(L002) What is Public Health? [TRAINING]

It’s a pleasure to be with you The title of this talk is “What is Public Health?” There are no disclosures for this presentation Objectives include: Review the definition of public health, Review primary, secondary and tertiary prevention and how primary prevention is the primary mission of public health, Review the six eras of public health history, Discuss the health promotion, disease prevention model, Discuss the need to couple individual responsibility with community and population health , Review the five public health values, Review the three core public health functions, Review the ten essential services of public health, and Discuss the life span impact of public health in the 20th century When asked what public health is people often have varying responses including: Public health is taking care of poor people, Public health is washing your hands, Public health is protecting the water and air, Public health is making sure food is safe to eat, etc Public health is all of those things but that’s just the tip of the iceberg The field of public health is broad, covering food and drug safety, environmental controls, disease control preventing diseases like tuberculosis or measles, vaccinations, prevention and response to disasters, etc The health and wellness of the whole population is the primary mission of public health The following is a definition that defined public health in the 20th century Public health is “…the science and art of preventing disease, prolonging life and promoting health…through organized community effort…” The 21st century is associated with several changes that impact the current definition including: Prolonged life associated with quality of life, Protection of health linked with promoting health when its at risk, A new definition of community with the advent and expansion of social media, New communication technologies, Expansion of public health and clinical interventions, Enhanced evidence-based research and data, Focus on harms, costs and benefits of interventions, and The essential need for more collaboration and partnerships to improve health and wellness outcomes A current working definition of public health for the 21st century could be, “The totality of all evidence-based public and private efforts that preserve and promote health and prevent disease, disability and death.” This definition broadens the public health mission to address all the determinants of health: social, economic, physical, spiritual and environmental To do this public health will need to collaborate and partner more than we have in the past Working in traditional silos will not accomplish the expanded 21st century mission of public health Let’s spend a few minutes discussing the three types of prevention including: primary, secondary and tertiary Primary prevention is eliminating risk factors that cause disease Primary prevention would be vaccinations for measles, hepatitis A, tetanus, human papilloma virus, etc. to prevent a person from getting the disease It would also be the result of effective tobacco prevention education programs preventing smoking related to diseases like cancer, chronic lung disease and cardiovascular disease Public health is the only health profession with the primary mission of primary prevention Secondary prevention is the detection, treatment, and curing of disease An example of secondary prevention would be the diagnosing of tuberculosis in a patient

via a skin test, chest x-ray and sputum culture, then treating the patient with antituberculosis antibiotics resulting in a cure Another example would be the detection of an inguinal hernia during a routine physical exam, subsequently performing a herniorrhaphy or hernia surgery and curing the patient of his or her inguinal hernia Tertiary prevention is associated with individuals who have been damaged by a disease and receive an intervention to mitigate the disability associated with that disease They will never be cured Hospice care for terminally ill patients would also fall into tertiary prevention Secondary and tertiary prevention are the primary mission of clinical care systems and professionals The Institute of Medicine in 2012 recommended the enhanced integration of public health and primary care to meet the health and wellness needs of the population Let’s review a brief history of public health There are essentially 6 eras of public health history including: 1 Health protection, 2 Hygiene movement 3 Contagious disease control 4 Filling medical care system holes 5 Health promotion and disease prevention, and 6 Population health Let’s first consider the health protection era The health protection era lasted from antiquity to the 1830’s The earliest civilizations integrated their concepts of prevention into their culture, religion and laws Some cultures prohibited or strongly discouraged eating certain foods: Jewish culture with pork, Indian subcontinent cultures with beef and East African tribes, like the Maasai, with fish Cannibalism was nearly universally prohibited by most cultures One possible reason could have been that cannibalism, practiced by certain tribes, was noted to be associated with central nervous system, dementing, fatal diseases Kuru could have been one of those diseases It was scientifically identified in the 1950’s in the Fore people of New Guinea, one of the rare tribes who ate human brains as part of a funeral ritual Some cultures prohibited or limited the use of alcohol to control unwanted behaviors Some sexual activities, thought associated with poor health, resulted in various religious, cultural, and legal practices including premarital abstinence, marital fidelity and ritualistic male and female circumcision Quarantine or the practice of separating afflicted individuals from others was often used Quarantine was used to hopefully control the black plague in Europe Plague was one of the most devastating pandemics in human history, resulting in the deaths of an estimated 75 to 200 million people in Eurasia peaking in Europe from 1347 to 1351 Plague is caused by a bacteria, Yersinia pestis During the epidemic, a form of quarantine, called cordon sanitaire, was used, which barred outsiders from entering walled European cities Unfortunately, cordon sanitaire was not effective since plague was passed by rats and their fleas not by human to human contact Having adequate science would have greatly helped control this epidemic Quarantine was used by some cultures to control leprosy The Biblical book of Leviticus, chapter 13, describes the ancient Jewish protocol for diagnosing and handling leprosy, including quarantine “If anyone notices a swelling in his skin, or a scab or boil or pimple with transparent skin, leprosy is to be suspected

