Zlib - Pub Encyclopedia of Public Health Principles People and Programs 2 Volumes

Encyclopedia of
Public Health
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Encyclopedia of
Public Health
Principles, People, and Programs
VOLUME 1: A–L
VOLUME 2: M–Z
SALLY KUYKENDALL, EDITOR

Copyright © 2018 by ABC-CLIO, LLC
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, except for the inclusion of brief quotations in a
review, without prior permission in writing from the publisher.
Library of Congress Cataloging in Publication Control Number: 2017045280
ISBN: 978-1-61069-982-2 (set)

978-1-4408-4809-4 (vol. 1)
978-1-4408-4810-0 (vol. 2)
978-1-61069-983-9 (ebook)
22 21 20 19 18 1 2 3 4 5
This book is also available as an eBook.
Greenwood
An Imprint of ABC-CLIO, LLC
ABC-CLIO, LLC
130 Cremona Drive, P.O. Box 1911
Santa Barbara, California 93116-1911
www.abc-clio.com
This book is printed on acid-free paper
Manufactured in the United States of America

Contents
Guide to Related Topics xv

Introduction xxi
Chronology xxvii
Volume 1
Acute Illnesses 1
Addictions 3
Administration, Health 7
Adverse Childhood Experiences (ACEs) 11
Affordable Care Act (ACA) 15
Aging 18
Agricultural Safety 22
Air Pollution 25
Alcohol 30
Alzheimer’s Disease (AD) 33
American Journal of Public Health (AJPH) 37
American Medical Association (AMA) 38
American Public Health Association (APHA) 40
Americans with Disabilities Act (ADA) 41
Ancient World, Public Health in the 44
Anderson, Elizabeth Milbank (1850–1921) 47
Antibiotic Resistance 50
Association of Public Health Laboratories (APHL) 53
Association of State and Territorial Health Officials (ASTHO) 54
vi C on te n ts
Attention-Deficit/Hyperactivity Disorder (ADHD) 57

Baker, Sara Josephine (1873–1945) 61
Beers, Clifford Whittingham (1876–1943) 64
Behavioral Health 69
Belmont Report, The 71
Biostatistics 73
Bioterrorism 75
Birth Defects 79
Blackwell, Elizabeth (1821–1910) 81
Body Mass Index (BMI) 86
Bousfield, Midian Othello (1885–1948) 88
Bowditch, Henry Ingersoll (1808–1892) 91
Cancer 97
Care, Access to 99
Causality 102
Centers for Disease Control and Prevention (CDC) 104
Centers for Medicare and Medicaid Services (CMS) 108
Certified in Public Health (CPH) 108
Chadwick, Edwin (1800–1890) 109
Child Maltreatment 113
Children’s Health 116
Cholera 119
Chronic Illness 123
Code of Ethics 126
Collaborations 130
Community Health 133
Community Health Centers (CHCs) 136
Community Organizing 139
Core Competencies in Public Health 141
C o ntents vii
Cornely, Paul Bertau (1906–2002) 146

Council on Education for Public Health (CEPH) 150
Cultural Competence 152
Cutter Incident, The 154
Dean, Henry Trendley (1893–1962) 159
Degrees in Public Health 162
Diabetes Mellitus 164
Diffusion of Innovations Theory 167
Disability 170
Disability Movement 173
Disease 175
Dix, Dorothea Lynde (1804–1887) 178
Drew, Charles Richard (1904–1950) 183
Dritz, Selma Kaderman (1917–2008) 187
Dunham, Ethel Collins (1883–1969) 190
Eating Disorders 193
Elder Maltreatment 195
Elders, Joycelyn (1933–) 198
Eliot, Martha May (1891–1978) 199
Ellertson, Charlotte Ehrengard (1966–2004) 203
Emergency Medical Treatment and L
abor Act (EMTALA) 205
Emergency Preparedness and Response 207
Environmental Health 210
Environmental Protection Agency (EPA) 213
Epidemic 216
Epidemiology 220
Ethics in Public Health and Population Health 223
Evaluation 226
Evidence-Based Programs and Practices 230
viii C on te n ts
False Claims Act (FCA) 233

Family Planning 234
Fluoridation 237
Food and Drug Administration (FDA) 240
Food Insecurity 243
Food Safety 245
Genetics 249
Global Health 251
Goals and Objectives 255
Grants 258
Greco-Roman Era, Public Health in the 260
Hamilton, Alice (1869–1970) 263
Handwashing 267
Health 269
Health and Medicine Division of the National Academies of Sciences,
Engineering, and Medicine 272
Health Belief Model 274
Health Care Disparities 276
Health Communication 281
Health Disparities 285
Health Education 291
Health Information Management (HIM) 295
Health Insurance Portability and Accountability Act (HIPAA) 295
Health Literacy 298
Health Policy 300
Health Resources and Services Administration (HRSA) 304
Healthy People 2020 306
Healthy Places 308
Heart Disease 311
C o ntents ix
Heart Truth® (Red Dress) Campaign, The 314

Hepatitis 317
Hinton, William Augustus (1883–1959) 321
Hippocrates (460–375 BCE) 323
Home Safety 326
uman Immunodeficiency Virus (HIV) and Acquired Immune
H
Deficiency Syndrome (AIDS) 331
Human Trafficking 336
Hypertension (HTN) 339
Immigrant Health 343
Indian Health Service (IHS) 345
Infant Mortality 349
Infectious Diseases 352
Influenza 355
Injuries 359
Intervention 362
Intimate Partner Violence (IPV) 366
Jenner, Edward (1749–1823) 371
Kelley, Florence (1859–1932) 373
Koch, Heinrich Hermann Robert (1843–1910) 377
Leading Health Indicators 383
Lesbian, Gay, Bisexual, and Transgender (LGBT) Health 385
Locus of Control 389
Logic Model 390
Volume 2
Mallon, Mary (1869–1938) 393
Master Settlement Agreement (MSA) 396
Maternal Health 397
Measles 404
x C on te n ts
Medicaid 406
Medicare 408
Medicine 410
Meningitis 412
Men’s Health 416
Mental Health 418
Mental Illness 420
Middle Ages, Public Health in the (500–1500 CE) 425
Modern Era, Public Health in the 428
Motor Vehicle Safety 430
Nader, Ralph (1934–) 435
National Association of County and City Health Officials (NACCHO) 438
National Cancer Institute (NCI) 439
National Center for Injury Prevention and Control (NCIPC) 441
National Health and Nutrition Examination Survey (NHANES) 443
National Heart, Lung, and Blood Institute (NHLBI) 444
National Institute on Drug Abuse (NIDA) 446
National Institutes of Health (NIH) 449
Nation’s Health, The 451
Needs Assessment 452
Nightingale, Florence (1820–1910) 455
Nutrition 460
Obesity 465
Oral Health 468
Pandemic 473
Pasteur, Louis (1822–1895) 475
Patient Safety 478
Penicillin 481
Physical Activity 484
C o ntents xi
Planned Parenthood 488

Polio 491
Population Health 494
Precaution Adoption Process Model (PAPM) 498
PRECEDE-PROCEED Planning Model 500
Prescription Drugs 502
Prevention 505
Public Health Department Accreditation 508
Public Health in the United States, History of 511
Public Health Law 515
Quarantine 519
RE-AIM (Reach, Effectiveness, Adoption, Implementation,
and Maintenance) 523
Reciprocal Determinism 525
Renaissance, Public Health in the 525
Research 529
Risk-Benefit Analysis 532
Roosevelt, Eleanor (1884–1962) 534
Roosevelt, Franklin Delano (1882–1945) 536
Rosen, George (1910–1977) 541
Rural Health 545
Sabin, Florence Rena (1871–1953) 549
Salk, Jonas (1914–1995) 552
Sanger, Margaret Louise Higgins (1879–1966) 554
School Health 559
Self-Efficacy 562
Shattuck, Lemuel (1793–1859) 564
Skin Cancer 567
Smallpox 570
Smith, James McCune (1813–1865) 573
xii C on te n ts
Snow, John (1813–1858) 577

Social Cognitive Theory (SCT) 579
Social Determinants of Health (SDOH) 582
Social Ecological Model 586
Social Security Act (SSA) 589
Society of Public Health Education (SOPHE) 592
Spiritual Health 594
Sports-Related Concussions (SRCs) 597
Stark Law 600
State, Local, and Territorial Health Departments 602
Substance Abuse and Mental Health Services
Administration (SAMHSA) 604
Surgeon General 607
Syringe Service Programs 609
Transtheoretical Model (TTM) 613
Truth Campaign, The 615
Tubman, Harriet (1822–1913) 618
Tuskegee Syphilis Study 620
Upstream Public Health Practices 625
U.S. Department of Agriculture (USDA) 626
U.S. Department of Health and Human Services (HHS) 628
U.S. Public Health Service (PHS) 630
Vaccines 633
Veterans’ Health 636
Violence 639
Wald, Lillian (1867–1940) 643
Waterborne Diseases 645
Wegman, Myron Ezra (1908–2004) 648
Winslow, Charles-Edward Amory (1877–1957) 650
C o ntents xiii
Women’s Health 653

World Health Organization (WHO) 657
Wynder, Ernst Ludwig (1922–1999) 660
Zombie Preparedness 665
Controversies in Public Health 669
Directory of Organizations 711
Glossary 717
About the Editor and Contributors 723
Index 729
Guide to Related Topics
Diseases, Health Problems, and Hepatitis

Wellness Home Safety
Human Immunodeficiency Virus
Acute Illnesses
(HIV) and Acquired Immune
Addictions
Deficiency Syndrome (AIDS)
Adverse Childhood Experiences
Human Trafficking
(ACEs)
Hypertension (HTN)
Air Pollution
Immigrant Health
Alcohol
Infant Mortality
Alzheimer’s Disease
Infectious Diseases
Antibiotic Resistance
Influenza
Attention-Deficit/Hyperactivity
Injuries
Disorder (ADHD)
Intimate Partner Violence (IPV)
Bioterrorism
Maternal Health
Birth Defects
Measles
Body Mass Index (BMI)
Meningitis
Cancer
Mental Illness
Care, Access to
Obesity
Child Maltreatment
Pandemic
Cholera
Polio
Chronic Illness
Prescription Drugs
Diabetes
Rural Health
Disability
School Health
Disease
Skin Cancer
Eating Disorders
Smallpox
Elder Maltreatment
Social Determinants of Health (SDOH)
Environmental Health
Sports-Related Concussions
Epidemic
Veterans’ Health
Food Insecurity
Violence
Food Safety
Waterborne Diseases
Genetics
Women’s Health
Global Health
Handwashing
Government Organizations
Health Care Disparities
Health Disparities Centers for Disease Control and
Heart Disease Prevention (CDC)
xvi G uide to R elat ed Topics
Centers for Medicare and Medicaid Public Health Law

Services (CMS) Social Security Act (SSA)
Community Health Centers (CHCs) Stark Law
Environmental Protection Agency
(EPA) Major Events in the History of
Food and Drug Administration (FDA) Public Health
Health Resources and Services
Administration (HRSA) Agricultural Safety
Indian Health Service (HIS) Ancient World, Public Health in the
National Cancer Institute (NCI) Americans with Disabilities Act (ADA)
National Center for Injury Prevention Cutter Incident, The
and Control (NCIPC) Family Planning
National Heart, Lung, and Blood Fluoridation
Institute (NHLBI) Food Safety
National Institute on Drug Abuse Greco-Roman Era, Public Health
(NIDA) in the
National Institutes of Health (NIH) Heart Disease
State, Local, and Territorial Health Infectious Diseases
Departments Master Settlement Agreement (MSA)
Substance Abuse and M ental Health Maternal Health
Services Administration (SAMHSA) Medicaid
Surgeon General Medicare
U.S. Department of Agriculture Middle Ages, Public Health in the
(USDA) Modern Era, Public Health in the
U.S. Department of Health and Motor Vehicle Safety
Human Services (DHHS) Oral Health
U.S. Public Health Service (PHS) Pandemic
World Health Organization (WHO) Penicillin
Polio
Public Health in the United States,
Laws and Guidelines History of
Affordable Care Act (ACA) Quarantine
Americans with Disabilities Act (ADA) Renaissance, Public Health in the
Belmont Report, The Social Security Act (SSA)
Emergency Medical Treatment and Tuskegee Syphilis Study
Labor Act (EMTALA) Vaccines
Evidence-Based Programs and
Practices
People
False Claims Act (FCA)
Health Insurance Portability and Anderson, Elizabeth Milbank
Accountability Act (HIPAA) (1850–1921)
Master Settlement Agreement (MSA) Baker, Sara Josephine (1873–1945)
G ui d e to R el ated T o p i c s xvii
Beers, Clifford Whittingham Wald, Lillian (1867–1940)

(1876–1943) Wegman, Myron Ezra (1908–2004)
Blackwell, Elizabeth (1821–1910) Winslow, Charles-Edward Amory
Bousfield, Midian Othello (1877–1957)
(1885–1948) Wynder, Ernst Ludwig (1922–1999)
Bowditch, Henry Ingersoll
(1808–1892)
Principles
Chadwick, Edwin (1800–1890)
Cornely, Paul Bertau (1906–2002) Behavioral Health
Dean, Henry Trendley (1893–1962) Belmont Report, The
Dix, Dorothea Lynde (1804–1887) Body Mass Index (BMI)
Drew, Charles Richard (1904–1950) Causality
Dritz, Selma Kaderman (1917–2008) Code of Ethics
Dunham, Ethel Collins (1883–1969) Collaborations
Elders, Joycelyn (1933–) Community Health
Eliot, Martha May (1891–1978) Community Health Centers (CHCs)
Ellertson, Charlotte Ehrengard Community Organizing
(1966–2004) Core Competencies in Public Health
Hamilton, Alice (1869–1970) Cultural Competence
Hinton, William Augustus Diffusion of Innovations Theory
(1883–1959) Disability Movement
Hippocrates (460–375 BCE) Emergency Preparedness and
Jenner, Edward (1749–1823) Response
Kelley, Florence (1859–1932) Ethics in Public Health and Population
Koch, Heinrich Hermann Robert Health
(1843–1910) Evaluation
Mallon, Mary (1869–1938) Food Safety
Nader, Ralph (1934–) Grants
Nightingale, Florence (1820–1910) Health
Pasteur, Louis (1822–1895) Health Belief Model
Roosevelt, Eleanor (1884–1962) Health Communication
Roosevelt, Franklin Delano Health Education
(1882–1945) Health Literacy
Rosen, George (1910–1977) Health Policy
Sabin, Florence Rena (1871–1953) Healthy P eople 2020
Salk, Jonas (1914–1995) Healthy Places
Sanger, Margaret Louise Higgins Intervention
(1879–1966) Leading Health Indicators
Shattuck, Lemuel (1793–1859) Lesbian, Gay, Bisexual, and
Smith, James McCune (1813–1865) Transgender (LGBT) Health
Snow, John (1813–1858) Locus of Control
Tubman, Harriet (1822–1913) Logic Model
xviii G uide to R elat ed Topics
Maternal Health Council on Education for Public

Medicine Health (CEPH)
Men’s Health Degrees in Public Health
Mental Health Grants
Needs Assessment Health and Medicine Division of the
Nutrition National Academies of Sciences,
Patient Safety Engineering, and Medicine
Physical Activity National Association of County and
Population Health City Health Officials (NACCHO)
Precaution Adoption Process Model National Health and Nutrition
(PAPM) Examination Survey (NHANES)
PRECEDE-PROCEED Planning Model Nation’s Health, The
Prescription Drugs Public Health Department
Prevention Accreditation
Quarantine Society of Public Health Education
RE-AIM (Reach, Effectiveness, (SOPHE)
Adoption, Implementation, and
Maintenance)
Programs
Reciprocal Determinism
Research Affordable Care Act (ACA)
Risk-Benefit Analysis Centers for Disease Control and
Self-Efficacy Prevention (CDC)
Social Cognitive Theory (SCT) Centers for Medicare and Medicaid
Social Determinants of Health Services (CMS)
(SDOH) Community Health Centers (CHCs)
Social Ecological Model Environmental Protection Agency
Spiritual Health (EPA)
Transtheoretical Model (TTM) Evidence-Based Programs and
Veterans’ Health Practices
Women’s Health Family Planning
Fluoridation
Food and Drug Administration (FDA)
Professional Organizations and
Genetics
Resources
Global Health
American Journal of Public Health Health and Medicine Division of the
(AJPH) National Academies of Sciences,
American Public Health Association Engineering, and Medicine
(APHA) Health Resources and Services
Association of Public Health Administration (HRSA)
Laboratories (APHL) Healthy P eople 2020
Association of State and Territorial Healthy Places
Health Officials (ASTHO) Heart Truth® (Red Dress) Campaign, The
Certified in Public Health (CPH) Home Safety
G ui d e to R el ated T o p i c s xix
Indian Health Service (IHS) Children’s Health

Logic Model Community Health Centers (CHCs)
Master Settlement Agreement (MSA) Community Organizing
Medicaid Emergency Preparedness and
Medicare Response
National Cancer Institute (NCI) Environmental Health
National Center for Injury Prevention Epidemiology
and Control (NCIPC) Ethics in Public Health and Population
National Heart, Lung, and Blood Health
Institute (NHLBI) Family Planning
National Institutes of Health (NIH) Food Insecurity
Needs Assessment Food Safety
Planned Parenthood Genetics
Social Security Act (SSA) Grants
State, Local, and Territorial Health Health Communication
Departments Health Education
Substance Abuse and M ental Health Health Information Management
Services Administration (SAMHSA) (HIM)
Surgeon General Health Policy
Syringe Service Programs Human Immunodeficiency Virus
Truth Campaign, The (HIV) and Acquired Immune
Upstream Public Health Practices Deficiency Syndrome (AIDS)
U.S. Department of Agriculture Immigrant Health
(USDA) Infectious Diseases
U.S. Department of Health and Injuries
Human Services (DHHS) Maternal Health
U.S. Public Health Service (PHS) Men’s Health
Vaccines Mental Health
Zombie Preparedness Nutrition
Oral Health
Population Health
Specialty Areas of Practice
Public Health Law
Administration, Health Research
Aging Risk-Benefit Analysis
Agricultural Safety Rural Health
Behavioral Health School Health
Biostatistics Social Determinants of Health
Bioterrorism (SDOH)
Care, Access to Vaccines
Introduction
Public health encompasses a broad array of programs, principles, and professional

disciplines. The field is a multidisciplinary science, drawing from medicine, biology,
sociology, management, psychology, political science, communications, marketing,
and engineering. Public health works with traditional medical practice to promote
health and well-being and to prevent disease and injury. Although the two systems
have similar goals, each uses different strategies to achieve the goals. Traditional West-
ern medicine focuses on individuals. Public health focuses on groups of people.
Western medicine is reactionary, responding to individual cases of injury or disease.
Public health is proactive, identifying at-risk groups and working to stop a problem
early, sometimes before the problem starts. Western medicine is treatment oriented.
Public health strives for prevention. Although the traditional medical system treats
individuals suffering from a health problem, public health intervenes to prevent
potential problems. The two systems work together to alleviate human suffering and
to promote quality of life.
The public health workforce is composed of diverse professionals who work
together through many different agencies and organizations. Common functions
are to monitor community health, investigate outbreaks of disease, empower com-
munities, mobilize partnerships, and care for vulnerable populations. Over the past
100 years, public health has realized significant achievements, increasing life span
and quality of life. Activities work at the macro-level with policies, regulations, and
programs and at the micro-level of influencing individual health behaviors. Public
health extends beyond the day-to-day tasks of disease prevention and health pro-
motion. Public health is a frame of mind, a political advocacy, a social movement
of advocating for o thers, especially those who lack the power and resources to secure
their own health. Public health professionals work t oward a common vision for equi-
table health and health care in the United States.
The origins of public health trace back to early h umans who devised ways to dis-
pose of human waste without contaminating drinking w ater. As bacteriology and
immunology emerged as scientific disciplines, so did the multidisciplinary field of
public health. The most commonly recognized definition of public health was
penned by Charles-Edward Amory Winslow, founder of the Yale School of Public
Health. In 1920, Winslow described the newly emerging public health profession as:
The science and art of preventing disease, prolonging life, and promoting health and
efficiency through organized community efforts for the sanitation of the environment,
xxii In troduction
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 organ
izing these benefits as to enable every citizen to realize his birthright of health and
longevity. (Winslow, 1920, p. 183)
Winslow’s definition is timeless. Key points are (1) public health uses systematic
investigations and organized knowledge to understand, predict, and intervene in
adverse health conditions; (2) public health uses creativity and collaboration to
design effective prevention activities; (3) public health encompasses a wide array of
topics including sanitation, hygiene, health education, administration of health ser
vices, and health policies; and (4) public health is founded in the basic principle of
human rights. More recently, the Essential Services Working Group defined the pur-
pose of public health as preventing the spread of disease; promoting safe environ-
ments for living, working, and recreating; preventing intentional and unintentional
injuries; promoting and encouraging healthy behaviors and mental health; respond-
ing to natural and man-made disasters and assisting communities in recovery; and
assuring readily accessible, quality health services. In summary, public health prac-
tice is a cross-disciplinary field, using science, creativity, and collaboration to pro-
mote human health.
Public health professionals firmly believe that physical and mental health is a
basic human right, not a choice, not a reward, not a privilege. Toward this vision,
public health is a social movement with health equity as the main objective. Just as
early man recognized that it was the responsibility of each and e very member of the
society to safeguard the community well or sources of drinking water, modern man
is responsible for the health of o thers in society. In the landmark document, The
Future of Public Health, the Institute of Medicine (1988) defined the mission of pub-
lic health as “the fulfillment of society’s interest in assuring the conditions in which
people can be healthy” (p. 40). The IOM points to the responsibility of government
and society in supporting and promoting health. This concept may seem a little
alien to American culture, which embraces the ideals of independence, individual-
ism, and self-determination. The idea that members of a group have responsibility
of caring for others in society requires individuals to consider the needs of others
before their own. This means that companies cannot dump waste into the ground
where toxic chemicals could potentially poison the w ater of local residents; tobacco
companies cannot market addictive and harmful products to c hildren; and bystand-
ers cannot turn away when they hear domestic violence. Public health requires
everyone, corporate leaders, businesses, politicians, communities, schools, police,
parents, neighbors, and individuals to consider the short-and long-term impact of
their own behaviors on others. Social justice requires society to balance benefits and
burdens. Members of society who experience burdens due to a particular action
deserve benefits, and t hose who enjoy benefits from a particular action should carry
a fair share of the burden.
I ntr o d uc ti o n xxiii
The precautionary principle is used to set the bar on social responsibility. The
precautionary principle states that if an action is believed to cause harm, even when
there is insufficient science to support a biological connection, the burden of proof
is on the actor not on the potential victim. In the case of toxic waste, the business
is responsible for proving that runoff is not hazardous. The company cannot dump
waste until the runoff is deemed safe through rigorous, impartial scientific study. It
is not the citizens’ responsibility to prove that waste products are causing disease.
The duty of providing public health services rests primarily on state, tribal, local,
and territorial health departments. These entities are managed and financed by dif
ferent sources. The issue of financing is important because microorganisms do not
recognize state, county, or city boundaries. Sufficient funding ensures problems are
addressed before they escalate out of control. State health departments are funded
by the federal government, Medicare, Medicaid, state funds, and monies collected
from fines for public health violations. State departments perform epidemiological
surveillance, disease screening, laboratory services, treatment, and technical assis-
tance. If t here is a major outbreak of tuberculosis, the state health department would
investigate, test, and treat. The majority of local public health departments are gov-
erned by local government. For example, the San Francisco Department of Public
Health is governed by the city of San Francisco through the San Francisco Health
Commission. The mayor of San Francisco appoints health commissioners who over-
see public health programs, hospitals, home health care, outpatient treatment, dis-
ease surveillance, vital records, primary care, dental services, and maternal health
services. A few states—Kentucky, Georgia, and Florida—share governance with local
authorities. Local health departments are financed through local, state, and federal
sources. Public health in U.S. territories of Puerto Rico, Guam, Virgin Islands, Ameri-
can Samoa, and the Commonwealth of Northern Mariana Islands and Freely Associ-
ated States of the Republic of Marshall Islands, Federated States of M icronesia, and
Republic of Palau is funded through federal grants and cooperative agreements.
Tribal health departments operate within the jurisdiction of the tribal nations to
serve the health needs of Native Americans.
In general, state, tribal, local, and territorial health departments provide many of
the day-to-day functions of public health, such as managing immunization pro-
grams; communicable disease screening, surveillance, and treatment; food safety and
nutrition education; and inspections of restaurants, schools, and day care centers. Dif
ferent populations may also present unique geographic, cultural, or economic chal-
lenges. For example, the World Health Organization reports that replacing traditional
diets of nutrient-dense foods with imported energy-dense foods is causing obesity
and other major health problems among Pacific Islanders (WHO, 2010). Thus, public
health departments serving Pacific Islanders must focus on the negative effects of
acculturation. Federal agencies are responsible for ensuring that state, tribal, local, and
territorial governments have the capability to provide needed services. The federal
government will only intervene if health threats extend beyond the region, require
solutions outside of state or local jurisdiction, or in which states do not have the
xxiv In troduction
capacity to act. A man-made or natural disaster, such as major flooding, will prompt
action by federal public health agencies.
Beyond assisting in natural or man-made health emergencies, the federal gov-
ernment manages the health of the nation by setting goals, policies, and standards,
managing resources and supporting scientific research t oward health solutions. Fed-
eral agencies responsible for ensuring public health include the Centers for Disease
Control and Prevention (CDC), Agency for Healthcare Research and Quality, Envi-
ronmental Protection Agency, Food and Drug Administration (FDA), Substance
Abuse and M ental Health Services Administration (SAMHSA), National Cancer
Institute (NCI), National Institute on Alcohol Abuse and Alcoholism (NIAAA),
National Institute on Drug Abuse (NIDA), Department of Agriculture (USDA), Office
of Minority Health (OMH), and the U.S. Public Health Service Commissioned Corps
(USPHSCC). Within the CDC is the Office for State, Tribal, Local, and Territorial
Support; Office of Public Health Preparedness and Response; National Institute for
Occupational Safety and Health; Center for Global Health; Office of Public Health
Scientific Services; Center for Surveillance, Epidemiology, and Laboratory Services;
National Center for Health Statistics; Office of Noncommunicable Diseases, Injury,
and Environmental Health; National Center for Birth Defects and Developmental
Disabilities; National Center for Chronic Disease Prevention and Health Promotion;
National Center for Environmental Health; Agency for Toxic Substances and Dis-
ease Registry; National Center for Injury Prevention and Control; Office of Infec-
tious Diseases; National Center for Immunization and Respiratory Diseases; National
Center for Emerging and Zoonotic Infectious Diseases; and the National Center for
HIV, Viral Hepatitis, STD, and TB Prevention. The multiple centers, institutes, and
offices within the CDC enable effective and efficient responses to public health
threats. Each group provides specialized expertise while still accessing valuable
resources from across the network.
Public health services are delivered by individuals of many different backgrounds
and skill sets working in for-profit and nonprofit agencies, communities, and all
levels of government. The public health workforce is one of the most professionally
diverse groups one could envision. Workers include physicians, nurses, nutritionists,
health inspectors, occupational health and safety workers, social workers, dentists
and dental assistants, emergency responders, health educators, journalists, labora-
tory workers, X-ray technicians, animal control, veterinarians, researchers, scien-
tists, statisticians, administrators, and policy experts. Each group offers their own
distinct professional skills and together, practitioners create a larger system of care.
Partnerships with the private sector, civic groups, nongovernmental organizations
(NGOs), faith communities, schools, hospitals, community centers, tribal health,
law enforcement, transit organizations, and employers develop a network, reaching
as many people as possible in as many ways as possible. Each entity contributes in
a unique way. In the case of head injuries, the National Operating Committee on
Standards for Athletic Equipment (NOCSAE) develops and publishes standards for
helmet safety; helmet manufacturers make helmets that meet the standards; parents
I ntr o d uc ti o n xxv
purchase safety helmets; athletic organizations require players to wear helmets con-
sistently and correctly; and coaches develop maneuvers to avoid high-impact plays
(National Center for Injury Prevention and Control, 2015). Creating systems of care,
developing policies, providing direct care and education, and advocating for health
and safety require many different skills and partnerships.
Over the past century, public health in the United States has emerged as a unique
discipline. Major achievements in the control of communicable diseases, oral
hygiene, family planning, motor vehicle safety, workplace safety, heart disease pre-
vention, and smoking cessation have extended h uman life span by approxi-
mately 25 years. These achievements were accomplished by many p eople and
groups working together toward the common goal of disease prevention and health
promotion.
The Encyclopedia of Public Health: Principles, People, and Programs describes selected
public health strategies, achievements, and challenges throughout U.S. history. The
entries featuring principles describe basic and complex concepts, and models and
theories that help to guide effective public health practice. T hese entries provide a
deeper understanding and appreciation of the field, the logic b ehind why public
health professionals do what they do. The entries on programs present a sample of
important, evidence-based interventions, policies, and organizations. There are
many, many health education and health promotion programs. Not every program
works, and some programs can cause more harm than good. The encyclopedia
entries highlight programs that serve as a positive model for other programs. The
context of why and how these programs were developed and implemented provides
an understanding of the history of public health and best practices for the future. The
entries on people detail the lives and achievements of social reformers, biologists,
microbiologists, medical doctors, nurses, dentists, and other health professionals.
The unique contributions of these men and women foster respect for all public health
professionals. The stories of t hese pioneers reveal insightful discoveries, dogged per-
severance, and dignity despite racism, gender biases, and professional or scientific
challenges. Their stories tell us where public health has been and where public health
must go. Their stories encourage emerging professionals to pursue a career in public
health, medicine, epidemiology, biostatistics, or research. The field offers so many
opportunities and needs p eople from diverse backgrounds with different skills. Pub-
lic health belongs to everyone, and everyone belongs in public health.
Sally Kuykendall
Further Reading
American Public Health Association. (n.d.). What is public health? Retrieved from http://www
.apha.org/∼ /media/files/pdf/factsheets/whatisph.ashx.
Essential Services Work Group. (n.d.). Ten essential services: Purpose and practices of public
health. Atlanta: Centers for Disease Control and Prevention. Retrieved from http://www
.cdc.gov/stltpublichealth/hop/pdfs/Ten_Essential_Public_Health_Services_2011-09
_508.pdf.
xxvi In troduction
Healthy people: The Surgeon General’s report on health promotion and disease prevention. (1979).
Rockville, MD: Department of Health, Education, and Welfare, Public Health Service,
Office of the Assistant Secretary for Health and Surgeon General.
Institute of Medicine. (1988). The future of public health. Washington, DC: The National Acad-
emies Press.doi:10.17226/1091. Retrieved from http://www.nap.edu/catalog/1091/the
-future-of-public-health.
National Center for Injury Prevention and Control. (2015). HEADS UP to youth sports. Atlanta:
Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/headsup
/youthsports/index.html.
Office of State, Tribal, Local and Territorial Support, Centers for Disease Control and Pre-
vention. (2013). United States public health 101. Retrieved from http://www.cdc.gov
/stltpublichealth/docs/usph101.pdf.
Winslow, C. E. A. (1920). The untilled field of public health. Modern Medicine, 2, 183–191.
World Health Organization. (2010). Pacific Islanders pay heavy price for abandoning tra-
ditional diet. Bulletin of the World Health Organization, 88(7), 481–560. Retrieved from
http://www.who.int/bulletin/volumes/88/7/10-010710/en.
Chronology
c. 1754 BCE Code of Hammurabi states laws of Mesopotamia including

medical fees
c. 1000 BCE Sushruta Samhita records Indian medical and surgical practices
c. 600 BCE Early bioterrorism: Assyrians poison e nemy wells with rye
ergot fungus
c. 460 BCE Hippocrates proposes that diseases are related to diet, activity,
lifestyle, and environment rather than punishment from the gods
c. 300 BCE Yellow Emperor’s Inner Canon documents Chinese medical practices
583 Roman Catholic Church isolates p
eople with leprosy
c. 860 Al-Risalah al-Dhahabiah (The Golden Treatise) records medicine and
wellness in Persia (Iran)
1346 Plague extends to Europe initiating the Black Death
1403 Venice establishes the first quarantine station
1431 Joan of Arc is declared a witch and burned at the stake
1492 Christopher Columbus sails to the Caribbean Islands
1520 Cortez exploration unintentionally introduces smallpox to the Aztec
1620 Pilgrims establish Plymouth colony
1628 William Harvey describes the circulatory system
1632 King Charles I licenses The Guinea Company to export African
slaves to America
1683 Anton Van Leeuwenhoek visualizes microscopic animals
1754 Indigenous Americans are intentionally infected by blankets from
smallpox victims
1775 American Revolutionary War begins
1776 Declaration of Independence
xxviii C hron ology
1783 American Revolutionary War ends with an estimated 4,435 U.S.

service member deaths; Yellow fever epidemic
1794 Philadelphia establishes the first local board of health
1796 Edward Jenner inoculates James Phipps with cowpox
1798 Marine Hospital Service is founded
1831 Forced removal of Native Americans begins with the
Choctaw Nation
1837 Great Plains smallpox epidemic decimates Native American p
eople
1838 Forced removal of the Cherokee Nation results in the Trail of Tears
1842 Edwin Chadwick publishes The Report on the Sanitary Conditions of
the Labouring Population of Great Britain
1843 Dorothea Dix publishes Memorial to the Legislature of Massachusetts
documenting the living conditions of mentally ill in Massachusetts
1847 American Medical Association is founded; Ignaz Semmelweis
recommends that doctors wash their hands to reduce infections
1848 Women’s rights convention held at Seneca Falls, New York
1849 Elizabeth Blackwell is the first female to earn a medical degree
from a U.S. college
1850 Lemuel Shattuck releases Report of the Sanitary Commission
of Massachusetts; Congress passes the Fugitive Slave Act
mandating all states to cooperate in the capture and return
of suspected slaves
1854 John Snow traces London cholera outbreak to the Broad Street
pump; Florence Nightingale establishes the first school of
nursing at Saint Thomas’s Hospital
1869 Massachusetts establishes the first state board of health
1861 American Civil War begins
1863 President Lincoln signs the Emancipation Proclamation
1865 American Civil War ends with an estimated 498,332 deaths
1871 John Maynard Woodworth is appointed the first supervising
surgeon (surgeon general) of the Marine Hospital Service
1876 Alexander Graham Bell invents the telephone; Robert Koch
discovers Bacillus anthracis
C h r o no l o g y xxix
1877 Louis Pasteur proves germ theory

1878 National Quarantine Act
1884 Robert Koch and Friedrich Loeffler propose Koch’s postulates,
scientific criteria used to determine causal organism of an
infectious disease
1885 Karl Benz builds the first gasoline-powered automobile
1886 Labor protests at Haymarket Square escalate to violence and
death
1889 Andrew Carnegie publishes The Gospel of Wealth encouraging
philanthropy; Jane Addams establishes Hull House
1891 Florence Kelley investigates working conditions in the garment
industry
1896 London pedestrian Bridget Driscoll is struck and killed by a
gasoline-powered automobile, becoming the first recorded motor
vehicle fatality; Wilhelm Conrad Roentgen discovers X-ray
1898 Spanish American War begins
1901 Oldsmobile introduces the speedometer
1902 Spanish American War ends with an estimated 2,446 U.S. service
member deaths
1904 National Child Labor Committee organized
1906 Upton Sinclair describes the meatpacking industry in The Jungle;
Meat Inspection Act and the Pure Food and Drugs Act are
passed
1907 George Soper traces Oyster Bay typhoid outbreak to cook
Mary Mallon
1908 Ford Motor Company produces the Model T; Clifford Beers writes
A Mind That Found Itself describing his experiences as a mentally
ill patient
1909 National Association for the Advancement of Colored P
eople forms
1910 Flexner Report; Alice Hamilton investigates occupation-related
diseases
1912 Titanic sinks
1913 American Society for the Control of Cancer (American Cancer
Society) is founded
xxx C hron ology
1914 World War I begins; Margaret Sanger publishes the birth control
pamphlet Family Limitation
1917 United States joins allied troops in World War I
1918 Flu pandemic
1919 World War I ends with 116,516 U.S. service member deaths
1923 George Papanicolau creates the Pap smear to detect cervical cancer
1924 Martha May Elliot directs the National Children’s Bureau Division
of Maternal and Child Health
1928 Alexander Fleming discovers penicillin
1929 Great Depression starts with the stock market crash of
October 29, Black Tuesday
1930 Veterans Health Administration (VHA) established
1931 FDR elected president
1932 Tuskegee Syphilis Study started
1933 Widespread amoebic dysentery cases traced to Chicago World’s
Fair hotel
1934 Midian Othello Bousfield advocates for health needs of African
American people
1935 Social Security Act signed into law
1937 The National Safety Council creates a national plan for farm safety
1939 World War II begins
1941 Charles Drew creates blood storage and transfusion techniques;
Japan attacks Pearl Harbor
1942 Explosion at the Benxihu Colliery in China kills 1,549 coal mine
workers
1945 World War II ends with 405,399 U.S. service member deaths;
Grand Rapids, Michigan, becomes the first community with
fluoridated water
1946 Centers for Disease Control and Prevention founded; National
Mental Health Act
1948 World Health Organization is founded; Donora smog incident
occurs; Framingham Heart Study begins
C h r o no l o g y xxxi
1949 Florence Sabin reorganizes Colorado State Board of Health

1950 Korean War begins
1951 Malaria eradicated in the U.S.
1952 International Planned Parenthood founded
1953 Korean War ends with 54,246 U.S. service member deaths;
James Watson and Francis Crick discover the chemical
structure of DNA
1954 Richard Doll and Austin Bradford Hill publish landmark study
linking smoking to lung cancer among doctors
1955 Vietnam War begins; Jonas Salk creates the polio vaccine;
Cutter Incident
1956 Mercury poisoning from industrial wastewater is identified in
Minamata, Japan; Min Chiu Li discovers chemotherapy for
cancer
1958 Working for Volvo, Nils Bohlin invents the three-point seat belt
1961 Food and Drug Administration approves oral contraceptives
1962 Rachel Carson publishes Silent Spring
1964 Civil Rights Act; Surgeon General’s report on Smoking and Health
1965 Medicare and Medicaid established; Ralph Nader publishes Unsafe
at Any Speed: The Designed-in Dangers of the American Automobile
1966 Narcotic Addict Rehabilitation Act
1968 First heart transplant surgery
1969 Time Magazine reports Cuyahoga River fires
1970 Occupational Safety and Health Act
1971 Ban on tobacco advertisements on television and radio
1972 Tuskegee Syphilis Study terminated
1974 The Belmont Report
1975 The Indian Self-Determination and Education Act; Vietnam War
ends with 90,220 U.S. service member deaths
1976 Nurses’ Health Study commences
1977 Smallpox eradicated
xxxii C hron ology
1979 First edition of Healthy People published

1981 AIDS epidemic begins in the United States
1983 Amsterdam establishes the first community organized needle
exchange program
1984 First seat belt law passed in New York; gas leak in Bhopal, India,
kills at least 3,787 people and injures an estimated 558,125
1985 Salmonella in milk from Hillfarm Dairy, Illinois, infects 16,284
people resulting in at least two deaths
1986 Chernobyl nuclear disaster; Emergency Medical Treatment and
Labor Act (EMTALA) established
1988 The Institute of Medicine releases The Future of Public Health
1990 Desert Storm War begins; Americans with Disabilities Act signed
into law; Researchers from the National Institutes of Health use
gene therapy to treat Ashanti DeSilva
1991 Desert Storm War ends with 1,948 U.S. service member deaths
1993 E. coli in undercooked hamburgers from Jack in the Box infects
over 700 people resulting in four deaths
1996 Lead eliminated from U.S. gasoline; Dolly, the first cloned
mammal, is born; Port Arthur massacre prompts Australia to
outlaw automatic and semiautomatic rifles
1997 WHO declares obesity a global epidemic
1998 Five tobacco companies settle a lawsuit brought by 46 states, five
U.S. territories, and the District of Columbia seeking
reimbursement for health care costs resulting from smoking
2001 September 11 terrorist attacks; Anthrax attacks on U.S. Senators
and news agencies; Global War on Terror begins
2003 Worldwide severe acute respiratory syndrome (SARS) outbreak;
Human Genome project completed
2005 London transit bombings; Hurricane Katrina
2007 Virginia Tech shooting
2010 Affordable Care Act passed
2011 Tōhoku earthquake and tsunami; Fukushima Daiichi nuclear
disaster
C h r o no l o g y xxxiii
2012 Ebola epidemic in West Africa

2013 Boston Marathon bombing
2015 Emmanuel African Methodist Church shooting
2016 Pulse nightclub shooting
A
ACUTE ILLNESSES
Acute illnesses are a category of health problems in which symptoms come on sud-
denly, within hours or days, and the person recovers fairly quickly, usually within
days to weeks. Examples include the common cold, ear infections, food poison-
ing, diarrhea, sprains, strains, animal bites, and other traumatic injuries. Most
people suffer from one or more acute illnesses at some point in life. Unintentional
injuries alone account for 40 million emergency room visits per year in the United
States (National Center for Health Statistics, 2016). Communities that lack proper
sanitation, resources, or suffer from major stressors are at higher risk for commu-
nicable disease and injury. Acute illnesses present special challenges to public
health systems. Generally, public health uses population- based approaches
to restore, promote, and maintain health. Disease prevention programs, such as
healthy eating to prevent diabetes or cardiovascular disease, may be offered to cli-
ents at any time of year. Programs can be planned in advance, and educating in
groups is cost effective. Conversely, acute illnesses require immediate or urgent,
individualized health services. The person experiences symptoms, seeks medical
care at a clinic, doctor’s office or hospital, and timely treatment is necessary to
prevent complications. This individualized care, while necessary, is resource

intensive and expensive. Whereas public health strives for integrated, holistic
care, acute illnesses demand unplanned, urgent treatment creating fragmented,
reactionary care.
The relationship between acute and chronic illness is complex. Although many
acute health problems resolve without treatment, some cases develop into more
severe or chronic health problems. For example, the common childhood disease of
strep throat can progress into rheumatic fever, a serious illness that causes stroke,
permanent heart damage, or death. Alternatively, chronic illnesses can lead to acute
problems. For someone with osteoporosis, a minor fall or traumatic blow can break
bones. Early identification and treatment of acute health problems are important to
prevent exacerbation to more serious problems. Health professionals must be able
to accurately diagnose and treat a wide variety of nondescript illnesses. This can
be a challenge. For example, the patient who presents with severe itching could
have poison ivy, sunburn, allergic reactions, diabetes, or multiple sclerosis. Practi
tioners must be able to differentiate symptoms in order to identify the underlying
cause and decide on the correct treatment. Although acute illnesses can be a chal-
lenge to public health, they do provide an entry point for holistic care. The per-
son with undetected osteoporosis may first present with a fracture. A fter initial
2 A C UTE ILLNESSES
treatment, the health care provider can refer the patient to a registered dietician
for nutrition education or physical therapist for balance and strength training.
Acute illnesses provide an opportunity to screen and connect patients to health
promotion activities.
Acute health problems are classified as communicable diseases, noncommuni-
cable diseases, and injuries. Local, state, territorial, and federal public health sys-
tems are responsible for monitoring and investigating communicable disease
outbreaks. Local and territorial health departments surveil for reportable diseases,
investigate cases, develop and implement plans to control spread, provide expert
advice, and disseminate health education materials. The National Notifiable Dis-
ease Surveillance System (NNDSS) is a national system listing 77 notifiable health
conditions. The database enables individuals and groups to share and analyze out-
breaks and trends. The CDC is responsible for providing timely and accurate infor-
mation to physicians, nurses, public health professionals, epidemiologists, and other
scientists by publishing the NNDSS data in Morbidity and Mortality Weekly Reports
(MMWR). The NNDSS lists health problems by name, not by acute versus chronic
categories. This means that we do not have clear data on the cost of acute illnesses
to society.
Although the healthy person recovers rapidly from an acute illness and suffers
few, if any, consequences, acute health problems create challenges to society. Acute
illnesses come on suddenly and unexpectedly, requiring personalized care that is
expensive and fragmented. Careful monitoring and timely treatment are critical to
controlling outbreaks. Public health professionals have developed systems to remain
alert for cases and act quickly when cases are detected. Although acute illnesses
challenge health systems, they also provide opportunities for ongoing health pro-
motion. The next steps are to increase systems of care within impoverished areas,
mea sure the overall financial burden of acute illnesses on society, develop
cost-effective systems, and improve integration of acute, chronic, and preventive
health care.
Sally Kuykendall
See also: Chronic Illness; Disability; Disease; Epidemic; Handwashing; Health; Infec-
tious Diseases; Influenza; Injuries; Medicine; Nutrition; Prevention
Further Reading
Centers for Disease Control and Prevention. (2015). National Notifiable Diseases Surveillance
System (NNDSS). Retrieved from https://wwwn.cdc.gov/nndss/history.aspx.
Hirshon, J. M., Risko, N., Calvello, E. B., Stewart de Ramirez, S., Narayan, M., Theodosis, C.,
& O’Neill, J. (2013). Health systems and services: The role of acute care. Bulletin of the
World Health Organization, 91(5), 386–388. doi:10.2471/BLT.12.112664
National Center for Health Statistics. (2016). National Hospital Ambulatory Medical Care Sur-
vey: 2011 Emergency department summary tables. Retrieved from http://www.cdc.gov
/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_t ables.pdf.
ADDIC TIONS 3
ADDICTIONS
Addiction is a chronic brain disease characterized by an overwhelming desire for
a specific substance or activity, such as tobacco, alcohol, drugs, or gambling. The
desire escalates to such a point that other basic needs, such as eating, sleeping, and
relationships, are ignored. Eventually, the individual may lose the ability to func-
tion at school, work, or home. The wide array of addictive substances, objects, and
activities mean that many different individuals and their loved ones are affected.
Addictions create unique challenges to public health. According to the National
Institute on Drug Abuse’s (NIDA) nationwide trends research (2015), 55.8 million
Americans aged 12 and older w ere current cigarette smokers, which constituted a
total of 21.3 percent of the U.S. population in 2013. More than 24 million Ameri-
cans aged 12 or older—9.4 percent of the population—have used an illicit drug in
the past month. After alcohol, marijuana has the highest dependency rate of all other
illicit substances. More than 4 million Americans met the clinical criteria for e ither
substance dependence or abuse of marijuana in the past year, while 1.9 million
Americans met the criteria for dependency or addiction to pain relievers. Substance
abuse accounts for many cases of intentional and unintentional injuries, lung and
cardiovascular diseases, stroke, cancers, and m ental health disorders.
The last c entury witnessed a major shift in the way addictions are viewed and
treated. One hundred years ago addictions were believed to be a moral flaw
related to weak willpower. Today, we understand addiction as a treatable disease of
the brain with psychological and social implications. Addiction research started in
the 1930s; however, it was not until 1963 that the American Public Health Associa-
tion published an official statement that identified alcoholism as treatable (White,
1998). Three years later, in 1966, the National Center for the Prevention and Con-
trol of Alcoholism was created as a subsection of the National Institute on M ental
Health. In the same year, the Narcotic Addict Rehabilitation Act was passed. This
marked a major turning point in the history of addiction treatment in the United
States. For the first time, the federal government provided support to develop
addiction treatment services in communities (White, 1998). One year later, in 1967,
the American Medical Association recognized alcoholism as a disease (White,
1998). The National Association of Alcoholism and Drug Abuse Counselors and
the National Institute on Drug Abuse (NIDA) were founded two years later, in
1972. Despite progress and efforts by public health and medical research, in 1987,
President Reagan announced the nation’s War on Drugs, replacing addictions
treatment with punishment and incarceration (White, 1998). That same year, the
American Medical Association expanded the definition of addictions by recognizing
all drug dependencies as diseases and helping to legitimize addiction treatment
within the medical field. In 1991, the American Society of Addiction Medicine
(ASAM) published Patient Placement Criteria for the Treatment of Psychoactive Sub-
stance Use Disorders. These guidelines set a precedent, tailoring treatment from a
single set of treatment criteria for all individuals to individualized care models
(White, 1998). Despite political setbacks and continued stigma against t hose with
4 ADDICTIONS
addictions, public health and medical organizations have made enormous strides
in the understanding and treatment of addictions.
How Addictions Begin
Public health uses the biopsychosocial model as a framework to understand dis-

eases. According to this model, biological, psychological, and social f actors all play
a role in human health and wellness. Biological factors that increase likelihood
of substance dependency are genetics, using addictive substances during critical
periods of brain development, existing medical conditions, and m ental health
disorders. Addictions start as a biological process within the brain. In a healthy
brain, nerves send, receive, and process information. Addictive drugs contain
chemicals that disrupt brain function and structure. Disruption can happen in two
ways. The first is by mimicking the brain’s natural chemical messages. The struc-
ture of some drugs, for example, marijuana and heroin, are highly similar to neu-
rotransmitters. In fact, the drugs are so similar that the brain is tricked into sending
abnormal messages when these substances enter the body. The second way that
drugs can disrupt brain function is by overstimulating the reward circuit. Some drugs
(e.g., methamphetamine and cocaine) cause neurotransmitters to release unnatu-
rally large amounts of dopamine. Dopamine controls motivation, emotion, move-
ment, and pleasure. Overproduction of dopamine produces feelings of euphoria,
creating a motivation for ongoing usage. Although the brain is initially rewarded
for using the drug, as substance use continues, the brain becomes used to the over-
supply of dopamine and compensates by decreasing its own production. The drug
has less of an impact—and to experience the same high the person must use more
of the substance—a condition known as tolerance. The brain adapts to using the
substance, and when the person tries to stop, he or she experiences painful physi-
cal and emotional withdrawal.
The teenage brain, which is going through rapid growth and development, is
particularly susceptible to physical and psychological dependence. Psychological
causes and consequences of substance addiction are intrinsically related to the brain
patterns described above. From a psychological perspective, drug addiction is con-
ceptualized as a chronic disease that results in compulsive and obsessive drug seek-
ing and use. The initial decision to take drugs is often voluntary; however, once an
individual becomes addicted to drugs, the physical brain changes over time. These
changes affect self-control and the ability to resist urges to take the drug. Just as
there are biological and psychological f actors that can predispose an individual to
substance addiction, there are both social and environmental factors that do the
same. For example, living in an environment where adults (e.g., parents) use illicit
substances during childhood is linked to a heightened likelihood of developing sub-
stance dependence in adolescence (Swadi, 1999). Other direct social and environ-
mental factors are poor parental monitoring, poor parental attachment, and affiliation
with drug-taking peer groups (Swadi, 1999). Substance use and eventually abuse
ADDIC TIONS 5
are used as a way to self-medicate for those living in harsh or disadvantaged

communities. Dealing with substance addiction creates a plethora of negative social
consequences, which include loneliness, familial and social rejection, poor
academic achievement, unemployment, and homelessness. These devastating con-
sequences lead, in turn, to further usage, which ultimately creates a vicious cycle.
Preventing Addictions
Public health breaks the cycle of addiction through effective, evidence-based pro-
grams. The Institute of Medicine categorizes prevention programs as universal,
selected, or indicated. Universal prevention, previously referred to as primary pre-
vention, prevents substance abuse before the behavior starts. Although people of
all ages can be susceptible to developing a substance dependency—even babies still
in utero—adolescents are most susceptible. According to NIDA’s nationwide trends
research (2015), 22.6 percent of 18-to 20-year-olds reported using an illicit drug
in the past month. For this reason, adolescence, generally occurring between ages
12 and 18 years of age, is considered the most critical time for universal prevention
of substance abuse. The Truth Campaign by the American Legacy Foundation is
an example of an effective cigarette smoking prevention program. By deconstruct-
ing the messages embedded in cigarette advertising, the Truth Campaign has effec-
tively reduced smoking among middle school students by 19 percent and among
high school students by 8 percent (Zucker, Hopkins, Sly, Urich, Kershaw, & Solari,
2000).
Selected prevention programs work by reducing risk f actors and enhancing pro-
tective factors. T
hese programs focus on at-risk populations and are often geared
toward a particular setting and audience (NIDA, 2014). The Model Adolescent Sui-
cide Prevention Program (MASPP) was developed to reduce trauma, violence, sub-
stance abuse, and suicides among a specific tribal nation of Native Americans in
New Mexico. Over the intervention period of 15 years, the program reduced self-
destructive behaviors by 73 percent (May, Serna, Hurt, & DeBruyn, 2005). Indi-
cated programs target people who are already using drugs with the goal of stopping
drug use, maintaining abstinence, and controlling long-term effects of the chronic
drug use. Indicated prevention programs, such as family therapy, are part of a com-
prehensive drug treatment program.
Treatment
The treatment of addictions is tailored to the type of drug being abused (stimulant,
depressant, hallucinogen, or opioid), length of abuse, and individual biopsycho
social circumstances. People who abuse drugs experience critical moments when
they recognize the need for help and actively seek treatment. Therefore, it is impor
tant that treatment centers are conveniently located within all communities and
continuously accessible. These critical moments may not necessarily be voluntary.
6 ADDI C TIONS
Interventions by family members or court mandates can be just as effective as vol-

untary treatment. The first stage of substance abuse treatment for mind-altering
substances is medical detoxification. During this stage, health professionals w ill sup-
port the patient through drug withdrawal, correct any malnutrition or electrolyte
imbalances, and screen for additional health issues related to substance abuse, such
as hepatitis B, HIV/AIDS, tuberculosis, or other infectious diseases. The length of
time for detoxification varies. With some drugs, detoxification takes months, and
adjunct therapies such as methadone may be used to alleviate cravings. Compre-
hensive drug treatment must also include the psychological and social aspects of
drug use. Long-term counseling, behavioral therapy, and monitoring help the per-
son to maintain abstinence, deal with stressors, problem solve effectively, avoid situ-
ations that might lead to relapse, establish healthy interpersonal relationships, and
treat comorbid mental health problems. Because the person is learning new ways
to interact in the world, the most effective treatments are long term, continuing for
more than three months and including loved ones. After initial withdrawal, the chal-
lenge is to keep the person engaged in recovery and to prevent relapses. Random
drug screens also help prevent relapse b ecause a positive screen indicates the need
to change or reassess therapy (NIDA, 2012).
Addictions are a chronic health problem affecting millions of Americans. For-
tunately, the disease is treatable. Due to the large variety of ways substance addic
tion disrupts individuals’ lives, effective treatment must incorporate many
components. Effective treatment assists individuals to stop taking drugs, maintain
sobriety, and regain productive functioning. When it comes to substance addic-
tion prevention, shaping youth’s perception about drugs is vital. Prevention pro-
grams should address all types of drug use, should be geared toward the specific
type of drug use prevalent in the local community, and finally should be specific to
the contextual characteristics (e.g., age, ethnicity, gender) of the population being
addressed.
Ariel A. Friedman and Nadav Antebi-Gruszka
See also: Alcohol; Cancer; Collaborations; Epidemic; Hepatitis; Human Trafficking;

Mental Health; National Institutes of Health; National Institute on Drug Abuse; Pre-
scription Drugs; Prevention; Substance Abuse and Mental Health Services Admin-
istration; Syringe Service Programs; Truth Campaign, The; Wynder, Ernst Ludwig;
Controversies in Public Health: Controversy 2
Further Reading
Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008).
A meta-analytic review of psychosocial interventions for substance use disorders. The
American Journal of Psychiatry, 165(2), 179–187.
Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective f actors for alcohol
and other drug problems in adolescence and early adulthood: Implications for sub-
stance abuse prevention. Psychological Bulletin, 112(1), 64.
AD M INIST R ATION, HEALTH 7
Kuss, D. J., & Griffiths, M. D. (2012). Internet gaming addiction: A systematic review of
empirical research. International Journal of M ental Health and Addiction, 10(2), 278–296.
Macleod, J., Oakes, R., Copello, A., Crome, I., Egger, M., Hickman, M., & Smith, G. D.
(2004). Psychological and social sequelae of cannabis and other illicit drug use by young
people: A systematic review of longitudinal, general population studies. The Lancet,
363(9421), 1579–1588.
Mathers, B. M., Degenhardt, L., Phillips, B., Wiessing, L., Hickman, M., Strathdee, S. A., &
Mattick, R. P. (2008). Global epidemiology of injecting drug use and HIV among people
who inject drugs: A systematic review. The Lancet, 372(9651), 1733–1745.
May, P. A., Serna, P., Hurt, L., & DeBruyn, L. M. (2005). Outcome evaluation of a public
health approach to suicide prevention in an American Indian tribal nation. American
Journal of Public Health, 95(7), 1238–1244. doi:10.2105/AJPH.2004.040410
McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a
chronic medical illness: Implications for treatment, insurance, and outcomes evalua-
tion. Journal of the American Medical Association, 284(13), 1689–1695.
National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-
based guide (3rd ed.). Retrieved May 27, 2016, from https://www.drugabuse.gov
/publications/principles-drug-addiction-treatment-research-based-guide-third-edition
/principles-effective-treatment.
National Institute on Drug Abuse. (2014). DrugFacts: Lessons from prevention research.
Retrieved January 11, 2016, from http://www.drugabuse.gov/publications/drugfacts
/lessons-prevention-research.
National Institute on Drug Abuse. (2015). DrugFacts: Nationwide trends. Retrieved January 5,
2016, from http://www.drugabuse.gov/publications/drugfacts/nationwide-trends.
Swadi, H. (1999). Individual risk factors for adolescent substance use. Drug and Alcohol
Dependence, 55(3), 209–224.
White, W. L. (1998). Slaying the dragon: The history of addiction treatment and recovery in Amer
ica. Bloomington, IL: Chestnut Health Systems/Lighthouse Institute.
Zucker, D., Hopkins, R. S., Sly, D. F., Urich, J., Kershaw, J. M., & Solari, S. (2000). Florida’s
“truth” campaign: A counter-marketing, anti-tobacco media campaign. Journal of Pub-
lic Health Management and Practice, 6(3), 1–6.
ADMINISTRATION, HEALTH
Health administration is a discipline that teaches individuals how to apply health
care technical skills in health care systems operation and management, health sys-
tem planning, human resources management, health law and regulations, health
information technology, health care resource allocation and policy making, busi-
ness and financial management, health care ethics, and public relations. Health
administration may be applied to any specific types of health care services involv-
ing clinical and nonclinical operation. In other words, health administration involves
integration and coordination of the various functions of clinical and nonclinical
delivery of health services, a management decision-making process with policies
and procedures that align toward achieving the health organizational goals and
objectives. Health administration is a discipline that deals with legal and profes-
sional management of health care operations, health policy formulation and analysis,
8 AD M INIST R ATION, HEALTH
leadership coordination, operational processes, and implementation of policies

toward the delivery of health care or health services across health systems. In health
administration, health organizational goals and objectives must align with (federal,
state, and local) health legislation, regulation, and constitutional provisions of the
respective region. Health administration is a discipline that studies the execution
of health care leadership shared decision and implementation processes of health
institution organizational policies t oward achieving organizational goals in the deliv-
ery of health services within the public and private sectors.
Basic Courses for Discipline and Degree
A health administration degree prepares prospective health care administrators to

be equipped with knowledge in achieving and fulfilling the demands and respon-
sibilities of health services delivery. The evolving nature of health care service deliv-
ery, the size and function of a health facility, and the evolving regulatory processes
make health care administration discipline draw more knowledge from the field of
business administration and management sciences (including economics, law, finan-
cial management, and organizational culture). Health administration programs are
structured toward developing business competencies and planning skills, under-
standing core organizational management theory, and understanding the essentials
of leadership ethics and communication, research analysis, and evaluation. Depending
on the types of health care administration degrees, core coursework usually
includes health care delivery systems, health regulation and policy, health econom-
ics, health care marketing, health care financing, health resources management, lead-
ership theory and practice, population health and epidemiology, medical terminology,
health information technology system, risk management and quality improvement,
managed health care and reimbursement, health program evaluation, and global
health care. At the undergraduate level, health administration core courses prepare
students for leadership skills, management concepts in administration, general con-
cepts on health administration, and health services delivery. Foundational courses
on health administration are blended with basic principles of business operation
and planning, accounting and financing, marketing, human resources administra-
tion, economics, law and policy, organizational leadership and culture, and basic
statistical analysis.
At the graduate level, health administration courses equip students with advanced
management skills and career opportunities for senior-level administrative and
health leadership positions. Graduate health administration programs are structured to
equip health administrators with advanced skills and competencies in health care
financial management, resources management, health evaluation, health policy and
regulation, strategic management and planning, risk analysis and quality improve-
ment, health analytic research, economics of health care, epidemiology, and popu-
lation health management. Health administration programs may be tailored for
different concentrations that will enable health care practitioners to improve their
AD M INIST R ATION, HEALTH 9
management skills in their specialties. At the graduate level, such concentrations

may include general health administration, nursing administration, long-term care
administration, behavioral health administration, hospital administration, geron-
tology, health education, health and wellness, health and h uman services, health
informatics, population health, and health policy administration. At the doctoral
degree level, health administration programs focus on leadership, scholarship, and
practice development. The doctoral level of health administration study involves
solving complex administrative and research problems in the delivery of health ser
vices. T hese programs prepare students to be new knowledge contributors, com-
plex health problem solvers, health policy analysts, developers of health policy
decisions of the future, and health care leaders within clinical and nonclinical fields
of health.
The study of health administration prepares students to become health admin-
istrators, health executives, or health leaders within nonclinical and clinical branches
of health care with the intention of managing health care operations and services,
managing staff, strategically planning, coordinating care, managing finance, mak-
ing policy decisions, and representing their organizations. Health administrators’
responsibilities may include organizing and managing health operations and busi-
nesses, preparing budgets and authorizing expenditures, strategically planning and
implementing policies and procedures, ratifying contracts or authorizations for pur-
chases, formulating and analyzing health policies, and engaging in health opera-
tions and research. Health administrators may work in all areas of health and health
service delivery within public and private health care organizations. They may work
in a government-owned health system, and health department, or agency. They
could also work for corporate for-profit and nonprofit health organizations (such
as hospitals, nursing homes, home health agencies, community health centers, and
human services), health insurance and managed care organizations, the pharma
ceutical industry, medical device and equipment companies, health consulting firms,
health-related national associations (American Hospital Association, America Health
Information Management Association, American College of Healthcare Executives),
and health research institutes.
Generalists and Specialists
Health administrators work as e ither generalists or specialists. They use their man-
agement and leadership skills to achieve customer-focused patient care and services
within a health system. The size and type of the health organization determines the
function and responsibilities of health administrators. For example, a large facility
may have a hierarchy of leadership from chief executive officer, senior director, direc-
tor, and manager, to unit head or coordinator. On the other hand, a health admin-
istrator of a smaller facility may be directly involved in operational decision making,
staffing, hiring and retention, financial management and disbursement, procure-
ment management, and vendor contracting.
10 AD M INIST R ATION, HEALTH
A generalist health administrator is a business-oriented manager with technical

skills and vast knowledge in leading and operating an entire health facility. Gener-
alist health administrators are expected to be experts with high efficiency in organ
izing quality patient medical care with the available resources, implementing the
organizational mission philosophy and strategic goals set forth by the hospital board,
directing and managing the day-to-day hospital business operation and administra-
tion, collaborating with interdisciplinary and multidisciplinary medical and non-
medical staff and leaders, building trust among all stakeholders, and ensuring
compliance to all health policies and regulations. Health administrators involved
in hospital management and administration are generalists whose responsibilities
may include managing multiple departments, building trust through open com-
munications, resolving conflicts, developing and implementing strategic goals, driv-
ing innovation and organization culture, representing the health organization, and
integrating various clinical and nonclinical departmental functions in the delivery
of hospital services.
Specialist health administrators are health care management experts who lead
and operate specific departments, clinical units, or health care programs within a
health system (health organization). Specialized health administrators may have
career paths within their field. For example, they may be nurses, pharmacists, radi-
ologists, health record administrators, or clinicians. Specialist health administra-
tors could also be specialists, managers, or directors who have a specific knowledge
about something or responsibilities to daily operations of health-specific strategic
goals and objectives.
Specialist health administrators may have responsibilities in day-to-day opera-
tions, program planning and management, policy implementation, program evalua-
tion, budgeting, staffing and retention, l egal claims, public relations, risk management,
and quality improvement. A specialist health administrator may become a director
of various things, such as a nursing staff, ancillary administration, an outpatient
facility, operations, hospital marketing, medical billing and reimbursement, human
resources, residential care, behavioral health, health finance, health research out-
come, an accounting department, or medical records.
Each of these specialties, units, or departments in health has strategic goals and
objectives t oward health care service delivery, which a specialist health administra-
tor may be given the mandate to achieve. A health administrator with the designa-
tion of clinical manager or director has the responsibilities to coordinate and manage
rehabilitation care, nursing care, surgical care, and other patient care activities in
their unit. Health administrators with state licenses to practice as nursing home
administrators operate the day-to-day activities across all units and departments
that work toward proper delivery of patient care to their residents. Nursing home
administrators implement cost containment measures, assist in h uman resources
retention, manage compliance to l abor and employment law, monitor and disburse
funds for procurement and medical supplies, and ensure compliance of quality
improvement to resident care and safety. Health administrators with designations
AD V E R SE C HILDHOOD E X PE R IEN C ES ( A C Es) 11
as medical records managers or health information managers secure patient health

records in compliance with the Health Insurance Portability and Accountability Act
of 1996 (HIPAA) regulation, assist in the collection of patient health records, pro
cess medical records related to patient treatment and diagnosis, and organize patient
health information about patient conditions. Medical practice administrators, man
agers, or directors with health administration qualifications coordinate and man-
age activities in a medical group practice, including patient scheduling, electronic
health record use and data capture, and maintenance of patient medical records.
They oversee medical billing and medical coding, supply inventory, accounting and
payroll, and medical staffing and evaluation. And they ensure regulatory compli-
ance on policy.
Godyson Orji
See also: American Public Health Association; Certified in Public Health; Code of
Ethics; Council on Education for Public Health; Degrees in Public Health; Health
Education; Nation’s Health, The; Public Health in the United States, History of; Sub-
stance Abuse and Mental Health Services Administration; Veterans’ Health
Further Reading
National Center for Education Statistics (NCES). (2010). Classification of Instructional Pro-
grams Code 51.0701: Health/Health Care Administration/Management. Retrieved from
http://nces.ed.gov/IPEDS/CIPCODE/cipdetail.aspx?y=55&cipid=88761.
National Center for Education Statistics (NCES). (2010). Classification of Instructional Pro-
grams Code 51.2211: Health Services Administration. Retrieved from https://nces.ed.gov
/ipeds/cipcode/cipdetail.aspx?y=5
5&cipid=8
7654.
ADVERSE CHILDHOOD EXPERIENCES (ACEs)

Adverse childhood experiences (ACEs) are traumatic experiences, such as abuse,
neglect, or household dysfunction, which occur during the first 18 years of life.
From 1995 to 1997, researchers at Kaiser Permanente health systems and the Cen-
ters for Disease Control and Prevention (CDC) surveyed 17,000 members of a health
maintenance organization to investigate childhood experiences and health status
(Felitti et al., 1998). The ACE study found significant relationships between d
istressing
experiences and heart disease, cancer, diabetes, and many other health problems.
Furthermore, results suggested dose-response relationships where respondents
with a higher number of ACEs w ere more likely to report health problems. Subse-
quent studies expanded to other diseases and other populations. Public health
experts believe that ACEs may be one of the most important determinants of health.
Early traumatic experiences are believed to impact brain and social develop-
ment, prompting unhealthy behaviors that result in antisocial behavior and dis-
ease. There is a need to increase public awareness of ACEs and to support
and implement evidence-based prevention and intervention programs. Through
12 AD VER SE C HILDHOOD EXPERIENCES (ACEs)
trauma-informed care, public health and medical professionals explore past trau-
mas that may have led to unhealthy behaviors. Validating adverse childhood experi-
ences frees the individual from guilt and shame and helps him or her to understand
motivations underlying unhealthy, potentially self-medicating behaviors. Treat-
ing and reducing ACEs can significantly reduce premature morbidity and mortality,
demands on health care systems, and the economic impact of disease, improving
the quality of life for millions of people.
The original ACE study compared three components: adverse childhood experi-
ences, negative health behaviors, and diseases. The adverse childhood experiences
chosen for the initial ACE survey included emotional abuse, physical abuse, sexual
abuse, violence against the mother, parental separation or divorce, emotional or
physical neglect, or living in a h ousehold with adults who w ere substance abusers,
mentally ill, suicidal, or incarcerated. The negative health behaviors studied were
smoking, obesity, physical inactivity, depressed mood, suicide attempts, alcohol-
ism, drug abuse, and high-risk sexuality (defined as 50 or more sexual partners).
Diseases selected for the survey were ischemic heart disease, cancer, stroke, chronic
bronchitis, emphysema, diabetes, hepatitis, and bone fractures. One final outcome
was response to the question, “Do you consider your physical health to be excel-
lent, very good, good, fair, or poor?” The study found that almost two-thirds of
participants had at least one ACE and 20 percent had at least three ACEs (CDC,
2016).
Since the original study, other research confirmed positive correlations between
ACEs and adolescent pregnancy, poor academic achievement, alcoholism, anxiety,
asthma, depression, diabetes, illicit drug use, intimate partner violence, obesity, sexually
transmitted diseases, smoking, suicide attempts, poor work performance, quality of
life, and interaction with the juvenile justice system (CDC, 2016; Huang et al.,
2015; Iniguez & Stankowski, 2016). Despite the many studies of ACEs as a disease
determinant, many questions remain. The ACE studies are retrospective, which
means researchers ask patients to recall past experiences. Researchers cannot say that
ACEs cause disease—only that ACEs and health problems exist together. Theoreti-
cally, a third unidentified factor may be present, which creates both ACEs and dis-
ease. Alternatively, p
eople with disease have had time and reason to reflect on their
life, which means they are more likely to recall ACEs in comparison to people
without disease.
Studies have also revealed conflicting results. One study found an inverse rela-
tionship between ACEs and hypertension, hypercholesterolemia, myocardial infarc-
tion, and cancer (Iniguez & Stankowski, 2016). Another study of more than
39,000 participants found gender differences in number of ACEs and risk behav
iors for HIV (Fang et al., 2016). Results showed a dose-response relationship between
ACEs and IV drug use, sexually transmitted infections, and anal sex among
males. Risk behaviors did not increase for females u ntil they accumulated three
ACEs. Schreier et al. (2015) found ethnic differences. Pregnant women with histo-
ries of physical or sexual abuse had high cortisol levels—a biological marker for
AD V E R SE C HILDHOOD E X PE R IENC ES ( A C Es) 13
stress—and the increases w ere more pronounced among African American w omen.
Despite the wealth of information, more studies are needed to understand how
ACEs impact health and why some people succumb to the damaging influences of
childhood experiences while others appear resilient.
Experts postulate the pathways between adverse experiences, risky behavior,
and disease. When dealing with a stressful experience, the body reacts with the
sympathetic-parasympathetic response. Behaviors associated with traumatic expe-
riences are violence (fight), truancy and running away (flight), or withdraw, depres-
sion, and self-medication (freeze). The adolescent living in a household with
domestic violence may initially use smoking to self-medicate, and as the stress
becomes more severe or tolerance to nicotine develops she may turn to other illicit
drugs or risky sexual behaviors. Smoking increases risk for lung cancer or chronic
obstructive pulmonary disease, and illicit drug use and high-risk sexuality would
increase risk of hepatitis or HIV/AIDS. Reluctance to seek medical care exacerbates
health problems. Alcalá, Mitchell, and Keim-Malpass (2016) found that women with
a history of physical or sexual abuse were less likely to get a Pap test. Failure to
obtain routine screening or medical care increases risk for cervical cancer.
One pathway to disease currently u nder investigation is early brain development.
During childhood, the h uman brain is constantly developing. Environmental stresses
create downstream consequences. De Brito et al. (2013) used MRI to compare the
brains of children with and without histories of maltreatment. The maltreated
children had decreased gray matter in the regions of the brain that regulate emo-
tions, decision making, and memory. The researchers propose that physiological
changes in the orbitofrontal cortex may lead to social impairment and increased
risk-taking. Changes in the m iddle temporal gyrus may contribute to depression
and PTSD. Edmiston et al. (2011) examined the effects of childhood maltreatment
on limbic brain structures in adolescents with no psychiatric diagnoses. Limbic
structures are involved with emotion, stress, learning, and memory. They found
higher scores on a maltreatment questionnaire were negatively correlated with gray
matter volumes in many brain regions, including the prefrontal cortex, striatum,
amygdala, sensory association cortices, and cerebellum. Different types of abuse
were associated with changes in different regions of the brain. Interestingly, females
had more changes in emotional regulatory regions while males had more changes
in impulse control regions. This study showed that, even in adolescents not suffer-
ing from psychiatric disorders, there are still changes that take place in the brain
because of ACEs that increase risk for behavioral problems. Poletti et al. (2015)
suggest that brain alterations may influence development of schizophrenia. The evi-
dence that ACEs create physiological changes to the brain that can influence later
behavior raises the question of w hether such changes are irreversible. If someone
is exposed to traumatic experiences during childhood, can the brain be rewired
toward healthy, prosocial behaviors?
Intervention and prevention are key to overcoming ACEs. Public health profes-
sionals use selected, indicated, and universal prevention mechanisms to prevent
14 AD V ER SE C HILDHOOD E XPE R IEN C ES ( A CEs)
ACEs and to create positive coping mechanisms among p eople who are already liv-
ing with ACEs (Black, Davis, & Dempsey, 2010). Universal prevention focuses on
preventing ACEs within the general population, regardless of risk. Ways to prevent
ACEs include early childhood education programs, public service announcements,
parenting education, dating violence prevention programs, and job training. Selected
prevention focuses on vulnerable populations and is achieved by educating health
care providers and community leaders on the effects of ACEs, screening for ACEs
during medical visits, and early referral to community resources. Indicated preven-
tion focuses on controlling the negative sequelae of ACEs among individuals who
are already experiencing or have experienced ACEs. Intervention includes coun-
seling to understand and change negative behaviors. A critical aspect of indicated
prevention is that individuals exposed to ACEs have unique personality character-
istics that make them resistant to treatment. People with ACEs have higher rates of
neuroticism, hopelessness, rumination, and loss of control than those who have
not experienced ACEs. They are less resilient when faced with anxiety or depres-
sion and are more likely to have lower levels of education and income. Indicated
prevention requires long-term commitment to change by the individual, family
members, and caregivers.
ACEs are complex social and medical problems that significantly impact mor-
bidity, mortality, and quality of life. By integrating ACE screening and awareness
into health care practices, public health professionals are developing new ways to
educate parents and communities on the impact of childhood experiences. For some
adult survivors of ACEs, recognizing and validating past traumas and helping the
person to draw connections between past experiences and current behaviors can
be enough to help him or her move beyond the trauma. For o thers, counseling with
long-term follow-up may be needed. Primary prevention by educating today’s par-
ents, grandparents, and community leaders on child brain development can prevent
ACEs. Efforts will require larger, systematic approaches by medical professionals,
counselors, policy makers, educators, criminal justice systems, and the larger
community.
Sarah R. Green and Maria DiGiorgio McColgan
See also: Behavioral Health; Child Maltreatment; Intimate Partner Violence; M

ental
Illness; Prevention; Social Determinants of Health; Controversies in Public Health:
Controversy 2
Further Reading
Alcalá, H. E., Mitchell, E., & Keim-Malpass, J. (2016). Adverse childhood experiences and
cervical cancer screening. Journal of Women’s Health, 26(1), 58–63.
Black, S., Davis, M. B., & Dempsey, S. H. (2010). Practitioner recommended practices for
children exposed to domestic violence. Health Promotion Practice, 11(6), 900–907.
Centers for Disease Control and Prevention. (2016). About the CDC-Kaiser ACE Study.
Retrieved from https://www.cdc.gov/violenceprevention/acestudy/about.html.
A F F O R DA B LE C A R E A C T ( A C A ) 15
De Brito, S., Viding, E., Sebastian, C., Kelly, P., Mechelli, A., Maris, H., & McCrory, E. (2013).
Reduced orbitofrontal and temporal grey m atter in a community sample of maltreated
children. Journal of Child Psychology and Psychiatry, 54(1), 105–112.
Edmiston, E., Wang, F., Mazure, C., Guiney, J., Sinha, R., Mayes, L., & Blumberg, H. (2011).
Corticostriatal-limbic gray m
atter morphology in adolescents with self-reported expo-
sure to childhood maltreatment. Archives of Pediatrics & Adolescent Medicine, 165(12),
1069–1077.
Fang, L., Chuang, D., & Lee, Y. (2016). Adverse childhood experiences, gender, and HIV
risk behaviors: Results from a population-based sample. Preventive Medicine Reports, 4,
113–120.
Felitti, V., Anda, R. F., Nordenberg, D., Williamson, D., Spitz, A. M., Edwards, V., Koss, M.,
& Marks, J. S. (1998). Relationship of childhood abuse and h ousehold dysfunction to
many of the leading causes of death in adults: The Adverse Childhood Experiences
(ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258.
Huang, H., Yan, P., Shan, Z., Chen, S., Li, M., Luo, C., & . . . Liu, L. (2015). Adverse child-
hood experiences and risk of type 2 diabetes: A systematic review and meta-analysis.
Metabolism, 64, 1408–1418.
Iniguez, K. C., & Stankowski, R. V. (2016). Adverse child experiences and health in adult-
hood in a rural population-based sample. Clinical Medicine & Research, 14(3–4),
126–137.
Poletti, S., Mazza, E., Bollettini, I., Locatelli, C., Cavallaro, R., Smeraldi, E., & Benedetti, F.
(2015). Adverse childhood experiences influence white m atter microstructure in patients
with schizophrenia. Psychiatry Research: Neuroimaging, 234, 35–43.
Robert Wood Johnson Foundation. (n.d.). Adverse childhood experiences: A collection of news,
perspectives, and other resources to help raise awareness, prevent ACEs and improve resil-
iency. Retrieved from http://www.rwjf.org/en/library/collections/aces.html.
Schreier, H. C., Enlow, M. B., Ritz, T., Gennings, C., & Wright, R. J. (2015). Childhood
abuse is associated with increased hair cortisol levels among urban pregnant women.
Journal of Epidemiology and Community Health, 69(12), 1169–1174.
AFFORDABLE CARE ACT (ACA)

The Patient Protection and Affordable Care Act, often referred to only as the Afford-
able Care Act (ACA), was instituted on March 30, 2010, and sustained by the United
States Supreme Court on June 28, 2012. The law was created to allow individuals
and businesses to be the primary decision makers in their health care, enabling
participants to choose a health care plan that fit within their budget while also
making the insurance marketplace more competitive. Under the ACA, employers
and individuals are eligible for tax credits to assist in covering the costs of their
chosen health plan. The ACA expands Medicaid eligibility and streamlines the appli-
cation process for the Children’s Health Insurance Plan (CHIP). HHS.gov states
that the ACA “gives flexibility to States to adopt innovative strategies to improve
care and the coordination of services for Medicare and Medicaid beneficiaries. And
it saves taxpayer money by reducing prescription drug costs and payments to sub-
sidize care for uninsured Americans, as more Americans gain insurance u nder
reform” (U.S. Department of Health and H uman Services, 2015).
16 AFFOR DA BLE CARE ACT (ACA)
Any nation’s health system is a unique product of its history, politics, and national
values. Canada, for instance, has a national health insurance model whereby the
government pays for health services for Canadian citizens; this is known as a single-
payer model. In contrast, the United States is primarily a private health system
whereby employers and employees pay the costs of private health insurance. Vet-
erans and Native Americans are covered by Veterans Affairs and the Indian Health
Service, respectively, wherein the U.S. federal government pays for these separate
health care systems. Finally, citizens and permanent residents 65 years and older
are covered by Medicare, and citizens and lawfully present immigrants who are
financially eligible for Medicaid receive health care comparable to Canada’s model.
Compared to Canada, the United States has a far more complex health system
because different groups in the population access health care in different ways.
Health care in the United States relies on costly, technologically advanced medi-
cine. Yet the U.S. health system has a long history of denying access to p eople who
are unemployed or cannot afford health insurance on their own. In 2010 it was
estimated that 50 million Americans, or 16 percent of the population, did not have
health insurance (U.S. Census Bureau, 2011). The past century has seen repeated
efforts to expand health insurance to uninsured populations, but these efforts
have been resisted by private stakeholders. Two of the most powerful groups are
Eleven-year-old Marcelas Owens watches as President Obama signs the Patient Protection
and Affordable Care Act. Marcelas’s mother died when she was unable to afford medical
care. The Affordable Care Act expanded access to health services for 50 million Americans.
(The White House/Pete Souza)
A F F O R DA B LE C A R E A C T ( A C A ) 17
physicians represented by the American Medical Association (AMA) and the health
insurance industry. The AMA’s concern has been that expanded health insurance
would shift power from physicians to other groups in the health system including
hospitals, the health insurance industry, and the government. The health insurance
industry has been concerned universal health insurance would have a negative
impact on the industry’s profit margins.
Successive attempts to provide health insurance to all American citizens have
failed b ecause of “path dependence” (Starr, 1982, p. 7): the present health system
is a product of historical decisions that have instituted a mode of delivery resistant
to change. A century of struggle to reform health care finally succeeded, however,
with the passage of the Affordable Care Act (ACA) in 2010. Cognizant of path depen-
dence, President Barack Obama’s administration carefully attended to the history
of failed attempts to introduce comprehensive insurance coverage in the United
States and so meticulously consulted stakeholders such as the health insurance
industry and the AMA in their health policy proposals. Continued opposition to
the ACA years after its passage reflects the complexity of health care reform wherein
politics and historical precedent play a major role in influencing policy design.
The ACA assigns the responsibility of health care to the individual. It eliminates
copays for preventive care. Individuals can now choose their preferred provider that
is available within their insurance network, and women can visit their OB-GYN
without preauthorization or referral. Parents have the ability to cover their depen-
dent child until 26 years of age without exclusion of life events such as marriage or
employment. An insurance carrier can no longer preclude a person or increase the
cost of premiums for a person with a preexisting condition such as diabetes or HIV.
Health insurance plans are required to eradicate their previously imposed lifetime
and annual limits for covered nonessential services (U.S. Department of Health and
Human Services, 2015). Companies are banned from increasing copays or coinsur-
ance amounts for emergency services or canceling a policy due to an honest error
made on the initial application. Plan summaries must be written in laymen’s terms
that are easily understood. Members can appeal their insurance decision to deny
services.
Since its passage in 2010, the ACA is beginning to deliver the benefits of expanded
health care coverage and lower costs. The latest estimates indicate substantial gains
in enrollment after enactment of the ACA, with the number of persons uninsured
having dropped to 33 million, or 10.4 percent of the population (U.S. Census
Bureau, 2014). However, the United States continues to be a global outlier in
health spending, with limited return on health quality or population health. U.S.
health expenditures in 2011, for example, w ere $8,500 per person, in comparison
with Canada, which spends approximately $4,000 per person on health. Despite
its expenditure, the United States performs the poorest across a range of indicators
of health care quality and population health in comparison with other Western
countries (Davis, Stremikis, Squires, & Schoen, 2014, p. 11). The ACA has made
significant improvements in broadening access to health care, yet comparisons
18 A G IN G
among Western countries show that further reform is needed. The lessons from the
past as well as analysis of the current political climate are important considerations
in analyzing health policy reform.
Catherine van de Ruit and Leapolda Figueroa
See also: Care, Access to; Centers for Medicare and Medicaid Services; Children’s
Health; Health Policy; Immigrant Health; Medicaid; Medicare; Public Health Law;
School Health; Controversies in Public Health: Controversy 5
Further Reading
Davis, K., Stremikis, K., Squires, D., & Schoen, C. (2014). Mirror, mirror on the wall mirror:
How the performance of the U.S. health care system compares internationally. New York:
The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/∼/media
/files/publications/fund-report/2014/jun/1755_davis_m
irror_mirror_2
014.pdf.
Starr, P. (1982). The social transformation of American medicine. New York: Basic Books.
U.S. Census Bureau. (2011). Income poverty and health insurance coverage in the United States:
2010. Washington, DC: U.S. Government Printing Office.
U.S. Census Bureau. (2014). 2013 and 2014 current population survey reports. Washington,
DC: U.S. Government Printing Office.
U.S. Department of Health and Human Services. (2015). Health care. About the law: The
Affordable Care Act section by section. Retrieved from http://www.hhs.gov/healthcare
/about-the-law/read-the-law/.
AGING
The many public health advancements of the 20th century allow p eople to live lon-
ger, healthier lives. However, more people living longer can prevent challenges for
public health. Aging involves changes that occur within organisms that lead to phys-
ical maturation and an eventual reduction in the ability of the body to function.
With humans, physical maturation typically stops a fter age 30. Subsequently, senes-
cence, the process of growing older, occurs. Systems that allow the body to survive
become increasingly vulnerable to physical breakdown and disease. This deterio-
ration eventually results in death. Though biological changes are the most visible
signs of senescence, aging also involves psychological and sociological aspects. As
the baby-boomer population ages, senior citizens may quickly outnumber younger
people. This demographic shift presents unique challenges. If the elderly, who often
suffer from chronic diseases or disabilities at greater rates than o thers in the general
population, require more health care and social services than the workforce can
provide, the nation will face a crisis in health care services. Public health offers one
mechanism for filling the disconnect between supply and demand. Invested devel-
opment of public health systems, such as home health care and visiting nurses, can
enable the elderly to remain in their homes and to actively contribute to society.
Promoting health throughout the life span and supporting people as they age
A G ING 19
supports healthy, diverse communities. Senior citizens have much to offer youth.
Daily or regular interaction and communication between different generations
allows for healthy discourse. Exposing youth to the elders of the society ensures
that cultural traditions and values, the roots of the community, are carried on into
future generations.
No single theory explains biological aging. A variety of theories exist that attempt
to clarify the process. The wear and tear perspective implies that the body breaks
down as a result of use. E very species has a predetermined life span, or maximum
age of survival. Depending on how the body is used, the body will simply wear out
while moving toward the end of life. With more specificity, cellular aging theory argues
that cells, the smallest structural unit of an organism, replicate slower as an organ-
ism moves toward death. Some cells in parts of the body only have a finite number
of replications. Consider T cells, which aid in the ability of the immune system to
fight disease. These cells lose their capacity to reproduce, and this reduces the abil-
ity of the human body to combat illnesses in later life. Some cells do not replicate
at all. This includes certain nerve, brain, and muscle cells. A fter maturation, any
irregularities in t hese areas are irreversible and permanent, though certain surgical
interventions may create functionality in some cases. Telomere theory states that every
time a cell divides, structures called telomeres at the end of DNA, shorten. Telo-
meres can act as a biomarker for health status. Elderly individuals with shorter telo-
meres have higher rates of cirrhosis of the liver and colon cancer. Analogous to the
rusting process in metals, free radical theory implies oxidative stress creates aging.
Atoms and molecules typically have paired electrons. A fter exposure to oxygen
through metabolic processes, damage occurs within cells and some end up with
free radicals. T hese are atoms or molecules with unpaired electrons that represent
oxidative damage. The accumulation of oxidative damage throughout life triggers
age-related biological decline. No one theory describes all aspects of aging. Com-
bined, the theories provide some explanation and understanding of the biological
aging process.
Advancements in medical technology and public health have significantly
increased average life span. As a greater number of p eople enter and experience
aging, techniques used to manage the aging process become more popular. Though
the success of such initiatives is limited, more p eople than ever are trying t hese dif
ferent therapies. Enzyme therapy has the potential to lengthen telomeres, but side
effects related to genetic mutations create tumors and currently limit widespread
use. F ree radical therapy involves the implementation of antioxidants. Antioxidants
are compounds that donate electrons to free radicals and create balance within a
cell. Though synthetic antioxidants exist, there are high levels of antioxidants in
natural food sources such as legumes, fruits, and vegetables, with the highest pres-
ence in beans, berries, apples, and artichokes. Caloric restriction, predominantly
through the reduction of fat and carbohydrates, is another technique used to c ounter
aging. Extreme variations focus on limiting all calories and encourage a perpetual
feeling of hunger for successful anti-aging results. Growth hormone therapy is
20 AG IN G
another procedure. One of the most common substances related to this is dehydro-
epiandrosterone (DHEA). The brain and adrenal glands produce DHEA. The body
then converts it to estrogen and testosterone. DHEA is the most abundant steroid
in the h uman body. Its production peaks in early adulthood and declines signifi-
cantly afterward. Older adults can take DHEA orally or through injections. The treat-
ment is effective in increasing skin thickness, but has limited impact in areas such
as brain functioning. Human growth hormone (HGH) treatments are also available.
HGH successfully improves muscle mass and bone density. Adverse effects occur
with prolonged use including joint pain and an elevated risk of diabetes.
Psychological aging involves both cognitive and personality changes. With cog-
nition, normal aging results in a natural decline in some aspects of intelligence and
memory. The two primary forms of intelligence are fluid and crystallized (Horn &
Cattell, 1966). Fluid intelligence concerns biologically related aptitude, independent
of personal experience. Commonly referred to as street smarts, fluid intelligence is
the ability to recognize and solve problems using natural intuition. Crystallized intel-
ligence involves the abilities and knowledge a person develops throughout life,
including book smarts. In the classic aging pattern, fluid intelligence declines as
crystallized intelligence becomes stronger. Elderly people do worse on performance-
based tests related to fluid intelligence. This may be because many tests have time
limits. The aged person, with slower reaction times related to age-related neuro-
logical declines, has the right answers, but cannot respond fast enough. Timed tests
also elevate the anxiety, interfering with the tests. Tests on spatial orientation and
reasoning also show a lower performance, regardless of time limits. Intelligence in
the aged person is related to educational attainment, occupational experiences, reac-
tion times, hearing, and vision.
As the brain ages, significant changes occur in working and long-term memory.
Working memory, referred to as short-term or primary memory, declines with age.
The decline is especially prevalent if an older person attempts to manage multiple
pieces of information at the same time. Decreased attention spans that occur in aging
challenge the brain’s ability to navigate complex tasks or systems. Aside from mem-
ory linked to verbal knowledge and performance memory related to carrying out
specific tasks, long-term memory is worsened for the aged. Accurately recalling
information from a distant time is difficult, u
nless the event had a significant impact
on the person. There are a number of techniques that older adults can use to improve,
sustain, or trigger memory. Mediators, such as acronyms, help with information
recall. For example, the American Cancer Society used the acronym CAUTION to
remind people of the warning signs of various forms of cancer. CAUTION stands
for “Change in bowel or bladder habits; A sore that does not heal; Unusual bleeding
or discharge; Thickening or lump in the breast, testicles, or elsewhere; Indigestion
or difficulty swallowing; Obvious change in size, color, or shape of a wart, mole, or
mouth sore; and Nagging cough or hoarseness.” Other external memory aids, such
as written lists, are also helpful in maintaining adequate psychological functional-
ity for activities of daily living.
A G ING 21
Stage theories propose that as p eople age, they move through different psycho-
logical phases. T hese stages may be displayed through personality and actions. For
example, compared to younger people, the elderly are more likely to have a greater
sense of purpose, as well as a greater sense of self. Elders may say or do t hings that
they did not have the confidence to say or do when they were younger. When used
to improve families, communities, and society, this increased sense of self can cre-
ate many positive results. However, patterns of interaction and cognitive impair-
ments may also be exhibited as negative personality traits. Life disruptions such as
divorce, death of a spouse, retirement, physical disability, or dementia may trigger
feelings of grief, remorse, sorrow, or depression. The resulting stress of these life
events not only impacts psychological well-being but also produces physical changes.
Telomere length is shortened lowering life expectancy—the statistical measure of
how long a person w ill live given his or her year of birth.
Sociological aging relates to the impact of social networks, institutions, and cul-
ture on the elderly. In many societies, the elderly maintain traditions and pass
important cultural values to the next generation. Continuity theory argues that the
more a person can maintain former roles through the aging process, the more posi-
tive the aging experience will be. This could include family caregiving, part-time
paid positions, or volunteer work. Activity theory implies sustaining social ties
through any form of interaction, new roles or old, leads to higher levels of life sat-
isfaction. Active social involvement can stabilize or elevate self-esteem as a person
ages. Maintaining positive support networks helps to counteract some of the nega-
tive emotional effects of aging. It can be difficult to maintain those networks when,
for example, employers push for premature retirements. Disengagement theory implies
that some cultures devalue the elderly. Institutional living drives senior citizens away
from valued social networks. This isolation hinders successful aging. Areas known
as blue zones exist throughout the world. Specific areas of Italy, Greece, Japan, and
Costa Rica have relatively high numbers of centenarians, people 100 and older.
Researchers identified similarities in cultural behavior patterns and found common-
alities in types of food eaten (semi-vegetarian), physical activity, and social integra-
tion (Buettner, 2010). Aging is influenced by biological and psychological dynamics
on top of sociocultural foundations. The ethical dimensions related to encouraging
or discouraging behaviors known to increase positive aging and prolong life are
currently being explored by public health professionals and researchers.
Aging is and will continue to be an important issue for years to come. An increased
understanding of the principles of biological, psychological, and sociological aging
is critical to promoting quality of life throughout the life span. With the baby-boomer
generation’s ongoing shift into old age, more adults will provide care for aged loved
ones and more health care workers will be dedicated to elder care. These caregivers
will need knowledge of best practices in elder care for those they care for and to
navigate their own aging processes.
Jason S. Ulsperger
22 A G R IC ULTU R AL SA F ETY
See also: Affordable Care Act; Alzheimer’s Disease; Chronic Illness; Community
Health; Disability; Elder Maltreatment; Medicaid; Men’s Health; Motor Vehicle Safety;
Prevention; Social Security Act; W omen’s Health
Further Reading
Bensadon, B. A. (2015). Psychology and geriatrics: Integrated care for an aging population. Lon-
don: Academic Press.
Buettner, D. (2010). The blue zones: Lessons for living longer from the people who’ve lived the
longest. Washington, DC: National Geographic.
Calado, R. T. (2014). Telomeres in health and disease. Waltham, MA: Academic Press.
Horn, J. L., & Cattell, R. B. (1966). Refinement and test of the theory of fluid and crystal-
lized general intelligences. Journal of Educational Psychology, 57, 253–270.
Epel, E. S., Blackburn, E. H., Lin, J., Dhabhar, F. S., Adler, N. E., Morrow, J. D., & Cawthon,
R. M. (2004). Accelerated telomere shortening in response to life stress. Proceedings of
the National Academy of Sciences, 101, 17312–17315.
Hooyman, N., & Asuman Kiyak, H. (2014). Social gerontology: A multidisciplinary perspec-
tive. Harlow, Essex: Pearson.
McDonald, R. B. (2014). Biology of aging. New York: Garland Science.
Merrill, G. F. (2015). Our aging bodies. New Brunswick, NJ: Rutgers University Press.
Verhaeghen, P. (2014). The elements of cognitive aging: Meta-analyses of age-related differences
in processing speed and their consequences. New York: Oxford University Press.
AGRICULTURAL SAFETY
Farming, ranching, and agricultural management are among the most dangerous
jobs in the nation. Agricultural workers die at a rate of 24.7 per 100,000 full-time
equivalent (FTE) workers, almost double the rate of police deaths, 13.5 per 100,000
FTE workers (U.S. Bureau of L abor Statistics, 2016). Farm laborers are vulnerable
to injuries through handling large, dangerous machinery, falls, extreme heat and
cold, heavy lifting and repetitive forceful body motions as well as working in
unsanitary conditions where they are exposed to pesticides, harsh chemicals, air
contaminants, zoonotic infections, and loud noises. The nature of farm work is dif-
ficult, grueling work, which puts great physical strain on the body. The digging,
cutting, chopping, and grinding necessary to grow the nation’s food is performed
using sharp, powerful tools and machinery. Because many farms are family oper-
ated, children frequently participate in dangerous tasks. Consider that when a
farmer plows the fields, it seems easier and more efficient to put young c hildren on
the back of a tractor rather than driving 20 miles to drop the child off at the local
day care center. Farm-associated injuries among youth cost an estimated $1 billion
annually (Zaloshnja, Miller, & Lee, 2011). Public health’s goal is to reduce work-
related deaths among farmers, fishers, and hunters by 10 percent over 10 years
(Office of Disease Prevention and Health Promotion, 2016). The U.S. Department
of Labor, National Institute for Occupational Safety and Health (NIOSH), and Cen-
ters for Disease Control and Prevention (CDC) offer multiple initiatives, training
A G R I C ULTUR AL SA F ETY 23
programs, grants, and publications to gather information on the dangers of farm-

ing and implement programs and policies to reduce agriculture-related injuries,
diseases, and deaths. The National C hildren’s Center for Rural Agricultural Health
and Safety established guidelines encouraging parents to match farm chores with
children’s age and developmental abilities. To date, efforts indicate some signs of
success. NIOSH reports a 56 percent reduction in farm-related injury rates among
youth between 1998 and 2009 (Ten Great Public Health Achievements—United
States, 2001–2010, 2011). However, the nature of agricultural workers as inde
pendent contractors, many of whom are poor, migrant workers, and the values
of farmers as autonomous agents, operating free from bureaucratic oversight, pres
ents obstacles in creating safe workplaces for workers, farm managers, and farm
families.
The health of agricultural workers lags behind other industries. Early efforts to
protect the U.S. workforce focused on miners, railroad workers, and steelworkers. As
independent self-employed workers, agricultural workers were not part of organized
labor unions advocating for safe working conditions. In the United States, farm
safety traces back to the First Cooperative Safety Congress in Milwaukee, Wisconsin
(1912). The Safety Congress evolved into the National Safety Council (1913) and
over time, a network of farm safety specialists evolved. In 1937, the National Safety
Council formally addressed the problem by creating a national plan for farm safety.
Today, the National Safety Council, U.S. Department of Agriculture (USDA), state
extension services, the 4H chapters, Future Farmers of America (FFA), and Bureau
of L
abor Standards create a network promoting agricultural worker safety.
Approximately half of all farm fatalities are the result of injury by motor vehicle.
Although no national data w ere collected on farm injuries prior to the invention of
the tractor, early safety experts claimed that the transition from horsepower to gas-
powered vehicles greatly increased the number and severity of injuries. A survey of
more than 6,000 farms in Kentucky found that 1 out of 10 farms experience a trac-
tor rollover and operators without rollover protective structures (ROPs) lose an
average of 98 workdays during recovery while operators with ROPs and seatbelts
lose an average of 22 workdays (Cole, Myers, & Westneat, 2006). Other vehicular
hazards are getting loose clothing or hair caught in an operating machine, dam-
aged or missing protective shields, carbon monoxide poisoning, sudden and unan-
ticipated changes in vehicular balance due to towed harvesting equipment, and
all-terrain vehicles. To prevent injuries, OSHA recommends using approved safety
equipment, following the manufacturer’s recommendations regarding use and safety,
shutting off the engine and removing keys from the ignition when the vehicle is not
in use, and storing fuel in a separate location from the equipment.
While working in the summer and winter, agricultural workers are exposed to
extremes in heat and cold. Prolonged exposure to heat can result in heat exhaustion,
heat cramps, heat stroke, and death. As the body attempts to cool itself through
sweating, water and salt are excreted. Initially, the person may experience symp-
toms of dehydration, thirst, irritability, dizziness, or confusion. Excessive sweating
24 A G R IC ULTU R AL SA F ETY
can lead to severe fluid and electrolyte imbalances with fainting, seizures, muscle
spasms, or death. Individuals with underlying health conditions of diabetes or alco-
holism and the young or old are at highest risk for heat-related illnesses. OSHA rec-
ommends knowing the signs of heat-related illnesses, drinking water every 15 minutes
regardless of thirst, wearing light clothing for protection from the sun, resting in the
shade, and using a buddy system to monitor the health of coworkers.
The rate of falls among agricultural workers (48.2 per 100,000 workers) is higher
than other hazardous industries (OSHA, n.d.). Falls occur while working on slip-
pery or unstable surfaces, at high elevations, or near unprotected shafts or manure
pits. Incidents can be prevented by identifying risky situations in advance, elimi-
nating the risk, installing fall prevention devices, and using safety nets, catch
platforms, or safety harnesses. Falls into silos or grain bins are a concern. Filling
the grain bin is a particularly high-risk agricultural task. The farmer loads grain
through high speed conveyors at the top of the silo and an auger pulls the grain
from the bottom. Many t hings can go wrong. The shafts can become blocked; pock-
ets of air or bridges of forage can form within the silo or methane gas buildup,
resulting in fire or asphyxiation. If the worker enters the grain bin while the auger
is operating, the grain acts like quicksand. The person can be trapped within 4 to
5 seconds, pulled under the pile of grain and suffocate within 22 seconds. An oper-
ator should never enter the storage bin to clear or check the grain flow. OSHA
provides specific safety and health information on grain h andling.
The physical labor of farming requires lifting, bending, twisting, and kneeling.
Forceful and repetitive motions cause work-related backache or pain in the shoul-
ders, arms, or hands. In California, the annual cost of farm workers’ compensation
for back injuries is estimated at $22 million (Baron, Estill, Steege, & Lalich, 2001).
Although technology can decrease some bodily strain, the task of h andling heavy
vibrating machinery or poorly designed tools can create other ergonomic problems.
The Centers for Disease Control and Prevention and NIOSH offer Simple Solutions to
reduce work-related musculoskeletal disorders recommending inexpensive tools and
collaborations between management and workers to improve work processes (Baron,
Estill, Steege, & Lalich, 2001).
Tractor rollovers, heat stroke, falls, dangerous gases, zoonotic infections, and mus-
culoskeletal disorders create a hazardous environment for the millions of agricul-
tural workers who grow and harvest the food that we eat. Despite the slow progression
of health and safety measures on farms, many groups are now working to address
the health and safety of farm workers. Partnering with community-based groups,
federal, state, and local organizations balance sharing best practices in farm safety
with the autonomous nature of farming.
Sally Kuykendall
See also: Health Resources and Services Administration; Rural Health; U.S. Depart-
ment of Agriculture; State, Local, and Territorial Health Departments
AI R POLLUTION 25
Further Reading
Baron, S., Estill, C.F., Steege, A., & Lalich, N. (2001). Simple solutions: Ergonomics for farm
workers. U.S. Department of Health and H uman Services, Public Health Service, Cen-
ters for Disease Control and Prevention, National Institute for Occupational Safety and
Health. Retrieved from https://www.cdc.gov/niosh/docs/2007-122/.
Cole, H. P., Myers, M. L., & Westneat, S. C. (2006). Frequency and severity of injuries to
operators during overturns of farm tractors. Journal of Agricultural Safety and Health,
12(2), 127–138.
International Society for Agricultural Safety and Health. (n.d.). Retrieved from https://isash
.org/.
National Institute for Occupational Safety and Health Division of Safety Research. (2014).
Agricultural safety. Retrieved from https://www.cdc.gov/niosh/topics/aginjury/.
Occupational Safety and Health Administration (OSHA). (n.d.). Agricultural operations. U.S.
Department of L abor. Retrieved from https://www.osha.gov/dsg/topics/agriculturalo
perations/.
Office of Disease Prevention and Health Promotion. (2016). Healthy people 2020. Retrieved
from https://www.healthypeople.gov/2020/topics-objectives/objective/osh-15.
Ten G
reat Public Health Achievements—United States, 2001–2010. (2011). Morbidity and
Mortality Weekly Report, 60(19), 619.
U.S. Bureau of Labor Statistics. (2016). Current Population Survey, Census of Fatal Occu-
pational Injuries. Retrieved from http://www.bls.gov/iif/oshwc/cfoi/cfoi_rates_2014hb
.pdf.
Zaloshnja, E., Miller, T., & Lee, B. (2011). Incidence and cost of nonfatal farm youth injury,
United States, 2001–2006. Journal of Agromedicine, 16(1), 6–18.
AIR POLLUTION
Air pollution is “a mixture of natural and man-made substances in the air we breathe”
(National Institute of Environmental Health Sciences, 2017). Outdoor air pollu-
tion consists of noxious gases, ozone, and fine particles released by burning fossil
fuels. Indoor air pollution consists of noxious gases, h ousehold products, building
materials, tobacco smoke, allergens, mold, and pollen. The direct health effects of
air pollution are asthma, birth defects, cancer, carbon monoxide poisoning, devel-
opmental disabilities, heart disease, heat stress, and reproductive problems. Some
of the same h uman activities that create air pollution warm the air creating climate
change. Global warming raises air temperature and impacts w ater temperature, air
quality, plant growth, and pathogens. Diseases related to global warming such as
asthma, malaria, and malnutrition are on the rise. Public health professionals attempt
to reduce the health hazards caused by air pollution by monitoring the environ-
ment and environmental health, responding to weather-related disasters, and edu-
cating the public on ways to reduce detrimental impact on the environment.
Environmental health scientists monitor and report Air Quality Index (AQI) to assist
individuals and communities in reducing harmful daily exposure.
The idea that our environment influences health traces back to the fourth c entury
BC when Hippocrates countered the belief that illnesses w ere punishment from the
26 AI R POLLUTION
Noon in the steel mill town of Donora, Pennsylvania, on October 29, 1948. As thick, cor-
rosive air pollution hung over the valley of the Monongahela River, residents struggled to
breathe. (Bettmann/Getty Images)
gods and encouraged physicians to examine the patient’s diet, personal behaviors,
and environment. In the United States, official recognition of air pollution as a health
hazard started with the Donora smog incident of 1948. Donora was a booming mill
town toiling to meet the nation’s post–World War II demand for steel and zinc prod-
ucts. Located in a valley on the Monongahela River, residents were accustomed to
morning fog. On October 26, smoke from the mills combined with thick fog to
form smog. The smog contained particulate pollution, ozone, and sulfuric acid. Ini-
tially, residents went about their daily business, expecting the smog to lift. However,
a temperature inversion acted like a cap over the valley, holding the yellow, acrid
smog in place. An estimated 5,000 to 7,000 workers and residents struggled to
breathe through the corrosive air. Four hundred p eople were hospitalized and 20
people died. Local doctors warned those who could get out of town to leave.
Although the mill owners did not believe the mills were the problem, they slowed
down production as a safeguard. On October 31, the toxic fumes dissipated as a
cold front moved in and rain cleaned the air. The Donora incident was investigated
by the Pennsylvania Department of Health, United Steelworkers, Donora Borough
Council, and the Division of Industrial Hygiene of the Public Health Service, and
Donora became the first official investigation of air pollution in the United States.
AI R POLLUTION 27
In 1955, Congress passed the Air Pollution Control Act supporting research and
prevention. The act was followed by the Clean Air Acts of 1963, 1970, and 1990.
Physiologically, the body needs oxygen to convert carbohydrates and fats into
energy in order to fuel body functions. Oxygen enters the body via the nasotra-
cheal pathways, travels through the bronchi and bronchioles, and into the micro-
scopic alveoli where oxygen is exchanged with carbon dioxide from the blood. Air
pollution damages the body in two ways, e ither by irritating sensitive respiratory
tissue or by functioning as an inhaled poison. Smoking and pollutants irritate the
airways causing inflammation, spasms, and shortness of breath. The irritation and
bronchospasms make it difficult for the person to inhale oxygen and to exhale carbon
dioxide resulting in classic symptoms of coughing, wheezing, and difficulty breath-
ing. Continued exposure to pollutants hardens or scars the respiratory tissue, per-
manently reducing the body’s ability to exchange gases. Diseases associated with
continued exposure are chronic obstructive pulmonary disease (COPD), emphy-
sema, chronic bronchitis, asthma, lung cancer, and pneumonitis. Toxic air pollut-
ants act as poisons, introduced into the body through the lungs. Air toxics include
benzene (found in gasoline), perchloroethylene (emitted by dry cleaning), methylene
chloride (a solvent and paint stripper), asbestos, toluene, cadmium mercury, chro-
mium, and lead. Exposure to air toxics can cause cancer, reproductive problems, and
birth defects. Air pollution is an insidious killer. In many cases, disease, symptoms,
and death may not occur for a decade a fter exposure or may be disguised as other
health problems. The World Health Organization (2014) estimates 7 million pre-
mature deaths each year due to air pollution and identifies the most common air
pollution–related diseases as ischemic heart disease, stroke, COPD, lower respira-
tory infections in c hildren, and lung cancer. Researchers at Massachusetts Institute
of Technology (MIT) estimate that combustion emissions account for 200,000 pre-
mature deaths per year in the United States and changes in ozone account for
10,000 deaths. The highest numbers of deaths are related to black carbon emis-
sions from road transportation and sulfur dioxide emissions from power generation
(Caiazzo, Ashok, Waitz, Yim, & Barrett, 2013).
Ozone (O3) is a powerful oxidizing agent found in two layers of the earth’s atmo-
sphere. In the upper atmosphere, ozone creates a protective layer, screening p eople,
animals, and plants from the sun’s damaging ultraviolet rays. At the ground level,
ozone forms when vehicle exhaust and by-products from manufacturing interact
with sunlight. The oxidizing agent irritates the respiratory system and c auses cough-
ing, pain on inhalation, wheezing, and difficulty breathing. People with preexisting
respiratory problems, older adults, babies, children, and people who work outside
are particularly vulnerable to high ozone levels. In addition to the problem of ground
level ozone, burning fossil fuels and other human activities increase the buildup of
carbon dioxide, methane, and other gases. This process warms the environment
and upsets the balance of nature. Climate change increases the frequency and sever-
ity of heat waves, floods, and other extreme weather events; expands the geo-
graphic regions of disease-carrying vectors (mosquitos and ticks); lengthens the
28 AI R POLLUTION
seasons for mold, plant allergen, and pollen growth; and raises sea levels contami-
nating water and food supplies. All of these problems increase public demand for
health care, stressing current health care systems. Additionally, the loss of property,
loved ones, and community caused by flooding, drought, or wildfires causes trauma
that impacts mental health.
Public health addresses air pollution and climate change through macro-, meso-,
and micro-level interventions. Macro-level interventions are laws, regulations, and
policies designed to achieve large-scale changes. The U.S. Environmental Protection
Agency (EPA) guides national efforts to reduce environmental risks, establishes envi-
ronmental policy, works to protect the home, work, school and community envi-
ronments, and works with other countries to protect the environment. The National
Institute of Environmental Health Sciences (NIEHS) works to increase public aware-
ness of how the environment influences health and supports environmental health
research. The American Lung Association educates, advocates, and supports
research to prevent lung disease and assists people affected by lung disease. The Air
Pollution and Respiratory Health Branch (APRHB) of the Centers for Disease Control
and Prevention performs surveillance, implements evidence-based programs, and
supports partnerships to prevent and reduce environmental-related respiratory ill-
nesses. AirNow is a group of federal, tribal, state, and local agencies that provide the
public with real-time air quality data. The Air Quality Index (AQI) is a composite
measure of ground-level ozone, particle pollution, carbon monoxide, sulfur diox-
ide, and nitrogen dioxide. AQI ranks the quality of air locally on a scale of 0 to 500
where 0 to 50 is good quality air and 301 to 500 is hazardous. People with existing
lung conditions or those vulnerable to air pollution are advised to monitor air quality
when planning outdoor activities and avoid hazardous conditions.
Meso-level interventions are organizational level changes. In anticipation of the
1996 summer Olympics, the city of Atlanta converted public transportation vehicles
from diesel to natural gas. As a result, acute asthma attacks decreased 44 percent
and peak ozone concentrations decreased 28 percent (Friedman, Powell, Hutwag-
ner, Graham, & Teague, 2001). Micro-level interventions are designed to impact
individual or community-level changes. Individuals can reduce their exposure and
generation of air pollution by following these recommendations:
• Don’t smoke or allow o thers to smoke in your home or workplace.

• Check air quality daily and plan outdoor activities based on personal health
status. Avoid outdoor exercise when air quality is poor, and avoid exercising
near heavy traffic.
• Reduce home energy use by turning off unused lights and electronics, use
shades and blinds to heat or cool your home, naturally, adjust the thermostat,
and buy electronics with the energy star label.
• Use environmentally safe paints and cleaning products.
• Opt for clean forms of transportation—walk, bicycle, carpool, public trans-
portation, r ide share, or drive a green vehicle.
AI R POLLUTION 29
• Reduce trips by planning shopping routes and combining errands.

• Refuel vehicles according to instructions and refuel after dusk to reduce
emissions.
• Don’t burn leaves, firewood, or trash.
• Use hand-powered or electric yard tools.
Small, step-wise changes can make an enormous difference to the environment
and population health.
Air pollution is an environmental issue that impacts public health directly and
indirectly. Although children and those with impaired respiratory systems are at
highest risk, the effects of global warming with severe weather events, elevated sea
levels, increased humidity, and drought affect everyone throughout the world. It is
imperative that individuals and communities recognize and reduce h uman activi-
ties that impact the environment. Government agencies designed to protect the
environment and public health provide numerous, science-based resources and
suggestions to understanding and alleviating this complex problem.
Sally Kuykendall
See also: Behavioral Health; Cancer; Centers for Disease Control and Prevention;
Environmental Health; Environmental Protection Agency; Global Health; Healthy
Places; Maternal Health; Motor Vehicle Safety; Physical Activity; World Health
Organization
Further Reading
AirNow. (2017). Retrieved from https://airnow.gov/index.cfm?action=airnow.main.
American Lung Association. (2017). 10 Tips to protect yourself from unhealthy air. Retrieved
from http://www.lung.org/our-initiatives/healthy-air/outdoor/air-pollution/10-tips-to
-protect-yourself.html.
Caiazzo, F., Ashok, A., Waitz, I. A., Yim, S. H., & Barrett, S. R. (2013). Air pollution and
early deaths in the United States. Part I: Quantifying the impact of major sectors in
2005. Atmospheric Environment, 79, 198–208. doi:10.1016/j.atmosenv.2013.05.081
Davis, D. L. (2002). When smoke ran like w ater: Tales of environmental deception and the b attle
against pollution. New York: Basic Books.
Friedman, M., Powell, K., Hutwagner, L., Graham, L., & Teague, W. (2001). Impact of
changes in transportation and commuting behaviors during the 1996 Summer Olym-
pic Games in Atlanta on air quality and childhood asthma. Journal of the American Medi-
cal Association, 285(7), 897–905.
Helfand, W. H., Lazarus, J., & Theerman, P. (2001). Donora, Pennsylvania: An environ-
mental disaster of the 20th century. American Journal of Public Health, 91(4), 553.
National Institute of Environmental Health Sciences. (2017). Air pollution. Retrieved from
https://www.niehs.nih.gov/health/topics/agents/air-pollution/index.cfm.
U.S. Environmental Protection Agency. Retrieved from https://www.epa.gov/.
U.S. Global Change Research Program. (2016). The impacts of climate change on human
health in the United States: A scientific assessment. A. Crimmins, J. Balbus, J. L. Gamble,
C. B. Beard, J. E. Bell, D. Dodgen, R. J. Eisen, N. Fann, M. D. Hawkins, S. C. Herring,
30 ALC OHOL
L. Jantarasami, D. M. Mills, S. Saha, M. C. Sarofim, J. Trtanj, & L. Ziska (Eds.). U.S.

Global Change Research Program, Washington, DC, 312 pp. Retrieved from https://
health2016.globalchange.gov/.
World Health Organization. (2014). 7 Million premature deaths annually linked to air pollution.
Retrieved from http://www.who.int/mediacentre/news/releases/2014/air-pollution/en/.
ALCOHOL
The consumption of alcoholic beverages and its consequences are of urgent con-
cern to public health. In the United States, alcohol is the third leading preventable
cause of death, causing the premature death of thousands of people as well as caus-
ing illness and injury. The field of public health seeks to understand alcohol use as
well as to curb its negative health impacts, in contrast to its very different picture
in popular culture.
Alcohol’s role in global public health is summarized in the following key facts
(WHO, 2014):
• Worldwide, 3.3 million p eople die e very year due to harmful use of alcohol,
which represents 5.9 percent of all deaths.
• The harmful use of alcohol is a causal factor in more than 200 disease and
injury conditions.
• Overall 5.1 percent of the global burden of disease and injury is attributable
to alcohol.
• Alcohol consumption c auses death and disability relatively early in life. In the
age group 20 to 39 years approximately 25 percent of the total deaths are
attributed to alcohol.
In 2013 in the United States, roughly half (52.2 percent) of those 12 years old
or greater are drinkers of alcohol, according to the National Survey on Drug Use
and Health. Nearly one-fourth (22.9 percent) of those 12 and older w ere binge
drinkers (sometimes called heavy episodic drinkers). Binge drinking is usually
defined for females as consuming four or more drinks in a row, and for males as
consuming five or more drinks, at least once in 30 days. Rates of current drinking
among youth aged 18 to 25 are 11.6 percent in 2013, with 6.2 percent of youth
binge drinking.
Harm to individual health from alcohol use includes its role as a h
uman carcinogen
(a cause of cancer). A substantial portion of liver cancer; cancers of the throat,
mouth, and esophagus; and breast cancer in women are attributable to alcohol use.
Many instances of liver cirrhosis are attributable to alcohol. Alcohol use by preg-
nant women poses a risk to the healthy development of the fetus. Many cases of
heart disease and hemorrhagic stroke are alcohol-attributable, though alcohol
in modest or small amounts is protective of heart disease and stroke. A pattern of
binge or heavy episodic drinking appears to carry increased risk for some cardio-
vascular problems such as stroke and sudden cardiac death. Alcohol intoxication
ALC OHOL 31
plays a significant role in unintentional injury, including motor vehicle accidents,

falls, drownings, and poisonings. As for intentional injuries, homicides, suicides,
and self-inflicted injuries are linked to alcohol use. Alcohol is often a primary com-
ponent of sexual assault and rape.
A major public health issue is driving a car under the influence of alcohol. In
2013, 1 in 10 Americans 12 or older drove under the influence, with the highest
rates among t hose in their twenties. Traffic accidents remain the single greatest cause
of death for young Americans. But the minimum drinking age of 21, along with
other reforms such as random breath testing and increased drunk driving penal-
ties, has led to a substantial drop in the death rate in this area.
Of particul ar concern for individual health is establishing whether an individual
has a continuing problem with alcohol. Earlier concepts such as alcoholism and
alcohol abuse and dependence have given way to the phrase “alcohol use disorder” or
AUD. An AUD is defined by the presence in an individual of at least two symptoms
such as unsuccessful efforts to cut down use, craving, use despite problems, haz-
ardous use, and tolerance. The AUD is classified as e ither mild (with two to three
symptoms), moderate (with four to five), or severe (with six or more symptoms).
Using these criteria, roughly 7.2 percent of Americans between the ages of 18 and
older had an AUD in 2012 (9.9 percent of men and 4.6 percent of w omen). But
only 8.4 percent of adults with an AUD received treatment. Of youth aged 12 to
17, 3.4 percent had an AUD, with only 8.9 percent of them receiving treatment.
Treatment for alcohol use disorders can range from inpatient care using pharma
ceuticals to many varieties of outpatient care, including psychotherapy and group
treatment. Many millions of problem drinkers have found that participation in Alco-
holics Anonymous and its 12-step program is helpful in seeking sobriety.
The U.S. Community Preventive Services Task Force suggests the following strat-
egies to reduce the harmful effects of alcohol: regulating of the density of alcohol
outlets, dram shop liability (making t hose who sell alcohol liable for serving intox-
icated patrons), increasing taxes on alcohol, monitoring the days and hours of the
sale of alcohol, electronic screening and brief interventions, and enhancing the
enforcement of laws that prohibit sales to minors.
There is a large gap between the costs of excessive alcohol consumption to soci-
ety and how much revenue alcohol taxes generate. In 2006, excessive drinking cost
an estimated $224 billion dollars or $1.90 per alcoholic drink (Bouchery, Harwood,
Sacks, Simon, & Brewer, 2011). Binge drinking cost an estimated $171 billion,
underage drinking cost an estimated $25 billion, and drinking during pregnancy
cost an estimated $5 billion. The estimated costs are calculated by examining the
major social factors impacted by alcohol use and abuse. When someone drinks
alcohol, this may have implications on work productivity, health status, or legal
ramifications. In the workplace, excessive alcohol can lead to illnesses, disability,
premature death, or absenteeism related to addiction treatment, alcohol-related
diseases, court appearances, or incarceration. Health care costs increase for those
who drink because alcohol is a toxin that damages the heart, brain, liver, and other
32 AL C OHOL
gastrointestinal organs. Alcohol impairs decision making, which increases risk of

motor vehicle crashes, sexually transmitted diseases, and intentional and uninten-
tional injuries. Drinking during pregnancy can lead to fetal alcohol syndrome (FAS),
spontaneous abortion, prematurity, and low birth weight. Alcohol is a major factor
behind many crimes. In 2006, criminal justice expenses related to alcohol were esti-
mated at $73 billion (Bouchery et al., 2011). Criminal justice costs result from
property damage, medical care, policing, court costs, incarceration, and lost pro-
ductivity. Overall, alcohol costs an average to $746 per person in the United States.
Although everyone bears the cost of excessive drinking, the federal, state, and local
governments bear the largest cost, paying $94 billion or 80 cents per alcoholic drink.
In comparison, federal and state taxes amount to only 14 cents per drink, leaving
a gap between tax and cost.
In summary, harmful alcohol use poses a major challenge to public health, but
public health, in spite of financial and cultural challenges, has made considerable
advances in understanding alcohol and in creating responses that can limit its harm.
George W. Dowdall
See also: Addictions; Adverse Childhood Experiences; Behavioral Health; Birth

Defects; Cancer; Heart Disease; Hepatitis; Infant Mortality; Injuries; Leading Health
Indicators; Men’s Health; M ental Health; M ental Illness; Motor Vehicle Safety;
National Institute on Drug Abuse; National Institutes of Health; Prevention; Public
Health in the United States, History of; Substance Abuse and Mental Health Ser
vices Administration; Violence; Controversies in Public Health: Controversy 2
Further Reading
Bouchery, E. E., Harwood, H. J., Sacks, J. J., Simon, C. J., & Brewer, R. D. (2011). Eco-
nomic costs of excessive alcohol consumption in the U.S., 2006. American Journal of
Preventive Medicine, 41(5), 516–524.
Bouchery, E. E., Harwood, H. J., Sacks, J. J., Simon, C. J., & Brewer, R. D. (2013). Correc-
tion: Economic costs of excessive alcohol consumption in the U.S., 2006. American Jour-
nal of Preventive Medicine, 44(2), 198.
Naimi, T. S. (2011). The cost of alcohol and its corresponding taxes in the US: A massive
public subsidy of excessive drinking and alcohol industries. American Journal of Pre-
ventive Medicine, 41, 546–547.
National Institute on Alcohol Abuse and Alcoholism. (2013). Alcohol use disorder: A com-
parison between DSM-IV and DSM-5. Bethesda, MD: National Institute on Alcohol Abuse
and Alcoholism.
National Institute on Alcohol Abuse and Alcoholism. (2014). Alcohol facts and statistics.
Retrieved from http://pubs.niaaa.nih.gov/publications/AlcoholFacts&Stats/Alcohol
Facts&Stats.p
df.
National Institute on Alcohol Abuse and Alcoholism. (2014). Rethinking drinking: Alcohol
and your health. Retrieved from http://rethinkingdrinking.niaaa.nih.gov.
Room, R., Babor, T., & Rehm, J. (2005). Alcohol and public health. The Lancet, 365,
519–530.
ALZ HEI M E R ’S DISEASE ( AD ) 33
Substance Abuse and M ental Health Services Administration. (2014). Results from the 2013
National Survey on Drug Use and Health: Summary of national findings. NSDUH Series
H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and
Mental Health Services Administration.
U.S. Centers for Disease Control and Prevention. (2014). Alcohol and public health home page.
Retrieved from http://www.cdc.gov/alcohol/.
World Health Organization. (2014). Alcohol fact sheet. Retrieved from http:www.who.int
/mediacentre/factsheets/fs349/en/.
ALZHEIMER’S DISEASE (AD)

More than 5.3 million Americans suffer from Alzheimer’s disease (AD), a chronic
disease characterized by gradual m ental and physical deterioration (Alzheimer’s
Association, 2015c). AD is a form of dementia that mostly affects people over the
age of 65. On any given day, normal, healthy, and alert individuals may forget the
name of someone they just met or where they placed their house keys. But with
AD, memory loss is more severe. P eople with AD may not remember the name or
face of a close family member, the tasks of common jobs that they worked at for
20 to 30 years, or familiar activities, such as driving. In the United States, AD is cur-
rently the sixth leading cause of death, and while the disease primarily affects people
over 65, adults may succumb to AD at younger ages (Alzheimer’s Association, 2015a;
Hebert et al., 2013). The gradual physical and cognitive decline of AD places enor-
mous burdens on f amily caregivers, public health systems, and long-term care insti-
tutions. The person with AD needs close supervision and help with normal daily
activities, such as dressing, bathing, and eating. As life expectancy increases and
the baby-boomer generation ages, public health researchers are challenged with
finding ways to improve early diagnosis and support long-term care for t hose affected
by AD. Support of family caregivers is particularly important with AD, and the les-
sons learned by improving social support could have application to caring for p eople
with other chronic, degenerative diseases.
AD was first identified by Dr. Aloysius “Alois” Alzheimer (1864–1915). Alzheimer
was a German doctor specializing in psychiatry. At the time that Alzheimer prac-
ticed medicine, little was known about mental illnesses or neurological diseases.
While diagnosing and treating patients with m ental disorders, Alzheimer noticed
differences and similarities between the symptoms and disease progression exhib-
ited among his patients. The variety of diseases and how the diseases represented
in the body and the mind puzzled Alzheimer. It is difficult to study the brain because,
unlike other organs and tissues, doctors cannot simply cut open the brain to see
how it works. We learn how various parts of the brain work when people undergo
insult to specific regions of the brain through traumatic brain injuries, strokes, or
tumors. But Alzheimer was in a unique position to observe various disorders related
to the brain, and he quickly became involved in the field of neuropathology, the
study of diseases of the nervous system. In 1901, Alzheimer met Frau Auguste Deter,
a 51-year-old woman with unique symptoms of early memory loss. Her young age
34 ALZHEI M ER ’S DISEASE (AD )
and rapid neurological deterioration perplexed Alzheimer. For the next five years,
he directly and indirectly followed Deter’s progress. Her symptoms and neurologi-
cal deterioration were carefully documented by doctors and nurses u ntil her death
in April 1906.
In an effort to understand her disease process, Alzheimer obtained Deter’s brain
tissue and her medical records. He intended to visually examine the tissue—a tech-
nique that would have had limited application. Coincidentally, a colleague of
Alzheimer’s—Dr. Franz Nissl—had recently refined a technique called silver stain-
ing, which allowed scientists to visualize brain tissue u nder the microscope. Using
Nissl’s silver staining technique, Alzheimer could more clearly study Deter’s brain
tissue. The examination revealed two abnormal structures. Areas within the nerve
cells that should have been straight w ere tangled, and areas between nerve cells
that should have been clear contained sticky clusters. These abnormalities were aptly
named “tangles” and “plaques” (Engelhardt & da Mota Gomes, 2015). Alzheimer’s
studies were groundbreaking because it was the first time that samples of brain tis-
sue were matched with the clinical history of a patient. He continued his research
of neurological diseases u ntil his death at the age of 51.
In individuals affected by AD, beta-amyloid proteins misfold and cause block-
age in the brain’s vessels, called plaques. Tangles, likewise, are caused by tau pro-
teins that become twisted into fibers. T hese strange structures block blood vessels
and interfere with nutrients reaching the brain cells. Signals in and to the brain are
no longer able to function properly. With continued malnourishment, the brain
matter and neurons eventually die, and connections in the brain are lost. The ves-
sels that create and recall new memory are affected first. And as memory continues
to deteriorate, individuals struggle with long-term information. Plaques and tan-
gles develop as a part of aging, but they develop at a much higher rate in those
affected by AD.
In public health, early diagnosis of the disease is important b ecause it expands the
choice of available treatment options, makes it easier to prevent complications, and
increases ability to access support systems. Once the disease has progressed, treat-
ment options may be limited. Early diagnosis of AD is challenging, though, because
diagnosis is made based on symptoms reported by the patient or caregivers, and the
patient or family caregiver may focus on what seems to be more pressing health
issues. Minor symptoms of forgetfulness may not be considered important at the
time of the medical appointment. The Behavioral Risk Factor Surveillance System
estimates that one out of eight adults over the age of 45 experiences some memory
loss, yet 77 percent have never reported the problem to their health care provider.
AD progresses in three stages. The presymptomatic or preclinical phase occurs as
the plaques and tangles are initially forming. This stage can last several years and
is frequently undiagnosed. The person appears to have no noticeable symptoms. In
the predementia phase, early memory and functional impairment is mild but pres
ent and visible to others. The person may exhibit psychological changes and some
mild forgetfulness, such as having trouble remembering something that they were
ALZ HEI M E R ’S DISEASE ( AD ) 35
just told, or they may forget someone’s name or have difficulty with planning. Both
the individual and family members may experience frustration with the repeated
forgetfulness. Mild symptoms may go unreported unless the health care professional
anticipates AD and screens for symptoms, using specific questions. During the third
phase of clinical dementia, cognitive and functional deficiencies are clearly present
and easily diagnosed. At this point, large amounts of plaques and tangles can be
detected in the vessels of the brain (De-Paula et al., 2012). Individuals may forget
important events in their life, such as where they went to school. They may have
trouble expressing themselves verbally, they may need help in getting dressed, or
they may have loss of bowel and bladder control. Sufferers often reverse day and
night activities, such as sleeping during the day and staying awake at night. Per-
sonality changes appear. The person may feel confused, frustrated, or suspicious
and may withdraw, wander off, or engage in compulsive behaviors, such as wring-
ing of the hands or shredding tissues. In later stages of AD, p eople lose the ability
to care for themselves. They have difficulty communicating, walking, and perform-
ing personal hygiene. Eventually, the person has difficulty swallowing, and the body
is at increased risk for malnutrition and infections. The body w ill eventually suc-
cumb to the physical deterioration of AD.
Increased awareness, research, and changes in practice are improving early diag-
nosis and treatment. Health practitioners are refining ways to screen for and diag-
nose AD. Rather than asking patients if they experience forgetfulness or difficulty
planning, the health care provider asks patients how their memory compares to
the past. This allows health care providers to use the individual’s own experiences
as a baseline for comparison. The term “subjective cognitive decline” is used to
describe this memory loss (Reisberg et al., 2010), and focuses on using the patient’s
own experiences of memory and cognition to diagnose early AD, rather than com-
paring the patient to others. Although t here is no cure for AD, pharmacologic treat-
ments are available to ease disease-related symptoms (such as agitation and anxiety)
and slow its progression.
Currently on the market are four medications thought to help slow the progres-
sion of AD called acetylcholinesterase inhibitors (AChEIs). These include tacrine,
donepezil, rivastigmine, and galantamine. Another medication is memantine, which
works against the nerve cell receptor N-methyl-D-aspartate (NMDA) to help reduce
abnormal activity in the brain. Although medications may ease some of t hese symp-
toms and potentially relieve caregiver burden, t hese medications contain side effects
such as nausea, vomiting, diarrhea, increased confusion, and dizziness (National
Institute on Aging, 2015). Current research seeks to identify the best combination
of drugs that will provide optimal benefit for patients (Shao, 2015).
As AD gradually robs the victim of personality, independence, and abilities, family
and other loved ones struggle to provide safety and around the clock care. Most
families must make the difficult decision of placing the individual in long-term care
or caring for the person at home. The continued loss of memory and the inability
to perform basic daily activities places great demands on spouses, partners, family
36 AL Z HEI M ER ’ S DISEASE ( AD )
members, and friends. Depression and anxiety are common among those taking
care of p
eople affected by the disease (Gallagher et al., 2011). Additionally, the care-
giver may be experiencing his or her own issues related to physical aging and
changing social demands. Supporting caregivers and finding ways to improve care-
giver coping mechanisms have become a focus of current research.
As the numbers of people suffering from AD and dementia continue to grow,
public health focuses on early diagnosis, improved quality of life, preventing com-
plications, unnecessary hospitalizations, and reducing the financial and emotional
cost of care. It is believed that if we can determine AD at an earlier age, more sup-
portive measures can be put into place to help the patient, caregivers, and family
members. New tests are being developed to identify AD earlier and to identify if
a person is at risk for development of AD. Pharmaceutical researchers will con-
tinue to identify new medications and possible cures for AD. Caregivers play a
vital role in helping the individual stay healthy and safe for as long as possible.
And while family and community caregivers provide a valuable resource, serving
the needs of those with AD and reducing the financial cost, it is important that
society takes responsibility to support the caregiver. The information learned from
this unique brain disease and the systems developed to support t hose with AD may
be used to help other people struggling with other chronic, degenerative diseases.
Eileen L. Sullivan and Sally Kuykendall
See also: Aging; Chronic Illness; Genetics; M

ental Health; National Institutes of
Health; Social Determinants of Health
Further Reading
Alzheimer’s Association. (2015a). Alzheimer’s disease and dementia. Retrieved from http://www
.alz.org/.
Alzheimer’s Association. (2015b). Public health Alzheimer’s Resource Center. Retrieved from
http://www.alz.org/publichealth/data-collection.asp.
Alzheimer’s Association. (2015c). 2015 Alzheimer’s disease facts and figures. Alzheimer’s &
Dementia: The Journal of the Alzheimer’s Association, 11(3), 332–384.
Alzheimer’s Foundation of America. (2015). Alzheimer’s disease and caregiving support.
Retrieved from http://www.alzfdn.org/.
De-Paula, V. J., Radanovic, M., Diniz, B. S., & Forlenza, O. V. (2012). Alzheimer’s disease.
Sub-Cellular Biochemistry, 65, 329–352.
Engelhardt, E., & da Mota Gomes, M. (2015, February). Alzheimer’s 100th anniversary of
death and his contribution to a better understanding of senile dementia. Arquivos de
Neuro-Psiquiatria, 73(2), 159–162.
Gallagher, D., Ni Mhaolain, A., Crosby, L., Ryan, D., Lacey, L., Coen, R. F., & . . . Lawlor, B. A.
(2011). Self-efficacy for managing dementia may protect against burden and depres-
sion in Alzheimer’s caregivers. Aging & Mental Health, 15(6), 663–670.
Hebert, L. E., Weuve, J., Scherr, P. A., & Evans, D. A. (2013, May 7). Alzheimer disease in
the United States (2010–2050) Estimated Using the 2010 Census. Neurology, 80(19),
1778–1783.
AMERICA N JO UR NA L O F P UB L I C H EA LTH ( A JP H ) 37
Maurer, K., & Maurer, U. (2003). Alzheimer: The life of a physician and career of a disease.
New York: Columbia University Press.
National Institute on Aging. (2015, June). Alzheimer’s disease medications fact sheet. Retrieved
from https://www.nia.nih.gov/alzheimers/publication/alzheimers-disease-medications.
Reisberg, B., Shulman, M. B., Torossian, C., Leng, L., & Zhu, W. (2010, January). Outcome
over seven years of healthy adults with and without subjective cognitive impairment.
Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 6(1), 11–24.
Shao, Z.-Q. (2015). Comparison of the efficacy of four cholinesterase inhibitors in combi-
nation with memantine for the treatment of Alzheimer’s disease. International Journal of
Clinical and Experimental Medicine, 8(8), 2944–2948.
AMERICAN JOURNAL OF PUBLIC HEALTH (AJPH)

The American Journal of Public Health (AJPH) is the official journal of the American
Public Health Association. First published in 1911, the journal is considered pub-
lic health’s premier journal. Professional journals allow researchers and practition
ers to share information quickly and effectively in order to advance the field and
improve practice. AJPH presents current issues in public health, law and policy, new
research, and job postings. The mission of the journal is “to advance public health
research, policy, practice, and education” (AJPH).
Public health professionals are expected to stay current in the field so that they
can provide the best possible care to patients and communities. The AJPH supports
professional competency through regular features in best clinical practices, research,
program evaluation, case studies, history, and commentary of old and new prob
lems. Journals have an advantage over books in that they have a shorter publica-
tion time. Health information changes rapidly. Books may take several years from
writing to publication, whereas journal articles may be reviewed and published
within months. The faster turnaround time makes professional journals the ideal
first venue for emerging health problems or critical research findings.
Submissions to the AJPH are reviewed by three peer reviewers, associate editor,
deputy editor, and editor in chief. Each reviewer critically evaluates the article to
ensure that the information has scientific foundation, is not exaggerating findings,
and follows ethical standards in research and public health. Fewer than one in five
articles submitted are accepted for publication. More recently, Kevin Smith, direc-
tor of Office of Copyright and Scholarly Communications at Duke University, criti-
cized the AJPH extending limitations on public access to published articles. When
authors submit an article for publication, they transfer copyright to the publisher.
Transferring copyright ensures that the author does not publish the same work in
multiple venues, protecting the publisher’s financial investment in reviewing and
editing the article. Previously, the AJPH restricted public access to articles for an
embargo period of two years. Only people who paid for the journal or had access
through library databases could access articles published within the last two years.
Authors could opt for their article to be freely accessible by compensating the pub-
lisher. In 2013, AJPH extended the embargo period to 10 years and increased the
38 A ME R I C AN M EDI C AL ASSO CIATION ( AM A)
author fee for open access to $2,500. Smith notes that a 10-year embargo period
seems excessive given the critical nature of public health information and the fact
that the AJPH frequently reports findings from taxpayer-funded research. Research
funded by taxpayers should be freely available u nder the public access to govern-
ment data laws.
Professional journals are critically important to health professionals and the gen-
eral public because they ensure that current practices are based on good science.
Sally Kuykendall
See also: American Public Health Association; Core Competencies in Public Health;
Winslow, Charles-Edward Amory
Further Reading
American Journal of Public Health. Retrieved from http://ajph.aphapublications.org.
Smith, K. L. (2013). Of predators and public health: Peer to peer review. Library Journal.
Retrieved from http://lj.libraryjournal.com/2013/05/opinion/peer-to-peer-review/of
-predators-and-public-health-peer-to-peer-review/#.
AMERICAN MEDICAL ASSOCIATION (AMA)

The American Medical Association (AMA) is the largest national professional
organization of medical residents, physicians, and medical students in the United
States. It was founded in 1847 and supports excellence in medical education and
physician practice with the overall goal of promoting health among all p eople in
the nation.
The AMA was founded by Nathan Smith Davis (1817–1904). Davis’s experiences
in early life greatly influenced his attitudes and values t oward medical training and
the medical profession. Growing up in a log cabin in upstate New York, Davis found
value and reward in hard l abor ( Johnson, 1904). In summers, he tended the f amily
farm, and in winter he attended school. He started medical training at the age of
17 and, soon a fter turning 20, graduated from the College of Physicians and Sur-
geons of New York. In his early medical career, Davis worked tirelessly on behalf
of his patients and advocated for rigorous medical training to ensure that others
practicing medicine were competent.
Recognizing the need to change medical training from within the academic sys-
tem, Davis became a professor at the College of Physicians and Surgeons of New
York. He later moved to Lind University in Chicago, now known as Northwestern
University. The AMA originated in 1845 when Davis chaired a committee to orga
nize the first national convention of medical societies and medical schools. This
event served as the foundation for the AMA. A prolific writer and editor of several
notable medical journals, Davis also served as the founding editor of the Journal of
the American Medical Association ( JAMA), which is still one of the most prestigious
AME R I C AN M EDI C AL ASSO C IATION ( A M A ) 39
medical journals in the world. Davis made a tremendous impact on the field of medi-
cine as a profession. Much of his stamina, efficiency, organization, and high stan-
dards had been a direct result of his farming work ethic.
The AMA currently serves approximately 225,000 members, representing about
one-fourth of the physicians in the United States. Its primary goals are to reduce
disease and improve public health, support and advance medical education, and
support doctors as independent practitioners and sources of credible medical infor-
mation. The AMA is important to public health in that the organization defines
standards for physician practices. Naming and sharing best practices with doctors
ensures that patients receive the best possible medical care and that communities
are well informed of potential health hazards and ways to minimize hazards. The
AMA provides members with many benefits, including continuing education, infor-
mation on best practices in medicine and patient safety office administration and
management, discounted insurance and other products, opportunities for profes-
sional networking, forums on health policy, and political advocacy. The AMA also
publishes several medical journals, including JAMA. To achieve healthy communi-
ties, the organization offers grants to promote healthy living, healthy communities,
and health literacy; scholarships to train f uture physicians; and presents awards to
medical students, residents, and physicians who advance the stature of the profes-
sion through volunteering, leadership, or professionalism. Criticisms of the AMA
center on past and current political activities. Historically, the AMA resisted gov-
ernment involvement in health care programs, such as Medicare and health care
reform, and advocated for limits to medical malpractice lawsuits. In order to achieve
the goals of improving public health and advocating for physician members, the
AMA must carefully balance responsibility to the public with responsibility to
physicians.
In private practice, health professionals work independently. This means that per-
sonal values, experiences, and priorities can influence patient care. The caregiver
may not consciously recognize the influence or may have difficulty with differing
points of view. For example, the pharmaceutical sales representative who visits phy-
sicians in their office and encourages them to prescribe specific medicine has the
opportunity to unduly influence patient care. To help guide patients, doctors, resi-
dents, and medical students, the AMA has a medical ethics division. The group
reviews the latest research in different areas, identifies ethical challenges, and devel-
ops guidelines for practice. The guidelines are directed by the core values of pro-
fessionalism, honor, compassion, and respect. The guidelines are described in the
AMA Code of Medical Ethics and cover topics such as social issues, professional
relations, advertising, fees, patient records, and professional rights and responsibili-
ties. But these guidelines are guides, not laws or policies. By advocating for doctors
to act as competent, professional, and knowledgeable caregivers, the AMA ensures
patients receive the best care possible.
Sally Kuykendall
40 A ME R I C AN PU BLI C HEALTH ASSO C IATION ( APHA )
See also: Code of Ethics; Core Competencies in Public Health; Ethics in Public
Health and Population Health; Health Insurance Portability and Accountability
Act of 1996; Health Resources and Services Administration
Further Reading
American Medical Association. (2014). Code of medical ethics of the American Medical Asso-
ciation, 2014–2015: Current opinions with annotations. Chicago, IL: American Medical
Association Press.
American Medical Association. (2015). About AMA. Retrieved from http://www.ama-assn
.org/ama.
Danforth, I. N. (1907). The life of Nathan Smith Davis, A.M., M.D., LL.D., 1817–1904. Cleveland:
Cleveland Press. Retrieved from https://books.google.com/books?i d=HRUJAAAAIAAJ&pg
=PA20&lpg=PA20&dq=the+life+of+nathan+smith+davis&source=bl&ots=v3UxFIsG
-8&sig=gSiVuHstGuKdZXTFG2jRrfVWRio&hl=en&sa=X&ved=0ahUKEwiLvqOZm
4XNAhVCJFIKHaLSAGIQ6AEIUDAN#v= o nepage&q= t he%20life%20of%20
nathan%20smith%20davis&f=false.
Johnson, F. S. (1904). Nathan Smith Davis. Science, 20, 237–240.
Jonsen, A. R. (2008). A short history of medical ethics. New York: Oxford University Press.
AMERICAN PUBLIC HEALTH ASSOCIATION (APHA)

The American Public Health Association (APHA) is the primary professional organ
ization of public health practitioners, administrators, researchers, and educators
in the United States. The organizational mission of the APHA is to “improve the
health of the public and achieve equity in health status” (APHA, 2017). Strategi-
cally, this mission is achieved by (1) building a public health movement that
sustains and advances core functions; (2) strengthening public health practice
through cross-cultural, interdisciplinary teams; and (3) aligning organizational
capacity and infrastructure. To promote advances within the major public health
disciplines, APHA members can chose from 31 different member sections. Exam-
ples of sections include alcohol, tobacco, and other drugs; epidemiology; environ-
ment; food and nutrition; health administration; injury control and emergency
health services; mental health; occupational safety and health; oral health; public
health social work; and vision care. Special Interest Groups (SPIGs) in pharmacy
and veterinary public health bring together members of common occupations with
unique perspectives. The Student Assembly (APHA-SA) connects students who
are interested in working together on public health-related issues. And while
APHA provides discipline-specific sections and SPIGs, anyone who is interested
in public health is welcome and eligible to join the organization. APHA recog-
nizes that advancing the health of the nation requires many different skills,
diverse expertise, and cultures. APHA seeks to join skills and perspectives opti-
mizing available talent and promoting public health.
APHA member benefits include access to news, professional development, net-
working, and other resources. APHA offers several news outlets and professional
A ME R I CANS W ITH DISA B ILITIES A C T ( ADA ) 41
journals. Available in both hard copy and electronic format, the American Journal
of Public Health (AJPH) is a monthly, peer-reviewed professional journal that covers
the latest research and evidence-based practices as well as editorial, historical, and
special reports. The Nation’s Health is published 10 times per year. The Nation’s Health
features the latest public health news and policies presented in a newspaper for-
mat. APHA Press publishes books and periodicals on public health topics. Inside
Public Health is APHA’s monthly newsletter covering public health news and profes-
sional events.
Members have an opportunity to network with other public health professionals
through APHA’s professional communities, committees, forums, and assemblies.
APHA’s Annual Meeting and Expo is the world’s largest gathering of public health
professionals. Each year, more than 12,500 professionals gather to share ideas, con-
cerns, and evidence-based practices, acquire new information, peruse the latest
resources and publications and to support one another. The Public Health CareerMart
lists jobs for public health professionals. The C
areer Development Center provides
discounted professional c areer services, such as résumé review and c areer coach-
ing. APHA supports student members and early career professionals with discounted
membership rates and specialized resources.
The APHA supports public health practitioners by communicating science, pol-
icies, news, concerns, and advancements related to public health practice. In sup-
porting public health professionals, the organization plays a key role in improving
health of current and future generations of Americans.
Sally Kuykendall
See also: American Journal of Public Health; Certified in Public Health; Code of Eth-
ics; Core Competencies in Public Health; Cornely, Paul B.; Eliot, Martha May; Nation’s
Health, The; Public Health in the United States, History of; Society of Public Health
Education; Wegman, Myron Ezra; Winslow, Charles-Edward Amory
Further Reading
American Public Health Association. (2017). Retrieved from https://www.apha.org/.
AMERICANS WITH DISABILITIES ACT (ADA)

The Americans with Disabilities Act (ADA) was passed into law by George H. W.
Bush on July 26, 1990. The act specifically prohibits discrimination to an individ-
ual with a qualified disability by employers; this includes federal, state, and local
government agencies. The ADA defines a covered employer as one who employs
15 or more workers. The ADA was molded a fter the Civil Rights Act of 1964 and
section 504 of the Rehabilitation Act of 1973. The ADA guarantees that p eople with
disabilities are provided the same opportunities as all others who “purchase goods
and services, as well as participate in state and local government programs and
42 AM ER IC ANS WITH DISABILITIES ACT (ADA )
services” (Department of Justice, 2017). The ADA is relevant to public health in

that it ensures that p eople with disabilities have the same rights and privileges in
seeking, attaining, and maintaining employment as abled-bodied people. The abil-
ity to engage in meaningful employment is a critical aspect of mental and physical
health.
A disabled person is defined as one who has a “physical or m ental impairment
that affects one or more major life activity, the impairment is recorded, or is regarded
as having such impairment” (Equal Employment Opportunity Commission, 2017).
A person (employee or applicant) who encompasses any of the above is one, who
with or without satisfactory accommodation can properly perform the fundamen-
tals of his or her job descriptions. Satisfactory accommodations are making the
workplace accessible, offering alternative work schedules, reassessment of job duties,
offering another unfilled position, modifying work equipment, or having training
resources available in braille or through interpreters.
The employer is required to make the appropriate adjustments so long as it
does not cause any difficulty on the employer’s business. According to the ADA,
“a hardship is defined as an action requiring significant difficulty or expense in rela-
tion to the size of the organization, financial resources, or the nature and structure
of the organization” (Equal Employment Opportunity Commission, 2017). Fur-
thermore, the employer does not have to provide any of the above changes unless
The Americans with Disabilities Act ensures that people with disabilities enjoy the same
opportunities to work, shop, travel, and visit public places as enabled people. (U.S. Census
Bureau)
A ME R I CANS W ITH DISA B ILITIES A C T ( ADA ) 43
they are requested by the employee. The business does not have to change their
standard of operation to make such accommodations. The employer reserves the
right to meet with the employee if their disability is resulting in poor perfor
mance or disciplinary issue. At this time, the employer can inquire how to
assist in correcting the negative issues and if the accommodation is ultima
tely required. If t here are multiple accommodations requested, then it is up to the
employer to determine the most cost effective or least imposing adjustment to their
organization.
The ADA also prohibits the employer’s ability to ask medical related questions
such as “the existence, nature, or severity of a disability” (Equal Employment Opport
unity Commission, 2017). Medical questions can only be asked if it was required
during the application process or o thers with similar position are required to
disclose such information. Employers must protect an employee’s records espe-
cially those relating to health conditions. They are forbidden to provide an
employee’s direct supervisor any information relating to diagnosis or course of
treatment. Finally, employers may not terminate or discriminate against t hose who
have requested, filed a complaint, or actively engaged in litigation u nder the ADA.
Although employers are bound by the strict regulations of the ADA, the employee
also has responsibilities and guidelines to follow. Those who are actively participat-
ing in the use of illegal drugs as defined by the federal government or alcohol abuse
are covered under the ADA. Furthermore, employers who require drug testing
are not in violation of the ADA and can hold t hose employees accountable.
The Americans with Disabilities Act protects and ensures that any employee with
a qualified disability is not discriminated against. To ensure that the regulations are
being followed, there are four governmental agencies tasked with enforcing the
regulations: the Equal Employment Opportunity Commission (EEOC), the Depart-
ment of Transportation, the Federal Trade Commission (FFC), and the Department
of Justice.
Leapolda Figueroa
See also: Disability; Disability Movement; Health; Leading Health Indicators; National
Institutes of Health; Obesity; Public Health Law; Social Security Act
Further Reading
Bayer, R. (2003). Workers’ liberty, workers’ welfare: The Supreme Court speaks on the rights
of disabled employees. American Journal of Public Health, 93(4), 540.
Department of Justice, Civil Rights Division. (2017). Introduction to the ADA. Retrieved from
https://www.ada.gov/ada_intro.htm.
Equal Employment Opportunity Commission. (2017). Facts about the Americans with Dis-
abilities Act. Retrieved from https://www.eeoc.gov//eeoc/publications/fs-ada.cfm.
Iezzoni, L. I., & O’Day, B. L. (2006). More than ramps: A guide to improving health care quality
and access for people with disabilities. New York: Oxford University Press. doi:10.1093
/acprof:oso/9780195172768.003.0002.
44 ANC IENT WORLD , PU BLIC HEALTH IN THE
Longmore, P. K. (1987). Uncovering the hidden history of people with disabilities. Reviews
in American History, 15(3), 355–364.
Shapiro, J. (1994). From charity to independent living. No pity: People with disabilities forg-
ing a new civil rights movement. New York: Times Books.
ANCIENT WORLD, PUBLIC HEALTH IN THE

The concept of public health, as we know it t oday, did not exist in the ancient world.
Public health measures w ere implemented primarily for aesthetic and religious rea-
sons, not as a form of disease control. Sewage was removed b ecause it was unsightly
and smelled, bathing was primarily a m atter of ritual purity, not cleanliness, and
medical care had more to do with magic than science. The study of public health
in the ancient world is an interdisciplinary effort engaging researchers from a num-
ber of fields including archaeology, paleobiology, history, linguistics, and entomol-
ogy, to name a few. The knowledge that we have about public health in the ancient
world comes primarily through the written records that w ere left b
ehind, and the
archeological evidence that has been uncovered. In all cases, the information is sub-
ject to interpretation, and these interpretations can change over time as new infor-
mation comes to light.
It is believed that h umans living in hunter-gather societies were beset by many
of the same illness that we still encounter today (Rosen, 1993). However, due to
the small size of these groups, and their limited contact with other h umans and
animals, epidemics of disease are thought to have been minimal, if they occurred
at all. As h
umans began to transition to an agrarian, settled existence, their interac-
tions with other p eople, and domesticated animals, increased, as did the popula-
tion. These interactions exposed humans to new and more numerous pathogens
and parasites than they had encountered in the past (Sherman, 2006). In addition,
nutritional deficiencies arose as diets became restricted to a few staple crops. They
also faced food insecurity issues due to the danger of crop failures caused by pes-
tilence or natural disasters. Problems with waste disposal and contaminated w ater
resources also occurred.
In dealing with the myriad of diseases and environmental problems that they
faced, most p eople in the ancient world turned t oward ritualistic cures. They viewed
disease, famine, and other ills as being caused by a god, spirit, or other supernatural
being. Consequently, they thought that the main way to cure the disease, or divert
a looming disaster, was to appease the offended entity. This was done with meth-
ods as benign as prayers or offerings of food, or on the other extreme, by perform-
ing human or animal sacrifices. The ancient peoples also thought that another source
of illness and misfortune could occur as a direct result of sorcery or the dead, each
of which required its own set of rituals to overcome. A part of this theurgical belief
was that cleanliness was a religious rite. People would bathe as a form of purifica-
tion before entering a temple or performing certain rituals. The Inca purification
AN C IENT WO R LD, PU B LIC HEALTH IN THE 45
festival of Citua, for example, required the act of ritual bathing and the purification
of homes with maize flour. These rituals w ere carried out as a means to rid the city
and its people of impurities, including illness (Staller, 2010). Many of these reli-
gious rituals and rules where codified, and they are known to us, in part, from the
surviving records.
Health care professionals in the ancient world ranged from medicine men and
shamans to physicians and midwives. In most ancient cultures, physicians used their
empirical knowledge in conjunction with magical spells or other rituals. Or, as in
Mesopotamia, they often worked in conjunction with a magician (Biggs, 2005). In
some regions, such as Sumeria, the priests not only served as religious and political
leaders, but they w ere also responsible for carrying out major public works proj
ects, such as the complex irrigation systems that brought water to farms and helped
to control flooding.
In addition, community leaders often used their influence to institute public
health projects. It is important to note that almost every ancient settlement that has
been studied, no m atter its size, shows evidence of some sort of sewage system.
These systems include what are thought to be the first flush toilets, dating to about
1850 BCE, which were found in Knossos on Crete. As well, excavations at Skara
Brae in the Orkney Islands of Scotland have uncovered small recesses in many of
the homes. These recesses, dating to around 3500 BCE, have drains in the floor
that lead outside and are thought to be primitive indoor toilets. In addition, most
of the large cities studied show evidence of detailed urban planning that included
not only the layout of the various towns, but also the development of w ater and
drainage systems, granaries, sewers, h ousehold plumbing, and systems to divert
storm runoff. A key example of the latter is the moats found around ancient Thai
villages that were uncovered at excavations in Ban Non Wat, Thailand. These moats
are thought to have served multiple purposes, including protection, but also as a
reservoir for water during the dry season and as a way to divert water away from
the villages during the wet seasons (Lawler, 2009). Examples of other towns that
show extensive urban planning include the ancient city of El Mirador, in Guate-
mala. This Maya pre-Columbian city is thought to have had more than 100,000
residents at its peak, and it appears to have been carefully laid out to coincide with
astronomical alignments of religious and agricultural significance (Sprajc, Morales-
Aguilar, & Hansen, 2009). The cities of Mohenjo-Daro and Harappa, located in the
Indus River Valley, are also thought to have been preplanned cities. They became
major urban centers around 2500 BCE. From the archaeological evidence that has
been uncovered, both of these cities featured paved streets, covered sewers, and a
complex water system that included indoor bathrooms. In addition, numerous
ancient cities uncovered throughout the Near East, Egypt, Asia, and Mesoamerica
all show evidence of urban planning.
There are many ancient Chinese medical texts that provide insights into the treat-
ment and theories about medicine in China. Two of them are attributed to mythical
46 AN C IENT W OR LD , PU BLI C HEALTH IN THE
emperors whose histories may have some basis in fact. The first of these is the
Emperor Shennong, who is credited with writing the Divine Husbandman’s Materia
Medica (Ben cao jing ji zhu), which lists various pharmaceuticals and how they were
made (Hsu & Harris, 2010). The other is the Yellow Emperor Huang Di, who is
credited with writing The Canon of Internal Medicine (Huangdi neijing), which offers
both magical and naturalistic explanations for the c auses of various diseases, along
with therapeutic treatments (Raphals, 2013). Although both emperors are thought to
have lived between 3000 and 2600 BCE, the actual books mentioned are not believed
to have been written until much later and are thought to be compilations of earlier
oral traditions and written texts (Hsu & Harris, 2010). Other texts that provide
insights into how residents of the ancient world viewed and treated illnesses included
the medical library of the Assyrian king, Ashurbanipal, held at Nineveh. It includes
descriptions of diseases, herbal remedies, and how to make and use various pharma
ceuticals. The Atharva Veda, a Hindu book of hymns from around 1500 to 1000 BCE,
includes spells and incantations that w ere used for medical purposes. Perhaps one of
the best-known texts to have survived from the ancient world is the Pentateuch (Five
Books of Moses), which contains a detailed list of prohibited foods, instructions on
cleanliness, and related issues that are thought to have had public health implica-
tions (Porter, 1998). Information on public health practices in the past have also
been garnered from the Mayan glyphs and Sumerian cuneiform writings, as well as
Egyptian medical papyri that include information on both the religious aspects of
healing as well as empirical-based observations. The Law Code of Hammurabi
includes references to malpractice by physicians. T here are letters from Kassite phy-
sicians discussing treatments, and many more examples, including the Mari letters,
from Mesopotamia, which deal with relocating people to try to stop the spread of
contagious illnesses (Biggs, 2005). In addition, there are still texts that have not been
translated, such as the writings left by the Harappan civilization that once flourished
in the Indus Valley region of ancient India. This is indicative of the fact that we still
have much to learn about public health in the ancient world, and that our current
understanding of the period is likely to change as new information is discovered.
Rochelle Caviness
See also: Greco-Roman Era, Public Health in the; Hippocrates; Infectious Diseases;
Locus of Control; M iddle Ages, Public Health in the; Modern Era, Public Health in
the; Renaissance, Public Health in the; Rosen, George; Spiritual Health
Further Reading
Biggs, R. D. (2005). Medicine, surgery, and public health in ancient Mesopotamia. Journal
of Assyrian Academic Studies, 19(1), 28–46.
Hsu, E., & Harris, S. (Eds.). (2010). Plants, health and healing: On the interface of ethnobotany
and medical anthropology. Volume 6 of Epistemologies of healing. New York: Berghahn
Books.
ANDER SON , ELI Z A B ETH M ILB ANK 47
Lawler, A. (2009, February). Bodies of evidence in Southeast Asia. Smithsonian Magazine,

39(11). Retrieved from http://www.smithsonianmag.com/history/bodies-of-evidence-in
-southeast-asia-44419614/?no-ist.
Porter, D. (1998). Health, civilization and the state: A history of public health from ancient to
modern times. New York: Routledge.
Raphals, L. (2013). Divination and prediction in early China and ancient Greece. New York:
Cambridge University Press.
Rosen, G. (1993). A history of public health: Expanded edition. Baltimore: Johns Hopkins Uni-
versity Press.
Sherman, I. W. (2006). The power of plagues. Washington, DC: Asm Press.
Sprajc, I., Morales-Aguilar, C., & Hansen, R. D. (2009). Early Maya astronomy and urban
planning at El Mirador, Peten, Guatemala. Anthropological Notebooks, 15(3), 79–101.
Staller, J. (2010). Maize cobs and cultures: History of zea mays l. New York: Springer.
ANDERSON, ELIZABETH MILBANK (1850–1921)

Elizabeth Milbank Anderson was an American philanthropist who used her wealth
and status to develop and promote public health. Elizabeth was born in New York
City (NYC) to parents Jeremiah and Elizabeth (Lake) Milbank. Jeremiah Milbank
was a wholesale grocer, banker, and financier. In 1858, he financed the struggling
New York Condensed Milk Company. The investment quickly paid off when the
U.S. government ordered 500 pounds of condensed milk for American Civil War
soldiers. When the veterans returned home, they continued to use the familiar prod-
uct. The company eventually became the Borden Condensed Milk Company with
Mr. Milbank as a stockholder. Milbank also invested in and became director of the
Chicago, Milwaukee, and St. Paul Railroad. Elizabeth’s early life was privileged. She
was taught by private tutors, attended religious services at Madison Avenue Baptist
Church, and traveled extensively. When her f ather died in 1884, Elizabeth inherited
$10 million, equivalent to $249 million today. In terms of economic power, the
influence and power to create further wealth, the inheritance would be equivalent
to $15.2 billion t oday.
On June 15, 1876, Elizabeth married Abraham Archibald Anderson (1846–1940).
A. A. Anderson was a portrait painter, born in Hackensack, New Jersey. He spent
10 years in Paris studying art with the masters, Léon Bonnat, Alexandre Cabanel,
Fernand Cormon, and Raphaël Collin. The couple had two c hildren, Eleanor (1878–
1959) and Jeremiah (c. 1879–1886). Jeremiah died of diphtheria at the age of seven.
Elizabeth blamed her son’s death on unsanitary conditions in New York City. At the
time, urban streets were filled with human waste, horse manure, and animal cadav-
ers. The decaying waste contaminated water sources. Crowded living conditions
resulted in multiple epidemics of cholera, diphtheria, typhus, and tuberculosis. The
loss of a child instilled a sense of determination. Elizabeth’s first public health effort
was building bathhouses, a place where the poor could bathe and maintain some
degree of personal hygiene. Elizabeth’s philanthropy was on the cusp of broader
48 ANDE R SON, ELIZ ABETH MILBANK
social reforms taking place around the nation. In 1889, steel industrialist Andrew
Carnegie published The Gospel of Wealth, calling on wealthy p eople to use their for-
tunes to benefit the poor. The Progressive Era (c. 1890–1920) was a period when
the wealthy attempted to bypass government corruption and give directly to col-
leges, hospitals, religious organizations, and science and community organizations,
which would benefit all of society.
Over time, A. A. Anderson and his wife developed separate interests and sepa-
rate lives. He split his time between Paris, New York, and their ranch in Wyo-
ming, advocating for preservation of national parks. President Theodore
Roosevelt named “Colon el” Anderson the first superintendent of the Yellowstone
Forest Reserve. In his 1933 autobiography, Experiences and Impressions: An Auto-
biography of Colonel A. A. Anderson, Anderson allocates three chapters to bear
hunts and little description of his wife and d aughter (Dickason, 2000). Unhin-
dered by marital responsibilities, Elizabeth took on the mission. In her mind, pre-
ventable disease and premature death were the main obstacles to human
happiness, and the government was primarily responsible for ensuring public health.
Her idea was to fill a void until the city was in a position to provide the necessary
social services.
In 1892, Elizabeth made her first major donation of $350,000 to Roosevelt
Hospital in New York City. Over the next two decades, she funded the Milbank
Public Baths for the New York Association for Improving the Condition of the
Poor, subsidized the NYC school hot lunch program, donated to the C hildren’s Aid
Society, and became trustee and supporter of Barnard College. During World War
I, Anderson supported orphans and homeless children of immigrant Europeans.
In 1905, with the help of her cousin, Albert G. Milbank, she established the Memo-
rial Fund Association. The mission of the organization was “to improve the physi-
cal, m
ental and moral condition of humanity and generally to advance charitable
and benevolent objects.” The foundation’s name was changed to the Milbank
Memorial Fund in 1921 in memory of her parents. The Milbank Memorial Fund
originally supported programs in public health and nutrition and established com-
munity health centers and dental clinics. In the 1920s, the fund expanded to sup-
port best practices in medical and health care delivery systems and health
demonstration projects. Overall, Mrs. Anderson endowed $9,315,175 to the Mil-
bank Foundation. The foundation continues today advancing evidence- based
practice in population health and studying social determinants of health.
In 1912, Elizabeth legally a dopted her granddaughter, Elizabeth Milbank Tan-
ner. Her daughter, Eleanor, had married medical doctor John Stewart Tanner. Tan-
ner had an extramarital affair and Elizabeth did not want her daughter to experience
the same, empty marital relationship, which she had endured. Elizabeth raised her
granddaughter while Eleanor studied at Boston University Medical School and
interned in NYC and Boston. Eleanor followed in her mother’s footsteps of social
activism, opening the Judson Health Center (1921) to serve the poor immigrant
Italian population living near Judson Memorial Church.
ANDE R SON , ELI Z A B ETH M IL B AN K 49
Elizabeth Milbank Anderson died of pernicious anemia on February 22, 1921.

At the time of her death, she held stock in Borden Company, Texas & Pacific Coal
& Oil Company, and Pacific Mutual Life Insurance Company and Liberty Bonds.
The major public health benefactors of her estate were the Memorial Fund Asso-
ciation ($1.5 million), National Committee for Mental Hygiene ($100,000),
Association for Improving Conditions of the Poor ($200,000), Henry Street
Settlement ($50,000), Harlem L egal Aid Society ($50,000), National Child L
abor
Committee ($25,000), and Tuskegee Institute ($25,000). Of her $7 million estate,
she left $50,000 to her husband, explaining that “ample provision had been made
for him previously” (New York Times, 1921). In the 1935 Annual Conference of
Secretaries of the County Medical Societies of Indiana, Albert G. Milbank remem-
bered his cousin’s contributions:
Elizabeth Milbank Anderson was one of those rare souls who combined a brilliant
mind, a love of humanity, a generous nature, and a keen sense of humor. She was an
unquestioned individualist but with a profound sense of her social obligations. She
mistrusted fads and visionary theories as solutions for current problems but the hon-
esty of her mind made it impossible for her to ignore a problem even when its solu-
tion called for changes in an established procedure.
Elizabeth believed that too many charities dealt with the symptoms of poverty, ignor-
ing the underlying urban and social problems. Her hope was that one day the
government would recognize the need for social services and finance public health
programs.
Elizabeth Milbank Anderson was a philanthropist who supported early public
health efforts in urban sanitation, women and c hildren’s health, and women’s edu-
cation. Her determination and support created public health programs in disease
prevention and health promotion, which benefit many p eople t oday.
Sally Kuykendall
See also: Baker, Sara Josephine; Children’s Health; Maternal Health; Social Determi-
nants of Health; Winslow, Charles-Edward Amory
Further Reading
Dickason, E. (2000). Eleanor Campbell. In E. Dickason & J. G. Dickason (Eds.), Remem-
bering Judson House (pp. 93–99). New York: Judson Church. Retrieved from http://classic
.judson.org/images/Judson_House_12_Elly_Dickason.p
df.
Milbank, A. G. (1935, January 27). Annual Conference of Secretaries of the County Medi-
cal Societies of Indiana in Indianapolis, IN. Yale University. Milbank Memorial Fund
papers, Sterling Library, Series II, Box 25. Retrieved from https://www.ncbi.nlm.nih.gov
/pmc/articles/PMC2690275/.
Miller, H. S., & Miller, H. S. (1971). Anderson, Elizabeth Milbank (Dec. 20, 1850–Feb. 22,
1921). In E. James, J. James, & P. Boyer (Eds.), Notable American women: 1607–1950.
Cambridge, MA: Harvard University Press.
New York Times. (1921, June 30). Half of $7,000,000 estate to public.
50 ANTIBIOTIC RESISTANCE
ANTIBIOTIC RESISTANCE
Antibiotics could be one of the most important public health advances ever. Before
the discovery of antibiotics, infectious diseases were the leading cause of death
worldwide. The use of antibiotics to prevent and control bacterial infections sig-
nificantly increased average life expectancy by reducing death and disability due to
communicable diseases. The list of antibiotics approved by Federal Drug Adminis-
tration (FDA) is extensive, but the main challenge in using antibiotics is that bac-
teria are living organisms that can adapt to changes in their environment.
Antibiotic resistance is the ability of bacteria to change so it is no longer destroyed
by an antibiotic. Resistance develops when a person misses critical doses, stops the
doses prematurely, or overuses or misuses antibiotics, such as using an antibiotic
for a viral infection rather than bacterial infections. Even though a person may take
an antibiotic in the correct manner and for the correct duration, the bacteria may
still resist its effect. In 2013, the Centers for Disease Control and Prevention (CDC)
reported more than 2 million bacterial-resistant illnesses occur each year, resulting
in more than 23,000 deaths (U.S. Department of Health and Human Services, Cen-
ters for Disease Control and Prevention, 2013).
Antibiotic resistance is problematic to public health b ecause antibiotic resistant
infections require stronger and stronger antibiotics. Yet, developing and testing anti-
biotics takes many years of pharmaceutical research. Thus, antibiotic resistance
becomes a race between pharmaceutical companies to develop effective drugs to
keep infectious diseases under control and bacteria that are constantly mutating in
an effort to survive.
Antibiotics are categorized as bactericidal or bacteriostatic. Bactericidal is when
an antibiotic “kills” the bacteria by interfering with its cell wall and substances within
the cell. Penicillin, for example, is bactericidal. Bacteriostatic stops bacteria from
multiplying but does not kill the infecting bacteria. It works with the host’s own
immune system to eliminate the bacteria. Bacteria fall into two main categories: gram
positive and gram negative. The goal of an antibiotic is to weaken the cell wall of
bacterial cells so the bacteria can no longer replicate, or to kill the bacteria directly.
Although antibiotics provide quick and effective relief from what w ere once deadly
diseases, antibiotic use presents a secondary issue of antibiotic resistance.
Antibiotic resistance occurs when the cell wall of the bacteria becomes resistant
to the antibiotic and, despite being in the presence of the antibiotic, the cell wall
continues to remain intact and unaffected. Multidrug-resistant (MDR) bacteria
develop when bacteria find ways to deter the effects of several different antibiotics.
Streptococcus pneumoniae is one bacteria associated with many infections seen in
communities including meningitis, pneumonia, sepsis (bacteria in the blood), and
ear infections. Streptococcus pneumoniae tends to be resistant to multiple antibiotics,
and researchers are studying this resistance (Borg et al., 2009). Antibiotic resistance
is not limited to h umans. Antibiotics are also used to control bacterial infections
among animals. Resistance can be transferred from animal to animal, animal to
human, and human to h uman. One common method is when an animal’s feces is
ANTIB IOTIC R ESISTAN C E 51
used to fertilize food crops. When humans consume the food, resistance is trans-
ferred. Drug-resistant bacteria can also remain within meat; improper cooking or
handling spreads the infection. Human carriers may then transfer the resistance
through poor sanitation (i.e., contaminated hands). Antibiotic resistance can spread
rapidly within hospitals or health clinics because the patients served may already
be immunocompromised due to cancer, cancer treatments, AIDS, or other disease.
The CDC divides antibiotic resistance into three categories based on threat to
public health: urgent, serious, and concerning (Centers for Disease Control and
Prevention, 2016). Urgent threats are bacteria that are labeled high consequence
because the bacteria can bring significant threat to the health of an individual or
community. They require aggressive action by our public health system. These
microorganisms are listed as urgent threats: Carbapenem-resistant Enterobacteria-
ceae, Clostridium difficile, and drug- resistant Neisseria gonorrhoeae. C. difficile
infects 250,000 p eople per year, causing 14,000 deaths. The cost to treat these
cases exceeds $1 billion per year (USDHHS, CDC, 2013). Serious threats are
antibiotic-resistant bacteria that do not rise to the level of urgent, yet require con-
stant surveillance and sustained intervention. There is the potential for serious
threats to become urgent threats. Current serious threats include multidrug-resistant
Acinetobacter, Fluconazole-resistant Candida, drug-resistant Campylobacter, extended
spectrum ant Candida, causing Enterobacteriaceae, Vancomycin-resistant Enterococ-
cus, drug-resistant Shigella, Methicillin-resistant Staphylococcus aureus (MRSA),
and drug- resistant tuberculosis. Multidrug- resistant Acinetobacter accounts for
7,300 infections per year and results in 500 deaths. Acinetobacter is resistant to
three different classes of antibiotics, and we no longer have a pharmaceutical agent
that can cure this dangerous strain of bacteria. MRSA, once found primarily in hos-
pital settings, is now found in many different communities. The threat category of
“concerning” presents a lower level of danger b ecause alternative treatment options
are still available. Bacteria in this category are monitored for incidence, rapid out-
breaks, further mutation, or locations. Examples include Erythromycin-resistant
Group A Streptococcus, Vancomycin-resistant Staphylococcus aureus, and Clindamycin-
resistant Group B Streptococcus. Erythromycin-resistant Group A Streptococcus is
associated with numerous common infections, such as strep throat, toxic shock
syndrome, scarlet fever, rheumatic fever, impetigo, and necrotizing fasciitis, com-
monly known as “flesh-eating” disease. One to two million people each year suffer
from strep throat caused by Streptococcus. As more and more antibiotics are manufac-
tured, many mimicking others, bacteria also advance in finding ways to resist not
one, but many, antibiotics.
Despite the dire consequences of antibiotic-resistant microorganisms, this seri-
ous problem can be controlled through good and sometimes easy public health mea
sures. The primary means of reducing antibiotic resistance is by stopping the
spread of infections. Following vaccination guidelines, using good hygiene during
food preparation, and proper handwashing are the first line of defense. A practice
as simple as good handwashing reduces upper respiratory infections 16 to 21 percent
52 ANTI B IOTI C R ESISTAN C E
(Aiello, Coulborn, Perez, & Larson, 2008; Rabie & Curtis, 2006) and diarrhea by
31 percent (Aiello, Coulborn, Perez, & Larson, 2008; Ejemot-Nwadiaro, Ehiri, Mer-
emikwu, & Critchley, 2015).
Local and state public health departments track reportable infectious diseases
and track cases to determine the severity of the problem. Tracking enables cases to
be handled rapidly and effectively to prevent the spread within a community or to
other communities. Good antibiotic stewardship refers to the practice of using anti-
biotics in humans and animals only when necessary and appropriate to the
microorganism, and ensuring the proper disposal of antibiotics. The final line of
defense is the search for new, effective drugs that can withstand bacterial resis
tance. One such antibiotic is teixobactin. Teixobactin is termed a “super antibi-
otic” because the chemical structure works against bacteria through several
modes of action. It is yet to be seen whether teixobactin can withstand resistance
(Ling et al., 2015). As bacteria become resistant to antibiotics, researchers are hop-
ing newly developed antibiotics can be effective agents in ceasing bacterial growth
with minimal side effects to the patient.
Antibiotic resistance is an area of concern nationally and internationally. As we
run out of drugs to treat various infections, we become vulnerable to novel strains
of microorganisms. The public health principles of immunizations, food safety, hand
hygiene, tracking infectious diseases, and good antibiotic stewardship go a long way
in preventing and controlling infectious diseases. When these mechanisms fail, it
is important to have an arsenal of effective antibiotics against bacteria.
Eileen L. Sullivan and Sally Kuykendall
See also: Agricultural Safety; Centers for Disease Control and Prevention; Commu-
nity Health; Disease; Food Safety; Handwashing; Infectious Diseases; Patient Safety;
Penicillin; Prevention; Vaccines
Further Reading
Aiello, A. E., Coulborn, R. M., Perez, V., & Larson, E. L. (2008). Effect of hand hygiene on
infectious disease risk in the community setting: A meta-analysis. American Journal of
Public Health, 98(8), 1372–1381.
Borg, M., Tiemersma, E., Scicluna, E., van de Sande-Bruinsma, N., de Kraker, M., Monen, J.,
& Grundmann, H. (2009). Original article: Prevalence of penicillin and erythromycin
resistance among invasive Streptococcus pneumoniae isolates reported by laboratories
in the southern and eastern Mediterranean region. Clinical Microbiology and Infection,
15, 232–237.
Centers for Disease Control and Prevention. (2016). National antimicrobial resistance moni-
toring system. Atlanta, GA: U.S. Department of Health and Human Services, CDC.
Retrieved from http://wwwn.cdc.gov/narmsnow/.
Ejemot-Nwadiaro, R. I., Ehiri, J. E., Arikpo, D., Meremikwu, M. M., & Critchley, J. A. (2015).
Handwashing promotion for preventing diarrhoea. The Cochrane Database of System-
atic Reviews, 9; CD004265. doi:10.1002/14651858.CD004265.pub3
ASSOCIATION OF PU B LIC HEALTH LAB O R ATO R IES ( APHL) 53
Ling, L. L., Schneider, T., Peoples, A. J., Spoering, A. L., Engels, I., Conlon, B. P., & Chen,
C. (2015). A new antibiotic kills pathogens without detectable resistance. Nature,
517(7535), 455–459.
Rabie, T., & Curtis, V. (2006). Handwashing and risk of respiratory infections: A quantita-
tive systematic review. Tropical Medicine & International Health, 11(3), 258–267.
U.S. Department of Health and Human Services, Centers for Disease Control and Preven-
tion. (2013). Antibiotic resistance threats in the United States, 2013. Retrieved from http://
www.cdc.gov/drugresistance/threat-report-2013.
World Health Organization. (2015, October). Antibiotic resistance fact sheet. Retrieved from
http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/.
ASSOCIATION OF PUBLIC HEALTH

LABORATORIES (APHL)
Public health laboratories are responsible for monitoring food safety; responding
to public health emergencies created by natural disaster, terrorist attack, hazardous
substances, or emerging infectious diseases; monitoring environmental conditions;
and screening all newborns for potentially life-threatening genetic and metabolic
disorders. Located in strategic positions throughout the United States, public health
laboratories are equipped to monitor and detect numerous health threats. Highly
trained scientists must be able to analyze a variety of specimens from different sources
and accurately report results. The Association of Public Health Laboratories (APHL)
is the national organization networking state and local government health labora-
tories, companies, laboratory professionals, and students interested in the labora-
tory sciences.
At the local level, APHL works with local health departments and practitioners
to support essential diagnostic services and promote best practices in testing to
ensure public health, environmental, agricultural, and food safety. At the national
level, APHL works with the Centers for Disease Control and Prevention (CDC), the
Environmental Protection Agency (EPA), the Food and Drug Administration (FDA),
and the Health Resources and Services Administration (HRSA) to provide surveil-
lance and rapid, effective response to public health threats. APHL also works inter-
nationally, consulting with developed and developing countries on strategic
planning, training, and quality assurance. APHL member benefits include access
to scientific protocols, continuing education courses, publications, leadership devel-
opment, and the annual meeting where members can share the latest research and
practices. As the main professional organization for public health laboratories,
APHL is active in public policy, advising decision makers on pending legislation.
One of the many, many critical functions performed in public health laborato-
ries is newborn screening. Four million babies are born e very year in the United
States and 1 out of 1,500 has an inborn error of metabolism. Inborn errors of metab-
olism are genetic disorders where the body cannot break down specific compo-
nents of food for conversion to energy or other functions in the body. The resulting
54 ASSO C IATION O F STATE AND TE RR ITO R IAL HEALTH O F F I C IALS ( ASTHO )
by-products build up and can cause a variety of health or developmental problems.

