Download Dr. Ken Warner (UM Public Health Professor)

What is “public health?”
PUBHLTH 200 – Sept. 13, 2011
What does the public think
“public health” means?
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Disaster response (e.g., post 9/11)
Health care for the poor
Behavior nannies (e.g., smoke-free laws)
Restaurant inspections for cockroaches, etc.
I dunno (No idea)
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How public health professionals
think of public health
• By purpose
• By groups of professionals who practice PH
• By methods most identified with PH:
epidemiology and biostatistics
• As governmental health services for the poor
• As the outcome: health of the public
Source: Turnock
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CEA Winslow’s 1920 definition
Public health is “...the science and art of preventing
disease, prolonging life and promoting health and efficiency
through organized community effort for the sanitation of the
environment, the control of communicable infections, the
education of the individual in personal hygiene, the
organization of medical and nursing services for the early
diagnosis and preventive treatment of disease, and for the
development of the social machinery to insure everyone a
standard of living adequate for the maintenance of health, so
organizing these benefits as to enable every citizen to realize
his [or her] birthright of health and longevity.”
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A more concise definition
Def’n:
Public health is the set of activities a society
undertakes to monitor and improve the health of
its collective membership.
Distinguishing features:
1. Focus on preventing disease & injury
2. “Patient” is entire community, not individuals
3. “Provider” is society, not individual professionals
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How does public health differ
from other health professions?
All other health professions (medicine, nursing,
dentistry, pharmacy, allied health, social work)
typically involve:
• An individual provider
• An individual patient
• Emphasis on treating illness or disability
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Example of the difference
Example of health care:
Dentist treats dental caries in an individual
patient.
Example of public health:
Government fluoridates the water supply, making
fluoridated water available to all members of the
community. Prevents dental caries.
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Primacy of public health in concept
Public health
Collective health services
Individual health services
Medicine Dentistry Nursing Pharmacy
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Hierarchy in practice
Medicine
Other individual health services
Public health
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Why is public health so important?
Factors that could avoid premature mortality
• Lifestyle (behavior)
50%
• Environment
20%
• Human biology (genetics)
20%
• Additional medical care
10%
Source: Adapted from CDC, 1979; IOM, 1988; and PHS, 1993
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Why is public health so important?
Contribution to life expectancy gain
• Of 30-year gain in life expectancy in U.S.
during 20th century…
– 5 years attributable to medical care system
– 25 years from public health improvements in
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Sanitation
Housing
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Nutrition
Job safety
Bunker et al., Milbank, 1994
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Relationship between public health (PH)
and the medical care system (MC):
Impact on premature mortality
PH
MC
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Relationship between PH and MC:
Expenditures
PH
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MC
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Why the PH/MC imbalance?
• Market systems (economic interests) cater to
services for individuals; PH is often a public
good (or relevant due to externalities)
• Interest group politics; often contentious
issues (more on this later)
• What people want (the “Rule of Rescue”)
– Current trauma vs. abstract future benefit
– Identifiable vs. “statistical” lives
• “Invisibility” of PH
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Benefits and costs of health
promotion programs
Benefits: abstract, deferred
Costs: tangible, immediate
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Benefits and costs of
disease promotion
Benefits: tangible, immediate
Costs: abstract, deferred
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Mission of public health
“Fulfilling society's interest in assuring
conditions in which people can be healthy.”
“[The] aim [of public health] is to generate
organized community effort to address the
public interest in health by applying
scientific and technical knowledge to
prevent disease and promote health.”
Source: IOM, Future of Public Health, 1988
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Core functions of public health
1. Assessment of the health of the
population
2. Development of public health policies
3. Assurance of the availability of needed
services
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1. Assessment of the public’s health
Requires:
1. Data collection
2. Statistical and epidemiologic
analysis
3. Dissemination of findings
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2. Development of public
health policies
Requires:
1. Use of a scientific
knowledge base
2. Appreciation and use of
the political process
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3. Assurance of the availability
of needed services
Relies on:
1. Encouraging appropriate actions by
other entities (public or private)
2. Requiring such actions through law or
regulation
3. Directly providing services
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10 essential public health services
1. Monitor health status to identify community health
problems
2. Diagnose and investigate health problems and
health hazards in the community
3. Inform, educate, and empower people about
health issues
4. Mobilize community partnerships to identify and
solve health problems
5. Develop policies and plans that support individual
and community health efforts
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10 essential public health services
6. Enforce laws and regulations that protect health
and ensure safety
7. Link people with needed personal health services
and assure the provision of health care when
otherwise unavailable
8. Ensure a competent public health and personal
health care workforce
9. Evaluate effectiveness, accessibility, and quality of
personal and population-based health services
10. Research for new insights and innovative solutions
to health problems
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Five core areas of public health
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Epidemiology
Biostatistics
Environmental Health Sciences
Health Behavior & Health Education
Health Management & Policy
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Epidemiology
Concerned with analyzing and describing
patterns of occurrence and determinants of
diseases in human populations.
Epidemiology is the core science of the
field of public health.
