UK A Professional in The Field of Public Health Summary Paper

*Part 1 learning summary *

The summary should address these two questions:

What were the key “take home” messages you acquired from the course materials in this session?

How can you apply these concepts into your current (or future) work in the public health or healthcare fields? Give a practical example(s).

Course Introduction and Overview:
Public Health Frameworks and
Evidence-Based Practices
Evidence-Based Public Health (MEDS 4053)
Kelley A. Carameli, DrPH
Week 1
2
Course Introductions
Syllabus
❖ Office Hours, Contact: carameky@ucmail.uc.edu
❖ Canvas: readings, assignment listing, grades
❖ Course Design and Assignments
Term divided into four parts: four weeks each, assignments
released/open only during that session window
• Articles/Readings + Instructor Videos
• Participation Submission (25% of grade, 8 over term, 5 pts. each)
• Learning Summaries (25% of grade, 4 over term, 10 pts. each)
• Course Quizzes (25% of grade, 3 over term, 15 pts. each)
• Video Article Presentation (25% of grade, 40 pts.)
• Virtual Class Discussion (Week 9 with 3 options for 45-min. log-in)
3
Course Overview
What is Public Health?
•
•
•
•
Preventing disease, prolonging life, promoting health
Assuring conditions exist in which all people can be healthy
Achieving health by fulfilling society’s interest
Using community/enterprise approaches
What is Evidence-Based Public Health?
• Using science and behavioral theory to measure change in public health
attitudes, beliefs, actions, programs, and policies
– Health status, disease/injury prevention, resources, quality of life
• Applying ‘testable’ (evidence-based) principles to public health programs
– Hypotheses, metrics, study design, critical skills assessment
• Making decisions based on evidence of the larger impact (benefits,
consequences) of public health programs and policies
– Political, economical, ethical, global, etc.
4
What is Public Health?
Public health applies a ‘population-level’ framework
• It is a social enterprise, or population health movement
– Identify health issue
– Call for collective action: protect, promote, improve
– Interdisciplinary actions, methods
– Touches govt. and political arenas
• Grounded in interdisciplinary practice and science
– Biology/Epidemiology: humans, vectors, microorganisms
– Behavioral: psychology, anthropology, sociology, education
– Biostatistics
– Environmental Science
– Leadership/Management
• Focused on prevention
• It is a functioning system (inputs, processes, outputs, outcomes)
5
What is Public Health?
Public health = ecological model of health
– Personal health determinants
• Biological (genetics), Attitudes/Perceptions, Behaviors
– Social-ecological health determinants
• Social, family, community networks (norms, culture, support)
• Physical/Living/Work conditions
• Environmental (clean water/air, transportation)
• Political (systems, policies)
• Economic (employment, fair market housing)
NOTE: Disparities in health outcomes are largely attributable to socialecological determinants (e.g., education, access to care, etc.).
6
What is Public Health?
Public health = ecological model of health
– Personal health determinants
• Biological (genetics), Attitudes/
Perceptions, Behaviors
– Social-ecological health determinants
• Social, family, community
• Physical/Living/Work conditions
• Environmental
• Political
• Economic
7
What does Public Health do?
Public Health Actions Across Time (U.S.)
• In the U.S. Constitution, ‘health’ is not a direct, but implied, Federal
power – i.e., ‘general welfare’, regulated commerce, exercised by States.
Time
Key Health Issues
Pre-1850
Epidemics of infectious disease
• Particularly around seaports: plague, smallpox, TB
• Prompts Marine Hospital Service: 1798 (Public Health Service)
1850-1949 State and local health infrastructures develop
• First county health depts. (1908); state and local health depts.
(1930s-1950s) focus on water safety, sanitation, food safety.
• ‘Science of public health’ takes root, CDC (1946)
1950-1999 Disparities in medical care delivery / Filling in gaps
• Medicare/Medicaid (1965), Clean Air Action (1971), WIC (1972)
1999Community + global health threats
Present
• Disasters/war, vaccines, mental health, violence, climate/envir.
8
What does Public Health do?
Public Health Core Functions
**PH is the interface between science and social values.
• Assessment
– Problem identification for a population (vs. medicine = diagnosis of an
individual)
– Surveillance of health problems, identify causes. (e.g., John Snow)
• Policy Development
– Collective decision of pop. actions: interventions, remedies
– Inform leaders and public, mobilize support, advocacy (e.g., child
welfare, pollution control, occup. safety, drug safety, sewage/water)
• Assurance
– Implementing actions: interventions, remedies (med. = treatment)
– Enforce laws (e.g., smoke-free restaurants), evidence-based actions
(Plan/Do/Study/Act), direct services (TB and HIV testing/clinics)
9
What does Public Health do?
Public Health Core
Functions
•
•
•
Assessment
– Surveillance of health
problems, identify causes.
– e.g., John Snow
Policy Development
– Inform leaders and public,
mobilize support, advocacy.
– e.g., vaccination programs
Assurance
– Enforce laws, evidencebased outreach
(Plan/Do/Study/Act)
– e.g., tobacco prevention
Essential Public Health Services
•
•
•
•
•
•
•
•
•
•
Monitor health status to identify community health
problems.
Diagnose and investigate health problems and health
hazards in the community.
Evaluate effectiveness, accessibility and quality of personal
and population-based health services.
Research for new insights and innovative solutions to health
problems.
Inform, educate and empower people about health issues.
Mobilize community partnerships to identify and solve
health problems.
Develop policies and plans that support individual and
community health efforts.
Enforce laws and regulations that protect health and ensure
safety.
Link people to needed personal health services and assure
the provision of health care when otherwise unavailable.
Assure a competent public health and personal health care
workforce.
What does Public Health do?
Public Health Core
Functions
•
•
•
Assessment
– Surveillance of health
problems, identify causes.
– e.g., John Snow
Policy Development
– Inform leaders and public,
mobilize support, advocacy.
– e.g., vaccination programs
Assurance
– Enforce laws, evidencebased outreach
(Plan/Do/Study/Act)
– e.g., tobacco prevention
10
Essential Public Health Services
•
•
•
•
•
•
•
•
•
•
Monitor health status to identify community health
problems.
Diagnose and investigate health problems and health
hazards in the community.
Evaluate effectiveness, accessibility and quality of personal
and population-based health services.
Research for new insights and innovative solutions to health
problems.
Inform, educate and empower people about health issues.
Mobilize community partnerships to identify and solve
health problems.
Develop policies and plans that support individual and
community health efforts.
Enforce laws and regulations that protect health and ensure
safety.
Link people to needed personal health services and assure
the provision of health care when otherwise unavailable.
Assure a competent public health and personal health care
workforce.
11
What does Public Health do?
Public Health Core
Functions
•
•
•
Assessment
– Surveillance of health
problems, identify causes.
– e.g., John Snow
Policy Development
– Inform leaders and public,
mobilize support, advocacy.
– e.g., vaccination programs
Assurance
– Enforce laws, evidencebased outreach
(Plan/Do/Study/Act)
– e.g., tobacco prevention
Essential Public Health Services
•
•
•
•
•
•
•
•
•
•
Monitor health status to identify community health
problems.
Diagnose and investigate health problems and health
hazards in the community.
Evaluate effectiveness, accessibility and quality of personal
and population-based health services.
Research for new insights and innovative solutions to health
problems.
Inform, educate and empower people about health issues.
Mobilize community partnerships to identify and solve
health problems.
Develop policies and plans that support individual and
community health efforts.
Enforce laws and regulations that protect health and ensure
safety.
Link people to needed personal health services and assure
the provision of health care when otherwise unavailable.
Assure a competent public health and personal health care
workforce.
12
What does Public Health do?
Traditional Public Health Programs
• Health Protection
– Emergency Management
– Environmental Health
• Health Promotion
– Education
– Outreach
– Planning
– Policy
NOTE: Cross-cutting public,
private, non-profit, CommunityBased (CBO), and Faith-Based
(FBO) Organizations.
13
Evidence-Based Public Health
What is Evidence-Based Public Health?
• Using data to inform public health interventions, outreach, or policy.
– Systematic evaluation planning and review is often lacking.
• Evaluation planning occurs before the program begins.
– Access to more and higher-quality data are needed.
• This requires: timely and relevant research, data-skilled leaders/staff,
access to information systems and resources, real-world application, and
data dissemination. Often depends on a political investment.
• Evidenced-based practices have a higher likelihood of success and more
efficient use of public/private resources.