Phenylketonuria (PKU) is an inborn error of metabolism resulting from mutation
of the phenylalanine hydroxylase (PAH) gene. The PAH gene provides instructions
for the body to make phenylalanine hydroxylase, the enzyme, which converts the
amino acid phenylalanine into tyrosine. Tyrosine is another amino acid, important
for neurotransmission and skin and hair pigmentation. Without phenylalanine
hydroxylase, phenylalanine builds up in the body and c auses seizures and perma-
nent brain damage. PKU is easily treated. The person with PKU must avoid food
products with phenylalanine, and food products containing phenylalanine carry a
warning label to help people with PKU. To avoid the complications of untreated
PKU, every state requires PKU screening within the first days of birth. Public health
laboratories screen over 97 percent of the 4 million babies born every year! As with
any disease detection, laboratory professionals want to be sure that anyone who
screens positive is in fact positive and anyone who screens negative is in fact nega-
tive. Thus, laboratories use the most precise equipment, careful procedures, double
checking of positive screens, and other procedures to ensure that test results are
accurate.
APHL ensures that laboratories and laboratory staff are adequately trained and
aware of changes in the field to protect us from environmental, food, genetic, infec-
tious disease, and global health hazards and that public policies on mandatory test-
ing are grounded in the best available science.
Sally Kuykendall
See also: Bioterrorism; Core Competencies in Public Health; Emergency Prepared-

ness and Response; Environmental Protection Agency; Infectious Diseases; Water-
borne Diseases
Further Reading
Association of Public Health Laboratories. (2017). Retrieved from https://www.aphl.org
/Pages/default.aspx.
Centers for Disease Control and Prevention (CDC). (2012). Good laboratory practices for
biochemical genetic testing and newborn screening for inherited metabolic disorders.
Morbidity and Mortality Weekly Report, 61(2). Retrieved from http://www.cdc.gov/mmwr
/pdf/rr/rr6102.pdf.
ASSOCIATION OF STATE AND TERRITORIAL HEALTH

OFFICIALS (ASTHO)
The Association of State and Territorial Health Officials (ASTHO) is a national non-
profit network of current and past public health officers in the United States, U.S.
territories, District of Columbia, Mexico, and Canada. The main functions of ASTHO
are to provide technical assistance to members, to disseminate best practices in public
ASSO CIATION OF STATE AND TER R ITO R IAL HEALTH O F F I C IALS ( ASTHO ) 55
health, and to identify, assess, and educate members on laws and policies impact-
ing public health practice. ASTHO’s overall vision is to support public health offi-
cials in achieving the goal of “Healthy people thriving in a nation free of preventable
illness and injury” (ASTHO, 2016).
The idea of a national association of health officials was first proposed in 1879
at a meeting of health officers from the state boards of health along the Mississippi
River. As people migrated west, communicable diseases endemic to other areas of
the globe w ere carried along. Multiple outbreaks of cholera, yellow fever, and small-
pox occurred along trade routes and spread inland. In 1878, an outbreak of yellow
fever in the Caribbean forced thousands of people to seek refuge in New Orleans.
In response, New Orleans health officials established a quarantine station south of
the city on the Mississippi River. All incoming ships were fumigated, and all pas-
sengers and sailors were checked for disease prior to docking. Ships with sick pas-
sengers or sailors were placed in quarantine. Efforts to thwart the virus failed, and
yellow fever quickly spread through towns and cities on the river and inland through-
out Louisiana, Mississippi, Tennessee, Kentucky, Indiana, Illinois, and Ohio. Cur-
rent medical treatments of bloodletting, carbolic acid, and quinine w ere also
ineffective. Before the epidemic faded out, 120,000 p eople contracted yellow fever
including 20,000 p eople who died (WHYY, 2006). In 1879, the Sanitary Council
of the Mississippi Valley convened delegates from the state boards of health to dis-
cuss measures to control future outbreaks. Although some attendees blamed New
Orleans health officials for their inability to stop the disease, overall, the group agreed
that a coordinated response was needed. Dr. J. M. Woodworth, Marine Hospital
Service Surgeon General compared communicable diseases to e nemy attack. Just
as the nation used well-planned strategies to guard against e nemy attacks, the nation
needed prevention and intervention strategies to guard against communicable dis-
ease attacks. Over the next 50 years, groups of health officials met formally and
informally. They primarily focused on quarantine rules and ways to control epi-
demics. U nder the Social Security Act of 1935, health policies and programs
expanded, and health officials needed technical assistance to navigate the many
complex federal, state, and local laws. On March 23, 1942, the ASTHO became an
official organization.
ASTHO’s mission, “To transform public health within states and territories to help
members dramatically improve health and wellness,” is achieved through several
pathways. ASTHO supports state and territorial health officials in becoming lead-
ers, strengthens the capacity of public health agencies, provides a collective voice
for state and territorial public health, coordinates public health efforts through dis-
semination of evidence-based programs and practices, and sustains the health and
status of the ASTHO as a professional organization (ASTHO, 2016). In example, in
2011, the ASTHO partnered with the Centers for Disease Control and Prevention
(CDC) to develop a toolkit for reducing and preventing healthcare–associated infec-
tions (HAI). The toolkit describes why controlling HAI is important and presents
56 ASSO C IATION O F STATE AND TE RR ITO R IAL HEALTH O F F I C IALS ( ASTHO )
the most effective state health policies to eliminate HAI. P eople go to hospitals and
health care centers for treatment of numerous injuries and illnesses. They also bring
germs. One in 20 patients contracts an infection during health care treatment.
Hospital-acquired infections cost an additional $33 billion in medical treatment
every year. Prescribing prophylactic antibiotics or antivirals is not an ideal solution
because excessive use produces drug resistance, immunocompromised patients are
still at risk, and one cannot guess which antibiotics to prescribe without knowing
which pathogens are lurking within or on the health center’s doorknobs, waiting
rooms, or countertops. The problem becomes more complicated because health care
organizations are reluctant to report HAI for fear that p eople w
ill stop using their
facilities. The toolkit suggests a multifaceted approach that includes mandatory and
accurate HAI reporting that allows health officials to monitor infections; creation
of advisory councils; accreditation, training, and licensure to encourage best prac-
tices; and financial incentives and oversight. The interventions may be tailored to
fit within various state health systems.
ASTHO serves as a clearinghouse of information for state and territorial health
officials. Knowing how other systems effectively address health problems empow-
ers members to fulfill their mission of promoting the health and safety of residents.
ASTHO activities strengthen public health partnerships by creating a network of
knowledgeable professionals who are engaged in continuous quality improvement
of public health systems and practices.
Sally Kuykendall
See also: Administration, Health; Antibiotic Resistance; Core Competencies in Public

Health; Epidemic; Health Policy; Infectious Diseases; Modern Era, Public Health in
the; National Association of County and City Health Officials; Public Health
Departments; Public Health Law
Further Reading
Association of State and Territorial Health Officials. (2016). Retrieved from http://www.astho
.org/.
Association of State and Territorial Health Officials and Centers for Disease Control and
Prevention. (2011). Eliminating healthcare associated infections: State policy options.
Retrieved from http://www.cdc.gov/hai/pdfs/toolkits/toolkit-hai-policy-final_03-2011
.pdf.
Sanitary Council of Mississippi Valley. (1879). Minutes of the meeting of organization and pro-
ceedings of the Sanitary Council of the Mississippi Valley, Memphis, April 30, May 1;
Atlanta, May 5–9. National Library of Medicine. Retrieved from https://archive.org
/details/63230070R.nlm.nih.gov.
Smillie, W. G. (1943). The National Board of Health 1879–1883. American Journal of Public
Health and the Nation’s Health, 33(8), 925–930. Retrieved from https://www.ncbi.nlm
.nih.gov/pmc/articles/PMC1527526/pdf/amjphnation00698-0009.p df.
WHYY. (2006). The great fever. American Experience. PBS. Retrieved from http://www.pbs
.org/wgbh/amex/fever/peopleevents/e_1878.html.
ATTENTION-DEF I C IT /HYPE R A C TI VITY DISO R DER ( ADHD) 57
ATTENTION-D EFICIT/H YPERACTIVITY

DISORDER (ADHD)
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder
where the nerve cells leading to the frontal lobe of the brain are missing the normal
coating of proteins and phospholipids. This fatty coating known as myelin speeds
up nerve transmission to create a superhighway for incoming information. With-
out myelin, messages are transmitted more slowly and the brain takes longer to
process information from the outside world. As a result, people with ADHD can
appear impulsive, have poor memory, or have difficulty paying attention. This inabil-
ity to process information quickly creates serious public health challenges. Children
and youth with ADHD are at higher risk of traumatic brain injury, car crashes, poi-
soning, self-injury, and suicide (Silva, Colvin, Hagemann, Stanley, & Bower, 2014).
ADHD can lead to lifelong disability and death. P eople with ADHD are twice as
likely to have other m ental health disorders, such as oppositional defiant disorder,
conduct disorder, learning disorders, anxiety, and depression (Cuffe, Visser, Hol-
brook, Danielson, Geryk, Wolraich, & McKeown, 2015). In 2011, 11 percent of
children in the United States held a diagnosis of ADHD (Visser et al., 2014). Econ-
omists estimate that the total cost of treatment and lost workdays to seek care for
ADHD amounted to $31.6 billion in 2000 (Birnbaum et al., 2005). Improved diag-
nosis and treatment may enable safe, productive, and satisfying lives for t hose with
ADHD.
ADHD-like symptoms w ere first noted and studied in 1798 by Sir Alexander
Crichton. In An Inquiry into the Nature and Origin of M ental Derangement, Crichton
described an attention disorder (Lange et al., 2010, 242). He believed that the abnor-
mality was due to an increased or decreased “sensibility of the nerves.” The British
pediatrician, Sir George Frederic Still (1868–1941), described cases of c hildren with
normal intelligence who appeared overly defiant and inattentive. Reflecting the
values of the Victorian era, Still believed the problem was due to defective moral
control. Still’s cases typically presented with symptoms prior to age seven and
displayed difficulty with delayed gratification and trouble concentrating (Lange
et al., 2010, 244). Though Still’s description does not completely fit the current
definition of ADHD, his descriptions do provide some of the earliest records of the
disorder. In 1932, a new disorder call hyperkinetic disease of infancy was coined
by physicians Franz Kramer and Hans Pollnow (Lange et al., 2010, 247). The phy-
sicians described c hildren with hyperkinetic disease as t hose who are always mov-
ing and cannot sit still for a second. The c hildren reportedly ran around the
room, climbed to worrisome heights, and were resistant when told to control their
impulses. The c hildren were unable to complete a set of tasks and were unrespon-
sive when spoken to. Kramer and Pollnow believed that the disease was not
restricted to children and may continue into adulthood.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the primary
handbook listing psychiatric problems and the associated symptoms. Psychia-
trists and medical doctors use the DSM to diagnose mental disorders. The listing of
58 ATTENTION -DEF ICIT /HYPERACTI VITY DISO R DER ( ADHD)
hyperkinetic reaction of childhood (or adolescence) first appeared in the Diagnostic and
Statistical Manual of Mental Disorders II of 1968. The American Psychiatric Associa-
tion described the disorder as, “characterized by over activity, restlessness, distract-
ibility, and short attention span, especially in young children; the behavior
usually diminishes by adolescence” (APA, 1968, p. 50). The third edition of the
DSM introduced attention deficit disorder with and without hyperactivity, shift-
ing the focus from hyperactivity to inattention and poor impulse control. The
fifth edition of the DSM divided ADHD into three subtypes: predominantly
hyperactive-impulsive presentation, predominantly inattentive, and combined pre
sentation, and added criteria to include diagnosis among older adolescents and
adults (APA, 2013).
Symptoms of ADHD vary by age, gender, and situation. Predominantly hyperactive-
impulsive presentation is characterized by excessive activity such as fidgeting, squirming,
pacing, running, talkativeness, and impatience. People with predominantly inatten-
tive type are easily distracted, messy, forgetful, and have trouble concentrating. They
often lose important documents or personal items. On the other hand, the pre-
dominantly inattentive type can also be highly focused, remaining on tasks long
after others would give up. The symptoms of both subtypes—hyperactivity and
inattention—occur equally with combined presentation. In order for health profes-
sionals to make a diagnosis of ADHD, c hildren must show at least six of the symp-
toms listed in the DSM, adults must show at least five of the symptoms, behaviors
must occur in multiple settings (school, home, extracurricular activities, work, and
community), symptoms must be severe enough to interfere with everyday life, and
symptoms must be present for at least six months. The symptoms of ADHD are
embarrassing and exhausting. Without treatment, the delayed ability to self-regulate
behavior may impact school, employment, and interpersonal relationships (Brassett-
Grundy & Butler, 2004). The person may have a history of suspension, expulsion,
or run-ins with the criminal justice system. Over time, the individual can become
withdrawn, anxious, depressed, suicidal, or self-medicate with alcohol or stimu-
lant drugs.
Because people with ADHD have a high or normal intelligence, they often learn
to compensate for the symptoms. However, as they get older and take on more
responsibilities, strategies that were once successful begin to fail. It is impor
tant to know that there are effective treatments available, and it is better to seek
effective treatment than to develop unhealthy behaviors. The Centers for Disease
Control and Prevention (CDC) currently recommend cognitive behavioral ther-
apy (CBT) as the first line of treatment. CBT teaches techniques to eliminate the
behaviors that create problems, to make the most of the positive characteristics
of the disorder and to learn new strategies to harness the power of hyperactivity
or hyperfocus. Parent therapy teaches skills to manage c hildren’s behavior and
develop a coordinated system of care for children with special health care
needs. Evidence-based programs recommended by the CDC are T riple P (Positive
ATTENTION -DE F IC IT /HYPE R A C TI V ITY DISORDE R ( ADHD ) 59
Parenting Program), Incredible Years, Parent-Child Interaction Therapy, and

New Forest Parenting Programme. Medications may also be prescribed to speed
up mental processes and help people with ADHD process information at a faster
rate. Medications have been shown to reduce disruptive behavior, improve social
interactions, improve goal- directed be havior and concentration, and reduce
aggression. There are drawbacks to medication. Side effects include loss of appetite,
weight gain, and trouble sleeping, and there is the potential for misuse of prescrip-
tion stimulants. Since some of these drugs have not been on the market for very
long, the long-term side effects of ADHD medications are still being explored
(Martin, 2016).
The causes of ADHD are unknown. T here appears to be a strong genetic com-
ponent. ADHD tends to run in families. Other factors that may contribute to devel-
oping ADHD are low birth weight, premature birth or birth complications, and
maternal tobacco, alcohol, and substance use while pregnant. Future directions for
ADHD research include finding a consistent genetic marker. Some studies are also
trying to determine if there are differences in genotypes that distinguish one type
of ADHD from another. Longitudinal studies are also in process to research the long-
term outcomes of individuals with ADHD.
The goal for public health is not to cure ADHD but to enable individuals to sur-
vive their impulses in order to maximize their potential in society. P eople who live
with ADHD can adapt to their environments and situations in highly creative,
humorous, and novel ways. They are not afraid to take risks, to challenge how we
think about and deal with problems, and to try new, ingenious solutions. Children,
youth, and adults with ADHD often struggle to overcome the perceptions and frus-
trations of o thers. Through these life experiences, they develop a strong sense of
justice, compassion, generosity, humility, and resilience. ADHD creates very power
ful and interesting personalities. The challenge for public health is to reduce stigma
against those with neurodevelopmental disorders, ensure early identification and
diagnosis, and secure early referral to evidence-based treatments.
Alison C. Walensky
See also: Behavioral Health; C

hildren’s Health; Genetics; M
ental Health
Further Reading
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
(2nd ed.). (1968). Washington, DC: American Psychiatric Association.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
(5th ed.). (2013). Arlington, VA: American Psychiatric Association.
Birnbaum, H., Kessler, R., Lowe, S., Secnik, K., Greenberg, P., Leong, S., & Swensen, A.
(2005). Costs of attention deficit-hyperactivity disorder (ADHD) in the US: Excess costs
of persons with ADHD and their family members in 2000. Current Medical Research
and Opinion, 21(2), 195–205.
60 ATTENTION -DEF ICIT /HYPERACTI VITY DISO R DER ( ADHD)
Brassett-Grundy, A., & Butler, N. (2004). Prevalence and adult outcomes of attention-deficit/
hyperactivity disorder: Evidence from a 30-year prospective longitudinal study. Bedford Group
for Lifecourse and Statistical Studies Occasional Paper: No. 2. London: Institute of Edu-
cation, University of London.
Cuffe, S. P., Visser, S. N., Holbrook, J. R., Danielson, M. L., Geryk, L. L., Wolraich, M. L., &
McKeown, R. E. (2015). ADHD and psychiatric comorbidity: Functional outcomes in
a school-based sample of children. Journal of Attention Disorders. Retrieved from http://
journals.s agepub.c om/d oi/a bs/1 0.1 177/1 087054715613437#articleCitation
DownloadContainer.
Lange, K. W., Reichl, S., Lange, K. M., Tucha, L., & Tucha, O. (2010). The history of atten-
tion deficit hyperactivity disorder. Attention Deficit and Hyperactivity Disorders, 2(4),
241–255.
Martin, B. (2016). Future directions in ADHD. Psych Central. Retrieved September 13, 2015,
from http://psychcentral.com/lib/future-directions-in-adhd/.
Silva, D., Colvin, L., Hagemann, E., Stanley, F., & Bower, C. (2014). C hildren diagnosed
with attention deficit disorder and their hospitalisations: Population data linkage study.
European Child & Adolescent Psychiatry, 23(11), 1043–1050.
Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, R. M.,
& Blumberg, S. J. (2014). New research: Trends in the parent-report of health care
provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United
States, 2003–2011. Journal of the American Academy of Child & Adolescent Psychiatry,
53, 34–46, e2.
B
BAKER, SARA JOSEPHINE (1873–1945)
Sara Josephine Baker revolutionized public health practices to create systems of care
for c hildren and infants. Many of the techniques Dr. Baker established are still used
today. “Jo” Baker was born to an affluent family in Poughkeepsie, New York. Her
father, Daniel Mosher Baker, was a lawyer. Her mother, Jenny Harwood Brown, was
alumna of the first degree-granting institution for w omen in the United States—
Vassar College. Jo was expected to follow her mother’s example until her father died
suddenly. To help support the f amily, Jo forfeited her scholarship at Vassar and spent
a year teaching herself biology so that she could attend the W omen’s Medical Col-
lege of the New York Infirmary founded by s isters Elizabeth and Emily Blackwell.
Elizabeth was the first female to earn a medical degree in the United States, and
Emily graduated from Case Western University School of Medicine after being
rejected by 12 other medical schools b ecause she was female. The Blackwells cre-
ated the medical school to support other females interested in medicine. Although
Baker was a good student, she failed one course on “The Normal Child.” Retaking
the course proved both a frustration and a revelation. Her interest in c hildren was
furthered through an internship at the New England Hospital for Women and
Children in Boston. In Boston, Jo was exposed to the horrors of poverty, addictions,
epidemics, and poor health.
In 1899, Dr. Baker opened a private practice in New York City. Living condi-
tions in New York City were particularly awful for her patients. Thousands of immi-
grants crowded into squalid tenement houses or lived on the streets. Young
orphaned and abandoned children begged, stole, or worked to survive. Children
drank beer b ecause it was more freely available and was safer than milk. Since her
clients w
ere unable to pay for medical services, Baker took a part-time job as a New
York City medical inspector to subsidize her practice. Baker’s autobiography, Fight-
ing for Life, describes her first experiences in Hell’s Kitchen, New York:
I climbed stair after stair, knocked on door after door, met drunk after drunk, filthy
mother a fter filthy m
other and met d ying baby after dying baby. . . . There was no
dodging the hopelessness of it all. It was an appalling summer, too, with an average
of fifteen hundred babies d ying each week in the city; lean, miserable, wailing little
souls carried off w holesale by dysentery. (1939)
New immigrants accustomed to living on farms with fresh air and nutritious foods
were ill-equipped to deal with crowded, urban living and fatal epidemics. In addi-
tion to alcoholism and dysentery, health officials battled smallpox, cholera, typhoid,
62 BAK ER , SAR A JOSEPHINE
Street c hildren in a tenement neighborhood of New York City, photo by Jacob Riis, ca.
1888. Abandoned c hildren begged, stole, or worked long hours to survive the streets of
New York City in the late 1800s. Homeless c hildren drank beer b
ecause it was cheap and
less contaminated than milk. (Library of Congress)
diphtheria, measles, and political corruption. Some health officials simply resigned
themselves to the hopeless situation, neglected patients, and fabricated notes. By
1907, Baker was appointed the assistant commissioner for health. She worked on
several projects of smallpox vaccinations and typhoid control. She was also involved
in the identification and capture of Mary Mallon, referred to as Typhoid Mary.
Within a year, Baker was appointed director of the New York City Bureau of Child
Hygiene—the first public health department in the nation to focus exclusively on
children’s health and welfare.
Through the Bureau of Child Hygiene, Baker revolutionized public health. Pre-
viously, health officials tracked down specific incidents of disease and provided indi-
vidualized treatment or control. Baker created a system of preventive care drawing
on ideas from social medicine. The bureau introduced initiatives in midwifery train-
ing, visiting nurses, school nurses, health education, disease prevention, well baby
care, stations providing safe milk and care for babies, and sibling care programs.
Visiting nurses checked on every new mother within a day of delivery providing
basic health education. The nurses encouraged mothers to breastfeed rather than
giving their infants beer (Epstein, 2013). They taught mothers about germs and how
B A K E R , SA R A JOSEPHINE 63
to keep babies safe. The L ittle Mothers Leagues was a program for girls, aged 12
and over, who w ere responsible for caring for younger siblings while the mother
worked. The bureau’s programs were realistic, embracing the reality of life for poor
immigrants in New York City while maximizing limited resources. Baker also cre-
ated a system for administering silver nitrate. Silver nitrate is dropped into the eyes
of infants to prevent blindness due to congenital syphilis. The delivery system fea-
tured ampules with the correct dose of medication.
In the early 1900s, birth control was nonexistent and abortions w ere dangerous.
Hundreds of newborns were abandoned on the streets every year. Catholic chari-
ties refused to accept the orphans under the assumption that the children were born
out of wedlock. The Bureau of Child Hygiene opened a special hospital where trained
nurses cared for these abandoned infants. Despite qualified care and good nutri-
tion, mortality rates w ere still high. Approximately 50 percent of abandoned infants
died. At the same time, Baker noticed that while the hygiene measures improved
life for infants born to poor mothers, infants born to wealthy mothers did not fare
as well. Baker hypothesized that in addition to nutrition and hygiene, infants needed
love and attention. As an experiment, the bureau paid some of the poor m others
who had worked with the visiting nurses to care for the sickest of the abandoned
infants. The experiment was a success. Infant mortality rates among this very
vulnerable population were cut in half. Baker proved that a safe, stable, loving home
environment is just as critical to healthy childhood development as nutrition and
hygiene. By the time Baker retired, infant mortality rate in New York City had
decreased from 115 deaths per 1,000 live births to 69 deaths per 1,000 live births
(Statistical Analysis and Reporting and Quality Improvements Units of the Bureau
of Vital Statistics, 2011). Baker’s vision of infant and child care was replicated in
other cities and states, although not without controversy. Some politicians and phy-
sicians, including representatives of the American Medical Association, objected to
Baker’s social medicine. Opponents believed that the high infant mortality rate of
poor communities was eugenics, a way to eliminate undesirable genetic traits. After
retirement Baker continued to advocate for children and disadvantaged populations.
She represented the United States at the League of Nations, was active in profes-
sional organizations, and wrote numerous books and articles on c hildren’s health.
What is particularly remarkable about Baker’s achievements is that she envisioned
and implemented major changes within a system dominated by male politicians,
health administrators, and physicians. Baker, like many other women of her era, was
all too familiar with gender discrimination. To blend into the system, she kept her
hair short and parted in the m iddle and wore men’s suits with collared shirts and ties.
The strategy worked because Baker joked that some of her male colleagues forgot that
she was female. In 1915, the dean of New York University and Bellevue Medical Col-
lege asked Baker to teach the child hygiene course as part of the doctorate in public
health program. Although the school only accepted males, Baker negotiated a condi-
tion that she be allowed to take courses in the program. Through the program, she
earned her doctorate in public health and continued to teach for another 15 years.
64 B EE RS , C LI FF O RD W HITTIN GHA M
Although Baker was a fearless role model for female physicians, Hansen (2002) notes
that Baker was a missed opportunity to serve as a role model for LGBTQ youth inter-
ested in the sciences. Despite dedicating her life to c hildren, Baker never had c hildren
of her own and never married. After retiring, Baker and her long-term partner, novel-
ist Ida Wylie, moved to New Jersey to live with Louise Pearce, another female physi-
cian. Baker and Wylie w ere members of a group where many of the members were
openly lesbian. Hansen speculates that although Baker kept her sexuality private,
there is a need to acknowledge and honor the achievements of LGBTQ individuals
within public health. Recognizing the achievements of individuals from minority
sexual groups encourages o thers to achieve incredible feats.
Sara Josephine Baker’s achievements in social medicine made her a leading fig-
ure in public health. Many of her programs in child welfare are still used today.
Visiting nurses is now recognized as a leading evidence-based program in child
development with lifelong benefits of reducing substance abuse, health care costs,
and poverty. The concepts that Baker used, strategically using limited resources to
empower people within the community to prevent disease, are highly applicable to
current public health challenges.
Sally Kuykendall
See also: Anderson, Elizabeth Milbank; Blackwell, Elizabeth; Children’s Health; Infant
Mortality; Mallon, Mary; Maternal Health; Public Health in the United States, His-
tory of
Further Reading
Baker, S. J. (1939). Fighting for life. New York: Macmillan.
Epstein, H. (2013). The doctor who made a revolution. The New York Review of Books.
Retrieved from http://www.nybooks.com/articles/2013/09/26/doctor-who-made-revo
lution/.
Hansen, B. (2002). Public careers and private sexuality: Some gay and lesbian lives in the
history of medicine and public health. American Journal of Public Health, 92(1): 36–44.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447383/.
National Library of Medicine. (n.d.). Dr. S. Josephine Baker. Retrieved from https://www
.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_19.html.
Statistical Analysis and Reporting and Quality Improvements Units of the Bureau of Vital
Statistics. (2011). Summary of vital statistics 2010, the City of New York: Population and
mortality. Retrieved from http://www.nyc.gov/html/records/pdf/govpub/6551as_2010
_final_population_&_ mortality.pdf.
BEERS, CLIFFORD WHITTINGHAM (1876–1943)

During the middle of the 19th century, pioneering m ental health reformer Doro-
thea Lynde Dix created state mental hospitals to remove mentally ill people from
prisons and jailhouses. Over time, these new m ental institutions struggled with
intractable chronic illness, lack of funding, and bad publicity. Society slipped back
B EE R S , C LIF F O R D WHITTIN G HAM 65
into old beliefs that people with mental illness had done something wrong to deserve
such a horrific fate and state mental hospitals fell into disrepair and disrepute. Suf-
fering from bipolar disorder, paranoia, and delusions, Clifford Whittingham Beers
spent three years in such institutions. His chronicles of thoughts, experiences, and
treatment revealed the world of a confused mind, greedy, negligent doctors, and
unqualified, abusive attendants. Beers’s autobiography challenged society to examine
current attitudes and care of the mentally ill. His efforts reignited the field of mental
health, leading to the creation of the National Institute of Mental Health.
Clifford was born on March 30, 1876, in New Haven, Connecticut, to Ida Cook
and Robert Beers. Ida was the oldest d aughter and primary caregiver of her birth
family. When she moved from her parent’s home in Marietta, Georgia, to live with
her husband in New Haven, her four unmarried sisters and one brother followed.
Ida’s siblings did not work. Despite being of modest means, Mr. Beers dutifully pro-
vided for the household’s needs. T here was no history of mental illness on the f ather’s
side. Mr. Beers was 27 years older than his wife, quiet, and conflict avoidant and
otherwise healthy. Members of the Cook family suffered from depression and were
known for exhibiting eccentric or erratic behavior. In those days, doctors avoided
assigning a diagnosis of mental illness for fear of stigmatizing the client and the
family. Of Ida and Robert’s six c hildren, one died during infancy, one died of a brain
tumor, and three died in mental institutions. Two of the sons committed suicide.
Clifford experienced emotional ups and downs as a child and adolescent. The
mood swings did not affect him academically or socially. In school, he was an aver-
age student who excelled when pushed. He did fear that his father might commit
suicide because of financial pressures. Otherwise, his childhood was atraumatic
and unremarkable.
In June 1894, as Clifford was preparing for college entrance exams, his older
brother Samuel had a g rand mal seizure. Since Clifford was a student and available
during the day, he became his brother’s main caregiver. As Clifford nursed his brother
through publicly embarrassing tonic-clonic seizures and loss of consciousness, he
became increasingly obsessed with the idea that he may also develop epilepsy, a
disease once believed to be a form of m ental illness. While attending classes at Yale’s
Sheffield Scientific School, Clifford experienced paralyzing anxiety attacks. He
stopped attending lessons and only returned a fter sympathetic professors prom-
ised not to call on him. Despite struggles and hypochondriacal fears, Clifford was
socially active. He held prestigious positions and wrote for the school newspaper.
After graduating, Clifford moved to New York City. On June 15, 1900, while work-
ing as a clerk at Bankers Life Insurance Company, he experienced a severe anxiety
attack. His voice was paralyzed, and his handwriting wobbly. Convinced that some-
thing was horribly wrong, he requested two weeks’ vacation, went back to his resi-
dence, destroyed personal papers, and journeyed back to New Haven.
In the family home, Sam was d ying of a brain tumor. Clifford spent the week in
bed, depressed and contemplating suicide. On June 23, he climbed out of his third-
story bedroom window, hung off the window ledge, and dropped to the ground.
66 BEER S, CLI FFORD W HITTINGHA M
His arms scraped against the house as he fell, breaking his fall. Missing the side-
walk by inches, he landed on his feet on soft ground. His point of impact was in
front of the dining room window where the f amily was eating lunch. Clifford recalled
that his hypochondriacal obsessions w ere immediately replaced by paranoid delu-
sions. He believed that he had committed some unknown crime and everyone
around him was a detective or spy attempting to gather evidence for his upcoming
trial. He refused to speak and was diagnosed with manic depression, now known
as bipolar disorder.
The Beers family arranged for Clifford’s physical and emotional recovery in a sana-
torium. Sanatoriums w ere private, for-profit institutions managed by doctors. Fami-
lies paid a basic per capita fee with additional charges for incidentals or private duty
care. Since little was known about m ental illness, the physician-administrators
were less interested in treatment and primarily concerned with making money.
Patients were crowded into rooms with a few untrained, supervising attendants. In
1901, the Beers family took Clifford out of the sanatorium and paid one of the
attendants to care for Clifford in his home in Wallingford. The Beers family visited
frequently. The attendant and his family were kind. However, Clifford’s paranoia,
delusions, and hallucinations continued. He believed that everyone in the village
knew of his imagined crime and that the p eople who came to see him were not
really his family but impersonators trying to trick him.
Seeing that he was not recovering in Wallingford, the Beers family committed
Clifford again, this time to a private, nonprofit m ental institution. His brother,
George Merwin Beers, assumed power of attorney. Clifford was comforted by a
regular routine. However, his mind continued to deceive him. He believed that
the staff and other patients were detectives conspiring against him and that the
George who visited him was an imposter. Clifford refused to speak to the visitor
George and devised an elaborate scheme to get a message to the real George. He
convinced a patient with outside privileges to get George’s address from the New
Haven directory. He wrote a letter to his brother and asked another patient to
address the envelope so that his imagined spies would not intercept it. In the let-
ter, Clifford explained his delusions and instructed his b rother to bring the letter
as proof that he was George. On August 30, 1902, George appeared for the
planned visit and produced the letter. Clifford described a moment of epiphany:
Untruth became Truth. A large part of what was once my old world was again
mine. To me, at least, my mind seemed to have found itself, for the gigantic web of
false beliefs in which it had been all but hopelessly enmeshed I now immediately
recognized as a snare of delusions. That the Gordian knot of m
ental torture should
be cut and swept away by the mere glance of a willing eye is like a miracle. (Beers,
1907, p. 85)
As the depression dissipated, Clifford progressed into mania. While attending

church, he heard the scripture and got the idea that God was sending him on a
B EE R S , C LIF F O R D WHITTIN G HAM 67
crusade to reform the m ental health system. Clifford became extremely hyperac-
tive, slept only two to three hours a day, wrote long letters to relatives and friends,
and started fighting the attendants who abused patients. Doctors placed him in a
straight jacket and moved him to a ward for violent patients.
On November 8, 1902, George arranged for Clifford’s transfer to a state-funded
mental hospital. This third institution was the worst. The guards were unqualified,
petty, and spiteful. They yelled at, choked, beat, and unnecessarily restrained
patients. It was not long before Clifford was placed on the violent ward again. For
four months, he lived in a small, barred cell with no bed. Personal hygiene was
restricted. At times, he was not able to shower for up to three weeks. When he
finally transferred out of the locked ward, he was granted outside privileges. With
freedom to walk into town under attendant supervision, Clifford purchased writ-
ing paper. He wrote a 32-page letter to the governor of Connecticut describing the
conditions of the state hospital. On his next visit to the city, he slipped the letter
into an unsold copy of the Saturday Evening Post with instructions to mail the letter.
He also included a warning that since he had attached a two cent stamp to the
envelope, not mailing the letter would be a federal crime b ecause one was interfer-
ing with the U.S. Postal Service. The shop clerk found and mailed the letter. In the
letter, Clifford introduced himself:
I take pleasure in informing you that I am in the Crazy Business and am holding
my job down with ease and a fair degree of grace. Being in the Crazy Business,
I understand certain phrases of the business about which you know nothing. (Beers,
1907, p. 196)
The letter described staff abuses against patients, including fatal assaults. He called
for reform of the state m ental hospital system and threatened to contact the press
if the state failed to investigate. The governor contacted the superintendent of the
asylum and conditions improved temporarily. Clifford realized that in order to bring
about real reform, he needed to get well. He wrote graphic descriptions about his
experiences and relationships, and on September 10, 1903, he was discharged. His
enlightened employer at Bankers Life Insurance Company offered him his job back.
The man believed that illness is illness and it did not matter whether an employee
was physically ill or mentally ill. He encouraged Clifford to take care of himself and
to rest as needed.
At the time, m ental illness was considered a sign of moral impairment, and
many people even believed that mental illness was caused by masturbation.
Thus, few people were willing to disclose personal struggles or history. Beers
consulted with colleagues at Yale and preeminent psychiatrists of the day. The
director of the Psychiatric Institute of the New York State Hospital system, Adolf
Meyer, and William James, professor of philosophy and psychology at Harvard
University, encouraged Beers to publish his experiences. In 1908, Beers pub-
lished A Mind That Found Itself. The autobiography described Beers’s delusions,
68 B EE RS , C LI FF O RD W HITTIN GHA M
paranoid responses, and treatment. He intentionally did not name the institutions
because he wanted readers to focus on the abuse of power and h uman rights
atrocities rather than blaming one specific institution. Although Clifford did not
condone the abuse, he understood it. Without proper training, guards developed
harsh treatments as a way to manage the large, crowded inpatient wards. Moti-
vating through fear seemed quicker and more effective than reasoning with a
confused mind. Furthermore, power corrupts. As the guards realized their
uncontested power over other h uman beings, ethical boundaries blurred and
egos inflated. Beers’s calm, s imple, and direct style of writing aroused public
sympathy and protest.
In 1908, Beers founded the Connecticut Society for M ental Hygiene, the organ
ization that eventually became the National Institute of Mental Health (1946). Its
mission was to improve public attitudes, improve services, prevent mental illness,
and promote m ental health. The first task was counting the number of mentally ill
patients in the country and medical professionals who could treat them. Subsequent
surveys and reports on the conditions of state mental hospitals prompted changes
such as hiring more social workers. In 1913, Beers founded the Clifford Beers Clinic,
the first outpatient mental health clinic in the United States. And in 1930, he orga
nized the International Congress on M ental Health. Over time, Beers’s paranoia
returned. His beloved brother George committed suicide after g oing to a psychiatrist
and being told that his complaints did not rise to hospitalization. Clifford was
severely affected. The disease he had worked to prevent had claimed the life of
another loved one. Clifford was hospitalized once again and eventually died of
bronchopneumonia.
Clifford Whittingham Beers led a crusade against mental illness, advocating for
humanity and compassion for those suffering from m ental illness. His willingness
to reveal his own vulnerability created a movement that recognized the rights of
those with mental illness and ways to prevent the downward spiral.
Sally Kuykendall
See also: Behavioral Health; Disability; Dix, Dorothea Lynde; M

ental Health; M
ental
Illness; Substance Abuse and M ental Health Services Administration; Controversies
in Public Health: Controversy 2
Further Reading
Beers, C. W. (1907). A mind that found itself. New York: Longmans, Green.
Beers, C. W. (2010). A mind that found itself: An autobiography. American Journal of Public
Health, 100(12), 2354–2356.
Capps, D. (2009). Mental illness, religion, and the rational mind: The case of Clifford W.
Beers. Mental Health, Religion & Culture, 12(2), 157–174. doi:10.1080/1367467080
2398543
Dain, N. (1980). Clifford W. Beers, advocate for the insane. Pittsburgh: University of Pittsburg
Press.
B EHAV IOR AL HEALTH 69
BEHAVIORAL HEALTH
Behavioral health is the medical science and art that relates personal behaviors to
health and well-being. This interdisciplinary field combines aspects of psychology,
sociology, health, and medicine to identify and apply effective ways to promote
health-enhancing behavior. T here is a wide range in severity and outcomes of behav-
ioral health problems. An estimated one out of seven children (ages two to eight)
is diagnosed with a m ental, behavioral, or developmental disorder (Bitsko, Hol-
brook, Robinson, Kaminski, Ghandour, Smith, & Peacock, 2016). In transition to
adulthood, the individual may mask socially unacceptable behaviors through sub-
stance abuse, overeating, physical inactivity, smoking, or self-harm. Long-term
behavioral problems interfere with social relationships, education, and employment
and increase risk of early mortality. Two-thirds of nursing home residents exhibit
emotional and behavioral problems (U.S. Department of Health and Human Ser
vices, Administration on Aging, 2001). There is an increasing need for behavioral
health specialists who work with elderly clients to manage behaviors related to
dementia, incontinence, depression, and anxiety as well as life transitions, death of
loved ones, chronic illnesses, or family discord. Regardless of age, early diagnosis
and intervention are important to deconstruct negative behaviors and learn new,
health-enhancing behaviors. Often used interchangeably with mental health, behav-
ioral health goes beyond the psychiatric diagnosis to include psychosocial care.
The goal of therapy is to help the individual attain normal developmental milestones,
enjoy healthy social interactions, and practice positive coping strategies. Criticisms
of behavioral health are that practices focus on symptoms rather than underlying
causes. Putting the responsibility for change on the individual, rather than society,
dismisses the impact of discrimination, poverty, or abuse on mental and behav-
ioral health. Public health addresses primary behavioral issues of attention-deficit/
hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disor-
der (ODD), as well as secondary problems of smoking, drinking, or overeating.
Behavioral health encompasses a range of neurological conditions and behav
iors. Among children and adolescents, ADHD, conduct disorder, ODD, and self-harm
are some of the classic behavioral health problems. ADHD is a neurodevelopmental
disorder where the nerve cells of the brain lack the fatty coating needed to expedite
nerve transmission. The ADHD brain takes longer to take in and process informa-
tion. As a result, p eople with ADHD appear impulsive or inattentive. Conduct
disorder is an emotional disorder characterized by aggressiveness, destructive-
ness, deceit, and persistent violation of normal social boundaries. ODD is exces-
sive and persistent rejection of authority with overly argumentative or vindictive
behavior. Self-harm is a behavioral condition where the individual purposely
injures himself or herself through cutting or burning. Behavioral health treat-
ments vary based on diagnosis and severity. Psychotherapy focuses on helping the
client to find positive ways to express and control negative emotions. Treatment
focuses on changing problem behaviors, building skills to help the individuals
manage their behaviors, and helping parents to manage c hildren’s behavior.
70 B EHAVIOR AL HEALTH
Although psychotherapy focuses on the individual client, public health uses a

population-based approach to prevent behavioral health problems and their sequelae.
Pediatric health clinics are a g reat opportunity to screen for m
ental, behavioral, and
developmental disorders (MBDDs) and to refer the patient for treatment. Population-
based approaches are visiting nurses, parent training classes, and early childhood
education programs. A large-scale study of more than 35,000 children found that
inadequate health care coverage, fair or poor parental mental health, living in a
family struggling to pay bills, difficulty in attaining child care, lack of neighbor-
hood social support, and lack of access to recreational amenities w ere risk factors
for MBDDs (Bitsko, Holbrook, Robinson, Kaminski, Ghandour, Smith, & Peacock,
2016). Results suggest that improving access to health care, supporting families,
and community improvement may promote healthy child development and reduce
the need for some behavioral health services.
Many chronic and acute health problems are related to personal lifestyle choices
and behavior. Smoking c auses chronic obstructive pulmonary disease and lung
cancer. Alcohol abuse causes pancreatitis, hepatitis, cirrhosis, and cancers of the
mouth, esophagus, breast, and liver. Physical inactivity and overeating cause cardio-
vascular disease, diabetes, and hypertension. Public health uses aspects of behavioral
health to change behaviors. There are numerous ways to change behaviors—scientific
research, food or health warning labels, financial incentives, cigarette or alcohol
taxes, even “nudges” (Galizzi, 2014). Simple nudges, such as putting fruits and
vegetables near the cafeteria checkout line rather than candy and cookies; using
100-calorie packs to limit caloric intake; or using smaller plates or dark-colored
plates are subtle, noncoercive ways to encourage good nutrition. The media,
particularly public service announcements on television, can effectively create
behavioral change (Das, 2016). The transtheoretical model is one of many models
used to create population-based behavioral change. By deconstructing misconcep-
tions, educating and empowering, p eople can stop smoking or adopt healthy behav
iors. Future directions are to investigate the most effective ways to achieve
population-based changes.
Lifestyle and cognition affect physical and mental health. Behavioral health is a
field of medicine and public health that addresses the unique conduct of individu-
als and the impact on health. The symptoms and consequences of behavioral health
problems can be seen from early childhood to late adulthood. Public health works
to prevent behavioral health disorders by supporting populations with special needs
and ensuring access to effective treatment programs.
Sally Kuykendall
See also: Adverse Childhood Experiences; Attention-Deficit/Hyperactivity Disorder;

Child Maltreatment; Children’s Health; Community Health Centers; Mental Health;
Mental Illness; National Institutes of Health; State, Local, and Territorial Health
B EL M O NT R EP O RT, TH E 71
Departments; Substance Abuse and Mental Health Services Administration; Social

Determinants of Health; Transtheoretical Model; Controversies in Public Health: Con-
troversy 2
Further Reading
American Psychological Association. (n.d.). Mental and behavioral health and older Ameri-
cans. Retrieved from http://www.apa.org/about/gr/issues/aging/mental-health.aspx.
Bitsko, R. H., Holbrook, J. R., Robinson, L. R., Kaminski, J. W., Ghandour, R., Smith, C., &
Peacock, G. (2016). Health care, family, and community factors associated with
mental, behavioral, and developmental disorders in early childhood—United States,
2011–2012. Morbidity and Mortality Weekly Report, 65(9), 221–226. doi:10.15585
/mmwr.mm6509a1
Das, S. (2016). Television is more effective in bringing behavioral change: Evidence from
heat-wave awareness campaign in India. World Development, 88, 107–121. Retrieved
from http://dx.doi.org.ezproxy.sju.edu/10.1016/j.worlddev.2016.07.009.
Galizzi, M. M. (2014). What is really behavioral in behavioral health policy? And does it
work? Applied Economic Perspectives and Policy, 36(1), 25–60.
Oyama, O. N., & Burg, M. A. (2016). The behavioral health specialist in primary care: Skills
for integrated practice. New York: Springer.
U.S. Department of Health and Human Services, Administration on Aging. (2001). Older
adults and mental health: Issues and opportunities.
BELMONT REPORT, THE

The principles within The Belmont Report represent the most important ethical guide-
lines for conducting biomedical and behavioral human research in the modern
United States. The purpose of The Belmont Report was to summarize the ethical
principles and guidelines essential to protecting the safety and well-being of patients
and human participants in research. This was particularly important in the post-
Tuskegee syphilis experiment era of the United States. The scientific community
was struggling with the ethical horrors of the Tuskegee Syphilis Study, Willowbrook
Hepatitis Studies, and the cancer studies at New York City’s Jewish Chronic Dis-
ease Hospital. In Tuskegee, Alabama, doctors did not use readily available cures for
patients with syphilis so that they could study the effects of untreated syphilis on
an African American community. The Belmont Report was commissioned to help pre-
vent such unethical research from ever occurring again. The Belmont Report guide-
lines are still used by researchers and research institutions in the United States.
In 1974, the National Commission for the Protection of Biomedical and Behav-
ioral Research was created by the National Research Act in 1974. One of the major
responsibilities of the commission was to identify the basic ethical principles that
should underlie how biomedical and behavioral research with h uman participants
is conducted (Office for H uman Research Protections, 2016). Issued in 1978, The
Belmont Report outlined three core ethical principles: respect for persons, beneficence,
72 BE LM ON T R EPORT, T HE
and justice. These core ethical principles are essential to contemporary research,
particularly because they ensure that h uman participants are protected from the
harms and dangers of unethical research. These recommendations and guidelines
still form the foundation of how research is conducted and regulated by the Depart-
ment of Health, Education, and Welfare. Additionally, institutional review boards
throughout the country rely on The Belmont Report to guide their decision making
for allowing or rejecting research studies.
The first of t hese core principles, respect for persons, involves the protection of
individual autonomy and the need for research scientists to treat human partici-
pants with dignity and honor participants’ right to make their own decision regard-
ing study participation. Respect for persons means that the researcher will provide
the participant with easily understandable information on the nature and purpose
of the study, what to expect during the study, potential risks or discomforts, antici-
pated benefits, and alternatives to participating in the study and that participants
have the right to ask questions, to not take part in the study or withdraw from a
study at any time, and be free of pressure to participate. As a result of The Belmont
Report, research scientists must provide informed consent to all h uman study
participants whenever t here are risks—even minor ones—to well-being as a result
of study participation. Informed consent is an ongoing process. As the study evolves,
researchers are obligated to keep participants advised of risks and changes to the
study.
The second core ethical principle, beneficence, involves the responsibility of the
researcher to not harm human participants. This is done by minimizing risks, max-
imizing benefits, and not carrying out research that is inappropriately harmful or
detrimental to human health. This ethical principle was likened within The Belmont
Report to the Greek maxim of “do no harm” and prohibits research that would seri-
ously harm participants. U nder the principle of beneficence, research like that done
in the Tuskegee syphilis experiment would not have been carried out due to the
patient harm that occurred from prolonged syphilis infection. A modern-day
example of beneficence in contemporary biomedical research is during clinical
trials with new medications; as soon as one medication in the trial shows greater
efficacy than the o thers, all patients must be switched to that medication to maxi-
mize their well-being, and likewise, if one medication shows worse outcomes
than the o thers, then the patients are asked to cease taking that medication. Accord-
ing to the concept of justice in The Belmont Report, it would be unethical to with-
hold human participants from a beneficial medication and likewise, it would be
unethical to ask human participants to continue taking a known harmful medi
cation. In this way, beneficence ensures that the well-being and protection of indi-
vidual human research participants is protected at all phases of the research endeavor.
The third principle outlined by The Belmont Report is that of justice. The concept
of justice concerns which populations receive the benefits of research and which
populations bear the burden of research. Justice means that research does not exploit
vulnerable populations and that all populations in society deserve to benefit from
B IOSTATISTI C S 73
the findings of biomedical and behavioral research. One example of the importance
of justice is how research scientists recruit human participants for their research. It
would be unjust for patients from one population to bear all of the burdens of
research so that a different population w ill benefit. Therefore, research scientists
attempt to ensure that the burdens of research are evenly and appropriately spread
throughout the population, and that the findings of research are distributed equi-
tably. Justice does not only include interracial justice, but intergender, intersocio-
economic, and other social differences.
The Belmont Report and its underlying ethical principles and guidelines have been
tremendously influential in shaping how modern research is ethically regulated and
protected from ethical misconduct. In this way, The Belmont Report represents one
of the most important ethical documents in the domain of human research in the
world.
Shayan Waseh
See also: Code of Ethics; Ethics in Public Health and Population Health; Greco-
Roman Era, Public Health in the; Hippocrates; Research; Tuskegee Syphilis Study
Further Reading
National Institute of Health. (2016). Protecting human research participants. Retrieved from
https://phrp.nihtraining.com/codes/02_codes.php.
Office for Human Research Protections. (2016). The Belmont Report. Retrieved from https://
www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html.
Sims, J. M. (2010). A brief review of the Belmont Report. Dimensions of Critical Care Nurs-
ing, 29(4), 173–174.
BIOSTATISTICS
Biostatistics is a specialty field, a branch of applied mathematics that focuses on
converting complex biomedical data into usable information. For example, many
people fear dying by plane crash, lightning, or assault with a firearm. Using biosta-
tistics to calculate the probability of fatal injuries, the odds of dying by plane crash
(1 in 96,566), lightning strike (1 in 164,968), or assault with a firearm (1 in 358)
are much less than motor vehicle crash (1 in 112) (National Safety Council, 2016).
Knowing the potential for death by motor vehicle crashes emphasizes safe driving
techniques, such as wearing a seat belt, respecting speed limits, not driving u nder
the influence, and not using a cell phone while driving. Public health practitioners
use biostatistics to understand the extent of a health problem and to identify effec-
tive treatment or prevention programs. Because biostatistics deals with critical health
issues, biostatisticians follow ethical guidelines in research.
Biostatistics is a portmanteau, created by blending the words “biology” and “sta-
tistics.” In practice, biostatistics encompasses other disciplines beyond biology. Bio-
statistical techniques are used in medicine, sociology, psychology, pharmacology,
74 BIOSTATISTI CS
health policy, program planning, and health education. T hese statistical analyses
study real-world problems as opposed to mathematical theory or abstract mathe-
matical concepts. Biostatisticians partner with program planners, community organ
izations, nonprofit groups, clinical staff, and public health practitioners to plan,
gather, and analyze data.
To create data for analysis, raw data are collected using the scientific method. To
review, the scientific method is the systematic process used by scientists to investi-
gate, explore, describe, or explain concepts. The scientific method commences with
an in depth review of the current literat ure in the field of interest, reading and study-
ing scholarly articles and books. The literature review spotlights what is known
and what needs to be known next to alleviate the problem. Scientists take ideas of
what needs to be studied and create the research hypothesis or research question.
The research hypothesis is used to design the research study and methods of col-
lecting the data. Once results are collected, statisticians use mathematical formulas
to convert the raw numbers into a form that tests the hypothesis. In public health,
common statistical calculations are means, medians, modes, standard deviations,
probabilities, confidence intervals, t-tests, analysis of variances (ANOVA), relative
risk, odds ratios, incidence, and prevalence rates. Once the study results are ana-
lyzed, researchers can draw logical inferences. Scientists can determine whether two
or more variables are correlated, existing together at the same point or within the
same group of p eople; w
hether a health problem is caused by a specific factor; or
whether one program or treatment is more effective than other treatments. Biosta-
tistics allows scientists to resolve questions of whether the results are significant
enough to qualify as a true difference. Imagine that the National Safety Council
develops a media campaign to reduce driving while intoxicated, speeding, and dis-
tracted. After one year, deaths from motor vehicle crashes decrease from 1.3 per
100 million miles traveled to 1.2 per million miles traveled. Biostatistics can deter-
mine whether the program made a significant impact on deaths due to motor vehicle
crashes.
In order to perform the correct mathematical calculation, the statistician must
know how data are constructed, collected, analyzed, and interpreted. For example,
it is impossible to calculate the average age of study participants from a survey that
asks study participants to check their age group from the following options: 18 to
29 years, 30 to 39 years, 40 to 49 years, or 50 years and above. Statisticians and
researchers know what one can legitimately do with specific types of data. Failure
to correctly analyze data could lead to misinformation and faulty decision making.
In public health, doctors could order medications that do not work, health policies
could be created that aggravate the health problem, or effective programs may be
displaced by ineffective programs. Therefore, in addition to understanding data and
mathematical calculations, biostatisticians follow a code of ethics to ensure accu-
rate and honest reporting of data.
Biostatistics is a specialized field of study within public health that takes raw
health data and converts the data into a form that is more easily understood. As
B IOTE R R OR IS M 75
new health issues and ways to measure health emerge, biostatisticians are challenged
to develop new methods to analyze data and promote public health.
Sally Kuykendall
See also: Administration, Health; Certified in Public Health; Code of Ethics; Core
Competencies in Public Health; Degrees in Public Health; Epidemiology; Infant
Mortality; Research; Wegman, Myron Ezra
Further Reading
American College of Epidemiology. (2017). Retrieved from https://www.acepidemiology.org/.
American Statistical Association. (2017). Retrieved from http://www.amstat.org/.
Department of Biostatistics, Vanderbilt University. (n.d.). What is biostatistics? Retrieved from
https://medschool.vanderbilt.edu/biostatistics/content/what-biostatistics.
International Society of Clinical Biostatistics. (2017). Retrieved from http://www.iscb.info/.
National Center for Health Statistics. (2017). Retrieved from http://www.cdc.gov/nchs/.
National Safety Council. (2016). Odds of d ying. Retrieved from http://www.nsc.org/act/events
/Pages/Odds-of-Dying-2015.aspx.
BIOTERRORISM
Bioterrorism is the intentional transmission of bacteria, viruses, or other pathogenic
organisms in order to incapacitate or kill a person or group of p eople. Advance-
ments in genetic technology created the potential for manipulation of naturally
occurring organisms. Enhancing toxicity, modes of transmission, or treatment resis
tance can create a weaponized organism, which is difficult to detect and easily
transmitted through air, w ater, or food. The victims may not realize they have been
attacked until symptoms occur hours or days later, or they may never realize that
they were intentionally sickened. Although any organism may be engineered, com-
monly weaponized organisms are Bacillus anthracis (anthrax), Clostridium botulinum
toxin (botulism), Ricinus communis (ricin toxin), salmonella, smallpox, and Yersinia
pestis (plague). The concept of intentionally developing and harvesting pathogenic
organisms is completely contrary to public health, which works to control and elim-
inate infectious diseases. In order to address the issue of bioterrorism and ensure
public safety, the specialized field of public health preparedness and response plans,
prepares, and practices for public health emergencies, including bioterrorism attacks.
The Division of Strategic National Stockpile maintains a stockpile of more than
$7 billion worth of drugs and medical supplies to respond to infectious dis-
eases, radiation/nuclear emergencies, chemical attacks, and natural disasters.
From a military perspective, bioterrorism is ideal for covert attacks. Military his-
torians believe that feuding tribes used h uman cadavers or dead animals to con-
taminate the water sources of enemies. The first documented bioterrorism occurred
in 600 BCE when the Assyrians poisoned wells with rye ergot fungus. In 1346,
Muslim soldiers chased Christian Italian merchants to Kaffa, a Crimean city on the
76 BIOTE R R OR ISM
Black Sea. The citizens of Kaffa closed the city gates to protect the Italians. The army
was suffering from the plague. Soldiers catapulted corpses over the walls in hopes
of spreading disease and weakening the city. The city eventually succumbed to the
plague. The Italians fled to Constantinople and Asia Minor on merchant ships and
so commenced the Black Death. During the French and Indian War (1754–1763),
British field marshal Jeffrey Amherst contrived to distribute smallpox-infected
blankets to indigenous people. The Delaware and Shawnee tribes were decimated
because they had no natural immunity. Amherst was later chastised by military
leaders for using such cowardly strategies.
World War II brought renewed interest in bioterrorism. In 1930, the Japanese
Unit 731 developed and tested biological agents in Northeast China. Scientists tested
weaponized agents on criminals, allied prisoners of war, political prisoners, and
local Chinese, Russian, and Korean citizens gathered by the military police. In 1942,
British military scientists at Porton Down tested anthrax on sheep placed on
Gruinard Island, Scotland. All 80 sheep died. The island remained contaminated
until mass decontamination efforts in 1986 and final safety testing in 1990. In 1943,
The Wampanoag p eople of Massachusetts are stricken by smallpox. Millions of indigenous

people died as European explorers brought deadly germs to the New World. British field mar-
shal Jeffrey Amherst exploited disease susceptibility by distributing smallpox-contaminated
blankets to Native Americans during the French and Indian War. (North Wind Picture
Archives)
B IOTER R O R IS M 77
the United States started their own biological weapons program engineering seven
lethal agents. Nazi Germany also pursued the development and use of biological
weapons.
On November 25, 1969, President Nixon renounced the use of biological weap-
ons. Within two years, U.S. bioterrorism facilities closed and weaponized agents
were destroyed. In 1975, the international treaty banning biological weapons, the
Convention on the Prohibition of the Development, Production and Stockpiling of
Bacteriological (Biological) and Toxin Weapons and on Their Destruction (now
known as the Biological Weapons Convention) went into effect. In April 2, 1979,
anthrax leaked from a military facility in Sverdlovsk, Russia, resulting in 100 deaths.
The event demonstrated that some countries were continuing to produce weapons
of mass destruction despite international agreements. U nder Saddam Hussein, the
Al Hakum facility in Iraq began mass production of weaponized anthrax in 1989
and is estimated to have produced half a million liters of weaponized organisms.
In 1992, Dr. Kanatjian Alibekov (later known as Ken Alibek) defected to the United
States. Alibekov was the former deputy chief of Biopreparat, the Soviet program
studying, developing, and stockpiling biological warfare. A fter immigrating to the
United States, Alibek worked with the U.S. government to develop biodefense strat-
egies. In 1995, the cult group Aum Shinrikyo released sarin gas in the Tokyo sub-
way. In September 2001, letters containing anthrax were sent to news offices and
U.S. senators. In total 22 people w ere infected including 5 people who died. The
FBI traced attacks to Bruce Edwards Ivins, a scientist working at Fort Detrick in
Frederick, Maryland. Ivins committed suicide in 2008. Although nations have vol-
untarily agreed not to develop, test, or stockpile biological weapons, the possibility
for attacks by rogue individuals or groups continues.
The public health system detects and responds to bioterrorism through surveil-
lance of communicable diseases, investigation of outbreaks, and mobilization of the
national stockpile. Bioterrorism agents are classified into three categories. Category
A agents are highly lethal, easily transmitted, and likely to result in panic and dis-
ruption of society. Anthrax, botulism, plague, smallpox, tularemia, and the viral
hemorrhagic fevers—Ebola, Marburg, and dengue—are Category A agents (Bay-
lor College of Medicine, n.d.). Category B agents are moderate priority, easy to
transmit, and carry lower mortality. Norovirus, E. coli, hepatitis A, ricin toxin,
salmonella, and West Nile Virus are Category B agents. Category C agents are
pathogens that are easily produced and engineered for high lethality. Influenza,
rabies, multidrug resistant tuberculosis, yellow fever, severe acute respiratory
syndrome (SARS), and M iddle East respiratory syndrome (MERS) are examples
of Category C agents.
The Health Alert Network (HAN) is a communication network. HAN dissemi-
nates trustworthy information during public health emergencies. Messages are clas-
sified as health alerts (high priority), health advisories (warnings), health updates,
and general information. Health alerts on weaponized organisms are tailored to
the specific agent, providing background information, at-risk groups or regions,
78 B IOTE R R OR IS M
and recommendations for treatment and prevention. The information is sent to

federal, state, territorial, and local health officers and public health practitioners.
The Crisis & Emergency Risk Communication (CERC) uses evidence-based prac-
tices to communicate with the public. The disastrous events of Hurricane Katrina
(2005) helped government agencies, emergency responders, and public health
professionals to see that they needed to do a better job in issuing warnings. During
a natural or man-made disaster, the public needs clear, concise, and accurate infor-
mation. CERC provides training, resources, and materials in how to communicate
with the public and to empower p eople to make wise, life-saving decisions. The
Department of Homeland Security, CERC, the Office of Public Health Preparedness
and Response, and the Centers for Disease Control and Prevention work with state,
local, and other federal agencies to coordinate responses to public health emergen-
cies. Because of lessons learned from Hurricane Katrina, the response to Hurricane
Sandy (2012) was very different. Days before Hurricane Sandy was predicted to
make landfall, residents were instructed to evacuate, police went door to door, news
agencies listed shelters that allowed pets, and utility trucks immediately outside of
the path of the hurricane were standing by to repair damaged power and commu-
nication lines.
Public health works to eliminate deadly pathogens. In 1796, Edward Jenner tested
his immunological theory by using cowpox serum to inoculate eight-year-old James
Phipps against the deadly smallpox virus. In 1950, the Pan American Health Organ
ization developed the goal of eradicating smallpox on the American continent and
by 1979, the World Health Organization officially declared global smallpox eradi-
cation. In the heat of conflict, weaponized organisms may be seen as a highly effec-
tive and covert means of disarming and destabilizing the e nemy. Fortunately, nations
around the globe realized that bioterrorism crosses the line between humanity and
inhumanity and developed the Biological Weapons Convention. T oday, bioterror-
ism is a health event that we hope w ill never happen. Unfortunately, it is necessary
for public health systems to plan for and prepare for such possibility. The lessons
learned and systems developed to respond to incidents of bioterrorism are also valu-
able for natural disasters or other man-made disasters.
Sally Kuykendall
See also: Centers for Disease Control and Prevention; Emergency Preparedness and
Response; Environmental Health; Global Health; Infectious Diseases; Smallpox;
State, Local, and Territorial Health Departments; World Health Organization; Zom-
bie Preparedness; Controversies in Public Health: Controversy 3; Controversy 4
Further Reading
Baylor College of Medicine. (n.d.). Potential bioterrorism agents. Retrieved from https://www
.bcm.edu/departments/molecular-virology-and-microbiology/emerging-infections
-and-biodefense/potential-bioterrorism-agents.
B I RTH DEF E C TS 79
Centers for Disease Control and Prevention. (2007). Emergency preparedness and response: Bio-
terrorism overview. Retrieved from https://emergency.cdc.gov/bioterrorism/overview.asp.
International Physicians for the Prevention of Nuclear War. Retrieved from http://www.ippnw
.org/.
Lillibridge, S. (2000). A public health response to bioterrorism. Medicine & Global Survival,
6(2), 82–85. Retrieved from http://www.ippnw.org/pdf/mgs/6-2-lillibridge.pdf.
tion. (2001). The public health response to biological and chemical terrorism: Interim plan-
ning guidance for state public health officials. Retrieved from https://emergency.cdc.gov
/Documents/Planning/PlanningGuidance.PDF.
U.S. Department of Homeland Security. Retrieved from https://www.ready.gov/.
BIRTH DEFECTS
Birth defects, also known as congenital disorders, are health problems that develop
before a baby is born. T hese can include a variety of conditions such as congenital
heart defects, developmental disorders, neural tube defects, and more. Although
different birth defects vary in their incidence rates, birth defects are overall rela-
tively common and occur in approximately 1 out of every 33 children (Centers for
Disease Control and Prevention [CDC], 2008). Globally, at least 8 million c hildren
are born each year with a birth defect, and more than 3 million of these children
die each year before the age of five (Weinhold, 2009). There is a wide range in the
severity of different birth defects, with some causing mild or superficial effects and
others causing life-threatening or life-ending conditions.
Birth defects can be the result of any one of many different factors. There are a
diverse variety of genetic conditions that can be passed from parents to their children,
and there is also a wide array of environmental factors that can greatly influence
the child’s development in the womb. Birth defects due to genetic conditions are
often caused when two parents are heterozygous for a recessive mutation. Although
each parent’s dominant alleles may protect them from the genetic condition during
their lifetime, their child may inherit both parents’ recessive allele and therefore
exhibit the signs of the birth defect. Additionally, t here are a variety of environmen-
tal factors that impact the development of the embryo or fetus. Toxic substances
and exposure to pollutants can play a large role in causing birth defects by harming
developmental processes during gestation. Even lifestyle decisions such as smok-
ing, alcohol intake, exercise levels, and weight can all play a role in increasing the
risk of having a child with a birth defect.
Throughout modern history, several environmental health cases related to birth
defects have brought great societal attention to the field of public health. The
birth defect crisis from the use of the antinausea medication Thalidomide was one
such event. In the late 1950s to the early 1960s, thousands of children through-
out the world were born with congenital deformities such as limb malformation. It
was only later discovered that Thalidomide acted as a teratogenic in pregnant
mothers. Teratogens are compounds that cause birth defects through toxic
80 BIRTH DEFEC TS
actions on the developing embryo or fetus. Since Thalidomide was marketed as

an antinausea medi cation, particularly for pregnant mothers suffering from
morning sickness, many children w ere negatively affected and developed moder-
ate to severe birth defects. In the United States, the refusal of the Food and Drug
Administration to approve Thalidomide for distribution was key in preventing
the birth defect effects from affecting large numbers of children. The case of Tha-
lidomide in the United States serves to highlight the role that public health and
other regulatory agencies can play in protecting populations from health prob
lems such as birth defects.
Nonetheless, contemporary birth defect rates in the United States and interna-
tionally are still relatively high and carry an immense associated cost. Therefore,
they are a matter of great interest to public health professionals and society as a
whole. Birth defects affect approximately 120,000 babies each year in the United
States alone and the cost of health care for a child born in the United States with
spina bifida, a birth defect of the backbone, can be more than $20,000 (Radcliff
et al., 2012). The medical costs for a child born with Down syndrome can be
approximately 10 to 12 times higher than for c hildren without Down syndrome
(Kageleiry, Samuelson, Duh, Lefebvre, Campbell, & Skotko, 2017). Additionally,
since many of these congenital disorders can be prevented through well-timed
and effective interventions, the role that public health can play in alleviating birth
defects is vital.
Many public health campaigns have therefore been initiated to reduce key behav
iors that place mothers at a higher risk of giving birth to a child with a congenital
disorder. For example, some public health interventions have sought to reduce the
number of women who drink alcoholic beverages during pregnancy. This is b ecause
the children of mothers who drink alcohol during pregnancy are much more likely
to suffer from a wide range of congenital health problems, including fetal alcohol
syndrome. Additionally, primary care physicians and other health care providers
encourage mothers to take nutritional supplements to prevent nutritional deficien-
cies from causing birth defects. Maternal folate deficiency, for example, is impli-
cated in a variety of congenital neural tube defect disorders such as spina bifida.
To prevent folate-deficiency-related congenital disorders, pregnant mothers are
often placed on a regimen of folic acid supplementation throughout their pregnancy.
Many public health educational interventions and medical association guidelines
have therefore been established to promote the prescribing of folic acid supple-
mentation regimens for pregnant m others. Some health centers and clinics even
offer free screenings and health services to mothers in order to encourage them
to follow proper folate supplementation protocols.
Since the child’s body is undergoing extensive development during the mother’s
pregnancy, it is in a susceptible state to influences such as environmental threats
and maternal behaviors. Although many causes of birth defects can be mitigated
through genetic screenings, positive lifestyle decisions, and other beneficial actions,
B LA C K W ELL , ELI Z A B ETH 81
chance mutations and unknown environmental exposures can still cause many
different types of congenital disorders. Even errors in the cell division of the gam-
etes proceeding the conception of a child can cause congenital disorders. Down
syndrome is a classic example of this type of birth defect.
Since birth defects are a relatively common phenomenon throughout the world,
greater attention is being given to effective interventions and policies in order to miti-
gate the opportunities for congenital disorders to develop. More work is needed to
accomplish greater reductions in preventable congenital disorders g oing forward.
The collaboration of government, health care, and families is essential to combating
the avoidable c auses of birth defects. By instituting policies that limit environmen-
tal toxins, promote proper screening and nutrition, and encourage healthy life-
style choices, the current birth defect rates can be reduced and more children can
enjoy fully healthy lives.
Shayan Waseh
See also: Air Pollution; Alcohol; C

hildren’s Health; Disability; Environmental
Protection Agency; Epidemiology; Family Planning; Genetics; Infant Mortality;
Leading Health Indicators; Maternal Health; Nutrition; Roosevelt, Franklin
Delano
Further Reading
Centers for Disease Control and Prevention. (2008). Update on overall prevalence of major
birth defects. Morbidity and Mortality Weekly Report, 57(1), 1–5.
Centers for Disease Control and Prevention. (2016). Birth defects.Retrieved from https://www
.cdc.gov/ncbddd/birthdefects/index.html.
Kageleiry, A., Samuelson, D., Duh, M. S., Lefebvre, P., Campbell, J., & Skotko, B. G. (2017).
Out-of-pocket medical costs and third-party healthcare costs for c hildren with Down
syndrome. American Journal of Medical Genetics, Part A, 173(3), 627. doi:10.1002
/ajmg.a.38050
National Center on Birth Defects and Developmental Disabilities.Retrieved from https://www
.cdc.gov/ncbddd/index.html
Pitkin, R. M. (2007). Folate and neural tube defects. American Journal of Clinical Nutrition,
85(1), 285S–288S.
Radcliff, E., Cassell, C. H., Tanner, J. P., Kirby, R. S., Watkins, S., Correia, J., et al. (2012).
Hospital use, associated costs, and payer status for infants born with spina bifida. Birth
Defects Research Part A: Clinical and Molecular Teratology, 94, 1044–1053.
Weinhold, B. (2009). Environmental factors in birth defects: What we need to know. Envi-
ronmental Health Perspectives, 117(10), A440–A447.
BLACKWELL, ELIZABETH (1821–1910)

Dr. Elizabeth Blackwell was the first female to earn a medical degree in the United
States. Her persistence and hard work improved care of w
omen and c hildren and
82 BLAC K WELL, ELIZ ABETH
created opportunities for other female leaders in medicine. Elizabeth was born on
February 3, 1821, the third of nine children of Hannah Lane and Samuel Blackwell.
The Blackwell family lived in Bristol, England, a city that thrived on the African
slave trade. Samuel Blackwell was partner in a series of sugar refinery businesses.
Sugar refineries imported sugar cane from slave plantations in the West Indies and
refined the product for use in food and drink, including tea.
Despite a series of unsuccessful business ventures, the family was modestly
affluent. Elizabeth and her siblings were homeschooled by private teachers. In
1832, the family immigrated to the United States so that Samuel Blackwell could
work toward the abolishment of slavery. With the help of old and new business
partners, Blackwell opened the Congress Steam Sugar Refinery in New York City.
He was unable to pay loans on the business. His business partner bought him out,
and the Blackwell family moved to Cincinnati. Samuel died of malaria in 1838, leav-
ing the family without any means of support. Hannah and Elizabeth’s two older
sisters took jobs teaching and later opened a school. These early experiences of
fortune, hardship, risk-taking, and interest in social reform left a lasting impression.
As adults, all of the Blackwell siblings were involved in the abolitionist movement
or women’s rights.
Elizabeth was not initially attracted to the field of medicine. She found the
study of the human body vulgar and preferred history and metaphysics. From
1845 to 1847, she worked as a teacher in Kentucky, North Carolina, and South
Carolina. The idea of attending medical school came as a friend was dying from
a gynecological disorder. Elizabeth’s friend believed that a female physician may
have been more empathetic to her complaints and alleviated some of her suffering.
Elizabeth did not want to get married and believed that she could avoid matri-
mony by going to medical school. She consulted with six prominent physicians on
next steps. All of them discouraged her noting, “That it was utter impossibility for
a woman to obtain a medical education; that the idea though good in itself, was
eccentric and utopian, utterly impracticable!” (Blackwell & Blackwell, 1863,
pp. 4–5). Friends and colleagues recommended that she e ither disguise herself as
a male or move to Paris where there were opportunities for female physicians.
Believing that the Quaker community might be supportive, Elizabeth moved to
Philadelphia. She borrowed medical books from friends and obtained a tutor in
anatomy and physiology. When it came time to apply to medical school, Elizabeth
applied to all of the medical schools in New York City and Philadelphia as well as
12 other schools in the Northeastern region. She was rejected by 29 schools.
Geneva Medical College (now Hobart and William Smith Colleges) in upstate New
York was the only school that did not reject her outright. The admissions commit-
tee was unable to agree on her application and decided to put the question to the
all-male student body for a vote. If just one of the 150 students voted against her,
the application would be denied. The students thought it was a joke. They voted
unanimously to approve her admission, and in 1847 Elizabeth started medical
B LAC K WELL , ELI Z A B ETH 83
school. Her struggles did not end there. Ms. Blackwell was scorned by people in
town who labeled her as “a bad woman whose designs would gradually become
evident, or that, being insane, an outbreak of insanity would soon be apparent”
(Blackwell, 1895, pp. 70–73). Although other students at the college harassed
her, the medical students came to respect her. Professors noted that the medical
students who were normally loud and crude became quiet and studious when
Elizabeth was present. She found it difficult to gain clinical experience. Profes-
sors banned her from anatomy and physiology labs, and patients refused to
allow her to examine them. To get experience, Elizabeth worked summers at
Blockley Almshouse in Philadelphia. Located in a dangerous section of the city,
Blockley treated Philadelphia’s poor, disabled, elderly, and mentally ill popula-
tions. Her doctoral thesis examined typhus fever, a disease contracted on coffin
ships used by Irish immigrants fleeing the G reat Famine of Ireland (1845–1852).
On January 23, 1849, Elizabeth
graduated first in her class from
Geneva Medical College. The
graduation ceremony was a curi-
osity. Townspeople and academ-
ics watched with anticipation as
the humble and slightly embar-
rassed Dr. Blackwell accepted
her diploma. Over the next three
years 20 other w omen graduated
from American medical schools,
including Emily Blackwell (1826–
1910), Elizabeth’s younger s ister.
After graduation, Elizabeth

moved to Paris to gain medical
experience and eventually spe-
cialize in surgery. While assisting
with a delivery at La Maternité,
gonorrhea-infected vaginal fluids
splashed into her face. Elizabeth
suffered a purulent eye infection
that resulted in permanent blind-
ness in one eye. The loss of depth
perception meant that she could
Refusing to yield to gender discrimination and
no longer safely perform surgery.
oppression, Elizabeth Blackwell became the first
Unyielding, Elizabeth turned to woman to earn a medical degree in the United States.
hygiene and sanitation as a spe- Her persistence improved the care of w omen and
cialty. The prevention of com- children, and created opportunities for other females
municable diseases was a natural in medicine. (Library of Congress)
84 BLAC K WELL, ELIZ ABETH
extension of her work in the almshouse, her interest in social reform, her doctoral
thesis, and her own disabling experience at La Maternité. In 1850, Elizabeth
returned to London to work at St. Bartholomew’s Hospital with the famous surgeon
Dr. James Paget (1814–1899). She was allowed to work in all wards except the
gynecology and pediatrics wards. In E ngland, she was befriended by many pro-
gressive w omen of the time, including Florence Nightingale (1820–1910). Night-
ingale and Blackwell shared an interest in hospital sanitation and hygiene and
professionalism of women in health and medicine. Nightingale wanted Elizabeth to
use her knowledge and skills to train nurses. Elizabeth was intent on training female
medical doctors.
In 1851, Elizabeth moved to New York City to start her own private medical
practice. She soon found that she was blacklisted as an abortionist, medical col-
leagues excluded her from educational opportunities, and patients w ere reluc-
tant to seek the services of a female physician. She applied for a position at the
city’s women’s clinic and was rejected. Undeterred, she worked as a freelance
writer, publishing a series of works entitled The Laws of Life, with Special Refer-
ence to the Physical Education of Girls. In 1853, Quaker friends helped Elizabeth to
start a health clinic treating indigent patients three afternoons each week. Within
four years, the clinic grew from a small rented room near Tompkins Square in
Manhattan to the New York Infirmary for Women and Children. The infirmary
attracted other female physicians including Drs. Emily Blackwell and Marie
Zakrzewska (1829–1902). Emily eventually took over day-to-day management
of the hospital leaving Elizabeth free to pursue her passion of women’s medical
education.
In 1860, Elizabeth published Medicine as a Profession for W omen. The essay
argued that the stereotypical female roles of housekeeper and teacher were also
relevant to the field of medicine. Reflecting the social values of the time, the article
explained that women who knew how to keep a house clean would also know how
to prevent communicable disease transmission. The American Civil War (1861–
1865) helped to advance women in medicine. Infection was one of the leading
causes of death. The overcrowded, unsanitary conditions of civil war hospitals
resulted in high postoperative infection and mortality rates. Modeling Nightingale’s
experiences and methods of controlling infection during the Crimean War (1853–
1856), the American government established the U.S. Sanitary Commission to care
for wounded soldiers. Elizabeth helped to organize the sanitary commission and
the Woman’s Central Relief Association. The general public started to envision
female nurses as the primary caregivers of diseased and injured men. The idea of
women in medicine, albeit in subservient roles, was no longer a utopian dream.
Emily and Elizabeth’s Address on the Medical Education of Women (1864) argued for
a medical school designed exclusively for female physicians. The sisters presented
the widely accepted view that there was a need for nurse training programs and
explained that female physicians w ere an ideal group to advance nurse training. In
B LA C K W ELL , ELI Z A B ETH 85
1867, the infirmary opened a medical college and offered both medical training
and clinical experience for women. Elizabeth ensured high standards in admission
and clinical training. In 1869, Elizabeth returned to London to establish a private
medical practice and to work t oward women’s medical education in G reat Britain.
In collaboration with Dr. Sophia Jex-Blake, a student of the New York Infirmary,
she established the London School of Medicine for W omen (1874). The following
year, she was appointed professor of gynecology at the London School of Medicine
for children. She was the first woman to have her name listed on the British Medi-
cal Register.
Reflecting on her life, Elizabeth noted an overwhelming loneliness. She was
often the target of harassment and institutional discrimination. Few colleagues
understood or recognized the obstacles she faced in society, in medicine and as a
woman. Where many p eople would have given up, she kept g oing. The persistent
humiliation and disparagement created a very fierce and relentless character. She
was often at odds with p eople, including her own sister, Emily. In 1856, while
establishing the New York Infirmary, Elizabeth a dopted Katherine “Kitty” Barry, an
Irish orphan. Elizabeth cared for Kitty, but she also used Kitty as a domestic servant
and never allowed Kitty to flourish on her own. The two women remained together
until Blackwell’s death on May 31, 1910. When Kitty died in 1930, she called
Elizabeth her “true love.”
Elizabeth Blackwell was an Anglo-American w oman who broke gender barriers
by becoming the first woman to graduate from a recognized medical school in the
United States. As a doctor, she worked to ensure sanitary conditions in hospitals,
to prevent communicable diseases, and to advance women’s health care. By devel-
oping training opportunities for w omen in medicine, she advanced the fields of
nursing and medicine.
Sally Kuykendall
See also: Baker, Sara Josephine; C

hildren’s Health; Handwashing; Infant Mortality;
Infectious Diseases; Maternal Health; Patient Safety
Further Reading
Blackwell, E. (1895). Pioneer work in opening the medical profession to w omen: Autobiographi-
cal sketches by Dr. Elizabeth Blackwell (pp. 70–73). London: Longmans, Green.
Blackwell, E., & Blackwell, E. (1863, December 19). Address on the medical education of w omen.
New York: Baptist & Taylor, Book and Job Printers. Retrieved from https://iiif.lib.harvard
.edu/manifests/view/drs:2582644$1i.
Hobart and William-Smith Colleges. (2016). Elizabeth Blackwell. Retrieved from http://www
.hws.edu/about/blackwell/.
U.S. National Library of Medicine. (2015). Dr. Elizabeth Blackwell. Changing the face of
medicine. Retrieved from https://cfmedicine.nlm.nih.gov/physicians/biography_35
.html.
86 BODY M ASS INDEX (BMI)
BODY MASS INDEX (BMI)

The body mass index (BMI)—also known as the Quetelet index—is a convenient
and inexpensive way to estimate body composition calculated from an individual’s
weight and height. BMI ranks the person’s body size relative to other people. Although
BMI is not a diagnostic test, health practitioners can use BMI to screen and monitor
health status. High BMI suggests high body fat or adipose tissue and is associated
with higher risk of chronic diseases, such as Type 2 diabetes, heart disease, osteoar-
thritis, stroke, gallstones, hypertension, breathing problems, sleep apnea, and
breast and colon cancer. Diseases associated with high BMI are some of the most
common in the United States and very costly to health care systems. When a patient
registers a high BMI, the health care provider will initially assess the patient’s diet,
physical activity, and family history to determine factors that may be related to high
BMI. If initial screening suggests high body fat, more extensive laboratory testing is
done to decide the extent of any problems and levels of risk for obesity-related
diseases. In addition to monitoring disease state, BMI can also be used to monitor
progress of p
eople who are adapting healthier lifestyles.
The formula to calculate BMI was developed by Lambert Adolphe Jacques Quetelet
(1796–1874). Quetelet was a Belgian mathematician, statistician, and astronomer
with an interest in social phenomena, art, and the h uman body. Quetelet used his
training as a mathematician and astronomer to study similarities in people, an
approach that was fairly novel at the time. While managing several large-scale stud-
ies of human development, Quetelet observed recurring body shapes and frames
that matched what he had seen as a painter and sculptor. In analyzing the data sets
of height and weight, Quetelet recognized a mathematical pattern. With the excep-
tion of childhood and puberty, when growth spurts occur, body weight increases
relative to the square of height. The Quentelet index was published in 1832. The
calculation was not fully appreciated u ntil more than a c entury later when scien-
tists discovered connections between body weight and heart disease. Hoping to
reduce one of the leading causes of death in the United States, experts sought ways
to define healthy weight ranges. The Quetelet index was recognized as an accurate
way to assess body fat with the major advantage that it does not require expensive
equipment. In 1972, Ancel Keys, a prominent nutrition scientist, renamed the Quen-
telet index the body mass index.
BMI calculators are available online, but the formula for an adult is the following:
BMI = weight (kg) / [height (m)]2
or
BMI = weight (lb) / [height (in)]2 × 703
Although BMI calculation is universal, the cutoff values indicating risk vary by
country. In the United States, an adult BMI of less than 18.5 is underweight, sug-
gesting possible malnutrition. BMIs between 18.5 and 24.9 are considered aver-
age, healthy values. BMIs between 25 and 29.9 are classified as overweight and at
B ODY M ASS INDEX ( B M I ) 87
risk for obesity-related health problems. BMIs between 30 and 34.9 are classified
as moderately obese (also referred to as Class I obesity). BMIs between 35 and 39.9
are severely obese or Class II obesity, and BMI above 40 is very severely obese or
Class III obesity. Adult BMI values cannot be applied to youth b ecause the charac-
teristic patterns of childhood and adolescent growth might give falsely high or low
results. C hildren and adolescents grow in periodic spurts, rather than as a con-
stant consistent process. With adequate nourishment, the body gains weight
immediately before a height spurt. Thus, the same child could be classified as
overweight before a height spurt and underweight a fter the height spurt. To
account for normal childhood growth patterns, medical professionals use BMI-
for-age where BMI is converted to a percentile and standardized to age and gender.
BMI-for-age percentile of 4 percent or less suggests the child is underweight.
Healthy weight range is 5 to 84.9 percent. A BMI-for-age percentile of 85 to
94.9 percent is classified as overweight. A BMI-for-age of 95 percent or greater is
considered obese. As in adults, high BMI-for-age in children is not a perfect diag-
nostic tool. High BMI warns the health care provider to explore diet, exercise, and
further diagnostic testing.
Although BMI is an easy and accurate form of measuring body fat, there are some
instances where the measure may be misleading. BMI calculation uses a person’s
weight, and it does not differentiate weight of adipose tissue from weight of muscle
or bone tissue. Muscle tissue is heavier by volume than adipose tissue. This means
that a very muscular person may register BMI in the overweight range. (It is unlikely
a muscular person would have a BMI in the obese range.) Therefore, highly mus-
cular p eople such as athletes may need to use other methods of measuring body
composition. Furthermore, a person with a large skeletal frame has more skeletal
muscle, and this may falsely elevate BMI into the overweight range; whereas some-
one with a small frame and excess adipose tissue may rank as normal weight. Body
fat also varies by gender and age. W
omen tend to have a higher percentage of body
fat than men. In the female body, the hormone estrogen directs fat to the breasts,
hips, waist, and buttocks. In males, fat is directed to the chest, abdomen, and but-
tocks. Percentage of adipose tissue also varies with age. With nutritious diet and
adequate exercise, muscle tissue increases until the mid-twenties. After the age of
50, the body loses muscle mass, a process known as age-related sarcopenia. Thus,
there are limitations to using BMI to interpret individual health. Alternative ways
to measure body composition include skinfold thickness, waist circumference, den-
sitometry, isotope dilution (hydrometry), dual energy X-ray absorptiometry, bio-
electrical impedance analysis, and magnetic resonance imaging. Each method has
advantages and disadvantages with respect to accuracy, accessibility, expense, and
ease of use.
Beyond assessing individual health risk, public health professionals use BMI to
study the general health of various populations. The Centers for Disease Control
and Prevention and National Center for Health Statistics currently collect BMI data
and develop maps, which allows epidemiologists to identify trends in obesity and
88 B OUS F IELD , M IDIAN OTHELLO
distribution by geography or other factors. Through such large-scale BMI studies,

program planners can develop programs for high-risk communities, public health
officials can develop policies, and local governments can plan neighborhoods that
promote healthy weight.
Sally Kuykendall
See also: Diabetes Mellitus; Disease; Eating Disorders; Food Insecurity; Heart Dis-
ease; Heart Truth® (Red Dress) Campaign, The; Hypertension; Obesity; Physical
Activity
Further Reading
Eknoyen, G. (2008). Adolphe Quetelet (1796–1874): The average man and indices of obe-
sity. Nephrology Dialysis Transplantation, 23(1), 47–51.
tion, Division of Nutrition, Physical Activity and Obesity. (2015). Body mass index (BMI).
Retrieved from http://www.cdc.gov/healthyweight/assessing/bmi/.
tion, Division of Nutrition, Physical Activity and Obesity. (2015). Data, trends and maps.
Retrieved from http://www.cdc.gov/obesity/data/prevalence-maps.html.
BOUSFIELD, MIDIAN OTHELLO (1885–1948)

Midian Othello Bousfield was a physician, insurance executive, and foundation offi-
cer who promoted public health, medical, and nursing training among African
Americans and advocated for the health needs of p eople of color. Midian was born
in Tipton, Missouri, to Cornelia Catherine Gilbert and Willard Hayman Bousfield.
The older Bousfield was a barber and businessman. In 1907, Midian earned a bach-
elor’s degree from the University of Kansas followed by a medical degree from
Northwestern University. He completed his internship and residency at Freedmen’s
Hospital in Washington, DC. Freedmen’s Hospital was affiliated with Howard Uni-
versity School of Medicine, serving the medical needs of African Americans, many
of whom were former slaves or children of former slaves. After medical residency,
Dr. Bousfield moved to Kansas City where he worked in the city hospital. In 1911,
he traveled to Brazil to establish a medical practice for African Brazilians. During
the slave trade, Brazil imported more Africans than any other country. Slaves w ere
used to work on sugar plantations, in gold and diamond mining, and ranching.
From a business perspective, there should have been a great need for health ser
vices. However, Bousfield’s efforts to open a private practice w ere unsuccessful. He
even tried panning for gold without success. A fter a year, Bousfield returned to Kan-
sas City.
In 1914, Bousfield met Maudelle Tanner Brown, a public school teacher. They
married and moved to Chicago where Bousfield started private practice, worked as
a health officer for the Chicago Public School District, and was on staff at Provident
B OUSF IELD, M IDIAN OTHELLO 89
Hospital. From 1915 to 1920, Bousfeld served as secretary of the Railway Men’s
International Benevolent Industrial Association. Railroads w ere the main mode of
transportation, and Chicago was a major gateway between the East and the West.
Many Chicago residents worked for the railway—jobs that demanded long danger-
ous hours and provided little job security. Starting in the mid-1800s the white railway
workers started u nionizing and striking for better working conditions (Thale,
2005). The union of master mechanics was followed by unionization of engineers,
freight handlers, track workers, and switchmen. One of the last groups to unionize
was the African American porters. The porters’ income came solely from tips. The
railway companies expected the porters to set up or clean up the restaurant and
sleeping cars without any additional reimbursement. The railway companies also
charged the porters for food, sleeping quarters, and uniforms, a sum that amounted
to approximately half of their income. And porters were responsible for reimburs-
ing the company if a passenger stole towels or kitchenware. When the porters
attempted to u nionize, the Pullman Company hired spies to squelch the labor move-
ment. However, the Railway Men’s International Benevolent Industrial Association
met secretly, organized, and hired outside organizers, beyond the reach of Pullman.
The Railway Men’s International Benevolent Industrial Association later became
the Brotherhood of Sleeping Car Porters (BSCP), one of the first African American
labor unions chartered by the American Federation of Labor. The BSCP founders
also became leaders in the black civil rights movement.
In 1919, Bousfield founded Liberty Life Insurance. The company was designed
to serve the needs of African Americans. At the time, life insurance for African Amer-
icans would not have been a lucrative business. By 1939 (the first year that data on
income by race was recorded), the average annual income of African Americans
was $537, half the annual income of whites, $1,234.41 (Maloney, 2002). Life span
was also much shorter. Whites born in 1900 had a life expectancy of 47.6 years
(46.6 years for males and 48.7 years for females), while African Americans had a
life expectancy of 33.0 years (32.5 years for males and 33.5 years for females) (U.S.
Census Bureau, 1999). The Liberty Life Insurance later merged with other compa-
nies to become Supreme Life Insurance Company. Dr. Bousfield served as medical
director and vice president of Supreme and chairman of the public health commit-
tee of the National Negro Insurance Association. In 1934, Bousfield became the
first African American to address the American Public Health Association (APHA)
annual meeting. This historic speech called attention to the living and working con-
ditions of African Americans. Bousfield described overcrowding, lack of fresh air
and recreational spaces, racial health disparities, segregated hospitals, refusal to treat
black patients, and limited health services. Bousfield encouraged public health pro-
fessionals to partner with black communities to provide treatment and preventive
health services. Bousfield’s ideas w
ere inspired by W. E. B. Du Bois, a sociologist who
advocated for solidarity among African Americans, education, and activism. Bous-
field envisioned education as a way to promote health and wellness and to reduce
health disparities. There is no doubt that Bousfield was also inspired by his wife.
90 B OUS F IELD , M IDIAN OTHELLO
Maudelle Bousfield made her own mark in history by becoming the first African
American high school principal in Chicago. In 1940, white males had an average
of nine years of education while African American males had an average of six years
of education (Maloney, 2002).
In 1935, Bousfield became director of the Negro Health Division of the Julius
Rosenwald Fund. In this role, he was able to work toward his vision. He focused
grant funds on supporting African American health services and hospitals and
expanded training opportunities in public health, nursing, and medicine and post-
graduate education for African American health professionals. Bousfield was also
instrumental in developing the Infantile Paralysis Units at Tuskegee Institute and
Provident Hospital. From 1933 to 1934, he served as president of the National Med-
ical Association (NMA), the national organization of African American physicians.
He was elected president of the Chicago Urban League in 1936 and appointed as
the first African American to serve on the Chicago School Board in 1939. In 1942,
he joined World War II efforts as the first African American colonel in the Army
Medical Corps. He commanded Station Hospital in Fort Huachuca, Arizona. Sta-
tion Hospital was a segregated hospital that served the medical and health needs of
14,000 African American military personnel. His time in the military was difficult.
Bousfield was criticized for contributing to segregated hospitals. He retired in 1945,
and died on February 16, 1948, of acute coronary disease.
Dr. Midian Othello Bousfield was a key figure in calling attention to the plight
of African Americans post-slavery. As a physician and life insurance executive, Bous-
field provided insights into social injustice and racial health disparities. Within his
lifetime, Bousfield was able to achieve some progress. By 1945, the gap in life expec-
tancy had started to narrow. The average life expectancy of African Americans
increased to 58 years while life expectancy of whites increased to 67 years (U.S.
Census Bureau, 1999). However, socioeconomic differences persisted where Afri-
can Americans continued to earn half that of whites. Today, Bousfield’s message is
acknowledged and embraced. Reducing health disparities is a primary goal of pub-
lic health professionals.
Sally Kuykendall
See also: Epidemic; Epidemiology; Health Disparities; Smith, James McCune; Social
Determinants of Health; Tubman, Harriet
Further Reading
Bousfield, M. O. (1934). Reaching the Negro community. American Journal of Public Health,
24, 209–215. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1558597
/pdf/amjphnation00913-0031.pdf.
Ewbank, D. C. (1987). History of black mortality and health before 1940. The Milbank Quar-
terly, 65, 100.
Gamble, V. N., & Brown, T. M. (2009). Midian Othello Bousfield: Advocate for the medical
and public health concerns of Black Americans. American Journal of Public Health, 99(7),
B O WDIT C H , HENRY ING E R SOLL 91
1186. Retrieved from http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2009

.163709?journalCode=a jph.
Maloney, T. (2002). African Americans in the twentieth century. R. Whaples (Ed.), EH.Net
Encyclopedia. Retrieved from https://eh.net/encyclopedia/african-americans-in-the
-twentieth-century/.
Thale, C. (2005). Railroad workers. Encyclopedia of Chicago. Chicago Historical Society.
Retrieved from http://www.encyclopedia.chicagohistory.org/pages/1038.html.
U.S. Census Bureau. (1999). Statistical abstract of the United States, annual and national vital
statistics reports. Retrieved from https://www.census.gov/library/publications/1999
/compendia/statab/119ed.html.
BOWDITCH, HENRY INGERSOLL (1808–1892)

Dr. Henry Ingersoll Bowditch was a Boston physician who established the first state
board of health in the United States. He encouraged colleagues to use scientific rea-
soning in medical practices and authored numerous books and brochures on top-
ics ranging from use of the stethoscope, physical examination techniques, supporting
the medical education of women, and advocating for emergency medical teams to
expedite treatment of wounded soldiers. Bowditch’s expertise in pulmonary dis-
eases greatly advanced the diagnosis and treatment of tuberculosis, bronchitis, pneu-
monia, and pneumothorax. Although his accomplishments in medicine are historic
and noteworthy, his most important contributions to society and public health were
in the area of social reform. Bowditch was a leader in the anti-slavery movement.
Working alongside notable abolitionists, Bowditch founded a secretive paramili-
tary force to foil slave hunters and drafted the Massachusetts state law protecting
fugitive slaves from recapture.
Henry was born on August 9, 1808, in Salem, Massachusetts, to Mary (Polly)
Ingersoll and Nathaniel Bowditch. The Bowditch f amily history is relevant to under-
standing Henry’s interests, talents, and values. Henry’s grandfather, Habakkuk
Bowditch, was the captain of a merchant ship. He was not very successful and the
Bowditch f amily often relied on aid from the Salem Marine Society to pay their bills.
On the nights that Habakkuk was at sea, Nathaniel sat in the window with his
mother, watching the moon and the stars. When Nathaniel was 10, his mother died
and Nathaniel had to leave school to work in his father’s new business venture,
making wooden barrels. This business was also unsuccessful and a fter two years,
Habakkuk indentured Nathaniel to a ship chandler for a period of nine years.
Nathaniel had an amazing ability to calculate numbers in his head. During times
when the shipping business was slow, Nathaniel taught himself algebra, calculus,
Latin, and French. He quickly advanced from bookkeeper to supercargo, the title
given to the ship owner’s representative. At sea, Nathaniel continued his self-study,
translating major literary works into English. However, he did not simply translate
the works, he also corrected errors, thereby improving and sometimes rewriting the
books. After completing his covenant, Nathaniel continued to work on ships, man-
aging the books, reading, and studying the stars and ocean. His enthusiasm for
92 BOWDIT CH, HENRY IN GERSOLL
learning was contagious. Onboard one ship, he taught the entire crew, including
the cook, to navigate by the stars. Nathaniel wrote The New American Practical Navi-
gator, an encyclopedia of navigation, which is still used today. He is also credited
with introducing America to the field of astronomy. Harvard University acknowl-
edged Mr. Bowditch’s accomplishments with an honorary master’s degree. When
Nathaniel married Polly Ingersoll, he settled into the prestigious position as head
of the Massachusetts Hospital Life Insurance Company. By the time his children
were born, Nathaniel had worked his way from an impoverished family and nine
years of indentured servitude to become one of the most prestigious and influential
members of Boston society.
Henry attended the Public Latin School and Harvard University where he
completed his bachelor’s degree (1828) and medical degree (1832). Part of his
medical training involved studying in London and France with the preemi-
nent physicians Gabriel Andral,
Auguste Francois Chomel, and
Pierre Charles Alexandre Louis.
In Paris, Henry and fellow class-
mate Oliver Wendell Holmes
developed a lifelong professional
connection with Dr. Louis. Louis
taught his students how use a
stethoscope, different sounds to
listen for when auscultating the
heart and lungs, and the benefits of
postmortem examinations. Louis
spoke out against the popular
therapy of bloodletting, believing
that the doctor’s role was to sup-
port natural recovery. His theories
and practices using the numerical
method in medicine were the
start of the field of epidemiology.
Bowditch was instrumental in
sharing Louis’s ideas and philos-
ophies with physicians in the
United States. In 1846, Bowditch
wrote The Young Stethoscopist or
the Student’s Guide to Auscultation
Mas sa
chusetts General Hospital threatened to
and l ater translated Louis’s ground-
revoke Dr. Henry Ingersoll Bowditch’s staff privi-
leges when he admitted the first African American breaking book, Anatomical, Path-
patient to the hospital. Bowditch designed the first ological and Therapeutic Researches
state board of health in the United States. (Wellcome upon the Disease Known u nder the
Collection) Name of Gasto-Enterite.
While Bowditch was in Europe, the British Parliament enacted the Slavery Abo-
lition Act 1833, a law that abolished slavery in the British Empire and compen-
sated slave owners for business losses because of losing slaves. The movement was
led by member of Parliament William Wilberforce. Wilberforce was a deeply reli-
gious man who believed that the use and abuse of slaves in the West Indies and the
depraved lifestyle of slave owners w ere an embarrassment to G reat Britain and an
affront to Christianity. P
eople admired Wilberforce’s ability to act on his faith. When
Wilberforce died, Bowditch attended his funeral and was deeply moved toward the
abolition of slavery.
On return to Boston, Bowditch resumed his position within Boston society. He
married Olivia Yardley, whom he had met in London, started a medical practice
with staff privileges at Massachusetts General Hospital, and participated in chari-
ties supporting the poor and less fortunate. Against hospital rules, Bowditch
attempted to admit an African American patient with pulmonary problems. Mas
sachusetts General Hospital refused the admission and the hospital board passed a
policy revoking staff privileges of any doctor who admitted African American
patients. Bowditch resigned in protest, forcing the board to withdraw the policy.
Bowditch joined the anti-slavery cause in 1835 a fter witnessing the attack and
attempted hanging of journalist William Lloyd Garrison. Garrison was scheduled
to speak to the Female Anti-Slavery Society of Boston when an angry pro-slavery
mob interrupted the meeting and dragged Garrison through the streets. Bowditch
saw the angry mob attacking Garrison. Their violent and abusive behavior would
have been repulsive to anyone who worked to help and heal people. Authorities
intervened and warned Garrison to leave Boston. The event was a turning point for
many Bostonians creating a foundation for the anti-slavery movement. In 1842, fugi-
tive slave George Latimer and his pregnant wife, Rebecca, fled to Boston. They
were recognized and reported to slaveholder James B. Gray. Gray traveled from
Virginia to reclaim Latimer and was met by serious resistance from the Boston abo-
litionists. Latimer sat in jail through a series of legal maneuvers intended to stop
Gray from reclaiming Latimer. Bowditch served on the Latimer Committee, a group
established to secure Latimer’s freedom. Frustrated, Gray eventually agreed to sell
Latimer for $400. The work of the Latimer Committee continued, drafting the first
law protecting fugitive slaves. The 1843 Personal Liberty Act banned Massachusetts
state officials from arresting or holding suspected slaves. The Personal Liberty Act
was overruled when Congress passed the Fugitive Slave Act of 1850. The Fugitive
Slave Act required free states to cooperate with the capture and return of slaves. In
1854, Anthony Burns was captured u nder the Fugitive Slave Act. Burns was a Bap-
tist minister and fugitive slave living and working in Boston. When officials
arrested Burns, Bostonians protested with riots, demonstrations, and attacks on the
federal courthouse. Efforts to keep Burns in Boston were unsuccessful, and the city
was placed u nder martial law while Burns was escorted to a ship returning him to
the South. A fter Burns left Boston, abolitionists continued attempts to purchase and
free Burns. However, the slaveholder refused. Eventually, Burns’s freedom was
94 B O W DIT C H, HEN RY IN GE RSOLL
secured through a series of purchases. In response to Burns’s case, Bowditch, Sam-

uel Gridley Howe, Bronson Alcott, and other prominent Bostonians established the
Anti-Man-Hunting League. The league was a secret society of more than 100 people
who devised plans to surround, overcome, and capture slave hunters while the fugi-
tive slave was moved to safety (Massachusetts Historical Society, n.d.).
During the Civil War, Bowditch served as medical examiner, screening soldiers
for the Massachusetts regiment. His beloved son, Nathaniel, joined the cavalry and
was severely injured during a charge at Kelly’s Ford, Virginia. Two surgeons saw
Lieutenant Bowditch fall but had no means to carry him off the battlefield. Another
soldier eventually draped Nat over the neck of his horse and carried him to a wagon
waiting to transport wounded soldiers. Nat died in the wagon without receiving
medical care. Bowditch was convinced that Nat may have survived if he had received
proper medical attention. In his sorrow, Bowditch wrote A Brief Plea for an Ambu-
lance System for the Army of the United States. The government responded by estab-
lishing an ambulance corps, which greatly reduced morbidity and mortality of both
Confederate and Union army soldiers.
After the war, Bowditch turned his attention to mending the division between
Northern and Southern physicians. He served as vice president and president of
the American Medical Association (AMA) where he proposed a medical code of eth-
ics and advocated for medical schools to accept women and former slaves. He
taught at Harvard Medical School and published numerous medical reports on
tuberculosis, inoculations, and public health. In 1869, Bowditch founded the
Massachusetts State Board of Health. He served as chairman of the board for 10 years
until he was appointed to the National Board of Health. He resigned from the
National Board of Health when President Chester A. Arthur cut funding. Bowditch
died in 1892. As he lay on his deathbed, the widow of Lewis Hayden, a former
slave and patient of Bowditch’s, insisted on sitting by his side. Mrs. Hayden was
determined that Dr. Bowditch should not die alone.
Dr. Henry Ingersoll Bowditch was a physician, social reformer, and father who
worked tirelessly to raise up those who society viewed as lesser than or not deserv-
ing of the same rights and privileges. Despite ostracism by friends, colleagues and
patients, Bowditch held firmly to his beliefs that all men and w omen should have
equal rights to health, education, and life’s liberties. His knowledge and efforts
advanced medical practice, founded state boards of health, and led to critical social
changes.
Sally Kuykendall
See also: American Medical Association; Shattuck, Lemuel; State, Local, and Terri-
torial Health Departments; Tubman, Harriet
Further Reading
The Boston Medical and Surgical Journal ( January 21, 1892). Obituary: Henry Ingersoll
Bowditch, M.D., 126(3), 67–70.
Bowditch, H. I. (1846). The young stethoscopist or the student’s guide to auscultation. New York:
J. & H. G. Langley. Retrieved from https://archive.org/details/63630550R.nlm.nih.go.
Bowditch, H. I. (1863). A brief plea for an ambulance system for the army of the United States, as
drawn from the extra sufferings of the late Lieut. Bowditch and a wounded comrade. Boston:
Ticknor and Fields. Retrieved from https://archive.org/details/briefpleaforambu00bowd.
Bowditch, H. I. (1881). The medical education of women. Boston Medical and Surgical Jour-
nal, 105(5), 109–110. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJM
188109291051301.
Cumbler, J. T. (2008). A family goes to war: Sacrifice and honor for an abolitionist family.
Massachusetts Historical Review, 10, 57–84.
Felts, J. H. (2002). Henry Ingersoll Bowditch and Oliver Wendell Holmes: Stethoscopists and
reformers. Perspectives in Biology and Medicine, 45(4), 539–548.
Massachusetts Historical Society. (n.d.). Collections online: Diagram to show the drill the Anti-Man-
Hunting League had for r unning off of a slave or man-hunter. Retrieved from https://masshist
.org/database/1668.
Rodriguez, J. P. (2007). Bowditch, Henry Ingersoll. In J. Rodriguez, Encyclopedia of emanci-
pation and abolition in the transatlantic world. London: Routledge.
C
CANCER
Cancer is characterized by the abnormal growth of cells in the body. Typically, the
cells of the human body are well regulated and their growth is tightly controlled by
a series of molecular signals and processes. However, when t hese guidance systems
and protective mechanisms are disrupted, the cells of the human body can prolif-
erate inappropriately. This abnormal proliferation of cells is then labeled as cancer.
Neoplasm is another term used to describe abnormal growths or cancers.
Cancers or neoplasms can be benign or malignant. Benign neoplasms still involve
the abnormal growth of cells, but these inappropriately proliferating cells remain
localized to one area, do not invade the surrounding tissue, and are generally not
harmful unless they restrict blood vessels, nerves, or other important body struc-
tures. Malignant neoplasms, however, are aggressively proliferative and invade the
surrounding tissue. They are often able to metastasize through the bloodstream and
grow to damage important body structures such as the lungs or brain. Typically, it
is malignant neoplasms that are thought of as the stereotypical example of deadly
cancer.
The c auses of cancer are diverse and can include genetic, behavioral, and envi-
ronmental factors. The genetic code of cells is essential for the regulation of cell
growth and behavior. Mutations in genes responsible for cellular growth and regu-
lation are implicated in causing a variety of cancers. These mutations can be inher-
ited from parents or developed throughout a person’s lifetime. Additionally, a variety
of behaviors and lifestyle decisions can contribute to the frequency and nature of
genetic mutations. Tobacco use, for example, often results in lung damage and the
ingestion of mutation-causing chemicals. With repeated tobacco usage, genetic
mutations can build up in the smoker’s cells and eventually result in cancer. In fact,
nearly a quarter of all cancer deaths are related to the use of tobacco (World Health
Organization, 2017). Finally, environmental factors such as air pollution, toxic
chemicals, and even unprotected sun exposure can increase the incidence of can-
cer through a variety of mechanisms that result in genetic damage and subsequently
lead to the development of cancer.
Cancer, which has become the second leading cause of death in the contemporary
world, has afflicted populations and been studied by physicians for thousands of
years. The term “cancer” itself derives from the Greek word karkinos, which was
used by Hippocrates to describe tumors. Even ancient Egyptian case records as far
back as 1500 BCE include mentions of breast cancer (Sudhakar, 2009). Through-
out different periods of time, new explanations and theories related to how cancer
98 C ANCER
occurs w ere developed. In Hippocrates’s time through the Middle Ages, the preva-
lent belief was that human health was governed by the balance between four dif
ferent types of bodily fluids and that the disruption of this balance could cause
cancer. In the 17th century, lymph theory was developed that proposed that cancer
formation was through the body’s lymph fluid. Johannes Peter Muller and Rudolf
Virchow however, in the 1800s, demonstrated that cancer is made up of cells and
not of lymph. They determined that cancer cells were derived from other cells,
and Virchow proposed that chronic irritation was the principle cause of cancer. In
the following c entury, scientists proposed a series of different potential c auses of
cancer. It was believed to be caused by trauma to the body. Then, it was believed
to be caused by infectious parasites. Finally, in the m
iddle of the 20th century, as
scientists began to discover and understand DNA and genetics, it became more
well understood that DNA damage could lead to unrestricted cellular growth and
result in cancer. The modern theory of cancer has now evolved to be more com-
plex, but it is still centered around the idea that the role of DNA and the genetic
code is to effectively regulate and control the growth of cells in the body. This sci-
entific paradigm stresses the importance of public health approaches that mitigate
the causes of cellular and genetic damage that are at the root of cancer.
The public health impact of cancer is keenly felt throughout the modern world.
Over one and a half million new cases of cancer are diagnosed each year in the
United States alone, and national expenditures for cancer care in the United States
are expected to reach over $150 billion a year by 2020 (Quintiles IMS Institute,
2017). More than a third of all men and w omen are estimated to be diagnosed
with cancer at some point in their lifetimes (National Cancer Institute, 2017).
Cancer, with its associated social, emotional, and financial challenges, is therefore
a large interest of public health interventions and professionals seeking to reduce its
incidence.
The prognosis, or course of disease, of patients diagnosed with cancer is often
largely impacted by the stage of their cancer. The later that patients are diagnosed,
the worse their prognosis tends to be. Therefore, many public health interventions
seek to improve the rate of cancer screenings so that patients are diagnosed in the
earliest stages of disease when treatments such as chemotherapy are the most effective.
These interventions have targeted screening rates through a variety of strategies,
including launching awareness campaigns about the importance of screening, pro-
moting the development of guidelines encouraging health care professionals to
recommend screening, and carrying out lobbying for the inclusion of screening
costs into health insurance plans to promote affordable access. The success of these
efforts has shown such approaches to be effective. The British health care system, for
example, launched a Breast Screening Programme in 1988 to invite all w omen
between the ages of 50 and 70 to be screened for breast cancer. Evaluation of the
program has shown that an estimated 1,400 lives are saved because of the program
each year (Advisory Committee on Breast Cancer Screening, 2006).
C A R E, A C C ESS TO 99
Although cancer is one of the biggest causes of death in the world, there are tens
of billions of dollars spent each year on cancer research with the hope of discover-
ing and developing new and improved cancer therapies. The discoveries of these
research scientists, coupled with the implementation and work of public health pro-
fessionals, will serve to alleviate a portion of the contemporary health burden of
cancer.
Shayan Waseh
See also: Addictions; Adverse Childhood Experiences; Air Pollution; Alcohol; Behav-
ioral Health; Birth Defects; Chronic Illness; Environmental Health; Environmental
Protection Agency; Epidemiology; Genetics; Health Disparities; Healthy Places; Hepa-
titis; Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome;
Leading Health Indicators; Men’s Health; Modern Era, Public Health in the; National
Cancer Institute; Nutrition; Prevention; Skin Cancer; Surgeon General; Women’s
Health; Wynder, Ernst Ludwig; Controversies in Public Health: Controversy 2
Further Reading
Advisory Committee on Breast Cancer Screening. (2006). Screening for breast cancer in
England: Past and future. Journal of Medical Screening, 13, 59–61.
National Cancer Institute. (2017, March). Cancer statistics. Retrieved from https://www.cancer
.gov/about-cancer/understanding/statistics.
Quintiles IMS Institute. (2017). Global oncology trends 2017: Advances, complexity and cost.
Retrieved from http://www.imshealth.com/en/thought-leadership/quintilesims-institute
/reports/global_oncology_trends_2017.
Ryerson, A. B., Eheman, C. R., Altekruse, S. F., Ward, J. W., Jemal, A., Sherman, R. L., . . .
Anderson, R. N. (2016). Annual report to the nation on the status of cancer, 1975–
2012, featuring the increasing incidence of liver cancer. Cancer, 122(9), 1312–1337.
Siegel, R. L., Miller, K. D., & Jemal, A. (2016). Cancer statistics, 2016. CA: A Cancer Journal
for Clinicians, 66(1), 7–30.
Sudhakar, A. (2009). History of cancer: Ancient and modern treatment methods. Journal of
Cancer Science Therapy, 1(2), 1–4.
World Health Organization. (2017, February). Cancer fact sheet. Retrieved from http://www
.who.int/mediacentre/factsheets/fs297/en.
CARE, ACCESS TO
Access to care is a concept in public health policy that describes the means of entry,
ease of use, and receipt of basic health care services and provisions by an individ-
ual or population. Access to care is defined as “the extent a population can reach
and utilize health services.” The concept is particularly important in public health
because it reflects the quality of life, disease detection, treatment, and disease and
disability prevention efforts of society. Experts divide access to care into four main
categories: affordability, availability, acceptability, and physical accessibility. Failure
100 C AR E, ACC ESS TO
to adequately address these factors can present barriers that impact public health
( Jacobs, Ir, Bigdeli, Annear, & Van Damme, 2012). Barriers to care can be allevi-
ated through national policies related to health financing and socioeconomic sta-
tus. In the United States, health programs and policies, such as the Patient Protection
and Affordable Care Act (PPACA) and Medicare regulate the level of access to care,
utilization, and coverage of health care costs.
Affordability is the minimal cost a patient or client can afford to pay for needed
medical care without suffering financial hardship. One out of 20 Americans do not
get needed medical treatment due to cost (Ward, Clarke, Nugent, & Schiller, 2016).
Affordability is determined by income, insurance, health care funding agreements,
and minimal cost payments. The United States uses a multi-payer mode with health
care financing by public and private payers dependent on market competition.
Working adults may be covered by employer-sponsored health insurance programs.
However, not all employer-sponsored programs are affordable (Levesque, Harris, &
Russell, 2013). Out-of-pocket payments may be prohibitive for low-income workers
or those with high monthly expenses. Taking time off work to travel to medical
appointments or receive treatment can also impact earning potential and affordabil-
ity. Government policies, resources, and funding allocation can improve afford-
ability. The PPACA removed some barriers in access to care by providing subsidies
for eligible beneficiaries and eliminating restrictions on preexisting conditions. Pro-
grams offering free maternal and child health care, HIV/AIDS treatment, or other
community-based treatment or prevention programs can also assist those who are
struggling to earn a living wage. In comparison to the U.S. system, other developed
countries use a single-payer health model dependent on community-based financ-
ing. Taxes are used to create a national system of care for protection during disease
or disability.
Availability of services refers to the geographic location of providers in relation
to the patient population, hours of operation, service wait times, accessible tech-
nology, qualified staff, and treatment interventions. The hours of operations and
service wait times are a reflection of system efficiency. Efficiency or capacity can be
improved through medical technology, telemedicine, human resources management,
and strategic planning. The Electronic Health Record (EHR) improves efficiency by
reducing the time needed for interdisciplinary collaboration and communication.
Having well qualified medical professionals with adequate equipment and technol-
ogy creates quality care. Yet, health professionals are in high demand, and human
resources must work to find effective and creative ways to attract and retain quali-
fied staff. Utilization review programs are used to assess the length of hospital stays,
preadmission certifications, disease management programs, and second opinions
for surgery or authorized referrals. This information is used to determine the best
ways to proactively manage population needs.
Acceptability of services refers to the ethical, social, and cultural values that influ-
ence a person’s decisions in accessing and accepting health services. Religious, social,
C A R E, A C C ESS TO 101
and cultural values associated with healing and treatment, language, communication,
diversity, gender, sexual preference, and ethnicity play a crucial role in patient care
and treatment. For example, some followers of conservative Islamic or Jewish
faiths w ill only permit female medical professionals to treat and provide care to
female patients. Understanding cultural values can reduce reluctance to seek care
and facilitate prevention and early diagnosis. Schools and programs in public health
integrate cultural competence and gender sensitivity into health professional train-
ing in order to promote acceptability of services.
Physical accessibility is the ability to reach and utilize health services through-
out all stages of care and treatment and to access health information in a timely
manner. Physical accessibility relates to how the environment or geographic loca-
tion affects the timely delivery of health services. A good transportation network,
personal means of transportation or mobility, and duration of travel are important
factors in measuring physical accessibility. To assess accessibility, location of avail-
able health facilities or providers are compared to the targeted population density,
population distributions and settlements, transport network, and duration of time
in seeking care. Such assessments help determine resource allocation, distribution,
and the extent of access to care.
Access to care is a complex concept with many moderating factors. Health policy,
funding arrangements, education, employment, income, physical environment, and
housing are all important in evaluating access to care. Societal and cultural values also
play a role. Cultural values such as beliefs, languages, and traditions are imperative
in determining the effectiveness of treatments and communication that enhances
health service delivery among patients and providers. Developing a public health
workforce that reflects the cultural diversity of the community they serve is critical
in promoting access to care.
Godyson Orji
See also: Affordable Care Act; C

hildren’s Health; Community Health Centers; Health
Care Disparities; Health Disparities; Health Policy; Immigrant Health; Medicare;
Rural Health; Social Determinants of Health; World Health Organization; Contro-
versies in Public Health: Controversy 1; Controversy 5
Further Reading
Centers for Disease Control and Prevention. (2016). Access to health care. Retrieved from
http://www.cdc.gov/vitalsigns/healthcareaccess.
Healthy People 2020. (2016). Access to health services. Retrieved from https://www.healthy
people.g ov/2020/t opics-objectives/t opic/Access-t o-Health-Services.
Jacobs, B., Ir, P., Bigdeli, M., Annear, P. L., & Van Damme, W. (2012). Addressing access
barriers to health services: An analytical framework for selecting appropriate interven-
tions in low-income Asian countries. Health Policy and Planning, 27(4), 288–300.
doi:10.1093/heapol/czr038
102 C AUSALITY
Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care:
Conceptualizing access at the interface of health systems and populations. International
Journal for Equity in Health, 12(1), 1. doi:10.1186/1475-9276-12-18
Ward, B. W., Clarke, T. C., Nugent, C. N., & Schiller, J. S. (2016). Early release of selected
estimates based on data from the 2015 National Health Interview Survey. National Center
for Health Statistics. Retrieved from http://www.cdc.gov/nchs/nhis.htm.
CAUSALITY
Causality looks at the relationship between one factor (the cause) and a subsequent
phenomenon (the effect). In public health, cause-effect relationships arouse particular
interest b
ecause cause-effect defines risk factors for disease, identifies at-risk groups,
and enables prevention efforts. However, public health researchers struggle when
investigating and reporting etiology, c auses of disease. Scientists want to be certain
that Risk Factor A causes Disease A before they encourage people to stop using a
product or to make lifestyle changes. Premature assumptions about cause and effect
create confusion and distrust. Therefore, in order to say that a factor causes a specific
health problem, the relationship must meet certain conditions of time sequence
(cause must precede effect), scientific credibility, consistency with other research,
covariation between the two factors, and other plausible causes are ruled out (Hen-
nekens, Buring, & Mayrent, 1987). Only when the causal factor meets most of these
conditions will public health practitioners take steps to ameliorate the causal factor.
Early studies of the safety of the artificial sweetener saccharin demonstrate the
importance of honoring the conditions of causality. Saccharin was discovered in
1879 by Dr. Constantin Fahlberg. Fahlberg was working late in the Johns Hopkins
University laboratory when he suddenly realized that he was about to miss his din-
ner. He rushed home, forgetting to wash his hands. During the meal, he noticed
that the bread tasted sweet. Wiping his mouth with his napkin and drinking a gulp
of water, he realized that his napkin was also sweet, even sweeter than sugar. He
realized that the sweetness came from chemicals he had spilled on his fingers during
the day. He returned to the lab, tasting each specimen u ntil he found the source.
(Fahlberg was apparently not a good model for occupational safety.) Thankfully,
none of the chemicals were corrosive, and saccharin became a major breakthrough
in food chemistry. Artificial sweeteners are used to sweeten b itter medicine, in food
preservation, to disguise inferior products in commercial goods, and improve food
taste for people who are diabetic or on special diets. Because saccharin was discov-
ered unintentionally, safety testing came later. Many scientists and members of the
public speculated that this artificial (unnatural) chemical was unsafe. In 1977, a
group of researchers published the Canadian Saccharin Study (Arnold, Moodie,
Stavric, Stoltz, Grice, & Munro, 1977). Study results indicated that saccharin caused
bladder cancer in laboratory rats. The study was highly publicized, and other sci-
entists, including those from the National Cancer Institute, endorsed the gener-
alization that saccharin would also cause bladder cancer in humans. In an effort
to protect the millions of people who used saccharin as a sweetener, the federal
C AUSALITY 103
government immediately listed saccharin as a carcinogen. All products containing

saccharin were required to have a warning label, and people were advised to avoid
ingestion. When other researchers attempted to repeat the study, they found that
rats have a unique mechanism of breaking down and excreting saccharin. H umans
do not have the same biological mechanism. Thus, saccharin c auses bladder cancer
in rats, not humans. When the later study results were released, nonscientists were
confused and questions lingered. Was saccharin safe? It took almost two decades
for the federal government to delist saccharin as a carcinogen and remove the warn-
ing. The saccharin studies show the impact of publicizing study results before the
conditions of causality are met. Researchers, eager to make a name for themselves,
are tempted to release results. True science is careful, patient, and thoughtful.
The first condition of causality, time sequence, means that the causal factor will
always occur before the outcome. For Factor A to cause Disease A, Factor A must
occur before Disease A. Using the example that tobacco smoking causes lung can-
cer, smoking (the cause) occurs before the lung cancer (the effect). Time sequence
can be difficult to detect when there is a long time period between the cause and
the effect. For example, the period between exposure to h uman immunodeficiency
virus (HIV) and seroconversion, when antibodies are first detected, is normally three
weeks to six months. In some cases, seroconversion may not occur for up to 12
months. The long and varying time sequence made it difficult for early AIDS research-
ers to identify the cause of AIDS. The second condition, scientific credibility, means
that science supports a logical connection between the cause and effect. The idea
that red wine lowers risk of heart disease seems contrary to what we know about
alcohol and health. Alcohol impairs fat metabolism and increases risk of heart dis-
ease. On further investigation, red wine contains antioxidants that remove harmful
molecules known to cause heart disease. In moderation, the antioxidants of red wine
lower the risk of heart disease. In higher doses, the damaging effects of alcohol over-
ride positive antioxidant effects. Scientific credibility is limited by what we know
about the human body. In some instances, credibility cannot be established u ntil
knowledge catches up with research findings. The third condition of causality, con-
sistency with other research, refers to the idea that different studies of the same prob
lem conclude similar results. The later safety studies of saccharin failed to support
earlier conclusions. The fourth condition of causality, covariation between the two
factors, means that as dose or exposure to the causal f actor increases, the effect also
increases. With cigarette smoking and lung cancer, the more a person smokes, the
greater the risk of lung cancer and other chronic lung diseases. Covariation is also
referred to as a dose-response relationship, where the higher the dose, the greater
the response. The final condition of causality is other plausible causes are ruled out,
which means the outcome cannot be explained by another factor. Social research-
ers struggle with this criterion. T
here are so many f actors and interactions between
factors that influence health, making it very difficult to rule out other possible causes.
A problem such as childhood obesity is caused by anything that increases calorie
intake beyond energy expenditure. Fast food companies can easily argue childhood
104 C ENTE RS F OR DISEASE C ONT R OL AND PR E V ENTION ( C D C )
obesity is not caused by fast food but by the lack of safe places to play and increased
screen time. It is difficult for scientists to separate out exposures in order to draw
a direct line between cause and effect.
Knowing what c auses a particular disease empowers health practitioners to take
efforts to stop, prevent, or reduce the risk or causal factor. Knowing that binge drink-
ing is associated with motor vehicle crashes, sexual assault, sexually transmitted
diseases (STDs), drownings, suicide, homic ide, and meningitis allows health edu-
cators to target binge drinking to reduce multiple health issues. However, proving
causality is a long and tedious process, and, even when scientists do collect enough
evidence, they are cautious in how to present the results. Before public dissemina-
tion, results should by reviewed and confirmed by other scientists, a process known
as peer review. Only a fter multiple researchers have studied the problem and come
to similar conclusions can health professionals claim causal relationships and advo-
cate for health policy and practices.
Sally Kuykendall
See also: Epidemiology; Koch, Heinrich Hermann Robert; Population Health;

Research; Social Determinants of Health; Wynder, Ernst Ludwig; Controversies in
Public Health: Controversy 4
Further Reading
Arnold, D. L., Moodie, C. A., Stavric, B., Stoltz, D. R., Grice, H. C., & Munro, I. C. (1977).
Canadian Saccharin Study. Science, 197(4301), 320.
Hennekins, C. H., Buring, J. E., & Mayrent S. L. (Eds.). (1987). Epidemiology in medicine.
Boston: Little, Brown and Company.
Reuber, M. D. (1978). Carcinogenicity of saccharin. Environmental Health Perspectives, 25,
173–200.
CENTERS FOR DISEASE CONTROL AND

PREVENTION (CDC)
The Centers for Disease Control and Prevention (CDC) is a unit of the U.S. Depart-
ment of Health and Human Services (DHHS) responsible for disease surveillance,
treatment, and prevention and response to man-made and natural disasters. B ecause
diseases and pathogens do not conform to man-made boundaries, the CDC is also
active in global disease prevention. The CDC offers accurate and up-to-date informa-
tion to the general public and health professionals. The CDC website and publica-
tions feature evidence-based programs and resources on emerging, remerging, and
potential health hazards. The agency is widely recognized as one of the preeminent
institutions promoting health and well-being, nationally and internationally.
The idea that the nation needed a central organization to monitor and manage
health challenges arose from an outbreak of amebic dysentery in 1933 (Andrews,
1946). Approximately 8.5 million people attended the Chicago World’s Fair. Cases
of fever, chills, severe abdominal pain, and bloody diarrhea were first reported in
CENTERS F OR DISEASE C ONTR OL AND P R E V ENTION ( C D C ) 105
August and followed by other cases spread widely across the nation. Without a for-
mal network of communicating unusual outbreaks of disease, local doctors did not
suspect a rare parasitic organism. Doctors suspected more common illnesses, such
as appendicitis or colitis. Patients w
ere referred for surgery, which spread the patho-
gen into the abdominal cavity, causing sepsis and death. By November, health
officials connected the cases and tracked the source to two hotels in Chicago. Inspec-
tors found old, rusty pipes. One sewer pipe passed over the drinking w ater tanks
of both h otels, contaminating the drinking water. Officials estimated 160,000 h otel
and restaurant guests w ere exposed to the tainted w ater, 1,704 p
eople w
ere infected,
and 98 p eople died. It was clear that the nation needed a centralized system of
reporting and tracking disease.
The organizational and physical structure of the CDC developed from the Malaria
Control in War Areas (MCWA) program. After the attack on Pearl Harbor, military
and support personnel were mobilized to training bases in the southern states. Per-
sonnel from the North did not have resistance to malaria that was endemic within
the southern states. Malarial infection could cause illness or death. The MCWA,
U.S. Public Health Service (USPHS), and state health departments joined together
to clear the areas surrounding military bases of mosquito vectors. The project imme-
diately hit an obstacle. Many qualified personnel were already involved with other
parts of the war effort. The MCWA had to train personnel. Workers w ere taught
A worker sprays pesticide around a pool of standing w ater as part of the National Malaria
Eradication Program of 1958. The first mission of the new Centers for Disease Control and
Prevention (CDC) was to eradicate mosquito breeding grounds near military bases. (Cour-
tesy CDC/Smith Collection/Gado/Getty Images)
106 C ENTER S FOR DISEASE CONT ROL AND PRE V ENTION ( C D C )
safe and effective application of DDT, identification and elimination of mosquito

breeding grounds, and working with members of the public to eliminate standing
water, places where mosquitos breed. The MCWA project was highly successful.
However, a second malaria threat arose when military personnel, including prison-
ers of war, returned from tropical battlegrounds. With the potential for malaria
spreading to new areas, Dr. Joseph Mountin, chief of the USPHS’s Division of Domes-
tic Quarantine, advocated expanding MCWA efforts throughout the susceptible
southern states.
The Communicable Disease Center (CDC) officially opened on July 1, 1946, with
369 staff of primarily entomologists and engineers. The initial budget of $10 mil-
lion was used to purchase DDT, shovels, sprayers, and trucks. Workers received
specialized training in epidemiology and disease surveillance. For logistical reasons,
the CDC was located in Atlanta while other federal organizations were located in or
near Washington, DC. The chairman of the board of Atlanta-based Coca-Cola,
Robert W. Woodruff, took a special interest in the organization. His favorite hunt-
ing land was infested with mosquitos. Here was an opportunity to resolve his prob
lem. Woodruff convinced Emory University to sell 15 acres of land to the CDC for
a token payment of $10. CDC employees collected the money themselves. By 1949,
workers had sprayed 4.6 million homes with DDT, drained numerous mosquito
breeding areas, and the nation was declared malaria free (Centers for Disease
Control and Prevention, 2012). The center’s responsibilities quickly expanded to
other infectious diseases: rabies, tuberculosis, typhus, dysentery, poliomyelitis,
plague, and histoplasmosis. Internal support and networks developed. Laboratory
staff researched ways to control and combat pathogens. Dr. Alexander Langmuir,
the director of the epidemiology division, started a national surveillance program.
Local doctors became the front line staff, reporting cases of unusual diseases to
the CDC.
The CDC programs and focus adapted to meet the nation’s health needs. In
1947, the CDC moved into disaster response when a cargo ship carrying ammo-
nium nitrate exploded in Texas City, Texas. The initial blast ignited a chain reaction
spreading to other ships, the oil terminal, freight trains, local businesses, and homes.
Over 5,000 people w ere injured and 581 p eople died. The Texas City Disaster is
considered one of the worst industrial incidents in U.S. history and forced the CDC
into the role of official government agency for disaster response.
The strategies that the CDC uses to respond to health issues, epidemiology (inves-
tigating outbreaks), the use of science to guide responses and developing multi-
level, planned responses are effective against numerous seemingly diverse health
issues. In 1950, CDC staff traveled to Southeast Asia to provide technical assistance
in malaria control. In 1955, the CDC led the investigation into the Cutter Incident,
an outbreak of polio caused by contaminated polio vaccine. Other highlights include
the First Surgeon General’s Report on Smoking and Health (1964), famine relief dur-
ing the Biafran War (1968), development of national health objectives (1978),
global eradication of smallpox (1980), investigation of early AIDS cases (1982),
C ENTE R S F O R DISEASE C ONT R OL AND P R E V ENTION ( C D C ) 107
elimination of polio in the Americas (1994), response to World Trade Center and
anthrax attacks (2001), response to the earthquake in Haiti (2010), response to the
Ebola outbreak in West Africa (2015), and response to lead contamination in the
Flint, Michigan, water supply (2016). As advancements in sanitation, vaccines, and
antibiotics reduced deaths due to infectious diseases, the CDC expanded efforts into
chronic disease prevention, maternal and child health, nutrition, and occupational
safety and health. The name of the institution changed to reflect changes in respon-
sibilities. In 1967, the Communicable Disease Center was renamed the National
Communicable Disease Center (NCDC). In 1970, the NCDC became the Center
for Disease Control and in 1992, the Centers for Disease Control and Prevention
emerged. Throughout the name changes, the center has maintained the universally
recognized initials, CDC.
Today, the Centers for Disease Control and Prevention works with local govern-
ment partners to monitor disease outbreaks (surveillance), and to intervene and
prevent health threats using evidence-based practices and programs. The CDC pub-
lishes numerous journals, resources, and toolboxes. The Morbidity Mortality Weekly
Report (MMWR) communicates timely, accurate, and objective health information
to more than 250,000 public health and medical professionals, academics, and
researchers. MMWR consistently ranks as one of the most influential publications
in the field of public, environmental, and occupational health. The CDC website
provides a wealth of resources on acute and chronic diseases and other health issues.
Information is listed in an easy to navigate A to Z index or by topic category.
Throughout the past 70 years, the CDC has crafted a unique niche as a national
and international leader in public health, disease prevention, health promotion, and
disaster preparedness. Although the organization is part of the federal government
and susceptible to changes in political opinions and climate, efforts are evidence-
based. This means that the CDC attempts to remain apolitical, using science and
action to address health problems.
Sally Kuykendall
See also: Bioterrorism; Cutter Incident, The; Emergency Preparedness and Response;
Maternal Health; National Institutes of Health; Public Health in the United States,
History of; State, Local, and Territorial Health Departments; Surgeon General; Tuske-
gee Syphilis Study; U.S. Department of Health and Human Services; U.S. Public
Health Service; Zombie Preparedness; Controversies in Public Health: Controversy 4
Further Reading
Andrews, J. M. (1946). Development of the Communicable Disease Center. Atlanta: CDC Bul-
letin. Retrieved from http://www.globalhealthchronicles.com/archive/files/d3dc844d0
235d315f0766d4c9521cb3b.p df.
Centers for Disease Control and Prevention. (2012). Elimination of malaria in the United States
(1947–1951). Retrieved from https://www.cdc.gov/malaria/about/history/elimination_us
.html.
108 C ENTE RS F OR M EDI C AR E AND M EDI C AID SE R V I C ES ( C M S)
CENTERS FOR MEDICARE AND MEDICAID

SERVICES (CMS)
The Centers for Medicare and Medicaid Services (CMS) is a division of the U.S.
Department of Health and H uman Services (DHHS) responsible for managing pro-
grams that finance health services for the elderly, people with special health needs,
those with limited income, or those who are not covered by employer-sponsored
health plans. Federally sponsored health care programs were first signed into law
in 1965 as an amendment to the Social Security Act. The Health Insurance for the
Aged (Medicare) Act and Medicaid provided hospital, extended care, and home
health care to all Americans aged 65 and over. In 1977, the Health Care Financing
Administration (HCFA) was established to manage the Medicare and Medicaid
programs. In 2001, HCFA was renamed the Centers for Medicare and Medicaid Ser
vices (CMS). Over time, federally sponsored health care has changed as needs change
and medical advances provide new and better opportunities for care. CMS cur-
rently manages Medicare, Medicaid, the Children’s Health Insurance Program
(CHIP), and the Health Insurance Marketplace programs. One out of three Ameri-
cans is currently enrolled in a CMS program. The agency works to promote opti-
mal medical and health care, reduce health disparities, and prevent fraud.
Sally Kuykendall
See also: Affordable Care Act; C

hildren’s Health; Emergency Medical Treatment and
Labor Act (EMTALA); F amily Planning; Health Disparities; Health Literacy; Medic-
aid; Medicare; Public Health Law; Roosevelt, Eleanor; Roosevelt, Franklin Delano;
Stark Law; Social Security Act; U.S. Department of Health and Human Services
Further Reading
Centers for Medicare and Medicaid Services.Retrieved from https://www.cms.gov.
Shalala, D. (2000). Remarks by the Hon. Donna E. Shalala, Former U.S. Secretary of Health
and H uman Services at the 35th Anniversary Event, Hubert H. Humphrey Building, U.S.
Department of Health and H uman Services, Washington, DC, pages 2–7. Retrieved from
https://www.cms.gov/About -CMS/Agency-Information /History /Downloads /CMS
35thAnniversary.pdf.
Tapia Granados, J. A., & Diez Roux, A. V. (2009). Life and death during the Great Depres-
sion. Proceedings of the National Academy of Sciences of the United States of America, 106(41),
17290–17295. Retrieved from http://doi.org/10.1073/pnas.0904491106.
CERTIFIED IN PUBLIC HEALTH (CPH)

Professional certification in public health is achieved by successfully passing the
Certified in Public Health (CPH) exam. The exam contains 200 questions on basic
principles in public health. The principles reflect foundational skills that e very
public health professional should possess in order to function efficiently within the
system. Core areas are biostatistics, environmental health sciences, epidemiology,
C HAD WI C K , EDWIN 109
health policy and management, and social and behavioral health sciences. Cross-
cutting areas are communication and informatics, diversity and culture, leadership,
public health biology, professionalism, program planning, and systems thinking.
The exam is offered by the National Board of Public Health Examiners (NBPHE).
Experienced public health professionals and graduates of the Council on Education
for Public Health (CEPH) accredited public health programs are eligible to take the
CPH. Professional credentialing demonstrates mastery of the basic concepts of
public health and a personal commitment to public health practice. The credential
is maintained by completing 50 CPH-approved continuing education credits every
two years. Continuing education credits are earned by attending public health pro-
fessional events or workshops; reading articles on public health research and prac-
tice; completing college level courses in public health or approved massive open
online courses (MOOCs); writing grants, articles, or books; completing a disser-
tation, fellowship, or residency; or completing unpaid service related to public
health. To ensure that the CPH accurately measures the knowledge and skills
necessary for public health practitioners, in 2014, the NBPHE completed a job
analysis study. Researchers surveyed 4,850 public health practitioners represent-
ing diverse fields of public health. Respondents provided feedback on the content
of the exam. Suggestions for improvement were to consider the roles of entry level
practitioners in sanitation, hygiene, and program planning as well as integrating
more clinical biomedical research and scientific methods into the core competen-
cies. As the field of public health continues to evolve, the examination will also need
to evolve.
Sally Kuykendall
See also: Administration, Health; American Public Health Association; Core Com-
petencies in Public Health; Council on Education for Public Health
Further Reading
Council on Linkages between Academia and Public Health Practice. (2014). Core competen-
cies for public health professionals. Retrieved from http://www.phf.org/resourcestools/pages
/core_public_health_competencies.aspx.
National Board of Public Health Examiners. (2016). Certified in public health. Retrieved from
https://www.nbphe.org/.
CHADWICK, EDWIN (1800–1890)

Sir Edwin Chadwick was a lawyer, civil servant, and crusader who wrote some of
the most important and influential documents in public health. In 1760, rapid
expansion of the textile industry, invention of the steam engine, factories, railroads,
and a new economic system of capitalism fueled the start of England’s Industrial
Revolution. In pursuit of factory jobs, working men crowded into the inner cities
bringing their families with them. Available housing failed to keep up with demand.
110 C HAD WICK , ED WIN
Between 1837 and 1841, Manchester’s population grew 47 percent while housing
increased 15 percent (Bloy, 2016). Bradford’s population grew 78 percent while
housing grew 12 percent (Bloy, 2016). In Liverpool, 39,000 p eople lived in 7,800
cellars (an average of five p eople per cellar), and 86,000 people lived in 2,400 court-
yards or alleyways (an average of 36 people per courtyard) (Bloy, 2016). Aging
water and waste systems could not handle the increasing demand. People shared
sleeping quarters with chickens, pigs, and sheep; refuse piled up in the streets; sewage
spewed from gutters; cholera, typhoid, and other communicable disease epidemics
were rampant. In his role of public servant, Chadwick laboriously investigated, ana-
lyzed, and documented the health of E ngland’s poor working families. Using detailed
statistics and graphic descriptions, he provided a clear and unquestionable image of
what life was like for the typical working-class individual. Yet, Chadwick did not
stop at investigating the problem. He suggested long-term sustainable and affordable
solutions. He advocated for public w ater systems, sewers, flush toilets, street clean-
ing, and city disposal of trash and refuse. Without any training in medicine or civil
engineering, Chadwick created systems of sanitation that saved numerous lives and
are still used t oday.
Edwin Chadwick was born on January 24, 1800, in Longsight, Manchester. His
mother died when he was young. His father, James Chadwick, was a newspaper
editor and the son of Andrew Chadwick, a close friend of the founder of methodism,
John Wesley. Edwin attended public and boarding school until his family moved to
London in 1810. In London, he was taught by private tutors, self-study, and his
father. B ecause both his father and grandfather held radical, reformist political views,
Edwin was enculturated with a strong sense of courage and public duty, empathy
for the disadvantaged, and contempt for power and wealth. As a young man, Edwin
apprenticed in a law office. He supplemented his meager earnings with income
moonlighting as a journalist. In 1823, Chadwick joined the Honourable Society of
the Inner T emple. By this time, his publications on life assurance, sanitation, and
prevention drew the attention of well-known radicals, John Stuart Mill, Nassau
Senior, and Jeremy Bentham. Chadwick became a protégé of Bentham’s, moving into
his h
ouse and working with the social reformer until Bentham’s death in 1832. The
founder of utilitarianism, Bentham believed that society should maximize utility where
utility is defined as the sum of all pleasure created by an action minus the sum of all
suffering created by an action. Chadwick progressed beyond Bentham’s philosophical
viewpoint to actually achieve the greatest good for the greatest number of p eople.
In 1832, Chadwick was appointed to the Poor Law commission with Nassau
Senior. The commission was responsible for administrating the New Poor Law. In
1834, Chadwick and Senior wrote the Report on the Poor Law, which recommended
reforms in how the poor who w ere unable to work w ere cared for. When administra-
tors changed, Chadwick frequently found himself disagreeing with the philosophy of
his superiors. The job of the Poor Law administrators was to keep the poor working
so that they could support production and national progress. The assumption was
that poor people were lazy and immoral and the role of the administrators was to
C HAD WI C K , EDWIN 111
get the poor working and to keep them working. One way to achieve this was by
making the alternative to not working, living in a workhouse, very unpleasant.
Chadwick believed that preventing poverty and suffering was preferable to hous-
ing and feeding p eople who w ere already in poverty. To examine poverty and
develop solutions, Chadwick proposed a detailed and impartial inquiry into pov-
erty, disease, and crime. His superiors, who had already labeled him as unsafe and
impractical, isolated him from the resources and functions of the office.
Unstoppable, Chadwick joined efforts with Dr. Thomas Southwood Smith. He
used his own funds, resources, and energy to investigate sanitary conditions. In
1838, Chadwick commissioned James Kay and Neil Arnott to investigate the c auses
of fever and prevention measures. London had suffered a series of severe cholera
outbreaks. Although Chadwick believed in miasma, he also believed that sanita-
tion measures could prevent further outbreaks. In 1840, Chadwick published the
Report on the Result of a Special Inquiry into the Practice of Interment in Towns followed
by The Report on the Sanitary Conditions of the Labouring Population of G reat Britain
(1842), commonly known as Chadwick’s Report. Despite the fact that Chadwick’s
Report was not an official document, the report had enormous impact. Thoughtful
data and detailed descriptions of the deplorable living and working conditions of
laboring class presented a convincing argument of the need for reform. The report
outlined the high mortality of working men, whose average life span was 29 years
lower than wealthy men. The researchers calculated that occupational hazards and
poor living conditions created 43,000 new widows and 112,000 new orphans per
year. Chadwick’s Report proposed government investment in sewer improvements,
trash removal from houses and roads, clean drinking water, and a medical officer
in each town. He argued that since a lot of poor relief went to families of working
men who died of infectious diseases, society could reduce spending through sani-
tary measures. The report formed the basis of Britain’s public health system, a sys-
tem that was later replicated in other countries.
Through utilitarian logic, Chadwick countered commonly accepted policies,
practices, and beliefs over and over again. In one study, Chadwick investigated the
practice of sending prisoners to the Australian penal colonies to alleviate overcrowding
in prisons. Merchant ships were paid a flat rate per prisoner. The ship owners packed
as many men as possible onto a ship. Since the owners w ere paid in advance, there
was no incentive to keep the prisoners alive. Approximately half of the men died
along the journey. Chadwick recommended a payment based on the number of
convicts who arrived safely, and the ship o wners quickly developed safety measures
and strategies to keep the prisoners alive and safe. In one case, the ship owner hired
a doctor to accompany voyages. Deaths were reduced. In 1846, Chadwick studied
worker fatalities during railroad construction. He found that companies hired the
least skilled and educated workers b ecause labor was cheaper. The lack of knowl-
edge and experience resulted in high rates of injury. Disabled workers and widows
and children of workers who died were supported by society. Chadwick advocated
shifting financial responsibility onto the construction com pany, and companies
112 C HAD W IC K , ED W IN
voluntarily implemented training and safety programs. In a study of w ater usage,

Chadwick showed that unsanitary conditions among the poor were not a matter of
choice but a m atter of economic necessity. Poor p eople would pay for drinking
water delivery but would not pay for water for sanitation. Chadwick proposed pip-
ing water directly into homes, allowing the price of water delivery for drinking to
offset the price of waste water for sewage disposal. Using policy and economics,
Chadwick repeatedly sought the greatest good for the greatest number of p eople.
After another cholera epidemic, the Public Health Act was passed in 1848. The act
established a Central Board of Health and local boards of health in districts where the
death rate was above 23 per 1,000 (Parliament, UK, n.d.). Chadwick became chief
member of the General Board of Health. However, his time on the board was brief and
tenuous. He had created many enemies, businessmen and politicians with vested
interests, supervisors who held tight to stereotypes against the poor, and civil engi-
neers who questioned aspects of the sewer pipeline. Chadwick’s dogmatic approach
and unrelenting push for centralized services made him an easy target for vilifica-
tion. In 1854, he was deposed from the General Board of Health. He continued his
work investigating and reporting on numerous health issues. Through recognition
by Prince Albert of Saxe-Coburg and Gotha, Chadwick was awarded a knighthood
in 1889.
Sir Edwin Chadwick was a public health crusader with enormous energy and
conviction. In his role as a civil servant, Chadwick’s primary aim was to increase
efficiency and minimize waste. Philosophically, Chadwick focused on achieving the
greatest good for the greatest number of people. Without any training in medicine or
civil engineering, he carefully collected and used public health statistics to advocate
for policies improving safety and sanitation. His ability to identify social problems
and see solutions led to massive transformations in urban structure, buildings, and
functions that we still enjoy today.
Sally Kuykendall
See also: Cholera; Health Policy; Infectious Diseases; Modern Era, Public Health in
the; Nightingale, Florence; Snow, John; Social Determinants of Health
Further Reading
Bloy, M. (2016). The Sanitary Report, 1842. A web of English history. Retrieved from http://
www.historyhome.co.uk/peel/p-health/sanrep.htm.
Finer, S. E. (1952). The life and times of Sir Edwin Chadwick. London: Methuen.
Hamlin, C. (1992). Edwin Chadwick and the engineers, 1842–1854: Systems and antisys-
tems in the pipe-and-brick sewers war. Technology and Culture, 33(4), 680.
Lewis, R. A. (1950). Edwin Chadwick and the railway labourers. The Economic History Review,
3(1). 107.
Parliament, UK (n.d.). The 1848 Public Health Act. Retrieved from http://www.parliament.uk
/about/living-heritage/transformingsociety/towncountry/towns/tyne-and-wear-case
-study/about-t he-group/p
ublic-a dministration/the-1848-public-health-act.
C HILD M ALT R EAT M ENT 113
CHILD MALTREATMENT
Child maltreatment is an umbrella term for the abuse and neglect of children. The
definition of child maltreatment varies between different organizations, profes-
sionals, and advocates. Child maltreatment is defined by the Federal Child Abuse
Prevention and Treatment Act (CAPTA) as “any recent act or failure to act on the
part of a parent or caretaker that results in death, serious physical or emotional
harm, sexual abuse or exploitation; or an act or failure to act, which presents an
imminent risk of serious harm” (Child Welfare Information Gateway, 2014). Accord-
ing to the Centers for Disease Control and Prevention (CDC), child maltreatment
includes abuse and neglect of a child less than 18 years of age by a parent, care-
giver, or another person in a custodial role. The World Health Organization (WHO)
estimates that approximately 40 million children are victims of maltreatment world-
wide annually. According to the Child Maltreatment Report 2014, compiled by the
Children’s Bureau of the U.S. Department of Health and Human Services, there w ere
more than 3 million reports of suspected child maltreatment made to Child Protec-
tive Services (CPS) with 702,000 confirmed victims.
Public policies against child maltreatment trace back to the M iddle Ages in Europe
with laws forbidding infanticide. Child mistreatment and exploitation w ere com-
mon. C hildren w
ere sold to provide money for families that struggled with poverty
and famine. The first documented cases of child abuse charges against parents and
the removal of c hildren from unfit homes were in the 1670s. In 1869, the Illinois
Supreme Court ruled that a parent treating a child inhumanely was punishable by
law after a father in Illinois was charged for locking his blind son in a cold base-
ment. During the Industrial Revolution, c hildren w ere forced to work long hours
in awful and often hazardous conditions. By 1900, every state in the United States
passed legislation that addressed the issues of child l abor, but it was not u ntil 1941
when the U.S. Supreme Court passed the Fair L abor Standards Act that limited child
labor (McCoy & Keen, 2009).
In 1912, the Children’s Bureau was founded to explore all issues regarding child
welfare. In 1944, the Supreme Court ruled in Prince v. the Commonwealth of Mas
sachusetts that states have the right to interfere in f amily relationships to protect
children. In 1974, the United States passed its first federal law on child abuse, the
Child Abuse Prevention Treatment Act (CAPTA), which provided funding for the
investigation and prevention of child abuse as long as states had mandated report-
ing laws. CAPTA also established the National Clearinghouse on Child Abuse and
Neglect (NCCAN) that serves as a national resource for professionals regarding child
maltreatment (McCoy & Keen, 2009).
According to the C hildren’s Bureau, t here are four main types of child maltreat-
ment: physical abuse, sexual abuse, emotional abuse, and neglect. Physical abuse is the
use of intentional physical force against a child that can potentially result in physi-
cal injury. Physical abuse includes hitting, kicking, shaking, burning, or other use
of force. Symptoms of physical abuse include unexplained injuries, injuries incon-
sistent with the history provided by the parent or caregiver, or the child seems
114 C HILD M ALTREATMENT
frightened of the caregiver. Sexual abuse is defined as engaging a child in sexual acts
or attempting sexual contact, including fondling, rape, and exposing a child to
other sexual activities. Emotional abuse is defined as behaviors that harm a child’s
self-worth or emotional well-being. Examples include name-calling, degrading,
rejecting, threatening, belittling, and isolating the child. Neglect, the most common
form of child maltreatment, is the failure to meet a child’s basic needs or the failure
to protect a child from harm or potential harm. T here are many forms of neglect.
Physical neglect includes the failure to provide adequate nutrition, clothing, hygiene,
or a safe living environment. Psychological or emotional neglect is the lack of emo-
tional support or bonding from the parent or caregiver. Medical neglect is the failure
to seek health care or the delay of medical care by the parent or caregiver. Educa-
tional neglect is when the parent or caregiver fails to enroll a child in an educational
institution or allows frequent school absences. Abandonment is when a child is left
alone for an extended period of time given the child’s age and capacities, including
leaving a child in a locked vehicle or incapacitation of the parent or caregiver due to
alcohol or substance use. Neglect also encompasses the lack of guidance, defined as
exposing a child to criminal activity, illicit drug use, or other risk-taking behaviors by
the parent or caregiver. Exposure to intimate partner violence is also considered a
form of child maltreatment by many public health professionals.
Knowing at-risk groups empowers health professionals to prevent abuse or to
be vigilant for potential cases. Children under the age of four years are at greatest
risk for severe injury and death from abuse. The group with the highest rate of child
victimization is infants in their first year of life. Approximately 27 percent of vic-
tims of child maltreatment and 70 percent of deaths due to child abuse occurred
in children under the age of three years (CDC, 2014). Traits that may increase the
likelihood of child maltreatment include persistent crying or having special needs,
such as a physical disability, an intellectual disability, or a chronic illness. Risk f actors
that increase the likelihood of a parent or caregiver to abuse or neglect a child include
stress in the home due to violence, drug or alcohol abuse, mental illness, poverty,
and chronic health problems. Parents who are young, single parents, have a history
of maltreatment as c hildren, experience financial difficulties, and/or are of low edu-
cational status have higher risk for perpetration. Community risk factors involve
neighborhood violence and crime, weak social connections among neighbors, high
unemployment rates, and high density of alcohol or illicit drug use. Protective
factors, factors that guard against child maltreatment, include supportive and
stable family and community environments, parental employment, and adequate
housing and access to health care.
Child maltreatment has long-term detrimental effects on child victims and their
families. Many studies have shown that child maltreatment can impact brain develop-
ment. Child victims demonstrate behavioral, physical, and mental health problems
such as increased aggression, anxiety, depression, post-traumatic stress disorder, cogni-
tive delays, problems in school and with peers, and disruption in nervous system
and immune system development. As adults, child victims are predisposed to mental
C HILD M ALT R EAT M ENT 115
illnesses, smoking, alcohol and drug use, high-risk sexual behaviors, sexually
transmitted diseases, unintended pregnancy, obesity, and heart disease (CDC,
2016). Experiences as a maltreated child influence relationships in adulthood. Vic-
tims are at risk for either perpetrating violence or being a victim of violence as an
adult. Socially, child maltreatment has a significant economic impact, including costs
of hospitalizations, child welfare and criminal justice systems involvement, and
long-term health care and mental health treatment. The CDC estimates the total
lifetime financial costs associated with one year of confirmed cases of child mal-
treatment is approximately $124 billion (Fang et al., 2012).
All states in the United States have laws regarding mandatory reporting of sus-
pected child maltreatment. Individuals that are considered mandated reporters may
include physicians, nurses, health care workers, teachers, social workers, counsel-
ors, therapists, child care providers, and law enforcement officers. In approximately
18 states and Puerto Rico, any person who suspects child maltreatment is man-
dated to report. However, any concerned individual can report suspicions of child
abuse or neglect, and an investigation into the situation will determine if interven-
tion is necessary. Information about how each state addresses reporting suspected
child abuse can be found on the Child Welfare Information Gateway website (www
.childwelfare.gov). The Childhelp National Child Abuse Hotline is also available
24 hours a day, seven days a week with trained counselors who have access to numer-
ous emergency, social service, and support resources.
Child maltreatment prevention entails a multifaceted approach. The CDC and the
World Health Organization (WHO) identify several strategies to prevent child mal-
treatment. T hese strategies aim to strengthen economic supports to families, change
social norms to support positive parenting, provide quality care and education early
in life, enhance parenting skills, and intervene to prevent future harm. Visits by
nurses to parents and children in their homes, parent education, and teaching
children the difference between safe and unsafe are also some effective methods
that can be implemented in programs in health care, schools, and social work.
Kim L. Nguyen and Maria DiGiorgio McColgan
See also: Adverse Childhood Experiences; C hildren’s Health; Hamilton, Alice; Inju-
ries; Intimate Partner Violence; Violence
Further Reading
Centers for Disease Control and Prevention (CDC). (2014). Child maltreatment: Facts at a
glance. Retrieved from https://www.cdc.gov/violenceprevention/pdf/childmaltreatment
-facts-at-a- glance.pdf.
Centers for Disease Control and Prevention (CDC). (2016). Child maltreatment. Retrieved
from http://www.cdc.gov/violenceprevention/childmaltreatment/index.html.
Child Welfare Information Gateway. (2014). Definitions of child abuse and neglect. Washing-
ton, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved
from https://www.childwelfare.gov/pubPDFs/define.pdf.
116 CHILDREN’S HEALT
Fang, X., Brown, D. S., Florence, C. S., & Mercy, J. A. (2012). The economic burden of child
maltreatment in the United States and implications for prevention. Child Abuse &
Neglect, 36(2), 156–165.
McCoy, M. L., & Keen, S. M. (2009). Child abuse and neglect. New York: Psychology Press.
U.S. Department of Health & H uman Services, Administration for C
hildren and Families,
Administration on Children, Youth and Families, Children’s Bureau. (2016). Child mal-
treatment 2014. Retrieved from http://www.acf.hhs.gov/programs/cb/research-data
-technology/statistics-research/child-maltreatment.
World Health Organization. (2016). Child maltreatment. Retrieved from http://www.who.int
/mediacentre/factsheets/fs150/en/.
C HILDREN’S HEALTH
The health of c hildren is always an important issue for any country, since children
are the f uture. T
here have been a number of important reviews of c hildren’s health
in the United States and commissions to discuss issues linked to the health of
children. One of the most important is the work of the National Research Council
and Institute of Medicine (2004). In that work, which began with a review of
the available literature as well as a consideration of important issues, the com-
mittee agreed on some important guiding principles, repeated below:
• children are vital assets of society;
• critical differences between children and adults warrant special attention to
children’s health;
• children’s health has effects that reach far into adulthood;
• the manifestations of health vary for different communities and different cul-
tures; and
• data on c hildren’s health and its influences are needed to maximize the health
of c hildren and the health of the adults they w
ill become. (National Research
Council and Institute of Medicine, 2004)
It is helpful to understand more about why it is in the national interest to have
healthy children. If children are healthy, they are more likely to be ready and able
to learn and, as adults, to be healthy and able to contribute to the workforce and
the overall vitality of society. In earlier eras, disease and death in c hildren w
ere due
largely to infections. Childhood deaths w ere common. In the 20th century, both
childhood mortality and infectious disease rates in the United States have been dras-
tically lowered; it is now uncommon for a child to die in childhood whereas in the
late 1800s, many families experienced the death of at least one child.
There are some interim health problems that have seen improvement in the
United States more recently, especially since 1970. One of the most important of
these is the reduction in negative health effects from lead as well as efforts in reduc-
tion of infant mortality and morbidity and accidental causes of injury. There have
also been improvements in increasing access to health care for children and reduc-
ing other environmental contaminants.
CHILDREN’S HEALT 117
In the area of improvement in ill effects from lead, major improvements have
been made in understanding how environmental contaminants such as lead impact
children and lead to adverse impacts on c hildren’s developments and reductions in
the ambient lead amounts and reduced childhood blood lead levels. Average con-
centrations of lead in the blood of c hildren younger than five dropped 78 percent
between 1976 and 1980, and between 1992 and 1994, and there was a decrease of
93 percent by 2011–2012, as compared with 1976–1980 (U.S. EPA, 2015).
Infant mortality, that is, deaths in the first year of life, are understood to be both
an important indicator of overall health in a country and an important indicator of
child health. In the United States, following a plateau from 2000 through 2005, the
U.S. infant mortality rate declined 12 percent from 2005 through 2011. Infant mor-
tality declined for four of the five leading c auses of death during the 2005–2011
period (MacDorman, Hoyert, & Mathews, 2016).
Other areas of improved child health are in the areas of access to care, absences
from school due to ill health, and teenage pregnancy. About 85 percent of school-
aged children 5 to 11 years of age are now reported as in excellent or very good
health. Slightly over 3 percent (3.2) of school-aged children 5 to 11 years of age
missed 11 or more days of school in the past 12 months because of illness or injury.
Partially due to greater coverage of c hildren from aspects of the Affordable Care Act
(also sometimes referred to as Obamacare) and the related expansions of Medic-
aid and the Children’s Health Insurance Program since 2009, only 5.1 percent of
children u nder 18 years of age w ere without health insurance, and only 4.0 percent
of children under 18 years of age were without a usual source of health care
(National Center for Health Statistics, 2017).
Another area of improvement is that fewer adolescents are having babies—in
1999, the teenage pregnancy rate reached the lowest recorded rate since 1976. Rates
continued to improve, with 24.2 births for every 1,000 adolescent females aged 15
to 19 in 2014, or 249,078 babies born to females in this age group. Nearly 89 percent
of these births occurred outside of marriage. The 2014 teen birth rate indicates a
decline of 9 percent from 2013 when the birth rate was 26.5 per 1,000. The teen
birth rate has declined almost continuously since 2000. Teen birth rates differ sub-
stantially by racial and ethnic group. Birth rates are higher among Hispanic and
black adolescents than among their white counterparts. In 2014, Hispanic adoles-
cent females aged 15 to 19 had the highest birth rate (38 births per 1,000 adoles-
cent females), followed by black adolescent females (34.9 births per 1,000 adolescent
females), and white adolescent females (17.3 births per 1,000 adolescent females).
Although Hispanics currently have the highest teen birth rates, they have had a dra-
matic recent decline in rates. Since 2007, the teen birth rate has declined by
50 percent for Hispanics, compared with declines of 44 percent for blacks and
36 percent for whites (Office of Adolescent Health, 2016).
The picture on usage of tobacco products is more complex, with some improve-
ment but also the introduction of new tobacco-related products and more usage of
those. Looking across several decades, daily cigarette use fell by more than 50 percent
118 CHILDREN’S HEALT
(from 10 to 5 percent) among 8th-grade students between 1996 and 2002, and by
more than two-fifths (from 18 to 10 percent) among 10th-grade students. From
2011 to 2015, current cigarette smoking declined among m iddle and high school
students. By 2015, about 2 of every 100 middle school students (2.3 percent)
reported that they smoked cigarettes in the past 30 days—a decrease from 4.3 percent
in 2011. By 2015, about 9 of e very 100 high school students (9.3 percent) reported
that they smoked cigarettes in the past 30 days—a decrease from 15.8 percent in
2011. However, current use of electronic cigarettes increased among middle and
high school students from 2011 to 2015. Around 5 percent of m iddle school stu-
dents reported in 2015 that they used electronic cigarettes in the past 30 days—an
increase from 0.6 percent in 2011. There was even more increase for high school
students, with 16 of e very 100 high school students reporting in 2015 that they
used electronic cigarettes in the past 30 days—an increase from 1.5 percent in 2011.
Use of other smoking products such as hookahs also increased from 2011 to 2015
(Centers for Disease Control, 2016).
Although some trends are positive or mixed, others are negative. Replacing the
problems of the previous 150 years of infectious diseases in the last 50 years is the
increase of some more serious chronic diseases, along with a number of health prob
lems that are a result of the interaction of genetics, behavior, and the environment.
Childhood obesity, diabetes, and asthma rates in the United States are among the
highest in the world and are increasing rapidly. Intentional and unintentional inju-
ries, mental health disorders, and attention deficit disorder are highly prevalent. A
few illustrations of some of these issues are that there are increases in obesity among
children with 17.4 percent of c hildren 6 to 11 years of age who are obese by 2013
to 2014. The number of c hildren with asthma is now more than 6.2 million, and
the p ercent of children with asthma is 8.4 percent (National Center for Health
Statistics, 2017). Attention-deficit/hyperactivity disorder (ADHD) has also been
increasing since 1990. Currently, 10.4 percent of children 5 to 17 years of age have
been diagnosed with ADHD in 2013–2015, with more boys (14.2 percent) diag-
nosed as compared to girls (6.4 percent) (National Center for Health Statistics,
2017).
Diabetes is a serious chronic disease, both for adults and c hildren. Although the
majority of c hildren u nder 21 with diabetes have Type 1 (what at one time was
known as juvenile diabetes), the major concern as an indicator of increases in poor
health in c hildren are linked to the rise of Type 2 diabetes in c hildren 10 and over,
a condition almost unheard of as recently as 20 years ago (Gebel, 2012). Type 2
diabetes in 10-to 19-year-olds increased 21 percent between 2001 and 2009, mostly
in Hispanic and non-Hispanic white youth.
Although more than a decade has passed since the National Research Council
and Institute of Medicine report, their goals are still important for future efforts.
Future systems need to incorporate a better conceptualization of children’s health
that considers prominent developmental characteristics of children as well as
C HOLE R A 119
positive aspects of health, along with a greater focus on collection of data on child
health problems.
Jennie Jacobs Kronenfeld
See also: Adverse Childhood Experiences; Behavioral Health; Birth Defects; Centers
for Medicare and Medicaid Services; Child Maltreatment; Dunham, Ethel Collins;
Family Planning; Healthy People 2020; Infant Mortality; Maternal Health; School
Health; Social Determinants of Health; Truth Campaign, The; Vaccines; Violence;
Wald, Lillian; Controversies in Public Health: Controversy 2; Controversy 3
Further Reading
Centers for Disease Control. (2016). Youth and tobacco use. Retrieved from https://www.cdc
.gov/tobacco/data_statistics/fact_sheets/youth_data/t obacco_use/.
Gebel, E.. (2012). More kids than ever have type 2 diabetes. Diabetes Forecast. Retrieved
from http://www.diabetesforecast.org/2012/nov/more-kids-than-ever-have-type-2
-diabetes.html 2012.
MacDorman, M. F., Hoyert, D. L., & Mathews, T. J. (2016). Recent declines in infant mortality
in the United States, 2005–2011. Centers for Disease Control. Retrieved from https://
www.cdc.gov/nchs/data/databriefs/db120.htm#x2013;2011%3C/a%3E.
National Center for Health Statistics. (2017). Faststats. Retrieved from http://www.cdc.gov
/nchs/fastats/child-health.htm.
National Research Council and Institute of Medicine. (2004). Children’s health, the nation’s
wealth: Assessing and improving child health. Washington, DC: National Academies Press.
doi:10.17226/10886
Office of Adolescent Health. (2016). Reproductive health. Retrieved from http://www.hhs.gov
/ash/oah/adolescent-health-topics/reproductive-health/teen-p regnancy/trends.h
tml.
U.S . EPA. (2015). America’s Children and the Environment (ACE). Biomonitoring: Lead. Indi-
cator B1. Retrieved from https://www.epa.gov/ace/biomonitoring-lead.
CHOLERA
Cholera is an intestinal infection caused by the bacterium Vibrio cholera. This bac-
terium is a type of facultative anaerobic organism that secretes cholera toxin or chol-
eragen in the digestive system. Symptoms of the disease range from mild diarrhea
and vomiting to severe dehydration depending on the variety of Vibrio cholerae
involved. The disease is spread predominantly through drinking water that has been
contaminated by sewage. Historically, instances of the disease were related to h uman
waste infiltrating the water supply. Cholera affects millions of individuals each year,
usually in developing countries where sanitation and preventative measures are
insufficient or nonexistent. In the past, the disease reached epidemic propor-
tions of 50 percent or higher mortality rate (World Health Organization, 2008).
Today, mortality may be as low as 1 percent for those who receive early treatment.
Although modern bacteriology and public health measures have eliminated or
120 C HOLER A
reduced waterborne illnesses in many developed countries, this deadly disease

remains a threat throughout the world and serves as a model for prevention and
control of similar acute infectious diseases.
Cholera is mainly transmitted through w ater or food in areas where poor or
inadequate sanitation exists. The microorganism moves from the initial human
host, also known as a reservoir, to the new susceptible host via the water table or
water source. The pathogen leaves the initial carrier through diarrhea. The infected
fecal matter contaminates the local w ater source. P
eople e ither drink the infested
water or certain varieties of seafood—plankton and shellfish—drawn from the
water transmit the bacteria. Not everyone who ingests the bacterium will become
infected. Susceptibility is related to a number of factors, including acidity of the
intestinal tract, age, amount of the bacterium ingested, exposure to other infec-
tious pathogens, and chronic diseases or genetic conditions such as cystic fibrosis.
The bacteria attack the carrier by embedding in the lining of the intestine. In order
to get into the lining, the bacteria must survive the stomach’s first line of defense,
the highly acidic gastric juices. The pathogens protect themselves from stomach
acids by conserving energy, primarily limiting protein production. Upon arrival in
the small intestine, they increase protein output to produce the toxin choleragen.
The interplay of chloride and sodium ions renders the interior of the intestine
saline, or like salt water. This process creates osmotic pressure. The osmosis pulls
gallons of water from the body of the host, resulting in large volumes of diarrhea
and subsequent dehydration. If fluid and electrolytes are not replaced, death
can occur.
Public health professionals diagnose cholera by the characteristic symptoms
and laboratory testing. The telltale symptoms of the disease are profuse diarrhea
and vomiting to such an extent that the excretions are nearly clear in appear-
ance. In some places, this excretion is nicknamed “rice water” because of its resem-
blance to the by-product of boiled rice. In its most severe cases, the disease can
cause up to three or four gallons of diarrhea to be passed by the host in a single
day. This extreme loss of fluids produces the second grouping of visible symp-
toms, namely dehydration and its related symptoms. The symptoms of dehy-
dration include wrinkled skin on the extremities, sunken eyes, and skin with a
bluish hue. Cholera was traditionally called the “Blue Death” because of this
change in skin color. The loss of electrolytes affects all of the body organs and
can decrease heart rate, impair the muscles that control breathing, and result in
coma. In addition to assessing symptoms, public health practitioners can diag-
nose cholera by administering a dipstick test on swab or stool samples from the
patient.
Cholera has most likely existed since ancient times, traced back to the Ganges
River delta of the Indian subcontinent. The name is derived from the Greek word
for “bile,” or kholera, which is from the “yellow bile” of humoral medical theory.
Ancient Greeks believed that when yellow bile was out of balance with the other
C HOLE R A 121
humors, this caused an aggressive or angry disposition. Today, the word for “anger”
in romance languages is derived from cholera. The disease of cholera should not be
confused with Cholera morbus, a term once used to distinguish gastroenteritis or
“stomach flu” from cholera.
Cholera was contained within certain geographic regions of India u ntil improve-
ments in transportation and trade infrastructure increased population move-
ment. As people moved into and out of the region, the disease progressed from an
endemic problem to pandemic proportions. Repeatedly throughout history, popu-
lation movements have spread infectious diseases to new, distant locations. Occur-
rences of cholera throughout much of Asia and Russia are traced to a major
outbreak in Bengal, India, in 1817. The disease first arrived in Europe and North
America along major shipping and trade routes between 1827 and 1835. The
transmission to new areas carried high mortality, killing large numbers of p eople,
especially in urban environments. For much of the 19th century there was no
effective remedy for cholera, and
the mortality rate was exception-
ally high. Cholera is attributed to
the deaths of Russian composer
Pyotr Tchaikovsky, King Charles
X of France, and U.S. president
James K. Polk, among others.
Subsequent pandemics struck
Europe, sub-Saharan Africa, and
South America, with the most
recent occurring as late as 1961.
Instances of cholera decreased in
the developed world during the
20th century due to advances
in water purification and public
health sanitation. However, the
disease is still a significant pres-
ence in developing countries.
Treatment of cholera advanced
significantly with the discovery
and development of a germ the-
ory in the later half of the 1800s.
Before germ theory, p eople did
not know how infections were
Children drawing contaminated w ater from the com-
spread. In 1854, John Snow traced munity pump. Despite Snow’s evidence that cholera
the transmission of cholera to con- was caused by contaminated water, city officials did
taminated w ater and introduced little to address the problem. (Centers for Disease
a new field of study known as Control and Prevention)
122 C HOLE RA
epidemiology. The bacterium was initially isolated in the same year by Filippo
Pacini, an Italian anatomist, and later by the German microbiologist Robert Koch
in 1883. Early vaccines were developed to combat cholera by the Spanish physi-
cian Jaume Ferran i Clua in 1885 and Russian bacteriologist Waldemar Haffkine in
1892. Despite these efforts, the disease continued to challenge public health sys-
tems with high mortality rates. In 1967, Robert Allan Phillips, an American research
scientist at Naval Medical Research Unit 2, developed a treatment schedule of rehy-
dration. Phillips later won the prestigious Lasker Award for his discovery.
Today, early rehydration therapy provides critical treatment for those suffering
from the effects of cholera or other diseases that produce massive fluid loss. Con
temporary cases of cholera can now be treated in a clinical setting with close
observation, hydration, and maintenance of healthy levels of electrolytes. In cases
of mild dehydration, the patient is encouraged to take oral fluids. With severe
cases, the administration of up to 10 percent of the patient’s body weight in fluids
may be necessary. In such cases, patients must be carefully monitored to ensure
that fluids and electrolytes are restored to the appropriate tissues in the body and
do not create other electrolyte imbalances that could lead to respiratory failure or
cardiac arrest.
With significant advances in treatment already achieved, in recent times the
medical and public health communities concentrated on preventative methods
and quality of life. The majority of these measures involve effective sanitation
and water filtration infrastructures. In developing countries a folded cloth sari is
recommended as a cheap and effective way to filter drinking w ater. Proper ster-
ilization and sanitation, when coupled with new developments in vaccines, anti-
biotics, and hydration/electrolyte therapy, have greatly decreased deadly cases of
cholera in the 21st century. Responding to outbreaks of the disease in Haiti, in
the early 2000s, the World Health Organization set the goal of eradicating chol-
era by 2020.
Sean P. Phillips
See also: Ancient World, Public Health in the; Chronic Illness; Environmental
Protection Agency; Epidemic; Epidemiology; Genetics; Immigrant Health; Indian
Health Service; Infectious Diseases; Koch, Heinrich Hermann Robert; Middle
Ages, Public Health in the; National Institutes of Health; Pandemic; Pasteur,
Louis; Waterborne Diseases, Winslow, Charles-Edward Amory; World Health
Organization
Further Reading
Hamlin, C. (2007). Cholera: The biography. Biographies of diseases 2. Oxford, UK: Oxford
University Press.
C H R ONI C ILLNESS 123
Kudlick, C. J. (1996). Cholera in post-revolutionary Paris: A cultural history. Studies on the

history of society and culture 25. Berkeley: University of California Press.
Rosenberg, C. E. (1987). The cholera years: The United States in 1832, 1849, and 1866. Chi-
cago: University of Chicago Press.
World Health Organization. (2008). WHO position paper on oral rehydration salts to reduce
mortality from cholera. Retrieved from http://www.who.int/cholera/technical/en/.
CHRONIC ILLNESS
Chronic illnesses are persistent health conditions that last three months or more.
They start discretely and progress to more serious problems over time. Sometimes,
the terms “chronic illnesses,” “chronic diseases,” and “noncommunicable diseases”
are used interchangeably. The term “chronic disease” refers to the biological prob
lem, such as heart disease, stroke, high blood pressure, cancer, diabetes, asthma,
or chronic obstructive pulmonary disease (COPD). The term “chronic illness” refers
to the biological disease as well as psychosocial issues related to long-term control
and management. Seven of the ten leading c auses of death are chronic diseases.
Nearly half of all Americans suffer from one or more chronic illnesses, and that
number increases to 85 percent for people over the age of 65 (Wiley et al., 2015).
Current public health efforts focus on research, prevention, screening, commu-
nity action, and once a condition is diagnosed, applying best clinical practice
guidelines, individual self-management, and coordinating health services. The
capacity to manage and treat multiple chronic conditions (MCC) is a significant
challenge. The current medical management model of treating each case of disease
individually is expensive and allows gaps to occur when each provider focuses
on one aspect of the patient, missing the bigger picture. New health care delivery
models provide a holistic approach and suggest promise in treating individuals
with MCC.
Over the 20th century, advances in science and medicine have fundamentally
changed the diseases the vast majority of the population contract. Improved sani-
tation, better hygiene, and the development of both vaccinations and antibiotics
means that infectious diseases, such as diphtheria and smallpox, are no longer the
public health threats they once w ere. The result of these advancements is that Amer-
icans are living significantly longer than past generations. Between 1880 and 2010,
life expectancy in the United States almost doubled from 39.4 years to 78.8 years
(Roser, 2016). The shift from acute illnesses to chronic illnesses meant that medi-
cal care also shifted from treating self-limiting communicable diseases to persistent
noncommunicable diseases. Although modern medicine has skillfully worked to
effectively find cures or eradicate many ailments prevalent over a century ago,
chronic illnesses raise other issues. As people live longer, their bodies are more sus-
ceptible to multiple chronic illnesses. In 2005, experts speculated that childhood
obesity may halt or reverse the upward trend in life expectancy (Olshansky et al.,
124 C HR ONIC ILLNESS
2005). Overweight and obese c hildren at risk for heart disease, stroke, and diabe-
tes are at greater risk for premature death.
Early diagnosis of chronic illness is crucial in securing treatment and controlling
the complications of any disease. Undiagnosed diabetes can result in blindness,
lower extremity amputations, kidney failure, and heart attack. Cancers may metas-
tasize to other organs. High blood pressure can cause stroke or kidney problems.
Chronic illnesses are first diagnosed when the patient reports symptoms to a
health care provider or abnormal results appear on regular physical examination or
screening. A routine sports physical can reveal asthma, epilepsy, congenital cardiac
disease, blood abnormalities, or cancer. Primary care providers check blood pres-
sure, blood cell count, and perform numerous screenings to identify chronic con-
ditions. Patients can also screen themselves through testicular self-examination
or breast self-examination. Although not as effective as other forms of screening,
the female who regularly practices breast self-examination can identify a lump the
size of a quarter (0.83 inches), whereas those who do not practice regular self-
examination can first identify a lump the size of a half dollar coin (1.42 inches).
Mammograms, recommended for women every one to two years after the age of
40, can identify a lump as small as 0.43 inches. Early identification can signifi-
cantly change the course of the disease. Unfortunately, many Americans do not
have access or do not practice regular screening. Only 8 out of 10 women (aged
50–75) report getting a mammogram within the past two years. Less than 4 out of
10 females (aged 13–15) get the HPV vaccine ( Johnson, Hayes, Brown, Hoo, &
Ethier, 2014).
Once diagnosed, chronic conditions can be challenging to both manage and treat.
Diabetics must learn to manage their diet and medications changing many lifelong
habits. Twenty-one percent of diabetics do not have their blood sugar under con-
trol ( Johnson, Hayes, Brown, Hoo, & Ethier, 2014). Individuals with chronic ill-
nesses require many visits to health care providers, pharmacies, and more than one
specialist, such as a cardiologist, endocrinologist, or oncologist. Although the pri-
mary care physician plays an important role in coordinating care, t hose with mul-
tiple chronic conditions are often required to take on a strong role as their own
advocate. Managing multiple visits and treatments can be tiring and frustrating.
Many chronic illnesses, particularly diabetes and heart disease, require vast personal
lifestyle changes and w ill get significantly worse if the disease is not managed well
or the patient is not compliant with medication and lifestyle changes. Studies have
shown that managing chronic illness can be extremely overwhelming and eventu-
ally can lead to depression.
The rising costs of managing and treating chronic illnesses is one of the most
pressing challenges for health care today. The health insurance system was estab-
lished to manage acute illnesses with the provider receiving a fee for each encoun-
ter or service. Medical expenditures for the average person cost about $4,400 per
year. The average patient with Type 2 diabetes costs about $11,700 per year. An
estimated 25.8 million people or 8.3 percent of the total population have diabetes
C H R ONI C ILLNESS 125
(Moran, Burson, Critchett, & Olla, 2011). Fee-for-service payment structures were
established in the early 20th century before chronic illnesses became the leading
causes of death. In order to address the rapidly rising costs of health care and improve
outcomes, innovative health care delivery models have been introduced. Health
insurance companies and policy makers suggest including quality as an aspect of
reimbursement. Rather than fee-for-service, health care providers receive an incen-
tive to establish ways in which patients can achieve a better overall outcome. In an
effort to reign in steeply rising health care costs, the Patient-Centered Medical Home
(PCMH) has emerged as a promising way to manage the large population of chron-
ically ill patients. The PCMH provides multiple, continuous touch points, preven-
tative services, and increased monitoring for disease complications. PCMHs have
been shown to reduce emergency room visits, reduce blood glucose levels among
diabetics, and achieve overall cost savings with better health outcomes. Although
some opponents argue that the cost to reorganize a medical practice is prohibitive,
data suggests that long-term savings can be realized through reduced adverse health
outcomes and better-quality health care. The need to reengineer medical practices
to address the ongoing need for chronic illness management is logical, but imple-
mentation costs and existing fee-for-service payment structures, rather than pay for
performance pay structures, continue to present challenges.
Prevention of chronic diseases is a primary goal of Healthy People 2020 and pub-
lic health efforts. Over the past several decades, multiple programs have been
launched to educate people on healthy choices and preventing chronic illnesses.
Chronic illnesses have many c auses, including genetics, a hereditary predisposition,
environmental factors, or can be directly attributed to lifestyle choices. For example,
heart disease can be caused in part by many factors, including heredity, a high cho-
lesterol diet, lack of exercise, and smoking, to name just several major risk factors.
However, if an individual can reduce risk f actors for heart disease by not smoking,
exercising regularly, and eating a healthy diet, the individual, even with hereditary
factors, may be able to reduce his or her risk or delay the onset of heart disease.
Given that chronic disease is often caused by many complex factors, it becomes a
challenging public health effort to educate the public about how lifestyle choices
may have an effect on one’s health later in life. Successful public health campaigns
have been launched in an effort to reduce incidences of heart disease and several
types of cancer.
Although the prevention, screening, and management of chronic diseases are con-
stantly improving, the rising epidemic of chronic illnesses and the resulting high
cost of health care are among the nation’s most pressing public health issues. Although
prevention is the ultimate goal, the statistics demonstrate that a large sector of our
population is suffering from at least one chronic illness. The cost of chronic illness
from an economic perspective is great, but the implications for society continue to
be a pressing issue as well. Patients, particularly t hose with more than one chronic
illness, struggle to manage lifestyle changes, medications, and health care costs,
which often result in overwhelming frustration and depression. If quality outcomes
126 C ODE OF ETHI C S
for chronic illnesses are going to continue to be a priority, the health care system
must continue to evolve. Payment structures can no longer depend on fee-for-service
payment structure alone, since so many chronic illnesses require many touch points
with health care staff. The approach to chronic illnesses must continue to be
multifaceted—prevention, screening, management, and the continued innovation
of health care delivery models w
ill all be necessary as the nation continues to address
this crisis.
Diana Bertorelli and Sally Kuykendall
See also: Acute Illnesses; Addictions; Alzheimer’s Disease; Beers, Clifford Whitting-
ham; Cancer; Diabetes Mellitus; Heart Disease; Men’s Health; Nutrition; Preven-
tion; Roosevelt, Franklin Delano; Social Determinants of Health; W omen’s Health
Further Reading
Johnson, N. B., Hayes, L. D., Brown, K., Hoo, E. C., & Ethier, K. A. (2014). CDC national
health report: leading c auses of morbidity and mortality and associated behavioral risk
and protective factors—United States, 2005–2013. Morbidity and Mortality Weekly Report
Supplements, 63(4), 3–27.
Moran, K., Burson, R., Critchett, J., & Olla, P. (2011). Exploring the cost and clinical outcomes
of integrating the registered nurse-certified diabetes educator into the patient-centered
medical home. The Diabetes Educator, 37(6), 780–793. doi:10.1177/0145721711423979
Olshansky, S., Passaro, D., Hershow, R., Layden, J., Carnes, B., Brody, J., Hayflick, L., But-
ler, R. N., Allison, D. B., & Ludwig, D. (2005). A potential decline in life expectancy
in the United States in the 21st century. New England Journal of Medicine, 352(11),
1138–1145.
Renedo, A., & Marston, C. (2015). Developing patient-centered care: An ethnographic study
of patient perceptions and influence on quality improvement. BMC Health Services
Research, 15(1), 1–11. doi:10.1186/s12913-015-0770-y
Roser, M. (2016). Life expectancy. Retrieved from https://ourworldindata.o rg/life-expectancy.
Sidorov, J. E. (2008). The patient-centered medical home for chronic illness: Is it ready for
prime time? Health Affairs, 27(5), 1231–1234. doi:10.1377/hlthaff.27.5.1231
Wiley, J. A., Rittenhouse, D. R., Shortell, S. M., Casalino, L. P., Ramsay, P. P., Bibi, S., &
Alexander, J. A. (2015). Managing chronic illness: Physician practices increased the use
of care management and medical home processes. Health Affairs, 34(1), 77–86.
doi:10.1377/hlthaff.2014.0404
CODE OF ETHICS
When people trust health professionals to care for them, they yield power over the
body and mind to the caregiver and the health care system. In return, the caregiver,
the organization, and the system have a moral responsibility to fulfill the duty of
care and not to abuse that power. Violations of trust or abuse of power can seri-
ously damage the reputation of the profession and undermine f uture trust and rela-
tionships. A code of ethics defines the expectations and boundaries of practice in
C ODE O F ETHI C S 127
order to protect people and to ensure ongoing trust in the profession. All moral
codes analyze the rightness or wrongness of a particular action or decision in pol-
icy or practice. The basic ethical principles of respect for persons, beneficence, and
justice are common throughout the health professions. Variations appear because of
the focus of the discipline. Bioethics is the study of ethical issues created by advances
in medical technology and biological sciences. Clinical ethics is the analysis of ethi-
cal issues in clinical practice, focusing on individual cases. Research ethics is the
protection of h uman participants in research studies. The main difference between
medical or research ethics and public health ethics is that medicine deals with indi-
vidual patients whereas public health deals with p eople. The collective nature of
public health means that conflicts between human rights and civil liberty may arise.
Because conflicts involve populations, ethical dilemmas are addressed in open dis-
cussion with key stakeholders and the affected populations. Decision making occurs
as a collaborative process following a bottom-up approach rather than the top-down,
authoritarian approach.
Moral codes have been a common theme throughout recorded civilization. The
Code of Hammurabi (c. 1760 BCE) established standard fees for medical services
and consequences for negligence or malpractice. Vaidya’s Oath (15th century BCE)
urges Hindu physicians to do no harm (maleficence), keep their nails cut short, tell
the truth, behave professionally, and to serve vulnerable populations. Health care
professionals taking the Hippocratic Oath (c. 400 BCE) promise to perform to the
best of their ability, respect patient privacy, and mentor the next generation of health
care workers. The Hebrew Oath of Asaph (sixth c entury CE) emphasizes ethical
standards of professional practice, banning sexual relations with patients, adultery,
and the use of poison for euthanasia or abortion. The Oath of Sun Simiao (581–682
CE) advised Chinese doctors to treat the patient as they would a close relative. The
Seventeen Rules of Enjun list expectations of Japanese doctors, citing devotion to
the patient, protecting medical information from misuse, and warning against
undue extravagance. In public health history, The Belmont Report summarizes the
basic ethical principles of respect for persons (autonomy), beneficence (nonmalefi-
cence), and justice (fair distribution of burdens and benefits) (National Commission
for the Protection of H uman Subjects of Biomedical and Behavioral Research, 1979).
In 2000, graduating students of the Public Health Leadership Institute devel-
oped the Principles of the Ethical Practice of Public Health (Thomas, Sage, Dillen-
berg, & Guillory, 2002). The developers identified 12 ethical principles reflecting
14 professional values and beliefs. A fter refining the document through consensus
building, the American Public Health Association formally adopted the Public
Health Leadership’s Principles of the Ethical Practice of Public Health:
1. Public health should address principally the fundamental c auses of disease

and requirements for health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the
rights of individuals in the community.
128 C ODE OF ETHICS
3. Public health policies, programs, and priorities should be developed and eval-
uated through processes that ensure an opportunity for input from commu-
nity members.
4. Public health should advocate for, or work for the empowerment of, disen-
franchised community members, ensuring that the basic resources and con-
ditions necessary for health are accessible to all people in the community.
5. Public health should seek the information needed to implement effective pol-
icies and programs that protect and promote health.
6. Public health institutions should provide communities with the information
they have that is needed for decisions on policies or programs and should
obtain the community’s consent for their implementation.
7. Public health institutions should act in a timely manner on the information
they have within the resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of approaches
that anticipate and respect diverse values, beliefs, and cultures in the
community.
9. Public health programs and policies should be implemented in a manner that
most enhances the physical and social environment.
10. Public health institutions should protect the confidentiality of information that
can bring harm to an individual or community if made public. Exceptions
must be justified on the basis of the high likelihood of significant harm to the
individual or others.
11. Public health institutions should ensure the professional competence of their
employees.
12. Public health institutions and their employees should engage in collaborations
and affiliations in ways that build the public’s trust and the institution’s effec-
tiveness. (PHLS, 2002)
The principles of ethical practice describe the obligation of the profession to the
people that they serve. As a living document, the principles will require ongoing
revision to accommodate expanding policy and practice, new technology, and emerg-
ing health issues (Lee, Fisher, & Jennings, 2016).
Courses in ethics are offered as basic curriculum in many undergraduate and
graduate public health programs. Ethics is the systematic study of morality, and
morality is the practice of furthering h
uman good by doing the right thing. Students
are taught strategies to ethical decision making: identify the ethical problem, assess
the facts, engage stakeholders, analyze underlying values, determine options, and
outline the steps to making the decision ( Jennings, Kahn, Mastroianni, & Parker,
2003). The case of Mary Mallon demonstrates common ethical dilemmas in public
health. Mary Mallon, pejoratively known as Typhoid Mary, was an Irish immigrant
who worked as a cook. After several outbreaks of typhoid fever, investigators tracked
the source to Mallon revealing the first known asymptomatic carrier of Salmonella
C ODE O F ETHI C S 129
Typhi. Uneducated and healthy, Mallon failed to understand how she could be mak-
ing o thers ill. She refused to consent to surgery to remove the source of the typhus.
To prevent further outbreaks, health officials held Mallon in isolation for three years
on North Brother Island in New York. The quarantine raised questions regarding
Mallon’s individual civil rights. She was released under the agreement that she would
no longer work as a cook. After several years of low-paying jobs in laundry, Mallon
changed her name and resumed working as a cook. Mallon’s employment at the
Sloane Hospital for W omen resulted in 25 cases of typhoid fever and two deaths.
In total, 51 cases of typhoid fever, including three deaths, were traced to Mallon.
Still refusing surgery, Mallon was placed back in quarantine on North B rother Island
for the remainder of her life. The struggle between protecting public health (benef-
icence) and individual civil rights (respect for persons) is a common theme in pub-
lic health. Public health ethics seek collaborative solutions that respect the rights
of individuals and communities.
The public health code of ethics ensures that public health professionals act in
the best interest of the populations that they serve. Public health professionals are
bound by the code of ethics balancing respect for persons, beneficence, and jus-
tice. As new fields, practices, and technology emerge, new choices challenging ethi-
cal principles will also emerge.
Sally Kuykendall
See also: Administration, Health; Belmont Report, The; Core Competencies in Public
Health; Ethics in Public Health and Population Health; Greco-Roman Era, Public
Health in the; Hippocrates; Mallon, Mary; Public Health Law; Research; Tuskegee
Syphilis Study; Controversies in Public Health: Controversy 4
Further Reading
Jennings, B., Kahn, J., Mastroianni, A., & Parker, L. S. (Eds.). (2003). Ethics and public health:
Model curriculum. U.S. Department of H uman Services, Association of Schools of Pub-
lic Health, Hastings Center. Retrieved from http://www.aspph.org/app/uploads/2014/02
/EthicsCurriculum.pdf.
Lee, L. M., Fisher, C. B., & Jennings, B. (2016, July). Revising the American Public Health
Association’s Public Health Code of Ethics. American Journal of Public Health, 1198–
1199. doi:10.2105/AJPH.2016.303208
National Commission for the Protection of Human Subjects of Biomedical and Behavioral
Research. (1979). The Belmont Report: Ethical principles and guidelines for the protection
of human subjects of research. Bethesda, MD: Author.
Public Health Leadership Society (PHLS). (2002). Principles of the ethical practice of public
health, version 2.2. Retrieved from https://www.apha.org/∼/media/files/pdf/membergroups
/ethics_brochure.ashx.
Thomas, J. C., Sage, M., Dillenberg, J., & Guillory, V. J. (2002). A code of ethics for public
health. American Journal of Public Health, 92(7), 1057–1059. Retrieved from https://www
.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/.
130 C OLLA BOR ATIONS
COLLABORATIONS
In public health, collaborations are working groups of p eople from different organ
izations serving together to prevent or reduce social problems. Many serious public
health issues are deeply rooted within communities. One institution, project, or
policy cannot fix problems of childhood obesity, heroin addiction, f amily violence,
teen pregnancy, or poverty. Collaborations connect fragmented systems of care, shar-
ing resources, expertise, and information to achieve a common goal. The groups
that make up the collaboration often have common missions, yet approach the prob
lem from different perspectives.
Collaborative activities go beyond networking, coordination, and cooperation.
Networking occurs when individuals exchange information, a technique common
in business practice. Coordination is both the exchange of information and linking
of service activities. For example, a public health practitioner providing care to an
overweight patient might coordinate services with a nutrition counselor or health
educator of a weight management program. Cooperation is the sharing of resources,
a technique that is common in social services and rarer in the business world. Col-
laboration uses all three techniques—networking, coordination, and cooperation—
to create and implement a prevention program or intervention activity. Collaborations
are highly effective ways to pool resources and optimize unique skills in order to
address complex issues. On the other hand, the collaborative process is time
intensive, requiring careful planning and oversight. Each organization must donate
time, talent, space, or finances to the project. Conflicting interests, poor commu-
nication, incongruent values, limited resources, or organizational dysfunction can
easily become an obstacle to effective collaboration.
Building an effective collaboration takes time. The major steps are (1) preforma-
tion, (2) formation, (3) strategic planning, (4) action, (5) closure or maintenance,
and (6) dissemination. During preformation, the initial organizers dialogue with the
affected community and key stakeholders around the problem. A needs assessment
is used to determine who is impacted by the problem and the severity of the
impact. An inventory assessment maps local resources and available expertise.
Through the needs and inventory assessments, organizers can identify potential part-
ners to fill specific roles within the collaboration. During the formation phase, the
organizers communicate with potential partners to determine willingness and level
of interest. Formal collaborations secure letters of commitment that outline spe-
cific roles of each member. A natural leader, someone who is invested in the cause
and can convene the coalition, typically emerges by this point. During the strategic
planning phase, the coalition identifies realistic goals and objectives and brainstorms
possible activities. The convener must manage meetings carefully, ensuring that
everyone is involved in decision making and remains committed to the project. Indi-
vidual members must be clear about their own role on the project and set bound
aries in terms of what is expected. Overinvestment can burn out members or stretch
resources too far, causing people to disengage. Once a plan of action is envisioned,
C OLLA B O R ATIONS 131
the group develops a timeline of events, identifies staffing needs, and secures fund-
ing support. The plan for evaluation takes shape as the group determines impact
and outcomes. A logic model is used to define the project, linking activities with
intended outcomes. Through strategic planning, coalition members build rela-
tionships that are important in moving the project forward. Individual members
(people) are what make collaborations successful, not the bricks and mortar of an
organization.
The action phase is the implementation and evaluation of the project, when the
group manages day-to-day activities of the program or outreach efforts. It is com-
mon for groups to come up against problems during this phase. Working within
existing systems creates additional, unexpected obstacles. The group can work
around or through obstacles using regular meetings to facilitate communication
between the individuals and organizations. Evaluations are used to determine
whether activities are efficient and effective. Through the evaluation, the group can
gain insights in how to improve practices for the future. As the project nears the
end of the proposed timeline, the group must assess sustainability, the ability of a
project to continue a fter initial oversight and resources end. In some cases, the col-
laboration will have successfully developed coordination and cooperation between
service organizations and the program will continue without major obstacles. In
other cases, the program must end b ecause funding is no longer available, trained
staff leave, or the activities are ineffective or poorly attended. The group must develop
ways e ither to continue the efforts or to formally end the project. At this point,
experts recommend that each collaborative takes time to acknowledge achievements.
Establishing a network of coordinated services for a complex problem is in itself a
successful outcome. The final stage is dissemination of the evaluation results. Dur-
ing this stage, evaluation findings and lessons learned are shared with key stake-
holders, participants, the public health community, and other researchers. Many
groups lose momentum at dissemination. Evaluation results may not show statisti-
cal significance or data may be incomplete, creating a reluctance to share results. It is
worth remembering Elkhorne’s (1967) quote of Thomas Edison, “I have not failed. I’ve
just found 10,000 ways that won’t work” (p. 52). In public health, it is just as impor
tant to know what does not work as it is to know what works. Dissemination of
successes helps to advance efforts in alleviating the health problem. Dissemination
of failures helps other collaborations to avoid pitfalls.
In 2006, a group of us established a collaborative to increase physical activity
among inner-city children living near our university. We gathered state and local
data on childhood obesity, searched the literature on suggested interventions, and
surveyed the surrounding area (preformation). Needs and inventory assessments
suggested that the community needed a playground. We met with nearby school
officials who agreed to allocate land at the local elementary school, a fenced area
adjoining the university grounds. The principal arranged a meeting between par-
ents, members of the community, students, teachers, and university faculty. Before
132 C OLLA BOR ATIONS
a packed auditorium, we presented the playground idea. We were unsure how the
community would respond. The playground could be viewed as a public nuisance,
creating additional traffic and unwanted visitors in the neighborhood. The com-
munity embraced the idea. We listened carefully to concerns of no adult-sized bas-
ketball hoops and the gates must be locked at dusk. Parents and grandparents
suggested a community-build in order to stretch the limited funds as far as possible.
The collaborative developed to include the school principal, district and university
legal consultants, a playground design consultant, the school’s physical educa-
tion teacher, university faculty in health services and education, and parent repre-
sentatives (formation). Over the school year and summer, the collaborative met to
plan the playground build (strategic planning). Children drew pictures that were
translated to a wish list of equipment. The lawyers nixed the swings, citing safety
concerns. The physical education teacher emphasized the need for climbing frames
to build upper body strength, an item identified for improvement on annual fitness
tests. The chair of the university’s art department assisted in developing a color
scheme. Before consulting with the community, we expected bright primary
colors—reds, blues, and yellows. The community requested browns and greens.
Their preference was to mimic the background of trees on the university property.
A contractor was hired to oversee construction. One weekend in September was
chosen for the build. Advertisements w ere posted for volunteers in the community,
the university, and the school district (action). Equipment was delivered to the work-
site. On Friday evening, the men’s lacrosse team set up benches and lay out the
equipment for easy identification and access. On Saturday, more than 600 volun-
teers came to the school. Community members stood at the gates, rotating volun-
teers on the building site. Three skilled construction workers directed volunteers
in assembling slides, ladders, climbing frames, and walkways. Additional volun-
teers painted the library, sorted donated clothing for charity, and organized school
supplies. The Parent-Teacher Association served meals and snacks in the cafeteria.
The college students were grateful for a home-cooked meal. Intended as a three-
day build (Friday evening, Saturday, and Sunday), the playground was completed
by Saturday evening. Evaluation results showed no significant difference between
average daily step count before and after the playground. There w ere challenges
during the project. Members of the community requested a second playground for
children aged three to five years. We were unable to fulfill this request due to lack
of funds. Some neighbors used the school wall to play wall ball. They were dis-
placed by the playground. Ensuring that no volunteer was turned away and every
one felt appreciated was an unexpected challenge. Evaluation results were shared
with the funder, the school district, and at professional conferences (dissemination).
However, the real, unmeasured successes w ere that c hildren who did not have access
to a playground now have access, university alumni report revisiting the playground
and proudly saying, “I put that bolt on,” and the network established between school,
community, and university.
C O M M UNITY HEALTH 133
Public health professionals collaborate with staff from hospitals, doctor offices,
community agencies, nonprofit organizations, media, academic institutions, and
businesses to prevent and reduce multiple public health problems. Combining skills,
talents, and resources can achieve outcomes that would not be possible by acting
alone or as separate systems. Collaborations can be highly successful tools of empow-
ering communities to resolve complex health issues.
Sally Kuykendall
See also: Community Health; Community Organizing; Evaluation; Intervention;