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Biostatistics
Focuses on the development and
application of statistical and
mathematical methods to the design
and analysis of public health problems
and biomedical research.
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Environmental Health Sciences
Aims to protect human health from
adverse environmental conditions -in particular from harmful practices
and harmful exposures in air, water,
and food in the workplace, home, and
ambient environment.
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Health Behavior & Health Education
Addresses the factors associated with
health-related behavior and health status,
and develops and evaluates educational
activities designed to improve individual
and community health and quality of life.
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Health Management & Policy
Focuses on improving access
to, financing of, and delivery
of high quality health
services, and on developing
and implementing costeffective public health policies
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Definition of disease prevention
[A]nticipatory action taken to reduce the
possibility of an event or condition
occurring or developing, or to minimize
the damage that may result from the
event or condition if it does occur.
Source: Pickett and Hanlon, 1990
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Levels of Prevention and Effects
Prevention
strategy
Disease status
Effects
Primary
Secondary
Tertiary
Susceptible Asymptomatic Symptomatic
Reduced
disease
incidence
Reduced
Reduced
prevalence/ complications/
consequence disability
Source: Turnock, Fig. 3-4
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Example of prevention levels:
Motor vehicle injuries
• Primary
– Building divided highways
• Secondary
– Requiring safer cars (e.g., airbags) or
driving practices (e.g., wearing seatbelts)
• Tertiary
– EMS system
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Example of prevention levels:
High blood pressure
• Primary
– Dietary education and exercise
• Secondary
– BP control medications
• Tertiary
– Treatment for disease sequelae
of HBP
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Agent, host, environment
model of disease
Agent
• Traditionally infectious
disease
• A.k.a. Epidemiological
Triangle
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Host
Environment
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Epi triangle adapted to nicotine
addiction & tobacco control
Agent
Tobacco products
Environment
Family, friends, culture, media
politics, economics, history
Host
Smoker/chewer
Vector
Incidental host
Involuntary smoker
Adapted from: Giovino 2002
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Tobacco product
manufacturers
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Why are public health issues
often contentious?
1. Restrictions on individual liberty
2. Debate over individual responsibility
(“blame the victim”)
3. Economic interests
4. Morality issues in public health measures
5. Politics in science
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1. Restrictions on individual liberty
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Why are they imposed?
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“Tragedy of the commons”: Must restrict individuals’
freedoms to protect the greater good of the entire
community (e.g., think pollution control).
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“Public goods”; “externalities”
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Paternalism (e.g., seat belt laws)
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Social norms, morals (e.g., sodomy laws)
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1. Restrictions on individual liberty
(cont’d.)
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Behavior that directly affects others (examples)
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Prohibitions against criminal activity (murder; abuse; theft)
Speed limits; traffic lights; etc.
Prohibiting drunk driving
Banning smoking in public places
Quarantining people with infectious disease
Requiring immunizations for school enrollment
Prohibiting various forms of pollution
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1. Restrictions on individual liberty
(cont’d.)
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Behavior that indirectly affects others (examples)
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Motorcycle helmet and seat belt laws
Bans on illicit drugs
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Sodomy laws
Abortion laws
UM campus-wide smoke-free policy (outdoors as well
as indoors)
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2. Debate over individual
responsibility (“blame the victim”)
Question: Are people suffering from problem
X at fault for the problem – and therefore
individually responsible for resolving it – or
are they victims who need and deserve
(public) assistance?
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2. Debate over individual
responsibility (“blame the victim”) (cont’d.)
Examples:
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Smoking
Obesity
HIV/AIDS
Drug/alcohol addiction
Homeless (including result of recent spate of foreclosures)
Poverty
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3. Economic interests
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Often powerful economic interests hurt by public
health regulations (e.g., tobacco, alcohol, food companies;
polluting firms; health care insurers, hospitals, providers; local retailers
such as restaurants and bars)
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Powerful economic interest = political lobby
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3. Economic interests (cont’d.)
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Cost burden falls on different people than does
benefit derived
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Benefit often to the poor and politically disenfranchised
Cost often from wealthy and politically connected
Politics of current costs for future (abstract) benefits
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Political interests
Budget balancing
Politicians’ discount rate
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4. Morality issues in public
health measures
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Intensely felt positions deriving from
sense of moral or religious right or norms
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Abortion
Sex ed
HIV/AIDS prevention (safe sex, clean needles)
Gay marriage
Stem cell research
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5. Politics in science
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Administrations often promote their social/
political agendas by interfering with science
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Withholding research resources (e.g., early AIDS)
Tying resources to compliance with policy
positions (e.g., no support through USAID to programs
promoting birth control)
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“Litmus tests” for high-level appointees
“Stacking” review bodies with “partisans” (e.g.,
corporate consultants)
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Misrepresenting or suppressing scientific
findings (e.g., global warming)
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What is public health?
• Under-appreciated (“invisible”),
under-funded, under-practiced
• Difficult
• Politically challenging
• Requires expert mix of science and
politics
• Last but not least: PH is important
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Thursday: History of public health
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