– Triangulate evidence: quantitative, qualitative, cultural/geographic
– Disseminate to key stakeholders:
• Practitioners with executive/management responsibilities
• Policy makers: local, regional, state, national
• Persons affected by the intervention
• Researchers of population health issues
14
Evidence-Based Public Health
Evidence-Based Public Health Processes
o Inputs
▪ Identifying the resources and relationships needed to carry out core public
health functions (capacity)
o Processes and Outputs
▪ Measuring what do we do and is it effective (process = theory)
▪ Measuring what we produces or services provided (outputs = count)
o Outcome and Impact
▪ Measuring if what we did had an effect on the health issue of interest
(outcome = if X, then Y)
▪ Measuring if what we did made a change or difference in the system
(impact = ROI, cost-benefit)
Inputs
Process
Outputs
Outcome
Impact
15
Evidence-Based Public Health
Evidence-Based Public Health Foundations
• Well-established in psychology, social work, nursing, and medicine.
• Public health evidence often derives from “natural” experiments.
– Cross-sectional studies, Quasi-experimental designs, Time-series analyses
– Cyclic action: evaluation  evidence  practice
•
Decision-making using public health data incorporates scientific results,
enhanced communication, common sense, and political acumen.
– Best available peer-reviewed evidence (qual/quant)
– Grounded in behavioral theory
– Engages community in assessment and decision-making
– Incorporates systematic program evaluation
– Disseminates what is learned – community, stakeholders, research
•
Evidence-based data tools in public health:
– Public health surveillance systems (e.g., lead, tobacco, influenza)
– Economic assessment: cost-effectiveness (relative to other), cost-benefit, ROI
– Health impact assessment: PH policy/program impact on non-health sector
16
Evidence-Based Public Health
Challenges Facing Evidence-Based Public Health
•
Public health is a social matter (social justice philosophy)
▪
▪
▪
•
Public health is political in nature
▪
•
Matching a social good to inherent values, funding, stakeholder interests
Public health is linked with government
▪
▪
•
Consider benefits and consequences/injustices of public health services
Individual vs. collective rights and responsibilities
Disparities in health outcomes. Social influences (e.g., unemployment)
Policies and programs – federal, state, local
Health equity and access; issues change with administrations/elections
Public health has an ever-expanding agenda
▪
Public health needs and services change to meet the current times in social
norms/beliefs/attitudes, technology, science, etc.
▪
▪
▪
▪
Epidemics: cholera, plague, etc. (pre-1850)
Public health infrastructure: federal, state, local (1850-1949)
Public Health / Medical Care models: chronic illness / prevention (1950-1999)
Community health threats: bioterrorism, outbreaks (1999-post)
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Chapter 1
Page 1
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What
Public
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OBJECTIVES
After completing Chapter 1, learners will be proficient in describing what
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public health is, including its unique and important features, to general audiOT FOR SALE OR DISTRIBUTION
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ences. Key aspects of this competency expectation include the following:
• Articulating several different definitions of public health
• Describing the origins and content of public health responses over history
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States& Bartlett Learning,
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• Broadly characterizing the contributions and value of public health FOR SALE OR DISTRIB
• Identifying three or more distinguishing features of public health
• Describing public health as a system with inputs, processes, outputs, and
results, including the role of core functions and essential public health
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services
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• Identifying
five or more Internet websites that
provide
useful
information
on the U.S. public health system
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The
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of
one
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another afford a rare
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NOT
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opportunity to look back at where public health has been and forward to the
challenges that lie ahead. Imagine a world 100 years from now where life
expectancy is 30 years longer and infant mortality rates are 95% lower than
they are today. The average human life span would be more than 107 years,
and
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seem
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less, they are no greater than the gains realized during the 20th century in the
United States. In 1900, few envisioned the century of progress in public
health that lay ahead; yet by 1925, public health leaders such as C.E.A.
Winslow were noting a nearly 50% increase in life expectancy (from 36 years
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to 53 years)
for residents
of New York City between
the years
1880 andLearning,
1920.1
Accomplishments
such as these caused Winslow
to speculate
whatOR
might
be
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possible through widespread application of scientific knowledge. With the
1
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CHAPTER 1: WHAT IS PUBLIC HEALTH? NOT FOR SALE OR DISTRIBUTION
even more spectacular achievements over the rest of the 20th century, we all
should wonder what is possible in the century that has just begun.
©This
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year&will
be remembered
many things, but it is©unlikely
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many people will remember it as a spectacular year for public health in the
United States. No major discoveries, innovations, or triumphs are likely to set
the year apart from other years in recent memory. Nevertheless, on closer
examination, maybe there are! Like the story of the wise man who invented
the game of chess for his king and asked for payment by having the king
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place one Learning,
grain of wheat
on the first square of the
chessboard,
two on the
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ond, four on the third, eight on the fourth, and so on, the small victories of
public health over the past century have resulted in cumulative gains so vast
in scope that they are difficult to comprehend.
This year there will be nearly 900,000 fewer cases of measles reported than
in 1941, 200,000 fewer cases of diphtheria than in 1921, more than 250,000
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fewer cases of whooping cough than in 1934, and 21,000 fewer cases of polio
2
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NOT
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ORwitnessing
DISTRIBUTION
the FOR
new century
50 million
than in 1951. The early years of
fewer smokers than would have been expected, given trends in tobacco use
through 1965. More than 2 million Americans are alive today who otherwise
would have died from heart disease and stroke, and nearly 100,000 Americans
are alive as a result of automobile seatbelt use. Protection of the U.S. blood
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supply has prevented more than 1.5 million hepatitis B and hepatitis C infecNOTinfections,
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tions and more than 50,000 human immunodeficiency virus (HIV)
as well as more than $5 billion in medical costs associated with these three
diseases.3 Today, the average blood lead levels in children are less than one
third of what they were a quarter century ago. This catalog of accomplishments could be expanded many times over. Figure 1-1 summarizes this
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progress, including two of the most widely followed measures of a populaNOT FOR SALE
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tion’s health status: life expectancy and infant mortality.
These results did not occur by themselves. They came about through decisions and actions that represent the essence of what is public health. It is the
story of public health and its immense value and importance in our lives that
is the focus of this text. With this impressive litany of accomplishments, it
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seem that public health’s ©
story
would
easily told.
For many
reasons,
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NOThealth
FOR remains
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however, it is not. As a result, public
poorly
understood by its
prime beneficiary—the public—as well as many of its dedicated practitioners.
Although public health’s results, as measured in terms of improved health status, diseases prevented, scarce resources saved, and improved quality of life,
are more apparent today than ever before, society seldom links the activities
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of ©
public
health
with its Learning,
results. This LLC
suggests that the public health
commuOR DISTRIB
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nity
must
more
effectively
communicate what public health NOT
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it
does so that its results can be readily traced to their source.
This chapter is an introduction to public health that links basic concepts
to practice. It considers three questions:
• What
is public health?
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•
Where
did it come from?
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• Why is it important in the United States today?
To address these questions, this chapter begins with a sketch of the historical development of public health activities in the United States. It then exam-
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A Brief History
Public
HealthOR
in the
United States
3
Life expectancy at birth (1900 – 2000)
Infant mortality rate (1900 – 2000)
60.3%
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NOT atFOR
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Life expectancy
birth (1950
– 2000)
12.6%
26.6%
Life expectancy at age 65 (1950 – 2000)
Cause-specific mortality* (1950 – 2000)
Infant mortality
Heart disease
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Stroke
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Unintentional injuries
Influenza and pneumonia
Tuberculosis
Uterine and cervical cancer
Stomach/gastric cancer
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*Age-adjusted.
0%
76.4%
56.1%& Bartlett Learning, LLC
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55.3%
50.7%
91.4%
72.5%
81.0%
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20%
60%
80%
100%
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Percentage improvement
Figure 1-1 Percentage improvement in selected measures of life expectancy and age-adjusted,
cause-specific mortality for the time periods 1900–2000 and 1950–2000, United States. Source:
Data from Centers for Disease Control and Prevention, National Center for Health Statistics.
Health, United
States &
2009.
Hyattsville,
MD: NCHS;
D, Fryer&
GE,
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Learning,
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Levine RS, Blumenthal DS. Triangulating on success: innovation, public health, medical care,
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and cause-specific U.S. mortality over a half century (1950–2000). Am J Public Health. 2010;
100:S95–S104.
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ines several definitions and characterizations of what public health is and
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explores some of its unique features. Finally, it offers insights into the value of
public health in biologic, economic, and human terms.
Taken together, the topics in this chapter provide a foundation for understanding what public health is and why it is important. A conceptual framework that
from a&systems
perspective
is introduced
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to identify the dimensions of the public health system and facilitate an underOT FOR SALE OR DISTRIBUTION
FORhealth
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ORcoexist
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standing of the various images NOT
of public
in the United
States today. We see that, as in the story of the blind men examining the elephant, with each blind person describing the animal in terms of the part that
they encountered, various sectors of our society have mistaken separate components
of public
health
for the entire
more thor© Jones
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Learning,
LLCsystem. Later chapters
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oughly examine and discuss the various components and dimensions of the
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public health system.