Logic Model; Prevention; RE-AIM (Reach, Effectiveness, Adoption, Implementation,
and Maintenance); U.S. Public Health Service; World Health Organization
Further Reading
Association of State and Territorial Dental Directors. (2012). Handbook on planning, evaluat-
ing, and improving collaboration for oral health programs. Retrieved from http://www.astdd
.org/docs/collaboration-evaluation-handbook-final.pdf.
Elkhorne, J. L. (1967). Edison: The fabulous drone. 73 Magazine XLVI(3), 52–54. Retrieved
from http://www.arimi.it/wp-content/73/03_March_1967.pdf.
National Association of County & City Health Officials. (2016). Pulling together, Section Two:
Building collaboration. Retrieved from http://archived.naccho.org/topics/environmental
/pullingtogether/sectiontwo.cfm.
Office of Public Health Scientific Services, Center for Surveillance, Epidemiology, and Lab-
oratory Services, Division of Scientific Education and Professional Development. (2013).
Public health and health care collaboration: The workforce perspective. Retrieved from
http://www.cdc.gov/ophss/csels/dsepd/strategic-workforce-activities/ph-healthcare
-collaboration.html.
COMMUNITY HEALTH
Community health is a field of study within public health sciences that focuses on
promoting, protecting, and preserving the health of a defined group of people (Green &
Ottoson, 1999). The word “community” refers to a group of people who live in the
same locality, adhere to similar norms or values, or are bound by common laws or
regulations (Green & Ottoson, 1999). The group may share similar experiences,
language, or activities. Commonalities create a sense of identity, which transcends
into emotional connections and mutual support (McKenzie et al., 2009). A com-
munity can also be viewed as a group of people who identify with particular issues,
such as cancer survival, physical disability, or survivors of emotional, physical, or
sexual abuse (Goodman et al., 2014). Community health programs focus on devel-
oping a healthy community, able to access resources and attain quality of life. The
process typically consists of organized efforts performed by functional partnerships
sharing resources. Common community health agendas are to prevent community
134 C OM M UNITY HEALTH
violence, promote safety, support m ental health, create linkages between commu-
nity resources and other health resources, or increase access to quality health care.
Some partnerships are formed between government and private agencies with the
goal of reducing risk f actors for disease, reducing the burden of disease, decreasing
intentional and unintentional injuries, or promoting wellness (Goodman et al.,
2014). Although this description provides a preliminary framework for understand-
ing community health, the definition continues to expand as our understanding
and interpretation of both community and health evolve. Experts recommend that
future definitions should consider the diversity of communities, how communities
connect, and how communities make decisions (Goodman et al., 2014).
Community health programs engage people from different organizations and
backgrounds to work together to address the health issues in a community. Mem-
bers may be from the community of interest, local government, community-based
organizations, public health departments, faith-based organizations, universities,
or hospitals. Each individual or group provides specialized skills, knowledge, con-
nections, or insights. Frontline support staff typically consist of locally trained vol-
unteers, community health advisers, community health representatives, health
advocates, or health promoters who are both members of the target community and
members of the community health partnership. Other workers may be public health
staff who have crafted close professional ties with the community. Community health
professionals are often university graduates with a bachelor’s, master’s, or doctoral
degree in community health and specialization in health education, health promo-
tion, or nutrition. To be effective, all staff must respect the values and culture of the
community.
Community health efforts start by formally identifying the community
health needs, determining priorities, defining goals, and establishing a common
agenda. The group must determine the most effective intervention or prevention
activities that w ill meet project goals. Examples include evidence-based pro-
grams or practices, outreach services, education programs, counseling, or advo-
cacy. During program activities, community health workers also have an opportunity
to connect members of the community with local health or social services. All
community health programs, and especially those receiving grant funding, should
include an evaluation component. Community health professionals may develop
their own tools or use published instruments to assess program impact and out-
comes. Some of the tools used are the Behavioral Risk F actor Surveillance System
(BRFSS), Youth Risk Behavior Survey (YRBS), and the National Health and Nutri-
tion Examination Survey (NHANES). Additionally, many different academic disci-
plines, such as health economics, behavioral sciences, health education, and law,
offer measurement tools and expertise to support community health practice
(Goodman et al., 2014).
There are multiple organizations and resources designed to support commu-
nity health partnerships and community health programs. The Centers for Disease
C O M M UNITY HEALTH 135
Community health workers erect a billboard encouraging residents of Columbus, Georgia,

to get vaccinated against polio. Community health programs engage p eople from different
organizations and backgrounds to work together to address the health issues of the com-
munity. (Centers for Disease Control and Prevention)
Control and Prevention (CDC) Community Health Program offers resources, best
practices, and innovative ideas for groups working toward community health.
The resources are designed to strengthen and support community health efforts,
especially in the prevention of chronic disease and in the promotion of healthy
living (CDC Division of Community Health, 2013). Kaiser Permanente’s Com-
munity Health Initiatives is an example of a community health program. The
Community Health Initiatives developed the HEAL (Healthy Eating Active Liv-
ing) program, a partnership of community-based organizations, local residents,
and Kaiser Permanente. The program is designed to promote healthy eating and
active living in local neighborhoods, schools, and workplaces (HEAL Cities,
2017). Community health is an evolving field with many challenges. F uture direc-
tions must focus on developing methods of data collection that are specifically
designed for community health practice. Data collection tools should serve to
assess, evaluate, and implement evidence-based principles while also considering
cost effectiveness. Some experts suggest the need for better integration between
community health practice and other public health disciplines (Goodman et al.,
2014).
Community health efforts focus on reducing disease, reducing health dispari-
ties, and improving health and wellness. Community health partnerships draw from
136 C OM M UNITY HEALTH C ENTE R S (C H Cs)
the combined efforts and knowledge and expertise of multiple agencies and dis-
ciplines. The Bureau of L abor Statistics (BLS) predicts that job opportunities in com-
munity health w ill continue to grow over the next decade. Thus, the vision of a
healthy community may be attainable.
Victor Okparaeke
See also: Collaborations; Community Organizing; Cultural Competence; Evidence-

Based Programs and Practices; F amily Planning; Goals and Objectives; Health
Education; Healthy Places; Needs Assessment; Population Health; RE-AIM (Reach,
Effectiveness, Adoption, Implementation, and Maintenance)
Further Reading
Centers for Disease Control and Prevention (CDC), Division of Community Health. (2013).
A practitioner’s guide for advancing health equity: Community strategies for preventing chronic
disease. Atlanta: U.S. Department of Health and H uman Services. Retrieved from https://
www.cdc.gov/nccdphp/dch/health-equity-guide/index.htm.
Goodman, R. A., Bunnell, R., & Posner, S. F. (2014). What is “community health”? Examin-
ing the meaning of an evolving field in public health. Preventive Medicine, 67(Suppl. 1),
S58–S61.
Green, L. W., & Ottoson, J. M. (1999). Community and population health (5th ed.). New York:
McGraw-Hill.
HEAL Cities. (2017). Healthy eating active living cities campaign. Retrieved from http://www
.healnation.com/.
Kaiser Permanente. (2017). Community health initiatives. Retrieved from https://share
.kaiserpermanente.org/article/community-health-initiatives-3/ .
McKenzie, J. F., Neiger, B. L., & Thackeray, R. (2009). Planning, implementing, & evaluating
health promotion programs: A primer (5th ed.). New York: Pearson.
COMMUNITY HEALTH CENTERS (CHCs)

Community health centers (CHCs) are public health clinics and medical facilities
that provide comprehensive primary and preventative health care to children and
adults. Nationwide, approximately 4,000 CHCs provide medical treatment,
behavioral health services, oral care, vision care, substance abuse treatment, and
pharmacy services to 24 million people (HRSA, 2017). Anyone may attend a
CHC. The centers are specifically intended to provide a medical home for p eople
with limited access to health care services due to poverty, geographic isolation,
homelessness, working as a migrant farmworker, or veteran. Patients pay for
treatment and care based on income. CHCs are the front line of public health for
many Americans. Physicians, nurses, social workers, podiatrists, dentists, labora-
tory technicians, pharmacists, health educators, and other health professionals
work in CHCs to reduce and prevent disease and improve health outcomes and
quality of life for p
eople in the surrounding community. CHCs differ from other
C O M M UNITY HEALTH C ENTE R S ( C H Cs) 137
health organizations in that they are designed to serve the community. This means
that services are tailored to the needs of the community rather than the potential
to make money.
CHCs are financed by the Health Resources and Ser vice Administration
(HRSA) under the Public Health Service Act. HRSA provides grants to local gov-
ernment, faith-based organizations, universities, or other organizations that
manage the center and provide direct care to residents. Each CHC has a board
of directors composed of members of the community and public health and medi-
cal professionals. The board determines what services are needed and what ser
vices will be offered. Localized planning ensures that local needs are being met.
Common medical services offered include annual physical examinations, medi-
cal care, immunizations, and dental care. Some centers offer specialty services
such as HIV/AIDS treatment, sexually transmitted disease screening and treat-
ment, reproductive ser vices, housing support ser vices, psychiatric care, or
chronic disease management. For example, the CHC in Eastport, Maine, offers
podiatric care, alcohol and substance abuse counseling, physical therapy, and
radiology services. The Curry Senior Center in San Francisco, California, offers
primary care and preventive services for residents aged 55 and older, deliv-
ered by staff fluent in English, Cantonese, Mandarin, Tagalog, Vietnamese,
Spanish, or Russian. The ability of centers to personalize care ensures that mem-
bers of the community receive the care that they need and that resources are
used wisely.
The public health accomplishments of CHCs and health center staff are par-
ticularly noteworthy. Health care costs of CHC-Medicaid patients are 24 percent
less than other patients. In comparison to patients who use other primary care
systems, CHC-Medicaid patients have fewer visits (22 percent), less specialty care
(33 percent), fewer admissions (25 percent), and lower inpatient care (27 percent)
costs (Nocon et al., 2016). Across the nation, 64 percent of diabetic patients have
their condition under control. Among CHC patients, 70 percent of diabetics
have their condition under control (HRSA, 2017). Fifty-two percent of non-CHC
patients diagnosed with high blood pressure have their condition under control,
compared to 64 percent of CHC patients diagnosed with high blood pressure. Bet-
ter patient outcomes are partially related to the fact that providers are able to
develop relationships with community members. Good patient-provider rela-
tionship enables regular screening, close monitoring of illnesses and progress,
and better follow-up. CHCs are able to break down many of the racial, gender,
and ethnic barriers that exist in health care. In addition to reducing disease and
health disparities, CHCs influence the local economy. When residents are able to
access treatment and preventive services, personal health improves and people are
able to work. Also, CHCs hire local residents as technicians, health administrators,
or health professionals and purchase supplies, which brings jobs to disadvantaged
communities.
138 C OM M UNITY HEALTH C ENTE R S (C H C s )
The Community Health Center of Northeastern Wetzel County of West Virginia serves as the
medical home for over 4,000 local residents. Doctors, nurses, physician assistants, dentists,
and dental hygienists provide medical, dental, and behavioral health services. (Brendan
Smialowski/AFP/Getty Images)
CHCs offer medical care and preventive services to p eople who may not normally
be able to access health services. The centers have direct benefits of keeping p
eople
healthy and indirect benefits of enhancing the health of the entire community.
Sally Kuykendall
See also: Administration, Health; Association of State and Territorial Health Offi-
cials; Community Health; Health Resources and Services Administration; Indian
Health Service; Medicaid; Medicine; Population Health; Prevention; State, Local,
and Territorial Health Departments; Controversies in Public Health: Controversy 3
Further Reading
health. Atlanta: Centers for Disease Control and Prevention. Retrieved from http://
www.c dc .g ov /s tltpublichealth /h op /p dfs /Ten _E ssential _P ublic _H ealth _S ervices
_2011-09_508.pdf.
Health Resources & Services Administration (HRSA). (2017). About the health center pro-
gram. Retrieved from https://www.bphc.hrsa.gov/about/index.html.
Institute of Medicine. (1988). The future of public health. Washington, DC: National Acad-
emies Press. doi:10.17226/1091. Retrieved from http://www.nap.edu/catalog/1091/the
C O M M UNITY O R G ANI Z ING 139
Nocon, R., Lee, S. M., Sharma, R., Ngo-Metger, Q., Mukamel, D. B., Gao, Y., White, L. M.,
Shi, L., Chin, M. H., Laiteerapong, N., & Huang, E. S. (2016). Health care use and
spending for Medicaid enrollees in federally qualified centers versus other primary
care settings. American Journal of Public Health, 106(11), 1981–1989.
COMMUNITY ORGANI ZING

Community organizing is the process of bringing together members of a commu-
nity in order to address the problems that affect the community. This grassroots
approach empowers individuals to solve issues and improve quality of life within
their own neighborhoods. The benefit of community organizing is that the p eople
who are affected the most by the problem are invested in finding solutions, and the
solutions are likely to continue a fter the task force disbands. Conversely, commu-
nity organizing requires certain skills to avoid political pitfalls while attracting,
engaging, and sustaining members. Organized leadership, consensus building, and
personal investment are critical to achieve the desired goal. Obstacles may arise from
changes in community structure, power imbalances, demographics, housing, job
demands, and organized activities. Any factor that influences the relationships
between neighbors can affect the community’s ability to address problems. Bedroom
communities, where p eople work outside of the place they live, lack of interaction
with neighbors, overscheduling, and poverty make it difficult to organize a com-
munity. In public health, community organizing is used to address many complex
issues such as youth violence, childhood obesity, social injustice, and lack of access
to health care. Community organizing is a time-tested technique that w ill continue
to evolve as our communities and social groups evolve.
Saul David Alinsky (1909–1972) is considered the father of community organ
izing. In the 1930s, Alinsky led a series of community efforts to improve living and
working conditions in impoverished areas of his hometown Chicago. Less fortu-
nate populations were blocked from improving conditions because power ful
stakeholders, businessmen, politicians, and the wealthy had a vested interest in
maintaining the status quo. In order to improve the communities, Alinsky and col-
leagues devised creative ways to empower the powerless, including threatening a
fart-in by sympathizers attending a Rochester Philharmonic Orchestra concert. In
his 1971 book, Rules for Radicals, Alinsky identifies two power groups, organized
money and organized people. By organizing people and media sympathy, Alinsky
was able to advance civil rights and create economic opportunities for the
“have-nots.”
Although there are some movements that follow Alinsky’s model of shocking
people into action, community organizing in public health aims for less militant
methods. At the heart of community organizing is organizing for the collective good.
The basic steps are (1) formation, (2) maintenance, and (3) institutionalization. During
formation, key stakeholders identify the problem or concern; assess local politics,
gatekeepers, and power holders; identify, recruit, and organize a task force; identify
needs, assets, and obstacles; prioritize goals; and select intervention strategies.
140 C OM M UNITY ORGANIZ IN G
During maintenance, the group initiates the plan of action and evaluates success.
In the final step, institutionalizing integrates efforts into existing systems. The
Community Organizing for Obesity Prevention in Humboldt Park (Co-Op HP) is
an example of community organizing in public health. A 2002–2003 health survey
by Sinai Urban Health Institute (SUHI) revealed that Chicago communities had
higher rates of obesity in comparison to the rest of the nation, increasing risk for
heart disease, diabetes, hypertension, depression, and arthritis. Fifty percent of
children in the Humboldt Park community w ere obese, significantly higher than
the national rate of 14 percent (Estarziau, Morales, Rico, Margellos-Anast, Whit-
man, & Christoffel, 2006). Co-Op HP was formed with financial support from
Otho S. A. Sprague Memorial Institute, people power from the Puerto Rican Cul-
tural Center and Centro Sin Fronteras, and technical support from the Consortium
to Lower Obesity in Chicago C hildren (CLOCC) and SUHI. Over the years, many
churches, colleges, communities, and nonprofit organizations have joined the effort.
The project uses existing resources to provide four interventions: increasing avail-
ability and demand for healthy foods, expanding and supporting fitness programs,
healthy living, and community development to coordinate health prevention
programs. A few of the many outreach and education programs are encouraging
store o wners to provide a better selection of fresh fruits and vegetables, fitness classes
at the YMCA, bilingual wellness programs by the Erie F amily Health Center, and
cooking classes. The co-op monitors success by tracking quantity and demand for
healthy food, participation in fitness programs, eating behaviors, bike lanes and foot-
paths, and number of organizations advocating health in the community. Co-Op
HP demonstrates how existing systems and resources can be leveraged to address
the multifactorial problem of obesity.
Underlying community organizing are certain hidden assumptions. Community
organizing assumes that p eople want to solve the problems that affect them and
that they are capable of creating sustainable solutions. There may be some issues
where p eople are reluctant to change. Changing diet and integrating physical activ-
ity into daily routine may not be desirable for some members of the community.
Therefore, it is important that the changes have meaning to the community mem-
bers. Community organizing assumes that a coordinated approach is more effective
than a fragments approach. The coordinated approach requires that people cooper-
ate. This may mean yielding to the needs of the group. The grocery store owners
may have a lower margin of profit on fruits and vegetables than they gain on
bags of chips or soda pop. Giving up a higher profit for the benefit of the custom-
ers’ health is something that store owners might struggle with. This is where it may
be difficult for community organizers to keep the store owners engaged. Successful
community organizing is able to foresee and navigate obstacles and come to con-
sensus on solutions.
Community organizing coordinates existing systems and community members
through efforts to improve their own community, health, or quality of life. The tech-
nique may be applied to numerous complex health issues that adversely affect
C O R E C O M PETEN CIES IN PU B LI C HEALTH 141
communities. And although community organizing can be challenging, juggling

multiple systems and people, the results are highly effective and lead to long-term
sustainable solutions.
Sally Kuykendall
See also: Collaborations; Community Health; Community Health Centers; Evaluation;

Intervention; Logic Model; Obesity; PRECEDE-PROCEED Planning Model; Preven-
tion; RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance)
Further Reading
Agency for Toxic Substances and Disease Registry, Clinical and Translational Science Awards
Consortium, Community Engagement Key Function Committee Task Force on the
Principles of Community Engagement. (2011). Principles of community engagement
(2nd ed.). Department of Health and Human Services. Retrieved from https://www.atsdr
.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.p df.
Alinsky, S. (1971). Rules for radicals: A practical primer for realistic radicals. New York: Ran-
dom House.
Estarziau, M., Morales, M., Rico, A., Margellos-Anast, H., Whitman, S., & Christoffel, K.
(2006). Report on the findings and recommendation of the community survey in Humboldt
Park: Preventing obesity and improving our health. Puerto Rican Cultural Center, Centro
Sin Fronteras, Sinai Urban Health Institute, Consortium to Lower Obesity in Chicago
Children. Retrieved from http://www.sinai.org/sites/default/files/comm%20surv%20
in%20HP%20prev%20obesity.pdf.
CORE COMPETENCIES IN PUBLIC HEALTH

The core competencies for public health professionals are the basic skills that e very
public health professional should possess. The public health workforce is made up
of many different people from many different fields. From health administrators to
epidemiologists, emergency medical technicians, optometrists, sanitarians, labora-
tory technicians, animal control workers, pharmacists, policy makers, health edu-
cators, researchers, and behavioral health professionals, each worker has unique
duties and responsibilities. Where an epidemiologist studies health issues in the
community and helps determine priorities, the public health nurse gives direct
patient care to alleviate such problems. Individuals work together to create a sys-
tem of care and prevention. Yet, the breadth and depth of public health practice
can be confusing. We don’t immediately think of the animal control officer as a pub-
lic health officer, unless we are experiencing an outbreak of ringworm, rabies, or
mad cow disease. Furthermore, when public health efforts are successful, disease
and illness do not occur. It is hard to measure and appreciate a problem that does
not affect us. When we eat at a restaurant, we assume the food was properly stored
and prepared, restaurant workers used good handwashing techniques, and the res-
taurant was clean and passed food safety inspections. If the meal was good and we
142 C OR E C OM PETENCIES IN PU BLIC HEALTH
idn’t get nausea or diarrhea after eating, we don’t stop to appreciate the fact that
d
we didn’t get sick. Public health counts the number of cases of salmonella poison-
ing. No one counts the number of people who don’t get salmonella poisoning. It is
hard to measure something that d oesn’t occur.
When public health is successful, diseases do not occur. Yet, without data and
public recognition, funding becomes a problem. In 1988, the Institute of Medi-
cine (IOM) called attention to the political and perceptual issues affecting public
health in the United States. The IOM noted that the public health system was
suffering from severe underfunding, resulting in outdated tools and materials, and
fragmented services. The IOM suggested developing a consensus on the role of
public health. The Council on Linkages between Academia and Public Health
Practice gathered faculty, experts, and practitioners from 20 different organ
izations to develop a list of common competencies, which all public health profes-
sionals should have. Public health core competencies are classified by eight domains
or skill sets:
• Program planning and policy development
• Community dimensions of practice
• Communication
• Cultural competency
• Analytical and assessment
• Public health sciences
• Financial planning and management
• Leadership and systems thinking
The core competencies provide a structure, defining who and what public
health is. The Council on Linkages between Academia and Public Health Practice
detail each competency by tier. Tier 1 workers, entry level staff, need a working
knowledge of each skill set to support optimal patient care. Tier 2, program man
agers and supervisory staff, need a greater level of expertise. Tier 3, executives, are
responsible for the highest level of skill in order to foster a professional culture.
The competencies are used by colleges and universities offering degrees in public
health or by local health departments building or maintaining a quality workforce.
Most importantly, the core competencies allow all public health professionals—
from entry level to senior administrators—to understand and appreciate the tal-
ents, efforts, and contributions of colleagues to the larger system of care.
Many of the core competencies require an interdisciplinary approach, being able
to take information and methods from different fields of study and piece them
together to create evidence-based practices. Program planning skills require public
health practitioners to identify health goals and objectives of a community, plan
workable and effective interventions, coordinate activities, evaluate efforts, and sug-
gest next steps. Today’s health issues are very complex, requiring multifaceted
solutions. One person or one agency alone cannot solve today’s convoluted
health issues. Problems, such as teen pregnancy, substance abuse, poverty, crime,
C O R E C O M PETEN C IES IN PU B LIC HEALTH 143
and violence, have deep roots that need to be addressed from both inside and out-
side of the affected community. Yet, as the IOM report noted, services are often
disjointed. Public health professionals must be able to work within and across
government agencies and nonprofit organ izations to coordinate resources.
Related to program planning are the community dimensions of practice, skills that
public health professionals need in order to interact with p eople and organizations
in the community. When community data show that teen pregnancy is a problem,
the public health professional would seek to coordinate resources from schools,
family planning centers, local hospitals, recreational centers, religious institutions,
businesses, and others within the community (Huberman, Klaus, & Davis, 2014).
Community collaborations can be difficult, particularly if organizations are com-
peting for the same grants or funding streams. To create coordinated systems of
care, public health program planners identify the key stakeholders, establish a
working group, develop shared vision, create a plan, coordinate, and mobilize ser
vices. It is also important to develop a plan to continue services after the initial
funding ends. It takes time to get a well-planned program up and running in a
community. Starting a program and then having to stop when funding has ended
may leave the community in worse condition than when they started. Public health
professionals must be competent to work with communities to establish effective,
long-term solutions. Policy development is one way to ensure long-term, sustainable
solutions. Policy development consists of working within government systems to
develop laws, regulations, strategies, organizations, and plans to enhance health.
Although not every public health professional w ill develop laws, they should be
able to understand and explain how policies on communicable disease surveillance,
immunizations, tuberculosis screening, and inspections of schools and day care
centers work to prevent the spread of disease. Policy development also helps to
determine resource allocation within the federal organizations that make up the
Department of Health and Human Services, local and state health departments,
and community grants.
Oral and written communication skills are necessary to be able to clearly interact
with patients, community members, stakeholders, and other professionals. T hose
providing direct and indirect care must be able to listen and respond appropriately
to concerns. Doctors and nurses must listen to patients and patient caregivers, assess
symptoms, and discuss proposed treatment plans. Even t hose who do not give direct
care must have good communication skills. Scientists must listen to participants in
order to gather accurate information, and administrators must listen to staff in order
to develop workable solutions. Clear, brief, and accurate messages are best. The
goal is to provide people with the information that they need to make educated
decisions. Using a variety of methods (e.g., community speaking, news outlets,
e-mails, or posters) ensures wider outreach and greater integration of health ideas
into everyday life. Cultural competency means recognizing the unique needs, val-
ues, social norms, experiences, and beliefs of minority individuals and popula-
tions in order to positively influence policies, programs and services. Cultural
144 C OR E C OM PETENCIES IN PU BLIC HEALTH
competency advocates and empowers p eople regardless of gender, ethnicity, lan-

guage, age, sexual affiliation, religious preference, ability, and experiences. Although
some cultural competency skills, such as language, may be taught, having a diverse
public health workforce is one of the most highly effective ways to develop and
maintain a culturally competent health center. The health educator who provides
parenting classes for teen m others and fathers must be able to understand the
unique needs of teen parents. The experiences of raising a child when one is still
finishing high school, living with parents, establishing a c areer, and/or dating are
very different from those who have already finished high school, have their own
home, and source of financial support. Furthermore, relationships between health
care workers and patients are based on mutual trust and respect. The patient must
trust that the health care worker will provide respect, maintain confidentiality, and
recommend treatments where the advantages (improved quality of life or reduced
disability and death) outweigh disadvantages (cost or inconvenience). Trust devel-
ops more easily and quickly when the patient can see that the health care worker
has had similar life experiences.
Future generations of health professionals must be able to think critically about
health issues in order to refine and improve practices. Analytical thinking skills are
the ability to recognize reputable sources of information, access data, accurately
interpret the results, and come to thoughtful and rational conclusions. Rigorous
scientific data allow us to assess where we are in conquering a health problem and
what we need to do next. Public health uses facts, discoveries, knowledge, and theo-
ries from biology, chemistry, medicine, social and behavioral sciences, psychology,
epidemiology, biostatistics, informatics, microbiology, and health administration to
build effective practices. Public health sciences are the scientific foundations on which
public health is practiced. Practitioners must have a functional knowledge of many
different disciplines in order to implement effective programs and activities. The
program planner working to prevent teen pregnancy needs a working understand-
ing of the community (sociology), teenage brain development (neuropsychology),
reproductive health (biology), evidence-based programs (health education), trends
in teen pregnancy rates (epidemiology), grant writing, management, and finance
(health administration). A well-rounded interdisciplinary education enables health
professionals to draw knowledge from a variety of sources, creating a coordinated
approach. Knowledge does not end with the awarding of a degree. Health profes-
sionals must stay up to date and relevant in their field. Membership in a profes-
sional organization, continuing education units, professional conferences, and trade
journals are some of the ways that professionals stay up to date. Some organizations
provide heavily discounted student memberships in order to encourage the life-
long habit of staying current in the field. The ability to read, understand, and cri-
tique health information empowers health care personnel to immediately employ
new research findings while dismissing questionable findings. Many public
health departments work with scholars from local colleges and universities to study
the needs of residents, evaluate efforts, and communicate successes and failures
C O R E C O M PETEN C IES IN PU B LIC HEALTH 145
through professional conferences and journals. Professional partnerships can ben-

efit the public health department, the scholar, local communities, and public health
in general.
With limited public funding and resources, meeting Healthy People goals and
objectives is challenging. Skills in financial planning and management support pro-
grams, advances, and day-to-day activities of local health departments. Financial
planning includes the ability to apply for federal, state, or nonprofit organization
funding, weigh costs of a program against benefits, and manage contracts and bud
gets. The health educator offering classes to teen m others may need to write grants
advocating for program funding, come up with a budget for food, supplies, and
incentives, manage the budget, and report expenses to program funders. Financial
management requires a different skill set than collaborating with community part-
ners or working with patients. Although some public health professionals may never
manage budgets, all must understand budget constraints in order to make maxi-
mum use of limited public resources. All public health personnel function as man
agers, e ither managing patient care, staff, programs, or policies. Each member of
the health care team contributes specialized skills and empowers colleagues to also
contribute their own skills. Management skills encompass supporting teams, hon-
oring different disciplines, motivating team members to work toward organizational
goals, performance management, and continuous process improvement. The pub-
lic health nurse serving a pregnant teen mom who is at risk for gestational diabetes
could provide preliminary diet counseling, yet would also refer the young m other
to a registered dietician. The nurse recognizes and respects that the registered dieti-
cian can provide more detailed, helpful nutritional information, resources, and tools.
Public health is carried out through careful resource planning, management, and
dedicated partnerships.
Leadership and systems thinking skills are used by all public health workers, from
frontline, entry level staff to senior executives. Leadership requires that public health
professionals possess a vision of what health looks like for the communities that
they serve. All programs, activities, and services are guided by strong ethical stan-
dards. Public health professionals are not simply performing a job. E very person,
every life, is important, regardless of sexual preference, ethnicity, or socioeconomic
status. Public health professionals are not only part of a system of care, they are
part of communities where they act as mentors, coaches, advisers, and trainers.
Community health workers are often the first ones that family members, friends,
neighbors, and colleagues look toward when health concerns arise. Questions are
posed that patients may be afraid to ask their own doctor. Making connections
between individuals, systems, and communities allows the health professional to
critically analyze internal and external f actors that may ultimately improve delivery
of care.
The core competencies provide clear and measurable outcomes for public health
training and professional standards. Schools of public health use the core competen-
cies to plan curricula, and health departments use the core competencies for
146 C OR NELY, PAUL BERTAU
workforce development. The field of public health is extremely complex with mul-
tiple interrelated concepts. As the field develops further and specialization increases,
schools will be challenged to fit everything that they need to fit into public health
curricula. Although the core competencies were developed as a tool, a way to ensure
competency within the field, the core competencies also effect a collegial and col-
laborative work environment. Public health professionals respect and appreciate the
individual expertise and function of each discipline within the larger system of care.
The sanitarian who performs health and safety inspections to ensure that the food
we eat in a restaurant is properly prepared, stored, and disposed of is just as critical
in preventing illness as the physician who diagnoses and treats salmonella.
Sally Kuykendall
See also: Certified in Public Health; Code of Ethics; Cultural Competence; Preven-
tion; Controversies in Public Health: Controversy 4
Further Reading
Association of Schools & Programs of Public Health. (2017). Retrieved from http://www
.aspph.org/.
Council on Linkages between Academia and Public Health Practice. (2014). Core competencies
for public health professionals. Retrieved from http://www.phf.org/resourcestools/pages
/core_public_health_competencies.aspx.
Huberman, B., Klaus, T., & Davis, L. (2014). Strategies guided by best practice for community
mobilization. Advocates for Youth. Retrieved from http://advocatesforyouth.org/storage
/advfy/documents/Factsheets/strategies%20guided%20by%20best%20practice_8-11
-14.pdf.
Institute of Medicine. (1988). The future of public health. Washington, DC: National Acad-
emies Press. doi:10.17226/1091. Retrieved from http://www.nap.edu/catalog/1091/the
Institute of Medicine. (2002). Who w ill keep the public healthy? Educating public health
professionals for the 21st century. Washington, DC: National Academies Press. doi:10.
17226/10542. Retrieved from http://www.nap.edu/catalog/10542/who-will-keep-the
-public-healthy-educating-public-health-professionals.
CORNELY, PAUL BERTAU (1906–2002)

Dr. Paul B. Cornely was the first person of color to earn a doctoral degree in public
health in the U.S. and the first person of color to serve as president of the American
Public Health Association (APHA). Born of Afro-Caribbean descent, Dr. Cornely wit-
nessed the injustices, indifference, and apathy of health, education, and social
systems toward the struggles of African Americans. He traveled across the nation,
investigating and documenting the living and working conditions of African Ameri-
cans, Latinos, and Native Americans. His lectures, articles, and speeches raised
awareness of overt and covert discrimination, which further subjugated racial
minorities. Cornely believed in social justice, that no one in society should carry a
C O R NELY, PAUL B E RTAU 147
larger burden of deprivation and hardship than o thers. With a vision toward volun-
tary desegregation of hospitals, he founded the Imhotep National Conference. When
he realized that those in power would not voluntarily yield their power, he joined
and became a leader in the American civil rights movement. Because of the civil
rights movement, discrimination based on race or ethnicity is illegal. However, many
of Cornely’s observations and recommendations continue to apply to health and
social services today.
Paul Bertau Cornely was born on March 9, 1906, in the French West Indies to
Adrienne (Mellon) and Eleodore Cornely. In 1921, the family immigrated to the states
and settled in Detroit. Thriving auto, coal mining, steel, and meatpacking indus-
tries attracted two main groups, Poles escaping the Russian invasion in Poland and
African Americans escaping poverty in the south. The promise of steady employ-
ment and financial opportunity was crushed by the Great Depression (1929–1939).
Competition for jobs and resources created tensions between Polish Americans and
African Americans, which escalated to frustration, anger, and contempt. Rather than
questioning the social systems that created hardship, the two groups argued for pref-
erential treatment. Since the recently immigrated Polish Americans were white, they
could blend in better than black Americans. In this tumultuous environment, Cornely
earned a BA (1928), an MD (1931), and a DrPH (1934) from the University of
Michigan.
Cornely’s choice of medical school and internship would have been very limited.
With the exceptions of Howard University and Meharry Medical College, medical
schools accepted few black students. Segregation meant that white doctors interned
at white hospitals and black doctors interned at black hospitals. The conditions of
black hospitals were well below health and safety standards. Black hospitals were
overcrowded and lacked supplies. In some hospitals, two to three patients shared
one bed. Cornely interned at Lincoln Hospital in Durham, North Carolina (1931–
1932). Lincoln Hospital was established by African American community leaders
who negotiated support from wealthy white donors because blacks worked in
close proximity to whites and treating disease among black people would prevent
spreading diseases to whites. As an intern, Cornely would have treated patients with
heart disease, cancers, respiratory illnesses, tuberculosis, influenza, typhoid fever,
renal problems, congenital malformations, and malnutrition. In 1934, Cornely became
a naturalized citizen and married Mae Stewart.
After earning his doctorate in public health, Cornely joined Howard University
as assistant professor in the Department of Bacteriology, Preventive Medicine, and
Public Health. In 1942, he was named chair of the department, and five years later
he became medical director of Freedmen’s Hospital. At Howard University, Cornely
was a prolific researcher and writer. In 1938–1939, Cornely visited historically black
colleges to investigate the quality of student health centers, dormitories, cafeterias,
showers, libraries, and other campus facilities. The 54 colleges employed 47 part-
time physicians, 2 part-time nurses, and 19 full-time nurses to serve the health and
medical needs of almost 24,000 students. In cafeterias, Cornely observed unsanitary
148 C OR NELY, PAUL BERTAU
food preparation, lack of handwashing facilities, cheap foods with poor nutritional
value, and use of unpasteurized milk. Dormitories were crowded and lacked basic
amenities for personal hygiene or studying. Rooms designed for two students
frequently h oused three or more students, forcing some students to share beds.
Buildings were in disrepair with sewage, plumbing, ventilation, or heating prob
lems. Many rooms had no desks and poor lighting, which meant that students had
to perch on the edge of their bed to study. Dormitory regulations requiring lights
out at 10, 10:30, or 11 p.m. forced students with a fter school jobs to study in dimly
lit hallways. Female dormitories were in slightly better condition than male dormi-
tories. Males carried the brunt of overcrowding and poor facilities. Cornely made
several recommendations to improve student life conditions including raising the
rate of student health fees from approximately three dollars to developing a task
force of faculty members to address the issues and hiring more health services
personnel.
In the 1950s, Cornely became active in the American civil rights movement. With
Dr. William Montague Cobb, Cornely planned the Imhotep National Conference
on Hospital Integration (1956). The conference was suitably named a fter the early
Egyptian physician, Imhotep, whose name translates as he comes in peace. The con-
ference was intended to lead a national discussion on voluntary desegregation of
hospitals, giving black patients the right to access care at premier medical institu-
tions. Sponsored by the Council on Medical Education and Hospitals of the National
Medical Association, the National Health Committee of the National Association
for the Advancement of Colored People (NAACP), and the Medico-Chirugical Soci-
ety of the District of Columbia, the meeting was held at the neutral location of the
Fifteenth Street Presbyterian Church. Sadly, the conference was boycotted by the
American Medical Association, American Hospital Association, American Nurses
Association, the National Health Council, the U.S. Public Health Service, the Ameri-
can Protestant Hospital Association, and the Catholic Hospital Association. No white
medical school, nursing school, or hospital sent an official representative (Byrd &
Clayton, 2000). Despite lack of support, Imhotep continued with annual meetings
until President Lyndon B. Johnson passed the 1964 Civil Rights Act requiring man-
datory desegregation. The conference was both a success and a failure. Despite the
boycott by large, influential institutions, the meeting raised public awareness of
racial discrimination in health care. White institutional disinterest forced Cobb
and Cornely to adopt more aggressive strategies. On August 28, 1963, Cornely
attended the March on Washington. With the passage of the Civil Rights Act, Presi-
dent Johnson convened a conference to discuss ways to disband segregated hospi-
tals. All of the formerly reluctant organizations attended.
In 1968, Cornely organized the Black Caucus of Health Workers. The following
summer, he toured the country with APHA president Lester Breslow investigating
the state of minority health. In Chicago, they observed children playing in aban-
doned cars surrounded by rotting garbage and broken sewers. In Houston, they
met a mother with eight c hildren whose welfare benefits were cut a fter two of her
C O R NELY, PAUL B E RTAU 149
c hildren participated in a demonstration against hunger. In California, Mexican

American agricultural workers reported headaches, dizziness, and sickness after
being sprayed with pesticides by crop dusters. In Montana, Native Americans only
received benefits during the winter. The assumption was that able-bodied men
could find work during the summer. Cornely noted chronic neglect and abuse by
government officials—those entrusted and empowered to care for vulnerable
populations.
hese visits revealed in dramatic and sometimes shocking fashion that millions of
T
Americans, and particularly ethnic minorities—20 million blacks, five million Mexican-
Americans, 400,000 to 500,000 Indians—are being brutalized by those governmen-
tal institutions that daily affect their lives; the police department, the welfare bureau,
the public employment services, the housing administration and the departments of
education, health and recreation. (Cornely, 1970a, p. 354)
Cornely’s descriptions provided real life examples of how minorities carry the weight
of social and economic burdens. American democracy favors the wealthy and dis-
advantages the poor. Minorities are at the mercy of the white majority for support,
and when support is given it is offered as charity, not as subsidy for the hardships
endured by discrimination, poverty, housing, unemployment, and limited access
to health care. B ecause of the investigation, Cornely reported the need to integrate
minorities into current political structures, to give minority communities a voice in
health care and social services, and expand opportunities for medical training of
people of color.
In 1969, Cornely was elected APHA president. As a public health leader, Cornely
continued to shed light on the issues of racism in health care. He encouraged redi-
rection and reorientation of research. He called out research studies that concluded
an inherent inferiority of blacks, ignoring social determinants of health. He recom-
mended that researchers focus on assets rather than deficiencies. Cornely advocated
for cultural sensitivity training of white health care providers and more minority
health professionals as leaders in health care. He called on psychiatrists and psy-
chologists to acknowledge the m ental health issues caused by racism and discrimi-
nation. He advocated to giving voice to black communities in decision making,
implementation, planning, and delivery of health services. To ensure health care
for all, Cornely advocated replacing the national system of charity medicine with a
national system of health care. He believed that the government should support “a
man in his home” before “a man on the moon” (Cornely, 2011, p. s163). In 1972,
Cornely was awarded APHA’s highest honor, the Sedgwick Memorial Medal.
Dr. Paul B. Cornely was a physician, a public health leader and a civil rights activ-
ist who highlighted the health and social injustices created by racial discrimina-
tion. He observed and called attention to the apathy, insensitivity, and neglect of
doctors, nurses, hospitals, and government officials toward the plight of minori-
ties. Although Cornely noted that, “Discrimination and segregation have no place
in health,” he also had a greater vision for public health (Cornely, 1985, p. 418).
150 C OUN CIL ON EDU CATION F OR PU BLIC HEALTH ( C EPH)
His vision was to address the social determinants of health to support quality of life
for all people.
Sally Kuykendall
See also: American Medical Association; American Public Health Association; Health
Care Disparities; Health Disparities; Indian Health Service; Social Determinants of
Health; U.S. Public Health Service
Further Reading
Byrd, W. M., & Clayton, L. A. (2000). An American health dilemma: A medical history of Afri-
can Americans and the problem of race: Beginnings to 1900. New York: Routledge.
Cornely, P. B. (1949). Nature and extent of health education among Negroes. Journal of Negro
Education, 18(3), 370–376.
Cornely, P. B. (1970a). Community participation and control: A possible answer to racism
in health. Milbank Memorial Fund Quarterly, 48(2), 347.
Cornely, P. B. (1970b). The Role of Public Health Associations. Canadian Journal of Public
Health/Revue Canadienne de Sante’e Publique, 61(6), 463.
Cornely, P. B. (1976). Racism: The ever-present hidden barrier to health in our society. Amer-
ican Journal of Public Health, 66, 246–247.
Cornely, P. B. (1985). Review: Crippling a nation: Health in apartheid South Africa by Aziza
Seedat. Journal of Public Health Policy, 6(3), 415–418.
Cornely, P. B. (2011). The health status of the Negro t oday and in the f uture. American Jour-
nal of Public Health, 101(Suppl. 1), S161–S163.
COUNCIL ON EDUCATION FOR PUBLIC HEALTH (CEPH)

The Council on Education for Public Health (CEPH) is an agency that reviews the
teaching, research, and service efforts of schools and programs in public health and
accredits t hose schools and programs that meet the documented standards. CEPH
reviews both the process (admissions, classes, and practical experiences) and the
outcomes (alumni satisfaction and job placement) of the education offered by each
school or program. Attaining CEPH accreditation is initially a three-year process
followed by regular reviews to ensure ongoing compliance to the accreditation cri-
teria. Although the criteria for reviewing programs and schools are slightly differ
ent, in general CEPH looks at w hether the curriculum teaches the core competencies
needed to become proficient in public health, recruits, retains, and supports quali-
fied faculty, has the fiscal resources to support the educational operations, and inte-
grates public health values into the academic experience. CEPH accreditation is a
mark of excellence and means that the school or program adequately prepares gradu
ates to work in the field. Accreditation is particularly important in professional
fields where p eople trust others with their lives.
Higher education is a major investment of time and finances. The U.S. Depart-
ment of Education (DOE) and the Council for Higher Education Accreditation
COUNCIL ON EDU C ATION F O R PU B LIC HEALTH ( C EPH) 151
(CHEA) approve regional organizations to review and accredit the more than
23,700 degree-granting higher education programs in the United States. Accredi-
tation is a sign that the education is a quality investment. The federal government,
some state governments, and many employers w ill only grant scholarships or
loans to students attending accredited colleges, universities, or institutions, and
some federal research grants are restricted to accredited institutions only. It is impor
tant to note that the regional accrediting organizations accredit all of the programs
in an institution and are not program specific. CEPH is the only agency recog-
nized by the Department of Education to accredit public health programs and
schools. This means that a program or school may have regional accreditation
without CEPH accreditation. CEPH reviews public health programs leading to
bachelor’s, master’s in public health (MPH), doctor of philosophy (PhD), or doctor
of public health (DrPH) degrees. Some public health fellowships, scholarships,
and job opportunities are limited to students attending CEPH-accredited schools
and programs.
Not everyone is a good fit with the field of public health, and it would be an
injustice to the individual and other students in the program to accept students
who are unable to be successful in a program. To ensure that the program or school
recruits and selects individuals who are capable of developing professional com-
petencies in public health, CEPH reviews recruitment materials, recruitment
policies, and admissions requirements. Each school provides data on number of
applicants, accepted students, enrolled students, and graduation rates. By review-
ing recruitment and admissions policies, CEPH provides a level of consumer protec-
tion. Students are assured that they are not attending a diploma mill, and the
institution follows best practices in selecting students who w ill benefit from the
educational experience and w ill be able to secure a job a fter graduation.
The CEPH-accredited bachelor’s degree in public health typically requires four
years of full-time study (120 credit units) and includes courses outside the major.
The CEPH-accredited MPH requires at least 42 credit hours, which is equivalent to
two and a half years of full-time study. (Full-time graduate study is nine credits per
semester.) Core curricula include biostatistics, environmental health sciences, epi-
demiology, health services administration, and social and behavioral health sciences
and the cross-cutting competencies of communication and informatics, diversity
and culture, leadership, public health biology, professionalism, program plan-
ning, and systems thinking. Public health programs provide a one-semester practi-
cum experience where the student plans and implements a public health activity.
The practicum experience is intended to bring concepts together and reinforce and
apply knowledge from individual courses.
Beyond the curriculum, CEPH ensures that programs and schools have systems
in place to support quality education. CEPH reviews the strength of academic advis-
ing and c areer counseling. Part of the accreditation process requires that schools or
programs survey past graduates to assess satisfaction with the education and sup-
port services. Institutions must also have an adequate number of professors to teach
152 C ULTUR AL COMPETENCE
in the programs, and the faculty must have the necessary expertise. The academic
system is unique in that faculty are partners in the governance of the university or
college rather than simply employees. Teaching faculty have a responsibility to pro-
vide quality teaching, engage in novel research, and provide service that will pro-
mote the good of the community. These activities allow faculty to maintain expertise
in their field, which ultimately supports student learning. By maintaining profes-
sional connections with government health authorities, public health clinics, hos-
pitals and local communities, academic institutions are able to offer practical and
relevant learning activities to students of public health.
CEPH accreditation is a sign that a school or program provides excellent preparation
for public health practice. By selecting a CEPH-accredited program or school, students
are assured a quality education by qualified professors. Successful completion of
the CEPH-accredited program or school ensures that the student is prepared to
function in the public health workforce.
Sally Kuykendall
See also: Certified in Public Health; Core Competencies in Public Health; Degrees
in Public Health
Further Reading
Council for Higher Education Accreditation. (2016). Retrieved from http://www.chea.org/.
Council on Education for Public Health. (2016). Retrieved from http://ceph.org/.
CULTURAL COMPETENCE
Culture influences lifestyle, attitudes toward health and wellness, health behaviors,
and perceptions of health care systems and providers. Differences in language, val-
ues, and habits between the patient and the provider can lead to misunderstandings
that impact quality of life and health outcomes. Public health professionals are
challenged to think beyond their own personal values and experiences in order to
work effectively with patients, family members, and other health care or social ser
vice providers. Cultural competence is the ability to understand and value another
culture and incorporate that culture’s beliefs, perceptions, and attitudes into prac-
tice. Experts define cultural competence as, “a set of congruent behaviors, attitudes,
and policies that come together in a system, agency or among professionals and
enable that system, agency, or t hose professionals to work effectively in cross-cultural
situations” (Cross et al., 1989). Since public health works with p eople and com-
munities of diverse cultures, professionals are responsible for developing and
maintaining cultural competence of the communities that they serve. Strategies to
achieve cultural competence include professional trainings, fostering a climate of
respect within the workplace, representation by members of the community, and
long-term commitment to cultural competence by the agency or system.
C ULTUR AL C O M PETEN C E 153
Culture is defined as a “structure of behaviors, ideas, attitudes, values, habits,

beliefs, customs, language, rituals, ceremonies, and practices of a particular group
of p eople that provides them with a general design for living and patterns for inter-
preting behavior” (Annie E. Casey Foundation, 2003). Many of the leading causes of
death in the United States, such as heart disease, stroke, cancer, and diabetes, are
related to lifestyle and culture. Differences in culture between patient and health care
provider can lead to harmful stereotypes, language barriers, or delays in dis-
ease detection, screening, and treatment compliance. The Office of Minority
Health (2016) reports numerous health disparities based on race and ethnicity.
African Americans have higher infant mortality, heart disease mortality, diabetes,
HIV/AIDS, and homicide in comparison to non-Hispanic whites. Latino Americans
have higher rates of tuberculosis, diabetes, obesity, hypertension, and low birth
weight infants. Asian and Pacific Islander Americans have higher rates of cervical
cancer, tuberculosis, and hepatitis. The connections between lifestyle, culture, and
health outcomes are important in that they allow public health professionals to tar-
get negative behaviors and improve health status.
At the individual level, cultural competence is displayed as the ability to reflect
on one’s own culture and the impact it has on o thers; the ability to value differences
and similarities among all p eople; the ability to respond effectively to cultural dif-
ferences; the ability to adapt services and service delivery to match community or
client needs; and the ability to sustain cultural competence within the institution
(Denboba, 1993). Cultural competence training is a tool that encourages health care
providers to examine their own cultural beliefs; to identify values, attitudes, and
assumptions that pose barriers to screening, diagnosis, or treatment of patients of
various cultures; and to practice framing effective messages. Dogra, Giordano, and
France (2007) note that cultural competency training is not as much about exper-
tise in a particular culture as it is about dealing with uncertainty. A list of dos and
don’ts may be an early step toward cultural competence. However, such a list will
not apply to e very person of that culture or every situation.
Organizational strategies to support cultural competence include providing for-
eign language or sign language interpreter services, recruiting and retaining staff
with shared customs, coordinating care with traditional healers, developing cultur-
ally competent health communication tools, and including the family or significant
community members in patient care (Brach & Fraser, 2000). Many large public
health departments employ professional medical interpreters to assist in patient-
provider communication. Medical interpreters adhere to a code of ethics that respects
patient confidentiality and ensures transparency, accuracy, and completeness (no
adding, omitting, or substituting) in translation. Interpreters use specific techniques
such as asking the patient and provider to speak directly to one another (using the
first person), positioning themselves equidistant from provider and patient yet out
of sight of both, and gathering feedback to ensure the correct message was received.
Whenever possible, public health clinics create and use language translations
of patient education forms, intake forms, consent forms, treatment instructions,
154 C UTTE R IN CIDENT, THE
discharge instructions, Patient Bill of Rights, privacy notices, and public ser
vice announcements. Some public health departments in large cities are pre-
pared to handle up to 500 different dialects! Another common technique is for
health centers to recruit and retain personnel from the same culture as the patient
population. However, it is important to note that common origin does not ensure
shared language, values, or beliefs. Differences may still exist due to social class,
religious practices, or education.
Cultural competence is an asset to the individual public health professional and
public health organizations. Through cultural competent care, health care providers,
patients, and members of the community can work together to reduce preventable
diseases and promote early diagnosis and treatment. Although there are many strate-
gies to achieve cultural competence, the primary foundation is willingness to respect
people’s similarities and differences and an earnest desire to help and support one
another.
Sally Kuykendall
See also: Code of Ethics; Core Competencies in Public Health; Health Care Dispari-
ties; Health Communication; Health Disparities; Indian Health Service; Social Eco-
logical Model
Further Reading
Annie E. Casey Foundation/AED Center on AIDS & Community Health. (2003). Cultural
Competency. 2003 Community Health Summit Toolkit. Author.
Brach, C., & Fraser, I. (2000). Can cultural competency reduce racial and ethnic health dis-
parities? A review and conceptual model. Medical Care Research and Review, 57(Suppl. 1),
181–217.
Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system
of care (Vol. 1). Washington, DC: Georgetown University Child Development Center,
CASSP Technical Assistance Center.
Denboba, D. (1993). MCHB/DSCSHCN Guidance for competitive applications, maternal and
child health improvement projects for children with special health care needs. U.S. Depart-
ment of Health and H uman Services, Health Services and Resources Administration.
Dogra, N., Giordano, J., & France, N. (2007). Cultural diversity teaching and issues of uncer-
tainty: The findings of a qualitative study. BMC Medical Education, 7.
Johnson, R. L., Saha, S., Arbelaez, J. J., Beach, M. C., & Cooper, L. A. (2004). Racial and
ethnic differences in patient perceptions of bias and cultural competence in health care.
Journal of General Internal Medicine, 19, 101–110.
Office of Minority Health. (2016). Minority population profiles. Retrieved from http://
minorityhealth.hhs.gov/omh/browse.aspx?lvl=2
&lvlid=2
6.
CUTTER INCIDENT, THE

Throughout the early half of the 20th century, mid-August to mid-September was
a time of fear and dread. It was poliomyelitis season, a time when the highly
infectious virus emerged, unabated and reaping havoc in communities. The deadly
C UTTE R INC IDENT, THE 155
virus attacked the nervous system causing motor paralysis within hours. C hildren
would complain of headache, nausea, or fatigue at bedtime and wake up para
lyzed. Five to ten percent of polio victims died due to respiratory paralysis (WHO,
2016). Survivors were doomed to life in an iron lung. In 1953, the year prior to
Salk’s large-scale polio vaccine trials, polio attacked 35,592 people in the United
States, resulting in 1,450 deaths and 15,648 cases of permanent paralysis (Freyche &
Payne, 1956). Young children of m iddle to high socioeconomic status families
were the most susceptible because they were the least likely to have been exposed
to the milder strains of polio earlier in life. When Salk’s vaccine was pronounced
“safe, effective, and potent,” church bells rang and air raid sirens shrieked. How-
ever, the joy was short-lived. Within a few weeks of the start of the nation’s mass
immunization campaign, six children immunized with vaccine from Cutter Labora-
tories were paralyzed. The event created confusion, fear, and distrust and exposed
weaknesses in the overly enthusiastic research and government program. Although
Cutter’s vaccines met government safety standards, the company was found liable
without fault. Since vaccines w ere sold to public health agencies and provided very
low profit margins, pharmaceutical companies responded by shying away from
the development and manufacture of vaccines. To encourage vaccine manufac-
ture, the federal government created the National Vaccine Injury Compensation
Program. The program compensates people who become ill or injured as a result
of vaccination and ensures that infectious diseases, such as polio, are kept under
control.
The factors that created the Cutter Incident started long before Cutter manufac-
tured their first batch of polio vaccine. Preventing poliomyelitis was a global prior-
ity. The National Foundation for Infantile Paralysis, founded by President Franklin D.
Roosevelt, funded multiple vaccine development studies. Albert Sabin’s polio vac-
cine contained attenuated forms of all three polio serotypes while Jonas Salk used
the deactivated Type 1 (Mahoney) poliovirus. The Mahoney serotype is the most
deadly of the poliovirus strains. Salk’s logic was that the deadliest strain would pro-
duce more antibodies than the less virulent serotypes. Salk’s vaccine was success-
fully field tested on 1.8 million schoolchildren and adults. On April 12, 1955,
Dr. Thomas Francis, Jr., director of the Poliomyelitis Vaccine Evaluation Center at
the University of Michigan School of Public Health, announced to nearly 200 jour-
nalists and 500 scientists that Salk’s vaccine was 60 to 90 percent effective. In prep-
aration for a nationwide mass immunization campaign, five phar ma ceu
ti
cal
companies were licensed to manufacture the vaccine. All of the companies had dif-
ficulty inactivating the Mahoney strain.
In mid-April, approximately 400,000 p eople, mostly children, w
ere inoculated
with vaccine manufactured by Cutter Laboratories of Berkeley, California. Cutter
was a small, family-owned business who had manufactured vaccines for anthrax
and swine fever. On April 24, the first victim was admitted to Michael Reese Hos-
pital in Chicago with paralysis of both legs. The infant had been immunized with
the Cutter vaccine on April 16. By April 27, five additional cases were reported,
and Surgeon General Dr. Leonard A. Scheele directed Cutter Laboratories to recall
156 C UTTE R IN CIDENT, THE
all of their vaccines. A committee of polio experts was established to investigate

and determine if the cases were caused by community exposure or the vaccine. As
more cases were reported, the answer became clear. Batches of the Cutter vaccine
as well as batches from some of the other laboratories contained live polio virus.
Yet, Cutter’s product had passed the government safety tests. The disaster revealed
serious deficits in manufacturing and safety testing. On May 5, the surgeon general
ordered a complete halt to the polio immunization program. Governments throughout
the world also put their immunization programs on hold. On May 27, the committee
announced new safety standards. The time period for deactivation of the live virus
was extended. Larger samples w ere used for testing of live virus. Batches w
ere tested
multiple times u ntil at least two successive negative tests w ere achieved, and batches
were tested an additional time a fter bottling to ensure against cross-contamination
within the factory. The government resumed the polio vaccination program in the
fall of 1955.
In 1957, the family of five-year-old Anne Gottsdanker sued Cutter Laboratories
for negligence and breach of implied warranty. The live virus administered by vac-
cine tended to attack the extremity where the person received the injection. Anne
suffered permanent paralysis of her right leg. The court found Cutter Laboratories
not guilty of negligence. The company had followed government safety precautions.
However, they w ere guilty of breach of implied warranty because the vaccine was
labeled “inactivated” virus when, in fact, it contained live virus. The legal prece
dent of liability without fault was a threat to public health. Pharmaceutical compa-
nies were reluctant to manufacture vaccines. Companies shied away from
manufacturing vaccines, prices skyrocketed, and vaccine shortages resulted. In
1986, the federal government created the National Vaccine Injury Compensation
Program to ensure that p eople who suffer from illness or injury due to a vaccina-
tion are compensated quickly and fairly and that pharmaceutical companies man-
ufacturing products intended to benefit public health are not penalized for their
efforts.
The Cutter vaccinations are estimated to have caused 40,000 cases of polio,
including 200 cases of paralysis and 10 deaths (Fitzpatrick, 2006). Vaccine-induced
cases of polio created an epidemic exposing family and community members to
the virus, and the pause in the national immunization campaign left children vul-
nerable to the polio epidemic of 1955. Furthermore, the incident damaged the rep-
utation of American vaccine manufacturers. Today, the government carefully
monitors vaccine manufacturers to ensure public safety and vaccine efficacy. As a
result, diseases such as polio, diphtheria, and smallpox are no longer the public
threat they once w ere.
Sally Kuykendall
See also: Infectious Diseases; Polio; Roosevelt, Franklin Delano; Salk, Jonas; Vac-
cines; Controversies in Public Health: Controversy 3
C UTTE R INC IDENT, THE 157
Further Reading
Fitzpatrick, M. (2006). The Cutter Incident: How America’s first polio vaccine led to a grow-
ing vaccine crisis. Journal of the Royal Society of Medicine, 99(3), 156.
Freyche, M. J., & Payne, A. M. (1956). Poliomyelitis in 1954. Bulletin of the World Health
Organization, 15(1–2), 43–121.
Nathanson, N., & Langmuir, A. D. (1963). The Cutter Incident. Poliomyelitis following
formaldehyde-inactivated poliovirus vaccination in the United States during the spring
of 1955. II. Relationship of poliomyelitis to Cutter vaccine. American Journal of Hygiene,
78, 29–60.
Offit, P. A. (2005). The Cutter Incident: How America’s first polio vaccine led to the growing vac-
cine crisis. New Haven, CT: Yale University Press.
Oshinsky, D. (2006). Polio: An American story. New York: Oxford University Press.
World Health Organization (WHO). (2016). Poliomyelitis. Retrieved from http://www.who
.int/topics/poliomyelitis/en/.
D
DEAN, HENRY TRENDLEY (1893–1962)
Henry Trendley Dean was a dentist who discovered fluoridation and improved oral
health for millions of people. “Bud” Dean was born in Winstanley Park, Illinois,
and grew up in St. Louis. After graduating from St. Louis School of Dentistry in
1916, he established his own dental practice. Dentistry was still developing as a
medical profession. The toothbrush had not been invented (variations existed, but
the first modern, nylon toothbrush came along in 1938). Almost everyone had cavi-
ties. Dentists assessed a patient’s oral health by counting the number of decayed,
missing, or filled teeth (DMFT). The lower the DMFT count, the better the oral
health.
After a year in private practice, Dean joined the army. The army needed dentists
to keep soldiers healthy and on the front lines. Missing or loose teeth meant that a
soldier could not chew food properly, which could lead to malnutrition, fatigue,
and decreased ability to fight infectious diseases. The soldier who succumbs to infec-
tion could pass the disease to other soldiers, disabling an entire military unit. Front
teeth are particularly important for pronouncing words with the sounds f, th, and
v. The inability to communicate clearly during military operations could jeopar-
dize lives. During the draft for World War I, 24 out of 1,000 men w ere rejected
because they did not have at least six opposing teeth—the minimum number of
teeth considered necessary to chew food (Britten & Perrott, 1941). Soldiers’ oral
health was further aggravated by a condition known as trench mouth. Trench mouth
or acute necrotizing ulcerative gingivitis (ANUG) is an infection of the mouth that
causes ulcers and gum deterioration and can result in tooth loss. ANUG is caused
by poor oral hygiene (not being able to regularly brush one’s teeth), smoking, stress,
and malnutrition. As a military dentist, Dean developed a program of oral hygiene
for soldiers in the trenches. The program was used throughout World War II. A fter
World War I, Dean returned to private practice and married Ruth Martha McEvoy.
However, he did not stay in private practice for very long. By 1921, he joined the
U.S. Public Health Service as acting assistant dental surgeon.
Even before Dean considered g oing to dental school, another dentist in Colo-
rado was laying the foundation for one of the greatest achievements in public health
history. In 1901, Dr. Frederick S. McKay graduated from dental school at Univer-
sity of Pennsylvania and moved west. Establishing a private dental practice in Col-
orado Springs, McKay was surprised to see that most of his patients had strangely
colored teeth, the color of brown chocolate. McKay called the abnormality Colo-
rado brown stain. He tried to convince other local dentists to study the problem but
160 DEAN , HEN RY TRENDLEY
none were concerned. So, he developed his own field study, tracing the affected
area to Pikes Peak watershed. In 1909, McKay presented his findings to other pro-
fessionals at a dental conference. His presentation aroused the curiosity of Dr. Green
Vardiman Black, the preeminent dental expert of the time. McKay and Black joined
together to study the problem that Black renamed mottled enamel. Although Black
died in 1915, their findings were not published until 1916. Mottled enamel seemed
to be more severe among children who had recently developed their second set of
teeth and appeared highly resistant to cavities. The idea that pitted enamel was less
resistant to cavities was completely contrary to logic and expert opinion. Most den-
tists assumed that pitted enamel would increase risk of cavities. However, McKay
and Black’s findings w ere quickly validated by other dentists working in areas with
mottled enamel. In 1923, McKay was invited to Oakley, Idaho, to investigate cases
of mottled enamel. McKay suspected the local w ater source. However, when he
tested the water, he found nothing unusual. He encouraged Oakley residents to use
another w ater source, and within a few years c hildren started having white teeth.
In 1926, Dr. F. L. Robertson, a dentist practicing in Benton, Arkansas, asked pub-
lic health officials to investigate cases of mottled enamel in the nearby town of
Bauxite. Bauxite was a corporate town of the Aluminum Company of America
(ALCOA). When the public health service did not respond, the superintendent of
the mining company contacted McKay. McKay and Grover Kempf of the Bureau of
Child Hygiene investigated the problem and found 100 percent of c hildren afflicted
with mottled teeth. ALCOA’s chief chemist Harry Van Osdall Churchill was con-
cerned that ALCOA would be blamed for the problem and started his own inves-
tigation. ALCOA laboratory attained and tested a sample of Bauxite’s water supply
using more sophisticated technology than McKay had access to. Analysis revealed
high levels of fluoride. Churchill contacted McKay, offering to test samples from
other affected towns. W ater from areas where mottled enamel was endemic all tested
high for fluoride.
Pressured by McKay, Robertson, and others, the National Institute of Health (NIH)
hired Dean to investigate mottled enamel in 1931. Dean approached the problem
in the same way that he had addressed trench mouth, as an infectious disease. He
searched medical reports from around the world, later recalling, “Many times, find-
ings, long buried in the literature and apparently unrelated to oral disease w ere
found on close study to be of unrealized value” (Dean, 1953, p. 705). He found
clues from dentists in Japan, Argentina, and E ngland. Based on the literature, Dean
devised an epidemiological study. He identified areas where mottled teeth occurred
and gathered a team of chemists, dentists, biologists, and engineers. The research
team analyzed w ater samples for hardness and fluoride. Dentists performed hun-
dreds of oral examinations, inspecting and reporting on the teeth of c hildren. Results
confirmed what McKay and o thers had observed. Children with mottled enamel
had fewer cavities. In Bruneau, Idaho, 33 percent of c hildren with mottled teeth
had cavities compared to 64 percent of c hildren with normal teeth (Dean, 1938).
DEAN , HEN RY T R ENDLEY 161
At Pima Indian School, 58 percent of children with mottled enamel had cavities
compared to 81 percent with normal teeth. Overall, children with mottled teeth
were five times more likely to be cavity-free than c hildren with normal teeth.
Dean had an idea. If fluoride made teeth resistant to cavities, then adding small
amounts of fluoride to local w ater supplies should reduce cavities. He renamed mot-
tled enamel fluorosis and set a new goal of identifying therapeutic levels of fluorine,
levels that protect against cavities yet do not cause fluorosis. In order to proceed,
dentists needed a more refined way to measure oral health than the crude DMFT
scale. Dean developed the Fluorosis Index. The Fluorosis Index measures the sever-
ity of tooth discoloration and pitting. Comparing degree of fluorosis with fluoride
levels in the local w ater supply, the researchers identified the therapeutic level of
1 ppm (part per million) of fluoride. The next step was to pilot test water fluorida-
tion as a public health program. In 1945, Grand Rapids, Michigan, fluoridated their
public w ater supply. Over the next 15 years, public health dentists and researchers
monitored the teeth of approximately 30,000 c hildren. The pilot was a success. Car-
ies rates in Grand Rapids dropped by 60 percent after w ater fluoridation, and there
were no adverse effects (Dean, 1953).
Dean modeled public health in practice. He recognized and respected the reports
and observations from clinicians, developed an epidemiological study, drew con-
clusions from the study findings and translated the research findings into public
health practice. In 1945, Dean became director of dental research at the NIH and
from 1948 to 1953, he served as director of National Institute of Dental Research
where he worked to bring water fluoridation to towns and communities across the
country. He also integrated other aspects of dental care into his work, advocating
for diets low in starch and sugar. In 1952, the American Public Health Association
recognized McKay and Dean for their pioneering studies and contributions to dis-
ease control with the prestigious Lasker Award. By 1953, fluoridation was being
used in 427 communities, benefiting 8.5 million people (Dean, 1953). Henry Trend-
ley Dean died in 1962 from emphysema complicated by asthma.
Dean’s intuition, logic, perseverance, and never-ending quest for ways to improve
public health embody the spirit of translational research. Dean saw a problem, lis-
tened to others, examined the facts, and made connections. Although dental car-
ies, gingivitis, and tooth loss still exist today, they are not the scourge that they once
were. Therapeutic fluoride in water, toothpaste, mouthwash, and dental practices
allow many people to enjoy healthy teeth, nutritious meals, and bright smiles. Dean’s
efforts in developing w ater fluoridation are recognized as one of the greatest public
health advancements of the 20th century.
Sally Kuykendall
See also: Epidemic; Epidemiology; Fluoridation; Oral Health; Population Health;

Research; Veterans’ Health
162 DEG R EES IN PU BLIC HEALTH
Further Reading
Britten, R. H., & Perrott, G. St. J. (1941). Summary of physical findings on men drafted in
the world war. Public Health Reports (1896–1970), 56(2), 41.
Centers for Disease Control and Prevention. (1999). Achievements in public health, 1900–
1999: Fluoridation of drinking w ater to prevent dental caries. Morbidity and Mortality
Weekly Report, 48(41), 933–940. Retrieved from https://www.cdc.gov/mmwr/preview
/mmwrhtml/mm4841a1.htm.
Centers for Disease Control and Prevention. (1999). H. Trendley Dean, D.D.S. Morbidity
and Mortality Weekly Report, 48(41), 935. Retrieved from https://www.cdc.gov/mmwr
/preview/mmwrhtml/mm4841bx.htm.
Dean, H. T. (1938). Endemic fluorosis and its relation to dental caries. Public Health Reports,
53(33), 1443–1452.
Dean, H. T. (1953). Some reflections on the epidemiology of fluorine and dental health.
American Journal of Public Health, 43, 704–709.
Dean, H. T., & McKay, F. S. (1939). Production of mottled enamel halted by a change in
common w ater supply. American Journal of Public Health, 29, 590–596.
Mottled teeth. (1940). Time, 35, 40.
National Institute of Dental and Craniofacial Research. (2014). The story of fluoridation.
Retrieved from https://www.nidcr.nih.gov/OralHealth/Topics/Fluoride/TheStoryof
Fluoridation.htm.
DEGREES IN PUBLIC HEALTH

Preparation for a c areer in public health is achieved through a variety of under-
graduate and graduate degree programs in public health, health administration,
health policy, or health services. Different jobs require different academic prepara-
tion, and while it is helpful to know which area of public health one wishes to pursue,
not knowing is not a major disadvantage. Public health professionals come from a
wide variety of backgrounds, and an undergraduate degree in public health is not
necessary for graduate study. An undergraduate degree in math can be used to craft
expertise in biostatistics or epidemiology. A foundational degree in sociology, psy
chology, or anthropology is helpful in behavioral health or community health practice.
Communications majors may pursue c areers in health communications. Business
majors can apply their skills in health administration. Political science majors
can find fulfilling positions in health policy. Biology, chemistry, physics, and engi-
neering majors can use their analytical skills in public health research. Under-
graduate preparation in a field other than public health strengthens public health
practice by drawing on the knowledge and skills of other disciplines.
The Council on Education for Public Health (CEPH) is an independent agency
approved by the U.S. Department of Education to review and accredit schools and
programs in public health. CEPH reviews public health programs to determine
whether the training meets standards of quality. Accreditation is a rigorous process.
Programs are assessed on ability to teach students the core competencies of public
health as well as any relevant specialty areas, integration of experiential learning into
DEG R EES IN PU B LIC HEALTH 163
the program, engagement of students in learning and community service, support

for qualified faculty who are recognized experts in the field, and successes of stu-
dents after graduation. CEPH accreditation demonstrates that the school or pro-
gram has met and continues to meet high standards in teaching, research, and
service. The Association of Schools and Programs of Public Health (ASPPH) is the
primary organization representing accredited public health schools and programs.
ASPPH advances the field of public health by educating the general public on the
role of public health, by helping students interested in public health navigate com-
plex academic systems, promoting evidence-based practices, and advocating for
public policies that strengthen public health education and research.
Many different types of programs and degrees can lead to c areers in public health.
A minimum of a bachelor’s degree is required for entry level positions in occupa-
tional or industrial hygiene, health and safety inspection, environmental health,
community health, and health administration. Undergraduate degrees are four-year
degrees in public health earning the bachelor of science (BS), bachelor of arts (BA),
or bachelor of science in public health (BSPH). Graduate degrees tend to be more
common, as these allow the student to develop an area of specialization. Some of
the many public health specialties are behavioral health, biostatistics, chronic ill-
nesses, community health, dental health, environmental health, epidemiology, food
safety, genetics, global health, health administration, economics, health education,
policy, research, infectious diseases, health information management, maternal and
child health, nutrition, occupational health, population health, emergency prepared-
ness and response, tropical medicine, veterinary medicine, and w omen’s health
(ASPPH, 2016). The master of public health (MPH), master of health administra-
tion (MHA), master of science (MS), and master of health sciences (MHS) require
two-year, full-time study, leading to job opportunities in hospitals, health depart-
ments, international, state and federal agencies, community organizations, and
managed care organizations. The MPH degree is a highly desirable degree. Many esta
blished doctors, nurses, dentists, pharmacists, statisticians, and environmental sci-
entists go back to school to earn their MPH degree. Early career students are
encouraged to consider dual degree programs, obtaining the MPH degree simulta
neously with a clinical or other degree. Common dual degree programs are medicine
(MD/MPH), law ( JD/MPH), nursing (MSN/MPH), business (MBA/MPH), phar-
macy (PharmD/MPH), physical therapy (DPT/MPH), and social work (MSW/
MPH). Doctoral degrees in public health are advanced graduate degrees, requiring
a doctoral dissertation to prepare for positions in research, teaching, or leadership.
Doctoral degrees include the doctor of philosophy (PhD), doctor of science (ScD),
and doctor of public health (DrPH). The Delta Omega Honorary Society in Public
Health is the national honor society recognizing excellence by students and faculty
in the field of public health.
The field of public health is increasing rapidly. As the population ages and new
specialties in health and medicine emerge, more qualified professionals w ill be
164 DIA BETES M ELLITUS
needed to meet the growing demands. The many different pathways allow the indi-
vidual to craft a unique niche providing important contributions to the field.
Sally Kuykendall
See also: Administration, Health; Core Competencies in Public Health; Council on

Education for Public Health
Further Reading
Association of Schools and Programs of Public Health (ASPPH). (2016). Retrieved from
http://www.aspph.org/.
Careers in public health.net. (2016). Retrieved from http://www.careersinpublichealth.net/.
Council on Education for Public Health. (2016). Retrieved from http://ceph.org/.
Delta Omega Honorary Society in Public Health. (2016). Retrieved from http://www.delta
omega.org/index.cfm.
Public health degrees.org. (2016). Retrieved from http://www.publichealthdegrees.org/.
DIABETES MELLITUS
Diabetes mellitus is a chronic disease where the body is either unable to produce
or to properly manage insulin, the hormone that converts glucose (sugar) from food
and drink into energy. The inability to use glucose results in high levels of sugar
circulating in the bloodstream, which interferes with functions. The body is forced
to divert protein from critical organ functions for use as energy. Approximately
29 million Americans are diabetic and 86 million are prediabetic, at risk for devel-
oping diabetes within the next 10 years. In many cases, diabetes comes on slowly
and the person is not aware of the problem. An estimated 25 percent of diabetics
and 90 percent of prediabetics are undiagnosed. Late diagnosis and treatment can
lead to many health issues, such as amputations of the toes, feet and legs, heart
disease, stroke, kidney failure, and blindness. Diabetes causes over 76,000 deaths
per year and is the seventh leading cause of death in the United States. Despite
advances in diabetes prevention and treatment, diabetes is likely to increase as
obesity increases and young children of minority ethnicities may end up carrying
much of the burden of disease. Public health efforts to reduce diabetes focus on
four disease transition points: (1) primary prevention, (2) medical screening for
early diagnosis, (3) better access to care, and (4) improved quality of care for
people living with diabetes. Twenty Healthy People 2020 objectives deal specifi-
cally with diabetes and diabetes-related care, an indication of how important this
problem is in moving the nation toward health and wellness.
When we eat fruits, vegetables, nuts, seeds, dairy products, rice, pasta, or sweets,
carbohydrates in t hese foods are converted into glucose (sugar). Glucose is a g reat
source of energy b ecause it can be easily utilized by the body. Insulin helps glucose
to enter the cell thereby providing energy for cell structure, function, and main-
tenance. Diabetics either do not make enough insulin (Type 1) or c an’t use the insulin
DIA B ETES M ELLITUS 165
that is produced (Type 2). If the cells cannot take in glucose, sugar stays in the blood-
stream. High blood sugar levels pull fluid out of the cell through osmosis, upsetting
fluid-electrolyte and acid-base balances. The kidneys w ill eventually spill some of
the excess sugar. However, the person w ill suffer health consequences b ecause of
high blood sugar, depletion of protein, and electrolyte imbalances. Characteristic
symptoms are frequent urination, polydipsia (excessive thirst), hunger, weight
loss, fatigue, numbness, or tingling of the hands or feet, changes in vision, dry
skin, and sores that take longer to heal than expected. The symptoms may be
subtle at first as the body tries to compensate for the malfunction. By the time the
person seeks medical advice, irreversible organ damage may occur.
Primary prevention is the technique of stopping a health problem before it occurs.
There are currently no known causes of Type 1 diabetes. Therefore, no programs
or mechanisms exist to prevent Type 1 diabetes. Type 2 diabetes accounts for 90 to
95 percent of cases of diabetes and is highly preventable. Risk factors are overweight
and obesity, physical inactivity, family history, age (45 years and older), and history
of gestational diabetes (diabetes while pregnant). African Americans, Hispanic/Latino
Americans, Native Americans, Pacific Islanders, and Asian Americans are at higher
risk in comparison to Caucasian Americans. The American Diabetes Association
provides a risk test (available at http://www.diabetes.org/are-you-at-risk/diabetes
-risk-test/). In 2016, the Centers for Disease Control and Prevention (CDC), Amer-
ican Diabetes Association, American Medical Association, and the Ad Council part-
nered to develop the first national prediabetes awareness campaign. Public service
announcements encourage p eople to check out their risk for prediabetes at DoI-
HavePrediabetes.org. Knowing one’s risk helps people to make educated decisions
about their health rather than waiting for warning signs to occur.
For anyone, and especially people who are at risk for diabetes, engaging in at
least 30 minutes of physical activity most days of the week (60 minutes for c hildren)
and maintaining a healthy weight are ideal ways to prevent onset. Reducing the
amount of fat and calories in the diet helps to maintain a healthy weight. Diet and
exercise can help p eople with prediabetes to halve their risk of developing the dis-
ease, and the benefits are multifold in that these lifestyle changes will also reduce
risk of cardiovascular disease, high blood pressure, stroke, some forms of cancer,
and many other obesity-related diseases. The National Diabetes Prevention Program
(DPP) is a national partnership of evidence-based programs with the goal of reduc-
ing diabetes and prediabetes. In order to be designated as a National DPP, the pro-
gram must use an approved curriculum, offer a minimum of 16 sessions over the
first six months taught by trained lifestyle coaches, offer access to a diabetes pre-
vention coordinator, and monitor program effectiveness through participant weight
loss and physical activity levels. National DPPs are located within communities
throughout the country. The CDC offers a searchable database of available programs
(https://www.cdc.gov/diabetes/prevention/index.html).
Screening and early diagnosis are critical to ensure effective disease maintenance.
Uncontrolled diabetes can lead to serious health complications of heart disease,
166 DIA BETES M ELLITUS
blindness, kidney failure, neuropathy, susceptibility to infections, atherosclerosis,

and lower extremity amputations. Diabetes is diagnosed through several different
laboratory tests. The blood test A1C measures average blood glucose over the
past two to three months. Normal range is less than 5.7 percent. An A1C of 5.7
to 6.4 percent on two separate occasions indicates prediabetes, and an A1C of
6.5 percent or higher on two separate occasions indicates diabetes. Healthy People
2020 objective D-1 is to reduce the rate of new cases of diabetes from 8 per 1,000
people (2006–2008) to 7.2 per 1,000 p eople. The United States is making good
progress toward this goal. In 2012–2014, incidence rates decreased to 6.7 per 1,000.
Rates among p eople on public insurance decreased from 17.2 per 1,000 to 11.5
per 1,000. Further efforts are needed for populations with high incidence rates,
people with less than a high school diploma (incidence rate = 12.9/1,000), living at
100 percent below the poverty line (incidence rate = 12.3/1,000), and living with
disabilities (incidence rate = 23/1,000). The Prevent Diabetes STAT Screen/Test/Act
Today Program is a partnership between the American Medical Association and the
CDC, which supports physicians, health care providers, and patients with resources
for best practices guidelines in screening and referral.
Access to health services is important to provide early and effective control of dia-
betes and to prevent complications. In 2010, 1 out of e very 5 Americans did not have
medical insurance and 1 out of 10 people did not have access to medical care, dental
care, or prescription medicines (Office of Disease Prevention and Health Promotion,
n.d.). Access to services means that people with prediabetes or diabetes are able to get
to a location where health services are offered, obtain services from that health system,
and meet with a qualified provider for treatment, care, and health education. The
Patient Protection and Affordable Care Act was enacted to close the gap between
insured and uninsured by providing health insurance coverage to all Americans.
The goal of diabetes treatment and management is to maintain normal blood glucose
levels while avoiding hyperglycemia and hypoglycemia. Successful management
requires changing lifetime habits of diet and exercise, calculating calories, moni-
toring blood sugar, insulin, or medi cation, and prevention of complications
through good skin care and careful selection of footwear. Infections, stress, men-
struation, alcohol, and eating disorders can all interfere with successful manage-
ment. Because blood sugar varies so much throughout the day, managing the disease
is a constant process. Primary responsibility falls on the individual and his or her
family. This means the patient and their loved ones must have the knowledge and
skills to adequately manage the disease and be able to work with various health
care providers to coordinate care. Teaching p eople to manage their disease takes
time. However, the rewards are great. Currently, an estimated 20 percent of all health
care spending is related to diabetes. Empowering people with diabetes can reduce
health care costs and decrease the number of p eople with lower extremity amputa-
tions, kidney failure, and blindness.
The CDC partners with local, state, and territorial health departments to track
trends in diabetes in order to provide evidence-based prevention, offer effective
DI F F USION O F INNO VATIONS THEORY 167
treatments, and support improved quality of care. Because Type 2 diabetes overlaps
with many other chronic diseases, efforts to reduce diabetes fall within the purview
of the National Center for Chronic Disease Prevention and Health Promotion
(NCCDPHP). The NCCDPHP oversees efforts to prevent or delay diabetes onset
through surveillance, environmental approaches, system interventions, and
community-based programs. Researchers are studying triggers for Type 1 diabetes
and are actively searching for new ways to prevent and treat both types of diabetes.
Techniques, such as pancreas and islet cell transplantations, offer promise for future
generations.
An estimated one in three individuals is living with prediabetes, and the major-
ity of these individuals do not know that they are at risk for this life-changing dis-
ease. Preventing diabetes is critical to reducing health care costs and improving
quality and length of life for many Americans. Diabetes prevention can be achieved
through increased public awareness of the disease, awareness of one’s own indi-
vidual risk level, lifestyle changes, and effective, coordinated efforts in self-
management and clinical management.
Sally Kuykendall
See also: Body Mass Index; Chronic Illness; Disability; Health Disparities; Healthy
Places; Heart Disease; Heart Truth® (Red Dress) Campaign, The; Hypertension;
Men’s Health; National Heart, Lung, and Blood Institute; Nutrition; Obesity; Physi-
cal Activity; Prevention
Further Reading
American Diabetes Association. (2017). Retrieved from http://www.diabetes.org/.
Centers for Disease Control and Prevention. (2016). National Diabetes Prevention Program.
U.S. Department of Health and H uman Services. Retrieved from https://www.cdc.gov
/diabetes/prevention/index.html.
Office of Disease Prevention and Health Promotion. (n.d.). Healthy People 2020: Access to
health services. Retrieved from https://www.healthypeople.gov/2020/data-search/Search
-the-Data#topic-area=3495.
Office of Disease Prevention and Health Promotion. (n.d.). Healthy People 2020: Diabetes.
Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes.
Prevent Diabetes STAT. (2017). Retrieved from http://www.ama-assn.org/sub/prevent
-diabetes-stat/index.html.
DIFFUSION OF INNOVATIONS THEORY

Diffusion of innovations theory describes how consumers accept and embrace new
technology, information, or lifestyle practices. The theory applies to public health
because it explains why and how people adopt health advancements in the form of
products, attitudes, or behaviors. According to the theory, people respond to a new
product or innovation in five progressive stages: initial exposure, piqued interest,
168 DIFFUSION OF INNOVATIONS THEORY
decision to try, pilot usage, and final adoption (Kaminski, 2011). The stages pro
gress at different rates. The initial stages depend on where and how people get infor-
mation and the value that they subscribe to that source. The decision to use stage
is based on the individual’s willingness to take risks and navigate unfamiliar sys-
tems. P eople are more likely to embrace innovations that are easy to use, easy to
undo (if the product fails), and seem superior to current alternative options. Rate
of adoption within a population is represented as e ither a bell-shaped or S-shaped
curve. As more people use the product or innovation, the curve rises. Diffusion of
innovations theory helps public health practitioners to understand why and how
people adopt new behaviors and the best ways to market novel health-enhancing
technology or practices.
French criminologist and social psychologist Jean-Gabriel De Tarde (1843–1904)
was the first person to propose that beliefs and actions are passed from person to
person and replicated within a community. As magistrate in Dordogne, France, Tarde
estimated that 99 percent of the defendants appearing in his courtroom w ere sim-
ply imitating other criminals. Although the defendants might add a few personal
adaptations to their crime, only about 1 defendant out of 100 had an original idea.
Tarde’s theory was revisited in 1943 when two Iowa sociologists studied farmers’
adoption and use of a new hybrid seed corn (Ryan & Gross, 1943). The new hybrid
seed yielded larger crops and was more drought resistant. Yet, the researchers found
a five-year gap between when the farmers first learned of the new seed and they
actually started using the seed. Although salesmen were important in introducing
the new product, word of mouth between the farmers and visible proof w ere more
important. The researchers mapped adoption of the hybrid seed and found that
the majority of farmers did not start using the corn u ntil they saw other farmers
successfully using the product. The son of one of t hose Iowa farmers was five-year-
old Everett “Ev” M. Rogers (Singhal, 2005). Although Ev’s father loved new farm
machines, he was reluctant to tinker with biology. In 1936, Mr. Rogers’s corn field
suffered from a terrible drought while the drought-resistant hybrid corn in a neigh-
boring field stood tall. Mr. Rogers started using the hybrid corn seed and Everett
Rogers grew up, went to college, and became the world’s leading expert on diffu-
sion of innovations!
Rogers (2003) divided adopters into five categories: innovators, early adopters,
early majority, late majority, and laggards. Innovators account for approximately
2.5 percent of the overall population. As the first group to try a new product or
idea, these are the p eople standing in line overnight when the latest technology is
due to be released for sale. Innovators get their information from multiple sources.
They know about new technology before it comes on the market. Innovators have
disposable income that allows them to take risks. The next group, early adopters,
account for 13.5 percent of the population. Early adopters tend to be popular social
leaders. They also have disposable income that allows for risks. However, they are
slightly more cautious than innovators b ecause they want to maintain credibility
and social prestige. Early majority adopters compose 34 percent of the population.
DI F F USION O F INNO VATIONS THEORY 169
This group makes careful, deliberate decisions but only a fter consulting with their
wide social network. On the downward slope of the curve are the late majority
adopters. Composing another 34 percent of the population, late majority adopters
value traditional methods or technology. They tend to be skeptical of new products
and believe they have less disposable income. Everett Rogers’s father would be a
late majority adopter with respect to the hybrid corn. The last group, laggards, make
up the remaining 16 percent of the population. Laggards get the majority of their
information from neighbors and friends, have no desire to influence others to try a
new product, and believe that they have less disposable income. Not every idea or
product reaches full dissemination. In some cases, failed diffusion occurs. Inherent
weaknesses in the product, competition with alternative products, or lack of aware-
ness of the new technology or idea can prevent the innovation from reaching criti-
cal mass saturation.
Diffusion of innovations theory is helpful to understand how and why p eople
embrace medical breakthroughs, such as robotic limbs, new vaccines, gene ther-
apy, wearable health sensors, or disease screening tests. Public health practitioners
can use the model to help reduce reluctance to novel health-enhancing behaviors.
For example, more public health groups are using social media to encourage evac-
uation during hurricanes, healthy eating, exercise, or screening for breast cancer.
On the other end of the spectrum, the theory also shows how social networking
and marketing can influence unhealthy choices. Human beings are social creatures
who may forgo values or adopt outrageous behaviors in order to feel accepted by
others. This means that social networking is an easy venue for unscrupulous mar-
keters. For example, in 1969, the tobacco companies intentionally misled people
into disbelieving that smoking is harmful to health. The industry purposely dis-
seminated misinformation in order to sell cigarettes. Cases such as this highlight
the lack of control on marketing and how easy it is to plant misinformation. Public
health organizations and professionals must remain vigilant for new products, ideas,
and trends designed to mislead p eople into buying and using harmful products. In
an effort to stay ahead of trends and educate p eople, the Centers for Disease Con-
trol and Prevention, Substance Abuse and M ental Health Services Administration,
National Institute on Drug Abuse, National Cancer Institute, and many nonprofit
organizations offer free online fact sheets to provide accurate information and dis-
pel myths, hoaxes, and marketing shams.
Diffusion of innovations theory is a framework used to describe how p eople adopt
novel technology and ideas. The model applies to a wide range of circumstances
and can be used by public health practitioners to disseminate health-enhancing ideas
and products. A limitation of the model is that not all ideas and products are wor-
thy of adoption. Public health practitioners must work to dispel misinformation
and encourage products, practices, and beliefs that improve quality and length of
life for all p
eople.
Sally Kuykendall
170 DISA B ILITY
See also: Epidemic; Epidemiology; Fluoridation; Health Communication; Health

Education; Oral Health
Further Reading
Glanz, K., Lewis, F. M., & Rimer, B. K. (Eds). (1997). Health behavior and health education:
Theory, research, and practice (2nd ed.). San Francisco: Jossey-Bass.
Kaminski, J. (2011). Diffusion of innovation theory. Canadian Journal of Nursing Informatics,
6(2). Theory in nursing informatics column. Retrieved from http://cjni.net/journal/?p
=1444.
National Cancer Institute. (2005). Theory at a glance: A guide for health promotion practice
(2nd ed.). NIH Publication Number 05-3896.
Rogers, E. (2003). Diffusion of innovations (5th ed.). New York: Free Press.
Ryan, B., & Gross, N. C. (1943). The diffusion of hybrid seed corn in two Iowa communi-
ties. Rural Sociology, 8(1), 15–24.
Singhal, A. (2005). Forum: The life and work of Everett Rogers—Some personal reflections.
Journal of Health Communication, 10(4), 285–288. doi:10.1080/10810730590949978
DISABILITY
The term “disability” encompasses many different physical, mental, emotional, and
social impairments or limitations. The Centers for Disease Control and Prevention
([CDC], 2017) define disability as “any condition of body or mind (impairment)
that makes it difficult for the person with the condition to do certain activities (activ-
ity limitation) and interact with the world around them (participation restric-
tions).” There are many different types of disabilities. The most common involve
hearing, vision, cognition, communication, and social, emotional, or physical func-
tion. Despite differences, people with disabilities (PWD) are related by common
social experiences, risk factors, and health challenges. PWD experience numerous
obstacles when accessing health, education, job, and community services. As a
result, PWD have significantly lower educational achievement, socioeconomic sta-
tus, quality of life, and health. Some public health experts purport that dis-ability
is a socially constructed condition rather than a medical condition. If society ade-
quately considered the needs of PWD when designing the built environment and
social systems, disabilities would not exist. Nationally, an estimated 37 to 57 mil-
lion people live with a disability (CDC, 2017). The World Health Organization
(WHO) and World Bank World Report on Disability (2011) presents a global picture
of the problem and offers recommendations for policy makers, health care, educa-
tion, and employment professionals.
The onset of a disability may occur suddenly, intermittently, or progressively.
Causes include genetic disorders (sickle cell disease), chromosomal disorders (Down
syndrome), in utero exposure to drugs, alcohol, or infections (fetal alcohol syn-
drome), developmental disorders (autism spectrum disorder), injury (spinal cord
injury), or chronic or acute diseases (complications of diabetes). The National
Health Interview Survey compares health behaviors and outcomes of PWD and
people without disabilities. PWD have higher rates of smoking, substance abuse, and
DISAB ILITY 171
depression. For example, among adults, 25 percent with disabilities smoke ciga-
rettes and 17 percent without disabilities smoke cigarettes (CDC, 2017). PWD face
multiple obstacles in maintaining healthy weight. Such obstacles include pain,
fatigue, activity limitations, and difficulty chewing or swallowing, side effects of pre-
scription medication leading to weight gain, limited access to healthy food choices,
or limited access to recreational areas. As a result, adults with disabilities have three
times higher risk of heart disease, stroke, diabetes, or cancer in comparison to adults
without disabilities (CDC, 2017). Hypertension is also more common among PWD
(34 percent) in comparison to people without disabilities (27 percent) (CDC, 2017).
To aggravate the problem, PWD are often reluctant to seek medical treatment and
preventive services. Negative attitudes by health care providers, lack of services,
difficulty accessing and navigating services, or policies and systems that fail to respect
the individual delay or obstruct needed care. The problem is likely to get worse.
The WHO reports that disabilities are increasing at a faster rate than previously esti-
mated due to the aging population and the increase in chronic health problems.
Women, the elderly, and people living in poverty carry a disproportionate share of
the burden of disability.
Social scientists purport that disability is not a medical condition. Ability or inabil-
ity is defined by society where people who can access buildings and communities
are considered able-bodied and people who cannot access are considered disabled.
If shops, schools, factories, public transportation, sidewalks, buildings, and
household items were designed and constructed to accommodate PWD, barriers
would no longer exist, and everyone would be abled. The WHO (2017) defines three
levels of disability: impairment, limitation in activity, and restriction in participa-
tion. Impairment refers to defects or injuries to body structure or function, includ-
ing mental faculties. Activity limitation refers to difficulty in independently performing
personal activities of daily living. Participation restriction refers to limitations on
engagement in social, recreational, or occupational activities. T hese levels provide
a common language to assess needs and identify appropriate accommodations. In
general, the WHO and the World Bank recommend the following practices and poli-
cies to reduce health disparities and improve quality of life for PWD:
1. Adopt a national plan that maximizes and coordinates services for PWD.
2. Include PWD in planning policies and services.
3. Use mainstreaming to provide equal access to quality educational, health,
employment, and social services.
4. Provide adequate funding for public services.
5. Offer rehabilitation ser vices and vocational training that promote
independence.
6. Train engineers, architects, and designers to integrate the needs of PWD in
the design, development, and construction stages of projects.
7. Deconstruct public myths and misconceptions that stigmatize PWD.
8. Support further epidemiological research on the impact of disabilities.
9. Identify ways to reduce social barriers. (WHO and World Bank, 2011)
172 DISA B ILITY
Some of the recommendations do not require additional resources and w ill greatly
improve communities by increasing diversity, social justice, and h uman resources.
The introduction to the WHO–World Bank report is written by world-renowned
physicist Dr. Stephen Hawking. At the age of 21, Hawking was diagnosed with amy-
otrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. ALS affects the
motor neurons, resulting in muscle paralysis and difficulty speaking, swallowing,
and breathing. T here is no known cure. Completely paralyzed, Hawking notes his
good fortune in that he benefits from the best medical care in the world, personal
care assistants, and advanced assistive technology. Yet, not everyone is as fortunate.
Hawking advocates on behalf of the less fortunate,
In fact we have a moral duty to remove barriers to participation, and to invest suffi-
cient funding and expertise to unlock the vast potential of p eople with disabilities.
Governments throughout the world can no longer overlook the hundreds of millions
of p
eople with disabilities who are denied access to health, rehabilitation, support,
education, and employment, and never get the chance to shine. (WHO and World
Bank, 2011, p. 3)
History provides numerous examples of people who, with appropriate support,

overcame physical and m ental challenges to achieve incredible accomplishments.
In The Future of Public’s Health, the Institute of Medicine (2003, pp. 179–180)
notes, “When p eople are healthy, they are better able to work, learn, build a good
life, and contribute to society.” PWD have much to contribute to society and want
to be a part of society. However, systemic, structural, and social barriers must be
removed so that PWD can become fully functioning in society.
Sally Kuykendall
See also: Americans with Disabilities Act; Behavioral Health; Birth Defects; Disability
Movement; Greco-Roman Era, Public Health in the; Health; Health Dispari
ties; National Center for Injury Prevention and Control; National Institutes of
Health; Obesity; Prevention; Roosevelt, Franklin Delano; Social Determinants of
Health; Social Security Act; Spiritual Health
Further Reading
Centers for Disease Control and Prevention. (2017). Disability and health. Retrieved from
https://www.cdc.gov/ncbddd/disabilityandhealth/index.html.
Institute of Medicine. (2003). The f uture of the public’s health in the 21st century. Washington,
DC: National Academies Press.
World Health Organization. (2017). Disability and rehabilitation. Retrieved from http://www
.who.int/disabilities/en/.
World Health Organization and World Bank. (2011). World report on disability. Switzerland:
World Health Organization. Retrieved from http://www.who.int/disabilities/world
_report/2011/en/.
DISAB ILITY M O VE M ENT 173
DISABILITY MOVEMENT
Over 53 million p eople in the United States, one in five adults, have at least one
form of disability (Prevalence, 2015). Aside from the primary health issue, people
living with disabilities have poorer overall health than t hose without disabilities. In
the past, people with disabilities were segregated in special schools or residential
facilities. More recently, attitudes have shifted toward an inclusionary model. This
perspective is referred to as the social model of disability. Accessibility policies now
target environmental and societal f actors that hinder access and equality, rather than
purely medical or physical barriers (World Health Organization, 2011). The dis-
ability movement is a global movement to secure equal rights and opportunities
for people with disabilities. The modern disability movement centers on improv-
ing accessibility and equality and therefore enhancing opportunities for and the pub-
lic health of p
eople living with disabilities.
Ed Roberts (1939–1995) is considered the father of the independent living move-
ment, the start of the disability movement. Roberts was a healthy, young man who
enjoyed baseball until he was stricken by polio at age 14. The infection left him com-
pletely paralyzed except for two fingers and a few toes. Dependent on his iron lung
ventilator, Roberts attended school via telephone. When he grew strong enough to
come off the ventilator for a few hours, his m other insisted that he attend school
for one day a week. Roberts was embarrassed and worried about the transition. He
quickly realized that the other students did not judge him and w ere simply curious to
meet the classmate whom they had talked with but had never seen. Roberts embraced
the attention. When it came time to graduate, a school administrator tried to deny his
diploma on the grounds that Roberts did not complete the required physical educa-
tion courses. Mrs. Roberts, a u nion activist, stepped in to advocate for her son. When
she was rebuffed, she contacted the media who pressured the school to count physical
therapy as the physical education requirement. After graduation, Roberts decided to
attend community college. He should have been eligible for a grant from the Califor-
nia Department of Rehabilitation. The department refused him on the grounds that
Roberts would never be able to hold a job. Again, Roberts used the power of the press
and the Department of Rehabilitation reconsidered their decision.
After community college, Roberts transferred to University of California at Berke-
ley. He lived in the student infirmary b ecause it was the only habitable structure
that could hold his iron lung. As the news spread of a wheelchair-bound student at
Berkeley, other quadriplegic students applied, w ere accepted, and moved into the
makeshift dormitory. The “rolling quads” enjoyed college life with the exception
that their fragile wheelchairs kept breaking down. They started improvising their
wheelchairs so that they could explore the city. When community members with
disabilities saw the more durable wheelchairs, they also wanted them. Able-bodied
friends and family members and disabled p eople from the community joined the
group and the Center for Independent Living was formed. Roberts eventually became
the director of the California Department of Rehabilitation, the same organization
174 DISA BILITY MOVEMENT
that told him that he would never be able to hold a job. Roberts was instrumental
in starting the disability movement and advocating for equal access and oppor-
tunities for p eople with disabilities in the United States.
In 1990, Congress, u nder advisement from the organization now known as the
National Council on Disability, passed the Americans with Disabilities Act (ADA),
which protects people with disabilities against discrimination in public services and
accommodations, as well as employment. The ADA affords similar protections to
the Civil Rights Act of 1964, with the notable exception that the ADA requires
employers to make reasonable accommodations for employees with disabilities. The
bill was signed into law by President George H. W. Bush on July 26, 1990 (Equal
Employment Opportunity Commission, n.d.). Although critics of the ADA claim
that it has negatively impacted the employment rate for p eople with disabilities,
citing the expenses for businesses hiring p eople with disabilities, no link has been
found (Picker, n.d.).
The modern social model of disability focuses on the barriers to accessibility
created by society. This model puts the responsibility of social change on society,
rather than the individual. Changes this model puts forward include altering soci-
ety’s attitude toward p eople with disabilities, Affirmative Action, and accessible
physical infrastructure. This model also posits that attempts to “fix” individuals with
disabilities are, in fact, discriminatory. The benefits of the social model include broad
improvements to infrastructure and social norms that all p eople benefit from. Some
of the more notable improvements include widespread installation of automatic
doors, curb cuts, and the movement to change the terms and words that are used
to describe p eople with disabilities.
Experts in the field argue that disability is constructed by society. If architects, builders,
city planners, and other policy makers considered p eople who have physical, visual,
hearing, or cognitive impairment when planning and building workplaces, schools,
recreational areas, and public spaces, t here would be no disability. The World Health
Organization (WHO) identifies three major societal barriers created by ableism, dis-
crimination against p eople with disabilities. The first is the most visible: environ-
mental barriers. These can vary based on the community. In general, barriers that
limit inclusion create disability. Such barriers can be natural or artificial and include
places inaccessible to t hose with physical disabilities (lacking wheelchair access) or
intellectual/sensory disabilities (lacking appropriate signage). The next set of bar-
riers are attitudinal, or barriers created by people who are incapable of seeing
people with disabilities as anything other than the disability. Attitudinal barriers
contribute to all others and lead to discrimination, bullying, and segregation. In
some cultures, disabilities are seen as a form of divine punishment. Frequently, for
children with disabilities, the fear of bullying is as real an issue as the bullying itself.
The final set of barriers is institutional barriers, which include laws and practices
that actively discriminate against p eople with disabilities. Although the ADA has
proven to be a positive force in American politics, there are still issues to be
addressed in American government with regard to accessibility (World Health
Organization, 2011).
DISEASE 175
Public health advocates for p

eople with disabilities by recognizing societal obsta-
cles and working to educate and eliminate obstacles. The 2005 Surgeon General’s
Call to Action to Improve the Health and Wellness of Persons with Disabilities recom-
mends supporting people with disabilities by recognizing and considering the whole
person, not just the disability; speaking directly with the person with the disability,
rather than a family member of third party; speaking in age appropriate language
(do not speak to disabled adults as if they are children); offer assistance but do not
assume help is required; allow additional time for the person with the disability to
speak or act; recognize what the person can do, not what he or she cannot do; and
recognize the obstacles to work, education, health care, and social activities can be
more frustrating than the actual disability. Anyone can have a disability. It is up to
others in society to ensure that physical or cognitive restrictions do not exclude
people from enjoying a happy, healthy, full life.
Mark Black and Sally Kuykendall
See also: Americans with Disabilities Act; Attention-Deficit/Hyperactivity Disorder;

Birth Defects; Health Disparities; Roosevelt, Franklin Delano; Social Determinants
of Health
Further Reading
Equal Employment Opportunity Commission. (n.d.). The Americans with Disabilities Act of
1990. Retrieved from https://www.eeoc.gov/eeoc/history/35th/1990s/ada.html.
Majer, I. M., Nusselder, W. J., Mackenbach, J. P., Klijs, B., & van Baal, P. H. (2011). Mortal-
ity risk associated with disability: A population-based record linkage study. American
Journal of Public Health, 101(12), e9. doi:10.2105/AJPH.2011.300361
Picker, L. (n.d.). Did the ADA reduce employment of the disabled? The National Bureau of Eco-
nomic Research. Retrieved from http://www.nber.org/digest/nov04/w10528.html.
Prevalence of Disability and Disability Type among Adults—United States, 2013. (Cover
story). (2015). Morbidity and Mortality Weekly Report, 64(29), 777–783.
U.S. Code Title 42, Chapter 126. Equal opportunity for individuals with disabilities. Legal Infor-
mation Institute: Cornell Law School. Retrieved from https://www.law.cornell.edu
/uscode/text/42/chapter-126.
U.S. Department of Health and Human Services. (2005). The 2005 surgeon general’s call to
action to improve the health and wellness of persons with disabilities: Calling you to action.
U.S. Department of Health and Human Services, Office of the Surgeon General. Retrieved
from https://www.cdc.gov/ncbddd/disabilityandhealth/pdf/whatitmeanstoyou508.pdf.
World Health Organization. (2011). World report on disability. Geneva: Author. Retrieved from
http://www.who.int/disabilities/world_report/2011/report.pdf.
DISEASE
Diseases are pathological conditions characterized by abnormal structure or func-
tion in the human body. Major diseases include cardiovascular disease (CVD), a
group of conditions resulting from structural damage to the heart or circulatory
system; chronic obstructive pulmonary disease (COPD), a disease that affects the
176 DISEASE
bronchi and alveoli impairing the body’s ability to oxygenate body tissues; and
infectious diseases, conditions resulting from pathogenic organisms. The word
disease blends the Latin prefix dis-, which means “opposite” or “reverse of” with
the Anglo-Norman word ese (ease), meaning “freedom from pain” or “freedom
from concern.” Based on the root words, dis-ease means “the opposite of pain-free
or anxiety-free.” A logical conclusion would suppose that disease is the opposite of
the World Health Organization (WHO, 1946) definition of health, “a state of com-
plete physical, mental and social well-being and not merely the absence of disease
or infirmity.” Defining disease as the opposite of health means that anything that
interferes with biological, emotional, social, or spiritual well-being would and should
be classified as disease. Under this definition, anger, greed, bullying, and racism
would be considered diseases. Scholars point out that the working definition of
disease is context-dependent and changes over time (Scully, 2004). It is important
to have a clear definition so that people experiencing health problems are able to
access treatment and so that health and medical professionals do not diagnose,
medicate, or treat p eople for behaviors that are not pathological.
Distinguishing between health and disease is a challenge because there is so much
that we do not know about the human body. Medical practice is highly dependent
on technology and science. For example, the invention of magnetic resonance imag-
ing (MRI) allowed scientists to visualize h uman brain development and structure
in ways that were not possible previously. The ability to scan the living brain refutes
the idea that addiction is caused by moral turpitude. We now know that addiction
is a dysfunction of neurotransmitters, and adolescents are at higher risk due to
unique brain structure and development (National Institute on Drug Abuse, 2015).
Even when medicine does possess the technology to examine and define illnesses,
society may not recognize or understand a pathological condition as such. Osteopo-
rosis, a weakening of the bone tissue, was once thought to be a normal part of aging.
In 1994, the WHO officially recognized osteoporosis as a disease. Classification as
a disease means that community agencies offering osteoporosis prevention pro-
grams can request grant or government funding, and health insurers will cover
access to diagnostic tests and treatment.
The classification of an entity as a disease state is also determined by social values.
Homosexuality is an example of how a behavior was at first considered natural,
became classified as a disease, and then became depathologized. The art and liter
ature of ancient civilizations suggest that same-gender sexual preferences existed
across cultures throughout recorded history. Indigenous North Americans revered
the healers, artists, and leaders who exhibited both male and female qualities. “Two-
spirits” were viewed as a third or fourth gender rather than a combination of male
and female. In Plato’s Symposium (385–370 BCE), the ancient Greek philosopher
theorizes on the nature and purpose of love. This literary work provides insights
into Greek life. Homosexuality is featured as an innate and natural sexual attrac-
tion. Early Christians were among the first to disapprove of men who had sex with
men. Women who had sex with women were ignored. Early U.S. laws, originating
DISEASE 177
in the Plymouth Colony, reflected Puritan values. The colonists feared punishment
by God and implemented laws that they believed would placate an angry and venge-
ful God. Treason, murder, witchcraft, arson, sodomy, rape, bestiality, and adultery
were punishable by death (Crompton, 1976). In 1886, the Austro-German psychia-
trist Richard von Krafft-Ebing portrayed homosexuality as a m ental disorder in his
book Psychopathia Sexualis. Classifying homosexuality as a disease created the mis-
belief that homosexuality could be cured. Social misperceptions, hatred, and rejec-
tion of homosexuals w ere furthered u nder Hitler’s fascism. By the 1950s, a series
of major research studies investigating h uman sexuality found that same-sex attrac-
tion and practices were more common than people believed. In 1973, the American
Psychiatric Association (APA) removed the listing of homosexuality as a psychiatric
illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Despite the
fact that medical and psychiatric professionals no longer consider homosexuality as
a disease, the idea that same-gender sexual preference is curable lingers. Such
misperceptions ostracize and harm LGBTQ individuals. From an ethical perspec-
tive, it is important that diseases are correctly classified as diseases and minority
characteristics are not misclassified as disease.
Physical and mental health diseases may be categorized as acute or chronic. Acute
diseases are health problems in which symptoms come on suddenly, within hours
or days, and the person recovers fairly quickly, usually within days to weeks. Exam-
ples of acute diseases are the common cold, food poisoning, sprains, strains, or
traumatic injuries. Chronic diseases are persistent health conditions, lasting three
months or more, which start discretely and progress to more serious problems over
time. Examples of chronic diseases are CVD, high blood pressure, cancer, diabetes,
asthma, or COPD. Both acute and chronic diseases are diagnosed through routine
medical examinations, screenings, or when patients report symptoms to their health
care providers. For example, the person with asthma may complain of shortness of
breath or wheezing. Disease management is a coordinated and systematic approach
of treating and controlling the disease. It is important that people suffering from
asthma take medication as prescribed so that symptoms do not interfere with work,
recreational activities, or sleep. Regularly cleaning of indoor living spaces to mini-
mize dust, molds, and pet dander can prevent asthma attacks. In addition to early
diagnosis and disease management, public health works to prevent disease. The
Environmental Protection Agency provides guidelines on cleaning up a fter hurri-
canes and floods to prevent mold spores, and the Air Pollution and Respiratory
Health Branch of the Centers for Disease Control combats environmentally related
respiratory diseases through surveillance, dissemination of information on effec-
tive interventions, and by encouraging local collaborations to develop, implement,
and evaluate asthma control programs.
Diseases are a medical classification that refers to a biological, social, or psycho-
logical condition, which creates malfunctioning of the human body. The classifica-
tion of a condition as a disease raises policy and ethical questions, regarding social
values, insurance reimbursement, and the ability of health care to diagnose and treat
178 DI X, DO ROTHEA LYNDE
the condition. Is a condition truly a physical or psychological malfunction or merely

a reflection of social norms and values? As science and technology advance, public
health and medical professionals are challenged to determine w hether a condition
is actually a disease or is instead, an unfamiliar attribute. Society must also guard
against the fabrication of diseases as for-profit health care groups or pharmaceuti
cal companies encourage or manufacture new diagnoses in order to create a market
for treatment.
Sally Kuykendall
See also: Acute Illnesses; Behavioral Health; Chronic Illness; Disability; Health; Heart
Disease; Infectious Diseases; Intervention; M iddle Ages, Public Health in the; Pre-
vention; Public Health in the United States, History of; Spiritual Health; Waterborne
Diseases
Further Reading
Centers for Disease Control and Prevention. (2016). Asthma. Retrieved from https://www
.cdc.gov/asthma/.
Crompton, L. (1976). Homosexuals and the death penalty in colonial America. Journal of
Homosexuality, 1(3), 277–293. Retrieved from http://citeseerx.ist.psu.edu/viewdoc
/download?doi=1 0.1 48.7044&rep=r ep1&type=pdf.
.1.6
Morris, B. J. (n.d.). History of lesbian, gay, & bisexual social movements. Washington, DC: Amer-
ican Psychological Association. Retrieved from http://www.apa.org/pi/lgbt/resources
/history.aspx.
National Institute on Drug Abuse. (2015). Drugs and the brain. Retrieved from https://www
.drugabuse.gov/related-topics/drugs-brain.
Scully, J. L. (2004). What is disease? EMBO Reports, 5(7), 650–653.
World Health Organization. (1946). Preamble to the Constitution of the World Health Organ
ization as adopted by the International Health Conference, New York; Official Records
of the World Health Organization. Retrieved from http://apps.who.int/gb/bd/PDF/bd47
/EN/constitution-en.pdf?ua=1 .
World Health Organization. (1994). Assessment of fracture risk and its application to screening
for postmenopausal osteoporosis. WHO Technical Report Series 843. Geneva: Author.
DIX, DOROTHEA LYNDE (1804–1887)

Dorothea Lynde Dix was a social reformer who observed and reported the living
conditions of the mentally ill in order to create mental hospitals. “Dolly” Dix was
born on April 4, 1802. Her father, Joseph, was the son of Dorothea and Elijah Dix.
Elijah was a wealthy physician and merchant who donated his time to many com-
munity service projects in Worcester, Massachusetts. In 1795, Elijah moved his
family to a community in Boston with other wealthy merchants. The neighbors made
their fortunes by the triangular trade of shipping rum and slaves from the West
Indies to America, exporting the rum to Africa in exchange for other slaves, and
shipping the African slaves to the West Indies to work on sugar cane plantations.
DI X , DOR OTHEA LYNDE 179
Dorothea’s f ather rebelled against his privileged upbringing. He dropped out of Har-
vard College, married a commoner, Mary Biglow, and worked as manager of sev-
eral of his father’s properties.
Named after her grandmother, Dorothea was a favorite grandchild. When Elijah
died, he left enough money for Dorothea to support herself u ntil she would be mar-
ried. However, other heirs contested the w ill, and Dorothea ultimately inherited
nothing. Joseph and Mary exchanged their inheritance for books, moved to a small
frontier town in Vermont, and lived as religious zealots. Joseph sold religious books.
Young Dorothea was responsible for collating the religious tracts and binding them
into books. She was also the primary caregiver of her two younger b rothers. She
was miserable. At the age of 12, she ran away and found her way to her grand
mother’s mansion. The grandmother and granddaughter clashed. Dorothea did not
measure up to Madame Dix’s image of a high society young lady. She sent Dorothea
to live with Sarah Fiske, a niece in Worcester.
The Fiske family offered culture and sophistication. Many young, educated
women of the time opened schools on the family property and taught until they
got married. Dorothea opened a school at the Fiske residence. She worked hard to
dress and act the part of a young lady and schoolteacher. In 1824, she returned to her
grandmother’s h ouse and opened another school. Her curriculum was haphazard.
Dorothea had never had a formal education herself. She offered lessons in botany
and moral development because those are the topics she was interested in. She also
gathered information by reading or attending public lectures. Her independent
study led to the publication of her first book, Conversations on Common Things. The
book provided a small, steady income.
Despite her efforts, Dorothea did not fit in socially. While other young ladies w ere
interested in getting married, Dorothea joined the Unitarian church and embraced
the values of personal restraint and social activism. In 1826, Dorothea moved to a
boardinghouse, proclaiming independence from her f amily. She worked as teacher,
coedited the first children’s magazine, and wrote religious meditations, poems, and
children’s stories. Her subsequent publications w ere not as successful, and her
employment as a teacher was sporadic. She frequently suffered from bouts of ill-
ness during which time she stayed with friends.
In 1841, a Harvard Divinity student asked Ms. Dix to teach his Sunday school
class at Middlesex County House of Correction in East Cambridge. The Industrial
Revolution was pulling rural youth into the cities to work in factories. Isolated from
family and friends, some developed m ental illness and w ere destined to almshouses
or jails where the mentally ill w
ere easy victims for physical, verbal, sexual, and
financial abuse. Dorothea was appalled by what she saw, frail men and women,
unkempt and shivering in cold cells. She asked the jailer to light a fire in the stove,
and he responded that lunatics did not feel the cold. With the help of two influen-
tial friends, Simon Gridley Howe and Charles Sumner, Dorothea went to the courts
to ask for help, and the jailer agreed to improve the conditions in the cell. This
experience prompted Dorothea to learn as much as she could about the mentally
180 DIX, DOR OTHEA LYNDE
Doctors and nurses operate on a patient at Bellevue Hospital, ca. 1870. After founding
specialized hospitals for mentally ill patients, Dorothea Dix studied best practices in care.
Although the practices w ere barbaric by t oday’s standards, philosophy of care shifted from
punitive morality-based practices to biological treatments. (Bettmann/Getty Images)
ill. Little was known about mental illness, and treatment followed two streams of
thought, heroic versus moral. Heroic treatment used emetics, laxatives, or narcotics
to remove the evil spirits. Moral treatment used a controlled environment with
scheduled activities, a nutritious diet, and restricted visiting hours. Moral treatment
was consistent with Dorothea’s Unitarian values. Howe, Sumner, and Horace Mann
encouraged Dorothea to investigate further.
Dorothea visited e very jail and almshouse in Massachusetts, recording the num-
ber of detainees, their physical, m ental, and spiritual status, and naming the insti-
tution and managing official. The findings were compiled into the Memorial to the
Legislature of Massachusetts. Howe presented the report to the Massachusetts legis-
lature. In comparison to other areas of the country, Massachusetts had better con-
ditions. However, Dix’s descriptions w ere moving, “The present state of insane
persons confined within this Commonwealth, in cages, closets, cellars, stalls, pens!
Chained, naked, beaten with rods, and lashed into obedience!” (Dix, 1843, p. 2).
According to the social norms of the day, it would have been very unladylike to
visit or describe such deplorable conditions. Dix used her femininity to her
advantage by claiming that female empathy forced her to use plain words, clear
descriptions, and to advocate for improved conditions. She implored politicians to:
DI X , DOR OTHEA LYNDE 181
Become the benefactors of your race, the guardians of the solemn rights you hold in
trust. Raise up the fallen, succor the desolate, restore the outcast, defend the helpless,
and for your eternal and great reward receive the benediction. ‘Well done, good and
faithful servants, become rulers over many t hings.’ (Dix, 1843, p. 25)
Thus, Dorothea played on the men’s sense of power and righteousness. The report
enraged the public. Opponents wanted this w oman to mind her own business. Some
officials claimed she was lying. Supporters defended her by noting that since w omen
could not run for political office, Dorothea had nothing to gain from lying. Howe,
Sumner, and Mann defended Dix and convinced the legislature to increase the num-
ber of beds for the mentally ill.
Dix set off traveling across New E ngland and Eastern Canada, documenting the
conditions of prisons and almshouses and calling on state legislators to provide beds
for the mentally ill. In the fall of 1843, she went to New York. The New York State
Lunatic Asylum of Utica had just opened with enough beds for 225 patients. The
problem was that the 1840 census had registered 2,300 mentally ill persons, and
the hospital would only accommodate treatable cases. Dorothea argued for the
intractable cases because mental illness is a consequence of social policies and should
be addressed through social policy. Dr. Amariah Brigham, the medical superinten-
dent of the New York hospital, opposed Dix on the argument that patients with
intractable mental illness were unmanageable and would ruin the system. Doro-
thea headed to Pennsylvania and New Jersey. This time she met with the superin-
tendents of m ental hospitals and asked for their support. Her reports evolved. She
praised modern medicine, advocated for early treatment, and cautiously suggested
public policy. Dix was moving away from her focus on moral care to a medical model.
By August 1845, Dix had visited 500 almshouses, 300 jails, and several hospi-
tals. She grew distant from friends. As a famous lobbyist and social reformer, she
spent more time with politicians and wealthy patrons and less time with the men-
tally ill patients, whom she had so strongly advocated for. In the summer of 1845,
she turned her focus to prison inmates. Prison reformers were debating keeping
prisoners separated or together. In 1845, Dix published Remarks on Prisons and Prison
Discipline in the United States. The document used the same ethnographic and epi-
demiological techniques, which Dix had used in previous efforts. To determine best
practices in prison management, Dix interviewed prison wardens and collected data
on corporal punishment. She noted:
While we diminish the stimulant of fear, we must increase to prisoners the incite-
ment of hope: . . . we should awaken and strengthen the control of the conscience. . . .
Man is not made better by being degraded; he is seldom restrained from crime by
harsh measures, except the principle of fear predominates in his character; and then
he is never made radically better for its influence. (Dix, 1845, p. 25)
Dix proposed that prison guards could serve as models for prisoners, providing
moral guidance. By this time, Dix had helped to establish 32 state mental institu-
tions across the United States. After unsuccessfully trying to convince Congress to
182 DIX, DOR OTHEA LYNDE
grant federal land for mental institutions, Dix traveled to Europe. She continued
her crusade of educating policy makers and advocating for m ental institutions u
ntil
1856 when she returned to the states.
The mental hospitals that Dix had established w ere becoming overcrowded. Med-
ical superintendents were resorting to the same harsh strategies that Dix had
opposed. She blamed the overcrowding on the influx of Irish immigrants escaping
the Irish Potato Famine. Reflecting the bigotry of the time, Dix believed that the
Irish were morally inferior and uneducable. To add to the dysfunction, the Civil
War was breaking out. Hoping to work on social reforms in the North and the South,
Dix stayed silent on the issue of slavery. This allowed her to travel throughout the
Southern states advocating for mental institutions.
Once the Civil War started, Dix volunteered to recruit nurses to care for the Union
soldiers. She wanted to replicate Florence Nightingale’s efforts in the United States,
and she believed her experience establishing mental hospitals provided the neces-
sary qualifications. On June 10, 1861, Dix was commissioned as the Superinten-
dent of Women War Nurses by Secretary of War Simon Cameron, making her the
first female to earn a federal appointment. The idea of females as nurses and Dix’s
moral stance clashed with the military doctors. The doctors preferred untrained
male assistants. Dix insisted that the doctors abstain from alcohol and that nurses
dress modestly. Jewelry or other frills w
ere banned. Any applicant u nder the age of
30 or who appeared to be looking for a husband was rejected. Dix was a one-person
show. She did not take a salary and used her own money to buy gowns and sup-
plies. Unfortunately, she was not trained to deal with infections, the leading cause
of death in Civil War hospitals. The final straw came with the b attle of Wilson’s
Creek, Missouri. One thousand injured men were transported 110 miles to the near-
est military hospital. Moving at her own pace, Dix had not set up the hospital.
Without beds or nurses, the local residents stepped in. When Dix arrived, she
neglected to notify the Sanitary Commission. The Sanitary Commission was furi-
ous and Secretary of War Edwin Stanton restricted Dix’s authority.
As the war escalated, both armies struggled to care for prisoners of war. In Elmira,
New York, officials estimated that 8,000 Confederate prisoners would die within a
year. Hoping to force the South to exchange prisoners, officials asked Dix to inspect
the prison and record conditions. To their disappointment, Dix stayed faithful to
her Northern allegiance and reported that the Confederate soldiers w ere receiving
adequate care. When the war ended, Dix resigned. Despite the problems, Dix is
recognized for advancing opportunities for women in nursing. Because of the power
struggles during the Civil War, Dix lost her political influence, and questions were
being raised about mental hospitals. Elizabeth Parsons Ware Packard (1816–1897)
spent three years falsely imprisoned at the Jasonville Insane Asylum in Illinois for
publicly disagreeing with her husband. She published several books on her expe-
riences and advocated for the rights of mentally ill patients and women. Packard’s
case revealed weaknesses in Dix’s ideas.
D RE W, C HA R LES R I C HA R D 183
In 1870, Dix was diagnosed with malaria. She spent three years recuperating,
staying at her favorite m
ental institution in New Jersey. In 1881, she moved into an
apartment at the state mental hospital in Trenton and gradually grew weaker. Dor-
othea Lynde Dix died in her sleep on July 18, 1887.
The techniques Dorothea Dix used are now known as ethnography or shoe leather
epidemiology. By investigating, reporting, and disseminating the living conditions
of the mentally ill, Dix was able to confront the stigma of mental illness and founded
32 mental institutions, 15 schools, and numerous training facilities.
Sally Kuykendall
See also: Beers, Clifford Whittingham; Blackwell, Elizabeth; Mental Health; Mental
Illness; Controversies in Public Health: Controversy 2
Further Reading
Dix, D. L. (1843). Memorial to the Legislature of Massachusetts. U.S. National Library of Medi-
cine. Retrieved from https://collections.nlm.nih.gov/catalog/nlm:nlmuid-7703963-bk.
Dix, D. L. (1845). Remarks on prisons and prison discipline in the United States. Philadelphia:
lm.nih.gov/bookviewer?PID=n
Joseph Kite. Retrieved from https://collections.n lm:nlmuid
-60540680R-bk.
Morin, I. V. (1995). 1: Dorothea Dix Superintendent of Army Nurses. Women Chosen for
Public Office, 10–23.
Muckenhoupt, M. (2003). Dorothea Dix: Advocate for m ental health care. New York: Oxford
University Press.
DREW, CHARLES RICHARD (1904–1950)

Charles Richard Drew was an African American surgeon and physiologist who devel-
oped techniques of preserving blood products for life-saving transfusions. “Char-
lie” was born on June 3, 1904, in Washington, DC, the eldest of five c hildren of
Nora Rosella Burrell and Richard Thomas Drew. Richard worked as a carpet layer
and was the financial officer of the predominantly white local trade union. Nora
was a graduate of Miner Normal School, a teacher training school for young w omen
of color. Nora was remembered as a graceful woman of great faith and culture. Char-
lie loved sports. Swimming in the harbor at Foggy Bottom and at the 12th Street
YMCA, he won his first athletic award. As a teenager, he attended Paul Lawrence
Dunbar High School, a segregated school for academically gifted minority youth.
In high school, Charles ran track and played football, basketball, and baseball. He
earned the James E. Walker Memorial Trophy for best all-around athlete in his junior
and senior years and at graduation was recognized as the most popular student and
the student who accomplished the most for Dunbar High School. By adolescence,
Charles had successfully embodied his mother’s graciousness and his father’s abil-
ity to organize and lead.
184 DR EW, CHARLES RICHA RD
Charles was awarded a partial college scholarship to Amherst College in Massa

chusetts. To cover his expenses, he worked, ran track, and played football. Despite
winning the football team’s most valuable player in his junior year, Drew was passed
over to become football captain for a white player. His time in football was marred
by racial prejudice. Opposing players frequently hurled racial slurs at him, and res-
taurants denied him service. He stayed s ilent, did not fight back, but instead turned
a deep shade of red, earning the nickname “Big Red.” Drew graduated in 1926 with
a bachelor of arts degree and was recognized with the Howard Hill Mossman Tro-
phy, awarded to the person who brought the most to Amherst athletics.
An injury from college football, the death of his younger sister, Elsie from
tuberculosis complicated by influenza, and encouragement from his biology pro-
fessor influenced Charles to go into medicine. To save money for medical school,
Charles worked for two years at Morgan State University in Baltimore as a biology
instructor and athletic director. Howard University Medical School, his dream
college, rejected him b ecause he did not have enough English credits. Harvard
University Medical School offered a deferred admission to start the following year.
McGill University offered unconditional acceptance, and Charles flourished in
Montréal. He won many athletic and academic awards and was admitted to the
Alpha Omega Alpha honor society. After graduating with honors, he completed
his internship and residency. Working with Dr. John Beattie at Montréal General
Hospital, Drew started studying the use of fluids and blood products as a treat-
ment for shock.
Drew wanted to continue his surgical training at a major medical institution in
the United States. However, large medical institutions rarely accepted African Amer-
ican residents b ecause white patients refused treatment by p eople of color. In
1935, he accepted a position as instructor of pathology at Howard University and
soon earned promotion to assistant instructor in surgery/assistant surgeon at Freed-
man’s Hospital. To advance further in academia, Drew needed an academic doc-
toral degree as opposed to a clinical doctoral degree. In 1938, Drew commenced
graduate studies at Columbia University. He also worked as surgical resident at Pres-
byterian Hospital. The combination of graduate student and surgical resident
afforded Drew the opportunity to work with Dr. John Scudder studying the fluid
and electrolyte balance of surgical patients. For his doctoral dissertation, Drew stud-
ied blood storage. At the time, blood donations w ere stored as w
hole blood. Since
red blood cells undergo hemolysis within two days, whole blood has a short shelf
life. To extend shelf life, Drew separated the plasma and red blood cells. Sepa-
rately, each product could be stored up to one week. Furthermore, plasma is a
protein-electrolyte solution, which means there is no need for cross-matching
blood type. The plasma could be used to treat critically ill patients who w ere dif-
ficult to cross-match.
In 1939, Drew traveled to Atlanta for a conference. On his way, he attended a
dinner party where he met Minnie Lenore Robbins, a teacher at Spelman College.
Not one to waste time, Drew continued to the conference and stopped at Spelman
D R E W, C HAR LES R I C HAR D 185
on his return trip. Arriving after midnight, he awoke the dormitory matron, insisted
that the matron ask Ms. Robbins to meet him outside, where he proposed on the
spot. The couple married six months l ater. Knowing that her husband worked long
hours, Lenore took a job as laboratory assistant at Columbia University. The fol-
lowing year, Dr. Drew became the first African American to receive a doctor of medi-
cal science degree from Columbia University.
The late 1930s w
ere marred by ethnocentricity, hyper-nationality, and oppression
of minority populations. Worldwide economic depression forced people to move
across the globe in search of job opportunities and survival. Anti-Asian sentiment
was growing across North America. Anti-Semitism was taking hold in Germany. In
the Soviet Union, Stalin organized the deportation, exile, or genocide of Volga
Germans, Soviet Koreans, Crimean Tatars, Chechens, Poles, Meskhetians, Ukrai-
nians, and Russian Jews. Racism was a key factor in World War II (1939–1945).
Each ethnic group believed that they w ere superior to o thers. In America, white
superiority was part of everyday life. Medical ideology supporting racial oppres-
sion originated from 1907 when scientists hypothesized that p eople of color w ere
closer to primitive man and apes than white people. African Americans were seen
as inferior. As a surgical resident at Columbia, Drew witnessed persistent racism
in patient care. And despite working long hours to develop superior medical and
surgical skills, Dr. Drew was denied acceptance into the American Medical Asso-
ciation and the American College of Surgeons.
In June 1940, Drew returned to Howard University School of Medicine as assis-
tant professor of surgery. By September, he was asked to assist with the Blood for
Britain program. World War II was raging in Europe. Germany routinely flew bomb-
ing raids over E ngland’s cities creating a severe blood shortage. Drew’s expertise was
needed to organize the Blood for Britain program. Through the Blood Transfusion
Betterment Association, Drew refined techniques to preserve plasma and suggested
the use of bloodmobiles, refrigerated vans to transport blood. In February 1941, he
was named the first director of the American Red Cross Blood Bank and organized
a blood drive of more than 100,000 donors. Yet, Drew found himself frustrated by
blood procurement and transfusion methods mandated by the U.S. Army and
Navy. The military insisted that the Red Cross segregate blood by race. Per transfu-
sion protocol, Caucasian blood recipients could only receive blood from white
donors. The idea had no scientific merit and falsely promoted the idea that whites
were superior to people of color. Drew denounced the policy, resigned from the
project, and returned to Howard University where he was appointed full professor
and chair of surgery and chief surgeon at Freedman’s Hospital.
In 1941, the American Board of Surgery acknowledged Drew with the appoint-
ment of surgical examiner. Three years later, Drew was awarded the prestigious Spin-
garn Medal from the National Association for the Advancement of Colored P eople
(NAACP). He was a model of professionalism, perseverance, and graciousness.
Drew’s philosophy toward racism is best described in a letter to Mrs. J. F. Bates
( January 27, 1947), a Fort Worth, Texas, schoolteacher:
186 DR EW, CHARLES RICHA RD
So much of our energy is spent in overcoming the constricting environment in which

we live that little energy is left for creating new ideas or things. Whenever, however,
one breaks out of this rather high-walled prison of the “Negro problem” by virtue of
some worthwhile contribution, not only is he himself allowed more freedom, but part
of the wall crumbles. And so it should be the aim of every student in science to knock
down at least one or two bricks of that wall by virtue of his own accomplishment.
(U.S. National Library of Medicine, n.d.)
Through science, knowledge, and creativity, Charles R. Drew knocked more than
a few bricks out of the wall.
On April 1, 1950, Dr. Drew was driving with three other surgeons to a confer-
ence at Tuskegee Institute. Exhausted a fter performing lengthy surgery the day
before, he fell asleep at the wheel. The car veered off the road. Drew was ejected
from the car and suffered a spinal cord injury and traumatic brain injury. Surgeons
at the hospital recognized the famous colleague and worked diligently to save his
life. Unfortunately, the injuries were too serious and at the age of 45, Dr. Charles
Richard Drew passed away. A fter his death, the American College of Surgeons elected
him as a fellow. The Charles R. Drew University of Medicine and Science in Los
Angeles is named in his honor.
Dr. Charles Richard Drew was an African American surgeon who overcame enor-
mous prejudice and discrimination to advance the use of blood products as a way
to treat victims of traumatic injury and blood dyscrasia. Dr. Drew offered his secret
to success as, “Excellence in performance will transcend artificial barriers created
by man” (Dedication: Charles Richard Drew, 2006). Sadly, the world w ill never know
what successes may have been realized if the barriers had never existed in the first
place.
Sally Kuykendall
See also: Health Care Disparities; Health Disparities; Infectious Diseases; Social Deter-
minants of Health
Further Reading
[Dedication: Charles Richard Drew]. (2006). Journal of Blacks in Higher Education, (52), 1.
Retrieved from http://www.jstor.org/stable/25073456.
Drew, C. R. (1942). Dr. C.R. Drew wins 29th Springarn medal. New York: NAACP Press Ser
vice, 28, March 1944, 1–3.
Drew, L. R. (1978). Unforgettable Charlie Drew. Reader’s Digest, 112, 135–140.
Ford, J. R., & Drew, C. R. (1950). Appendicitis in the American Negro. American Journal of
Surgery, 80(3), 341–344.
Gordon, R. C. (2005). Charles R. Drew: Surgeon, scientist, and educator. Journal of Investi-
gative Surgery, 18(5), 223–225. doi:10.1080/08941930500350601
Pearson, P. A. (2001). Charles R. Drew. Black heroes (pp. 192–196). Ipswich, MA: History
Reference Center.
D R IT Z , SEL M A K ADE R M AN 187
U.S. National Library of Medicine. (n.d.). The Charles R. Drew papers. Profiles in science.
Bethesda, MD: National Institute of Health. Retrieved from https://profiles.nlm.nih.gov
/ps/retrieve/Narrative/BG/p-nid/336.
Wynes, C. E. (1988). Charles Richard Drew: The man and the myth. Urbana: University of
Illinois Press.
DRITZ, SELMA KADERMAN (1917–2008)

Selma Kaderman Dritz was a physician and epidemiologist who investigated unusual
cases of amoebic dysentery, pneumocystis carinii pneumonia, and Kaposi’s sarcoma
among young gay men in San Francisco. The early investigation of acquired immune
deficiency syndrome (AIDS) is a good example of how public health epidemiolo-
gists must navigate and collaborate with disenfranchised p eople in order to prevent
and treat disease. With little support from the federal government and few resources,
San Francisco public health staff worked long hours tracking cases, interviewing
patients, and characterizing symptoms. Dritz would often say, “We can’t let those
kids die” (Perlman, 2008). Her analytical approach and knowledge of the victims
allowed San Francisco’s health department to identify the mechanism of transmis-
sion of human immunodeficiency virus (HIV) and to start programs to reduce the
spread of AIDS. Dritz’s shoe leather epidemiology and dedication to the cause
earned the respect of scientists, health professionals, and most importantly, young
men who had been discarded and dismissed by society.
Selma Kaderman was born on June 29, 1917, in Chicago. In 1941, she gradu-
ated from medical school at the University of Illinois and completed an internship
and residency at Cook County Contagious Disease Hospital. A fter residency, Selma
moved into private practice specializing in pediatrics. This was prior to the discov-
ery of the polio vaccine, and many young patients suffered from the long-term effects
of polio or other infectious diseases. From 1946 to 1947, Selma worked as a con
sultant to Illinois State Health Department. She married H. Fred Dritz during her
pediatric residency. Soon after the union, her husband shipped overseas to serve in
the navy. When he returned from World War II, the couple moved to San Fran-
cisco. Rather than starting with a new practice, Selma decided to take a break from
her career and raise her c hildren. When her c hildren became teenagers, Selma deci
ded to return to work. However, medicine had changed. Vaccines had been inven
ted, and Selma noticed greater focus on problems of premature birth and mental
health. Also, Dritz preferred working with groups of p eople rather than individual
patients. She had enjoyed her work with the state health department and decided
to pursue a career in public health. In 1967, she earned her master’s degree in pub-
lic health at the University of California at Berkeley and went to work with the San
Francisco Public Health Department.
In the role of assistant director of the Disease Control department, Dritz was
responsible for investigating outbreaks of measles, mumps, and whooping cough
and some incidents of occupational illnesses. In 1974, the Board of Supervisors
188 DR ITZ, SEL M A KADE RMAN
passed a bill that decriminalized private sexual acts between consenting adults.
Escaping homophobia across the United States, gay men flocked to San Francisco.
The population movement tripled the number of homosexual men in the city. Bars,
bookshops, and bathhouses developed as places where gay men could meet. The
massive population movement and sexual freedom converged to create an epidemic
of syphilis and gonorrhea. The San Francisco health department had a specific
division to investigate sexually transmitted diseases (STDs) and tuberculosis. The
Disease Control department was responsible for investigating other communica-
ble diseases, which included an epidemic of enteric infections and hepatitis A and
B. Dritz quickly learned about the sexual practices of young gay men and began
working with local community groups to educate men on safe sex. Her no non-
sense approach and clear concern earned the trust and respect of the gay commu-
nity and physicians. She was able to influence men who w ere suspicious of those
in positions of power.
In June 1981, the Centers for Disease Control (CDC) reported five cases of pneu-
mocystis carinii pneumonia (PCP) in Los Angeles. PCP is a deadly lung infection,
typically seen among cancer patients with severe immune suppression resulting
from chemotherapy. In late July, the San Francisco Department of Public Health
received the first report of Kaposi’s sarcoma, a rare, slow-growing cancer. Within a
month, 20 cases of Kaposi’s sarcoma w ere reported and two victims had already
died. Cases of PCP had also started to appear in San Francisco. Health professionals
were bewildered. PCP was a very rare disease as was Kaposi’s sarcoma. Kaposi’s
sarcoma was typically limited to older men living in the Mediterranean or North
Africa, and the men died of other c auses, not Kaposi’s sarcoma. Dritz started meet-
ing weekly with gay and lesbian health services to review the number of cases and
deaths.
By this point, public health professionals in major cities across the country were
reporting similar cases of unusual communicable diseases. In an attempt to iden-
tify the cause, the CDC developed a 24-page questionnaire. Dritz administered the
questionnaire to approximately 100 patients. The data w ere not analyzed for another
two years because the CDC could not get funding for a statistician. In the meantime,
epidemiologists and physicians interviewed patients and worked every lead that
they could. Dritz employed techniques used by Dr. John Snow to investigate Lon-
don’s cholera epidemic of 1854. She confiscated an old blackboard, listed and
mapped cases. She connected 44 cases that could have been transmitted through
sexual or blood contact. Her hypothesis that the problem was blood borne was con-
firmed when a baby developed AIDS-like symptoms. The baby suffered from Rh
factor disease and had received multiple blood transfusions. Dritz recognized the
name of one of the 13 donors as a name on her blackboard. Evidence of blood borne
transmission meant that health officials could start prevention programs. However,
the federal government refused to fund research, treatment, or prevention. Dritz
developed partnerships with journalists, nonprofit organizations, and community
D R IT Z , SEL M A K ADE R M AN 189
groups. Working together, they established health education for the gay community
and services for people with AIDS. Dritz became recognized as the go-to person
within the health department. She worked tirelessly, giving seminars. She taught
men to recognize the symptoms of opportunistic infections. She trained bartenders
to refer patrons with health concerns to the health department. She encouraged
men to reduce the number of sexual contacts. She met with personnel departments
of large businesses to allay concerns that AIDS could be transmitted in the work-
place. She was instrumental in the health department’s biggest challenge, closure
of the city’s bath h ouses. Bath houses were large, crowded venues where gay men
enjoyed multiple anonymous sexual partners. Dritz knew that men with AIDS w ere
still attending the bath houses and possibly transmitting disease. Under the law,
health officials could close the bath houses as a potential health hazard. However,
members of the gay community fought closure. The men w ere not going to volun-
tarily give up their newfound sexual freedom. Public health officials also knew that
closing the bath houses could force high-risk sexual behaviors underground. Dritz
was instrumental in negotiating the bath h ouse closures because the gay commu-
nity realized that her chief motive was public health, not condemnation of their
lifestyle. Dritz retired from the health department on April 24, 1984, a fter HIV was
discovered.
Dr. Jonathan Mann, founder of the World Health Organization’s Global Pro-
gramme on AIDS, described the contributions of early public health professionals
and researchers, “Our responsibility is historic. For when the history of AIDS and
the global response is written, our most precious contribution may well be that,
at the time of plague, we did not flee, we did not hide, we did not separate our-
selves” (Mann, 1998). Selma Dritz serves as a role model for other public health
professionals. Her thorough analysis of medical reports, carefully detailed inter-
views with patients, and nonjudgmental interactions helped to identify an unknown
disease. Dritz worked around social stigmas and limited support to focus on stop-
ping AIDS.
Sally Kuykendall
See also: Blackwell, Elizabeth; Community Health Centers; Community Organizing;

Epidemiology; Hepatitis; Human Immunodeficiency Virus and Acquired Immune
Deficiency Syndrome; Infectious Diseases; Lesbian, Gay, Bisexual, and Transgender
Health; Snow, John
Further Reading
Bacchetti, P., Osmond, D., Chaisson, R. E., Dritz, S., Rutherford, G. W., Swig, L., & Moss,
A. R. (1988). Survival patterns of the first 500 patients with AIDS in San Francisco.
Journal of Infectious Diseases, 157(5), 1044–1047.
Curran, J. W., & Jaffe, H. W. (2011). AIDS: The early years and CDC’s response. Morbidity
and Mortality Weekly Report Supplements, 60(4), 64–69.
190 DUNHAM , ETHEL COLLINS
Dritz, S. K. (1995). Charting the epidemiological course of AIDS, 1981–1984, an oral history
conducted in 1992 by Sally Smith Hughes in the AIDS epidemic in San Francisco: The medical
response, 1981–1984. Volume I. Regional Oral History Office, Bancroft Library, Univer-
sity of California, Berkeley. Retrieved from https://archive.org/stream/aidsepidemi
cinsf01chinrich/aidsepidemicinsf01chinrich_djvu.txt.
Mann, J. M. (1998, June 28–July 3). Presentation at XII International Conference on AIDS,
Geneva.
Perlman, D. (2008). Selma Dritz, tracked early AIDS cases, dies. SFGate. Retrieved from
http://www.sfgate.com/bayarea/article/Selma-Dritz-tracked-early-AIDS-cases-dies
-3270092.php.
Roehr, B. (2008). Selma Dritz, obituary. British Medical Journal, 337(7676), 997.
DUNHAM, ETHEL COLLINS (1883–1969)

Ethel Collins Dunham was a pediatrician who developed clinical standards for the
medical care of premature infants. Ethel was born on March 12, 1883, in Hartford,
Connecticut, the eldest of six c hildren of Alice Collins and utility executive Samuel
Gurley Dunham. As wealthy aristocrats, the Collins children and their 14 cousins
were encouraged to support charitable organizations. After graduating from high
school, Dunham spent two years at Miss Porter’s School in Farmington, Connecti-
cut. From 1903 to 1909, she played golf, traveled around Europe, and volunteered.
She found the life of leisure unfulfilling and decided to go to medical school. After
completing prerequisite courses in physics, she enrolled at Bryn Mawr College. At
Bryn Mawr, Ethel met Martha May Eliot. Martha and Ethel decided to attend medical
school together. They enrolled and were accepted at Johns Hopkins University. This
was unusual b ecause few medical schools accepted female students. At Hopkins,
the two women studied and attended public lectures on the suffrage movement and
philanthropy.
After graduation, Dr. Eliot and Dr. Dunham applied for internships in pediatrics
at Johns Hopkins. With limited spaces for female students, they had to sepa-
rate. Dunham completed her internship in pediatrics at Johns Hopkins, working
under Dr. John Howland at Harriet Lane Home while Eliot interned in Boston. In
1919, Dunham moved to Connecticut where she became the first female house
officer at New Haven Hospital and professor at Yale University. Dunham’s ability to
recognize and solve problems garnered the respect of her male colleagues. At Yale,
she purchased a car so that interns could make h ouse calls to new m others and
infants. At New Haven’s outpatient clinic, she implemented an appointment system
to reduce overcrowding and improve patient care. In the hospital nursery, Dunham
convinced the chief obstetrician to allow pediatricians to care for infants. Consis-
tent with her philanthropic roots, Dunham would forgo salary in order to obtain
resources that might improve patient care.
Dunham’s interest and expertise in the medical care of infants gained recogni-
tion. In 1927, she joined the U.S. Children’s Bureau as medical officer in charge
of neonatal studies. This position allowed her to stay in New Haven where she
DUNHA M , ETHEL C OLLINS 191
researched, developed, and piloted best practices in the care of newborns. In 1935,
she left her position at Yale so that she could focus exclusively on developing national
standards for the care of newborns. Within a year, she published her first study,
a statistical analysis of infant mortality. Infant mortality rates w ere horrifying. In
1934, 1 out of 18 infants died within the first year of life and 1 out of 11 infants of
color died (Department of Commerce, 1938). Prematurity was the leading cause of
death in the first year of life. Dunham organized nurses and social workers from
the Children’s Bureau to perform home visits. The nurses monitored infant devel-
opment and nutrition while the social workers supported first-time mothers in the
transition to motherhood. In 1943, Dunham published the Standards and Recom-
mendations for the Hospital Care of Newborn Infants, Full Term and Premature. The
nation was immersed in World War II. Qualified doctors and nurses w ere called to
army field hospitals, tending to the wounded. The health care needs of infants and
mothers at home were overlooked. Dunham recommended regular medical rounds,
coordination of obstetrical and pediatric services, trained pediatric nurses, nurse-
to-patient ratios of 1 to 8 for full-term infants and 1 to 4 for premature infants. The
standards also recommended infection control measures, ventilation and control of
temperature in nurseries, equipment, infant care, and preparation for discharge
(Dunham, 1943). The hospital standards w ere followed by a handbook for physi-
cians. From 1949 to 1951, Dunham worked with the World Health Organization
developing international recommendations in the prevention of premature births.
After retiring in 1952, she continued to advocate for the specialized care of prema-
ture infants. Dunham’s efforts were recognized by the American Pediatric Society
when she became the first female to receive the John Howland Medal for her con-
tributions as a teacher, researcher, and public servant. In 1957, lifelong partners
Ethel and Martha moved to Cambridge to enjoy time together. Ethel died of bron-
chial pneumonia in 1969.
Dr. Ethel Collins Dunham laid the foundation for the fields of neonatology and
perinatology. Her efforts to promote child and maternal health led to one of the
greatest achievements in public health today. Hospitals have specialized nurseries
and trained staff to care for premature infants, and health professionals support
young mothers before, during, and a fter pregnancy. Dunham’s ability to see a prob
lem and identify solutions benefited millions of w omen and c hildren around the
world.
Sally Kuykendall
See also: Children’s Health; Eliot, Martha May; Infant Mortality; Maternal Health;
World Health Organization
Further Reading
Centers for Disease Control and Prevention. (2016). Maternal and infant health. Retrieved
from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/.
192 DUNHAM , ETHEL COLLINS
Department of Commerce. (1938). Birth, stillbirth, and infant mortality statistics: 1936. Wash-
ington, DC: U.S. Government Printing Office. Retrieved from https://www.cdc.gov
/nchs/data/vsushistorical/birthstat_1936.pdf.
Dunham, E. C. (1943). Standards and recommendations for the hospital care of newborn infants,
full term and premature. Washington, DC: U.S. Government Printing Office. Retrieved
from https://archive.org/stream/standardsrecomme00dunh#page/n5/mode/2up.
Dunham, E. C. (1945). Progress in the care of premature infants. American Journal of Nurs-
ing, 45, 515–518.
E
EATING DISORDERS
Eating disorders are serious but treatable m ental disorders that threaten nutritional
status, physical, and emotional health. Mental health professionals recognize three
main types of eating disorders: anorexia nervosa, bulimia nervosa, and binge-eating
disorder (American Psychiatric Association [APA], 2013). Although each disorder
is characterized by different behaviors, common symptoms include obsessions with
food, body weight, and body shape (National Institute of Mental Health [NIMH],
2016). Eating disorders affect males, females, c hildren, and adults and are most com-
mon during adolescence. Underlying causes are thought to be a combination of
genetic, biological, behavioral, psychological, and social factors (NIMH, 2016).
Treatment occurs through a team approach consisting of a primary care provider
for medical care, psychologist and/or psychiatrist for psychotherapy and medication,
and a registered dietitian for nutritional counseling (APA, 2013). Treatment plans
are tailored to the individual’s unique needs.
Individuals with anorexia nervosa are severely underweight yet see themselves
as being overweight. The diagnostic criteria for anorexia nervosa are “[1] persistent
energy intake restriction; [2] intense fear of gaining weight or of becoming fat, or
persistent behavior that interferes with weight gain; and [3] a disturbance in self-
perceived weight or shape” (APA, 2013). There are two types of anorexia nervosa
behaviors. One is the restricting type where one’s weight loss is accomplished by
dieting, fasting, and/or excessive exercise for the last three months (APA, 2013).
The second type, binge-eating/purging type, is accomplished by self-induced vom-
iting or the misuse of laxative, diuretics, or enemas for the last three months. Anorexia
nervosa can be fatal (NIMH, 2016). Hospitalization is necessary to restore fluids
and electrolytes and ensure adequate nutrition for basic body functions.
Individuals with bulimia nervosa may be hard to detect because they usually
maintain a normal weight. The diagnostic criteria for bulimia nervosa are “[1] recur-
rent episodes of binge eating, [2] recurrent inappropriate compensatory behav
iors to prevent weight gain, and [3] self-evaluation that is unduly influenced by
body shape and weight” (APA, 2013). Individuals with bulimia nervosa binge eat
and then force themselves to vomit, exercise, fast, and/or use laxatives or diuretics
(NIH, 2016). The level of disease severity is defined by the APA (2013): mild,
average of 1–3 episodes per week; moderate, average of 4–7 episodes per week;
severe, average of 8–13 episodes per week; and extreme, average of 14 or more epi-
sodes per week. As the level of severity increases, so does the degree of functional
disability.
194 EATIN G DISO R DE RS
The most common eating disorder in the United States is binge-eating disorder.
The diagnostic criteria for binge-eating disorder are: “[1] recurrent episodes of binge
eating; [2] binge-eating episodes are associated with three (or more) [criteria set by
the APA]; [3] marked distress regarding binge eating is present, [4] the binge eating
occurs, on average, at least once a week for 3 months; and [5] the binge eating is
not associated with the recurrent use of inappropriate compensatory behavior as in
bulimia nervosa and does not occur exclusively during the course of bulimia ner-
vosa or anorexia nervosa” (APA, 2013). Shame and the attempt to conceal one’s
symptoms may lead an individual to hide their binge-eating behaviors. The follow-
ing are triggers: “interpersonal stressors; dietary restraints; negative feelings related
to body weight; body shape and food; and boredom” (APA, 2013). The level of
severity for binge-eating disorder is defined by the APA (2013): mild, 1–3 episodes
per week; moderate, 4–7 episodes per week; severe, 8–13 episodes per week; and
extreme, 14 or more episodes per week. As the level of severity increases, so does
the degree of functional disability.
There is another category of eating disorders called the “other specified feeding
or eating disorder.” In order for an individual to qualify for a diagnosis of anorexia
nervosa, bulimia nervosa, and/or binge-eating disorder, the “behaviors must occur,
on average, at least once per week for 3 months” (APA, 2013). However, if an indi-
vidual has symptoms characteristic of an eating disorder that do not meet the full
criteria of anorexia nervosa, bulimia nervosa, and/or binge-eating disorder, the indi-
vidual would fit into this category.
Individual treatment of eating disorders consists of fluid and electrolyte replace-
ment, nutritional counseling, and psychotherapy and medication, as needed. Pub-
lic health works to prevent eating disorders through universal and indicated
prevention programs and comprehensive school health education. Examples of
evidence-based programs to prevent eating disorders are The Weight to Eat (Neumark-
Sztainer & Butler, 1995), Planet Health (Austin et al., 2005), Student Bodies (Taylor
et al., 2006), The Body Project (Stice et al., 2006), New Moves (Neumark-Sztainer
et al., 2010) and Eating, Aesthetic Feminine Models and the Media (González et al.,
2011). A review of nine evidence-based programs discovered common character-
istics among evidence-based eating disorder prevention programs (Ciao, Loth, &
Neumark-Sztainer, 2014). All programs w ere based on health theory, addressed one
or more risk factors, were implemented through multiple sessions over a period of
time, and provided hands-on activities. T here is a need to continue assessing and
evaluating programs to determine which are most effective and to expand programs
to reach a wider range of audiences.
Susana Leong
See also: Body Mass Index; M ental Health; Nutrition; W

omen’s Health; Controver-
sies in Public Health: Controversy 2
ELDE R M ALT R EAT M ENT 195
Further Reading
American Psychiatric Association. (2013). Feeding and eating disorders. In Diagnostic and
Statistical Manual of M ental Disorders (5th ed.). Arlington, VA: Author. doi:10.1176
/appi.books.9780890425596.dsm10
Austin, S. B., Field, A. E., Wiecha, J., Peterson, K. E., & Gortmaker, S. L. (2005). The impact
of a school-based obesity prevention trial on disordered weight-control behaviors in
early adolescent girls. Archives of Pediatrics & Adolescent Medicine, 159(3), 225–230.
Ciao, A. C., Loth, K., & Neumark-Sztainer, D. (2014). Preventing eating disorder pathol-
ogy: Common and unique features of successful eating disorders prevention programs.
Current Psychiatry Reports, 16(7), 453. doi:10.1007/s11920-014-0453-0
González, M., Penelo, E., Gutiérrez, T., & Raich, R. M. (2011). Disordered eating preven-
tion programme in schools: A 30-month follow-up. European Eating Disorders Review,
19(4), 349–356. doi:10.1002/erv.1102
National Institute of M ental Health. (2016). Eating disorders. Retrieved from https://www
.nimh.nih.gov/health/topics/eating-disorders/index.shtml.
Neumark-Sztainer, D., & Butler, R. (1995). Eating disturbances among adolescent girls: Eval-
uation of a school-based primary prevention program. Journal of Nutrition Education,
27(1), 24.
Neumark-Sztainer, D. R., Friend, S. E., Flattum, C. F., Hannan, P. J., Story, M. T., Bauer, K. W.,
& . . . Petrich, C. A. (2010). New moves-preventing weight-related problems in adoles-
cent girls a group-randomized study. American Journal of Preventive Medicine, 39(5),
421–432. doi:10.1016/j.amepre.2010.07.017
Stice, E., Shaw, H., Burton, E., & Wade, E. (2006). Dissonance and healthy weight eating
disorder prevention programs: A randomized efficacy trial. Journal of Consulting and Clin-
ical Psychology, 74(2), 263–275. doi:10.1037/0022-006X.74.2.263
Taylor, C. B., Bryson, S., Luce, K. H., Cunning, D., Doyle, A. C., Abascal, L. B., & . . .
Wilfley, D. E. (2006). Prevention of eating disorders in at-risk college-age women.
Archives of General Psychiatry, 63(8), 881–888.
ELDER MALTREATMENT
Elder maltreatment involves any form of abuse that leads to harm or loss for a vul-
nerable person who is older than 60 to 65 years old. The damage could be physical,
sexual, emotional, financial, or neglect, which includes failure to provide adequate
care or supervision. Elder maltreatment is on the rise. Since 1986, a 150 percent
increase in elder abuse occurred. Around 2 million elders experience abuse or
neglect every year (Snyder, 2014, p. 132). Elder maltreatment can occur within
personal relationships, as well as abuse and neglect of the aged within institu-
tions. Cases are rarely resolved through the criminal justice system, and serious
cases that occur in long-term care facilities and are reported typically end up in
civil courts.
A variety of theories attempt to explain elder maltreatment. Social learning theory
proposes that violence is learned. An abused child is more likely to grow up and
abuse his or her own children. Extended to elder abuse, some adults caring for aged
loved ones were socialized to believe that violence is an appropriate form of
196 ELDER M ALTREATMENT
interaction and will act violently toward elders. Perpetrators normalize violence,
sometimes as a legitimate response to stress, without being aware of it. Abuse also
occurs when adult children consciously engage in violence toward vulnerable elders
as a form of retribution. Old conflicts can reemerge or are aggravated by contra-
dictory ideas on religion, politics, child rearing, or work. Stressed caregiver theory
describes caretakers who are suffering from the strains associated with the responsibil-
ity of providing constant care. When the caregiver experiences peak stress levels,
maltreatment is more likely. Not all caregivers respond to stress the same, so the
psychopathology of caretakers is relevant. Isolation theory holds that the elderly
experience a drop in social bonds, and this facilitates abuse. Diminished social
networks help abusers avoid detection, increase dependence of the elder person,
and amplifies the maltreatment. Dependency theory relies on traditional models
in the field of victimology. It argues that anyone with fewer physical or mental
resources is more susceptible to abuse and neglect. With that in mind, women,
people over the age of 80, and those suffering from dementia suffer from highest
rates of elder maltreatment.
Elder maltreatment is all too prevalent and the most common perpetrators are,
sadly, t hose who are closest to the elder person. Ninety p
ercent of abusers are f amily
members (NCEA, 2015). In intrafamilial cases, abusers have higher unemployment
rates, drug and alcohol problems, a higher rate of previous incidents with the crim-
inal justice system, and are more likely to have a history of hospitalization for
mental health issues. Situations involving one adult child as the exclusive caregiver
are more likely to exhibit elder maltreatment. Adult sons are perpetrators in
64 percent of cases, and in 30 percent of cases perpetrators contend the elder pre-
viously abused them (Ulsperger, 2007, p. 291). In personal care situations, abusers
fall into three categories—hostiles, authoritarians, and dependents. Hostile abus-
ers tend to blame the elder parent for limiting their potential and dominating their
personal resources. Authoritarian abusers tend to be married, have aged parents
living with them, and are more likely to infantilize an elderly parent. Dependent
abusers are financially reliant on the elder. In 77 percent of cases, the caretaker is
somewhat or fully financially dependent on the person cared for, and in 65 percent
of cases, the perpetrator is somewhat or completely dependent on the cared for with
housing (Ulsperger, 2007, p. 292). Although the majority of family perpetrators
are adult c hildren, in a small number of cases the intimate partner may perpetrate
maltreatment. The statistics on elder maltreatment and relatives are believed to be
inaccurate. The sensitive nature of family relationship dynamics means that many
cases go unreported.
Institutionalized maltreatment, which includes long-term care facilities, has devel-
oped into an important issue. In the 1970s, reports of residents receiving inedible
food, staff leaving residents unattended lying in their own excrement, and physi-
cally assaulting the elderly made headlines. Reform movements led to the Omni-
bus Budget Reconciliation Act (OBRA) of 1987. OBRA implemented provisions on
privacy rights, physical restraint use, and new requirements related to managing
ELDE R M ALT R EAT M ENT 197
personal funds. It tightened the survey and certification requirements for nursing
homes, but also made nursing homes one of the most highly regulated industries
in the United States. Intentional elder maltreatment takes place in elder care envi-
ronments due to a variety of reasons, such as racial tension, class conflict, and indi-
vidual psychopathologies. However, research shows that elevated levels of bureaucracy,
promoted by legislation such as OBRA, unintentionally facilitates abuse and neglect.
Inundated with rules and demands for efficiency, staff focus on quality resident
care diminishes. Residents turn into objects of labor. Victimology theory reasons
that when perpetrators view other people as objects, the likelihood of maltreat-
ment increases. Currently, more than 3 million people live in nursing homes in the
United States. Around 44 percent report experiencing abuse, and 95 percent report
either experiencing neglect or witnessing another resident neglected. More than
80 percent of staff report witnessing emotional abuse and 36 percent physical
abuse (Snyder, 2014, p. 136).
The U.S. government currently provides little funding to protect against elder
maltreatment. Organizations dedicated to addressing and reducing elder maltreat-
ment often operate through state and local health agencies. Adult Protective Ser
vices (APS) is one organization dedicated to the issue. APS educates and encourages
individuals to report maltreatment, provides a hotline to report suspected abuse
and neglect, and provides legal services to individuals who experience maltreat-
ment. As the baby-boomer generation ages, awareness of maltreatment issues is
essential to reversing rates of abuse. This includes becoming familiar with specific
laws within your jurisdiction, developing the ability to recognize signs of mistreat-
ment, and having the capacity to assess relationships in order to understand motives
for family involvement.
Jason S. Ulsperger
See also: Aging; Alzheimer’s Disease; Behavioral Health; Care, Access to; Mental
Health; Violence
Further Reading
Gibbs, L., & Mosqueda, L. A. (2014). Medical implications of elder abuse and neglect. Phila-
delphia: Elsevier.
National Center on Elder Abuse. (2015). Statistics/data. United States Department of
Heath and Human Services. Retrieved from http://www.ncea.aoa.gov/Library/Data
/index.aspx.
Payne, B. (2011). Crime and elder abuse: An integrated perspective. Springfield, IL: Charles C.
Thomas.
Snyder, D. R. (2014). Elder crimes, elder justice. Burlington, MA: Jones & Bartlett.
Ulsperger, J. (2007). Elder abuse perpetrated by adult c hildren. In A. Jackson (Ed.), Ency-
clopedia of domestic violence (pp. 290–296). New York: Routledge.
Ulsperger, J. S., & Knottnerus, J. D. (2011). Elder care catastrophe: Rituals of abuse in nursing
homes and what you can do about it. Boulder, CO: Paradigm.
198 ELDER S, JOYCELYN
ELDERS, JOYCELYN (1933–)