He must be brought to Aaron the priest or to one of his sons for the spot to be examined If the hair in this spot turns white, and if the spot looks to be more than skin-deep, it is leprosy, and the priest must declare him a leper… If a man is burned in some way, and the burned place becomes bright reddish white or white, then the priest must examine the spot If the hair in the bright spot turns white and the problem seems to be more than skin-deep, it is leprosy that has broken out from the burn, and the priest must pronounce him a leper… Anyone who is discovered to have leprosy must tear his clothes and let his hair grow in wild disarray, and cover his upper lip and call out as he goes, “I am a leper, I am a leper.” As long as the disease lasts, he is defiled and must live outside the camp… (a fairly severe form of quarantine and stigmatization) If leprosy is suspected in a woolen or linen garment or fabric, or in a piece of leather or leatherwork, and there is a greenish or a reddish spot in it, it is probably leprosy, and must be taken to the priest to be examined… The priest will put it away for seven days, and look at it again on the seventh day If the spot has spread, it is a contagious leprosy, and he must burn the clothing, fabric, linen or woolen covering, or leather article, for it is contagious and must be destroyed by fire.” We know that the presence of white hair is relatively common on wound edges due to the damage of pigmented cells There are many non-leprous and non-contagious causes of the conditions described in Leviticus 13 The Biblical use of the term leprosy applies to many skin afflictions, not just Hanson’s disease, caused by mycobacteriae leprae, a relative of tuberculosis The use of quarantine in these passages is excessively aggressive, and once again underlines the importance of science in making good, informed public health decisions In 1740 a British naval commander, James Lind discovered that providing sailors with lemons and other citrus fruits during long voyages prevented scurvy The picture shows the bleeding gums and periodontal problems associated with scurvy He was providing vitamin C even though vitamins had not yet been identified Edward Jenner was an English physician who developed the the world’s first vaccine The terms “vaccine” and “vaccination” are derived from Variolae vaccinae, the virus that causes a pox-like illness in cattle Vacciniae was the term Jenner used to denote cowpox illness He used cowpox from infected pustules from cattle in 1796 to vaccinate people, starting with a dairymaid named Sarah Nelmes These vaccinations prevented smallpox, when vaccinated individuals were exposed to people who had disease Jenner is called “the father of immunology His work is said to have “saved more lives than the work of any other human” In Jenner’s time, smallpox killed around 10 percent of the general population, with that number as high as 20 percent in towns and cities where infection spread more easily The lower picture on this slide demonstrates the classic rash of smallpox All of these approaches to disease prevention were used before organized public health existed Public health awareness started to grow in Europe and the United States in the mid- 1800’s with the idea that social conditions of inequality were associated with health and wellness issues, introducing the concept of social justice and public health’s focus on vulnerable populations Next, let’s consider the hygiene movement era for a few minutes This era had a focus on sanitation even though the germ theory had not yet been

