data/idb/informationGateway.php. Accessed
July 14, 2017
BOX 1.2 looks at the impacts that an increasing elderly population can be
expected to have in the United States in the coming years and the challenges
faced by public health.
BOX 1.2 Aging as a Public Health Issue
The proportion of the elderly in the United States is increasing rapidly in the second decade of the 21st century as
the “baby boomers” born between 1946 and 1964 enter the 65- to 74-year-old age group. FIGURE 1.7 illustrates
the rapid increase that is occurring and is expected to continue in the coming decades among those 65 and over
and 85 and over. By 2030 the proportion of those over 65 is expected to reach approximately 25% of the population
compared to the current level of approximately 15%.
FIGURE 1.7 Population Aged 65 and Over and Age 85 and Over, Selected Years 1900–2014 and Projected Years
2020–2060
Reproduced from Federal Interagency Forum on Aging-Related Statistics. Older Americans 2016: Key Indicators of Well-Being. Federal Interagency
Forum on Aging-Related Statistics. Washington, DC: U.S. Government Printing office. August 2016 page 2. Available at:
https://agingstats.gov/docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf. Accessed July 14, 2017.
The impact of aging is felt throughout the life span as working aged adults are increasingly responsible for taking
care of their aging parents as well as their own children, and all taxpayers shoulder the costs of programs for the
elderly. Government programs for the elderly are already under financial strain. The finances of Social Security,
Medicare, and Medicaid-financed nursing home care have become key issues in national political debates.
67
The ability of a slowly growing workforce to support a rapidly aging population will have major implications in the
United States for decades to come. These impacts, though great, are not expected to have the same
consequences as in Japan and areas of Europe where overall population numbers are declining, while the elderly,
especially those over 85, continue to increase.
The social and economic consequences of an aging population will be felt personally by most of today’s college
students. They will face a future with elderly parents and a society which is challenged to help address their needs.
The most dramatic impacts of an aging population will occur as a higher percentage of the elderly population reach
age 85 and over. Dementia, including Alzheimer’s disease and other conditions that chronically impair memory,
rapidly increases among those 85 and older. Less than 4% of those 65 to 69 are diagnosed with dementia, but the
percentage rises to almost 25% from ages 85 to 90 and over 35% beginning at age 90.18
The burden of dementia is rapidly becoming a major financial and social burden to the elderly and their families.
The social isolation and depression that often accompanies aging in general and dementia in particular is one
factor that can and should be addressed by public health and healthcare interventions.
Those 85 and over are the largest contributor to a vulnerable population known as the frail elderly. Over 25% of
those over 85 can be classified as frail elderly. The frail elderly are susceptible to a range of health issues including
falls, infection, and depression.
Gerontologists suggest that if someone has three or more of five factors, then that person should be considered
frail.19 These factors are:
■ Unintentional weight loss (10 pounds or more in a year)
■ General feeling of exhaustion
■ Weakness (as measured by grip strength)
■ Slow walking speed
■ Low levels of physical activity
Fortunately there are a number of public health, healthcare, and social interventions that can prevent frailty or
minimize its consequences; they are often described as follows:
Food- maintain intake
Resistance exercises
Atherosclerosis prevention (e.g., blood pressure, low-density lipoprotein cholesterol reduction, smoking cessation,
etc.)
Isolation prevention
Limit pain
Tai Chi or other balance exercises
Yearly check for testosterone deficiency
Impaired vision, impaired hearing, and dental problems are perhaps the most common modifiable incapacitating
impairments of the elderly. Yet Medicare does not generally provide coverage for these treatable conditions. Efforts
to support the frail elderly and prevent falls, social isolation, and other preventable conditions are increasingly seen
as part of the population health’s commitment to improving the health of the elderly.
Focusing on the health of the elderly is an increasingly important part of population health. It is becoming an
important way to improve the health of the community both for the elderly and for those who hope to live a long life.
A second transition has been called the epidemiological transition,20 or
public health transition. The epidemiological transition implies that as social
and economic development occurs, different types of diseases become
prominent. Deaths in less developed societies are often dominated by
epidemic communicable diseases and diseases associated with malnutrition
and childhood infections. As a country develops, communicable diseases
68
often come under control, and noncommunicable and chronic diseases, such
as heart disease, often predominate.
A related transition known as the nutritional transition21 implies that
countries frequently move from poorly balanced diets often deficient in
nutrients, proteins, and calories to a diet of highly processed food, including
fats, sugars, and salt. The consequences of both under- and overnutrition
affect and will continue to affect the public’s health well into the 21st century.
As we have seen, population health focuses on the big picture issues and the
determinants of disease. Increasingly, publi…

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