Joycelyn Elders is a famous physician and health administrator who served as the
first African American and second w oman surgeon general of the United States, serv-
ing in Bill Clinton’s presidential administration. She was trained as a pediatrician
and was a faculty member for many years at the University of Arkansas Medical
Center, beginning in 1967. As surgeon general, she was best known for her discus-
sions of sensitive issues such as drug legalization, teenage sexuality, and distribu-
tion of contraception in schools.
She was born as Minnie Lee Jones in Schaal, Arkansas, and later changed her
name to Minnie Joycelyn Lee. She grew up in a poor family, with her father work-
ing as a sharecropper. She received her BS degree in biology from Philander Smith
College in Little Rock, Arkansas, in 1952. She then worked as a nurse’s aide in a
veteran’s administration hospital in Milwaukee, before joining the U.S. Army in
May 1953. While in the army, she trained as a physical therapist. After leaving the
army, she attended the University of Arkansas Medical School and obtained her
medical degree in 1960. She completed an internship at the University of Minne-
sota Hospital, followed by a residency in pediatrics at the University of Arkansas
Medical Center. She also earned
an MS degree in biochemistry. As
a faculty member at the Univer-
sity of Arkansas Medical Center,
she advanced from assistant pro-
fessor to professor by 1976. She
received a National Institutes of
Health c areer development award
while there, and certification as a
pediatric endocrinologist in 1978.
Her political and administra-
tive career, rather than her career
as a medical school faculty mem-
ber, began in 1987 when then
Governor Bill Clinton appointed
her as the director of the Arkansas
Department of Health. Among her
proudest achievements in that
position were a tenfold increase
in the number of early childhood
The daughter of a poor Southern sharecropper, Sur-
screenings annually and almost a
geon General Joycelyn Elders gives voice to the
struggles of poor, young minority females. Contro- doubling of the immunization
versies over birth control and sex education led to rates of two-year-old children in
her forced resignation as the nation’s top doctor. Arkansas. Elders pushed aggres-
(National Institutes of Health) sive campaigns to reduce teen
ELIOT, MA RTHA MAY 199
pregnancy by making birth control and sex education more readily available to
teenagers. She also endorsed HIV testing and counseling in the state. She was
elected the president of the Association of State and Territorial Health Officers
in 1992.
President Bill Clinton appointed her the U.S. surgeon general in January 1993.
She was a strong supporter of his health plan and became a controversial nominee
whose appointment was not confirmed u ntil September 7, 1993. She was a strong,
outspoken advocate for health-related causes, such as the distribution of contracep-
tives in school, the exploration of drug legalization, and abortion rights. In 1994, at
a speech at the United Nations, she said schools should consider teaching mas-
turbation to students as a means to prevent sexually transmitted diseases. This
statement was attacked by right wing activists, and the ensuing controversy led to
her being removed from this position by President Clinton in December 1994. She
returned to the University of Arkansas Medical Center and to public lecturing on
issues related to AIDS and teen pregnancy. She continues to live in Little Rock,
Arkansas, as a semiretired professor emerita.
See also: C
hildren’s Health; Human Immunodeficiency Virus and Acquired Immune
Deficiency Syndrome; Men’s Health; Nation’s Health, The; School Health; Surgeon
General; W omen’s Health
Further Reading
Elliott, J. C. (2001). Joycelyn Elders. Black heroes (pp. 216–221). Ipswich, MA: History Ref-
erence Center.
Kronenfeld, J. J. (2011). Elders, Joycelyn. In M. Z. Stange, C. K. Oyster, & J. G. Golson (Eds.),
Multimedia encyclopedia of women in today’s world (pp. 470–471). Thousand Oaks, CA:
Sage.
ELIOT, MARTHA MAY (1891–1978)

Martha May Eliot was a public health pediatrician who advocated for federal poli-
cies to support disadvantaged m others and children. Martha was born on April 7,
1891, in Dorchester, Massachusetts, the second of three c hildren of Christopher
Rhodes and Mary Jackson May Eliot. The Eliot family was a member of a society
referred to as the Boston Brahmins. This powerful and elite group dominated art,
drama, education, politics, and philanthropy on the East Coast. Martha’s grandfather
was the first chancellor of Washington University in St. Louis, her father was a
respected Unitarian minister, and her cousin was the Nobel Prize–winning poet, play-
wright, and literary critic T. S. Eliot. Martha attended Radcliffe College, majoring in
200 ELIOT, M ARTHA MAY
classical literature. During her undergraduate studies, she spent one year at Bryn
Mawr College where she met her future partner, Ethel Collins Dunham. Ethel was
eight years older but one academic year behind Martha. In order that they could
attend medical school together, Martha spent a gap year working in the Social Ser
vice Department at Massachusetts General Hospital. This experience gave her direct
experience with poor w omen and c hildren and introduced her to the concept of
social medicine.
Martha’s first choice of medical school was Harvard School of Medicine. How-
ever, Harvard rejected her because she was female. Johns Hopkins University School
of Medicine accepted both Ethel and Martha. During their time at Hopkins, they
attended lectures on the suffragette movement and philanthropy. Dr. Eliot gradu-
ated with honors and was offered an internship at Johns Hopkins. She turned the
internship down because she wanted to stay near Dunham who was denied a posi-
tion. However, as males were being called to war, Hopkins was forced to expand
their pool and subsequently offered an internship to Dunham. Thus, Dunham stayed
in Baltimore while Eliot interned at Peter Bent Brigham Hospital in Boston. A fter
an additional year in pediatrics residency at Saint Louis C hildren’s Hospital, Dr. Eliot
joined Dr. Edwards A. Parks, teaching and researching at Yale Medical School’s new
Department of Pediatrics.
In 1923, the U.S. Children’s Bureau reached out to the Yale researchers request-
ing collaboration in a study of rickets. Rickets is a disease caused by vitamin D defi-
ciency. Descriptions of the disease are recorded as early as the first and second
centuries CE by the Greek physician Sorano of Ephesus. In places with less sun-
light or dietary sources of vitamin D, c hildren’s bones do not develop normally. The
bones are soft and weak, causing structural deformities. In 1890, zookeepers in Lon-
don successfully treated ricketed monkeys with cod liver oil and ultraviolet light.
The U.S. C hildren’s Bureau decided to test similar treatments among young c hildren
in Boston. Within the first year of the study, pediatricians observed remarkable
success. In the two untreated control groups, 23 percent and 34 percent of c hildren
developed moderate to severe rickets. In the treatment group, 4 percent of the
children developed moderate rickets, and none developed severe rickets (Eliot,
2004). Parks and Eliot presented their results to the American Medical Association,
recommending widespread use of cod liver oil and sunlight to treat and prevent
rickets. B
ecause of these s imple treatments, rickets is now considered an extremely
rare disease.
In 1924, Eliot was named director of the Division of Child and Maternal Health
within the U.S. Children’s Bureau. Led by Katharine Frederica Lenroot (1891–
1982), the Children’s Bureau focused on improving health outcomes for w omen
and c hildren. At the time that Eliot took public office, infant mortality rate was
128 deaths per 1,000 live births, maternal deaths due to sepsis were 23 deaths per
1,000 live births, and maternal deaths due to “other puerperal c auses” (i.e., hem-
orrhage, hypertension or embolism during pregnancy, and childbirth) were 43
ELIOT, M A RTHA M AY 201
deaths per 1,000 live births (Department of Commerce, 1927). Qualified doctors
shunned obstetrics, leaving the care of pregnant w omen and infants to untrained
staff. Lenroot and Eliot designed and drafted federal policies to support maternal
and infant nutrition, prenatal services, postnatal home visits by trained nurses,
parent education, and formal medical training in obstetrics and pediatrics. Title
IV, the Aid to Dependent Children, Title V, and Title VII of the Social Security Act
of 1935, and later, the child labor laws of the Fair L abor Standards Act of 1938
were critical in advancing maternal and child health and continue to support the
health and well-being of women and children t oday. Over the next 80 years, child
welfare policies and advancements in science and clinical care reduced infant
mortality rate to 7.2 per 1,000 live births and reduced maternal mortality rate to
less than 0.1 per 1,000 live births (Centers for Disease Control and Prevention,
2016).
In 1934, Eliot was appointed assistant chief of the Children’s Bureau. The fol-
lowing year, Dunham joined the C hildren’s Bureau as director of child development.
Eliot’s responsibilities included managing the Emergency Maternity and Infant Care
Program. The program provided medical, nursing, and hospital care for the wives
and children of men enlisted in World War II. The program was designed to allevi-
ate servicemen’s concerns for their wives and children at home so that they could
focus on war efforts. Eliot traveled to England to investigate the impact of war on
children. The British government was evacuating c hildren, m others, and disabled
people from areas heavily bombed by Germany to the safety of rural villages. Eliot
studied the British system and c hildren’s ability to cope with the trauma of war.
Her interviews and field study published as Civil Defense Measures for the Protection
of Children advocated for more social workers to support children displaced by war.
After the war, Eliot moved into global advocacy, working with the United Nations
Children’s Fund (UNICEF) and helping to establish the World Health Organization
(WHO). Eliot was the only female to sign the founding documents of the WHO. In
1949, she served as assistant director general of the WHO and in 1957, became
chair of the Department of Child and Maternal Health at the Harvard School of
Public Health (the school that had rejected her for medical school). Eliot retired in
1960 but continued her work with UNICEF and the WHO, advancing care for
women around the world.
Eliot’s public health advocacy was well recognized within her lifetime. In 1947,
she was elected the first female president of the American Public Health Associa-
tion (APHA). In 1948, she was awarded the prestigious Lasker Award for her work
with the Emergency Maternal and Infant Care Program and was also elected presi-
dent of the National Conference on Social Welfare. In 1958, the APHA awarded
Eliot the Sedgwick Memorial Medal for distinguished service and advancement of
public health knowledge and practice. In 1964, the APHA established the Martha
May Eliot award recognizing outstanding service in maternal and child health.
Despite numerous professional awards and acknowledgments, Eliot was often the
202 ELIOT, M ARTHA MAY
target of gender and heterosexual biases. Critics questioned how an unmarried

woman without children could know how to care for pregnant women and children.
Politicians referred to her as “Godmother to the Nation’s Youngsters.” Despite criti-
cism, Eliot stayed focused on her mission. In personal notes to f amily members, she
relates how her relationship with Dunham provided personal and professional
support as well as reprieve from her work. In 1957, Ethel and Martha moved to
Cambridge, Massachusetts. Ethel died of bronchial pneumonia in 1969. Martha died
on Valentine’s Day in 1978.
Martha May Eliot was a member of the far-reaching, liberal Eliot clan, a family
that masterminded the culture, education, and social welfare of a developing nation.
Unmarried, without children of her own, and openly lesbian, Eliot was a woman
of enormous influence and resilience dedicated to the physical and emotional devel-
opment of c hildren. Her efforts in maternal and child health research, advocacy,
and policy proved to be enormously successful, creating a downward trend in infant
and maternal mortality rates that continued into the next c entury.
Sally Kuykendall
See also: Blackwell, Elizabeth; Dunham, Ethel Collins; Infant Mortality; Maternal
Health; World Health Organization
Further Reading
Barclay, D. (1952, April 6). Godmother to the nation’s youngsters. New York Times Maga-
zine, 17.
from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/.
Department of Commerce. (1927). Mortality statistics: 1924. Washington, DC: U.S. Govern-
ment Printing Office. Retrieved from https://www.cdc.gov/nchs/data/vsushistorical
/mortstatsh_1924.pdf.
Eliot, M. (2004). The control of rickets. American Journal of Public Health, 94(8), 1321–1323.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448445/.
Eliot, M. M. (1942). Effect of war and civil defense on children: The British experience.
Social Service Review, 16, 1–36.
Hansen, B. (2002). Public careers and private sexuality: Some gay and lesbian lives in
the history of medicine and public health. American Journal of Public Health, 92(1),
36–44.
Lasker awards for 1948. (1948). American Journal of Public Health, 38, 1717.
Parry, M. S., & Tedeschi, S. K. (2004). Martha May Eliot: “Spinster in steel specs adviser on
maternity.” American Journal of Public Health, 94(8), 1322.
Schmidt, W. M. (1979). Some kind of a social doctor: Martha May Eliot, 1891–1978. Pedi-
atrics, 63(1), 146.
U.S. National Library of Medicine. (2015). Martha May Eliot. Retrieved from https://
cfmedicine.n lm.nih.g ov/physicians/b
iography_99.h
tml.
ELLERTSON , C HAR LOTTE EH R EN G A R D 203
ELLERTSON, CHARLOTTE EHRENGARD (1966–2004)

Charlotte Ehrengard Ellertson advocated for women’s right to self-determination in
reproductive health. Maternal mortality increases among women who have four or
more c hildren (WHO, 2017). The use of birth control to space pregnancy provides
multiple health and social benefits. Birth control improves maternal health and well-
being, reduces the need for abortion, allows parents to focus resources and atten-
tion on a fewer number of c hildren, and empowers w omen to pursue further
education, employment, or community service. Male and female condoms have the
added advantage of protecting against h uman immunodeficiency virus (HIV) and
other sexually transmitted diseases (STDs). Nationally and internationally, birth con-
trol slows population growth, supporting the earth’s resources and the health of
nations. Ellertson was instrumental in identifying the most effective methods of birth
control when regular methods fail or sex is forced.
Charlotte was born in 1966 in Johannesburg, South Africa, to Gabrielle and
Reverend Carroll Ellertson. Gabrielle was an artist. Carroll was a Lutheran minis-
ter based in Minnesota. The Lutheran ministry worked against apartheid in South
Africa, providing education to black men and women and advocating for women’s
rights and racial equality. The family lived in the ZwaZulu-Natal province. Char-
lotte learned to speak several languages and developed a passion for exotic ani-
mals. Gabrielle and Carroll were active supporters of the Rorke’s Drift Art and
Crafts Centre. Established in 1962, the arts center was designed to train local
women in the traditional African arts of weaving and pottery. The hope was that
the women would work as art therapists at Ceza Mission Hospital in Zululand.
The center provided a rigorous education to aspiring artists and is now world
renowned for advancing African arts and crafts. In addition to his work at the
mission, Reverend Ellertson directed a radio show, the Radio Voice of the Gospel.
In 1979, the Ellertsons moved to Minnesota. Gabrielle went back to school for her
bachelor’s degree in fine arts, and Reverend Ellertson continued his work with the
Lutheran church.
In 1987, Charlotte graduated from Harvard University with a degree in bio-
logical anthropology. Her roommates recalled her love of practical jokes and her
pet python, “Precious.” During her undergraduate studies, Charlotte worked as
a contraceptive counselor. She continued her education at Princeton University,
earning a master’s in public affairs (1992) and a PhD in demography and public
affairs (1993). A fter graduation, Dr. Ellertson moved to Africa, working on
reproductive rights with the U.S. Agency for International Development and as a
health educator providing family planning information to a radio broadcasted
soap opera.
In 1995, Ellertson joined the Population Council, an international organ
ization, which works to empower adolescent girls, support family planning, pre-
vent STDs, and eliminate sexual and gender violence. The Population Council
supported research into emergency contraception, medical and surgical abor-
tions, unintended pregnancy, the point of pelvic examinations prior to contraceptive
204 ELLE RTSON , CHA R LOTTE EHR ENGAR D
prescription, intimate partner violence, adolescent pregnancy, and STDs. The

intention was to develop evidence-based programs and practices in family plan-
ning. Ellertson developed expertise in emergency contraception (EC), an oral for-
mula of estrogen and progestin used by women to prevent pregnancy when the
woman is mid-cycle and other birth control methods either failed or were not
used. EC was discovered in the 1920s when researchers noticed that estrogenic
extracts interrupted pregnancy. Soon after discovery, veterinarians used EC to
avert pregnancy in dogs and h orses. If an animal mated too early, before the
female was physically mature enough to carry a pregnancy or while she was still
recovering from a previous birth, the veterinarians could stop the pregnancy. In
the 1960s, Dutch doctors successfully used EC on a 13-year-old who had been
raped during the middle of her menstrual cycle (Haspels, 1994). Women began
to use EC with some harmful side effects. In the 1970s Dr. Albert Yuzpe developed
a regimen that featured four doses of easily accessible hormones and had fewer
side effects (Ellertson, 1996). Independent researchers found Yuzpe’s method to
be safe and effective. In 1994, the International Conference on Population and
Development officially supported women’s right to use EC. During her research,
Ellertson often found that women w ere reluctant to report intimate sexual behav
iors and concerns to their health care providers, and some health care providers
refused to provide services, referrals, or information to women seeking EC. In
2002, she founded the organization Ibis Reproductive Health. The purpose of Ibis
was to bridge research and women’s health practices. In 2004, at the age of 38,
Ellertson died of breast cancer. In her short lifetime, she published more than 100
journal articles, book chapters, and technical reports. Her research continues to
raise questions of w hether women need a pelvic examination in order to use birth
control and w hether prescriptions are truly needed for birth control (Grossman,
Ellertson, Abuabara, Blanchard, & Rivas, 2006).
Charlotte E. Ellertson performed multiple research studies comparing effectiveness
and cost of birth control and emergency contraception. From her research, public
health organizations were able to develop programs and guidelines to promote
women’s health and reduce maternal and infant mortality. Ellertson believed in
demedicalization of family planning. She believed that women are capable of
identifying their own needs for birth control, are capable of attaining birth control
pills from a local pharmacy, and are capable of following the instructions on the
package. She was instrumental in improving w omen’s health by advocating for FDA
approval of RU-486 and emergency contraception. Today, many women enjoy a
better quality of life, free from the fear of unintended pregnancy, due to the efforts
of Charlotte Ellertson.
Sally Kuykendall
See also: Elders, Joycelyn; Family Planning; Maternal Health; Planned Parenthood;
Sanger, Margaret Louise Higgins; W omen’s Health
EMERGENCY MEDICAL T R EATM ENT AND LAB O R A C T ( E M TALA ) 205
Further Reading
Ellertson, C. (1996). History and efficacy of emergency contraception: Beyond Coca-Cola.
Family Planning Perspectives, 28(2), 44–48.
Grossman, D., Ellertson, C., Abuabara, K., Blanchard, K., & Rivas, F. T. (2006). Barriers to
contraceptive use in product labeling and practice guidelines. American Journal of Pub-
lic Health, 96(5), 791–799.
Haspels, A. A. (1994). Emergency contraception: A review. Contraception, 50, 101–108.
doi:10.1016/0010-7824(94)90046-9
Population Council. (2017). Available at http://www.popcouncil.org/.
Princeton Alumni Weekly. (2016). Charlotte E. Ellertson *93. Retrieved from https://paw
.princeton.edu/memorial/charlotte-e-ellertson-93.
Trussell, J., Stewart, F., Potts, M., Guest, F., & Ellertson, C. (1993). Should oral contracep-
tives be available without prescription? American Journal of Public Health, 83(8),
1094–1099.
World Health Organization. (2017). Family planning/contraception. Retrieved from http://www
.who.int/mediacentre/factsheets/fs351/en/.
EMERGENCY MEDICAL TREATMENT AND

L ABOR ACT (EMTALA)
Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) in
response to patient dumping, a practice where private hospitals would discharge
or transfer medically indigent patients even when the patient was not stable. The
maneuver was primarily motivated by finances, an effort by hospitals to avoid treat-
ing patients on Medicare. Physicians at Cook County Hospital in Chicago were
concerned for the patients and shed light on the practice through published research
studies. The research indicated that 87 percent of patient transfers to other hospi-
tals w
ere due to lack of insurance, 24 percent of the transferred patients were unsta-
ble at the time of transfer, and transferred patients were twice as likely to die in
comparison to other patients in the receiving hospital (Ansell & Schiff, 1987; Schiff,
Ansell, Schlosser, Idris, Morrison, & Whitman, 1986). The doctors concluded that
dumping jeopardized patient safety and that minority and unemployed individuals
were disproportionately targeted. Under EMTALA, emergency departments must
screen and stabilize patients before transfer or discharge. Anyone with a medical
emergency who seeks treatment at an emergency room, regardless of ability to pay,
has the right to medical screening and stabilization. The law applies to all facilities
that accept Medicare, approximately 98 percent of all U.S. hospitals (Zibulewsky,
2001). Transfers are permitted under certain conditions. Facilities are responsible
for posting notices advising patients of their rights to treatment. Although EMTALA
was originally designed for emergency departments, the regulations have expanded
to all aspects of patient care in hospitals. The law is one of the most comprehensive
laws prohibiting discrimination against individuals based on ability to pay. EMTALA
supports public health by ensuring that people receive the emergency care that they
need, when they need it.
206 EM ER G EN C Y MEDICAL TREATMENT AND LAB O R A C T ( E M TALA )
There are four key parts to EMTALA: (1) the patient, (2) an emergency medical
condition, (3) right to medical screening, and (4) right to stabilization or medically
indicated transfer. EMTALA states that anyone who comes to the emergency depart-
ment with a medical condition cannot be turned away. The statute does not simply
mean patients who are formally admitted. Someone who collapses on the street out-
side of the emergency department or has a heart attack in the ambulance on the
way to the emergency department is covered by the law. The person does not have
to be physically in the hospital building. The emergency medical condition includes
acute illnesses as well as labor and delivery when the woman is having contractions
or there is not enough time for transfer to a maternity hospital. Medical screening
is defined as the type of screening exam provided to insured patients. Medical
screening goes beyond history and physical exam to include blood tests, X-rays, or
consults by specialists (Zibulewsky, 2001). The obligation of medical screening
is fulfilled when possible diagnoses are ruled out or stabilized. Stabilization varies
by disease or injury. Stabilization may mean medication, immobilization, fluid
replacement, or mechanical ventilation. For the purposes of the law, stabilization
means that the patient is not reasonably expected to deteriorate due to transfer or
during transfer. Patients may be transferred if the patient requests transfer or the
physician advises transfer for medical reasons and the benefits of transfer outweigh
the risks. As part of the regulations, hospitals that specialize in certain diseases or
treatments must accept medically indicated transfers. As with any law, penalties are
imposed for violation. Fines range from $25,000 (for hospitals fewer than 100
beds) to $50,000 per patient. The fines are paid out of pocket and are not covered
by malpractice insurance. Physicians and hospitals found in violation may be denied
future participation in the Medicare program, which essentially means they are
out of business.
EMTALA, also known as the patient antidumping law, was passed as part of the
Consolidated Omnibus Reconciliation Act (COBRA) of 1986. EMTALA requires hos-
pitals to provide adequate care to uninsured or underinsured individuals. The law
has become a significant factor in ensuring that patients who are supported through
public funds have access to the emergency care that they need.
Leapolda Figueroa and Sally Kuykendall
See also: Administration, Health; Centers for Medicare and Medicaid Services; Public
Health Law
Further Reading
Ansell, D. A., & Schiff, R. L. (1987). Patient dumping. Status, implications, and policy rec-
ommendations. Journal of the American Medical Association, 257(11), 1500–1502.
Centers for Medicare and Medicaid Services. (2016). Emergency Medical Treatment & Labor
Act (EMTALA). Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legis
lation/EMTALA/.
EMERG EN C Y P R EPA R EDNESS AND R ESPONSE 207
Schiff, R. L., Ansell, D. A., Schlosser, J. E., Idris, A. H., Morrison, A., & Whitman, S. (1986).
Transfers to a public hospital: A prospective study of 467 patients. The New E ngland
Journal of Medicine, 314(9), 552–557.
Zibulewsky, J. (2001). The Emergency Medical Treatment and Active Labor Act (EMTALA):
What it is and what it means for physicians. Proceedings (Baylor University. Medical Center),
14(4), 339–346. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305897/.
EMERGENCY PREPAREDNESS AND RESPONSE

Emergency preparedness and response is a specialized field of public health that
plans for, prepares, and practices responses to public health emergencies resulting
from natural disasters, infectious diseases, bioterrorism, chemical, or radiation and
nuclear threats. Although different incidents require different interventions, there
are common actions individuals and organizations may take to minimize the impact
of a disaster. Public health organizations play critical roles in identifying threats,
mobilizing resources, aiding victims, and supporting communities.
The need for a specialized field in public health emergency preparedness and
response was first realized with the 2001 World Trade Center terrorist attacks. On
9/11, 2,996 people died and more than 6,000 were injured. Emergency responders
pulled victims from the wreckages, sacrificing their own lives to help o thers. Critically
ill survivors were taken to the nearest hospitals. In New York City, non-critically
injured survivors w ere ferried to waiting ambulances in Jersey City. Physicians,
nurses, and medical technicians treated thousands of victims through the organized
chaos. Dust, rubble, and smoke filled the air. Confused and shocked residents walked
for miles to safety. Teachers carried wheelchair-dependent students by piggyback.
People with respiratory conditions covered their faces with wet towels to filter the air.
Before the nation had time to recover, a second bioterrorist attack occurred, deadly
anthrax delivered via the U.S. Postal Service to media outlets and senate offices. The
horrific events exposed the need for an organized public health response to disasters.
In public health, the first line of defense is the 250,000 public health workers,
760,000 doctors, 2.7 million nurses, and other medical staff who screen, diagnose,
and treat patients every day. Medical professionals are trained to detect unusual dis-
eases, patient complaints, or symptoms that may signal a threat to public health. The
Centers for Disease Control and Prevention (CDC) Emergency Operations Center
(EOC) fields calls from health professionals, government officials, and members of
the general public. A team of experts reviews all reports to identify possible pat-
terns of disease and at-risk groups and to recommend a plan of action. Public
health laboratories are on call 24 hours a day. Located throughout the nation, pub-
lic health laboratories are equipped to handle and test potentially biohazardous spec-
imens. When an urgent threat is identified, the CDC deploys scientists to the area
to provide expert advice. The threat is communicated to the Division of Strategic
National Stockpile, a stockpile of over seven billion dollars’ worth of drugs and med-
ical supplies, which may be needed for catastrophic events.
208 EM ER G EN C Y PREPAREDNESS AND RESPONSE
During a natural or man-made disaster, the general public needs clear, concise,
and accurate information in order to make smart decisions to e ither move to safety
or shelter in place. Scare tactics do not work. Fright paralyzes people. Health com-
munications is a specialized field of public health. The Health Alert Network (HAN)
is a communication network that disseminates clear and accurate information
during public health emergencies. Messages are classified as health alerts (high
priority), health advisories (warnings), health updates, and general information.
Health alerts provide background information on the specific causal mechanism,
identify at-risk groups, and provide recommendations for intervention, treatment,
and prevention. The information is disseminated directly to federal, state, territo-
rial, and local health officers, public health practitioners, health organizations, and
the media. The Crisis & Emergency Risk Communication (CERC) uses evidence-
based practices to communicate with the general public. CERC provides training,
resources, and materials on how to communicate in ways that empower people
to make life-saving decisions. The CDC supports health communications in a
disaster by maintaining an online database of fact sheets for use by the public in an
emergency.
Individuals play a critical role in emergency situations. Failure to act or to respond
wisely threatens the life of the person, family members, and first responders who
may need to deploy search and rescue. Individuals can prepare for emergencies by
knowing potential natural disasters or weather emergencies that occur within their
geographic region. Planning for severe earthquakes, floods, hurricanes, landslides,
tornadoes, tsunamis, volcanoes, wildfires or extreme heat or cold can save precious
minutes. The CDC recommends gathering a three-day supply of food and water,
personal care items, safety supplies, electronics, important documents, and cash.
Depending on individual and family circumstances, it may also be necessary to pack
prescription medicine, medical supplies, infant formula, or baby or pet supplies.
The supplies should be stored in portable waterproof containers. Homeowners and
renters can control damage by knowing where and how to turn off residential gas,
electric, and w ater supplies. It is important for friends and family members to have
a plan to communicate during an emergency. Children should be taught to dial 911
and how to respond to an emergency. It is helpful to memorize important telephone
numbers or keep a contact card with telephone numbers in a wallet, purse, or book
bag. Beyond communicating with family members, individuals should listen to cred-
ible sources of information to determine what is going on in the area, safe places to
go, and how to access shelter resources.
The CDC is prepared to respond to numerous anticipated and unanticipated
emergencies, for example, an anthrax attack. Anthrax is a deadly bacterium that
lives in the soil, easily grown in a laboratory and manipulated as a weapon of bio-
terrorism. Anthrax is tasteless and odorless. It could be released in the air, water,
or food without immediate detection. To prevent unintentional transmission, the
federal government and international agreements regulate the possession and
use of hazardous biological materials. To control intentional transmission, the CDC
E ME R G EN C Y P R EPA R EDNESS AND R ESPONSE 209
educates local, state, territorial, and tribal health departments on ways to detect
and respond to threats. Initially, a patient may appear at a clinic, doctor’s office, or
hospital with signs of anthrax. The health care provider would contact the EOC.
Specimens would be sent to public health laboratories through the Laboratory
Response Network (LRN), and the patient would start treatment with antibiotics.
Federal agencies would deploy field staff to complete an epidemiological investiga-
tion, identifying the source of contamination. And doctors would treat symptom-
atic patients using best practices clinical guidelines published by the CDC. If the
event is a mass-casualty incident, beyond the scope and ability of local health care
services, the CDC would deploy medical professionals and stockpiled medical
countermeasures (MCMs) to Points of Dispensing (PODs). PODs are schools, com-
munity centers, or areas familiar and easily accessible to local residents. Residents
would be directed by the media and local officials to report to the PODs, where
symptoms would be assessed and possibly exposed people would be treated with
antibiotics or antitoxins. A fter the threat is contained, the CDC assesses what
worked and what did not work in order to improve future responses.
People respond to traumatic events in different ways. It is normal to feel sorrow,
anxiety, or grief a fter a life-challenging event. Many p eople can become overwhelmed
by shock, fright, sorrow, or anger. Public health assists in recovery after natural and
man-made disasters. Experts recommend that survivors stay informed, take care of
themselves, rest, and connect with others. Volunteering, creative expression, stress
management, and advocacy can help survivors to create their own story out of disas-
ter. To assist individuals and families, the Substance Abuse and M ental Health
Services Administration (SAMHSA) offers the Disaster Distress Helpline (1-800-
985-5990 or TTY for the hearing impaired, 1-800-846-8517).
Responding to disasters and assisting in control and recovery are part of the mis-
sion of public health of preventing infectious diseases, controlling injuries, protect-
ing against environmental hazards, facilitating access to quality health services, and
promoting overall well-being. The public health system detects and responds to
disasters by maintaining a formal surveillance system for sudden and urgent health
events. In the event of an emergency, the Department of Homeland Security, CERC,
the Office of Public Health Preparedness and Response, and the Centers for Dis-
ease Control and Prevention work with state, local and other federal agencies to
coordinate effective responses. The main goal of public health preparedness and
response is to empower individuals in order to contain the event, minimize loss,
and restore health and well-being.
Sally Kuykendall
See also: Antibiotic Resistance; Association of Public Health Laboratories; Bioter-

rorism; Centers for Disease Control and Prevention; Environmental Health; Envi-
ronmental Protection Agency; Epidemiology; Infectious Diseases; Substance Abuse
and Mental Health Services Administration; Violence; Zombie Preparedness
210 EN VIR ON M ENTAL HEALTH
Further Reading
Centers for Disease Control and Prevention. (2007). Emergency preparedness and response.
Retrieved from https://emergency.cdc.gov/.
Centers for Disease Control and Prevention. (2016). Coping with a disaster or traumatic event.
Retrieved from https://emergency.cdc.gov/coping/index.asp.
Substance Abuse and Mental Health Services Administration. (n.d.). Disaster distress helpline.
Retrieved from http://www.samhsa.gov/find-help/disaster-distress-helpline.
tion. (2001). The public health response to biological and chemical terrorism: Interim plan-
ning guidance for state public health officials. Retrieved from https://emergency.cdc.gov
/Documents/Planning/PlanningGuidance.PDF.
U.S. Department of Homeland Security. (2017). Retrieved from https://www.ready.gov/.
ENVIRONMENTAL HEALTH
A recent report published by the World Health Organization (WHO) estimated that
12.6 million p eople die each year due to unhealthy living or working environments
(WHO, 2016). The National Environmental Health Association Committee (NEHA,
2013) defines environmental health as a component of public health that prevents
injury and illness, promotes wellness, reduces the impact of hazardous agents in
the environment, and improves the safety of air, food, w ater, and soil. Hazards
develop as a result of interaction between human beings and their environment.
Environmental health focuses on assessing, evaluating, and controlling environmen-
tal contaminants that pose threat to human health, and seeking ways to prevent
against diseases and injury caused by pollutants. The most critical environmental
toxins are those that affect the quality of the outside air, surface, or ground w ater
supply. The presence of such contaminants adversely affects body systems and qual-
ity of life detracting from years of healthy life.
The average adult breathes more than 24 kilograms of air daily (Moeller, 2005).
Disposal of airborne waste in the form of gases, droplets, or particulates pollutes
the air and impairs the ability to breathe. Environmental health researchers study
air quality. The most common air pollutants come from emissions by automobiles,
airplanes, or industrial sites; dust raised during agricultural processes; and smoke
from forest fires or wood burning. Pollution is created when engine and fuel gases
interact with the air under direct sunlight. The pollution contributes to poor air
quality. Secondhand smoke is another serious air pollutant. The World Health
Organization (WHO, 2016) reports an estimated 8.2 million people die annually
due to secondhand inhalation of cigarette smoke. Direct and indirect smoking irritates
the eyes, respiratory tract, and lungs, resulting in coughing, sneezing, asthma, tight-
ness of the chest, or death due to severe acute respiratory syndrome (SARS), lung
cancer, or cardiovascular disease. Air pollution also occurs within homes.
Household pollutants occur from cooking and heating homes with stoves, wood,
or other nonventilated fires. Household air pollution contributes to pneumonia,
stroke, ischemic heart disease, chronic obstructive pulmonary disease (COPD), lung
EN VI R ON M ENTAL HEALTH 211
cancer, and premature death (WHO, 2016). Environmental health focuses on

improving the quality of air, both outside and inside the home, as a way to mini-
mize health issues and promote quality of life.
Global warming is a specific environmental health problem evidenced by rising
average temperature across the globe. Higher temperatures are caused by large
amounts of carbon dioxide and greenhouse gases in the atmosphere. H uman activ-
ities, such as burning fossil fuels, forest fires, industrial processes, and agricultural
practices, create global warming with subsequent climate change. Climate change
affects the environment in a variety of ways, including persistent rising ocean tides
and sea levels, heavy rains, floods, storms, winds, and severe heat waves. Changes
result in reduced air quality, promotion of communicable pathogens, and potential
for more frequent national disasters. All of these factors affect h uman health and
promote h uman suffering. The role of the U.S. Environmental Protection Agency
(EPA) is to control and monitor greenhouse gas (GHG) emissions, to protect human
life, and to minimize human suffering. The EPA works through partnership with
private sectors and local government to promote voluntary energy and climate pro-
grams. To reduce GHG, the EPA initiated several regulatory initiatives, including
vehicle greenhouse gas rules. T hese rules are expected to eliminate 6 billion metric
tons of GHG pollution and save $1.7 trillion at the pump by 2025 (EPA, 2016).
Ground and surface water are the main sources of drinking water for many families.
In many areas of the country, ground w ater can be accessed from rain, snow, well,
or bore hole. Using ground or surface w ater provides an inexpensive and conve
nient source of water. However, such sources can be easily contaminated by
human activities. Lakes, rivers, and streams may become polluted with inorganic
contaminants, volatile organic chemicals, pesticides, radioactive materials, or min-
erals (Moeller, 2005). Environmental health focuses on providing safe, clean water
for drinking and sewage.
Another component of environmental health is monitoring and promoting a
healthy environment by reducing exposure to harmful waste products. Hazardous
wastes are solid wastes produced from manufacturing and industrial processes that
have been identified by the Environmental Protection Agency (EPA) to cause seri-
ous disease or illness. Nonhazardous wastes are often called municipal wastes, and
they include refuse, garbage, sludge, plastics, and municipal trash. Experts estimate
that the United States produces about 6 billion tons of hazardous waste and 160
million tons of municipal waste each year (Moeller, 2005). Government and local
environmental health officials take the disposal of toxic and hazardous waste seri-
ously. Whereas municipal waste, which has minimal health risks to h umans, is bur-
ied under the ground, hazardous waste is carefully disposed through sanitary
landfill. Toxic substances and hazardous wastes are classified as solid waste by Con-
gress in the Resource Conservation and Recovery Act (RCRA) of 1976. The EPA
has the jurisdiction to enforce the mandate of the RCRA.
An environmental health professional or specialist is a university graduate
with a bachelor’s degree and certification from an approved environmental health
212 EN V IR ON M ENTAL HEALTH
program. Additional specialization is available to those individuals who want to

pursue advanced degrees in environmental health, environmental epidemiology,
toxicology, or public health. Environmental health specialists are trained to investi-
gate and assess air, water, soil, and the living and working environments in order
to determine compliance with government regulations. Responsibilities include
handling complaints, collecting data, interpreting evidence, resolving concerns, and
providing health education to the public. Positions are available in government and
private sectors, as well as in academic, research, and consulting firms. According
to the Bureau of Labor Statistics, the salary for an environmental health specialist
ranges from $36,300 to $102,610 per year.
The field of environmental health continues to expand and embrace emerging
issues that affect human health. In the United States, as well as in other parts of the
world, climate change and global warming, disaster preparedness, exposure to
unknown hazards, and bioterrorism are becoming g reat challenges to the field of
environmental health, especially as they relate to human safety. Furthermore, global
warming is changing the nature of public health to include greater focus on natural
disasters due to floods, hurricanes, and drought. Although current efforts focus on
disaster readiness to protect h uman health and safety, future efforts must include
structural designs for solid roads, bridges, water banks, and a transportation sys-
tem that can withstand strong storms, wind, and tornados. Emerging issues, such
as clean energy, disposal of electronic devices, and overuse of plastic, should be
part of the national agenda. Achievement of these goals begins with creating and
supporting strong alliances with environmental shareholders, policy makers, gov-
ernment, and community leaders.
Victor Okparaeke
See also: Air Pollution; Bioterrorism; Environmental Protection Agency; Global

Health; Modern Era, Public Health in the; Population Health; Prevention; U.S. Pub-
lic Health Service; World Health Organization; Controversies in Public Health: Con-
troversy 4
Further Reading
Environmental Protection Agency (EPA). (2016). Climate change indicators in the United States
(4th ed.).
Moeller, D. W. (2005). Environmental health (3rd ed.). Cambridge, MA: Harvard University
Press.
National Environmental Health Association. (2013). New perspective on environmental
health: The approval of new definition. Journal of Environmental Health, 76(3), 72–73.
Retrieved from http://neha.org/sites/default/files/about/JEH-Oct-2013-Definition
-Environmental-Health.p
df.
World Health Organization (WHO). (2016). Preventing disease through healthy environments
(2nd ed.). Geneva: Author.
ENVIRON M ENTAL P R OTEC TION A G EN C Y ( EPA ) 213
ENVIRONMENTAL PROTECTION AGENCY (EPA)

Life on earth depends on water, nutrients from the soil, energy from the sun, and
oxygen from the atmosphere. Environmental degradation c auses disease. W ater pol-
lution causes hepatitis, cholera, typhus, yellow fever, and West Nile virus. Water
pollution disrupts the food chain and destroys the ecosystem, increasing infec-
tious diseases. Land pollution causes cancer and respiratory prob lems and
breeds rats and other vectors that transmit disease. Air pollution causes asthma,
birth defects, cancer, developmental disabilities, heart disease, and reproductive
problems. Global warming increases the frequency and severity of heat waves,
floods, and other extreme weather events, which expands the regions of disease-
carrying vectors (mosquitos and ticks) and lengthens the seasons for mold, plant
allergen, and pollen growth. Rising sea levels contaminate water and food supplies.
The Environmental Protection Agency (EPA) is the federal agency responsible for
supporting public health by protecting the air, w ater, and land.
The social and political movement of conservation and environmentalism started
with environmental degradation. During colonial times, drinking water was drawn
from a centralized spring or well or a nearby river. Boston was the first city to build
waterworks to provide a plentiful source of clean water (Kempe, 2006). Boston’s
Conduit was not so much for drinking, bathing, or cleaning as it was for fighting
fires. The thatched rooves of the city spread fires quickly. The system of wooden
pipes was intended to fight fires. As city populations grew, so did refuse, waste,
noise, and odors. People disposed of garbage and trash wherever they could,
attracting rats and other vermin. In urban communities, neighbors shared an out
house. Animals wandered through the streets, dropping refuse and spreading
germs. Industries discharged waste and chemicals into rivers, streams, and lakes.
Cemeteries sprung up near lakes and streams, contaminating drinking water dur-
ing rainy seasons. Not surprisingly, deadly epidemics of cholera, typhoid, small-
pox, and yellow fever occurred regularly. The industrial movement of the 1800s
further compounded overcrowding, lack of sanitation, and deadly diseases. Atti-
tudes and practices started to change with John Snow’s study of cholera and Robert
Koch’s four postulates of infectious disease. Although germ theory created aware-
ness, the problems of bacterial contamination were limited by the lack of tests for
contamination. It was not u ntil Julius Richard Petri’s discovery of Apgar in 1887
that state boards of health could test public drinking water for bacterial contamina-
tion. Even with available testing, boards did not have the authority to close public
wells or waterworks. Boards could only recommend that a community stop
using a contaminated source. In 1893, the Quarantine Act gave boards of health
the authority and responsibility to prevent the transmission of communicable dis-
eases, which included ensuring the safety of public sources of drinking water.
As humans invaded forests, fields, and mountains, interest in conservationism
grew. The literature of Herman Melville, Henry David Thoreau, John Burroughs,
and John Muir presented people with the beauty and spirituality of nature (EPA,
214 EN VIR ON M ENTAL PROTECTION AGENCY (EPA )
1992). Preservation of natural resources became a priority u nder President Theo-

dore Roosevelt. In 1916, President Woodrow Wilson founded the National Park
Service. In 1933, President Franklin Roosevelt founded the Civilian Conservation
Corps, a work relief program aimed at protecting natural resources. After World
War II, economic growth and the baby boom pushed families into the suburbs,
replacing farms and fields with housing developments. Confronted directly by
nature, interest in land preservation and ecology increased along with fears of radio-
active fallout and air and water pollution. When marine biologist Rachel Carson
published Silent Spring (1962), the nation took notice. Carson’s book warned of the
harmful effects of indiscriminate pesticide use. The landmark event that led to the
creation of the EPA occurred in 1969. Oil, trash, and debris floating on the Cuyahoga
River in Ohio caught fire (Rotman, 2016). The river had actually caught fire several
times. The largest and most destructive fire was in 1952 and caused more than $1
million in damage. Ohio’s factories and towns had dumped waste, sewage, and trash
into the river for decades. When industries closed, Cleveland residents were left
with the most polluted river in America. A fter the 1969 fire, Time magazine pub-
lished a photograph from the 1952 fire, the image of a small tugboat fighting mul-
tistory flames with thick, black, oil-fueled smoke.
A combination of events, the publication of Silent Spring, the Cuyahoga River
fire, and public concern launched the environmental movement and demand for
action by federal and state authorities. Wisconsin senator Gaylord Nelson brought
the environmental movement to Washington, DC. The founder of Earth Day, Nel-
son believed, “Environment is all of America and its problems. It is rats in the
ghetto. It is a hungry child in a land of affluence. It is housing not worthy of the
name; neighborhoods not fit to inhabit” (Nelson Institute for Environmental Studies,
n.d.). Presidents Kennedy, Johnson, and Nixon used the popularity of the environ-
mental movement to campaign for and win their presidencies. U nder public and
political pressure, Nixon created the EPA in 1970. The regulatory agency provided
an umbrella for what w ere previously piecemeal efforts in pesticide research and
control, air pollution, water quality, solid waste management, and radiation con-
trol. The EPA assumed responsibilities from the Department of Agriculture, Depart-
ment of Health, Education and Welfare, Department of the Interior, Food and
Drug Administration, and the Bureaus of Solid Waste Management, Water Hygiene
and Radiological Health. Nixon named William D. Ruckelshaus as the first EPA
administrator.
Today, the EPA’s purpose is to (1) protect all Americans from significant environ-
mental health risks, (2) ensure that efforts to reduce environmental health risks are
based on accurate science, (3) provide fair and effective enforcement of federal laws
designed to protect the environment, (4) integrate environmental protection prac-
tices into new federal policies, (5) ensure access to accurate environmental infor-
mation by all members of society, and (6) support and lead international efforts in
protecting the global environment (EPA, 2017). As history has shown, not everyone
EN V IR ON MENTAL P R OTE C TION A G EN C Y ( EPA ) 215
hildren playing near a dead horse in New York City, ca. 1905. As city populations grew,
C
so did refuse, waste, noise, odors, and pollution. Deadly epidemics of cholera, typhoid,
smallpox, and yellow fever occurred regularly and local health officers held l ittle authority.
In 1970, President Richard Nixon created the Environmental Protection Agency (EPA) to
protect Americans from environmental hazards. (Library of Congress)
voluntarily supports environmental protections. The EPA fulfills its mission

through regulations and enforcement, grant funding, research, partnerships with
businesses, nonprofit agencies, state and local governments, and health and envi-
ronmental education. Some of the many public health concerns covered by the EPA
are acid rain, air quality, bed bugs, climate change, drinking water, hazardous waste
cleanups, lead poisoning, mold, pesticides, radon, and recycling. The agency is
critical in ensuring that businesses, communities, and nations respect the earth and
do not cause harm to human life.
Sally Kuykendall
See also: Air Pollution; Association of Public Health Laboratories; Centers for Dis-
ease Control and Prevention; C hildren’s Health; Disease; Environmental Health;
Food Safety; Grants; Quarantine; Waterborne Diseases
216 EPIDEM IC
Further Reading
Environmental Protection Agency (EPA). (1992). The guardian: Origins of the EPA. Retrieved
from https://archive.epa.gov/epa/aboutepa/guardian-origins-epa.html.
Environmental Protection Agency (EPA). (2017). Retrieved from https://www.epa.gov/.
Kempe, M. (2006). New England w ater supplies: A brief history. Journal of the New England
Water Works Association, 120(3), 1–158. Retrieved from http://www.mwra.com/04water
/html/historypaper/historypaper-mwra-kempe.html.
Nelson Institute for Environmental Studies. (n.d.). Gaylord Nelson and Earth Day: The mak-
ing of the modern environmental movement. Madison: University of Wisconsin. Retrieved
from http://www.nelsonearthday.net/nelson/.
Rotman, M. (2016). Cuyahoga River fire. Cleveland historical. Retrieved from https://
clevelandhistorical.org/items/show/63.
EPIDEMIC
Epidemic is defined as an unexpected outbreak or spread of disease(s) within a
group of p eople at a specific period of time. The word epidemic is a combination of
two Greek words epi, meaning “upon, among, t oward,” and demos, meaning “com-
mon people.” The term may apply to both infectious and noninfectious diseases.
Noninfectious disease epidemics are health events, occurrences, conditions, or cases
affecting a particular population. Examples of noninfectious epidemics are lead poi-
soning among children living on former Superfund sites, mesothelioma related to
asbestos exposure among shipyard workers, or post-traumatic stress disorder (PTSD)
among veterans. In comparison to sporadic cases of disease, epidemics are statisti-
cally significant increases in cases. For example, in 2013, there were 2,372 cases of
pertussis (whooping cough) in California. In 2014, cases increased to 10,831, and
by 2015 the number of cases decreased to 4,683 (California Department of Public
Health, 2016; Winter, Glaser, Watt, Harriman, & CDC, 2014). The 2014 incidence
rates were in excess of expected. When an epidemic spreads beyond the initial,
immediate region or across continents, the spread is upgraded to a pandemic. Car-
diovascular disease, obesity, and HIV/AIDS are pandemic health issues. When a dis-
ease is contained within a population and becomes a natural part of life, the problem
is classified as endemic. Rocky Mountain spotted fever is endemic to certain areas
on North, Central, and South America. Travelers to and residents of endemic
regions are warned to take precautions to avoid tick bites. An epidemic with an
alarmingly high rate of mortality is referred to as a plague. The Justinian plague
(541–542) is estimated to have killed more than 25 million people throughout the
Mediterranean region. Understanding the history and science of epidemics offers
insight into public health prevention and control of future epidemics and significant
loss of life.
Since epidemics are an emerging health threat, as opposed to an existing prob
lem, several commonalities exist in when or how epidemics occur. Epidemics
develop when the virulence of the pathogen or strength of the causal mechanism
increases, the pathogen develops new portals of entry or modes of transmission, or
EPIDE M I C 217
the host becomes more susceptible to the causal agent. In 2000, the bacteria Clos-
tridium difficile mutated to a stronger strain and over the next seven years, deaths
increased 400 percent (CDC, 2013). Multiple environmental, socioeconomic, cul-
tural, and geographic conditions influence susceptibility of potential hosts. Cases
of mosquito borne diseases are higher in years with a mild winter, early and warm
spring, dry spring and summer, or wet autumn. Geography can e ither facilitate or
inhibit the spread of infections. Mountain ranges, deserts, and dense forests limit
human interaction, stopping the spread. Waterways and transportation routes
enhance opportunities for communicable disease transmission. Scientists note that
the genomes of Zika have not changed in more than 70 years (Maron, 2016). What
did change was geography. Zika was traditionally contained within remote areas of
Uganda, Nigeria, Senegal, Malaysia, and South Africa, and health professionals were
unaware of the health consequences. When the virus spread to other areas of the
globe, public health professionals noted severe birth defects among infants of
mothers who contracted the virus. Cultural practices may also facilitate disease
transmission. In some cultures, funeral goers kiss the body of the departed loved
one. This tradition can spread highly contagious microorganisms, such as Ebola.
Therefore, at a time when p eople need the comfort of cultural traditions, public
health professionals must intervene to stop practices. Although epidemic diseases
may appear to be new and unexpected health threats, in reality, t here are common
characteristics that can be used as warning signs of impending problems.
Epidemics are classified based on the source of outbreak. The two main classifi-
cations are common source outbreak and multiple source outbreak. With common source
outbreak, t here is one reservoir. The pathogen is transmitted from this reservoir to
potential victims from this one common source. Exposure from common source
outbreaks may be e ither point, continuous, or intermittent. Point source outbreak refers
to one source that infects people over a short period of time and within a limited
geographic area. Food poisoning or cholera in the water supply are examples of
point source outbreaks. It is easier to identify point sources b ecause the victims
will all report the same common exposure, eating at the same restaurant, living in
the same area, or using water from the same well. In a continuous common source
outbreak or intermittent outbreak, the individuals are exposed to the source of dis-
ease over an extended period. This is critical because prolonged exposure can
lengthen time of recovery and may make it difficult to identify the source. Some
people exposed to the source may not get ill, depending on how virulent the source
is at the time of exposure.
Multiple source outbreak means that there are multiple sources transmitting the
pathogen. Multiple source outbreaks are classified as propagated, vector borne, vehicle
borne, and seasonal. Propagated refers to when one infected person transmits the
disease to a second, uninfected person. Pertussis is an example of propagated
transmission. Bordetella pertussis is passed from person to person through infected
respiratory secretions. Vectors are insects (mosquitos, fleas, or lice) or arachnids
(mites or ticks) that carry a parasite from area to area. The Zika virus is carried and
218 EPIDEM IC
transmitted by mosquitos. Vehicle borne transmission is transmission of the infec-

tion through inanimate objects. Meningitis may be spread by sharing drinking
straws, toothbrushes, lipstick, or cigarettes. Seasonal outbreaks are influenced by
climatic factors, such as seasons, prevailing wind conditions, and excess rainfall.
For example, cold breezy weather during the winter season helps in the spread and
transmission of influenza (flu). In the United States, seasonal flu epidemics occur
from October to May, peaking in the winter. Regional air streams and local and
seasonal prevailing wind conditions are a medium of transmission. Prevailing
winds may help in arthropod transmission and migration of vectors. Heavy rainfall
and flooding are associated with sewage overflow leading to widespread food and
drinking water contamination with diseases such as dysentery, cholera, viral
gastroenteritis (stomach flu), cryptosporidiosis (water diarrhea), Escherichia coli,
and norovirus.
Numerous biological, behavioral, environmental, and socioeconomic factors
influence the spread of diseases and resulting epidemics. F actors that create oppor-
tunities for an epidemic are deforestation, population movement, globalization, and
overcrowding. Deforestation displaces animals from their natural habitat, which
forces the migration and spread of vector borne illnesses. When p eople move from
one area to another, they are at risk for new diseases and also carry pathogens that
are endemic to their homeland. In the summer of 1837, the steamboat SS St. Peter’s
sailed from St. Louis to the fur trading post of Fort Union, delivering supplies along
the Missouri River. Several of the deckhands and passengers w ere suffering from
smallpox. Native Americans had struggled with smallpox epidemics since Spanish
exploration in the 1500s. Inoculation practices, common throughout Europe and
the East were unheard of among Native Americans. As the St. Peter’s sailed along
the route, it spread smallpox at each stop. More than 15,000 Native Americans died
and several tribes w ere wiped out by the 1837 Great Plains smallpox epidemic.
Socioeconomic f actors can compound the threat of an epidemic. Overcrowding puts
a strain on public amenities, resulting in poor living conditions, environmental
health, hygiene, and unsafe food and drinking water. Areas with high population
density suffering from unemployment, poverty, lack of education, and access to
medical care are the most vulnerable.
Public health management of epidemics involves forecasting, investigation, con-
trol, and prevention. Through forecasting, public health professionals recognize the
potential for an epidemic and take measures to prepare for the threat. Infectious
disease scientists monitor the virulence and modes of transmission of various patho-
gens in order to categorize threats as urgent, serious, or concerning (CDC, 2013).
State and local public health departments monitor immunization rates to ensure
that an adequate number of people within the population receive vaccination
and therefore cannot transmit the communicable disease. High immunization rates
function similar to geographic obstacles. When 92 to 94 percent of the population
are immunized against pertussis, it is harder for the bacterium to move from host to
host. The probability of an infected host coming in contact with another susceptible
EPIDE M I C 219
person is low, a concept known as herd immunity. Events of man-made disasters

(war or nuclear explosion) or natural disasters (famine, flooding, mud slides, tropical
storms, hurricanes, earthquakes, or drought) are the perfect storm for potential epi-
demics. Forecasting can prevent or control the potential damage of an epidemic by
ensuring that communities and health systems are prepared and the public is warned
of impending threat and necessary precautions. During investigation, experts seek
to identify the impact of the outbreak, time trend, affected population, and geo-
graphic location. Through such investigation, epidemiologists can identify causes,
sources, and patterns in order to suggest ways to control epidemics. Controlling an
epidemic involves identification of the source and mode of transmission. The
goal of control is to eliminate the source, treat affected p
eople, and prevent further
spread. Affected individuals are treated through isolation, quarantine, vaccination,
use of personal protection equipment, and education in personal hygiene. Fighting
an epidemic requires the coordinated efforts of many individuals and groups from
inside and outside of the affected community.
Epidemics of communicable diseases have plagued mankind since early civiliza-
tion. As p eople, animals, and insects moved from one area to another, they carried
tiny microorganisms capable of reaping immense havoc. Advances in microbiol-
ogy, immunizations, and surveillance systems improved public health responses
to these potential threats. Currently, public health professionals monitor epidem-
ics around the world in order to forecast and prevent future outbreaks. As systems
are developed to control the spread of infectious diseases, the nature of epidemics
seems to change to the noninfectious communicable diseases of obesity, violence,
and substance abuse. F uture directions include applying the science of infectious
diseases to noninfectious diseases in order to prevent the spread of imminent
health threats.
Godyson Orji
See also: Cholera; Epidemiology; Global Health; Immigrant Health; Infectious Dis-
eases; Influenza; Mallon, Mary; Measles; Middle Ages, Public Health in the; Mod-
ern Era, Public Health in the; Obesity; Pandemic; Polio; Quarantine; State, Local,
and Territorial Health Departments; World Health Organization; Controversies in
Public Health: Controversy 3; Controversy 5
Further Reading
California Department of Public Health. (2016). Pertussis summary report. Retrieved from
http://www.cdph.ca.gov/programs/immunize/pages/pertussissummaryreports.aspx.
Centers for Disease Control and Prevention (CDC). (2012). Principles of epidemiology in pub-
lic health practice (3rd ed.). Atlanta: U.S. Department of Health and H uman Services.
Retrieved from http://www.cdc.gov/ophss/csels/dsepd/ss1978/.
Centers for Disease Control and Prevention (CDC). (2013). Antibiotic resistance threats in
the United States, 2013. U.S. Department of Health and H uman Services. Retrieved
from http://www.cdc.gov/drugresistance/threat-report-2013.
220 EPIDEM IOLOGY
Centers for Disease Control and Prevention (CDC). (2016). Zika virus. Retrieved from http://
www.cdc.gov/zika/index.html.
Maron, D. F. (2016). The Zika virus has changed little over 70 years—So why is it a prob
lem now? Scientific America. Retrieved from http://www.scientificamerican.com/article
/the-zika-virus-has-changed-little-over-70-years-so-why-is-it-a-problem-now/.
Winter, K., Glaser, C., Watt, J., Harriman, K., & Centers for Disease Control and Prevention
(CDC). (2014). Pertussis epidemic—California, 2014. Morbidity and Mortality Weekly
Report, 63(48), 1129–1132. Retrieved from http://www.cdc.gov/mmwr/preview
/mmwrhtml/mm6348a2.htm?hc_location=u fi.
EPIDEMIOLOGY
The word epidemiology is a combination of three Greek words epi, meaning “upon,
among,” demos, meaning “people, district,” and logos, meaning “study, word, dis-
course.” From the three Greek words, epidemiology literally means the study of
what is upon the people or what befalls the population. Epidemiology investigates
health-related issues in a particular place at a specific time. By studying and map-
ping events and health outcomes, such as cases of infections, disabilities, birth
defects, suicides, or injuries, health professionals can identify who gets the dis-
ease and possibly why. This information can spur ideas for cure and prevention.
Epidemiology maps disease of a specific population at a particular place and time. For
example, 7,840 men (population) w ere diagnosed with prostate cancer (disease)
in New Jersey (place) in 2011 (time), which calculates to a prostate cancer inci-
dence of 16 per 100 men, or 16 percent. Population might be an individual, group,
community, or persons with defined characteristics, such as a specific age group,
gender, ethnicity, profession, or socioeconomic status. Time could be measured in
seconds, minutes, hours, days, weeks, duration, season, frequency of occurrence, or
as a set period in time (one year after childbirth). Place focuses on the geographic
locations of community, neighborhood, town, city, state, country, continent, or other
location affected by the problem. Epidemiology is an interdisciplinary science, using
scientific practices from public health, life sciences, biomedical, mathematical,
behavioral, and social sciences. Through systematic inquiries and investigations,
epidemiologists collect and analyze data in order to interpret and understand disease
occurrences or other health-related events.
Outbreaks of disease follow logical patterns. Historically, infectious diseases w ere
spread by people moving along heavily traveled ports and roads. AIDS transmis-
sion in Europe can be traced along trade routes in West-Central Africa. By mapping
cases, epidemiologists estimate how a disease is spread and suggest ways to inter-
rupt transmission. Similar to other disciplines, epidemiological studies are under-
taken through systematic scientific methods. The process of studying a disease
consists of (1) reviewing previous studies of similar health topics to identify best
approaches, (2) developing research questions or hypotheses, (3) planning the study
design and procedures, (4) collecting and analyzing data, and (5) drawing logical
conclusions, based on the study results. The aims and objectives for epidemiological
EPIDE M IOLOG Y 221
studies vary based on needs and our current understanding of the disease of inter-
est. With emerging diseases, where the mode of transmission is unknown, epide-
miologists might be interested in investigating etiology, transmission, risk f actors,
and how the disease is distributed within a population. This information allows
public health to predict at-risk populations and to implement selective prevention
programs. With reemerging diseases or health problems where the etiology is
known, epidemiologists might study treatment and policy interventions as ways to
mitigate or eradicate the problem. Epidemiological studies also look at the number
of people affected by a specific disease or health status within a population of inter-
est. One example might be investigating overweight and obesity among children and
adolescents. Epidemiologists would want to study how many youth are affected
overall and differences by gender, geographic region, or age.
Health data can be collected directly through interviews, observation, or survey
of the affected population or indirectly through school records, public health rec
ords, census reports, medical records, registries (birth, death, cancer, immuniza-
tion, or reportable diseases), insurance claims, or previous surveys. Collecting data
directly from the affected population is referred to as primary data collection, whereas
collecting data through intermediate sources is secondary data collection. Once the
numbers of cases are tallied, results are analyzed by mathematical formula, stan-
dardizing the number of cases per 100, 1,000, 10,000, or 100,000 p eople in the
population of interest. Incidence rates, prevalence rates, morbidity rates, and mor-
tality rates allow statisticians to make comparisons between groups to determine
which groups are at lowest, moderate, or highest risk. In Philadelphia, Pennsylva-
nia, 13.7 per 100 (13.7 percent) of female high school students drink one soda two
to three times per day. In comparison, 3.5 per 100 (3.5 percent) of female high
school students in San Diego, California, drink one soda two to three times per day
(Kann et al., 2016). Identifying risk allows professionals to focus limited public
health resources or policy on those who are most affected by the problem. In an
effort to counteract advertising by the beverage industry, Philadelphia became one
of the first major cities in the United States to implement a soda tax. Identifying
low-risk groups informs public health professionals of ways to build resistance
against the health problem. By investigating why youth in San Diego drink less soda
or pop than youth in other areas of the country, program planners can suggest other
ways to reduce sugary beverage consumption and ultimately childhood obesity.
There are two major branches of epidemiology: descriptive epidemiology and ana-
lytic epidemiology. Descriptive epidemiology describes the pattern, distribution, and
occurrences of a disease within a population in relation to the characteristics of the
people (gender, race, or age), geographic location, and time (duration, season, or
year). In addition to using numbers, descriptive epidemiologic studies also use qual-
itative methods. Interviewing p eople affected by the disease can provide insight
into prevention and management. Analytic epidemiology measures cause-effect rela-
tionships and risk factors of disease, seeking to answer the why and how a disease
affects specific populations. John Snow used descriptive epidemiology to map
222 EPIDEM IOLOGY
cholera cases in London in 1854. His map directed him to the cholera source, a
contaminated water pump in Soho. Officials removed the pump h andle, limiting
further transmission and saving numerous lives. Analytic epidemiology is used to
compare groups. Analytical epidemiologists analyze data through specialized
mathematics, known as biostatistics. Complex mathematical calculations allow
epidemiologists to control for differences between groups in order to draw infer-
ences about the data.
Epidemiologic study designs are categorized as experimental or observational.
Experimental designs manipulate a variable in order to test a research hypothesis.
Clinical trials, cluster randomized trials, and field and community trials are used
to test treatments or confirm causal relationships. These study designs provide strong
evidence, linking exposure to outcomes. Observational studies measure the natu
ral degree of exposure and status of disease within populations through cohort, case-
control, and cross-sectional study methods. Cohort studies are used to estimate
disease incidence over time or in comparison to other populations with varying
levels of exposure. A cohort study may be both analytic and descriptive and may
study present disease conditions (concurrent or prospective) or past disease (retro-
spective). Investigators do not manipulate variables or provide interventions in
cohort studies. The Nurses’ Health Study, the Framingham Heart Study, and the
Black Women’s Health Study are examples of large cohort studies. The Nurses’ Health
Study started in 1972 when Dr. Frank Speizer wanted to study long-term effects of
oral contraceptive use. Dr. Speizer chose to study nurses because of their health
knowledge and ability to report health information accurately and thoroughly. Since
data collection started in 1976, more than 280,000 nurses have participated. Large
cohort studies provide a wealth of information. Case control studies are used to com-
pare p eople with disease (cases) to p eople without disease (controls). Data may be
collected directly from the patient or indirectly from medical, laboratory, employ-
ment, or pharmacy records. Comparing cases to controls provides insights into
potential risk or protective f actors. Prospective study designs look forward in time,
tracking people without the disease to learn who becomes affected by the disease
and who does not. Retrospective studies investigate p eople with the disease and
people without the disease to determine what exposures may have caused the dis-
ease. Prospective study designs are scientifically stronger b ecause prospective studies
collect data as events occur whereas retrospective studies rely on the individual’s
memory. People with disease w ill often reflect on past experiences and exposures,
wondering why or how they got the disease. Thus, people with disease are more
likely to recall exposures that those without disease may have forgotten. This time
or reason to reflect creates a limitation known as recall bias. Cross-sectional studies
provide a snapshot in time, examining rates of exposure and rates of disease at the
same point in time. Cross-sectional studies are used to collect information about
health and risk factors. Although cross-sectional studies are useful for preliminary
investigation, planning and allocation of health resources and prevention programs,
cross-sectional studies also have limitations. Cross-sectional studies only tell us
ETHI C S IN PU B LI C HEALTH AND POPULATION HEALTH 223
hether two variables existed together in higher numbers than expected. The designs
w
do not tell us w
hether one variable caused the other. For example, a cross-sectional
survey of student athletes may reveal that football players report higher rates of trau-
matic brain injury (TBI) than track and field athletes. B ecause cross-sectional sur-
veys only measure variables at one point in time, we d on’t know w hether football
increases risk of TBI or w
hether athletes with TBI are more attracted to football, or
if a third, moderating variable influences the relationship. Only prospective studies
can tell us which came first, football or TBI.
Epidemiological studies are embedded in scientific research using carefully
planned methods, data collection, and statistical analysis to identify trends in dis-
ease and to find solutions to cure, treat, prevent, and control diseases. Descriptive
and analytic studies analyze patterns of disease to identify who is affected, where,
and when. Results provide information on risk factors, effects, causes, preven-
tion, and control. Epidemiology provides a backbone to public health planning
and action, exploring the c auses of disease, and suggesting ways to advance preven-
tion, treatment, and cure.
Godyson Orji
See also: Cholera; Epidemic; Food Safety; Global Health; Infectious Diseases; Mod-
ern Era, Public Health in the; Pandemic; Research; Snow, John
Further Reading
American College of Epidemiology. (2017). Retrieved from http://acepidemiology.org/.
Aschengrau, A., & Seage, G. R. (2013). Essentials of epidemiology in public health. Burlington,
MA: Jones & Bartlett.
Epimonitor. (2017). The epidemiology monitor. Retrieved from http://www.epimonitor.net/.
Friis, R. H., & Sellers, T. (2013). Epidemiology for public health practice. Burlington, MA: Jones &
Bartlett.
Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Hawkins, J., & Zaza, S.
(2016). Youth risk behavior surveillance—United States, 2015. Morbidity and Mortality
Weekly Report. Surveillance Summaries (Washington, DC: 2002), 65(6), 1–174. doi:10.15585
/mmwr.ss6506a1. Retrieved from http://www.cdc.gov/healthyyouth/data/yrbs/pdf/2015
/ss6506_updated.pdf.
Nurses’ Health Study. (2017). Retrieved from http://www.nurseshealthstudy.org/.
Rothman, K. J., Greenland, S., & Lash, T. L. (1998). Types of epidemiologic studies. Modern
Epidemiology, 3, 95–97. Retrieved from http://www.medicine.mcgill.ca/epidemiology
/hanley/bios601/Comparativegeneral/..%5CRothmanGreenland98/RothmanGreenlan
d05TypesEpiStudies.p df.
ETHICS IN PUBLIC HEALTH AND

POPULATION HEALTH
Public health ethics is an interdisciplinary field where ethical issues and possible
interventions are investigated and analyzed in order to develop ethically sound
224 ETHICS IN PUBLIC HEALTH AND POPULATION HEALTH
health promotion policies and practices. Public health refers to the network of health
promotion and disease prevention systems designed to meet the needs of the gen-
eral population and at-risk populations. Population health refers to the health out-
comes of a population or the general population’s health status in reference to the
existing health care systems. Improving population health means reducing health
disparities, enhancing overall quality of the health care system, and promoting a
health-conscious culture. The fundamental ethical principles that guide public
health practice and research are respect for persons, beneficence, and justice. T hese
ethical principles define professional boundaries and norms of conduct that dif-
ferentiate acceptable from unacceptable behavior. Problems arise when two or more
ethical principles come in conflict with each other. For example, consider the idea
that laws requiring p eople to eat healthily would be a quick and highly effective
way of reducing heart disease, diabetes, high blood pressure, and other obesity-
related diseases. However, public health is guided by ethical principles, one of which
requires practitioners and policy makers to respect the autonomy (free will) of indi-
viduals. Public health ethics present a systematic process of identifying, prioritiz-
ing, and justifying a course of action based on ethical principles.
The principle of respect for persons demands that each person has the right to
be treated with dignity and respect. The principle of beneficence dictates a respon-
sibility to promote and enhance the good of o thers. Beneficence complements non-
maleficence, which prohibits the infliction of harm, injury, or death. Nonmaleficence
originates from the Hippocratic Oath. In ancient Roman medicine, beneficence is
presented in the negative form. The agent is cautioned not to inflict harm, injury,
or death on others. Justice refers to the fair distribution of burdens and benefits
where vulnerable populations, groups lacking political or social power, do not have
a greater burden of illness or responsibility than others in society. Ethical issues in
population health research and policy often revolve around the concept of distribu-
tive justice. The issue of distributive justice begins with designating a particular pop-
ulation group. The group typically already exists and has agreed to basic sociopolitical
systems through formal or informal social contract. Attempts t oward just distribu-
tion of health (and health care) resources are determined by or within the social
system.
The traditional sense of distributive justice (henceforth “justice”) is justice as des-
ert, that is, everyone should get what they deserve. However, this view is too simple
to employ for our complex capitalist system. Also, it has apparent difficulty locat-
ing the meaning of what kind of health resource in what quality is deserved, who
deserves it, and how much one deserves; thus, it lacks practical import to become
our ethical justification. Needs-based theory of justice states that goods must be
distributed based on everyone’s needs. However, this is fundamentally the Marxist/
Communist ideology, which does not fit in with the current health care system in
the United States. The U.S. capitalist health and health care economy is run by a
free market economy where better quality of care or “luxury care” is available for
those who can pay. The ethical justification we are looking for is a type of market
distributive justice. Contribution- based theory argues that goods should be
ETHICS IN PU B LIC HEALTH AND POPULATION HEALTH 225
distributed to match an individual’s overall contribution to the society. However,

the theory justifies the system that the vulnerable in society continuously suffers
because, according to the theory, it is ethically just to let the poor and the handi-
capped access poor quality of or less health care because they contribute to the
society less than other members. However, the theory is fragile b ecause it is
exposed to a practical contraction. For example, the capitalist society allows, say,
a handicapped person to be treated with g reat health care when the patient’s rich
family members who contribute greatly to the society pay for the patient. Then, the
same act will be considered just and unjust at the same time. Another popular
theory of justice, utilitarianism, says that just distribution will be allocating goods in
the way of producing the best consequences for the greatest number of p eople by
taking everyone’s goods impartially into account. However, this may demand sac-
rifice of some members for the good of others in an unrealistic, utopian fashion.
Since the poor outnumber the rich, the just distribution of health for the greatest
number will be to provide health resources for the poor via harsh taxation for the
rich, which is against the principle of market economy.
Philosopher John Rawls’s difference principle argues that social and economic
inequalities are granted but to be arranged in such a way that the least privileged
have the greatest benefit. Granted that population health thinking concerns, first,
improving the overall quality of general health system while, second, reducing health
and health care disparities, the difference principle gives the ethical direction in
which the former concern should be fulfilled in reference to the latter concern. In
other words, the effort to improve the overall health system should be carried out
in order for the most vulnerable population to have the greatest benefit. There is
difficulty coming to an agreement on the identification of the most vulnerable group
and also the greatest benefit for them. However, this is not a notorious difficulty.
We have a specific focus, the health system in the capitalist-liberal democratic coun-
try. Also, there exists the relatively accurate statistics that shows that racial/ethnic
minorities and low-income individuals are the most vulnerable groups. T here is a
pretty good sense of distinguishing basic health care from luxury care. T here should
be other ethical concerns to deal with along the way, as particular health policies
or programs develop. However, provided that we have agreed on t hese basic terms
and data, the policies developed and refined in accordance with the difference princi
ple can be ethically sound interventions.
Through such consideration, scholars may suggest ethical justifications and
directives for particular population health research and policies in order to obtain
ethical soundness. In many cases, ethical principles are what differentiate public
health from other professions and businesses. Pharmaceutical companies are not
held to the same level of responsibility for beneficence; otherwise they would not
be earning millions of dollars per year. In all functions and all m atters, public
health professionals consider the ethical implications of each decision, action,
and policy.
Marvin J. H. Lee
226 E VALUATION
See also: Belmont Report, The; Code of Ethics; Epidemiology; Greco-Roman Era,
Public Health in the; Health Care Disparities; Hippocrates; Population Health,
Tuskegee Syphilis Study; Controversies in Public Health: Controversy 1; Contro-
versy 3; Controversy 4; Controversy 5
Further Reading
Allingham, M. (2014). Distributive justice. London and New York: Routledge.
Beauchamp, T. L., & Childress, J. F. (1994). Principles of biomedical ethics. New York: Oxford
University Press.
Department of Health, Education, and Welfare. (1979). The Belmont report. Retrieved from
http://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/.
Rawls, J. (1993). Political liberalism. New York: Columbia University Press.
EVALUATION
Public health professionals use a wide variety of initiatives, interventions, treatments,
and programs to promote health and prevent illness. Evaluations are a type of
research design used to investigate w hether these activities are (1) feasible for the
target audience, (2) effective in addressing the health concern of interest, and/or
(3) cost effective. Ideally, evaluation results add to our existing knowledge of the
topic and guide ways to improve practices, new policy, or community initiatives.
Program objectives are used to guide and structure the evaluation. A program to
reduce smoking among teenagers is evaluated by investigating whether the youth
who attended the program actually stopped or reduced cigarette smoking. Program
objectives may be short term, such as improving knowledge about the adverse effects
of cigarette smoking; intermediate, changing attitudes to decrease the attraction of
smoking; or long term, reducing the number of people who currently smoke.
Through program evaluations, public health professionals can determine which pro-
grams work for the target population, and stakeholders can determine if program
funding should continue. Limitations of program evaluations are that they often
measure outcomes over a short period. If the behavior relapses or improves outside
of the evaluation period, this result may not be captured by the evaluation study.
Also, many different factors influence health behaviors. The smoking cessation
program may successfully educate participants on the negative effects of smoking.
However, if the participants are simultaneously exposed to heavy product place-
ment, where tobacco companies embed their product into popular movies or vid-
eos, the evaluation could show increased usage. Evaluations tell us if a program
works; they do not tell us how a program works. The field of evaluation research
continues to develop as a science, seeking to inform communities on the best ways
to allocate public health resources.
Evaluation studies range in formality and purpose. Formal evaluations are planned
in advance, before the program or treatment is offered. Preplanning with an evalu-
ation expert ensures that the evaluation is feasible, follows ethical practice guide-
lines, legitimately measures what it is intended to measure, and addresses the needs
E VALUATION 227
of funders, collaborators, and participants. Data are collected at the start and the end
of the program and sometimes, throughout the program. For example, the
researchers evaluating a smoking cessation program might collect urine samples
from participants to measure urine cotinine levels. (Cotinine is produced when the
body breaks down nicotine.) The first cotinine levels, collected before the program
starts, are referred to as pretest or baseline data. Posttest data are gathered at the
end of the program or at a set time point, such as six months or one year post-
program. The evaluator compares posttest results with pretest to identify any changes
that occurred. Although urine cotinine levels are a convenient and accurate way to
measure smoking, the transtheoretical model tells us that p eople typically take two
years to change a health behavior. An evaluation that measures cotinine immedi-
ately at the end of the program will miss participants who stop smoking within the
two years a fter the program. Informal evaluations are less structured and may con-
sist of asking participants or the instructor what they feel are strengths and weak-
nesses of the program or how the program could be improved. Formal evaluations
are designed to gather credible evidence that a program is effective. Informal evalu-
ations are designed to describe, improve, or refine a program.
Whenever possible, evaluations use existing instruments with proven validity and
reliability. Instruments are the tools that researchers use to collect data. Examples
of instruments are height and weight scales to measure BMI, a sphygmomanometer
to measure blood pressure, or a survey to measure participant knowledge, attitudes,
and behaviors. Validity and reliability assess the quality of the instrument. Validity
describes how well the instrument measures what it is intended to measure. With
a few exceptions, using a good quality medical scale to assess BMI is a fairly valid
measure of underweight, normal weight, overweight, or obese status. Reliability
describes how stable the instrument is over time. We expect a good quality medical
scale to give the same results u nder the same circumstances. If someone weighs
135 pounds today and does not gain or lose weight, we expect the scale to mea
sure 135 pounds the next day, and the next day, as long as the individual’s weight
does not change. An instrument could be invalid, measuring 5 pounds higher than
the person actually weighs. However, as long as the scale is consistently 5 pounds
higher, it is still reliable. On the other hand, BMI is less valid when used to assess
athletes with high muscle mass, w omen who are pregnant, and c hildren. The
evaluator w ill select a quality instrument with proven validity and reliability when-
ever possible because using the same instrument allows researchers to compare
study results. With some health topics, instruments do not exist and the evaluator
must develop a new instrument.
There are different types of evaluations that target different aspects of a program.
Formative evaluations, also known as process evaluations, assess the project dur-
ing planning and/or implementation. Process evaluations gather information from
participants, the instructor, or key stakeholders on how the program is progress-
ing. Formative assessment of the smoking cessation program may survey partici-
pants to see if they prefer certain learning activities over others, whether they feel
228 EVALUATION
the instructor is qualified, or if the classroom or physical surroundings are com-

fortable. Summative evaluations assess the outcomes of the program. Ideally, the
smoking cessation program would measure the number of participants who stop
smoking. Summative evaluations allow reviewers to draw conclusions on how
effective the program is by studying impact and/or outcome. Impact evaluations
examine the short-term or intermediate benefits, such as changes in knowledge, atti-
tudes, or skills. Outcome evaluations study long-term benefits, such as improving
quality of life or reducing morbidity and mortality. Evaluation studies can be s imple,
studying only one aspect such as process, or very complex, studying process,
impact, and outcome. Larger studies use the concept of triangulation, evaluating
several different impact and outcome measures in order to get a bigger picture of
program effects.
Although it seems that all evaluations should focus on process, impact and out-
come simultaneously, in reality the type of evaluation depends on where we are in
understanding the problem. In the early days of smoking research, the researchers
did not have a set definition for smoking. They needed to perform a process evalu-
ation, developing and testing a definition. A fter experts agreed on the definition, it
became important to measure program impact, whether programs changed attitudes
toward smoking. T oday, evaluators look at process, impact, outcome, and an addi-
tional variable, fidelity of implementation. Fidelity of implementation measures
whether the instructors are presenting the program as it was intended by the origi-
nal program author. Evaluation studies are like relay races. The first evaluator com-
pletes a process evaluation, passing the results to the next evaluator who confirms
or refutes the initial results, and enhances ideas for the next study, which are passed
to the next evaluator. Results and ideas for improving evaluations are communi-
cated through technical reports, conferences, professional journals, and books. This
process ensures that the field of research continues to move forward, improving
techniques and understanding of the issue. When enough evidence is gathered to
suggest that a program works, the evaluation studies are reviewed by groups of
independent experts. This review determines whether the program meets the
criteria necessary to be granted the status of evidence-based program. Examples of
evidence-based programs in smoking cessation are Adolescent Smoking Cessation:
Escaping Nicotine and Tobacco Program (ASCENT), Good Behavior Game, Not On
Tobacco (N-O-T), and Project EX.
Evaluations are an unusual form of research known as translational research. In
some disciplines, the scholar depends primarily on books or existing documents
for ideas and information. This ivory tower research remains disconnected from
the real world, providing few practical benefits. The evaluation researcher must
take complex models and theories from the ivory tower and translate the concepts
into real-world practices. This is particularly important where p eople want a
quick fix or have ill-conceived ideas as to how to fix a problem. For example,
many schools like bringing the local police in for smoking and drug prevention
education. In theory, using the local police as health educators seems like a great
idea. Police-sponsored programs are usually f ree, officers are readily available, and
E VALUATION 229
this seems like a great way to build community connections. In practice, police are
not trained as health educators, often lack knowledge of the unique traits of ado-
lescent brain development and how this applies to health promotion programs, or
have severely alienated at-risk populations. What message is conveyed to the vic-
tim of bullying when a police officer walks into the classroom with a gun and
suddenly commands immediate respect? A well-planned and insightful evaluation
is like a finger on the pulse of the community, constantly assessing and evaluating
whether the program works the way that it was intended to work. Translational
research not only tells us what happened within the program but also what needs
to be done next.
The real-life nature of program evaluations presents limitations. It may be hard
to measure the variable of interest or new technology may come out that changes
behavior. Smoking cigarettes is being replaced by e-cigarettes, which can also be
harmful to health. New forms of social media provide tobacco companies with never-
ending ways to sell their product. Program planners may be wary of the evaluator
or the evaluation instrument, resulting in reluctance to share data or access partici-
pants. A major issue with program evaluations is that typically when a program is
implemented, participant awareness increases. Individuals who previously consid-
ered themselves nonsmokers b ecause they only smoked one to two cigarettes a week
may now realize that they are, in fact, smokers.
People might have a wonderful idea of how to address a health issue. However,
if the idea does not work in the real world or makes the problem worse, w e’ve wasted
precious funding and resources, while allowing the problem to continue. Evalua-
tions are a unique part of program implementation that studies whether public
health initiatives, techniques, treatments, or programs work to enhance health and
prevent disease. Through evaluation studies, we are able to move forward and
develop better ways to handle health issues.
Sally Kuykendall
See also: Body Mass Index; Causality; Evidence-Based Programs and Practices; Goals
and Objectives; Health Education; PRECEDE-PROCEED Planning Model; Public
Health Department Accreditation; RE-AIM (Reach, Effectiveness, Adoption, Imple-
mentation, and Maintenance); Research; Syringe Service Programs; Transtheoreti-
cal Model; Truth Campaign, The
Further Reading
Craig, P., & Campbell, M. (2015). Evaluability assessment: A systematic approach to decid-
ing whether and how to evaluate programmes and policies. What works Scotland.
Retrieved from https://edge.sagepub.c om/system/files/Evaluability%20Assessment.p
df.
Newcomer, K. E., Hatry, H. P., & Wholey, J. S. (2015). Handbook of practical program evalu-
ation (4th ed.). San Francisco: Jossey-Bass.
Smith, M. F. (2015). Evaluability assessment. In S. Mathison (Eds.), Encyclopedia of evalu-
ation. Thousand Oaks, CA: Sage. Retrieved from https://edge.sagepub.com/system
/files/Evaluability%20Assessment.pdf.
230 EVIDENC E-B ASED PROGRAMS AND PRACTI C ES
EVIDENCE- B ASED PROGRAMS AND PRACTICES

Evidence-based programs and practices are health promotion or disease preven-
tion activities that have been tested and proven to work. Evidence-based medicine
has been around since ancient healers first recorded which herbs successfully treated
diseases. The same logic and science is applied to social and behavioral programs.
Teams of researchers, experts, and practitioners review evidence from program
evaluations to determine which programs are effective. Organizations, such as the
Campbell Collaboration, the Center for the Study and Prevention of Violence of
the University of Colorado at Boulder, Cochrane Collaboration, Office of Juvenile
Justice and Delinquency Prevention (OJJDP), and the Substance Abuse and M ental
Health Services Administration’s National Registry of Evidence-Based Programs and
Practices (NREPP) list and report effectiveness of programs. Several groups provide
searchable databases for community members to assist in deciding on which pro-
gram is best for a particular school or community. The databases allow users to
search by gender, age of the target population (middle school or high school), demo-
graphic location (urban, suburban, or rural), and purpose (bullying prevention,
substance abuse prevention, or other behavior). The main advantage to evidence-
based programs is that the curriculum or activities are already developed, refined,
and tested, saving a g reat deal of time, resources, and effort. Unfortunately, some
people have strong views on how to fix social problems and are e ither unable or
unwilling to use the available science. There is still a misconception that the flashy,
expensive program advertised by a popular talk show host is preferable to a scien-
tifically developed and tested program.
In 2001, public health experts produced Youth Violence: Report of the Surgeon
General. The report reviewed existing violence programs and concluded that some
of the most popular and well-recognized programs did not work. The problem with
using ineffective programs is that they distract attention and resources from pro-
grams that do work. Community leaders, school officials, and parents are not likely
to use an evidence-based program if they believe (incorrectly) that the current pro-
gram w ill prevent violence or substance abuse. The surgeon general’s report was
followed up with work by researchers at the Center for the Study and Prevention
of Violence (CSPV) at the University of Colorado at Boulder. A fter reviewing more
than 600 programs, the researchers found that only 20 percent actually reduced
youth violence. Some of the most popular programs w ere e ither ineffective or caused
greater harm. For example, group therapy for young offenders can increase risk of
offending because the group provides informal training in antisocial behavior. Lower
offending youth learn worse behaviors.
When experts assess program effectiveness, they look at how the program was
implemented and evaluated, the quality of evaluation measures, and evaluation
results. They carefully review the evidence supporting the program. Effective pub-
lic health programs are carefully planned integrating models and theories of how
people learn and how p eople change health behaviors. Program outcomes should
match program objectives. A program designed to prevent smoking should, in fact,
prevent smoking. Quality evaluations compare data before and after the program
E VIDEN C E - B
ASED PR O G RA MS AND P RA CTI CES 231
and to a similar control group. Results are expected to show statistical significance.
This means that the smoking prevention program does not simply lower the num-
ber of smokers, but the differences are large enough that they did not occur by
chance. After review of the evidence, the program is categorized as harmful, unsup-
ported, promising, supported, or well supported. Communities are advised not to
use harmful programs. Unsupported programs or promising programs may be used
within particular contexts. Ideally, the program designers need to gather further evi-
dence and resubmit the program for review. When available, supported and well-
supported programs are preferred.
Implementing evidence-based practices can be challenging. In schools, teachers
may need to change practices and learn new ways to address behavioral problems.
In communities, adults in positions of power may need to give up power in order
to work with public health educators. The benefits of using evidence-based pro-
grams are substantial. Researchers estimate using evidence-based bullying programs
in 125,000 public and private schools would cost $625 million per year. With school
violence costing $14.4 billion to $40.3 billion per year, evidence-based programs
would save up to $39.7 billion per year (Pereznieto, Harper, Clench, & Coarasa,
2010). Even after a program has achieved model status, program authors will con-
tinue to evaluate, review, and update program materials to proactively address health
problems. For example, early evidence-based bullying prevention programs did not
include cyberbullying because at the time they w ere created most c hildren did not
have regular access to technology. With the growth in social networking, programs
were updated to include cyberbullying.
In the past, social programs were controversial because many did not work, and
stakeholders felt that the resources used t oward such programs w ere wasteful. Efforts
by the federal government, academics, researchers, and public health practitioners
identified effective and ineffective programs, developing databases for use by com-
munities. In using evidence-based programs, communities can effectively reduce
issues of substance abuse and youth violence. The next steps are to educate politi-
cians, educators, and parents on the science and benefits of evidence-based
programs.
Sally Kuykendall
See also: Addictions; Behavioral Health; Causality; Evaluation; Goals and Objec-
tives; Health Education; Intervention; Research; Substance Abuse and Mental Health
Services Administration; Violence
Further Reading
Campbell Collaboration. (2016). What helps? What harms? Based on what evidence? Retrieved
from http://www.campbellcollaboration.org/.
Injury Prevention and Control, Division of Violence Prevention, Centers for Disease Con-
trol and Prevention. (2017). Violence education tools online. Retrieved from Centers for
Disease Control and Prevention, http://vetoviolence.cdc.gov/.
232 EVIDENC E-B ASED PROGRAMS AND PRACTI C ES
Institute of Behavioral Science, University of Colorado Boulder. (2016). Blueprints for healthy
youth development. Retrieved from http://www.blueprintsprograms.com/.
Office of Juvenile Justice and Delinquency Prevention. (2016). Model programs guide.
Retrieved from http://www.ojjdp.gov/mpg/.
Pereznieto, P., Harper, C., Clench, B., & Coarasa, J. (2010). The economic impact of school
violence: A report for plan international. London: Overseas Development Institute.
Retrieved from http://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion
-files/6289.pdf.
Substance Abuse and Mental Health Services Administration. (2016). NREPP: SAMHSA’s
National Registry of Evidence-Based Programs and Practices. Retrieved from http://www
.samhsa.gov/nrepp.
U.S. Department of Health and H uman Services. (2001). Youth violence: A report of the sur-
geon general. Rockville, MD: U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center for Injury Prevention and Con-
trol; Substance Abuse and M ental Health Services Administration, Center for M ental
Health Services; and National Institutes of Health, National Institute of M ental Health.
F
FALSE CLAIMS ACT (FCA)
The False Claims Act (FCA) was not originally intended for the health care industry.
Started during the Civil War, the FCA was established to combat merchants who
tried to defraud the federal government by selling rancid food, poor quality shoes
and clothing, broken down h orses and mules, and faulty rifles to the Union and
Confederate Armies. Also referred to as the “Lincoln Law,” the law contained a pro-
vision compensating whistleblowers who reported fraud that resulted in recovery
for the government. Qui tam is a legal term that means “who as well for the king
[government] as for himself sues in this matter.” The term refers to a civil suit where
the person is suing on behalf of the government. By World War II, people had found
ways to manipulate the system. When the Department of Justice filed criminal
charges, lawyers would file civil suits claiming a qui tam reward. Congress was g oing
to eliminate the FCA and instead ruled to reduce the amounts paid to whistleblowers.
In 1986, the law was extended to make it a crime for any individual to defraud the
federal government, including making a false medical record or payment claim.
False Medicare and Medicaid claims w ere a growing concern. U nder the FCA, pro-
viders cannot knowingly make a false claim, submit a false record, misrepresent
goods, or buy government property from other than authorized sellers. In 2010, the
FCA was further refined by the Affordable Care Act. Under the ACA, only the origi-
nal source of a fraud disclosure may file for qui tam reward. If the fraud has already
been disclosed through public sources, qui tam suits are automatically dismissed.
Under the FCA, health providers and those who do business with local depart-
ments of public health must have a strong compliance plan. Penalties range from
$5,000 to $11,000 per claim as well as additional penalties three times the initial
claim. Between 1996 and 2005, the government recovered $9.3 billion of fraudu-
lent Medicare and Medicaid claims (Kesselheim & Studdert, 2008). Of the 379
cases, only 13 cases w ere against pharmaceutical companies, yet those cases totaled
$3.6 billion. Whistle blowers were primarily physicians or business executives
motivated by a sense of integrity and ethics. As health care systems continue to
grow and become more complex, health care fraud will most likely continue to be
a problem. Given the temptations of some, it is the responsibility of the individual
employee to report suspected abuse. Unfortunately, many employees fear retaliation
by those in positions of power within the company. Finding ways to protect and sup-
port whistleblowers can reduce fraud and increase available health care resources.
Sally Kuykendall and Leapolda Figueroa
234 FAMILY PLANNIN
See also: Administration, Health; Affordable Care Act; Public Health Law; Stark Law
Further Reading
Kesselheim, A. S., & Studdert, D. M. (2008). Whistleblower-initiated enforcement actions
against health care fraud and abuse in the United States, 1996 to 2005. Annals of Inter-
nal Medicine, 149(5), 342–371.
Stubbs, J. D. (2013). The 2009 Amendment expands the types of fraud subject to the fed-
eral false claims act. Florida Bar Journal, 87(2), 16–23.
Total Healthcare. (2016). False claims act overview. Retrieved from https://thcmi.com/PDF
/common/False%20Claims%20Act%20Policy.pdf.
FAMILY PLANNING
Family planning refers to health and medical services that empower w omen to con-
trol the timing, spacing, and number of pregnancies. The services include access to
contraception, pregnancy testing, counseling, preconception health screening and
treatment, infertility care, and screening and treatment for sexually transmitted dis-
eases (STDs). The ability to control reproduction promotes maternal, infant, family,
and community health. Reproductive health services reduced maternal death rate
from 608 women per 100,000 live births to 12 women per 100,000 live births (Hoy-
ert, 2007). Contraceptives prevent 1.9 million pregnancies per year, reducing the
demand for elective abortions (Guttmacher Institute, 2016). F amily planning builds
healthier communities with less poverty and better quality of life. W omen are free
to work or volunteer and can focus their time and resources on fewer children. Every
tax dollar spent on f amily planning services saves $7 in Medicaid and other expen-
ditures (Guttmacher, 2016). Contraceptive and infertility services also provide an
opportunity for health care providers to screen for breast or cervical cancer, hyper-
tension, lipid disorders, skin cancer, osteoporosis, and intimate partner violence.
Early screening, referral, and treatment improve health and reduce premature
mortality. The major obstacles to family planning are a lack of education, limited
access to services, and lack of support by partners or society.
In the United States the birth control movement was started by a public health
nurse. Working with poor, immigrant w omen in New York City, Margaret Sanger
witnessed a frighteningly high number of infant and maternal deaths. For every
1,000 live births, 102 to 181 infants died and 6 to 11 w omen (Lindner & Grove,
1947, tables 26 and 36). (The lower numbers report “white” death rates, and the
higher numbers report death rates of “other races,” i.e., African American, Italian
American, Greek American, and Jewish American, the community that Sanger
served.) The medical causes of infant death, infectious diseases, diarrhea, prema-
ture birth, congenital malformations, pneumonia, and injury were primarily due to
social problems of poor nutrition, poverty, and neglect. Without the benefit of unlim-
ited resources, m others struggled to care for their c hildren. Sanger witnessed how
botched abortions, too many pregnancies, and f amily violence claimed the physical
FAMILY PLANNIN 235
and emotional lives of women. She started teaching her patients about birth con-
trol, reproduction, and w omen’s health. The information was considered radical and
immoral, a threat to puritan values. Sanger was charged and indicted with violating
federal obscenity laws. She fled to E ngland. However, as she left U.S. territory, she
signaled a publisher to print and distribute 100,000 copies of Family Limitation, a
16-page booklet describing different methods of birth control. Sanger returned from
England the following year and opened the first birth control clinic in the United
States. Women stood in line for care until the New York police closed the clinic.
Sanger’s case stimulated public discourse, and physicians were given permission to
counsel patients on birth control. In 1952, Sanger founded International Planned
Parenthood and a decade l ater, the United States legalized birth control for married
couples. As concerns for population growth increased, the federal government
established the Family Planning Services and Population Act (1970) and created
Title X of the Public Health Service Act. Title X is the health program of the Office
of Population Affairs designed to provide family planning and related health
services.
As the cost of raising children increased and opportunities for females expanded,
the image of the ideal family size dropped from four children to two children (Gao,
2015). The American Academy of Pediatrics describes many benefits to smaller
family size. Parents can focus attention, resources, and educational opportunities
on a fewer number of c hildren, which means higher self-esteem for the child, lower
household costs, fewer families in poverty, better life-career balance, less stress, and
greater financial security. This means that many women spend the majority of their
reproductive lives trying to avoid pregnancy. Too often, the 30-year effort results in
at least one error. By the age of 45, 49 percent of women report an unintended
pregnancy and 3 out of 10 w omen report having an abortion (Guttmacher, 2016).
Highest risk groups for unintended pregnancy are adolescents, minority w omen,
and women with incomes below the federal poverty line. The United States has one
of the highest teen pregnancy rates (40 pregnancies per 1,000 females aged 15 to
17) (Office of Disease Prevention and Health Promotion, 2017). Healthy People 2020
lists 16 family-planning objectives. The objectives focus on increasing the number of
females and males who use reproductive health services and contraception; increas-
ing the proportion of intended pregnancies; increasing the number of teenagers
who receive formal instruction on reproductive health; increasing the number of
teenagers who talk with a parent or guardian about reproductive health; reducing
teen sexual activity and pregnancies; reducing pregnancies that occur as a result of
contraceptive failure; reducing the number of pregnancies that occur within 18
months of previous childbirth; and increasing publicly funded family planning
clinics and health insurance plans that offer access to FDA-approved contraception
(Office of Disease Prevention and Health Promotion, 2017).
Healthy People 2020 objectives show how family planning extends beyond contra-
ception to include comprehensive sex education, STD prevention, preconception
health, infertility treatment, pregnancy testing and counseling, and postpartum care.
236 FAMILY PLANNIN
Since the publication of Family Limitation, contraceptive options have significantly

increased and improved. Although abstinence is the most effective method of pre-
venting pregnancy and STDs, sexually active women and men can choose from a
wide variety of birth control methods. Choice varies based on individual prefer-
ences, safety, efficacy, reversibility, accessibility, and need for protection from STDs.
National and local organizations, such as Planned Parenthood, offer free family plan-
ning services. Preconception care can significantly reduce infant mortality. An esti-
mated 23,000 infants die each year, and more than half of these deaths are caused by
birth defects, preterm birth, maternal complications due to pregnancy, sudden infant
death syndrome (SIDS), and injuries (Centers for Disease Control and Prevention,
2017). Pregnancy planning and counseling gives health care professionals time to
screen for and detect preventable diseases, improving the health of the m other and
improving pregnancy outcomes. Unfortunately, the quality of services can vary. The
key features of quality health services are the provision of safe, effective, client-
centered, timely, efficient, accessible, and equitable value-based care. Public health
clinics use these features to assess the quality and value of their services.
Family planning is one of the greatest public health achievements of all time.
Comprehensive sex education, contraception, and pregnancy counseling empower
women to control the number and spacing of pregnancies, thus promoting mater-
nal and child health. Despite successes, restrictive policies and laws often limit fund-
ing. Public health efforts to reduce unintended pregnancies and provide an array
of reproductive health services are challenged by personal values and misconcep-
tions that limit funding and service provision. As populations grow and demands
on natural resources exceed supply, the need for f amily planning services will con-
tinue to grow.
Sally Kuykendall
See also: C
hildren’s Health; Dunham, Ethel Collins; Ellertson, Charlotte Ehrengard;
Healthy People 2020; Infant Mortality; Maternal Health; Planned Parenthood; Sanger,
Margaret Louise Higgins; W omen’s Health; World Health Organization
Further Reading
American Academy of Pediatrics. (2017). Small families. Retrieved from https://www
.healthychildren.org/English/family-life/family-dynamics/types-of-families/Pages
/Small-Families.aspx.
Centers for Disease Control and Prevention. (1999). Achievements in public health, 1900–
1999: Family planning. Morbidity and Mortality Weekly Report, 48(47), 1073–1080.
Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.htm.
from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/.
Gao, G. (2015). Americans’ ideal f amily size is smaller than it used to be. Pew Research Center.
Retrieved from http://www.pewresearch.org/fact-tank/2015/05/08/ideal-size-of-the
-american-family/.
F LUOR IDATION 237
Gavin, L. Moskosky, S., Carter, M., et al. (2014). Providing quality family planning services:
Recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recom-
mendations and Reports, 63(4).
Guttmacher Institute. (2016). Publicly funded family planning services in the United States.
Retrieved from https://www.guttmacher.org/fact-sheet/publicly-funded-family-planning
-services-united-states.
Henshaw, S. K. (1998). Unintended pregnancy in the United States. Family Planning Per-
spectives, 30, 24.
Hoyert, D. L. (2007). Maternal mortality and related concepts. National Center for Health
Statistics. Vital Health Statistics, 3(33). Retrieved from http://www.cdc.gov/nchs/data
/series/sr_03/sr03_033.pdf.
Lindner, F. E., & Grove, R. D. (1947). Vital statistics rates in the United States 1900–1940.
Washington, DC: U.S. Government Printing Office. Retrieved from http://www.nber
.org/vital-stats-books/vsrates1900_40.CV.pdf.
Office of Disease Prevention and Health Promotion. (2017). Healthy People 2020. Retrieved
from https://www.healthypeople.gov/.
World Health Organization (WHO). (2017). Family planning/contraception. Retrieved from
http://www.who.int/mediacentre/factsheets/fs351/en/.
FLUORIDATION
Fluoridation is the process of adding therapeutic doses of fluoride to public drink-
ing water in order to promote oral health. The history of fluoridation is a classic
example of public health in action (CDC, 1999). Initially, dentists from the western
and midwestern United States and Argentina, Japan, and England reported cases
of brown stained and pitted tooth enamel. Dental experts assumed that the irregu-
lar teeth w ere susceptible to decay. In 1931, the National Institutes of Health hired
public health dentist Henry Trendley Dean to investigate. Dean’s team traced the
problem to high levels of fluoride in local water sources. To their surprise, they found
that children with mottled teeth had fewer cavities. Dean suggested adding low doses
of fluoride to public water sources and today, millions of people benefit fluoridation
with better oral health and fewer cavities. Despite numerous studies supporting the
safety and efficacy of fluoridation, the practice remains a controversial issue. Oppo-
nents question the government’s right to add chemicals to public w ater supplies
while advocates argue that public benefit outweighs individual rights.
The story of fluoridation started in 1901 when Dr. Frederick S. McKay graduated
from University of Pennsylvania dental school and moved to Colorado Springs. He
noticed a permanent brown stain on the teeth of long-term residents and named the
condition Colorado brown stain. McKay was curious and wanted to learn more about
the condition. However, other local dentists and colleagues on the East Coast were
uninterested. He started his own local field study, tracking the source to Pike’s Peak
watershed. In 1909, McKay presented clinical cases of Colorado brown stain to the
Colorado Springs Dental Society. His presentation attracted the attention of preemi-
nent dental expert Dr. Green Vardiman Black. McKay convinced Black to visit Colo-
rado Springs and collaborate in his research. Black recalled his first visit to the area:
238 FLUO R IDATION
I spent considerable time walking on the streets, noticing c hildren in their play, attract-
ing attention and talking to them about their games, e tc., for studying the general
effect of the deformity. I found it prominent in every group of children. One does not
have to search for it, for it is continually forcing itself on the attention of the stranger
by its persistent prominence. (National Institute of Dental and Craniofacial Research,
2014)
Black renamed the problem mottled enamel. By 1915, McKay and Black had discov-
ered that mottled enamel was more severe among long-term residents and espe-
cially c hildren. C
hildren who lived in the region when they were developing their
secondary teeth appeared to have the most obvious discoloration. McKay believed
that the cause of the problem was trace elements in drinking water. But water analyses
revealed nothing unusual. In 1920, 78 c hildren in Oakley, Idaho, developed similar
characteristics of brown, pitted teeth. Townspeople dug a well to a different spring,
and within eight years the c hildren had normal teeth. In Arkansas, Dr. F. L. Robert-
son also noticed mottled enamel among children living in nearby Bauxite. Suspect-
ing the town’s water source, local officials dug a new well. Bauxite was owned by the
Aluminum Company of America (ALCOA). ALCOA’s chief chemist H. V. Churchill
was worried ALCOA might be blamed for water contamination. He instructed an
assistant to test the town’s water supply using the company’s sophisticated photo-
spectrometer. Analysis revealed high levels of fluoride. Churchill contacted McKay
and offered to test samples from other affected areas. Tests revealed similar results,
high levels of fluoride in the w ater supply. The U.S. Public Health Service sent
health alerts to 300 areas warning that minute amounts of fluorine could cause pit-
ted teeth.
Robertson, McKay, and others were frustrated by the lack of support and inter-
est from government officials. They spoke out publicly, pushing public health
officials to act. In 1931, the National Institutes of Health engaged the services of
Dr. Henry Trendley Dean. Dean was a public health dentist who served in World
War I providing oral care to soldiers suffering from trench mouth. He was very ana-
lytical and methodical. Colleagues described his innate ability to look at clinical
cases and epidemiological data and to develop workable solutions. Dean read reports
from around the world and designed a large-scale epidemiological study. Dental
researchers studied children’s teeth while chemists analyzed water samples. The
NIH’s investigation revealed high levels of fluoride in the w ater where mottling
existed along with significantly lower levels of caries. Dean designed a second study
comparing levels of fluoride in the local w ater supply to degree of dental fluorosis
in c hildren. This correlational study identified levels of fluoride that were ineffec
tive, safe, or harmful. With this new information, Dean designed a third study to
evaluate the impact of titrated fluoridation of public drinking w ater. G
rand Rapids,
Michigan, agreed to serve as a pilot site, adding the recommended level of fluoride,
one part per million to the public water system. Over the next 15 years, public health
dentists and researchers monitored the oral health of around 30,000 children. The
F LUOR IDATION 239
pilot was a success. Caries rates decreased 60 percent (Arnold Jr., Dean, Jay, & Kunt-
son, 1953). Other large cities soon a dopted fluoridation methods. In 1999, the
Centers for Disease Control and Prevention estimated that fluoridation improves
oral health by 68 percent.
Fluoride works in several ways. When we eat, bacteria in the mouth produce
acid that initiate the breakdown of carbohydrates. The acid does not differentiate
between food and teeth. The acid will attack and demineralize enamel, the hard,
protective, outer layer of teeth. Fluoride protects tooth enamel by adhering to the
surface and attracting calcium ions. The calcium ions bond with phosphate ions
forming an acid-resistant protective layer. Fluoride in the mouth enters the bacte-
rial cell and interrupts acid production. Reducing the amount of acid in the mouth
minimizes tooth decay. In c hildren who are developing their second set of teeth,
fluoride strengthens tooth structure by replacing the mineral hydroxyapatite
(Ca5(PO4)3OH) with the harder, more durable fluorapatite (Ca5(PO4)3F. Water fluo-
ridation benefits p eople of all ages, socioeconomic status, or dental practices. This
means that community members who are least able to afford dental care also ben-
efit, which ultimately reduces health disparities. The American Dental Associa-
tion (2016) estimates that each dollar spent on fluoridation saves $38 in dental
treatment.
Fluoridation is one of the greatest public health achievements of the 20th century.
Unfortunately, fluoridation occurred during the Cold War (1947–1991) and was
quickly overshadowed by the fear-mongering and conspiracy theories of the time.
Some conspiracy theorists believed that ALCOA was intentionally dumping toxic
chemicals into the local water system. Others believed fluoridation was a communist
plot to control the minds of American citizens. Antifluoridationist groups continue
today with claims that fluoridation causes AIDS, Alzheimer’s, low IQ, cancer,
and gastrointestinal diseases. Seventy years of research have shown that, at the cor-
rect levels, fluoride is safe and effective in improving dental health.
Ethicists point out that fluoridation creates an ethical dilemma pitting the com-
mon good against individual rights. With respect to the common good, federal, state,
local, and territorial governments have the power and responsibility to develop poli-
cies and procedures that benefit all or most members of society. This is why Oakley
and Bauxite dug new wells. Authorities had a responsibility to protect c hildren’s
teeth. Individuals also have rights. T hose advocating for individual rights point out
that fluoridation is a medical treatment, and thus local governments are medicat-
ing people without their consent. Fluoride is not a necessary ingredient of w ater
purification, and individuals should have the right to refuse unnecessary water addi-
tives. The dilemma was created by science and, like other dilemmas, it may end
with science. Fluoride is now readily available in bottled w ater, toothpastes,
mouthwashes, and tablets. Starting in the 1970s, West Germany, Sweden, Japan,
and the Netherlands stopped fluoridating public water supplies. E ngland allows
local health authorities to determine if fluoridation is necessary based on local
240 F OOD AND DR UG AD M INIST R ATION (F DA )
data. As new techniques emerge, the necessity for public water fluoridation may
diminish.
Fluoridation, adding fluoride to the water supply, protects teeth, making them
resistant to decay. Prior to fluoridation, most people lost their teeth by the age of
40. Today, many Americans enjoy nutritious foods, clear speech, and attractive smiles
because of the efforts and perseverance of a few dedicated public health dentists.
From a public health perspective, fluoridation is ideal b ecause it helps those who
can least afford dental care. Fluoridation benefits everyone, the young and old,
healthy or ill, and rich and poor.
Sally Kuykendall
See also: Community Health; Dean, Henry Trendley; National Institutes of Health;
Nutrition; Oral Health; U.S. Public Health Service
Further Reading
American Dental Association. (2016). 5 Reasons why fluoride in w ater is good for communities.
Retrieved from http://www.ada.org/en/public-programs/advocating-for-the-public
/fluoride-and-fluoridation/5-reasons-why-fluoride-in-w
ater-is-good-for-communities.
Arnold, F.A., Jr., Dean, H., & Knutson, J. (1953). Effect of fluoridated public water supplies
on dental caries prevalence: Seventh year of Grand Rapids-Muskegon study. Public Health
Reports, 68(2), 141–148.
Centers for Disease Control and Prevention (CDC). (1999). Achievements in public health,
1900–1999: Fluoridation of drinking w ater to prevent dental caries. Morbidity and Mor-
tality Weekly Report, 48(41), 933–940. Retrieved from https://www.cdc.gov/mmwr
/preview/mmwrhtml/mm4841a1.htm.
Centers for Disease Control and Prevention (CDC). (1999). H. Trendley Dean, D.D.S. Mor-
bidity and Mortality Weekly Report, 48(41), 935. Retrieved from https://www.cdc.gov
/mmwr/preview/mmwrhtml/mm4841bx.htm.
Dean, H. T. (1938). Endemic fluorosis and its relation to dental caries. Public Health Reports,
53(33), 1443–1452.
Dean, H. T., & McKay, F. S. (1939). Production of mottled enamel halted by a change in
common water supply. American Journal of Public Health, 29, 590–596.
Mottled teeth. (1940). Time, 35, 40.
National Institute of Dental and Craniofacial Research. (2014). The story of fluoridation.
Retrieved from https://www.nidcr.nih.gov/OralHealth/Topics/Fluoride/TheStoryof
Fluoridation.htm.
FOOD AND DRUG ADMINISTRATION (FDA)

The Food and Drug Administration (FDA) is the oldest comprehensive consumer
protection agency in the United States. It has been known as the FDA since 1930,
but it has earlier origins. It is an agency of the U.S. Department of Health and H
uman
Services. Major responsibilities include protecting and promoting public health
through the regulation and supervision of a variety of types of food and drug
F OOD AND D R U G AD M INIST R ATION ( F DA ) 241
products. This includes tobacco products, dietary supplements, prescription and

over-the-counter drugs, vaccines, biopharmaceuticals, blood transfusions, medi-
cal devices, and electromagnetic drugs. The FDA also enforces other laws, some
of which are not directly related to food or drugs, such as sanitation requirements
on interstate travel and control of disease on products for pets. A commissioner
of Food and Drugs heads the FDA and reports to the secretary of Health and
Human Services.
Although perhaps the best-known and most-important parts of the FDA are its
regulation of drugs and approval of new drugs, these responsibilities are only a small
part of the overall agency scope. The FDA regulates more than $1 trillion worth of
consumer goods, about 25 percent of consumer expenditures in the United States,
including food sales, drugs, cosmetics, and vitamin supplements. It is also respon-
sible for an array of goods imported into the United States. In terms of its costs and
generated revenues, it is a large agency with a budget of more than $4 billion, about
half of which is generated by user fees, most paid by pharmaceutical firms to expe-
dite drug reviews.
The history of the agency is important to understand its current roles. Its ori-
gins date back to the appointment of Lewis Caleb Beck around 1848 in the patent
office, where he was given a responsibility to carry out chemical analyses of agri-
cultural products. This was shifted to the newly created Department of Agricul-
ture in 1862 when chemist Charles L. Wetherill was appointed to head the Chemical
Division. What we think of now as among the most essential functions of the FDA
began with the passage of the 1906 Pure Food and Drug Act, a law that prohibited
interstate commerce in adulterated or misbranded food and drugs. The agency
responsible for FDA has been modified many times. The agency was shifted in
1940 to the newly created Federal Security Agency. It was moved to the newly
created Department of Health, Education and Welfare (HEW) in 1953, becoming
part of the Public Health Service within HEW in 1968. It was moved to the
Department of Health and Human Services in 1980 when the education function
was removed from HEW. Most federal laws concerning the FDA are part of the
Food, Drug, and Cosmetic Act, first passed in 1938 and extensively amended since.
This act improved the 1906 legislation by mandating that all new drugs be proved
safe before marketing, by making therapeutic devices and cosmetics subject to
regulation, and by requiring that standards of identity and quality be estab-
lished for foods. The law also made explicit FDA’s ability to conduct factory
inspections.
Although most offices of the FDA are located around Washington, DC, and are
part of the Headquarters Division, two important parts have field offices and a work-
force spread across the United States, the Office of Regulatory Affairs (ORA) and the
Office of Criminal Investigation (OCI). The ORA conducts most of the FDA’s work in
the field. Consumer safety officers, commonly called investigators, inspect produc-
tion and warehousing facilities, investigate complaints, illnesses, or outbreaks, and
review documentation in the case of medical devices, drugs, biological products, and
242 F OOD AND DR UG AD M INIST R ATION (F DA )
other items where it may be difficult to conduct a physical examination or take a

physical sample of the product. The ORA is divided into five regions and, within
those, 13 districts. The OCI is a newer part of the FDA, established in 1991 to inves-
tigate criminal cases, such as fraudulent claims, or knowingly and willfully shipping
adulterated goods in interstate commerce.
Two of the best-known activities of the FDA are food and drug regulation. For
foods, the Center for Food Safety and Applied Nutrition h andles most safety and
labeling concerns for food products except for t hose with meat, which are handled
by the Department of Agriculture, and alcohol-related products, which are also han-
dled separately. The Dietary and Supplement Health and Education Act of 1994
led to the FDA regulating dietary supplements, but as foods, rather than as drugs.
Thus, these products are not subject to safety and efficacy testing. Action can only
occur against supplements if they are unsafe. Manufacturers of dietary supplements
are permitted to make specific claims of health benefits but they may not claim to
treat, diagnose, cure, or prevent disease and must include a disclaimer on the label.
Bottled water is also regulated by the FDA.
For drug regulation, there are different requirements for each of three types of
drugs: new drugs, generic drugs, and over-the-counter drugs. A “new” drug is a
product made by a different manufacturer using different or inactive or other ingre-
dients, and with a different purpose than the older drug. The most rigorous require-
ments apply to drugs not based on existing medications. T hese new drugs receive
extensive scrutiny before FDA approval. Once approved, the sponsor must
review and report to the FDA every patient adverse drug experience. If the drug
event is an unexpected serious and fatal one, it must be reported within 15 days.
Other events are reported quarterly. Generic drugs are chemical equivalents of name-
brand drugs whose patents have expired. They are generally less expensive. Generic
drug approval requires scientific evidence that the generic drug is interchangeable
with or therapeutically equivalent to the originally approved drug. Over-the-counter
(OTC) drugs are those that do not require a doctor’s prescription. Often, they were
previously approved prescription drugs but now considered safe for use without a
physician’s supervision.
See also: Food Insecurity; Food Safety; Nutrition; Prescription Drugs; Prevention;
Public Health in the United States, History of; Vaccines; Controversies in Public Health:
Controversy 1
Further Reading
Food and Drug Administration, DHHS. (2012). Retrieved from http://www.fda.gov.
Healy, D. (2012). Pharmageddon. Berkeley: University of California Press.
Hilts, P. J. (2003). Protecting America’s health: The FDA, business, and one hundred years of regu-
lation. New York: Alfred E. Knopf.
F OOD INSEC U R ITY 243
FOOD INSECURITY
Food insecurity is the inability to attain an adequate or consistent supply of nutri-
tious food in socially acceptable ways. The definition includes three main concepts:
1. quantity, quality, or variety of food is inadequate for nutritional needs;

2. limited availability of food leads to feelings of deprivation and anxiety; and
3. food can only be obtained through stealing, begging, trash-picking, or charity.
Food insecurity goes beyond hunger in that hunger is a physiological state,

relieved by eating. Food insecurity is a socioemotional state of poverty, anxiety, and
disordered eating. Effective, sustainable interventions work to address the lack of
food, unstable household finances, and negative emotions.
The h uman body is amazingly resilient to food deprivation. However, over time,
chronic nutrient deprivation leads to fatigue, malnutrition, muscle wasting, sus-
ceptibility to infection, and death. Infants and children are particularly vulnerable
because micronutrients and macronutrients are needed for physical, social, and
emotional development. With an inconsistent food supply, the body attempts to
compensate. During times of plenty, the person overeats. More expensive or nutri-
ent dense foods, milk, milk products, fruits and vegetables, are neglected in favor
of inexpensive high-fat, high-calorie foods. This hunger-obesity paradox creates
mental health issues of helplessness, shame, humiliation, stress, anxiety, and depres-
sion and long-term problems of obesity, diabetes, cardiovascular disease, and
hypertension. The body also compensates by slowing down metabolic processes,
which exacerbates the potential for obesity. One in seven U.S. h ouseholds suffers
from food insecurity (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2016). C hildren
and females are at highest risk. Chronic food insecurity is associated with alcohol,
tobacco, and substance abuse, cravings for unhealthy comfort foods, and high-risk
sexuality (trading sex for food). Children suffer from delayed development, protein-
energy malnutrition (PEM), and behavioral problems. The need for food competes
with other needs, such as housing or medical care. Caregivers will often forgo their
own nutritional or medical needs so that their children may eat. The adverse con-
sequences of food insecurity affect females and female-headed h ouseholds more than
males.
Although extreme weather events, such as droughts or floods, can destabilize
local food supplies, on the broad level, food insecurity is related to political and
social injustices. The inability to access nutritious food is rooted within the h
ousehold
economy. The inability to earn a living wage, chronic poverty, low educational
achievement, limited job skills, and gender and racial inequities create social dis-
advantage and limit the ability to access and utilize nutritious foods. Programs
designed to address food insecurity are Supplemental Nutrition Assistance Program
(SNAP)/food stamps, the Women, Infants, and Children (WIC) program, National
School Lunch program, food distribution programs, disaster assistance, and financial
244 FOOD INSE CURITY
assistance to families living below the poverty line. Formerly known as food stamps,
the Supplemental Nutrition Assistance Program (SNAP) is a program of the U.S.
Department of Agriculture (USDA) Food and Nutrition Service. SNAP provides
electronic debit cards to eligible, low-income individuals and families. The major-
ity of SNAP recipients are children (44 percent) and/or households with at least
one working adult (75 percent). The debit cards are limited to food purchases. The
Women, Infants, and Children (WIC) program provides supplemental food, nutri-
tion education, and health referrals for low-income, at-risk infants, children up to
age five, and pregnant and postpartum women. WIC is offered through county and
city public health departments, health centers, schools, and community centers.
The National School Lunch Program (NSLP) is a federally assisted program avail-
able in public and private schools and residential child care institutions. The NSLP
provides free or reduced-price lunches to school-aged children. Food distribution
centers provide a safety net for people regardless of federal income guidelines on
nutritional assistance. Food pantries accept donations from the community and
redistribute food to p
eople in need. Other policies and programs that work to alle-
viate the problems of food insecurity are laws and policies that raise families out of
poverty, govern minimum wage, or provide earned income tax credit (EITC) and
Temporary Assistance to Needy Families (TANF). In addition to providing a secure
source of safe and nutritious foods, these programs provide opportunities for
Daniel Katz sorts food at SF-Marin Food Bank in San Francisco, California. The food bank
supports 225,000 p eople through neighborhood pantries, morning snacks for high-need
students, nutrition education, and home-delivered groceries to seniors and people with
disabilities. (Justin Sullivan/Getty Images)
F OOD SA FETY 245
health screening and referrals, nutrition education, and courses in literacy or

English as a second language. A major obstacle to nutritional assistance programs
is the stigma associated with food stamps and free school lunches. Many c hildren
and families who need and are eligible for nutritional assistance programs refuse to
use the programs b ecause they do not wish to be labeled as poor.
Food insecurity is a problem that extends beyond hunger and the need for nour-
ishment. The inability to attain a steady source of food leads to long-term emo-
tional and physical health problems. Government and nonprofit organizations offer
a number of programs designed to address food insecurity. Policies focused on social
inequity and living wages among the nation’s working poor may empower households
to achieve a reliable and steady source of food. For public health, challenges remain
in how to identify and interrupt the cycle of disordered eating.
Sally Kuykendall
See also: Body Mass Index; Food and Drug Administration; Food Safety; Nutrition;
Obesity; Rural Health; Social Determinants of Health; U.S. Department of
Agriculture
Further Reading
Coleman-Jensen, A., Rabbitt, M., Gregory, C., & Singh, A. (2016). Household food security
in the United States in 2015. Economic Research Report No. (ERR-215). Retrieved from
https://www.ers.usda.gov/publications/pub-details/?pubid=7
9760.
Dixon, L., Winkleby, M., & Radimer, K. (2001). Dietary intakes and serum nutrients differ
between adults from food-insufficient and food-sufficient families: Third National
Health and Nutrition Examination Survey, 1988–1994. Journal of Nutrition, 131(4),
1232–1246.
Ivers, L. C. (2015). Food insecurity and public health. Boca Raton, FL: CRC Press.
Radimer, K. L. (2002). Measurement of household food security in the USA and other indus-
trialised countries. Public Health Nutrition, 5(6A), 859–864.
United States Department of Agriculture. (2017). Retrieved from https://www.usda.gov/wps
/portal/usda/usdahome.
FOOD SAFETY
Every day, p eople take fruits, vegetables, meat, eggs, and other products from the
outside environment into their body. The potential for consumption of pesticides,
bacteria, allergens, or other toxic substances is not unreasonable. Public health
focuses on keeping food safe and preventing foodborne illnesses. The most common
sources of foodborne illnesses are bacterial, viral, or other contamination during
growing, harvesting, transporting, processing, storing, handling, or service. Food
poisoning affects 48 million people each year, causing 128,000 hospitalizations
and 3,000 deaths (CDC, 2016). Common pathogenic contaminants are Salmo-
nella, Norovirus, Campylobacter jejuni, Escherichia coli, Listeria monocytogenes, and
Clostridium perfringens. Although many pathogens are killed by salivary enzymes
246 FOOD SAFETY
or stomach acid, some get past the body’s natural defenses. Secondary lines of
defense are attempts to isolate, expel, or kill the organism through nausea, vomit-
ing, diarrhea, or high fever. Healthy individuals can recover from bouts of illness
with only brief and transient incapacitation. Infants, young children, elderly, people
with chronic diseases, and people with immune suppression are highly vulnera-
ble to infections. Some strains of Salmonella can cause intestinal rupture, leaking
contaminated gastrointestinal contents into the abdominal cavity causing sepsis
and death. Clostridium botulinum secretes a deadly toxin, which blocks nerve trans-
mission. The resulting paralysis can extend to facial and respiratory muscles, inter-
fering with speaking, swallowing, or breathing. Beyond health consequences, the
financial implications of foodborne illnesses are devastating to the food industry.
The estimated cost of foodborne illnesses is as high as $152 billion per year (Scharff,
2012).
Methods in food safety go beyond preventing microbial contamination to
include prevention of intentional or unintentional contamination by chemical resi-
dues, potential allergens, or other hazardous additives. Multiple agencies work
together to ensure that the food we eat is safe for consumption. The Environmental
Protection Agency (EPA) regulates the use of harmful pesticides and monitors water
quality. The Food Safety and Inspection Service (FSIS) is responsible for inspecting
food products for bacterial contamination, allergens, correct labeling, hazardous
chemical residues, and foreign materials; promoting food safety; studying food-
borne illnesses in order to identify emerging risks; and developing policies to pro-
tect the public from food borne illnesses (USDA, 2013). Environmental health
specialists, formerly known as sanitarians, are employed by local and state public
health departments to inspect restaurants, grocery stores, school cafeterias, nurs-
ing homes, and other food establishments to ensure food safety protocols are in
place and followed. Many health departments post inspection results online for
consumers to review. Health departments are also responsible for investigating and
reporting cases of food borne illness. The CDC monitors cases nationwide in order
to manage product recalls. The CDC also promotes food safety through health
education.
Foodsafety.gov is an educational website of the Centers for Disease Control and
Prevention (CDC), Food and Drug Administration (FDA), National Institutes of
Health (NIH), and U.S. Department of Health and H uman Services. The resource
gives four primary steps to food safety: clean, separate, cook, and chill. Cleaning
hands, food preparation surfaces, utensils, and fruits and vegetables stops the
transmission of bacteria. Best practice in cleaning fruits and vegetables is to remove
any damaged or bruised sections, rinse the produce under running w ater (scrub-
bing with a clean produce brush, if necessary), and dry with a paper towel or clean
cloth. It is not necessary to wash eggs, meat, or poultry because eggs are washed
before sale and washing raw meat can cause the juices to splash onto and contami-
nate food preparation areas. Separating aims to stop cross-contamination. Grouping
food types into their own spaces while grocery shopping, transporting, storing,
F OOD SA FETY 247
and preparing helps prevent contamination of bacteria from meats or seafood onto
ready-to-eat foods. Using separate plastic grocery bags for meats and seafood, stor-
ing meats in a bowl in the refrigerator (or freezing) to contain leakage, and using
different cutting boards, bowls, or serving plates during food preparation are a few
of the recommended strategies. The site calls attention to common practices that
enable cross-contamination. For example, when barbecuing outside, cooked food
should go on a clean plate, not the same (unwashed) plate that was used to carry
raw meat to the grill. Cook refers to heating and maintaining food at safe tempera-
tures to prohibit the growth of bacteria. Temperatures between 40°F and 140°F are
considered the danger zone. Microwaved meals should be heated to at least 165°F.
Food waiting to be served should be kept at 140°F or above. Chill means using
the recommended techniques to thaw frozen foods, refrigerating or freezing food
promptly a fter serving, and throwing out food that is past the recommended use
date. The safest way to thaw frozen meat, poultry, or seafood is in the refrigerator,
in cold w ater (changing the w
ater every 30 minutes), in the microwave, or to cook
directly from frozen. Meats, such as the Thanksgiving turkey, should never be thawed
on countertops as this is within the danger zone. Leftovers should be stored in the
refrigerator within two hours of cooking during cooler seasons and one hour dur-
ing warmer seasons. Foodsafety.gov provides several charts with recommended
cooking temperatures, food storage times, and thawing times.
Public health focuses on preventing food poisoning through food safety systems,
processes, inspections, training, and education. Public health allows us to safely
ingest, digest, and metabolize foods. The fact that p eople do not experience food
poisoning more often is a credit to the many systems and personnel who work to
keep food safe.
Sally Kuykendall
See also: Centers for Disease Control and Prevention; Food and Drug Administra-
tion; Food Insecurity; Handwashing; Infectious Diseases; Mallon, Mary; National
Institutes of Health; U.S. Department of Agriculture; U.S. Department of Health
and Human Services
Further Reading
Centers for Disease Control and Prevention (CDC). (2016). Foodborne germs and illnesses.
Retrieved from https://www.cdc.gov/foodsafety/foodborne-germs.html.
Scharff, R. (2012). Economic burden from health losses due to foodborne illness in the
United States. Journal of Food Protection, 75(1), 123–131.
U.S. Department of Agriculture (USDA). (2013). One team, one purpose, Food Safety Inspec-
tion Service: Protecting public health and preventing foodborne illness. Retrieved from https://
www.fsis.usda.gov/wps/wcm/connect/7a35776b-4717-43b5-b0ce-aeec64489fbd
/mission-book.pdf?MOD=A JPERES.
U.S. Department of Agriculture (USDA). (2017). Retrieved from https://www.usda.gov/wps
G
GENETICS
Genetics is a field of biology that studies genes and heredity. Genetic mutations can
create a spectrum of disorders ranging from minor deficiencies (color blindness) to
life-threatening diseases (cystic fibrosis). Abnormalities are commonly caused by the
insertion or deletion of a base pair, chromosomal abnormality, or extended length of a
gene. Although some mutations cause a problem directly, others act indirectly, pre-
disposing the individual to disease or malfunction. Examples of genetic disorders
are alcoholism, Alzheimer’s disease, hemochromatosis, hemophilia, Huntington’s
disease, Marfan syndrome, phenylketonuria, sickle cell anemia, Tay-Sachs, and
breast, colon, and prostate cancers. The genetic field offers new perspectives for
public health helping to understand disease, identify at-risk groups, and develop
personalized treatments. Genetic science is used in newborn screening, carrier
screening, pharmacogenetics, and ecogenetics. It is worth noting that such applica-
tions stretch the concept of public health. Whereas public health traditionally works
at the population level, genetics functions on the individual level. As a result, public
health administrators must consider whether screening, treatment, or interventions
are warranted. Decisions are made based on how common a genetic disease is,
whether effective treatments exist, and cost of treatment. It may be difficult to jus-
tify universal screening for rare genetic diseases that only affect few individuals
or have limited, expensive treatment options. The application of genetics to medi-
cine and public health raises ethical and legal concerns of how genetic informa-
tion is used, confidentiality, DNA banking, and potential for discrimination or
embryo selection.
Cystic fibrosis (CF) is one example of how genes influence health. CF is trans-
mitted as an autosomal recessive condition. Both parents carry the mutated gene,
typically without signs or symptoms. The point of mutation is the cystic fibrosis
transmembrane conductance regulator (CFTR) gene, the gene that provides the body
with instructions on how to make a particular protein, which allows chloride ions
to move in and out of cells. Chloride ions are critical to the body’s fluid and elec-
trolyte balance. CFTR malfunction replaces normal mucus secretions with thick,
sticky secretions. Body systems that are dependent on lubrication to function are
affected, the respiratory, pancreatic, gastrointestinal, and reproductive systems. The
person with CF struggles to clear respiratory passages and is at high risk for clogged
airways, chronic lung infections, and formation of scar tissue in the lungs. Gastro-
intestinal (GI) problems include blockage of the GI system or pancreatic ducts, diar-
rhea, malnutrition, failure to thrive, weight loss, and cystic fibrosis–related diabetes
250 G ENETI CS
mellitus. Early diagnosis is important to prevent and control adverse health conse-
quences. Physicians make the diagnosis based on physical examination, personal
and family medical history, and laboratory tests, including genetic testing. Inter-
ventions focus on keeping the airways clear with postural drainage, regular chest
physiotherapy, deep breathing exercises, and medicine to thin mucus secretions.
Malnutrition is prevented by high protein/high calorie diet, vitamin supplements,
and pancreatic enzymes. Efforts in the home are to avoid dust, fumes, mold, or
mildew, drink plenty of fluids, and exercise regularly. Pharmaceutical treatments to
address the physiological problem are coming on the market. Ivacaftor (Kalydeco)
works to open new channels for chloride ions, correcting the underlying deficiency.
The drug costs more than $300,000 per year. The only way to prevent CF is carrier
screening, genetic screening of c ouples prior to pregnancy. Carrier screening informs
the c ouple of their chance of transmitting mutations to a child. For example, if both
biological parents carry the mutated CFTR gene, there is a 25 percent chance that
the child will have CF. Genetic counselors work with the couple to determine repro-
ductive options based on the couple’s values.
Phenylketonuria (PKU) is a good example of genetic screening in public health.
All infants are screened for PKU at birth by drawing a tiny drop of blood from the
heel. PKU testing is simple, and early intervention is highly effective in reducing
long-term disability. Newborn screening is also used to diagnose congenital hypo-
thyroidism, sickle cell disease, tyrosinemia, or galactosemia. Genetic screening raises
ethical concerns of potential stigma, confidentiality, cost, insurability, and employ-
ment. Insurance companies or employers could use genetic information to discriminate
or deny coverage. Since genes are transmitted within the family, genetic information
of one individual may confer information about other family members. This raises
concerns regarding confidentiality and informed consent. To overcome concerns,
it is important to ensure that a community or population supports screening and
does not believe they are being targeted for discrimination. Depending on the dis-
order, screening efforts may be cost-contained by focusing on populations at risk.
For example, CF affects 1 in 2,500 Caucasian Americans, 1 in 2,270 Ashkenazi
Jewish Caucasians, 1 in 13,500 Hispanic Americans, 1 in 15,100 African Ameri-
cans, and 1 in 35,100 Asian American couples (Palomaki, FitzSimmons, & Had-
dow, 2004). If testing is expensive, it may not be necessary to screen all populations
for all genetic disorders.
Two emerging fields of genetics with application to public health are behavioral
genetics and precision medicine. Behavioral genetics proposes that individuals are
born with certain traits that are only exhibited when switched on by environmental
factors. Behavioral genetic theories have been applied to alcohol abuse, violence,
and criminality. The premise of behavioral genetics should be used to strengthen
public and policy concern for the social determinants of health. Precision medicine
optimizes disease treatments and prevention by considering the individual’s life-
style, environment, and genetic makeup. For example, trastuzumab (Herceptin) is
used to treat breast cancer among women with a specific genetic profile known as
G LO B AL HEALTH 251
HER-2 positive (The Cancer GenomeAtlas, n.d.). Precision medicine allows physi-
cians to individualize treatments for more effective results.
The application of genetics to public health offers promise to understanding,
treating, and preventing common diseases and health issues. However, like many
scientific advances, the information can also be used to hurt or to harm. The eugen-
ics movement advocated to use genetic screening to eliminate “undesirable traits”
(alcoholism, criminality, feeble-mindedness, poverty, and deafness) and replace with
“desirable traits” (whatever those in power determine is desirable). The horrors of
Nazi Germany helped people to realize how arrogant, ridiculous, and narrow-
minded such ideas were. Eliminating people with “undesirable traits” would
deprive the world of the genius and contributions of Abraham Lincoln (Marfan syn-
drome), Frédéric Chopin (believed to have CF), Vincent van Gogh (bipolar disor-
der), Henri de Toulouse-Lautrec (pycnodysostosis), Miles Davis (sickle cell anemia),
Niccolò Paganini (Ehlers-Danlos syndrome), John F. Kennedy (Addison’s disease),
King Charles II (prognathism), and Queen Victoria (hemophilia).
Sally Kuykendall
See also: Association of Public Health Laboratories; Bioterrorism; Birth Defects; Can-
cer; Eating Disorders; Health; Health Care Disparities; Hypertension; Maternal
Health
Further Reading
The Cancer Genome Atlas. (n.d.). Impact of cancer genomics on precision medicine for the treat-
ment of cancer. National Cancer Institute. Retrieved from https://cancergenome.nih.gov
/cancergenomics/impact.
Cystic Fibrosis Foundation. (2017). Retrieved from https://www.cff.org/.
Ho, N. C., Park, S. S., Maragh, K. D., & Gutter, E. M. (2003). Famous people and genetic
disorders: From monarchs to geniuses—A portrait of their genetic illnesses. American
Journal of Medical Genetics, Part A, 118A(2), 187–196.
Palomaki, G. E., FitzSimmons, S. C., & Haddow, J. E. (2004). Clinical sensitivity of prena-
tal screening for cystic fibrosis via CFTR carrier testing in a United States panethnic
population. Genetics in Medicine: Official Journal of the American College of Medical Gene
tics, 6(5), 405–414.
U.S. Department of H uman Services. (2017). Genetics home reference. Retrieved from https://
ghr.nlm.nih.gov/.
GLOBAL HEALTH
Global health is a process of international collaboration focused on addressing com-
plex and challenging public health issues or threats. Global health issues of Zika
virus, severe acute respiratory syndrome (SARS), avian influenza, and Ebola affect
people directly and indirectly. T hese illnesses cause disability and death and
strain health services, impacting regional and national economies. The issues cross
252 G LO BAL HEALTH
geographic and regional boundaries and demand a high level of cooperation between
nations. Courses in global health engage multidimensional approaches in health
promotion, health equity, disease prevention, epidemiology, and health policy. As
an interdisciplinary field, global health adopts information and practices from pub-
lic health, medicine, biology, economics, environmental sciences, social sciences,
and behavioral sciences. The United States spends about $10.2 billion annually on
global health programs (Wexler & Kates, 2016). The President’s Malaria Initiative
(PMI), the President’s Emergency plan for AIDS Relief (PEPFAR), the Global Fund,
United States Agency International Development (USAID), and the Global Health
Security Agenda provide services in family planning and reproductive health, mater-
nal and child health, nutrition and treatment and prevention of AIDS, tuberculosis,
and malaria. Collaborative actions draw scientific and technical assistance, human
resources, and capital development from many countries to strengthen health sys-
tems in regions of need.
Historically, communicable diseases w ere blocked by geographic landforms.
Mountains, deserts, or large bodies of water impaired face-to-face contact. Air travel
and the expansion of international commerce and trade created new social and envi-
ronmental conditions leading to urbanization, food borne illnesses, climate change,
and microbial adaptations (De Cock, Simone, Davison, & Slutsker, 2013). Endemic
and epidemic diseases are easily spread through h uman migration and international
travel. Infectious diseases crossing transnational boundaries can create public health
emergencies. In 2014, passengers returning from the West African countries of
Guinea, Liberia, and Sierra Leone spread Ebola virus to the United States. Although
the cases w ere contained and treated, the potential exists for other communicable
diseases. Preventing, controlling, or extinguishing diseases at the place of origin
saves lives and resources.
Infectious diseases are illnesses caused by pathogenic microorganisms, such as
bacteria, viruses, parasites, or fungi. The diseases can be transmitted directly or indi-
rectly through contact with infected bodily fluids, air, w ater, food, or vectors. Dis-
eases spread through direct bodily fluid contact include HIV/AIDS, Ebola, and
hepatitis C. Tuberculosis, influenza, measles, SARS, and pertussis are transmitted
through the air. Malaria and Zika virus are vector borne infectious diseases trans-
mitted by mosquitoes to humans. Cholera is transmitted through contaminated
water. Infectious diseases account for 19 percent of deaths internationally (Lozano
et al., 2013). HIV/AIDS, tuberculosis, and malaria are the leading c auses of death.
Internationally, 37 million people are infected with HIV, and more than 10.4 mil-
lion people are infected with tuberculosis (WHO, 2017b). P eople living in
developing countries, low socioeconomic status, malnourished, unemployed,
with inadequate education, poor sanitation, inadequate health care, and lacking
basic amenities are most affected. In Africa, infectious diseases, malnutrition, and
maternal and child health problems accounted for 56 percent of deaths in 2015
(WHO, 2017a). Sub-Saharan Africa accounts for 50 percent of infectious disease
deaths, globally (WHO, 2017a). Infectious diseases such as HIV/AIDS, malaria,
G LO B AL HEALTH 253
diarrhea, and lower respiratory tract infections are the leading causes of death in
Africa.
Food marketing and trade are a global health concern. Varying standards in food
safety, production, and processing create the potential for food borne illnesses. Forty-
eight million Americans are affected by food borne illness yearly (CDC, 2016a).
Salmonella infections account for more cases of hospitalizations, illness, and death
than any other food borne pathogen. To prevent food borne illnesses, Congress
enacted the Food Safety Modernization Act (2010). The law empowers and man-
dates the Food and Drug Administration (FDA) to recall contaminated food from
the United States and other countries.
Anthropogenic activities such as the emission of radioactive materials, burning
of fossil fuels, use and improper disposal of industrial chemicals, w ater pollution,
and deforestation due to urbanization threaten global health. Anthropogenic activ-
ities increase climatic temperatures, creating factors that promote communicable
diseases. Global warming enhances the survival, breeding, and transmission of vec-
tor borne diseases such as malaria, dengue, and yellow fever. Rising sea levels cre-
ate flooding conditions promoting waterborne illnesses of viral gastroenteritis and
cholera.
Noncommunicable diseases (NCDs) are chronic and acute diseases that affect
millions of p eople around the world. NCDs account for 80 percent of all deaths
globally and include various types of cancers, chronic respiratory diseases, cardio-
vascular diseases, and diabetes (WHO, 2017c). T hese conditions are not contagious
but require costly long-term management. Sufferers experience pain, disability, loss
of income, disruption of family stability, and impaired quality of life. Globally, car-
diovascular disease accounts for 17.7 million deaths, cancers cause 8.8 million
deaths, chronic lung diseases cause 3.9 million deaths, and diabetes causes 1.6 mil-
lion deaths (WHO, 2017b). In developed countries, individuals ages 60 and below
account for 13 percent of NCD-related deaths, while low and m iddle income coun-
tries consist of 29 percent of NCD-associated deaths (Baldwin & Amato, 2012).
The WHO (2011) projects a 15 percent increase in NCDs globally by 2025 and a
20 percent increase in South-East Asia, Africa, and the Eastern Mediterranean. NCDs
carry substantial health care costs. For e very dollar spent on health care in the United
States, seventy cents goes t oward treating chronic health conditions (CDC, 2016b).
NCDs can be prevented by reducing common risk factors such as tobacco use, alco-
hol use, physical inactivity, and unhealthy diet.
Global health interventions are collaborative strategies focusing on identification,
control, prevention, and treatment of disease, and overall improvement of health.
Global health challenges are organized mostly through United Nations agencies,
nongovernmental organizations (NGOs), charities and foundations, and private
donors. These agencies coordinate funds and share information on disease outbreaks
and containment. Global health agencies include the United Nations agencies such
as the WHO, UNICEF, and UNIAIDS. USAID is an agency under the Department
of State with responsibilities for coordinating and organizing the U.S. global health
254 G LO B AL HEALTH
programs. The Clinton Foundation and the Bill and Melinda Gates Foundation are
private organizations with initiatives on global health challenges. Global health inter-
ventions involve coordination and collaborative actions that aim at disease surveil-
lance and mitigation, health system strengthening through scientific and technical
assistance, human resource management, and capital development. Other global
health interventions include vaccination and immunization programs, medical and
pharmaceutical product supply, community advocacy and education programs, pov-
erty reduction programs, and provision of medical equipment and infrastructural
amenities that meet the needs of vulnerable or special populations.
The study of global health investigates international environmental and socio-
economic determinants of health. Issues include outbreak of emerging or reemerg-
ing infectious diseases, food safety, bioterrorism, global warming, vaccines and
immunizations, access to health care, chronic diseases, and the proliferation of con-
taminated or counterfeit pharmaceutical products. Comparing data on health out-
comes and living standards and infant and child mortality highlights the differences
between developing and developed countries. Because infectious and chronic dis-
eases do not recognize political boundaries, efforts to train medical personnel, share
medical information, and strengthen the infrastructure of existing health systems
are needed to treat and prevent global health concerns.
Godyson Orji
See also: Bioterrorism; Epidemic; Immigrant Health; Pandemic; Smallpox; World

Health Organization
Further Reading
Baldwin, W., & Amato, L. (2012). Fact sheet: Global burden of non-communicable diseases.
Retrieved from http://www.prb.org/Publications/Datasheets/2012/world-population
-data-sheet/fact-sheet-ncds.aspx.
Centers for Disease Control and Prevention (CDC). (2016a). Estimates of foodborne illness in
the United States. Retrieved from http://www.cdc.gov/foodborneburden/2011-foodborne
-estimates.html#annual.
Centers for Disease Control and Prevention (CDC). (2016b). Multiple chronic conditions.
Retrieved from http://www.cdc.gov/chronicdisease/about/multiple-chronic.htm.
De Cock, K. M., Simone, P. M., Davison, V., & Slutsker, L. (2013). The new global health.
Emerging Infectious Diseases, 19(8), 1192–1197. doi:10.3201/eid1908.130121
Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K.,
& Wasserheit, J. N. (2009). T owards a common definition of global health. The Lancet,
373(9679), 1993–1995. doi:10.1016/S0140-6736(09)60332-9
Lozano, R., Naghavi, M., Foreman, K., Lim, S., Shibuya, K., Aboyans, V., & AlMazroa, M. A.
(2013). Global and regional mortality from 235 c auses of death for 20 age groups in
1990 and 2010: A systematic analysis for the global burden of disease study 2010. The
Lancet, 380(9859), 2095–2128. doi:10.1016/S0140-6736(12)61728-0
Smith, K. F., Goldberg, M., Rosenthal, S., Carlson, L., Chen, J., Chen, C., & Ramachan-
dran, S. (2014). Global rise in h uman infectious disease outbreaks. Journal of the Royal
G OALS AND O B JE C TI V ES 255
Society Interface, 11(101), 20140950. doi:10.1098/rsif.2014.0950. Retrieved from http://

rsif.royalsocietypublishing.org/content/11/101/20140950.
Wexler, A., & Kates, J. (2016, January 20). The US global health budget: Analysis of appropria-
tions for fiscal year 2016. Retrieved from http://kff.org/global-health-policy/issue-brief
/the-u-s-global-health-budget-analysis-of-appropriations-for-fiscal-year-2016/.
World Health Organization (WHO). (2011). Burden: Mortality, morbidity and risk factors.
Global status report on non-communicable diseases, 2011. Retrieved from http://www.who
.int/nmh/publications/ncd_report_full_en.pdf.
World Health Organization. (2017a). Global health observatory (GHO) data. Retrieved from
http://www.who.int/gho/en/.
World Health Organization. (WHO). (2017b). HIV/AIDS data and statistics. Retrieved from:
http://www.who.int/hiv/data/en/.
World Health Organization (WHO). (2017c). Noncommunicable diseases fact sheet. Retrieved
from http://www.who.int/mediacentre/factsheets/fs355/en/.
GOALS AND OBJECTIVES

In public health, goals and objectives define the intended aim or outcome of a par
ticular health promotion or disease prevention activity. Goals and objectives are tools
used to focus the project, motivate participants, and evaluate efforts. Goals are broad
statements that name the population of interest and what is expected to happen
because of the planned activity. Objectives are precise statements that define the
interim steps or tasks necessary to meet the intended goal. Due to this precision,
health educators follow common rules in writing goals and objectives. The main
advantage of goals and objectives is that they ensure that projects stay on track. A
disadvantage is that even well-developed objectives are susceptible to moderating
influences. Goals can only be accomplished with adequate resources, knowledge,
and effort.
The idea of goals and objectives originated from business psychology. In 1897,
Dr. William Lowe Bryan and Mr. Noble Hartner studied p eople learning the skill
of telegraph code-writing. The researchers concluded that learners w ere more suc-
cessful when given progressive tasks with specific targets for achievement. In 1911,
Dr. Frederick Winslow Taylor studied time and motion in factories. He concluded
that businesses could improve output (and therefore profit) by identifying specific
and challenging tasks for each worker. At the time, workers were viewed as raw
materials, a commodity for making money. Winslow failed to consider factors that
might influence the individual worker, moderating the relationship between
goals and achievement. Wyatt, Frost, and Stock (1934) studied industrial workers
assigned to boring, repetitive tasks. They noted that workers paid by work output
(number of widgets produced) w ere more productive than workers paid by the
hour (time on the work clock). The researchers cautioned that while financial
incentives compensated for boring tasks, the incentives did not compensate for
tasks that the workers disliked or thought were meaningless. In 1935, Dr. Cecil
Alec Mace further discredited the belief that employees are motivated by money.
256 G OALS AND OBJECTI VES
Mace proposed the idea of goal setting. Dr. Edwin A. Locke (1968) investigated the
relationship between goals, aims, and task performance and surmised that high
goals are better motivators than low, easy goals and defined goals are more effective
than general goals (“do your best”). Locke and Latham (1990) developed a formal
theory of motivation and task performance. Goal setting theory (GST) outlines
the various moderating and mediating factors that influence motivation, such as
financial incentives, time constraints, competition, praise, punishment, shared
knowledge of outcomes, and personal intentions (Latham & Locke, 2007). GST
is applicable to business, education, psychology, sociology, and health behavioral
change.
Goals describe broad, long-range states or conditions that the individual or group
hopes to achieve. One example is the Healthy P eople 2020 goal for adolescents (aged
10–19) and young adults (aged 20–24): “Improve the healthy development,
health, safety, and well-being of adolescents and young adults” (Office of Disease
Prevention and Health Promotion [ODPHP], 2016). Improving health encompasses
multiple components for adolescents and young adults; this means reducing hom
icides, suicides, motor vehicle crashes, substance abuse, smoking, sexually trans-
mitted diseases, unplanned pregnancies, and homelessness. In comparison to goals,
objectives address short, intermediate, or long-term outcomes. Objectives state a
specific measure of achievement and time period. Health educators and program
planners use the acronym SMART (Specific, Measurable, Achievable, Relevant, and
Time-bound) to write program objectives. One Healthy People 2020 objective for
adolescent and young adult m ental health is: “Reduce the proportion of adolescents
who engage in disordered eating behaviors in an attempt to control their weight.”
The defined outcome is a reduction of 10 percent. The objective is specific, target-
ing one aspect of mental health, disordered eating among adolescents (aged
10–19). Disordered eating is clearly defined as fasting in order to lose weight or
prevent gaining weight; using pills, powders, or liquids without a doctor’s advice
in order to lose weight or prevent gaining weight; or taking laxatives to lose weight
or prevent from gaining weight. This high degree of specificity sets conditions on
who, what, where, or how. The adolescent who loses weight due to food insecurity
is excluded from the count b ecause weight loss is unintentional. Measurable defines
how much of a change is desired. The objective seeks to reduce the proportion of
teens affected by 10 percent, from 14.3 percent to 12.9 percent. Achievable means
that the objective is realistic. With sufficient support for evidence-based programs,
a reduction of 10 percent is not unreasonable. Relevant means that the objective
logically relates to the overall goal. Reducing disordered eating not only improves
mental health, but also improves other aspects of health, such as reducing malnu-
trition, osteoporosis, kidney failure, electrolyte imbalances, gastric ulceration, tooth
decay, and heart disease. Time-bound refers to the period of time in which the out-
come w ill be achieved. Healthy People 2020 objectives are 10-year objectives, start-
ing in 2010 and completing in 2020. Other programs might use a particular time
G OALS AND O B J E C TI VES 257
point (by the end of the program), a particular time period (within one year), or an
event frame (after childbirth). Since program objectives are accomplished through
program activities, the objectives convey active learning. Verbs, such as recognize,
describe, apply, demonstrate, construct, and evaluate, are used to define what the
participants must achieve in order to meet the objective. Some grant writers, pro-
gram planners, and evaluators use templates to write objectives. For example, “By
[date/time], [who] w ill [verb] [noun] at [level/condition]” translates to “By the end
of the program, adolescents w ill construct healthy daily menus that reflect adequate
protein, carbohydrate, and fat intake.”
Goals and objectives define the aims of a health program that will be accom-
plished through program activities. They provide program organizers with realistic
and measurable targets for participants. The most effective and useful objectives are
practical, well written, logical, and clearly state desired outcomes. Although goals
and objectives are used in many disciplines, they serve a special purpose in public
health, aiding in grant writing, program planning, evaluation, and national health
planning.
Sally Kuykendall
See also: Administration, Health; Eating Disorder; Evaluation; Evidence-Based Pro-

grams and Practices; Grants; Healthy People 2020; Heart Truth® (Red Dress) Cam-
paign, The; Intervention; Leading Health Indicators; Logic Model
Further Reading
Bryan, W. L., & Hartner, N. (1897). Studies in the physiology and psychology of the tele-
graphic language. Psychological Review, 4, 27–53.
Latham, G. P., & Locke, E. A. (2007). New developments in and directions for goal-setting
research. European Psychologist, 12(4), 290–300. doi:10.1027/1016-9040.12.4.290
Locke, E. A. (1968). Toward a theory of task motivation and incentives. Organizational Behav
ior & Human Performance, 3(2), 157–189.
Locke, E. A., & Latham, G. P. (1990). A theory of goal setting and task performance. Engle-
wood Cliffs, NJ: Prentice Hall.
Mace, C. A. (1935). Incentives: Some experimental studies. Industrial Health Research Report
(Great Britain), 72.
Office of Disease Prevention and Health Promotion. (2016). Healthy People 2020: Adolescent
health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic
/Adolescent-Health.
Taylor, F. (1911). Principles of scientific management. New York: Harper.
Tulane University. Tips for writing goals and objectives. Retrieved from http://www2.tulane
.edu/publichealth/mchltp/upload/Tips-for-writing-goals-and-objectives.pdf.
Wyatt, S., Frost, L., & Stock, F. G. L. (1934). Incentives in repetitive work. Industrial Health
Research Board (Great Britain) Report, No. 69.
258 G R ANTS
GRANTS
Grants are funds disbursed by government or nonprofit organizations, corporations,
or foundations to support a specific research or intervention project. The grant sys-
tem is designed to support public health research and prevention efforts in HIV/
AIDS, suicide, health disparities, neurosciences, substance abuse, smoking, com-
municable diseases, and sleep disorders as well as numerous other problems.
Although many public health grants are related to health goals identified by Healthy
People 2020, grants may also support research and development in novel emerging
health issues. Grant funding is competitive or noncompetitive depending on the
source and the focus of the grant. Grants allow public health professionals to
investigate problems, develop solutions, evaluate programs, and suggest policies
to enhance health and alleviate disease.
Grant application is a very detailed process. Grant announcements are adver-
tised in professional newsletters, government listservs, and on grants.gov. A research
or community group interested in addressing a specific problem would start by iden-
tifying relevant grant opportunities. Announcements typically list the number of
awards available, whether the grant requires the recipient to match the grant funds
with other funding sources, start date and end date of the award, eligibility criteria,
and proposed grant amount. Prior to full application, the grantor may suggest fil-
ing a letter of intent. The letter of intent allows the funder to filter applicants based
on advertised criteria. For example, the letter of intent would screen community
agencies from applying for a grant specifically for schools. In public health, grant
applications present a brief review of the science behind the health problem; describe
the purpose of the proposed project and the intended target population; methods;
timeline for completion; and budget. Nonprofit organizations are required to
show nonprofit status. The grant application is very specific. Failure to follow instruc-
tions may result in automatic rejection.
Once a grant is awarded, the grantor may formally announce grantees through
the media. All government grants are announced to the public. The funding is allo-
cated throughout the project based on length of the grant. The funder may check
in at regular intervals to ensure that the project is progressing as planned. At the
end of the grant, the recipients submit a technical report detailing the project, out-
comes, successes, and next steps. Research findings or program outcomes are dis-
seminated to other public health professionals through conference presentations
and professional journals. One issue that grant recipients face is that many grants
are budgeted for short-term use. If the group is working on a chronic health issue,
they may need to apply for several grants to sustain their efforts. Application and
reapplication can create gaps in the project. People working on the grant may leave
for more secure, permanently funded positions.
The advantage of grants is that they support collaborations in addressing issues
of concern within the community or support researchers in novel research, which
could lead to cures, treatments, programs, or enhance knowledge within a particular
G R ANTS 259
field. The grant system ensures that the recipients use the award for what it was
intended. Grantors are able to set conditions on how funds are used and require
regular progress reports to monitor budget and progress. A disadvantage is that
grants are easily influenced by politics. In 1990, doctors and researchers at Univer-
sity of Washington Harborview Medical Center released a study comparing suicides
in King County, Washington, and Vancouver, British Columbia (Sloan et al., 1990).
Data analysis found that while suicide rates did not vary, suicide by firearm was
almost six times lower in Vancouver where gun laws were stricter. The researchers
concluded that stricter gun laws may reduce suicide among people aged 15 to 24.
The research was followed up with another study reviewing household risk factors
for homicide (Kellermann et al., 1993). This study found that a gun in the home
was more likely to be used to kill a f amily member or friend than a stranger or home
invader. In response to the information, the National R ifle Association (NRA) cam-
paigned to eliminate the Centers for Disease Control and Prevention’s National Center
for Injury Prevention and pressured Congress to reallocate $2.6 million budgeted
for firearm injury research ( Jamieson, 2013). The injury center survived. However,
the message was clear. Firearm injury prevention research was off limits, and
engaging in such research could jeopardize financial support from the federal gov-
ernment. For the next 20 years, research on gun violence was stalled. After the
Sandy Hook Elementary School shooting, public attention shifted back to gun vio
lence. In 2013, President Barack Obama released a national plan to “end the freeze
on gun violence research” (White House, Office of the Press Secretary, 2013). Restored
funding enables researchers to study this critical public health problem, which
claims the lives of 30,000 people every year. In order to address some of the most
pressing health concerns and to inform effective policies, government agencies must
be able to support unbiased scientific research, free from political manipulation.
Grants enable public health agencies to explore pressing health problems, trans-
lating federal goals to individuals in homes, communities, and businesses across
the nation. Although grants offer a well-established system for allocating and mon-
itoring government funds, the application system is tedious and time consuming.
There is also a need to improve the system so that public health scientists may engage
in uninterrupted projects without fear of reprisal from powerful political groups.
Sally Kuykendall
See also: Collaborations; Evaluation; Healthy People 2020; Intervention; Prevention;

Substance Abuse and Mental Health Services Administration; Controversies in Pub-
lic Health: Controversy 1
Further Reading
Jamieson, C. (2013). Gun violence research: History of federal funding freeze. Psychological
science agenda. Retrieved from http://www.apa.org/science/about/psa/2013/02/gun
-violence.aspx.
260 G R ECO-R OM AN ERA, PU BLIC HEALTH IN THE
Kellermann, A. L., Rivara, F. P., Rushforth, N. B., Banton, J. G., Reay, D. T., Francisco, J. T., &
Somes, G. (1993). Gun ownership as a risk factor for homicide in the home. New
England Journal of Medicine, 329(15), 1084–1091. doi:10.1056/NEJM199310073291506
Sloan, J. H., Rivara, F. P., Reay, D. T., Ferris, J. A., & Kellermann, A. L. (1990). Firearm
regulations and rates of suicide: A comparison of two metropolitan areas. New England
Journal of Medicine, 322(6), 369–373. doi:10.1056/NEJM199002083220605
U.S. Department of Health and Human Services. (2017). Retrieved from http://www.grants
.gov/.
White House, Office of the Press Secretary. (2013). Now is the time: The president’s plan to
protect our c hildren and our communities by reducing gun violence. Retrieved from http://
www.washingtonpost.com/wp-srv/politics/documents/gun-proposals/GunViolence
ExecutiveSummary.pdf.
GRECO- R OMAN ERA, PUBLIC HEALTH IN THE

The Greco-Roman Era started with the rise of Greek philosophy and ended with
the fall of the Roman Empire. This lengthy period of history is particularly rele-
vant to public health b ecause this is when beliefs regarding the c auses of disease
shifted from the supernatural to the natural and man sought ways to prevent ill-
ness. Greek philosopher-physicians encouraged healers to move away from magical
potions and instead examine the patient’s diet, activity, lifestyle, and environment.
As the perceived power of the gods decreased, man’s control over health increased.
The use of observation, investigation, and logic shifted the locus of control (place
of control) from external forces (the gods) to internal (the individual and physi-
cian) and created the new field of medicine. Greek philosopher-physicians endowed
their wisdom by defining and describing the basic bioethical principles that guide
today’s medical practice. The early Roman civilization developed their own system
of public health, which used engineering and architecture to promote sanitation
and hygiene and prevent disease. The numerous philosophical and practical
advances passed down from early Greek and Roman civilizations form the founda-
tions of current public health practices.
Historical documents indicate that the ancient Greeks and Romans suffered from
numerous infectious diseases, injuries, and chronic illnesses, specifically epilepsy,
depression, sciatica, and kidney disease. The average life span in ancient Greece was
35 years and 32 years in ancient Rome (Deevey, 1950). L ater investigation suggests
longer lives, averaging 72 years and up to 107 years (Montagu, 1994). However,
these calculations are based on famous men in history who were not enslaved and
probably enjoyed wealth and good fortune. Ancient physicians followed the
humoral theory of medicine, which supposes that the body consists of four humors:
black bile, yellow bile, blood, and phlegm. Each humor reflects a particular natural
element, earth (black bile), fire (yellow bile), air (blood), and w
ater (phlegm). Imbal-
ances in the humors resulted in disease or disability. Medical treatment aimed to
restore balance through counterbalance or in some cases with the same humor. The
Greek approach was both analytical and holistic. The role of the physician was to
GREC O -R O M AN E R A , PU B LIC HEALTH IN THE 261
support the body in natural healing. By the first century CE, the Romans conquered
most of Europe. Greek philosophies w ere saved but given lesser prominence. Nat-
uralistic treatments w ere considered too passive by Roman standards.
The Greeks did not have a formal system of health care. Itinerant healers trav-
eled from town to town treating the sick. The major disadvantage to this system
was that a physician may not be in town when an epidemic struck. Over time, towns
organized to pay a regular salary to a physician, encouraging him to stay in the area
and treat townspeople regardless of ability to pay. This was the first system of pub-
lic health care in Western civilization. To earn the privilege of a steady wage, the
physician must be both skilled and trustworthy. Skill did not mean that everyone
was healed and no one died. It was better for a physician to accurately predict
disease outcome, even if the outcome was negative, than to give false hope or prom-
ises. Inaccurate prognosis made the physician appear incompetent, greedy,
or deceitful. Thus, Greek doctors focused on diagnosing illnesses and accurate
prognoses.
Hippocrates of Cos (Kos) is recognized as the F ather of Western Medicine for
his role in transforming medicine into a science and developing a code of medical
ethics. Hippocrates advocated for a formal process of medical care that consisted
of (1) patient examination, (2) diagnosis, (3) prognosis, and (4) treatment. As phy-
sicians supplanted the gods of healing, Hippocrates also recognized the potential
for abuse of power. Trust between physician and the community was critical to
quality care. Lying, cheating, or abuse of power not only affected the individual
physician, it marred the profession. Hippocrates advised physicians to act with
humanity, honesty, and integrity, to respect h uman life and the power of medicine.
The Hippocratic Oath, which was not actually written by Hippocrates, summa-
rizes ethical guidelines for medical practice. Graduating medical students use an
updated version of the Hippocratic Oath, vowing to protect the sanctity of h uman
life and to avoid causing pain, injury, or death.
Under the Roman Empire, interest in health was limited to practices that for-
warded the agenda of building military might, government, and economy. Main-
taining the empire required large armies of strong, healthy men. However, as t hese
large armies moved from area to area, they spread diseases that w ere once contained
within smaller areas. Roman doctors and architects suspected that diseases w ere
caused by contaminated w ater, foul air, sewage, and lack of hygiene. To prevent
diseases, army camps were set up away from swamps and foul odors, or swamps
were drained to make room for encampments. Freshwater aqueducts, drains, sew-
ers, public baths, and toilets were built to bring in clean, fresh water and dispose
of contaminants. Ill or injured soldiers were treated in military hospitals by army
doctors.
Although Greek medical practices fell out of favor with the rise of the Roman
Empire, ethical principles were translated into Latin and withstood the test of time.
Primum non nocere (Firstly do no harm) is reflected in the public health code of
ethics, and Ne quid nimis (Nothing in excess) is a basic concept of public health
262 G R ECO-R OM AN ERA, PU BLIC HEALTH IN THE
prevention. The Hippocratic principles of medicine and medical ethics are the foun-
dation of today’s public health, and medical practices and Roman sanitation cre-
ated ways to ensure the public health of large masses of people living in urban
environments.
Sally Kuykendall
See also: Ancient World, Public Health in the; Code of Ethics; Core Competencies
in Public Health; Hippocrates
Further Reading
Deevey, E. S. (1950). The probability of death. Scientific American, 182, 58–60.
Koloski-Ostrow, A. O. (2015). The archaeology of sanitation in Roman Italy: Toilets, sewers,
and water systems. Chapel Hill: The University of North Carolina Press.
Magner, L. (1992). A history of medicine. New York: Marcel Dekker.
Montagu, J. D. (1994). Length of life in the ancient world: A controlled study. Journal of the
Royal Society of Medicine, 87(1), 25.
Rosen, G. (1993). A History of Public Health (Expanded ed.). Baltimore: The Johns Hopkins
University Press.
Tountas, Y. (2009). The historical origins of the basic concepts of health promotion and
education: The role of ancient Greek philosophy and medicine. Health Promotion Inter-
national, 24(2), 185. doi:10.1093/heapro/dap006
H
HAMILTON, ALICE (1869–1970)
Alice Hamilton was a pioneering physician who used techniques from social medi-
cine, pathology, and epidemiology to create a new field in public health, occupa-
tional health and safety. Alice was born in New York City, the second of four girls
and a much younger b rother. Soon a fter the girls w
ere born, the family moved to
Fort Wayne, Indiana, to live on their grandfather’s estate. The estate served as a
family compound. Eleven cousins also lived in homes on the estate. The cousins
created their own games, social norms, and rules for resolving conflicts. Alice’s par-
ents, Montgomery Hamilton and Gertrude Corinne (Pond) Hamilton, did not hold
the local public school in high regard and opted to homeschool. The homeschool-
ing focused on what the parents thought was important: literature, languages, and
religion. Despite the fact that the family was fairly wealthy and socially isolated,
Mr. and Mrs. Hamilton instilled a strong sense of social consciousness, caring for
poor and minority groups. The experience of growing up on a compound and a
deep commitment to social justice remained with Alice throughout her life.
At the age of 17, Alice attended Miss Porter’s School in Farmington, Connecticut.
At Miss Porter’s, Alice elected to study languages and philosophy. In Fort Wayne, the
family fortune was slowly declining, and Alice needed to move toward training,
which would bring in a steady income. She decided to become a physician, not
because she was good in sciences, but b ecause she would be able to travel. Over
the next two years, she studied physics, chemistry, biology, and anatomy to gain
entry into medical school. After earning her medical degree from the University of
Michigan, Dr. Hamilton interned at Northwestern Hospital for W omen and C hildren
in Minneapolis and New E ngland Hospital for Women and Children near Boston.
Alice preferred science to clinical medicine, and in 1895 Alice and her sister Edith
sailed to Germany to study. Alice planned to study bacteriology and pathology, and
Edith planned to study classical literature. (Edith Hamilton later became a famous
author.) The w omen were initially refused admission because German universities
did not accept female students. Alice was eventually accepted to study in Munich
and at the University of Leipzig u nder the condition that she kept a low profile and
did not disturb the male students. On return to the United States, Alice realized
that she would not be able to get a job in pathology and bacteriology. She enrolled
at Johns Hopkins University, working in the pathology lab with Dr. Simon Flexner.
(Dr. Flexner later became a famous physician-pathologist.)
In 1897, Hamilton was offered a teaching position at Northwestern University
in Chicago. Moving to Chicago afforded her the opportunity to join Hull House,
264 HAM ILTON , ALICE
Immigrant factory workers sewing shoes in Syracuse, New York, 1895. Dr. Alice Hamilton
noticed unusual illnesses among immigrant residents of Hull House. Her epidemiological
investigations created the field of occupational health and safety. (New York Public Library)
an early settlement house founded by Jane Addams and Ellen Gates Starr. The idea
of settlement h ouses originated in London through the social reform movement. In
America, settlement h ouses w ere h
ouses where p
eople emigrating from Europe
could stay while they settled into life and community within the new country. Aca-
demic scholars, volunteers, and new immigrants lived, ate, and socialized together.
Through day-to-day interactions and planned programs, the academics learned to
appreciate the culture, wisdom, and struggles of immigrants and the immigrants
learned language, skills, and customs, which helped them to gain employment and
blend into American culture. In her autobiography, Hamilton explained, “When I
see the varied diet modern mothers give their babies, anything apparently from
bacon to bananas, I realize that those Italian women knew what a baby needed far
better than my Ann Arbor professor did.” The settlement compound served as the
center of community life for many, creating social networks, advocating for social
justice, and preventing racism. Hull House flourished to include a nursery, kinder-
garten, public baths, and a playground. While treating and interacting with the
immigrants of Hull House, Dr. Hamilton started to notice common ailments: car-
bon monoxide poisoning, lead poisoning, pneumonia, and rheumatism. P eople who
had come to the United States seeking a better life w ere suddenly stricken by odd
HAM ILTON, ALI C E 265
illnesses. Even more troubling was the fact that in the old world, the workers had
a network of friends, neighbors, and family members to help them. In the new world,
they were alone, and if the main breadwinner became incapacitated and unable to
work, the family became destitute.
In 1910, Dr. Hamilton joined a working group led by Professor Charles Hen-
derson, sociologist at the University of Chicago. Henderson received state support
to study occupation-related diseases among the working class. The Occupational
Disease Commission of Illinois was granted one year and quickly realized that
they needed to focus. They decided on occupational poisons, specifically lead.
Lead is a highly toxic poison. Symptoms of lead poisoning include headache,
abdominal pain, muscle pain, fatigue, radial nerve palsy, delirium, seizures, and
coma. To investigate the problem, the researchers interviewed workers, docu-
mented symptoms, and hypothesized that toxins in the workplace may cause
health problems. Although Hamilton did not have the power to demand entry
into workplaces, many business owners willingly let her in. The commission was
surprised to learn that lead was used in many different industries, trimming cof-
fins, decorating pottery, as seals on freight cars, cigar wraps, and enamel bathtubs.
Hamilton also discovered that employers preferred to hire men with families
because family men would continue to work despite poor health. Given that lead
workers can bring the toxin home on clothing or skin, not only w ere workers
exposed but also their f amily members including c hildren. B ecause of the investi-
gation, Illinois and six other states passed laws requiring employers to develop
safety measures to protect workers and to provide regular physical exams to mon-
itor employee health.
By 1911, Dr. Hamilton was a leading authority on industrial toxins and appointed
as special investigator for the U.S. Bureau of L abor. While continuing to reside at
Hull House, Hamilton traveled the country studying occupational health. She was
known for shoe leather epidemiology, visiting workshops, construction sites, and fac-
tories, observing working conditions, and interviewing workers and employers
(Rainhorn, 2012). Through careful, detailed epidemiological investigation, Hamil-
ton created a toolbox of industrial surveys of employee health and safety. Hamil-
ton’s family supported her both emotionally and financially during this period of
research.
In 1919, Harvard Medical School offered Dr. Hamilton a position teaching
industrial medicine. The offer came with conditions. She was not allowed to buy
football tickets, proceed with other faculty in the commencement ceremony, or use
the Faculty Club. The announcement of the first female professor at Harvard
attracted g reat media attention. The New York Tribune headlined, “A Woman on
Harvard Faculty—The Last Citadel Has Fallen—The Sex Has Come Into Its Own.”
Consistent with her spirit of honesty, humor, and seriousness, Hamilton noted,
“Yes, I am the first w
oman on Harvard faculty, but not the first one who should
have been appointed!” (Corn, 1999). Until retirement in 1935, Hamilton taught
266 HA M ILTON , ALI CE
one semester per year. She lived at Hull House and continued her research during
the remainder of the academic year. Hamilton never achieved tenure, never pro-
gressed beyond the rank of assistant professor, and was only granted a series of
three-year contracts.
Hull House was more than a home and research laboratory to Dr. Hamilton.
Through Hull House, Hamilton was active in social reform and the women’s peace
movement. She protested against McCarthyism and the Vietnam War. In 1915,
Hamilton attended the International Congress of Women at The Hague with Jane
Addams and other influential women. The attendees endorsed a commission of a
worldwide organization of nations where conflicts are mediated by neutral nations.
Although Hamilton was a pacifist, she advocated for U.S. participation in World
War II. A fter witnessing the racism and cruelty of Nazi Germany, she believed that
isolationism would be selfish. By entering World War II, the United States could
end the war and Nazi atrocities.
After a period of ill health, Dr. Alice Hamilton died on September 22, 1970, in
Hadlyme, Connecticut. Throughout her lifetime, Hamilton was honored with many
awards, including the National Achievement Award of the Chi Omega Sorority pre-
sented by Eleanor Roosevelt (1935), Men in Science (1944), and Time Woman of the
Year (1956). On December 29, 1970, three months after her death, Congress
passed the Occupational Safety and Health Act. In 1987, the National Institute of
Occupational Safety and Health named its research facility the “Alice Hamilton Lab-
oratory for Occupational Safety and Health.” The contributions of this remarkable
woman ensure safety for many workers throughout the country.
Sally Kuykendall
See also: Epidemiology; Immigrant Health; Social Determinants of Health
Further Reading
American Chemical Society National Historic Chemical Landmarks. (2002). Alice Hamilton
and the development of occupational medicine. Retrieved from http://www.acs.org/content
/acs/en/education/whatischemistry/landmarks/alicehamilton.html.
Corn, J. K. (1999). Alice Hamilton. American national biography (Vol. 9, pp. 910–912). New
York: Oxford University Press.
Fee, E., & Brown, T. M. (2001). Alice Hamilton: Settlement physician, occupational health
pioneer. American Journal of Public Health, 91(11), 1767.
Hamilton, A. (1943). Exploring the dangerous trades: The autobiography of Alice Hamilton, M.D.
Boston: Little Brown & Co.
Rainhorn, J. (2012). The “shoeleather epidemiology” or the reinvention of medical survey:
Alice Hamilton and industrial medicine in early 20th century Americ a. Gesnerus, 69(2),
330–354.
Sicherman, B. (2003). Alice Hamilton: A life in letters. Cambridge, MA: Harvard University
Press.
Windsor, L. L. (2002). Women in medicine: An encyclopedia. Santa Barbara, CA: ABC-CLIO.
HAND WASHIN G 267
HANDWASHING
Germs get onto people’s hands when they sneeze, cough, handle raw meat, eat con-
taminated food, defecate, or touch contaminated objects or infected people. Normally,
the body has defenses to keep pathogens from attacking the body. However, micro-
organisms can get past the body defenses when people touch their mouth, nose, or
eyes. Germs may also be spread to o thers through doorknobs, railings, desks, tables,
or toys. Handwashing is the easiest and most effective way to prevent germs from
entering the body and from being transmitted to other p eople. Handwashing is an
important health practice for everyone and particularly for workers who interact
with other people.
The science of handwashing dates back to 1843 when Boston physician Oliver
Wendell Holmes Sr. published “The Contagiousness of Puerperal Fever.” Puer-
peral fever is a complication of childbirth caused by bacterial infection. Patho-
genic bacteria spread from the uterus, along the fallopian tubes and into the
peritoneum, resulting in peritonitis, septicemia, or death. Infants are exposed to
the deadly microorganisms during or a fter childbirth. Holmes believed that puer-
peral fever was transmitted from patient to patient by doctors and suggested that
doctors take precautions. Opponents argued that doctors were gentlemen and
gentlemen did not have dirty hands. In 1847, Hungarian obstetrician Ignaz
Philipp Semmelweis (1818–1865) served as h ouse officer of two obstetrical
wards at the University of Vienna Allgemeine Krankenhaus. Per hospital policy,
patients in the First Division ward were cared for by male physicians while patients
in the Second Division ward were cared for by nurse midwives. Semmelweis
observed:
Newly admitted patients . . . enter the building in terror, b ecause it is well known to
them how large a contingent the institution gives over to death each year . . . That
they really dread the First Division can readily be demonstrated, b ecause one must
endure heart-rendering scenes, when w omen, wringing their hands, beg on bended
knee . . . for their release, in order to seek admission to the Second Division, a fter
having hit upon the First Division b ecause of unfamiliarity with the place, which the
presence of many men made clear to them. Puerperae with uncountable pulse-rates,
enormously distended abdomens, dry tongues, i.e. gravely ill with puerperal fever,
assured me a few hours before death, that they were entirely well, in order to escape
treatment by the physicians, because they realized that such treatment was the fore-
runner of Death. (Semmelweis & Murphy, 1981, p. 809)
Division One had such an awful reputation in the community that w omen who
were in circulatory shock would beg to be discharged from Division One so that
they could be readmitted to Division Two. Semmelweis compared mortality
rates of the two divisions for the years 1841–1846. The mortality rate of Divi-
sion One was 9.9 percent while the mortality rate of Division Two was 3.4 percent
(Semmelweis & Murphy, 1981). Semmelweis supposed that many puerperal
infections in Division One w ere related to poor hand hygiene. He observed
268 HAND WASHIN G
as medical students and doctors performed autopsies on w omen who died

from puerperal fever and then went straight into the delivery room. Semmelweis
recommended that doctors wash their hands in chlorine solution before and
after patient care. Although his suggestions w ere met with resistance, some doc-
tors a dopted the practice, and over the next seven months infections in Division
One decreased to 3 percent. Dr. Semmelweis is considered the father of hand
hygiene.
The Centers for Disease Control and Prevention (CDC, 2016) recommend hand-
washing before, during, and a fter preparing food or drinks; before eating; before
and after caring for someone who is sick; after using the bathroom, changing dia-
pers, or helping a child to use the bathroom; after sneezing, coughing, or blowing
the nose; a fter touching animals, animal waste, or animal cages, and a fter feeding
animals; after touching garbage; or whenever hands are dirty or greasy. Multiple
studies support handwashing as an easy way to reduce the spread of infection and
improve individual and community health. Adults who use proper handwashing
technique report 31 percent less diarrhea and 21 percent fewer colds (CDC, 2016).
The results are even more impressive for people with weakened immune systems
among whom good handwashing reduces diarrheal illnesses by 58 percent (CDC,
2016). Handwashing helps children in unexpected ways. Children who are taught
to wash their hands achieve developmental milestones in motor movement,
interpersonal skills, and communication six months earlier than other c hildren
(CDC, 2016). In order to effectively eliminate germs, p eople must use effective
technique. Proper handwashing technique is: (1) Wet both hands with clean
running water; (2) use plain liquid soap or bar soap to lather hands, rubbing the soap
between both hands; (3) rub the palms, back of hands, and fingers for at least 20
seconds; (4) rinse dirt, grease, and soap off of hands u nder clean, r unning water;
and (5) dry hands with a clean towel or air dry. If soap and w ater are not available,
alcohol-base sanitizers with at least 60 percent alcohol may be used. Alcohol-
based sanitizers are effective against some but not all germs and will not clean dirty
or greasy hands.
Handwashing is the simplest and most effective way to prevent illnesses, the
spread of germs to o thers, and to support healthy childhood development. The main
advantage of hand hygiene is that anyone can perform this action.
Sally Kuykendall
See also: Antibiotic Resistance; Epidemic; Influenza; Food Safety; Infectious Dis-
eases; Mallon, Mary; Patient Safety
Further Reading
Centers for Disease Control and Prevention (CDC). (2016). Handwashing: Clean hands save
lives. Retrieved from https://www.cdc.gov/handwashing/index.html.
HEALTH 269
Global Public-Private Partnership for Handwashing with Soap. (2015). Retrieved http://
globalhandwashing.org/.
Semmelweis, I. P., & Murphy, F. P. (1981). Childbed fever. Reviews of Infectious Diseases, 3(4),
808–811. Retrieved from http://www.jstor.org.ezproxy.sju.edu/stable/4452613.
World Health Organization (WHO). (2006). WHO guidelines on hand hygiene in health care
(Advanced draft). Geneva: World Alliance for Patient Safety. Retrieved from http://www
.w ho .i nt /p atientsafety /i nformation _c entre /L ast _A pril _v ersionHH _G uidelines%
5B3%5D.pdf.
HEALTH
In 1946, the World Health Organization (WHO) defined health as “a state of com-
plete physical, m ental, and social well-being, and not merely the absence of dis-
ease.” The WHO definition of health converted the idea of health from physical
fitness to a multidimensional concept of biopsychosocial well-being. The inclusion
of mental and social health reflected the events and circumstances of the time period.
After two world wars, the Great Depression, and the playground movement, the
idea of h uman beings as more than biological creatures was emerging. Sociology
and psychology were becoming academic disciplines in their own right. Despite
being more than 70 years old, the WHO definition of health is timeless, still used
by public health students and professionals today.
Physical, mental, and social health may be understood as simultaneously inde
pendent and interdependent. Physical health is how well the body systems func-
tion to support movement, oxygenation, fluid and electrolyte balance, hormone
regulation, nutrient ingestion, digestion and metabolism, temperature regulation,
response to stimuli, protection from the external environment, and excretion of
toxins and waste. The body that is physically fit and well nourished is able to
respond to potential illness or injury more effectively. Social health is the ability to
feel comfortable around others and to enjoy the companionship of friends, family, and
colleagues. Humans are social beings. Throughout civilization, individuals depended
on one another for survival. People who lived in groups were able to share food,
protection, shelter, and work. Individuals who lived alone w ere susceptible to star-
vation, harsh elements, or attack from predators, both animal and human. In pro-
social societies, most people have an intrinsic need to feel valued, accepted, and
belonged. Mental health may be further delineated as emotional, intellectual, and
spiritual health. Emotional health is the feelings that one has about self, other p
eople,
circumstances, and the surrounding environment. Positive connections with the
social and physical world influence the mind and bodily functions. Chronic stress
is associated with numerous health problems, including cardiovascular disease,
hypertension, substance abuse, obesity, and susceptibility to infection. Intellectual
health refers to how people acquire, filter, and use information. People with high
intellect gather information from credible sources, are able to critique the quality of
the information, and make smart decisions on how to use the information. The
270 HEALTH
person with intellectual health seeking diet changes would use information from
reputable sources and avoid sources selling commercial products. Health literacy
gives people the ability to make wise choices about their health. Spirituality is the
feeling that life is in harmony with one’s thoughts, practices, and physical surround-
ings. Spirituality may be expressed as the belief in higher being(s) or an apprecia-
tion of nature, art, literature, gardening, woodworking, or other activity, which
allows one to feel interconnected with the world. Spiritual health is achieved when
thoughts and actions are in harmony. This means that all of the yoga in the world
will not counterbalance lying and cheating o thers. For spiritual health to occur,
thoughts and actions must be consistent. The phrase “state of complete . . . well-
being” refers to the overall condition created by the interrelationships of physical,
emotional, and social health. Regular walks in beautiful settings can enhance physi-
cal, emotional, and social health, lowering blood pressure, increasing high-density
lipoproteins (HDL), and building flexibility and balance. Meanwhile, excessive
exercising, a form of eating disorder, is associated with anxiety, depression, and
amenorrhea. Some experts criticize the WHO definition, claiming that it does not
take into account obsessive and harmful health behaviors such as excessive exercis-
ing, orthorexia, or obsessive hygiene seen with obsessive compulsive disorder. As
scientists explore the complex relationships between physical, mental, and social
health, we discover more and more about emotions, the brain, life experiences, and
social determinants of health.
According to the WHO, health is not the achievement of the perfect physical,
emotional, intellectual, social, and spiritual body. Such perfection would be out of
reach for many p eople. Health is a state of wellness based on individual circum-
stances. P eople with disease, disabilities, or adverse childhood experiences can
achieve health by optimizing those aspects of health that are within their control.
History provides numerous examples of p eople who have overcome physical and
mental challenges to achieve incredible accomplishments. Although deaf, Ludwig
van Beethoven continued to compose music. Albert Einstein is said to have had a
learning disability. Franklin Delano Roosevelt was wheelchair dependent when he
served as 32nd president of the United States. Mathematician John Forbes Nash Jr.
struggled with paranoid schizophrenia when he was awarded the Nobel Memorial
Prize in Economic Sciences (1994). Social scientists purport that disability is not a
medical condition. Disability is a socially constructed condition. This means that
ability or inability is defined by society. For example, before the Americans with
Disabilities Act Accessibility Guidelines (ADAAG), buildings and communities w ere
constructed for people who could walk. Sidewalks, shops, even bathrooms were
built for the upright body. P eople in wheelchairs w ere limited. Shops, schools, fac-
tories, public transportation, sidewalks, and most buildings were not designed to
accommodate for wheelchairs. ADAAG did not change the p eople in the wheel-
chairs. The act removed barriers established by society, requiring new construction
or major renovations to existing facilities to ensure equal access. Similar obstacles
exist in social stigmas against people with mental illness. People with paranoid
HEALTH 271
schizophrenia are not accepted by society b ecause society frowns on p eople who
hear voices, suffer from delusions or paranoia, unexplained bouts of anger or anxi-
ety, or detachment from the social group. Health is not simply a reflection of the
physical and mental status of the individual. Health is dependent on the built envi-
ronment, social norms, and cultural values.
Riegelman and Kirkwood (2015) used the mnemonic BIG GEMS to list the
numerous factors that influence health and therefore disease. Health determinants
are Behavior, Infection, Genetics, Geography, Environment, Medical care, and
Socioeconomic-cultural status. Behavior refers to personal actions. Daily exercise
and a diet low in concentrated carbohydrates and saturated fats promote well-being.
Smoking cigarettes, drinking alcohol, or risky sexual activities threaten health. Infec-
tions, such as polio, cholera, or malaria are potential health risks, attacking the
body and resulting in death or disability. On the other hand, the hygiene hypoth-
esis or alternatively, the microbial deprivation hypothesis, proposes that reduced
exposure to germs in early childhood may increase incidence of asthma and aller-
gic diseases. Genetics is the genes we inherit from biological parents. Problems occur
through hereditary transmission or mutation. Genetic disorders include single gene
disorders (such as sickle cell anemia), chromosomal disorders (such as Down syn-
drome), and complex disorders (such as colon cancer). On the other hand, some
genetic conditions provide resistance against disease. Sickle cell carriers infected
by parasites with malaria do not succumb to the disease. An enzyme expressed by
the sickle hemoglobin produces small amounts of carbon monoxide that protect
against malaria. Other genetic disorders that convey resistance are cystic fibrosis
and cholera, Tay-Sachs disease and tuberculosis, and myasthenia gravis and rabies.
Geography influences disease through climate, location, and geological conditions.
Hot, wet climates are perfect habitats for wildlife that carry pathogenic organisms.
Vast mountain ranges or deserts tend to inhibit disease transmission. Environment
includes the natural and the man-made world. The World Health Organization
(2016) reports that air, w ater and soil pollution, climate change, ultraviolet radia-
tion, and toxic substances at work and home contribute to more than 100 different
health problems. Medical care impacts health by providing immunizations against
deadly diseases, regular monitoring for early disease identification and treat-
ment, and health education. Conversely, medical care is also responsible for the
increase in antibiotic resistant organisms. Socioeconomic-cultural determinants of
health are level of education, income, and occupation. Poverty is associated with
lower life expectancy, higher rates of chronic and acute diseases, and poor mental
health. The chronic stress of poverty can lead to decreased white blood cell count,
gastrointestinal bleeding, enlargement of the adrenal cortex, and physical deterio-
ration. The BIG GEMS determinants of health suggest opportunities for improving
public health as well as challenges to building and sustaining health.
As public health improves, the ability to measure health becomes more important.
Historically, health was measured by counting the number of p eople with a specific
disease or the number of infants and people who died each year. Morbidity and
272 HEALTH AND M EDI C INE DI V ISION O F THE NATIONAL A C ADE M IES
mortality rates measure death and disease of a population, not health. The purpose of
public health is to promote health, and measuring health is a challenge. Measuring
the number of p eople who remain healthy by not contracting diabetes is impossible
unless every
one in the population is regularly screened for diabetes. As health
improves, researchers work to develop and refine instruments to measure health. Sur-
veys are used to measure various aspects of health. Instruments exist to gauge social
functioning, psychological well-being, functional activity, m ental status, pain scale,
and quality of life. Ideally, it would be nice if one instrument could be used to mea
sure the health of all individuals under all circumstances in all societies. Such an
instrument would enable clear comparisons across groups. Unfortunately, it is
unlikely that one instrument, one set of questions w ill apply to all p
eople and nations.
Therefore, measuring health remains an elusive goal for public health researchers.
Health exists as a continuum of interrelated physical, emotional, and social factors.
In the seminal work, The Future of Public’s Health in the 21st Century, the Institute of
Medicine (2003, pp. 179–180) noted, “When people are healthy, they are better
able to work, learn, build a good life, and contribute to society.” The goal of public
health, to support the health of all persons, is fundamental to ensuring quality of
life, a productive workforce, successful future generations, and global capacity.
Sally Kuykendall
See also: Behavioral Health; Environmental Health; Immigrant Health; Population