A BRIEF HISTORY OF PUBLIC HEALTH IN THE UNITED STATES
Early
Influences
on American
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NOTisFOR
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Although
the complete history of public health
a fascinating
sagaDISTRIBUTION
in its
own right, this section presents only selected highlights. When ancient cultures perceived illness as the manifestation of supernatural forces, they also
felt that little in the way of either personal or collective action was possible.
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For many centuries, disease was synonymous with epidemic. Diseases, including horrific epidemics of infectious diseases such as the Black Death (plague),
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leprosy,
and &
cholera,
were
phenomena
to be accepted. It was not
until the&soNOT
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called Age of Reason and the Enlightenment that scholarly inquiry began to
challenge the “givens” or accepted realities of society. Eventually, the expansion of the science and knowledge base would reap substantial rewards.
With the advent of industrialism and imperialism, the stage was set for
epidemic diseases to increase their terrible toll. As populations shifted to
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urban centers
for purpose
public
conditions
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worsened. The mixing of dense populations living in unsanitary conditions
and working long hours in unsafe and exploitative industries with wave after
wave of cholera, smallpox, typhoid, tuberculosis, yellow fever, and other diseases was a formula for disaster. Such disaster struck again and again across
the globe, but most seriously and most often at the industrialized seaport
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cities that provided the portal of entry for diseases transported as stowaways
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alongside commercial cargo. TheNOT
experience
and subsequent
susceptibility of
different cultures to these diseases partly explain how relatively small bands of
Europeans were able to overcome and subjugate vast Native American cultures. Seeing the Europeans unaffected by scourges such as smallpox served to
reinforce beliefs that these light-skinned visitors were supernatural figures,
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unaffected by natural forces.4
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The British colonies in North America and the fledgling United
tainly bore their share of the burden. American diaries of the 17th and 18th
centuries chronicle one infectious disease onslaught after another. These epidemics left their mark on families, communities, and even history. For example, the national capital had to be moved out of Philadelphia because of a
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devastating yellow fever epidemic in 1793. This epidemic also prompted the
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city to develop its first board of health in that same
year.
The formation of local boards of distinguished citizens, the first boards of
health, was one of the earliest organized responses to epidemics. This response
was revealing in that it represented an attempt to confront disease collectively. Because science had not yet determined that specific microorganisms
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were the
causes of epidemics, avoidance
long been
the primary
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used. Avoidance meant evacuating
theFOR
general
location
the epidemic until
it subsided or isolating diseased individuals or those recently exposed to diseases on the basis of a mix of fear, tradition, and scientific speculation. Several
developments, however, were swinging the pendulum ever closer to more
effective counteractions.
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Jones
Learning,
LLCsuch as Edward Jenner,
© Jones
& Bartlett Learning,
work&ofBartlett
public health
pioneers
John Snow,
NOT when
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OR DISTRIB
NOT
FOR
SALE OR
DISTRIBUTION
and
Edwin
Chadwick
illustrates
the value of public health, even
its
methods are applied amid scientific uncertainty. Long before Koch’s postulates established scientific methods for linking bacteria with specific diseases
and before Pasteur’s experiments helped to establish the germ theory, both
Jenner and Snow used deductive logic and common sense to do battle with
© Jones & Bartlett
© Jones
& Bartlett
Learning, LLC
smallpox Learning,
and cholera,LLC
respectively. In 1796, Jenner
successfully
used vaccinaNOT FOR SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
tion for a disease that ran rampant through communities across the DISTRIBUTION
globe.
This was the initial shot in a long and arduous campaign that by the year
1977 had totally eradicated smallpox from all of its human hiding places in
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A Brief History
Public
HealthOR
in the
United States
5
every country in the world. The potential for its reemergence through the
actions of terrorists is a topic left to Chapter 8.
©Snow’s
Jonesaccomplishments
& Bartlett Learning,
LLC advanced the art and
© Jones
& of
Bartlett Learning,
even further
science
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public health. In 1854, Snow traced an outbreak of cholera to the well water
drawn from the pump at Broad Street and helped to prevent hundreds, perhaps thousands, of cholera cases. In that same year, he demonstrated that
another large outbreak could be traced to one particular water company
that drew its water from the Thames River, downstream from London, and
© Jones & Bartlett
Learning,
LLC
© Jones
& London
Bartlettwas
Learning,
LLC
that another
company
that drew its water upstream
from
not
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OR
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NOT
FOR
SALE
OR
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linked with cholera cases. In both efforts, Snow’s ability to collect and analyze
data allowed him to determine causation, which in turn allowed him to
implement corrective actions that prevented additional cases. All of this
occurred without the benefit of the knowledge that there was an odd-shaped
little bacterium that was carried in water and spread from person to person by
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LLC
© Jones & Bartlett Learning, LLC
hand-to-mouth contact!
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England’s General Board of NOT
Health
conducted
its own
investigations of
these outbreaks and concluded that air, rather than contaminated water, was
the cause.5 Its approach, however, was one of collecting a vast amount of
information and accepting only that which supported its view of disease causation. Snow, on the other hand, systematically tested his hypothesis by
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
exploring evidence that ran in contrast to his initial expectations.
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Chadwick was a more official leader of what has become known
the sanitary movement of the latter half of the 19th century. In a variety of official
capacities, he played a major part in structuring government’s role and responsibilities for protecting the public’s health. Because of the growing concern
over the social and sanitary conditions in England, the National Vaccination
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Learning, LLC
© Jones & Bartlett Learning, LLC
Board was established in 1837. Shortly thereafter, Chadwick’s “Report on an
NOT FOR SALE
OR
DISTRIBUTION
NOT FOR
SALE OR
Inquiry into the Sanitary Conditions of the Laboring
Population
of DISTRIBUTION
Great
Britain” articulated a framework for broad public actions that served as a blueprint for the growing sanitary movement. One result was the establishment in
1848 of the General Board of Health. Interestingly, Chadwick’s interest in public health had its roots in Jeremy Bentham’s utilitarian movement. For ChadJones & Bartlett Learning,
LLC was viewed as causing
© Jones
& Bartlett
Learning,
LLC for
wick, disease
poverty,
and poverty
was responsible
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OR DISTRIBUTION
the great social ills of the time, including
societal
disorder
and high taxation to
provide for the general welfare.6 Public health efforts were necessary to reduce
poverty and its wider social effects. This view recognizes a link between
poverty and health that differs somewhat from current views. Today, it is more
common to consider poor health as a result of poverty, rather than as its cause.
©Chadwick
Jones &was
Bartlett
Learning,
LLC
Jones
& Bartlett Learning,
also a key
participant
in the partly scientific, ©
partly
political
NOTshould
FOR SALE
OR DISTRIB
NOTthat
FOR
SALE
DISTRIBUTION
debate
took
placeOR
in British
government as to whether deaths
be
attributed to clinical conditions or to their underlying factors, such as hunger
and poverty. It was Chadwick’s view that pathologic, as opposed to less proximal social and behavioral, factors should be the basis for classifying deaths.6
Chadwick’s arguments prevailed, although aspects of this debate continue to
© Jones & Bartlett
LLC
© Jones
& Bartlett
Learning, LLC
this day. Learning,
William Farr,
sometimes called the father
of modern
vital statistics,
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OR
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championed the opposing view.
In the latter half of the 19th century, as sanitation and environmental engineering methods evolved, more effective interventions became available against
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CHAPTER 1: WHAT IS PUBLIC HEALTH? NOT FOR SALE OR DISTRIBUTION
epidemic diseases. Furthermore, the scientific advances of this period paved the
way for modern disease control efforts targeting specific microorganisms.
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© Jones & Bartlett Learning,
NOT FOR SALE OR DISTRIB
Growth of Local and State Public Health Activities in the United States
In the United States, Lemuel Shattuck’s “Report of the Sanitary Commission of Massachusetts” in 1850 outlined existing and future public health
needs for that state and became America’s blueprint for development of a
© Jones & Bartlett
Learning,
© Jones & of
Bartlett
Learning,
LLC
public health
system. LLC
Shattuck called for the establishment
state and
local
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health departments to organize public efforts aimed at sanitary inspections,
communicable disease control, food sanitation, vital statistics, and services for
infants and children. Although Shattuck’s report closely paralleled Chadwick’s
efforts in Great Britain, acceptance of his recommendations did not occur
for several decades. In the latter part of the century, his farsighted and farJones & Bartlett Learning,
LLC
© Jones & Bartlett Learning, LLC
reaching recommendations came to be widely implemented. With greater
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understanding of the value of environmental
controls
water and sewage
and of the role of specific control measures for specific diseases (including
quarantine, isolation, and vaccination), the creation of local health agencies
to carry out these activities supplemented—and, in some cases, supplanted—
local boards of health. These local health departments developed rapidly in
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
the seaports and other industrial urban centers, beginning with a health
NOTwhere
FORthe
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NOT
FOR
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OR
DISTRIBUTION
department in Baltimore in 1798, because these were the settings
problems were reaching unacceptable levels. An illustration of such local public health efforts is presented at the end of this chapter in a Public Health
Spotlight, which traces public health activities in Chicago from 1834 to 2003.