developed The fundamental concepts of epidemiology developed during this era John Snow, who lived from 1800 to1899, was an anesthesiologist by training John Snow is known as the father of the field of epidemiology He studied the cholera epidemic in London and identified the cause: contaminated water, associated with the Broad street pump circled on the map Each mark on the map is the physical location of a case of cholera and helped Snow deduce that the pump was essentially the geographic center of the epidemic and could likely be the culprit His method was what is termed in epidemiology a natural experiment that is still commonly used today A natural experiment is defined as a “Naturally occurring circumstance in which subsets of a population have different levels of exposure to a supposed causal factor in a situation resembling an actual experiment, where human subjects would be randomly allocated to groups.” This slide lists the major contributions John Snow made to the field of epidemiology including: The powers of observation and written expression, Description of Epidemiologic methods, including mapping and data tables to describe the outbreak, The use of the “Natural Experiment” epidemiologic method, Developing recommendations based on the data; Using that data to develop a practical solution to the problem In this case, remove the pump handle, which Snow did His actions quickly terminated the epidemic This picture is the famous Broad street pump with the handle removed There were other events that impacted the hygiene movement in the mid-1800’s Semmelweis was an Austrian physician who sought to control puerperal fever or fever during childbirth Puerperal fever was a major cause of maternal mortality in Europe and the United States Semmelweis noted the association of puerperal fever with physicians who went straight from the autopsy room to the delivery room without washing their hands He instituted strict handwashing and documented a dramatic decline in puerperal fever in his institution Unfortunately, his practice was not adopted by medical colleagues until the germ theory was later described by Louis Pasteur and Robert Koch Vital statistics or birth and death records were developed in England in the mid-1800’s Vital statistics established a basis for population-wide assessment of health status From the onset there was a spirited discussion over how to define the cause of death Edwin Chadwick argued for specific pathologic conditions or diseases as the causal basis where William Farr argued for underlying risk factors including social conditions as the real cause of death The American Public Health Association (APHA) was formed in 1872 and identified two main goals: 1 Advocacy for scientific advances related to the health of the public, and 2 Public education to improve community health Let’s now consider the contagious disease control era This era ran from approximately 1880 to the 1940’s Identification of the germ theory was the major focus of this period Louis Pasteur identified and postulated that germs caused several diseases as early as 1860 The practical application of that theory related to the work of Robert Koch in 1890 Koch proposed 4 postulates that defined infectious causes of disease This slide lists the 4 Koch postulates 1

The same microorganisms are present in every case of a disease 2 The microorganisms are isolated from the tissues of a dead animal, and a pure culture is prepared 3 Microorganisms from the pure culture are inoculated into a healthy susceptible animal The disease is reproduced in that animal 4 The identical microorganisms are isolated and re-cultivated from the tissue specimens of the experimental animal This era also saw the merging of the new field of epidemiology started by John Snow’s work, germ theory & immunology resulting in public programs to control infectious diseases like tuberculosis Scientists could now identify tuberculosis by a skin test, culture and chest x-ray Many tuberculosis sanitoriums were developed during this period of public health history New toxin vaccines against tetanus and diphtheria were developed Without antibiotics, control of infectious diseases was the priority with public health focusing on prevention, isolation and case finding to prevent further spread In the early 20th century, Dr. Joseph Goldberger, a physician in the U.S. government’s Hygienic Laboratory, the predecessor of the National Institutes of Health, identified the cause of pellagra, a vitamin B6 or niacin deficiency, in poor Southern sharecroppers, tenant farmers and mill workers due to deficient diets Pellagra causes skin, mucosal and mental symptoms and signs His work contradicted medical thinking of the time that attributed the cause to an infectious agent The link of pellagra to poverty underlined the importance of the social determinants of health and social justice in public health The 1920’s and 30’s saw significant advances not only in the understanding of contagious diseases but also in vitamin and nutrition research The next era is filling medical care system holes which extended from the 1940’s to approximately the mid-1980’s Penicillin was discovered in 1928 by Scottish scientist Alexander Fleming but wasn’t used in human medicine until 1942 The introduction and development of antibiotic therapy allowed clinicians to cure many infectious diseases During this period, public health helped integrate preventive services into clinical practice Randomized clinical trials emerged The Food and Drug Administration (FDA) developed the foundations for evidence-based public health and medicine Epidemiological methods were developed for non-communicable diseases resulting in the 1964, Dr Luther Terry, Surgeon General’s report linking tobacco use to cancer and the 1948 Framingham study linking high blood pressure, cholesterol, cigarette smoking and obesity to cardiovascular disease The Framingham study is currently evaluating it’s third cohort Smallpox was officially recognized as eradicated in 1980 Eliminating smallpox was an incredible public health achievement The last naturally acquired case was seen in Somalia in 1977 The last laboratory related death from smallpox virus was in 1978 at the University of Birmingham, England where they had 6 cases and 3 deaths In 1980 the World Health Assembly of the World Health Organization certified the global eradication of small pox Eradication was not achieved by mass vaccination but by a ring vaccination technique There were three components to the ring vaccination concept: 1 Isolation of confirmed and suspected cases to further prevent spread,