Health; Prevention; Social Determinants of Health; Spiritual Health
Further Reading
Institute of Medicine. (2003). The future of the public’s health in the 21st Century. Washington,
Riegelman, R., & Kirkwood, B. (2015). Public health 101: Healthy people—healthy popula-
tions (2nd ed.). Burlington, MA: Jones & Bartlett.
World Health Organization (WHO). (1946). Preamble to the Constitution of the World Health
Organization as adopted by the International Health Conference. New York: Official Rec
ords of the World Health Organization. Retrieved from http://apps.who.int/gb/bd/PDF
/bd47/EN/constitution-en.pdf?ua=1.
World Health Organization (WHO). (2016). Environmental health. Retrieved from http://www
.who.int/topics/environmental_health/en/.
HEALTH AND MEDICINE DIVISION OF THE

NATIONAL ACADEMIES OF SCIENCES, ENGINEERING,
AND MEDICINE
Formerly known as the Institute of Medicine (IOM), the Health and Medicine Divi-
sion (HMD) of the National Academies of Sciences, Engineering, and Medicine (the
National Academies) provides independent, nonpartisan advice to Congress and
HEALTH AND MEDICINE DI VISION O F THE NATIONAL A C ADE M IES 273
the White House to ensure that each new or revised policy has a valid scientific
basis. The National Academies consist of three private, nonprofit organizations that
collaborate with noted experts in various fields. The National Academies and the
experts work free of charge so that they can maintain professional and scientific
integrity and are not influenced by money or power. The National Academies are
consistently recognized for providing valuable information, which benefits the
nation and public health.
The National Academies are made up of the National Academy of Sciences
(NAS), the National Academy of Engineering (NAE), and the National Academy
of Medicine (NAM). The original agency, the NAS, was founded by congressional
charter and approved by President Abraham Lincoln on March 3, 1863. The Civil
War–era group consisted of 49 experts who were willing to share their knowledge
and expertise in ways that advanced the nation. Today, the NAS has more than
3,000 experts, 200 of whom are Nobel Prize winners. The HMD focuses on finding
the most effective and efficient ways to alleviate pressing medical and health
issues. The division supports medical science by funding research studies and
fellowships, rewarding outstanding contributions to the field, and developing
collaborations to solve complex problems. In the past, IOM experts addressed
malaria, vaccine safety, medical errors, the nursing shortage, public health pre-
paredness, and end-of-life care. Current working groups address global health,
food and nutrition, health care services, public health, veterans’ health, and children’s
health. To create expert consensus, HMD develops a formal statement of task that
defines the problem scope. A committee of individual experts is convened. Com-
mittee members are selected based on their ability to provide expertise, wisdom,
and balanced perspectives. All committee members are screened for potential
conflicts of interest at the beginning of the project and throughout the project.
HMD schedules forums, workshops, roundtables, and committees to collect infor-
mation on the defined health issue. The committee reviews and critiques informa-
tion from the meetings, published literature, and their own research to develop a
report that summarizes the science and provides objective recommendations. The
expert consensus meetings are closed to avoid undue pressure from businesses or
other interested groups. Final reports are reviewed by a second group of indepen
dent experts who provide feedback to the committee. HMD goes to g reat lengths
to ensure that each report provides valuable, credible, and objective advice that
adheres to the highest scientific standards.
HMD promotes effective public health policies by gathering the best and the
brightest of the nation’s scholars and putting them to work on critical health issues.
The resulting recommendations can have widespread utilization. For example, in
2003, the National Academies released the report The Future of the Public’s Health in
the 21st Century. The landmark report described the importance of health determi-
nants, ways to strengthen public health infrastructure and partnerships, improving
accountability, and enhancing systems communication. The report is used by the
274 HEALTH B ELIE F M ODEL
American Public Health Association (APHA) and Schools of Public Health to edu-
cate and prepare the next generation of public health professionals.
Sally Kuykendall
Health; Health Disparities; Health Policy; Patient Safety
Further Reading
Institute of Medicine. (2003). The f uture of the public’s health in the 21st century. Washington,
National Academies of Sciences. (2017). About HMD. Retrieved from http://www.national
academies.o rg/hmd/A
bout-HMD.a spx.
HEALTH BELIEF MODEL

The health belief model is a diagrammatic representation of the psychological and
social factors that influence an individual’s willingness and likelihood to take action
to prevent disease. The model was developed by public health practitioners to under-
stand the thought processes p eople go through when deciding w hether to use
health services. It is now one of the preeminent public health models used to moti-
vate people to adopt disease management activities or healthy behaviors. The model
applies to numerous health behaviors from tuberculosis screening to smoking, safe
sexual practices, or dental flossing. Benefits of the health belief model are that it
provides a deeper understanding of motivation and suggests techniques that can
be used to motivate people toward health. Criticisms are that while the model
explains motivation, it cannot predict motivation. Further refinement of the model is
needed to test and ensure effective application.
The health belief model originated in the 1950s after the U.S. Public Health Ser
vice offered mass disease campaigns with limited success. One such campaign was
screening services for the deadly infectious disease, tuberculosis (TB). At the time,
TB was known as the white plague. Mortality rates varied from 6.2 per 100,000 people
in Wyoming to 59.6 per 100,000 in Arizona (Division of Chronic Disease and Tuber-
culosis, 1953). Mycobacterium tuberculosis is easily transmitted. Once the bacterium
enters the body, it may become latent (noninfectious) TB infection or active TB dis-
ease attacking the lungs and other parts of the body. More than one-third of the
world’s population currently has latent TB (WHO, 2016). In an effort to combat
the disease, public health professionals offered free neighborhood screenings. Mobile
X-ray units were dispatched to at-risk communities. The plan was to screen for TB
using X-rays and refer cases for antibiotic treatment, thus reducing transmission.
Very few people came for screening. Social psychologists decided to explore
why people did not come (Hochbaum, 1958; Rosenstock, 1960, 1966, 1974). The
researchers focused on p eople’s readiness for screening, beliefs about susceptibility,
HEALTH B ELIEF M ODEL 275
and perceptions of w hether X-ray was an effective method of detection. The stud-
ies found that the decision to go for screening was dependent on how susceptible
the person believed he or she was to TB and perceptions about the severity of the
disease. Since initial conception, behavioral theorists have refined the model to
include concepts from cognitive theory, and translational researchers extended appli-
cation to preventive actions, sick-role behaviors, and disease management.
The key concepts of the health belief model are perceived susceptibility, perceived
severity, cues to action, perceived benefits, and perceived barriers. Perceived suscep-
tibility is one’s belief of vulnerability to the health issue. A simple and common prob
lem, such as oral hygiene, may be used to demonstrate the constructs and value of
the health belief model. Dental caries affects 91 percent of U.S. adults, aged 20 to
64 (CDC, National Center for Health Statistics, 2016). The American Dental Asso-
ciation (ADA) recommends using an interdental cleaner (flossing) at least once a
day (ADA, 2016). Yet, only 4 out of 10 people floss on a daily basis, and 2 out of
10 p eople never floss (ADA, 2014). The health belief model outlines demographic
and other factors that might influence one’s perception of susceptibility. Age, gen-
der, race, socioeconomic status, and education or knowledge may influence how
one thinks about his or her vulnerability to cavities. If one recognizes susceptibil-
ity, the next question is perceived severity. Is the problem serious enough to warrant
action? If the person feels that cavities are unimportant and can be easily remedied,
then he or she will be less likely to brush and floss. If someone has experienced
cues to action, the pain of a cavity, difficulty chewing food, the irritating sound of
the dental drill, or the inconvenience of Novocaine, perceived threat (severity)
increases. Other cues to action are health education in schools or by dental staff,
public service announcements, or posting a note on the bathroom mirror to remind
self to floss. The final considerations are perceived benefits minus perceived barriers.
Decisional balance, weighing advantages (pros) and disadvantages (cons), is a con-
cept used and repeated throughout health. The benefits of flossing are a beautiful
smile, the ability to enjoy crunchy foods, and not having to go to the dentist more
often than every six months. The disadvantages or barriers to flossing are the addi-
tional time that it takes each day (2 to 3 minutes), purchasing and maintaining a
supply of floss, and having to clean the particles of food that are projected through-
out the area during flossing. The final consideration is, do the benefits outweigh
the barriers? If so, the person is likely to take action (floss) to prevent periodontal
disease.
In summary, the health belief model proposes that individuals w ill take action
to prevent disease (or injury) if they perceive that they are susceptible to the dis-
ease, the disease is severe enough to warrant a course of action, and the benefits of
taking action outweigh the barriers to behavioral change. The health belief model
is an amazingly basic and easily understood model that can be applied to bicycle
helmets, diabetes management, and numerous other health issues.
Sally Kuykendall
276 HEALTH C A R E DISPA R ITIES
See also: Epidemiology; Health Communication; Intervention; Population Health;

Social Determinants of Health
Further Reading
ADA. (2014). Survey finds shortcomings in oral health habits. Retrieved from http://www.ada
.org/en/publications/ada-news/2014-archive/october/survey-finds-shortcomings-in
-oral-health-habits.
ADA. (2016). Federal government, ADA emphasize importance of flossing and interdental clean-
ers. Retrieved from http://www.ada.org/en/press-room/news-releases/2016-archive
/august/statement-from-the-american-dental-association-about-i nterdental-cleaners.
Centers for Disease Control and Prevention, National Center for Health Statistics. (2016).
Oral and dental health. Retrieved from http://www.cdc.gov/nchs/fastats/dental.htm.
Division of Chronic Disease and Tuberculosis. (1953). Tuberculosis mortality by state, 1950.
Public Health Reports, 68(6). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles
/PMC2024038/pdf/pubhealthreporig00186-0086.pdf.
Glanz, K., Lewis, F. M., & Rimer, B. K. (1997). Health behavior and health education: Theory,
research, and practice (2nd ed.). San Francisco: Jossey-Bass.
Hochbaum, G. M. (1958). Public participation in medical screening programs: A sociopsycho-
logical study. PHS Publication no. 572. Washington, DC: U.S. Government Printing
Office.
Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice,
and commitment. New York: F ree Press.
Rosenstock, I. M. (1960). What research in motivation suggests for public health. American
Journal of Public Health and the Nation’s Health, 50, 295–302.
Rosenstock, I. M. (1966). Why p eople use health services. The Milbank Memorial Fund Quar-
terly, 44(3), 94–127.
Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education
Monographs, 2, 328–335.
World Health Organization (WHO). (2016). Tuberculosis. Fact Sheet No. 104. Retrieved from
http://www.who.int/mediacentre/factsheets/fs104/en/.
HEALTH CARE DISPARITIES

Health care disparities refer to inequities experienced by different populations in
obtaining medical treatment. Health care disparity is not to be confused with health
disparity. Health care disparities refer to “differences between groups in health insur-
ance coverage, access to and use of care, and quality of care” (Artiga, 2016). Health
disparity refers to “a higher burden of illness, injury, disability, or mortality experi-
enced by one population group relative to another group” (Artiga, 2016). Health
disparity refers to clinical health problems. Certain diseases may be more prevalent
in one population group than others due to culture or genetics. Sickle cell disease
affects people of African, Hispanic, southern European, Middle Eastern, and Asian
backgrounds. Tay-Sachs disease, an autosomal recessive trait, is more common
among the Cajun, French Canadian, and the Ashkenazi Jewish populations. On the
other hand, health care disparity is a problem of the health care system, thereby
HEALTH C A R E DISPAR ITIES 277
making it a social justice concern. Health disparity and health care disparity are
closely related b ecause addressing health care disparities naturally closes some of
the gap created by health disparities. When a population suffers higher rates of dis-
ease, accessing health services is critical for early diagnosis and treatment. Early
services can reduce adverse consequences and promote better quality and length
of life.
Health care disparity is a persistent sociopolitical problem. People who are His-
panic, black, Native American, Alaskan Native, and Asian/Pacific Islander or low
income do not have the same opportunities for services as affluent whites. Race
and income are not separate or isolated issues. In 2013, wealth inequality between
blacks and whites reached the highest point since 1989. White h ouseholds are
17 times wealthier than black h ouseholds (Kochhar & Fry, 2014). Wealth pro-
vides privilege, the benefit of insurance, access to services, care by highly qualified
medical professionals, diagnostic testing, treatment, and rehabilitation programs.
Disparities also exist by age, gender, geographic location, disability, citizenship
status, and sexual identity. P eople aged 65 and older receive worse care than p eople
aged 18 to 44, and residents of rural areas have poorer access to care than urban
dwellers (Agency for Healthcare Research and Quality, 2012). Challenges in obtain-
ing medical care are compounded for undocumented immigrants who struggle
with language barriers, in low-paying jobs without health insurance, and live in
fear that accessing care could lead to jail or deportation.
Beardsley (1992) presents the historical background of racial health care dispari-
ties in the United States as three time periods: the era of denial (1900–1930), the
era of inclusion (1930–1960), and the era of attempted restitution (1960–?). Dur-
ing the era of denial, many white Americans, including politicians, doctors, soci-
ologists, and respected scholars, believed that black Americans w ere inherently
lazy, ignorant, and self-destructive, and therefore any efforts to improve health were
futile. Some white supremacist groups preferred the high mortality rates suffered
by black communities. White supremacists feared that treating and preventing dis-
eases among black communities would increase the numbers of black people, dis-
placing white power and privilege. Politicians w ere pressured not to provide services
to black communities. As a result, the majority of black people were cared for out
of hospital by less qualified community health workers. T hose who were able to
afford hospitalization were required to use segregated black hospitals. Black hospi-
tals provided primitive care with outdated equipment and poorly trained staff. In
some areas, hospitals for black people did not even exist. In South Carolina, the
sanatorium to treat black patients with tuberculosis opened five years after the
white sanatorium and offered fewer beds, even though rates of tuberculosis w ere
four to five times higher among blacks than whites. The black community had to
raise partial funding in order to build the sanatorium. In 1911, malaria was a major
health issue throughout South Carolina and affected blacks at rates of two to four
times that of whites. When South Carolina state health officer James A. Haynie
requested federal support for malaria eradication, he argued on the grounds that
278 HEALTH C AR E DISPARITIES
eliminating malaria would allow whites to reinhabit South Carolina’s fertile coastal
lowland regions, areas that w ere currently inhabited by blacks. T oward the end of
the 1930s, small gains were made in improving health care systems for black
patients. The Duke Endowment invested millions of dollars to improve Carolina
hospitals for both blacks and whites. Dr. Matilda Evans opened the Evans Clinic in
Columbia, South Carolina, treating hundreds of patients daily. The Atlanta Project
started by Lugenia Hope created a settlement house, medical clinic, nursing clin-
ics, and mobile health clinics.
The Great Depression of the 1930s unraveled many of the advancements achieved
during the preceding decade. Yet, mutual suffering also spurred solutions. With high
unemployment among both blacks and whites, government officials instituted pro-
grams such as the New Deal, Federal Emergency Relief Administration to hospi-
tals, school lunch programs, investments in the public health workforce, and the
Social Security Act. The policies did not discriminate between black and white
because everyone was struggling. Even the horror of two world wars brought med-
ical advancements. Venereal diseases, which had long been a problem among black
communities, became a national priority. Politicians w ere concerned with the high
number of American soldiers contracting syphilis and gonorrhea overseas. The fed-
eral government invested in research and treatment. Penicillin was discovered.
Effective community-based treatment programs w ere funded. Perhaps one of the
biggest steps t oward social justice occurred through Emergency Maternal and Infant
Care Program (EMIC), a federal effort to support military families. The federal gov-
ernment realized that in order to support soldiers, they needed to support the
men’s families on the home front. EMIC subsidized hospital care for wives of military
men in the lowest pay grades. Since the lowest pay grades were disproportionately
black men, EMIC improved care for black families. EMIC led to the Hospital Sur-
vey and Construction Law (1946), a program offering states matched funding for
the construction of new hospitals and clinics. A condition of the funding was that
the state must plan construction based on needs. In so d oing, state health officials
were forced to look at the health of populations throughout the state. Despite fed-
eral efforts, racism continued at regional levels. Chicago’s hospitals designated 315
beds to care for the city’s population of 350,000 black residents (Beardsley, 1992).
Twelve private hospitals systematically excluded black patients, even those who
could afford to pay. Hospital beds designated for white p eople sat empty while black
patients, including expectant m others, vied for care.
The civil rights movement of the 1960s banned segregation and outright discrimi-
nation. Beardsley (1992) suggests that programs such as Medicare, food stamps, and
WIC provide attempted restitution. Data from multiple sources contradict this idea.
The Centers for Disease Control and Prevention, Office of Minority Health (2016),
reports that African Americans have double the infant mortality rate, a 40 percent
higher rate of death due to heart disease, and an 80 percent higher rate of diabetes,
compared to non-Hispanic whites. Death rates due to HIV/AIDS are seven times
higher, and homicide is six times higher among African Americans in comparison
HEALTH C A R E DISPAR ITIES 279
to non-Hispanic whites. Other races are not immune from such disparities. Latinos
have higher rates of tuberculosis, diabetes, obesity, hypertension, and low birth
weight infants. Low birth weight is associated with poor lung development and
infant death. Asian and Pacific Islanders suffer from higher rates of cervical cancer,
tuberculosis, and hepatitis. Even more alarming is the fact that t hese disparities can-
not simply be ascribed to lifestyle. African American women perform mammogra-
phy screening at the same rate as white women, yet die of breast cancer at much
higher rates. Our health care system continues to fail minority ethnic groups.
Today, public health is actively seeking solutions to health care disparities. The
1998 surgeon general’s report, Tobacco Use among U.S. Racial/Ethnic Minority Groups,
addressed the need for tobacco control measures for the racial/ethnic minority
groups and contributed to the enactment of the Minority Health and Health Dis-
parities Research and Education Act of 2000. The act led to the establishment of
National Center on Minority Health and Health Disparities (NCMHD), which is
now the National Institute on Minority Health and Health Disparities (NIMHD).
Investment in health care disparities research has provided further insight in achiev-
ing inclusion. Medical researchers have begun to produce significant works on
health and health care disparities. The Patient Protection and Affordable Care Act
(PPACA) enacted in 2010 will reduce disparities by increasing coverage options for
low and moderate income populations. The Department of Health and Human Ser
vices Office of Minority Health (HHS) produced the 2011 Action Plan to Reduce
Racial and Ethnic Health Disparities under the vision of “a nation free of disparities
in health and healthcare.” The major focus of the HHS Action Plan is on increasing
culturally appropriate health care services for the minority populations by hiring
more ethnic-minority health care providers and providing training and language
translation services.
The measures discussed so far are a standard, top-down approach, relying pri-
marily on federal and state policies. Inner-city public health clinics are challenged
with treating populations who speak different dialects and engage in many differ
ent health practices. Community collaborations suggest one possible solution. Each
community has unique concerns with unique demographics, and reducing health
care disparities sometimes requires dramatically different solutions for different com-
munities. The collaborative approach is an attempt to find solutions through the
network of community members, particularly with the help of the community lead-
ers. Community health promotion programs are one way to improve care among
impoverished neighborhoods. Under the Emergency Medical Treatment & Labor
Act (1986), local hospitals are legally required to medically stabilize patients admit-
ted to their emergency rooms. In many regions, hospital emergency rooms have
become clinics for t hose without health insurance and undocumented immigrants.
In Philadelphia, three hospitals of the Mercy Health System hospitals were in a
financial quandary regarding how to provide medical services to low income
patients. In 2012, Mercy partnered with academics at Saint Joseph’s University
Institute of Clinical Bioethics (ICB). The group reached out to the community
280 HEALTH C A R E DISPA R ITIES
religious leaders and began Health Promoters. Mercy medical residents run f ree
monthly clinics focusing on preventive medicine and nutritional and lifestyle
counseling. Goals are to improve the general health of the community and
reduce the number of preventable emergency room visits (Ochasi & Clark,
2014). The next steps are evaluation of the project as an evidence-based program.
The multifaceted grassroots approach suggests promise in reducing health care
disparities.
Through political and social policies and practices, the United States systemati-
cally neglected and deprived minorities and low income populations of needed med-
ical care. Today, the U.S. population is becoming increasingly heterogeneous. Each
population shares the work of maintaining the nation. Yet, racial minorities and the
poor carry a higher burden of injury, disability, and death. Social justice demands
shared responsibility and benefits. By 2044, p eople of color w
ill account for more
than half of the population, with the largest growth occurring among people of His-
panic race (Colby & Ortman, 2015). This shift raises questions of how society w ill
look in terms of income, race, and health care expenses. Building equitable health
care systems now w ill ensure success for future generations.
Marvin J. H. Lee and Sally Kuykendall
See also: Affordable Care Act; Care, Access to; Emergency Medical Treatment and
Labor Act; Epidemiology; Ethics in Public Health and Population Health; Health
Disparities; Population Health; Social Determinants of Health
Further Reading
Agency for Healthcare Research and Quality. (2012). Disparities in healthcare quality among
racial and ethnic groups: Selected findings from the National Healthcare Quality and Dis-
parities Reports. Washington, DC: U.S. Department of Health and Human Services.
Retrieved from http://archive.ahrq.gov/research/findings/nhqrdr/nhqrdr11/minority
.html.
Artiga, S. (2016). Disparities in health and health care: Five key questions and answers. Wash-
ington, DC: Kaiser F amily Foundation. Retrieved from http://kff.org/disparities-policy
/issue-brief/disparities-in-health-and-health-care-fi
ve-key-q
uestions-and-a nswers/.
Beardsley, E. (1992). Race as a factor of health. In R. Apple (Ed.), Women, health, and medi-
cine in America: A historical handbook. New Brunswick, NJ: Rutgers University Press.
Betancourt, J., Green, A., Carrillo, J., & Park, E. (2005). Cultural competence and health
care disparities: Key perspectives and trends—Among stakeholders in managed care,
government, and academe, cultural competence is emerging as an important strategy
to address health care disparities. Health Affairs, 24(2), 499–505.
Bylander, J. (2016). Tackling disparities with lessons from abroad. Health Affairs (Project
Hope), 35(8), 1348–1350. doi:10.1377/hlthaff.2016.0794
Colby, S. L., & Ortman, J. M. (2015). Projections of the size and composition of the U.S. popula-
tion: 2014 to 2060. U.S. Census Bureau. Retrieved from http://www.census.gov/population
/projections/data/national/2014/publications.html.
HEALTH C O M M UNI C ATION 281
Evans, R. G., Barer, M. L., & Marmor, T. R. (1994). Why are some p eople healthy and o thers
not? The determinants of health of populations. New York: Aldine de Gruyter.
Kochhar, R., & Fry, R. (2014). Wealth inequality has widened along racial, ethnic lines since end
of great recession. Washington, DC: Pew Research Center. Retrieved from http://www
.pewresearch.org/fact-tank/2014/12/12/racial-wealth-gaps-great-recession/.
Ochasi, A., & Clark, P.A. (2014). Mercy health promoter model: Meeting needs of specific
immigrant communities. Health Progress, 33–37. Retrieved from https://www.chausa.org
/publications/ health-progress/ article/ march-april-2014/mercy-health-promoter-model
-meeting-needs-of-specific-immigrant-communities.
Office of Minority Health. (2016). Minority population profiles. Retrieved from http://
minorityhealth.hhs.gov/omh/browse.aspx?lvl=2 &lvlid=2 6.
Purnell, T. S., Calhoun, E. A., Golden, S. H., Halladay, J. R., Krok-Schoen, J. L., Appelhans,
B. M., & Cooper, L. A. (2016). Achieving health equity: Closing the gaps in health care
disparities, interventions, and research. Health Affairs (Project Hope), 35(8), 1410–1415.
doi:10.1377/hlthaff.2016.0158
HEALTH COMMUNICATION
Health communication is defined as “the study and use of communication strate-
gies to inform and influence individual and community decisions that enhance
health” (National Cancer Institute [NCI], 1989). Health communication trans-
lates complex scientific information into clear, understandable language in order
to enhance health. The discipline draws on knowledge from engineering, psychol
ogy, sociology, business, and medicine. And while one would think that policy
makers, patients, and members of the general public would be interested in infor-
mation intended to improve quality and length of life, unfortunately, this is not
always the case. Public health communication must overcome skepticism and
compete with wealthy businesses trying to sell products or services.
Health communication practice developed from engineering and telecommuni-
cations. Dr. Harry Nyquist (1889–1976) was a Swedish American electronics engi-
neer who worked at AT&T and Bell Telephone Laboratories, investigating ways to
optimize communications systems. Although the telephone had been invented in
1876, Morse code was still used for critical communication, such as between mili-
tary bases, ships, and warplanes in World Wars I and II. In researching ways to
optimize communications, Nyquist noticed that the most efficient Morse code read-
ers w ere not translating the procedural signal as alphanumeric characters, but w ere
listening to the rhythm of the signal and translating the code as a language. He noted
that how the recipient receives and decodes the message is an important compo-
nent of telecommunication. Instead of using the term “message,” Nyquist used the
term “intelligence” to name the information that was transmitted from sender to
recipient. Nyquist’s work was continued by Dr. Claude E. Shannon, also an engi-
neer at Bell Telephone Laboratories. Shannon developed a diagram outlining five
major elements of communication. Intelligence starts at the information source and
is passed to the transmitter. The transmitter interprets, writes, or codes the message
282 HEALTH C OMMUNICATION
and selects a channel. The channel carries the message to the receiver where the mes-
sage is decoded and reconstructed. The reconstructed message is passed to the
destination. Since Shannon was an engineer, working in telecommunications, he
added a sixth intervening element of noise. Noise is something that interferes with
transmission between transmitter and receiver. The Shannon-Weaver model or
information theory was reprinted and published by scientist and mathematician
Dr. Warren Weaver (1894–1978). The model was picked up by social scientists who
envisioned application to interpersonal communication. And the model is highly
applicable to social sciences in that the psychosocial attributes of the sender and
receiver can impact how a message is transmitted or perceived. Social science appli-
cation also brought criticism because the model is one-directional. The message is
transmitted without feedback, acceptance, acknowledgment, or clarification by the
receiver. In normal, healthy human relationships, feedback is essential to the com-
munication process.
In 1972, a group of scholars recognized the opportunity to apply communica-
tion science to public health. Members of the International Communication
Association (ICA) formed the Therapeutic Communication interest group. The
group attracted educators, researchers, and practitioners with varied interests in
Health communication translates complex scientific information into clear, s imple, and
memorable messages. This public service announcement gives bus riders straightforward
tips for mosquito control and where to go for further information. (Sara Ann Kuykendall)
HEALTH C O M M UNI C ATION 283
interpersonal communication, mass communication campaigns, and health ser

vices. The National Cancer Institute (NCI) quickly embraced health communica-
tion as a way to refute common myths about cancer, increase public knowledge,
influence attitudes, prompt behavioral changes, advocate for policy, and strengthen
health care systems (NCI, 1989). The first professional journal of the field, Health
Communication, was started in 1989. Seven years later, the Centers for Disease
Control (CDC) developed an office of communications. The following year, the
American Public Health Association (APHA) formed the Health Communication
division. Today, the field of health communication has evolved greatly, employing
the media, entertainment industry, interactive technology, and direct patient-
provider communication to inform and influence health behavior and decisions.
The task of health communication is onerous and requires a mixed skillset. Health
communicators must be able to read, understand, and interpret difficult, tedious,
and technical scientific information, identify the key points of interest to different
audiences, and translate that information into an easily understandable mes-
sage, web page, poster, brochure, or tweet. The basic steps in developing health
communications are:
• Gather accurate information from reliable sources and identify five or fewer
key points.
• Identify the goals or objectives of the communication.
• Identify the target audience.
• Identify the channel or medium to transmit the message.
• Create and pilot test the message.
• Develop a plan for promotion.
• Implement the strategy.
• Evaluate process, impact, and outcome.
Note that the steps include components of the Shannon-Weaver model with the
addition of defined goals or objectives, pilot testing, and feedback (evaluation).
Health educators must be able to identify what information is most relevant to a
particular audience and to tailor the message to the audience. This is where other
models or theories are useful. For example, the health communicator could use the
health belief model, social cognitive theory, transtheoretical model or diffusion or
innovations theory to develop the message. Healthy People 2010 lists and describes
the attributes of effective health communication as accuracy, availability, balance,
consistency, cultural competence, evidence base, reach, reliability, repetition, time-
liness, and understandability (U.S. Department of Health and H uman Services,
2000).
Evaluating the success of health communication programs can be very difficult
because mass communication campaigns have little direct follow-up with the recip-
ients. In 2012, researchers at Kings College in London partnered with Cancer
Research UK to evaluate E ngland’s national smoking cessation campaign,
Stoptober. Based on a nationally representative sample of 31,566 smokers,
284 HEALTH C O MM UNI C ATION
the researchers estimated that Stoptober was related to 350,000 quit attempts and
saved 10,400 discounted life years at a cost of £415 per life year (Brown, Kotz,
Michie, Stapleton, Walmsley, & West, 2014). Researchers from the CDC evaluated
the cost benefit of the National Colorectal Cancer (CRC) Action Campaign, Screen
for Life. They estimated that if the campaign influenced only 0.5 percent of viewers
who did not regularly screen for CRC to get screened, the campaign would lead to an
additional 251,000 people getting screened for CRC at a cost of $2.44 per person. If
the campaign influenced 10 percent of the population, an additional 5.01 million
people would be screened at a cost of $0.12 per person (Ekwueme, Howard, Gelb,
Rim, & Cooper, 2014). Finding ways to measure the impact of health communica-
tion campaigns can help to create the most effective messages and advance the field
of health communications.
Obstacles to health communication include personal attitudes toward the mes-
sage, competition for public attention, and competition with businesses marketing
unhealthy products. Gollust and Cappella (2014) propose that the receiver may
reject messages that elicit anger or counterargument or are perceived as weak. Health
communicators must walk a line between providing information that empowers
people and appearing too weak or too dictatorial. One of the largest obstacles to
health communication is competition with business. In 2013, businesses spent $165
billion on advertising (GroupM, n.d.). The tobacco industry spent $244 million
and food and beverage companies spent $136 million (Kantar Media & OAAA,
n.d.a; Kantar Media & OAAA, n.d.b). In comparison, the CDC budget for chronic
disease prevention and health promotion—which includes surveillance, interven-
tions, and research—was $1.1 billion (CDC, 2014). It is difficult to compete with
businesses with much deeper pockets. Furthermore, health communicators must
work within ethical boundaries, providing honest and accurate information, while
businesses are not constrained to the same ethical principles. One highly effective
public health campaign was the Truth campaign by the American Legacy Founda-
tion. The Truth campaign presented the target audience with facts about tobacco
products and the tobacco industry in powerful and memorable advertisements. The
campaign successfully deconstructed tobacco marketing to influence youth attitudes
and behaviors toward smoking.
Health communication takes difficult to understand information and turns it into
easily understandable concepts. The goal is to empower p eople with the latest sci-
ence and information so that they can make educated decisions regarding their
health. The discipline employs techniques from the fields of science, medicine, psy
chology, and human development to meet the needs of different audiences.
Sally Kuykendall
See also: Health Belief Model; Health Education; Health Literacy; Healthy P
eople 2020;
Social Cognitive Theory; Society of Public Health Education; Transtheoretical Model;
HEALTH DISPA R ITIES 285
Further Reading
Brown, J., Kotz, D., Michie, S., Stapleton, J., Walmsley, M., & West, R. (2014). How effective
and cost-effective was the national mass media smoking cessation campaign “Stoptober”?
Drug and Alcohol Dependence, 135, 52–58. doi:10.1016/j.drugalcdep.2013.11.003
Centers for Disease Control and Prevention (CDC). (2017). Gateway to health communication
and social marketing practice. Retrieved from https://www.cdc.gov/healthcommunication
/healthbasics/whatishc.html.
Ekwueme, D. U., Howard, D. H., Gelb, C. A., Rim, S. H., & Cooper, C. P. (2014). Analysis
of the benefits and costs of a national campaign to promote colorectal cancer screen-
ing: CDC’s Screen for Life—National Colorectal Cancer Action Campaign. Health Pro-
motion Practice, 15(5), 750–758. doi:10.1177/1524839913519446
Gollust, S. E., & Cappella, J. N. (2014). Understanding public resistance to messages about
health disparities. Journal of Health Communication, 19(4), 493–510. doi:10.1080/108
10730.2013.821561
GroupM. (n.d.). Advertising spending in the United States from 2011 to 2017 (in billion U.S.
dollars). In Statista—The Statistics Portal. Retrieved from https://www-statista-com
.ezproxy.sju.edu/statistics/236958/advertising-spending-in-the-us/.
Kantar Media & OAAA. (n.d.a). Advertising spending of the cigarettes and tobacco industry in
the United States in 2013, by medium (in thousand U.S. dollars). In Statista—The Statistics
Portal. Retrieved from https://www-statista-com.ezproxy.sju.edu/statistics/245332
/advertising-spending-of-the-ttobacco-industry-in-the-us-by-medium/.
Kantar Media & OAAA. (n.d.b). Advertising spending of the food and beverage industry in the
United States in 2013, by medium (in thousand U.S. dollars). In Statista—The Statistics
Portal. Retrieved from https://www-statista-com.ezproxy.sju.edu/statistics/319053/food
-beverage-ad-spend-medium/.
National Cancer Institute. (1989). Making health communications work. Pub. No. NIH 89-1493.
Washington, DC: U.S. Department of Health and H uman Services. Retrieved from
https://www.cancer.gov/publications/health-communication/pink-book.pdf.
Shannon, C. E., & Weaver, W. (1949). The mathematical theory of communication. Urbana:
University of Illinois Press.
U.S. Department of Health and Human Services. (2000). Healthy People 2010 (2nd ed.).
Health communication. Washington, DC: U.S. Government Printing Office. Retrieved
from http://www.healthypeople.gov/2010/document/pdf/Volume1/11HealthCom.pdf.
U.S. Department of Health and Human Services. (2014). HHS FY2015 Budget in brief.
Retrieved from https://www.hhs.gov/about/budget/fy2015/budget-in-brief/cdc/index
.html.
HEALTH DISPARITIES
The Institute of Medicine defines health care disparities as differences in treatment
or access between population groups that cannot be justified by different pref-
erences for services or differences in health (McGuire, Alegria, Cook, Wells, &
Zaslavsky, 2006). Health disparities are defined as differences in health outcomes
across population groups (Schnittker & McLeod, 2005). Within the United States,
much of the focus on health and health care disparities has turned to differ-
ences in access and quality across racial and ethnic groups, along with differences in
286 HEALTH DISPARITIES
socioeconomic status (SES), especially education and income and factors such as geo-
graphic location, gender, and sexuality.
The growth in interest in research about social differences in health and health
care disparities was summarized well by the Adler and Rehkopf (2008) review of
U.S. disparities in health by examining literature for the term “health disparities.
Although this was a key word in only one article in 1980, and fewer than 30 in the
1990s, it went up to more than 400 articles from 2000 to 2004. If the term “health
inequalities” was used instead, the pattern of increase was similar. That term is used
more often in British studies.
Within the United States, some of these earlier studies led to the now well-known
efforts in the United States to examine and try to eliminate health disparities due
to race/ethnicity and socioeconomic status in the Healthy People series. From the
federal government level, one of the pushes for more research on health care inequal-
ities came from the passage of Public Law 106–129, the Healthcare Research and
Quality Act of 1999. That law called for two annual reports, one focused on quality
and one focused on disparities. Within the work on disparities was a call to track
prevailing disparities in health care delivery as they relate to racial and socioeco-
nomic factors among priority populations such as low income groups, racial and
Cuicani Villegas stops playing to use her asthma inhaler. Children in inner city neighbor-
hoods are regularly exposed to industrial pollutants leading to higher burdens among poor
black and Hispanic c hildren. (Bob Chamberlin/Los Angeles Times via Getty Images)
ethnic minorities, women, children, the elderly, individuals with special health care
needs, the disabled, people in need of long-term care, p eople requiring end-of-life
care, and places of residence (rural communities). A first National Healthcare Dis-
parities Report (2004) built on previous efforts in the federal government, espe-
cially Healthy People 2010 (U.S. Department of Health and Human Services, 2000)
and the IOM Report, Unequal Treatment: Confronting Racial and Economic Disparities
in Healthcare (Smedley, Stith, & Nelson, 2003). Elimination of disparities in health
was a goal of Healthy P eople 2010. Unequal Treatment extensively documented health
care disparities in the United States and focused on those related to race and eth-
nicity, but not on SES, a weakness of the report. The Institute of Medicine (IOM)
report on Unequal Treatment also looked at factors related to providers of care and
argued that providers’ perceptions and, from that, their attitudes toward patients
can be influenced by patient race or ethnicity (Smedley, Stith, & Nelson 2003).
The National Healthcare Disparities Report (2004) did focus on the ability of Amer-
icans to access health care and variation in quality of care. Disparities related to
socioeconomic status were included, along with racial/ethnic disparities. Some key
findings from the report included that inequality in quality of care continues to exist
and that disparities often are particularly true for some more serious health care
problems, such as minorities being diagnosed with cancer at later stages, less often
receiving optimal care when hospitalized for cardiac problems, and higher rates of
avoidable hospital admissions among blacks and poorer patients.
In 2005, the third National Healthcare Disparities Report (2005) was released. The
2005 report focused on findings from a set of core report measures and indicated
that disparities still existed, but some disparities w ere diminishing. Disparities
remained in areas of access, quality, and across many levels and types of care includ-
ing preventive care, treatment of acute conditions, and management of chronic
disease. This applies to a variety of specific clinical conditions including cancer,
diabetes, end stage renal disease, heart disease, HIV disease, mental health and sub-
stance abuse, and respiratory diseases.
Major issues of disparity occur for poor people and Hispanics, with lesser but
important issues for blacks, American Indians, and Asians. Poor people have worse
access to care than high income people for all eight core report measures. Hispan-
ics have worse access for 88 percent of the core report measures, while blacks and
American Indians have worse access on half of the measures. Asian Americans have
worse access on 43 percent of the measures. The 2005 report also tracks changes
in the core measures over time. For racial minorities, more disparities in quality of
care w
ere becoming smaller rather than larger, while for Hispanics, 59 percent w ere
becoming larger and 41 percent smaller (National Healthcare Disparities Report,
2005).
Federal government focus on these efforts has continued, with the Healthy People
2020 publication, much of which is now easily obtainable through U.S. govern-
ment websites through the U.S. Department of Health and Human Services. For
the 2020 effort, the report points out that in Healthy People 2000, the goal was to
reduce health disparities among Americans, and in Healthy People 2010 the goal was
to eliminate, not just reduce, health disparities. By Healthy People 2020, that goal
was expanded even further: to achieve health equity, eliminate disparities, and
improve the health of all groups. Healthy P eople 2020 defines health equity as attain-
ing the highest level of health for all p
eople. It points out that both efforts to elimi-
nate disparities and achieve health equity have focused primarily on diseases or
illnesses and on health care services.
In the United States, in addition to federal government efforts, some important
private foundations such as the Commonwealth Foundation now have programs
that focus on health differences and health disparities (Commonwealth Fund, 2013).
The goals of the Commonwealth Fund’s Program on Health Care Disparities are to
improve the overall quality of health care delivered to low income and minority
Americans, and to eliminate racial and ethnic health disparities.
Geographical and Place F actors and Disparities
In some ways, it is difficult to discuss the issue of geographical and place factors,
since they become so intertwined with SES and race/ethnicity. More recently, t here
has been a concern to include the environment as part of the social ecological
approach (Parcel & Baranowski, 1981, 2002). Social ecological theory emphasizes
a holistic approach to environmental factors. There has also been growth in recent
years in articles that look at geographic factors as one component of disparity. For
example, one article has focused on place and geography for chronic kidney dis-
ease (McClellan, Plantinga, & McClellan, 2012). This article was a review article
that included geographic attributes such as diversity in the physical environment
as well as socioeconomic and medical care characteristics of the environment. Out-
side of the United States, examining differences between rural and urban areas in
terms of health variations has been particularly important in Canada, and a recent
article points out that not only are there rural urban differences, but that heteroge-
neity in health is also found within rural areas (Lavergne & Kephart, 2012).
An important set of studies examining geographic disparities in health care use
have been those linked with the Dartmouth Atlas Project (Fisher & Wennberg, 2003;
Wennberg, 1984; Wennberg & Gittelsohn, 1973). This project, beginning with early
work in the 1970s and continuing into the present, has demonstrated the impor-
tance of what w ere initially called small area variations (focusing on geographic dif-
ferences) in the types and amounts of health care used within the United States.
As the work of this group has expanded, they have looked at cost and quality
variations as well, and documented major variations in how medical resources are
distributed and used in the United States. T oday, the research group maintains a
website that provides much greater detail, much of which uses Medicare data to
provide information and analysis about national, regional, and local markets, as
well as hospitals and affiliated physicians (Dartmouth Atlas of Health Care, 2013).
Cooper argues that meaningful health care reform w ill need to accept the reality
that poverty and its cultural extensions are the major c auses of geographic variation
in health care utilization and also a major source of escalating health care spending
(Cooper, 2011).
Health Problems and Disparities
This section w ill review a few interesting studies on heart disease related mortality
trends, specialty care use with chronic diseases, and also one study that examines
functional limitations across states. Looking at the latter issue first, Asada, Yoshida,
and Whipp (2013) point out that among the challenges of reporting on health dis-
parities, one often overlooked is how best to report health disparities associated
with multiple attributes. They report a general lack of consistency in the rankings
of overall and attribute-specific disparities in functional limitation across states.
Wyoming has the smallest overall disparity and West Virginia the largest. In their
analysis, they found three different disparity profiles across states: (1) the largest
contribution from race/ethnicity (34 states), (2) roughly equal contributions of race/
ethnicity and socioeconomic factor(s) (10 states), and (3) the largest contribution
from socioeconomic factor(s) (7 states).
Two heart disease related studies both use major U.S. databases to examine coro-
nary artery disease mortality trends and stroke mortality trends. The article on
coronary heart disease (CHD) mortality trends uses the U.S. mortality files for 1977–
2007, as obtained from the Centers for Disease Control and Prevention in the United
States (Gillum, Mehari, Curry, & Obisesan, 2012). They found higher death rates
for African American men and w omen as compared to European American men
and women. Although rates declined in all groups over the time period studied, in
women rates declined more in later years of life. For men, rates declined less for
African Americans. Rates were higher in the Ohio and Mississippi River areas. In
the study looking at stroke mortality over the same time period, rates declined in
all groups, but declined less for African American males (Gillum, Kwagyan, & Obis-
esan, 2011).
See also: Bousfield, Midian Othello; Community Health; Cultural Competence; Dis-
ability; Ethics in Public Health and Population Health; Leading Health Indicators;
Population Health; Rural Health; Social Determinants of Health
Further Reading
Adler, N. E., & Rehkopf. (2008). U.S. disparities in health: Descriptions, causes and mech-
anisms. Annual Review of Public Health, 29, 235–252.
Asada, Y., Yoshida, Y., & Whipp, A. M. 2013. Summarizing social disparities in health. Mil-
bank Quarterly, 91(1), 5–36.
Commonwealth Fund. (2013). Retrieved from http://www.commonwealthfund.org/Program

-Areas/Archived-Programs/Health-Care-Disparities.aspx.
Cooper, R. A. (2011). Geographic variation in health care and the affluence poverty nexus.
Advances in Surgery, 45, 63–82.
Dartmouth Atlas of Health Care. (2013). Retrieved from http://www.dartmouthatlas.org/.
Fisher, E. S., & Wennberg, J. E. (2003). Health care quality, geographic variations,
and the challenge of supply-sensitive care. Perspectives in Biology & Medicine,
46(1), 69.
Gillum, R. F., Kwagyan, J., & Obisesan, T. O. (2011). Ethnic and geographic variation in
stroke mortality trends. Stroke, 42(11), 3294–3296.
Gillum, R. F., Mehari, A., Curry, B., & Obisesan, T. O. (2012, June 6). Racial and geographic
variation in coronary heart disease mortality trends. BMC Public Health, 12, 410.
doi:10.1186/1471-2458-12-410
Lavergne, M., & Kephart, G. (2012). Examining variations in health within rural Canada.
Rural & Remote Health, 12(1), 1.
McClellan, A. C., Plantinga, L., & McClellan, W. M. (2012). Epidemiology, geography and
chronic kidney disease. Current Opinion in Nephrology and Hypertension, 21(3),
323–328.
McGuire, T., Alegria, M., Cook, B. L., Wells, K. B., & Zaslavsky, A. M. (2006). Implement-
ing the Institute of Medicine definition of disparities: An application to mental health
care.” Health Services Research, 41:1979–2005.
National healthcare disparities report: Summary. (2004, February). Agency for Healthcare
Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/qual /nhdr03
/nhdrsum03.htm.
National healthcare disparities report. (2005, December). Agency for Healthcare Research and
Quality, Rockville, MD. AHRQ Publication No. 06-0017. Retrieved fromwww.ahrq.gov
/qual/nhdr05/nhdr05.pdf.
Parcel, G., & Baranowski, T. (1981). Social learning theory and health education. Health
Education, 12, 14–18.
Parcel, G., & Baranowski, T. (2002). How individuals, environments, and health behavior
interact: Social cognitive theory. In K. Glanz, B. Rimer, & F. Lewis (Eds.), Health behav
ior and health education: Theory, research and practice (pp. 165–184). San Francisco:
Jossey-Bass.
Schnittker, J., & McLeod, J. D. (2005). The social psychology of health disparities. Annual
Review of Sociology, 31, 75–103.
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confront-
ing racial and ethnic disparities in health care. Institute of Medicine. Washington, DC:
National Academies Press.
Truman, B. I., Smith, C. K., Roy, K., Chen, Z., Moonesinghe, R., Zhu, J., Crawford, C. G.,
& Zaza, S. (2011, January 14). Rationale for regular reporting on health disparities
and inequalities—United States. Morbidity and Mortality Weekly Report Supplements,
60(1), 3–10.
U.S. Department of Health and Human Services. Healthy People 2010 (2nd ed.). (2000,
November). With understanding and improving health and objectives for improving
health. Washington, DC: U.S. Government Printing Office.
U.S. Department of Health and H uman Serv ices. Healthy P eople 2020. (2013, March).
Retrieved from http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx.
HEALTH EDU C ATION 291
Wennberg, J., & Gittelsohn, A. (1973). Small area variations in health care delivery: A
population-based health information system can guide planning and regulatory decision-
making. Science, 182, 1102–1108.
Wennberg, J. E. (1984). Dealing with medical practice variations: A proposal for action.
Health Affairs, 3(2), 6–32.
HEALTH EDUCATION
Health education is the acquisition of health-enhancing knowledge, attitudes, or
skills as a result of planned learning experiences. Health education can occur through
a variety of channels, such as books, pamphlets, courses, videos, demonstrations,
guided discovery, or social media. The key concepts of health education, as opposed
to marketing or other activities that mimic health education, are that the learning is
intentional (planned), information is delivered by health educators following a pro-
fessional code of ethics, and activities utilize health promotion theories and evidence-
based practices. Health education follows an established procedure of (1) needs
assessment, (2) setting project goals, (3) planning, (4) implementation, and (5) eval-
uation. Health educators continually assess, revise, and refine activities with the goal
of improving programs and services for the people and the communities they serve.
The term “health education” is used to describe any activity or combination of
activities designed to encourage, support, or reinforce healthy behaviors. Health
education is a form of health promotion in that health education empowers indi-
viduals to self-determine their health. However, health promotion is a broader term,
which includes health policy, health regulations, social and environmental inter-
ventions, and organizations that support health. Health education is also a form of
health communication in that health educators use communication strategies to
inform people. However, health communication goes beyond health education to
address health literacy. Some health communications, such as mass media cam-
paigns, involve one-way communication whereas health education activities tend to
take place in formal, interactive settings, delivered as face-to-face, online, lectures,
workshops, or seminars. Some advertisers use the guise of health education to
market products, programs, or services. A major difference between marketing and
health education is that health educators are bound by a code of professional eth-
ics. Professional health educators have a responsibility to act with honesty and
integrity in all interactions with communities and individuals. Health educators w ill
not try to sell a product or program that is not beneficial to the client.
The Society of Public Health Educators (SOPHE) is the main professional organ
ization supporting health education practice by school, community, and public
health professionals. SOPHE sets standards for professional practice, which include
the following:
• Accurate representation of information, products, programs, or services
• Speaking out against ideas, products, or issues that may be harmful to health
292 HEALTH EDU CATION
• Protecting the dignity and privacy of clients

• Protecting individual right to make his or her own decisions about health
• Maintaining professional competency by staying up to date in the field
• Promoting open criticism and opportunities to improve the profession
• Encouraging diversity in representation, thought, and action
• Reporting unethical behaviors by peers
Ethical standards ensure that health educators work for the benefit of patients,
clients, and communities as opposed to personal benefit and interests.
The steps of the health education process are (1) assess health needs of the com-
munity or individual, (2) develop learning goals and objectives, (3) plan curricu-
lum and learning activities, (4) implement program and learning activities, and
(5) evaluate program effectiveness. The first step, the needs assessment, collects
information on the health and education needs of the community, available resources,
and opportunities for collaboration. The needs assessment helps the planning com-
mittee to establish learning goals and objectives for the project. Goals are broad
statements that name the population of interest and what is expected to happen
because of the learning activity. Objectives are precise statements that define the
steps or tasks necessary to meet the intended goal. Goals and objectives help to
focus the project’s efforts and keep the planned activities manageable. The next step
is to plan learning activities. Effective programs require detailed planning for the
allocation of resources, marketing, development of program materials, and needs
of the target population. Implementing effective health education programs requires
an understanding of how people learn and what motivates people to improve health
behaviors. Learning is most effective when the lessons are enjoyable, learning is
active and involves multiple senses (visual, auditory, touch, taste, and smell), the
learner is prepared and ready to learn, the environment is free of distractions, les-
sons are appropriately paced, and information progresses from simple to complex
with reinforcement of the more difficult concepts through repetition or hands-on
activities (McKenzie, Neiger, & Thackeray, 2012). Adult learners are motivated to
learn when they understand why the information is important, feel valued for their
ideas, wisdom, and expertise, and the information relates to life experiences. The inter-
vention phase can use a variety of learning activities. Common educational activi-
ties are presentations, videos, web programs, social media, printed materials, role
play, case studies, debates, experiments, and discussion. Evidence-based programs
promise the most effective ways to improve behavior or knowledge. Evidence-
based programs are health promotion or disease prevention activities that have
been tested and proven to work in research. Several federal and nonprofit organ
izations list and report recommended evidence-based programs. The final stage of
the health education cycle is program evaluation. Health educators build evalua-
tion procedures into the program during the planning stage. S imple measures
of program evaluation are attendance, participant satisfaction, or key stake-
holder satisfaction. Other ways to measure program effectiveness assess changes
HEALTH EDU C ATION 293
On a Friday evening in the Castro District of San Francisco, community health educators
set up health information materials on the street, and offer screening and counseling for
sexually transmitted diseases. (Sara Ann Kuykendall)
in knowledge, attitudes, or behavior because of program participation. The results

of the evaluation are used to improve the program for future use.
One of the most commonly recognized venues of health education is schools.
More than 50 million children attend public schools with classes on nutrition,
physical activity, oral health, decision-making skills, healthy personal boundaries,
disease, and injury prevention. To promote personal, family, and community
health, the American Public Health Association (APHA), the American School
Health Association (ASHA), and the Society of Health and Physical Educators
(SHAPE) developed standards for school health education. The National Health
Education Standards (NHES) identify benchmarks of what c hildren should know
by grades 2, 5, 8, and 12. Teachers, administrators, and policy makers can use the
standards to select topics, plan curriculum, instruct, and assess learning. Improving
the health of children provides academic and social benefits. Studies show improved
concentration, memory, and mood, improved academic achievement, increased
attendance and graduation rates, and decreased school dropout and behavioral
problems among children who are physically active and enjoy a nutritious diet. To
support the NHES, the Substance Abuse and Mental Health Services Administra-
tion (SAMHSA) offers a searchable database of evidence-based programs, and the
294 HEALTH EDU C ATION
Centers for Disease Control and Prevention (CDC) offers professional development
tools for school health educators and the Health Education Curriculum Analysis
Tool (HECAT). The School Health Policies and Practices Study suggests additional
ways to enhance school health education, such as not withholding recess as a pun-
ishment for bad behavior, not using physical activity (running laps or pushups) as
punishment for poor athletic performance, encouraging walking or biking to
school, integrating physical activity into the classroom schedule, and providing club
or intramural sports programs. Expanding school policies and procedures to support
health education lessons supports learning and positive behavioral change.
A major limitation of health education is that giving people the information that
they need to act in healthy ways does not necessarily lead to healthy behaviors.
People who smoke know that smoking is bad for them. They know that smoking
causes cancer, chronic obstructive pulmonary disease, coronary heart disease, stroke,
birth defects, rheumatoid arthritis, Type 2 diabetes mellitus, and many other dis-
eases. Yet, people still smoke! Improving knowledge does not mean that people will
change behavior. This is where health models and theories are useful. The transtheo-
retical model, health belief model, social cognitive theory, and diffusion of innovations
theory consider the wider array of social, physical, and emotional factors that play a
role in personal health behaviors. Health programs that use health theories and mod-
els are more successful than programs that rely on conveying information alone.
Health education is a professional field that seeks to improve health behaviors
by building accurate knowledge and understanding of health, wellness, and dis-
ease prevention. Health educators follow a code of professional ethics, which require
them to act in ways that advance the health of others. Health educators plan, develop,
and evaluate programs in order to promote individual and community health. Pub-
lic health can be further enhanced through policy and practices that are consistent
with health education.
Sally Kuykendall
See also: Core Competencies in Public Health; Ethics in Public Health and Popula-
tion Health; Evaluation; Evidence-Based Programs and Practices; Goals and Objec-
tives; Grants; Healthy People 2020; Intervention; Logic Model; Society of Public
Health Education
Further Reading
American School Health Association. (n.d.). Retrieved from http://www.ashaweb.org/.
Centers for Disease Control and Prevention (CDC). (2016). CDC training tools for healthy
schools: Professional development. Retrieved from https://www.cdc.gov/healthyschools
/trainingtools.htm.
Joint Committee on Health Education and Promotion Terminology. (2012). Report of the
2011 joint committee on health education and promotion terminology. American Jour-
nal of Health Education, 43, 1.
HEALTH INSU RAN C E PO RTABILITY AND A C C OUNTA B ILITY AC T (HIPAA) 295
SHAPE America. (n.d.). Retrieved from http://www.shapeamerica.org/.

Society of Public Health Educators. (2017). Retrieved from http://www.sophe.org/.
Substance Abuse and Mental Health Services Administration. (2016). NREPP: SAMHSA’s
national registry of evidence-based programs and practices. Retrieved from http://www
.samhsa.gov/nrepp.
HEALTH INFORMATION MANAGEMENT (HIM)

In order to ensure the best possible care, patients must be able to report symptoms
and attain treatment confident that health care providers will not misuse personal
and private information or report a stigmatizing disease to the patient’s employer.
Under the Health Insurance Portability and Accountability Act (HIPAA) Privacy
Rule, patients have the right to such privacy and to determine who has access to
their personal health information. This means that public health organizations must
have systems in place to secure personal health information. Health information
management (HIM) is a field of public health that deals with the documentation,
collection, maintenance, organization, and legal adherence in the use, transmission,
and management of patient records. The American Health Information Management
Association defines HIM as “the practice of acquiring, analyzing, and protecting digi-
tal and traditional medical information vital to providing quality patient care” (AHIMA,
2016). HIM oversees medical records including diagnosis, treatment, procedure clas-
sification, coding, billing, and reimbursement. The computerization of health rec
ords has made the management of health records easier and more accurate,
contributing to quality patient care. As methods of recording patient information
evolve, the field of HIM also evolves.
Godyson Orji
See also: Administration, Health; Degrees in Public Health; Health Insurance Por-
tability and Accountability Act; Public Health Law
Further Reading
American Health Information Management Association (AHIMA). (2016). What is health
information? Retrieved from http://www.ahima.org/careers/healthinfo.
Zeng, X., Reynolds, R., & Sharp, M. (2009, Summer). Redefining the roles of health infor-
mation management professionals in health information technology. Perspective in Health
Information Management, 6, 1–11. Retrieved from https://www.ncbi.nlm.nih.gov/pmc
/articles/PMC2781729/pdf/phim0006-0001f.pdf.
HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT (HIPAA)
More commonly referred to as HIPAA, the Health Insurance Portability and Account-
ability Act of 1996, also known as the Kennedy-Kassebaum Act, consists of two parts.
The first part, Title I, sets guidelines on how much agencies offering health plans can
296 HEALTH INSURANCE PORTA BILITY AND ACC OUNTA B ILITY A C T ( HIPAA )
limit coverage when employees change jobs. To stop people from waiting to pur-
chase health insurance only when they get sick, health insurance companies can
refuse to pay for preexisting conditions—health problems the person already knew
about. Title I limits how much a plan can restrict paying for preexisting health con-
ditions. If the worker can show consistent credible coverage, as defined by Title I,
the insurance company is obligated to cover preexisting conditions with some
exceptions. Title II is primarily aimed at preventing health care fraud and abuse by
securing the privacy of confidential health information. Title II has far-reaching
implications for everyday health care practice. The HIPAA Privacy Rule is a national
law ensuring individuals’ rights to determine who has access to their personal and
private health information, mandating organizations and individuals to have sys-
tems in place to secure personal health information, and setting civil and criminal
penalties for violations of privacy. HIPAA does not restrict the patient’s rights to
access information. Patients and their recognized caregiver or legal representative
have full access to the protected health information. Patients may review their own
medical chart or ask for copies of medical records. A health care provider or admin-
istrator will typically sit in on the chart review to answer any questions.
Throughout history, sensitive health information, diagnoses, treatments, or bill-
ing have been used to hurt p eople, socially and financially. The unscrupulous
employer who learns that an employee has been diagnosed with HIV could take
action to terminate the employee. Colleagues and acquaintances could use sensi-
tive information to coerce a person to do things that they would not normally do.
The Privacy Rule controls what information may be shared and whom it may be
shared with. Under the law, all “individually identifiable health information” is
protected. The patient’s name, address, birth date, social security number, and
demographic information; past, current, and future physical and mental health
issues; treatments; and billing for health services are considered confidential and
cannot be shared with outside persons or agencies unless the patient gives express
permission or the disclosure is part of the organized system of care or payment.
HIPAA is important in public health b ecause patients must be able to seek treatment
for health issues without fear that their personal information w ill be revealed to
others. On July 4, 2015, New York Giants’ football player Jason Pierre-Paul injured
the index finger of his right hand when a firework that he was attempting to light
exploded. Hospital workers leaked pictures of the football player’s medical chart
along with news that the finger was amputated. The personal health information
was tweeted to more than 4 million people by ESPN reporter Adam Schefter, and
the New York Giants rescinded Pierre-Paul’s $60 million contract offer. Pierre-Paul
recovered from his injury and uses his experience to educate o thers on fireworks
safety. The leak was traced to two hospital employees, an operating room nurse,
and a unit secretary, who w ere fired. Under HIPAA regulations, the hospital could
be fined $50,000 for each violation. ESPN and Schefter are excluded from HIPAA
rules because they are not health care organizations or health professionals. The
HEALTH INSU RAN C E PO RTABILITY AND A C C OUNTA B ILITY AC T (HIPAA) 297
Privacy Rule only applies to health providers, health plans, health care clearing
houses, and business associates.
There are intentional exceptions to the Privacy Rule. As part of normal opera-
tions, health care facilities maintain a list of current inpatients or residents. When
a friend, family member, or religious leader calls in person or on the phone, it is
assumed that patients want the operator to share their room number and general
condition with callers. When the patient is not in a condition to grant permission
or make health care decisions, due to stroke, injury, or other illness, the physicians,
nurses, or therapists may discuss progress and treatment plans with the primary
caregivers. The patient does not need to give permission b ecause the Privacy Rule
assumes that the patient would give permission if he or she w ere able to do so.
Protected health information must be disclosed to federal, legal, and local health
authorities. The Department of Health and H uman Services may access personal
health information when performing a compliance review. Health professionals are
required to release records to legal authorities where the patient has been the vic-
tim of abuse, neglect, domestic violence, or other crime; when a subpoena or court
order has been issued for the information; or where there has been a death or a
crime. They are also obligated to share necessary information with organ or tissue
donation organizations, the Food and Drug Administration, if the patient suffered
an adverse reaction to a medication or medical devise, or for the benefit of public
health. Public health agencies need to be notified regarding outbreaks of infectious
diseases or other events that threaten the public health. In such cases, patient infor-
mation may be shared fully, partially, or as de-identified information. De-identified
information, where the patient cannot be identified, may be shared as long as the
knowledge cannot be traced back to the patient. De-identified data allow public
health administrators, researchers, or epidemiologists to study trends in health and
disease in order to prioritize community efforts. HIPAA rules include companies or
individuals who provide or pay for health, dental, vision, prescription, or long-term
care services. Companies providing services for health through workman’s compen-
sation, motor vehicle, or property insurance are not covered.
This extensive law was implemented not only to protect patients but providers
as well. HIPAA provides guidelines of how patient health information should be
used, what information may be shared and whom information may be shared with.
Other best practices and health laws have developed through HIPAA.
See also: Administration, Health; Health Information Management; Patient Safety;

Public Health Law
Further Reading
Health Information Privacy (HHS). (2015). HIPAA for professionals. Retrieved from http://
www.hhs.gov/hipaa/for-professionals/index.html.
298 HEALTH LITERACY
HEALTH LITERACY
Health literacy is the degree to which an individual has the capacity to obtain, com-
municate, process, and understand basic health information and services to make
appropriate health decisions (Centers for Disease Control and Prevention, 2016).
Having health literacy does not simply mean being able to read health information.
It means being able to use a broad range of skills, including self-advocacy, to make
informed health care decisions for oneself, one’s family, and one’s community (Zar-
cadoolas et al., 2006). Some reports have noted that at least half of the adults in the
United States have difficulty understanding and acting upon health-related infor-
mation, such as health plan communications, medication instructions, and public
health warnings (Nielson-Bohlman et al., 2004; Zarcadoolas et al., 2006). Further,
according to the 2003 National Assessment of Adult Literacy, 12 percent of Ameri-
can adults have adequate health literacy; that is, 9 out of 10 adults lack the broad
range of skills needed to proficiently manage their health (Department of Health
and Human Services).
Health literacy is a growing and dynamic field. For instance, the ability to
understand and use health information and services shifts with scientific discov-
ery, urbanization, changes in the education system, and technological and med-
ical advances. The term “health literacy” was first used in 1974 by Scott Simonds,
in his argument that it would be good social policy for schools to prioritize health
education in all grade levels (Ratzan, 2001). The early use of the term demon-
strates the link between health literacy and health education: poor health edu-
cation is related to poor health literacy (Ratzan, 2001). However, health literacy
issues have grown more complex as the health system has become more difficult to
navigate. Today, the term is understood in relation to not only health education,
but also treatment options, diagnoses, preventive behaviors, and chronic disease
management.
Major advances have been made in the field of health literacy, particularly over
the past 15 years. In 2003, Louisiana became the first state to enact legislation to
improve health literacy, setting the stage for other states to follow (Parker & Rat-
zan, 2010). In 2007, the National Health Literacy Act, a bill seeking to ensure that
Americans have basic health literacy skills, was introduced before the Senate. More-
over, President Barack Obama’s Patient Protection and Affordable Care Act, signed
into law in 2010, includes the definition of health literacy and formally integrated
health literacy into the law (Parker & Ratzan, 2010). A growing body of research
in the scientific community continues to inform programs and policies that impact
health literacy.
There is ample evidence to suggest that low health literacy impacts a person’s
health. People with low health literacy may be less likely to use preventive services
and have difficulty reading instructions for taking medications, following public
health warnings, or reading emergency information (Nielson-Bohlman et al., 2004;
Zarcadoolas et al., 2006). People with low health literacy also may have difficulty
accessing health care. They may not be able to understand health plan information
HEALTH LITER A C Y 299
or medical treatment options. As a result, many chronic diseases, such as heart dis-
ease and diabetes, go untreated or undiagnosed (Zarcadoolas et al., 2006).
Low health literacy also affects our health system. When people cannot under-
stand or follow medical regimens, properly take medications, or understand and
act upon risk avoidance and health prevention guidelines, they may overuse or mis-
use the health care system (Zarcadoolas et al., 2006). Some reports have demon-
strated that lower health literacy is associated with higher rates of hospitalization
and use of emergency services (Nielson-Bohlman et al., 2004). Overall, studies have
shown an association between health literacy and health care costs; one analysis
estimates that low health literacy in the United States results in $69 billion in addi-
tional health spending (Nielson-Bohlman et al., 2004).
Limited health literacy influences all adults, although rates vary by race/ethnic-
ity, education level, age, and insured status. According to the National Assessment
of Adult Literacy, 28 percent of white adults had basic or below basic health liter-
acy, compared to 34 percent of those in the “other” category (including Asians, Native
Americans, and multiracial adults), 57 percent of black adults, and 65 percent of
Hispanic adults (Department of Health and H uman Services [DHHS], n.d.). Health
literacy tends to increase with higher educational attainment. In the survey, more
than 75 percent of adults with less than a high school degree w ere at the basic or
below basic level, compared to 12 percent of college graduates (DHHS, n.d.). Adults
65 or older were more likely to have basic or below basic health literacy skills than
those under 65, and t hose over 75 had the lowest levels (DHHS, n.d.). Finally, adults
who were uninsured and t hose enrolled in Medicare or Medicaid w ere more likely
to have low health literacy; over half of people who were uninsured, on Medicare,
or on Medicaid had basic or below basic health literacy, compared to one-fourth of
people with employment-based health insurance (DHHS, n.d.).
Health literacy is an important public health issue that requires attention from
health care administrators, policy makers, educators, practitioners, researchers, and
public health professionals, all of whom can affect p eople’s ability to find, use, and
understand health services and information. Although much work has been done
in health literacy over recent years, disparities in and levels of health literacy suggest
that there is more work to do. Recommendations to advance the field and improve
people’s health literacy include (1) making accessible and easy to understand health
information more widely available; (2) educating health professionals about how
to be better communicators; (3) encouraging funding of research that will lead to
a better understanding of how to measure, monitor, and improve health literacy
levels; and (4) developing health literacy learning standards across the life course
that incorporate health literacy into school-based education (DHHS, n.d.; Parker
& Ratzan, 2010). T hese measures and o thers may help to address the gap that cur-
rently exists between health information available and the skills p eople have to
understand and use this information.
Elizabeth Y. Barnett
300 HEALTH POLICY
See also: Health; Health Communication; Health Education
Further Reading
Centers for Disease Control and Prevention. (2016). Health literacy. Retrieved from https://
www.cdc.gov/healthliteracy/index.html.
Department of Health and Human Services, Office of Disease Prevention and Health Pro-
motion. (n.d.). Quick guide to health literacy. Retrieved from https://health.gov/com
munication/literacy/quickguide/Quickguide.pdf.
Nielson-Bohlman, L., Panzer, A., & Kindig, D. (Eds.). (2004). Health literacy: A prescription
to end confusion. Washington, DC: National Academies Press.
Parker, R., & Ratzan, S. (2010). Health literacy: A second decade of distinction for Ameri-
cans. Journal of Health Communication, 15(S2), 20–33.
Ratzan S. (2001). Health literacy: Communication for the public good. Health Promotion
International, 16(2), 207–214.
Zarcadoolas, C., Pleasant, A. F., & Greer, D. S. (2006). Advancing health literacy: A frame-
work for understanding and action. San Francisco: Jossey-Bass.
HEALTH POLICY
Policy refers to the overall goals, principles, actions, or practices by the govern-
ment or on behalf of the government. Policies guide decision making for laws and
allocating resources. Policy makers are responsible for designing plans to accom-
plish intentional goals. In public health, overall goals are to promote good health
through physical and social environments, childhood development, and lifestyle
choices, in order that all p eople may enjoy long lives free of disease, disability, and
injury (Office of Disease Prevention and Health Promotion, 2016). In the United
States, policy occurs at the federal, state, tribal, territorial, and local levels of gov-
ernment. Any significant reform to health policy can have important economic and
political implications by altering the health care system that comprises both indi-
viduals and private stakeholders. Health professionals, health insurance companies,
pharmaceutical companies, hospitals, and patients are all impacted by changes in
health policy. Comprehensive policy analysis requires not only assessing the tech-
nical content of a health policy document but also understanding the historical con-
text and politics that influence the policy design process.
Health policies are created through a systematic process of conceptualization,
development, adoption, and evaluation (Centers for Disease Control, 2014). The
policy process starts with problem identification. Data are collected and analyzed
to determine the nature of the problem. Policy developers examine how people and
society are impacted and determine the severity of the problem. Childhood obesity
may be examined as one such critical issue that could be reduced through health
policy. The health consequences of obesity are heart disease, diabetes, stroke, and
some types of cancers. For many, obesity starts in childhood. C hildren who are obese
are more likely to become obese as adults. Experts estimate that obesity adds $19,000
per person over a lifetime of direct medical costs (Finkelstein, Wan Chen Kang, &
HEALTH POLI C Y 301
Malhotra, 2014). In 1998, 10.5 percent of youth, aged 2 to 19, w ere obese (National
Center for Health Statistics, 2016). Within less than 20 years, obesity increased to
affecting twice as many youth (20.5 percent) with the highest rates among African
American females (24.4 percent) and males (20.9 percent), Mexican females
(24.2 percent) and males (22.8 percent), and Hispanic or Latino females (22.8 percent)
and males (22.7 percent). Youth who live below the poverty line had rates of up to
25.7 percent.
The second step of policy development is to identify possible options, consider-
ing the economic and health impact of each potential policy. This is achieved by
reviewing scholarly literature. Kristensen and colleagues (2014) compared the cost
benefit analysis of three commonly proposed obesity prevention policies: after-
school programs encouraging physical activity, ban on fast food marketing target-
ing children, and a one cent per ounce excise tax on sugar-sweetened beverages.
The scholars predicted that after-school activity programs would reduce child-
hood obesity by 1.8 percentage points among c hildren who would most likely
participate in such programs. For example, if 20 percent of the population of
children aged 6 to 12 is obese, after-school activity programs would reduce obe-
sity to 18.2 percent. A ban on fast food advertisements would reduce obesity by
0.9 percentage points. An excise tax on sugar-sweetened beverages would reduce
obesity by 2.4 percentage points among adolescents, 13 to 18 years of age. All three
policies would have a greater impact on c hildren of minority race, which means
the policies would have an added benefit of reducing racial disparities in health.
Consistent with the Kristensen et al. analysis, Ludwig, Peterson, and Gortmaker
(2001) found that risk of obesity increases 60 percent for each additional soda or
pop that a child drinks daily, and Wang, Coxson, Shen, Goldman, and Bibbins-
Domingo (2012) estimated that a penny-per-ounce tax on sugar-sweetened bever-
ages would prevent 26,000 premature deaths, 95,000 cardiac events, 8,000
strokes, and 2.4 million years of individuals living with diabetes. Thus, the cost-
benefit analyses suggest that an excise tax on sugar-sweetened beverages of $0.01
per ounce would have a significant impact on overall health.
The third step of policy development is developing a vision of what the policy
will look like in reality. During this stage, strategic planners examine how the pol-
icy will be applied and the key p eople who can implement the policy. The pro-
posed tax on sugar-sweetened beverages would need to be communicated to grocery
and convenience store owners as well as the general public through letters, news
releases, and media notices. People debate health policies that they perceive as
impacting personal rights. A tax on sugar-sweetened beverages is criticized as gov-
ernment overreach and impacting those who least can afford higher grocery bills.
Beverage manufacturers claim that obesity is a multifactorial issue, p eople should
be able to enjoy their product, and that policy should focus on physical activity.
Others may question the science behind the policy, especially when businesses
finance their own studies countering unhealthy foods as a cause of increasing obe-
sity. The fourth step to policy development is enactment, writing the regulation and
302 HEALTH POLICY
passing it through the law approval process. This phase might include setting up
the administrative systems to collect the sugar-sweetened beverage tax. The fifth
step is policy implementation. During implementation, the administrators must
ensure sufficient capacity to implement and sustain the policy. This stage is the nuts
and bolts of implementation, how the taxes are collected, where the funds go, and
monitoring effectiveness of the policy and the system. Stakeholder engagement
and education are critical to each phase of policy development. Public health
policy experts do not only partner with those who support the policy, but they
must also engage with t hose who are against the policy. Understanding and respect-
ing objections facilitates communication between groups and ensures plans can
move beyond potential barriers. Formal evaluation of the policy is also important.
If the sugar-sweetened beverage tax does not reduce obesity, public health profes-
sionals may need to consider changing the policy or using other policies.
Although policies can be highly effective in addressing public health issues, pol-
icy development can be complex, and the intended outcomes may be difficult to
achieve. Systems often resist change due to path dependence, the concept that people
make decisions based on past habits, behaviors, and perceptions. Obesity preven-
tion has been a goal of national health policy since 1980. The first Healthy People
report (1979) targeted individual behavior by focusing on healthy eating and
increased physical activity. Yet, over the late 1980s and 1990s, obesity rates con-
tinued to escalate (Mokdad et al., 1999). Reasons for the failure of the original
guidelines are multifaceted. Historically, public health policy focused too narrowly
on individual behaviors and paid less attention to wider societal factors such as
access to safe recreational areas, obesogenic environments, and the difference in
cost between nutritious foods and unhealthy, affordable fast foods. Eating healthily
may pose an economic hardship for low income populations. Politics has been a
further deterrent; the U.S. Congress has been unwilling to allocate significant
resources to support obesity prevention policy, and the fast food and soda indus-
tries oppose health policy reforms when these measures threaten company profits.
In 2013, beverage manufacturers spent $866 million advertising unhealthy drinks
to youth (Rudd Center for Food Policy & Obesity, 2014). Spanish-speaking youth
are targeted disproportionately by advertising. Policies, alone, are not sufficient to
impact multifactorial health problems. Solutions require socially responsible,
balanced approaches that respect the health and welfare of all communities.
Recent policy guidelines by federal health agencies (U.S. Department of Health
and Human Services, and Office of Disease Prevention and Health Promotion, 2010)
have begun to embrace ambitious proposals to address obesity. At the federal level,
provisions to address obesity are included in the ACA. Former First Lady Michelle
Obama’s Let’s Move campaign raises the public profile of childhood obesity. States,
in turn, are developing guidelines for providing obesity-related services to adults and
children on Medicaid. Finally, municipalities are reforming urban policies to encourage
physical fitness and improve access to healthful foods. This interagency collaboration
HEALTH POLI CY 303
traversing federal, state, and local levels reflects how policy makers are learning from
past mistakes by actively engaging with stakeholders to address the problem.
Catherine van de Ruit and Sally Kuykendall
See also: Administration, Health; Affordable Care Act; Body Mass Index; Health
Resources and Services Administration; Motor Vehicle Safety; Public Health Law;
Social Security Act; Winslow, Charles-Edward Amory
Further Reading
American Public Health Association. (n.d.). Taxes on sugar-sweetened beverages. Retrieved
from https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy
-database/2014/07/23/13/59/taxes-on-s ugar-sweetened-beverages.
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and
cost. Health Affairs, 27(3), 759–769.
Centers for Disease Control and Prevention (CDC). (2014). Using evaluation to inform CDC’s
policy process. Atlanta: Centers for Disease Control and Prevention, U.S. Department of
Health and Human Services. Retrieved from http://www.cdc.gov/policy/analysis/process
/docs/usingevaluationtoinformcdcspolicyprocess.pdf.
Davis, K., Stremikis, K., Squires, D., & Schoen, C. (2014). Mirror, mirror on the wall mirror:
How the performance of the U.S. health care system compares internationally. New York:
The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/∼/media
/files/publications/fund-report/2014/jun/1755_davis_m irror_mirror_2
014.pdf.
Finkelstein, E. A., Wan Chen Kang, G., & Malhotra, R. (2014). Lifetime direct medical costs
of childhood obesity. Pediatrics, 133(5), 854–862. doi:10.1542/peds.2014-0063
Healthy People: The Surgeon General’s report on health promotion and disease prevention. (1979).
Department of Health, Education, and Welfare, Public Health Service, Office of the
Assistant Secretary for Health and Surgeon General. Washington, DC: For sale by the
Superintendent of Documents, U.S. Government Printing Office.
Kristensen, A. H., Flottemesch, T. J., Maciosek, M. V., Jenson, J., Barclay, G., Ashe, M., &
Brownson, R. C. (2014). Reducing childhood obesity through U.S. federal policy:
A microsimulation analysis. American Journal of Preventive Medicine, 47(5), 604–612.
doi:10.1016/j.amepre.2014.07.011
Let’s move: America’s move to raise a healthier generation of kids. (2017). Retrieved from
http://www.letsmove.gov/.
Ludwig, D. S., Peterson, K. E., & Gortmaker, S. L. (2001). Relation between consumption
of sugar-sweetened drinks and childhood obesity: A prospective, observational analy
sis. Lancet, 357(9255), 505–508.
Mokdad, A. H., Serdula, M. K., Dietz, W. H., Bowman, B. A., Marks, J. S., & Koplan, J. P.
(1999). The spread of the obesity epidemic in the United States, 1991–1998. Journal
of the American Medical Association, 282(16), 1519–1522.
National Center for Health Statistics. (2016). Health, United States, 2015: With special feature
on racial and ethnic health disparities. Hyattsville, MD. Retrieved from https://www.cdc
.gov/nchs/data/hus/hus15.pdf#053.
304 HEALTH R ESOURCES AND SERVICES AD MINIST R ATION ( H R SA )
Rudd Center for Food Policy & Obesity. (2014). Sugary drink F.A.C.T.S.: Food advertising to
children and teens score. Retrieved from http://www.sugarydrinkfacts.org.
Starr, P. (1982). The social transformation of American medicine. New York: Basic Books.
United States Census Bureau. (2011). Income poverty and health insurance coverage in the
United States: 2010. Washington, DC: U.S. Government Printing Office.
United States Census Bureau. (2014). 2013 and 2014 current population survey reports. Wash-
ington, DC: U.S. Government Printing Office.
United States Department of Health and Human Services, and Office of Disease Prevention
and Health Promotion. (2010). Healthy People 2020. Retrieved fromhttps://www
.healthypeople.gov/.
Wang, Y. C., Coxson, P., Shen, Y. M., Goldman, L., & Bibbins-Domingo, K. (2012). A
penny-per-ounce tax on sugar-sweetened beverages would cut health and cost bur-
dens of diabetes. Health Affairs, 31(1), 199–207.
Weissert, C. S., & Weissert, W. G. (2008). Governing health: The politics of health policy. Bal-
timore: Johns Hopkins University Press.
HEALTH RESOURCES AND SERVICES

ADMINISTRATION (HRSA)
The U.S. Health Resources and Services Administration (HRSA) is the federal agency
responsible for ensuring that people who are geographically isolated, economically
disadvantaged, or medically vulnerable are able to access quality health care. In other
words, HRSA ensures that people who live in isolated areas, such as rural Alaska
or the Pacific Islands, and people who are disabled or who have HIV/AIDS are able
to get the care that they need in a timely manner. To achieve this mission, HRSA
responsibilities range from supporting health workforce development, identifying
at-risk groups, to improving access to quality care services. HRSA also protects the
public and those who are working on behalf of the public, by monitoring organ,
bone marrow, and cord blood donation, compensating p eople who have been
harmed by vaccinations, and preventing malpractice, fraud, or abuse by health care
providers. The overall vision of the agency is to reduce health inequities and to build
healthy communities.
HRSA roles and responsibilities are managed by five bureaus and 11 offices. The
Bureau of Health Workforce (BHW) supports training and development of health
professionals through scholarships, loans, and loan repayment programs and con-
nects graduates to communities with health professional shortages. The BHW man-
ages the National Health Service Corps, NURSE Corps, Native Hawaiian Health
Scholarship Program, and other health professional scholarship and loan pro-
grams. More than 11 million people live in underserved communities and benefit
from BHW-supported health professionals (HRSA, 2017). The Bureau of Primary
Health Care (BPHC) funds 1,400 health clinics and centers delivering primary and
preventive health care services to over 24 million p eople (HRSA, 2017). The
Healthcare Systems Bureau (HSB) manages specific health programs, including
organ donation and transplantation programs, the C. W. Bill Young Cell Transplant
HEALTH RESOU RCES AND SER V I C ES AD M INIST R ATION ( H R SA ) 305
Program, Poison Control Program, 340B Drug Pricing Program, the National Vac-
cine Injury Compensation Program, the Countermeasures Injury Compensation
Program, and the National Hansen’s Disease (Leprosy) Program. Each year, HRSA’s
transplantation programs facilitate more than 33,000 organ transplants and 6,000
bone marrow and cord blood transplants (HRSA, 2017). The HIV/AIDS Bureau
(HAB) manages the Ryan White HIV/AIDS Program that provides primary medical
care and support services to more than 500,000 economically disadvantaged p eople
each year (HRSA, 2017). The Maternal and Child Health Bureau (MCHB) funds
programs, research, and clinical practices that support medical and mental health
care to women, infants, and children, promote optimal child development, and
reduce health disparities. More than 50 million women and children benefit from
MCHB programs. The Federal Office of Rural Health Policy (FORHP) provides grant
funding to support quality health services within rural communities. An estimated
57 million p eople living in isolated communities benefit from access to health cen-
ters and hospitals (HRSA, 2017). The Office of Communications manages internal
and external communications, responding to media queries, updating the HRSA
website, and creating health communications for the agency. The Office of Civil
Rights, Diversity, and Inclusion ensures fair and just distribution of HRSA grants
and funds. The Office of Federal Assistance Management monitors grant programs
to ensure honest, effective, and efficient use of funds. The Office of Global Health
(OGH) safeguards health by supporting border health programs, advancing United
Nations Sustainable Development Goals, and strengthening global health systems
to address acute and chronic diseases and conditions. The Office of Health Equity
works to reduce health disparities experienced by minority racial groups, people
with disabilities, and rural and urban communities. The Office of Legislation pro-
vides information to congressional committees preparing HRSA-related legislative
proposals. The Office of Operations manages the finances, h uman, and material
resources of HRSA bureaus and offices. The Office of Planning, Analysis, and Eval-
uation (OPAE) prioritizes issues and initiatives, analyzes public policies related to
health care financing and regulation, supports evaluation and research of HRSA
programs, and manages quality improvement. The Office of Regional Operations
(ORO) provides regional outreach and technical assistance to support local, state,
and federal partnerships. The Office of W omen’s Health (OWH) supports
health-related policies, programs, and outreach and education for women and
girls who are geographically isolated and economically or medically vulnerable.
OWH focuses on three priority areas: preventive services, violence prevention,
and trauma-informed care.
HRSA services support health professional training, public health clinics, spe-
cialized programs, such as the Poison Control Center, and rural hospitals and ensure
that millions of p
eople who are disadvantaged by finances, geography, or medical
condition are able to obtain needed medical care.
Sally Kuykendall
306 H E A LTH Y P
E OPLE 2020
See also: Centers for Disease Control and Prevention; C

hildren’s Health; Commu-
nity Health Centers; Cutter Incident, The; Food and Drug Administration; Mater-
nal Health; U.S. Department of Agriculture; U.S. Department of Health and H uman
Services
Further Reading
Health Resources and Services Administration (HRSA). (2017). HRSA Agency overview.
Retrieved from https://www.hrsa.gov/about/budget/hrsabudgetoverview-2017.pdf.
HEALTHY P EOPLE 2020

When the U.S. Public Health Services released Healthy People: The Surgeon General’s
Report on Health Promotion and Disease Prevention in 1979, the report was the first
of its kind to identify goals for the health of the nation. Previous government reports
focused on the number of people who died and the leading causes of death. Healthy
People looked forward, toward preventing illness and injuries. Healthy People (1979)
was followed by Promoting Health/Preventing Disease (1980). This second report iden-
tified 226 health objectives to be achieved within 10 years. Identifying, naming,
and disseminating goals and objectives proved to be a valuable tool. Healthy People
defined direction for the resources and efforts of government organizations, non-
profit agencies, businesses, workers, health professionals, and communities. The
goals and objectives brought diverse groups together to collaborate t oward a com-
mon goal. The tradition of developing and reporting 10-year goals continued with
Healthy People 2000, Healthy People 2010, and Healthy People 2020 published by the
Office of Disease Prevention and Health Promotion (ODPHP). Although the objec-
tives change with advancements in science and medicine, evolving health behav
iors and emerging diseases, the overall vision of increasing quality of life and length
of life remain unchanged. The nation is making progress t oward Healthy People goals.
Over the past decade, the number of c hildren who received vaccinations according
to schedule increased 54 percent, adults who were physically active increased
13 percent, homicides decreased 13 percent, and children exposed to secondhand
smoke decreased 20 percent (Office of Disease Prevention and Health Promotion,
2017). Healthy People continues to influence public policy, education, and commu-
nity efforts in increasing years of potential life and improving quality of life in the
United States.
Over the past c entury, life expectancy in the United States increased dramati-
cally. In 1900, the average life expectancy was 47 years (National Center for Health
Statistics, 2016). Many people died from the communicable diseases, pneumonia,
influenza, tuberculosis, and diarrhea. Discoveries in public health, microbiology,
virology, and medicine improved sanitation, created immunizations, and eliminated
many infectious diseases. By 2014, the average life expectancy was 79 years (NCHS,
2016). However, the advantages w ere not equally dispersed. Men have lower life
expectancy (76 years) than females (81 years), and people with dark skin color have
H EA LTH Y P
EO P L E 2020 307
lower life expectancy (76 years) than people with light skin color (79 years). Aver-
age life expectancy for black men is 73 years, 8 years less than white women who
have a life expectancy of 81 years (NCHS, 2016). Healthy People sets the goal of
increasing life expectancy for all people with a special focus on disadvantaged pop-
ulations. In addition to reducing health disparities related to ethnicity and gender,
Healthy People seeks to reduce health disparities based on sexual identity, disability
status, and geographic location.
Each health objective listed in Healthy People is grouped by health indicator or
health topic. For example, under the health topic of heart disease and stroke (HDS),
the second objective (HDS-2) is to “reduce coronary heart disease deaths.”
Objectives are expressed clearly and concisely. The targeted change is quantified
by incidence, prevalence, or mortality rate. For example, coronary heart disease
(CHD) accounted for 129.2 deaths per 100,000 p eople in the baseline years of
2007–2009. The ODPHP selects a reasonable target that is achievable within the
10-year period. In the case of CHD, the nation seeks to reduce deaths by 20 percent
(2 percent per year). Therefore, the aim is to reduce CHD mortality to 103.4 deaths
per 100,000 people. Healthy People outlines ways to achieve the various objectives.
CHD may be reduced by increasing the number of adults who can recognize and
respond to the early warning signs of heart attack, increasing the number of adults
who can perform cardiopulmonary resuscitation (CPR) in the community, increas-
ing the number of people who receive electrical shock within the first six minutes of
a heart attack, and increasing the number of heart attack victims who receive artery-
opening treatment. By outlining secondary objectives, Healthy People suggests prac-
tical areas for collaboration by community groups, nonprofit organizations, local
emergency response associations, and individuals.
Funding for the goals of Healthy People presents a challenge. Although U.S. citi-
zens enjoy some of the best medical care in the world, other countries enjoy better
quality and length of life at a lower cost. Health care accounts for 17.1 percent of
the U.S. gross domestic product (GDP). The average U.S. citizen spends $9,403
per year on health care. People in Sweden spend $6,808 per person and have a life
expectancy of 82 years. P eople in Canada spend $5,292 per person and have a
life expectancy of 82 years. Denmark has the same life expectancy as the United
States but spends $6,463 per person and consistently ranks as the happiest coun-
try on earth. So, while the United States spends more on health care than many other
countries, the nation does not have the best value for the money. The United States
ranks 42nd in life expectancy, between the Virgin Islands at 41 and the Turks
and Caicos Islands at 43 (CIA, 2016). Achieving Healthy People goals w ill require
a reevaluation of how health care dollars are spent.
The scientific, medical, and public health advancements of the 20th century sub-
stantially increased life expectancy and changed the focus of public health from
reducing deaths to preventing illnesses and injury. Healthy People establishes a road-
map for the nation and calls on individuals, community groups, businesses,
and state and local governments to collaborate in disease prevention and health
308 HEALTHY PLA C ES
promotion. The Healthy People reports are now recognized as one of the most
important public health documents in the nation, providing direction and focus.
Sally Kuykendall
See also: Goals and Objectives; Health Care Disparities; Health Disparities; School
Health; Violence
Further Reading
Central Intelligence Agency. (2016). Country comparison: Life expectancy at birth. The world
fact book. Retrieved from https://www.cia.gov/library/publications/the-world-factbook
/rankorder/2102rank.html.
National Center for Health Statistics (NCHS). (2016). Health, United States, 2015: With spe-
cial feature on racial and ethnic health disparities. Hyattsville, MD. Retrieved from https://
www.cdc.gov/nchs/data/hus/hus15.pdf#053.
World Bank Group. (2017). Health expenditures per capita (current US$). Retrieved from http://
data.worldbank.org/indicator/SH.XPD.PCAP?end=2
014&start=1
995&view=c hart&year
_high_desc=true.
HEALTHY PLACES
The homes, buildings, and neighborhoods where people live, learn, work, and play
control health and wellness. Physical, mental, and spiritual health are enhanced by
walking, bicycling, and communing in nature. When isolated, sporadic develop-
ments replace farms, woods, parks, and other recreational areas, physical activity
decreases and reliance on motor vehicles increases. A lack of safe places to exercise
and play increases risk of obesity, hypertension, diabetes, asthma, pedestrian inju-
ries, and some cancers. Increased motor vehicle traffic causes air, land, and water
pollution and creates global warming. The inability to walk in one’s neighborhood
and regularly interact with neighbors undermines social integrity, leaving individu-
als feeling isolated and powerless. Urban sprawl can be minimized and reversed by
thoughtful planning. The Centers for Disease Control and Prevention’s (CDC) Built
Environment and Health Initiative (Healthy Places) is a resource for local township
officials and community members to assist in designing and planning communities
that support and enhance health. Creating safe spaces for physical activity yields a
valuable return on investment. Dr. Gotschi (2011) of the University of Zurich, Swit-
zerland, analyzed the cost benefit of one project creating bicycle paths in Portland,
Oregon. Results showed that by 2040, an investment of $138 to $605 million would
save $388 to $594 million in health care costs, $143 to $218 million in fuel, and
$7 to $12 billion in the value of statistical lives. Every dollar spent on bicycle paths
saved $1.2 to $3.8 in health care and fuel. Prevention experts calculate that design-
ing urban and suburban infrastructures for physical activity could reduce the national
HEALTHY PLAC ES 309
cost of treating the obesity-related diseases by $147 billion per year (in 2008 dol-
lars) (Finkelstein, Trogdon, Cohen, & Dietz, 2009).
Healthy Places partners with many other nonprofit, government, and business
agencies to assist with local community planning. The main public health strate-
gies are to minimize pedestrian and motor vehicle injuries, reduce global warming,
reduce air and w ater pollution, and promote physical activity, m
ental health, and
access to nutritious foods. The American Planning Association (2002) defined the
tenets of smart growth as planning, developing, or revitalizing communities in a
way that fosters a sense of uniqueness, preserves natural and cultural resources,
ensures just distribution of costs and benefits, promotes public health, honors sus-
tainability, and enhances housing, employment, and transportation in a fiscally
responsible manner. The National Park Service offers the Parks, Trails, and Health
Workbook (CDC and National Park Service, 2015). This workbook presents steps
and resources to planning trails and recreational areas:
• Community health profile
• Site assessment
• Site planning
• Park and trail system planning
• Monitoring and evaluation
The community health profile gathers data on population density, socioeconomic
status, disease prevalence, and potential partners. Potential sources of data are the
census bureau, county or local public health departments, hospitals, and other local
health agencies. The U.S. Department of Transportation provides data comparing
health and transportation within and between specific regions and states. Site assess-
ment maps existing geographic conditions, existing resources, potential hazards,
and sites of cultural or historic significance. Site planning is the more detailed plan-
ning, of planning amenities, entry and exit points, signage, w ater features, shade
protection, areas for social interaction, and security. Park and trail system planning
refers to a larger network of linked trails. As new developments are proposed, local
planners can identify ways to link existing or future parks. Monitoring and evalua-
tion help determine whether a project met the intended objectives. Tools to evaluate
successes include case studies, photo voice, regular site inspections, and a variety of
audit instruments. In addition to promoting physical activity and healthy areas to
live and recreate, Healthy Places encourages town and city planners to consider an
equal and fair share of burdens and benefits. This means that poor or minority
neighborhoods do not carry the burden of heavy traffic, sparse recreational facili-
ties, and limited educational and job opportunities while wealthy neighborhoods
enjoy taxpayer-funded, protected open spaces.
A health impact assessment (HIA) is a tool used to assist local officials in evaluat-
ing the potential health effects of a proposed policy or project. In Antwerp, Belgium,
researchers used an HIA to assess the Ringland Project, a proposal to replace the
current open air ring road with a filtered tunnel ring road. The HIA predicted that
310 HEALTHY PLA C ES
the filtered tunnel would reduce air particulate matter, PM2.5 (a measure of air pol-
lution), and save 21 lives each year out of 352,000 inhabitants. The predicted
impact on lung cancer mortality and myocardial infarctions was less than expected
with a reduction of 0.1 per 100,000 inhabitants (Van Brusselen et al., 2016). Using
an HIA empowers local township and city planners to make smart, long-range deci-
sions regarding community design and improvement. The Pew Charitable Trusts
and Robert Wood Johnson Foundation developed and offer an HIA that identifies
potential health considerations, assesses risks and benefits, provides recommenda-
tions, and facilitates reporting and project evaluation.
Urban sprawl results from unplanned or poorly planned growth. In an effort to
encourage communities to support public health, Healthy Places provides a variety
of tools, resources, and suggestions. The general suggestions for community design
or redesign are to maximize the use of the existing infrastructure, encourage the
cleanup and renovation of brownfields, urban centers, and older towns, plan for
mixed-use communities that integrate residential and business and serve p eople of
varied socioeconomic status, integrate walking paths and bicycle routes, and pre-
serve open spaces (National Center for Environmental Health, n.d.). The long-term
cost benefit of developing walkable and bicycle rideable communities are enormous
in terms of reducing disease and disability and enhancing physical, emotional, and
social health.
Sally Kuykendall
See also: Environmental Health; Obesity; Physical Activity; Social Determinants of

Health; Social Ecological Model
Further Reading
American Planning Association. (2002). APA policy guide on smart growth. Retrieved from
https://www.planning.org/policy/guides/adopted/smartgrowth.htm.
Centers for Disease Control and Prevention. (2013). Addressing obesity disparities. Retrieved
from https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health-equity/framing
-the-issue.html.
Centers for Disease Control and Prevention and National Park Service. (2015). Parks, trails,
and health workbook. Washington, DC: National Park Service. Retrieved from https://
www.nps.gov/public_health/hp/hphp/press/Parks_Trails_and_Health_Workbook
_508_Accessible_PDF.pdf.
Finkelstein, E., Trogdon, J., Cohen, J., & Dietz, W. (2009). Annual medical spending
attributable to obesity: Payer-and service-specific estimates. Health Affairs, 28(5),
W822–W831.
Gotschi, T. (2011). Costs and benefits of bicycling investments in Portland, Oregon. Jour-
nal of Physical Activity & Health, 8, S49–S58.
National Center for Environmental Health. (n.d.). Healthy community design: Fact sheet series.
Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov
/healthyplaces/factsheets/healthy_community_design_factsheet_final.pdf.
HEART DISEASE 311
The Pew Charitable Trusts. (2017). Health impact project. Retrieved from http://www.pewtrusts
.org/en/projects/health-impact-project.
Van Brusselen, D., Arrazola de Oñate, W., Maiheu, B., Vranckx, S., Lefebvre, W., Janssen, S.,
& . . . Avonts, D. (2016). Health impact assessment of a predicted air quality change by
moving traffic from an urban ring road into a tunnel: The case of Antwerp, Belgium.
Plos ONE, 11(5), 1–19. doi:10.1371/journal.pone.0154052
HEART DISEASE
Heart disease is the leading cause of death in the United States and is also the lead-
ing global cause of death. Although in the past, many p eople thought of heart dis-
ease as more of a male disease, it is the leading cause of death for both men and
women in the United States. It is also the leading cause for most racial/ethnic groups
in the United States, including African Americans, Hispanics, and whites. It is the
second leading cause of death for Asian Americans or Pacific Islanders and Ameri-
can Indians or Alaska Natives (second to cancer) (CDC, 2017a). Among the most
important risk factors for heart disease overall are high blood pressure, high LDL
cholesterol, and smoking. Almost half of Americans (49 percent) have at least one
of these three risk factors) (CDC, 2017a). In addition to these three factors, some
other lifestyle choices and related health problems also increase the probability of
the occurrence of heart disease. This includes diabetes, obesity and overweight, poor
diet, physical inactivity, and excessive alcohol use.
In some ways, it is a simplification of the complexity of heart disease to discuss
it as one term. One of the first issues in any discussion of heath disease is what do
we mean by the term and what aspects of the term are being covered in this entry.
Heart disease as a term can be used to describe a broad range of conditions that affect
the heart. Typically, diseases under the heart disease umbrella include blood vessel
diseases, such as coronary artery disease and heart rhythm problems (arrhythmias).
Sometimes people also include heart defects a person is born with (congenital
heart defects), but this entry will not cover congenital heart defects. In addition to
the question of how broadly one can interpret the term “heart disease,” another
complication is that the term is sometimes used interchangeably with the term “car-
diovascular disease.” Cardiovascular disease most typically refers to conditions
that involve narrowed or blocked blood vessels that can lead to a heart attack, chest
pain (angina), or stroke. Other heart conditions, such as those that affect a heart’s
muscle, valves, or rhythm, at times are also considered forms of heart disease. This
entry will focus on coronary artery disease, heart rhythm problems, and stroke.
Coronary Artery Disease (Blood Vessel Problems)
The most common type of heart disease in the United States is coronary artery
disease, which affects the blood flow to the heart (Kochanek, Murphy, Xu, &
Arias, 2014). Coronary artery disease is a result of plaque buildup in the arteries.
312 HEA RT DISEASE
Arteries in young people start out as smooth and elastic, but over time they can
acquire plaque on their inner walls, which can make them more rigid and nar-
rowed. Plaque can inflame the walls and raises the risk of blood clots and even heart
attacks. Plaque makes the inner walls of vessels sticky, allowing things such as
inflammatory cells, lipoproteins, and calcium to also travel in the bloodstream. As
more of these inflammatory cells join in, along with cholesterol, plaque increases,
both pushing the artery walls outward and growing inward. That makes the vessels
narrower. This process is often known as atherosclerosis, or a buildup of the fat
plaque in the arteries. As these fat deposits build up, they put too much pressure
on the artery, which restricts the blood flow in the body.
Thus, blood flow to the heart can be restricted, and the arteries can become
starved of oxygen. Over time, this plaque can even rupture, leading to a heart attack
or sudden cardiac death. Cardiac ischemia can occur when plaque and fatty m atter
narrow the inside of an artery so much that it cannot supply enough oxygen-rich
blood to the heart. Heart attacks can occur either with or without chest pain and
other symptoms.
Arrhythmias (Heart Rhythm Problems)
Heart rhythm problems (heart arrhythmias) occur when the electrical impulses that
coordinate heartbeats do not work properly. This causes the heart to beat inappro-
priately, either too fast, too slow, or irregularly. Heart arrhythmias can be relatively
harmless and merely feel like a fluttering or racing heart or more serious. Most of
those considered harmless are not treated. Some heart arrhythmias cause bother-
some and at times life-threatening signs and symptoms. T hese can be managed by
heart arrhythmia treatment to control or eliminate fast, slow, or irregular heartbeats.
Often, troublesome heart arrhythmias do not occur alone, but are e ither made worse
or in some cases even caused by a weak or damaged heart. Therefore, some of the
same preventive efforts to deal with other aspects of heart disease may also be help-
ful with heart arrhythmias. One solution to heart rhythm problems is a pacemaker,
a small device that helps the heart beat more regularly. A pacemaker uses electrical
stimulation to help control heartbeat. Generally, pacemakers are put u nder the skin
in the chest and hooked to the heart with very small wires. Some people only need
these devices for a short time, such as after a heart attack and for this there are
external devices, but other people live with these for many years.
One particular type of health rhythm problems is atrial fibrillation (AFib). This
is an irregular heartbeat where the atria beat too fast. Generally, AFib keeps the atria
and ventricles from working together normally. Typically, the heart contracts and
relaxes to a regular beat. In atrial fibrillation, the upper chambers of the heart (the
atria) beat irregularly (quiver) instead of beating effectively to move blood into
the ventricles. As a result, blood can clot in the atria, and if part of a clot breaks
free, that part could break off and enter the bloodstream and then travel to the
brain and lead to strokes. T here are medical treatments with blood thinning drugs
HEA RT DISEASE 313
that are used to treat this problem, or pacemakers can be used, depending on a
variety of clinical factors. About 15to 20 percent of people who have strokes have
this heart arrhythmia.
Stroke
A stroke occurs when there are blood supply problems to the brain, such as the
blood supply being blocked or a blood vessel within the brain rupturing. In e ither
case, the blood supply to part of the brain is interrupted or severely reduced, depriving
brain tissue of oxygen and nutrients. A stroke is a medical emergency because within
minutes, brain cells begin to die. Thus, immediate treatment is critical. Early action
can minimize the danger to the brain and some of the more serious complications of
stroke. Since the beginning of the 21st century there have been improved ways to
prevent stroke and treat strokes if detected early enough. Given this, the death rate
from stroke has been decreasing in the United States. Since 2010, the death rate from
stroke in the United States has fallen about 34 percent, and the number of stroke
deaths has dropped about 18 percent. Despite these improvements, stroke is still the
fifth leading cause of death overall in the United States. For African Americans, stroke
is the third leading cause of death. In the world, stroke is now the second leading
cause of death (American Heart Association, 2017). Stroke is a leading cause of dis-
ability and the leading cause of preventable disability in the United States.
There are three different kinds of strokes: ischemic strokes, hemorrhagic strokes,
and transient ischemic attacks (TIAs), also known as ministrokes. Ischemic strokes
are caused by a narrowing or blocking of arteries to the brain. They are the most
common type of stroke, accounting for about 85 percent of all strokes. Hemorrhagic
strokes are caused by blood vessels within or around the brain bursting or leaking.
Treatment varies by the type of stroke. Ischemic strokes can be treated with “clot-
busting” drugs such as tissue plasminogen activators (TPAs), but these drugs must
be given within 4.5 hours of the beginning of the stroke, which is one of the reasons
why rapid treatment is so critical. Hemorrhagic strokes are generally treated with
surgery to repair or block blood vessel weakness. Healthy lifestyles are one of the
most effective ways to prevent strokes. TIAs are different from the other two types
of strokes because the flow of blood to the brain is only briefly interrupted. Never-
theless, they are also medical emergencies even if the blockage of the artery is tem-
porary. They are also viewed as important warning signs for future strokes, and
about one-third of people who have a TIA w ill have a major stroke within a year if
they do not receive further treatment. It is estimated that about 10 to 15 percent of
people who have a TIA w ill have a major stroke within three months (CDC, 2017b).
See also: Air Pollution; Body Mass Index; Diabetes Mellitus; Environmental Protec-
tion Agency; Heart Truth® (Red Dress) Campaign, The; Hypertension; Leading
314 HEA RT TR UTH ® (R ED D RESS ) C A MPAI G N , THE
Health Indicators; Men’s Health; National Heart, Lung, and Blood Institute; Nutri-
tion; Physical Activity; Prevention; W
omen’s Health
Further Reading
American Heart Association. (2017). Heart disease, stroke and research statistics at-a-glance.
Retrieved from http://www.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd
/documents/downloadable/ucm_480086.pdf.
Centers for Disease Control and Prevention (CDC). (2017a). Heart disease fact sheet. Retrieved
from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm.
Centers for Disease Control and Prevention (CDC). (2017b). Stroke. Retrieved from https://
www.cdc.gov/stroke/.
Kochanek, K. D., Murphy, S. L., Xu, J., & Arias, E. (2014). Mortality in the United States,
2013. NCHS data brief, no 178. Hyattsville, MD: National Center for Health Statistics,
Centers for Disease Control and Prevention, U.S. Department of Health and H uman
Services.
HEART TRUTH ® (RED DRESS) CAMPAIGN, THE

More w omen die of heart disease each year than of stroke, chronic obstructive
pulmonary disease, Alzheimer’s disease, and diabetes, combined. Despite the high
mortality rate (one in four), heart disease was not always recognized as a disease
of women. Early investigations of cardiovascular disease focused on men who w
ere
believed to be at higher risk due to work stressors. Misperceptions and misinfor-
mation resulted in medical neglect and misdiagnosis. Meanwhile, many women suf-
fered sudden, premature, and unnecessary deaths. The Heart Truth® is a public
health program to prevent and reduce heart disease among w omen. Program objec-
tives are to:
1. Increase awareness of heart disease as the number one cause of death among
women.
2. Increase awareness of risk factors for heart disease.
3. Increase awareness of the severity of heart disease.
4. Increase perceived susceptibility to heart disease.
5. Increase the number of women who act to reduce risk factors and prevent
heart disease. (National Heart, Lung, and Blood Institute)
The campaign combines health behavior theory, specifically the health belief model,
with branding strategy from social marketing. Using the red dress logo, The Heart
Truth®/Red Dress Campaign partners with airports, schools, worksites, health care
organizations, faith-based organizations, stores, and shopping malls to hold fashion
displays and rallies with health screenings and health education programs. Within
the first four years of implementation, program developers reported an outreach
of 348 events with over a quarter of a million participants (Long, Taubenheim,
McDonough, Austin, Wayman, & Temple, 2011).
HEART T R UTH ® ( R ED D R ESS ) C A M PAIG N , THE 315
Early physicians believed that heart disease primarily affected men. In summa-
rizing an 1872 lecture by the preeminent physician Sir Richard Quain to the British
College of Physicians, the British Medical Journal reported:
Enlargement of the heart, one of the most distressing and fatal diseases, is more than
twice as frequent in males as in females, the precise proportion being 8 to 3. This
remarkable liability to enlargement of men’s hearts, as compared to those of women,
is, he [Quain] thinks, unquestionably due to the greater amount of work and anxiety
which, u nder the present dispensation, falls upon men. Ladies may take this fact to
heart, and reflect whether, in claiming the rights of women, they may not at the same
time incur the risks of men, and with them a new and unexpected form of disability.
They might do wisely to rest content for their sex, with hearts suffering, it may be,
from those tender affections which often pain, but never kill. (Influence of Sex on
Heart-Disease, 1872, p. 347)
Thus, the world’s most respected medical professionals not only supposed that
women were immune to heart disease, but they used the argument to suppress equal
rights of women. Over the next c entury, misconceptions influenced research, diag-
noses, and treatment of heart disease. W omen who complained of heart palpita-
tions or chest discomfort w ere misdiagnosed or labeled as hysterical. It was not u
ntil
several large-scale surveys identified high rates of heart disease among women that
experts started to take notice. Despite epidemiological data, public misperceptions
continued. The majority of w omen w ere unaware of heart disease risk factors and
symptoms. This means that when a woman experienced palpitations or moderate
chest discomfort, she may very likely ignore the signs and subsequently die of sud-
den cardiac arrest or she might go to the doctor or hospital only to be told that she
had indigestion or bronchitis. Doctors who believed that women were less likely to
suffer from heart disease neglected to order EKGs or cardiac enzyme tests. Without
treatment, a second, more serious heart attack was highly likely.
Beyond lack of awareness, another major obstacle to screening and prevention
was lack of time. The highest risk age group, w omen 40 to 60 years of age, com-
pose the sandwich generation, responsible for caring for aging parents while also car-
ing for c hildren and partners. Multiple demands for time, resources, and emotional
support interfere with self-care. In 2001, the National Heart, Lung, and Blood Insti-
tute partnered with Ogilvy Public Relations Worldwide to develop a national social
marketing campaign to increase public awareness of w omen and heart disease. With
a special focus on minority w omen (the highest risk group for heart disease), the
program planners undertook formative research to identify and develop a public
health program. Focus group participants preferred the name The Heart Truth®
because it was strong, clear, and simple. The play on words with the phrase “the
hard truth” was easy to remember. The w omen overwhelmingly preferred the red
dress logo. As one participant noted, “The red color of the dress catches your eye,
and the message is very clear. Heart disease doesn’t discriminate” (Wayman et al.,
2008, p. 44). Through alliances with businesses and nonprofit organizations, The
316 HEA RT TR UTH ® (R ED D RESS ) C A MPAI G N , THE
Heart Truth®/Red Dress Campaign was sent out into communities and was quickly
embraced by top designers at New York Fashion Week and America’s First Ladies.
In addition to The Heart Truth® website, the program is represented on national
wear red day (the first Friday in February), heart healthy cereal boxes, and by the
iconic red dress pins available in a s imple version from the American Heart Asso-
ciation, with dazzling Austrian crystal beads, or as a Native American buckskin tunic
from the Association of Black Cardiologists.
The program motto “Heart Disease Doesn’t Care What You Wear—It’s the #1
Killer of W
omen” was and is highly effective. The percentage of women who rec-
ognized that heart disease was the leading cause of death among w omen increased
from 30 percent in 1997 to 56 percent in 2012 (Mosca et al., 2013). Despite pro
gress, racial disparities exist where many at-risk minority w omen do not recognize
their own susceptibility to heart disease. Although 65 percent of white w
omen rec-
ognize heart disease as the leading cause of death, only 36 percent of w omen of
color recognize the problem. The Heart Truth /Red Dress Campaign is a model for
®
other public health programs. The key components of formative research, program
branding, successful campaign launch, widespread outreach, and maintaining pro-
gram integrity with partners can be applied to other public health problems.
Sally Kuykendall
See also: Body Mass Index; Diabetes Mellitus; Health Belief Model; Heart Disease;
Hypertension; Leading Health Indicators; National Heart, Lung, and Blood Insti-
tute; Nutrition; Obesity; Physical Activity; Prevention; W
omen’s Health
Further Reading
Centers for Disease Control. Heart disease fact sheet. Retrieved from https://www.cdc.gov
/dhdsp/data_statistics/fact_sheets/fs_heart_disease.h
tm.
Influence of Sex on Heart-Disease. (1872). The British Medical Journal, 1(587), 347–347.
Retrieved from http://www.jstor.org.ezproxy.sju.edu/stable/25231769.
Long, T., Taubenheim, A. M., McDonough, S., Austin, P., Wayman, J., & Temple, S. (2011).
Delivering The Heart Truth® to w omen through community education. Social Market-
ing Quarterly, 17(4), 24–40. doi:10.1080/15245004.2011.620682
Mosca, L., Albert, M. A., Hammond, G., Harvey-Berino, J., McSweeney, J., Mochari-
Greenberger, H., & . . . Bezanson, J. L. (2013). Fifteen-year trends in awareness of
heart disease in women results of a 2012 American Heart Association National Survey.
Circulation, 127(11), 1254–1263. doi:10.1161/CIR.0b013e318287cf2f
National Heart, Lung, and Blood Institute. The Heart Truth®. Retrieved from https://www
.nhlbi.nih.gov/health/educational/hearttruth/
Thomas, J. L., & Braus, P. A. (1998). Coronary artery disease in w omen. Archives of Internal
Medicine, 158(4), 333.
Wayman, J., Long, T., Ruoff, B. A., Temple, S., & Taubenheim, A. M. (2008). Creating a
women and heart disease brand: The heart truth campaign’s red dress. Social Marketing
Quarterly, 14(3), 40–57. doi:10.1080/15245000802279409
HEPATITIS 317
HEPATITIS
Hepatitis is the inflammation, swelling, and irritation of the liver. Because hepatitis
may be a severe and fatal disease, public health practitioners focus on prevention
of the disease.
The liver is an organ that is essential for life, performing almost 500 tasks in the
body (Zakim, 2003). The liver is able to achieve t hese many, many functions b ecause
it is highly vascular. Blood cells pick up nutrients and toxins from the stomach and
intestines and travel through the liver before flowing to the heart to be pumped out
to the entire body. The liver helps break down food components, process and store
nutrients, break down toxic chemicals, and helps blood to clot or fight infections
(Maton, 1993). Hepatitis can interfere with these functions by impairing the blood
flow through the liver. Left untreated, hepatitis can progress to more serious health
problems and death.
Hepatitis may be “acute” or “chronic.” Acute hepatitis is a new onset or rapid onset
of liver inflammation. Most cases of acute hepatitis resolve, or go away without treat-
ment or long-term damage to the liver. In rare cases, acute hepatitis may escalate to
severe damage or even death (Ryder & Beckingham, 2001). Chronic hepatitis is liver
inflammation that perseveres for more than six months. It can continue for many,
many years and usually lasts u ntil the factors causing the inflammation are eliminated.
Chronic hepatitis may result in serious liver damage, liver cancer, cirrhosis, and
death (Dienstag, 2012). Cirrhosis—scarring of the liver—is a serious complication.
As the liver tissue scars, the liver cells can no longer clean or process the blood.
Hepatitis affects millions of p eople around the world. It is difficult to accurately
predict how many p eople live with hepatitis because many cases go undiagnosed
and untreated. About 1 million p eople die each year from cirrhosis, and liver cancer
has become the third most common type of cancer worldwide (WHO, 2008). Some
regions of the world have higher rates of hepatitis than o thers.
There is no one, specific cause of hepatitis. Inflammation is caused by many dif
ferent f actors. Most cases of hepatitis are viral hepatitis, due to viral infections such
as mononucleosis. The most common viruses are hepatitis A virus (HAV), which
causes hepatitis A; hepatitis B virus (HBV), which c auses hepatitis B; and hepati-
tis C virus (HCV), which c auses hepatitis C. Excessive consumption of alcohol
can cause alcoholic hepatitis. Autoimmune hepatitis is a form of hepatitis that
occurs when the body attacks its own immune system, including the liver cells.
Bacterial or parasitic hepatitis are caused by bacteria and parasites, respectively.
Toxin-induced hepatitis is caused by chemicals, including some over-the-counter
and prescription medicines. Ischemic hepatitis is caused by reduced blood flow to
the liver. Other known c auses of hepatitis include excess fat in the liver (steatosis);
inherited conditions, such as diseases that allow a buildup of iron or copper in the
liver; and complications during pregnancy ( Jacobsen & Wiersma, 2010). The
major c auses of hepatitis vary from region to region and often reflect the public
health problems of the region.
318 HEPATITIS
Worldwide, HAV infects 119 million p eople and results in 34,000 deaths each year
( Jacobsen, 2010). In 2012, there w ere approximately 3,500 cases of HAV in the
United States (CDC, 2015). Typically, a person becomes infected with HAV a fter swal-
lowing viral particles. Infected p eople shed the virus in their feces. Other p eople
become infected when food, water, or surfaces are contaminated with particles of the
infected feces. This is more common in areas with poor sanitation and hygiene, but it
can happen anywhere. Concern about hepatitis A is one reason you see signs in res-
taurant restrooms reminding employees to wash their hands thoroughly before return-
ing to work. There is a vaccine for hepatitis A, and it is recommended that all babies
born in the United States receive this vaccine during infancy or early childhood.
HBV has infected more than 2 billion people worldwide, and 240 million remain
chronically infected (WHO, 2015). HBV is responsible for 500,000 deaths annu-
ally (WHO, 2008). In the United States, between 1 and 2 million people have chronic
HBV (CDC, 2015). It can be transmitted to o thers through contact with an infected
person’s bodily fluids or blood. This may happen during sexual intercourse, child-
birth, or sharing n eedles. It may also happen if instruments for health care, tattoos,
or piercing are not sterilized (CDC, 2015). It’s recommended that all newborn babies
in the United States receive the vaccine for HBV.
More than 150 million people have chronic HCV infections, and worldwide
roughly 350,000 people die from HCV-related liver damage annually (WHO, 2008).
In the United States, 3.2 million p eople have chronic HCV (CDC, 2015). HCV can
be passed to others if they come in contact with the blood or some types of bodily
fluid from an infected person. This may occur when people inject drugs, experi-
ence childbirth, or have sexual intercourse. It may also take place during health-
care procedures, tattooing, and piercing. There is no vaccine for HCV.
Because many people with hepatitis have no symptoms, it is referred to as a
“silent” condition. In fact, most p eople with hepatitis d on’t know it. They feel fine.
People may appear and feel healthy, as the liver is being damaged and while cir-
rhosis or cancer set in. If symptoms do appear, they may be mild and similar to
other illness, or they may be severe and debilitating. The symptoms of hepatitis are
generally the same, regardless of the cause. The most common symptoms include
tiredness, loss of appetite, low-grade fever, nausea and vomiting, or weight loss.
Less common symptoms are pain or bloating in the belly, dark urine and light-
colored feces, itching, or yellowing of the skin or eyes, a condition known as jaun-
dice ( Jacobsen & Wiersma, 2010).
It is important to identify hepatitis before liver damage occurs and to help pre-
vent transmission of communicable particles to others. Even if a person has no
symptoms, hepatitis may be identified through physical exams with blood tests.
Health care providers check the upper right side of the abdomen, just u nder the
ribs, for signs of liver enlargement. Blood tests look for signs of liver inflamma-
tion, poor function, or viruses. P eople who drink alcohol regularly, work with
hazardous chemicals, or take medicines known to affect the liver should be routinely
monitored for hepatitis and cirrhosis. People with exposures to viruses, bacteria,
HEPATITIS 319
and parasites known to cause hepatitis should be tested for infections. The risks of
exposure vary by type of bacteria, virus, or parasite.
The major risk factors for hepatitis include the following:
• Travel to countries where hepatitis is common
• Being born in or to parents from a country where hepatitis is common, par-
ticularly Asian and Pacific Island countries
• Having family members with hepatitis
• Consuming food or water that may be contaminated
• Engaging in unprotected sex or having multiple sexual partners
• Being a man having sex with another man
• Using drugs, particularly injecting drugs
• In the United States, being born between 1945 and 1965
• Receiving blood transfusions before 1992
• Exposure to blood or body fluids of other people who are infected, such as
sharing needles or syringes or unintentional needle sticks among health care
workers. (CDC, 2015)
If hepatitis is suspected, health care providers usually try to identify the cause, deter-
mine the amount of liver damage, and consider what treatment is most appropriate.
The first step is to screen patients through interview. To determine the cause, the
health care provider w ill ask the patient about recent travel, family history, medi
cations, exposure to chemicals, sexual practices, and drug and alcohol use. Blood
tests, laboratory, and imaging tests, like ultrasound and MRI, may be used to
determine the degree of liver damage. Treatment varies by cause and severity of the
damage. Some patients will need no treatment at all. Some patients may need to
change their diet or reduce alcohol or chemical exposure. Some patients may need
medications or procedures like dialysis or surgery to support the liver or other
organs. Some medications are available to treat infectious hepatitis. Patients with
severe liver damage may need a liver transplant. T hose with liver cancer may need
medications and surgery.
Treatment of viral hepatitis varies according to the type of virus involved. Infec-
tions may eventually go away untreated. This usually happens with hepatitis A, hepa-
titis E, and the virus that c auses mononucleosis. Hepatitis B and D infections may go
away after a few months, or stay and become chronic infections. Children are more
likely than adults to develop chronic hepatitis B and D. Medications that try to keep
the infection under control may be prescribed. Most people with hepatitis C
(80 percent) become chronically infected. Hepatitis C can be treated with medi
cations, and many p eople treated with these medicines will be cured. Treatment
works for many p eople, but some patients do die from the effects of hepatitis. Risk
of liver failure and cancer can be reduced if people are diagnosed early and get
proper care.
Prevention of hepatitis is an important public health care initiative. Hepatitis may
be prevented by avoiding or limiting alcoholic beverages; using medicines only as
320 HEPATITIS
directed; accurately reporting all current medicines, even vitamins and nutritional
supplements, to health care providers and pharmacists so that they may consider the
potential cumulative effects of on the body; wearing protective clothing and equip-
ment when working with hazardous chemicals; getting vaccinated against hepatitis
A and B; using condoms or other barriers during sexual intercourse; washing hands
before food preparation and consumption; and avoiding drug use. If someone is
already using drugs, harm-reduction actions such as using only sterile needles and
syringes may reduce the risk of hepatitis. Make sure to follow the warnings of health
officials when drinking water or eating food from areas that are contaminated with
hepatitis-causing organisms. To avoid contracting hepatitis in areas where the disease
is more common, travelers are advised to check the official safety recommendations
for that area. The Centers for Disease Control and Prevention maintains a website for
traveler information (http://wwwnc.cdc.gov/travel/page/traveler-information-center).
Amy Jessop
See also: Addictions; Alcohol; Behavioral Health; Centers for Disease Control and
Prevention; Dritz, Selma Kaderman; Global Health; Infectious Diseases; Preven-
tion; Syringe Service Programs; Vaccines; Waterborne Diseases; World Health
Organization
Further Reading
Boyer, T. D., Manns, M. P., & Sanyal, A. J. (2012). Zakim and Boyer’s hepatology: A textbook
of liver disease (6th ed.). Philadelphia: Saunders Elsevier.
Centers for Disease Control and Prevention (CDC). (2015, January 5). Surveillance for viral
hepatitis—United States, 2012. Weekly Epidemiological Record. Retrieved from http://
www.cdc.gov/hepatitis/Statistics/2012Surveillance/Commentary.htm#hepA.
Centers for Disease Control and Prevention (CDC). (2015, May 31). Hepatitis B information
for health professionals. Retrieved from http://www.cdc.gov/hepatitis/hbv/StatisticsHBV
.htm.
Centers for Disease Control and Prevention (CDC). (2015, May 31). Hepatitis C FAQ’s for
health professionals. Retrieved from http://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#
section1.
Dienstag, J. L. (2012). Harrison’s principles of internal medicine (18th ed.). New York:
McGraw-Hill.
Jacobsen, K. H., & Wiersma, S. T. (2010). Hepatitis A virus seroprevalence by age and world
region, 1990 and 2005. Vaccine, 28, 6653–6657.
Maton, A. (1993). Human biology and health. Englewood Cliffs, NJ: Prentice Hall.
Ryder, S. D., & Beckingham, I. J. (2001). Acute viral hepatitis. British Medical Journal, 322,
151–153.
World Health Organization (WHO). (2008). The global burden of disease: 2004 update.
World Health Organization Press. Retrieved from http://www.who.int/healthinfo/global
_burden_disease/GBD_report_2004update_full.pdf?ua=1.
World Health Organization (WHO). (2015, July). Hepatitis B. Retrieved from http://www
.who.int/mediacentre/factsheets/fs204/en/.
Zakim D. (2003). Hepatology: A textbook of liver disease (4th ed.). Philadelphia: Saunders.
HINTON, WILLIA M AUG USTUS 321
HINTON, WILLIAM AUGUSTUS (1883–1959)

Dr. William Augustus Hinton was a physician who specialized in microbiology
and pathology. Hinton set milestones in public health history as the first African
American to publish an American medical textbook and the first African American
professor at Harvard University. Hinton’s most important contribution to public
health was developing a convenient, inexpensive, and accurate test to detect
syphilis.
William Hinton was born in Chicago, Illinois, to Marie Clark and Augustus Hin-
ton. Both parents were former slaves. William’s father worked as a railroad porter,
a job that required long hours of service without additional pay. While William was
young, the family moved to Kansas City, Kansas. At the age of 16, he entered the
premedical program at University of Kansas and a fter two years, he transferred to
Harvard University. Harvard offered him a scholarship designed specifically to sup-
port students of color. Hinton turned the offer down so that he could apply for a
more competitive scholarship. He earned the scholarship and graduated with a
bachelor of science degree in 1905. Lacking funds to go directly to medical school,
Hinton taught at Meharry Medical College (1905–1909). Meharry was the first his-
torically black medical school in the southern states. He also taught at Agricultural
and Mechanical College in Langston, Oklahoma, and took summer courses in bac-
teriology and physiology at the University of Chicago. In Langston, Hinton met and
married Ada Hawes. In 1909, Hinton returned to Harvard to attend medical school
and graduated within three years.
Laws segregating patients and medical practitioners by the color of their skin
prohibited Dr. Hinton from interning in Boston. Instead, he volunteered as a research
assistant at the Wasserman Laboratory, a clinical laboratory of Harvard Medi-
cal School and Massachusetts General Hospital. The Wassermann Laboratory
was founded by August von Wassermann, inventor of the first blood test for syphi-
lis. Syphilis is a disease that has both plagued and perplexed mankind for centu-
ries. Syphilis is a sexually transmitted disease caused by the bacterium Treponema
pallidum. The disease follows a very unusual clinical progression. Initial symp-
toms appear 3 to 90 days after direct contact with Treponema pallidum. The primary
stage, known as Stage 1, is characterized by the eruption of one or more chancres
at the site where the bacteria entered the body (mouth, genitals, or anus). Chancres
are firm, painless ulcers. Within about three weeks, the chancre w ill disappear
without treatment. During the secondary stage, a rash develops across the body
with telltale rough, reddish brown spots on the palms of the hand or the soles of
the feet. The infected person may also experience wart-like lesions in moist areas of
the body (groin, mouth, or u nder the arms) along with signs of infection, fever, swol-
len lymph glands, sore throat, muscle aches, fatigue, and weight loss. The symp-
toms will again go away at which point the disease progresses into the latent phase.
The person may not have symptoms during the latent phase. However, the infec-
tion is still alive and the person can infect o thers. The latent phase can last for
many years. This is a problem as the person may not be aware they are infected and
322 HINTON , WILLIA M AUGUSTUS
can pass the disease on to sexual partners and unborn c hildren. Tertiary syphilis
occurs 10–30 years after first exposure. The disease attacks the nervous system, brain,
heart, liver, bones, and eyes resulting in paralysis, dementia, permanent blindness,
stroke, meningitis, aneurysm, multisystem organ failure, and death. Syphilis
transmitted to unborn infants results in miscarriage, stillbirth, or neonatal death.
The transient symptoms and differing stages of syphilis make it a challenging
disease to diagnose. Victims may be too embarrassed to seek treatment or may
think that they no longer have the disease when symptoms disappear. Official
records from the Department of Commerce (1922) report the 1915–1920 mortal-
ity rates due to syphilis as 8.6–10.4 deaths/100,000 people. However, the report
also clarifies, “The data for syphilis . . . are presented largely as a matter of record,
for it is generally recognized that certification of syphilis has been and is still so
incomplete that death rates from this cause are almost valueless” (Department of
Commerce, 1922, p. 89). The actual death rates are estimated at 16.3–19.8
deaths/100,000 population (Department of Commerce, 1922). Wassermann’s test
enabled a diagnosis of syphilis, albeit, with a high percentage of false positives.
False positives are p eople who test positive who are, in fact, negative. False posi-
tives raise questions regarding the credibility of scientists and doctors and may
lead to unnecessary treatment. Hinton’s duties included performing autopsies on
patients suspected of dying of syphilis. Supervisors were impressed by his skill
and knowledge, and he was eventually offered a part-time paid position, which
progressed to a full-time position. When the lab was transferred to the Massachu
setts Department of Public Health in 1915, Hinton was named assistant director
and later, director. In 1927, Hinton developed a s imple, quick, and highly repli-
cable test for syphilis that was 98 percent accurate and could be used for mass
public health screenings.
For the remainder of his work life, Hinton served as director of the Massachu
setts Department of Public Health Laboratory studying syphilis, tuberculosis, influ-
enza, and other venereal diseases. The laboratory was responsible for all syphilis
testing in the state of Massachusetts, a requirement for a marriage license. Hinton
partnered with John Davies to create an even more accurate test for syphilis, the
Davies-Hinton test. He also taught at Harvard University Medical School, earning
promotion to professor in 1923. Despite ground-breaking discoveries in medicine
and public health, Hinton kept a low profile. He joined professional organizations
but did not attend conferences. He feared that his research would be dismissed or
demeaned because of the color of his skin. Colleagues at Harvard aided his ano-
nymity, knowing that racism could thwart the scientific progress that Hinton had
worked so hard to achieve. In 1936, Hinton published the first medical textbook
written by an African American physician, Syphilis and Its Treatment. When awarded
the prestigious Springarn Medal from the National Advancement of Colored P eople
(NAACP) in 1939, Hinton refused to accept.
Dr. William Augustus Hinton saved thousands of lives by developing accu-
rate tests to diagnose syphilis. Throughout his lifetime, he published 21 articles in
HIPPO C R ATES 323
professional journals and served as consultant to the U.S. Public Health Service. In
1974, the Massachusetts Department of Public Health in Boston dedicated their
new clinical laboratory building in his name. To empower other scientists, Hinton
bequeathed funds for the Eisenhower Scholarship at Harvard University in memory
of his parents.
Sally Kuykendall
See also: Bousfield, Midian Othello; Health Disparities; Tuskegee Syphilis Study
Further Reading
Centers for Disease Control and Prevention. (2017). Sexually transmitted diseases: Syphilis.
Retrieved from https://www.cdc.gov/std/syphilis/default.htm.
Cobb, W. M. (1957). William Augustus Hinton, M.D., 1883–. Journal of the National Medi-
cal Association, 49(6), 427–428.
[Dedication: William Augustus Hinton]. (2007). The Journal of Blacks in Higher Education,
(58), 1. Retrieved from http://www.jstor.org.ezproxy.sju.edu/stable/25073801.
Department of Commerce. (1922). Mortality statistics 1920. Washington, DC: U.S. Govern-
ment Printing Office. Retrieved from https://www.cdc.gov/nchs/data/vsushistorical
/mortstatsh_1920.pdf.
Ferguson, J. H., & Greenfield, E. C. (1929). Value of the Hinton test in the serum diagnosis
of syphilis in comparison with the Kahn and Wassermann reactions. The British Medi-
cal Journal, 1(3558), 492–494.
Hinton, W. A. (1936). Syphilis and Its treatment. New York: Macmillan.
HIPPOCRATES (460–375 BCE)

Hippocrates II, also known as Hippocrates of Cos, was a Greek physician who lived
during the Age of Pericles, the Greek classical period. Many ancient civilizations
believed that disease and disability w ere caused by angry gods as punishment for
human transgressions. People used magic, mysticism, and sacramental rites to please
the gods into healing the sick or injured. Hippocrates argued that if disease was
based on one’s ability to please the gods, then wealthy people should have less dis-
ease than poor p eople since wealthy p
eople had more to sacrifice to the gods. How-
ever, the wealthy also suffered illness. So Hippocrates proposed that disease is
caused by biological imbalance related to the person’s diet, activity, lifestyle, or liv-
ing environment. Hippocrates traveled extensively throughout Greece and Asia
Minor, teaching student physicians to use the medical procedure of patient exami-
nation, diagnosis, prognosis, and treatment. His philosophy and approach shifted
medicine from a theurgical or supernatural practice to a scientific discipline. As phy-
sicians supplanted the gods of healing, Hippocrates recognized the potential for
abuse of power. He advised physicians to act with humanity, honesty, and integrity,
and to respect human life and the power of medicine. The Hippocratic Oath is a
vow physicians make to follow strict ethical standards. No business makes such an
324 HIPPO C R ATES
earnest promise to put the p eople whom they serve before their own needs. The
Hippocratic principles of medicine and medical ethics are the foundation of t oday’s
public health and medical practices. Hippocrates is recognized as the Father of West-
ern Medicine for his role in transforming medicine into a science and developing a
code of ethics for physician-healers.
Hippocrates was born on the Island of Cos (Kos) in the southeastern Aegean
Sea. According to legend, Hippocrates’s m other, Praxitela (also referred to as Phen-
aerete), descended from Hercules, son of Zeus. His father, Heraclides, descended
from Asclepius, god of medicine. Hippocrates’s father, grandfather (Hippocrates I),
two sons, and son-in-law w ere all physicians. Plato referred to Hippocrates as
“Hippocrates the Asclepiad of Cos.” The Asclepiad was a family of well-known
physicians. It is unclear w hether Plato was referring to a biological f amily or a pro-
fessional society, similar to a religious order.
Little is known of Hippocrates’s life. He is believed to have learned medicine by
working as an apprentice with his father, formal study at the Asklepieion of Kos,
and studying with the physician Herodicus of Selymbria. Consistent with the phi-
losophy of the time, Hippocrates subscribed to humoral theory. The physical body
consisted of four humors: black bile, yellow bile, blood, and phlegm. Diet, activity,
season, the environment, and vapors created imbalances or deficits in the humors
that caused disease or disability. Each humor was associated with a particular ele
ment: earth (black bile), fire (yellow bile), air (blood), and water (phlegm). Medi-
cal treatment aimed to restore balance with counterbalance. For example, swollen
lymph nodes indicated excessive phlegm (water). Balance was restored with hot
and drying (yellow bile/fire) treatments, such as mustard seed poultice.
Hippocrates’s writings demonstrate diagnosis and treatment of many different
types of injuries, diseases, and infections, including sepsis, epilepsy, depression,
tetanus, sciatica, and kidney disease. His approach was a balance of analytic and
holistic. The role of a physician was to support the body to allow natural healing to
occur. The Latin phrase attributed to Hippocrates, natura sanat, medicus curat
translates to “the physician treats, nature heals.” Hippocratic treatments, in order
of preference, w ere medication, surgery, and cautery. He cautioned against aggres-
sive treatments that caused harm to the patient.
With the benefit of generations of medical knowledge, Hippocrates advocated
for a formal process of medical care that consisted of examination, diagnosis, prog-
nosis, and treatment. Patient examination consisted of interviewing the patient,
learning about the patient’s diet, behavior, and living environment and performing
a physical examination. Physical examination included auscultation and listening to
the lungs and other organs. Accurate diagnosis and prognosis were equally important.
The Greeks did not have a formal system of health care. Physician-healers traveled
from town to town, treating the sick. This was a very hit-or-miss form of care because
a physician may not be in town when an epidemic struck. Over time, some towns
organized to pay a regular salary to entice a physician to stay in the area. Hence, the
HIPPO C R ATES 325
ancient Greeks started public health! To earn the privilege of a steady salary, the
physician must be both skilled and trustworthy. Skill did not mean that everyone
was healed and no one died. It was better for a physician to accurately predict
disease outcome, even if the outcome was negative, than to give false hope or
promises. Inaccurate prognosis made the physician appear incompetent, greedy, or
deceitful. Trust between physician and the community was a critical part of care.
Lying, cheating, or abuse of power not only affected the individual physician,
but it also created a stain on the profession. The Hippocratic Oath is a vow
taken by doctors to protect the sanctity of human life and to avoid causing pain,
injury, or death. The oath was not written by Hippocrates but contains the ideas
of the time.
Much of what is known about Hippocrates and classical Greek medicine is drawn
from the Hippocratic Corpus or Corpus Hippocraticum. The Hippocratic Corpus is a
collection of 72 books gathered by the Museum of Alexandria, Egypt, almost a
century a fter Hippocrates’s time. The works carry Hippocrates’s name. However,
experts believe that only the first 28 were actually written by Hippocrates. Differ-
ences in writing style and conflicting ideas suggest different authors, possibly some
of Hippocrates’s students. The topics vary greatly. For example, Epidemics presents
weather and weather-associated diseases with case examples and treatment; Dis-
eases describes health problems, symptoms, prognosis, and treatment, moving from
head to feet; and On the Physician describes how physicians should conduct them-
selves. The works believed to be written by Hippocrates include On Ancient Medi-
cine; On Airs, Waters, and Places; On Fractures; Nutriments; On the Nature of the
Child; Epidemics 1 and 3; Prognostics; On the Injuries of the Head; On the Articulations;
Aphorisms; On the Sacred Disease, and On Humors. Overall, the body of work
describes Greek medicine in simple and direct terms without technical jargon. The
treatises (written arguments) present strong support for new medical ideas or theo-
ries and convey an earnest desire to help people. What is particularly amazing is
how much the ancient Greeks knew about the body. Since dissection was taboo,
any knowledge of anatomy or physiology came from direct experiences of treating
patients with a specific injury or illness. The Hippocratic Corpus presents an amaz-
ing degree of anatomical detail and physiological accuracy. For example, the brain
is described as two halves, filled with fluid, and surrounded by the meninges.
Notes report that injury on one side of the brain may affect movement on the other
side of the body. The work even describes coup contrecoup injury—injuries caused
when the brain impacts one side of the skull and bounces back to hit the other side
of the skull. The coup injury is at the site of impact, and the contrecoup injury is
on the opposite side of the brain. The Hippocratic Corpus demonstrates how dedi-
cated early Greek physicians w ere to share their knowledge and help people who
were suffering.
When the Roman Empire rose in power, Greek philosophies were saved but given
lesser prominence. The Romans focused on the military, the government, and the
326 HO M E SA FETY
economy. They believed that the naturalistic medicine was akin to a death watch,
and Hippocratic methods fell out of favor. The image of Hippocrates carried on
through fictional literature, linking him to historical events in Kos and Greece. These
stories exaggerated his achievements and required medical historians to work dili-
gently to discern an image of the true Hippocrates. The Latin translations of Hip-
pocratic philosophy apply to public health practice today. Ne quid nimis (Nothing
in excess) can apply to the public health recommended diet of low fat, low salt,
and low concentrated carbohydrates. Primum non nocere (Firstly do no harm) is
reflected in the public health code of ethics.
Sally Kuykendall
See also: Ancient World, Public Health in the; Code of Ethics; Core Competencies
in Public Health; Ethics in Public Health and Population Health; Greco-Roman Era,
Public Health in the
Further Reading
Breitenfeld, T., Jurasic, M., & Breitenfeld, D. (2014). Hippocrates: The forefather of neurol-
ogy. Neurological Sciences, 35(9), 1349–1352. doi:10.1007/s10072-014-1869-3
Scarborough, J. (2002). Hippocrates and the Hippocratic ideal in modern medicine: A review
essay. International Journal of the Classical Tradition, 9(2), 287–297.
Suvajdžić, L., Đendić, A., Sakač, V., Čanak, G., & Dankuc, D. (2016). Hippocrates: The f ather
of modern medicine. Vojnosanitetski Pregled, 73(12), 1181–1186. doi:10.2298/
VSP150212131S
HOME SAFETY
Home safety refers to the ability to identify and address the potential dangers within
and surrounding the household that may result in injury, or in extreme cases death,
to occupants or visitors. Approximately 18,000 individuals, including 2,200 c hildren,
die from unintentional home injuries each year in the United States (Mullins, 2009;
Safe Kids Worldwide, 2016). Children and the elderly are at highest risk. Approxi-
mately 3.5 million c hildren go to the emergency department each year due to unin-
tentional injuries (Safe Kids Worldwide, 2016). Injuries are one of the leading
public health problems and easily preventable. To change public perceptions of the
problem, public health professionals refer to events that result in physical or emo-
tional harm as injuries, rather than accidents. The term “accidents” suggests that the
event was unavoidable. Intentional and unintentional injuries are avoidable if
people are equipped with safety knowledge. A variety of organizations and educa-
tional efforts focus on providing individuals with training to increase awareness of
dangers in the home. Public health education in fall prevention, poisoning, fire,
burns and scalds, gun safety, safe sleep, and carbon monoxide poisoning can miti-
gate and prevent injuries and prevent many unnecessary deaths or disability.
HO M E SA F ETY 327
Fall Prevention
Unintentional falls are the leading cause of nonfatal injuries treated in hospital emer-
gency departments and the third leading cause of injury death for all ages in the
United States (Mullins, 2009). Although falls impact people of all ages, they are the
most common in young c hildren and older adults; falls are the leading cause of
death among older adults and are the leading nonfatal injury in all age groups u nder
the age of 15. F actors such as muscle weakness, impaired vision, sensory and per-
ception issues, side effects of medications, and other medical conditions may put
older adults at an increased risk for falls. Falls in the home can be prevented with
secure stair railings, good lighting, eliminating clutter, and using age appropriate
child gates at the top and bottom of the landings. Be aware that not all child gates
are appropriate to use at the top of the stairs. Mats, decals, handrails in the tub and
shower, and anti-slip rugs may also help prevent falls. Organizations, such as the
University of Southern California (USC) Leonard Davis School of Gerontology
(http://stopfalls.org/), collaborate with service providers, individuals, families,
researchers, and educators to reduce falls among the elderly.
Poisoning
The second leading cause of home injury death is poisoning (Mullins, 2009). The
Centers for Disease Control (CDC) estimates that in the United States, 2 children
die and more than 300 o thers are treated in the emergency department as a result
of poisoning-related injuries. Unintentional poisoning is in the top 10 c auses of
death for c hildren 5 to 24 years of age in the United States (CDC, 2015). Poison
Help (https://poisonhelp.hrsa.gov/) is a resource of the Health Resources & Services
Administration (HRSA), which provides information on poisonings and connects
individuals with poison control experts in their local area.
Laundry Detergent
One form of ingested poisoning can occur when c hildren ingest laundry detergent.
Specifically, laundry detergent pods, which are single-use capsules of concentrated
detergent introduced in the United States in 2010, are quickly becoming a case for
concern. From 2013 to 2014, there was a 17 percent increase in cases reported to
poison control centers of children who ingested laundry detergent packets (CDC,
2012a). Children u nder five years of age are at high risk for digesting pod and non-
pod detergent. Laundry pods may be attractive to c hildren b ecause they resemble
candy. Digestion of detergent may result in adverse effects such as gastrointestinal
and respiratory complications, altered m ental status, and in the most serious cases,
death. Recommendations are to keep detergents out of sight and reach, teach c hildren
the dangers of toxic substances, and keep a close eye on c hildren, especially in areas
of the h
ouse where h ousehold cleaning products are stored.
328 HO M E SAFETY
Medication
Poisoning can also occur from ingestion of medication or medicines. Given frequent
use of over-the-counter medications, the potential of unintentional overdose also
increases. It is estimated that roughly 70,000 children u
nder the age of 18 visit the
emergency department annually because of unintentional medication overdoses
(CDC, 2012b). To prevent unintentional overdoses in c hildren, medications should
be stored out of reach and sight. Adults must not refer to medicine as being or tast-
ing like candy, as this may encourage children to ingest the medication. Individuals
should also be cautious about taking multiple medications at the same time, as they
may result in unplanned side effects or lethal combinations. Lastly, even if the medi
cations in your home are securely stored, be aware that guests may enter the house
with unsecure belongings. The best way to prevent unintentional medication inges-
tion is close supervision.
Fire, Burns, and Scalds
Home fires and burns are the third leading cause of accidental home injury deaths
and claim approximately 3,000 lives each year (Mullins, 2009). The American Red
Cross recommends installing smoke detectors on each floor of the residence and
testing them on an annual basis. Members of the household should know how to
and practice more than one way to escape from the house. If clothing catches on
fire, individuals should stop, drop, and roll to extinguish a fire. House fires can be
prevented through safe cooking practices such as monitoring food while it is cook-
ing, wearing clothing that w ill not catch fire (e.g., tight fitting, rolled sleeves) while
preparing food, and ensuring that grills are a safe distance from the h ouse.
According to data from the American Burn Association from 2016, approximately
486,000 burn injuries require medical treatment each year. A scald injury is an injury
that occurs when an individual comes into contact with a hot liquid or steam. The
populations at the highest risk for liquid burn injuries are children under 5, adults
over 65 years of age, and individuals with disabilities. Common house locations of
scald injury include the kitchen, dining area, and bathroom. Home safety recom-
mendations to avoid childhood scald injury are to designate “kid-free zones,” turn
pot and pan h andles toward the back of the stove and away from reach of children,
and not leave hot liquids unattended where they could be knocked over or within
reach of children. C hildren need to be supervised while they are using the micro
wave to prepare quick meals in an effort to prevent scald burns, but they should
also have limited mobility within the kitchen area where hot objects are commonly
found. Hot w ater heaters should be adjusted so that the maximum temperature of
water is 120°F, and w ater temperature should always be checked before placing a
child in the tub. The U.S. Fire Administration (USFA) works with local fire depart-
ments, the media, and researchers to prevent home fires (https://www.usfa.fema.gov
/index.html).
HO M E SA F ETY 329
Gun Safety
Suicide and homicide by firearm are the fourth and fifth leading causes of violence-
related deaths in the United States, respectively. One-third of homes with c hildren
under the age of 18 report having a firearm in the residence, and approximately
75 percent of c hildren aged 5 to 14 report knowing where these firearms are kept
(Grodzinski, 2015). The U.S. General Accounting Office estimates that approxi-
mately 31 percent of unintentional deaths caused by firearms may have been pre-
vented if gun owners used both a child-proof safety lock and a loading indicator.
Recommendations to reduce suicides and homicides in the household are to not
keep a gun in the home or to provide safe storage using a cable lock, trigger lock,
lock box, or gun safe, store the ammunition in a separate location, and disassemble
the gun when not in use. For many years, laws prohibited federally funded research
and education in firearm injury prevention. Despite the ban, several organizations,
such as the Harvard Injury Control Research Center at the T. H. Chan School of
Public Health (https://www.hsph.harvard.edu/hicrc/) and the Brady Campaign to
End Gun Violence (http://www.bradycampaign.org/about-gun-violence) worked to
understand and prevent homicides, suicides, and injuries due to firearms.
Safe Sleep
Approximately 3,500 infants die e very year from sleep-related deaths in the United
States. Sleep-related deaths can occur from sudden unexpected infant death (SUID)
and sudden infant death syndrome (SIDS). SUID is an unexpected death, whether
explained or unexplained, that occurs during infancy. Specifically, SIDS refers to
infant deaths that cannot be explained, even a fter thorough investigation. Identified
risk factors for SUID and SIDS are bed-sharing, prone sleeping, smoke exposure, and
the use of blankets and bedding in the sleep area. Although there are devices on the
market that claim to make bed-sharing safe and monitor a sleeping baby, these devices
have not been thoroughly tested or evaluated. The American Academy of Pediatrics
recommends that parents engage in the following behaviors to promote safe sleep:
place baby on back on a firm surface with a tight-fitting sheet, avoid soft bedding
(e.g., bumpers, blankets, pillows, and toys) in the crib, do not share the same sleep
surface, but do share a bedroom (for at least six months), avoid exposure to smoke,
alcohol, and drugs, and offer a pacifier. Safe to Sleep is a public health campaign
administered by the Eunice Kennedy Shriver National Institute of Child Health and
Human Development. Formerly known as the Back to Sleep program, the campaign
reminded parents, grandparents, and caregivers to place babies on their backs to
sleep. The program reduced SIDS rates by 50 percent (Trachtenberg et al., 2012).
Carbon Monoxide
Carbon monoxide (CO) is an odorless, colorless gas that may specifically impact
infants, the elderly, and individuals with breathing issues. CO is produced by
330 HO M E SAFETY
burning fuels in cars, trucks, heaters, and even fireplaces. Common symptoms
of CO poisoning are headache, dizziness, weakness, upset stomach, vomiting,
chest pain, and confusion. High levels of CO poisoning along with increased
time of exposure may result in more severe symptomatology. Approximately 400
Americans die annually from CO poisoning, and close to 25,000 have encoun-
ters that lead them to visit the emergency department, and in severe cases undergo
hospitalization (CDC, 2015). Ways to prevent CO fumes from building up in the
home include regularly servicing appliances powered by gas, coal, or oil; pur-
chasing gas equipment that has been tested by a nationally certified agency; and
making sure heating devices are approved for use inside the home and used in
properly ventilated areas. To avoid CO poisoning from an automobile, be sure
to regularly inspect your exhaust system and never run your car inside your
garage, especially if it is attached to your house. Battery-operated detectors can
be purchased to detect the amount of CO present in the home and alert the
homeowner.
For most p eople, the home is a place of safety and refuge. Unfortunately, there
are many hidden dangers in the home. Many public health professionals and
organizations work together to educate the public on home hazards and ways to
effectively improve home safety for all.
Autumn Nanassy and Rochelle Thompson
See also: Adverse Childhood Experiences; Aging; Children’s Health; Infant

Mortality; Injuries; Intervention; National Center for Injury Prevention and
Control
Further Reading
American Academy of Pediatrics. (2016, October 24). American Academy of Pediatrics
announces new safe sleep recommendations to protect against SIDS, sleep-related infant
deaths. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/pages
/american-academy-of-pediatrics-announces-new-safe-sleep-recommendations-to
-protect-against-sids.aspx.
Centers for Disease Control and Prevention (CDC). (2012a, October 19). Health hazards
associated with laundry detergent pods—United States. Morbidity and Mortality Weekly
Report. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6141a1
.htm.
Centers for Disease Control and Prevention (CDC). (2012b). The PROTECT initiative: Advanc-
ing children’s medication safety. Retrieved from https://www.cdc.gov/medicationsafety
/protect/protect_Initiative.html.
Centers for Disease Control and Prevention (CDC). (2015). Carbon monoxide poisoning.
Retrieved from https://www.cdc.gov/co/faqs.htm.
Centers for Disease Control and Prevention (CDC). (2016). Poisoning prevention. Retrieved
from https://www.cdc.gov/safechild/poisoning/index.html.
HIV AND AIDS 331
Grodzinski, A. (2015). University of Michigan Injury Center: Parents’ guide to home fire-
arm safety. Retrieved from http://yvpc.sph.umich.edu/parents-guide-home-firearm
-safety/.
Mullins, L. (2009, August 9). The top 5 causes of accidental home injury deaths—and how
to prevent them. U.S. News & World Report. Retrieved from http://money.usnews.com
/money/blogs/the-home-front/2009/08/31/the-top-5-causes-of-accidental-home
-injury-deathsand-how-to-prevent-them.
Safe Kids Worldwide. (2016). We work to prevent injuries in the home. Retrieved from https://
www.safekids.org/general-home-safety.
Trachtenberg, F. L., Haas, E. A., Kinney, H. C., Stanley, C., & Krous, H. F. (2012). Risk f actor
changes for sudden infant death syndrome after initiation of Back-to-Sleep campaign.
Pediatrics, 129, 630–638. Retrieved from http://pediatrics.aappublications.org/content
/early/2012/03/21/peds.2011-1419.abstract.
UMAN IMMUNODEFICIENCY VIRUS (HIV) AND