The history summarized in this case study parallels that of other American
© Jones & Bartlett
Learning, LLC
© Jones & Bartlett Learning, LLC
cities through the 19th and 20th centuries.
NOT FOR SALE
OR
DISTRIBUTION
NOTare
FOR
SALE ORofDISTRIBUTION
Because infectious and environmental hazards
no respecters
local
jurisdictional boundaries, states began to develop their own boards and agencies after 1870. These agencies often had very broad powers to protect the
health and lives of state residents, although the clear intent at the time was
that these powers be used to battle epidemics of infectious diseases. In later
Jones & Bartlett Learning,
LLC
Jones
Bartlett
Learning,
LLC
chapters,
we revisit these powers©
and
duties&because
they
serve as both
a stimOT FOR SALE OR DISTRIBUTION
NOTbeFOR
OR DISTRIBUTION
ulus and a limitation for what can
doneSALE
to address
many contemporary
public health issues and problems.
Federal Public Health Activities in the United States
©This
Jones
& Bartlett
Learning, LLC
JonesStates
& Bartlett Learning,
sketch
of the development
of public health in the ©
United
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OR DISTRIB
NOTbeFOR
SALE OR
DISTRIBUTION
would
incomplete
without
a brief introduction to the roles NOT
and powers
of
the federal government. Federal health powers, at least as enumerated in the
U.S. Constitution, are minimal. It is surprising to some to learn that the word
health does not even appear in the Constitution. As a result of not being a
power granted to the federal government (such as defense, foreign diplomacy,
© Jones & Bartlett
Learning,
LLC commerce, or printing
© Jones
& Bartlett
Learning,
LLC
international
and interstate
money),
health became
a
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OR
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FOR
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power to be exercised by states or reserved to the people themselves.
Two sections of the Constitution have been interpreted over time to allow
for federal roles in health, in concert with the concept of the so-called implied
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A Brief History
Public
HealthOR
in the
United States
7
powers necessary to carry out explicit powers. These are the ability to tax in
order to provide for the “general welfare” (a phrase appearing in both the pre© Jones
& Bartlett
Learning, LLC
Jonescom& Bartlett Learning,
amble
and body
of the Constitution)
and the specific power to©regulate
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FOR
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NOT
FOR
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OR
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merce, both international and interstate. These opportunities allowed the federal government to establish a beachhead in health, initially through the
Marine Hospital Service (eventually to become the Public Health Service).
After the ratification of the 16th Amendment in 1916, authorizing a national
income tax, the federal government acquired the ability to raise vast sums of
© Jones & Bartlett
Learning,
LLC be directed toward promoting
© Jones the
& Bartlett
Learning, LLC
money, which
could then
general welfare.
NOT FOR SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
The specific means to this end were a variety of grants in aid to state andDISTRIBUTION
local
governments. Beginning in the 1960s, federal grant-in-aid programs designed
to fill gaps in the medical care system nudged state and local governments
further and further into the business of medical service provision. Federal
grant programs for other social, substance abuse, mental health, and commuJones & Bartlett Learning,
LLC
© Jones & Bartlett Learning, LLC
nity prevention services soon followed. The expansion of federal involvement
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NOT
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into these areas, however, was not
accomplished
by these
means alone.
Before 1900, and perhaps not until the Great Depression, Americans did
not believe that the federal government should intervene in their social circumstances. Social values shifted dramatically during the Depression, a period
of such great social insecurity and need that the federal government was now
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
permitted—indeed, expected—to intervene. Chapters 4, 5, and 8 expand on
NOT activities
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NOT
FOR
SALE
OR
DISTRIBUTION
the growth of the federal government’s influence on public health
and its impact on the activities of state and local governments.
To explain more easily the broad trends of public health in the United
States, it is useful to delineate distinct eras in its history. One simple scheme,
illustrated in Table 1-1, uses the years 1850, 1950, and 2000 as approximate
© Jones & Bartlett
Learning, LLC
© Jones & Bartlett Learning, LLC
dividers. Prior to 1850, the system was characterized by recurrent epidemics of
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OR
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infectious diseases, with little in the way of collective
response
possible.
During the sanitary movement in the second half of the 19th and first half of the
20th century, science-based control measures were organized and deployed
through a public health infrastructure that was developing in the form of
local and state health departments. After 1950, gaps in the medical care sysJones & Bartlett Learning,
LLC
© Jones
& to
Bartlett
LLC of a
tem and
federal grant dollars acted
together
increaseLearning,
public provision
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NOT
FOR set
SALE
OR DISTRIBUTION
wide range of health services. That
increase
the stage
for the current reexamination of the links between medical and public health practice. Some
retrenchment from the direct service provision role has occurred since about
1990. As we will examine in subsequent chapters, a new era for public health
that seeks to balance community-driven public health practice with prepared© Jones
& Bartlett
Learning,
LLC
© Jones & Bartlett Learning,
ness
and response
for public
health emergencies
lies ahead.
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Table 1-1 Major Eras in Public Health History in the United States
1850
Battling epidemics
© Jones &Before
Bartlett
Learning,
LLC
© Jones & Bartlett Learning, LLC
1850–1949
Building state and local infrastructure
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Filling gaps in medical care delivery
After 1999
Preparing for and responding to community health threats
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CHAPTER 1: WHAT IS PUBLIC HEALTH? NOT FOR SALE OR DISTRIBUTION
IMAGES AND DEFINITIONS OF PUBLIC HEALTH
©The
Jones
& Bartlett
Learning,
LLChealth activities in the©United
JonesStates
& Bartlett Learning,
historical
development
of public
provides
a basis
for understanding
what public health is today.
Nonetheless,
NOT
FOR SALE OR DISTRIB
NOT FOR
SALE
OR DISTRIBUTION
the term public health evokes several different images among the general public and those dedicated to its improvement. To some, the term describes a
broad social enterprise or system.
To others, the term describes the professionals and workforce whose job it
© Jones & Bartlett
LLC health problems. At©aJones
LLC
is to solveLearning,
certain important
meeting&inBartlett
the earlyLearning,
1980s
to planOR
a community-wide
to OR
encourage
NOT FOR SALE
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NOT campaign
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early prenatal care in order to reduce infant mortality, a community relations
director of a large television station made some comments that reflected this
view. When asked whether his station had been involved in infant mortality
reduction efforts in the past, he responded, “Yes, but that’s not our job. If you
Jones & Bartlett Learning,
© Jones
& Bartlett
Learning,
LLC be
peopleLLC
in public health had been
doing your
job properly,
we wouldn’t
called on to bail you out!” Obviously,
this SALE
man viewed
public health as an
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OR DISTRIBUTION
effort of which he was not a part.
Still another image of public health is that of a body of knowledge and
techniques that can be applied to health-related problems. Here, public
health is seen as what public health does. Snow’s investigations exemplify
© perspective.
Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
this
Similarly,
many people
perceive public health primarily asNOT
the activities
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NOT
FOR SALE
OR DISTRIBUTION
ascribed to governmental public health agencies. For the majority of the public, this latter image represents public health in the United States, resulting in
the common view that public health primarily involves the provision of medical care to indigent populations. Since 2001, however, public health has also
© Jones & Bartlett
Learning,
LLC
© Jones
& Bartlett
LLC
emerged as
a front-line
defense against bioterrorism
and other
threats Learning,
to personal security
and safety.
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OR DISTRIBUTION
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A final image of public health is that of the intended results of these
endeavors. In this image, public health is literally the health of the public, as
measured in terms of health and illness in a population. The term population
health, often defined as health outcomes and their distribution in a popula7
tion, isLLC
increasingly used for this ©
image
of public
health.Learning,
Jones & Bartlett Learning,
Jones
& Bartlett
LLC
This
chapter
focuses
primarily
on
the
first
of
these
images,
public
health
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as a social enterprise or system. It is important to understand what people
mean when they speak of public health. As presented in Table 1-2, the profession, the methods, the governmental services, the ultimate outcomes, and
even the broad social enterprise itself are all commonly encountered images
of ©
what
public
is today.