2 Identification, vaccination, and surveillance of significant contacts of proven cases: the 1st ring to prevent further spread 3 Vaccination of household contacts of contacts: the 2nd ring or safety net Smallpox immunization is 95-99% effective in preventing disease in those exposed That’s good but not 100%, therefore the 2nd ring was felt essential Mass vaccination was considered an adjunct measure if indicated Routine smallpox vaccination was discontinued in the US in 1972, and generally discontinued in the world in 1982 The US military discontinued vaccination in 1990 Select vaccination was reinstituted post 9/11 due to bioterrorism concerns The next era is health promotion and disease prevention This era lasted from approximately the mid-1980’s to 2000 and focused on individual responsibility Health promotion and disease prevention targeted individuals to effect behavioral change and reduce risk factors associated with disease This would include cardiovascular risk factors identified in the Framingham study: high blood pressure, cholesterol, smoking and obesity Behavioral change strategies were also used to help prevent the spread of HIV/AIDS Health promotion was defined by the World Health Organization’s Bangkok Charter for Health Promotion in a Globalized World as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health“, emphasizing the concept of individual responsibility This slide is a representation of Pender’s health promotion model The first column lists personal and historical influences on behaviors including prior experiences and personal biological, psychological and socio-cultural factors The middle column lists some specific cognitive influences including a person’s perceptions of benefits, barriers, efficacy and activity-related impacts Interpersonal influences of family, peers, models, societal and community norms, etc., situational influences and immediate competing demands also have an impact as diagrammed All of these influences ultimately impact individual decisions and the final output, health related behaviors Health promotion and disease prevention strategies aim at neutralizing negative and enhancing positive influences of this model Screening efforts were emphasized in this era, like mammography to detect early breast cancer and Pap smears for cervical cancer Newborn screening for various genetic diseases was also implemented Environmental movements enhanced public awareness of lead in gasoline and paint, radon, holes in the ozone atmospheric layer, air pollution, etc Reductions in air pollution and smoking had positive impacts on chronic lung disease, asthma and coronary artery disease That brings us to the final and current era of public health history, population health Population health is transforming the way professionals and the public think about health Community-wide or population-wide public health efforts are needed to address issues like bioterrorism, the opioid crisis, the high cost of health care, access to health care, control of pandemic influenza, HIV / AIDS, suicide, disparities, climate change, emerging and reemerging infectious diseases, environmental contamination, international health issues, etc The new public health paradigm is individual responsibility coupled with community and