H
ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
Human immunodeficiency virus (HIV) infection and acquired immune deficiency
syndrome (AIDS) refer to a disease that attacks the immune system. This entry will
first present the etiology and prevalence of the disease. Next, the history of HIV/
AIDS w ill be discussed, focusing on historical trends of cultural perception of HIV
in the United States. Finally, this entry w
ill discuss the contributing factors and
determinants of HIV, concluding with evidence-based prevention methods. Biologi-
cal, social, and psychological factors play significant roles in the prevalence and
epidemic of HIV and AIDS. In the United States, 1.2 million p eople are expected to
be living with HIV (Welcome to AIDS.gov).
HIV is disease that targets the immune system in h umans, ultimately resulting
in AIDS if left untreated. HIV/AIDS is primarily spread through sexual behaviors
and needle or syringe use (Vermund, 2014). Needle sharing allows for contact of
bodily fluids that may be already infected by HIV. Bodily fluids must enter the blood-
stream for disease transmission using n eedles or syringes (Welcome to AIDS.gov).
In addition, HIV may be transmitted through sexual contact, blood, drug usage,
breastfeeding, and blood transfusions, to name a few. HIV targets cells within the
immune system and eventually leads to immunodeficiency and serious health con-
sequences. Over time, many cells die, thus rendering the body incapable of fight-
ing infections or diseases. Although HIV is treatable, it is a lifelong disease, meaning
that once someone has HIV, it becomes chronic. Approximately 12 percent of HIV-
positive individuals are unaware that they carry the disease (Welcome to AIDS.gov).
Furthermore, about one in four new HIV infections is among young p eople aged
13–24 (Welcome to AIDS.gov). From 2006 to 2009, HIV infections among 21 to
29-year-olds increased by 21 percent; this increase demonstrated how youth pop-
ulations in the United States are gradually becoming more at risk for developing
HIV (Prejean et al., 2011). Although the disease can be treatable, more than 675,000
332 HI V AND AIDS
eople have died of AIDS in the

p
United States since the 1970s
(Centers for Disease Control and
Prevention, 2016). Due to its
prevalence and death rates, HIV
is considered a serious epidemic,
which must be both treated and
prevented.
Documentation of HIV/AIDS
has existed in the United States
since the 1970s. Scientists believe
the virus came about from chim-
panzees in West Africa. It is
believed that humans obtained
the disease when coming into
contact with these chimpanzees
by means of hunting, as early as
the 1800s (CDC, 2017). Over
time, the disease spread across
Africa and eventually reached
countries all over the world. His-
torically, AIDS has been a contro-
ACT UP (AIDS Coalition to Unleash Power) protest- versial topic in public and social
ers demonstrate at Food and Drug Administration media. During Ronald Reagan’s
(FDA) headquarters to call attention to slow, tedious, presidency in the 1980s, for
and elitist clinical drug t rials. L
ater social movements example, political and govern-
model the thoughtful, creative, and highly effective mental involvement in the AIDS
strategies of early AIDS groups. (Catherine McGann/
epidemic was essentially nonex
Getty Images)
istent. As tens of thousands of
Americans developed both HIV/
AIDS during these years, there was little federal attention; and as a result, more than
30,000 Americans died of AIDS during Reagan’s presidency. Today, HIV/AIDS is
recognized as a global epidemic that must be both researched and prevented. For
example, in July 2015, the White House released a Federal Action Plan to update
the national strategy to combat HIV/AIDS. This plan included more than 170
action items intended to achieve strategy goals and prevent the spread of HIV/AIDS
(Welcome to AIDS.gov). Effective planning strategy includes understanding popu-
lations at risk, as well as making compassionate medical care and increasing social
awareness accessible to all Americans, regardless of socioeconomic status, gender,
race, or sexual orientation.
Certain social determinants explain how HIV incidence may be more prevalent
within specific social groups and demographics. Specifically, sexual orientation,
HIV AND AIDS 333
race, and socioeconomic status all impact the likelihood of developing HIV. Popu-
lations at the greatest risk for developing HIV/AIDS include members of the gay,
bisexual, and transgender communities, especially those of color. In 2011, men
who have sex with men accounted for 54 percent of all p eople living with HIV in
the United States (CDC, 2015). Therefore, it is recommended that sexually active
gay and bisexual men get tested for HIV as often as every three to six months to
prevent the spread of HIV (CDC, 2015). As for the transgender community, it was
reported that 90 percent of trans women diagnosed between 2007 and 2011 were
African American/black or Latina (CDC, 2015). Race also plays a significant role;
black and African American p eople are the greatest at-risk population for develop-
ing HIV among all racial groups. This group made up 44 percent of new HIV/AIDS
infections in 2010 (Welcome to AIDS.gov). Socioeconomic status plays an addi-
tional role; low income communities are also at a greater risk for developing the
disease. For example, studies have shown that inadequate access to housing puts
individuals at great risk for developing HIV (Aidala et al., 2016). Members of lower
socioeconomic status experience less economic and social equality, as exemplified
by both racial and housing inequality. As a result, these groups of p eople are less
likely to receive adequate education and awareness of how HIV is both caused and
prevented.
Biological factors that put p eople at risk for HIV include contact and trans-
mission of bodily fluids. Ways that HIV can spread sexually include through
semen, rectal fluid, and vaginal fluid. Among the sexual methods of transmis-
sion, anal intercourse is the highest risk sexual behavior for developing HIV/
AIDS. The second highest risk sexual behavior for transmitting HIV is vaginal
intercourse (Welcome to AIDS.gov). HIV is not spread by saliva, air, or casual
contact such as shaking hands. T hese are common misconceptions of HIV
transmission.
The interplay of biological and social factors additionally contributes to
poor mental health, which many people living with HIV develop. For example,
HIV-positive individuals are at great risk for abusing substances and develop-
ing mental disorders such as depression (Cramer, 2015). HIV-positive young
men who have sex with men, for example, demonstrate disproportionate rates of
depression compared to heterosexual HIV-positive young individuals (Salomon
et al., 2009). Depressive symptoms may be explained by the effects of experi-
encing HIV stigma. One example is stereotypes that include assumptions of
immorality about people with HIV/AIDS. For example, people with HIV are less
likely to get tested for the disease due to social misconceptions and stigma. HIV-
positive individuals may develop poor mental and physical health in efforts to
escape certain forms of prejudice. Forms of prejudice against p eople with HIV/
AIDS include social isolation or lack of comprehensive health care. In 1988, the
United States banned workplace discrimination against p eople infected with
HIV (Welcome to AIDS.gov). Public policy such as this is needed to combat
334 HI V AND AIDS
HIV/AIDS because it prevents the systematic discriminatory perpetuation of the

disease.
Despite increasing the likelihood for poor m ental and physical health
outcomes, HIV and AIDS may both be prevented. Intervention programs
that attempt to spread awareness and prevent the spread of HIV range from the
individual level to a more systematic governmental level. Condom distribution
is an example of individual-level intervention aimed at preventing the disease
from spreading. At a more systemic level, evidence-based interventions include
the most effective methods of public health strategies based on scientific liter
ature (CDC, 2015). For example, the CDC Division of HIV/AIDS prevention
plans to fund programs targeted for young men of color who have sex with men
and young transgender persons of color because these two groups are at such
high risk for HIV (CDC, 2015). Furthermore, social awareness and interven-
tion programs aimed at high-risk communities are needed to help prevent the
spread of HIV. One benefit of the Internet is accessibility to information that
may prevent the spread of HIV. Studies show that the use of technology as a pre-
vention method may be useful; prevention interventions on the Internet include
enhancing HIV testing, increasing the likelihood to seek treatment, and aware-
ness of how HIV can be spread (Rietmeijer & Shamos, 2007). Testing for
HIV is also considered a form of HIV prevention as it additionally decreases
the chances of developing AIDS if the disease is diagnosed in time. Regular test-
ing for HIV may also benefit high-risk populations b ecause their primary care
provider can supply useful information about how HIV can be both treated and
prevented.
Studies suggest that an additional effective method of preventing the spread of
HIV is treatment itself (Vermund, 2014). Those receiving treatment for HIV can
expect to live a normal life span; however, if untreated, p eople living with AIDS
have a life expectancy of about three years. Treatment for HIV is called antiretrovi-
ral therapy (ART), which includes taking daily medicines, also known as an HIV
regimen. If taken correctly and daily, ART can slow or prevent the disease from pro-
gressing to the next stage. Benefits of ART include reduction of HIV in the blood,
reduction of HIV-related illness, and reduction of spreading the disease to others
(CDC, 2015). Currently, there are 31 antiretroviral drugs approved by the Food
and Drug Administration designed to treat HIV infection (National Institute of
Allergy and Infectious Diseases, 2015).
Resilience factors should also be taken into account when examining causes and
consequences of HIV/AIDS. For example, HIV-positive people who have v iable
sources of support are more likely to overcome the negative effects of HIV stigma,
and may, in turn, develop positive mental health and well-being. Moreover, both
HIV/AIDS-positive individuals and high-risk populations such as gay and bisexual
men who develop resilience may be more likely to seek treatment or develop phys-
ical, emotional, and functional well-being (Fang et al., 2015). Individuals living with
HI V AND AIDS 335
HIV/AIDS therefore have the ability to live normal, healthy lives despite social stigma
and prejudice.
Caitlin Monahan and Nadav Antebi-Gruszka
See also: Affordable Care Act; Care, Access to; Community Health Centers; Dritz,
Selma Kaderman; Epidemic; Global Health; Lesbian, Gay, Bisexual, and Transgen-
der Health; National Institutes of Health; Substance Abuse and Mental Health
Services Administration; Syringe Service Programs
Further Reading
Aidala, A. A., Wilson, M. G., Shubert, V., Gogolishvili, D., Globerman, J., Rueda, S., &
Rourke, S. B. (2016). Housing status, medical care, and health outcomes among people
living with HIV/AIDS: A systematic review. American Journal of Public Health, 106(1).
Centers for Disease Control and Prevention. (2016). HIV surveillance report, 2015 (Vol. 27).
Retrieved from https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-survei
llance-report-2015-vol-2
7.pdf.
Centers for Disease Control and Prevention. (2017). HIV/AIDS. Retrieved from https://www
.cdc.gov/hiv/.
Cramer, R. J., Colbourn, S. L., Gemberling, T. M., Graham, J., & Stroud, C. H. (2015).
Substance-related coping, HIV-related factors, and mental health among an HIV-positive
sexual minority community sample. AIDS Care, 27(9), 1063–1068.
Fang, X., Vincent, W., Calabrese, S. K., Heckman, T. G., Sikkema, K. J., Humphries, D. L., &
Hansen, N. B. (2015). Resilience, stress, and life quality in older adults living with
HIV/AIDS. Aging & Mental Health, 19(11), 1015–1021.
Fumaz, C. R., Ayestaran, A., Perez-Alvarez, N., Muñoz-Moreno, J. A., Moltó, J., Ferrer, M. J., &
Clotet, B. (2015). Resilience, ageing, and quality of life in long-term diagnosed HIV-
infected patients. AIDS Care, 27(11), 1396–1403.
HIV/AIDS. (2015, July). Retrieved January from http://www.mayoclinic.org/diseases
-conditions/hiv-aids/basics/definition/con-20013732.
National Institute of Allergy and Infectious Diseases. (2015, December 23). Retrieved Janu-
ary 6, 2016, from https://www.niaid.nih.gov/topics/hivaids/Pages/Default.aspx.
Prejean, J., Song, R., Hernandez, A., Ziebell, R., Green, T., Walker, F., & Lansky, A. (2011).
Estimated HIV incidence in the United States, 2006–2009. PLoS One, 6, e17502.
Rietmeijer, C. A., & Shamos, S. J. (2007). HIV and sexually transmitted infection preven-
tion online: Current state and future prospects. Sexual Research and Social Policy, 4,
65–73.
Salomon, E. A., Mimiaga, M. J., Husnik, M. J., Welles, S. L., Manseau, M. W., Montenegro, B., &
Mayer, K. H. (2009). Depressive symptoms, utilization of m ental health care, substance
use and sexual risk among young men who have sex with men in EXPLORE: Implica-
tions for age-specific interventions. AIDS and Behavior, 13, 811–821.
U.S. Department of Health and Services. (2015, December 7). Centers for Disease Control
and Prevention. Retrieved December 30, 2015, from http://www.cdc.gov/hiv/.
Vermund, S. H. (2014). Global HIV epidemiology: A guide for strategies in prevention and
care. Current HIV/AIDS Reports, 11(2), 93–98. Retrieved January 13, 2016.
336 HUMAN TRA F FICKIN
Walensky, R. P., Auerbach, J. D., Office of Aids Research Advisory Council, Carpenter, C. J.,
Auerbach, J. D., Agosto-Rosario, M., . . . Walensky, R. P. (2014). Focusing National
Institutes of Health HIV/AIDS Research for Maximum Population Impact. Clinical Infec-
tious Diseases, 60(6), 937–940.
Welcome to AIDS.g ov. (n.d.). Retrieved December 9, 2015, from https://www.aids.gov/.
H UMAN TRAFFICKING
Human trafficking is a form of slavery where individuals are forced to perform l abor
or sexual acts against their w ill. The Trafficking Victims Protection Act defines sex
trafficking of c hildren as “the recruitment, harboring, transportation, provision, or
obtaining of a person for the purpose of a commercial sex act, in which the com-
mercial sex act is induced by force, fraud, or coercion or in which the person induced
to perform such act has not attained 18 years of age” (U.S. Department of State,
2014). Labor trafficking is defined as “the recruitment, harboring, transportation,
provision, or obtaining of a person for l abor or services, through the use of force,
fraud, or coercion for the purpose of subjection to involuntary servitude, peon-
age, debt bondage, or slavery” (U.S. Department of State, 2014). Both types of
trafficking happen at the global, national, and local levels. Victims may be brought
from other countries into the United States, exported from the United States to
other countries, transported to different locations within the United States, or
kept in close vicinity to where they w ere initially trafficked. H
uman trafficking is
a serious human rights violation. Public health clinicians work to identify victims
during diagnostic health screenings, provide education and resources for victims,
reduce the demand for h uman trafficking, empower survivors to engage in preven-
tion and intervention activities, and change cultural norms that promote abusive
relationships.
Because h
uman trafficking is a heinous crime, it is hard to get clear statistics on
the exact number of victims. Across the globe, an estimated 2 million children are
exploited by sex traffickers (UNICEF, 2005). Nationally, an estimated 105,000
children are victims of sex trafficking (Estes & Weiner, 2002, as cited in Clayton,
Krugman, & Simon, 2013). The average age of “turning out” or entry into sex traf-
ficking is 12 to 14 years old for females and 11 to 13 years old for males (Estes &
Weiner, 2001). C hildren who are victims of sex traffickers may age into adult sex
work. However, the health issues of sex trafficked victims, violence, substance abuse,
and sexually transmitted diseases significantly reduce life span. The majority of vic-
tims (98 percent) are w omen and girls (ILO, 2005). Youth who identify as lesbian,
gay, bisexual, transgender/transsexual, queer (LGBTQ) are five times more likely to
be trafficked than heterosexual youth (USDHHS, 2013). Seventy to 90 percent of
sex trafficked youth have a history of child sexual abuse (AYCF, 2013). L ittle is
known about sex trafficked males b ecause many victims either do not self-identify
as victims or do not seek help due to shame, stigma, lack of screening, limited out-
reach, and limited resources (AYCF, 2013).
HUMAN TRAF FICKIN 337
Internationally, 15.4 million adults and 5.5 million c hildren are victims of labor
trafficking (ILO, 2012). Labor traffickers disproportionately target foreign nationals
(Family and Youth Services Bureau, 2016). The majority of labor trafficked foreign
nationals are legal immigrants. However, by the time they escape victimiza-
tion, 69 percent are undocumented or have expired documentation (Bañuelos et al.,
2014). In the United States, two-thirds of all victims are male (Bañuelos et al., 2014).
Further research on incidence, prevalence, and risk f actors for trafficking can help to
prevent and reduce the problem.
Traffickers may be a relative, friend, intimate partner, neighbor, or stranger (Smith
et al., 2009). The perpetrator targets vulnerable individuals, p eople who are home-
less, abusing substances, rejected by family, socially isolated, or experiencing inti-
mate partner violence or economic hardship. To gain control, the trafficker targets
the person’s vulnerabilities, using physical or psychological needs to manipulate
the intended victim (Smith et al., 2009). Victims are lured by charisma, flattery,
unctuousness, promises, threats, or intimidation (Estes & Weiner, 2001). Once
the trafficker controls the relationship, the victim is isolated from potential social
supports. The victim’s sense of self-worth and autonomy are commandeered
by the abuser (Smith et al., 2009). Control is maintained by mental, physical, or
sexual abuse.
Although trafficking victims can be hard to identify b ecause they represent dif
ferent genders, sexual orientations, citizenships, or socioeconomic statuses, health
screenings provide one opportunity for identification and intervention. Victims of
labor and sex trafficking suffer from many negative health outcomes and may appear
at health clinics or emergency rooms for treatment. Physically, victims suffer from
traumatic brain injury, broken bones, fractures, strangulation, bruising, and other
trauma due to physical abuse by the traffickers or patrons. Victims of sex traffick-
ing are traumatized by sexual abuse. They may present with sexually transmitted
diseases, pelvic pain, rectal trauma, or urinary difficulty (Ark of Hope for Children,
2016). Psychologically, victims experience depression, anxiety, and shame. Psycho-
somatic disorders can arise, such as stomachache, headache, or backache. Sex traf-
ficking victims in particular may move into addiction. Addictions stem from the
abuser drugging the victim or from the victim using drugs as a form of self-medication
to cope with the abuse. In e ither case, addiction compounds other health prob
lems. Sex trafficked youth have difficulty achieving key developmental tasks (devel-
oping independence and trusting relationships) needed to transition into adulthood
(Clayton et al., 2013). If sex trafficking victims reach adulthood, they have a high
mortality rate. W omen who have been trafficked for sex have mortality rates almost
200 times greater than their demographic counterparts (Shively et al., 2012). The
most common causes of death in sex trafficked victims include, in order of frequency:
homicide, suicide, drug and alcohol-related problems, HIV infection, and uninten-
tional injuries (Shively et al., 2012).
The League of Nations, which convened a fter World War I, was the first interna-
tional organization of nations to address h
uman trafficking. In 1921, The International
338 HUMAN TRA F FICKIN
Convention for the Suppression of Traffic in W

omen and C hildren was signed by 33 coun-
tries. However, this legislation only covered trafficking for the purposes of sex-
ual exploitation and prostitution. In 1949, after the League of Nations
transitioned into the United Nations (UN), the UN created the first legally bind-
ing international agreement on human trafficking, titled The United Nations Con-
vention for the Suppression of the Traffic in Persons and of the Exploitation of the
Prostitution of O thers. As of 2015, only 66 nations ratified the agreement. Inter-
national law and the laws of 134 countries criminalize sex trafficking (Equality
Now, 2016). In the United States, the use of c hildren in commercial sex trade is
prohibited by law and statute (U.S. Department of State, 2014). In 2007, Polaris
created the National Human Trafficking Resource Center (NHTRC) as a clearing
house and hotline for victims and survivors of trafficking (NHTRC, 2016).
When a call is placed to the hotline at 1-888-373-7888, the caller is directed to
resources and assistance in their local area. In addition, NHTRC and Polaris
compile statistical data from their callers, providing insight into the scope of the
problem. This national resource, along with local resources across the country,
is a first step in helping victims and survivors leave the violence.
Current approaches to human trafficking focus on arrest and criminal prosecu-
tion of traffickers and victim support. T here is the need and potential to expand
efforts, using the framework of public health. Knowing risk and protective factors
for victimization can identify at-risk youth and adults and suggest prevention strat-
egies. Education of health care workers in early diagnosis, screening, and interven-
tion can intercept and connect victims with available resources. Listening and
empowering survivors can help identify best practices in anti-trafficking interven-
tion and prevention. Human trafficking can only exist in cultures with deep-rooted
feelings of entitlement, hierarchy, privilege, and inequity. The most effective way to
stop this slavery is by addressing the social dynamics that enable perpetrators to
feel entitled to take and abuse the lives of other men, women, and children.
Julia Hanes and Maria DiGiorgio McColgan
See also: C
hildren’s Health; Immigrant Health; Violence; W
omen’s Health
Further Reading
Ark of Hope for Children. (2016). Child trafficking statistics: U.S. and international. Retrieved
from http://arkofhopeforchildren.org/child-trafficking/child-trafficking-statistics.
Bañuelos, I., Breaux, J., Bright, K., Dank, M., Farrell, A., Heitsmith, R., McDevitt, J., Owens, C.,
& Pfeffer, R. (2014). Understanding the organization, operation, and victimization process
of labor trafficking in the United States. Washington, DC: Urban Institute/Northeastern
University.
Clayton, E. W., Krugman, R. D., & Simon, P. (Eds.). (2013). Confronting commercial sexual
exploitation and sex trafficking of minors in the United States. Washington, DC: National
Academies Press.
HYPERTENSION ( HTN ) 339
Equality Now. (2016). Global sex trafficking fact sheet. Retrieved from http://www.equalitynow
.org/traffickingFAQ.
Estes, R., & Weiner, N. (2001). The commercial sexual exploitation of children in the U.S., Can-
ada, and Mexico. Philadelphia: University of Pennsylvania.
Family and Youth Services Bureau. (2016). Identification of domestic labor trafficking.
Webinar.
International Labour Office (ILO). (2005). Minimum estimate of forced labour in the world.
Geneva: ILO.
International Labour Office (ILO). (2012). ILO global estimate of forced labour: Results and
methodology. Geneva: Special Action Programme to Combat Forced L abour (SAP-FL).
National H uman Trafficking Resource Center (NHTRC). (2016). Mission. Retrieved from
https://traffickingresourcecenter.org/mission.
Shively, M., Kilorys, K., Wheeler, K, & Hunt, D. (2012). A national overview of prostitu-
tion and sex trafficking demand reduction efforts. Washington, DC: National Institute of
Justice.
Smith, L., Vardaman, S., & Snow, M. (2009). The national report on domestic minor sex traf-
ficking: America’s prostituted children. Vancouver, WA: Shared Hope International.
UNICEF. (2005). Children out of sight, out of mind, out of reach: Abused and neglected, millions
of children have become virtually invisible. New York: Brodock Press.
U.S. Department of Health and Human Services, Administration for Children, Youth, and
Families. (2013). Guidance to states and services on addressing h uman trafficking of c hildren
and youth in the United States. Retrieved from http://www.acf.hhs.gov/programs/cb
/resource/human-trafficking-guidance.
U.S . Department of State. (2014). What is trafficking in persons? Fact sheet. Retrieved from at
https://www.state.gov/j/tip/rls/fs/2014/233732.htm.
HYPERTENSION (HTN)
Hypertension (HTN) is a medical condition where the pressure exerted by blood
against the arterial walls is higher than normal and, if left untreated, w
ill cause major
organ damage. High blood pressure harms the arterial walls causing serious dam-
age to the delicate arterioles that feed the kidneys, heart, eyes, and brain. The dam-
aged surfaces attract low density lipoproteins (LDL), known as bad cholesterol. Over
time, a thick, hard deposit builds up to create partial or complete blockage. The
consequences of HTN are heart attack, stroke, heart failure, vision loss, sexual dys-
function, and kidney disease. Certain conditions, such as diabetes, aggravate the
onset and seriousness of HTN. In the United States, one out of three adults has
HTN. The disease has few warning signs, which means many people do not realize
that they have high blood pressure. Fortunately, the condition is highly prevent-
able. Public health efforts focus on patient education, early detection and treatment,
creating healthy communities, building collaborative partnerships, and supporting
research, policies, and programs to prevent heart disease.
Blood pressure consists of two numbers: systolic and diastolic. Systolic pressure is
the maximum force against the walls of the arteries, the pressure created when the
heart contracts and pumps blood into the arteries. Diastolic pressure is the resting
340 HYPE RTENSION (HTN)
pressure, the force against the walls of the arteries when the heart is filling with blood,
preparing for the next contraction. Both systolic and diastolic pressures are measured
in millimeter of mercury (mmHg), the standard unit of pressure in scientific disci-
plines. Blood pressure varies with circadian rhythm, activity, emotion, and hydration
but typically stays within a range of 15 mmHg throughout the day. In 2014, the National
Heart, Lung and Blood Institute (NHLBI) convened a panel of medical experts to
review and update the clinical guidelines for diagnosis and treatment of HTN ( James
et al., 2014). Physicians use clinical guidelines to determine need and type of treat-
ment. According to national guidelines, normal blood pressure is defined as a systolic
pressure of less than 120 mmHg and a diastolic pressure of less than 80 mmHg.
Prehypertension, an indication that someone is bordering on hypertension, is a systolic
pressure of 120 to 139 mmHg or diastolic pressure of 80 to 89 mmHg. HTN Stage 1
is a systolic pressure of 140 to 159 mmHg or diastolic pressure of 90 to 99 mmHg.
HTN Stage 2 (severe HTN) is a systolic pressure of 160 mmHg or higher or diastolic
pressure of 100 mmHg or higher. Treatment is based on the overall health status of
the individual and any comorbidity. Hypertensive crisis is a systolic pressure higher
than 180 mmHg or a diastolic pressure higher than 110 mmHg. Hypertensive crisis
is a medical emergency. The patient needs immediate medical treatment to allay
stroke, heart attack, or other irreversible organ damage.
An estimated 75 million people in the United States have high blood pressure.
Major risk factors are related to lifestyle, aging, heredity, and stress. An unhealthy
diet, physical inactivity, excessive body weight, tobacco use, and alcohol abuse increase
risk of HTN. Diets high in saturated fat and sugar act directly and indirectly. Obesity
and atherosclerosis force the heart to work harder and increase vascular resistance
through atherosclerosis. As people age, the blood vessels lose elasticity. Arterioscle-
rosis builds and c auses a further narrowing of the arteries. Men are at higher risk
until age 45 a fter which risk levels due to gender equalize. A fter age 64, women are
at higher risk. Race is also a critical factor. More than 40 percent of African Ameri-
cans are hypertensive, and the condition tends to have earlier onset and greater
severity among certain minority populations. Racial differences may be related to
salt sensitivity. Salt sensitivity is a genetic trait that c auses the individual to retain
sodium in the body. Scientists believe salt sensitivity evolved as a mechanism for
survival (Campese, 1997). Populations that suffered periods of famine, such as Afri-
cans, Pima Indians, Asian Indians, Micronesians, and Polynesians developed physi-
ological mechanisms to store sodium and calories. Today, the gene is not necessary
due to changes in food availability. However, the physiological mechanism has not
changed, and mechanisms that once protected and helped with survival now
increase risk for HTN, diabetes, and obesity. P eople with salt sensitivity respond to
salt intake with abnormally high blood pressure increases. Stress increases blood
pressure by triggering the fight or flight reaction of the sympathetic nervous system.
When p eople use tobacco or alcohol to self-medicate stressors, these may also
increase blood pressure. Tobacco causes vasoconstriction, temporarily increasing
blood pressure, and both tobacco and alcohol increase risk of atherosclerosis.
HYPERTENSION ( HTN ) 341
Public health clinics address HTN through early detection, patient education,
evidence-based treatments, and prevention. Blood pressure is routinely measured
and assessed at every health care visit. Patients who meet the criteria for treatment
are prescribed antihypertensive or other medications according to the recommended
guidelines. Antihypertensive medication reduces the risk of organ damage. Unfor-
tunately, many p eople do not take their blood pressure medicine due to cost or
undesirable side effects. Helping patients to know what the systolic and diastolic
pressures mean and discussing obstacles to treatment can help improve medication
compliance and to achieve adequate blood pressure control. The economic cost of
medical treatment is high. In 2011–2012, hypertension-related hospitalizations,
health care, medication, and lost productivity totaled $48.6 billion per year (Mozaf-
farian et al., 2016). When the costs of heart disease and stroke are included in the
overall cost, direct and indirect costs total $316.6 billion per year.
Preventing HTN could potentially save billions of dollars each year and save
countless lives. Risk factors, such as diet, exercise, and lifestyle, are easily modifi-
able. To control or prevent HTN, experts recommend the following:
• the DASH (dietary approaches to stop hypertension) eating plan: a low-sodium,
low-fat diet high in fresh fruits and vegetables,
• maintaining a healthy weight: maintaining a healthy body mass index (18.5
to 24.9 for adults),
• physical activity: two hours and thirty minutes of moderate-intensity aerobic
activity each week plus muscle-strengthening activities on two days of each
week,
• no tobacco,
• no alcohol or alcohol in moderation, and
• healthy stress management practices.
The recommendations support normotensive blood pressure by reducing the
buildup of cholesterol and reducing demand on the heart. These recommendations
have the added benefit of reducing risk of other chronic and acute health condi-
tions, such as cancer, chronic obstructive pulmonary disease (COPD), diabetes, heart
disease, and stroke.
Cardiovascular diseases (CVD) are the leading cause of death in the United
States. There is a lot that individuals can do to reduce their risk of CVD, and
numerous government and nonprofit organizations are working to reduce or pre-
vent the problem. The American Heart Association offers brochures, newsletters,
fact sheets, and other educational materials for patients and health care providers.
The website features recipes that adhere to the DASH eating plan as well as a sup-
port network for those recovering from the devastating effects of CVD and caregiv-
ers who support them. The NHLBI is an institute of the National Institute of Health
(NIH) with the mission of promoting the prevention and treatment of heart,
lung, and blood diseases through research and education. In addition to advanc-
ing the science of heart, lung, and blood diseases, the NHLBI works with patients,
342 HYPE RTENSION (HTN)
families, advocacy, and community groups to translate the latest research findings
into practice. The American Society of Hypertension (ASH) is a professional net-
work of physicians, researchers, pharmacists, and health care professionals work-
ing in the diagnosis, treatment, and prevention of HTN and HTN-related diseases.
Future efforts seek to increase self-monitoring of blood pressure, reduce the high
costs of treatment, and support obesity prevention programs.
Hypertension is a chronic health problem that can cause irreversible organ dam-
age. Over time, the condition can lead to heart attack, stroke, aneurysm, or kidney
failure. Treatment is available, but many p
eople with high blood pressure have dif-
ficulty controlling the disorder. Fortunately, many cases are preventable through
individual, systems, and population-based approaches. Individuals can reduce risk
by following the DASH eating plan, getting the recommended amount of exercise,
and abstention from smoking and excess alcohol. Health care systems can reduce
the prevalence of HTN by offering regular screening and encouraging patients and
providers to engage in healthy behaviors. Population-based approaches use poli-
cies or target schools, workplaces, and communities for environmental and behav-
ioral changes. Comprehensive approaches to HTN offer promise in reducing the
cost of the disease and reducing complications.
Sally Kuykendall
See also: Body Mass Index; Health Disparities; Healthy Places; Heart Disease; National
Heart, Lung, and Blood Institute; Nutrition; Obesity; Physical Activity
Further Reading
American Heart Association. (2017). High blood pressure. Retrieved from http://www.heart
.o rg /H EARTORG /C onditions/H ighBloodPressure/H igh -B lood -P ressure_U CM
_002020_SubHomePage.jsp.
American Society of Hypertension. (2017). Retrieved from http://www.ash-us.org/.
Campese, V. M. (1997). Why is salt-sensitive hypertension so common in blacks? Nephrol-
ogy, Dialysis, Transplantation: Official Publication of the European Dialysis and Transplant
Association—European Renal Association, 12(3), 399–403.
Centers for Disease Control and Prevention. (2014). High blood pressure. Retrieved from
https://www.cdc.gov/bloodpressure/.
James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J.,
& . . . Ortiz, E. (2014). 2014 Evidence-based guideline for the management of high
blood pressure in adults: Report from the panel members appointed to the Eighth Joint
National Committee ( JNC 8). Journal of the American Medical Association, 311(5), 507–
520. doi:10.1001/jama.2013.284427
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., & . . .
Turner, M. B. (2016). Heart disease and stroke statistics—2016 update: A report from
the American Heart Association. Circulation, 133(4), e38– e360. doi:10.1161/
CIR.0000000000000350
National Heart, Lung, and Blood Institute. (2017). Retrieved from https://www.nhlbi.nih
.gov/.
I
IMMIGRANT HEALTH
According to the Department of Homeland Security (DHS), immigrants, refugees,
and migrants to the United States make up a significant portion of the American
public. This population is composed of 13.2 million legal permanent residents, 11.4
million unauthorized immigrants, and 1.7 million nonresident visitors (U.S. Depart-
ment of Homeland Security, 2016). Health concerns among t hese groups vary due
to the large number of countries that refugees and immigrants originate from. In
order to improve and maintain the health of immigrants, refugees, migrant workers,
and Americans that immigrant p eople come in contact with on a daily basis, the
Centers for Disease Control and Prevention (CDC) provides guidelines for screen-
ing, intervention, and services for immigrants and refugees (Centers for Disease
Control and Prevention, 2017). Additionally, the CDC tracks, reports, and responds
to communicable diseases within these populations. Refugees and immigrants
applying for a visa are required to have a medical examination prior to admission.
Immigration officers and overseas consular officers have the power to require that
temporary visitors have medical examinations if there is suspicion of a health-related
condition (Centers for Disease Control and Prevention, 2017). Some diseases, such
as cholera, diphtheria, infectious tuberculosis, viral hemorrhagic fever, and influ-
enza warrant quarantine. Cases of polio, plague, severe acute respiratory syndrome,
smallpox, yellow fever, and pandemic flu are reported as a public health emergency
of international concern.
The United States is a nation of immigrants. The first humans inhabited North
America approximately 13,000 years ago when nomadic hunter-gatherers migrated
from Siberia to Alaska and later to the Pacific Northwest, Canada, and South Amer
ica. Population migration allows pathogens that are endemic to one area to be car-
ried to new groups of susceptible hosts. Depending on the severity of the pathogenic
strain and the vulnerability of the new population, the disease could have serious
repercussions. Spanish explorers brought smallpox to the New World. European
immigrants brought the bubonic plague, cholera, diphtheria, scarlet fever, small-
pox, typhoid, typhus, tuberculosis, and sexually transmitted diseases. Likewise, trav-
elers can carry pathogens back to the place of origin. Some scholars propose that
syphilis was first present in the new world and introduced to Europe by Colum-
bus’s crew. In colonial America, early efforts to control the transmission of com-
municable diseases w ere haphazard, regulated by state or local governments. In
1647, Boston passed an ordinance requiring all arriving ships to stop at the harbor
entrance for inspection. In 1663, New York City passed a law requiring people
344 I M M IG R ANT HEALTH
arriving from areas with smallpox to be reviewed by sanitary officials before enter-
ing the city. Seventy-five years later, New York City established a quarantine station
at Bedloe’s Island. The station isolated immigrants, travelers, and sailors who may
be carrying smallpox or yellow fever.
Today, immigration health is regulated under the Division of Global Migra-
tion and Quarantine, part of the Centers for Disease Control and Prevention’s
National Center for Emerging and Zoonotic Infectious Diseases. Immigration
personnel review the origin of each traveler to assess health risk and determine
the appropriate response. Although these measures help to ensure that the
health of legal permanent residents and visitors is serviced, many barriers exist
for unauthorized immigrants to attain health services in the United States (Wal-
lace et al., 2013). The majority of people in the United States with health care
have access to their plans through their employers. Many unauthorized immi-
grants work in industries that do not provide health insurance. Unauthorized
immigrants are not eligible for public health insurance. They may therefore be
required to wait until their conditions have worsened to attain care at emergency
rooms, made possible by the Emergency Medical Treatment and Active Labor Act
(Caplan & Bateman-House, 2017). Fear of deportation by Immigration and
Customs Enforcement may prevent unauthorized immigrants from seeking
care. Health care facilities requiring proof of income or residence prior to treat-
ment may also prevent unauthorized immigrants from receiving the care they
need. Language is another barrier. Many unauthorized immigrants do not speak
English as a primary language, hampering communication between patients and
their public health providers (Portes & Fernández-Kelly, 2012). In order to mini-
mize the obstacles to medical treatment and encourage personal responsibility for
health, some cities have adopted sanctuary policies. Sanctuary cities are towns
and cities that limit reporting of undocumented immigrants in order to encour-
age illegal immigrants to report crimes and to use health, social, and educational
services.
The Centers for Disease Control and Prevention promotes immigrant, refugee,
and migrant health by providing guidelines for disease screening and treatment,
tracking and reporting communicable diseases, offering leadership, expertise, and
care during public health emergencies, and by partnering with immigrant and ref-
ugee groups to enhance health among migrant people.
Matthew Black
See also: Affordable Care Act; Association of State and Territorial Health Officials;
Baker, Sara Josephine; Epidemic; Global Health; Hamilton, Alice; Human Traf-
ficking; Indian Health Service; Infectious Diseases; Quarantine; Sanger, Margaret
Louise Higgins; U.S. Department of Agriculture; World Health Organization; Con-
troversies in Public Health: Controversy 5
INDIAN HEALTH SER VI C E ( IHS ) 345
Further Reading
Biswas, D., Toebes, B., Hjern, A., Ascher, H., & Norredam, M. (2012). Access to health care
for undocumented migrants from a h uman rights perspective: A comparative study of
Denmark, Sweden, and the Netherlands. Health and H uman Rights, 14(2), 49.
Caplan, A. L., & Bateman-House, A. (2017, July). “Alien” health care. American Journal of
Public Health, 1029–1030. doi:10.2105/AJPH.2017.303850
Centers for Disease Control and Prevention. (2017). Immigrant and refugee health. Retrieved
from https://www.cdc.gov/immigrantrefugeehealth/index.html.
Edward, J. (2014). Undocumented immigrants and access to health care: Making a case for
policy reform. Policy, Politics, & Nursing Practice, 15(1–2), 5–14. doi:10.1177/1527
154414532694
Portes, A., Fernández-Kelly, P., & Light, D. (2012). Life on the edge: Immigrants confront
the American health system. Ethnic & Racial Studies, 35(1), 3–22. doi:10.1080/01419
870.2011.594173
U.S. Department of Homeland Security. (2016). Population estimates. Retrieved from https://
www.dhs.gov/immigration-statistics/population-estimates.
Wallace, S. P., Rodriguez, M., Padilla-Frausto, I., Arredondo, A., & Orozco, E. (2013).
Improving access to health care for undocumented immigrants in the United States.
Salud Pública De México, 55, S508–S514.
INDIAN HEALTH SERVICE (IHS)

In 1787, the U.S. federal government recognized the inherent rights of the first
people of North America by granting unique legal status. Article I, Section 8 of the
Constitution mandates that Native American tribes are domestic dependent nations
with parallel sovereignty within the federal government. This means that the fed-
eral government has a duty to protect Native American and Alaskan Native people
and indigenous tribes have the power of self-determination. Federal, state, or local
governments have no authority over tribal land or tribal m atters. This unusual proc-
lamation was made in an attempt to amalgamate the many formal treaties between
the U.S. government and Native American tribes. B ecause the Native Americans
suffered from numerous communicable diseases, treaties for Native American land,
supplies, and services often included the provision of medical care. The Indian
Health Service (IHS) is an agency within the U.S. Department of Health and Human
Services (DHHS) responsible for fulfilling the nation’s obligation to provide com-
munity health services and primary health care to 2.2 million indigenous Ameri-
cans from 567 tribes. The mission of IHS is to ensure access to culturally competent,
quality health care. Participation in IHS programs does not exclude individuals from
participating in other federally supported health care programs.
The first h
umans inhabited North America approximately 13,000 years ago.
Anthropologists believe that nomadic hunter-gatherers migrated from Siberia
to Alaska and later trekked to the Pacific Northwest, Canada, and South America.
Ancient North America civilizations created their own communities, architecture,
art, and culture. DNA analysis of ancient h uman skeletons matches the DNA of
346 INDIAN HEALTH SERVICE (IHS)
living Native American p eople. In the late 1700s, Europeans discovered the new
world. Without regard for the current inhabitants, Spanish and English explorers
claimed the land and resources as their own. Native American tribes w ere massa-
cred, forced into slavery, and exposed to infectious diseases for which they had no
natural immunity. European immigrants transmitted the bubonic plague, cholera,
diphtheria, scarlet fever, smallpox, typhoid, typhus, tuberculosis, and sexually
transmitted diseases to vulnerable populations. Catholic priests enslaved natives
to build missions along the California coast. Death by malnutrition, suicide, and
homicide were common among the forced laborers. Given the rate of disease and
violence suffered by the indigenous people, peace and land treaties often included
some promise of protection from harm or provision of health services. In some
regions, military physicians provided care to the p eople of neighboring tribes.
Maintaining the health of indigenous p eople reduced communicable diseases and
protected early settlers. In 1832, Congress allocated $12,000 for smallpox vaccina-
tion of Native Americans. Four years l ater, the federal government started a formal
health service program for members of the Ottawa and Chippewa tribes.
As European immigrants moved westward, they v iolated treaties and encroached
on land owned and inhabited by the first p eople. In 1828, the state of Georgia
attempted to seize Cherokee tribal land. The case of the Cherokee Nation v. Georgia
went to the Supreme Court. The Court ruled that the Cherokee Nation was a sover-
eign nation and the state of Georgia had no authority over Cherokee land. Chief
Justice John Marshall compared the relationship between tribes and the federal
government as that of a legal guardian relationship. The federal government is
legally obligated to act as a guardian to Native American tribes. Despite the rul-
ing, President Andrew Jackson and Martin Van Buren ordered the aggressive removal
of Cherokee people. The Trail of Tears was a forced march of people from Cherokee,
Choctaw, Muskogee, and Seminole tribes from the southeastern states to west of the
Mississippi River. An estimated 2,000 to 6,000 Native American p eople died of com-
municable diseases, exposure to the elements, starvation, or violence suffered during
the forced march.
In 1849, responsibility for Indian health was transferred from the War Depart-
ment to the Department of the Interior. In 1867, the U.S. government purchased
the Alaskan territory, expanding U.S. territory to include land inhabited by p eople
of Inuit and Alaskan Native culture. In 1911, the federal government established a
separate funding line for Native American health services. Despite the government’s
legal obligation to Native Americans and Alaskan Natives, indigenous p eople were
not officially recognized as citizens. This means that they were not eligible for the
same rights and privileges as other citizens. Exclusionary attitudes started to change
with World War I when Cherokee and Choctaw code talkers were instrumental in
transmitting classified military information. The Snyder Act of 1921 granted offi-
cial U.S. citizenship to Native Americans who served in World War I. The act also
highlighted the dire health needs of the Indian population by defining federal obli-
gations for the “relief of distress and conservation of health of Indians” (IHS, 2005).
INDIAN HEALTH SER VI C E ( IHS ) 347
Dr. Lillie Rosa Minoka-Hill examines June Marie House in her kitchen clinic while Loretta
House and Roger Dunks watch, 1947. Dr. Hill tended to members of the Oneida Nation of
Wisconsin for almost 50 years. Dr. Hill’s a dopted name was Yo-da-gent, meaning “she who
serves.” (MPI/Getty Images)
The Hoover Commission (1947) was developed to recommend ways for the fed-
eral government to increase efficiency and decrease expenditures. The commission
recommended eliminating duplicate government services, including services to
Native Americans, and introduced the concept of forced termination. Forced termi-
nation involved repealing laws that differentiated Native Americans from other citi-
zens, relocating native p eople from reservations to cities, assimilating Native
Americans and Alaskan Natives into the larger population, dismantling the Bureau
of Indian Affairs, and transferring any remaining Indian health or social programs
to state governments. The legislature failed to pass. However, supporters developed
other ways to achieve forced termination. The Transfer Act of 1955 established the
Indian Health Service (IHS) as part of the U.S. Public Health Service (USPHS) within
the Department of Health and Human Services. The USPHS offered central-
ized health services with care by white European American health care profes-
sionals. The combination of a paternalistic health care system and majority-culture
professionals meant that caregivers could not or did not understand or respect
differences between Native American medicine and Western medicine or between
the medical practices of various tribes. Forced termination did not work. The con-
cept deepened distrust among Native Americans and increased dependence on the
federal government.
348 INDIAN HEALTH SE RV I C E ( IHS )
The civil rights movement of the 1960s empowered Native American/Alaskan

Native (NA/AN) people. President Richard M. Nixon opposed the concept of forced
termination. He believed that Indian health and social services were a “solemn
obligation” forged by historic legal agreements (Kunitz, 1996). The Nixon admin-
istration passed the Indian Self-Determination and Education Assistance Act (1975)
and the Indian Health Care Improvement Act of 1976. These laws empowered
tribes to take control of their own health and social service programs and led to the
creation of community health boards, hiring of Native American/Alaskan Native
(NA/AN) professionals and paraprofessionals and culturally competent, decen-
tralized services. Today, the Indian Health Service is a self-governed program
which respects that tribal leaders and tribal members are in the best position to
determine, direct, and administer health care needs. The system works through
collaborative partnerships that assess health issues, the types of care needed, ser
vice delivery, and evidence-based care (IHS, 2005). The system is not perfect. It is
extremely underfunded. Congress currently allocates $3,000 per person to IHS, sig-
nificantly less than the budgeted $5,000 per person to prison inmates and $12,000
per person to Medicare beneficiaries (Davidson, 2017). This disparity raises ques-
tions of covert racism or care rationing.
The living history of North America’s indigenous people presents unique health
and social needs. Native Americans and Alaskan Natives started as nomadic hunter-
gatherers who developed thriving settlements and cultures. European invasion
brought infectious diseases, war, slavery, and oppression that almost decimated
Native Americans. The people who survived represent ancient cultures dating back
thousands of years and are one of the nation’s most precious resources. The federal
government, state governments, and descendants of European immigrants have a
moral obligation to reconcile the actions of forefathers and preserve the unique cul-
ture of each tribe. IHS works to support and promote the biological, psychological,
social, environmental, and spiritual health and well-being of indigenous p eople.
Yet, their services are severely restricted by underfunding. Centuries of adversity
and disease created populations with dire health needs that will require intensive,
specialized resources to survive.
Sally Kuykendall
See also: Addictions; Cornely, Paul Bertau; Epidemic; Health Care Disparities; Health
Disparities; Health Resources and Services Administration; Maternal Health; Small-
pox; Spiritual Health; U.S. Department of Agriculture
Further Reading
Davidson, J. (2017). Staffing, budget shortages put Indian Health Service at “high risk.”
Washington Post. Retrieved from https://www.washingtonpost.com/news/powerpost/wp
/2017/02/20/staffing-budget-shortages-put-indian-health-service-at-high-risk/?utm
_term=.eaf628947972.
INFANT M O RTALITY 349
Indian Health Services (IHS). (2005). The first 50 years of the Indian Health Service: Caring
and curing. IHS Gold Book Part 1, Department of Health and Human Services. Retrieved
from https://www.ihs.gov/newsroom/factsheets/.
Kunitz, S. J. (1996). The history and politics of US health care policy for American Indians
and Alaskan Natives. American Journal of Public Health, 86(10), 1464–1473.
INFANT MORTALITY
Infant mortality is the death of a baby within the first 12 months of birth. In the
United States, an estimated 23,000 infants die each year (Centers for Disease Con-
trol and Prevention [CDC], 2016b). Data from vital statistics, birth, and death rec
ords are used to calculate infant mortality rate (IMR), the number of infant deaths
per 1,000 live births. IMR is a standardized number serving as an important health
indicator of h uman and social development. Public health professionals use the data
to compare groups, communities, and nations in order to identify health needs.
Monaco and Japan have the lowest IMRs at 1.8 and 2.0, respectively (Central Intel-
ligence Agency [CIA], n.d.). IMR in the United States is 5.8 deaths per 1,000 live
births. Most developing countries of Africa and Asia have higher IMRs. Infants in
Afghanistan fare the poorest with an IMR of 112.8. The leading c auses of infant
death are birth defects, preterm birth, injuries, malnutrition, diarrhea, birth com-
plications, infectious diseases, measles, and malaria (O’Brien, Usher, & Maughan
1966). Threats to infant health vary by geographic region, race, age, environmental
conditions, and mother’s level of education, socioeconomic status, and lifestyle.
Quality prenatal services, medical care, good nutrition, immunizations, and home
safety can prevent many of t hese untimely deaths.
Infant mortality is categorized as neonatal mortality and postneonatal mortality.
Neonatal mortality is the death of a live-born baby within the first 28 days after
delivery. Early neonatal mortality is death of a live-born baby within the first 7 days
after delivery. Neonatal mortality rate (NMR) is the number of deaths of live-born
babies within 28 days a fter delivery per 1,000 live births. NMR is used to assess
prenatal, intrapartum, and neonatal care. Postneonatal mortality is the death of a baby
from 29 days a fter birth to 12 months (364 days). Postneonatal mortality rate (PNMR
or PMR) is the death of a live-born baby aged 28 days to less than 12 months (364
days) per 1,000 live births.
The major factors associated with neonatal mortality are congenital malforma-
tions, asphyxia and birth trauma, low birth weight, short gestation, and poor prena-
tal care. F
actors associated with postneonatal mortality include maternal complications
during pregnancy and delivery, sudden infant death syndrome (SIDS), infectious
disease, premature births, unintentional birth injuries, congenital malformations,
and malnutrition.
Every four and a half minutes in the United States, an infant is born with
birth defects (CDC, 2016a). A defect may be mild or severe, structural or physi-
ological, visible or invisible. Also referred to as congenital disorders, congenital
350 IN FANT M ORTALITY
abnormalities, congenital deformations, or congenital malformations, many

defects develop during the first three months of pregnancy. This is a time when
major organs form, and yet the woman may not realize she is pregnant. The causes
of birth defects are often multifactorial, a combination of genetics, environment,
paternal, and maternal health. Known risk factors include tobacco, alcohol, illicit
drugs, acne medication, exposure to radioactive environment, sexually transmitted
diseases (STDs), prenatal nutrition, and preexisting health conditions of the mother,
such as obesity or diabetes. Alcohol and drug abuse significantly increases the risk
of fetal deformation and birth complications. Environmental hazards include expo-
sure to radioactive environment such as mines, chemicals, waste sites, and pesti-
cides. Common nutritional causes are folate or iodine deficiency. In low and middle
income countries, gonorrhea, rubella, hepatitis B virus (HBV), human immunodefi-
ciency virus (HIV), and syphilis cause many congenital anomalies and infant death.
In some countries, low birth weight and short gestation birth account for up to
80 percent of infant mortalities (Andrews, Brouillette, & Brouillette, 2008; Stanley,
Huber, Laditka, & Racine, 2016). In the United States, 8 percent of live births are
low birth weight (CDC, 2016b). Low birth weight is defined as weighing less than
2,500 grams (5 pounds 8 ounces) at birth. Below 2,500 grams, the infant has dif-
ficulty with breathing, drinking, and fighting infections. At 1,000 grams (2.2 lb) or
less, the infant struggles to survive the neonatal period. Low birth weight is typi-
cally associated with short gestation, less than 37 weeks. Causal f actors include alco-
hol or drug use, poor nutrition, teenage pregnancy, poor prenatal care, maternal
sickness, and multiple pregnancies.
Sudden unexpected infant death (SUID) or sudden infant death syndrome
(SIDS) is the third leading cause of infant mortality in the United States (CDC,
2016c). SIDS is the unexpected, sudden death of a healthy infant aged less than 12
months. Over 1,500 such deaths occur each year in the United States. Ninety p ercent
occur within the first six months of birth. SIDS is unexplainable. There are no known
natural or physical c auses or medical explanations. Medical examiners, forensic
pathologists, autopsy and death scene investigators attribute SIDS to environmental
stressors, accidental suffocation or strangulation in bedding materials, poor housing
ventilation, poor sleeping position, or exposure to secondhand smoke. Genetic dis-
order, respiratory infections, premature birth, hypothermia, hyperthermia, neglect,
low birth weight, and birth defects are also attributed as possible c auses of SIDS.
Maternal complications are health problems experienced by the mother during
pregnancy or a fter delivery. Maternal complications are associated with high infant
mortality. Maternal complications may be due to previous illness, chronic disease,
or disability, inadequate prenatal care, gestational diabetes, or placental abruption.
Complications during delivery include mother to infant transmission of blood-borne
infections or virus, asphyxia, birth trauma, or injury.
Infant mortality and IMR reflect the social, economic, and environmental devel-
opment of a country. In 2015, the World Health Assembly (WHA) updated stra-
tegic plans to reduce infant and maternal mortality. “The Global Strategy sets out
IN FANT M ORTALITY 351
to ensure every w oman, child and adolescent, in any setting, anywhere in the
world, is able to survive and thrive by 2020” (World Health Organization [WHO]
& UNICEF, 2017, p. 4). The global milestones include:
1. Establishing systems to gather accurate IMR data.

2. National policies and plans for quality health services.
3. Research and development in maternal and infant care.
4. Experts to champion the cause of maternal and infant health and welfare.
Many stillbirths of poor families are not recorded by birth or death certificate. Accu-
rate data on births, deaths, and c auses help identify areas for public health interven-
tions. The WHA recommends that e very country establish national policies and plans
to provide quality health services to mothers and newborns. The WHO Quality of
Care Framework defines quality services as following evidence-based practices in
maternal and infant care, ensuring functional referral to other systems, offer-
ing clear and competent patient-provider communication, adhering to profes-
sional ethics of practice, offering emotional support, recruiting and retaining
competent health care staff, and ensuring access to essential physical resources.
Future research should focus on effective, innovative practices with special atten-
tion to stillbirth prevention. Pediatric champions are doctors, nurses, public health,
or other medical professionals who commit to sharing best practices with col-
leagues and advocating for w omen and children who are not in a position to
advocate for themselves.
Prevention and reduction of infant mortality are important health indices used
to guide and formulate public health policies of maternal and infant care. Oppor-
tunities to improving maternal and infant care aim at increasing accessibility to
prenatal, neonatal, and postneonatal care; addressing social determinants of health
care coverage; educating expecting mothers on nutrition and lifestyle; promot-
ing healthy postpartum behaviors; smoking and alcohol cessation; and breast
feeding to provide nutrients and protection from infection during the critical first
year of life.
Godyson Orji
See also: Baker, Sara Josephine; Birth Defects; C

hildren’s Health; Dunham, Ethel
Collins; Ellertson, Charlotte Ehrengard; F
amily Planning; Health Care Disparities;
Maternal Health; Measles; Polio; Sanger, Margaret Louise Higgins; Wegman, Myron
Ezra; World Health Organization
Further Reading
Andrews, K. M., Brouillette, D. B., & Brouillette, R. T. (2008). Mortality, infant. Ipswich,
MA: Elsevier, Inc. Gale Virtual Reference Library.
Centers for Disease Control and Prevention. (2016a). Birth defects. Retrieved from https://
www.cdc.gov/ncbddd/birthdefects/facts.html.
352 IN FECTIOUS DISEASES
Centers for Disease Control and Prevention. (2016b, January 12). Infant mortality. Retrieved
from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm.
Centers for Disease Control and Prevention. (2016c, June 8). Sudden unexpected infant death
and sudden infant death syndrome. Retrieved from https://www.cdc.gov/sids/.
Centers for Disease Control and Prevention. (2017). Infant mortality. Retrieved from https://
www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm.
Central Intelligence Agency. (n.d.). Country comparison: Infant mortality rate. World FactBook.
Retrieved from https://www.cia.gov/library/publications/the-world-factbook/rankorder
/2091rank.html.
Healthy Newborn Network. Retrieved from http://www.healthynewbornnetwork.org/.
O’Brien, J. R., Usher, R. H., & Maughan, G. B. (1966). Causes of birth asphyxia and trauma.
Canadian Medical Association Journal, 94(21), 1077. Retrieved from http://www.ncbi.nlm
.nih.gov/pmc/articles/PMC1935461/.
Stanley, W. A., Huber, L. R. B., Laditka, S. B., & Racine, E. F. (2016). Association of type of
birth attendant and place of delivery on infant mortality in sub-Saharan Africa. African
Health Sciences, 16(1), 1–9. doi:10.4314/ahs.v16i1.1
WHO & UNICEF. (2017). Reaching the every newborn national 2020 milestones: Country pro
gress, plans and moving forward. Geneva: World Health Organization. Retrieved from
http://apps.who.int/iris/bitstream/10665/255719/1/9789241512619-eng.pdf?ua=1
.
INFECTIOUS DISEASES
Infectious diseases are illnesses caused by viruses, bacteria, or other pathogens,
transmitted to a h uman host through w ater, food, rodents, insects, air, direct phys-
ical contact, or body fluids. The infectious diseases—cholera, smallpox, meningitis,
influenza, and sexually transmitted diseases—were the scourge of ancient civiliza-
tions. Until the early 1900s, the average life span was 47 years, 33 years for African
Americans (National Center for Health Statistics, 2011). The top three leading
causes of death w ere pneumonia/influenza, tuberculosis, and diarrhea. Advance-
ments in sanitation, microbiology, antibiotics, and vaccinations significantly affected
health, increasing life span to 78 years (74 years for African Americans). Pneumo-
nia/influenza dropped to eighth place as a leading cause of death. Despite progress
against communicable diseases, ongoing vigilance is necessary. Infectious diseases
are still the leading cause of death in many areas throughout the world, and patho-
gens are living organisms, capable of creative mutations involving drug resistance,
mode of transmission, and lethality. Public health professionals are constantly sur-
veilling for emerging and reemerging infectious diseases and working to control
outbreaks throughout the world.
Infectious diseases have been the bane of humanity since early civilization. In
1346–1353, the bacterium Yersinia pestis killed an estimated 100 million p eople in
the plague known as the Black Death. The caduceus, the medical symbol of two
snakes wrapped around a pole, is an altered image of early treatment for guinea
worm disease (GWD). The disease is contracted by ingesting water contaminated
with the GWD nematode. The infected host remains asymptomatic for about a
year after which time the mature female guinea worm blisters through the skin to
INF E C TIOUS DISEASES 353
discharge her larvae in w ater sources. Emergence is slow and painful, and efforts
to pull the worm out more quickly can damage nerves or blood vessels. Forced
removal could also break the nematode into pieces, leaving parts within the body
to decay (putrefy) or harden (petrify). Ancient healers treated GWD by wrapping
the emerging worm around a small stick, about the size of a matchstick. As the
worm emerged, the stick was turned, successfully removing the intact organism.
The symbol of a single serpent wrapped around a staff is the Rod of Asclepius,
which was the original symbol of medicine and health care. The caduceus features
two snakes around a pole with wings at the top of the pole. Both symbols indicate
the significance of infectious diseases throughout history and ingenious methods
devised by ancient healers to prevent or reduce the spread of such diseases.
Prior to the discovery of bacteria, p eople believed that infectious diseases were
due to miasma, poisonous odors in the air. Soon after Dutch trader Anton van Leeu-
wenhoek refined glass lenses so that he could examine the delicate weave of linen,
he turned his attention to nature. Through the microscope, van Leeuwenhoek and
other scientists were able to view previously unknown organisms, and the fields of
microbiology, epidemiology, and infection control were created. Today, many systems
are in place to protect us from infectious diseases. Sanitation workers ensure that food
in restaurants is properly stored and prepared, public health laboratories test for
harmful microorganisms, and health prac ti
tioners administer vaccinations to
guard against deadly childhood diseases. Yet, emerging and reemerging infectious
diseases remain a threat to h uman existence. Infectious diseases commonly occur
with deforestation, population movement, globalization, and overcrowding. Defor-
estation displaces animals and insects from their natural habitat. As the animals
move to new areas, they bring organisms capable of causing disease. Population
movement creates the same dynamic. Diseases that are endemic to a particular
population move into new, unprotected populations. Globalization and overcrowd-
ing create interactions where formerly isolation may have prevented the spread of
disease. World health officials are vigilant for catastrophic events, mass immigra-
tion, or global changes that could create new epidemics or pandemics.
The chain of infection, also known as the chain of transmission, is a schematic
diagram showing how infections are passed to h umans. The chain of infection is
visualized as six links: pathogen, reservoir, portal of exit, mode of transmission,
portal of entry, and susceptible host. The first link is the pathogen. Although many
microorganisms are benign and fulfill important functions in nature, bacteria,
fungi, viruses, helminths, protozoa, rickettsia, and prions can also cause disease.
Pathogens are found in habitats that support their survival. Such habitats are
known as reservoirs. In the case of GWD, the pathogen is dracunculiasis medinensis,
and the reservoir is the h uman body that carries the nematode for over 12 months,
providing nourishment for the larvae to mature (Office of Public Health Scientific
Services, Center for Surveillance, Epidemiology, and Laboratory Services, and
Division of Scientific Education and Professional Development, 2012). Other res-
ervoirs are soil (Clostridium botulinum), animals (rabies), insects (Yersinia pestis), and
354 IN FECTIOUS DISEASES
ater (Legionella pneumophilia). The portal of exit is how the pathogen leaves the
w
host. Typical portals of exit from the h uman body are respiratory secretions, urine,
feces, blood, or other body fluids. With GWD, the portal of exit is the outbreak
through the skin. Means of transmission refers to how the pathogen moves to the
new host. Direct contact is undeviating transmission between individuals through
kissing, skin-to-skin contact, sexual intercourse, sneezing, coughing, or airborne
droplets. Indirect contact refers to transfer by air currents, food, water, clothing,
insects, or rodents. When the female guinea worm deposits her larva into
water, they are ingested by copepods (small crustaceans). The copepods act as
vectors, carrying the infective larvae. The portal of entry is how the pathogen
enters the susceptible host. In most cases, the portal of exit is similar to the portal
of entry. In the case of GWD, people drink water containing copepods contami-
nated with dracunculiasis medinensis. The final link in the chain is the susceptible
host. In the normal healthy individual, skin, respiratory secretions, white blood
cells, enzymes in tears, antigens, and acidic gastric juices will stop or contain many
potential invaders. People who are struggling with compromised immune systems
due to AIDS, leukemia, or other preexisting conditions are not able to combat
pathogens as effectively. Additionally, certain behaviors, such as smoking mari-
juana or cigarettes, can impair the respiratory system increasing risk of infection.
Susceptibility is also influenced by virulence and dosage of the pathogen. A minor
exposure to the cold virus may be fended off with adequate rest and good nutri-
tion. A major exposure where someone repeatedly coughs and sneezes in closed
spaces may be harder to avoid. The beauty of the chain of infection is that it not
only describes transmission from the original source to new hosts, but the diagram
suggests multiple places to disrupt transmission.
Infection control measures seek to interrupt transmission at specific points. Anti-
biotics, antivirals, and other drugs interfere with pathogenic life cycle and replica-
tion. Reducing the number of pathogens in the environment reduces the potential
for communicable disease transmission. Emptying standing w ater from old tires,
pots, or stagnant pools (reservoirs) reduces West Nile virus. Good handwashing,
personal hygiene, and cough etiquette intercepts pathogens at the portal of exit.
Mode of transmission may be blocked by not sharing contaminated vehicles such
as straws, needles, or cigarettes or through vector control, eliminating rats,
roaches, fleas, and ticks. The human body has multiple natural defenses against
pathogens. Immunity can be further enhanced through vaccinations, good nutri-
tion, and adequate rest. Studying the chain of infection for each pathogen sug-
gests numerous opportunities to control specific infectious diseases.
For many Americans, the days of overcrowded, unsanitary living conditions are
long gone. The threat of losing loved ones to cholera, smallpox, polio, pneumonia,
influenza, or typhoid is unfamiliar. One of the greatest advancements of public health
in the past century is conquering communicable diseases through sanitation, food
and water safety, infection control, and immunizations. Yet, as living organisms,
pathogens are capable of interesting mutations, and public health professionals must
IN F LUEN Z A 355
remain vigilant for emerging and reemerging pathogens. The public can play an
important role in securing health by following immunization guidelines, and employ-
ing good respiratory and personal hygiene including good handwashing.
Sally Kuykendall
See also: Ancient World, Public Health in the; Antibiotic Resistance; Cholera; Epi-
demic; Greco-Roman Era, Public Health in the; H uman Immunodeficiency Virus
and Acquired Immune Deficiency Syndrome; Immigrant Health; Meningitis; Pan-
demic; Public Health in the United States, History of; Renaissance, Public Health
in the; Roosevelt, Franklin Delano; Smallpox; Snow, John; Vaccines; Controversies
in Public Health: Controversy 3; Controversy 5
Further Reading
Centers for Disease Control and Prevention (CDC). (2012). Respiratory hygiene/cough eti-
quette in healthcare settings. Atlanta. Retrieved from http://www.cdc.gov/flu/professionals
/infectioncontrol/resphygiene.htm.
on death and dying. Hyattsville, MD. Retrieved from http://www.cdc.gov/nchs/data/hus
/hus10.pdf.
Office of Public Health Scientific Services, Center for Surveillance, Epidemiology, and Lab-
oratory Services, and Division of Scientific Education and Professional Development.
(2012). Principles of epidemiology in public health practice: An introduction to applied
epidemiology and biostatistics (3rd ed.). Atlanta: Centers for Disease Control and Pre-
vention. Retrieved from http://www.cdc.gov/OPHSS/CSELS/DSEPD/SS1978/Lesson1
/Section10.html#ALT120.
INFLUENZA
Influenza is a communicable disease caused by strains of the influenza virus. The
pathogen is transmitted from the infected host to the potential host as respiratory
droplets expelled during coughing, sneezing, or talking. Viral particles enter poten-
tial victims through the mouth or nose. Susceptible targets experience symptoms
within one to four days after initial infection. Common symptoms include sore
throat, cough, nasal congestion, fever, chills, body aches, headaches, and/or fatigue.
Influenza, commonly known as the flu, is a serious public health problem. The dis-
ease causes widespread incapacitation and can progress to serious complications
of pneumonia, sepsis (blood infection), myocarditis (inflammation of the heart
muscle), encephalitis (inflammation of the brain), rhabdomyolysis (serious mus-
cle injury), or multisystem organ failure. P eople with compromised immunity,
children, the elderly, and those with preexisting health conditions are at high risk for
infection and complications. The flu can be fatal, especially within t hese vulnerable
populations. Fortunately, the disease is highly preventable through vaccination, basic
infection control (public health) practices, and early treatment to limit continued
356 IN FLUEN ZA
transmission. Influenza is a classic example of how tiny, microscopic particles can

pose an enormous threat to public health and how s imple efforts can effectively
prevent or control such threats.
The flu pandemic of 1918 was one of the worst public health disasters in mod-
ern history. An estimated one-fifth of the world’s population, 50 to 100 million
people, died. Experts are unsure where the virus originated. The first report is in
an article in the British medical journal, The Lancet. The article describes an out-
break of severe respiratory infection at the Etaples military base in 1916 (Oxford
et al., 2002). Located on the coast of northern France, Etaples was a strategic mili-
tary base during World War I (1914–1918). Historians estimate that over one mil-
lion allied troops moved through the Etaples base during World War I. With 22
hospitals, Etaples treated soldiers from around the world. The massive population
movement combined with the stressful conditions of the battlefields (malnourish-
ment, overcrowding, poor hygiene, and limited access to health and medical care)
were ideal for infectious diseases. The first recorded flu case in the United States
presented in January 1918 at Camp Devens (Auerbach, 2014). Devens was a military
hospital and training base near Boston, Massachusetts. This case was followed by
a minor epidemic that went largely unnoticed. The war was coming to an end, and
people looked forward to celebrating the return of surviving sons, brothers, f athers,
and boyfriends. A second wave of infection struck Devens on September 7, 1918.
A soldier in D Company, 42nd Infantry presented with symptoms of meningitis.
The following day, 12 other patients appeared. Within a week, the number of cases
rose to 599. The virus strain, later identified as H1N1 avian influenza A, was unusual
and lethal. Although most flu strains attack children and the elderly, this strain
attacked young, healthy adults. Within a few hours of the initial symptoms, the
victim’s lungs filled with respiratory secretions and the patient would slowly drown.
The infection spread quickly within the body and between victims. Healthy men
and women died within hours of the initial complaints. Bodies w ere stacked in
makeshift morgues. The Devens epidemic peaked on September 20, 1918, with
1,543 cases admitted on this one day, alone. Yet, Devens was not unique. Military
bases, hospitals, and communities across the world w ere hit as 70 million military
personnel returned from Europe, Asia, Africa, the M iddle East, the Pacific Islands,
and the Indian Ocean. In remote Brevig Mission, Alaska, 72 residents died within
five days (Carroll, 2013). The only survivors w ere eight c hildren and teenagers.
Nurses and physicians w ere already in short supply b ecause just about anyone with
medical training had been deployed to field hospitals overseas. Desperate govern-
ment officials implemented whatever measures they deemed appropriate. Cur-
fews, bans on public gatherings, bans on commercial sales that might entice
shoppers, and bans on spitting, sneezing, or coughing in public were implemented.
By the end of 1919, the virus mutated to a less lethal form, and the pandemic sub-
sided almost as quickly as it started. Within this one year alone, the flu pandemic
reduced overall life expectancy by 12 years in the United States.
INF LUENZ A 357
Nurses load St. Louis residents into a Red Cross ambulance during the flu pandemic of
1918. Closing all schools, churches, businesses, and public gathering places, health commis-
sioner Dr. Max C. Starkloff secured a death rate of half that of other major cities. (American
Red Cross)
In 1918, there was no treatment for flu. People resorted to a variety of mixtures,
tonics, or herbs. Other “treatments” included rolling in the snow, hot baths, or ine-
briation with alcohol. In Great Britain, authorities asked factories to “fumigate” the
air with industrial smoke (Semiatin, 2012). T oday, public health officials recom-
mend three (more effective, less harmful) steps to flu prevention and treatment:
(1) vaccinate, (2) stop germs, and (3) treat with antiviral medicine. The Centers for
Disease Control and Prevention (CDC) recommends that everyone should get the
flu vaccine e very year and especially high-risk populations of young children (older
than six months), pregnant women, p eople with chronic illnesses, adults over the
age of 65, and health care staff (CDC, 2016). The vaccine should not be used in
infants under six months. People with severe allergies to eggs or other vaccine ingre-
dients should only get the vaccine under strict medical supervision. Flu vaccina-
tions are manufactured to protect against specific strains of the virus. The seasonal
flu vaccine protects against viruses that are predicted to strike in the upcoming year.
Trivalent flu vaccines protect against influenza A (H1N1) virus, influenza A (H3N2)
virus, and influenza B virus. Vaccinations work on two levels. They protect the
358 IN FLUEN ZA
individual from illness, and they prevent the microorganism from spreading within
a community. When the flu vaccine matches the strain of virus presenting in the
community, vaccination reduces flu-related doctors’ visits by 50–60 percent (CDC,
2016). When 80–90 percent of p eople in a community are vaccinated, it is much
harder for a pathogen to find susceptible hosts. In this way, vaccines also protect
children and adults who are unable to get the vaccine. To prevent the spread of
influenza, Healthy People 2020 recommends that 70 percent of c hildren and adults
and 90 percent of health care professionals obtain the seasonal flu vaccine. During
the early part of the 2016 flu season, 40 percent of children and adults and 69 percent
of health care professionals obtained the flu vaccine (CDC, 2016). Thus, t here is a
need to increase flu vaccination rates among all p eople.
Basic infection control practices can reduce susceptibility to infectious diseases
and prevent transmission to friends, family members, or coworkers. To prevent flu
outbreaks, the CDC (2016) recommends:
1. Optimize immunity: Create a strong immune system through regular physical

activity, nutritious diet, and stress reduction activities.
2. Limit exposure: Prevent infection by avoiding contact with people who are
coughing, sneezing, or have a fever. Disinfect your work spaces at school or
the office. Use good handwashing techniques and avoid touching your eyes,
nose, or mouth.
3. Protect others: When you are sick, stay home from work, school, and other
public spaces. Get plenty of rest, stay hydrated, and eat healthy foods. Cover
your mouth and nose with a tissue when coughing or sneezing, use good hand-
washing techniques, and disinfect your living or working spaces to avoid
contaminating others.
hese s imple methods can effectively break the transmission of a pathogen from
T
one person to another and stop flu epidemics.
Antiviral drugs are prescription drugs used to treat p
eople with the flu. The med-
icine works by binding to the neuraminidase protein of the flu virus and prevent-
ing replication. For best results, treatment should start within the first two days
(36–48 hours) of infection. When used as prescribed, antivirals can lessen the symp-
toms of the flu, shorten illness by one to two days, and/or reduce complications.
As with any prescription drug, antiviral medications can have adverse side effects
and should only be used under medical supervision.
The influenza virus has the potential to disable schools, workplaces, communi-
ties, and nations. And yet, it can be stopped with s imple techniques of vaccination,
good hygiene, and early, effective treatment. Public health efforts to prevent this
annual scourge focus on increasing vaccination rates, protecting at-risk populations,
and early detection.
Sally Kuykendall
INJU R IES 359
See also: Epidemic; Epidemiology; Handwashing; Infectious Diseases; Koch, Hein-

rich Hermann Robert
Further Reading
Auerbach, M. P. (2014). An army physician on the 1918 flu pandemic. Defining Documents:
World War I, 267–269.
Carroll, A. (2013). An Alaskan village holds the key to understanding the 1918 Spanish flu.
American History, 48(4), 29–30.
Centers for Disease Control and Prevention (CDC). (2016). Seasonal influenza: Flu basics.
Retrieved from https://www.cdc.gov/flu/about/disease/index.htm.
Morens, D. M., & Taubenberger, J. K. (2015). Historical review. A forgotten epidemic that
changed medicine: Measles in the US Army, 1917–18. The Lancet Infectious Diseases,
15, 852–861. doi:10.1016/S1473-3099(15)00109-7
Oxford, J. S., Sefton, A., Jackson, R., Innes, W., Daniels, R. S., & Johnson, N. S. (2002).
World War I may have allowed the emergence of “Spanish” influenza. The Lancet Infec-
tious Diseases, 2(2), 111–114.
Semiatin, S. (2012). The g reat flu pandemic of 1918. History Magazine, 14(2), 31–33.
Soper, G. A. (1918). The influenza pneumonia pandemic in the American army camps dur-
ing September and October. Science, 48(1245), 451–456.
INJURIES
Injuries are a category of health issues characterized by damage to the body caused
by an external force or forces. Injuries are the leading cause of death among young
people and create huge economic, social, and emotional burdens. More than 199,000
people die annually due to injuries, the equivalent of one person every three min-
utes (National Center for Injury Prevention and Control [NCIPC], 2016). In 2013,
injuries cost an estimated $671 billion (NCIPC, 2016). The most common injuries
are prescription drug overdoses, falls, motor vehicle crashes, traumatic brain injury,
child abuse and neglect, and violence. In the past, injuries were referred to as acci-
dents. The term “accident” is misleading because it infers that health-related inci-
dents occur by random and are unavoidable. When someone gets drunk and gets
behind the wheel of an automobile, the resulting crash is not an accident. When a
child finds a loaded, unlocked gun, the subsequent shooting is not an accident.
And when a worker fails to follow instructions on Material Safety Data sheets, chem-
ical burns are not an accident. Injuries are not random and are easily prevented. In
public health, injuries are classified as intentional or unintentional. Intentional inju-
ries are violence-related. Physical and emotional harm caused by child abuse and
neglect, youth violence, intimate partner violence, sexual violence, and self-directed
violence are intentional injuries. Unintentional injuries include prescription drug
overdose, falls, motor vehicle crashes, and traumatic brain injuries. Grouping inju-
ries into categories enhances prevention efforts and may impact several health issues
simultaneously. For example, alcohol and substance abuse increases risk of both
intentional and unintentional injuries. Policies and education on substance abuse
360 IN JUR IES
decreases homic ides, suicides, intimate partner violence, child abuse, motor vehicle
crashes, workplace injuries, and falls.
The causes of injuries and potential prevention mechanisms may be understood
through physics. When kinetic, thermal, chemical, electrical, or radiation energy
exceeds the threshold of body defenses, injury is likely to result. Kinetic energy is
the energy created by motion. A car moving at 15 mph has less kinetic energy than
a car moving at 100 mph. The faster a car moves, the harder it is to stop and the
greater the risk of injury to pedestrians, the driver, and passengers. Speed limits
control kinetic energy, thereby reducing injuries. Thermal energy is energy from
heat. Burns from hot food or drinks or frostbite are examples of thermal injuries.
To protect customers from scalds and still ensure a satisfactory product, scientists
recommend that restaurants serve coffee, tea, or other hot drinks at 136°F or 57.8°C
(Brown & Diller, 2008). Chemical injuries occur when chemicals are ingested,
injected, inhaled, or come in contact with the body at the level where toxicity or
impaired body function occurs. Examples include carbon monoxide poisoning, her-
oin overdose, or corrosive burns due to high acid or alkali content. Poison control
centers provide free emergency information and prevention materials to avoid
household poisonings. Electrical injuries are caused by electrical shock from a high-
voltage or low-voltage source and can result in tingling, burn, respiratory paralysis,
or cardiac shock. Electrical safety standards of the Occupational Safety and Health
Administration (OSHA) are designed to protect electricians, engineers, and other
workers from electrical shock, electrocution, fires, and explosions. Although the
majority of exposures are acute and may be cared for at home, repeated exposure
can lead to chronic health problems. For example, jolts to the head a fter a concus-
sion may lead to more severe brain injury; ongoing exposure to asbestos can lead
to lung cancer, mesothelioma, or asbestosis; and repeated exposure to sunlight may
lead to skin cancer.
Public health addresses injuries through systematic approaches using surveil-
lance, identifying risk and protective factors, developing and evaluating strategies,
and encouraging widespread adoption of evidence-based programs. Applying the
example of falls, surveillance indicates that 2.8 million people are treated in the
emergency room every year due to falls (CDC, NCIPC, Division of Unintentional
Injury Prevention, 2016). Elderly people are at highest risk. One out of four elderly
people w ill experience a fall each year. The program STEADI (Stopping Elderly Acci-
dents, Deaths, and Injuries) was developed to prevent falls in the elderly. STEADI
provides resources for patients and their health care providers to evaluate individual
risk of falling and potential for injury. Interventions include the following: review-
ing medications to see whether prescribed medications cause dizziness or sleepi-
ness; regular eye exams, keeping eyeglass prescriptions up to date; regular exercises
to increase strength and balance; calcium and vitamin D supplements to strengthen
bones and reduce the risk of fracture if a fall does occur; and removing home
hazards, such as loose rugs or uneven pavement, and installing handrails or extra
IN J U R IES 361
lighting. The cost of an evidence-based prevention program such as STEADI is

minimal in comparison to the $31 billion currently spent on annual medical costs
due to falls.
Injuries are one of the most pressing public health concerns of the nation. Cur-
rent prevention efforts employ policies, laws, education, engineering, and science
at the federal, state, and local levels. Efforts have been highly successful in improv-
ing community and occupational health. Between 1925 and 1997, advances in road
and vehicle safety decreased motor vehicle fatalities from 18 per 100 million vehi-
cle miles traveled (VMT) to 1.7 per 100 million VMT (Centers for Disease Control
and Prevention [CDC], 1999a). Occupational safety and health policy and pro-
grams decreased unintentional work-related fatalities from 37 per 100,000 workers
in 1933 to 4 fatalities per 100,000 workers in 1997 (CDC, 1999b). Through col-
laborative efforts, the Centers for Disease Control National Center for Injury Pre-
vention and Control, public health professionals, National Highway Traffic Safety
Administration (NHTSA), National Institute of Occupational Safety and Health
(NIOSH), businesses, workplaces, schools, communities, hospitals, and many
other organizations are working to further reduce the physical, emotional, social,
and financial burden of injuries through research, education, and practice.
Sally Kuykendall
See also: Aging; Agricultural Safety; Centers for Disease Control and Prevention;
Child Maltreatment; Elder Maltreatment; Epidemiology; Healthy Places; Home
Safety; Infant Mortality; Intimate Partner Violence; Kelley, Florence; Men’s Health;
Middle Ages, Public Health in the; Motor Vehicle Safety; National Center for Injury
Prevention and Control; Prevention; Sports-Related Concussions; Violence
Further Reading
Brown, F., & Diller, K. R. (2008). Calculating the optimum temperature for serving hot bev-
erages. Burns, 34, 648–654. doi:10.1016/j.burns.2007.09.012
Centers for Disease Control and Prevention. (1999a). Achievements in public health, 1990–
1999 motor vehicle safety: A 20th century public health achievement. Morbidity and
Mortality Weekly Reports, 48(18), 369–374. Retrieved from https://www.cdc.gov/mmwr
Centers for Disease Control and Prevention. (1999b). Achievements in public health, 1990–
1999: Improvements in workplace safety—United States, 1990–1999. Morbidity and
Mortality Weekly Reports, 48(22), 461–469. Retrieved from https://www.cdc.gov/mmwr
Centers for Disease Control and Prevention, National Center for Injury Prevention and Con-
trol, Division of Unintentional Injury Prevention. (2016). Important facts about falls.
Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html.
National Center for Injury Prevention and Control. (2015). CDC Injury Center research pri-
orities. Atlanta: U.S. Department of Health and H uman Services, Centers for Disease
362 INTE R VENTION
Control and Prevention. Retrieved from http://www.cdc.gov/injury/pdfs/researchpri

orities/cdc-injury-research-priorities.pdf.
National Center for Injury Prevention and Control. (2016). Cost of injuries and violence in
the United States. Atlanta: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention. Retrieved from http://www.cdc.gov/injury/wisqars
/overview/cost_of_injury.html.
INTERVENTION
An intervention, typically a health program, is a systematically planned effort or
set of activities intended to bring about a health improvement to a specific com-
munity or population. Interventions are developed to address a need that was for-
mally identified by a needs assessment. The vast majority of interventions aim at
changing three major f actors that affect health: knowledge, attitudes, and behavior
(Gilbert, Sawyer, & McNeil, 2011). The population targeted by an intervention
differs based on the need being addressed, and may include, among others, neigh-
borhood residents, organization directors or staff members, community leaders, or
policy makers. By influencing the people and factors that impact health, the inter-
vention can improve the long-term wellness of a population. There is a plethora of
intervention strategies, such as media campaigns or public service announce-
ments, conveying health information, modifying public policy, restructuring how
organizations operate, and creating partnerships between organizations. Interven-
tions can vary widely; they can use any of these strategies independently or several
strategies in combination. For example, an intervention to prevent skin can-
cer might consist of a poster explaining the negative consequences of direct
sun exposure or a program that offers free skin cancer screenings in local commu-
nity centers.
There are many examples of interventions throughout the history of public health.
One landmark example is that of Dr. John Snow in London, E ngland. During the
mid-1800s, Snow observed that many individuals w ere suffering from cholera, an
intestinal disease that can result in death. T hose who were most affected lived in
Soho, an area of the West End of London. On investigation, Snow believed that
contaminated drinking water may have caused many of the cholera-related deaths.
At that time, sewage was disposed of in the Thames River. Water from the river
mixed with water in nearby communal wells, which was the source of water for
most local townspeople. Snow recommended that the pumps of contaminated wells
be removed to prevent individuals from drawing up the water. Once implemented,
the number of cholera-related deaths decreased dramatically. The action by Snow to
eliminate hand pumps was considered an intervention. He changed the way indi-
viduals could obtain clean drinking water and successfully reduced deaths and
improved the health of Londoners. Other examples of public health interven-
tions throughout history include the widespread addition of fluoride into public
drinking water to prevent tooth decay and anti-smoking laws that prohibit indoor
INTER V ENTION 363
smoking to prevent the negative consequences of secondhand and side stream

smoking.
There are four main phases in public health interventions: assessment, planning,
implementation, and evaluation (Bartholomew, Parcel, Kok, Gottlieb, & Fernan-
dez, 2011). In the assessment phase, project collaborators perform needs and assets
assessments. The needs assessment identifies the specific health problem that needs
to be addressed, the number of p eople impacted by the issue, and the short-and
long-term impact of the problem on individuals and the community. During the
planning phase, key stakeholders decide which program or actions may be most
effective for the p eople or community experiencing the health issue. The program
planners may obtain existing program materials or design a new intervention. Plan-
ning requires a great deal of time and consideration. Multiple factors must be taken
into consideration, such as competing priorities, engaging key stakeholders and par-
ticipants, and securing resources. Implementation is the time period when the pro-
gram activities are delivered. The program evaluation involves assessing the
activities that were delivered and the outcomes, or changes, the intervention
sought to achieve. Although the components seem to appear in chronological
order, all of the components occur as ongoing and iterative processes. For example,
if participant attendance is low during implementation, program planners may
need to adjust the original implementation plans.
Thoughtful planning is critical to the success of an intervention. Planning begins
with selecting a program-planning model, theory, or evidence-based practice that
will guide the intervention. T here are a wide variety of systematic program plan-
ning models and frameworks available to develop health interventions. In many of
these models, a systems thinking approach, such as the social ecological model, is
utilized to provide a big picture view of the issue. That is, the health of individuals
is impacted by various factors, such as their knowledge and beliefs, their family
and friends, their community, and state and federal laws. Interventions are most
successful when they target the modifiable factors that influence health. For
example, an intervention that changes p eople’s attitudes, knowledge, and behavior
toward using sunscreen is more feasible, and w ill be more successful, than an inter-
vention that creates a law requiring individuals to wear sunscreen when outdoors.
Other important tasks in the planning phase are identifying key stakeholders, cre-
ating a working group, developing goals and objectives, and identifying safe, con
venient, and appropriate locations for program implementation.
Public health interventions are most effective when they are based on a recog-
nized model or theory. Theories help explain why p eople do or do not become
involved in particular health-related behaviors and the most effective ways to modify
health behaviors. Evidence-based practices are those techniques that have proven
to be effective through empirical research and evaluation. For example, if previous
research suggests that training lifeguards is effective at reaching and educating
members of a community about skin cancer, then it would be considered an
evidence-based practice. Thus, training and employing lifeguards could be used in
364 INTE R VENTION
the development of other beach and pool based interventions, as it has been proven
to work. Evidence-based practices and programs tend to be more effective than
programs not based on scientific theory.
Interventions that are developed using a framework and informed by theories
and evidence-based practices are more successful at achieving their stated out-
comes. The logic model is one of the most common ways to organize information
and plan an intervention. The logic model is a visual representation of the inter-
vention that outlines the connections between the underlying public health the-
ory and specific components of the intervention. For example, one widely used
theory in intervention planning is the health belief model, which describes why
people may or may not engage in certain health-related behaviors. Such an under-
standing would help a public health practitioner to understand the problem better
and devise solutions accordingly as part of the intervention. One construct of the
health belief model is perceived susceptibility. Perceived susceptibility describes
how much individuals believe they are at risk of a condition. If individuals do not
believe they are at risk for skin cancer, then they may not use sunscreen when at
the beach or pool. Thus, they have low perceived susceptibility of skin cancer.
Using the health belief model, the interventionist might aim to increase perceived
susceptibility by designing messages and materials to increase awareness of risk
factors for skin cancer. The logic model draws the link between perceived sus-
ceptibility and health education to increase awareness of the risk factors of skin
cancer.
The third phase of conducting an intervention is the implementation phase. In
the implementation phase, those who w ill be delivering the intervention are trained
and instructed on the curriculum or protocols. Participants are recruited from the
target community, and the intervention is delivered to the participants. Leading or
administering an intervention requires a fine balance between staying true to the
original program design and customizing the intervention to meet the needs of the
participants. The program coordinator must make sure that the intervention meets
the needs of the participants and must also work to achieve buy-in of the partici-
pants and key stakeholders. Multiple demands on people’s time can interfere with
attendance and participation. To ensure that interventions are implemented in the
way that they were meant to be implemented, fidelity of implementation may be
measured. Fidelity of implementation measures how faithful the intervention is to
the original program design.
The final phase of performing an intervention is to conduct an evaluation.
There are two types of evaluations, process evaluation, which assesses how well the
intervention was delivered, and outcome evaluation, which measures how well
the intervention achieved its intended objectives. The process evaluation is an
ongoing assessment that occurs during the implementation of the intervention and
measures how many people are interacting with the intervention and whether
people find the materials helpful. The final outcome evaluation is conducted after
INTE R V ENTION 365
the intervention has been delivered and measures if and how participants’ knowl-
edge, attitudes, or behaviors changed after the intervention. The evaluations’
results inform decisions about modifying the current health program or develop-
ing future health interventions.
The gold standard for evaluation is a randomized controlled trial design. That
is, there is one group of individuals who receives the intervention, known as the
intervention group, and one group who does not, known as the control group. By
using such a design, the public health practitioner can compare the two groups
and effectively understand if observed outcomes were a result of the intervention
or simply by chance. For example, an intervention that aims to decrease skin can-
cer within a community distributes brochures about safe sun practices and free
bottles of sunscreen to individuals at one community pool (intervention group),
but not to others at another pool within the same community (control group). If a
comparison between the two groups shows that those in the intervention group
engaged in more safe sun practices than those in the control group, then it could
suggest the intervention was successful. However, if the comparison between the
two groups does not reveal such findings, then it could suggest the intervention
was not successful. Though the randomized controlled trial is usually the gold stan-
dard, in many other instances it may be unethical to deny a group of individuals
access to a program that could help them; thus, other implementation designs can
be used.
Public health interventions are programs and practices designed to improve the
knowledge, attitudes, or behaviors of individuals or groups of individuals in order
to improve health and well-being. Interventions are planned and designed by pub-
lic health professionals, and they are based on scientific theory and practices.
Implementation requires sensitivity to the needs of the target population and under-
standing of the core program components. The most effective interventions are
evidence-based programs and practices, which have been studied and proven to
work in various communities.
Noora F. Majid and Nadav Antebi-Gruszka
See also: Cholera; Community Organizing; Evaluation; Emergency Preparedness and

Response; Evidence-Based Programs and Practices; Fluoridation; Health Education;
Logic Model; Needs Assessment; Prevention; RE-AIM (Reach, Effectiveness, Adop-
tion, Implementation, and Maintenance); Risk-Benefit Analysis; Snow, John; Social
Ecological Model; Syringe Service Programs; Transtheoretical Model
Further Reading
Bartholomew, L. K., Parcel, G. S., Kok, G., Gottlieb, N. H., & Fernandez, M. E. (2011).
Planning health promotion programs: An intervention mapping approach. San Francisco:
Jossey-Bass.
366 INTIM ATE PA RTNER VIOLENCE (IP V)
Centers for Disease Control and Prevention. (2014, February 4). Assessment and planning
models, frameworks and tools. Retrieved from http://www.cdc.gov/stltpublichealth/cha
/assessment.html.
Community Preventive Services Task Force. (2015, March 5). The community guide, what
works to promote health: Plan an intervention. Retrieved from http://www.thecommunity
guide.org/toolbox/plan-an-intervention.html.
Gilbert, G. G., Sawyer, R. G., & McNeil, E. B. (2011). Health education: Creating strategies
for school and community health. Sudbury, MA: Jones & Bartlett.
INTIMATE PARTNER VIOL ENCE (IPV)

Intimate partner violence (IPV) is a serious, preventable health problem, defined as
“any behavior within an intimate relationship or former relationship that causes
physical, psychological, or sexual harm” (Feder, 2016). Such harm includes:
• Physical aggression, such as hitting, kicking, and beating.
• Psychological violence, such as intimidation and humiliation.
• Controlling behaviors, such as isolation from family and friends, monitoring
of movements, and controlling finances.
• Sexual violence, such as forced intercourse.
The term is often used synonymously with domestic violence (DV). Differences are
that DV refers to acts of violence committed by any family member, including inti-
mate partners (Garcia-Moreno et al., 2012) whereas IPV occurs among heterosex-
ual or same-sex couples with or without sexual intimacy (Feder, 2016). More than
32 million men and women experience IPV in the United States. Females who report
IPV at least once in their lifetime have three to four times more emotional distress,
suicidal thoughts, and suicide attempts than nonabused women (Ellsberg et al.,
2008).
American attitudes toward violence against women (VAW) originated from
England where women w ere traditionally viewed as personal property of the hus-
band. Most legal and social structures established prior to the 19th century sup-
ported IPV against wives as a right of the husband. During the mid-1800s, social
views began to change. By 1871, Alabama and Massachusetts prohibited IPV. In
1878, E ngland passed the Matrimonial Causes Act giving both women and men
the right to legal separation, custody of their children, and earnings from the sepa-
ration in cases of cruelty, desertion, or adultery. As female empowerment grew
through feminism, so did recognition of IPV as a health issue. T oday, cases of IPV
have captured widespread media attention, increasing awareness of the issue as a
public health problem.
IPV affects p eople of all ages, socioeconomic classes, ethnicities, gender identi-
ties, and sexual preferences. The World Health Organization (WHO) surveyed
24,097 women in 10 countries about experiences with physical and sexual IPV. Life-
time prevalence ranged from 15 to 75 percent and in 6 of 15 study sites, prevalence
INTIM ATE PA RTNE R VIOLEN C E ( IPV) 367
was 50 percent or greater (WHO, 2013). Physical violence was the most common
form, and 30 to 56 percent of w omen experienced both physical and sexual vio
lence. In reviewing homicide data from 66 countries, researchers found that
39 percent of female homicides and 6 percent of male homicides were committed
by an intimate partner (Feder, 2016; Stöckl et al., 2013). IPV is the second leading
cause of homicide for w omen in the workplace (Tiesman, Konda, & Amandus,
2012). Victims can change their telephone number, address, and appearances. It is
harder to change one’s workplace. Data show that IPV is a pandemic problem. Fur-
thermore, only about one out of five female sexual assault victims, one out of four
physical assault victims, and one of two stalking victims report the aggression; male
victims are even less likely to report (Tjaden & Thoennes, 2000). Reasons for non-
reporting originate from outdated attitudes and legal systems that viewed female
partners as property to be mistreated at w ill. Public service announcements and
media campaigns are working to change attitudes toward IPV and increase victim
willingness to report. The next steps are to incorporate strategies to prevent and
respond to IPV within workplace safety programs.
A combination of individual, relationship, community, and societal factors are
associated with victimization and perpetration; however, they are not in themselves
causes of IPV (Heise & Garcia-Moreno, 2002). Individual factors for victimization
include young age (less than 24 years), heavy drinking, depression, low academic
achievement, low income, and exposure to violence in childhood. Relationship
factors are poor family functioning, marital instability, male dominance, and eco-
nomic stress. Community f actors are weak sanctions against violence, poverty, and
economic inequality. Societal factors include rigid gender norms and positive atti-
tudes toward violence (Abramsky et al., 2011; Feder, 2016). Risk factors for per-
petration include exposure to childhood violence, unresolved post-traumatic stress
disorder, recent job loss, and substance abuse (Renner & Whitney, 2012). Child-
hood history of maltreatment is a risk factor for both victimization and perpetra-
tion. Although it is important to be aware of risk factors in order to identify those
at risk, a growing number of public health and medical professionals routinely screen
for IPV during the history and physical exam.
Patients typically do not present with the chief complaint of IPV. Instead, prac
titioners might notice a history of multiple injuries, injuries that are not consistent
with the patient’s explanation, or delays in seeking medical care (Feder, 2016). The
most common injuries related to IPV are trauma to the head, face, neck, teeth, or
genital area. Victims also present with musculoskeletal injuries, sprains, fractures,
or dislocations. Injuries often reflect the mode of attack, with marks suggesting
strangulation, or hitting by a hand or household object. Use of a knife or gun is
comparatively less common (Feder, 2016). Many victims have no signs of obvious
trauma and instead present with chronic somatic complaints of headache or back-
ache, or nonspecific complaints of difficulty with daily activities, memory loss,
or dizziness (Ellsberg et al., 2008). Irritable bowel syndrome, fibromyalgia, and
vari ous chronic pain syndromes are commonly associated with victimization
(Heise & Garcia-Moreno, 2002). Victims of sexual violence suffer from a range of
sexual and reproductive health effects, including unintended pregnancy, abor-
tion, sexually transmitted infections, and sexual dysfunction. Psychosocial prob
lems, such as difficulty in negotiating contraceptive or condom use with a partner,
can be harder to identify but are important health consequences that demand con-
sideration (Garcia-Moreno et al., 2012). Violence will often escalate with the stress
of pregnancy or childbirth, and violence against pregnant w omen is of particular
significance due to the risk of harm to both mother and fetus. Patterns of injury
during pregnancy tend to be more central, such as blunt trauma to the head, torso,
abdomen, breasts, and genitalia (Feder, 2016). Miscarriage, late entry into prenatal
care, perinatal death, and preterm labor and birth are associated with IPV (Garcia-
Moreno et al., 2012). The effects of abuse do not end when the abuse ends. Abused
women are twice as likely as nonabused women to self-report poor health and
physical and mental health problems, even if the violence occurred years before
(Garcia-Moreno et al., 2012). C hildren in families with IPV also exhibit symptoms,
regardless of whether they are also victims of violence. Children of abused mothers
exhibit significantly more internalizing, externalizing, and total behavioral prob
lems than children of nonabused m others. When a patient presents with unex-
plained injuries or nonspecific complaints, health care practitioners will first rule
out medical c auses.
Without realizing it, the victim is caught up in a controlling cycle of abuse, con-
sisting of romance, tension building, and abuse and returning to romance. In the
romance or honeymoon phase, the partner is attentive and charming. As life’s strug
gles and difficulties overwhelm, the abuser views the victim as e ither the cause of
the problem or an acceptable scapegoat. The batterer responds to tensions with
physical, verbal, sexual, or emotional violence directed at the victim. A fter an abu-
sive incident, the batterer w ill blame the victim, apologize, try to console the vic-
tim with promises or gifts, or pretend that the abuse never happened. The romance
phase confuses the victim into thinking that the abuse never happened, was some-
how his or her fault, or was simply a one-off occurrence. The romance phase also
confuses friends and family members who question the victim’s judgment of the
situation. The cycle is difficult to break for reasons mentioned previously. Through
childhood experiences, the victim may have a distorted view of relationships, not
knowing or understanding respect between partners. Rigid gender norms, lack of
economic opportunity, and disparities in earning potential motivate female part-
ners to stay with male abusers, especially when c hildren are involved. Internally,
the victim believes that the partner regrets the abuse and intends to change. The
health care practitioner must respond to suspected IPV in ways that protect and
support the victim. Recognizing that the victim may not be prepared to make major
life changes by leaving the relationship, public health professionals can refer the
victim to a hotline or onsite domestic violence counselor who can provide practical
INTI M ATE PA RTNE R VIOLEN C E (IPV) 369
safety tips to de-escalate the violence and protect the victim. Numerous programs
exist for both batterers and victims.
Given the long-lasting and detrimental effects of intimate partner violence,
increased efforts toward prevention are u nder way. Active screening in clinical set-
tings contributes to greater identification of victims. The national hotline is available
for victims in the United States (http://www.thehotline.org/). Multiple organ
izations and coalitions, such as the Battered Women’s Justice Project, Child Wel-
fare League of Americ a, National Coalition Against Domestic Violence, Institute
of Domestic Violence in African American Communities, and women’s shelters are
focused on combating IPV through awareness, prevention, and victim support. An
effective approach toward alleviating the public health burden of intimate partner
violence requires continued collaboration of individuals, communities, and insti-
tutions as well as changes in social norms.
Nooshin Asadpour and Maria DiGiorgio McColgan
See also: Adverse Childhood Experiences; Child Maltreatment; Children’s Health;

Family Planning; Injuries; Lesbian, Gay, Bisexual, and Transgender Health; Mater-
nal Health; Violence; W
omen’s Health
Further Reading
Abramsky, T., Watts, C. H., Garcia-Moreno, C., Devries, K., Kiss, L., Ellsberg, M., & . . .
Heise, L. (2011). What factors are associated with recent intimate partner violence?
Findings from the WHO multi-country study on women’s health and domestic vio
lence. BMC Public Health, 11(1), 109–125.
Battered W omen’s Justice Project. (2017). Retrieved from http://www.bwjp.org.
Dobash, R., & Dobash, R. (1992). Women, violence & social change. New York: Routledge.
Ellsberg, M., Jansen, H. M., Heise, L., Watts, C. H., & García-Moreno, C. (2008). Intimate
partner violence and women’s physical and mental health in the WHO multi-country
study on w omen’s health and domestic violence: An observational study. The Lancet,
371(9619), 1165–1172.
Feder, G. (2016). Beyond identification of patients experiencing intimate partner violence.
American Family Physician, 94(8), 600.
Feder, G., & Macmillan, H. (2012). 249: Intimate partner violence. Goldman’s Cecil Medi-
cine, 1571–1574.
Feder, G., Wathen, C. N., & MacMillan, H. L. (2013). An evidence-based response to inti-
mate partner violence: WHO guidelines. Journal of the American Medical Association,
310(5), 479–480.
Garcia-Moreno, C., Guedes, A., & Knerr, W. (2012). Understanding and addressing violence
against women: Intimate partner violence. World Health Organization.
Heise, L., & Garcia-Moreno, C. (2002). Violence by intimate partners. In E. G. Krug, L. L.
Dahlberg, J. A. Mercy, A. B. Zwi, & R. Lozano (Eds.), World report on violence and health
(pp. 87–121). Geneva: World Health Organization.
National Domestic Violence Hotline. (2017). Retrieved from http://www.thehotline.org and
1.800.799.SAFE (7233).
Renner, L. M., & Whitney, S. D. (2012). Risk factors for unidirectional and bidirectional
intimate partner violence among young adults. Child Abuse & Neglect, 36, 40–52.
Stöckl, H., Devries, K., Rotstein, A., Abrahams, N., Campbell, J., Watts, C., & Moreno, C. G.
(2013). The global prevalence of intimate partner homicide: A systematic review. The
Lancet, 38(2), 859–865.
Tiesman, H. M., Konda, S., & Amandus, H. E. (2012). Workplace homicides among U.S.
women: The role of intimate partner violence. Annals of Epidemiology, 22(4), 277–284.
Tjaden, P. G., & Thoennes, N. (2000). Extent, nature, and consequences of intimate partner
violence. Washington, DC: U.S. Department of Justice, Office of Justice Programs,
National Institute of Justice.
World Health Organization. (2013). Responding to intimate partner violence and sexual vio
lence against women: WHO clinical and policy guidelines. Retrieved from http://apps.who
.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf.
J
JENNER, EDWARD (1749–1823)
Edward Jenner was a British physician and ornithologist (a person who studies birds)
who lived in the late 18th and early 19th centuries. Jenner contributed to the field
of natural history and h uman medicine, and he was a noted philanthropist and pro-
moter of public health initiatives. He is best remembered for his pioneering work
in the discovery and propagation of the smallpox vaccination.
Jenner was born in 1749, the eighth son of the Reverend Steven Jenner, in the
predominantly rural area of Berkeley, Gloucestershire, in E ngland. Reverend Jen-
ner’s prominent position in the community allowed Edward to pursue a classical
education. At the age of 14, Edward began an apprenticeship with a local surgeon
that lasted seven years. In 1770, he continued his studies u nder the Scottish sur-
geon John Hunter (1728–1793), who during his tenure at London’s St. George’s
Hospital advocated the use of observation and scientific method in medicine. In
1773, Jenner returned to his native Berkeley where he established a successful med-
ical practice.
Jenner was a respected pillar of his local community. He helped establish scien-
tific societies such as the Fleece Medical Society or Gloucestershire Medical Soci-
ety. In 1788 he was elected to the prestigious Royal Society for his work on the
nested cuckoo. Through diligent observation and dissection he challenged the long-
held belief that the adult cuckoo pushed the eggs and hatchlings of its host from
the nest, demonstrating that it was the newly hatched cuckoo instead.
Shortly after his election into the Royal Society, in 1792 Jenner completed his
medical studies and received his doctorate from the distinguished medical faculty
of the University of St. Andrews in Scotland. His work centered on Angina pectoris,
or chest pain related to obstruction or spasm of the arteries around the heart.
Jenner was not the first to discover an immunological connection between the
benign bovine disease of cowpox and the immunity of milkmaids to deadly small-
pox. Observers throughout Europe suggested the idea as early as the 1760s but
with few tangible results. On May 14, 1796, Jenner took scrapings from cowpox
blisters on the hand of Sarah Nelmes, a milkmaid, and inoculated an eight-year-old
boy named James Phipps. Later, when exposed to smallpox, the child did not catch
the disease. A fter subsequent experimentation, Jenner reported to the Royal Soci-
ety the immunological importance of vaccination.
By 1803 the combined efforts of doctors and governments witnessed the increase
of vaccination throughout Europe and the world. That year Jenner became presi-
dent of the Jennerian Society, the purpose of which was to promote the eradication
372 J ENNE R , ED WA RD
Dr. Edward Jenner transfers cowpox virus from dairymaid to young patient. Jenner care-
fully studied and tested his hypothesis that inoculation with weaker viral material protects
against deadly infectious disease. (Wellcome Collection)
of smallpox through vaccination. The society was dissolved in 1809 and replaced
by the National Vaccine Establishment, whose conflicts in leadership convinced Jen-
ner to return to his practice in Berkeley.
Jenner was instrumental in the creation of the Medical and Chiurgical Society of
London, which became the Royal Society of Medicine. King George IV granted him
the honorary post of physician extraordinary in 1821. The remainder of Jenner’s
life was dedicated to further work in ornithology before his death from stroke com-
plications at the age of 73 in 1823.
Sean P. Phillips
See also: Bioterrorism; Infectious Diseases; Prevention; Smallpox; Vaccines
Further Reading
Bazin, H. (2000). The eradication of smallpox: Edward Jenner and the first and only eradication
of a human infectious disease. London: Academic Press.
Dawtrey Drewitt, F. (2013). The life of Edward Jenner M.D., F.R.S.: Naturalist, and discoverer
of vaccination. Cambridge, UK: Cambridge University Press.
Riedel, S. (2005). Edward Jenner and the history of smallpox and vaccination. Proceedings
(Baylor University, Medical Center), 18(1), 21–25.
K
KELLEY, FLORENCE (1859–1932)
Florence Kelley was a social reformer of the Progressive Era who studied and
documented the living and working conditions of America’s poor and immigrant
men, w omen, and children. Her political strategy was to “investigate, educate,
legislate, and enforce.” Initially, Kelley worked with politicians to legislate pro-
tections for women and children in the workplace. When these efforts failed, she
encouraged civic leaders and consumers to use their economic power to create and
maintain protections against abuse. Kelley was instrumental in developing the 1921
Sheppard-Towner Maternity and Infancy Protection Act, the first law that allocated
federal funds for health care. Some of the most important occupational health and
safety laws today are the result of Kelley’s tenacious efforts.
Florence Kelley was born on September 12, 1859, to Caroline Bartram-Bonsall
and William Durrah Kelley. Mr. Kelley was a powerful member of the Philadelphia
community. He served as a judge, 15-term congressman, founding member of the
Republican Party, and friend of President Abraham Lincoln. Religiously and politi
cally, he was a Quaker with a deep commitment to the abolition movement and the
rights of African Americans. Florence’s great-aunt, Sarah Pugh, was also a social
reformer. Pugh founded the Philadelphia Female Anti-Slavery Society (PFASS) and
promoted the boycott of sugar and cotton, goods made by slave labor. The PFASS
lobbied for emancipation, supported the Underground Railroad, and started a school
for African Americans. As a young girl, Florence’s father taught her to read using a
book that described the horrific working conditions of c hildren. Within a few years,
she read her father’s entire library. Through her young eyes, she started to notice
injustices and atrocities that even the adults failed to see. Florence recalled join-
ing her father on late night tours of Pennsylvania’s steel mills and glass factories.
While her father was awestruck by the sight of huge, bright, burning cauldrons
and loud, massive machines, Florence was horrified by young boys working in dan-
gerous jobs in dark, dirty, and hot factories. Kelley recalled “the utter unimpor-
tance of c hildren compared with products, in the minds of the people whom I am
among” (Child labor reforms and the National Child Labor Committee, n.d., p. 24)
In 1882, Florence graduated from Cornell University where she studied Greek,
Latin, algebra, and c hildren and the law. She wrote and published her senior the-
sis on legal policies affecting c hildren and founded the New C entury Guild for
Working Women in Philadelphia. She hoped to continue her studies at the Uni-
versity of Pennsylvania but was denied admission b ecause University of Pennsyl-
vania refused to accept females. Instead, she moved to Switzerland to study law at
374 K ELLEY, FLO RENCE
the University of Zurich. Zurich was a refuge for Europe’s anarchists, socialists,
and political radicals. Here, Florence was introduced to Frederick Engels. Social-
ism validated Florence’s early impressions of the exploitive conditions suffered by
the working class. It also opened her eyes to how capitalism pits worker against
worker in order to control discourse, the economy, and politics (Clark & Foster,
2006). Florence’s translation of Engels’s Condition of the Working Class in England in
1844 provided the English-speaking world with new perspectives on the Indus-
trial Revolution. The book documented the hardships, diseases, and mortality
rates of workers in Manchester and Liverpool, E ngland before and during the
Industrial Revolution. Problems w ere not specific to England. Worker oppression
by wealthy businessmen was a universal problem in the industrial age. Engels
wrote the preface to Kelley’s translation, recommending shorter working days, legal
limits on overtime for females and children, and breaking up the monopolies that
enabled worker abuse.
In 1884, Florence met and married Lazare Wischnewetzky, a Russian-Polish med-
ical student. Within three years, Mrs. Wischnewetzky gave birth to three c hildren.
The family moved to New York in 1886. However, Lazare was physically abusive
and after five years Florence fled with her c hildren to Hull House in Chicago. Hull
House was an organized community founded by Jane Addams to provide social
support, education, and cultural opportunities to new immigrants. The settlement
attracted many famous social reformers, such as Alice Hamilton, Clarence Darrow,
John Dewey, and Julia Lathrop. Florence worked evenings as a librarian and contin-
ued using the title “Mrs.” so that her children would not be stigmatized as illegiti-
mate. She reverted to her original name of “Kelley.”
Chicago was a major gateway between the East and the West, home to thriving
railroad, garment, and meatpacking industries. The city attracted new immigrants
and free men and w omen from the southern states, disadvantaged populations who
were highly vulnerable to financial abuse. Poorly paid workers and their families
lived in slums and suffered high rates of disease. For many years, wealthy business
owners hired private henchmen to prevent organized labor. In 1886, workers pro-
tested in Haymarket Square. What started as a peaceful rally with workers demon-
strating for an eight-hour workday quickly turned into a massacre. Eleven people
died a fter someone threw a bomb and the police opened fire. In 1894, Pullman
railroad workers went on strike in response to company cutbacks. Pullman reduced
wages and laid off employees without a commensurate reduction in the monthly
rent of company housing.
Kelley was interested in the garment industry. Originally, all clothing was made
by skilled tailors who sewed individual items from start to finish. The combination
of machines and cheap, unskilled labor opened the possibility of manufacturing
less expensive clothing using assembly lines. The problem was that machines moved
at much higher rates than h umans. Workers had to work faster plus endure 10-to
12-hour days without a break in order to keep up with the machines. The factories
were hot from the steam driven machines, and the work was repetitive and

K ELLEY, F LO R EN C E 375
constant. In order to meet consumer demand for cheap clothing, business owners
cut corners. They ran businesses out of converted basements, attics, or homes to
avoid paying rent. They crowded as many workers as they could into small quarters,
and they demanded long hours from the cheapest labor possible, women and
children. The heat from the machines, overcrowding, and cramped and exhausting
working conditions created sweatshops where communicable diseases spread
easily.
In 1892, Kelley convinced the Illinois Bureau of L abor Statistics to hire her
to investigate the garment industry. She discovered three-year-old children working
in sweatshops along with exhausted adults, high rates of occupational injuries, work-
places with no bathroom facilities, and areas that doubled as living and working
areas. Her reports described horrific working conditions in graphic detail. She
escorted politicians and civic leaders on tours so that they could see conditions first-
hand. In 1893, Illinois passed legislature that limited w omen’s workday to eight
hours, prohibited employment of children u nder 14 years old, and required a signed
work affidavit by parent or guardian for youth aged 14–16. The state hired Kelley as
the chief factory inspector. Her efforts w ere frequently met with obstructionism.
At one point, someone tried to shoot her. Angry and frustrated by the political and
Young c hildren fixing broken threads and empty bobbins on a spinning frame at a textile
mill in Macon, Georgia, 1909. To meet consumer demand for inexpensive clothing the gar-
ment industry exploited poor and immigrant women and children. Minimum wage and child
labor laws were developed to protect Americans from hazardous working conditions.
(Library of Congress)
376 K ELLEY, FLO RENCE
legal system, Kelley took night classes to earn her law degree, and in 1894 she gradu-
ated from Northwestern University School of Law. In 1895, the Illinois Supreme
Court struck down the eight-hour day ruling as unconstitutional and with a subse-
quent change in political administration, Kelley was fired as chief inspector.
In 1898, Kelley collaborated with Ellen Henrotin to form the Illinois Consum-
ers’ League. The group encouraged w omen to use their purchasing power to pres-
sure factories into improving working conditions. A year later, she moved to the
Henry Street Settlement in New York to develop and manage the National Con-
sumers’ League (NCL). The NCL compiled lists of factories that paid living wages,
limited workdays to no more than 10 hours per day, did not hire c hildren, and pro-
vided safe working conditions. These factories used white labels, labels that noted
the garment was made in a factory that obeyed state labor laws. Leveraging the eco-
nomic power of consumers turned out to be a successful ploy. Over the next few
years, Kelley helped to establish 64 local consumer leagues and collaborated with
labor unions to develop stricter regulations. When a businessman in Oregon chal-
lenged the 10-hour workday rule, Kelley worked with Josephine Clara Goldmark
to develop the Brandeis Brief. The Brandeis Brief was a lengthy report that presented
health data to highlight the adverse health effects of repetitive tasks and long work-
days. The report focused on women’s health and used the (outdated) argument that
women were weaker than men and therefore needed special protections. Supreme
Court Justice Louis Brandeis used the Brandeis Brief to support the rights of states
to enact laws limiting women’s workday. The Brandeis Brief is noteworthy because
it relied on medical and health data to determine law rather than legal arguments.
Based on the information in the report, the Supreme Court determined that Ore-
gon’s laws did not violate the constitution.
Throughout the remainder of her life, Kelley continued her efforts advocating
for minimum wage laws for w omen, campaigning against child labor, helping to
create the Federal Children’s Bureau and the 1921 Sheppard-Towner Maternity and
Infancy Protection Act. Her efforts served as the foundation for the 1938 Fair L abor
Standards Act and the allocation of federal funds for health care. She also helped
organize the National Association for the Advancement of Colored P eople (NAACP).
In her later years, she was criticized for opposing the Equal Rights Amendment
(ERA). Kelley believed the ERA would undermine many of women’s rights that she
had fought so hard to earn.
Florence Kelley grew up in a time when the United States was moving toward a
mechanized, consumer-driven society. P eople who immigrated to the United States
came for opportunity and were greeted with poverty, overcrowding, and physically
and emotionally abusive working conditions. Women and children w ere forced to
work long hours at low pay to meet consumer demand for cheap clothing. Following
her Quaker formation, Kelley was determined to improve the lives of vulnerable pop-
ulations. Many of the laws on minimum wage and child labor trace back to Kelley.
Sally Kuykendall
K O C H , HEIN R I C H HE R M ANN R O B E RT 377
See also: Bowditch, Henry Ingersoll; C hildren’s Health; Immigrant Health; Contro-
versies in Public Health: Controversy 5
Further Reading
Child labor reforms and the National Child L abor Committee. (n.d.). Retrieved from https://
www.upress.pitt.edu/htmlSourceFiles/pdfs/9780822943778exr.pdf.
Clark, B., & Foster, J. B. (2006). Florence Kelley and the struggle against the degradation
of life: An introduction to a selection from modern industry. Organization and Environ-
ment, 19(2), 251–263.
Dreier, P. (2012). Florence Kelley: Pioneer of labor reform. New Labor Forum, 21(1), 71–76.
doi:10.4179/NLF.211.0000011
Fee, E., & Brown, T. (n.d). Florence Kelley: A factory inspector campaigns against sweat-
shop labor. American Journal of Public Health, 95(1), 50.
Flannery, J. (2009). The glass h ouse boys of Pittsburgh. Pittsburgh: University of Pittsburgh
Press.
Kelley, F., & Sklar, K. K. (1986). Notes of sixty years: The autobiography of Florence Kelley;
with an early essay by the author on the need of theoretical preparation for philanthropic
work. Chicago: Published for the Illinois L abor History Society by C. H. Kerr.
Spargo, J. (1916). The bitter cry of the children. New York: MacMillan. Retrieved from https://
archive.org/details/bittercryofthech029787mbp.
The Sweating System. (2005). American Journal of Public Health, 95(1), 49–52.
KOCH, HEINRICH HERMANN ROBERT (1843–1910)

The identification and control of infectious diseases is one of the greatest public
health accomplishments of the 19th and 20th centuries. Prior to vaccinations, anti-
biotics, and the sanitation movement, outbreaks of cholera, dysentery, tuberculosis
(TB), typhoid fever, influenza, yellow fever, and malaria regularly appeared and
claimed many lives. Advancements in the treatment and prevention of infectious
diseases w ere possible because of the early microbiologists who identified bacteria
and demonstrated the association between pathogens and disease. German physi-
cian and bacteriologist Robert Koch isolated and identified the causal agents of
tuberculosis and cholera and made numerous scientific advances in the study of
anthrax, plague, malaria, and sleeping sickness. Koch’s staining and culture meth-
ods enabled others to study microorganisms and eventually find ways to control
infectious diseases. Koch’s postulates outline conditions that must be met in order
to prove that a particular pathogen c auses a specific disease. The postulates are still
used in medical research today. In 1905, Koch was awarded the Nobel Prize in
medicine.
Early Life and Research
Heinrich Hermann Robert Koch was born on December 11, 1843, in Clausthal,
Germany. Robert was 1 of 13 c hildren born to Mathilde Julie Henriette (Biewend)
378 K OCH, HEINRICH HE RMANN ROBERT
and Hermann Koch. Robert’s father was a mining official who earned a respectable
salary and worked diligently managing mines. Robert spent a lot of time with his
uncle, Eduard Biewend. Biewend was a well-educated man who took Robert on
field trips to collect plants, insects, and minerals. The specimens were examined by
magnifying glass, classified, and photographed. Robert planned to study linguistics
in college. However, the school headmaster encouraged him to study natural sci-
ences. He attended the University of Göttingen where he initially majored in botany,
physics, and mathematics before changing to medicine. The University of Göttin-
gen is a world-renowned university, claiming 40 Nobel Prize winners. Koch stud-
ied u nder Professor Friedrich Gustgav Jakob Henle, an early proponent of the germ
theory of disease. In 1866, Koch completed his medical degree, married Emmy Fratz,
and worked at the General Hospital in Hamburg. From 1870 to 1871, Koch served
as military surgeon in the Franco-Prussian War, gaining expertise in wounds and
septicemia. After leaving the military, he was appointed district physician in the
small, rural town of Wollstein. Isolated from libraries, equipment, and the scientific
community, Koch set up his own laboratory and launched vigorously into studying
bacteria. With Emmy working as an unpaid laboratory assistant, Koch developed
innovations such as the hanging-drop method for microscopic investigations and,
later, the use of photography and staining techniques to study bacteria.
By the m iddle of the 19th century, no diseases had been conclusively traced to
bacteria. However, there was growing evidence that anthrax was bacterial in origin.
Anthrax was an ideal microorganism for Koch to study. Wollstein was surrounded by
fields and potentially infected farm animals. The anthrax bacillus is gigantic in com-
parison to other bacteria, making it relatively easy to observe. Preventing the disease
would have enormous economic ramifications for Koch and the European livestock
industry. Koch isolated Bacillus anthracis and traced the life cycle from large rodlike
bacterium to tiny spore and back to bacterium. He presented his research to Fer-
dinand Cohn, professor of botany at the University of Breslau. Cohn immediately
recognized the significance and published Koch’s work in his botanical journal.
Koch continued his research in Wollstein until 1880 when he accepted an appoint-
ment at the Imperial Gesundheitsamt (Imperial Health Bureau) in Berlin. The
bureau provided Koch with equipment and qualified research assistants. Agar, the
jelly-like substance used as a growth medium for bacteria and fungi, was the idea
of Fannie Hess. Hess worked as an unpaid assistant alongside her husband, Wal-
ther Hesse. The flat dish that holds agar, a petri dish, was invented by Koch’s labo-
ratory assistant Julius Richard Petri. The solid-culture media allowed Koch to
cultivate pure cultures and to develop Koch’s postulates. Koch’s postulates expanded
on work by Henle, defining necessary conditions to prove that a particular patho-
gen causes a specific disease. The postulates are: (1) the microorganism must
be found in abundance within or on the infected organism (animal or h uman body)
and is not present in healthy organisms; (2) the microorganism can be collected from
the organism, isolated, and grown in pure culture; (3) inoculation of the cultured
microorganism into a healthy organism causes disease; and (4) microorganisms
collected from the inoculated, diseased organism are identical to the original
microorganism. Once Koch a dopted the postulates, he repeatedly insisted that only
by following those steps could causation be conclusively established.
Conflict with Pasteur
Koch’s anthrax research brought him into direct competition with French microbi-
ologist Louis Pasteur who, in contrast to the young and aspiring Koch, was at the
crest of a long and distinguished career. At first, Pasteur praised Koch’s innovations,
but later, largely b
ecause of Koch’s harsh and often personal attacks, their relations
became hostile. Ultimately, each claimed to have provided the final proof that the
anthrax bacillus caused anthrax. Pasteur’s argument rested on isolating the sus-
pected causal organism and on inoculating pure strains into otherwise healthy
animals—a procedure matching Koch’s postulates. Ironically, at no point in his
work on anthrax did Koch ever actually follow the postulates. In fact, his failure to
isolate and inoculate the organism was one basis for Pasteur’s criticism of Koch’s
purported proof.
Work on Tuberculosis
In the late 19th century, tubercu-

losis was the single most promi-
nent disease in the Western world.
There had been repeated, but
unsuccessful, attempts to show
that it was bacterial in origin.
Koch began studying the disease
in August 1881. His work was
kept absolutely secret and was
conducted at a frantic pace. Rely-
ing, as usual, on technological
innovations, Koch identified the
causal organism and proved cau-
sation by meticulously following
the postulates.
His first paper on tuberculosis,
which was presented on March
24, 1882, in a meeting of the
Berlin Physiological Society, was
Dr. Robert Koch contradicted popular miasma theory
a stunning success. The younger by isolating pathogens that cause cholera and tuber-
biologist Paul Ehrlich described culosis. Koch’s postulates name four criteria neces-
the meeting as his greatest expe- sary to match causal pathogen with disease. (Library
rience in science. Within two of Congress)
380 K O C H, HEIN R I C H HE RM ANN R O BE RT
years, Koch had also identified the causal organism for cholera. T hese achievements,
together with Pasteur’s successful anthrax and rabies inoculations, which came at
about the same time, probably did more than anything else to persuade the world
of the germ theory of disease in particular and of what has been called the etiologi-
cal research program in general.
Recognition and Setbacks
In 1891, the German government opened the Institute for Infectious Diseases and
appointed Koch as the first director. Among Koch’s students and colleagues at the
institute were Emil Adolf von Behring, who discovered diphtheria antitoxin; Wil-
liam Henry Welch, who was central to the rise of American bacteriology; Shibasa-
buro Kitasato, who helped develop tetanus antitoxin and identified the plague
bacillus; Gerhard Hansen, who discovered the leprosy bacillus; Christiaan Eijkman,
whose work led to the discovery of vitamins; and August von Wasserman and Paul
Ehrlich, who made important contributions to immunology.
All of this work brought world recognition to Koch, but there w ere clouds on
the horizon. Probably hoping to emulate Pasteur’s heralded and lucrative anthrax
inoculations, in 1890 Koch had prematurely announced discovery of a substance,
called tuberculin, which was expected to have prophylactic (preventive) or thera-
peutic significance for tuberculosis. As evidence accumulated that tuberculin was
ineffective, Koch’s professional credibility was tarnished. His reputation was also
compromised by developments in his personal life. Around 1890, Koch fell in love
with a 17-year-old actress named Hedwig Freiberg; he hastily divorced Emmy and
married Freiberg. Society ostracized the c ouple.
Embarrassed by professional setbacks, rejected by Berlin society, and dogged by
endless squabbles with competitors and former students, Koch spent more and more
time away from Berlin. In 1896 he was invited to investigate rinderpest, a disease
that was ravaging c attle in the British colony of South Africa. He next traveled to
Asia to study the bubonic plague. In 1898 and 1899, he visited Italy, Indonesia, and
New Guinea. Between 1902 and 1907, he made several trips to Africa to investigate
a range of human and animal diseases. In 1908, Koch visited Americ a and Japan.
After suffering a severe heart attack, Koch died on May 27, 1910, in Baden-Baden,
Germany. His ashes were deposited in a mausoleum in the Institute for Infectious
Diseases in Berlin.
K. Codell Carter and Sally Kuykendall
See also: Bioterrorism; Cholera; Emergency Preparedness and Response; Infectious

Diseases; Pasteur, Louis; Controversies in Public Health: Controversy 3
Further Reading
Brock, T. D. (1988). Koch: A life in medicine and bacteriology. Madison, WI: Science
Tech.
Byrne, J. P. (Ed.). (2008). Encyclopedia of pestilence, pandemics, and plagues. Westport, CT:
Greenwood Press.
Carter, K. Codell. (Trans.). (1987). Essays of Robert Koch. Westport, CT: Greenwood Press.
Carter, K. Codell. (2003). The rise of causal concepts of disease. Burlington, VT: Ashgate.
Centers for Disease Prevention and Control. (1999). Achievements in public health, 1900–
1999: Control of infectious diseases. Morbidity and Mortality Weekly Report, 48(29), 621.
Gradmann, C. (2000). Money and microbes: Robert Koch, tuberculin and the Foundation
of the Institute for Infectious Diseases in Berlin in 1891. History and Philosophy of the
Life Sciences, 22(1), 59–79. Retrieved from http://www.jstor.org.ezproxy.sju.edu/stable
/23332275.
Kaufmann, S. E. (2001). Koch’s dilemma revisited. Scandinavian Journal of Infectious Diseases,
Supplement, 33(12), 14–17. doi:10.1080/003655401753382468
Koch, R. (1891). Professor Koch’s remedy for tuberculosis. The British Medical Journal,
1(1568), 125–127.
Koch, R. (1900). The combating of tuberculosis in the light of the experience that has
been gained in the successful combating of other infectious diseases. Public Health, 13,
764–777. doi:10.1016/S0033-3506(00)80175-4
Koch, R. (1901). An address on the fight against tuberculosis in the light of the experience
that has been gained in the successful combat of other infectious diseases. The British
Medical Journal, 2(2117), 189–193. Retrieved from http://www.jstor.org.ezproxy.sju.edu
/stable/20269087.
Koch, R., Brock, T. D., & Fred, E. B. (1982). The etiology of tuberculosis. Reviews of Infec-
tious Diseases, 46(6), 1270–1274.
Lienhardt, C., Glaziou, P., Uplekar, M., Lönnroth, K., Getahun, H., & Raviglione, M. (2012).
Global tuberculosis control: Lessons learnt and f uture prospects. Nature Reviews Micro-
biology, 10(6), 407. doi:10.1038/nrmicro2797
Ligon, B. L. (2002). Biography. Robert Koch: Nobel laureate and controversial figure in
tuberculin research. Seminars in Pediatric Infectious Diseases, 13, 289–299. doi:10.1053
/spid.2002.127205
Morens, D. M. (2003). Characterizing a “new” disease: Epizootic and epidemic anthrax,
1769–1780. American Journal of Public Health, 93(6), 886–893.
Tuberculosis: A menace and a mystery and $4,500,000 in Christmas Seals. (1937). Life,
3(22), 30–37.
L
LEADING HEALTH INDICATORS
Health indicators are behaviors and characteristics that can be used to gauge quality
of life, health, or wellness of a community. For example, high levels of tobacco use
suggest the presence of cancer, heart disease, stroke, chronic obstructive pulmonary
disease (COPD), birth defects, and sudden infant death syndrome (SIDS). Public
heath efforts to reduce and prevent smoking would significantly improve health
within the community. Healthy People 2020 outlines 1,200 health objectives for the
nation. Health and medical experts from the U.S. Department of Health and H uman
Services (DHHS) Office of Disease Prevention and Health Promotion (ODPHP) ana-
lyzed the most important health issues of the nation and reduced the problems into
related categories. The 12 Leading Health Indicators (LHIs) are access to health ser
vices; clinical preventive ser vices; environmental quality; injury and vio lence;
maternal, infant, and child health; mental health; nutrition, physical activity, and
obesity; oral health; reproductive and sexual health; social determinants; substance
abuse; and tobacco use. Public health professionals use the LHIs to identify program
priorities, policies, partnerships, and progress toward goals. Reducing and improv-
ing the LHIs is an important step toward reducing disease and improving health
across the nation.
The 12 LHIs are described in detail by Healthy P eople 2020 resources. This
entry w ill highlight the LHI of tobacco. Tobacco use is the leading cause of death
in the United States. Tobacco c auses more deaths than HIV, alcohol, illicit drug
use, violence, and motor vehicle crashes, combined. Preventing the initiation of
tobacco use, promoting cessation, eliminating exposure to secondhand and side-
stream smoke, and eliminating tobacco-related disparities will go a long way
toward preventing disease, disability, death, and health disparities (Office on
Smoking and Health, 2017). Healthy People 2020 lists 21 tobacco use (TU) objec-
tives that range from reducing smoking (individual level) to increasing and
expanding medical screening for tobacco use (health systems level) or increasing
cigarette taxes (policy level). More recent surveys indicate positive progress
toward reducing cigarette smoking. Tobacco Use Objective 1.1 (TU-1.1), “Reduce
cigarette smoking by adults,” started at a baseline with 20.6 percent of adults report-
ing smoking and has decreased to 18.2 percent of adults (ODPHP, 2017). The
target is to reduce cigarette smoking to 12 percent of adults by 2020. Meanwhile,
adolescent smoking (TU-2.2) has shown no significant change. The goal is to reduce
adolescent smoking to 16 percent. Most recently, 18.1 percent of adolescents smoke.
384 LEADIN G HEALTH INDI C ATO RS
One area to focus public health efforts is cigarette smoking by race. Among adults,
mixed race and white, non-Hispanic populations have the highest rates of smok-
ing (24.5 percent and 20.6 percent, respectively), twice the rate of Asian Ameri-
can populations (10.2 percent). Focusing efforts within high-risk communities
ensures good stewardship of limited public health resources and maximizes
impact.
The Office of Smoking and Health’s Tips from Former Smokers program presents
the life stories of real p
eople whose lives w
ere altered due to tobacco. The cases are
presented by ethnic group, social group, person’s name, or disease. For example,
Ellie was a bartender who worked in a bar catering to LGBT patrons. Tobacco com-
panies actively targeted certain communities, including the LGBT community with
cigarette advertising. Although Ellie never smoked, her parents and patrons did.
Exposure to secondhand smoke resulted in asthma and severe, disabling attacks. In
order to stay alive, she had to quit her job. The Tips campaign offers free resources to
quit smoking (1-800-QUIT-NOW). The campaign is very successful. An estimated
500,000 p eople have quit smoking at a cost of $480 per person. Considering that
asthma cost approximately $3,300 per person per year between 2002 and 2007,
the cost benefit of the Tips campaigns is enormous (American Academy of Allergy
Asthma and Immunology, 2017). The Tips campaign demonstrates how targeting
one LHI has the potential to decrease many diseases, to help p eople live more
productive, healthier lives, and yield significant cost savings to individuals and
communities.
LHIs are useful tools to guide planning and implementing public health policy,
intervention, and prevention. LHIs allow public health professionals to ascertain
the leading health problems within communities, determine who is impacted the
most, and evaluate efforts.
Sally Kuykendall
See also: Birth Defects; Cancer; Care, Access to; Children’s Health; Goals and Objec-
tives; Healthy People 2020; Heart Disease; Nutrition; Social Determinants of Health;
Further Reading
Academy of Allergy Asthma and Immunology. (2017). Asthma statistics. Retrieved from http://
www.aaaai.org/about-aaaai/newsroom/asthma-statistics.
on racial and ethnic health disparities. Hyattsville, MD: Author. Retrieved from https://
Office on Smoking and Health, Centers for Disease Control and Prevention. (2017). Retrieved
from https://www.cdc.gov/tobacco/.
LESBIAN, GAY, BISEXUAL , AND T R ANSG ENDE R ( L G B T ) HEALTH 385
LESBIAN, GAY, BISEXUAL, AND

TRANSGENDER (LGBT) HEALTH
Nonheterosexual and transgender populations are at greater risk for many health
problems, such as bullying victimization, substance abuse, depression, sexually
transmitted diseases, intimate partner violence, and suicide. Lesbian, gay, bisexual,
and transgender (LGBT) health refers to the m ental and physical health of p eople
of minority sexual orientation as well as transgender individuals. Many of the health
problems experienced by LGBT populations—of which there are 5 million in the
United States (Ward, Dahlhamer, Galinsky, & Joestl, 2014)—are directly related to
lack of social acceptance and support. Due to persistent social rejection, LGBT youth
and adults are more likely to self-medicate with risky behaviors and are less likely
to access and use health care systems. Improving the health of this vulnerable pop-
ulation is an important goal of Healthy People 2020.
The first step t oward alleviating the health disparities of LGBT individuals is to
accurately identify the prevalence rates of sexual orientations (National LGBT
Cancer Network, n.d.). Since questions about LGBT identity w ere not included in
national, population-based surveys, it is difficult to estimate what percentage of the
population is LGBT. Given the multidimensional nature of sexual orientation, sur-
veys use different ways to capture this information (Institute of Medicine, 2011).
The four main methods are (1) self-identification as LGBT, (2) past or current
sexual activity, (3) sexual attraction, and (4) sexual fantasies (thoughts). Each form
of measurement yields different rates. Current estimates suggest that approxi-
mately 2 to 4 percent of U.S. adults self-identify as LGBT (Gates, 2011; Ward,
Dahlhamer, Galinsky, & Joestl, 2014). When assessing sexual orientation by
sexual activity, approximately 25 percent of U.S. adults report same-sex or bisexual
behavior (Gates, 2011). It appears that some individuals may engage in homo-
sexual or bisexual behaviors, yet still self-identify as heterosexual. Obtaining accu-
rate prevalence rates is an important first step toward improving public health.
This means that individuals must feel comfortable disclosing sexual behaviors and
trust that disclosures w ill not result in judgment, rejection, or stigma. Public health
communities strive to recognize the difficulties and complications posed by com-
ing out to multiple health providers and overcome obstacles using LGBT liaisons
within advisory and planning committees.
Historically, t here has been confusion regarding the health status of LGBT people.
In the early 1960s, LGBT identity was framed as a health problem by the American
Psychiatric Association (APA) when homosexuality was classified as a mental dis-
order in the Diagnostic and Statistical Manual of M ental Disorders (DSM), which is
one of the most commonly used and recognized resources by medical profession-
als around the world.
In the 1960s, it was believed that gay and lesbian individuals were internally
disordered and that homosexuality may be caused by traumatic events or psycho-
logical issues in early childhood or young adulthood. The listing of homosexuality
386 LES BIAN, G AY, BISEXUAL, AND TRANSGENDE R ( L G B T ) HEALTH
as a pathological problem was based on popular thought rather than rigorous sci-
ence. The DSM listing was eventually challenged by gay-affirmative research, which
showed that gay men are not psychologically different from their heterosexual
counterparts. In 1973, homosexuality was removed from the DSM as a m ental dis-
order. Although mental health professionals now recognize homosexuality as a
healthy expression of h uman sexuality, the stigma of homosexuality as a m
ental dis-
ease continues. In 1980, the third edition of the DSM listed transsexualism as a
mental disorder. Transsexualism was defined as a continuous desire to transform
one’s physical body to match self-ascribed gender identity. The fifth edition of the
DSM (2013) was updated to focus on the mental health aspects of transgendered
individuals. The updated term “gender dysphoria” describes the discontent and dis-
tress that transgender individuals experience as a result of the mismatch between
sexual anatomy at birth and cognitive identity. Past rejection, misdiagnosis, and mal-
treatment by such notable and prestigious medical organizations as the APA left a
scar on the LGBT community, which makes the stigmatized individuals reluctant
to seek treatment. Securing the health of the LGBT population requires health pro-
fessionals to acknowledge and compensate for past traumas.
Following the removal of homosexuality from the DSM, LGBT health research
shifted from studying homosexuality as a disorder to studying the health problems
experienced by LGBT people (Meyer & Northridge, 2007). LGBT health dispari-
ties refer to the differential health status between LGBT populations and non-
LGBT populations, specifically heterosexual and cisgender (nontransgender)
populations. Compared to heterosexual/cisgender individuals, LGBT individuals
have higher rates of many different mental and physical health problems. Health
problems vary by subgroup (Institute of Medicine, 2011). Men who have sex with
men (MSM) as well as transgender w omen are among the most vulnerable popula-
tions for human immunodeficiency virus (HIV). Seventy-eight percent of new HIV
infections in 2010 were among MSM (Centers for Disease Control and Prevention,
2012). The risk of obesity and obesity-related diseases are two times higher among
lesbian women compared to heterosexual and bisexual women (Boehmer, Bowen, &
Bauer, 2007). All LGBT individuals are at greater risk for substance abuse and
other mental health problems. Cigarette smoking rates are twice as high among
LGBT individuals (American Lung Association, 2010). Alcohol abuse, depression,
and suicide attempts also run approximately two times higher among LGBT adoles-
cents (Russell & Joyner, 2001). Public health addresses the unique needs of LGBT
individuals by ensuring the use of culturally competent health education materials
and health promotion activities. For example, smoking cessation materials should
contain images and language that include p eople from across the sexual orienta-
tion spectrum. Inclusive materials demonstrate respect and concern for sexual
minorities.
One of the most widely used theories to explain health disparities among
LGBT individuals is the minority stress model. According to this theory, p eople who
self-identify as LGBT are members of a stigmatized group. Although everyone
LESBIAN, GAY, BISEXUAL , AND T R ANSG ENDE R ( L G B T ) HEALTH 387
experiences some degree of stress, stigma and discrimination increase stress over
and above other normal life stressors. This additional burden increases the likeli-
hood of high-risk or escapism behaviors such as smoking, drinking alcohol, illicit
drug use, or high-risk sexuality. Over time, these behaviors increase the risk of
other health problems, such as sexually transmitted diseases, intentional and
unintentional injuries, and heart and lung diseases. To apply the minority stress
model, many LGBT individuals report harassment, teasing, and bullying in school.
These stressful incidents are on top of the normal stressful life events such as con-
cerns about dating partners, finances, or future. Experiencing verbal or physical
attacks and other social injustices can lead to running away, truancy, or substance
abuse. Avoiding or dropping out of school robs LGBT youth of educational oppor-
tunities that may limit future earning potential. A significant percentage of the
homeless youth are LGBT. Homelessness leads to other health problems, such as
substance use and limited access to health care services.
Other factors may compound the health disparities. Racial or ethnic identity,
nationality, education level, income, social class, religion, disability status, obesity,
and gender nonconformity can inflame social stigmas. These factors complicate and
further increase the likelihood of health problems. For example, gay and bisexual
men and transgender w omen of color are more likely to become HIV-positive com-
pared to white gay and bisexual men and transgender women. LGBT people of color
are at a higher risk of experiencing health problems due to the negative consequences
of both homophobia and racism.
When considering the health status of LGBT individuals, it is crucial to consider
protective f actors and personal resilience. Protective f actors guard against the adverse
health effects that accumulate from negative life experiences. For the LGBT indi-
vidual, protective factors may counteract the consequences of stigma and discrimi-
nation. Some known protective factors are connectedness to community, social
support, family support, and self-accepting the LGBT identity. Research shows that
LGBT individuals who are accepted and supported by their friends and family are
better able to cope with and manage stigma and discrimination. In fact, the strength
of parental acceptance is alarming. LGB adolescents rejected by their families are
eight times more likely to report attempted suicide, six times more likely to report
depression, three times more likely to report illegal drug use, and three times more
likely to report unprotected sex in comparison to LGB adolescents with low or no
family rejection (Ryan, Huebner, Diaz, & Sanchez, 2009). An emerging field of study
is in the area of resilience. It is believed that because of their exposure to stigma
and discrimination, LGBT individuals may develop positive psychological attributes
that benefit society as a whole. Experiences with stigma and discrimination create
a heightened sense of empathy and compassion toward the suffering of other people.
This knowledge and attitude promote connection with o thers in the community
and may, in turn, diminish the negative consequences of stigma and discrimination
for other disadvantaged groups. Future research may focus on how to foster resil-
ience without subjecting people to damaging experiences.
388 LES BIAN , G AY, B ISEX UAL, AND TRANS GENDE R ( L G B T ) HEALTH
LGBT individuals are at risk for a plethora of m

ental health disparities compared
to heterosexual and cisgender counterparts. Many of the health problems are directly
related to the stigma, discrimination, and prejudice associated with LGBT identity.
The goal of public health is to ensure the safety and social acceptance of all indi-
viduals in order to promote health and well-being. The next steps are to educate
the general public on diverse sexual orientations and gender identity in order to
reduce and eliminate discrimination and ensure that all members of society have
an opportunity to reach their maximum potential.
Nadav Antebi-Gruszka
See also: Addictions; Health Disparities; Healthy People 2020; Human Immunodefi-
ciency Virus and Acquired Immune Deficiency Syndrome; Prevention; Substance
Abuse and Mental Health Services Administration
Further Reading
American Lung Association. (2010). Smoking out a deadly threat: Tobacco use in the LGBT
community. Retrieved from http://www.lung.org/assets/documents/research/lgbt-report
.pdf.
Boehmer, U., Bowen, D. J., & Bauer, G. R. (2007). Overweight and obesity in sexual-minority
women: Evidence from population-based data. American Journal of Public Health, 97(6),
1134–1140. doi:10.2105/AJPH.2006.088419
Centers for Disease Control and Prevention. (2012). Estimated HIV incidence in the United
States, 2007–2010. HIV Surveillance Supplemental Report 2012, 17(4). Retrieved from
http://www.cdc.gov/hiv/topics/surveillance/resources/reports/#supplemental.
Gates, G. J. (2011). How many people are lesbian, gay, bisexual and transgender? UCLA: The
Williams Institute. Retrieved from http://escholarship.org/uc/item/09h684x2.
Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Build-
ing a foundation for better understanding. Washington, DC: The National Academies
Press.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual
populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5),
674–697.
Meyer, I. H., & Northridge, M. E. (2007). The health of sexual minorities: Public health per-
spectives on lesbian, gay, bisexual, and transgender populations. New York: Springer.
National LGBT Cancer Network. (n.d.). Best practices in creating and delivering LGBTQ cul-
tural competency trainings for health and social service agencies. Retrieved from http://www
.cancer-network.org/downloads/best_practices.pdf.
Russell, S. T., & Joyner, K. (2001). Adolescent sexual orientation and suicide risk: Evidence
from a national study. American Journal of Public Health, 91(8), 1276–1281. doi:10.2105/
AJPH.91.8.1276
Ryan, C., Huebner, D., Diaz, R., & Sanchez, J. (2009). Family rejection as a predictor of
negative health outcomes in white and Latino lesbian, gay, and bisexual young adults.
Pediatrics, 123(1), 346–352.
Savin-Williams, R. C. (2009). The new gay teenager (Vol. 3). Cambridge, MA: Harvard Uni-
versity Press.
LO C US O F C ONTR OL 389
Ward, B. W., Dahlhamer, J. M., Galinsky, A. M., & Joestl, S. S. (2014, July 15). Sexual ori-
entation and health among U.S. adults: National health interview survey, 2013. National
Health Statistics Reports, 77. Hyattsville, MD: National Center for Health Statistics.
Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr077.pdf.
LOCUS OF CONTROL
Locus of control is a principle that describes a person’s perception of the factors
that influence his or her life. Locus is Latin, meaning “place.”. Locus of control means
the “place of control.” The concept of locus of control traces back to ancient reli-
gions when p eople believed that disease was generated by supreme beings as pun-
ishment for sin or misdeed. In the treatise On the Sacred Disease (400 BCE) Hippocrates
proposed that the brain, not supernatural powers, effected disease and infirmity.
Scientific discoveries in bacteriology, virology, and pathophysiology proved that
many diseases are preventable and unrelated to what society dictates as moral or
immoral. Dr. Julian B. Rotter developed the modern concept of locus of control. As
a clinical psychologist, Rotter was interested in personality types and motivation
for achievement. Rotter defined internal versus external control as “the degree to
which persons expect that a reinforcement or an outcome of their behavior is con-
tingent on their own behavior or personal characteristics versus the degree to which
persons expect that the reinforcement or outcome is a function of chance, luck, or
fate, is under the control of powerful others, or is simply unpredictable” (Rotter,
1990, p. 489). For example, an individual with cardiovascular disease (CVD) may
perceive that the disease is the result of genetics (fate) and t here is little that can be
done to prevent or control disease progression. This person demonstrates an exter-
nal locus of control. Another individual with CVD may perceive that the disease is
related to personal lifestyle, and increasing physical activity and healthy diet can
prevent adverse consequences. This person demonstrates an internal locus of con-
trol. Locus of control is a fundamental principle of behavioral health b ecause the
person with internal locus of control starts from a place of personal empowerment.
It can be more difficult to motivate behavioral change among people with external
locus of control. Although locus of control is often presented as a dichotomous scale,
Rotter believed that perspectives exist on a continuum and may vary, depending on
the circumstances. This concept was confirmed by researchers in Scotland who
found that patients undergoing coronary bypass surgery scored higher on external
locus of control during the perioperative period and higher on internal locus of
control during rehabilitation (Rideout, Tolmie, & Lindsay, 2017). The concepts of
locus of control apply to many health topics, such as dietary supplements, brain
exercises, dental visits, violent offenders, and occupational health. The principle is
often used as a construct of health behavior theories and models, most notably social
cognitive theory. Imbedding the idea of locus of control within a broader theory
allows program planners and health educators to consider other factors that
influence locus of control. Overall, locus of control is a good starting point to
390 LO G I C M ODEL
understanding why some people are able to change behavior while others appear
resistant to change.
Sally Kuykendall
See also: Greco-Roman Era, Public Health in the; Hippocrates; Self-Efficacy; Social
Cognitive Theory
Further Reading
Lefcourt, H. M. (1982). Locus of control: Current trends in theory and research. Hillsdale, NJ:
Erlbaum.
Rideout, A., Tolmie, E., & Lindsay, G. (2017). Health locus of control in patients under
going coronary artery surgery—changes and associated outcomes: A seven-year cohort
study. European Journal of Cardiovascular Nursing, 16(1), 46–56. doi:10.1177/1474
515116636501
Rotter, J. B. (1954). Social learning theory and clinical psychology. Englewood Cliffs, NJ: Pren-
tice Hall.
Rotter, J. B. (1966). Generalized expectancies for internal versus external control of rein-
forcement. Psychological Monographs: General and Applied, 80(1), 1–28. doi:10.1037/
h0092976
Rotter, J. B. (1990). Internal versus external control of reinforcement: A case history of a
variable. American Psychologist, 45(4), 489–493. doi:10.1037/0003-066X.45.4.489
LOGIC MODEL
A logic model is a tool used to define, develop, and evaluate public health pro-
grams. The program planner draws the various program components as a flowchart,
and the chart becomes an organizational tool, providing an overview of the pro-
gram. Similar to a road map, a logic model helps users to see where they are and
the path they need to take to achieve a desired goal. By presenting the program as a
sequential arrangement, the logic model allows the viewer to map connections
between the efforts required to implement the program and the intended outcomes.
Public health professionals use logic models to represent the activities, functions, and
goals of a program. This valuable tool may be used to map one-time health promo-
tion events, programs, interventions, working groups, organizations, or health com-
munication brochures or other materials. It is a useful tool to outline the connections
between program parts in order to show how the program activities work.
There are different kinds of logic models. Most models are presented as t ables or
flowcharts and consist of four sections. The sections may be presented vertically
(from top to bottom) or horizontally (from left to right). The main sections are inputs,
activities, outputs, and outcome/impact. Inputs refer to the main resources that are
necessary for the program to occur, and they might include the staff, funding, an
advisory board, infrastructure, or equipment. Activities are the tasks that must be
conducted in order to plan and deliver the intervention. Development activities
LO G I C M ODEL 391
might include involving stakeholders, creating training manuals or other program

materials, or training those who will implement the program. Delivery activities are
related to the intervention itself, such as inviting individuals to participate in the
program, hosting workshops, or distributing brochures. Outputs are the products
of the activities and include the number of people trained or number of people par-
ticipating. Outcomes and impacts describe the desired changes as a result of the
project. Outcomes are the benefits and goals that the intervention aims to achieve,
and they are subdivided into three types: short-term, medium-term, and long-term.
Short-term outcomes describe changes in health opinions, attitudes, knowledge,
and skills. Medium-term outcomes refer to action-related changes such as behav-
ioral changes, changes in public health policy, or social changes. Long-term out-
comes, referred to as impacts, describe the sustained influence that the program
has on the individual or community. By stating the activities of the project, the pro-
gram planner, the funder, and the evaluator can track the program to ensure that it
is progressing as expected. If the project is not progressing, adaptations may be made
early, ensuring that any problems are corrected and conserving precious resources.
Program outcomes state the desired benefits and goals of the program, defining how
and what the program evaluator w ill study to ensure that the program achieved
what it promised to achieve.
The main benefit of using the logic model tool is that the public health practi-
tioner can visualize the intervention in its entirety, from the beginning to end. For
example, as an intervention against skin cancer, public health professionals decide
to design a poster to educate individuals about the harmful effects of direct sun
exposure and to encourage individuals to wear sunscreen. Health educators, fund-
ing, and a graphic designer (inputs) come together to plan and produce a poster
(output). The poster is displayed at local community pools (activities). Through
the outreach, sunbathers learn about skin cancer and the benefits of sunscreen
(short-term outcome), use sunscreen (medium-term outcome), and ultimately
reduce the number of p eople in the community diagnosed with skin cancer (long-
term outcome/impact). The logic model is a useful tool that defines a public health
project, identifies the resources and activities needed, and determines the desired
outcomes of the project.
Noora F. Majid
See also: Administration, Health; Centers for Disease Control and Prevention; Col-
laborations; Community Organizing; Evaluation; Intervention
Further Reading
Logic models in public health program management. (2012). Centers for Disease Control’s
National Public Health Improvement Initiative. Retrieved from http://www.doh.wa.gov
/Portals/1/Documents/1000/PMC-Logic%20Models%20May_16_12forWeb.pdf.
392 LO G IC M ODEL
Pell Institute. (2015). Using a logic model. The Pell Institute and Pathways to College Net-
work. Retrieved from http://toolkit.pellinstitute.org/evaluation-guide/plan-budget/using
-a-logic-model/.
W. K. Kellogg Foundation. (2006, February 2). Using logic models to bring together planning,
evaluation, and action: Logic model development guide. East B attle Creek, MI: Author.
Retrieved from https://www.wkkf.org/resource-directory/resource/2006/02/wk-kellogg
-foundation-logic-model-development-guide.
M
MALLON, MARY (1869–1938)
Mary Mallon was born in Ireland and immigrated to the United States in 1883 or
1884. A strong, healthy w oman, Mallon sought work in domestic service, advanc-
ing from maid to cook. Mallon would have passed unnoticed through history if it
were not for epidemiologist and sanitation engineer George Soper. In the winter of
1906–1907, Soper was hired to investigate an outbreak of typhoid in Oyster Bay,
New York. Typhoid is caused by the gram-negative bacterium Salmonella typhi.
The pathogen attacks the heart, brain, and respiratory systems, causing high
fever, headache, delirium, abdominal pain, intestinal hemorrhage, inflammation,
and in severe cases, death. Typhoid epidemics w ere not uncommon. They mostly
occurred in large, crowded cities, military bases, colleges, and universities. In 1906,
New York City recorded 3,467 cases and 639 deaths (Soper, 1939). Many more
cases probably went unreported. Doctors and public officials believed that typhoid
was caused by polluted water, milk, or sewer gas. Soper suspected human transmis-
sion by an asymptomatic carrier. When Mallon refused to provide bodily samples
for microscopic analysis, public health authorities imprisoned her. On release,
Mallon promised not to work as a cook. However, she soon returned to cooking,
including holding a position at a hospital where employees nicknamed her “Typhoid
Mary.” After evading public health authorities for several years, Mallon surrendered
and lived her final years on North B rother Island in New York. She is suspected of
infecting at least 51 p eople.
Mallon presents an interesting case study from several perspectives. From a
historical-biological perspective, Mallon was living evidence of asymptomatic h uman
carriers of disease. Tracking her—and the bacterium inside of her—provided pub-
lic health officials with essential clues regarding how to combat the spread of infec-
tious disease. From a social perspective, Mallon’s story is the case of a disadvantaged
immigrant worker who did not understand how she could make others sick when
she was not sick herself. She is an example of the many people who prepare food
in restaurants, hospitals, and h otels across the country and the need for public health
education on good handwashing and food preparation practices. From an ethical
perspective, Mallon’s case raises the question of how much authority public health
officials have, specifically, whether they possess the authority to imprison someone
who poses a danger to public health.
Little is known of Mallon’s childhood or family. She was a very private person,
and no family ever visited her during her time on North B rother Island. Mallon
first came to the attention of scientific communities in 1907. In the summer of 1906,
394 M ALLON, M ARY
Mallon was hired through Mrs. Stricker’s employment agency to cook for the f amily
and domestic staff of New York banker Charles Henry Warren. Warren rented a
house on Oyster Bay, Long Island, from Mrs. George Thompson. Six of the eleven
people in the h ouse came down with typhoid. A number of inconclusive reports
were written about this incident, but Thompson realized that mysteries regarding
the source of this contagion had to be revealed before the dwelling could be rented
again. Thompson hired George Soper, who had gained a reputation as an epidemic
fighter. A
fter inspecting the well, the overhead water tank, the cesspool, the privy
(outhouse), the food supplies, the bathing facilities, and eventually the sanitary con-
dition of the h ouse next door, Soper concluded that a h uman carrier might be
responsible. The timing of the illnesses coincided with a Sunday when the cook
had prepared a special treat of fresh peaches and ice cream. Soper surmised, “I sup-
pose no better way could be found for a cook to cleanse her hands of microbes and
infect a family” (Soper, 1939, p. 702).
Soper traced the cook and her employment history through Mrs. Stricker’s agency.
He found seven typhoid epidemics related to Mallon’s employment. Four months
into his investigation, Soper learned that Mallon was working as a cook on Park
Avenue in New York. He went to her place of employment:
I had my first talk with Mary in the kitchen of the house. I suppose it was an unusual
kind of interview, particularly when the place is taken into consideration. I was as
diplomatic as possible, but I had to say I suspected her of making people sick and
that I wanted specimens of her urine, feces, and blood.
It did not take Mary long to react to this suggestion. She seized a carving fork and
advanced in my direction. I passed rapidly down the long narrow hall, through the
iron gate, out through the area and so to the sidewalk. I felt rather lucky to escape.
(Soper, 1939, p. 704)
Soper attempted a second intervention with Mallon, confronting her at a rooming
house. Mallon denied ever having any symptoms of the illness or causing any cases
of typhoid. She again refused to give specimens. When Soper heard that Mallon
was leaving the Park Avenue position, he feared another epidemic. He contacted
the New York City health department who sent Dr. Josephine Baker to collect the
specimens. Mallon refused and Baker returned with two police officers. Mary ran
away. A
fter a three-hour manhunt, Mallon was found hiding in a neighbor’s out-
building. Dr. Baker recalled:
She fought and struggled and cursed. I tried to explain to her that I only wanted the
specimens and that then she could go back home. She again refused and I told the
policemen to pick her up and put her in the ambulance. This we did and the ride
down to the hospital was quite a wild one. (Soper, 1939, p. 706)
Mallon was placed in locked isolation at Willard Parker Hospital. Her fecal speci-
mens contained the typhoid bacteria. For several years, Mallon was forced to stay
in a small cottage at the Riverside Hospital on North B rother Island. Mallon sued
the city for imprisonment without due process of law. The judge dismissed her case
M ALLON , M A RY 395
on the grounds that the court was unwilling to take responsibility for releasing her.
In 1910, the public health department released her on the condition that she prom-
ise to avoid employment undertakings that involved food preparation. Moreover,
she was supposed to report to the New York State Department of Health every three
months. Mallon did not keep her promise, and for several years, the Department
of Health lost track of her.
Soper considered his investigation closed u ntil 1915 when Dr. Edward B. Cra-
gin of the Sloan Hospital for women contacted him. The hospital had an outbreak
of 25 cases of typhoid fever. The staff referred to the cook as “Typhoid Mary.” Cra-
gin asked Soper to come to the hospital. Soper confirmed that the cook was indeed
Mary Mallon. Mallon was sent back to the bungalow on North B rother Island. This
time she did not fight. She was older and life had been a struggle. For the next
23 years, Mallon lived in relative isolation on North B rother Island. She trained as
a laboratory technician and earned a fair wage. She took occasional trips to the city.
On December 25, 1932, a delivery man found Mallon on the floor, paralyzed by a
stroke. She was moved to Riverside Hospital and died on November 11, 1938. Bac-
teriologists and public health officials surmised that Mallon must have gotten a
mild case of typhoid fever as a child.
For a number of decades, Mallon would become an object of attention as count-
less numbers of bacteriologists, public health officials, lawyers, and local magistrates
sought to find ways of protecting the individual rights of potential typhoid carriers
while they worked at controlling the spread of typhoid. Historian Judith Walzer
Leavitt argued that in Mallon’s “epic b attle with public health officials she won a
pyrrhic victory,” in that public health theorists learned that in their “subsequent
interactions with healthy carriers,” they needed to base their actions on both “labo-
ratory findings” and “socially sensitive policies.” Historian John Andrew Men-
delsohn disagreed with some of Leavitt’s interpretations and argued that what
public health officials learned was that isolation needed to be the exception and
not the rule—typhoid carriers needed to be kept under constant surveillance for
reasons of personal hygiene and food handling regulation. Researcher Norman
Gibbins noted that “Typhoid Mary’s” plight has a g reat deal to tell us about how to
cope with contemporary emergent diseases, including AIDS, Ebola virus, and
bovine spongiform encephalopathy.
Marouf A. Hasian Jr. and Sally Kuykendall
See also: Baker, Sara Josephine; Code of Ethics; Epidemic; Food Safety; Handwash-
ing; Infectious Diseases; Quarantine
Further Reading
Byrne, Joseph P. (Ed.). (2008). Encyclopedia of pestilence, pandemics, and plagues. Westport,
CT: Greenwood.
David, M. Z. (Ed.). (2015). Infectious diseases: An encyclopedia of causes, effects, and treatments
(3 vols.). Santa Barbara, CA: Greenwood.
396 M ASTE R SETTLEMENT AGREE MENT (MSA)
Gibbins, L. (1998). Mary Mallon: Disease, denial and detention. Journal of Biological Educa-
tion (Society of Biology), 32(2), 127.
Greenwood, V. (2015). The frightening legacy of Typhoid Mary. Smithsonian, 45(11), 1.
Leavitt, J. W. (1992). Typhoid Mary strikes back: Bacteriological theory and practice in early
twentieth-century public health. Isis, 83(4), 608–629.
Marineli, F., Tsoucalas, G., Karamanou, M., & Androutsos, G. (2013). Mary Mallon (1869–
1938) and the history of typhoid fever. Annals of Gastroenterology: Quarterly Publication
of the Hellenic Society of Gastroenterology, 26(2), 132–134.
Soper, G. A. (1939). The curious c areer of Typhoid Mary. Bulletin of the New York Academy
of Medicine, 15(10), 698–712.
Tunc, T. E. (2008). Mallon, Mary (1869–1938). Santa Barbara, CA: ABC-CLIO.
MASTER SETTLEMENT AGREEMENT (MSA)

Between 1987 and 1993, medical expenditures due to smoking increased from
$21.9 billion to $50 billion. Over 43 percent of the costs w ere paid by Medicare,
Medicaid, and other federal and state sources (Medical-Care Expenditures Attrib-
utable to Cigarette Smoking—United States, 1993, 1994). In 1994, the state of Mis-
sissippi filed a lawsuit against the tobacco industry seeking to recover $940 million.
Other states quickly followed aiming to recover payments made by Medicaid for
patients that had experienced smoking-related illnesses. The Master Settlement
Agreement (MSA) was the resolution of the class action lawsuit filed by attorney
generals representing 46 states, five U.S. territories, and the District of Columbia
against tobacco companies Philip Morris USA, R. J. Reynolds, Brown and William-
son, and Lorillard. During the lawsuit, it was revealed that the tobacco companies
were intentionally targeting young p eople with cigarette advertising. Marketing plans
focused on replacing smokers who died with younger smokers, who, once addicted,
would purchase cigarettes for 20–40 years.
The MSA dictated that the petitioners could not file any future claims due to
unforeseen conditions. Secondly, the monetary judgments awarded would be paid
only to the states, territories, and District of Columbia that initiated the lawsuit and
that individuals seeking to obtain a financial judgement w ere prohibited. The “par-
ticipating manufacturers” w ere required to make yearly payments compensating the
above states for medical costs related to smoking-associated health conditions that
were paid by their state-run programs. In addition, criteria were established for a
code of conduct, how sales are conducted, the advertisement of tobacco-related
products, as well as levying penalties for the failure to adhere to the standards set
forth. Although the MSA originally only included five tobacco producers, l ater other
manufacturers decided to participate and agreed to follow the original terms of the
agreement.
The MSA was a way to allow the concerns of the litigants to be addressed with-
out the need for additional taxpayer dollars being spent on a prolonged lawsuit that
could have a potentially upsetting outcome. On the side of the manufacturers, they
were required to finance a national campaign targeting minors on the dangers of
M ATE R NAL HEALTH 397
smoking while also making annual payouts to the litigants. This lawsuit only
addressed the needs of the respective parties and did not prohibit f uture class action
lawsuits brought about by individuals, labor unions, or private health insurance
carriers (The Master Settlement Agreement, 2015).
The yearly payout calculations are completed by an independent auditor who
determines the amount to be paid by each “participating manufacturer.” Should
there ever be a disagreement regarding the amount to be paid the issue would then
be assessed by three arbitrators. Payments that are in dispute are held in an interest
earning escrow account while the dispute is being resolved. Additionally, a payment
of $12.75 billion was determined for the first five years. This amount can be adjusted
based on a ctual cigarette shipments and sales. The health care–related payments w ill
be made indefinitely, although the base payment would see a gradual increase.
Furthermore, the restrictions imposed on cigarette manufacturers are the strict-
est that have been implemented. These restrictions include targeting minorities, the
use of animated characters (cartoons), giving out complimentary samples, adver-
tising products if it is not within the location of a sales office, offering trademarked
apparel and merchandise, and petitioning the legislature for the benefit of the tobacco
industry. The MSA is an ongoing settlement contract, making it the largest civil reso-
lution in history.
Leapolda Figueroa
See also: Leading Health Indicators; Public Health Law; Truth Campaign, The; Con-
Further Reading
Apollonio, D. E., & Malone, R. E. (2010). The “We Card” Program: Tobacco industry “Youth
Smoking Prevention” as industry self-preservation. American Journal of Public Health,
100(7), 1188–1201. doi:10.2105/AJPH.2009.169573
Healton, C., & Nelson, K. (2004). Reversal of misfortune. American Journal of Public Health,
94(2), 186–191.
The Master Settlement Agreement: An overview. Tobacco Control L egal Consortium. (2015).
Retrieved from http://www.publichealthlawcenter.org/sites/default/files/resources/tclc-fs
-msa-overview-2015.pdf.
Medical-care expenditures attributable to cigarette smoking—United States, 1993. (1994).
Morbidity and Mortality Weekly Report, 43(26), 469.
Northridge, M. E. (2005, March). It takes lawyers to deliver health care. American Journal
of Public Health, 95(3), 376.
Sepe, E., Ling, P. M., & Glantz, S. A. (2002). Smooth moves: Bar and nightclub tobacco
promotions that target young adults. American Journal of Public Health, 92(3), 414–419.
MATERNAL HEALTH
Maternal health encompasses the health of women before, during, and after child-
birth. The experience of pregnancy and childbirth is individual to each m
other. For
398 M ATER NAL HEALTH
many, it is a time of celebration and personal fulfillment. For others, it is a time of

pain, suffering, and ill health. Each year, 65,000 women in the United States expe-
rience severe complications related to pregnancy, a condition known as severe
maternal morbidity (SMM) (CDC, 2016). Six hundred of these women die due to
infections, bleeding, high blood pressure, heart, or other conditions during preg-
nancy. Internationally, 830 women die e very year as a result of complications dur-
ing pregnancy and childbirth (WHO, 2015). Maternal mortality is higher among
women living in rural and poor communities. About 99 percent of deaths occur in
developing countries with scarce resources; about half of maternal deaths occur
in sub-Saharan Africa and one-third in South Asia. In many cases, complications
could be prevented. Public health clinics provide family planning care to men and
women of child bearing age, typically aged 15 to 49 years. Caring for both the
mother and the baby are crucial to ensure full-term delivery with as few birthing
complications as possible and the best start in life.
Historically, maternal health in America can be traced to Native American and
European practices, which viewed childbirth as a natural, nonmedical experience.
To early Native Americans, childbirth was a spiritual experience. Native women
limited activities and followed diets consistent with tribal beliefs. The Cherokee
avoided squirrel, raccoon, pheasant, speckled trout, rabbit, and salt during preg-
nancy. Although some beliefs were superstition—wearing a scarf around the neck
was believed to cause strangulation of the umbilical cord—other beliefs are consis-
tent with good health practices. Limiting salt intake reduces risk of high blood
pressure, preeclampsia and eclampsia, potentially fatal conditions. Some Native
American w omen went off alone to give birth in a quiet, comfortable place while
others gave birth in dwellings specifically constructed for pregnant w omen. Histo-
rians believe that most births w ere attended by one or more female companions,
family members, a doula, or elders of the community (Pearson, n.d.). Notes from
the time period suggest that Native American women experienced few complica-
tions and returned to normal activity levels soon after childbirth. Pilgrims followed
European practices of using female birth attendants. Mrs. Bridget Lee Fuller (d.
1667) is credited with delivering two or three babies on board the Mayflower in
1620. However, records show that Mrs. Fuller did not actually sail to America until
1623 when she arrived on the Anne (Beal, 2015). Midwives filled a social and reli-
gious role, teaching and encouraging young w omen how to care for themselves and
their babies. Midwives w ere highly respected and in demand. Mrs. Wiat of Dorches-
ter (d. 1705) reportedly attended over a thousand births, and Ruth Barnaby of
Boston (1664–1765) practiced for 40 years. As the New World expanded, Euro
pean midwives w ere recruited by towns, colonies, and even the Dutch West India
Company. In the South, female slaves tended to births of blacks and whites, alike.
Lacking formal education, midwives typically learned through hands-on practice.
Midwifery was considered a calling. Formal training, apprenticeship, or professional
organizing were considered unnecessary because childbirth was seen as a natural
process. Medical interventions w ere thought to be dangerous. This is not to say that
M ATER NAL HEALTH 399
childbirth was without danger. Maternal and infant deaths occurred due to bacte-
rial infections, epidemics such as smallpox, and diphtheria, or postpartum bleeding
and puerperal fever.
The medicalization of childbirth started in the middle of the 18th century with
the development of doctor of medicine as a professional field. Prior to this time,
anyone could practice medicine. Working as a doctor did not require a license or
professional training. To develop as a profession, doctors needed to define their role
and develop formal training schools. Originally, doctors intended to share obstetri-
cal cases with midwives. Midwives would tend to routine cases while doctors tended
to more complex deliveries. Midwife training schools w ere established in New York
City and Philadelphia. However, the cost of attending was prohibitive to w omen,
and practicing midwives believed that childbirth was a natural process. Midwives’
allegiances w ere to the individual patient, not an organized profession.
Dr. William Smellie (1697–1793) and Dr. William Hunter (1718–1783) are con-
sidered the f athers of obstetrics. The London physicians studied difficult cases and
devised procedures for resuscitating stillborn newborns and disentangling stran-
gulating umbilical cords. Since social norms of modesty frowned on males being
present during delivery, man-midwives, as they w ere known, had to make a strong
case for wealthy w omen to seek out recommended procedures. Although Smellie
believed that childbirth was a natural process, he also invented forceps to aid
delivery. Their experiences, knowledge, procedures, and diagrams were carefully
Pregnancy poses special health risks for mother and fetus in that new health problems may
emerge or existing health problems are aggravated. (Serhii Bobyk/Dreamstime.com)
documented and widely disseminated. Smellie’s book, a Treatise on the Theory and
Practice of Midwifery (1752), was published in nine editions, translated into French,
German, and Dutch, and sold throughout Europe and North America. Although
the book is described as “by far the finest obstetric text of the day, and still a treat
to read” (Dunn, 1995, p. F77), one New Zealand author questions how Smellie
and Hunter accessed their anatomical models. Most scholars assume that the
women died of natural causes. In a self-published book, Don Shelton asserts that
Smellie and Hunter hired p eople to murder pregnant w omen on the streets of Lon-
don, a practice known as burking. Shelton’s claim is based on statistical analysis of
the mortality rates during the time period of the studies (Shelton, 2010). It would
have been statistically improbable for Smellie and Hunter to gather 30 w omen in
their ninth month of pregnancy other than through burking. Historian Helen King
and others refute Shelton’s claims, noting that one cadaver could be used for mul-
tiple drawings, features may have been enhanced to compensate for body decom-
position, or the artist used nonhuman models (King, 2011). Regardless of how
Smellie and Hunter obtained their models, history shows that doctors were eager
to step into the role of midwives, and in doing so, pregnancy and childbirth were
transformed from a natural event to a medical procedure.
Employing both doctors and midwives, public health approaches reproductive
health from a biological, spiritual, and social perspective. Maternal care starts before
a woman gets pregnant. Family planning is critical. Unintended pregnancies, either
unwanted or mistimed, have serious health implications. Unwanted pregnancies are
those where the woman did not intend to get pregnant and does not want the child.
With mistimed pregnancies, the mother planned on getting pregnant. Yet, the preg-
nancy occurred earlier or later than expected. If the m other does not realize that
she is pregnant or is in denial, she is less likely to get prenatal care and may con-
tinue using alcohol, tobacco, or other teratogens. She may seek an abortion, which
puts her at risk for infection, bleeding, and depression. Mistimed pregnancies have
slightly better outcomes than unwanted pregnancies. Babies born of unwanted preg-
nancies are more likely to be low birth weight. Mothers are less likely to breast
feed, missing an important opportunity for early nutrition and building immunity.
Poor, young, and single females with low self-efficacy, poor communication skills,
and questionable support from partners are the least likely to plan pregnancy.
Although some families are able to handle the additional stresses of an infant in the
household, for many young girls, pregnancy aggravates existing dysfunctions and
increases risk of physical or emotional victimization. Public health services focus
on reducing unintended pregnancies, spacing c hildren, and limiting family size to
ensure better maternal and child health. Family planning services are considered
one of the greatest public health achievements of all time. The birth control move-
ment, led by Margaret Sanger (1879) legalized birth control counseling and clinics.
Today, public health f amily planning services prevent 1.3 million unintended preg-
nancies each year (CDC, 1999). Maternal death rate is down from 608 deaths per
100,000 live births in 1915, when family counseling was illegal, to 12 deaths per
M ATER NAL HEALTH 401
100,000 live births (Hoyert, 2007). National and local organizations, such as Planned
Parenthood, offer free family planning services. Future steps are to continue to
reduce unintended pregnancies. Currently, 49 percent of pregnancies are unin-
tended, and over half of t hose pregnancies are expected to result in abortion (Hen-
shaw, 1998).
The Progressive Era brought forth a series of public health movements to both
reform and promote maternal and child health care. The Maternity and Infancy
Care Act of 1921 provided funding services for m others and set a foundation for
other programs that still exist today. The Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC) was established for families on medical
leave to ensure a proper diet for children and their caregivers. Other programs
include the National Easter Seal Society and the March of Dimes Birth Defects
Foundations, which are known for prevention and treatment efforts. The United
Nations Population Fund works around the world collaborating with govern-
ments and health experts to train workers and improve conditions of reproductive
health services to promote an international standard for quality maternal health
(UNFPA, 2016).
Maternal care may be separated into preconception, antenatal, pregnancy, and
postpartum. Preconception planning is critical to ensure a healthy mother and child.
Plans should be realistic, taking into consideration health care, financial, social, and
material needs. The United States Department of Agriculture (USDA) calculates that
the average national costs for an infant are $16,175 in the first year (USDA, 2016).
Under the Family and Medical Leave Act (FMLA), mothers in the United States are
eligible for 12 weeks (84 days) of unpaid maternity leave. In comparison to other
countries, the United States falls short in supporting new mothers and fathers. Only
12 percent of U.S. workers are eligible for paid f amily leave, and the disadvantaged
are at greatest disadvantage. Twenty-two percent of those in the highest income
bracket are eligible for paid leave while only 4 percent of t hose in the lowest income
bracket are eligible (Bureau of Labor Statistics, 2013). Norway offers 322 days of
paid maternity leave. Fathers are eligible for 70 days of paid leave with an addi-
tional 26 weeks at 100 percent pay or 36 weeks at 80 percent pay (Citation, 2014).
Additionally, many countries offer a c hildren’s allowance, a small stipend to be used
toward baby clothes, diapers, food, and other supplies. Internationally, there is a
move to alleviate the disparity between new maternal leave and paternal leave.
Ensuring equal benefits supports the idea of equal responsibility in parenting, which
supports healthy childhood development and equality in other aspects of society.
The United States can learn much by following the lead of other countries in how
they perceive and support young m others and fathers.
Pregnancy is a high-risk time. New health problems may emerge or existing health
problems are aggravated as one body assumes responsibility for nurturing two. Dur-
ing preconception, w omen should discuss contraception and pregnancy plans with
their health care provider, consider screening for genetic diseases, address any
chronic illnesses, stop smoking, limit alcohol, and maintain a healthy life style. Being
aware of potential problems can prevent or compensate for difficulties. An estimated

10 percent of women of reproductive ages have difficulty getting pregnant. Through
careful screening and diagnosis, doctors can identify and treat possible causes of
infertility. With an estimated 60 percent of w omen in the United States overweight
or obese, weight gain during pregnancy is increasingly a concern. Recommended
weight gain during pregnancy for the woman of normal weight (BMI of 185–24.9)
is 25 to 35 pounds. Weight gain is important to ensure healthy fetal development.
Too little weight gain and the infant will be small. Small infants have difficulty breast-
feeding, which creates other developmental delays. W omen who are overweight or
obese are limited to gaining 15 to 25 pounds or 11 to 20 pounds, respectively. Too
much weight gain creates larger babies, which can cause difficulties in labor and
delivery. Also, the mother will have problems losing the weight after the baby is
born, increasing her risk for heart disease, diabetes, high blood pressure, stroke,
gall bladder disease, and some forms of cancer. Preconception is a good time to
connect with health education resources, create a healthy lifestyle, and start prac-
ticing pelvic floor muscle training to reduce the risk of urinary or fecal inconti-
nence, a condition that affects 6 to 29 percent of w omen (Mason, Glenn, Walton, &
Appleton, 1999).
Expecting mothers attend regular antenatal visits at doctors’ offices or clinics.
Visits increase in frequency as they get closer to the anticipated due date. At the
first visit, the health professional performs a routine physical exam, screens for
chronic or genetic diseases, orders antenatal lab work, prescribes prenatal vitamins,
and counsels the mother on diet and activity. Subsequent appointments monitor
the weight of m other and baby, progress to date, nutritional status, and connect the
parents with antenatal classes to develop birth and postpartum plans. Antenatal
appointments are important as many birth complications come with l ittle warning.
The major health problems experienced during pregnancy or a fter delivery are bleed-
ing, infection, high blood pressure, excessive weight gain, gestational diabetes,
hyperemesis gravid arum, and depression. Severe bleeding, infections, or high blood
pressure leading to eclampsia can result in death. Knowing and monitoring the preg-
nancy may prevent or alleviate problems. Postnatal care begins within the first 24
hours of delivery. The mother is monitored for bleeding, sepsis, blood pressure,
uterine prolapse, and other problems that may have presented during delivery. In
addition to mothers, this is a crucial time to monitor breathing, nutrition, and devel-
opment of the newborn.
Traditionally, women’s reproductive health was viewed as falling under social and
religious purview. Midwives cared for the mother and baby following natural, holis-
tic practices. With the development of medicine as a professional field of study,
birth and death w ere medicalized. Medicine introduced formal practices, tools, and
drugs to support and promote healthy births. Yet, the event that made the biggest
impact on maternal health was not having babies or at least not having babies in
close succession. As w omen’s rights expanded, so did the use of contraceptives,
family planning, and ultimately, improved health for women. Today, maternal care
M ATE R NAL HEALTH 403
starts preconception and continues throughout the months after birth. Midwives,
nurse practitioners, and obstetricians who use a combination of natural and medi-
cal techniques are further refining the field. W
omen are advised to follow a healthy
lifestyle of nutritious, balanced diet and physical activity. Although public health
has achieved g reat success in the area of maternal health, we still have a long way
to go. Other countries around the world provide better support during the first years
of life. Expanding maternity and paternity leaves to support young parents can cre-
ate a ripple effect influencing other aspects of society.
Christine M. Thomas and Sally Kuykendall
See also: Anderson, Elizabeth Milbank; Baker, Sara Josephine; Birth Defects; Dun-
ham, Ethel Collins; Eliot, Martha May; Ellertson, Charlotte Ehrengard; F amily
Planning; Infant Mortality; Intimate Partner Violence; Planned Parenthood; Sanger,
Margaret Louise Higgins; W omen’s Health
Further Reading
American College of Nurse Midwives. (2017). Retrieved from http://www.midwife.org/.
Beal, J. (2015). Bridget Lee Fuller: Mayflower myth vs. historic midwife. Midwifery T oday
with International Midwife, 115, 50.
Bureau of L abor Statistics. (2013). National Compensation Survey, March 2013. U.S. Depart-
ment of L abor. Retrieved from http://www.bls.gov/ncs/ebs/benefits/2013/ebbl0052.pdf.
Centers for Disease Control and Prevention (CDC). (1999). Achievements in public
health, 1900–1999: Family planning. Morbidity and Mortality Weekly Report, 48(47),
1073–1080.
Centers for Disease Control and Prevention (CDC). (2016). Maternal and infant health.
Retrieved from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/.
Citation. (2014). Parental employment benefits around the world. Retrieved from https://www
.citation.co.uk/news/parental-employment-benefits-around-t he-world.
Dunn, P.M. (1995). Perinatal Lessons from the Past: Dr. William Smelley (1697–1763), the
master of British midwifery. Archives of Disease in Childhood, 72, pp. F77–F78. Available
at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528415/pdf/archdischfn00061
-0079.pdf.
Henshaw, S. K. (1998). Unintended pregnancy in the United States. Family Planning Per-
spective, 30, 24.
Hoyert, D. L. (2007). Maternal mortality and related concepts. National Center for Health
Statistics. Vital Health Statistics, 3(33). Retrieved from http://www.cdc.gov/nchs/data
/series/sr_03/sr03_033.pdf.
King, H. (2011). Second opinion: History without historians? Medical history and the Inter-
net. Social History of Medicine, 24(2), 212. Retrieved from http://www.academia.edu
/643250/History_without_historians_Medical_history_and_the_i nternet.
Mason, L., Glenn, S., Walton, I., & Appleton C. (1999). The prevalence of stress inconti-
nence during pregnancy and following delivery. Midwifery,15, 120.
Pearson, E. H. (n.d.). Native American customs of childbirth. National History Education
Clearinghouse. Retrieved from http://teachinghistory.org/history-content/ask-a-historian
/24097.
404 M EASLES
Shelton, D. (2010). The emperor’s new clothes. Journal of the Royal Society of Medicine,
103(2), 46.
UNICEF. (2016). Maternal and newborn health. Retrieved from http://www.unicef.org/health
/index_maternalhealth.html.
United Nations Population Fund (UNFPA). (2016). Maternal health. Retrieved from http://
www.unfpa.org/maternal-health.
USDA. (2016). Cost of raising a child calculator. Retrieved from http://www.cnpp.usda.gov
/tools/CRC_Calculator/default.aspx.
Wertz, R. W., & Wertz, D. C. (2013). Notes on the decline of midwives and the rise of medi-
cal obstetricians. In P. Conrad & V. Leiter (Eds.), The sociology of health & illness: Critical
perspectives. New York: Worth.
World Health Organization (WHO). (2015). Maternal mortality: Fact sheet no. 348. Retrieved
from http://www.who.int/mediacentre/factsheets/fs348/en/.
MEASLES
Measles, also known as rubeola, is an airborne infectious disease that affects over
20 million p eople throughout the world and c auses over 200,000 deaths each year
(Caserta, 2014). Although a measles infection often begins with general symptoms
such as fever, coughing, and runny nose, individuals afflicted with measles begin
to form a characteristic rash on the face and body as well as small white spots on
the inside of the cheeks. Suspected measles infection can then be confirmed through
laboratory testing.
Measles, which is typically seen in children, is highly contagious and can spread
through coughing and sneezing. Although common in developing countries, mea-
sles is a very rare disease in the United States due to the comprehensive system of
vaccination that American children undergo, which includes building immunity to
the measles virus. The World Health Organization declared measles to be the fifth
vaccine-preventable disease to be eradicated from the Americas (World Health
Organization, 2016). They attributed this to a comprehensive 22-year effort to
implement mass vaccination against measles as part of the measles, mumps, and
rubella vaccine. A cost-effectiveness study on measles in Latin America and the
Caribbean alone estimates that vaccination will prevent over 3 million measles cases
and 16,000 deaths between 2000 and 2020. The success of measles vaccination
serves to underline the efficacy and importance of vaccination.
Although measles has been eradicated in the Americas and other areas through-
out the world, some countries still face the risk of measles infection due to lack of
vaccination. Measles is particularly dangerous b ecause of its high rate of complica-
tions such as diarrhea and secondary bacterial infections. Diarrhea from measles
can often cause death through severe dehydration and often necessitates the use of
medical management to maintain proper hydration levels. In countries like the
United States where such medical management and proper nutrition are available,
the measles-attributable fatality rate can be as low as 0.3 percent (Perry & Halsey,
2004). In underdeveloped countries, however, where such health care resources
M EASLES 405
are limited and populations suffer from high levels of malnutrition, the measles-
attributable fatality rate can reach as high as nearly 30 percent. Therefore, the prog-
nosis of measles in infected patients is often very dependent on external conditions
such as health care access and the ability to receive proper hydration, nutrition,
and medical care.
The history of measles affecting humanity is an extensive one. In the tenth century,
Rhazes, an ancient Persian physician, was one of the first clinicians to systematically
describe measles and disseminate that information between the M iddle East and
Europe. Throughout the following millennium, measles outbreaks affected Europe
and other continents on the planet, killing millions of individuals. It is estimated
that between the mid-19th century and 2005 alone, measles was responsible for
killing over 200 million p eople throughout the world (Torrey & Yolken, 2005).
Measles has been an endemic disease throughout h uman history, meaning that
many human populations have been chronically exposed to the disease. Through-
out this exposure, those populations developed a collective resistance against mea-
sles. This occurs when individuals who are unable to survive the illness are eliminated
from the population, leaving a population of individuals who show greater ability
to survive the measles virus. Additionally, since many of the adults in a population
were exposed to measles during their childhood, they developed an immune-based
resistance. Therefore, it is primarily the c hildren of these populations who do not
have immune-based resistance and are therefore at risk of becoming infected with
active measles virus. With the use of vaccination however, these children can become
protected through an artificially induced immune resistance, and t hese vaccinated
children can even act as a buffer to protect unvaccinated children from measles
infection.
Another fascinating discovery regarding measles, which can be applied to many
different human-to-human infectious diseases, is the idea of critical community size.
The critical community size is the lowest population size in which an infectious
disease can survive indefinitely. Studies regarding a series of measles outbreaks in
the 1950s in the United States led to the observation that measles only persisted in
communities above a certain size threshold. This observation led to the theory that
in communities with populations below the critical community size, there were too
few susceptible hosts and too many resistant individuals that measles and other
infectious diseases could not continue their transmission and would become extinct.
This theory serves to support the importance of vaccination, since the number of
resistant individuals can be artificially inflated through vaccination and therefore
prevent measles and other infectious diseases from being able to efficiently find sus-
ceptible hosts. The idea that t here can be a true and full population-wide resistance
against an infectious disease has been enabled by the advent of vaccination.
This population-wide resistance to measles, however, played a large role in h
uman
history before vaccination, particularly in interactions between civilizations that w ere
resistant and civilizations that w ere not resistant. When the European explorers and
settlers came to the Americas, the indigenous populations had not been exposed to
406 M EDI C AID
a variety of diseases, including measles. Since they did not exhibit this resistance,
and measles was endemic in the Europeans, many indigenous people became
infected with the measles virus. The death toll of such infections, which not only
included measles but also smallpox, diphtheria, typhoid, and tuberculosis, was stag-
gering and led to the collapse of the indigenous populations in the Americas.
Although clinicians may view measles from the perspective of treating individu-
als, public health professionals seek to alleviate the burden of measles at a population-
wide level. Widespread vaccination is undoubtedly the most effective and crucial
strategy for eradicating measles in each country of the world. Logistical challenges
in distributing measles vaccines to underdeveloped countries are a barrier, and inno-
vative approaches to vaccine manufacturing, quality control, and distribution are
being developed to overcome such challenges. As more governmental and non-
governmental humanitarian funds are poured into global vaccination efforts, the
21st century is likely to include the global eradication of measles.
Shayan Waseh
See also: Epidemic; Global Health; Infant Mortality; Infectious Diseases; Influenza;
Vaccines; World Health Organization; Controversies in Public Health: Controversy 3
Further Reading
Caserta, M. T. (2014). Measles. Merck Manual: Professional edition. Kenilworth, NJ: Merck
& Co.
Perry, R. T., & Halsey, N. A. (2004). The clinical significance of measles: A review. Journal
of Infectious Diseases, 189(S1), 4–16.
Torrey, E. F., & Yolken, R. H. (2005). Their bugs are worse than their bite. Washington Post.
Retrieved from http://www.birdflubook.org/a.php?id=40&t=p.
World Health Organization. (2016, September). Region of the Americas is declared free of mea-
sles. Retrieved from http://www.paho.org/hq/index.php?option=com_c ontent&view
=article&id=12528:region-a mericas-declared-f ree-measles&Itemid=1926&lang=en.
MEDICAID
Medicaid is a health insurance program for low income p eople, those who e ither
do not earn enough money or do not have enough resources to cover health care
needs. The Medicaid program is administered by the Centers for Medicare and Med-
icaid Services (CMS), a division of the U.S. Department of Health and Human Ser
vices (DHHS). The program was designed to ensure that America’s poor population
has access to affordable, quality medical services. Medicaid was created on July 30,
1965, when President Lyndon B. Johnson enacted Title XIX of the Social Security
Act. The Health Insurance for the Aged (Medicare) Act and Medicaid offered states
matched funding to support health care for low income children, their caretaker
relatives, p
eople who are blind, and p
eople with certain disabilities. Although states
are not required to participate in Medicaid, all states currently do participate. A
M EDI C AID 407
condition of funding is that the state follows federal Medicaid laws on basic eligi-
bility, scope, and type of services. Otherwise, states can tailor their benefits. This
means that Medicaid programs vary from state to state. The CMS monitors systems
to ensure adherence to federal guidelines and to prevent fraud.
Over the years Medicare eligibility, services, and requirements have evolved as
health and medical needs change. In 1967, Medicare introduced the Early and Peri-
odic Screening, Diagnosis, and Treatment (EPSDT) program. The EPSDT program
ensures that c hildren covered by Medicaid receive regular medical screening to assess
childhood development and to provide recommended immunizations, health edu-
cation, and dental care. EPSDT services are critical to early identification and treat-
ment to prevent long-term health problems. The Medicaid and CHIP Payment and
Access Commission (MACPAC) estimate that more than 40 million children were
eligible for EPSDT in 2014. Yet, less than 60 percent took advantage of these ser
vices. In 1981, the federal government implemented freedom of choice waivers.
These waivers allow the states to waive certain federal requirements in order to test
new programs or services. The federal government also introduced the idea of Dis-
proportionate Share Hospitals (DSHs). Prior to the DSH ruling, patients covered
by Medicaid w ere often turned away from or quickly transferred out of prestigious
or wealthy medical institutions. DSH-supported hospitals willing to accept and pro-
vide care to a higher proportion of low income patients to receive additional incen-
tives. In 1986, Medicaid was expanded to include infants and pregnant w omen with
income up to 100 percent of the Federal Poverty Level (FPL). The following year,
coverage was expanded to mandate coverage for c hildren up to 6 years old and
pregnant w omen who earned up to 133 percent of the FPL. In the 1990s, prescrip-
tion drug rebate program was created and phased-in coverage for children aged 6
to18. The Affordable Care Act (ACA) expanded Medicaid further and offered sub-
sidies for individuals who are not covered by employer health insurance plans and
willing to purchase insurance through the health insurance marketplace. Challenges
remain in how to ensure accessible, quality health care within an environment of
rising health care costs.
Sally Kuykendall
See also: Affordable Care Act; Centers for Medicare and Medicaid Services; Children’s
Health; Maternal Health; Medicare; Planned Parenthood; Prescription Drugs; Roo
sevelt, Franklin Delano; Social Security Act; U.S. Department of Health and Human
Services; Controversies in Public Health: Controversy 1
Further Reading
Centers for Medicare and Medicaid Services. (2017). Retrieved from https://www.cms.gov/.
Medicaid. (2017). Retrieved from https://www.medicaid.gov/index.html.
Medicaid and CHIP Payment and Access Commission. (2017). Retrieved from https://www
.macpac.gov/.
408 M EDIC AR E
MEDICARE
Medicare is a health insurance program for people with certain disabilities, people
with end stage renal disease (ESRD), or p eople age 65 and older. The Medicare pro-
gram is administered by the Centers for Medicare and Medicaid Services (CMS), a
division of the U.S. Department of Health and Human Services (DHHS). The pro-
gram was designed to ensure that the U.S. elderly population has access to afford-
able, quality medical services and does not fall into poverty due to the combination
of fixed income and rising medical costs.
After the G
reat Depression of the 1930s, the United States moved into a period
of economic expansion. Contrary to what one would expect, life expectancy increases
during times of economic recession or depression and decreases during times of eco-
nomic growth. (Experts believe that people are more likely to engage in unhealthy
behaviors—smoking, drinking, or lack of exercise—during times of economic
boom.) From 1933 to 1936, life expectancy decreased for all groups. Nonwhite
Hungry, unemployed men wait for meals at crime boss Al Capone’s charitable soup kitchen
in Chicago. President Franklin D. Roosevelt envisioned a system of care for the elderly liv-
ing on fixed income. On July 30, 1965, President Lyndon B. Johnson enacted The Health
Insurance for the Aged (Medicare) Act providing hospital, extended care, and home health
care to all Americans age 65 and over. (Social Security Administration)
M EDI C A R E 409
males lost over six years of average life span (Tapia Granados & Diez Roux, 2009).
President Franklin Roosevelt feared the rising costs of medical care for elderly
people who were living on fixed incomes. He dreamed of a national system of
health insurance. However, he also knew that the American Medical Association
opposed the idea, and in order to get the Social Security Act passed, he removed
national insurance from Social Security legislation. President Harry S. Truman was
more vocal in calling for national health insurance. Many seniors lived in poverty
and only about half had health insurance. In 1949, Minnesota senator Hubert
Humphrey proposed the first national health care bill entitled Post Hospital Care
for the Aged. Humphrey explained, “the moral test of a government is how that
government treats those who are in the dawn of life—the children; the twilight of
life—the elderly, the shadows of life—the sick, the needy, and the handicapped”
(Shalala, 2000, p. 2). Humphrey’s Bill did not pass; however, his efforts were con-
tinued by President Lyndon B. Johnson. On July 30, 1965, Johnson enacted an
amendment to the Social Security Act. The Health Insurance for the Aged (Medi-
care) Act and Medicaid provided hospital, extended care, and home health care to
all Americans age 65 and over. Johnson signed the bill into law at the Truman
Library in Independence, Missouri, in the presence of former president Truman.
Immediately after signing the legislation, Johnson enrolled Truman as the first
Medicare beneficiary. Mrs. Truman was the second. Louisiana senator Russell Long
described the bill as “the largest and most significant piece of social legislation ever
to pass Congress in the history of our country. It w ill do more immediate good, for
more p eople, who need the attention of their government, than any other Bill that
Congress has ever enacted” (Shalala, 2000, p. 4). More than 19 million people
enrolled in Medicare within the following year.
Over time, Medicare has evolved as needs and health services change. In 1972,
Medicare eligibility was expanded to include p eople with disabilities and people
with end stage renal disease (ESRD). The following year, Medicare was amended to
include coverage by health maintenance organizations (HMOs). In 1977, the Health
Care Financing Administration (HCFA) was established to manage the Medicare
and Medicaid programs. In 1988, coverage was expanded further to include hos-
pital and skilled nursing facilities, outpatient prescriptions (later repealed), and caps
on liability.
Today, Medicare is managed by the Centers for Medicare and Medicaid Services.
The program consists of three main parts. Medicare Part A (Hospital Insurance)
covers inpatient hospital care, skilled nursing care, hospice care, and some home
health care. Part A is financed through taxes paid while working. Medicare Part B
(Medical Insurance) covers necessary medical supplies, doctors’ services, and out-
patient care, such as physical and occupational therapy. Part B is financed through
insurance premiums. Medicare prescription drug coverage is an insurance program
that covers prescription drug costs. As of 2017, more than 57.6 million people
were enrolled in Medicare plans with 25 million p eople enrolled in Medicare’s
410 M EDI C INE
prescription drug plans (Centers for Medicare and Medicaid Services). The retiring
baby-boom generation is expected to push enrollment over 80 million, creating
an enormous challenge for the federal government and younger generations.
Sally Kuykendall
See also: Affordable Care Act; Aging; Centers for Medicare and Medicaid Services;
Disability; Disability Movement; Medicaid; Prescription Drugs; Roosevelt, Frank-
lin Delano; Social Security Act; U.S. Department of Health and Human Services;
Further Reading
Centers for Medicare and Medicaid Services. (2017). Retrieved from https://www.cms
.gov/.
Medicare. (2017). Retrieved from https://www.medicare.gov/.
Shalala, D. (2000). Remarks by the Hon. Donna E. Shalala, Former U.S. Secretary of Health
and Human Services at the 35th Anniversary event, Hubert H. Humphrey Building, U.S.
Department of Health and Human Services, Washington, DC, pp. 2–7. Retrieved from
https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/CMS35th
Anniversary.pdf.
Tapia Granados, J. A., & Diez Roux, A. V. (2009). Life and death during the Great Depres-
sion. Proceedings of the National Academy of Sciences of the United States of America, 106(41),
17290–17295. Retrieved from http://doi.org/10.1073/pnas.0904491106.
MEDICINE
Medicine is the science and practice of diagnosing, treating, and preventing disease
at the individual level. Medicine is part of public health in that medicine promotes
health and prevents disease. The main difference between medicine and public
health is that medicine focuses on individual patients and public health focuses on
groups of p eople. The two systems are separate yet related. Community health
centers, also known as public health clinics, practice medicine, serving as medical
homes for vulnerable populations. Medicine plays an important role in ensuring
that some conditions, such as meningitis, do not become an epidemic. On the other
hand, individualized medical care requires a high level of expertise and is very
expensive. Society struggles to sustain a health care system that primarily depends
on individualized medicine. To ensure the best possible care while still maintaining
health care costs, experts are seeking optimal ways to integrate medicine and pub-
lic health services (Committee on Integrating Primary Care and Public Health, 2012).
Medical services are typically provided by a doctor, nurse, dentist, nutritionist,
or other licensed health care professional who has completed the education, train-
ing, and licensing requirements to practice in the clinical area. Preparation for a
professional c areer in medicine typically requires that students complete courses
in the social sciences, natural sciences, and mathematics. Courses in anatomy and
M EDI C INE 411
physiology are central to understanding normal and abnormal functions of the

human body and to advance to caring for patients. Training also includes time in
supervised clinical practice where the student gains hands-on experience in interact-
ing with patients (and diseases), learning clinical routines and observing experienced
professionals. A fter basic training, the health professional may specialize in a certain
type of medicine. Medical specialties are often categorized by body system (cardiol-
ogy, neurology, or endocrinology), patient type (pediatrics, adolescent health, or geri-
atrics), or disease (trauma, oncology, or HIV/AIDS). All medical professionals work
under a code of ethics requiring honesty, integrity, professionalism, and respect for
others. The code of ethics promotes trust between patient and provider.
Under the medical model, care is individualized to the patient. For example, if
individuals develop symptoms of difficulty breathing, they can go to a doctor’s office
or clinic where they are assessed, examined, and interviewed. The doctor, physi-
cian assistant (PA), or nurse practitioner (NP) gathers information on symptoms,
past medical history, family history, and recent exposures. The health care profes-
sional orders diagnostic tests, such as lung function tests, allergy testing, chest X-ray,
or electrocardiogram. Based on the physical exam and test results, the medical pro-
vider rules out certain diseases and makes a possible diagnosis. If the patient is
diagnosed with asthma, the caregiver would prescribe medicine for long-term asthma
control and quick relief in emergencies. Together, the patient and health care pro-
vider develop a personal asthma action plan that includes how to use the prescribed
treatment, how to recognize and avoid asthma triggers, and how to use tools, such
as a peak flow meter to monitor the treatment plan. The health care provider fol-
lows up regularly with the patient to ensure effective asthma control. Each phase
of care (diagnosis, treatment, and prevention of reoccurrences) is individualized to
the patient. Medicine works in parallel to public health preventing further exacer-
bation of disease and promoting health.
Unfortunately, the current system of medical care is reactionary, expensive, and
fragmented. In 2007, the American Academy of Family Physicians (AAFP), American
Academy of Pediatrics (AAP), American College of Physicians (ACP), and Ameri-
can Osteopathic Association (AOA) developed the Joint Principles of the Patient-
Centered Medical Home (PC-MH). Under the PC-MH model, each person has a
medical home, a place where he or she can get comprehensive medical services.
Each patient has a personal physician who monitors the patient’s health and pro
gress. The person can go to the medical home for acute medical care, chronic dis-
ease care, wellness, and health promotion services. The system is oriented t oward
caring for the w hole person across all health care systems, clinics, hospitals, reha-
bilitation units, and community-based services. Advantages of the PC-MH model
are that the patient can access uninterrupted, comprehensive, culturally competent
medical care, and the care can be coordinated through a central archive of medical
records (AAFP, AAP, ACP, & AOA, 2007). The PC-MH system mimics the national
health services of other countries. Challenges exist in how to secure and coordinate
such a complex system of care for so many people.
412 M ENIN G ITIS
The main difference between medical care and public health is that medicine
focuses on individual treatment whereas public health focuses on groups of p
eople.
Neither system is superior to the other. Both systems work together to prevent dis-
ease and promote health. The next steps are to find ways to integrate medicine and
public health in order to ensure the best possible care with minimal public and
personal expenses.
Sally Kuykendall
See also: American Medical Association; Community Health Centers; Greco-Roman