Jones
& health
Bartlett
Learning, LLC
© Jones & Bartlett Learning,
With
varying
images
of
what
public
health
is,
we
would
expect
shortNOTno
FOR
SALE OR DISTRIB
NOT FOR SALE OR DISTRIBUTION
age of definitions. There have been many, and it serves little purpose to try to
catalog all of them here. Three definitions, each separated by a generation,
provide important insights into what public health is; these are summarized
in Table 1-3.
© Jones & Bartlett
Learning,
LLC Institute of Medicine
© (IOM)
Jonesprovided
& Bartlett
Learning,
LLC
In 1988,
the prestigious
a useful
definitionOR
in DISTRIBUTION
its landmark study of public health
in the
United
“The
NOT FOR SALE
NOT
FOR
SALEStates,
OR DISTRIBUTION
Future of Public Health.” The IOM report characterized public health’s mis-
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© Jones & Bartlett Learning, LLC
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Images
andSALE
Definitions
Public Health
9
Table 1-2 Images of Public Health
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
• Public
health:
system OR
and social
enterprise
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NOT
FORtheSALE
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• Public health: the profession
• Public health: the methods (knowledge and techniques)
• Public health: governmental services (especially medical care for the poor)
• Public health: the health of the public
© Jones & Bartlett Learning, LLC
NOT FOR
OR DISTRIBUTION
TableSALE
1-3 Selected
Definitions of Public Health
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• “The science and art of preventing disease, prolonging life, and promoting health and
efficiency through organized community effort . . .”9 (Winslow, 1920)
10 (Vickers, 1958)
• “. . . successive
Jones & Bartlett Learning,
LLC re-definings of the unacceptable”
© Jones &
Bartlett Learning, LLC
• “fulfilling society’s interest in assuring conditions in which people can be healthy”8 (IOM,
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NOT
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1988)
Source: Data from Institute of Medicine, National Academy of Sciences. The Future of Public Health,
Washington, DC: National Academy Press; 1988; Winslow CEA. The untilled field of public health.
Mod Med. 1920;2;183–191; and Vickers G. What sets the goals of public health? Lancet. 1958;1:
599–604.
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NOT FOR SALE OR DISTRIB
sion as “fulfilling society’s interest in assuring conditions in which people can
be healthy.”8 This definition directs our attention to the many conditions
that influence health and wellness, underscoring the broad scope of public
health and legitimizing its interest in social, economic, political, and medical
© Jones & Bartlett
Learning,
© Jones premise
& Bartlett
LLC
care factors
that affectLLC
health and illness. The definition’s
that Learning,
society
has anOR
interest
in the health of its members implies
that SALE
improving
NOT FOR SALE
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OR condiDISTRIBUTION
tions and health status for others is acting in our own self-interest. The assertion that improving the health status of others provides benefits to all is a
core value of public health.
Another core value of public health is reflected in the IOM definition’s
use of LLC
the term assuring. Assuring
in which Learning,
people can be
healthy
Jones & Bartlett Learning,
©conditions
Jones & Bartlett
LLC
means
vigilantly
promoting
and
protecting
everyone’s
interests
in
health
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and well-being. This value echoes the wisdom in the often-quoted African
aphorism that “it takes a village to raise a child.” Former Surgeon General
David Satcher, the first African American to head this country’s most
respected federal public health agency, the Centers for Disease Control and
Prevention
onceLearning,
described aLLC
visit to Africa in which©he
met with
© Jones (CDC),
& Bartlett
Jones
& Bartlett Learning,
African
teenagers
to
learn
firsthand
of
their
personal
health
attitudes
NOT FORand
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NOT FOR SALE OR DISTRIBUTION
behaviors. Satcher was struck by their concerns over the rapid urbanization
of the various African nations and the changes that were affecting their culture and sense of community. These young people felt lost and abandoned;
they questioned Satcher as to what the CDC, the U.S. government, and the
world community
to Jones
help them
surviveLearning,
these
© Jones & Bartlett
Learning, would
LLC be willing to do ©
& Bartlett
LLC
changes.
one young man put it, “Where will
we find
village?”
NOT FOR SALE
ORAsDISTRIBUTION
NOT
FORour
SALE
OR Public
DISTRIBUTION
health’s role is one of serving us all as our village, whether we are teens in
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Africa or adults in the United States. The IOM report’s characterization of
public health advocated for just such a social enterprise and stands as a bold
© Jones &statement
Bartlett Learning,
LLCpurpose.
© Jones & Bartlett Learning,
philosophical
of mission and
NOThealth
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NOT
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DISTRIBUTION
The IOM report also sought to define the boundaries of public
by
identifying three core functions of public health: assessment, policy development, and assurance. In one sense, these functions are comparable to those
generally ascribed to the medical care system involving diagnosis and treatment. Assessment is the analogue of diagnosis, except that the diagnosis, or
© Jones & Bartlett
Learning, LLC
© Jonesof
& individuals.
Bartlett Learning,
LLC
problem identification,
is made for a group or population
SimiNOT FOR SALE
OR
DISTRIBUTION
NOT
FOR
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OR
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larly, assurance is analogous to treatment and implies that the necessary
remedies or interventions are put into place. Finally, policy development is an
intermediate role of collectively deciding which remedies or interventions are
most appropriate for the problems identified (the formulation of a treatment
plan is the medical system’s analogue). These core functions broadly describe
Jones & Bartlett Learning,
LLC
© Jones & Bartlett Learning, LLC
what public health does (as opposed to what it is) and are examined more
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thoroughly in Chapters 5 and 6. NOT FOR SALE OR DISTRIBUTION
The concepts embedded in the IOM definition are also reflected in
Winslow’s definition, developed nearly a century ago. His definition describes
both what public health does and how this gets done. It is a comprehensive
definition that has stood the test of time in characterizing public health as
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
The FOR
science
and art
of DISTRIBUTION
preventing disease, prolonging life, and
NOTproFOR SALE OR DISTRIB
NOT
SALE
OR
moting health and efficiency through organized community effort
for the sanitation of the environment, the control of communicable
infections, the education of the individual in personal hygiene, the
organization of medical and nursing services for the early diagnosis
and preventive
of disease, and for
the development
© Jones & Bartlett
Learning,treatment
LLC
© Jones
& BartlettofLearning, LLC
the
social
machinery
to
insure
everyone
a
standard
of
living adeNOT FOR SALE OR DISTRIBUTION
NOT FOR SALE
OR DISTRIBUTION
quate for the maintenance of health, so organizing these benefits as
to enable every citizen to realize his birthright of health and
longevity.9
There is much to consider in Winslow’s definition. The phrases “science
Jones & Bartlett Learning,
LLC“organized community
© Jones
& and
Bartlett
Learning,
LLC and
and art,”
effort,”
“birthright
of health
OT FOR SALE OR DISTRIBUTION
FORofSALE
DISTRIBUTION
longevity” capture the substanceNOT
and aims
public OR
health.
Winslow’s catalog
of methods illuminates the scope of the endeavor, embracing public health’s
initial targeting of infectious and environmental risks, as well as current activities related to the organization, financing, and accountability of medical care
services. His allusion to the “social machinery to insure everyone a standard
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& Bartlett
LLC
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& Bartlett Learning,
of ©
living
adequate
for theLearning,
maintenance
of health” speaks to the
relationship
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OR and
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between
socialSALE
conditions
health in all societies.
There have been many other attempts to define public health, although
these have received less attention than either the Winslow or IOM definitions.
Several build on the observation that, over time, public health activities
reflect the interaction of disease with two other phenomena that can be
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Learning, LLC
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Learning,
LLC
roughly characterized
as science and social values:
what do&weBartlett
know and
what
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do we choose to do with that knowledge?
A prominent British industrialist, Geoffrey Vickers, provided an interesting addition to this mix a half century ago while serving as secretary of the
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Public
Health
as a System
11
Medical Research Council. In identifying the forces that set the agenda for
public health, Vickers noted, “The landmarks of political, economic, and
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LLC
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social
history&are
the moments
when
some condition passed ©
from
the cateNOT
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gory of the given into the category of the intolerable. I believe that the history
of public health might well be written as a record of successive re-definings of
the unacceptable.”10
The usefulness of Vickers’ formulation lies in its focus on the delicate and
shifting interface between science and social values. Through this lens, we can
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Learning,
LLC
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Bartlett Learning,
LLC
view a tracing
of public
health over history, facilitating
of
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OR
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why and how different societies have reacted to health risks differently at various points in time and space. In this light, the history of public health is one
of blending knowledge with social values to shape responses to problems that
require collective action after they have crossed the boundary from the
acceptable to the unacceptable.
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Each of these definitions offers important insights into what public health
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ORdescribe
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is and what it does. Individually NOT
and collectively,
they
a social enterprise that is both important and unique, as we see in the sections that follow.