population health So, from that history, public health values, core functions and essential services should make sense We’ll start with values since it’s upon those deeper cultural layers of public health beliefs and values that pubic health functions and essential services are built The American Public Health Association has identified 5 key values that represent public health practice These values have propelled public health for nearly 150 years and continue to form the skeletal backbone of the field Those five values include: 1 Community We believe we have greater potential for impact when we create community to solve problems, share new ideas and explore different perspectives Community engagement skills and competencies are essential for public health practice 2 Science and evidence-based decision-making The best policies and practices are ones based on research, with evidence that demonstrates effectiveness The best innovations come from testing new ideas and approaches Not all best practices have been identified There will always be a need for innovation This is especially true for rural areas and special population groups 3 Health equity We believe in conditions that give everyone the opportunity to reach their best health This requires valuing all individuals and populations equally It means addressing inequities in the places where people are born, grow, live, work, learn and age When will we know we have succeeded? When health disparities are eliminated 4 Prevention and wellness Preventing disease and injury, mitigating the impact of disasters through preparedness and ensuring an environment where the healthy choice is the easy choice are worthwhile investments that lead to an overall improved human condition 5 Real progress in improving health Our effort must result in forward movement in health impact Sometimes that is a leap forward Other times it’s small steps But always, it is real progress These are a good set of public health values upon which to build a strong equitable, effective public health system and practice This slide lists the three core public health functions including: 1 The assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities To accomplish this function enhanced collaboration and partnership between academic institutions and public health departments is required Health departments are generally data rich but have limited capacity to research and analyze that data On the other hand, academic institutions have that research and analysis capability but often limited access to data A marriage between academia and practice is beneficial to both parties 2 The formulation of public policies designed to solve identified local and national health problems and priorities Public health professionals must position themselves to appropriately advocate with policy makers 3 To assure that all populations have access to appropriate and cost-effective care, including health promotion, disease prevention services, population and community health programs and evaluation of the effectiveness of those services and programs To accomplish this function enhanced collaboration and partnership with a variety of stakeholders including healthcare systems is essential Public health can’t provide the resources necessary to plug all access gaps to services and programs

Finally, the five public health values and 3 core functions translate into the 10 essential public health services, identified in 1994 by the Core Public Health Functions Steering Committee The committee included representatives from US Public Health Service agencies and other major public health organizations The ten essential services include: 1 Monitor health status to identify and solve 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 and action to identify and solve health problems 5 Develop policies and plans that support individual and community health efforts 6 Enforce laws and regulations that protect health and ensure safety 7 Link people to needed personal health services and assure the provision of health care when otherwise unavailable 8 Assure competent public and personal health care workforce 9 Evaluate effectiveness, accessibility, and quality of personal and populationbased health services 10 Research for new insights and innovative solutions to health problems This is what we do in public health, our actions and behaviors that support the 3 functions and 5 values of public health So, does public health actually work, or is it all theory? The CDC demonstrated that the life span of Americans increased by approximately 30 years from 1900 to 1999 Twenty-five of those years were due to public health interventions Five years could be attributed to healthcare advances including medications like antibiotics, surgical technology, or life support The ten health achievements that significantly impacted life span in the 20th century included: Vaccinations, the most effective public health tool in history, Motor vehicle safety, Safer work places, Control of infectious diseases including water protection, sanitation, etc., Declines in cardiovascular heart disease and stroke deaths, Safer and healthier foods, Healthier mothers and babies, Family planning, Fluoridation of water, and Recognizing tobacco as a health hazard Many of these achievements were accomplished through public health professionals working in collaboration with other stakeholders including healthcare colleagues Effectively applying the 3 functions and 10 essential services, previously discussed, will continue to positively impact the public’s health and wellness in the 21st century as it had in the last century In summary: The mission of public health is to effectively address all the social determinants of health Primary prevention is the primary mission of public health Public health practice progressively evolved through the six historical eras Health promotion and disease prevention strategies aim at neutralizing negative and enhancing positive influences on behavior Public health values and functions express themselves in the ten essential public health services In the United States, public health was responsible for 25 of the 30 years of increased life span noted during the 20th century We support lifelong learning for public health professionals That’s why we provide — and will always provide — many of our classes for free

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