Era, Public Health in the; Health; Health and Medicine Division of the National
Academies of Sciences, Engineering, and Medicine; Hippocrates; Renaissance, Pub-
lic Health in the
Further Reading
AAFP, AAP, ACP, & AOA. (2007). Joint principles of the PCMH. Retrieved from http://www
.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint
.pdf.
Committee on Integrating Primary Care and Public Health. (2012). Primary care and public
health: Exploring integration to improve population health. Washington, DC: National Acad-
emies Press.
National Heart, Lung and Blood Institute. (2014). What is asthma? Retrieved from https://
www.nhlbi.nih.gov/health/health-topics/topics/asthma.
MENINGITIS
Meningitis is an acute inflammation of the membranes—called the meninges—that
surrounds and protects the central nervous system (CNS). The inflammation is pri-
marily caused by bacterial or viral infection and may also be caused by head injury,
cancer, or certain drugs. Meningitis outbreaks are serious public health emergen-
cies. Invasion of the host and reproduction of the infectious organism can progress
rapidly, within hours, and fatality rates can be as high as 10 to 15 percent. Twenty-
percent of those who recover suffer from long-term disabilities, such as memory
impairment, hearing and vision loss, or learning difficulties (Centers for Disease
Control and Prevention, 2016). Incidence rates vary by location and type. Bacterial
meningitis affects approximately 4,000 people, and viral meningitis affects approxi-
mately 1 in every 10,000 people in the United States where rates have been on the
decline (Thigpen, Whitney, Messonnier, Zell, Lynfield, & Hadler, 2011). Other areas
of the world, such as northern Africa, Brazil, and India, are more susceptible to
recurrent outbreaks. Although anyone may contract meningitis, infants, the elderly,
and p eople with compromised immune systems are more susceptible. Severity var-
ies based on many factors, including the strain and dosage of microorganism, host
immunity, and access to effective treatment. Meningitis outbreaks require a care-
fully planned, coordinated approach by public health staff, the local community,
M ENING ITIS 413
and medical professionals. As soon as a case is identified, public health epidemi-

ologists identify the mechanism and source of infection. Health departments alert
local schools and community centers. Information on means of transmission, symp-
toms, and prevention is disseminated through newsletters, news reports, social
media, television, and radio. The overall goal during an outbreak is to ensure early
identification and prevention so that t hose who are affected w ill seek treatment and
those who are at risk w ill get vaccinated.
Throughout history, meningitis has raised curiosity and spurred medical progress.
The earliest case is found in the m ummy of Pharaoh Amenemope (1300–1075 BCE)
on display in the Museum of Egyptian Antiquities in Cairo, Egypt. Examination of
the remains reveals that this Egyptian ruler probably died from meningitis. The ear-
liest documentation of symptoms is attributed to the ancient Greek physician and
Father of Western Medicine, Hippocrates (c. 460 BCE–c. 375 BCE). Hippocrates
studied and documented many different ailments and symptoms. His detailed
descriptions of seizures, aphasia, paralysis, and fever spurred him to openly refute
the common belief that neurological disorders w ere caused by evil spirits possess-
ing the body. This knowledge meant that care and treatment of p eople with neuro-
logical problems transferred from religious leaders, who attempted to rid the body
of evil spirits through harmful, aggressive means to medical practitioners, who used
carative therapies. In 1768, the Scottish physician Robert Whytt identified a spe-
cific type of meningitis, tuberculosis meningitis. The relationship between micro-
organism and disease was not identified u ntil the 19th century. The movement of
one early and severe epidemic of meningitis can be found in a description from
Switzerland in 1805 with o thers following in the United States, Europe, and Africa
soon after. In 1884, a Russian physician described the common symptoms of men-
ingitis, and in 1891 a new and effective diagnostic tool, the lumbar puncture, was
devised. Lumbar puncture collects a sample of cerebral spinal fluid (CSF) from the
spinal column, which allows the organism to be identified and correct treatment
administered. By the early 20th century specific viral strains w ere identified as
sources of infection leading to meningitis and the first vaccines w ere created. When
penicillin was discovered in 1944, it became an effective treatment for bacterial
meningitis.
The CNS is composed of the brain and spinal cord, which are surrounded by a
series of membranes called the meninges. The meninges consist of three layers: the
dura mater, the arachnoid mater, and the pia mater. The primary function of the
meningeal layers is to protect the CNS. The meninges contain the cerebral spinal
fluid (CSF), the liquid that bathes and sustains the CNS. The fluid is located within
the space between the arachnoid and pia mater, known as the subarachnoid space,
and supplies mechanical and immunological support for the CNS. Meningitis is
most often caused by an infection of the CSF resulting in inflammation of the menin-
ges and producing potential damage to the CNS.
Meningitis symptoms vary depending on age group and type of infection. In
adults, many symptoms are shared regardless of their source and can arise within
414 M ENIN G ITIS
24 hours of contraction. Common symptoms include severe headache, fever, vom-

iting, stiffness in the neck, altered mental status, and sensitivity to light and noise.
In a particular type of bacterial meningitis, there may be an accompanying rash. In
small children and infants, obvious symptoms can be difficult to determine but may
include irritability, altered feeding patterns, and vomiting. Often, infants with men-
ingitis can present with an enlarged fontanelle, the soft spot on the skull, or poor
reflex responses.
Bacterial meningitis may be highly contagious and cause severe symptoms and
long-term complications. The most common sources of bacterial meningitis in the
United States are Haemophilus influenza, Listeria monocytogenes, Streptococcus pneu-
moniae, and Neisseria meningitidis, which affect different age groups with varying
frequency. The bacteria that cause meningitis are typically not spread in the air but
by the exchange of fluids from the throat and respiratory tract. Bacterial meningi-
tis, specifically the Neisseria meningitidis strain, can easily spread in communal liv-
ing settings such as college dormitories and military barracks.
Viral meningitis typically produces less severe symptoms than bacterial menin-
gitis and is the most common type contracted. Although contact with an infected
individual may spread the virus, it does not mean that the newly infected individ-
ual will contract meningitis as a result. Viruses that may produce meningitis include
herpes, mumps, non-polio enteroviruses, influenza, measles, arboviruses, and Lym-
phocytic choriomeningitis. Adults usually recover from viral meningitis within 10
days if they are otherwise healthy.
Fungal meningitis is a relatively rare condition and is not spread as easily as bac-
terial or viral infections. Although anyone is susceptible to contracting fungal men-
ingitis, it is typically contracted by individuals with compromised immune systems
and spreads through soil contaminated with infected fecal matter whereby fungal
spores are inhaled and spread to the CNS. The most commons types of fungal men-
ingitis are caused by Cryptococcus, Histoplasma, Blastomyces, and Coccidioides.
Parasitic meningitis, otherwise known as primary amebic meningoencephalitis
(PAM), is a rare, noncontagious condition that is fatal if contracted. PAM is caused
by Naegleria fowleri entering an individual through the nasal passage and infecting
the CNS, causing death within 12 days. It is found around the world but only in
freshwater such as lakes, rivers, geothermal sources, and poorly maintained swim-
ming areas. Meningitis can also result from noninfectious sources but produce the
same set of symptoms. Noninfectious meningitis is not contagious, and its sources
include traumatic head injury, cancer, complications following surgery, and systemic
lupus erythematosus.
Meningitis is typically diagnosed by the presence of elevated inflammatory sig-
nals and/or infectious agents in blood or CSF collected from the patient. Other means
of diagnosis are based on rectal or naso-oropharyngeal swabs or stool samples. Iden-
tifying the exact source of infection is crucial to effective treatment, and bacteria
can be cultured to identify their specific strain and viruses identified by analyzing
their DNA for the presence of specific genes. Bacterial meningitis can be treated
M ENIN G ITIS 415
effectively with appropriate antibiotics, particularly if treatment starts soon a fter the
initial infection. The recovery rate following antibiotic treatment is high, though
long-term effects may include brain damage and impaired hearing. No direct treat-
ment exists for viral meningitis, but the infection typically subsides in 7 to 10 days,
after which most infected individuals recover. Depending of the severity of inflam-
mation, long-term complications following treatment may still persist and include
seizures, hydrocephalus, hearing loss, and brain damage. Fungal meningitis is typi-
cally treated with antifungal drugs that can be delivered intravenously. Despite
successfully being able to treat Naegleria fowleri in the laboratory, the source of para-
sitic meningitis, treatment has been unsuccessful in infected individuals. Vaccines
exist for many strains of meningitis-causing bacteria but not for the most common
sources of viral, fungal, or parasitic meningitis. Corticosteroids may be adminis-
tered to help decrease the likelihood of complications from the meningeal inflam-
mation that results from infection.
Meningitis is a frightening and deadly disease that spreads rapidly among people
who are in close contact with others. When an outbreak emerges, public health
professionals must move quickly to identify the causal organism, sources of the out-
break, individuals who need early treatment, and to prevent continued transmis-
sion. People who contract the disease require intensive monitoring, treatment, and
medical support to prevent long-term complications. The most effective way to con-
trol meningitis is through prevention. Following recommended vaccination sched-
ules, maintaining a healthy immune system through good nutrition, adequate sleep,
avoiding direct or indirect tobacco smoke, and good hygiene and handwashing are
the best ways to prevent and limit transmission.
Simon Waldbaum
See also: Antibiotic Resistance; Epidemic; Epidemiology; Handwashing; Infectious

Diseases; Influenza; Penicillin; Prevention; Vaccines
Further Reading
Centers for Disease Control and Prevention. (2016). Information for healthcare professionals
about adolescent vaccines. Retrieved from http://www.cdc.gov/vaccines/who/teens
/downloads/hcp-factsheet.pdf.
Harrison, L. H., Trotter, C. L., & Ramsay, M. E. (2009). Global epidemiology of meningo-
coccal disease. Vaccine, 27, B51–B63.
Rosenstein, N. E., Perkins, B. A., Stephens, D. S., Lefkowitz, L., Cartter, M. L., Danila, R.,
et al. (1999). The changing epidemiology of meningococcal disease in the United States,
1992–1996. Journal of Infectious Diseases, 180, 1894–1901.
Rosenstein, N. E., Perkins, B. A., Stephens, D. S., Popovic, T., & Hughes, J. M. (2001).
Meningococcal disease. New England Journal of Medicine, 344, 1378–1388.
Thigpen, M. C., Whitney, C. G., Messonnier, N. E., Zell, E. R., Lynfield, R., Hadler, J. L.,
et al. (2011). Bacterial meningitis in the United States, 1998–2007. New England Jour-
nal of Medicine, 364, 2016–2025.
416 M EN ’S HEALTH
Yoder, J. S., Eddy, B. A., Visvesvara, G. S., Capewell, L., & Beach, M. J. (2010). The epide-
miology of primary amoebic meningoencephalitis in the USA, 1962–2008. Epidemiol-
ogy Infections, 138, 968–975.
MEN’S HEALTH
Men’s health is a branch of public health that aims to promote men’s physical, mental,
and social well-being and to prevent or treat diseases or conditions that uniquely
affect males. In terms of health promotion, men’s health encompasses educating
males on physical and emotional wellness, how to care for their body, and how to
prevent injuries and diseases. With respect to prevention and treatment, men’s health
focuses on diseases or conditions that are more common, more serious, or specific
only to men, exhibit different risk f actors or symptoms among men, or require dif
ferent treatments (Rich & Roe, 2002). Examples of such diseases include impo-
tence (erectile dysfunction), heart disease, prostate and testicular cancer, genitourinary
disorders, or male pattern baldness. As a group, men are a special population with
unique health challenges. Males suffer from heart disease, cancer, unintentional inju-
ries, stroke, chronic respiratory disease, diabetes, suicide, and chronic liver dis-
eases at greater rates than females. On average, men die five to eight years earlier
than w omen. Gender disparities exist because men are more likely to engage in risky
behaviors or work in dangerous jobs and less likely to participate in regular health
care screening and preventive practices. In addition to addressing pathophysiolog-
ical and physiological conditions, men’s health explores the unique psychosocial
experiences of males in society with respect to prevention, treatment, and coping
with illness. Men’s health is a developing field with enormous opportunities for fur-
ther investigation and specialty practice.
Men suffer higher rates of both acute and chronic diseases than w omen. Men are
1.5 times more likely to die from heart disease, cancer, and respiratory diseases
(Centers for Disease Control and Prevention [CDC], 2015). Men are two times more
likely to die of heart disease. The majority of sudden cardiac events (70–89 percent)
occur among men (CDC, 2015). Prostate cancer is the most frequently diagnosed
cancer among men, accounting for 185,000 cases and 29,000 deaths annually
(Wilkins & Savoye, 2009). Colorectal cancer affects 71,099 men and causes
27,230 male deaths annually. Many of these health problems can be prevented
through healthy eating, regular physical activity, maintaining a healthy weight,
controlling stress, not smoking, and avoiding excessive alcohol consumption.
Regular prostate specific antigen (PSA) screening and physical examination can
detect and treat prostate problems early. Regular colorectal examinations can
detect abnormal growths in the colon or rectum and eliminate polyps that lead to
colorectal cancer.
Despite opportunities in health promotion and disease prevention, men are less
likely to visit health care providers for screening or care. Men have higher rates of
cigarette smoking, alcohol, and substance abuse and are more likely to suffer motor
M EN ’ S HEALTH 417
vehicle crashes, homic ide, or on-the-job injuries (Barua, 2009; Shmerling, 2016;
White & Holmes, 2006). Men are 25 percent less likely to visit a health care pro-
vider and 40 percent less likely to undergo preventive screening (Murray-Law, 2011).
Researchers believe that there are multiple factors that create reluctance to visit a
health care provider. Men do not have to access medical care for birth control or
for fatherhood, as w omen do. Hence they do not have the opportunity to develop
a habit of health promotion in adolescence or early adulthood. In American cul-
ture, traditional male traits encouraging the suppression of emotion, promotion of
aggression, or increased risk-taking may also inhibit health-seeking behaviors
(Murray-Law, 2011; Oliffe et al., 2010).
Men present a unique population for public health practice. Socially, men par-
ticipate in many high-risk behaviors, yet are less likely to engage in regular medical
screenings. Research in men’s health is developing slowly. There are many oppor-
tunities in this field, such as considering the impact of class, culture, or socioeco-
nomic status on male health. To protect this population, public health is challenged
to find new ways to increase and support healthy behaviors.
Godyson Orji
See also: Cancer; Chronic Illness; Health; Health Disparities; Healthy People 2020;
Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome;
Leading Health Indicators; Lesbian, Gay, Bisexual, and Transgender Health; Tuske-
gee Syphilis Study; Women’s Health; Wynder, Ernst Ludwig; Controversies in Public
Health: Controversy 2
Further Reading
Barua, K. (2009). Why men die earlier than w omen: 56. Journal of Men’s Health, 6(3), 241–
241. doi:10.1016/j.jomh.2009.08.054
Centers for Disease Control and Prevention (CDC). (2015). Leading c auses of death in males
United States, 2013. Retrieved from https://www.cdc.gov/healthequity/lcod/men/2013
/index.htmMurray-Law, B. (2011). Why do men die earlier? Monitor on Psychology, 42(6),
58–63. Retrieved from http://www.apa.org/monitor/2011/06/men-die.aspx.
National Center for Health Statistics (NCHS). (2016). Health, United States, 2015: With spe-
cial feature on racial and ethnic health disparities. Hyattsville, MD. Retrieved from https://
Oliffe, J. L., Robertson, S., Frank, B., McCreary, D. R., Tremblay, G., & Goldenberg, S. L.
(2010). Men’s health in Canada: A 2010 update. Journal of Men’s Health, 7(3), 189–
192. doi:10.1016/j.jomh.2010.07.001
Rich, J., & Roe, M. (2002). A poor man’s plight: Uncovering the disparity in men’s health. Retrieved
from http://health-equity.pitt.edu/38/.
Shmerling, R. H. (2016). Why men often die earlier than women. Boston: Harvard Health.
Retrieved from http://www.health.harvard.edu/blog/why-men-often-die-earlier-than
-women-201602199137.
White, A., & Holmes, M. (2006). Patterns of mortality across 44 countries among men and
women aged 15–44 years. Journal of Men’s Health & Gender, 3(2), 139–151.
418 MENTAL HEALT
Wilkins, D., & Savoye, E. (2009). Men’s health around the world: A review of progress and
policy across 11 countries. European Men’s Health Forum (EMHF). Retrieved from http://
www.emhf.org/wp-content/uploads/2013/12/EMHFreport_globalmenshealthLR.pdf.
M ENTAL HEALTH
Many public health issues are related to mental health or mental illness. Promoting
positive mental health is integral to reducing addictions and violence and to help-
ing people live healthy, fulfilling lives. The World Health Organization (WHO)
defines good mental health as “a state of well-being in which the individual realizes
his or her own abilities, can cope with the normal stresses of life, can work produc-
tively and fruitfully, and is able to make a contribution to his or her community”
(WHO, 2013, p. 6). Although m ental health is a concern for all age groups, ado-
lescence is a critical period in developing lifelong attitudes and practices. For all
age groups and particularly adolescents, good m ental health includes four aspects:
(1) a positive identity, (2) the ability to manage thoughts and emotions, (3) the
ability to build social relationships, and (4) the aptitude to learn and to acquire an
education.
A positive self-identity is made up of values, those intangible elements of per-
sonality that are behaviorally expressed on a regular basis. The Search Institute (SI),
a nonprofit foundation focused on helping communities raise c hildren and adoles-
cents into happy, healthy adults, has conducted more than 80,000 surveys in order
to identify values associated with good m ental health. They include integrity, hon-
esty, responsibility, restraint, power, self-esteem, purpose, and optimism (SI, 2006).
Integrity is a matter of adhering to what is right even when no one is looking.
Honesty means telling the truth, even about m istakes, accidents, or having done
something wrong. Responsibility is about holding yourself accountable for what
you say and do, and not blaming others. Restraint is the ability to hold back impulses
and assess a situation completely before speaking or acting. Power refers to exerting
influence on those things in life you can control—such as what you say and do—
and not trying to control what you cannot, such as what others say and do. Good
self-esteem is about liking yourself. Adolescents who practice and develop those
aspects about themselves that they like enjoy good mental health. This includes
addressing weaknesses. Having a purpose or meaning in life is associated with well-
being among all age groups (Steger et al., 2009, pp. 43–52). People whose purpose
is to help others, such as by correcting social ills (inequality, hunger, or poverty),
are mentally healthier than those who are only out for themselves (SI, 2006). Opti-
mism is having a positive future perspective that ultimately things will turn out
alright. Optimism is about trying, even if you fail.
Stress is inherent in life’s e very change and challenge. Without stress t here is bore-
dom. With too much stress we feel overwhelmed. Learning how to manage stress
entails predicting it, preparing for it through rehearsal or seeking support, and—
after the stress passes—recovering through rest and relaxation.
MENTAL HEALT 419
A main source of stress are the expectations held about how things should turn
out. Unrealistically high expectations of o thers, oneself, and life in general typically
lead to disappointment. Adolescents who check their self-expectations with par-
ents or trusted adults to ensure they are high but realistic have better mental health
than those who do not (SI, 2006).
The wise use of time is an essential stress management technique associated with
good m ental health. Time spent planning and making decisions is a good invest-
ment. Adolescents who read, engage in creative or artistic pursuits, organized sports,
or volunteer in their community for three or more hours per week generally enjoy
good mental health, as compared to t hose who do not (SI, 2006). The same holds
true for participating in religious or spiritual pursuits; but the m ental health ben-
efit is achieved with just one hour per week or more.
During adolescence, one of the best uses of time is to initiate and develop healthy
relationships. However, those who limit time spent “just hanging out” to two or
fewer nights per week tend to be happier than adolescents who “do nothing” three
or more nights per week (SI, 2006).
Humans are the most social species on the plant, as evidenced by the length of
time human children remain connected to their caregivers, and our reliance on social
networks to work, play, and love. Social support is one of the main f actors in m ental
well-being (Morgan et al., 2008). Using your network to problem solve or get reas-
surance promotes good m ental health (SI, 2006). But simply having a strong sup-
port network—even if you do not use it—is protective of mental health.
The WHO (2013) identifies safety, stability, and nurturance as key aspects of
healthy relationships. T hese features are important in family relationships, as well
as with teachers, coaches, or friends’ parents, who may be supportive. These adults
may serve as one-time advisers or as role models. Same-age peers who model pro-
social (as opposed to antisocial) behaviors also contribute to good mental health
(SI, 2006). One 2017 study identified 55 ways to foster and deepen healthy rela-
tionships, such as talking out problems together and sharing things you admire
(Roehlkepartain et al., 2017). Key aspects that lead to their development include
empathy. Empathy is one social skill that is associated with increased life satisfac-
tion (SI, 2006). Empathy is about understanding where another person is coming
from both logically and emotionally. Two negative aspects of social relationships
include conflict and pressure. Conflict and disagreements are an occasional part of
relationships. Being able to problem solve and negotiate in order to resolve con-
flicts peacefully is associated with greater life satisfaction (SI, 2006). Threats of vio
lence or intimidation have no place in a healthy relationship.
Another form of social conflict is feeling pressured to do something that you do
not believe in. When this pressure comes from others of a similar age or status it is
known as peer pressure. Being able to resist social pressure is associated with m ental
well-being (SI, 2006). Believing that others who love and respect you would never
pressure you into d oing something you did not believe in can help you stand your
ground.
420 MENTAL ILLNES
Most adolescents spend a large portion of their time in school. Education is asso-
ciated with long-term m ental health. Graduating high school and immediately
pursuing college increases the likelihood of graduating with a bachelor’s degree
(Radford et al., 2010). Delaying by one year reduces your chances by 20 percent;
waiting two years between high school and college, your chances drop by 68 percent.
High school and college students whose parents are involved in schooling have bet-
ter m
ental health than those without it (SI, 2006). Parents may be able to help main-
tain motivation to do well in school, such as by setting up rewards for outstanding
performance, or withholding certain incentives when performance is inadequate.
Communicating expectations, such as expectations for school performance, can
result in positive m
ental health (SI, 2006).
David J. Reynolds
See also: Beers, Clifford Whittingham; Behavioral Health; M ental Illness; National
Institutes of Health; Spiritual Health; Substance Abuse and Mental Health Services
Administration; Veterans’ Health; Violence; World Health Organization; Controver-
Further Reading
Morgan, A., Currie, C., Due, P., Gabhain, S. N., Rasmussen, M., Samdal, O., and Smith, R.,
(2008). Mental well-being in school-aged c hildren in Europe: Associations with social
cohesion and socioeconomic circumstances. In A. Mathieson & T. Koller (Eds.), Social
cohesion for mental well-being among adolescents. Copenhagen, Denmark: World Health
Organization Regional Office for Europe. Retrieved from http://www.euro.who.int/_
_data/assets/pdf_file/0005/84623/E91921.pdf.
Radford, A. W., Berkner, L., Wheeless, S. C., & Shepherd, B. (2010). Persistence and attain-
ment of 2003–04 beginning postsecondary students: After 6 years (NCES Publication
No. 2011-151). Retrieved June 27, 2017, from http://nces.ed.gov/pubs2011/2011151
.pdf.
Roehlkepartain, E. C., Pekel, K., Syvertsen, A. K., Sethi, J., S ullivan, T. K., & Scales, P. C.
(2017). Relationships first: Creating connections that help young people thrive. Minneapo-
lis: Search Institute. Retrieved July 2, 2017, from http://page.search-institute.org
/relationships-first-020217a?submission=233714421.
Search Institute. (2006). 40 developmental assets for adolescents (ages 12–18). Minneapolis:
Author. Retrieved June 27, 2017, from www.search-institute.org.
Steger, M. F., Oishi, S., & Kashdan, T. B. (2009). Meaning in life across the life span: Levels
and correlates of meaning in life from emerging adulthood to older adulthood. The Jour-
nal of Positive Psychology, 4(1), 43–52.
World Health Organization. (2013). Mental Health Action Plan 2013–2020. Geneva: WHO
Press. Retrieved June 25, 2017, from www.who.int.
M ENTAL ILLNESS
Mental illness is defined as “collectively all diagnosable mental disorders” or “health
conditions that are characterized by alterations in thinking, mood, or behavior
MENTAL ILLNES 421
associated with distress and/or impaired functioning” (Department of Health and

Human Services, 1999). One in five U.S. adults, 43.8 million individuals, experi-
ence some type of m ental illness each year (National Institutes of M ental Health
[NIMH], n.d.). Individuals with m ental illness are at increased risk of other chronic
medical problems and die approximately 25 years earlier than other p eople. Unfor-
tunately, the health needs of the mentally ill are not being met. Only 41 percent of
adults with mental illness and 63 percent of adults with serious mental illness receive
mental health services (Center for Behavioral Health Statistics and Quality, 2015).
Public health agencies, such as the NIMH, Substance Abuse and M ental Health Ser
vices Administration (SAMHSA), local, state, and territorial health departments,
and community-based organizations, are working to reduce the stigma of mental
illness and to provide effective, accessible, evidence-based treatments and programs
within communities.
Mental illnesses are defined by the Diagnostic and Statistical Manual (DSM), cur-
rently in the fifth edition of publication. The manual divides mental illnesses into
discrete categories, outlines diagnostic criteria, and provides inclusion and exclu-
sion criteria for each diagnosis. Major categories are schizophrenia spectrum and
other psychotic disorders, anxiety disorders, and depressive disorders. Schizophre
nia is arguably one of the most devastating illnesses affecting about 1 percent of the
population. Schizophrenia presents as a wide range of symptoms. Hallmark fea-
tures are hallucinations, delusions, and disorganization in thought and behavior.
Anxiety disorders are characterized by excessive or unrealistic worry, which may
be related to specific tasks, events, objects, or rituals. About 10 percent of the U.S.
population suffers from an anxiety disorder. Depressive disorders are characterized
by a period of chronic sadness associated with changes in energy, sleep, weight, or
attention. Almost 10 percent of the American population suffers from some mood
disorder. Major depression affects 7 percent of the adult population and 12.5 percent
of adolescents. Major depression is twice as common in adult females as in adult
males and four times more common in adolescent females as in adolescent males.
Of those with severe depressive symptoms, 43 percent report difficulties in work,
home, and social activities (Pratt & Brody, 2014). Of t hose with severe symptoms,
only 35 percent report contact with a mental health worker in the past year. Depres-
sion has a significant association with medical problems. Those with depression
are more likely to have heart disease, obesity, alcoholism, smoking, and other m ental
health problems such as anxiety disorders, substance use disorders, and eating dis-
orders. Depression is also associated with lower workplace productivity and greater
absenteeism, resulting in unemployment. The economic burden for depression,
including workplace costs and the costs of medical and psychiatric services, was
estimated to be $210.5 billion in 2010.
Many adult mental illnesses begin in childhood. Half of all cases of m ental ill-
ness begin by age 14 and 75 percent by age 24. About 1 out of every 10 minors
meet criteria for a serious emotional disturbance, which is defined as a mental health
problem that interferes with the child’s ability to function socially, academically,
or emotionally (Pratt & Brody, 2014). As in the adult population, depression and
422 MENTAL ILLNES
anxiety are most prevalent. M ental illnesses have important implications on long-
term health and wellness. Thirty-seven percent of students with a mental health
condition drop out of school (Center for Behavioral Health Statistics and Quality,
2015). This represents the highest dropout rate of any disability group. Seventy
percent of youth in state and local juvenile justice systems have a m ental illness
(NIMH, n.d.). Unfortunately, as with adults, many c hildren with m ental health
problems do not receive m ental health care. Only 50 percent of children with
mental health disorders received treatment for their disorder within the past year.
Suicide is the third leading cause of death for p eople aged 10–24 and the second
leading cause of death for p eople aged 15–24. If you know someone who is strug-
gling with life-threatening mental illness, the National Suicide Prevention Lifeline
(1-800-273-8255) is available 24 hours a day, seven days a week for assistance.
Mental illnesses are categorized as serious when they substantially interfere or
limit one or more major life activity, such as self-care, personal relationships, or
workplace functioning. Serious m ental illness affects 4.1 percent of the adult
population—roughly 1 in 25 adults, or 10 million individuals—in a given year
(National Institutes of M ental Health, n.d.). M ental illness occurs frequently in con-
junction with substance use issues. Of 20.2 million Americans with substance use
issues, 50.5 percent—10.2 million adults—had a co-occurring m ental illness (Cen-
ter for Behavioral Health Statistics and Quality, 2015).
Social and cultural factors interact with mental illness. The relationship between
homelessness and m ental health problems is well documented. For example,
26 percent of homeless adults staying in shelters live with serious mental illness
(Center for Behavioral Health Statistics and Quality, 2015). An estimated one out
of two homeless adults in shelters have a severe mental illness or substance use
disorder. Individuals within the criminal justice system are also disproportionately
more likely to have mental health problems. Studies estimate that 20 percent of
state prisoners and 21 percent of local jail prisoners have a recent history of a mental
health condition (Glaze & James, 2006). Individuals of different races are at different
risk for having a m ental illness. For example, 16.3 percent of Hispanic adults,
19.3 percent of white adults, 18.6 percent of black adults, and 28.3 percent of Amer-
ican Indian/Native Alaskan adults live with a m ental health condition (NIMH, n.d.).
Mental illnesses are treatable diseases of the brain. Current evidence suggests that
the combination of psychotherapy and medication management is most effective
in controlling symptoms of mental illness. Cognitive behavioral therapy has been
shown to be effective in treating depression, anxiety disorders, eating disorders,
post-traumatic stress disorder (PTSD), and schizophrenia. Dialectical behavioral
therapy has been shown to be effective in the treatment of borderline personality
disorder. If psychotherapy alone does not adequately treat symptoms, medication
management may be indicated. For major depressive disorder (MDD), antidepres-
sants are the class of medication shown to be most effective. Selective serotonin reup-
take inhibitors (SSRIs) are the first line antidepressant. If symptoms of depression are
severe and refractory to pharmacologic treatment, brain stimulation interventions
MENTAL ILLNES 423
Dior Vargas attends her weekly counseling session to manage major depressive disorder.
Vargas founded the People of Color & Mental Illness Photo Project deconstructing stigmas
of mental illness. (Shaul Schwarz, Verbatim/Getty Images for Be Vocal)
such as electroconvulsive therapy may be indicated. Some anxiety disorders may

also be treated by antidepressant, as well as anxiolytics, another class of medications
that includes benzodiazepines. Schizophrenia is treated by a class of medication
called antipsychotics, which itself is subdivided into typical antipsychotics and aty
pical antipsychotics. Bipolar disorder is predominantly treated with lithium and/or
anticonvulsant medication (Sadock, Sadock, Sadock, & Ruiz, 2015).
One of the largest barriers to treatment is the stigma of mental illness. Although
much has been done to reduce the stigma through education and public service
announcements, attitudes that blame the victim continue to severely inhibit treat-
ment seeking.
Prevention efforts focus on promoting mental health. Mental health is “a state of
well-being in which the individual realizes his or her own abilities, can cope with
the normal stresses of life, can work productively and fruitfully, and is able to make
a contribution to his or her community” (World Health Organization, 2016). Mental
health maximizes m ental assets rather than disability. Generally, the notion of well-
being includes the presence of positive moods and emotions (like happiness and
contentment), the absence of negative emotions (like depression and anxiety),
and a sense of life satisfaction and fulfillment. There are no absolute determi-
nants. For example, paid employment is important for accessing resources and
developing meaning and purpose. Income has a positive effect among p eople of
424 MENTAL ILLNES
lower socioeconomic levels and lessens for those of higher incomes. Generally,
well-being is closely associated with and dependent on good health, positive rela-
tionships, and availability and access to basic resources like food, shelter, and
income. Positive emotions are more closely associated with having supportive
and healthy social relationships.
Mental illnesses are extremely common among Americans. Many p eople suffer
from depression or anxiety. And while mental illnesses are treatable, many people
do not recognize the symptoms or neglect to seek treatment. Current public health
efforts focus on reducing the stigma of m
ental illness in order to facilitate early diag-
nosis and treatment. Friends, family members, and coworkers are critical in sup-
porting people with mental illness in seeking treatment.
Timur Suhail-Sindhu, Maria DiGiorgio McColgan, and Sally Kuykendall
See also: Addictions; Adverse Childhood Experiences; Beers, Clifford Whittingham;

Behavioral Health; Child Maltreatment; Children’s Health; Dix, Dorothea Lynde; Eat-
ing Disorders; Intimate Partner Violence; Men’s Health; M ental Health; Substance
Abuse and M ental Health Services Administration; Syringe Service Programs; Vet-
erans’ Health; Violence; W
omen’s Health
Further Reading
Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the
United States: Results from the 2014 National Survey on drug use and health (HHS Publica-
tion no. SMA 15-4927). Retrieved from https://www.samhsa.gov/data/sites/default
/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf.
Department of Health and Human Services. (1999). Mental health: A report of the Surgeon
General. Rockville, MD: U.S. Department of Health and Human Services; Substance
Abuse and Mental Health Services Administration, Center for Mental Health Services,
National Institutes of Health, National Institute of Mental Health. Retrieved from https://
profiles.n lm.nih.g ov/ps/r etrieve/ResourceMetadata/N
NBBHS.
Glaze, L. E., & James, D. J. (2006). Mental health problems of prison and jail inmates. Bureau
of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice, Office
of Justice. Retrieved from https://www.bjs.gov/content/pub/pdf/mhppji.pdf.
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs,
NJ: Prentice Hall.
National Alliance for Mental Illness. Retrieved from https://www.nami.org.
National Institutes of Mental Health. (n.d.). Statistics. Retrieved from https://www.nimh.nih
.gov/health/statistics/index.shtml.
Pratt, L. A., & Brody, D. J. (2014). Depression in the U.S. h ousehold population, 2009–
2012. NCHS data brief, no 172. Hyattsville, MD: National Center for Health Statistics.
Retrieved from https://www.cdc.gov/nchs/data/databriefs/db172.pdf.
Sadock, B. J., Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadocks synopsis of
psychiatry: Behavioral sciences/clinical psychiatry. Philadelphia: Lippincott Williams &
Wilkins.
World Health Organization. (2016). Mental health: Strengthening our response. Fact sheet.
Geneva: WHO. Retrieved from http://www.who.int/mediacentre/factsheets/fs220/en.
MIDDLE AGES, PUBLIC HEALTH IN THE 425
IDDLE AGES, PUBLIC HEALTH IN THE (500–1500 CE)

M
The M iddle Ages spanned the era between the Fall of the Roman Empire and the
beginning of the Renaissance. Corruption, abuse, and civil insurrection gradually
eroded the power of the Roman Empire. The Western Roman Empire entered the
Dark Ages, a period marked by ignorance, chaos, conflicts over power, famine, and
disease. The Eastern Roman or Byzantine Empire thrived u nder Emperor Constan-
tine I. With Constantinople serving as the center, Spain, North Africa, Eastern
Europe, and the M iddle East enjoyed great economic and military power. The most
common health problems during this era were cholera, typhoid, typhus, bubonic
plagues, dysentery, malnutrition, and injuries. Many people never survived past
childhood. The average life span was about 30 years old. Public health problems
were caused by the large population movements of war and trade. Although the
period was a terrible time for population health, the hardships ultimately created
the foundations for early, organized systems of care.
During the early Middle Ages, health care was primarily administered by older
women who learned the art of healing from earlier generations and by hands on
experience. Members of the Crafte of the Wise also worshipped the gods, goddesses,
and priestesses that predated Christianity. T hese peasant healers practiced midwifery
and used herbs, spells, incantations, and charms to treat the ill or disabled. Their
pagan rituals included dances, feasts, sexual intercourse, and animal sacrifices. The
power and respect earned through healing combined with salacious pagan rituals
were a threat to the emerging Christian church. In an effort to gain followers and
to become the one, true religion, the church labeled the healers as deviants pos-
sessed by the devil. Anyone who healed and was pagan, peasant, or female was
killed or driven into secrecy. A cottage industry grew around witch-hunting. The
church and state persecuted and executed thousands of female healers. Christian
priests and wealthy patrons who practiced a combination of Christianity and pagan-
ism w ere let off with a warning or a few Hail Marys (Campbell, 1978). The emerg-
ing medical profession was complicit in the mass executions. Witch hunts forced
peasants to seek care from physicians while also diverting attention from the popu
lar and ineffective medical practices of the day, bloodletting and leeches. The sup-
pression of female healers helped to legitimize medicine as a patriarchal profession
and institutions of higher learning as the main source of medical knowledge. Early
on, these early medical doctors separated into two guilds, one for medicine and
one for surgery. Physicians formed the Apothecary Guild and surgeons formed the
Barber’s Guild.
The church collected and secured Greek and Roman medicine albeit through a
theological lens. Medicine was considered inferior to religion. Disease and healing
were explained by theological rationalization. Sickness was deemed a punishment
for sin or a test of faith. H
uman medicine, diet, herbs, surgery, or bleeding could
be used, but heavenly medicine of prayers, exorcism, relics, and incantations was
preferred. The church monopolized medicine, education, philosophy, and art. Greek
temples w ere transformed into churches. Monasteries h oused libraries and herbal
426 MIDDLE AGES, PUBLIC HEALTH IN THE
gardens, eventually becoming centers of education and health care. Priests trans-
lated Greek medical texts into Latin, merging medicine and morality. Few medieval
medical texts survive because parchment was valuable and reusable and medicine
was perceived as less important in comparison to religion. Charity and mercy for
the poor existed alongside the ascetic lives of monks and priests. Over time, medi-
cal institutions and hospitals emerged from the Christian monasteries. Consistent
with church teachings, w omen were excluded from academic medical institutions.
Starting in 1275, pack ice shifted from the Arctic region into the North Atlantic,
creating the L ittle Ice Age and the Great Famine of 1315–1322. Low temperatures
shortened the growing seasons. Heavy rains flooded and damaged crops. Wide-
spread famine caused malnutrition, disease, cannibalism, infanticide, and death.
The story of Hansel and Gretel, two children abandoned by their parents and cap-
tured by a cannibalistic witch, originated from this time period. Millions of p eople
died. Structural poverty became deeply ingrained in British society. Approximately
60 percent of families w ere exempt from paying taxes due to poverty (Dyer, 2012).
The English government established several laws during the mid to late 14th century
that formed the foundation of community care. The first law restricted begging to
those who were unable to work. The able-bodied w ere required to work. With man-
datory work requirements, local towns and villages implemented laws to prevent
local residents from demanding higher wages. Townspeople could not work out-
side of the village during harvest season. Subsequent laws required that beggars
return to the community where they w ere born or best known and that the com-
munity care for them. Hospitals and almshouses developed to care for the poor,
elderly, disabled, orphans, widows, and ill. These institutions relied on charity and
were often located on main roads where travelers might stop and donate resources.
Although the wealthy were constantly reminded of their responsibility to the poor,
there is little evidence that poor relief was sufficient to meet the needs of the large
population of poor. Local governments tried to establish long-term support through
taxes, parish collections, and estate planning. However, communities also trimmed
their expenses by kicking out t hose whom they deemed not worthy of poor relief.
These early systems of community relief w ere the foundation of government-
organized health care.
One of the most devastating health events of human history occurred during the
Middle Ages. The Black Death pandemic of 1346–1353 killed one-third to one-
half of the world’s population, an estimated 100 million people. The plague came
in waves, starting in Asia and spreading along the Silk Road and into the M iddle
East and Europe. The causal pathogen, Yersinia pestis, was carried by fleas on rats
living on merchant ships. As the ships sailed along trade routes, they carried the
rats with plague-infested fleas. The disease was transmitted from harbors and ports
inland. The thatched countryside roofs attracted rodents and insects. Few areas w ere
left unscathed. The bubonic plague is a particularly horrific disease. Bacteria enter
the skin through a flea bite. The body attempts to fight the infection with swollen
lymph nodes, fever, and chills. Within a few days, the victim experiences headache,
MIDDLE AGES, PUBLIC HEALTH IN THE 427
seizures, and muscle cramps. As the body succumbs to the infection, organs begin
to fail. The victim vomits blood. Extremities and skin decay. Death occurs within
10 days. Priest-physicians using heavenly medicine hastened the spread by bring-
ing people together in prayer and religious services. Physicians who practiced
human medicine did better, advising the patients to rest and creating unintentional
isolation. The plague permanently impacted social structures and economies in
Western Europe. So many peasants died that there was a shortage of workers. The
poor who survived could negotiate higher wages, thereby improving their quality
of life and social status.
The M iddle Ages were a challenging time for public health. The medical advances
of the ancient Greeks and Romans w ere dismissed and disregarded due to politics
and arrogance. The knowledge that had been transmitted between generations of
female lay healers was vilified and extinguished. Mankind struggled with war, deadly
epidemics and pandemics, poverty, and famine. The darkness of the M iddle Ages
stands in sharp contrast to the illuminating philosophies and discoveries of the
Greco-Roman period and the Renaissance. Unfortunately, some of the misguided
values continue today. Diseases, such as AIDS, are perceived by some as punish-
ment for sin. Victims of violence, substance abusers, smokers, and people who are
obese are too frequently blamed for their health problems. Victim blaming under-
mines public health efforts. P eople suffering from a stigmatized health problem are
less likely to seek treatment. Service agencies have to work harder for funding. The
second carryover from the M iddle Ages is the representation of groups that sup-
port women’s health as evil and harmful. Planned Parenthood provides numerous
services to women and is the ongoing target of vilifying accusations. The Middle
Ages left a lasting impression of ideas, values, and perceptions, some good, some
harmful.
Sally Kuykendall
See also: Ancient World, Public Health in the; Epidemic; Greco-Roman Era, Public
Health in the; Infectious Diseases; Quarantine; Smallpox
Further Reading
Brodsky, P. L. (2006). Childbirth: A journey through time. International Journal of Childbirth
Education, 21(3), 10–15.
Campbell. M.-A. (1978). Labeling and oppression: Witchcraft in medieval Europe. Mid-
American Review of Sociology, 3(2), 55–82.
Dyer, C. (2012). Poverty and its relief in Late Medieval England. Past & Present, 216(1),
41–78.
Lippi, D. (2012). Witchcraft, medicine and society in Early Modern Europe. Archives of the
History & Philosophy of Medicine, 75(1), 68–73.
Magner, L. (1992). A history of medicine. New York: Marcel Dekker.
Minkowski, W. L. (1992). W omen healers of the Middle Ages: Selected aspects of their his-
tory. American Journal of Public Health, 82(2), 288–295.
428 M ODER N ER A, PU BLIC HEALTH IN THE
Rosen, G. (1993). A history of public health (Expanded ed.). Baltimore: The Johns Hopkins
University Press.
MODERN ERA, PUBLIC HEALTH IN THE

The modern practice of public health encourages and organizes states, communi-
ties, and individuals in order to promote h uman health by means of certain prac-
tices, such as education, sanitation, and improved medical infrastructure. The
creation of a national, coordinated system of public health from the often haphaz-
ard arrangement of individual charity, religious devotion, or private business that
were prevalent in the Early Modern Era was assisted by the birth of the modern
nation state, where administrative powers broadened following the French Revo-
lution (1789–1799), as well as advances in medical science such as bacteriology
and epidemiology.
The proliferation of hospitals funded at public expense and often supporting a
school of medical students was the setting for the transition to modern practices of
public health. This process was aided by the political and social revolutions that
rocked Europe at the end of the 18th century following the French Revolution. The
older system of religious charity and aristocratic patronage that had been the pri-
mary means of supporting public health initiatives in previous centuries was swept
aside by the egalitarian, secular leanings of revolutionary governments. In their
place, at least in theory, a system of state funded and guided medical institutions
would radiate from a central organization situated in the national capital, which
was better equipped to efficiently administer medical aid and alleviate disease in
the furthest corners of nation and empire in a timely manner. In practice, this lofty
plan took a full century or more to be developed in some countries.
Epidemic diseases such as yellow fever or cholera were opposed with many of
the same practices available to health professionals in previous centuries, such as
quarantine or a “cordon sanitaire.” However, as doctors determined that diseases
were transmitted by germs and bacteria rather than miasmas (“bad air”) as previ-
ously thought, the development of preventative medicine gained a greater appre-
ciation among public health officials. The development of a vaccine for smallpox
by Edward Jenner (1749–1823) in the last decade of the 18th century led to a new-
found confidence in the power of preventative measures to eradicate various dis-
eases. The new governments of Europe determined to apply their centralized
apparatus to the dissemination of these new vaccines and medical techniques
through education or legal compulsion.
The epidemic of cholera that struck Europe in the 1830s also shook the confi-
dence of medical professionals in the ability of medicines alone to prevent disease.
As displaced agrarian populations flooded European cities in search of work dur-
ing the Industrial Revolution, poor living conditions among the urban poor under-
lined the importance of sanitation and public hygiene in public health. Sir Edwin
Chadwick in Great Britain and François-Vincent Raspail in France determined that
M ODER N E R A , PU B LIC HEALTH IN THE 429
access to clean w ater, efficient waste disposal, and open-air spaces such as parks
could improve the health of urban dwellers nearly as effectively as vaccines and
medicines. In 1848, Great Britain passed the Public Health Act, which combined
once separate administrative bodies in order to efficiently administer sanitation and
clean w ater, and in 1851 vaccination for smallpox became compulsory. These devel-
opments resulted in the contemporary fields of urban planning and engineering as
prominent contributions to public health initiatives. Notable examples are the foun-
tains erected by Sir Richard Wallace throughout the city of Paris during the 1870s
and later.
The cholera epidemics allowed European doctors firsthand experience observ-
ing the effects of environment on patients often squeezed into cramped, ad hoc hos-
pitals. The rise of hospitals occurred alongside the birth of the medical laboratory,
where researchers could observe, experiment, and develop new approaches to med-
icine outside of the clinical environment. T hese laboratories would grow through-
out the late 19th and 20th centuries into the major university and pharmaceutical
research laboratories of the Modern Era. Although the hospital and the laboratory
had much to teach one another, at times they went their separate ways between the
“practical” clinical doctor and the “impersonal, objective” researcher. In this way,
the clinical applications of medicine lagged at times behind the discoveries of their
more sensational research colleagues.
Public health was often allied to the European imperial system, and it reflected
the prejudices prevalent in society. The encounter between the European powers
and their colonies throughout the world, in particular Africa and Asia, included a
dichotomy between the “civilizing mission” of Western medicine, with its desire to
better humankind through the eradication of various diseases, and imperialist expan-
sion and power. Developments in bacteriology allowed medical professionals to
isolate c auses of diseases to particular pathogens. At the turn of the 20th century,
British physician Ronald Ross identified the mosquito as the carrier of malaria, while
Walter Reed and James Carroll (both physicians in the U.S. Army) found likewise
for yellow fever. Advances in sanitation and hygiene, combined with new vaccines
and medicines, made a positive contribution to the standard of living in what was
called “the third world.” The building of the Panama Canal, among other colonial
projects, would have been far more costly in manpower without these advances.
However, extreme interpretations of eugenics divided populations into “white” hos-
pitals and “native” ones, which caused a crisis of identity for the humanitarian
philosophy of medicine as the benevolent healer of all humankind.
According to the theory of epidemiological transition proposed in 1971 by Abdel
Omran, as medical advances ensure a higher rate of survival in a population through
the control of epidemic disease, the prevalence of infectious diseases in a popula-
tion is overcome by chronic diseases, such as cancer or heart disease. Throughout
the 20th century, public health expanded from merely responding to health emer-
gencies to inculcating preventative measures. These included the chlorination of
drinking w ater in cities, dietary education programs, occupational safety procedures,
430 M OTO R V EHI C LE SA F ETY
f amily planning, and tobacco education. These developments in public health, while
increasing the h uman life span, have led to concern in some quarters for the level
of government control in decisions which, they propose, are best left to individual
conscience. In part, the development of Public Health 2.0 in the beginning of the
21st century sought to alleviate these concerns by involving public health profes-
sionals and interested individuals by direct communication, such as grassroots activ-
ity and social media.
Sean P. Phillips
See also: Ancient World, Public Health in the; Greco-Roman Era, Public Health in
the; M
iddle Ages, Public Health in the; Renaissance, Public Health in the
Further Reading
Berridge, V. (2016). Public health: A very short introduction. Oxford, UK: Oxford University
Press.
Porter. D. (1998). Health, civilization, and the state: A history of public health from ancient to
modern times. London and New York: Routledge.
University Press.
MOTOR VEHICLE SAFETY

Motor vehicle crashes (MVCs) are one of the leading c auses of death in the United
States. Each year, over 30,000 people die and more than 2.5 million people are
treated in emergency departments as a result of MVCs. The cost of medical care and
lost productivity for MVCs exceed $80 billion per year. Motor vehicle safety is a
specialty area within public health policy and practice. Engineers, policy makers,
epidemiologists, motor vehicle manufacturers, health educators, pediatricians, hos-
pitals, insurance companies, city planners, public safety, and even restaurant servers
all work to enhance car, bicycle, motorcycle, pedestrian, and child passenger safety;
promote safety of inexperienced or aging drivers; and prevent impaired or distracted
driving. Collaborations in civil engineering, public planning, automobile design and
manufacturing, driver education programs, and government regulations have signifi-
cantly reduced motor vehicle fatalities. Between 1925 and 1997, deaths due to MVCs
decreased from 18 per 100 million vehicle miles traveled (VMT) to 1.7 per 100 mil-
lion VMT (Motor-Vehicle Safety: A 20th Century Public Health Achievement, 1999).
Despite progress, MVC death rates in the United States are about two times higher
than comparable countries (Centers for Disease Prevention and Control [CDC],
2016). Many more injuries and deaths could be prevented through compliance with
seat b
elt laws, speed limits, proper use of child car or booster seats, strengthening the
skills of young d rivers, and reducing impaired or distracted driving.
The first recorded motor vehicle fatality occurred in London in 1896 when pedes-
trian Bridget Driscoll was struck and killed by a gasoline-powered motor vehicle
M OTO R VEHI C LE SA F ETY 431
during a demonstration at Crystal Palace. Driving u nder the influence was first
reported in 1904. The Quarterly Journal of Inebriety issued the warning:
We have received a communication containing the history of twenty-five fatal acci-

dents occurring to automobile wagons. Fifteen persons occupying t hese wagons w ere
killed outright, five more than two days l ater, and three persons died l ater. . . . A care-
ful inquiry showed that in nineteen accidents the drivers had used spirits within an
hour or more of the disaster. . . . [M]anagement of automobile wagons is far more dan-
gerous for men who drink than for driving of locomotives on steel rails. . . . The
precaution of railroad companies to have only total abstainers guide their engines will
soon extend to owners and d rivers of these new motor wagons. (Crothers, 1904,
pp. 308–309)
From early on, car manufacturers worked to protect their customers. In 1901,
Oldsmobile introduced the speedometer. General Motors added headlights in
1908. Further safety developments included shatterproof glass, tinted windshields,
rear turn signals, seat b elts, and air bags.
In 1966, Congress passed the National Traffic and Motor Vehicle Safety Act and
the Highway Safety Act. The first National Highway Traffic Safety Administration
(NHTSA) director, Dr. William Haddon Jr., was a public health physician. Haddon
is credited with introducing driver licensing, regulations on driving u
nder the influ-
ence, and motorcycle safety. Under his leadership, car manufacturers developed
new features, and road engineers implemented improved lighting, safety barriers,
guardrails, roadside signage, and better delineation of curves. Holden’s success is
attributed to using the agent-host-environment model to identify specific risk factors
and to develop interventions for each factor. U nder the agent-host-environment
model, MVCs are not unavoidable “accidents.” It is not an “accident” when some-
one drinks alcohol, gets behind the steering wheel, and crashes into a telegraph
pole. Injury and death are caused by adverse interaction of three f actors: the agent,
the host, and the environment. The agent is the vector or factor that controls the
energy. When energy of the force exceeds the body’s ability to provide physical pro-
tection, injury occurs. In the case of MVCs, the moving motor vehicle is the agent.
Potential and type of injury is influenced by the condition of the vehicle, tires, air
bags, and speed. The host is the driver. Host factors for injury or safe driving are
skill, experience, knowledge, and physical and mental condition. The environment
is the physical and social environment. Physical environment is road and weather
conditions, guardrails, and signs. Social environment is opportunities for driver
training, traffic laws, and social attitudes toward driving. The advantage of using
the agent-host-environment model is that it points to multiple areas for interven-
tion. Using the model, windshields were modified so that they did not become jag-
ged pieces of glass that could sever the carotid artery of the driver or passenger;
steering wheels w ere engineered so that they collapsed on impact rather than caus-
ing chest injuries; vehicle doors were strengthened so that doors held passengers
in; and safety b elts became standard equipment. Holden also took the model one
432 M OTOR VEHICLE SAF ETY
step further by considering precrash, crash, and postcrash f actors. Postcrash factors
included the integrity of the vehicle’s fuel system to withstand impact, emergency
medical services (EMS), and rehabilitation systems.
Different motor vehicles have different inherent risk f actors. Mopeds and scoot-
ers move at slower speeds, which reduces risk of injury. However, drivers have very
little skin protection. Even in minor crashes, the rider is likely to experience road
burn with embedded gravel and high potential for infection. Trail bikes and motor-
cycles travel at faster speeds, increasing potential for leg and head injuries. All-terrain
vehicles tip over easily, trapping the victim and causing crush injuries. Snowmobile
drivers are at risk for neck, face, and head injuries due to low branches. Automo-
biles provide greater protection for the driver and passengers. However, cars
travel at faster speeds, and SUVs have a higher center of gravity, increasing the
likelihood of rollover. Motor vehicle manufacturers work to design safe vehicles
that protect the occupant and passengers. Interventions include automatic seat
belts, full face helmets for motorcyclists, leg protection, bumpers, air bags, and larger,
more visible instrument panels. Regular vehicle inspections ensure that safety mech-
anisms are maintained a fter purchase and delivery.
Eighty-five percent of crashes are attributed to human error. At the host level,
age, skill, physical development, knowledge, fatigue, and m ental capacity play a
Collaborations in civil engineering, public planning, automobile design and manufacturing,

driver education programs, and government regulations significantly reduced motor vehicle
fatalities from 18 per 100 million vehicle miles traveled (VMT) in 1925 to 1.7 per 100 million
VMT in 1997. (Anastasia Aleksandrenko/Dreamstime)
M OTO R V EHI C LE SA F ETY 433
role in motor vehicle crashes. The requirement to pass a driving test before attain-
ing a driver’s license is an example of a host level intervention. In 1975, the NHTSA
created the Fatal Accident Reporting System, now known as the Fatality Analysis
Reporting System (FARS). FARS is a national database compiled from police reports,
automobile registration files, driver license files, highway department data, hospi-
tal records, emergency medical services records, death certificates, and medical
examiner and coroner reports. The database contains 127 data points describing
the make and model of the vehicle, weather conditions, extent of damage, and driver
and passenger characteristics, among other important features to consider. FARS is
a valuable source of information helping to identify problems and solutions and
evaluate interventions.
Motor vehicle safety is an excellent example of the depth and breadth of public
health. As the number of vehicles on the road increased, MVCs have also increased.
Car manufacturers, lawmakers, safety and road engineers, and public health edu-
cators have carefully and thoughtfully collaborated to improve the safety of d rivers,
passengers, and pedestrians. Future directions focus on high-risk groups of young
drivers, elderly drivers, and reducing driving under the influence.
Alex Black and Sally Kuykendall
See also: Agricultural Safety; Alcohol; Biostatistics; Healthy Places; Injuries; Nader,
Ralph; National Center for Injury Prevention and Control; Public Health Law; Risk-
Benefit Analysis; Rural Health
Further Reading
Centers for Disease Prevention and Control. (2016). Motor vehicle safety. Retrieved from
https://www.cdc.gov/motorvehiclesafety/index.html.
Crothers, T. D. (1904). Editorial: Announcement. The Quarterly Journal of Inebriety, XXVI(3),
308–309.
Motor-vehicle safety: A 20th century public health achievement. (1999). Morbidity and Mor-
tality Weekly Report, 48(18), 369.
National Highway Traffic Safety Administration. Road safety. Retrieved from https://www
.nhtsa.gov/road-safety.
Pfizer, Inc. (2006). Milestones in public health. New York: Pfizer Global Pharmaceuticals.
Ten G reat Public Health Achievements—United States, 1900–1999. (1999). Journal of the
American Medical Association, 281(16), 1481.
Waller, P. F. (2002). Challenges in motor vehicle safety. Annual Review of Public Health,
23(1), 93.
N
NADER, RALPH (1934–)
Lawyer and activist Ralph Nader was one of the most influential figures of the twen-
tieth century. He founded and led the consumer rights movement in the United
States for nearly four decades and was instrumental in raising awareness and
improving the safety of automobiles, workplaces, food, air, and water. Nader helped
develop and pass tobacco regulations, the Wholesome Meat Act of 1974, the Occu-
pational Safety and Health Act of 1970, and the Safe Drinking W ater Act of 1974.
“Naderism” has become synonymous with the use of citizen action to combat busi-
ness and government practices deemed detrimental to public health and public
interest. Many of the issues that Nader selected for improvement went unrecog-
nized until he brought them to the forefront of public interest. Reviled by big busi-
ness, Nader worked tirelessly to raise awareness of injustices, abuse of power, and
corporate greed. In later years, Nader focused on reducing obesity and achieving
living wages and universal health care.
Nader was born in Winsted, Connecticut, on February 27, 1934, the son of Leba-
nese immigrants who instilled in him strong moral and democratic values. A fter
attending Winsted’s Gilbert School, Nader enrolled at the Woodrow Wilson School
of Public and International Affairs at Princeton University, graduating magna cum
laude with a major in government and economics in 1955. He then entered Har-
vard Law School, where he was editor of the Harvard Law Record. Nader became
aware of the problem of automobile safety through several experiences. Through-
out high school and college he had several friends who w ere disabled or died by
car crash, and he noticed that the driver was often blamed for the crash. During
summers, he worked as a cook at Yosemite National Park. Hitchhiking across the
country, he was often one of the first people on the scene of a car crash. While in
law school, he published his first article on the subject, “American Cars: Designed
for Death,” in the Harvard Law Record. In 1958, Nader earned his law degree with
distinction. He spent six months working as an army cook at Fort Dix, New Jersey.
During the Korean War (1950–1953), more airmen died in car crashes in the states
than through the war. The army investigated ways to prevent deaths due to car
crashes. When Nader realized that car crashes were preventable, he was angry. In
1959, he started a small law practice in Hartford, Connecticut. Once again, he was
confronted by cases of preventable motor vehicle crashes.
Becoming convinced that he could accomplish little on the local level, Nader
moved to Washington, DC, in 1964. As a staff consultant on highway safety to
Daniel Moynihan (then assistant secretary of labor for policy planning), Nader
436 NADE R , R ALPH
compiled a massive report on the subject, which became the best-selling muckrak-
ing book Unsafe at Any Speed: The Designed-in Dangers of the American Automobile
(1965). In it, Nader charged that the automobile companies sacrificed safety for
speed and appearance, citing the Chevrolet Corvair as especially unsafe. The book
raised concerns regarding the use of reflective materials for dashboards, creating
glare and temporarily blinding d rivers and manufacturers’ failure to provide seat
belts and anti-roll bars. More importantly, Nader explains how experts within the
industry failed to speak out against corporate greed and dangerous designs:
here are men in the automobile industry who know both the technical capability
T
and appreciate the moral imperatives. But their timidity and conformity to the rigid-
ities of the corporate bureaucracies have prevailed. When and if the automobile is
designed to f ree millions of h
uman beings from unnecessary mutilation, t hese men,
like their counterparts in universities and government who knew of the suppression
of safer automobile development yet remained s ilent year after year, w
ill look back
with shame on the time when common candor was considered courage. (Nader,
2011, p. 256)
General Motors (GM) responded by hiring a detective to uncover damaging mate-

rial on Nader’s private life. The effort not only failed to compromise Nader, but also
embarrassed GM president James M. Roche, who had to apologize before a Senate
committee. Nader’s book led Congress to pass the Traffic and Motor Vehicle Safety
Act of 1966, which called on the federal government to set safety standards that
must be met by all cars sold in the country.
Directing his attention to other areas involving health and safety, Nader became
involved in efforts that helped to bring about the Wholesome Meat Act of 1967
and legislation providing for better safety standards in the construction of natural
gas pipelines and underground mining. In 1969, Nader helped establish in Wash-
ington, DC, the Center for Study of Responsive Law, which conducted investiga-
tions of such federal commissions as the Federal Trade Commission, suspected of
being unduly influenced by the very industries it were supposed to be regulating.
In 1970, Nader started the Public Interest Research Group (PIRG) to work for con-
sumer and political reform on the community and college campus level. In 1971,
he launched Public Citizen, Inc., a consumer lobbying group to counteract the influ-
ence of powerful corporate lobbies.
Inspired by Nader’s idealism, many young p eople, who became known as Nad-
er’s Raiders, joined his crusades through t hese and other organizations like the Cen-
ter for Auto Safety, the National Insurance Consumer Organization, and the Health
Research Group. Relying on individual contributions, on foundation grants, and
on Nader’s earnings as a writer and speaker for funds, t hese organizations conducted
investigations of a wide range of consumer issues, including the environment,
nuclear power, health care, freedom of information in government, and tax reform.
They also pushed for legislative and judicial remedies for the abuses they uncov-
ered, using class-action suits and other legal tools to achieve their goals.
NADER , R ALPH 437
Nader and his various groups influenced the creation of several new government
“watchdog” agencies, including the Occupational Safety and Health Administration,
the Environmental Protection Agency, and the Consumer Product Safety Commis-
sion. They were also largely responsible for at least eight federal consumer protection
laws, among them laws regulating radiation dangers, the use of cyclamates in diet
foods, and the use of DDT in the control of insect pests. On the local level, Nader and
his associates sparked the establishment of consumer affairs commissions in most
major cities and aroused public concern about product safety and value.
Despite their accomplishments, Nader and his associates drew fire for being fanat-
ics and for conducting superficial and slanted research. Moreover, in the conserva-
tive climate of the 1980s, Nader’s brand of activism seemed doomed to extinction.
Nevertheless, he and his associates kept up their crusades on a variety of fronts.
In 1980, Nader resigned as president of Public Citizen, Inc., so that he could
devote more time to organizing citizens on the community level. With Ronald Rea-
gan’s election to the presidency in 1980, Nader attacked the administration for offer-
ing a government that favored business and ignored consumer interests. The
following year, a Nader group published a study of the Reagan administration enti-
tled Reagan’s Ruling Class: Portraits of the President’s Top One Hundred Officials. Con-
tinuing his critique of corporate influence, Nader in 1986 coauthored The Big Boys:
Power and Position in American Business, a study of nine powerful chief executive
officers of corporations. Two years later, he helped bring about the passage of Propo-
sition 103 in California, a law that lowered some auto insurance costs. The following
year, GM announced that air bags would become standard equipment on many 1990
models, something that Nader had fought for during the past decade. Also around
this time, Nader used national radio talk shows to forestall a congressional pay hike.
A firm believer in the power of the ordinary citizen to effect change, Nader in
the early 1990s set out to make his Connecticut hometown a model democracy. In
the presidential election of 1996, Nader, r unning as the candidate for Green Party
USA, received some 580,000 votes, nearly 1 percent of the national total and about
3.5 percent of the total votes cast in California. He ran for president again in 2000,
this time garnering 3 percent of the nationwide vote, as well as considerable con-
troversy for siphoning Democratic votes from Vice President Al Gore.
One of the greatest achievements of public health during the 20th century was
a 90 percent reduction in motor vehicle deaths (Motor-Vehicle Safety: A 20th Century
Public Health Achievement, 1999). Safety belts, head rests, shatter-resistant wind-
shields, and energy-absorbing steering wheels are just a few of the many advances
that make vehicles safer for drivers and passengers. Yet, none of these would be
possible without Nader’s willingness to recognize a problem, reject the status quo,
and stand in opposition to those with power and money. As the leader of the
consumer movement for a quarter c entury, Nader remains a living symbol of the
importance of individual commitment to social and public health reform.
James M. McPherson, Gary Gerstle, and Sally Kuykendall
438 NATIONAL ASSO C IATION OF C OUNTY AND C ITY HEALTH O F F I C IALS ( NA C C HO )
See also: Air Pollution; Healthy Places; Injuries; Motor Vehicle Safety; National Cen-
ter for Injury Prevention and Control; Public Health Law
Further Reading
Bollier, D. (1989). Citizen action and other big ideas: A history of Ralph Nader and the modern
consumer movement. Washington, DC: Center for Study of Responsive Law.
Buckhorn, R. (1972). Nader: The p eople’s lawyer [e-book]. Prentice Hall. Available from Book
Review Digest Retrospective: 1903–1982 (H. W. Wilson), Ipswich, MA.
Burt, D. M. (1982). Abuse of trust: A report on Ralph Nader’s network: Capital Legal Founda-
tion. Washington, DC: Regnery Gateway.
Kaplan, D. A. (2014). Ralph Nader: The Fortune interview. Fortune, 169(3), 94.
Motor-Vehicle Safety: A 20th Century Public Health Achievement. (1999). Morbidity and
Mortality Weekly Report, 48(18), 369–374. Retrieved from https://www.cdc.gov/mmwr
Nader, R. (1965). Unsafe at any speed: The designed-in dangers of the American automobile.
New York: Grossman.
Nader, R. (2011). Unsafe at any speed: The designed-in dangers of the American automo-
bile. American Journal of Public Health, 101(2), 254–256.
Nader, R. (2016). Breaking through power: It’s easier than we think. San Francisco: City Lights.
Nader, R., & Gordan, J. (1968). Safety on the job. New Republic, 158(24), 23–25.
Parry, M. (2011). Ralph Nader: Public health advocate and political agitator. American Jour-
nal of Public Health, 101(2), 257. doi:10.2105/AJPH.2009.191163
Whiteside, T. (1972). The investigation of Ralph Nader: General Motors vs. one determined man.
Gettysburg, PA: Arbor House.
NATIONAL ASSOCIATION OF COUNTY AND CITY

HEALTH OFFICIALS (NACCHO)
In addition to the day-to-day tasks of immunizations, prenatal care, nutrition edu-
cation, sexually transmitted disease treatment and prevention, and policies to con-
trol urban sprawl, local public health departments and their staff are prepared to
deal with a myriad of life-threatening emerging and reemerging health issues. The
National Association of County and City Health Officials (NACCHO) is a nonprofit
organization serving approximately 1,500 local health departments and 13,000
individual members. Founded in the 1960s, the mission of NACCHO is “to be a
leader, partner, catalyst, and voice for local health departments” (NACCHO, 2016).
NACCHO supports local health department administrators and practitioners by
providing skill-building resources and networking opportunities. Programs include
the philanthropic effort, Foundation for the Public’s Health, the NACCHO c areer
network, internships, and consulting in performance improvement, process design,
workforce development, or technical assistance. The organization adheres to the
core values of health equity, excellence in practice, collaboration, respect, integrity,
leadership, evidence-based practice, and innovation. NACCHO notes that many
health determinants exist within the community, and public health departments are
in the ideal position to alleviate community health hazards. By training local public
NATIONAL C AN CE R INSTITUTE ( N C I ) 439
health officials to function as strategists, coalition builders, policy makers, and

researchers, NACCHO advances community health. The organization also works
to reduce obstacles related to insufficient funding, politics, and the quiet, unas-
suming, confidential nature of public health practices. To overcome obstacles,
NACCHO works to raise public awareness of critical issues in public health and
advocate for public health funding and support. The organization is also open to
individuals with professional interest in public health.
Sally Kuykendall
See also: Administration, Health; Association of State and Territorial Health Offi-
cials; Centers for Disease Control and Prevention; Collaborations; Community
Health Centers; State, Local, and Territorial Health Departments
Further Reading
National Association of County and City Health Officials. (2016). Retrieved from http://
www.naccho.org/.
NATIONAL CANCER INSTITUTE (NCI)

The National Cancer Institute (NCI) is one of the major institutes within the National
Institutes of Health (NIH), which itself is within the U.S. Department of Health and
Human Services. The primary purpose of the NCI is to coordinate the federal gov-
ernment’s National Cancer Program and to support cancer research and treatment.
The NCI uses a variety of approaches to accomplish these goals, including conduct-
ing and disseminating research and providing grant funding to basic and clinical
cancer research labs at a variety of research institutions.
The funding of the NCI is appropriated by Congress through the traditional fed-
eral budget process, which involves the participation of the legislative and execu-
tive branches of the federal government. In the 2016 to 2017 year, the budget
allocated to the NCI was nearly $5.4 billion; this budget covers many diverse objec-
tives including basic science research, cancer prevention, cancer diagnosis, survi-
vorship support, cancer risk f actor research, and more (NCI, 2016). Additionally, the
NCI provides financial support for workforce training of students and professionals
in order to foster development of the future cancer scientist workforce. The benefi-
ciaries of the workforce support programs that include high school and college
students, graduate and doctoral students, and early c areer scientists. In the 2016 to
2017 year, over 3,600 individuals w ere supported by this program.
The NCI is also responsible for coordinating the cancer research work of a net-
work of nearly 70 NCI-designated Cancer Centers, which are the universities and
research centers at the forefront of NCI-funded cancer research. These 69 NCI-
designated Cancer Centers include a spectrum of sites, from basic science laborato-
ries to comprehensive cancer centers. In order to qualify to become an NCI-designated
440 NATIONAL C ANCER INSTITUTE (NCI)
Cancer Center, institutions must participate in combining laboratory science, pop-

ulation science, and clinical studies in a coordinated and high-quality way (Ameri-
can Cancer Society, 2014). NCI-designated Cancer Centers perform the bulk of
the cancer research work that NCI grants are meant to fund. Examples of some of
the ongoing research proj ects carried out by NCI- designated Cancer Centers
include research into the biological mechanisms that protect cells against cancer,
clinical trials of new or modified cancer medications, and sociological and public
health–oriented cancer research.
The history of the NCI, as well as its NCI-designated Cancer Centers, can be
traced back nearly three quarters of a c entury to 1937, when President Franklin D.
Roosevelt signed legislation establishing the NCI. It was only about two decades
later, in 1955 and 1960, that anticancer drugs began to be tested with NCI funding
and that the NCI-designated Cancer Center status was formally established and
given to research institutions, respectively.
Another tremendous step in the growth of the scope and work of the NCI came
in 1973 when the institute established the Surveillance, Epidemiology, and End
Results (SEER) program, which is responsible for collecting population-level data
regarding cancer incidence, survivorship, and mortality. SEER collects statistics from
a massive cancer registry that covers approximately a quarter of the entire U.S. pop-
ulation. With this information, the SEER database serves to inform public health
professionals and researchers about trends in cancer rates. It is in this way that the
SEER program has been responsible for some of the most significant epidemiologi-
cal and sociological cancer research findings in the United States. Some of these
research findings include showing the correlation between race and higher mortal-
ity in some cancers, such as prostate cancer. Additionally, the SEER program can
be used by public health professionals in order to inform initiatives that target par-
ticularly cancer-vulnerable populations such as African Americans and Hispanics
in order to promote health equity.
Over the decades following the establishment of the SEER program, the NCI has
established and participated in a variety of other important programs that serve the
cancer-oriented mission. In 1983, the NCI launched the Community Clinical Oncol-
ogy Program, also known as CCOP, which connects patients of cancer doctors with
ongoing clinical t rials. In the year 2000, the NCI established the Center to Reduce
Cancer Health Disparities (CRCHD), which works to alleviate racial and ethnic dis-
parities in cancer outcomes and health of patients undergoing cancer treatment. In
2005, the NCI worked in conjunction with the National Human Genome Research
Institute to establish the widely used Cancer Genome Atlas. The Cancer Genome
Atlas allows researchers to access a deep body of knowledge regarding the genomic
changes behind cancer etiology. The NCI has evolved approaches and programs to
adapt to contemporary challenges in cancer treatment and resource allocations. The
institute creates and supports initiatives that range from precision medicine to global
cancer medicine, as well as genome-based clinical drug research.
NATIONAL C ENTE R F O R IN JU RY PR E VENTION AND CONTR OL (N C IPC ) 441
The NCI was created in response to the immense public health challenge of alle-
viating cancer in the American and world population. Cancer, as the second lead-
ing cause of death in the United States, represents a complex disease with many
causes, mechanisms of pathology, and harmful effects. Therefore, the coordinated
research efforts carried out by and supported through the NCI are essential to bet-
ter understanding how cancer operates and how to best approach managing and
curing cancer. The NCI is at the forefront of cancer research in the United States as
well as the entire world, and serves to enable advancements in cancer research in
a rich diversity of ways.
Shayan Waseh
See also: Cancer; Environmental Protection Agency; Genetics; Health Communica-

tion; Healthy Places; Leading Health Indicators; Men’s Health; National Institutes
of Health; Nutrition; Prevention; Research; Skin Cancer
Further Reading
American Cancer Society. (2014). National Cancer Institute Cancer Center program informa-
tion. Retrieved from https://www.cancer.org/treatment/finding-and-paying-for-treatment
/choosing-your-treatment-team/nci-cancer-center-programs.html.
Mohanty, S., & Bilimoria, K. Y. (2014). Comparing national cancer registries: The national
cancer data base (NCDB) and the surveillance, epidemiology, and end results (SEER)
program. Journal of Surgical Oncology, 109(7), 629–630.
National Cancer Institute. (2016). NCI overview. Retrieved from https://www.cancer.gov
/about-nci/overview.
NATIONAL CENTER FOR INJURY PREVENTION AND

CONTROL (NCIPC)
In the United States, intentional and unintentional injuries are the leading cause of
death for people aged 1 to 44. Beyond the number of p eople who die each year,
many, many more seek treatment in emergency departments, clinics, and doctor
offices. Motor vehicle crashes, falls, prescription drug overdoses, gunshot wounds,
suicides, and other incidents affect young, working populations, those with the
greatest potential to contribute to society. The National Center for Injury Preven-
tion and Control (NCIPC) strives to reduce injuries by identifying, monitoring, and
studying injuries, supporting prevention research, and creating and offering
evidence-based programs. The NCIPC is a valuable resource for accurate data, qual-
ity resources, and evidence-based programs in injury prevention.
WISQARS (Web-based Injury Statistics Query and Reporting System) is the injury
center’s online database. WISQARS collects injury data from hospitals, national sur-
veys, death certificates, and Census Bureau to provide accurate data on fatal and
nonfatal injuries. A chief advantage of WISQARS is that the data are easy to retrieve
442 NATIONAL C ENTE R F O R IN J U RY PR EVENTION AND CONTR OL (N C IPC )
and many times have already been analyzed and charted for easy visualization in
reports or presentations. For example, the NCIPC’s Ten Leading Causes of Death and
Injury charts are helpful in providing background information to audiences. The
charts present the most recent national mortality or nonfatal injury data highlighting
why injuries are a leading health problem. Alternatively, students, public health prac
titioners, researchers, and o thers can use the WISQARS database to search injury-
related data. For example, if a student is writing a paper on traumatic brain injuries
(TBIs) and wants to know the annual cost of emergency department (ED) visits for
TBIs among young p eople (aged 5–21), the student would enter the search criteria
into the database and WISQARS would provide results. In 2010, there were 657,864
emergency department visits for TBIs. Total medical costs w ere $2,726,495,000
(average = $4,144/ED visit). Loss of work costs totaled $3,276,481,000. Thus, total
combined costs for ED visits for TBIs for p eople aged 5 to 21 years w ere more than
$6 billion. The data may be used to inform audiences, compare age groups, examine
trends, or map rates. Providing accurate data allows communities and policy makers
to make smart decisions regarding health care needs, policies, and resources.
The NCIPC also acts as a resource, providing information on programs and best
practices in injury treatment and prevention. HEADS UP is a series of NCIPC resources
designed to educate parents, youth, school personnel, and health care providers on
prevention, early detection, and response to brain injuries. The materials provide
information on the basics of brain injury, symptoms, recovery, recommendations for
safe return to activities, policies, and prevention. STEADI (Stopping Elderly Acci-
dents, Deaths & Injuries) is a training course for health care providers to help identify
falls risk among elderly patients, modifiable risk factors, and effective interventions.
The PROTECT Initiative is a collaboration of public health organizations, private
companies, consumer advocates, and scholars developing ways to keep children safe
from unintentional drug overdose. The group investigates and recommends ways to
improve medication packaging to prevent unsupervised ingestion by c hildren, create
dosing methods, which reduce the potential for parent/caregiver dosing error, and
create effective educational campaigns. The NCIPC continues to develop programs
and campaigns to reduce specific intentional and unintentional injuries.
The National Center for Injury Prevention and Control is a clearinghouse of infor-
mation on some of the leading c auses of death and disability in the United States.
The center provides accurate, unbiased information on issues such as prescription
drug overdoses, gun violence, sports-related concussions, falls, motor vehicle safety,
and suicide prevention.
Sally Kuykendall
See also: Aging; Agricultural Safety; Centers for Disease Control and Prevention;
Child Maltreatment; Elder Maltreatment; Epidemiology; Healthy Places; Home
Safety; Infant Mortality; Injuries; Intimate Partner Violence; Motor Vehicle Safety;
Prevention; Sports-Related Concussions; Violence
NATIONAL HEALTH AND NUTRITION E X A M INATION SUR VEY ( NHANES ) 443
Further Reading
National Center for Injury Prevention and Control. (2017). Retrieved from https://www.cdc
.gov/injury/index.html.
NATIONAL HEALTH AND NUTRITION EXAMINATION

SURVEY (NHANES)
The National Health and Nutrition Examination Survey (NHANES) investigates the
nutrition, health, and physical activity of c hildren and adults in the United States.
It is an ongoing program of the National Center for Health Statistics. The NHANES
project started in the 1960s, following the National Health Survey Act of 1956—a
bill authorizing federal research to study disease, injury, and disability across the
nation. Previous methods had become outdated, and the federal government needed
better data to identify and quantify health problems in order to plan health pro-
grams, promote the health of the nation’s workforce, estimate f uture needs for med-
ical devices and medical care, and suggest what issues need further investigation.
The NHANES project is unique b ecause study teams travel to the area of interest
that currently includes up to 15 communities across the United States. The study
personnel interview and examine people to learn more about the inhabitants, health
behaviors, and health concerns. Each member of the team contributes unique skills.
The team consists of bilingual interviewers, a physician, a dentist, medical techni-
cians, nurses, health educators, and phlebotomists. Five thousand p eople are selected
to participate each year, and they are identified based on their ability to represent
other people of their age, gender, and racial or ethnic group. Each participant rep-
resents approximately 50,000 other p eople. Study participants are initially inter-
viewed in their home and then undergo a detailed physical examination in a specially
designed mobile laboratory. The interviewers ask questions about diet, physical
activity, sexual experiences, drug, alcohol, and tobacco use. The clinical examina-
tions gather information on height, weight, blood pressure, bone density, eyesight,
kidney function, sexually transmitted diseases, blood tests, and other physiological
functions. The NHANES primarily focuses on common health-related behaviors
such as substance abuse, physical fitness, and sexual practices, and diseases such
as diabetes, anemia, cardiovascular disease, obesity, kidney disease, osteoporosis,
respiratory diseases, and sexually transmitted diseases. All information gathered by
the interviews and medical staff is confidential. Data are entered into a database
with any personal identifiers removed. Researchers who are interested in tracking
a specific disease can download and analyze the de-identified data. The NHANES
provides valuable information to both the individual participants and public health
professionals who work for government, nonprofit, and for-profit organizations. Par-
ticipants receive the results of their physical exam, dental exam, eye exam, and
hearing exam, blood tests, body scan, and lung function tests. The Department of
Health and H uman Services, among other interested organizations, receives infor-
mation on emerging health issues and the need for public health policies and
444 NATIONAL HEA RT, LUNG, AND BLOOD INSTITUTE ( NHL B I )
programs, and add to our knowledge about the connections between health behav
iors and disease.
Many important health milestones developed from NHANES data, such as the
growth charts that pediatricians use to compare a child’s weight and height to other
children of the same age and gender in order to screen for delayed growth or devel-
opment; policies to remove lead from gasoline, food, and soft drinks; tracking the
increase in obesity throughout specific areas of the country; identifying the need
for diabetes prevention programs among ethnic minorities; targeting heart disease
prevention programs among at-risk groups of people; and developing new ways to
measure lung function in order to study asthma. As health concerns evolve, scien-
tists continue to refine the NHANES instrument and procedures. The NHANES pro-
gram provides valuable insights and opportunities to advance our knowledge of
diseases and ways to prevent and treat health issues.
Sally Kuykendall
See also: C
hildren’s Health; Community Health; Environmental Health; Healthy
People 2020; Nutrition; Obesity; Prevention; Research
Further Reading
Centers for Disease Control and Prevention. (2015, August 17). National health and nutri-
tion examination survey homepage. Retrieved from http://www.cdc.gov/nchs/nhanes.htm.
Division of Public Health Methods, Office of the Surgeon General, Public Health Service.
(1957). The National Health Survey Act. Public Health Reports, 72(1), 1–4.
U.S. Department of Health and Human Services. (2014). National health and nutrition exam-
ination survey, 2013–2014.
NATIONAL HEART, LUNG, AND BLOOD

INSTITUTE (NHLBI)
The National Heart, Lung, and Blood Institute (NHLBI) is a federal agency respon-
sible for advancing knowledge of the causes, treatment, and prevention of heart,
lung, and blood disorders. The mission of the NHLBI is to provide “global leadership
for a research, training, and education program to promote the prevention and treat-
ment of heart, lung, and blood diseases and enhance the health of all individuals
so that they can live longer and more fulfilling lives” (NHLBI, 2017). In the United
States, cardiovascular disease claims more lives than any other health problem. One
in four deaths is due to heart disease (CDC, 2015). In addition to the leading killer,
the NHLBI addresses anemia, asbestos-related lung diseases, bone marrow trans-
plants, congenital heart defects, cystic fibrosis, insomnia, Marfan syndrome, pneu-
monia, sarcoidosis, Von Willebrand disease, and many other medical problems. The
NHLBI supports and encourages research into the c auses of heart, lung, and blood
disorders, translation of research findings into clinical practice, training of special-
ists in heart, lung, and blood disorders, and education of the general public on recent
NATIONAL HEART, LUN G , AND B LOOD INSTITUTE ( NHL B I ) 445
scientific advancements. Working u nder the auspices of the National Institutes of

Health, the NHLBI collaborates with scientists, physicians, patients, families, and
communities to reduce risk of disease and improve quality of life for those living
with these diseases. Among the many notable prevention campaigns sponsored by
the NHLBI are the National Wear Red Day and the Heart Truth® Campaign. Recog-
nizing that w omen will often care for their c hildren, spouses, parents, and friends
before taking care of themselves, these campaigns remind w omen that heart dis-
ease is a leading cause of death and women need to take care of themselves. The
programs encourage people to wear red on the first Friday in February as a way to
raise awareness of heart disease among women. The campaigns have been very suc-
cessful in reaching busy w omen.
Insomnia is one example of the many, many health issues that the NHLBI addresses
and offers a good example of the NHLBI in action. Sleep deprivation is a public
health problem. Chronic sleep insufficiency increases risk of motor vehicle crashes,
home and workplace injuries, obesity, heart disease, hypertension, stroke, diabe-
tes, depression, and infections. Socially, people who do not get enough sleep are
moody, irritable, forgetful, and make poor decisions. Sleep deprivation impairs aca-
demic and job performance and interferes with interpersonal relationships. The
American Academy of Sleep Medicine recommends 8 to 10 hours of sleep per
24 hours for adolescents (aged 13–18 years) and 7 or more hours per 24 hours for
adults (over 18 years) (Paruthi et al., 2016). When adults are able to sleep without
limitation, the average sleep time is 8 to 8.5 hours (Roehrs, Timms, Zwyghuizen-
Doorenbos, & Roth, 1989). A nationwide survey shows that one out of three adults
reports insufficient sleep on 14 or more of the last 30 days (CDC, 2009). The most
common causes of sleep disorders are obstructive sleep apnea, insomnia, restless
legs syndrome and periodic limb movements in sleep, narcolepsy, and prescription
or over-the-counter drugs, such as caffeine, alcohol, and nicotine. Shift workers and
adolescents are at risk due to lifestyle f actors that alter the circadian rhythm. Chronic
sleep deprivation creates a cumulative sleep debt that increases risk of harmful con-
sequences. Healthy People 2020 Objective SH-4 aims to “increase the proportion of
adults who get sufficient sleep.” To improve sleep health, the NHLBI convenes work-
ing groups to review and summarize sleep disorder research, identify genetic,
pathological, environmental, and cultural and lifestyle factors that disrupt healthy
sleep, suggest ways to improve prevention efforts, and translate the science of sleep
from research to bedside and community practice. The NHLBI provides materials
to health care practitioners on screening and diagnosis of sleep disorders and ways
to manage disorders. Treatment addresses the underlying medical or psychological
condition and in cases where the underlying condition is unknown or resistant to
treatment, behavioral or pharmacological therapy may be used. Behavioral treat-
ment replaces maladaptive behaviors with therapeutic interventions such as relax-
ation therapy, sleep restriction therapy, stimulus control therapy, or cognitive therapy.
Pharmacological treatment consists of hypnotic medications, antidepressants,
antihistamines, or melatonin. To prevent sleep disorders and the consequences
446 NATIONAL INSTITUTE ON DR UG A B USE ( NIDA )
of sleepiness, the NHLBI recommends educating at-risk populations (young p eople,

shift workers, and p eople with sleep disorders) on the hazards of sleep depriva-
tion, promoting rumble strips to alert drowsy drivers, delaying high school start
times, driver education, safe rest areas for d
rivers, and interactive curricular mate-
rials for teachers and students. The NHLBI maintains a database of sleep education
materials with information tailored to selected audiences. The work supported
by the NHLBI brings attention to this often unrecognized health issue and prevents
numerous motor vehicle crashes.
The NHLBI supports rigorous investigations into the c auses, treatment, and pre-
vention of heart, lung, and blood disorders. Through intramural and extramural
research, training, and education, the NHLBI works with other agencies, scientists,
health care professionals, and community members to determine effective methods
for prevention and treatment. As a result, the NHLBI has designed some unusually
creative and highly effective prevention campaigns that can influence hard-to-reach
audiences.
Sally Kuykendall
See also: Centers for Disease Control and Prevention; Heart Disease; Heart Truth®
(Red Dress) Campaign, The; Healthy People 2020; Hypertension; National Institutes
of Health; Physical Activity; U.S. Department of Health and Human Services
Further Reading
Centers for Disease Control and Prevention (CDC). (2009). Perceived insufficient rest or
sleep among adults—United States, 2008. Morbidity and Mortality Weekly Report, 58(42),
1175–1179.
Centers for Disease Control and Prevention (CDC). (2015). Heart disease facts. Retrieved
from https://www.cdc.gov/heartdisease/facts.htm.
National Heart, Lung, and Blood Institute. (2017). Retrieved from https://www.nhlbi.nih
.gov/.
Paruthi, S., Brooks, L. J., D’Ambrosio, C., Hall, W. A., Kotagal, S., Lloyd, R. M., & . . . Wise,
M. S. (2016). Recommended amount of sleep for pediatric populations: A consensus
statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine,
12(6), 785–786. doi:10.5664/jcsm.5866
Roehrs, T., Timms, V., Zwyghuizen-Doorenbos, A., & Roth, T. (1989). Sleep extension in
sleepy and alert normals. Sleep: Journal of Sleep Research & Sleep Medicine, 12(5),
449–457.
NATIONAL INSTITUTE ON DRUG ABUSE (NIDA)

The National Institute on Drug Abuse (NIDA) conducts and supports research on
the causes and consequences of addictive substance use and translates this science
into practical advice for policies, programs, and practices in public health. NIDA
is 1 of the 27 institutes within the National Institutes of Health (NIH). The NIH is
the largest biomedical research agency in the world. The NIH mission is to enhance
NATIONAL INSTITUTE ON D R U G A B USE ( NIDA) 447
quality and length of life by improving health and reducing illness and disability.
NIDA focuses exclusively on studying the biological, neurological, social, and behav-
ioral mechanisms that promote or inhibit substance use and abuse. NIDA research-
ers study the brain to determine the effects of illicit drug use. Research findings are
translated into evidence-based programs and practices for use in schools, hospi-
tals, outpatient clinics, community, and public health. NIDA provides a wealth of
information for students, patients and family members, other researchers, health
professionals, and policy makers. Information ranges from safe disposal of unused
medicines to opioid abuse to adolescent brain cognitive development.
Following the Protestant values of early colonial America, addictions were origi-
nally believed to be a moral flaw. In An Inquiry into the Effects of Ardent Spirits upon
uman Body and Mind, professor of medicine of the University of Pennsylvania
the H
Dr. Benjamin Rush (1812) presented a continuum of beverages with their associated
personality traits, diseases, vices, and consequences. Rush associated w ater, milk,
and “small beer” with health, happiness, and “serenity of mind.” Cider, wine, porter,
and strong beer in moderation were associated with cheerfulness and nourish-
ment. Grog, bitters, cordials, and gin, brandy, or rum in the morning were associ-
ated with idleness, fighting, lying, stealing, burglary, and murder in addition to
tremors, vomiting, jaundice, dropsy, epilepsy, depression, palsy, and insanity. Rec-
ommended treatments w ere whipping, immersing the body in cold w ater, or induc-
ing vomiting, terror, anger, or sweating. Rush reported, “Many hundred drunkards
have been cured of their desire for ardent spirits by a practical belief in the doc-
trines of Christian religion” (Rush, 1812, p. 32). This medical classic shows how
the leading doctors promulgated misconceptions about addictions as a moral fail-
ing. The fallacies continued throughout the 20th century with America’s War on
Drugs and the Just Say No campaign. Misconceptions regarding substance abuse
are dangerous b ecause they lead to harmful stereotypes that blame the victim
and encourage communities to use treatments that do not actually work. With lim-
ited resources in health, it is imperative that addictions are accurately understood
and that treatments are based on the science of addiction rather than personal or
religious beliefs.
NIDA started in 1935 as a research facility connected to a Public Health Service
hospital in Lexington, Kentucky. In 1948, the center became the Addiction Research
Center (ARC). ARC researchers achieved several ground-breaking discoveries, such
as the use of methadone to treat heroin addiction, mechanisms of drug relapse, the
role and function of opioid receptors, use of opioid antagonists to treat heroin over-
dose, and creating drug profiles to evaluate the potential for addiction of new
drugs on the market. Starting in the 1970s, NIDA commenced a regular, large-scale
survey of America’s high school and m iddle school students to identify the inci-
dence and prevalence of substance use and abuse. The Monitoring the Future Survey
allows public health professionals to monitor trends in drug abuse and to identify
populations at risk. In addition to understanding what drugs are increasing in pop-
ularity, the researchers have noted some unique problems, namely the honeymoon
448 NATIONAL INSTITUTE ON DR UG A B USE ( NIDA )
period and generational forgetting ( Johnston et al., 2017). The honeymoon period is
the time between when a drug first becomes accessible and information on adverse
consequences is widely recognized. For example, methylenedioxypyrovalerone
(“bath salts”) is a synthetic cathinone offered as a cheap substitute for methamphet-
amine or cocaine. Promotional advertising spreads quickly through word of mouth
before researchers have the opportunity to study short-and long-term effects. With
more p eople trying or using the drug, adverse effects start to become apparent.
People using bath salts have committed some very gruesome murders. Synthetic
cathinones are addictive and cause anxiety, paranoia, hallucinations, extreme agita-
tion, and violence (NIDA, 2016). Generational forgetting is when younger genera-
tions rediscover drugs that were used by older generations and fell out of popularity.
Comeback drugs include heroin, LSD, ecstasy, and methamphetamine. NIDA works
with numerous audiences to reduce the exploitation of the honeymoon period or
generational forgetting. NIDA develops fact sheets on specific drugs, creates cur-
ricula for use in schools, offers research-based guides in drug treatment and pre-
vention, and partners with other agencies to promote evidence-based programs and
practices in substance abuse prevention.
NIDA is a great resource for people seeking detailed, accurate, and up-to-date
information on addictions in general or on a specific drug or type of addiction. NIDA
for Teens (https://teens.drugabuse.gov/drug-f acts) is a library of information featur-
ing the definition, street names, physical and emotional effects, side effects, adverse
effects, and risks for particular drugs. The website also features where to turn if you
or a friend is in crisis. The National Suicide Prevention Lifeline (1-800-273-TALK)
assists those who are struggling with addictions firsthand or with someone they
love. The Substance Abuse Treatment Facility Locator (1-800-662-HELP) is a
searchable database of substance abuse treatment facilities, m ental health centers,
health care centers, and physicians. Accurate information is one of the most power
ful tools in addressing addictions. NIDA is the best source for accurate information
on drug facts.
Sally Kuykendall
See also: Addictions; Alcohol; National Institutes of Health; Prescription Drugs; Sub-
stance Abuse and M ental Health Services Administration; Syringe Service Programs;
Further Reading
Johnston, L. D., O’Malley, P. M., Meich, R. A., Bachman, J. G., & Schulenberg, J. E. (2017).
Monitoring the future national survey results on drug use, 1975–2016: Overview, key find-
ings on adolescent drug use. Ann Arbor: Institute for Social Research, University of
Michigan.
NIDA. (2016). Synthetic cathinones (“bath salts”). Retrieved from https://www.drugabuse.gov
/publications/drugfacts/synthetic-cathinones-bath-salts.
NIDA. (2017). Retrieved from https://www.drugabuse.gov/.
NATIONAL INSTITUTES O F HEALTH ( NIH ) 449
Rush, B. (1812). An inquiry into the effects of ardent spirits upon the human body and mind. Boston:
Manning & Loring. Retrieved from https://archive.org/details/2569027R.nlm.nih.gov.
University of Michigan. (2017). Monitoring the future. Retrieved from http://monitoringthefuture
.org/.
NATIONAL INSTITUTES OF HEALTH (NIH)

The National Institutes of Health (NIH) is the federal agency responsible for advanc-
ing scientific knowledge on the c auses, treatment, and prevention of h uman dis-
eases in order to promote the well-being of the nation. The agency’s mission is to
“seek fundamental knowledge about the nature and behavior of living systems and
the application of that knowledge to enhance health, lengthen life, and reduce ill-
ness and disability” (NIH, 2017). Founded in 1887 as part of the Marine Hospital
Service, the organization’s original purpose was to study pathogenic organisms in
order to prevent epidemics. NIH research gradually moved from studying cholera
and yellow fever to fungal infections, fluoridation, treatment of bipolar disorder,
human retroviruses, Lyme disease, HIV, enzyme deficiencies, HPV vaccine, congeni-
tal heart diseases, addictions, Alzheimer’s disease, chronic fatigue, and many other
behavioral health, mental health, and medical problems. NIH researchers have
A researcher at the National Institutes of Health (NIH) studying cancer therapy. The NIH is
the largest biomedical research agency in the world. NIH researchers hold 88 Nobel Prizes
and 195 Lasker Awards for groundbreaking achievements in medicine and human physiology.
(David Sone/National Institutes of Health)
450 NATIONAL INSTITUTES OF HEALTH (NIH )
earned 88 Nobel Prizes and 195 Lasker Awards. T oday, the NIH is the largest bio-
medical research agency in the world, operating u nder the U.S. Department of
Health and H uman Services (DHHS) and managing over $32 billion in research
grants each year.
The responsibility to ensure judicious use of taxpayer funds creates challenges.
One review of NIH-funded research claimed that NIH grant reviewers preferred
cautious, conservative projects that were within the scope of the reviewer’s own
research interests rather than ground-breaking research (Nicholson & Ioannidis,
2012). The reviewers shied away from studies that could be a financial risk. Other
reports suggest that researchers who are good at networking and self-promotion
are more likely to attain NIH grant support than other competent scientists. In
response to these criticisms, the NIH established a new line of grants for novel, pio-
neering research. The current goals of the NIH are to foster and support:
1. Scientific collaborations that protect and improve individual and public health.
2. Development of health researchers and biomedical research facilities.
3. Discovery of biomedical knowledge and technology.
4. Scientific integrity, professionalism, accountability, and social responsibility
within biomedical research.
Federal support of biomedical research ensures that researchers are free to study
challenging diseases and health problems without financial or administrative
pressures.
The NIH supports multiple types of health-enhancing research and is especially
valuable to scientists studying unusual topics. Pharmaceutical or biomedical agen-
cies will not invest in studying problems that are expected to yield little return on
investment. Therefore, researchers studying rare or unusual diseases face obstacles
in funding and other stages of the research process. Typically, there is limited infor-
mation on the disease. Finding other scientists interested in studying the disease
may be difficult b ecause journals are hesitant to publish articles with limited reader
interest. Locating and enrolling research participants can be challenging. The NIH’s
Office of Rare Diseases Research (ORDR) supports researchers interested in rare dis-
eases by providing access to resources, dissemination of research, customized liter
ature reviews, lists of advocacy organizations, access to study participants, and
funding opportunities. The benefit to studying rare diseases is that study findings
can provide common insights that apply to other health issues.
Public health researchers need a source of support that follows ethical guide-
lines of practice. Researchers and the public cannot and should not depend on busi-
nesses to determine what diseases or health issues warrant investigation. The NIH
supports a healthy nation by prioritizing research studies and allocating support to
promising studies, thus enhancing health promotion in areas of critical need.
Sally Kuykendall
NATI O N’S H EA LTH , TH E 451
See also: Centers for Disease Control and Prevention; Healthy P eople 2020; National
Cancer Institute; National Heart, Lung, and Blood Institute; Public Health in the
United States, History of; Research; U.S. Department of Health and H uman Ser
vices; U.S. Public Health Service; Controversies in Public Health: Controversy 1
Further Reading
National Institutes of Health. (2017). Retrieved from https://www.nih.gov.
Nicholson, J. M., & Ioannidis, J. A. (2012). Research grants: Conform and be funded. Nature,
492(7427), 34–36. doi:10.1038/492034a
NATION’S HEALTH, THE

The Nation’s Health is a newspaper reporting local, state, national, and global news
of interest to public health students, professionals, and policy makers. The news-
paper is published 10 times per year by the American Public Health Association
(APHA). The publication originally developed from a Chicago monthly medical
magazine, Modern Medicine. Started in 1919, Modern Medicine published articles on
medical advances, industrial and social health, and health administration. One sec-
tion, entitled “The Nation’s Health,” was edited by C. E. A. Winslow and featured
information on public health administration and public welfare. In May 1921, Mod-
ern Medicine changed into The Nation’s Health. Unlike other professional publi-
cations The Nation’s Health did not publish original research articles and instead
focused on explaining how new ideas, science, and laws impact public health
and public health practice. In 1927, The Nation’s Health was once again dele-
gated to status as a section, this time within the American Journal of Public Health.
In January 1971, The Nation’s Health became a separate publication following the
original intention of providing current news on developments in public health. The
first issue contained letters to the editor and articles on Medicaid, cardiovascular dis-
eases, mental illness, nurse-midwifery, a recent epidemic of falls from high places
among c hildren, and health of Mexican Americans. Dr. Paul B. Cornely offered his
insights into public health with an article entitled “The Hidden Enemies of Health
and the American Public Health Association.” Cornely reported 1970s concerns as
a national addiction to the abundant life, perversion of democracy, pollution of the
mind, racism, and the impact of technology on human connections. He offered
solutions such as deconstructing consumerism, developing social responsibility,
putting humans before technology, and protecting vulnerable populations from
abuse and tyranny by an economic oligarchy. With the exception of an epidemic
of falls from urban buildings, Cornely’s topics and concerns could be headlines in
today’s public health news! Currently, The Nation’s Health presents headline news
and offers regular sections entitled APHA Advocates, Vital Signs, Journal Watch,
APHA in brief, The Globe, The Nation, state & local, health findings, student focus,
book reviews, on-the-job, and classified advertisements. The publication pro-
vides information relevant to public health professionals and policy makers in a
452 NEEDS ASSESS M ENT
clear, easy to understand format, a necessary asset in ensuring a professional and

qualified workforce.
Sally Kuykendall
See also: American Journal of Public Health; American Public Health Association;
Cornely, Paul Bertau; Rosen, George; Winslow, Charles-Edward Amory
Further Reading
American Public Health Association. (2017). Retrieved from https://www.apha.org/.
Cornely, P. B. (1971). The hidden enemies of health and the American Public Health Asso-
ciation. American Journal of Public Health, 61(1), 7–18.
Editorial. (1971). The nation’s health. American Journal of Public Health, 61(1), 1.
The Nation’s Health. (2017). Retrieved from http://thenationshealth.aphapublications
.org/.
NEEDS ASSESSMENT
A needs assessment is a planned series of actions designed to identify and under-
stand the conditions or resources that are required to achieve ideal wellness of an
individual, community, or population of interest. In public health, need is a noun
(as opposed to a verb), broadly defined as the gap between current health status
and desired health status. Put another way, a need is an identified concern or prob
lem. The needs assessment aims to understand, in detail, what the gap is and why
the problem exists within a specific group. For example, suppose there was an
abnormally high prevalence of childhood obesity in one area (current situation).
The desired situation would be that all c hildren in that area are within healthy weight
range (ideal situation). The need is the gap between the current condition, high rates
of childhood obesity, and the desirable, healthy weights.
In a sense, the need would also be the problem that c hildren in the community
are overweight or obese. The objective of the needs assessment would be to under-
stand why children are overweight or obese, what factors contribute to the prob
lem, and the consequences of the disease on the community. In this case, children
may have limited areas for recreational activity, a high-fat diet, or concerns for neigh-
borhood safety that may limit outdoor activities. By investigating the behaviors of
who has the disease and who doesn’t have the disease, public health professionals
determine how and why the disease occurs and what needs to be done to stop the
disease. Knowing the specific factors that enable the problem allow public health
professionals to allocate resources where they w ill be most effective. A needs assess-
ment does not necessarily focus on one need or disease. A needs assessment can
take into account numerous needs at the same time and can help to prioritize those
needs, as in cases of impoverished communities that suffer from numerous health
problems. In addition to public health, needs assessments are widely used in edu-
cation, business, government, and marketing.
NEEDS ASSESS M ENT 453
The practice of performing needs assessments was formally developed in the late
1970s by Roger Kaufman. Considered the “father of needs assessment,” Kaufman
combined concepts from psychology, sociology, industrial engineering, and mathe
matics to develop planning strategies for needs assessments. He identified three lev-
els, known as levels of planning. The mega, macro, and micro levels of planning
form the foundation and principles for needs assessments performed today (Kaufman,
Rojas, & Mayer, 1993). Mega-level planning starts by developing an idealistic vision
for society. In an ideal society, all children would have equal opportunities for healthy
social, emotional, and physical development, safe places to play, and a nutritious,
balanced diet. Macro-level planning looks at the organizational, community, or
group or population-based level. The ideal community to prevent childhood obe-
sity would have safe and convenient recreational sites, access to fresh fruits and
vegetables to support healthy diet, and quality health education in preschool, ele-
mentary, middle, and high schools. Micro-level planning looks at the individual or
family level. F actors that support healthy weight are regular physical activity and a
diet that is low in refined sugars and fat. Needs assessments can include data col-
lection and planning on all three levels or may address a single level. By envision-
ing and striving toward the ideal society, community, or individual, the needs
assessment becomes proactive rather than reactive.
There are generally three phases to conducting a needs assessment: pre-assessment,
assessment, and post-assessment (Witkin & Altschuld, 1995). During the pre-
assessment phase, practitioners develop a work group, examine what is already
known about the needs in the community, set the purpose and goals for the assess-
ment, and identify methods for conducting the needs assessment. During the pre-
assessment phase, secondary data collection methods are used. Secondary data
collection is when the public health practitioner obtains information from empiri-
cal research studies, literature reviews, policies, and government or agency reports
related to the community, population, or problem being assessed. The assessment
phase of the needs assessment occurs when the practitioner gathers information
directly from individuals and stakeholders within the community specific to the
need being addressed. This process is known as primary data collection. Primary
data collection includes quantitative methods, qualitative methods, or both. Quan-
titative data enumerate the problem (number of p eople impacted) and qualitative
data describe the problem (adverse health effects). The most commonly used quan-
titative method is surveys, which can be mailed, e-mailed, delivered over the
phone or online, or administered in person to participants. The most commonly
used qualitative methods include in-depth interviews, focus groups, and commu-
nity observations. In the post-assessment phase of the needs assessment, the prac-
titioner uses the findings from the needs assessment to develop practical strategies
to address and improve the need within the community. The findings can be used to
inform decisions to reallocate resources within a community or create policies,
health education materials, or public health programs and interventions to address
the need, ultimately improving the lives of the population in need.
454 NEEDS ASSESS M ENT
More recently, capacity assessments—also known as assets assessments—are per-

formed at the same time as needs assessments. Capacity assessment is similar to
needs assessment in that it is a planned process, but it is different from a needs
assessment because the assets of the individual, community, or population are
assessed rather than the needs (Gilmore, 2012). Capacities, or assets, are the resources
that the individual, community, or population has available and what they are
capable of doing. Assets can be utilized to address the problems or needs within
a community. For example, in a community with a predominance of a prevent-
able condition, such as obesity, some assets would include hospitals, health care
community centers or organizations, and safe parks or other recreational areas.
Assets assessments can also inform needs assessments because if there is a resource
missing in the community that would help to address the need, then it would be
necessary to introduce that resource to the community. For example, if the assets
assessments did not identify any recreational centers in that community with a pre-
dominance of obesity, then recreational centers would have to be built to provide
safe places for physical activity.
Many models are available to help a public health practitioner systematically con-
duct needs and assets assessments. Commonalities among the models include uti-
lizing a social ecological approach and a general three-phase process (pre-assessment,
assessment, post-assessment). One of the most widely used approaches that can be
applied to needs assessment is the social ecological approach. This approach is based
on the belief that one’s health is influenced by many factors, including family and
friends, the organizations that exist in their neighborhood, the community in which
they live, and the policies that affect them. This allows the public health practitio-
ner to gain a better understanding about the need b ecause it assesses the issue(s)
in different ways. An analysis of these f actors can collectively describe what is lack-
ing, which can explain why the need exists. For example, in a community with a
predominance of obesity, it may be that the individuals within the community do
not exercise or eat a balanced diet b ecause they believe it is too hard to exercise,
they do not like the taste of healthier foods, and they do not have friends who
encourage them to exercise or eat better. There also may be a lack of access to healthy
foods and recreational centers in the neighborhood, and there may be many fast
food restaurants available. Finally, there may be policies that make nutritious foods,
such as vegetables, more expensive than less healthier options, such as candy bars,
in the neighborhood. By understanding individual characteristics, the public health
practitioner can get a clear picture of the current situation, understand why there
is a gap that exists between the current and ideal situations, and advocate reducing
obesity within the community.
Noora F. Majid and Nadav Antebi-Gruszka
See also: Collaborations; Community Health; Core Competencies in Public Health;

Environmental Health; Evaluation; Evidence-Based Programs and Practices; Health
NI G HTIN GALE , F LO R EN C E 455
Education; Intervention; PRECEDE-PROCEED Planning Model; Prevention; Pub-

lic Health Department Accreditation; Research
Further Reading
Gilmore, G. D. (2012). Needs and capacity assessment strategies for health education and health
promotion. Burlington, MA: Jones & Bartlett.
Kaufman, R., Rojas, A. M., & Mayer, H. (1993). Needs assessment: A user’s guide. Englewood
Cliffs, NJ: Educational Technology.
Witkin, B. R., & Altschuld, J. W. (1995). Planning and conducting needs assessments: A practi-
cal guide. Thousand Oaks, CA: Sage.
Your Complete Resource Site on Needs and Needs Assessments. (2008). Retrieved from
http://www.needsassessment.org.
NIGHTINGALE, FLORENCE (1820–1910)

Known the world over as the “The Lady with the Lamp,” Florence Nightingale r ose
to fame during the Crimean War (1853–1856) for introducing the first female nurses
to military medical facilities. Her determination to provide wounded and sick sol-
diers with the best possible care brought her to the battlefield, as well as to war-
time hospitals. After the war, she convinced the government of Great Britain to
reexamine its medical facilities and sanitation procedures for all soldiers. Respon-
sible for transforming nursing from a disreputable practice to a professional c areer
fit for educated and genteel women, Nightingale pioneered professional training
for nurses and indelibly shaped the nature of nursing throughout the world.
Born on May 12, 1820, in Florence, Italy (from which she got her name), Flor-
ence was the d aughter of William Edward and Frances (Smith) Nightingale. The
Nightingales w ere well-educated members of the British upper class. Therefore, Flor-
ence and her older sister Parthenope (named a fter the Greek city in which she was
born) lived privileged lives and spent their time on the European continent and in
their two homes in E ngland, one in Derbyshire and one in Hampshire. Both girls
were educated by their father, who gave them rigorous instruction in several for-
eign languages, history, philosophy, literature, and mathematics. A charming and
beautiful girl, Nightingale was expected to enjoy a successful social life and marry
well. Instead, she chose a life of social service, prompted by a general seriousness in
her disposition and an incident when she was 17 that convinced her to devote her
life to a worthy cause. On February 7, 1837, while in the garden at the family home
in Hampshire, Nightingale believed that God spoke to her and told her that she had
a great calling in life. Nightingale was mystified as to the exact nature of the calling
but began actively seeking ways to answer God’s call.
To the dismay of her family, Nightingale turned her attention to nursing. She
had always been interested in tending the sick in the country villages near her f amily’s
homes, a responsibility that fit well with her genteel status. Professional nursing at this
time was nonexistent, and informal nursing was widely regarded as a disreputable
456 NI G HTING ALE, F LORENCE
profession, not far removed from prostitution. Nightingale’s father, therefore, refused
her request to study nursing by working in a hospital, although she began visiting
hospitals around 1844 to inspect conditions there. Her father suggested instead
that she study parliamentary reports dealing with the subject of public health and
sanitation, a task that she undertook with energy. Within a few months, she had
become an expert on the government’s role in these fields. Her interest in public
health and sanitation was also encouraged by her neighbor, Sidney Herbert, a
prominent politician of the British Liberal Party. Herbert was enthusiastic about all
kinds of reform and spent long hours discussing medical reform with Nightingale.
Nightingale’s interest in nursing and health remained strong throughout the
1840s. She received her first practical experience nursing at the end of the decade
while traveling on the European continent with her friends Charles and Selina
Bracebridge. The trio journeyed to Egypt in 1849. On their return in the sum-
mer of 1850, they passed through the town of Kaiserwerth, Germany, where
the Institution of Protestant Deaconesses gave training to women to tend the sick.
Nightingale was fascinated by the
school, the first of its kind, and
returned the following year to
complete the four-month training
course. This experience strength-
ened her resolve to pursue a
career in nursing and to make the
profession a respectable one for
women.
In 1853, Nightingale finally
overcame the objections of her
parents to her chosen career. Her
father granted her an independent
income of £500 a year and his
permission to study nursing. That
same year, she accepted her first
professional position, as superin-
tendent of the Establishment for
Gentlewomen during Illness. In
this capacity, Nightingale showed
herself well suited to administra-
tive work.
When newspapers reported high death rates due to The following year, British
filth, shoddy care, and lack of supplies, Florence
society was scandalized by reports
Nightingale organized 38 nurses to care for wounded
soldiers of the Crimean War. Despite appalling con- of hospital conditions for soldiers
ditions and hostility from male medical staff, Night- fighting in the Crimean War. The
ingale’s nurses reduced patient mortality rates from reports, written by London Times
45 percent to 2 percent. (Library of Congress) correspondent William Howard
NIG HTIN G ALE, F LO R EN C E 457
Russell, detailed the filth, shoddy care, and lack of supplies that contributed to a
high death rate for wounded and ill soldiers. At the prompting of her old friend
Herbert, who was then the British secretary of state, Nightingale organized a bri-
gade of 38 women and traveled to the Crimea to help nurse the soldiers. Departing
England on October 21, 1854, Nightingale and her entourage arrived at the mili-
tary hospital at Scutari, Turkey, on November 5.
The doctors at Scutari greatly resented the presence of the nurses and initially
refused to allow them access to the wards. As the casualties from the B attle of Inker-
man (fought on the very day of the nurses’ arrival) began to pour into the hospital,
however, Nightingale and her nurses leaped into action and began providing aid
to the wounded. Despite this much-needed help, the all-male staff at the hospital
continued to resent Nightingale’s presence and worked to undermine her mission
throughout her stay in the Crimea.
The challenges for Nightingale w ere substantial. In addition to the hostility of
the medical staff, the conditions in the hospitals w ere appalling. Russell had not
exaggerated the plight of the wounded soldiers; if anything, he had glossed over
them. The hospital at Scutari was overcrowded, filthy, disease-ridden, and infested
with rats, mice, lice, and other vermin. In addition, most of her nurses were inex-
perienced, and some behaved poorly. Nightingale was forced to send a few of them
home because of drunkenness or improper relations with the soldiers. Although
only a few of the nurses behaved in such a manner, news of their misconduct spread
quickly and did much to harm the reputation of the fledgling nursing program.
Nevertheless, Nightingale tackled t hese challenges with vigor. Reportedly on her
feet 20 hours a day, she established a laundry and a kitchen, purchased much-needed
supplies with funds gathered from a private subscription in E ngland (one of her
first purchases was 200 scrub brushes), and brought order and cleanliness to the
institution. It was during this period that she earned her famous sobriquet, “The
Lady with the Lamp,” as she solely and personally attended the soldiers in the wards
at night so as not to tempt any of her nurses into indiscretions or promote false
rumors of the nurses’ conduct. Within a m atter of months, these reforms had resulted
in a dramatic lowering of the fatality rate among soldiers brought to the hospital;
it dropped from roughly 45 percent to 2 percent. For her efforts, Nightingale earned
the undying adoration of the wounded soldiers, many of whom viewed her as noth-
ing less than a saint.
With the hospital at Scutari r unning more smoothly, Nightingale embarked on
an expedition to visit other military hospitals in the Crimea in May 1855. Already
exhausted from overwork, she contracted what was known as Crimean fever dur-
ing the trip and became violently ill in Balaclava. Although she recovered sufficiently
within a few weeks to return to Scutari and resume her duties there, her health
never fully recovered. Nevertheless, she remained in the Crimea u ntil August 1856.
Nightingale’s work in the Crimea had been well publicized in Britain, and the
country anticipated giving her a warm welcome on her return. Instead, she slipped
quietly into the country without fanfare. She could not escape the attentions of a
458 NI G HTING ALE, F LORENCE
grateful public, however. The sultan of Turkey gave her a diamond bracelet in appre-
ciation for her efforts, while Britain’s Queen Victoria sent her a personal letter and
a brooch designed by Prince Albert. Even before Nightingale’s return from the
Crimea, the public had established a fund so that she could establish a nursing
school after her return to Britain. Before she could turn her attention to this endeavor,
however, she felt compelled to publicize the need for a professional nursing corps
in the military and the imperative of medical reform in general. In October 1856,
she had a private audience with Queen Victoria, Prince Albert, and Secretary for
State Lord Panmure.
Following the interview, Panmure established a royal commission to report on
sanitary conditions in the Crimea and asked Nightingale to serve on it. She wrote
most of the commission’s final report, demanding that the military reevaluate its
medical facilities and take steps to improve sanitary conditions among all soldiers,
not just the sick or wounded. This report prompted the founding of the Army Medi-
cal School shortly thereafter. In 1857, her attention turned to the Indian Rebellion
and focused on concern with the general welfare of British soldiers, both at home
and abroad. Two years later, she served on another royal commission investigating
sanitary conditions in India, which ultimately led to the establishment of a sanitary
department in the British government’s India office.
By 1860, Nightingale was able to turn her attention back to nursing. The public
fund taken up in her behalf during the Crimean War totaled some £45,000 by that
point. She used the money to establish a nursing school at St. Thomas’ Hospital in
London. The first of its kind in the world, the Nightingale School for Nurses sought
to train women to undertake nursing as a profession. The school was unique not
only for its emphasis on both classroom work and hands-on training but also b ecause
it was the only secular institution to undertake this task. The few other nursing
schools that existed in the world at this time w ere all associated with religious o rders
and functioned as part of established churches. Furthermore, the Nightingale School
refused to train nurses just for genteel patients but educated w omen to work in
workhouses and public facilities as well. Nightingale took on all of the administra-
tive work associated with the school, although she had little time to personally teach
or supervise her students. Nonetheless, she had a tremendous impact on her gradu
ates, who traveled all over the world and established nursing schools patterned
after her own. She also published a book, Notes on Nursing, in 1860 that outlined
her philosophy and methods. This book was eventually translated into 11 languages
and is still widely read throughout the world.
Starting in 1859, a wealthy merchant from Liverpool, William Rathbone, hired
nurses to care for the sick and poor people of his district. When he tried to expand
health services to other districts, he could not find enough trained nurses. He con-
tacted Nightingale hoping that she would send nurses from the St. Thomas school.
Instead, Nightingale suggested that Rathbone open a nurse training school at the
Royal Liverpool Infirmary. The Liverpool school was opened to train nurses as dis-
trict nurses. By 1864, Rathbone had another request. The Liverpool Workhouse
NI G HTIN GALE , F LO R EN C E 459
Infirmary housed 1,200 sick poor people. Rathbone wanted Nightingale to use her
influence to convince the workhouse administrators that the institution needed a
nursing staff and matron (director of nursing). However, Nightingale was focused
on sanitation in India. Her attention shifted a fter the death of a workhouse patient.
One newspaper reported that the death was due to “filthiness caused by gross
neglect” (Monteiro, 1985, p. 182). Nightingale seized on the opportunity for
advocacy. She developed a three-part plan for the nursing care of ailing poor people.
The plan included a tax for the Medical Relief Fund, providing finances to care for
poor patients. Rathbone’s model of district nurses was replicated in other large cit-
ies and eventually became the field of public health nursing. Nightingale’s vision of
the Medical Relief Fund became the United Kingdom’s National Health System.
Nightingale’s accomplishments are all the more remarkable in that she was phys-
ically disabled after 1857. Her fragile health following her bout with Crimean fever
could not sustain an active life a fter her return to E
ngland. Instead, she maintained
a voluminous correspondence with her many friends and allies in British society
and government, thus lobbying effectively on behalf of her c auses. From her bed,
she managed the affairs of the Nightingale School and promoted several other reform
efforts, most of which were related to public health. She remained one of the most
revered figures of the Victorian Age and was idolized by much of British society.
Near the end of her life, she received two prestigious awards for her work: the Royal
Red Cross in 1883 and the Order of Merit in 1907. She was the first w oman to
receive the latter award. A fter more than seven decades of public service, Nightin-
gale died in her home at London on August 13, 1910. In her will, she refused the
government’s offer to bury her in Westminster Abbey with a national funeral. Instead,
she was interred near her parents’ home in Hampshire.
Sally Kuykendall
See also: Chadwick, Edwin; Dix, Dorothea Lynde; Infectious Diseases; Shattuck,
Lemuel
Further Reading
Baly, M. E. (1986). Florence Nightingale and the nursing legacy. London: Croom Helm.
Cope, Z. (1958). Florence Nightingale and the doctors. Philadelphia: J. B. Lippincott.
Garofalo, M. E., & Fee, E. (2010). Florence Nightingale (1820–1910): Feminism and hos-
pital reform. American Journal of Public Health, 100(9), 1588. doi:10.2105/AJPH.2009
.188722
Huxley, E. (1975). Florence Nightingale. New York: Putnam.
Lynn, M. (2006, January 1). Florence Nightingale as a social reformer: Lynn McDonald
describes the lasting impact of Florence Nightingale on improving public health for
the poor. History Today, 56(1), 9.
Monteiro, L. A. (1985). Florence Nightingale on public health nursing. American Journal of
Public Health, 75(2), 181.
Smith, F. B. (1982). Florence Nightingale: Reputation and power. London: Croom Helm.
460 NUT R ITION
NUTRITION
Nutrition is a scientific field encompassing the biology, chemistry, psychology and
sociology of food selection, intake, digestion, catabolism, absorption, and excre-
tion. Many of the leading causes of death are related to nutrition. Overweight and
obesity, malnutrition, iron-deficiency anemia, hypertension, dyslipidemia, and tooth
and gum diseases are just a few diseases directly related to diet. Heart disease, stroke,
diabetes, cancer, birth defects, and substance abuse are nutrition-related problems
that top the list of public health concerns. The healthy body requires a balanced
intake of macronutrients (carbohydrates, proteins, and fats), micronutrients (vita-
mins and minerals), and water to stay healthy and to resist disease. Carbohydrates,
proteins, and fats are macronutrients that provide carbon, oxygen, and hydrogen to
the body. These nutrients give the body the energy that it needs to perform basic and
advanced functions. Proteins also provide nitrogen for body structures. Micronutri-
ents (vitamins and minerals) provide other essential and nonessential components.
Water facilitates biochemical reactions and lubricates organs and systems. To support
public health, the U.S. Department of Agriculture (USDA) studies food and recom-
mends optimal levels of macronutrients and micronutrients. Individuals, registered
dieticians, nutritionists, and health professionals use these guidelines to prevent
and control disease. Government agencies and organizations offer many helpful
resources on nutrition. One easy-to-use tool is MyPlate. Helping people to under-
stand nutrition and to follow a healthy diet can reduce many of the leading c auses
of death.
Healthy sources of carbohydrates are fruits, vegetables, and grains. The fruit group
consists of any fruit that is fresh, canned, frozen, and dried or 100 percent fruit
juice. Fruits are a great source of fiber, potassium, fiber, vitamin C, and folate (folic
acid). The vegetable group consists of any vegetable that is raw, cooked, fresh, fro-
zen, canned, and dried/dehydrated or 100 percent vegetable juice. T here are five
subgroups of vegetables: dark-green, starchy, red and orange, beans and peas, and
other vegetables. Vegetables are a good source of potassium, dietary fiber, folate (folic
acid), vitamin A, and vitamin C. Fruits and vegetables reduce the risk of heart dis-
ease, stroke, certain types of cancers, obesity, and Type 2 diabetes. A diet rich in
fruits and vegetables may help maintain healthy weight, lower blood pressure, and
prevent kidney stones. Whole and refined grains provide calories, dietary fiber,
B vitamins (e.g., thiamin, riboflavin, niacin, and folate), and minerals (e.g., iron, mag-
nesium, and selenium). The difference between w hole grains (e.g., whole-wheat
flour, cracked wheat, oatmeal, whole cornmeal, and brown rice) and refined grains
(white flour, degermed cornmeal, white bread, and white rice) is that the former
contains the entire grain kernel (i.e., bran, germ, and endosperm), whereas, the lat-
ter no longer has the bran and germ. The USDA recommends at least 50 percent of
all grains eaten per day should be whole grains as whole grain is important in
maintaining a healthy weight and digestive system, and reducing the risk of heart
disease, diabetes, and high blood pressure.
NUT R ITION 461
Proteins provide vitamin B (e.g., niacin, thiamin, riboflavin, and B6), vitamin E,
iron, zinc, magnesium, and amino acids. Amino acids are the building blocks for
body structure, growth, and maintenance. There are 20 different amino acids,
9 essential and 11 nonessential. Each amino acid fulfills a specific function. Essential
amino acids must be taken in through the diet b ecause the body cannot manufacture
that specific amino acid. It is important that people take in the correct amount and
proportion of amino acids. Animal meat, poultry, seafood, eggs, and dairy products
are complete sources of protein b ecause they contain all of the nine essential amino
acids as well as some nonessential amino acids, in the correct proportions needed
for the body. It is unwise to rely on protein supplements because some amino acids
displace other amino acids, creating a deficit and impairing with the body’s ability
to build proteins which rely on that amino acid. Vegetarians use the concept of
mutual supplementation, balancing sources of incomplete protein such as beans
and rice, hummus (chickpeas and sesame seeds), tofu and broccoli or spinach salad
with pine nuts. Although easier to digest than many plant sources of protein, ani-
mal sources of protein can be high in saturated fat, which can lead to cardiovascu-
lar disease. It is important to select protein sources that are low in saturated fats
and cholesterol and to follow the recommended guidelines. Excess protein is not
stored by the body. It is converted into body fat. Insufficient protein intake, a prob
lem known as protein energy malnutrition, is a major problem in third world coun-
tries where raising animals to eat is prohibitively expensive. Kwashiorkor is a
disease that affects c hildren aged 1–4. The term kwashiorkor means “rejected one,”
referring to when a m other must wean her child from breastfeeding because she is
due to have a second child. The mother replaces the easily digested and protein-
rich breast milk with the local diet, typically one high in starchy vegetables. The
classic symptoms of kwashiorkor are lack of energy, and fluid and electrolyte imbal-
ances that cause swelling and bloating, enlarged liver, thinning hair, and skin prob
lems. In countries such as the United States where protein is readily available, protein
energy malnutrition is rare and typically due to alcohol or substance abuse, wast-
ing diseases (cancer or AIDS), or living in an abusive h ousehold where diet and
activities are highly controlled.
The dairy group provides calcium and vitamin D, which help to build strong
bones. All foods that are made from milk such as yogurt and cheese as well as
calcium-fortified soymilk are part of the dairy food group. Foods that are made from
milk that have little to no calcium are not part of the dairy group (e.g., cream cheese,
cream, and butter). When making dairy choices, it is recommended to select fat
free and low fat foods since fat does not have any nutrients. Calcium is also found
in nondairy products such as kale, collard and turnip greens, bok choy, calcium-
fortified juices, cereals, breads, rice milk, almond milk, canned fish, soy products,
and beans. However, the absorption rate of calcium varies for nondairy foods.
In the United States, many adults take dietary supplements in the form of vitamins,
minerals, herbals, botanicals, amino acids, or enzymes. Since a dietary supplement is
462 NUT RITION
a supplement, it does not go through the same research and development as pre-
scriptions and over-the-counter drugs. This means that the FDA does not regulate,
review, or approve dietary supplements. Pregnant or lactating w omen, newborns,
infants, the elderly, p
eople with AIDS or other wasting diseases, p eople recover-
ing from severe burns, or people taking medications that interfere with normal
body metabolism may need supplements. For the most part, normal, healthy indi-
viduals do not require dietary supplements because they can get the macronutri-
ents and micronutrients that they need through eating a balanced diet, which
includes a variety of foods. Health care providers can assist individuals in deciding
whether dietary supplements are beneficial to their overall health.
There are several tools designed to help people plan and follow a balanced diet.
MyPlate is a color-coded plate that reminds individuals to eat the correct propor-
tions of the five food groups. A healthy diet is made up of grain (color-coded as
orange), protein (purple), vegetables (green), fruits (red), and dairy (blue). The rec-
ommended amounts depend on one’s age, gender, and level of physical activity.
The U.S. Department of Agriculture created a f ree user-friendly website called Food-
A-Pedia. Individuals can look up nutrition information of over 8,000 foods and
compare the foods side-by-side to evaluate nutritional values. The USDA (2016,
n.d.-c) also created a free website called Food Tracker for p eople to keep track of
their food intake and nutrition goals. There is an option for the users to track their
food consumptions over time by signing up for a free account. Users may also per-
sonalize their profile to age, gender, level of physical activity, height, and weight.
This information helps calculate the user’s daily calorie limit.
Food nourishes the body and ensures that cells and organs can function prop-
erly. However, too much, too little, or the wrong types of food can lead to malnutri-
tion, chronic illnesses, or premature death. Public health professionals work with
individuals, communities, and organizations to ensure that people have sufficient
knowledge to select nutritious foods and to access nutritious foods. Nutritionists
and health educators continue to improve and refine diet planning tools to ensure
that members of the public are able to easily and effectively plan healthy diets.
Susana Leong
See also: Cancer; Diabetes Mellitus; Eating Disorders; Food and Drug Administration;
Food Insecurity; Global Health; Heart Disease; Leading Health Indicators; Maternal
Health; National Health and Nutrition Examination Survey; Obesity; Physical Activ-
ity; Rural Health; School Health; U.S. Department of Agriculture; W omen’s Health
Further Reading
Energy, food, and you: An interdisciplinary curriculum guide for secondary schools. (1979).
[Seattle, Wash.]: State Office of Health Education [1979]. Retrieved from https://babel
.hathitrust.org/cgi/pt?id=umn.3
1951002865703i;view=1up;seq=9.
NUT R ITION 463
Sizer, F. S., & Whitney, E. (2008). Nutrition: Concepts and controversies (11th ed.). Belmont,
CA: Thomson Wadsworth.
The Surgeon General’s report on nutrition and health. (1989). Washington, DC: U.S. Depart-
ment of Health and Human Services, Public Health Service: For sale by the Superin-
tendent of Documents, U.S. G.P.O., 1988 [i.e. 1989].
U.S. Department of Agriculture. (n.d.-a). Choose MyPlate. Retrieved July 25, 2016, from
http://www.choosemyplate.gov.
U.S. Department of Agriculture. (n.d.-b). Food-A-Pedia. Retrieved July 25, 2016, from https://
www.supertracker.usda.gov/foodapedia.aspx.
U.S. Department of Agriculture. (n.d.-c). Food Tracker. Retrieved July 25, 2016, from https://
www.supertracker.usda.gov/foodapedia.aspx.
U.S. Department of Agriculture. (2016). Smart Nutrition 101. Retrieved July 25, 2016, from
https://www.nutrition.gov/smart-nutrition-101.
U.S. Department of Health and Human Services. (2015). Antioxidants. Retrieved July 25,
2016, from https://medlineplus.gov/antioxidants.html.
O
OBESITY
Obesity occurs when the individual consumes more calories than the body needs
and excess body fat accumulates. Excess weight damages the body’s organ systems
leading to chronic health problems. Adults who are overweight or obese are at greater
risk for cardiovascular disease, hypertension, Type 2 diabetes, dyslipidemia, stroke,
fatty liver disease, gallbladder disease, respiratory illnesses, cancers (breast, colon,
gallbladder endometrial, prostate), arthritis, chronic back pain, and infertility. Even
moderate overweight or obesity increases the risk of disability and premature death
(Office of the Surgeon General, 2001). C hildren who are overweight or obese suf-
fer from unique problems. As their small bodies struggle to carry additional weight,
they are at risk for heart attack, difficulty breathing, and bone and joint problems.
Moderately overweight children have elevated low density lipoprotein (LDL) lev-
els, and markedly obese children exhibit increased blood pressures, high triglycer-
ide levels, and reduced high-density lipoprotein (HDL) levels (Reilly et al., 2003).
Being overweight and obese as an adolescent is a risk factor for obesity in adult-
hood. Obese children and adults suffer from social stigmas, anxiety, depression, and
binge-eating disorders. The c auses of obesity are complex and multifactorial, depen-
dent on genetic, metabolic, cultural, environmental, socioeconomic, and behav-
ioral factors (Tappy, Le, Tran, & Paquot, 2010). In the United States, obesogenic
factors include food insecurity, aggressive marketing of junk foods and drinks, and
social and cultural traditions (sedentary lifestyle, Western diet, large portion sizes
normalized). Obesity is treatable. Long-term weight loss is achieved through a com-
bination of interventions focused on a healthy, low-calorie diet, increased physical
activity, and behavior therapy. Public health professionals work with communities,
parents, and patients to prevent and address this growing epidemic.
Health professionals use a number of methods to assess obesity. Body mass index
(BMI) compares weight relative to height and is calculated using this equation:
weight (kilograms) divided by height (meters) squared. In the United States, the
average BMI is 26.6 and 26.5 for adult men and women, respectively. Obesity is
defined as a BMI of 30.0 kg/m² or higher. A BMI of 40.0 kg/m² or higher denotes
extreme, or morbid obesity (Pi-Sunyer et al., 1998). For c hildren and adolescents,
aged 2 to 19, growth occurs at various rates. As a result, BMI is plotted on growth
charts and translated into a percentile ranking for children of the same age and gen-
der. If a child’s BMI is above the 85th percentile for his or her age, he or she is
considered overweight. If a child’s BMI is above the 95th percentile, the child is
classified as obese. BMI should be used with caution as it can overestimate body fat
466 OBESITY
in individuals who are muscular and can underestimate body fat in people who
have lost muscle mass, such as the elderly (Office of the Surgeon General, 2001).
An alternative measure of obesity, waist circumference compares abdominal fat
content to total body fat content. In comparison to BMI, waist circumference is a
stronger predictor of heart disease and diabetes. A waist circumference greater than
35 inches (88 cm) or 40 inches (102 cm) in w omen and men, respectively, corre-
lates to increased risk of obesity-associated diseases (Pi-Sunyer et al., 1998). Other
ways to assess obesity are waist to hip ratio, skinfold thickness, bioelectrical imped-
ance, magnetic resonance imaging, and underwater weighing.
Globally and nationally, obesity is an epidemic. An estimated 66 million Ameri-
can adults are obese, and 74 million adults are overweight (CDC). From 1980 to
2000, the prevalence of obese adults increased from 13 percent to 28 percent in
men and from 17 to 26 percent in women, respectively (CDC). During that time,
the total prevalence of overweight or obese adults in the United States increased
from 56 to 64 percent (CDC). Overweight and obesity are more common in minor-
ity groups and individuals with lower socioeconomic status and education level
(Pi-Sunyer et al., 1998). Since the 1970s, childhood obesity has more than tripled
(Ogden et al., 2016). From 1980 to 2010, the prevalence of obesity increased from
6.5 to 18 percent for c hildren 6–11 years old and 5 to 18.4 percent for adolescents
12 to 19 years old (Ogden et al., 2014). As of 2014, the prevalence of obesity for
all American children was 17 percent ( Johnson et al., 2014). The prevalence is higher
among minority children and c hildren from low income communities (Ogden et al.,
2014). Mexican American and non-Hispanic blacks have higher prevalence com-
pared to their non-Hispanic white counterparts ( Johnson et al., 2014; Ogden et al.,
2010). Annual medical costs attributed to obesity are estimated to be as high as
$190 billion, which amounts to approximately 21 percent of all medical spending
(Cawley & Meyerhoefer, 2012).
The safest and most effective treatments for obesity are diet and exercise. In the
clinical setting, physicians w ill first rule out or treat any underlying medical c auses,
such as hypothyroidism or Cushing’s syndrome. Patients with high waist circum-
ference or two or more risk factors for obesity-related diseases may be referred for
nutritional or behavioral counseling to learn strategies in self-monitoring, contin-
gency planning, cognitive restructuring, problem-solving, and reinforcement. Moti-
vation is key to successful weight loss. Weight reduction goals must be realistic and
achievable. An initial goal of 10 percent weight loss (approximately 1-pound loss
per week) over the first six months is recommended. After initial weight loss, the
body may compensate by lowering energy expenditure. This syndrome may appear
as weight gain. Knowing what to expect and when empowers the patient to attain
and maintain weight loss goals. Prescription medications, such as those approved
by the Food and Drug Administration, can also be used to invoke weight loss,
although data to support long-term effects are minimal (Office of the Surgeon Gen-
eral, 2001). As with any medication, the benefit of the drug should outweigh the
risks of side effects. Finally, bariatric surgery is an alternative option for extremely
O B ESITY 467
obese individuals where medical therapy has failed. Weight loss surgery options of
gastric restriction, gastric banding, and gastric-bypass surgery have shown success
in appropriate surgical candidates (Pi-Sunyer et al., 1998). As with any surgery,
patients must meet eligibility criteria to qualify for surgery. In the pediatric popula-
tion, weight loss surgery is recommended for obese adolescents who have exhausted
all other medical weight loss options and are greatly impacted by their weight.
Weight loss surgery is only offered to adolescents who are no longer growing, failed
to lose weight within six months of a weight loss treatment program under guid-
ance of a physician, remain drug free, and demonstrate commitment to the lifestyle
changes required for the surgery (Hassink, 2014). The good news is that weight
loss can successfully reduce risk of heart disease, diabetes, and hypertension
(Pi-Sunyer et al., 1998). Carefully planned treatment and follow-up can help
individuals maintain a healthy weight. Effective treatments consider long-term
weight management.
Obesity is costly to both individuals and society. Obesity is responsible for
increased hospitalization, longer hospital stays, decreased life expectancy, and
increased mortality. Moreover, obesity is responsible for lost productivity, lost wages,
and disability (Office of the Surgeon General, 2001). Medical costs related to obe-
sity have increased and will continue to rise as more people live with multiple chronic
illnesses. As with other public health concerns, obesity must be tackled aggressively
and effectively. F actors such as income, inaccessibility to healthy foods (food des-
erts), nutrition education, and motivation hinder weight loss. Given the investments
in research and programming to combat the obesity epidemic, it is more impor
tant, now than ever before, for the government to garner support and develop part-
nerships for our nation’s future.
Maria DiGiorgio McColgan and Staceyann Smith
See also: Body Mass Index; Diabetes Mellitus; Global Health; Heart Disease; Lead-
ing Health Indicators; Maternal Health; National Health and Nutrition Examina-
tion Survey; Nutrition; Physical Activity; U.S. Department of Agriculture; Women’s
Health
Further Reading
Cawley, J., & Meyerhoefer, C. (2012). The medical care costs of obesity: An instrumental
variables approach. Journal of Health Economics, 31(1), 219–230.
Centers for Disease Control and Prevention (CDC). National Center for Health Statistics.
National Health and Nutrition Examination Survey. Retrieved from http://www.cdc.gov
/nchs/nhanes/ nhanes_questionnaires.htm.
Finkelstein, E. A., Trogden, J. G., Cohen, J. W., & Dietz, W. (2009). Annual medical spend-
ing attributable to obesity: Payer-and service-specific estimates. Health Affairs, 38(5),
w822–w831.
Flegal, K. M. (2010). Changes in terminology for childhood overweight and obesity. National
health statistics reports; no. 25. Hyattsville, MD: National Center for Health Statistics.
468 OR AL HEALTH
Hassink, S. G. (2014). Pediatric care: Prevention, intervention and treatment strategies for pri-
mary care (2nd ed.). Elk Grove Village, IL: American Academy of Pediatrics.
Johnson, C. L., Dohrmann, S. M., Burt, V. L., & Mohadjer, L. K. (2014). National health and
nutrition examination survey: Sample design, 2011–2014. National Center for Health Sta-
tistics. Vital Health Statistics, 2(162).
Office of the Surgeon General. (2001). The Surgeon General’s call to action to prevent and
decrease overweight and obesity. Office of Disease Prevention and Health Promotion, Cen-
ters for Disease Control and Prevention, National Institutes of Health. Rockville, MD.
Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of childhood
and adult obesity in the United States, 2011–2012. Journal of the American Medical Asso-
ciation, 311(8), 806–814.
Ogden, C. L., Carroll, M. D., Lawman, H. G., et al. (2016). Trends in obesity prevalence
among children and adolescents in the United States, 1988–1994 through 2013–2014.
Journal of the American Medical Association, 315, 2292.
Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). Obesity and socioeco-
nomic status in adults: United States, 2005–2008. National Center for Health Statistics
Data Brief. Number 51. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db51
.pdf.
Pi-Sunyer, X., Becker, D., Bouchard, C., Carleton, R. A., Colditz, G. A., Foreyt, et al. (1998).
Clinical guidelines on the identification, evaluation, and treatment of overweight and
obesity in adults—The evidence report. Obesity Research, 6(Suppl. 2), 51S–209S.
Reilly J. J., Methven, E., McDowell Z, C., Hacking, B., Alexander, D., Stewart, L., & Kelnar,
C. J. H. (2003). Health consequences of obesity. Archives of Disease in Childhood, 88(9),
748.
Tappy L., Le, K., Tran, C., & Paquot, N. (2010). Fructose and metabolic diseases: New find-
ing, new questions. Nutrition, 26, 1044–1049.
tion Division of Nutrition, Physical Activity and Obesity. (2017). Body mass index (BMI).
Retrieved from http://www.cdc.gov/healthyweight/assessing/bmi/.
ORAL HEALTH
Dental caries is one of the most common diseases, affecting 37 percent of c hildren
aged 2 to 8 and 91 percent of adults aged 20 to 64 (CDC/National Center for Health
Statistics, 2016). People of low income, low education, minority status, disability,
or other chronic illnesses are at greatest risk. Tooth and gum decay can cause pain,
inability to chew, taste, or smell food, malnutrition, weight loss, facial disfigure-
ment, speech disorders, and is the leading cause of school absences. Despite the
widespread epidemic, oral and craniofacial problems are easily preventable. Good
oral hygiene, consisting of regular dental screenings, flossing, brushing, healthy diet,
and avoiding tobacco and alcohol, help protect teeth, heart, and overall health. Pub-
lic water fluoridation decreases dental caries by up to 30 percent, and dental seal-
ants decrease cavities by 60 percent. Healthy People objectives are to reduce dental
caries among all age groups, increase access to preventive services, including den-
tal sealants and water fluoridation, and build public health infrastructure so that
more public health clinics have a dental professional with cross-training in public
health.
O R AL HEALTH 469
To avoid tooth and gum disease, the American Dental Association (2016) and
the American Heart Association (AHA, 2013) recommend maintaining good oral
health. Gum disease is an infection of the tissues that support the teeth. Both the
ADA (2016) and AHA (2013) state that visiting the dentist regularly, eating a bal-
anced diet, limiting snacks between meals, brushing twice a day, and flossing daily
are important in preventing tooth decay and cavities. Seeing a dentist regularly for
a dental cleaning and examination along with education on good oral hygiene can
help prevent most dental diseases (ADA, 2016). The recommendation from dental
professionals is to have your teeth cleaned professionally every six months (USD-
HHS, 2016). This is important, even if individuals are brushing and flossing regu-
larly, b
ecause a dentist is able to help remove plaque that individuals are not able
to remove with brushing and flossing alone and provide fluoride treatment (USD-
HHS, 2016). During a routine dental exam, the dentist may take X-rays to catch
potential problems in the early stages. This prevents the problem from becoming
more serious and also expensive to fix in the future. In addition to regular routine
visits, the dentist will check for symptoms, which may include pain in a tooth for
no particular reason or pain that is caused by food, beverages, brushing, or floss-
ing. Instead of waiting for the next scheduled appointment, it is important to call
a dentist if one is feeling sensitivity to hot and cold foods and/or drinks. The longer
a problem remains untreated, the more difficult it is to repair.
The foods we eat can also enhance oral health. Dairy products such as milk and
yogurt strengthen teeth since they are full of calcium, a mineral that forms the hard
A dentist screens her patient for tooth or gum diseases. Oral problems are easily preventable
with a healthy diet, regular dental checkups, flossing, and brushing. (iStockphoto.com)
470 OR AL HEALTH
enamel protecting the teeth (ADA, 2016). Lean proteins, such as chicken and fish,
help rebuild tooth enamel. Fruits and vegetables have high water content, so they
are helpful when it comes to washing away acids, bacteria, and food particles in
one’s mouth. Another way to reduce one’s risk for tooth decay is by chewing nuts.
Chewing nuts helps stimulate saliva production, reducing tooth-destroying acids.
Foods to avoid are hard, sticky candies or acidic beverages such as lemon w ater
(ADA, 2016). Coffee and tea with added sugar can cause dry mouth and dehydra-
tion, as do alcoholic drinks. Crunchy foods such as chips are high in carbohydrates.
Easily trapped between teeth, the carbohydrates turn into sugar, attacking tooth
enamel.
Water is best in helping the human body to stay hydrated, distributing nutri-
ents, getting rid of waste, keeping your skin healthy, and aiding in the movements
of your muscle (ADA, 2016). Sport drinks and energy drinks are not good for the
teeth as they have a lot of added sugar. When an individual drinks soda or juice
with meals, cavity-causing bacteria from the leftover food stuck to the teeth w ill
come in contact with the sugar and will produce acid to wear out the teeth. Drink-
ing water with one’s meals lowers the chance of the cavity-causing bacteria eating
the unwanted sugar. The acids that are in one’s mouth are diluted by the water,
which aids in keeping one’s teeth cavity-free. The fluoridated tap water from the
kitchen sink helps make one’s teeth stronger b ecause the fluoride is resistant to acid
attack. As of 2012, approximately 75 percent of individuals in the United States
had access to fluoridated w ater from their kitchen sinks.
In order to keep one’s teeth cavity-free, it is important for individuals to brush
their teeth for two minutes when they wake up in the morning and before they go
to sleep. The American Dental Association recommends flossing at least once a day.
Flossing helps remove plaque, prevent gum disease, and prevent cavities in hard to
reach areas. Toothbrushes should be replaced every three to four months or after
experiencing a cold (USDHHS, 2016). If you brush your teeth with a worn-out
toothbrush, the toothbrush will not clean the teeth as well. Some research studies
have shown that an electric toothbrush is able to clean teeth better than manual
toothbrushes (USDHHS, 2016). Your dentist can recommend what kind of tooth-
brush is best and areas to concentrate on while brushing. In addition to caring for
teeth with brushing, flossing and regular dental checkups, athletes should take addi-
tional precautions, wearing mouth guards during activities with high risk of injury.
According to the AHA (2013), researchers have noted an association between sev-
eral heart conditions and oral health. More studies are being done to gather data
on a possible connection.
Approximately 108 million Americans do not have dental insurance (U.S. Depart-
ment of Health and Human Services [USDHHS], 2014). Medicare does not cover
checkups, cleanings, and fillings, as it only covers dental services that are related to
certain medical conditions or treatments. The National Institute of Dental and Cra-
niofacial Research’s website (NIDCR) provides information for the public on where
to find low-cost dental care near where they live. If anyone has questions about
O RAL HEALTH 471
where to find dental care near where they live, there is a toll free number at 1-866-
232-4528, and you can also e-mail them at nidcinfo@mail.nih.g ov for more informa-
tion. Some options for low-cost dental care are dental schools and dental hygiene
schools (http://www.ada.org/en/coda/find-a-program/search-dental-programs); com-
munity health centers (http://www.hrsa.gov/index.html); Medicaid state-run pro-
grams (https://www.medicaid.gov); and Medicare for individuals 65 and older and
for individuals who are u nder 65 with specific disabilities (https://www.medicare.gov
/coverage/d
ental-services.h
tml).
Fewer people are suffering from gum and tooth decay due to advancements in
dentistry, health education, fluoridated water sources, and good personal hygiene.
From a policy perspective, advancements are fairly inexpensive and cost effective.
Community-wide water fluoridation costs $0.11 to $4.92 per person per year (for
equipment, maintenance, and monitoring) and saves $5.49 to $93.19 per person
per year (in treatment and other costs) with larger communities benefiting the most.
On the downside, we have seen an increase in the number of preschool c hildren
suffering from tooth decay, and more education is needed to prevent baby b ottle
tooth decay. School-based dental sealant programs, where a thin layer of plastic is
applied to the tooth as a protective barrier, can provide easily accessible dental ser
vices, protect the teeth of those who are at greatest risk, and promote lifelong oral
hygiene habits.
Susana Leong
See also: Dean, Henry Trendley; Fluoridation; Health Belief Model; Nutrition
Further Reading
American Dental Association (ADA). (2016). Mouth healthy. Retrieved from http://www
.mouthhealthy.org.
American Heart Association (AHA). (2013). Dental health and heart disease. Retrieved from
http://www.heart.org/HEARTORG/HealthyLiving/Dental-Health-and-Heart-Health
_UCM_459358_Article.jsp.
CDC/National Center for Health Statistics. (2016). Oral and dental health. Retrieved from
http://www.cdc.gov/nchs/fastats/dental.htm.
Centers for Disease Control and Prevention (CDC). (2016). Division of oral health. Retrieved
from http://www.cdc.gov/oralhealth.
Guide to Community Preventive Services. (2016). Preventing dental caries: Community w ater
fluoridation. Retrieved from https://www.thecommunityguide.org/findings/dental-caries
-cavities-community-water-fluoridation.
National Institute of Dental and Craniofacial Research. (2016). Finding low-cost dental care.
Retrieved from http://www.nidcr.nih.gov/oralhealth/PopularPublications/FindingLow
CostDentalCare.
U.S. Department of Health and Human Services. (2014). Oral health. Retrieved from http://
www.hrsa.gov/publichealth/clinical/oralhealth.
U.S. Department of Health and Human Services. (2016). Dental care: Adults. Retrieved from
https://medlineplus.gov/ency/article/001957.htm.
P
PANDEMIC
The word pandemic is a combination of two Greek words pan, meaning “all,” and
demos, meaning “people or population.” Pandemic is defined as a rapid, widespread
outbreak of any infectious disease(s), affecting multiple human populations across
geographic al countries and continents at a particular point in time. Examples of
infectious disease pandemics are the 2009 H1N1, h uman immunodeficiency virus
(HIV) and acquired immune deficiency syndrome (AIDS), and the 2013 to 2015
Ebola virus. According to the World Health Organization (WHO), the 2009 H1N1
pandemic was a worldwide infectious disease that caused 18,138 deaths across 74
countries, mostly in America, Asia, and Europe continents (2010). The HIV/AIDS
pandemic has caused the death of 35 million people globally, with 36.7 million
people currently living with HIV across the world ( Joint United Nations Program
on HIV/AIDS [UNAIDS], 2017; WHO, 2016). A 2016 Ebola virus report by the WHO
identified 28,657 suspected cases and 11,325 deaths affecting p eople from Sierra
Leone, Liberia, Guinea, Senegal, Nigeria, Mali, United Kingdom, Italy, Spain, and
the United States (Piot, Muyembe, & Edmunds, 2014).
Pandemic is an epidemic of a worldwide spread or a global infectious disease
outbreak. The World Health Organization (2014) identified past and present epi-
demic outbreaks that equate to pandemic or epidemic with the capabilities of become
globally pandemic. The WHO (2014) identification includes:
• Airborne diseases: influenza (seasonal, pandemic, avian), severe acute respira-
tory syndrome (SARS), Middle East respiratory syndrome coronavirus
(MERS-CoV)
• Vector-borne diseases: yellow fever, chikungunya, Zika virus, West Nile fever
• Waterborne diseases: cholera, shigellosis, typhoid fever
• Rodent-borne diseases: plague, leptospirosis, Hantavirus, Lassa fever, rickettsia
(murine typhus)
• Hemorrhagic fevers: Ebola virus disease, Marburg virus disease, Crimean-Congo
hemorrhagic fever, Rift Valley fever
• Other zoonotic diseases: Nipah virus infection, Hendra virus infection
Pandemics may affect susceptible and vulnerable populations of any age, gender,
race, or geographic al regions or continents. Initial impact is typically realized within
6 to 12 weeks. Further spread beyond 12 weeks depends on the causes and strength
of the pathogen. Otherwise, mitigation can be very effective toward control and
minimizing the number of deaths. Climatic factors such as prevailing winds
474 PANDEM IC
transporting aerosol particles and migration of infected people, animals, or insects

make it difficult to control a pandemic. Uncontrolled pandemic poses challenges
to regional and global economies, strains available resources (medical supplies, vac-
cine, antiviral medications, medical facilities, hospital beds, and medical staff ), and
threatens h uman resources through illness and death. Government officials may
contain the outbreak through travel restrictions, trade restrictions, border closures,
or business restrictions. Vaccinations may be recommended in cases where there
are known c auses.
Classifications or Phases
Prior to the 2009 H1N1 outbreak pandemics were not classified. The WHO (2009)
pandemic alert levels are:
• Phase 1: “No viruses circulating among animals have been reported to cause
infections in humans.”
• Phase 2: “An animal influenza virus circulating among domesticated or wild
animals is known to have caused infection in h umans, and is therefore con-
sidered a potential pandemic threat.”
• Phase 3: “An animal or human-animal influenza reassortant virus has
caused sporadic cases or small clusters of disease in p eople, but has not
resulted in human-to-human transmission sufficient to sustain community-
level outbreaks.”
• Phase 4: “Characterized by verified human-to-human transmission of an ani-
mal or human-animal influenza reassortant virus able to cause ’community-
level outbreaks.’ The ability to cause sustained disease outbreaks in a community
marks a significant upwards shift in the risk for a pandemic.”
• Phase 5: “Characterized by human-to-human spread of the virus into at least
two countries in one WHO region.”
• Phase 6: “The pandemic phase, is characterized by community level outbreaks
in at least one other country in a different WHO region in addition to the cri-
teria defined in Phase 5. Designation of this phase w ill indicate that a global
pandemic is under way.”
The pandemic alert levels are used to guide the activities toward management and
control of potential or actual disease outbreaks. The classifications provide the
benchmark for assessing disease outbreaks and spread within a population. A limi-
tation of the classification system is that the first three phases are often unrec-
ognized, and the pathogen may achieve widespread circulation before official
detection.
During Phases 1 to 3, public health agencies work to prevent and control pan-
demics by encouraging timely vaccinations among at-risk populations, establish-
ing clinical guidelines on treatment and quarantine, educating the public on personal
hygiene, proper handwashing, and social distancing (isolation, quarantine, and
PASTEU R , LOUIS 475
cancellation of public gatherings including school closures), and supporting

health professionals in the use of personal protective equipment (PPE). These
phases serve as an important precursor to preparedness with the goal of reducing
morbidity and mortality, planning the roles of medical staff and stakeholders,
allocating scarce health resources, and surveillance to control local epidemics
from becoming global pandemics. Phase 4 poses significant risk of spreading to
neighboring regions or other countries. During Phase 4, public health agencies
refine surveillance operations, reduce risk among the vulnerable populations, and
coordinate and communicate with various stakeholders. Phase 5 and Phase 6 are
very high pandemic alert levels with planned mitigation such as implementing
containment measures and deployment of vaccine. During Phases 5 and 6, part
of the mitigation goals to reduce risk includes mobilization of resources to reduce
the societal and economic impact of the affected countries, provision of pharma
ceutical interventions through the various levels of the health system, and recov-
ery. By following the WHO guidelines, local, regional, and global public health
systems protect limited health resources and ensure effective response to potential
pandemic threats.
Godyson Orji
See also: Centers for Disease Control and Prevention; Epidemic; Epidemiology;
Global Health; Immigrant Health; Influenza; M
iddle Ages, Public Health in the; Vac-
cines; World Health Organization; Zombie Preparedness; Controversies in Public
Health: Controversy 3; Controversy 5
Further Reading
Joint United Nations Program on HIV/AIDS (UNAIDS). (2017). UNAIDS data 2017. Retrieved
from http://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017
_en.pdf.
Piot, P., Muyembe, J. J., & Edmunds, W. J. (2014). Ebola in West Africa: From disease out-
break to humanitarian crisis. The Lancet Infectious Diseases, 14(11), 1034–1035. Retrieved
fromhttp://dx.doi.org/10.1016/S1473-3099(14)70956-9.
World Health Organization (WHO). (2009). Current WHO phase of pandemic alert for pan-
demic (H1N1) 2009. Retrieved from http://www.who.int/csr/disease/swineflu/phase/en/.
World Health Organization (WHO). (2010). Pandemic (H1N1) 2009–update 103. Retrieved
from http://www.who.int/csr/don/2010_06_04/en/.
World Health Organization (WHO). (2014). Pandemic and epidemic diseases (PED).
Retrieved from www.who.int/csr/disease/WHO_PED_flyer_2014.PDF.
World Health Organization (WHO). (2016). Global health observatory (GHO) data HIV/AIDS.
Retrieved from http://www.who.int/gho/hiv/en/.
PASTEUR, LOUIS (1822–1895)

French chemist Louis Pasteur is known as the F ather of Microbiology for his land-
mark discoveries in the germ theory of disease, vaccinations, and safe methods of
476 PASTEUR , LOUIS
food preservation. His experiments in bacteriology and immunology provided valu-

able information that helped to significantly reduce mortality due to infectious
diseases in the 20th century.
Pasteur was born on December 27, 1822, in Dôle, France, to Jeanne-Etiennette
(Roqui) and Jean-Joseph Pasteur. The son of a tanner, Pasteur was not particularly
studious. He enjoyed drawing and intended to study art. In 1840, he earned his
bachelor of letters degree at the Collège Royal de Besançon. He worked as a tutor
at the college while taking science courses and eventually earning a general degree
in science. In 1842, Pasteur studied for his master of science degree at the École
Normale Supérieure in Paris. In 1849, he was appointed acting professor of chem-
istry at the University of Strasbourg. From 1854 to 1857 he was professor of chemistry
and dean of sciences at the University of Lille, eventually returning to the École
Normale Supérieure as administrator and director of scientific studies. In 1867 the
Sorbonne appointed him professor of chemistry.
From his early work on crystals, such as those of tartaric acid (a product in the
fermentation of grapes), Pasteur proceeded to examine the process of fermentation
itself, a topic that would provide him with important background information and
methods for his later research on contagious diseases. Yeast had been thought to be
a chemical structure that served as a catalyst in the conversion of sugar into alco-
hol, but Pasteur discovered that yeast was organic m atter, feeding on sugar and thus
producing alcohol. When wine soured, it simply indicated the presence of the
“wrong” kind of microorganisms. Pasteur conducted numerous experiments to prove
his point, also examining the souring of milk. Pasteur’s discoveries raised the
question of how microorganisms got into the wine. At the time, scientists believed
in spontaneous generation; microorganisms could come into existence without
parental organisms. Pasteur disproved spontaneous generation by demonstrating
that nothing would happen with a fermentable fluid when surrounded by sterile
air. As soon as regular air was brought in contact with the substance, microorgan-
isms began to develop. Hence, he concluded that air contains spores of microbes.
The next step for Pasteur was to examine the problem of contagious diseases
that seemed to spread through direct or indirect contact. The question was whether
microorganisms could possibly cause these as well. T here had been germ theories
of disease for a long time, yet they could not be proven u ntil Pasteur’s day. Pasteur
was aware of these theories, and in 1857 he became convinced that microorgan-
isms might also be responsible for infectious diseases. Though at first it was only a
theoretical concept, in the mid-1860s Pasteur began to work on an actual problem:
he was asked to examine a deadly disease of the silkworm, which threatened to
ruin the silk industry in France. By the late 1860s Pasteur had identified two dif
ferent silkworm diseases and the microbes that w ere responsible for them. Although
in the middle of his investigation Pasteur suffered a stroke that left the left half of
his body permanently paralyzed, he continued to work.
Pasteur’s findings did not have an immediate effect, as many physicians did not
think that a link existed between the ailments of the silkworm and t hose of human
PASTEUR , LOUIS 477
beings. In 1876 and 1877, how-

ever, Pasteur showed that micro-
organisms w ere the cause for
anthrax disease in animals and
human beings. At about the same
time, Robert Koch came to the
same conclusion. In 1877 Pasteur
published a study on anthrax, a
paper that became a significant
document in supporting the germ
theory of disease. Pasteur applied
the methods he had used in his
experiments with fermentation
to prove that anthrax bacteria
spread the disease. These exper-
iments showed that no m atter
how often an infected substance
was passed from animal to ani-
mal, anthrax bacteria continued
to multiply and thus remained
potentially as deadly as in the
blood of the first infected animal.
Once he had established the
Louis Pasteur creates a vaccine against the highly
germ theory of disease, Pasteur
fatal bacterium anthrax. (Library of Congress)
wondered what could be done to
protect human beings and ani-
mals from deadly infectious diseases. He thus became interested in the concept of
vaccination that had first been applied by the English physician Edward Jenner. Pas-
teur realized that a germ can change and consequently can actually be used as a vac-
cine. He first experimented with the problem of fowl cholera in chickens and found
that some cultures of microorganisms did not cause the disease and instead made
chickens resistant against virulent cultures in the future. Pasteur became convinced
that it would be possible to produce vaccine in the laboratory. He proceeded to create
a vaccine against anthrax, the effectiveness of which he demonstrated in a well-
publicized demonstration in 1881. However, his antirabies treatment is usually cited
as Pasteur’s greatest triumph. In July 1885 he successfully treated the first h uman
being, Joseph Meister, a boy suffering from rabid dog bites.
Pasteur’s own microbiological research center, the Pasteur Institute, was inaugu-
rated in Paris in 1888. Even before the opening of the institute, Pasteur had many
students who would make important contributions to microbiology. Pasteur believed
that many factors, other than microorganisms, effect the course of infectious ill-
nesses, such as the hereditary constitution of a patient, nutritional state, emotional
equilibrium, season of the year, and climate.
478 PATIENT SA F ETY
Pasteur died on September 28, 1895, in Marnes-la-Coquette, France. Today the

Pasteur Institute is a private nonprofit foundation with about 20 establishments on
five different continents. Research is focused on fighting infectious viral, bacterial,
and parasitic diseases such as AIDS.
Anja Becker and Sally Kuykendall
See also: Bioterrorism; Emergency Preparedness and Response; Food Safety; Infec-
tious Diseases; Jenner, Edward; Koch, Heinrich Hermann Robert; Sabin, Florence
Rena; Vaccines
Further Reading
Achievements in public health, 1900–1999: Control of infectious diseases. (1999). Morbid-
ity and Mortality Weekly Report, 48(29), 621–629. Retrieved from https://www.cdc.gov
/mmwr/preview/mmwrhtml/mm4829a1.htm.
Debré, P. (1998). Louis Pasteur. Baltimore: Johns Hopkins University Press.
Dubos, R. (1988). Pasteur and modern science. Madison, WI: Science Tech.
Geison, G. L. (1995). The private science of Louis Pasteur. Princeton, NJ: Princeton Univer-
sity Press.
PATIENT SAFETY
Patient safety is a field of health care that focuses on the prevention of adverse effects
or events suffered by patients because of health care intervention. Examples of
adverse events include medication errors, surgery on the wrong body part, iatro-
genic infections, patient falls, or impersonation of hospital staff to commit a crime.
In 1999, the Institute of Medicine issued the landmark report, To Err Is H uman.
The report noted that approximately 100,000 patients die each year due to lapses
in patient safety. The Institute of Medicine challenged the health care industry to
reduce the number of iatrogenic incidents and deaths. Over the next 10 years, health
care systems undertook risk management efforts to reverse the alarming statistics.
Despite the efforts, data suggest that there has been no real improvement. The
upward trend continues. Death due to iatrogenic events is one the leading causes
of mortality in the United States. In addition to deaths, there are numerous other
health care–related events resulting in injury or disability. The actual number of
incidents is difficult to measure. Occurrences are not always reported as a medical
event or error. The reasons for such errors are complex and multifactorial. Every
one has a role in making health care safe, including the providers, the health care
team, and the patient. As consumers of health care, it is important for patients to
know and practice strategies to enhance patient safety.
The patient is the hub of the health care spokes of a wheel that need to work
together to assure patient safety. Patients should be engaged, actively involved, and
informed of their health care concerns, recommended treatment, and medications.
Patients and families that understand their care and the reasons for treatment more
PATIENT SA F ETY 479
readily identify potential errors and play a significant role in avoiding events. Antic-
ipating the possibility that an event may occur, and taking steps to avoid problems,
is the role that all participants in health care, including the patient, need to pursue
to manage the risks that are associated with health care. A proactive role by the
patient and family will help to decrease risk. Patients should take part in discus-
sions and decisions regarding the care that is needed. Engaged and involved patients
become better health care consumers by seeking information about illnesses or con-
ditions that affect them. Asking questions of physicians and their assistants, as
well as the health care team, helps patients to have a better understanding of their
diagnosis and treatment. The patient may consider obtaining a second opinion to
reassure best possible treatment options are being considered. Health care con-
sumers should pay attention to care and treatment; if something does not seem
right, bring it to the attention of the care team. Health care consumers should keep
track of their medical history by maintaining a log or journal of important medical
issues as well as dates of treatments and initiation of medications. The journal
should include medical conditions, illnesses, immunizations, allergies, and hospi-
talizations. A responsibility of the health care consumer is to prepare for physician
appointments by writing down questions regarding health problems, change in
medicines, medical tests, surgery, or treatment options. During the a ctual appoint-
ment with the physician, refer to the list and ask pertinent questions. Take notes
and if there is something not understood, request a further explanation. Clarify
with the physician when follow-up care is needed if the medical symptoms should
continue.
The physician should be informed of things that may affect treatment, including
previous conditions, reactions to medications and treatments, and allergies and reli-
gious beliefs that could impact the care provided (e.g., administration of blood
products). Decreasing risks for patient safety continue following the physician
appointment. The health care consumer should follow physician instructions by
obtaining prescriptions and scheduling tests, lab work, and follow-up appointments.
Medications should be taken exactly as prescribed. When tests and studies are com-
pleted, make sure the results are obtained. The patient should not assume that “No
news is good news.” If there is no communication regarding test results, contact
the physician to verify the test results.
Medication events are usually preventable, but can occur when medication is
not taken as prescribed. Lack of communication, illegible handwriting, and not fully
understanding the purpose of the medication or how to take it are risk f actors that
can result in errors. T
hese events can occur at the time the medication is prescribed
by the physician, dispensed by the pharmacist or at time of administration, and
can result in risks for health care consumers. Prevention measures include scrutiny
and observation of medications and instructions. The best prevention measure is
to ask questions, especially if something does not seem correct. Inform the physi-
cian of every medication that is being taken, including over-the-counter medi
cations, vitamins, and herbal supplements. A current list of all medications should
480 PATIENT SAFETY
be maintained and kept in a wallet or purse to have it readily available for physi-
cian visits or emergencies.
Health care consumers can also play a role in inpatient medication safety. The
hospital staff and providers should be informed of all medications that are being
taken by the consumer, including over-the-counter medications, vitamins, and
herbal supplements. Lists of allergies should include those related to food, Latex,
and intravenous dye as well as the reactions that occur when consumed or contact
occurs. The consumer should have an identification band on at all times that should
be verified by all staff prior to administration of medications, lab work, tests, and
treatments. The verification should be completed before initiation of medications.
If the medication does not appear to be correct, question if it is correct before tak-
ing the medication. The transition from inpatient status to home at time of discharge
can cause discrepancies and potential medication events. Before leaving the hospi-
tal, there should be a review of the medications that were taken prior to admission
and the ones that are to be taken when returning home. The review should include
the time the medication was last taken and when the next dose will be due. If a
medication that was taken prior to admission is not discussed at time of discharge,
question if it is to be resumed at home. Question any concerns and follow instruc-
tions for medications at home.
Health care acquired infections are ones that occur while being treated for a
health-related diagnosis, and an infection occurs while under treatment. Infections
can occur in hospitals, outpatient clinics, dialysis centers, and long-term care facil-
ities. Prevention is the key to decrease the risk of infection. Frequent handwashing
by health care staff, patients, and visitors is very important as a preventive measure.
Take antibiotics as directed and for as long as requested by the physician. Preparation
for surgery includes infection preventive measures. Patients are usually required to
wash with an antibacterial soap prior to surgery and to use an antibacterial oint-
ment in the nares of the nose. Patients play a key role in preventing infections by
following the preventive measures required before surgery.
There are times surgery is needed to correct a medical problem. Preventive safety
measures need to be followed by patients and health care professionals to decrease
the risk of a surgical event or occurrence. Each physician, nurse, and health care
staff that comes in contact with the patient prior to and during surgery will ask the
patient to state his or her name, date of birth, and to confirm surgical procedure to
be completed. The patient needs to answer the questions each time. This is a safety
measure and not meant to be an annoyance or inconvenience. Surgical sites should
be marked by the physician to assure that the correct side is verified by all staff
involved with the procedure. At any time that the patient has a concern about the
procedure, questions should be asked.
In 2002, The Joint Commission, the accrediting body for health care facilities,
established the Speak Up program. S-P-E-A-K-U-P for Patient Safety encourages
health consumers to recognize the need to be engaged and involved with their care.
The acronym encourages patients to ask questions and to voice their concerns, to
PENI C ILLIN 481
pay attention to care received, and to be knowledgeable about their illness and
medications. When in doubt, patients should speak up and ask questions, with-
out hesitation.
Health care organizations are focused on patient safety and assuring that pre-
ventive measures are in place to decrease the risk of harm or injury. All members
of the health care team and the patient have a responsibility for patient safety. Engaged
patients are informed patients. Understanding patient safety practices is the first
step to navigating the health care system safely.
Kristie Lowery
See also: American Medical Association; Antibiotic Resistance; Emergency Medical

Treatment and L abor Act; Handwashing; Health Information Management; Health
Insurance Portability and Accountability Act; Infectious Diseases; Prescription Drugs;
Controversies in Public Health: Controversy 1; Controversy 2
Further Reading
Centers for Disease Control and Prevention (CDC). (2014). Patient safety: What you can do
to be a safe patient. Retrieved from http://www.cdc.gov/HAI/patientSafety/patient-safety
.html.
The Joint Commission. (2002). Speak Up initiatives. Retrieved from http://www.jointcommission
.org/s peakup.aspx.
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health
system. Washington, DC: National Academy Press.
PENICILLIN
Antibiotics, particularly penicillin, are one of the most important public health
advances of all time. Penicillin was the first known antibiotic, and before it was
discovered, infectious diseases w ere the leading cause of death around the world.
Penicillin is an antibiotic that falls u
nder the group called B-lactams. This grouping
is based on its chemical structure, which contains a B-lactam ring. Penicillin binds to
proteins contained within certain bacteria, triggering impairment of the bacteria’s cell
wall. This impairment c auses the cell to die off, inhibiting the growth of the bacteria.
Penicillin is considered “bactericidal” since it kills the cells, as opposed to slowing
them down. It is available as penicillin V and penicillin G. Penicillin G is available as
penicillin G sodium, penicillin G benzathine, and penicillin G potassium, based on
variations in its chemical structure. Penicillin V is available as penicillin V potassium
with a unique ability to uphold stability in an acidic environment. Penicillin G is
administered intravenously (IV) or intramuscularly (IM) but is not stable in an acidic
environment; therefore, if administered orally penicillin G becomes ineffective. In
contrast, penicillin V potassium has the ability to be administered orally and finds
success in an acidic environment, holding up against gastric acid found within the
stomach, and is therefore available as an oral tablet and oral liquid.
482 PENI C ILLIN
Penicillin is dosed in units with an average dose of penicillin G, ranging from

300,000 units to 4 million units on an e very 6-to 8-hour basis. For the venereal
disease syphilis, penicillin G is given as a large injection and for a multitude of infec-
tions. Penicillin V is administered in tablets and oral solution—the average dose
ranging from 250 mg (400,000 units) to 500 mg (800,000 units) every 6 to 8 hours
from 7 to 20 days (National Library of Medicine, 2015a).
Penicillin was discovered in London (1928) by Alexander Fleming—a researcher
who focused on the characteristic properties of the blood and its ability to fight
against bacteria. While conducting another study, Fleming discovered a mold that
was growing due to contamination in one of his laboratory dishes. He realized the
mold was destroying staphylococci bacteria. When viewing areas of the mold, a
ring was seen around each area of mold that was free of any staphylococci. With
this discovery, Fleming disbanded his other experiments and focused his energy
on identifying this mold for its potential affects to fight infectious diseases. Fleming
isolated the mold and was able to identify its properties conclusive with Penicillium
notatum. Hence, the name Penicillium converted to penicillin. Although there was
still much to investigate, Fleming published his findings in 1929, indicating the
potential use of penicillin in treating certain infectious diseases (Wennergren &
Lagercrantz, 2007).
Fleming’s experiments failed clinical attempts with penicillin, but he continued
to seek its use. He found penicillin to be unstable and sought out additional ways
to concentrate the strains. In 1940, Ernst B. Chain and Sir William Dunn success-
fully purified penicillin crude extract. Chain, who was a chemist, and Dunn, a
pathologist, had been working in similar experimental areas as Fleming. Chain and
Dunn discovered Fleming’s 1929 publication and continued their investigation in
mice, showing increased survival rates among mice that had been infected with
streptococci. With results published in 1940 in The Lancet, studies w ere then initiated
in human trials, and Fleming came back to the forefront with his research. After
successful treatment of one of Fleming’s dear friends via the use of penicillin, Lon-
don news flurried with announcements of this groundbreaking finding (Wenner-
gren & Lagercrantz, 2007).
Earning the Nobel Prize in Medicine in 1945, acknowledgment was made to Sir
Alexander Fleming, Dr. Ernst B. Chain, and Sir Howard Flory. Penicillin became
available during World War II to help treat wounds stricken by infection and to aid
in the treatment of venereal disease and postwar recovery. Government officials coor-
dinated the distribution of penicillin to military soldiers and finally to public dis-
tribution in March 1945 (Quinn, 2013).
Penicillin is prescribed for infections produced by gram positive bacteria, includ-
ing streptococcus, staphylococcus aureus, and pneumococcus. T hese bacteria can
cause infections including the skin and surrounding tissue, upper respiratory tract,
pneumonia, wounds, and meningitis, Lyme disease, and syphilis, to name a few.
One of the biggest challenges experienced with penicillin is with allergic reactions
and bacterial resistance. Allergic reaction to penicillin occurs in approximately
PENI C ILLIN 483
8 percent of people in the United States whereby alternative antibiotics must be

used. Allergic reactions can range from nonsevere to rare, but fatal, hypersensitivi-
ties. Penicillin allergies can be difficult to assess since many allergic reactions, when
retested, may not present themselves again. These are called “unverified” penicillin
allergies, and it is difficult to know if these reactions would occur again if admin-
istered the antibiotic. In the case of allergic reactions, many individuals are then
switched to a class of antibiotics called cephalosporins or nonpenicillin beta-lactams
(Macy, 2014).
Bacterial resistance is another huge obstacle with broad range antibiotic use and
bacteria, which have mutated throughout the years. Cells that once died off when
in contact with penicillin have now evolved against protein binding. Bacteria have
developed the activity to work around B-lactam, and it is the B-lactam component
that has provided such past success for penicillin. Bacteria have now started to pro-
duce something called B-lactamase—what researchers call drug resistant—due to
changes in penicillin-binding proteins (PBPs) (Zervosen et al., 2012). B-lactamase
produced by current bacteria breaks down the B-lactam ring of the penicillin, ren-
dering it ineffective. Current bacteria also have altered their cell wall, changing their
protein structure that was once an effective binding site for penicillin. Penicillin
remains highly dependent on cellular proteins to bind to the cell, alter the cell wall,
and produce death of the cell. As drug-resistant PBPs develop, the efficacy of peni-
cillin continues to change (Macheboeuf et al., 2006).
Toxicity can occur with penicillin, which causes toxic effects to the liver, kid-
neys, and other organs. It is affected only against bacterial infections and should
not be administered for viral infections. Although a person may feel better after the
first few doses of penicillin, it is very important to continue with the full prescribed
regimen of treatment. If the full length of treatment is interrupted, effectiveness can
be decreased and bacterial resistance increased. The most common side effects seen
with penicillin include nausea, vomiting, diarrhea, and gastrointestinal upset. There-
fore penicillin is best taken one hour before meals or 45 minutes after meals to
maintain absorption yet decrease gastrointestinal side effects. Ampicillin and amox-
icillin are close cousins to penicillin with variations to their structure, allowing for,
in some cases, better efficacy in ridding the body of certain bacteria (National Library
of Medicine, 2015b).
Antibiotics have created a large breakthrough in the treatment of bacterial infec-
tions. With its discovery in 1928, penicillin has provided substantial treatment to
numerous bacterial infections, creating the path for all current antibiotics on the
market t oday. Penicillin continues to remain a large part of public policy, continu-
ing to enhance the collaboration of scientific research. Penicillin mold strains con-
tinue to be used in the development of new antibiotics, new bacterial strain
identification, and continued research regarding dosing, administration, and chem-
ical stability of antibiotics. Although many pharmaceutical companies have decreased
their research of antibiotics, penicillin still remains as one of the most widely studied
chemical entities (Quinn, 2013). Drug resistance still remains as one of the major
484 PHYSI CAL AC TI VITY
drawbacks to penicillin and continues to be heavily studied by chemists. Even

though pharmaceutical manufacturers have decreased marketing of new penicillin-
based antibiotics, PBPs remain a focus of researchers to decrease continued resis
tance and increase efficacy in the continued effort to cure infectious diseases
(Macheboeuf et al., 2006).
Eileen L. Sullivan
See also: Antibiotic Resistance; Handwashing; Infectious Diseases; Prescription