PUBLIC HEALTH AS A SYSTEM
©So
Jones
& Bartlett Learning, LLC
© Jones & Bartlett Learning,
what is public health? Maybe no single answer will satisfy everyone.
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There are, in fact, several views of public health that must be considered.
or more of them may be apparent to the inquirer. The public health described
in this chapter is a broad social enterprise, more akin to a movement, that
seeks to extend the benefits of current knowledge in ways that will have the
maximum impact on the health status of a population. It does so by identify© Jones & Bartlett
Learning, LLC
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ing problems that call for collective action to protect, promote, and improve
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OR
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health, primarily through preventive strategies.NOT
This FOR
publicSALE
healthOR
is unique
in its interdisciplinary approach and methods, its emphasis on preventive
strategies, its linkage with government and political decision making, and its
dynamic adaptation to new problems placed on its agenda. Above all else, it is
a collective effort to identify and address the unacceptable realities that result
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LLC and avoidable health
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Learning,and
LLC
in preventable
and quality
of life outcomes,
it is the
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OR
composite of efforts and activities
that FOR
are carried
out
by DISTRIBUTION
people and organizations committed to these ends.
With this broad view of public health as a social enterprise, the question
shifts from what public health is to what these other images of public health
represent and how they relate to each other. To understand these separate
© Jones
& Bartlett
© Jones &an
Bartlett Learning,
images
of public
health, aLearning,
conceptualLLC
model would be useful. Surprisingly,
NOT has
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OR DISTRIBUTION
understandable
and useful
framework to tie these pieces together
been
lacking. Other enterprises have found ways to describe their complex systems,
and from what appears to be an industrial production model, we can begin to
look at the various components of our public health system.
This framework brings together the mission and functions of public
© Jones & Bartlett
Jonesand
& Bartlett
LLC
health inLearning,
relationshipLLC
to the inputs, processes, ©
outputs,
outcomesLearning,
of the
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system. Table 1-4 provides general descriptions for the terms used in this
framework. It is sometimes easier to appreciate this model when a more
familiar industry, such as the automobile industry, is used as an example.
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CHAPTER 1: WHAT IS PUBLIC HEALTH? NOT FOR SALE OR DISTRIBUTION
Table 1-4 Dimensions of the Public Health System
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Capacity
(Inputs):
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• The resources and relationships necessary to carry out the core functions and essential
services of public health (e.g., human resources, information resources, fiscal and physical resources, and appropriate relationships among the system components)
Process (Practices and Outputs):
Those collective
practicesLLC
or processes that are necessary
and sufficient
to assureLearning,
that
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Learning,
© Jones
& Bartlett
LLC
the coreOR
functions
and essential services of public health
areFOR
being SALE
carried out
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NOT
OReffecDISTRIBUTION
tively, including the key processes that identify and address health problems and their
causative factors and the interventions intended to prevent death, disease, and disability
and to promote quality of life
Outcomes (Results):
• Indicators
of health status, risk reduction,
and quality-of-life
enhancement
outcomes
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Learning,
LLCare
long-term objectives that define optimal,
measurable
future levels
health status; maxiOT FOR SALE OR DISTRIBUTION
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mum acceptable levels of disease, injury, or dysfunction; or prevalence of risk factors
Source: Adapted from Centers for Disease Control and Prevention, Public Health Program Office,
1990.
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
The
mission
purpose
be expressed as meeting the personal
transNOT FOR
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NOT
FORor
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ORmight
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portation needs of the population. This industry carries out its mission by
providing passenger cars to its customers; this characterizes its function. In
this light, we can now examine the inputs, processes, outputs, and outcomes
of the system set up to carry out this function. Inputs would include steel,
rubber, plastic,
and soLLC
forth, as well as the workers,
know-how,
technology,
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Learning,
© Jones
& Bartlett
Learning, LLC
facilities,
machinery,
and
support
services
necessary
to
allow
the
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NOT FOR SALEraw
ORmateriDISTRIBUTION
als to become automobiles. The key processes necessary to carry out the primary function might be characterized as designing cars, making or acquiring
parts, assembling parts into automobiles, moving cars to dealers, and selling
and servicing cars after purchase. No doubt this is an incomplete listing of
this industry’s
processes; it is oversimplified
here to make
the point.
In any
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Learning,
LLC
event, these processes translate the abstract concept of getting cars to people
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into the operational steps necessary to carry out this basic function. The outputs of these processes are cars located where people can purchase them. The
outcomes include satisfied customers and company profits.
Applying this same general framework to the public health system is also
possible
but &
may
not beLearning,
so obvious LLC
to the general public. The
and
© Jones
Bartlett
© mission
Jones &
Bartlett Learning,
functions of public health are well described in the IOM report’s framework.
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The core functions of assessment, policy development, and assurance are considerably more abstract functions than making cars but can still be made operational through descriptions of their key steps or practices.11,12 The inputs of
the public health system include its human, organizational, informational,
fiscal, andLearning,
other resources.
relationships
are structured
to
© Jones & Bartlett
LLC These resources and ©
Jones & Bartlett
Learning,
LLC
carry out public health’s core functions through a variety of processes that can
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also be termed essential public health practices or services. These processes
include a variety of interventions that result from some of the more basic
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Public
Health
as a System
13
processes of assessing health needs and planning effective strategies.13 These
outputs or interventions are intended to produce the desired results, which,
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with public health, might well be characterized as health or quality-of-life outNOT FOR SALE OR DISTRIB
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comes. Figure 1-2 illustrates these relationships.
In this model, not all components are as readily understandable and
measurable as others. Several of the inputs are easily counted or measured,
including human, fiscal, and organizational resources. Outputs are also generally easy to recognize and count (e.g., prenatal care programs, number of
© Jones & Bartlett
Learning, LLC
© Jones & Bartlett Learning, LLC
immunizations provided, health messages on the dangers of tobacco). Health
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outcomes are also readily understood in terms of
mortality,
morbidity,
functional disability, time lost from work or school, and even more sophisticated
measures, such as years of potential life lost and quality-of-life years lost. At
an aggregate level, outcomes reflect how effective the system is (improved
population health status), how equitable it is (eliminating or reducing dispariJones & Bartlett Learning,
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© Jones & Bartlett Learning, LLC
ties among segments of the population), and how efficiently (or cost benefiOT FOR SALE OR DISTRIBUTION
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cially) the system performs. TheNOT
elements
areOR
most
difficult to understand and visualize are the processes or essential services of the public health
system. Although this is an evolving field, there have been efforts to characterize these operational aspects of public health. By such efforts, we are better
able to understand public health practice, to measure it, and to relate it to its
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
outputs and outcomes. A national work group was assembled by the U.S. PubNOT
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lic Health Service in 1994 in an attempt to develop a consensus
statement
of
what public health is and does in language understandable to those both
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DISTRIBUTION
P
© Jones & Bartlett Learning, LLC
Structural
Capacity NOT FOR SALE OR DISTRIBUTION
u
b
l
i
c
Information Resources
M
Organizational Resources
a
Physical Resources
c
r
Human Resources
PHS Mission
H
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LLC
© Jones
& Bartlett Learning, LLC
o
Fiscal Resources
e
and Purpose
a
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l
o
Philosophy
t
n
h
Goals
t
“Core
e
S
Processes
Outcomes
Functions”
x
y
t
s
© Jones
& Bartlett Learning,The
LLC
© Jones & Bartlett Learning,
Ten Essential
Effectiveness
t
Public
Health
Efficiency
e
NOT
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Services
m
Equity
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© Jones & Bartlett Learning, LLC
Figure 1-2 Conceptual framework of the public health system as a basis for measuring
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OR DISTRIBUTION
system performance. Source: From Handler A, Issel LM, Turnock
BJ. ASALE
conceptual
framework to measure performance of the public health system. Am J Public Health. 2001;91(8):
1235–1239. © 2001, American Public Health Association.
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CHAPTER 1: WHAT IS PUBLIC HEALTH? NOT FOR SALE OR DISTRIBUTION
inside and outside the field of public health. Table 1-5 presents the result of
that process in a statement entitled “Public Health in America.”14 The con© Jones
& Bartlett
Learning,
LLC
Jones & Bartlett Learning,
ceptual
framework
identified
in Figure
1-2 and the narrative ©
representation
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in the “Public Health in America” statement are useful models forFOR
understanding the public health system and how it works, as we see throughout
this text.
This framework attempts to bridge the gap between what public health is,
what it does (purpose/mission and functions, Figure 1-2), and how it does
© Jones & Bartlett
Learning,
© outcomes).
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what it does
(throughLLC
its capacity, processes, and
It also allows
us
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to examine the various components of the system so that we can better appreciate how the pieces fit together. Subsequent chapters refer back to this model
as the capacity, processes, and outcomes of the public health system are
examined in greater depth.
