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The Roles of the State in
Disease Control: Public Health
Thomas E. Novotny, M.D., M.P.H.
Definitions
• Public Health: “the science and art of
preventing disease, prolonging life, and
promoting health and efficiency through
organized community effort”
• Mission of public health: “fulfilling
society’s interest in assuring conditions in
which people can be healthy”
• Core Function No. 1: Prevent epidemics
and the spread of disease
Source: Institute of Medicine, The Future of Public Health
Dimensions of the Public Health
System: Role of Government
• Capacity (inputs): resources,
relationships, information and evidence
• Processes (practices and outputs): core
functions and essential service provision
• Outcomes (results): health indicators, risk
factor prevalence, quality-of-life
Essential Public Health
Practices
• Monitor health status to identify community
health problems;
• Diagnose and investigate health problems and
health hazards in the community;
• Inform, educate, and empower people about
health issues;
• Mobilize community partnerships to identify and
solve health problems;
• Develop policies and plans that support
individual and community health efforts;
Essential Public Health
Practices, continued
• Enforce laws and regulations that protect health
and ensure safety;
• Link people with needed health services and
assure the provision of care;
• Assure a competent health workforce;
• Evaluate effectiveness, access, and quality of
health services;
• Research for new insights and solutions to
health problems.
Unique Features of Public
Health
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Basis in social justice philosophy
Inherently political nature
Dynamic, ever-expanding agenda
Grounding in the sciences
Prevention is prime strategy
Link with government
Link with Government
• Assessment, assurance, and policy
development to support public health mission;
• Enforcing provisions of policy that may limit
personal and property rights for the greater
public good;
• Convening partners and facilitating planning to
identify and solve population health problems.
Underlying Principle of
Government Role
• Beneficence: government exists to
improve the well-being of it members;
• Beneficence involves a balance between
maximizing benefits and minimizing
harms;
• Beneficence also involves principle of
primum non nocere (doing no harm).
The Public Health Prevention
Continuum
Government
Roles
Pure public
goods
Mixed public
and private
goods
Pure
private
goods
Population
Health
Primary
prevention
Secondary
prevention
Tertiary
prevention
General Government Strategies
to Influence Public Health
• Policy development to influence social
and environmental conditions:
– Education
– Employment and workplace safety
– Housing regulations
– Public safety
– Pollution control and sanitation
• Direct provision of services
Historical Process
• Conflicting value systems of public health
and wider community;
• Often takes outbreak, disaster, or other
tragedy to implement public health
strategies;
• Little attention paid to financing core
public health functions (pure public
goods).
HIV infections newly diagnosed per million
population, by year of report (1993-2001) and
geographic area, WHO European Region
350
C ases
p er m illio n
East
300
250
200
150
Update at 31 December 2001
100
50
West *
0
Centre
1993
1994
1995
1996
1997
1998
1999
2000
2001
Year o f rep o rt
* Austria, France, Italy, Netherlands, Portugal, Spain excluded: national data not available for the whole period
EuroH
Public Health is Firmly
Grounded in Law
• Success of health education, infection
control, or non-compulsory actions
depends on ultimate availability of legal
sanctions such as fines, injunctions,
license revocation;
• Police power of the State (power to
provide health, safety, and welfare);
• Balance of regulation and service
provision.
Example: SARS
• Since November 1, 2002, reported 3,547
cases with 182 deaths;
• Affecting 27 countries (including Hong
Kong);
• New disease or recurrent pattern of
emerging infectious diseases?
• Government response??
Example: SARS
SARS in Hong Kong
Example: SARS
Critical Government Response
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Political leadership
Communications strategy (info and education)
Surveillance and contact tracing
Diagnostics
Quarantine and isolation
Treatment, including RCT
Hospital infection control
Environmental investigation and control
Example: SARS
EXECUTIVE ORDER 13295: REVISED LIST OF QUARANTINABLE COMMUNICABLE
DISEASES (April 9, 2003)
By the authority vested in me as President by the Constitution and the laws of the United
States of America, including section 361(b) of the Public Health Service Act (42 U.S.C.
264(b)), it is hereby ordered as follows:
Section 1. Based upon the recommendation of the Secretary of Health and Human Services, in
consultation with the Surgeon General, and for the purpose of specifying certain
communicable diseases for regulations providing for the apprehension, detention, or
conditional release of individuals to prevent the introduction, transmission, or spread of
suspected communicable diseases, the following communicable diseases are hereby specified
pursuant to section 361(b) of the Public Health Service Act:
Severe Acute Respiratory Syndrome (SARS), which is a disease associated with fever and
signs and symptoms of pneumonia or other respiratory illness, is transmitted from person to
person predominantly by the aerosolized or droplet route, and, if spread in the population,
would have severe public health consequences.
Global Dimension of Infectious
Diseases
• Need for international cooperation
• Common interests and values
• International law: International Health
Regulations (WHO)
– Now under revision
– Currently cover cholera, plague, yellow fever
• Externalities of infectious diseases such as
HIV/AIDS, MRTB, etc., require global efforts.
Globalization of Public Health
• Travel and trade across borders;
• Inadequate public health and sanitation
systems; declining effectiveness of drugs
• Socioeconomic disparities: urbanization,
poverty, environmental degradation;
• Global economic interdependence and
integration (loss of State control over
economy)
International Health
Regulations
• Established under WHO in 1951: ‘Sanitary and
quarantine requirements and otheer procedures
designed to prevent the international spread of
disease;’
• Lack of compliance almost universal;
• Epidemiologic networks will help (public good)
• Revisions (1995): Surveillance, response,
increased number of diseases covered.
Disease Control Priorities:
Infrastructure Development
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Political commitment
Financing of public health infrastructure
Surveillance
Scientific investigation
Communications
Therapeutics (policy and development)
Critical evaluation of interventions
Shaping Public Health Policy:
Roles of Society AND the State
• Highly credible scientific evidence
(especially surveillance);
• Public health advocacy (civil society);
• Media advocacy;
• Enforceable and enforced sensible public
health laws.
Closing Thought
Life is filled with golden opportunities,
carefully disguised is irresolvable
problems.
-- John Gardner
former Secretary of Health,
Education, & Welfare
References
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Institute of Medicine. The Future of Public Health. Washington DC: National
Academy Press, 1988.
Fidler DP. International Law and Infectious Diseases. New York: Oxfod
University Press, 1999.
Grad FP. The Public Health Law Manual, 2nd Edition. Washington DC:
American Public Health Association, 1990.
Hong Kong Department of Health. A Briefing on SARS in Hong Kong, 16
April 2003.
Isaacs SL, Schroeder SA. Where the public good prevailed—lessons from
success stories in health. The American Prospect, June 4, 2001.
Turnock BJ. Public Health: What It is and How It Works. Gaithersburg,
Maryland: Aspen Publishers, Inc., 2001.
World Bank. Public Health In Eastern Europe and Central Asia—A Decade
of Experience In Transition. (In Press), April 15, 2003