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Table 1-5 Public Health in America
Vision:
Healthy People in Healthy Communities
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Mission:
NOT FOR SALEPromote
OR DISTRIBUTION
Physical and Mental Health
and Prevent Disease, Injury, and Disability
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Public Health
• Prevents epidemics and the spread of disease
Protects against environmental hazards
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Learning, LLC
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• Prevents injuries
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Promotes and encourages healthy behaviors
• Responds to disasters and assists communities in recovery
• Assures the quality and accessibility of health services
Essential Public Health Services
• Monitor health status to identify community health problems
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Learning,
• Diagnose
and investigate health problems
and health
hazards in the
communityLLC
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• Inform, educate, and empower peopleNOT
about health
• Mobilize community partnerships to identify and solve health problems
• Develop policies and plans that support individual and community health efforts
• Enforce laws and regulations that protect health and ensure safety
• Link people with needed personal health services and assure the provision of health
care
otherwise
unavailable
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Jones
& Bartlett
Learning, LLC
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• Assure
a competent public health and personal healthcare workforce
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• Evaluate effectiveness, accessibility, and quality of personal and population-based
health services
• Research for new insights and innovative solutions to health problems
Source: From Essential Public Health Services Working Group of the Core Public Health Functions
Committee,
U.S. Public LLC
Health Service, 1994.
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& Bartlett
Learning,
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Unique
Features
Public Health
15
Table 1-6 Selected Unique Features of Public Health
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• Basis
in social
philosophy
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• Inherently political nature
• Dynamic, ever-expanding agenda
• Link with government
• Grounding in the sciences
Use of prevention as a prime strategy
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Learning, LLC
Uncommon culture and bond
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UNIQUE FEATURES OF PUBLIC HEALTH
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Several unique features of public health individually and collectively
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serve to make understanding and appreciation of this enterprise difficult
(Table 1-6). These include the underlying social justice philosophy of public
health; its inherently political nature; its ever-expanding agenda, with new
problems and issues being assigned over time; its link with government; its
grounding
broad base
of biologic,
social, &
and
© Jonesin& aBartlett
Learning,
LLC physical, quantitative,
© Jones
Bartlett Learning,
behavioral sciences; its focus on prevention as a prime intervention strategy;
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and the unique bond and sense of mission that links its proponents.
Social Justice Philosophy
© Jones & Bartlett
Learning,
LLC the social justice orientation
© Jonesof&public
Bartlett
Learning,
LLC
It is vital
to recognize
health
and
even more
critical to understand the potential for
conflict
confrontation
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that it generates. Social justice is the foundation of public health. The concept first emerged around 1848, a time that might be considered the birth of
modern public health. Social justice argues that public health is properly a
public matter and that its results in terms of death, disease, health, and wellbeing reflect
that
society makes,
for good
Jones & Bartlett Learning,
LLC the decisions and actions
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& aBartlett
Learning,
LLCor for
15 Justice is an abstract concept that determines how each member of a
ill.
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society is allocated his or her fair share of collective burdens and benefits.
Societal benefits to be distributed may include happiness, income, or social
status. Burdens include restrictions of individual action and taxation. Justice
dictates that there is fairness in the distribution of benefits and burdens;
injustices
occur
when persons
are denied
they &are
© Jones
& Bartlett
Learning,
LLC some benefit to which
© Jones
Bartlett Learning,
entitled
or
when
some
burden
is
imposed
unduly.
If
access
to
health
services,
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or even health itself, is considered to be a societal benefit (or if poor health is
considered to be a burden), the links between the concepts of justice and
public health become clear. Market justice and social justice represent two
forms of modern justice.
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Learning,
LLC
© Jones
&basis
Bartlett
Learning, LLC
Market
justice emphasizes
personal responsibility
as the
for distributing burdens
and benefits. Other than respecting
theFOR
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of others,
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CHAPTER 1: WHAT IS PUBLIC HEALTH? NOT FOR SALE OR DISTRIBUTION
individuals are responsible primarily for their own actions and are free from
collective obligations. Individual rights are highly valued, whereas collective
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Learning,
LLC
© Jones
& Bartlett Learning,
responsibilities
are minimized.
In terms
of health, individuals assume
primary
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responsibility for their own health. There is little expectation that society
should act to protect or promote the health of its members beyond addressing
risks that cannot be controlled through individual action.
Social justice argues that significant factors within the society impede the
fair distribution of benefits and burdens.16 Examples of such impediments
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Learning,
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Learning, LLC
include social
class distinctions,
heredity, racism,
and ethnism.
Collective
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action, often leading to the assumption of additional burdens, is necessary
to
neutralize or overcome those impediments. In the case of public health, the
goal of extending the potential benefits of the physical and behavioral sciences to all groups in the society, especially when the burden of disease and ill
health within that society is unequally distributed, is largely based on princiJones & Bartlett Learning,
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ples of social justice. It is clear that many modern public health (and other
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public policy) problems disproportionately
affectOR
some
groups, usually a
minority of the population, more than others. As a result, their resolution
requires collective actions in which those less affected take on greater burdens, while not commensurately benefiting from those actions. When the
necessary collective actions are not taken, even the most important public
© Jones & Bartlett Learning, LLC
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policy problems remain unsolved, despite periodically becoming highly visi16
NOT problems
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ble. This scenario reflects responses to such intractable American
as inadequate housing, poor public education systems, unemployment, racial
discrimination, and poverty; however, it is also true for public health problems such as tobacco-related illnesses, infant mortality, substance abuse, mental health services, long-term care, and environmental pollution. The failure
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to effect comprehensive national health reform in 1994 is an example of this
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NOTdeemed
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phenomenon. At that time, middle-class Americans
the modest
price
tag of health reform to be excessive, refusing to pay more out of their own
pockets when they perceived that their own access and services were not
likely to improve. The bitter political conflict accompanying the enactment of
national health reform legislation in 2010 further illustrated these sentiments.
Jones & Bartlett Learning,
LLCand similar examples©suggest
Jonesthat
& Bartlett
These
a criticalLearning,
challenge LLC
for public
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health as a social enterprise lies NOT
in overcoming
the social
and ethical barriers
that prevent us from doing more with the tools already available to us.16
Extending the frontiers of science and knowledge may not be as useful for
improving public health as shifting the collective values of our society to act
on what we already know. Recent public health successes, such as public atti© Jones
BartlettinLearning,
LLC
Jones
& Bartlett Learning,
tudes
toward&smoking
both public
and private locations ©
and
operating
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NOTvehicles
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motor
after alcohol
consumption, provide evidence in support
of this
assertion. These advances came through changes in social norms, rather than
through bigger and better science.
Inherently
Political
Nature
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Learning,
LLC
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NOT serve
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The social justice underpinnings of public health
stimulate
political conflict. Public health is both public and political in nature. It serves populations, which are composites of many different communities, cultures, and
values. Politics allows for issues to be considered, negotiated, and finally
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Unique
Features
Public Health
17
determined for populations. At the core of political processes are differing values and perspectives as to both the ends to be achieved and the means for
© Jonesthose
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Learning,causes
LLC and agitating various
© segments
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Bartlett Learning,
achieving
ends. Advocating
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society to identify and address unacceptable conditions that adversely affect
health status often lead to increased expectations and demands on society,
generally through government. As a result, public health advocates appear at
times as antigovernment and anti-institutional. Governmental public health
agencies seeking to serve the interests of both government and public health
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are frequently
caughtLLC
in the middle. This creates
tensions
conflict
that
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can put these agencies at odds with governmental leaders on the one hand
and external public health advocates on the other.
Expanding Agenda
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A third unique feature of public health is its broad and ever-increasing
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scope. Traditional domains of public
include
biology, environ-
ment, lifestyle, and health service organization. Within each of these domains
are many factors that affect health status; in recent decades, many new public
policy problems have been moved onto the public health agenda as their predisposing factors have been identified and found to fall into one or more of
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these domains. A multilevel, multidimensional view of health, often termed
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an ecological model of health (Figure 1-3), has emerged to guideNOT
public
health
practice. Chapter 2 examines this model in some depth.
The assignment of new problems to the public health agenda is an interesting phenomenon. For example, before 1900, the primary problems
addressed by public health were infectious diseases and related environmental
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risks. After 1900, the focus expanded to include problems and needs of chilNOT FOR SALE
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dren and mothers to be addressed through health
andOR
maternal
and child health services as public sentiment over the health and safety of
children increased. In the middle of the century, chronic disease prevention
and medical care fell into public health’s realm as an epidemiologic revolution began to identify causative agents for chronic diseases and links between
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health services and health©
outcomes.
substance
abuse, mental
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ness, teen pregnancy, long-term NOT
care, and
other
issues
to public health, as
did several emerging problems, most notably the epidemics of violence and
HIV infections, including acquired immune deficiency syndrome (AIDS). The
public health agenda expanded even further as a result of the recent national
dialogue over health reform and how health services will be organized and
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managed.
Bioterrorism
is an even more recent addition
to &
this
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agenda
and expectations after the NOT
eventsFOR
of September 11, 2001, and the anthrax attacks the following month.
Link with Government
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A fourth unique facet of public health is its link with government.
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Although public health is far more than the activities of federal, state, and
local health departments, many people think only of governmental public
health agencies when they think of public health. Government does play a
unique role in seeing that the key elements are in place and that public
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CHAPTER 1: WHAT IS PUBLIC HEALTH? NOT FOR SALE OR DISTRIBUTION
So
c
nati
tate, and loc
al le
onal, s
vel
The biology
of disease
s
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Living and working
conditions may include
• Psychosocial factors
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& Bartlett
Learning, LLC
• Employment
and
occupational
factors
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• Socioeconomic status
(income, education,
and occupation)
• The natural and builtc
environments
• Public health
services
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a l,
B roa
d so
cia
l a,
e
lob
ks
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eg
th
co
n
at
nd environme
alth, a
ntal
, he
l
con
a
r
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dit
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i
k
g
r
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c
,
o
w
nditi
d
s
n
ic
b
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a
ons
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om
Liv
and community
ne
ily,
m
tw
or
, fa
l
b
e
l
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a
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d
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Ind
© Jones & Bartlett Learning, LLC
Innate © Jones & Bartlett Learning, LLC
individual traits:
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age, gender,
race, and biological
Over the life span
factors
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Figure 1-3 A guide to thinking about the determinants of population health.
Notes: Adapted from Dahlgren and Whitehead, 1991. The dashed lines between levels of the
model denote interaction effects between and among the various levels of health determinants (Worthman, 1999).
Social conditions include, but are not limited to: economic inequality, urbanization, mobilJones & Bartletta.
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ity, cultural values, attitudes, and policies related to discrimination and intolerance on the
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basis
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b. Other conditions at the national level might include major sociopolitical shifts, such as
recession, war, and governmental collapse.
c. The built environment includes transportation, water and sanitation, housing, and other
dimensions of urban planning.
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Source: From The Committee on Assuring the Health of the Public in the 21st Century, InstiNOT FORDC:
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OR
tute of Medicine.
TheSALE
Future of
theDISTRIBUTION
Public’s Health in the 21st Century. Washington,
National Academy Press; 2003. Reprinted with permission, copyright 2003, National Academy
of Sciences.
health’s mission gets addressed. Only government can exercise the enforce© Jones & Bartlett
Learning, LLC
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ment provisions of our public policies that limit the personal and property
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rights of individuals and corporations in areasNOT
such FOR
as retail
foodOR
establishments, sewage and water systems, occupational health and safety, consumer
product safety, infectious disease control, and drug efficacy and safety. Gov-
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Unique
Features
Public Health
19
ernment also can play the convener and facilitator role for identifying and
prioritizing health problems that might be addressed through public resources
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Bartlett
© beneficence,
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and
actions. &
These
roles Learning,
derive from LLC
the underlying principle of
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in that government exists to improve the well-being of its members.FOR
Beneficence often involves a balance between maximizing benefits and minimizing
harms on the one hand and doing no harm on the other.
Two general strategies are available for governmental efforts to influence
public health. At the broadest level, governments can modify public policies that
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influence Learning,
health through
social and environmental
conditions,
such as policies
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for education, employment, housing, public safety, child welfare, pollutionDISTRIBUTION
control, workplace safety, and family support. In line with the IOM report’s definition of public health, these actions seek to ensure conditions in which people
can be healthy. Another strategy of government is to provide directly the programs and services that are designed to meet the health needs of the population.
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It is often easier to garner support for relatively small-scale programs directed
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toward a specific problem (suchNOT
as tuberculosis
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infections) than to
achieve consensus around broader health and social issues. This strategy is basically a “command-and-control” approach, in which government attempts to
increase access to and use of services largely through deployment of its own
resources rather than through working with others. A variation of this strategy
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for government is to ensure access to healthcare services through public financNOT FOR
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ing approaches (Medicare and Medicaid are prime examples) or through
specialized delivery systems (such as the Veterans Administration facilities, the Indian
Health Service, and federally funded community health centers).
Whereas the United States has generally opted for the latter of these strategies, other countries have acted to place greater emphasis on broader social
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policies. Both the overall level of investment for and relative emphasis between
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these strategies contribute to the widely varying
results
achieved
terms
of
health status indicators among different nations (discussed in Chapter 2).
Many factors dictate the approaches used by a specific government at any
point in time. These factors include history, culture, the structure of the government in question, and current social circumstances. There are also several underJones & Bartlett Learning,
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Bartlett Learning,
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that support government
For paternalistic
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sons, governments may act to control
or restrict
theOR
liberties
of individuals to
benefit a group, whether or not that group seeks these benefits. For utilitarian
reasons, governments intervene because of the perception that the state as a
whole will benefit in some important way. For equality considerations, governments act to ensure that benefits and burdens are equally distributed among
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& Bartlett
Learning, LLC
© Jones &in
Bartlett Learning,
individuals.
equity considerations,
governments justify interventions
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order
to FOR
distribute
theOR
benefits
of society in proportion to need.NOT
TheseFOR
motivations reflect the views of each society as to whether health itself or merely access
to health services is to be considered a right of individuals and populations
within that society. Many societies, including the United States, act through
government to ensure equal access to a broad array of preventive and treatment
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services. Equity
in health
the society
may not
be an
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explicit aspiration, however, even where efforts are in place to ensure equality in
access. Even more important for achieving equity in health status are concerted
efforts to improve health status in population groups with the greatest disadvan-
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CHAPTER 1: WHAT IS PUBLIC HEALTH? NOT FOR SALE OR DISTRIBUTION
tage, mechanisms to monitor health status and contributing factors across all
population groups, and participation of disadvantaged population groups in the
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Bartlett Learning,
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key
decision-making
processes
within the society.17 To ©
theJones
extent &
that
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equity in health status among all population groups does not guide actions of a
society’s government, these other elements will be only marginally effective.
As noted previously, the link between government and public health
makes for a particularly precarious situation for governmental public health
agencies. The conflicting value systems of public health and the wider commu© Jones & Bartlett
Learning,
LLC
© Jones
Learning,
LLC
nity generally
translate
into public health agencies
having&toBartlett
document
their
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failure in order to make progress. It is said that only the squeaky wheel gets the
grease; in public health, it often takes an outbreak, disaster, or other tragedy to
demonstrate public health’s value. Since 1985, increased funding for basic public health protection programs quickly followed outbreaks related to bacteriacontaminated milk in Illinois, tainted hamburgers in Washington State, and
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contaminated public water supplies in Milwaukee. Following concerns over
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preparedness of public health agencies
to deal
with
bioterrorism
and other
public health threats, a massive infusion of federal funding occurred.
The assumption and delegation of public health responsibilities are quite
complex in the United States, with different patterns in each of the 50 states
(described in Chapter 4). Over recent decades, the concept of a governmental
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning,
presence in health has emerged and gained widespread acceptance within the
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public health community. This concept characterizes the role of
localFOR
government, often, but not necessarily always, operating through its official health
agencies, which serve as the residual guarantors that needed services will actually be there when needed. In practice it means that, no matter how duties are
assigned locally, there is a presence that ensures that health needs are identi© Jones & Bartlett
Learning, LLC
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fied and considered for collective action. We return to this concept and how it
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is operationalized in Chapters 4, 5, and 6.
Grounded in Science
One of the most unique aspects of public health—and one that continues
Jones & Bartlett Learning,
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& Bartlett
Learning,
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to separate
other social
movements—is
its grounding
18
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in science. This relationship isNOT
clear FOR
for the
medical
physical sciences
that govern our understanding of the biologic aspects of humans, microorganisms, and vectors, as well as the risks present in our physical environments;
however, it is also true for the social sciences of anthropology, sociology, and
psychology that affect our understanding of human culture and behaviors
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& Bartlett
Learning,
LLC
© Jones &
Bartlett Learning,
influencing
and illness.
The quantitative
sciences of epidemiology
and
NOT practice.
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biostatistics
tools and methods of public health
Often five basic sciences of public health are identified: epidemiology, biostatistics, environmental science, management sciences, and behavioral sciences.
These constitute the core education of public health professionals.
The importance of a solid and diverse scientific base is both a strength and
© Jones & Bartlett
LLC Surely there is no substitute
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Bartlett
Learning,
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weakness Learning,
of public health.
for &
science
in the
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NOT
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