Drugs; Prevention; Controversies in Public Health: Controversy 2
Further Reading
Kardos, N., & Demain, A. L. (2011, November). Penicillin: The medicine with the greatest
impact on therapeutic outcomes. Applied Microbiology and Biotechnology, 92(4),
677–687.
Macheboeuf, P., Contreras-Martel, C., Job, V., Dideberg, O., & Dessen, A. (2006, Septem-
ber). Penicillin binding proteins: Key players in bacterial cell cycle and drug resistance
processes. FEMS Microbiology Reviews, 30(5), 673–691.
Macy, E. (2014, November). Penicillin and beta-lactam allergy: Epidemiology and diagno-
sis. Current Allergy and Asthma Reports, 14(11), 476.
National Library of Medicine. (2015a). Penicillin g and v. Retrieved from http://livertox.nih
.gov/PenicillinGandPenicillinV.htm.
National Library of Medicine. (2015b). USP penicillin v potassium. Retrieved from http://
dailymed.n lm.nih.g ov/dialymed/f da/fdaDrugXsl.
Quinn, R. (2013, March). Rethinking antibiotic research and development: World War II
and the penicillin collaborative. American Journal of Public Health, 103(3), 426–434.
Wennergren, G., & Langercrantz, H. (2007, January). One sometimes finds what one is
not looking for (Sir Alexander Fleming): The most important medical discovery of the
20th century. Acta Paediatrica (Oslo, Norway, 1992), 96(1), 141–144.
Zervosen, A., Sauvage, E., Frère, J.-M., Charlier, P., & Luxen, A. (2012). Development of
new drugs for an old target: The penicillin binding proteins. Molecules (Basel, Switzer-
land), 17(11), 12478–12505.
PHYSICAL ACTIVITY
Physical activity is any bodily movement that works muscles and requires more
energy than resting (Brehm, 2014; National Heart, Lung, and Blood Institute
[NHLBI], 2016). Some examples of physical activity are walking, r unning, dancing,
and gardening. Physical activity is not the same as exercise. Exercise is a type of
physical activity that is planned and structured, done with the intention of improv-
ing fitness and/or sport performance (Brehm, 2014; NHLBI, 2016). Some examples
of exercise are weightlifting, taking a group exercise class, and playing on a sports
team.
Physical inactivity has been classified as the fourth leading risk factor for mortal-
ity, causing over 3 million deaths around the world (WHO, 2010). Regular physical
PHYSI C AL A C TI V ITY 485
activity helps improve overall health and fitness, and reduces the risk for many
chronic diseases (ODPHP, 2008). For example, being physically active lowers the
risk of heart disease, stroke, Type 2 diabetes, depression, and some cancers. Ade-
quate levels of physical activity also improve bone health and help control weight
(ODPHP, 2008; WHO, 2010). In addition, people who are physically active tend to
live longer (ODPHP, 2008).
Released in 2008 by the United States Department of Health and H uman Ser
vices, the Physical Activity Guidelines for Americans provide evidence-based guidance
to help Americans aged six and older understand how to improve their health
through physical activity (ODPHP, 2008). This resource, the first publication of
physical activity national guidelines, serves as the primary voice of the U.S. gov-
ernment’s guidance on physical activity for Americans. The guidelines focus on three
types of physical activity: aerobic, muscle strengthening, and bone strengthening.
Aerobic activities are t hose in which p
eople move their large muscles rhythmically
for a sustained period. Some examples of aerobic activity are running, bicycling,
swimming, and dancing. Aerobic activities make a person’s heart and cardiovascular
system stronger by making the heart beat more rapidly to meet the demands of the
activity. Aerobic activities can be done with light, moderate, or vigorous intensity. It
is recommended that most physical activity be moderate or vigorous intensity,
Regular physical activity strengthens bones and muscles, including the heart muscle.
(Kaspicreative/iStockphoto.com)
486 PHYSIC AL ACTI VITY
although light activity is better than no activity at all. Light-intensity activities are
everyday activities that do not require very much effort, such as walking slowly or
doing the dishes. During moderate-intensity activities, the heart will beat faster
than usual and breathing will be harder than usual. The “talk test” is an easy way
to assess intensity; people d oing moderate-intensity activities can usually talk, but
not sing, while d oing the activity. During vigorous-intensity activity, when the
heart beats much faster and breathing is much harder than usual, people generally
are not able to say more than a few words without pausing for a breath. Although the
intensity level of an activity varies depending on the person (e.g., gardening may
be more difficult for some people than others), different activities have been clas-
sified as moderate or vigorous based on the amount of energy that the body tends
to use while d oing the activity. For example, moderate activity examples are
bicycling slower than 10 miles per hour and brisk walking; vigorous activity
examples are bicycling 10 miles per hour or faster, jogging, and r unning (NHLBI,
2016; ODPHP, 2008).
Muscle-strengthening activities increase bone strength, improve muscular fitness,
and help maintain muscle mass by making muscles do more work than they are
used to d oing. Examples of muscle-strengthening activities include carrying heavy
loads, lifting weights, or activities that use body weight as resistance (e.g., push-ups
or pull-ups) (ODPHP, 2008).
Bone-strengthening activities promote bone growth and strength by placing a
force on the bones, often through impact with the ground. Bone-strengthening
activities can be aerobic and/or muscle strengthening. Some examples are running,
jumping rope, playing basketball, and playing tennis (ODPHP, 2008).
For children and adolescents, the 2008 guidelines recommend engaging in at
least one hour of physical activity each day. The guidelines also state that it is impor
tant to encourage youth to participate in activities that are enjoyable and age-
appropriate, and offer variety. Most of the hour should be e ither moderate or vigorous
activity, and vigorous activity should be included at least three days per week.
In addition, youth should complete a muscle-strengthening and a bone-strengthening
activity at least three days of the week.
For adults, the guidelines recommend engaging in at least 150 minutes per week
of moderate or 75 minutes per week of vigorous aerobic physical activity. Adults
also should participate in muscle-strengthening activities (involving all major muscle
groups) on at least two days per week. In addition to specific guidelines for c hildren
and adults, the ODPHP also puts forth messages and guidelines for older adults,
pregnant and postpartum w omen, adults with disabilities, and p eople with chronic
health conditions (ODPHP, 2008).
The guidelines state that some physical activity is better than none, and that
people who participate in any amount of activity gain some health benefits. In gen-
eral, the benefits of physical activity outweigh the risks. Heart problems, for example,
are rarely a result of physical activity; in most cases, physical activity–related heart
problems happen to people who have existing heart conditions (NHLBI, 2016).
PHYSI CAL A C TI V ITY 487
Despite the clear guidelines and scientific data that support the benefits of phys-
ical activity, many Americans do not get enough physical activity. Studies have shown
that only about 20 percent of adults and 30 percent of high school students meet
the physical activity guidelines put forth by the Office of Disease Prevention and
Health Promotion (CDC, 2014). Rates of activity and inactivity vary geographically
and demographically. Americans living in the South are more likely to be inactive
compared to those living in other regions of the country. Lower physical activity
levels have been observed among minority groups and those with lower socio-
economic status. More white adults (23 percent) meet the physical activity guide-
lines than black adults (18 percent) and Hispanic adults (16 percent). Adults with
more education are more likely to meet the activity guidelines than adults with less
education. Finally, men (54 percent) are more likely than w omen (46 percent) to
meet the guidelines (CDC, 2014).
Physical inactivity is an important public health issue, requiring consideration
from policy makers, educators, practitioners, researchers, and public health pro-
fessionals, all of whom play a role in p eople’s understanding of and ability to carry
out physical activity guidelines. Although the 2008 Physical Activity Guidelines for
Americans provide an authoritative voice on physical activity and health, disparities
in and levels of physical activity suggest that there is more to be done. The ODPHP
is currently working with the CDC, the National Institutes of Health, and the Presi-
dent’s Council on Fitness, Sports, and Nutrition to develop a second edition of the
physical activity guidelines, estimated to be released in 2018. The second edition
is expected to build on the first, with the addition of information about federal phys-
ical activity and education programs. Recommendations to improve people’s activ-
ity levels include (1) encouraging funding of research that will lead to a more
comprehensive understanding of how to measure, monitor, and improve physical
activity levels; (2) creating or modifying environments that facilitate walking or bicy-
cling (e.g., safer sidewalks, crosswalks, and bike lanes); and (3) supporting the
development of physical activity policy, including school policies that focus on phys-
ical activity (CDC, 2014; WHO, 2010). Following these suggestions may help to
address the gap that currently exists between the physical activity recommenda-
tions and the reported physical activity levels.
Elizabeth Y. Barnett
See also: Body Mass Index; Diabetes Mellitus; Healthy Places; Heart Disease; Heart
Truth® (Red Dress) Campaign, The; Hypertension; Leading Health Indicators;
Nutrition; Obesity; PRECEDE-PROCEED Planning Model; Prevention; Social Deter-
minants of Health; Social Ecological Model
Further Reading
Brehm, B. A. (Ed.). (2014). Psychology of health and fitness. Philadelphia: F. A. Davis.
Centers for Disease Control and Prevention (CDC). (2014). Facts about physical activity.
Retrieved from https://www.cdc.gov/physicalactivity/data/facts.htm.
488 PLANNED PARENTHOOD
National Heart, Lung, and Blood Institute. (2016). Physical activity and your heart. Retrieved
from https://www.nhlbi.nih.gov/health/health-topics/topics/phys.
Office of Disease Prevention and Health Promotion (ODPHP). (2008). 2008 Physical activity
guidelines for Americans summary. Retrieved from http://www.health.gov/paguidelines
/guidelines/summary.aspx.
World Health Organization (WHO). (2010). Global recommendations on physical activity for
health. Geneva: Author.
PLANNED PARENTHOOD
Planned Parenthood Federation of America, Inc. (Planned Parenthood) is a non-
profit organization that provides sexual and reproductive health care to men and
women. The organization provides 5 million services, regardless of sexual orienta-
tion, gender identity and expression, or ability to pay (Planned Parenthood 2015–
2016 Annual Report, 2017). In the United States, 2.4 million men, women, and
young adults utilized a Planned Parenthood facilit y in 2015. The majority (85 percent)
of those who accessed services at Planned Parenthood w ere 20 years or older, with
11 percent of the population served being men (Planned Parenthood 2015–2016
Annual Report, 2017). Services include low-cost sexual, reproductive, and preven-
tative health care, comprehensive sex education, and advocacy. Programs are
designed to advance health equity and reproductive justice and to address the
societal barriers that inhibit women’s reproductive autonomy (Stevens, 2017, p. 8;
“What Is Planned Parenthood’s Mission Statement?” 2017).
History
The origins of Planned Parenthood date back a c entury ago. Margaret Sanger and
her sister, Ethel Byrne, established the first birth control clinic on October 16, 1916,
in Brooklyn, New York. Sanger was later jailed for sharing information on birth con-
trol, catapulting her to the forefront of the reproductive rights movement. The
history of Planned Parenthood is not only rooted in Sanger’s relentless fight for access
to birth control and f amily planning, but also in her controversial beliefs in eugen-
ics (a doctrine that supports forced or planned breeding and sterilization) (Burke &
Castaneda, 2007). Sanger’s nuanced relationship with the eugenics movement was
strategically used to develop a language that legitimized birth control, moving the
conversation away from social welfare and into the realm of science (Ordover, 2003,
p. 138). Despite her belief that all women are entitled to sexual and reproductive
autonomy, Sanger’s legacy is tainted with the development of class and disability-
based eugenics doctrine and the endorsement of race-based surgical experimen-
tation. Planned Parenthood openly addresses this aspect of their founder’s convoluted
beliefs in order to create an inclusive discourse that elevates reproductive justice
for all w
omen today (Ordover, 2003).
Through the leadership of the current president, Cecil Richards, Planned Par-
enthood provides a wide array of services at more than 600 active health care
PLANNED PA R ENTHOOD 489
centers nationwide (Planned Parenthood 2015–2016 Annual Report, 2017). T hese

services include reproductive and sexual health care, preventative services, LGBT
services, abortion services, men and women’s general services, and patient educa-
tion such as cancer screening and birthing classes (“Our Services,” 2017). In 2015,
Planned Parenthood, along with their 56 governed affiliates, provided health care
services to 2.4 million people Planned Parenthood 2015–2016 Annual Report,
2017). Of those services provided, 45 percent w ere STI testing and treatment,
30 percent were contraception services, 14 percent were other women’s health ser
vices, 7 percent w ere cancer screenings, 3 percent w ere abortion services, and the
remaining 1 percent defined as other services (Planned Parenthood 2015–2016
Annual Report, 2017). As the largest provider of sex education in the United States—
reaching schools, communities, incarcerated populations, and faith-based entities
through various programs provided by the organization—Planned Parenthood is
also spearheading the movement for comprehensive sex education. This is most
evident in the middle school program, Get Real: Sex Education That Works, an age
appropriate school-based program with interactive f amily activities recently placed
on the U.S. Department of Health and Human Services list of evidence-based sex
education programs in 2015 (“Get Real,” 2015).
Planned Parenthood also provides interactive online tools such as the Online
Health Services (OHS) Program, which gives users easy access to contraceptives, as
well as medication for urinary tract infections; Consent 10, an online video series
that takes an in depth look into consent; as well as their app, Spot On, a period
tracker that helps w omen predict their menstrual cycle, locate clinics nearby, and
provides tips from Planned Parenthood providers. Planned Parenthood was recently
showcased at the Sun Dance Festival and won a People’s Choice Award for their
documentary fiction, Across the Line, a virtual reality that walks the viewer through
the eyes of a patient seeking abortion services. Through global partnerships, Planned
Parenthood works with 12 countries that foster 230,000 mobile sites for reproduc-
tive education and services worldwide (Planned Parenthood 2015–2016 Annual
Report,” 2017). More recently, Planned Parenthood engaged religious leaders as criti-
cal community stakeholders in Burkina Faso by educating them on the importance
of sexual and reproductive health to promote culturally relevant ideals around the
value of family and community.
Despite these positive impacts, Planned Parenthood faces many obstacles. With
opposition from conservative right-wing, anti-choice politicians, Congress recently
voted to block over $200 million in Title X funding to Planned Parenthood and
any facility that provides abortion services (Desjardins, 2017). Additionally, 24 states
have attempted to remove Planned Parenthood health centers and restrict their abil-
ity to participate in the Title X program or be refunded by Medicaid. Extremists
have also used deadly force. A more recent case took place in a Colorado Springs
center in November 2015 where a gunman entered a facility and killed three inno-
cent p eople. Finally, recent allegations claiming that Planned Parenthood sold fetal
tissue in an anti–Planned Parenthood documentary was recently discredited and
490 PLANNED PA R ENTHOOD
the documentary’s creators charged with 17 felonies in the state of California (Karimi,
2017). Despite false allegations, political opposition, and physical attacks, Planned
Parenthood continues to fight back, filing suits against the removal of health facili-
ties that block access to services and challenging states that have falsely claimed the
organization profited from fetal tissue donation.
Planned Parenthood continues to create new opportunities to support the sex-
ual and reproductive health of women, men, and youth both h ere and abroad. Pres-
ently, Planned Parenthood is looking to design more comprehensive health care
through the expansion of services to the trans community as well as men. By spon-
soring partnerships such as Trust Black W omen and Latino Community Investment
Grants, Planned Parenthood’s f uture work involves amplifying the voices of women
of color as they work closely with leaders and organizations to elevate the repro-
ductive justice agenda and increase service use in black and brown communities.
Additionally, Planned Parenthoods around the country are working more closely
with youth through young adult community programs such as PPFA’s Generation
(PPGen) and Planned Parenthood Action Fund’s Generation Action (PPGenAction) to
increase advocacy across generations. Both programs are campus groups across the
United States, designed to enhance reproductive health and freedom by combating
abortion stigma; addressing sexual assault on campuses; creating and advocating
for innovative reproductive health legislation; and enhancing inclusivity regardless
of race, sexual orientation, expression, and identity. The organization seeks to
advance reproductive health by supporting an average of 70 research studies a year
on topics ranging from contraception to the HPV vaccination (Planned Parenthood
2015–2016 Annual Report, 2017).
It is estimated that one in five women will use services at Planned Parenthood
in her life (Planned Parenthood 2015–2016 Annual Report, 2017). For many, this
organization is the only health care provider who can support vulnerable w omen
in their time of need. For others, Planned Parenthood is a staple in their commu-
nity known to provide care and services founded on respect and patient autonomy.
Whether in support of or against Planned Parenthood, it must be acknowledged as
fact that the defunding of this organization will result in the loss of more than 1.5
million people having access to health care and preventative services (Planned
Parenthood 2015–2016 Annual Report, 2017). This not only includes safe and
legal abortion services but access to routine screenings and care that support and
sustain healthy communities worldwide. The acknowledgment of this fundamental
fact herein lies the truth b ehind Planned Parenthood’s tenacity and their relent-
less fight to provide access to services that sustain reproductive self-determination—
no m atter what.
Tenille J. Torres
See also: F
amily Planning; Maternal Health; Sanger, Margaret Louise Higgins;
Women’s Health
POLIO 491
Further Reading
Burke, C. S., & Castaneda, C. J. (2007). The public and private history of eugenics: An
introduction. The Public Historian, 29(3), 5–17. Retrieved from https://doi.org/10.1525
/tph.2007.29.3.5.
Desjardins, L. (2017, March 30). Why the Senate voted to block funding for Planned Parenthood
and other abortion providers. Retrieved from http://www.pbs.org/newshour/updates
/senate-vote-block-abortion-funding-affects-planned-parenthood/.
“Get real: Comprehensive sex education that works” joins list of evidence-based programs from
U.S. Department of Health and Human Services. (2015, February 5). Retrieved from
https://www.plannedparenthood.org/planned-parenthood-massachusetts/newsroom
/g et -real -c omprehensive-s ex -e ducation-t hat -w orks -j oins -l ist -o f -e vidence -b ased
-programs-from-us-department-of-health-and-human-ser.
Karimi, F. (2017, March 29). Planned Parenthood: Anti-abortion activists behind secret videos
charged—CNNPolitics.com. Retrieved August 2, 2017, from http://www.cnn.com/2017
/03/29/politics/planned-parenthood-video-charges/index.html.
Margaret Sanger—Our founder. (n.d.). Retrieved from https://www.plannedparenthood.org
/uploads/filer_public/b5/d4/b5d47c32-89f2-45d9-b28c-243cb85f3f55/sanger_fact
_sheet_oct_2016.pdf.
Ordover, N. (Ed.). (2003). Margaret Sanger and the eugenic compact. In American Eugenics
(NED–New ed., pp. 137–158). Minneapolis: University of Minnesota Press. Retrieved
from http://www.jstor.org/stable/10.5749/j.ctttt7tz.19.
Our services, affordable healthcare & sex education. (2017). Retrieved from https://www
.plannedparenthood.org/get-care/our-services.
Planned Parenthood 2015–2016 annual report. (2017). Retrieved from https://www
.plannedparenthood.org/uploads/filer_public/18/40/1840b04b-55d3-4c00-959d
-11817023ffc8/20170526_annualreport_p02_singles.pdf.
Planned Parenthood at a glance. (2017). Retrieved from https://www.plannedparenthood.org
/about-us/who-we-are/planned-parenthood-at-a-glance.
Stevens, A. B. (2017). What is reproductive justice? Against the Current, 32(188), 8–8.
What is Planned Parenthood’s mission statement? (2017). Retrieved from https://www
.plannedparenthood.org/about-us/who-we-are/mission.
POLIO
Polio is among one of the most well-known vaccine-preventable infectious diseases
in the world. Also known as poliomyelitis, the polio disease is caused by an entero-
virus called poliovirus. Like other enteroviruses, the poliovirus enters the gastroin-
testinal tract through the mouth and then spreads into the lymph nodes and the
bloodstream. From the bloodstream, poliovirus can enter the central nervous sys-
tem and cause permanent damage that leads to paralysis. In some cases, where paral-
ysis occurs in muscles necessary for vital functions such as breathing, death w ill
also occur.
The transmission of poliovirus between individuals typically occurs through a
fecal-oral route. Usually, the poliovirus from infected patients’ stools can contami-
nate the hands of the carrier, which then touch a variety of surfaces such as cook-
ing or eating utensils. These then carry the poliovirus to the mouth of o thers who
492 POLIO
subsequently become infected themselves. This route of transmission is highly con-

tagious. Research studies have found that nearly 100 percent of the h ousehold
contacts of infected c hildren showed antibodies that indicate the transmission of
poliovirus (Centers for Disease Control and Prevention, 2000).
Regardless of the contagious nature of poliovirus, most affected children are
asymptomatic and do not show any signs of being infected. The polioviruses are
shed from their body through the stool with no central nervous system damage. It
is important to note that the stool of these children is still contagious and could
spread poliovirus to o thers. In a smaller subset of infected c hildren, t here are some
minor symptoms such as low-grade fever, sore throat, or abnormal nerve sensa-
tions. Less than 1 percent of children infected with polio show “flaccid paralysis,”
which involves diminution of muscular reflexes and the aching or spasm of the
muscles. In some of these children with “flaccid paralysis,” muscle function never
recovers to the same degree and therefore causes permanent mild to severe paraly-
sis or even death (Centers for Disease Control and Prevention, 2015). Therefore,
much emphasis has been placed on eradicating polio throughout the world with
the use of vaccinations that build immunity to the poliovirus in both c hildren
and adults.
Although ancient artwork and descriptions have supported the claim that polio-
myelitis has afflicted humanity for thousands of years, it was first definitively char-
acterized by an English physician named Michael Underwood in the late 18th century,
who described polio as a progressive debilitation of the lower extremities in children.
Poliomyelitis outbreaks throughout Europe and the United States continued to be
reported in the following c entury with worsening effect. Even one of the U.S. presi-
dents in the mid-20th century, Franklin Delano Roosevelt, was thought to have suf-
fered from poliomyelitis and was dependent on iron braces when walking. The
peak polio outbreak in the United States was reached in 1952, when over 21,000
cases of paralytic poliomyelitis were reported in that year alone.
With the advent and spread of the poliovirus vaccine a few years after 1952, the
incidence of poliomyelitis began to decline sharply until it was completely eradi-
cated in the Western Hemisphere by 1991. Although poliomyelitis still occurs not
uncommonly in Afghanistan, Pakistan, and Nigeria, the world as a w hole has made
remarkable progress through systematic vaccinations and polio education. Its inci-
dence has diminished far below historic levels with generations of c hildren through-
out the world who have not experienced or even seen poliomyelitis paralysis. Private
nongovernmental organizations such as the Bill and Melinda Gates Foundation
and Rotary have been instrumental in providing the funding needed to eliminate
poliomyelitis through the Global Polio Eradication Initiative alongside national
and international governmental agencies such as the Centers for Disease Control,
the United Nations C hildren’s Fund, and the World Health Organization. Over
$15 billion has been spent for polio eradication around the world since 1988,
with another $7 billion anticipated to be spent between 2013 and 2019 (Global
Polio Eradication Initiative, 2017).
POLIO 493
Oral polio vaccine is administered to a young patient during Afghanistan’s national immuni-
zation days in 2015. During immunization campaigns, polio teams go door-to-door immu-
nizing all children under the age of five. (Shah Maria/AFP/Getty Images)
The poliovirus vaccine that has been responsible for this g reat advancement in
polio eradication has itself undergone an evolution throughout its existence. Jonas
Salk, an American medical virologist, discovered and developed the first poliovirus
vaccine. He chose to leave it unpatented u nder the belief that public health should
be a moral commitment. This inactivated poliovirus vaccine (IPV) was first licensed
in 1955 and was hailed as a great accomplishment.
The IPV was used for approximately six years before being replaced with oral
vaccines, which w ere themselves replaced by an enhanced-potency IPV by 1988.
The enhanced IPV has become more commonly used since then, particularly in
the United States. The enhanced IPV is very effective, with greater than 99 percent
of vaccine recipients developing antibodies against all three major serotypes of
poliovirus a fter three doses; this immunity is likewise suspected to be lifelong (Cen-
ters for Disease Control and Prevention, 2015).
Although the oral vaccine is still used in many parts of the world b ecause of its
efficacy and low cost, physicians in the United States use the enhanced IPV because
it minimizes the risk of very rare negative side effects such as vaccine-associated
paralytic polio. The future of polio eradication involves the building of capacity in
developing countries to shift from oral vaccinations to IPV. Advancements in IPV
manufacturing and logistical capacity are needed to lower costs, build supply stores,
494 POPULATION HEALTH
and allow for safe transportation to make IPV a feasible alternative to oral vaccines
in developing countries.
Whatever form of the poliovirus vaccine is used, however, it has undoubtedly
been credited with saving millions of lives from crippling paralysis and/or death in
the United States and throughout the world since its inception. The advent of vac-
cinations has served to transform poliomyelitis from an epidemic threat into an erad-
icated disease in the course of several decades.
Shayan Waseh
See also: Cutter Incident, The; Epidemic; Infant Mortality; Infectious Diseases;
Influenza; Roosevelt, Franklin Delano; Salk, Jonas; Vaccines; Controversies in Public
Further Reading
Centers for Disease Control and Prevention. (2000). Updated recommendations of the Advi-
sory Committee on Immunization Practices. Morbidity and Mortality Weekly Report,
49(RR-5), 1–22.
Centers for Disease Control and Prevention. (2015). Epidemiology and prevention of vaccine-
preventable diseases. Washington, DC: Public Health Foundation.
Chan, M. (2014). The contribution of immunization: Saving millions of lives, and more.
Public Health Reports, 129(S3), 7–8.
Global Polio Eradication Initiative. (2017). History of polio. Retrieved from http://
polioeradication.o rg/polio-t oday/history-o f-polio.
POPULATION HEALTH
The term “population health” appears increasingly in today’s public health, health
services, and administration arena, yet without a precise meaning. Although the
general public tends to view “population health” as exchangeable with “public
health,” there is no general agreement on the use of the term among contemporary
medical scientists and health administrators. To explain its origin, the term was first
introduced to the public, arguably, by a group of Canadian medical researchers,
Evans, Barer, and Marmor (1994), in their book Why Are Some People Healthy and
Others Not? The Determinants of Health of Populations. Since then the meaning has
undergone some changes and contexts. Two major meanings are used today. One
meaning defines population health from the perspective of those who investigate
causes of health disparity in a given population and thus defines the term as the
“health outcomes of a population.” Therefore, improving population health means
reducing the health disparities of at-risk populations. The other meaning is “popula-
tion health” from the standpoint of the general public’s demand that the current
health care system should be improved and promoting ways to a healthier lifestyle,
thereby giving meaning the “general population’s health status in reference to the
existing health care systems and lifestyle.” This definition sees “improving population
POPULATION HEALTH 495
health” as referring to developing and enhancing the overall quality of the present health
care system and promoting health-conscious culture among the general population. The
former sense of the term originates in Why Are Some People Healthy and Others Not?
So it is the original or traditional meaning of the word. However, when Marmor
and his colleagues first introduced it to the public, they never formally defined it
in their essays. Rather, their work was focused on the understanding of the deter-
minants of health of populations without giving a clear meaning to the term. It is
later that the medical scientists David Kindig and Greg Stoddart undertook efforts
to give a definitive meaning to the term, drawing on Marmor’s work. In Kindig and
Stoddart’s 2003 article, “What Is Population Health?,” they state that population
health should be defined as “the health outcomes of a group of individuals, includ-
ing the distribution of such outcomes within the group” (2003). And they add:
“These populations often are geographic regions like nations or communities but
also can be other groups, like employees, specific ethnic groups, disabled persons,
or prisoners” (2007).
Those who understand population health in the traditional meaning see “popu-
lation health” associated with the two fundamental inquiries: first, why some people
live healthier and longer lives than o thers; second, how to ensure that e very person
has equal opportunity for quality life free of disease and disability. To answer the
first, the researchers examine multiple varying determinants, such as the popula-
tion’s general income level, genetic traits, environmental exposures, communicable
diseases, general work environment, work-life balance, availability of health care
resources (and services), and others. The researchers’ overall focus tends to be on
economic factors, which are many times associated with geographic area. In other
words, they believe that the c auses of the health disparity should be investigated
within or in reference to the economic framework. Their argument follows that the
reason why life expectancy of residents in Appalachia is shorter and lifestyle is
unhealthier than those living in the other parts of the eastern United States is pri-
marily due to economic factors creating low incomes. This form of investigative
inquiry has great common sense. It is a common truth that in a capitalist society an
individual’s income level determines length and quality of life. The wealthier one
is, the better nutrition, recreational facilities, and health care one can access, and
poverty creates a cycle. Physicians graduating from U.S. medical schools are reluc-
tant to practice in poor communities. As a result, low income families have less
access to quality health services.
How to improve the health of the underprivileged population is a serious chal-
lenge, which leads to the second concern of the population health inquiry, how to
eliminate health disparities. The primary task involved here is to find relatively cost-
effective ways of allocating health care resources and services to disadvantaged popu-
lations while also tackling the sources of health inequity. The financial-administrative
concern is significant because, whether the population in question is seen in a global,
domestic, or local level, the available resources are not unlimited. In most cases,
policy makers are u nder tight budget constraints. Thus, achieving maximum return
496 POPULATION HEALTH
from the invested resources is a crucial part of population health thinking. Mech-
anisms to achieve the best cost benefit are expanding insurance coverage, increasing
health education, promoting community health promotion programs, and using
evidence-based programs.
The other prevalent meaning of “population health” used today is found in a
group of researchers’ effort to respond to the public’s alleged demand or outcry that
the current society can and should do better about providing health care. As a meth-
odological solution, the researchers put their focus on improving the overall qual-
ity of the existing health care system and propagating health-conscious culture. In
this scheme of thought, the population health is defined as the “general popula-
tion’s health status in reference to the existing health care system and the popula-
tion’s health lifestyle.” The most organized type of this population health thinking
may be found in Berwick, Nolan, and Whittington’s 2008 article, “The Triple Aim:
Care, Health, and Cost.” Berwick and his colleagues, a team of medical researchers-
administrators from the Institute for Health Improvement (IHI), argue that the
U.S. health care system should pursue, simultaneously, three aims to improve its
overall quality: patients’ experience of health care, which includes quality and sat-
isfaction; the health of populations; and reducing per capita costs of health care
(2008). With respect to quality of care and patient satisfaction, 4 out of 10 Medi-
care patients treated for congestive heart failure are readmitted to the hospital within
90 days. Studies show that the rate can be reduced to less than 1 out of 10 readmis-
sions. According to the 2006 WHO statistics, “the United States ranks thirty-first
among nations on life expectancy, thirty-sixth on infant mortality, twenty-eighth
on male healthy life expectancy, and twenty-ninth on female healthy life expectancy”
(2008). Based on these data, T riple Aim scholars call for greater investment to
improve the health care system, as well as to encourage healthier lifestyles in the
entire population, including increased physical activity, healthy eating, and avoid-
ance of smoking, alcohol, and other substances. Efforts to achieve this goal are clearly
focused on improving the system for all populations typically in a national scale,
instead of addressing the health inequality of specific populations, the fact of which
has invited criticisms particularly from the users of the former meaning of popula-
tion health. The main criticism is that this approach to population health draws
attention away from the economic factor of the health care system. The critics also
recommend that this approach to population health should use the terms “popula-
tion health management,” “population medicine,” or “population health movement,”
instead of “population health.” The two definitions of population health are neither
logically contradictory to each other in their linguistic contents, nor practically
opposed to each other when the policy implementations are carried out with good
plans. Given that the former group of researchers’ concern as a way of improving
population health is primarily closing the gap of the health disparity of popula-
tions, they do not mean closing the gap by downgrading the quality of health for
the wealthy but by uplifting the standard of care for the poor. The latter researchers
can say that improving the general standard of health care system and educating
POPULATION HEALTH 497
the public in healthy lifestyle is an effective way to provide better health care for
all, including the poor, though the disparity between the rich and the poor may
be unavoidable. One important component measuring the success of any type of
health care system is whether it makes the most vulnerable classes suffer less.
The proposed program (e.g., T riple Aim) attempts to provide the most suffering
population with a better health care than now by improving the system’s general
quality and thereby seeks medical justice, as much as the former group does. It is
true that uplifting the general standard of health care w ill improve the quality of
care for the poor. However, it remains also true that, as mentioned above, the group’s
emphasis and focus take attention away from the particular problems that the geo
graphically isolated impoverished groups are facing. Thus, it is best to conceive
both definitions of population health as complementary to each other. Accordingly,
the health policy makers and administrators should be sensitive to the claims from
both groups.
There are other interpretations of population health worthy of mention. Dunn
and Hayes (1999) and Jacobson and Teutsch (n.d.) engage in a similar research on
the health of population and health disparity as Kindig and Greg, but with slightly
different foci. Dunn and Hayes pay particular attention to measurement and iden-
tify population health as the health of a population measured by health status indi-
cators and influenced by social, economic, and physical determinants. The latter
group proposes to clarify the ambiguity of the term by abandoning it and replacing
population health with “total population health.” Another prominent researcher,
T. Kue Young, defines population health as “a conceptual framework for thinking
about why some populations are healthier than o thers, as well as the policy devel-
opment, research agenda, and resource allocation that flow from it.” This defini-
tion sets the investigative perimeter to include health determinants affecting not
just ill but the entire populations.
The many and various definitions of population health, backed by respectable
scholarly positions, roughly fall into or revolve around two major meanings. Popu-
lation health refers to health of the population, systems used to ensure and pro-
mote health, and seeking equality of health between various populations. More
important than any particular scholarly definition is how to draft and implement
effective health care policies and regulations based on science derived from the many
definitions.
Marvin J. H. Lee
See also: Epidemiology; Ethics in Public Health and Population Health; Health Dis-
parities; Social Determinants of Health
Further Reading
Berwick, D., Nolan, T., & Whittington, J. (2008). The triple aim: Care, health, and cost.
Health Affairs, 27(3), 759–769.
498 PR EC AUTION ADOPTION PROCESS MODEL ( PAP M )
Dunn, J. R., & Hayes, M. V. (1999). T oward a lexicon of population health. Canadian Jour-
nal of Public Health, 90(Suppl. 1), S7.
Evans, R. G., Barer, M. L., & Marmor, T. R. (1994). Why are some p eople healthy and o thers
not? The determinants of health of populations. New York: Aldine de Gruyter.
Hartley, D. (2004). Rural health disparities, population health, and rural culture. American
Journal of Public Health, 94(10), 1675–1678.
Jacobson, D. M., & Teutsch, S. (n.d.). An environmental scan of integrated approaches for defin-
ing and measuring total population health by the clinical care system, the government public
health system, and stakeholder organizations. Washington, DC: National Quality Forum.
Retrieved from http://www.improvingpopulationhealth.org/PopHealthPhaseIICommis
sionedPaper.pdf.
Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public
Health, 93(3), 380–383.
Kindig, D. A. (2007). Understanding population health terminology. Milbank Quarterly,
85(1), 139.
Young, T. K. (2004). Population health: Concepts and methods. New York: Oxford University
Press. doi:10.1093/acprof:oso/9780195158540.001.0001
PRECAUTION ADOPTION PROCESS MODEL (PAPM)

The precaution adoption process model (PAPM) presents the sequence of cognitive
and behavior stages that individuals go through when confronted with a health
hazard. The model proposes that when individuals first encounter a health issue,
they are in a state of ignorance. As they gain more information on the topic, they
move to a state of awareness and subsequently decide w hether to address the prob
lem. The stages or constructs are:
• Unaware of the issue
• Aware of the hazard, not concerned
• Concerned with the hazard and deciding on possible actions
• Deciding not to act
OR
• Deciding to act
• Acting
• Maintaining
Each PAPM stage has different characteristics of decision making and action as well
as factors or determinants that influence the process. Public health professionals
use the PAPM to study, plan, and understand individual motivation and behavior
in health promotion and disease prevention.
There are several well-known stage models in the field of behavioral health. Stage
models propose that people do not stop, start, or change health behaviors suddenly.
Individuals go through stages. First, the individual must recognize the issue as a
potential threat or desired change. After acknowledgment, the individual weighs
the benefits and costs of change, develops a plan of action, implements the plan
(act), and works to sustain the behavioral change. Stage theories are useful in that
P RE CAUTION ADOPTION P R O C ESS M ODEL ( PAP M ) 499
they define very clear steps and what an individual thinks and needs at a particular
stage. The earliest and most well-recognized stage model, the transtheoretical model
(TTM) or stages of change model was developed from observations of p eople who
were trying to quit smoking (Prochaska & DiClemente, 1983). Initially, the smoker
is unaware of the health consequences of smoking (unaware of the hazard). Small
signs, such as a morning cough, smelly clothes, bad breath, stained teeth, the cost
of cigarettes, or loss of free w
ill may force the smoker to acknowledge health, social,
and financial cost of smoking (aware of the hazard but not concerned). As the signs
become unavoidable, the smoker will start to recognize the problem and investigate
options (concerned with the hazard and deciding what to do). If the smoker decides
to act, he or she w ill develop a plan of action. Action involves seeking profes-
sional help, destroying any remaining cigarettes, or purchasing nicotine replace-
ment therapy. While the person is in action and maintenance stages, he needs to
avoid places and p eople that might exacerbate cravings. W hether the individual is
stopping a harmful behavior or adopting a positive behavior, there is a clear and
logical sequence to changing behavior. The PAPM varies from the TTM in three
ways. The PAPM adds an earlier stage of completely unaware; separates the first
TTM stage, precontemplation, into aware/not concerned and aware/deciding; and
separates the second TTM stage, contemplation, into decided to act and decided not
to act. The PAPM categories provide further distinction of the different cognitive
stages. A practical limitation of these refinements is that each stage requires a clear
definition. In order to follow the PAPM with integrity, researchers and program
planners must recruit and retain participants that represent each stage. This means
many more program and study participants and greater costs to run the study or
program.
In comparison to models that present behavioral change as a continuum, stage
theories can be complex and challenging to use. The advantage of these models is
that they apply to just about e very intentional behavioral change from developing
a daily routine of dental flossing to practicing regular breast self-exam or testicular
self-exam. The PAPM has been used in disaster preparedness, mature driver safety,
premenstrual syndrome, oral hygiene, falls in the elderly, and home radon testing.
Further testing and refinement of the PAPM may help public health professionals
to personalize disease prevention and health promotion programs to individual par-
ticipants and have greater impact of health behaviors.
Sally Kuykendall
See also: Behavioral Health; Environmental Health; Evidence-Based Programs and

Practices; Transtheoretical Model
Further Reading
Elliott, J. O., Seals, B. F., & Jacobson, M. P. (2007). Use of the Precaution Adoption Process
Model to examine predictors of osteoprotective behavior in epilepsy. Seizure: European
Journal of Epilepsy, 16, 424–437. doi:10.1016/j.seizure.2007.02.016
500 PR EC EDE-PR OCEED PLANNING MODEL
Hassan, H., King, M., & Watt, K. (2017). Examination of the precaution adoption process
model in understanding older d rivers’ behaviour: An explanatory study. Transportation
Research: Part F, 46, 111–123. doi:10.1016/j.trf.2017.01.007
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smok-
ing: Toward an integrative model of change. Journal of Consulting and Clinical Psychol
ogy, 51, 390–395.
Weinstein, N. D. (1988). The precaution adoption process. Health Psychology, 7(4), 355–386.
doi:10.1037/0278-6133.7.4.355
Weinstein, N. D., & Sandman, P. M. (1992). A model of the precaution adoption process:
Evidence from home radon testing. Health Psychology, 11(3), 170–180. doi:10.1037
/0278-6133.11.3.170
Weinstein, N. D., Sandman, P. M., & Blalock, S. J. (2008). The precaution adoption process
model. In K. Glanz, B. K. Rimer, K. Viswanath, K. Glanz, B. K. Rimer, & K. Viswanath
(Eds.), Health behavior and health education: Theory, research, and practice (4th ed.,
pp. 123–147). San Francisco: Jossey-Bass.
PRECEDE-P ROCEED PLANNING MODEL

The predisposing, reinforcing, and enabling constructs in educational diagnosis and
evaluation—policy, regulatory, and organizational constructs in educational and envi-
ronmental development (PRECEDE-PROCEED) planning model is a framework
for public health program planning and evaluation (Green, Kreuter, Deeds, & Par-
tridge, 1980). The model consists of nine phases: (1) social diagnosis, (2) epide-
miological diagnosis, (3) behavioral and environmental diagnosis, (4) educational
and organizational diagnosis, (5) administrative and policy diagnosis, (6) imple-
mentation, (7) process evaluation, (8) impact evaluation, and (9) outcome evalua-
tion. The phases are represented as a diagram that starts with the desired goal of
the project. Phase 1 identifies the health problem of interest, and Phases 2 to 5 exam-
ine factors that inhibit or promote the health issue. T hese moderating f actors lead
into Phase 6, public health actions, policies, or interventions. Phases 7 to 9 repre-
sent process and impact evaluations of the planned action, leading back to the health
problem identified in Phase 1. The main advantage of the model is that it outlines
the many, many factors the program planner or policy maker must consider when
addressing complex health issues. Use of the model promotes efficiency and effec-
tiveness of efforts. A disadvantage of the model is that it is very complex and requires
a diverse set of knowledge and skills. It is easy to become lost in all of the possible
options the model presents. The PRECEDE-PROCEED model is different from other
public health models because it is typically used in conjunction with other pub-
lic health models or theories, such as the health belief model or the transtheoreti-
cal model.
Phase 1 of the PRECEDE-PROCEED model is social diagnosis. In social diagno-
sis, the public health planner works with key stakeholders in the community to
identify health concerns that interfere with quality of life. Consulting with members
of the community, a concept known as public participation, ensures that the project
identifies issues that community members believe are important, not the program
P R E C EDE -PR O C EED PLANNIN G M ODEL 501
planner. The process of gathering community consensus is time consuming, but it

supports community empowerment, and community members w ill be more likely
to support and sustain the effort. Defining the problem or quality of life issue may
be difficult. For example, community members may express concern with increas-
ing rates of Type 2 diabetes among area youth. B ecause Type 2 diabetes is a conse-
quence of obesity or overweight, the true underlying issue is actually childhood
obesity. Identifying the underlying problem rather than a consequence or symp-
tom of the larger problem ensures that efforts are focused in the right direction and
expands the possibility for grant funding, community collaborations, or other
support.
Phase 2, epidemiological diagnosis, examines the health problems related to the
quality of life issue. In addition to Type 2 diabetes, c hildren who are overweight or
obese are at risk for arthritis, asthma, impaired self-esteem, cardiovascular disease,
and social discrimination. Through a needs assessment, public health program plan-
ners might gather data on c hildren’s weight from local schools, health clinics, or
other sources. The needs assessment would enumerate and validate the commu-
nity’s concerns. The planning group would use the data to develop a measurable
objective. For example, if the needs assessment showed that 16 percent of local
youth were obese, the planning group may select a target goal of reducing obesity
to 14.5 percent of area youth. The objective should be specific, measurable, accu-
rate, realistic, and timely (SMART). The epidemiological diagnosis considers behav
ior, lifestyle, and environment that impact the quality of life issue. Phase 3, the
behavioral diagnosis, may reveal lifestyle choices such as sedentary activities whereas
the environmental diagnosis may reveal a lack of safe places to play. Phase 4 is edu-
cational and organizational diagnosis. This phase identifies enabling, predisposing,
and reinforcing factors that initiate or maintain the desired behavioral change.
Enabling factors are resources such as sports programs, access to recreational areas,
or access to nutritious fresh fruits and vegetables. Predisposing factors are influ-
ences related to the individual, such as knowledge, attitudes, or beliefs that pro-
mote healthy weight. Predisposing factors that affect weight management include
social attitudes, knowledge of nutrition information, or food preferences. Reinforc-
ing factors are influences that occur subsequent to health actions, which strengthen
the behavior. Reinforcing f actors might be emotional incentives such as compliments
or praise from peer or f amily in reaction to weight loss. Phase 5, administrative and
policy diagnosis, identifies policies, assets, or conditions that promote or interfere
with implementation. Policies limiting park usage could interfere with organized
athletic groups. The program group would focus on organizing resources that pro-
mote physical activity and minimize barriers. The program, policy, or activity is
implemented during Phase 6.
The final phases consist of evaluating the program activities. Process evaluation
(Phase 7) measures short-term changes in the predisposing, reinforcing, and enabling
factors. Impact evaluation (Phase 8) measures changes in behavioral and environ-
mental factors. Outcome evaluation (Phase 9) measures how well the project affected
502 P R ES C R IPTION DR UG S
quality of life. Did the project reach the goal of reducing childhood obesity to
14.5 percent? One limitation of this last phase is that it may take several years to
realize changes. To implement the entire model, from start to finish, may not be
possible within the two-to three-year time frame of many public health grants.
The PRECEDE-PROCEED planning model is used by public health planners to
understand, investigate, and plan public health interventions. The model applies
to complex health issues that are influenced by lifestyle, personal behaviors, the
environment, public policy, and knowledge of health. It allows practitioners to think
on a broad scale considering all of the factors, while still keeping focus on the pri-
mary quality of life issue.
Sally Kuykendall
See also: Community Organizing; Evaluation; Health Belief Model; Health Educa-
tion; Health Policy; Healthy P
eople 2020; Needs Assessment; Transtheoretical Model
Further Reading
Glanz, K., Lewis, F. M., & Rimer, B. K. (Eds.). (1997). Health behavior and health education:
Green, L. W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education plan-
ning: A diagnostic approach. Mountain View, CA: Mayfield.
National Cancer Institute. (2005). Theory at a glance: A guide for health promotion practice
(2nd ed.). NIH Publication Number 05-3896.
PRESCRIPTION DRUGS
Prescription drugs, or medications, continue to be prescribed at an increasing rate
as disease states become more and more complex. Many individuals now seek to
self-treat certain ailments with over-the-counter medications, but based on the sever-
ity of the ailment a prescribed medication may be necessary. Prescription medi
cations are broken up into multiple categories, or classes, to include treatments to
help fight infectious diseases, diabetes, chronic pain, high blood pressure, depres-
sion, mental illness, cancer, and gastrointestinal disorders, to name a few.
Prescription medication spending grew at the highest rate in 2014 with the last
growth of this magnitude seen in 2011. Accounting for $373.9 billion in costs in
2014, which was up by 13.1 percent since 2001 (growth of 17 percent in spend-
ing), prescription medication sales increased due to medicines innovative in nature,
patents that were not up for expiration, and prices that were listed as a higher dol-
lar amount than previous years. Implementation of the Affordable Care Act (ACA)
in 2014 expanded the ability for some patients to fill prescription medication requests
than were able in previous years. Forty-two new ingredients, active in nature, were
brought to the market in 2014, up from 36 introduced in 2013. Specialty medi
cations continue to rise as illnesses become more and more complex with the major-
ity of today’s research focused on cancer (oncology), diabetes (antidiabetics), pain
P R ESC R IPTION D R U G S 503
(analgesics), high blood pressure (antihypertensives), infectious diseases (antibac-

terials), and m ental health (IMS Institute, 2015).
Medications to treat pain continue to be dispensed at a high rate by pharmacists.
Continued focus is being placed on identifying safe practices behind prescribing
and dispensing medications for pain relief as increased deaths are on a rise with the
inappropriate use of pain medications by patients. Drug poisoning and misuse of
pain medication called “opioids” has been on a rise since 1990 and is being called
an epidemic of national magnitude (Paulozzi, Budnitz, & Xi, 2006). Prescription
medication must be prescribed by health care professionals who are licensed to pre-
scribe medication. Prescription medications are then filled and dispensed through
a licensed pharmacy with final approval from a state licensed and boarded phar-
macist. New research is being conducted to identify advanced roles of pharmacy
technicians related to filling and checking of prescription medications providing
pharmacists greater time to counsel patients on the proper use of such medications.
Additional one-on-one time with pharmacists and patients has become increasingly
necessary due to complex prescription medication dosing, decreased time spent with
physicians, nurses and prescribers, and multiple prescription medications for many
patients (Adams, Martin, & Stolpe, 2011).
Prescription medications must be approved by the Federal Drug Administration
(FDA) and must follow a stringent approval process. This approval is called the
“drug review process” and includes stages that must thoroughly be met in order for
approval review. The drug review process is best described in 12 stages with the
first stage being preclinical testing or animal testing. Once preclinical testing is com-
plete, manufacturers submit an Investigational New Drug (IND) application, which
describes proposed human testing. Human testing is then conducted in three phases:
(1) healthy volunteers to identify any medication side effects, drug metabolism in
the body, and excretion of the medication; (2) those affected by the disease or ill-
ness to show if the medication is effective; and (3) studies the safety and additional
effectiveness of the medication (U.S. Food and Drug Administration, 2015a). Once
all of these phases are met and safety and efficacy are ensured, the manufacturer
can submit a New Drug Application (NDA) asking the FDA to consider approval.
Drugs may enter into the animal testing stage and never make it to an NDA or review
of approval by the FDA. All clinical testing must follow strict approvals starting with
a protocol to explain the manufacturer’s intent to study the drug, how they plan to
perform these studies, and approval of a local institutional review board (IRB).
There are a number of medications that are on the market that treat the same
illnesses and the same symptoms; however, medications may work very differently
on different individuals. Brand medications are t hose that are patented by the found-
ing manufacturing company. Once the medication goes off patent, the medication
is available for generic companies to manufacture and sell. Generic medications are
sometimes sought out by individuals as they can be less expensive, and insurance
companies now seek to identify generic alternatives with the rising costs of pre-
scription medications. Patients with and without prescription medication coverage
504 PR ES C R IPTION DRUGS
many times struggle to pay for necessary medications. This can inadvertently result
in the lack of medication adherence, where individuals may take less medication
than prescribed to stretch the medication over longer periods of time. Illegal purchase
of prescription medications can also occur where individuals purchase prescribed
medications outside of the country to avoid the high U.S. medication costs. This
can be dangerous to patients if the medication is of a different chemical formula,
dosage, or quantity than prescribed by their health care professional (Kesselheim
et al., 2015).
In 2000, researchers reported approximately 44,000 to 98,000 deaths annually
in hospitals from medical errors with a high rate of these deaths occurring because
of medication errors. In 1993, medication errors attributed to 7,391 deaths com-
pared to 2,876 in 1983 (Institute of Medicine [U.S.] Committee on Quality of Health
Care in America, 2000). The FDA currently reports one death per day from medi
cation errors and approximately 1.3 million annual patient injuries in the United
States due to “prescribing, repackaging, dispensing, administering, or monitoring”
with causes resulting from communication gaps, confusion in names, directions,
and abbreviations of prescription medications, and the lack of understanding of
medication use by patients (U.S. Food and Drug Administration, 2015b). Enhanced
systems must continually be put into place to help reduce the risk of errors faced
with prescription medications (Adams, Martin, & Stolpe, 2011).
The terms “on label” and “off label” arise quite frequently when discussing pre-
scription medications. “On label” is when the medication is prescribed for an FDA-
approved use and listed in the FDA-approved package insert, or otherwise called
“labeling” for that medication. “Off label” is when a medication is prescribed for a
use, which has been discussed in the medical literature, but such a use has not been
approved by the FDA and is therefore not listed in the FDA-approved package insert
for that medication. Prescription medications used in an off label manner can offer
great insight to the medical community and to drug manufacturers. However, since
there is no FDA approval for these off label uses, risk versus benefit needs to fully
be assessed by prescribing health care professionals. Important uses of prescription
medications may be found accidentally through their use off label. It is, however,
critical to keep in mind that the FDA approval process should be sought for all pre-
scription medication uses to ensure the appropriate drug trials have been per-
formed, safety and efficacy are properly shown, and the medication is reviewed in
a multidisciplinary fashion (U.S. Food and Drug Administration, 2015a).
Continued education is necessary regarding prescription medications. Both health
care professionals and patients require additional knowledge regarding the safety,
efficacy, and proper use of such medications. As chronic illnesses rise and continue
to become more complex, misuse potential rises with prescription medications. This
misuse potential can be a result of increased illness-related symptoms, increased
communication gaps between health care professionals and patients, increased
dosing complexity of specialty medications, and changes in health care coverage
regarding prescription medications. As one can attest, health care is in a state of
P RE V ENTION 505
significant change, and more and more focus must be placed on the safety, efficacy,
and appropriate use of prescription medications.
Eileen L. Sullivan
See also: Affordable Care Act; Care, Access to; Elder Maltreatment; Food and Drug
Administration; Controversies in Public Health: Controversy 1
Further Reading
Adams, A. J., Martin, S. J., & Stolpe, S. F. (2011, October 1). Tech-check-tech: A review of
the evidence on its safety and benefits. American Journal of Health-System Pharmacy,
68(19), 1824–1833.
IMS Institute. (2015). Medicine use and spending shifts: A review of the use of medicines in the
U.S. in 2014. Retrieved from http://www.fdanews.com/ext/resources/files/04-15/IIHI
_Use_of_Medicines_Report_2015.pdf?1429048559.
Institute of Medicine (U.S.) Committee on Quality of Health Care in America. (2000). To
err is h uman: Building a safer health system. In L. T. Kohn, J. M. Corrigan, & M. S. Don-
aldson (Eds.). Washington, DC: National Academies Press. Retrieved from http://www
.ncbi.nlm.nih.gov/books/NBK225182/.
Kesselheim, A. S., Huybrechts, K. F., Choudhry, N. K., Fulchino, L. A., Isaman, D. L., Kowal,
M. K., & Brennan, T. A. (2015, February). Prescription drug insurance coverage and
patient health outcomes: A systematic review. American Journal of Public Health, 105(2),
e17–e30.
Paulozzi, L. J., Budnitz, D. S., & Xi, Y. (2006, September). Increasing deaths from opioid
analgesics in the United States. Pharmacoepidemiology and Drug Safety, 15(9), 618–627.
U.S. Food and Drug Administration. (2015a). The FDA’s drug review process: Ensuring drugs
are safe and effective. Retrieved from http://www.fda.gov.
U.S. Food and Drug Administration. (2015b). U.S. Food and Drug Administration medication
error report. Retrieved from http://www.fda.gov/Drugs/DrugSafety/MedicationErrors
/ucm080629.htm.
PREVENTION
Each year in the United States, approximately 600,000 people die of heart disease,
590,000 people die of cancer, 145,000 people die of lower respiratory illnesses,
136,000 people die of unintentional injuries, 128,000 people die of stroke and cere-
brovascular diseases, 76,000 p eople die of diabetes, and 43,000 p
eople die of sui-
cide (National Center for Injury Prevention and Control, 2015). The majority of
these deaths are linked to four lifestyle behaviors: high fat, high concentrated car-
bohydrate diet, lack of physical activity, tobacco use, and alcohol abuse (National
Center for Chronic Disease Prevention and Health Promotion, 2009). The financial
cost of lifestyle-related illnesses is enormous. Americans pay an average of $9,403
per year for health care (World Bank Group, 2017). Prevention is a medical strategy
that aims to stop health problems before they start or before they progress to more
serious problems. Prevention activities work by enhancing knowledge, attitudes, and
506 PR EVENTION
behaviors or through policy or environmental actions. Over time, public health

practitioners learned to tailor programs to the target population’s level of risk.
Despite a critical need for prevention programs, such programs frequently
encounter cultural and political obstacles. American society is an impatient culture,
a society that values instant results. Prevention programs offer delayed benefits.
Thus, the hard work of prevention is often overlooked in favor of programs that
promise instant results, even if the promises are false. Furthermore, cost versus ben-
efit calculations can be difficult. When prevention is effective, health problems do
not occur. It is difficult to measure a problem that does not occur, which means it
is difficult to justify program costs.
The idea of preventive medicine emerged from several sources. As advancements
in sanitation, microbiology, and immunizations reduced deaths due to infectious
illness, medical professionals turned their attention to chronic illnesses. In 1949,
the American Hospital Association, the American Medical Association, the Ameri-
can Public Health Association, and the American Public Welfare Association founded
the Commission on Chronic Illness. The first objective of the commission was to:
modify the attitude of society that chronic illness is hopeless; to substitute for the
prevailing over-concentration on the provision of institutional care, a dynamic pro-
gram designed as far as possible to prevent chronic illness, to minimize its disabling
effects, and to restore its victims to a socially useful and economically productive place
in the community. (Commission on Chronic Illness, 1949, p. 1344)
In the first of four volumes, the commission identified the importance and role of
prevention. Primary prevention was defined as “averting the occurrence of disease,”
and secondary prevention was defined as “halting the progression of disease from
its early unrecognized stage to a more severe one and preventing complications”
(Commission on Chronic Illness, 1957, pp. 1–68). In 1953, Drs. Leavell and Clark
published a handbook on preventive medicine for community practitioners. They
presented a theoretical framework with five levels of prevention: (1) health promo-
tion, (2) targeted protection, (3) early diagnosis and treatment, (4) disability limi-
tation, and (5) rehabilitation. In later editions, Leavell and Clark reduced the
framework to three levels, primary prevention (health promotion), secondary
prevention (combining targeted protection and early diagnosis and treatment), and
tertiary prevention (combining disability limitation and rehabilitation).
The emerging field of psychology formally entered the prevention arena in 1964.
Several decades earlier, on November 28, 1942, 492 p eople died and hundreds w
ere
injured when Boston’s popular Cocoanut Grove nightclub caught fire. Although
the nightclub had a maximum occupancy rate of 460 p eople, more than 1,000
people crowded into the club that evening. A member of the staff lit a match so that
he could see to change a lightbulb. The match ignited the fronds of fake palm trees
and highly flammable wall coverings and decorations. The fire spread throughout
the building. Fire exits w ere e ither hidden or nonfunctional. Patrons pushed and
stampeded toward the main entrance. Piles of bodies jammed the revolving exit
P R E VENTION 507
doors. The disaster shocked the nation. Because of the Cocoanut Grove fire, the
nation initiated new fire safety regulations. Two psychiatrists at Massachusetts Gen-
eral Hospital—Eric Lindemann and Gerald Caplan—treated Cocoanut Grove sur-
vivors and f amily members of victims. Their clinical observations helped to develop
crisis theory, how people respond to and recover from traumatic experiences. Using
the framework of primary, secondary, and tertiary prevention, Caplan expanded the
field of prevention into counseling, m ental health, and public health (Caplan, 1964).
The idea of primary, secondary, and tertiary prevention applies to a vast array of
public health problems. Primary prevention aims to stop the problem before it
occurs. Secondary prevention aims to detect the problem early in order to halt pro-
gression. Tertiary prevention aims to stop adverse consequences a fter a problem
has already begun. In the case of fires, primary prevention consists of eliminating
fire hazards in the home and workplace, regulations against open flames, and fire
safety education. Secondary prevention consists of smoke detectors, fire sprinkler
systems, and functional fire escapes. Tertiary prevention includes specialized burn
units, pain management, physical therapy, and mental health treatment.
In 1987, Dr. Robert S. Gordon Jr., special assistant to the director of the National
Institutes of Health, suggested using a risk perspective for prevention activities. Gor-
don noted that the terms “primary,” “secondary,” and “tertiary” could be confusing
to nonpractitioners. On the surface, primary sounds preferable to secondary, when,
in fact, all three types of prevention are equal and necessary. Gordon also noted
that the current terminology focused on biomedical chronology (before or after diag-
nosis). Public health and epidemiology consider level of risk. Gordon proposed the
terms “universal prevention,” “selective prevention,” and “indicated prevention.”
Universal prevention focuses on preventing illness among the broad population
regardless of level of risk. Selective prevention aims at people with heightened risk.
Indicated prevention aims at people who currently manifest the behavior or condi-
tion. Gordon also differentiated between intervention and treatment, noting that
treatment relieves symptoms while interventions are used for asymptomatic clients.
Experts continue to refine the definitions with some advocating that indicated pre-
vention should apply to both symptomatic and asymptomatic populations. Weisz,
Sandler, Durlak, and Anton (2005) added two new categories of prevention to create
the scale: health promotion/positive development strategies, universal, selective,
indicated, and treatment interventions. Whereas universal prevention aims to reduce
risk factors, health promotion/positive development strategies aim to enhance pro-
tective factors in order to promote health and well-being. And where indicated pre-
vention focuses on t hose with symptoms of a disorder who do not meet diagnostic
criteria, treatment interventions focus on those with diagnosable disorders.
Many doctors, nurses, physical therapists, and health care providers enter pub-
lic health after decades of caring for patients with devastating injuries or disease.
For many experienced health professionals, preventing disease is preferable to treat-
ing disease. Prevention saves lives, resources, and promotes quality of life, free
from disability. Prevention is key in public health. Sanitation, mass immunizations,
508 PU B LI C HEALTH DEPA RTMENT ACCR EDITATION
mammography screenings, heart health programs, and substance abuse prevention

programs are all designed to reduce potential for disease. With the rising cost of
health care and increasing aging population, prevention programs will continue to
play an important role in helping to enhance quality of life.
Sally Kuykendall
See also: Centers for Disease Control and Prevention; Chronic Illness; Intervention;
National Center for Injury Prevention and Control; Social Determinants of Health;
Truth Campaign, The; Upstream Public Health Practices
Further Reading
Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books.
Commission on Chronic Illness. (1949). Announces its program. American Journal of Public
Health, 39(10), 1343–1344.
Commission on Chronic Illness. (1957). Chronic illness in the United States (Vol. 1). Cam-
bridge, MA: Harvard University Press.
Gordon, R. (1987). An operational classification of disease prevention. In J. A. Steinberg &
M. M. Silverman (Eds.), Preventing m ental disorders (pp. 20–26). Rockville, MD: Depart-
ment of Health and Human Services.
Leavell, H.R., & Clark, E.G. (1953). Preventive medicine for the doctor in his community: An
epidemiologic approach. New York: McGraw-Hill.
National Center for Chronic Disease Prevention and Health Promotion. (2009). The power
of prevention: Chronic disease . . . the public health challenge of the 21st century. Centers for
Disease Control and Prevention. Retrieved from https://www.cdc.gov/chronicdisease/pdf
/2009-Power-of-Prevention.pdf.
National Center for Injury Prevention and Control. (2015). 10 Leading c auses of death by age
group, United States—2014. National Vital Statistics System, National Center for Health
Statistics, CDC. Retrieved from https://www.cdc.gov/injury/wisqars/leadingcauses.html.
Weimar, R. H. (1973). T oward a model of primary prevention of drug abuse in elementary
schools. British Journal of Addiction to Alcohol & Other Drugs, 68(1), 57.
Weisz, J., Sandler, I., Durlak, J., & Anton, B. (2005). Promoting and protecting youth mental
health through evidence-based prevention and treatment. American Psychologist, 60(6),
628–648.
data.worldbank.org/indicator/SH.XPD.PCAP?end=2 014&start=1 995&view=c hart&
year_h igh_desc=t rue.
PUBLIC HEALTH DEPARTMENT ACCREDITATION

Public health department accreditation is a voluntary review to determine w hether a
state, tribal, local, or territorial health department’s processes, services, and outcomes
meet nationally recognized, evidence-based standards in public health practice.
Many government and health care service institutions, such as schools, hospitals,
and nursing homes, undergo an accreditation process. Accreditation ensures that
the organization is providing quality services and achieving intended outcomes. The
PU BLIC HEALTH DEPA RT M ENT A C C R EDITATION 509
standards by which public health departments are judged are based on the Ten Essen-
tial Public Health Services (Essential Services Work Group, n.d.). Accreditors assess
the health department’s ability to identify community health needs, investigate
health hazards, communicate health m atters to the general public, engage with the
community in health promotion activities, develop public health policies and strate-
gic plans, enforce public health laws, promote access to quality health care, maintain
a competent public health workforce, ensure quality improvement, employ evidence-
based practices, maintain an effective system of management, and collaborate with
the governing entity. The goal of accreditation is to “protect and improve the
health of the public by advancing the quality and performance of all public health
departments in the country—local, state, territorial and tribal” (Centers for Disease
Control and Prevention [CDC], 2017).
In 2003, the Institute of Medicine report The Future of the Public’s Health in the
21st Century recommended action items to improve public health. One recommen-
dation was to create a formal system of accreditation for health departments. With
leadership and support from the Centers for Disease Control and Prevention (CDC)
and the Robert Wood Johnson Foundation (RWJF), approximately 400 public health
leaders and experts developed accreditation standards and measures. It was impor
tant that the standards would work for any health department regardless of size,
governance, internal structure, and community health needs (De Milto, 2015). In
2007, the Public Health Accreditation Board (PHAB) was incorporated as the
independent accrediting body. From 2009 to 2010, the standards and accredita-
tion process w ere pilot tested in 30 different health departments. The standards
and measures w ere finalized to 12 domains, and formal accreditation assessment
was launched in 2011. The first 11 health departments were awarded accreditation
on February 27, 2013.
The accreditation process requires a serious commitment of time, resources, and
expertise. To become accredited, the health department undergoes rigorous self-
review, reporting, and external evaluation. PHAB lists seven steps to accreditation:
pre-application, application, document selection and submission, site visit, accred-
itation decision, reports, and reaccreditation. During the pre-application stage, the
health department learns about the accreditation process, standards, and measures
and appoints their accreditation coordinator. The accreditation coordinator leads the
accreditation review. Both the accreditation coordinator and the health department
director must complete PHAB’s online orientation. To proceed to the next stage, the
health department registers an intention to apply for public health accreditation. In
the application stage, the health department submits the formal application with the
accreditation fee. PHAB is a 501(c)3 nonprofit organization. Accreditation fees are
used to support PHAB services and staff. In 2014–2015, fees varied from $12,720
to $95,400 based on size of the population that the health department served. In
comparison, the Joint Commission International (n.d.), the organization which
accredits hospitals, reports an average fee of $46,000 in 2010. Accreditation fees
are consistent with similar agencies. A fter application, the accreditation coordinator
510 PU BLI C HEALTH DEPARTMENT ACCREDITATION
attends a two-day, in person training to review PHAB standards, measures, and the
documentation needed to support accreditation.
For the health department, the document selection and submission stage is
the most intensive part of accreditation. PHAB sets up an electronic database
whereby members of the health department’s accreditation team can upload doc-
uments. The documents provide evidence of the department’s ability to meet the
required standards. For example, Domain 10 assesses the health department’s
use of evidence-based practices. The health department staff would identify a
few strong, evidence-based programs and practices and upload grants, advertise-
ments, technical reports, or published research that showed the successful use of
evidence-based programs or practices. All documents must be submitted within
12 months of database access. During the site visit, PHAB volunteers go to the
health department and check to ensure that the documents match what is actually
happening at the site. The visitors also clarify any ambiguity or questions regarding
the documents, highlight areas of excellence, and discuss areas for improvement.
The site visitors report to the Accreditation Committee who reviews the evidence
and makes a final determination on accreditation. Health departments that fail to
meet accreditation standards may submit an action plan. The Accreditation Commit-
tee and site visitors review the action plan to determine whether the plan is realistic
and adequately addresses any deficiencies. If the plan is sufficient, the Accreditation
Committee can grant accreditation at that time. To maintain accreditation, the health
department must submit annual reports showing evidence of ongoing commitment
to high-quality, evidence-based practice and progress in any areas identified for
improvement. Accreditation is granted for five years at which time the health depart-
ment must submit a new application and documents and undergo a new site visit.
Public health department accreditation is a comprehensive review of current
resources and public health practices. PHAB examines a department’s performance,
use of evidence-based practices, ability to engage community partners, and plans
for ongoing quality improvement. Reviewers look for a system of shared decision
making, strong community partnerships, quality services and programs, and a pro-
gram for ongoing evaluation and improvement. Whether the department achieves
accreditation or not, the process requires that the applicant consider current ser
vices, community needs, best practices, strengths and weaknesses, areas for improve-
ment, and future directions. Going through the accreditation process encourages
accountability and transparency and improves communication within the depart-
ment and with external partners (Kronstadt, Meit, Siegfried, Nicolaus, Bender, &
Corso, 2016). Accreditation enhances the credibility and reputation of the depart-
ment and expands opportunities for grant funding. Clients of accredited public
health departments are assured that the department uses resources appropriately,
delivers quality services, and is accountable to the populations that it serves. The
goal for public health is to have the majority of Americans covered by an accred-
ited public health department.
Sally Kuykendall
PU B LI C HEALTH IN THE UNITED STATES , HISTO RY O F 511
See also: Community Health Centers; Core Competencies in Public Health; National
Association of County and City Health Officials
Further Reading
Centers for Disease Control and Prevention. (2017). National voluntary accreditation for
public health departments. Retrieved from https://www.cdc.gov/stltpublichealth
/accreditation.
De Milto, L. (2015). Establishing a national public health accreditation organization. Robert
Wood Johnson Foundation. Retrieved from http://www.rwjf.org/en/library/research
/2015/05/establishing-a-national-public-health-accreditation-o rganization.html.
Essential Services Work Group. (n.d.) Ten essential services: Purpose and practices of public
_508.pdf.
Institute of Medicine. (2003). The future of the public’s health in the 21st Century. Washing-
ton, DC: The National Academies Press.
Joint Commission International. (n.d.). Costs of accreditation. Retrieved from https://web
.archive.org/web/20111016171113/http://www.jointcommissioninternational.org
/Cost-of-Accreditation.
Kronstadt, J., Meit, M., Siegfried, A., Nicolaus, T., Bender, K., & Corso, L. (2016). Evaluat-
ing the impact of National Public Health Department accreditation—United States,
2016. Morbidity and Mortality Weekly Report, 65(31), 803–806. doi:10.15585/mmwr.
mm6531a3
Public Health Accreditation Board. Retrieved from http://www.phaboard.org.
Riley, W. J., Bender, K., & Lownik, E. (2012). Public health department accreditation imple-
mentation: Transforming public health department performance. American Journal of
Public Health, 102(2), 237–242. doi:10.2105/AJPH.2011.300375
PUBLIC HEALTH DEPARTMENTS

See State, Local, and Territorial Health Departments
PUBLIC HEALTH IN THE UNITED STATES, HISTORY OF

The annals of public health in the United States are rich with g reat accomplish-
ments, daunting challenges, and even cautionary events. Public health in the United
States is as old as the country itself and has always responded to the conditions of
the country particular to each unique stage of its history.
At the end of the 18th century, Congress passed one of its first great public health
laws, the Act for the Relief of Sick and Disabled Seamen. Since seamen were a tran-
sient population, they faced difficulty in securing health care in local towns. Con-
gress used the act to authorize the formation of a U.S. Marine Hospital Service. The
Marine Hospital Service provided health care for all merchant sailors. This univer-
sal health care service was originally paid for by a twenty-cents-per-month tax on
512 PU BLI C HEALTH IN THE UNITED STATES, HISTO RY O F
seamen before eventually becoming allocated for by congressional funds over a

century l ater. This act marked the first time that the U.S. federal government worked
to coordinate a public health service for a specific population of citizens. Albeit,
the primary motivation was a concern for national security rather than a desire to
promote public and general welfare.
The 19th century was filled with public health actions and achievements in the
United States, even more so than in the preceding century. The development of
systematic record-keeping and the implementation of vital public health legislation
were instrumental in setting the stage for a vibrant and effective public health sys-
tem in the United States. At the initial turn of the c entury, in the year 1800, Dr. Ben-
jamin Waterhouse (1754–1846) introduced the smallpox vaccine into the United
States for the first time, indicating the initial step in a journey that would lead to the
eradication of smallpox. In 1842, Massachusetts began to keep records of births and
deaths; this record-keeping was then emulated by the other states in the country,
allowing public health professionals to study the c auses of mortality in the population
and craft public health interventions more effectively for the first time. In the later
part of the 19th century, Massachusetts again took the lead in establishing laws
that implemented a precursor to mandated reporting, which requires all dangerous
communicable diseases to be reported to a central public health authority. This
requirement forms the foundation of the contemporary Centers for Disease Control
and Prevention’s ability to track epidemics and disease outbreaks throughout the
nation and to respond swiftly and effectively to curtail their spread. The end of the
19th century was also responsible for the creation of the precursor of the National
Institutes of Health (NIH), which provides immense public health and biomedical
research funding and direction for the country in modern times (Boston Univer-
sity of Public Health, 2015). A modest laboratory was established in New York to
study and diagnose infectious diseases in sea travelers. This laboratory would later
move to Washington, DC, and evolve into the NIH.
Although many of the laws and accomplishments of the 19th century were mon-
umental in establishing the framework b ehind many of the g reat public health
systems in the United States in the Modern Era, the 20th century was responsible
for the birth of some of the great and most famous public health laws in the United
States. Upton Sinclair, an American journalist and novelist, wrote the famous expos-
itory novel The Jungle in 1906, which brought national attention to the gruesome
health violations and poor conditions in the meatpacking industry. In response to
the national outcry related to the reality depicted in The Jungle, Congress passed
the Federal Meat Inspection Act and the Pure Food and Drug Act. This gave the
federal government a tremendous amount of regulatory power and control to assure
that different foods and drugs were prepared and distributed in a manner that was
conducive to the public’s health and well-being. For the first time, the federal gov-
ernment of the United States was able to mandate that foods be appropriately labeled
and chemicals remain unadulterated and pure. Likewise, the Pure Food and Drug
Act of 1906 mandated that chemicals such as alcohol, caffeine, and morphine be
PU BLIC HEALTH IN THE UNITED STATES, HISTO RY O F 513
accurately labeled and appropri-

ately dosed so that overdose and
harmful side effects be mitigated.
In fact, these laws at the begin-
ning of the 20th century were
instrumental in establishing the
federal government as a power
ful regulatory agent in matters
related to the public health and
well-being of the country.
Throughout the 20th century,
landmark public health studies
and epidemiological investigations
began to find important results
with far- reaching implications.
In the middle of the century, the
Framingham Heart Study began
to show findings that linked
behavior, diet, and exercise with
physiological issues such as heart
disease. This was influential in
highlighting the need for public
health interventions that tar- Inspectors at the Swift & Company meatpacking
geted the determinants of health plant in Chicago, ca. 1906. Upton Sinclair’s descrip-
before health problems develop. tion of filthy conditions in the meatpacking industry
Around the same time, the first sparked public outcry, forcing Congress to create the
large-scale clinical trial of the Federal Meat Inspection and Pure Food and Drug
Acts of 1906. (Library of Congress)
Salk polio vaccine was beginning,
eventually leading to the eradica-
tion of crippling polio before 1980.
While public health organizations and regulatory laws w ere being established,
environmental protection was likewise slowly developing. In the second half of the
1900s, laws such as the Clean Water Act, the Clean Air Act, the Safe Drinking Water
Act, and the Comprehensive Environmental Response, Compensation, and Liabil-
ity Act w ere passed by Congress. T hese laws were instrumental in public health
even though they were concerned with regulating the levels of chemicals in the
environment. By regulating the amount of chemicals such as lead in the w ater,
particulate matter in the air, and other hazardous materials at sites such as landfills,
the public was increasingly becoming shielded from the harms of environmental
exposure to harmful chemicals that cause cancer, respiratory issues, and other
diseases.
It is important to note, however, that the history of public health in the United
States, no matter how filled with g reat accomplishments and achievements, was
514 PU B LI C HEALTH IN THE UNITED STATES , HISTO RY OF
also marred by some deeply troubling ethical violations. The United States Public
Health Service, which evolved from the marine health service system established
in the Act for the Relief of Sick and Disabled Seamen, was responsible for one of
the greatest public health misconducts in h uman history during the syphilis-related
Tuskegee Study. In 1932, the Public Health Service began to study the effects of
syphilis in black males (Centers for Disease Control and Prevention, 2016). The
population that was studied was in Tuskegee, Alabama, and did not give appropri-
ately informed consent for the study. The public health and health care profession-
als involved in the study examined the course of disease in nearly 400 individuals
while withholding the appropriate treatment that could have protected them from
the terrible and harmful effects of untreated syphilis infection. This study went on
for nearly 40 years while the patients did not receive the readily available treatment
for syphilis infection. The ethical issues and inhumanity of the actions of the gov-
ernment and public health professionals responsible for the Tuskegee Study are of
great importance in public health throughout the world. Now, public health pro-
fessionals learn about the Tuskegee Study, and institutions such as institutional
review boards are required at every facility in the United States that carries out
research; the aim of such requirements is to avoid unethical studies such as the one
in Tuskegee from ever happening again. Any members of the public participating
in research must receive ample information regarding risks and procedures so that
they can give informed consent for their participation, and unethical studies that
cause undue harm to patients are forbidden.
The history of public health in the United States is one that is filled with many
profound events, both good and bad. The public health domain in the United States
grew by dealing with the specific events and challenges faced by the American pop-
ulation at each point in time throughout its history. The accomplishments and
growing powers of public health agencies in the United States, such as the Centers
for Disease Control and U.S. Food and Drug Administration, were incremental and
attributable to the needs of each era that the United States went through. Impor-
tantly, the accomplishments of the United States in many public health arenas, such
as vaccination and the eradication of multiple infectious diseases, w ere not only
vital for the domestic public health but w
ere also responsible for saving many mil-
lions of lives throughout the world. The polio vaccine, for example, has helped erad-
icate polio from nearly every country in the world. By understanding the history of
such public health accomplishments in the United States, the role that public health
has played in shaping the country’s history as a w hole is more readily discernable.
Shayan Waseh
See also: Affordable Care Act; Centers for Disease Control and Prevention; Food
and Drug Administration; Medicaid; Medicare; Modern Era, Public Health in
the; National Cancer Institute; National Center for Injury Prevention and Con-
trol; National Heart, Lung, and Blood Institute; National Institute on Drug Abuse;
National Institutes of Health; Planned Parenthood; Social Security Act
PU B LIC HEALTH LAW 515
Further Reading
Boston University of Public Health. (2015). Public health in the United States. Retrieved from
http://sphweb.bumc.bu.edu/otlt/mph-modules/ph/publichealthhistory/publichealth
history8.html.
Centers for Disease Control and Prevention. (2016). Tuskegee Study—Timeline. Retrieved
from https://www.cdc.gov/tuskegee/timeline.htm.
Duffy, J. (1974). A history of public health in New York City, 1866–1966. New York: Russell
Sage Foundation.
University Press.
Sinclair, U. (1906). The jungle. New York: Doubleday, Jabber & Company.
Tulchinsky, T. H., & Varavikova, E. (2000). The new public health: An introduction for the
21st Century. San Diego: Academic Press.
Turnock, B. J., & Atchison, C. (2002). Governmental public health in the United States:
The implications of federalism. Health Affairs, 21(6), 68–78.
PUBLIC HEALTH LAW

Laws are the rules that society uses to resolve disagreements between members.
Some of the greatest public health achievements were accomplished through pub-
lic health law. The 100 percent reductions in deaths due to smallpox, diphtheria,
poliomyelitis, and measles w ere achieved through mandatory vaccinations (CDC,
1999a). The Highway Safety Act and National Traffic and Motor Vehicle Safety Act
decreased motor vehicle fatalities from 18 deaths per million vehicle miles traveled
to 1.7 deaths per million miles traveled (CDC, 1999b). The Occupational Safety
and Health Administration (OSHA) and Fair L abor Standards Act (FLSA) w ere
critical in reducing unintentional work-related injuries from 37 injuries per
100,000 workers to 4 injuries per 100,000 workers (CDC, 1999c). Laws are highly
effective tools used by federal, state, tribal, local, and territorial authorities. Because
laws are so effective, we see many, many different laws, regulations, statutes, and
ordinances designed to prevent disease and promote health. T here are laws restrict-
ing the sale of pet turtles to prevent salmonella transmission, laws on tobacco
advertising to reduce lung cancer, and laws on preparing for emergencies to pre-
vent death and injury due to natural and man-made disasters. Although states and
local health authorities carry substantial responsibility for protecting health, they
must do so within the constraints of the individual freedoms guaranteed by the
U.S. Constitution. Throughout history, efforts in disease prevention come in con-
flict with personal liberties. The Clean Indoor Air Act, regulating smoking in the
workplace, was initially criticized as violating the rights of smokers. As society
develops legislation on pressing issues such as opioid addictions, environmental
health, food safety, emergency preparedness, and childhood obesity, public health
administrators are challenged to balance the health of the community with personal
freedom.
Public health law is a vast database of constitutional, legislative, administra-
tive, and judicial laws. Legal authority comes from five sources: (1) federal, state,
516 PU BLI C HEALTH LAW
tribal, and territorial constitutions; (2) international agreements; (3) legislative

or administrative; (4) regulations; and (5) common law. Federal law, primarily the
Constitution, defines how legal powers are divided between individual states and
federal authorities. Although the majority of power is directed to individual states,
territories, and tribal nations, the federal government has ultimate authority in
matters related to national defense, foreign diplomacy, and the economy. This is
why, despite mass shootings in many places throughout the United States, state and
local authorities are unable to pass legislation controlling gun ownership. Consti-
tutional law supersedes local laws. International agreements include historical
agreements, such as the Declaration of Helsinki (1964), which provides ethical
guidelines for medical research involving h uman participants. More recent agree-
ments include the International Health Regulations (2005), which build capacity
and coordinate services in response to global health alerts. In addition to devel-
oping a worldwide response, the International Health Regulations also provide
guidelines to control transmission of disease at international airports, ports, and
ground crossings. Legislative or statutory laws and regulations reflect state and local
government choices and priorities. These laws determine funding allocations, pro-
gram support, and prohibitions of certain activities. Oftentimes, laws are established
in reaction to events or experiences. After residents converted a rental dumpster into
a swimming pool for a block party, the City of Philadelphia’s Department of Licenses
and Inspections issued the statement: “In view of the City’s commitment to public
health, safety, and basic common sense, we w ill not issue permits for block party
dumpster pools. And while you would think this decision would not require an
explanation, three days of press requests have proven otherwise. So, Philly, h
ere’s why
you shouldn’t swim in a receptacle most often used for waste . . .” (Peralta, 2016).
From international agreements to local ordinances, public health laws and regulations
are intended to protect health. The final form of legal authority is common law or
judicial law, which is based on previous court cases. To ensure consistency and fair-
ness, legal precedents are used whenever possible.
All laws, even laws regarding health behaviors, are enforced by police powers.
Punishments for violation can range from warnings to misdemeanor fines to felony
charges with imprisonment. U nder police power, public health officials have the
authority to investigate outbreaks of infectious diseases, mandate vaccinations, seize
property, destroy toxic substances, and involuntarily detain individuals who are a
threat to the public health. The case of Kaci Hickox demonstrates the use and haz-
ards of such power. On October 24, 2014, Kaci Hickox arrived in Newark Airport
returning from a month in Sierra Leone where she worked as a nurse with the inter-
national aid organization Médecins Sans Frontières (Doctors Without Borders). In
Africa, Hickox cared for patients with Ebola, a rare, frightening, and fatal viral dis-
ease transmitted through direct contact. While providing patient care, Médecins
Sans Frontières workers adhered to strict infection control protocols, washing hands
in chlorinated w ater, using protective gear, and not touching infected people. In
response to Ebola, the state of New Jersey implemented a 21-day mandatory
PU B LI C HEALTH LAW 517
quarantine for anyone arriving from Sierra Leone, Liberia, or Guinea with possible
Ebola contact. Despite following infection control procedures and being asymp-
tomatic, the nurse was held involuntarily for 80 hours including quarantine in a
tent. Hickox believed that her well-publicized custody and comments that she was
infectious were based on political aspirations by the New Jersey governor, rather
than public health science. She later sued Governor Chris Christie alleging false
imprisonment, invasion of privacy, and violation of due process. Although public
health authorities have powers equal to police officers, enforcement must be used
judiciously. In neighboring New York City (NYC), officials developed different
strategies, an algorithm of education, identification, and monitoring. Working
with many diverse groups and focusing efforts on at-risk West African communi-
ties in the Bronx, Harlem, and Staten Island, the NYC Department of Public Health
asked people to report potential exposure to their Active Monitoring Call Center.
At-risk individuals took their own temperature and communicated regularly with
the Department of Public Health through the call center. By the end of the global
outbreak, NYC personnel had worked with more than 5,000 individuals (NYC
Health, 2016). The NYC algorithm became a model for other cities throughout the
nation. Although public health officials have the authority to enforce laws, educating
and empowering the affected community is often the preferred course of action.
The field of public health law encompasses many different jobs. Lawyers provide
legal advice to public health administrators, try cases, write contracts for services,
draft and interpret statutes, conduct research, advocate for marginalized groups,
and develop policies. Lawyers interpret existing laws, such as HITECH, EMTALA,
and the Stark law, and provide advice on Medicare, Medicaid, the Affordable Care
Act or private health insurance coverage. Not typically viewed as public health,
medical examiners who investigate deaths are part of the larger public health system
of a city or county. In general, public health law professionals must have the ability
to balance legal practices, policies, social justice, and ethics.
Public health law is made up of a complex patchwork of statutes, regulations,
and litigation. Laws ranging from state laws mandating immunizations at school
entry to local ordinances forbidding unleashed dogs in public parks are highly effec-
tive in promoting health. However, the complexity of the legal system and varying
authority can result in conflict. Public health has the responsibility to promote pub-
lic good yet must do so within constitutional rights to personal freedom and prop-
erty ownership. Other problems occur when laws are overly zealous or poorly
contrived in response to health alerts. Thoughtful regulations, based on science and
trust, can impact challenging health problems.
See also: Affordable Care Act; Emergency Medical Treatment and Labor Act; False
Claims Act; Health Information Management; Health Insurance Portability and
Accountability Act; Health Policy; Stark Law
518 PU BLI C HEALTH LAW
Further Reading
Association of State and Territorial Health Officials. (2016). Public health law. Retrieved from
http://www.astho.org/Public-Policy/Public-Health-Law/?terms=p ublic+health+law.
Centers for Disease Control and Prevention (CDC). (1999a). Achievements in public health,
1990–1999 impact of vaccines universally recommended for children—United States,
1990–1998. Morbidity and Mortality Weekly Reports, 48(12), 243–248. Retrieved from
https://www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm.
Centers for Disease Control and Prevention (CDC). (1999b). Achievements in public health,
1990–1999 motor vehicle safety: A 20th century public health achievement. Morbidity
and Mortality Weekly Reports, 48(18), 369–374. Retrieved from https://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (1999c). Achievements in public health,
1990–1999: Improvements in workplace safety—United States, 1990–1999. Morbid-
ity and Mortality Weekly Reports, 48(22), 461–469. Retrieved from https://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2016). Public health law program.
Retrieved from https://www.cdc.gov/phlp/.
Health Care (HHS). (2014). The role of public programs. Retrieved from http://www.hhs.gov
/healthcare/about-the-law/read-the-law/.
Hickox, K. (2014). Her story: UTA grad isolated at New Jersey hospital in Ebola quarantine.
The Dallas Morning News. Retrieved from http://www.dallasnews.com/ebola/headlines
/20141025-uta-grad-isolated-at-new-jersey-hospital-as-part-of-ebola-quarantine.ece
and http://www.dallasnews.com/ebola/headlines/20141025-uta-grad-isolated-at-new
-jersey-hospital-as-part-of-ebola-quarantine.ece.
The Network for Public Health Law. (2016). Public health law. Retrieved from https://www
.networkforphl.org/.
NYC Health. (2016). With Guinea declared Ebola-free, health department concludes its response
and closes monitoring program for incoming travelers. Press Release # 002-16. Retrieved
from https://www1.nyc.gov/site/doh/about/press/pr2016/pr002-16.page.
Peralta, E. (2016, August 4). Philadelphia to its residents: D on’t swim in dumpsters. NPR. Retrieved
from http://www.npr.org/sections/thetwo-way/2016/08/04/488695414/philadelphia-to
-its-residents-dont-swim-in-dumpsters.
Q
QUARANTINE
Quarantine is a public health measure dating back to early civilization where p eople
or animals arriving from foreign areas are isolated from others to prevent the spread
of communicable disease. The practice of isolation is routinely used in health care.
Isolation separates people with infectious diseases from healthy p eople. The prac-
tice stops transmission from the infected carrier to a new host. Quarantine sepa-
rates and restricts movement for a period of time. During this time, the isolated
person is monitored to determine if he or she has a communicable disease. The
term “quarantine” originates from Italian, quaranta giorni, meaning 40 days, the
length of time used to monitor for illness. Before antibiotics and routine childhood
immunizations, quarantine was a common (and frequently ineffective) way to pre-
vent an epidemic. The control or eradication of cholera, yellow fever, smallpox, and
typhus has reduced the need for quarantine stations. In 2017, 20 quarantine sta-
tions were located at strategic entry points throughout the United States in cities
such as Anchorage, Seattle, San Francisco, Honolulu, El Paso, Miami, New York
City, Boston, Chicago, and Minneapolis. Quarantine personnel are federal govern-
ment employees empowered to apprehend, detain, examine, or conditionally release
individuals suspected of carrying the quarantinable diseases of cholera, diphtheria,
infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers (e.g.,
Ebola), or severe acute respiratory syndrome (SARS).
Early records of quarantine practices date to 549 CE (Tyson, 2004). In a world
besieged by the bubonic plague, Eastern Roman Emperor Justinian enacted a law
to isolate people arriving from plague-infested regions. In 583 CE, the Council of
the Roman Catholic Church in Lyon, France, isolated people with leprosy from soci-
ety. In the 600s CE, China detained sailors and passengers who appeared to be
suffering from the plague. In the 1300s, European and Asian countries created areas
of forced quarantine. Surrounded by guards, victims who attempted to escape were
either captured and returned to the area or executed. In 1348, Venice appointed a
committee to detain ships in the harbor for up to 40 days. Quarantine was intended
to prevent the Black Death from entering the city. Efforts were unsuccessful. In 1403,
Venice established one of the first quarantine stations, located on an island in the
Venice lagoon. In colonial America, early efforts of quarantine were sporadic, regu-
lated by state or local governments. In 1647, Boston passed an ordinance requiring
all arriving ships to stop at the harbor entrance for inspection. In 1663, New York
City passed a law requiring people arriving from areas with smallpox to be reviewed
by sanitary officials before entering the city. Seventy-five years later, New York City
520 QUA R ANTINE
established a quarantine station at Bedloe’s Island. The station isolated immigrants,

travelers, and sailors who may be carrying smallpox or yellow fever. New York’s
quarantine act passed in 1863, giving quarantine officials the power to detain a ship
or to order fumigation before permission to dock. In 1878, Congress passed the
National Quarantine Act, a law that focused primarily on yellow fever prevention.
In 1892, a cholera epidemic forced President Benjamin Harrison to expand the
National Quarantine Act, allowing officials to order detention of 20 days or longer.
Local quarantine stations were gradually turned over to the federal government with
the last station passing to federal control in 1921.
Although the idea of confining individuals in order to protect a greater number
of people seems like a logical action, t here is, unfortunately, the potential for abuse.
In 1900, Chick Gin, a Chinese businessman died of bubonic plague in a San Fran-
cisco basement. Officials allowed whites to leave the area and cordoned off a 15-
block neighborhood, closing many Chinese American businesses. The court later
ruled that the quarantine was unjust and based on racism and lifted the restriction.
From 1907 to 1910 and from 1915 until her death in 1938, Irish immigrant, Mary
Mallon (Typhoid Mary) was held on North B rother Island. The intention was to
prevent Mary from spreading typhoid fever. However, she was held without trial,
raising the question of public health’s right to detain p eople. From 1917 to 1919,
the federal government was concerned with the high number of young men ineli-
gible for the draft due to sexually transmitted infections. Authorities incarcerated
more than 30,000 women suspected of having syphilis or gonorrhea. Many of the
women were poor and unable to afford treatment, and some of the w omen were
married, having been infected and reported to authorities by vindictive spouses
(University of Kansas, 2015). On October 24, 2012, Doctors Without Borders nurse
Kaci Hickox returned from treating patients with Ebola in West Africa and was invol-
untarily held for three days by New Jersey officials. Hickox was never infected with
the virus and later sued for false imprisonment, violation of due process, and inva-
sion of privacy. Hickox asserted that her detention was based on fear and politics
rather than on the science of disease transmission. Any law that allows officials the
right to limit the individual freedom of other p eople has the potential for abuse. It
is critical that such policies have a system of checks and balances in place to pre-
vent abuse and to protect vulnerable populations of immigrants, minorities, w omen,
children, and poor p eople.
Today, quarantine is regulated u nder the Division of Global Migration and
Quarantine, part of the Centers for Disease Control and Prevention’s (CDC) National
Center for Emerging and Zoonotic Infectious Diseases. Quarantine personnel
review the origin of each traveler to assess health risk and determine the appropri-
ate public health response. To minimize the need for quarantine, the CDC moni-
tors global epidemics and works with countries to intervene at the source of the
contamination.
Sally Kuykendall
Q UA RANTINE 521
See also: Ancient World, Public Health in the; Cholera; Epidemic; Infectious Dis-
eases; M
iddle Ages, Public Health in the; Renaissance, Public Health in the; Small-
pox; Surgeon General; U.S. Public Health Service; World Health Organization;
Further Reading
Centers for Disease Control and Prevention (CDC). (2017). Quarantine and isolation. Retrieved
from https://www.cdc.gov/quarantine/index.html.
Tyson, P. (2004). A short history of quarantine. NOVA. Retrieved from http://www.pbs.org
/wgbh/nova/body/short-history-of-quarantine.html.
The University of Kansas. (2015). Researcher documents gender, class bias in quarantine law
measures. Retrieved from https://news.ku.edu/2015/07/29/researcher-documents-gender
-class-bias-quarantine-law-measures.
R
RE- A IM (REACH, EFFECTIVENESS, ADOPTION,
IMPLEMENTATION, AND MAINTENANCE)
RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) is a
model to plan and evaluate community health programs. Before RE-AIM was devel-
oped, public health program evaluations mirrored clinical studies. This means that
programs w ere primarily assessed on w hether they worked or not. The problem is
that clinical studies are carried out under highly controlled conditions with partici-
pants who meet certain criteria. Community-based programs are carried out in the
real world and must navigate day-to-day problems. For example, clinical or pilot
studies in smoking prevention attract and recruit highly motivated individuals.
Selected participants are more likely to stay in the program, take the necessary steps
to stop smoking, and w ill yield high rates of program success. Unfortunately, hand-
selected study participants may not represent smokers in the community, people
that a program hopes to help. U nder real-world conditions, such as with larger
groups of people or with people at the earlier stages of change, programs may not
demonstrate the same effectiveness. Selective recruitment, limited resources, con-
flicting priorities, and day-to-day demands create gaps between clinical research
findings and findings in the real world. To correct the issue, researchers from the
AMC Cancer Research Center in Denver, Colorado, the Kaiser Permanente Center
for Health Research, and the Oregon Research Institute developed a model that
included program outreach and participants (Glasgow, Vogt, & Boles, 1999). RE-
AIM considers the broader effects of a program, such as how many p eople are
impacted, how participants are impacted, and who is impacted.
The RE-AIM model consists of five major constructs, presented in chronological
order: reach, effectiveness, adoption, implementation, and maintenance. Reach describes
how well the project attracts and retains people who need the program the most.
Effectiveness refers to the program’s ability to achieve the intended changes in par-
ticipant knowledge, attitude, or behavior. This construct also notes any adverse con-
sequences experienced by participants as a result of participating in the program.
Adoption assesses how well other sites or settings are able to use the program. Another
term for adoption is replicability, which means how well a program can be repro-
duced at another site. Implementation reflects how well the content and materials
presented during the program match the program developer’s original program. Also
known as fidelity of implementation, this construct shows whether the program
required major modifications in order to meet the audience’s needs and whether
the changes altered the program to such a degree that it was no longer consistent
with the original program. Maintenance refers to whether the individual participants
524 R E -AI M
are able to sustain the changes and w hether the organization is able to integrate the
program into day-to-day operations after initial support ends. The model outlines
all of the various factors that program managers need to consider in planning and
evaluating a program.
The GLAMA! (Girls! Lead! Achieve! Mentor! Activate!) program is an example
of how public health professionals use the RE-AIM framework to plan and assess
programs ( Jenkinson, Naughton, & Benson, 2012). GLAMA! is a school-based
program designed to develop leadership skills, social connectedness, and physical
activity among adolescent females. School-based interventions are a popular forum
for community-based interventions. Schools have sustained access to a wide audi-
ence of youth throughout critical periods of emotional, social, and physical devel-
opment. School buildings offer suitable program sites without having to worry about
transportation, outside activities, or personal schedules. The GLAMA! program was
piloted in Melbourne, Australia. Researchers used the RE-AIM framework to assess:
1. Reach: Who participated in the program and why? Who did not participate in
the program and why?
2. Effectiveness: How did the program impact participants?
3. Adoption: What factors attracted the schools to accept the program?
4. Implementation: Which program components did the schools use?
5. Maintenance: Did participants and schools continue the intervention and if
so, which parts of the intervention did they use?
Based on the pilot program, the researchers concluded that teacher professional
development, integration of the program into the school schedule, and more prac-
tical opportunities to apply leadership skills could enhance future GLAMA! inter-
ventions ( Jenkinson, Naughton, & Benson, 2012). The RE- AIM model was a
valuable framework to identify and analyze specific parts of the program, obsta-
cles, and opportunities for improvement.
The RE-AIM model has been used to develop programs in residential dementia
care, chronic kidney disease, c hildren’s nutrition and physical activity, Type 2 dia-
betes, workplace wellness programs, and many other public health topics. The
framework helps program planners to consider the multiple factors that influence
program success in order to maximize program effectiveness.
Sally Kuykendall
See also: Community Health; Evidence-Based Programs and Practices; Logic Model;
Prevention
Further Reading
Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of
health promotion interventions: The RE-AIM framework. American Journal of Public
Health, 89(9), 1322–1327.
R ENAISSAN CE , PU B LI C HEALTH IN THE 525
Jenkinson, K. A., Naughton, G., & Benson, A. C. (2012). The GLAMA (Girls! Lead! Achieve!
Mentor! Activate!) physical activity and peer leadership intervention pilot project: A
process evaluation using the RE-AIM framework. BMC Public Health, 12, 55. doi:10
.1186/1471-2458-12-55
RE-AIM. Retrieved from http://re-aim.org.
RECIPROCAL DETERMINISM
Reciprocal determinism describes mutuality between the individual and the envi-
ronment where the environment influences the individual and the individual influ-
ences the environment. The concept of reciprocal determinism developed from
social cognitive theory (SCT) by Dr. Albert Bandura. SCT describes how individu-
als learn new skills or behavior by watching o thers (Bandura, 1986). Public health
professionals use the concept of reciprocal determinism to understand, investigate,
and change negative behaviors or to promote positive behaviors. The concept applies
to numerous public health topics such as job stress, pediatric obesity, nutrition, pre-
natal health, workplace safety, and social activism. For example, when someone
starts a new job at a restaurant, he or she learns skills and practices by watching
the experienced workers. If mentoring workers use good handwashing techniques,
the individual will also learn to use and practice good handwashing techniques.
Likewise, if senior workers neglect food safety practices, the new employee is also
likely to neglect such practices. Over time, the employee becomes a model for other
trainees. Thus, the environment of good food safety practices influences the individ-
ual, and the individual eventually becomes part of an environment to influence others.
Once food safety practices are established, good handwashing becomes endemic,
engrained in the environment of this particular restaurant. Social cognitive theory
describes additional factors that impact the individual’s ability to learn and practice a
task. Overall, reciprocal determinism is useful in helping public health practitioners
to identify ways to disrupt negative behaviors and introduce positive behaviors.
Sally Kuykendall
See also: Handwashing; Social Cognitive Theory
Further Reading
Bandura, A. (1962). Social learning through imitation. In M. R. Jones (Eds.), Nebraska
Symposium on Motivation, 1962 (pp. 211–274). Lincoln: University of Nebraska Press.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Engle-
Glanz, K., Lewis, F. M., & Rimer, B. K. (Eds). (1997). Health behavior and health education:
RENAISSANCE, PUBLIC HEALTH IN THE

The social and civilizational forces operating during the Renaissance w
ere respon-
sible for birthing some of the most foundational components of public health,
526 R ENAISSANCE, PU BLIC HEALTH IN THE
particularly in the fields of epidemiology, infectious disease, and medical science.

As the structure of society was transformed during the Renaissance, especially
throughout Europe between the 14th and 17th centuries, public health began to
become of greater importance. Public health approaches became empowered with
a greater understanding of how wellness and disease operate. Additionally, the
scientific and intellectual advancements of the Renaissance were essential in laying
the framework for contemporary public health and medical practice. In this way,
the evolution of public health during the Renaissance is still of tremendous import
today, and the accomplishments and discoveries of the Renaissance Era have pro-
duced profound reverberations in the history of both public health and medicine.
Interestingly, one of the most infamous public health problems in humanity’s his-
tory was at least partly responsible for contributing to the start of the Renaissance
itself. In the era immediately preceding the Renaissance, the feudal structure of soci-
ety was incrementally dissolving, and populations of p eople became increasingly
connected. As medieval trade and commerce began to spread and evolve to include
trade with far off lands and peoples, outbreaks of communicable diseases such as
syphilis became more common, and outbreaks of these infectious diseases were fre-
quent and harmful. The most influential of these communicable diseases was Yer-
sinia pestis—commonly known as the Black Death—which devastated European
and worldwide populations. This population depletion was partly responsible for
creating the conditions of ample land, high workforce demand, and concentrated
wealth that contributed greatly to the start of the Renaissance (Woodville, 2013).
Although much of the understanding of disease at that time was related to spiritu-
ality and divinity, the devastation of the Black Death was enough to motivate the
initial attempts at raising the level of public sanitation and developing greater gov-
ernmental regulation in public life (University of V irginia, 1994). It was the epide-
miological challenge of the Black Death and other profound infectious disease
outbreaks that motivated much of the public health advances in sanitation and
hygiene at a population level.
Although the Black Death devastated much of the trade and commercial networks
within the world and Europe, the post–Black Death Renaissance period was marked
by an increase of trade beyond the original baseline level, and the management of
communicable diseases became of even greater importance. Therefore, communi-
cable disease management techniques and regulations w ere implemented through-
out the world. For example, in order to combat the spread of syphilis in Europe—an
illness that was attributed at that time to travelers returning from the New World
as well as prostitution—public health regulations w ere implemented that mandated
the registration of prostitutes, the reporting of disease cases, and the quarantining
of sick patients.
Additionally, throughout the Renaissance, the European monarchs and govern-
ments invested greater amounts of capital and resources to establishing a stronger
public health care framework to foster the growth and health of their populations.
Utilizing his available resources, the Russian czar Ivan IV developed a network of
R ENAISSAN C E , PU B LIC HEALTH IN THE 527
major health care pharmacies in large urban centers and began to open the first
series of secular hospitals to meet the health care needs of the population (Tulchin-
sky & Varavikova, 2009). This represents one of the first large coordinated efforts
in Russia to establish a coherent and comprehensive health network to meet the
civilian and military health needs of the country. In E ngland, the increasing urban-
ization of the population provided the needed impetus to encourage the develop-
ment of hospitals. In addition, the urban sprawl and pollution on city streets drove
the British government to clarify that responsibility for sanitation, and public health
fell on local British government at the level of the parish; this responsibility at the
time was then placed on individual citizens who w ere then responsible for ensur-
ing that their strip of the street was clean and well kept. Although this governmen-
tal regulation did not effectively prevent streets from becoming overcrowded with
fecal matter and disease in Renaissance England, the clarification of the public
health responsibility of local government was important in establishing public health
as a responsibility of local authorities.
In addition to the fact that the societal advancements in the way that European
countries conceived of and dealt with public health challenges w ere highly influ-
ential and laid the foundation of future public health practice, the scientific advance-
ments of the Renaissance were of even greater importance. T hese scientific discoveries,
in the fields of medicine, chemistry, and public health, w ere of immense importance
in the path to humanity’s contemporary understanding of health and disease. The
natural science-based disciplines of anatomy and physiology contributed to the
systematization of the clinical practice of medicine. For one of the first times in
Western medicine, the internal anatomy of the body began to be extensively and
systematically studied, and new theories about cardiovascular structure, hemody-
namics, and neuromuscular function w ere born.
The contagion theory of disease was also developed in this era, profoundly influ-
encing the way that public health professionals conceived of hygiene and health.
This model of infectious diseases is still prevalent today and is the foundation of
society’s approach to managing disease outbreaks. Rather than consider diseases as
exclusively divine punishment, or as resulting from bad air, public health profes-
sionals began to understand the microbial basis of infectious diseases for the first
time. This scientific understanding was made possible in no small part by the inven-
tion of the microscope by van Leeuwenhoek in 1676, allowing scientists and phy-
sicians to see the microorganisms b ehind disease for the first time. The development
of a microbial (or contagion) understanding of disease allowed public health pro-
fessionals and physicians to understand the importance of tracking the spread of
diseases through regulations that established and mandated record-keeping of
deaths and causes of death.
One example of how government regulation aided public health was the imple-
mentation of the “Bills of Mortality” in English society. These bills kept records of
deaths by cause, allowing public health professionals to analyze trends and notice
epidemics and outbreaks. Much like the Centers for Disease Control and Prevention’s
528 R ENAISSANCE, PU BLIC HEALTH IN THE
reportable disease system in the

modern-day United States, the
Bills of Mortality in E ngland
allowed the public health authori-
ties to better understand how dis-
eases were spread and impacted
on society. This was important in
informing attempts to curtail and
diminish the spread of disease.
Building on this, another large
development for public health
during the Renaissance came in
the middle of the 17th century
in England, where John Graunt
analyzed these Bills of Mortality
and was therefore able to artic-
ulate how mortality was deeply
connected to the living condi-
tions in which p eople lived. John
Graunt is now considered one of
the first demographers in the
During the Great Plague of London (1665–1666), world due to his work with the
parish clerks recorded local deaths in Bills of Mor-
Bills of Mortality. His observa-
tality. Records indicate that bubonic plague killed
almost one out of four Londoners. ( Jupiterimages)
tions represented one of the first
times that statistical analysis was
used with governmental mortal-
ity data to generate public health insights. This practice is now essential to con
temporary public health practice and is one of the most common ways that public
health organizations and governmental agencies shape and guide their initiatives
and projects. Additionally, the record-keeping and systematization of health infor-
mation of the Renaissance Era is responsible for the development of the disci-
plines of demography and vital statistics, and it is even responsible for the practice
of collecting basic population health measurements such as height, age, weight,
and race.
The period of the Renaissance, which was born from one of the greatest public
health catastrophes of all time—the Black Death—became one rich with an evolv-
ing understanding of the fundamental disciplines of medical science, infectious dis-
ease, sanitation and hygiene, and population health. With the emergence of great
thinkers and revolutionary scientists that shed new insights on anatomy, physiol-
ogy, microbiology, clinical science, and epidemiology, the foundational understand-
ing of the human body and population health was transformed and was started on
the path to society’s contemporary understanding. The Renaissance, in this way, was
a great transitional era where medicine and public health moved from the religious
R ESEA R C H 529
and spiritual domain into the natural sciences. This transition set the foundation
for the following Enlightenment Era and the next few centuries of rapid medical
advancements. Another important aspect of the Renaissance was that as the
structure of civilization changed throughout Europe and the rest of the world to
become more urbanized, the need for public health approaches to urban sprawl,
pollution, and contamination became more urgent and clearly discernible. This phe-
nomenon set the stage for public health to evolve to the level of importance and
influence that it has t oday in the modern world. The Renaissance, in this way, served
as the launching pad for modern public health practice.
Shayan Waseh
See also: Ancient World, Public Health in the; Infectious Diseases; Middle Ages,
Public Health in the; Quarantine; Smallpox
Further Reading
Cipolla, C. M. (1976). Public health and the medical profession in the Renaissance. Cambridge,
UK: Cambridge University Press.
MacNalty, A. S. (1945). The Renaissance and its influence on English medicine, surgery,
and public health. The British Medical Journal, 2(4430), 755–759.
Tulchinsky, T. H., & Varavikova, E. (2009). The new public health. Cambridge, MA: Academic
Press.
University of Virginia. (1994). Plague and public health in Renaissance Europe. Retrieved from
http://www2.iath.virginia.edu/osheim/plaguein.html.
Woodville, L. (2013). The Black Death. Retrieved from https://www.khanacademy.org
/humanities/renaissance-reformation/late-gothic-italy/beginners-guide-late-gothic/a
/the-black-death.
RESEARCH
Public health research is a systematic process that explores problems and provides
insights so that public health professionals can develop the knowledge and skills
needed to prevent and treat diseases and to improve quality of life for individuals
and communities. P eople do informal research e very day. From identifying the best
type of pet for a family to adopt, exploring new career options, or improving an old
family recipe, people collect information, develop new ideas, and pilot test their
ideas. Formal research uses a methodical, planned approach. To perform research,
the investigator learns as much as possible about the subject of interest, designs
a study, collects data, analyzes the results, and reports the results to other p eople.
A research study can be simple or elaborate, inexpensive or expensive. Regardless of
effort and cost, t here is no guarantee of success. Sometimes research studies produce
usable results, sometimes they do not. Research guides practice by informing pro-
fessionals of the best treatment options, the most effective prevention mechanisms,
or how to streamline systems. Conversely, practice guides research. Researchers
530 R ESEA R C H
develop research studies based on current and emerging health problems reported
by public health professionals.
The research process starts with reading and reviewing what experts have writ-
ten and what is known about the topic of interest. The literature review is an essen-
tial first step in planning a research study. The Nuremberg Code—a set of guidelines
developed as a result of the atrocities committed by Nazi scientists during World
War II—requires the investigator to justify the research. No research study should
be undertaken without first determining what is known about the problem and what
needs to be studied next. To do this, the researcher reads as many books, articles,
and publications as possible. Reading materials are carefully selected. Only good
quality resources are read, not popular articles, advertisements, or other sources
that might have a vested interest in the information presented. By excluding lower
quality resources, the researcher ensures that the justification is based on scientific
evidence, not personal or political beliefs. Through reading what o thers have writ-
ten and published on the topic, the researcher learns how other experts defined
and limited the problem, how the problem affects humans and societies, how many
people are impacted by the problem, high-risk groups, and recommendations for
other researchers. The literature review helps the researcher to develop research
questions or a research hypothesis of what needs to be studied next.
The research question is a general question that describes what the researcher
would like to explore. H ere are some examples: “What factors increase risk of
autism?” “Which program is more effective in reducing substance abuse?” “How
does social support influence diabetes management?” The research hypothesis is a
testable statement, phrased as a statement. An example of a research hypothesis is:
“Diabetic patients with positive social support will report more stable blood sugars
than diabetic patients without positive social support.” The research hypothesis
names the variables (social support and stability of blood sugar) and the relation-
ship between the variables (the higher the social support, the more stable the blood
sugar). The research question or research hypothesis provides structure to the
research study. Compare the research hypothesis provided above with the research
hypothesis: “After receiving positive social support, diabetic patients w ill report
greater stability of blood sugars.” The first hypothesis compares two groups of dia-
betic patients, an experimental and control group. The experimental group has posi-
tive social support, and the control group does not have positive social support. The
second hypothesis compares blood sugars of one group of diabetic patients, pre-
intervention and post-intervention. The research hypothesis states the study group,
the variables that the researcher is studying, and the expected outcome of the study.
Research hypotheses provide clues as to who the researcher w ill study (sample popu-
lation), what data are collected (variables), and how data are analyzed.
After designing the study, the researcher collects information or data directly or
indirectly from the study sample. In public health, the study sample is often p eople.
However, the study sample could also be patient charts, water samples, or adver-
tisements in magazines that influence p eople’s health behaviors. The researcher
R ESEAR C H 531
obtains or recruits the study sample and collects data from the sample. Public health
researchers perform research studies in many different locations, such as hospitals,
clinics, communities, schools, businesses, and homes. The data collected may be
qualitative or quantitative. Qualitative data are descriptions using words and ideas.
Quantitative data are descriptions using numbers. In the study of blood sugar man-
agement and social support, the qualitative researcher might investigate how social
support influences diabetic management. The qualitative researcher may learn that
positive social networks provide a sense of belonging that reduces stress and makes
it easier to manage the challenges of diabetes; increases self-esteem, encouraging
the person with diabetes to take good care of his or her body; and increases access
to information providing guidance that helps the diabetic patient to manage poten-
tial problems and concerns more quickly and easily. The qualitative researcher looks
at how social support works and develops major themes or ideas that are common
across the study sample of diabetic patients. The quantitative researcher looks at how
social support works by counting the concepts of interest. The quantitative researcher
would measure social support and blood sugar and calculate any differences. The
quantitative researcher may conclude that the blood sugars of diabetic patients with
positive social support are not significantly different from diabetic patients without
positive social support. However, diabetic patients with positive social support are
70 percent more likely to check their blood sugars regularly, which could prevent
complications due to too high or too low of a blood sugar. Neither form of data,
qualitative or quantitative, is superior to the other. Both forms of data work together
to help public health professionals to understand and address health problems.
After collecting the data, the researcher presents the results. This process, known
as data conversion, requires the researcher to take large masses of data and convert
them into understandable concepts while still maintaining accuracy of the results.
To convert the data, the researcher may need to read more than 100 pages of inter-
view transcripts or enter and calculate answers from thousands of surveys. Fortu-
nately, computer software packages are available for some types of data conversion.
Analyzing the data and presenting the data in a format that is easy to understand
requires critical thinking and mathematical skills. The researcher attempts to focus
the data so that readers can pull out the most important and relevant results without
getting lost in details. The ultimate purpose of presenting the data is to share the
information with others so that health professionals can improve the current ways
that they work and take care of p eople. Researchers are responsible for sharing results
with interested communities through books and popular social media and reporting
results to other scientists through professional conferences and journal articles. Pre-
senting results allows the researcher to share information with o thers, encourages the
exchange of ideas, and provides a check that results are accurately reported. Results
are discussed, questioned, or confirmed. These discussions are critical to ensuring
that changes in practice and further research are based on good science.
Throughout history, there have been times when researchers w ere too e ager
to make new discoveries and ignored the health, safety, and free will of study
532 R IS K -B ENE FIT ANALYSIS
participants. Experiments, such as the Tuskegee Syphilis Study, Willowbrook Hep-

atitis Studies, or cancer studies at New York City’s Jewish Chronic Disease Hospital,
reveal an embarrassing history of unethical h uman experimentation. To ensure
that researchers focus on the rights and welfare of study participants, the National
Commission for the Protection of Human Subjects of Biomedical and Behavioral
Research was formed and developed The Belmont Report (1979). The Belmont Report
is a document that outlines and describes the three basic bioethical principles of
respect for persons, beneficence, and justice. Respect for persons requires research-
ers to treat participants as autonomous individuals who are able to make their own
decisions regarding study participation. According to this principle, selected popu-
lations may be more vulnerable to coercion or manipulation. Vulnerable popula-
tions require more stringent safeguards. The second principle, beneficence, obligates
researchers to maximize the benefits to study participants and minimize the harms.
The final principle, justice, mandates that each person is treated fairly and provided
the same benefits and opportunities as others. All research studies involving human
participants are reviewed for human participant protections by an independent
group of scientists and nonscientists known as an institutional review board (IRB).
The IRB members review studies to ensure that the study is founded in good sci-
ence and follows the bioethical principles of human participant protections.
Research is an ongoing cycle of learning and investigation designed to discover
new information and make connections between what we know and what we need
to know. Research seeks to improve how public health practitioners identify, treat,
and prevent illnesses. Researchers are bound by a code of ethics and professional
practices that ensure protection of h uman participants and honesty in collecting
and reporting results.
Sally Kuykendall
See also: Belmont Report, The; Causality; Code of Ethics; Ethics in Public Health and
Population Health; National Cancer Institute; Tuskegee Syphilis Study
Further Reading
Babbie, E. R. (2015). The practice of social research. Independence, KY: Cengage.
National Institute of Health, Office of Extramural Research. (2015, July 1). Protecting human
research participants. Retrieved from https://phrp.nihtraining.com/users/login.php.
U.S. Department of Health and Human Services, Office of Human Research Protections.
(2015, July 1). The Belmont Report. Retrieved from http://www.hhs.gov/ohrp/human
subjects/g uidance/belmont.h
tml.
RISK-B ENEFIT ANALYS IS

Risk-benefit analysis, also referred to as cost-benefit analysis or benefit-cost analysis,
is a principle of public health that compares the risk or cost of an action to financial
and human gains. The concept is used in many disciplines and is particularly
R IS K -B ENE F IT ANALYSIS 533
relevant to public health where interventions and programs are often financed
through public funds or private foundations. Risk-benefit analysis tells w hether the
expected or actual outcomes of a policy or program justify the risk or cost. The
concept has been used to quantify the value of syringe exchange programs, new-
born phenylketonuria (PKU) testing, early childhood education programs, the Clean
Air Act, m ental health services, vaccinations, and stroke prevention efforts.
Risk-benefit comparison requires a careful consideration of all relevant factors.
In public health, such considerations encompass financial costs, likelihood of the
disease or injury, likelihood of serious complications or adverse consequences due
to disease or injury, life expectancy, current quality of life, and currently available
alternatives. In terms of life expectancy, a public health action that prevents 10 pre-
mature deaths of newborns has greater value than 10 premature deaths of octoge-
narians (O’Brien, 2002). The challenge is in quantifying the value of h uman life.
To ensure accurate and honest comparisons, statisticians must identify a logical
common denominator or adjust for risk. For example, when comparing the num-
ber of deaths due to automobiles in 1997 to 1925, statisticians must account for
the fact that t here w
ere fewer vehicles on the roads in 1925. Instead of comparing
the actual number of deaths, safety experts calculate deaths per 100 million vehicle
miles traveled (VMT). Standardizing to 100 million VMT yields better comparable
data and more accurate conclusions. In 1925, t here w ere 18 deaths per 100 million
VMT. In 1997, there were 1.7 deaths per 100 million VMT (Achievements in pub-
lic health motor-vehicle safety: A 20th century public health achievement, 1999).
A 90 percent reduction in deaths due to motor vehicle crashes demonstrates sig-
nificant advancements in driver, passenger, and pedestrian safety. A risk-benefit
analysis would also consider the cost of t hose advancements, that is, the cost of the
National Highway Safety Act, the cost of raising the minimum drinking age, and
the cost of driver education programs, sidewalks, restricted traffic flow, seat belts,
air bags, and child safety seats. To keep it simple, let’s examine one intervention,
graduated driver licensing programs. Between 1995 (before graduated driver licens-
ing programs) and 2008 (after graduated driver licensing programs), fatal crashes
of 16-year-old drivers decreased from 13.4 per 100 million VMT to 9.1 per 100
million VMT (National Safety Council, 2015). Allstate Foundation estimates that
implementing comprehensive graduated driver licensing programs in all states could
save 2,000 lives and $13.6 billion per year. Oregon, reported to have the strictest
graduated driver licensing program, estimates annual administrative costs of
$150,000 and annual estimated savings of $11 million (Insurance Institute for High-
way Safety, n.d.). Thus, for every $1 that Oregon invests in graduated driver licens-
ing program, $73 is saved.
With limited funding for public health programs, risk-benefit analysis is a use-
ful tool to assess the value of a program. On the other hand, cost-benefit analyses
raise ethical questions, such as what is the dollar value of a life or of quality of life,
and whether all lives have equal value or are some more valuable than others. Focus-
ing exclusively on cost-benefit analyses could eliminate public investment in
534 R OOSE VELT, ELEANO R
valuable research and treatment of rare diseases or emerging health problems.

There are dangers in trying to reduce the value of a program or policy to a quantita-
tive number.
Sally Kuykendall
See also: Anderson, Elizabeth Milbank; Syringe Service Programs; Truth Campaign,
The; Veterans’ Health
Further Reading
Achievements in public health motor-vehicle safety: A 20th century public health achieve-
ment. (1999). Morbidity and Mortality Weekly Report, 48(18), 369–374. Retrieved from
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.htm.
Allstate Foundation. (2016). Teen safe driving. Retrieved from https://www.allstatefoundation
.org/teen_safe_driving_driver_license.html.
Boden, L. I. (1979). Cost-benefit analysis: Caveat emptor. American Journal of Public Health,
69(12), 1210.
Insurance Institute for Highway Safety. (n.d.). Graduated driver licensing. Retrieved from
http://adtsea .org/Resources%20PDF%27s /NHTSA%20Graduated%20Driver%20
Licensing.p df.
National Safety Council. (2015). Injury Facts®, 2015 edition. Itasca, IL: Author. Retrieved
from http://www.nsc.org/Membership%20Site%20Document%20Library/2015%20
Injury%20Facts/N SC_InjuryFacts2015Ed.p df.
Neenan, W. B. (1971). Distribution and efficiency in benefit-cost analysis. Canadian Journal
of Economics, 4(2), 216.
O’Brien, B. J. (2002). Book review: Risk-benefit analysis. New England Journal of Medicine,
346, 1099–1100.
Reid, R. J. (2000). A benefit-cost analysis of syringe exchange programs. Journal of Health
& Social Policy, 11(4), 41–39.
Wilson, R., & Crouch, E. A. C. (2001). Risk-benefit analysis. Cambridge, MA: Harvard Uni-
versity Press.
ROOSEVELT, ELEANOR (1884–1962)

Eleanor Roosevelt was the first wife of a president to use her position to fight for
the rights of disadvantaged populations. Eschewing a life of privilege and ease, Roo
sevelt worked diligently to improve living and working conditions of minorities,
women, and the destitute. Her efforts in public advocacy and legislature created a
safety net for many Americans. After her husband died, she expanded her respon-
sibilities, playing an important role in human rights through the fledgling United
Nations.
Anna Eleanor Roosevelt was born on October 11, 1884, to Anna Rebecca (Hall)
and Elliott Bulloch Roosevelt. Her parents were members of New York City’s wealthy
elite related to Philip Livingston (signer of the Declaration of Independence), Wil-
liam Livingston (signer of the U.S. Constitution), and President Theodore Roosevelt.
R OOSE V ELT, ELEANO R 535
Although her wealthy background assured her social position and her attendance at
the best private schools provided her with ample training, she had a difficult child-
hood with an unsympathetic m other and an alcoholic father. Her parents died
when she was very young, leaving her to be raised by a strict grandmother. Roose
velt attended finishing school at Allenswood Academy, Wimbledon, England. U nder
the progressive leadership of the headmistress Marie Souvestre, Roosevelt flourished.
However, in 1902, her grandmother summoned her home for her formal social
debut. As a young, social debutante, Roosevelt volunteered at the Rivington Street
Settlement House and the Consumers League where she was confronted by the low
wages and working conditions of New York City’s poor. The young Roosevelt con-
sidered herself unattractive and never acquired a superior upper-class demeanor.
Shy instead of coy, clumsy instead of poised, she was just as surprised as everyone
else when her dashing, handsome, distant cousin Franklin D. Roosevelt proposed
marriage.
For 14 years after their marriage, u
ntil 1919, Roosevelt dutifully suffered domi-
nation by Franklin’s mother, Sara; bore six children; and fulfilled the traditional
social obligations of a wealthy politician’s wife. The discovery at the end of World
War I that her husband loved another woman prompted Roosevelt to establish an
identity of her own. Instead of devoting an afternoon a week to aid the less fortu-
nate, she made it a full-time career. She also became active in women’s affairs and
the Democratic Party. When Franklin was stricken later that year with polio, she
helped him to continue his political c areer by taking over some of his tasks. Frank-
lin returned to active political life in 1928 and won election as governor of New
York, and Roosevelt resumed her own growing public life.
After her husband’s election as president in 1932, Roosevelt refused to live only
in Franklin’s shadow. After the inauguration, her first official act was touring poor
neighborhoods in Washington, DC. The unsanitary living conditions prompted her
to start a campaign to provide decent affordable housing with indoor plumbing and
toilets to every home in America. In her capacity as first lady, Roosevelt visited work-
ers in mines and factories, held press conferences, and wrote a newspaper column.
Strongly committed to civil equality for African Americans, she was often the only
person close to the White House who was willing to speak up on race issues. FBI
director J. Edgar Hoover compiled a report of over 3,000 pages documenting Roose
velt’s activities against segregation, fascism, racial injustice, and later, the Cold
War and nuclear weapons. When Eleanor’s sometimes controversial statements
and behavior on behalf of the less fortunate worried his aides, Franklin smiled
and replied, “I can always say, I can’t do a thing with my wife.” Although despised by
some for her outspokenness, Roosevelt was admired and loved by many more for her
tireless efforts to encourage social reform for African Americans, women, youth, and
the poor. In a half-hearted apology to her friend, Roosevelt wrote, “I am sorry that all
these attacks against me are causing so much grief to my friends. But in these trou-
bled times I intend to go right on saying and doing what must be said and done. And
I intend to provide lots of ammunition for attack in the future” (Cook, 1993, p. 26).
536 R OOSE VELT, F RAN KLIN DELANO
In 1939, when the Daughters of the American Revolution refused to let Marian
Anderson, an African American singer, perform in Washington’s Constitution Hall,
Roosevelt resigned from the organization. Then she helped arrange for Anderson
to give a triumphant outdoor concert on federal property at the Lincoln Memorial.
Roosevelt’s frequent trips across the country enabled her to learn the mood of
the public. She became a major domestic policy adviser in her husband’s adminis-
tration. As one New Deal aide recalled, “No one who ever saw Eleanor Roosevelt sit
down facing her husband, and holding his eye firmly, say to him, ‘Franklin, I think
you should . . .’ ever forgot the experience.” Eleanor Roosevelt was instrumental in
the development of the National L abor Relations Act, the Fair L
abor Standards Act,
and the Social Security Act. She served briefly as codirector of the Office of Civilian
Defense in 1941 and played a major role in Franklin’s selection of Frances Perkins
as secretary of labor, the first woman to hold a Cabinet-level position.
During World War II, Roosevelt visited troops in the United States, England, the
Caribbean, and the South Pacific. After Franklin’s death in 1945, she continued her
public life, writing her newspaper column, serving as a delegate until 1952 to the
United Nations (where she was instrumental in drafting the Declaration of H uman
Rights), and working with emotionally disturbed children. She supported reform
Democrats in New York and worked for Adlai Stevenson in his campaigns for presi-
dent in 1952 and 1956. President John F. Kennedy reappointed her to the United
Nations in 1961, the year before she died on November 7, 1962.
Steven G. O’Brien and Sally Kuykendall
See also: Centers for Medicare and Medicaid Services; Medicaid; Medicare; Roose
velt, Franklin Delano; Social Security Act; Wald, Lillian
Further Reading
Cook, B. W. (1992). Eleanor Roosevelt. New York: Viking.
Cook, B. W. (1993). Eleanor: Loves of a First Lady [Cover story]. Nation, 257(1), 24–26.
Hareven, T. K. (1968). Eleanor Roosevelt: An American conscience. Chicago: Quadrangle Books.
Lash, J. P. (1972). Eleanor: The years alone. New York: Norton.
O’Farrell, B. (2009). Restoring workplace democracy: Eleanor Roosevelt and labor law
reform. Journal of Workplace Rights, 14(3), 329–350. doi:10.2190/WR.14.3.e
Roosevelt, E. (1937). This is my story. New York: Harper.
Roosevelt, E. (1949). This I remember. New York: Harper.
Roosevelt, E. (1958). On my own, Part Three: I learn about communists. Saturday Evening
Post, 230(34), 30–62.
Roosevelt, E. M. (1958). On my own. New York: Harper.
ROOSEVELT, FRANKLIN DELANO (1882–1945)

Franklin Delano Roosevelt was the 32nd president of the United States and the only
president to serve more than two terms. His presidency marked numerous advance-
ments in public health. Stricken with polio at the age of 39, Roosevelt was the first
R OOSE V ELT, F R ANK LIN DELANO 537
president with a noticeable disability. His experience with chronic illness provided
insight and empathy for the suffering of disadvantaged people in the United States.
Roosevelt led the fight against polio, introduced the New Deal, enhanced the U.S.
Public Health Service, implemented Social Security, and initiated a national hous-
ing program. His major contributions to public health were providing economic
security and supporting m ental health, proper nutrition, and access to medical care
for millions of Americans.
Franklin Delano Roosevelt was born on January 30, 1882. He enjoyed a privi-
leged youth, spending his early years at the family estate in Hyde Park, New York,
and attending the exclusive Groton School before g oing on to Harvard University
and Columbia University Law School. In 1905, he married Eleanor Roosevelt, his
distant cousin and the niece of former president Theodore Roosevelt. He was
elected to the New York Senate in 1910 and quickly made a name for himself by
challenging the Tammany Hall political machine’s control over the Democratic
Party. In 1920, Roosevelt ran as
the vice presidential candidate
with James M. Cox. Although the
Democratic Party lost the elec-
tion, Roosevelt used the oppor-
tunity to establish a national
reputation. His political future
seemed assured until he was
stricken with polio and paralyzed
in the lower extremities. B ecause
polio tended to strike infants and
children, Roosevelt was initially
misdiagnosed. The first consult-
ing doctor believed that Roose
velt suffered a blood clot in his
spinal cord or a spinal lesion and
prescribed regular back massages.
The doctor who made the diag-
nosis of polio stopped the mas-
sages believing that the massages
may have spread the infection.
For two years, Roosevelt strug
gled to teach himself how to cope
with the loss of physical func-
tion. On the recommendation of
a friend, he sought treatment at a
Knowing that his paralysis would be perceived as
resort in Warm Springs, Georgia. infirmity or defect, Roosevelt and his aides carefully
The warm mineral waters w ere orchestrated public appearances. This picture is one
said to cure infantile polio. Roo of three known photographs of Roosevelt in his
sevelt was not cured but enjoyed wheelchair. (Franklin D. Roosevelt Library)
538 R OOSEVELT, F RANKLIN DELANO
the resort so much that he continued to make regular visits. In 1926, the resort
experienced financial difficulties. The Roosevelts bought the resort and converted it
to a hydrotherapeutic center for polio survivors. The treatment center struggled to
survive until 1934 when, in lieu of birthday gifts, Roosevelt encouraged friends and
colleagues to donate money to the Georgia Warm Springs Foundation. The first
annual Birthday Ball raised one million dollars. Subsequent Birthday Balls were also
highly successful.
In 1937, Roosevelt decided that a more comprehensive approach to polio con-
trol was needed. In notes, Roosevelt explains the purpose and mission of a National
Foundation for Infantile Polio:
The general purpose of the new foundation w ill be to lead, direct, and unify the fight
on e very phase of this sickness. It will make e very effort to ensure that every respon-
sible research agency in this country is adequately financed to carry on investigations
into the cause of infantile paralysis and the methods by which it may be prevented.
It will endeavor to eliminate much of the n eedless after-effect of this disease—wreckage
caused by the failure to make early and accurate diagnosis of its presence. We all know
that improper care during the acute stage of the disease, and the use of antiquated
treatment or downright neglect of any treatment, are the cause of thousands of crip-
pled, twisted, powerless bodies now. Much can be done along these lines right now.
The new foundation w ill carry on a broad-gauged educational campaign, prepared
under expert medical supervision, and this will be placed within the reach of the doc-
tors and hospitals of the country. (Roosevelt, 1937)
The National Foundation for Infantile Polio funded massive research toward the
discovery of a vaccine against polio, the most notable of which w ere Drs. Jonas Salk
and Albert Sabin. A fter the discovery of the polio vaccine, the foundation evolved
into the March of Dimes with the mission of reducing infant mortality and prevent-
ing birth defects.
Many people thought Roosevelt’s paralysis would end his political career. The
image of a “cripple” might prevent many Americans from voting for him. With Elea-
nor’s help, Roosevelt developed a bold personal style. The press was complicit in
covering up his disability. Very few pictures exist of Roosevelt in a wheelchair. He
posed for pictures in a standing position, leaning on his cane, a podium, or personal
aide for balance. His leg braces were painted black so as not to be seen in photo
graphs. His charming, persuasive persona outshone his disability. In 1928, Roosevelt
won the race for governor of New York.
The roaring twenties brought enormous growth and prosperity to the inner cit-
ies. Consumer confidence was high, and easy credit enticed p eople to take out large
loans. The Federal Reserve and economists warned that the boom could not last
forever. The warning triggered investors to sell stocks, causing the stock market to
drop. Hoping to stabilize the market, big banks purchased large blocks of blue chip
stocks, stocks in corporations that had a solid reputation for making a profit. The
strategy worked temporarily and the market rallied. However, the events were
reported in the weekend newspapers and by Monday, many investors tried to sell
R OOSE V ELT, F R ANK LIN DELANO 539
stocks in order to get out of the market. By Tuesday October 29, 1929, widespread
panic and chaos ensured. The Dow lost 30 points. “Black Tuesday” triggered the
start of the Great Depression. Consumer confidence in the market dropped, people
stopped making large purchases, businesses closed, unemployment rates reached
25 percent, full-time workers were relegated to part-time work, banks foreclosed,
and people lost homes and properties. Roosevelt established a reputation as a com-
passionate, reform-oriented governor.
In 1932, Roosevelt became the presidential nominee for the Democratic Party.
During the campaign, he promised to balance the federal budget and to provide
aid to the needy. Confident that he would win the election, Roosevelt began pre-
paring for the presidency. He enlisted the aid of a number of experts and college
professors to assist him so that he could move quickly to deal with the national
crisis. This group of professors—Rexford Tugwell, Adolph Berle Jr., and Raymond
Moley—were nicknamed the brain trust. In his inaugural address, Roosevelt
announced that he would call Congress into an immediate special session to pass
the New Deal legislation necessary to deal with the banking crisis and the collapse
of the economy. The special session of Congress lasted from March 9, 1933, to
June 16. During that period of 100 days, more important legislation was passed
than at any other comparable period in U.S. history.
The three aims of the New Deal were recovery, relief, and reform. To stop the
rush on bank withdrawals, banks closed temporarily. The Agricultural Adjustment
Administration (AAA) was established to limit production and increase farm prices.
The Civil Works Administration, the Civilian Conservation Corps, the Public Works
Administration, and l ater the Works Progress Administration were created to relieve
unemployment by providing temporary jobs. The Federal Emergency Relief Admin-
istration was created to provide funds to local relief agencies. Other innovative
programs were:
• The Home Owners’ Loan Corporation, which worked to protect p eople from
mortgage foreclosures.
• The National Recovery Administration (NRA), which was designed to regu-
late business competition.
• The National Labor Relations Board, which was established to guarantee the
right of labor to organize.
• The Tennessee Valley Authority project, which brought low-cost power and
jobs to millions of people in the Tennessee River Valley area.
Among the many relief efforts was the Social Security Act, a landmark policy to
provide social insurance for the elderly. The idea of social insurance for the elderly
was first proposed by Isaac Max Rubinow. Rubinow was a Russian immigrant, econ-
omist, and medical doctor caring for poor immigrants in New York City’s Lower
East Side. The elderly were at high risk for suffering the effects of inflation and unem-
ployment. Using data from the U.S. Department of Commerce and Labor, Rubinow
estimated that 500,000 men and 1,400,000 women over the age of 65 were unable
540 R OOSEVELT, F RANKLIN DELANO
to earn a living wage. The burden of care often shifted to families or charities. In
the summer of 1934, Roosevelt named the Committee on Economic Security with
Rubinow serving as consultant. On August 14, 1935, Roosevelt signed the Social
Security Act, providing social insurance for the nation’s elderly into law.
Although these efforts failed to end the G reat Depression, they provided a sense
of the government’s commitment to relieving people’s suffering and led to Roose
velt’s landslide reelection in 1936. They also marked the first extensive use of the
government’s fiscal powers to stimulate mass purchasing and thereby promote eco-
nomic recovery. Although New Deal legislation provided substantial relief for the
American people, it was World War II that returned the United States to prosperity.
By the time Roosevelt won reelection in 1936, he had realized that the dictato-
rial regimes in Japan, Germany, and Italy were hoping to solve their economic prob
lems through military expansion. Although Roosevelt wanted to keep the United
States out of war, he provided aid to Great Britain. In 1940, Roosevelt decided to
run for an unprecedented third term. Roosevelt promised to keep Americans out
of any foreign wars and easily defeated his Republican rival, Wendell Willkie. Japan’s
surprise attack on Pearl Harbor on December 7, 1941, forced a declaration of war
against Japan. Germany and Italy then declared war on the United States, and the
United States found itself fighting in both Asia and Europe. On the home front,
Roosevelt issued Executive Order 9066, authorizing the “relocation” of more than
100,000 Japanese Americans in the United States. The Japanese American intern-
ment has since been recognized as a gross violation of civil liberties.
Roosevelt was severely criticized for some of the ways he directed the war effort,
but he behaved in his characteristically pragmatic fashion. His goal was to win the
war with as few American casualties as possible. To do this, he needed to keep the
wartime alliance of G reat Britain, the Soviet Union, and the United States together
until after Germany and Japan were defeated, and he did. Meanwhile, war created
prosperity, and Americans widely believed that they were fighting “the Good War.”
These factors sustained national unity and enough popularity for Roosevelt for him
to win reelection to a fourth term in 1944.
In 1945, the Allies (the United States, G reat Britain, and the Soviet Union) met
in Yalta to discuss the composition of postwar Europe. After Roosevelt returned from
Yalta, his doctors ordered him to rest. He traveled to his retreat at Warm Springs,
Georgia, where he suffered a massive cerebral hemorrhage and died on April 12,
1945. Roosevelt’s vice president, Harry Truman, succeeded him as president.
No other president in the 20th century was as adored by the masses as Roose
velt. Through his speeches and famous “fireside chats,” Roosevelt spoke to millions
of Americans. Hundreds of thousands sent him letters detailing their hardships, ask-
ing for assistance, and thanking him for his help. Reporting on Roosevelt’s death,
the American Journal of Public Health noted:
[Roosevelt] was a g reat humanist in the sense defined by Archibald MacLeish when
he said, ‘It is necessary to believe in man, not only as the Christians believe in man,
R OSEN , G EO R G E 541
out of pity, or as the democrats believe in man out of loyalty, but also as the Greeks
believed in man, out of pride.’ Humanism in this connotation was perhaps the keynote
of President Roosevelt’s personality. He understood h
uman needs and he had faith in
human power. To justify that faith by carrying forward the age-long struggle for a
better world is our obligation and our opportunity. (Roosevelt, 1945)
Roosevelt inspired both intense loyalty and opposition. His critics and supporters
agree, however, that he did more to establish the U.S. welfare state and govern-
ment responsibility for individual social welfare than any other president has. Roo
sevelt’s impact on the United States through his social and economic legislation was
huge and lasting.
Sally Kuykendall
See also: Centers for Medicare and Medicaid Services; Cutter Incident, The; Infec-
tious Diseases; Medicaid; Medicare; Polio; Roosevelt, Eleanor; Salk, Jonas; Social
Security Act; Vaccines
Further Reading
Berish, A. (2016). FDR and polio. FDR Presidential Museum and Library. Retrieved from
https://fdrlibrary.org/polio.
Brown, T. M., & Fee, E. (2002). Isaac Max Rubinow. American Journal of Public Health, 92(8),
1224–1225.
Burns, J. M. (1956). Roosevelt: The lion and the fox. New York: Harcourt Brace.
Burns, J. M. (1970). Roosevelt: The soldier of freedom. New York: Harcourt Brace Jovanovich.
Fraser, S., & Gerstle, G. (Eds.). (1989). The rise and fall of the New Deal order, 1930–1980.
Princeton, NJ: Princeton University Press.
Helfand, W. H., Lazarus, J., & Theerman, P. (2001). “. . . So that others may walk”: The
March of Dimes. American Journal of Public Health, 91(8), 1190.
Lash, J. P. (1971). Eleanor and Franklin: The story of their relationship, based on Eleanor Roo
sevelt’s private papers. New York: Norton.
Parran, T. J. (1936). Health security. American Journal of Public Health, 26, 329–335.
Richardson, S. (2015). FDR on global disease threats, 1940. (2015). American History,
49(6), 14.
Roosevelt, F. D. (1937). Personal notes. FDR Library. Retrieved from https://fdrlibrary.org
/d ocuments /3 56632 /3 90886 /p olio _n fipcreation .p df /e 0c36fdc -5 a79 -4 d7c -a 57c
-c8b43637e019.
Roosevelt, F. D. (1945). American Journal of Public Health, 35(5), 509.
Schlesinger, A. M., Jr. (1957–1960). The age of Roosevelt (Vols. 1–3).
Troy, T. (2017). Presidents and public-health crises. National Affairs, 31, 54–66.
ROSEN, GEORGE (1910–1977)

George Rosen was a prolific writer, medical historian, public health physician, and
social scientist. Rosen’s drive, determination, energy, and vision created two unique
fields within public health: history and social medicine. Repeatedly denied entrance
542 R OSEN , G EORGE
into the hallowed halls of academia, Rosen stood firmly between the worlds of pub-
lic health practice and academic scholarship. From his research on miners’ diseases
to factory conditions, he was an advocate for the working people. He carefully
detailed the conflicting interests of industry, public policy, and occupational health.
The resulting observations and insights brought social medicine to the forefront of
public health practice. Throughout his lifetime, Rosen authored more than 200 arti-
cles and nine books and translated numerous medical-historical texts into English.
His greatest contribution was in researching and documenting the history of public
health through which he highlighted the relationship between social circumstances
and health. Although he was never a political activist, Rosen worked steadily to edu-
cate others on the living and working conditions of the poor and disadvantaged.
The son of working-class Jewish immigrants, Rosen was born in Brooklyn and
grew up in a world where social status determined health. His father, Morris Rosen,
was a shirt presser and union activist. As a child, George tagged along to union
functions, although he was uninterested in u nion politics. His mother, Rose Handel-
man Rosen, was homemaker for the f amily of four. George did not learn English
until he started elementary school and quickly became an avid reader of any and
every subject. In 1930, he completed his undergraduate degree at the College of
the City of New York and applied to medical school. Denied admission due to nume-
rus clausus, an anti-Semitic practice, which limited the number of Jewish students
attending an institution, a friend suggested g oing to medical school in Germany.
In the fall, Rosen joined other American medical students in attending Berliner
Universität.
The Berlin University was not the traditional backup or safety school. Also known
as Friedrich Wilhelms Universität and Humboldt Universität, the university boasts
40 Noble Prize winners along with notable alumni and lecturers, W. E. B. Du Bois,
Albert Einstein, James Franck, Robert Koch, Max Planck, and Erwin Schrödinger,
to name a few. In Germany, Rosen was introduced to a lifestyle far different from
that of his working-class roots. He was impressed by the national health system,
European culture, and most of all by his medical school classmate and f uture wife,
Beate Caspari. The Caspari family, also Jewish, had survived the turmoil of World
War I and hyperinflation of the Weimar Republic. Believing that the worst was
behind them, the Caspari family enjoyed a comfortable life. Beate intended to fol-
low her father’s example as a family physician. However, their time at school coin-
cided with the Nazi rise to power. Rosen’s American citizenship protected him.
Beate’s family was not as fortunate. The American students walked a fine line of
wanting to help the Jewish families, yet enjoying immunity from a growing anti-
Semitic movement. Beate Caspari recalled one incident where the family feared that
their house would be searched by the Schutzstaffel (SS). Her f ather carried a pistol
to protect himself from robbery during house calls. If the SS found the pistol, her
father could be jailed. To protect the family, George wrapped the pistol in paper
and threw it in a nearby river. Beate and George intended to be married but moved
their wedding earlier so that Beate would also have the protection of American
R OSEN , G EO R G E 543
citizenship and thus be able to finish medical school. The partnership proved to be
long, successful, and productive.
Rosen’s medical program included a dissertation requirement. He was determined
to write on the little known topic of the history of American medicine. His adviser
referred him to Dr. Henry Ernest Sigerist, director of the Institute of the History of
Medicine at Johns Hopkins and the world’s leading expert on the history of medi-
cine. Sigerist and Rosen worked well together. The final dissertation was on Ameri-
can physician and physiologist William Beaumont. Rosen would have liked to work
full-time with Sigerist after graduation. However, Hopkins did not have funding
for another medical historian. The Rosens moved to New York City where George
began an internship at Beth-El Hospital in Brooklyn and regularly contributed arti-
cles to Sigerist’s journal Bulletin of the History of Medicine. The responsibility of regu-
lar articles with monthly deadlines forced George to investigate numerous different
topics. He decided to write a book, and Sigerist suggested the topic of the history
of miners’ diseases. Mining was and is one of the most dangerous jobs in the world.
Miners risk injury and death from collapsed mine shafts, explosions, and collisions
with locomotives or mine cars. In 1930, the Bureau of Mines reported 103,821 inju-
ries and 2,063 fatalities (Adams, Geyer, & Chenoweth, 1932). Rosen’s book, The
History of Miners’ Diseases: A Medical and Social Interpretation, carefully studied min-
ing practices and diseases, advancing from ancient Greece and Rome through the
1900s. The work presented social reforms in Belgium, Britain, Germany, and France,
which led to improvements in the industry. Rosen’s ability to simultaneously dis-
sect and weave together history, economy, occupational health and safety, social con-
ditions, and acute and chronic diseases appealed to a wide audience of physicians,
engineers, historians, chemists, and social scientists.
In 1937, Rosen started his own medical practice and took a part-time job at New
York City Department of Public Health to help pay the bills. He would have pre-
ferred working as a university scholar. He enjoyed reading and writing and lacked
or did not care to invest in developing the interpersonal skills of a bedside doctor.
The public health experience created the desire to get a master of public health
(MPH) degree. In the fall of 1939, Rosen started sociology courses at Columbia Uni-
versity. Continuing to juggle his clinical practice and scholarship, Rosen earned his
PhD in sociology while working full-time as a health officer with the NYC Depart-
ment of Health (1942) and for the United States Army (1943). The army sent him
to England to interview German doctors about Nazi experimentation on humans.
In Great Britain, Rosen connected with Henry Schulman who invited him to edit
the Journal of the History of Medicine and Allied Sciences.
Discharged from the army in 1946, Rosen returned to the NYC Department of
Health and enrolled in the MPH program at Columbia University. By this time, Siger-
ist was retiring from Johns Hopkins. Rosen, having established himself as a medi-
cal historian in his own right, was hoping to take Sigerist’s positon. Race and politics
once again stood in the way. Johns Hopkins would not consider a Jewish chair-
holder. Sigerist, a vocal advocate for social medicine, created enemies within the
544 R OSEN , G EO RG E
institution. Rosen was guilty of communism by association. Therefore, he contin-

ued his day job in public health, writing on the side. In 1949, Rosen became the
director of health education for NYC and founded the Department of Health Edu-
cation and Preventive Services at the Health Insurance Plan of Greater New York
(HIP). Through HIP, Rosen was able to apply his ideas of social medicine. He became
active in the American Public Health Association and eventually became editor for
the American Journal of Public Health (AJPH). Through the AJPH, Rosen focused efforts
on bringing public health together as a profession. This was a challenging task since
public health professionals encompass a wide array of professions. As a natural
extension of his interests, Rosen started the AJPH feature Public Health: Then and
Now. The feature continues t oday, reflecting on the history of public health and les-
sons for the future. In 1951, Rosen finally earned an appointment as part-time
faculty at Columbia University School of Public Health. The position later became
full-time, and in 1969 he moved to Yale University to become professor of history
of medicine and public health. Rosen continued to lecture and write about social
medicine from a global/historical perspective u ntil his sudden death by heart attack
( July 27, 1977) while on lecture tour in England.
The legacy of George Rosen is a reflection of his life experiences. The son of poor
Jewish immigrants, repeatedly denied entry into elite institutions, and witness to
the overexaggerated nationalism of Nazi Germany, George Rosen worked tirelessly
to envision a public health system that focused on the needs of the people, effec-
tively sidestepping ethnocentric, class-centric politics. Although he was never a vocal
political activist, Rosen used his pen to create activism. He presented unavoidable
facts, forced enlightened knowledge, and drove logical reasoning. His pen was his
political activism. And through his writing, he advocated for those who could not
advocate for themselves. Rosen died at the relatively young age of 67, which begs
the question, if Rosen or o thers like him had the voice, power, and support of for-
mal institutions earlier in life, what would our public health system look like today?
Sally Kuykendall
See also: American Journal of Public Health; Modern Era, Public Health in the; Social
Determinants of Health
Further Reading
Adams, W. W., Geyer, L. E., & Chenoweth, L. (1932). Coal-mine accidents in the United States.
U.S. Department of Commerce. Washington, DC: U.S. Government Printing Office.
Retrieved from http://digital.library.unt.edu/ark:/67531/metadc12525/m2/1/high_res_d
/Bulletin0355.pdf.
Caspari-Rosen, B. B. (n.d.). Autobiographical essays, posted by Susan Koslow (née Susan Joan
Rosen). Retrieved from http://profkoslow.com/beatecasparirosen/index.html.
Hamilton, A. (1944). The history of miners’ diseases: A medical and societal interpretation
[Book]. New Republic, 111(10), 283.
R U R AL HEALTH 545
Mormon, E.T. (2015). George Rosen: Public health and history. In G. Rosen, A history of
public health (Rev. expanded ed.). Baltimore, MD: Johns Hopkins University Press.
Rosenkrantz, B. G. (1979). George Rosen: Historian of the field. American Journal of Public
Health, 69(2), 165.
Schmacke, N. (1998). Health promotion through Neighborhood Health Centers: A tribute
to George Rosen on the 20th anniversary of his death. Health Promotion International,
13(2), 151.
Terris, M. (1979). George Rosen and the American public health tradition. American Jour-
nal of Public Health, 69(2), 173–176.
RURAL HEALTH
The first important issue in discussing rural health is the definition of “rural.” The
federal government uses two different major definitions of “rural.” The Census
Bureau defines as rural all population, housing, and territory that does not fit within
the urban definitions of e ither urbanized areas of 50,000 or more p eople or urban
clusters of at least 2,500 and less than 50,000 p eople. The Office of Management
and Budget (OMB) classifies counties as metropolitan, micropolitan, or neither. A
metro area will have a core urban area of 50,000 people or more, while a micro
area has an urban core of at least 10,000 people but less than 50,000 people. All
counties that are not part of a metropolitan statistical area are considered rural. Using
this definition, about 15 percent of the population of the United States is rural, cov-
ering roughly 72 percent of the land area of the United States. The general consen-
sus is that each definition has limitations, with the Census Bureau standard providing
an overcount of the rural population whereas the OMB standard represents an
undercount. The Federal Office of Rural Health Policy (FORHP) classifies all non-
metro counties as rural and uses an additional adjustment, coming up with about
18 percent of the population and 84 percent of the land area of the United States
as rural (FORHP, 2017).
Most experts in public health agree that there are obstacles faced by both rural
health care providers and patients that are different from those in urban areas. Impor
tant differences include workforce shortage problems, socioeconomic factors, and
health inequalities. Considering first the issue of workforce shortages, access to phy-
sicians and other health care services is much more difficult in rural areas. The
patient to primary care physician ratio in rural areas is only 39.8 physicians per
100,000 people, as compared with a figure of 53.3 physicians per 100,000 people
in urban areas. The same is true for other types of health providers, such as den-
tists, where there are only 22 per 100,000 in rural areas versus 30 per 100,000 in
urban areas (National Rural Health Association, 2017). Given the lower numbers
of providers, access to care is a problem even if people have good health insurance
and transportation (National Rural Health Association, 2017).
The next issue, socioeconomic factors, helps to illustrate why issues of access to
care become even more complicated and problematic in rural areas than the s imple
546 R UR AL HEALTH
figures on workforce shortages might indicate. P eople living in rural areas tend to
be poorer than those in urban areas. Per capita income in rural areas is over nine
thousand dollars lower than the average per capita income in the United States. As
part of this, rural Americans are more likely to live below the poverty level. This is
even truer for minorities and a major problem for c hildren (about 25 percent of
rural children live in poverty). Rural residents are more likely to depend on the
Supplemental Nutrition Assistance Program (SNAP), with almost 15 percent of rural
households using the benefits versus less than 11 percent of metropolitan h ouseholds
(National Rural Health Association, 2017). Adding to the issues of greater poverty
are more transportation problems, both because of the greater distances that must
be traveled and the less reliable transportation sources of the rural poor. In addi-
tion, rural communities have more uninsured p eople, along with higher rates of
unemployment. In this era of the importance of the Internet as a source of health
information, rural residents also have problems with access to high-speed Internet
connections, with over half of rural residents not having Internet connections of
the basic bandwidth recommended by the Federal Communications Commission.
Given these problems, it is perhaps not surprising that rural residents report a
range of more serious and concerning health issues. Some of t hese apply to all rural
populations, and some are of special concern to the young or to older age groups.
For the young, one example is tobacco use. Over a quarter of rural youth over the
age of 12 smoke cigarettes versus 19 percent in large metro areas. The rates of smoke-
less tobacco usage are three times higher for rural youth (National Rural Health
Association, 2017). Another example is that rural youth are twice as likely to com-
mit suicide. For middle-aged and older rural populations, diabetes and coronary
heart disease are more common. A recent Centers for Disease Control and Preven-
tion (CDC) study found that rural Americans are more likely to die from five lead-
ing c auses of death than those living in urban areas. Many of these deaths w ere
considered potentially preventable by the CDC, such as 25,000 from heart disease,
19,000 from cancer, 11,000 from chronic lower respiratory disease, and 4,000 from
stroke (CDC, 2017). In general, rural residents are poorer, older, and sicker than
urban counterparts. Rural residents have higher rates of cigarette smoking, high
blood pressure, and obesity. They have less leisure-time physical activity and lower
seat b elt use than their urban counterparts.
For all rural residents, injuries are more common, with a 22 percent greater risk
of injury-related death. Some of this relates to vehicle crashes, as more than 50 percent
of vehicle crash-related fatalities occur in rural areas, even though the miles trav-
eled are less (only one-third of miles traveled in vehicles occur in rural areas)
(National Rural Health Association, 2017). In the CDC study, they found 12,000
potentially preventable deaths in rural areas from unintentional injuries (CDC,
2017). Also in the CDC study, they reported that unintentional injury deaths were
approximately 50 percent higher in rural areas than in urban areas, partly due to
greater risk of death from motor vehicle crashes and opioid overdoses. Additionally,
R U R AL HEALTH 547
the greater distances between health care facilities and trauma centers create more
issues of gaining access to specialized care for people injured in rural areas.
A last area of greater problems for rural residents is m
ental health. Issues of avail-
ability of m
ental health professionals are one problem, as is the issue of accessibility
due to travel times and lack of insurance. Another issue is that rural residents have
more negative views about m ental health services, leading to reluctance to use
such services, in addition to the barriers of cost, travel time, and lack of enough
professionals providing these services. A recent issue that crosses boundaries
between physical and m ental health but is a serious problem in rural areas is opi-
oid addiction.
See also: Food Insecurity; Health Disparities; Health Resources and Services Admin-
istration; Nutrition; U.S. Department of Agriculture
Further Reading
Centers for Disease Control and Prevention (CDC). Rural health. Retrieved from https://www
.cdc.gov/ruralhealth.
Centers for Disease Control and Prevention (CDC). (2017). Rural Americans at higher risk of
death from five leading causes. Retrieved from https://www.cdc.gov/media/releases/2017
/p0112-rural-death-risk.html.
Eberhardt, M. S., & Pamuk, E. R. (2004). The importance of place of residence: Examining
health in rural and nonrural areas. American Journal of Public Health, 94(10), 1682–1686.
Federal Office of Rural Health Policy (FORHP). Basic website information. Retrieved from
https://www.hrsa.gov/ruralhealth/index.html.
Hale, N. L., Smith, M., Hardin, J., & Brock-Martin, A. (2015). Rural populations and early
periodic screening, diagnosis, and treatment services: Challenges and opportunities for
local public health departments. American Journal of Public Health, 105(S2), S330–S336.
doi:10.2105/AJPH.2014.302449
National Rural Health Association. (2017). About rural health. Retrieved from https://www
.ruralhealthweb.org/about-nrha/about-rural-health-care.
S
SABIN, FLORENCE RENA (1871–1953)
Florence Sabin, born in 1871, is regarded as one of the outstanding woman scien-
tists in the medical field in the first half of the 20th century. Sabin was the first female
professor at Johns Hopkins School of Medicine, the first female elected to the National
Academy of Sciences, and the first female to direct a department at the Rockefeller
Institute for Medical Research. After ground-breaking discoveries in the lymphatic
system and tuberculosis, Sabin focused on reorganizing public health in Colorado.
In 1951, she was awarded the prestigious Lasker Award for public service.
Florence Rena Sabin was born on November 9, 1871, in Central City, Colorado.
Her mother, Rena (Miner), was a schoolteacher from Vermont who taught in the
South u ntil the Civil War (1861–1865), before moving west. Florence’s father,
George Kimball Sabin, was from a prestigious New E ngland family. He abandoned
his plans to study medicine following the gold rush and becoming a mining engi-
neer. Florence attended school at the Vermont Academy at Saxton’s Rover, Vermont.
In 1893, she graduated from Smith College with a bachelor of science degree. She
hoped to study medicine. However, many medical schools did not accept females,
and George Sabin did not have the funds to send his daughter to medical school.
Dr. Grace Preston, the resident physician at Smith College, told Sabin that Johns
Hopkins was trying to start a medical school with the aid of a group of prominent
women. The founders gave two conditions. The medical school must have high
standards for admission and must accept women who met the entrance criteria.
With the plan to save money for medical school, Sabin returned to Colorado and
taught mathematics at Wolf Hall in Denver. In Denver, Sabin also worked as a
private tutor, teaching the children of Ella Strong Denison. A wealthy philanthro-
pist, Denison partially supported Sabin through medical school. Sabin returned to
Smith College where she worked during the school year as a substitute teacher and
during the summer as a researcher at the Biological Laboratory in Woods Hole,
Massachusetts.
When Sabin attended Johns Hopkins Medical School, she found gender stereo
types were not completely eliminated. All of the professors w ere male, and many
refused to mentor female students on the assumption that the w omen would only
drop out of medicine and have babies. Female students w ere easily overlooked for
valuable clinical and research opportunities. Dr. Franklin Mall, chair of the Anat-
omy Department, noticed that Sabin showed great interest in research. He encour-
aged her to study the controversial topic of the origin of the lymphatic system.
Injecting lymphatic channels with India ink, Sabin showed that the vessels derived
550 SABIN , FLO R ENCE RENA
from the venous system. Sabin

published her first paper and
continued research into the brain
anatomy of newborns, leading
to several publications before
graduation.
Sabin received her medical
degree in 1900 and chose to
continue in research and teach-
ing. Her major areas of research
were lymphatic vessels, red and
white blood cells, development
of supravital staining techniques
for living cells, and the identifi-
cation of the monocyte as a defin-
itive type of white blood cell. In
1902, Johns Hopkins Medical
School appointed her as the first
female instructor, and by 1917
she had advanced to full professor.
After retiring from her prestigious career at the A few months a fter her promo-
Rockefeller Institute for Medical Research in New tion, her mentor, Dr. Mall, died.
York, Dr. Florence Rena Sabin returned to her native Sabin seemed a natural choice
Colorado where she completely reorganized the State for the chair’s position. However,
Board of Health. (National Library of Medicine)
Johns Hopkins administration
passed her over and awarded the
position to Sabin’s student Lewis Weed. Other current and former students were
furious. Many assumed she would leave Johns Hopkins. However, she stayed with
the explanation that she had research projects in progress. In 1925, Simon Flexner
convinced Sabin to leave Johns Hopkins to direct the new Department of Cellular
Studies at the Rockefeller Institute.
The Rockefeller Institute was modeled a fter the Pasteur Institute in France
and the Koch Institute in Germany. Offering a well-equipped research laboratory,
decent salary, and freedom from teaching responsibilities and university poli-
tics, the Rockefeller Institute attracted the best U.S. scientists. Sabin studied
the role of white blood cells in fighting infections. Her research led to a major
interagency project studying the body’s response to tuberculosis. Although the
scientists were unable to find a cure for tuberculosis, they did gain benchmark
discoveries into the anatomy and physiology of the immune system. Living in
New York, Sabin enjoyed an active social life of concerts, museums, and dinner
parties.
Sabin retired from the Rockefeller Institute in 1938 and returned to her native
Colorado where she wrote up her research, traveled, and served on several
SA B IN , F LO R EN C E R ENA 551
foundations, including the Henry Strong Denison Foundation. In 1944, the governor
of Colorado was establishing a postwar committee on health. He wanted a w oman
who would not challenge the status quo to lead the group. A journalist from the
Denver Post recommended the l ittle old lady, except, Sabin was not unfamiliar with
public health. She had volunteered at a w oman’s health clinic in Baltimore and
worked closely with public health departments on the tuberculosis project. On
appointment, Sabin immediately applied her research skills and infectious disease
training to Colorado’s public health system. Her first project was to conduct health
surveys of Colorado residents and to consult with public health experts. The sur-
veys showed high morbidity and mortality rates. Yet, state funding for public health
allocated less than ten cents per person per year. Sabin wrote and introduced sev-
eral pieces of public health legislation to address the poor health care systems in
the state. The “Sabin Bills” reorganized Colorado’s State Board of Health so that
administrative positions in the board could not be used as political patronage
appointments; provided district health services using federal, state, and local funds;
increased the stipends for indigent hospitalized tuberculosis patients; and gave pro-
visions so that the Department of Public Health could obtain funding for the con-
struction of new hospitals u nder the Hill-Burton Act. In December 1947, Sabin was
appointed manager of Denver’s Department of Health and Charities. In the most
populated city of Colorado, Sabin worked on improving sanitation in restaurants
and hospitals, regulating the milk industry to ensure safe, uncontaminated milk, and
reducing industrial contamination of waterways. She finally retired in 1951 and died
on October 3, 1953, a fter a prolonged case of pneumonia.
Sabin was recognized for many scientific and public health accomplishments.
She was the first w oman elected to the National Academy of Sciences (1925) and
the first female president of the American Association of Anatomists (1924–1926).
She received honorary degrees from a dozen universities. Among her other honors
and awards w ere the National Achievement Award (1932), the M. Carey Thomas
Prize (1935), the Trudeau Medal of the National Tuberculosis Association (1945),
and the Albert Lasker Public Service Award (1951). A bronze statue was placed in
her honor in Statuary Hall in Washington, DC. In addition to her numerous scien-
tific papers, she was the author of An Atlas of the Medulla and Mid-Brain (1901) and
Biography of Franklin Paine Mall (1934). She was a member of the American Asso-
ciation for the Advancement of Science, the American Physiological Society, the Soci-
ety for Experimental Biology and Medicine, the Harvey Society, and the National
Tuberculosis Association, and an honorary member of the New York Academy of
Sciences. In public health, Sabin is credited with reorganizing Colorado’s public
health system to ensure that positions in a state public health department are not
used as a reward for political contributions or support.
Tiffany K. Wayne and Sally Kuykendall
See also: Health Policy; Infectious Diseases

552 SALK , JONAS
Further Reading
Andriole, V. T. (1959). Florence Rena Sabin—Teacher, scientist, citizen. Journal of the His-
tory of Medicine & Allied Sciences, 14(3), 320–350.
Dunn, E. C. (2011). The pasteurized state: Milk, health and the government of risk. Endeav-
our, 35(2/3), 107–115. doi:10.1016/j.endeavour.2011.06.004
National Institutes of Health. The Florence R. Sabin Papers. Profiles in Science, National Library
of Medicine. Retrieved from http://profiles.nlm.nih.gov/RR.
Sabin, F. R. (1947). P eople win for public health in Colorado. American Journal of Public
Health, 37, 1311–1316.
Sabin, F. R. (1948). Ailments of health departments. American Journal of Public Health, 38,
1508–1511.
Sabin, F. R. (1952). Trends in public health. American Journal of Public Health, 42,
1267–1271.
Wayne, Tiffany K. (Ed.). (2010). American w omen of science. Santa Barbara, CA: ABC-CLIO.
SALK, JONAS (1914–1995)

Jonas Salk developed the first safe and effective vaccine against poliomyelitis (polio).
Polio is a devastating illness that primarily affects c hildren. The deadly virus moves
rapidly, attacking the nervous system. Five to ten p ercent of polio victims died due
to respiratory muscle paralysis (World Health Organization, 2016). The introduc-
tion of the inactivated polio vaccine in 1955 was one of the most important public
health advances of the 20th century.
Salk was born on October 28, 1914, in New York City to Russian immigrant
parents. He was a young child during the beginnings of epidemic polio. He attended
New York University School of Medicine and became a physician, but he was drawn
to research rather than to direct patient care. Salk’s interest in virology (the study
of viruses) was piqued by a lecture in medical school. The lecturer stated that the
only way for a person to become immune to a viral disease was to suffer the dis-
ease, b ecause a killed vaccine would not work on viruses. The lecturer also said
that it was possible to make a person immune to the bacterial disease diphtheria by
inoculation with a vaccine made from killed bacteria. Salk felt that the statements
were contradictory. Both statements could not be true.
After completing his medical training, Salk entered the University of Michigan’s
School of Public Health working as assistant professor of epidemiology and research-
ing influenza virus. In 1947, biochemist and virus researcher Max Lauffer recruited
Salk to move to the University of Pittsburgh. In a note of reference, Salk’s former
laboratory supervisor at Columbia Medical School described his former student,
“[Salk] showed a high aptitude for experimental work . . . Casual encounters since
that time have left me with the impression that he has continued to be very fond
of himself” (Pitz, 2014). Salk became director of the virus research laboratory and
professor in bacteriology (1949–1954) and preventive medicine (1954).
Salk obtained a research grant to participate in a poliovirus-typing project com-
missioned by the National Foundation for Infantile Paralysis (NFIP). Scientists across
SAL K , JONAS 553
the country w ere in a race to find

a safe and effective polio vaccine.
Albert Sabin’s vaccine used atten-
uated (weakened) forms of all
three polio serotypes while Jonas
Salk used the most deadly Type 1
(Mahoney) poliovirus. Salk’s lab
adopted a new technique that
allowed the growth of the virus
on monkey kidney tissue. Poliovi-
rus could suddenly be grown in
large amounts with less time,
money, and monkey specimens.
Salk deactivated (killed) the virus
with formalin so that the body
still produced antibodies, but
there was no possibility of trans-
mitting disease. A fter successfully
testing the vaccine in rhesus mon-
keys, a small trial was conducted
with previously infected c hildren.
In 1953, 35,592 Americans
were infected with polio, result- Dr. Jonas Salk tests his polio vaccine in a large-scale
ing in 1,450 deaths and 15,648 placebo-controlled trial of 1.8 million children.
When Salk’s vaccine was pronounced “safe, effective,
cases of permanent paralysis and potent,” church bells rang and air-raid sirens
(Freyche & Payne, 1956). The shrieked. (Library of Congress)
following year, Salk commenced
a placebo-controlled trial of the
vaccine with 1.8 million children. When Salk’s vaccine was pronounced “safe,
effective, and potent,” church bells rang and air raid sirens shrieked. However, the
joy was short-lived. Within a few weeks of the start of the nation’s mass immuniza-
tion campaign, six children immunized with vaccine from Cutter Laboratories
became paralyzed. Although the Cutter vaccine had passed government safety stan-
dards, some of the potent Mahoney virus had survived the manufacturing process,
causing an estimated 40,000 cases of polio, including 200 cases of paralysis and 10
deaths (Fitzpatrick, 2006). The Cutter cases revealed serious flaws in manufacturing,
bottling, and quality assurance testing. The government revised safety standards and
resumed the polio vaccination program in the fall of 1955. Five years a fter introduc-
tion of the Salk vaccine, the incidence of poliomyelitis cases dropped 90 percent, and
the vaccine proved to be safe, potent, and effective. In September 2015, world health
experts announced the worldwide eradication of Type 2 polio, and the last cases of
Type 3 wild poliovirus were seen in November 2012. The Global Polio Eradication
Initiative is working to eradicate polio throughout the world.
554 SAN G E R , M ARG A RET LOUISE HI GG INS
In 1960, Salk established the Salk Institute in California, a nonprofit research

institution devoted to biological research related to health. After his work on the
polio virus, Salk began research on the AIDS virus and contributed his remaining
career in search of a cure. Salk died in La Jolla, California, on June 23, 1995.
Lara J. Kunschner and Sally Kuykendall
See also: Cutter Incident, The; Infectious Diseases; Polio; Roosevelt, Franklin Delano;
Vaccines; World Health Organization; Controversies in Public Health: Controversy 3
Further Reading
Blum, N., Katz, E., & Fee, E. (2010). Professor Natan Goldblum: The pioneer producer of
the inactivated poliomyelitis vaccine in Israel. American Journal of Public Health, 100(11),
2074–2075. doi:10.2105/AJPH.2010.192922
Bredeson, C. (1993). People to Know. Jonas Salk: Discoverer of the polio vaccine. Berkeley
Heights, NJ: Enslow.
Byrne, J.P. (Ed.). (2008). Encyclopedia of pestilence, pandemics, and plagues. Westport, CT:
Greenwood.
Fitzpatrick, M. (2006). The Cutter incident: How America’s first polio vaccine led to a grow-
ing vaccine crisis. Journal of the Royal Society of Medicine, 99(3), 156.
Freyche, M. J., & Payne, A. M. (1956). Poliomyelitis in 1954. Bulletin of the World Health
Organization, 15(1–2), 43–121.
Global Polio Eradication Initiative. (2017). History of polio. Retrieved from http://
polioeradication.o rg/polio-t oday/history-o f-polio.
Kluger, J. (2004). Splendid solution: Jonas Salk and the conquest of polio. New York: G. P. Put-
nam’s Sons.
Martin, W. (1977). Medical heroes and heretics. Old Greenwich, CT: Devin-Adair.
Offit, P. A. (2005). The Cutter incident: How America’s first polio vaccine led to the growing vac-
cine crisis. New Haven, CT: Yale University Press.
Pitz, M. (2014, May 21). Letters reveal how Pitt recruited Dr. Jonas Salk. Pittsburgh Post-
Gazette (PA).
Salk, J. E. (1951). Direction of research on vaccination against influenza. American Journal
of Public Health, 41, 669–677.
World Health Organization. (2016). Poliomyelitis. Retrieved from http://www.who.int/topics
/poliomyelitis/en.
SANGER, MARGARET LOUISE HIGGINS (1879–1966)

Margaret Sanger was a social reformer who advocated for the right of poor men
and women to control the number and spacing of their c hildren. As a visiting nurse,
Sanger witnessed hemorrhage, sepsis, and deaths that resulted from self-induced and
backstreet abortions. Determined to stop the unnecessary fatalities, Sanger provided
sex education through news columns and pamphlets. Through multiple arrests
and prosecutions, Sanger persevered and started the nation’s first birth control
clinic. In the end, public opinion and the demand for birth control overruled
SANG E R , M A R G A R ET LOUISE HIG G INS 555
regulations. T oday, f amily planning and women’s reproductive health are one of
the greatest health achievements of the 20th century.
Margaret was born on September 14, 1879, in Corning, New York, to Anne
Purcell and Michael Hennessey Higgins. Mr. Higgins was a stone carver, sculpting
angels for tombstones. When he declared himself an atheist, local churches ostra-
cized him. In her autobiography, Margaret recalled life as the sixth of 11 children
of Irish immigrants: “Very early in my childhood, I associated poverty, toil, unem-
ployment, drunkenness, cruelty, quarreling, fighting, debts, and jails with large
families” (Sanger, 1931, p. 5). Despite family dysfunction, Michael taught his
children to stand up for what they believed in and to accept the consequences of
those beliefs. Margaret’s m other, Anne, died at the age of 48 from tuberculosis, a
bacterial infection of the lungs that causes severe muscle wasting. Margaret blamed
her father for her m other’s death. Pregnant 18 times, including seven miscarriages,
Anne was very frail and weak when she died. Margaret decided to become a nurse,
caring for pregnant women. She started her studies at Claverock College and
Hudson River Institute before transferring to the nursing program at White Plains
Hospital.
Before graduating from nursing school, Margaret married architect William
Sanger. She contracted tuberculosis the following year and, like her mother, strug
gled with the wasting disease for the rest of her life. The c ouple moved to Hastings-
on-Hudson where they had three c hildren—Stuart, Peggy, and Grant. William was
happy in the suburbs, but Margaret yearned for the intellectual stimulation of the
city. In 1910, the family moved to New York City (NYC). Margaret worked as a visit-
ing nurse on the Lower East Side, and William struggled as a painter. The couple
immersed themselves in the life, activities, and culture of Greenwich Village. Marga-
ret joined the Liberal Club and the W omen’s Committee of the New York Socialist
Party, taking part in many pickets and worker strikes.
Margaret’s patients were a continual reminder of her own childhood of poverty,
immigrant health, food insecurity, and competition for food and resources within
the family. In July 1912, truck driver Jack Sachs called Sanger to attend to his
wife, Sadie Sachs. Mrs. Sachs was 28 years old, pregnant, and the mother of three
children. Jack barely earned enough to support the f amily. Mrs. Sachs had attempted
a self-abortion and almost died. Sanger provided around the clock care for three
weeks. As the young woman recovered from severe sepsis, she asked the doctor
how she could avoid another pregnancy. The doctor responded that Jack should
sleep on the roof. Three months later, Jack Sachs called Sanger again. Sanger
recalled:
His wife was sick again and from the same cause . . . Mrs. Sachs was in a coma and
died within ten minutes. I folded her still hands across her breast, remembering
how they pleaded with me, begging so humbly for the knowledge which was her
right . . . Jake was sobbing, running his hands through his hair and pulling it out
like an insane person. Over and over again he wailed, “My God! My God! My God!”
(Sanger, 1931, p. 900)
556 SAN G ER , M ARGARET LOUISE HIGGINS
Sadie Sachs was one of more than 2 million w omen who attained illegal abortions
each year in the United States. Another 25,000 w omen died in childbirth while
others committed suicide (Coigney, 1969). Sanger decided to shift her attention
from treating abortions to preventing abortions, a public health principle known
as upstream.
Sanger wrote a series of seven news articles on female reproduction and sex edu-
cation. The articles, entitled “What Every Girl Should Know,” were published in
the socialist newspaper, the New York Call. However, when Sanger attempted to
publish an article on syphilis and gonorrhea, the New York Call rejected it. Under
federal Comstock Law (1873), information on sex education, prevention of con-
ception, and abortion was illegal and banned from distribution by the U.S. Post
Office. The chief proponent of the law, Anthony Comstock, served as special agent
to the post office. Rather than drawing a salary, he kept a portion of the fines gath-
ered from violations. Comstock was relentless in seeking offenders. Storekeepers
who left mannequins unclothed in store windows were liable to prosecution. Med-
ical schools could not send books through the mail. Doctors, such as the Sachs’s
doctor, w
ere banned from discussing birth control with one exception. They could
counsel men on the use of condoms as a way to prevent sexually transmitted
infections.
On October 27, 1916, women with baby carriages queue for birth control outside Margaret
Sanger’s clinic at 46 Amboy Street in Brooklyn, New York. Police raided the clinic multiple
times, arresting Sanger, confiscating medical records, and holding patients until they gave
names and addresses. (Library of Congress)
SANG E R , M A R G A R ET LOUISE HIG G INS 557
Sanger viewed birth control as a human rights issue and a w omen’s rights issue.
She tried collaborating with the suffragettes and with labor groups. However, the
groups w ere focused on their own c auses, and birth control seemed too radical. In
1914, the Sanger family traveled to France. William studied art while Margaret inves-
tigated birth control in Europe. Within a month, Margaret returned to the United
States and began publishing a monthly newspaper, The Woman Rebel. The publica-
tion was the first to introduce the term “birth control.” She was immediately con-
victed and indicted on three counts of violating Comstock Law. Facing 45 years in
prison, Sanger fled to E ngland. However, as she left the United States, she signaled
a printer to distribute 100,000 booklets. Family Limitation detailed the various birth
control methods she had learned about in France and England. Back in Europe,
Sanger met with birth control experts, toured health clinics, and prepared birth con-
trol brochures in multiple languages. She once again joined with groups of artists
and authors, a lifestyle that resulted in multiple extramarital affairs and raised ques-
tions of whether her efforts w
ere for her own benefit. Margaret eventually sent a letter
to William asking for a divorce. Ironically, Comstock was setting a trap for William.
He tricked William into giving away his last copy of Family Limitation. William was
jailed for 30 days but refused to reveal his wife’s location.
When Peggy—the Sanger’s six-year-old daughter—contracted pneumonia, Mar-
garet returned earlier than planned. Despite intensive nursing care by Margaret, Peggy
died. Margaret became despondent. Her crusade for birth control was partially driven
by a desire to make a better life for Peggy. With Sanger back in the states, Comstock
was seeking aggressive prosecution. He wanted Sanger to serve five years of hard
labor for each copy of Family Limitation. However, he underestimated the power
of public opinion. By now, the majority of Americans favored birth control. And
the news images of a pale, tiny woman suffering from a lifetime of tuberculosis and
despondent over the death of her d aughter attracted public sympathy. The govern-
ment dropped all charges against Sanger.
In 1916, Sanger opened the first birth control clinic in the United States. The
location was carefully selected based on invitations from the community and mater-
nal health data from the NYC Board of Health. A patron living in California donated
$50 for rent. A sympathetic landlord gave discounted rent of 46 Amboy Street in
Brooklyn and even helped paint the clinic rooms. The Brownsville clinic staff con-
sisted of Margaret Sanger, Ethel Byrne (Sanger’s s ister who was also a nurse), and
Fania Mindell (a translator). The opening was well advertised with 5,000 flyers
printed in English, Italian, and Yiddish. Sanger contacted Brooklyn’s district attor-
ney to let him know she intended to distribute birth control information. Clients
traveled from New Jersey, Pennsylvania, Massachusetts, and Connecticut. Women
who were unable to come sent their husbands in their place. On the first day, the
staff saw 100 w omen and 80 men ( Jacobs, n.d.). Women with baby carriages lined
the street waiting for care. Sanger was prepared for any legal consequences. The
police raided the clinic multiple times, arresting Sanger and the o thers, holding
patients in the waiting rooms until they gave their names and addresses, and
558 SAN G ER , M ARGARET LOUISE HIGGINS
confiscating medical records. Each time, Sanger paid her bail and reopened the
clinic. After nine days, the clinic closed. Once again, the case attracted public
attention. Sanger was convicted and served 30 days in jail. Byrne was sentenced to
30 days and immediately went on a hunger strike. The hunger strike attracted even
more attention. When Byrne became seriously ill, the governor pardoned her. Min-
dell was convicted and fined. The case resulted in a landmark ruling that allowed
physicians to provide medically indicated birth control information. This meant
that doctors could legally run birth control clinics. Unfortunately, the Comstock
Law had stymied medical training. Doctors did not know how to counsel patients
on birth control. Margaret hired a physician to travel around the country to edu-
cate doctors. They collected a list of 20,000 doctors willing to provide counseling
on birth control. W omen wrote to Sanger from across the nation, seeking advice on
where and how to find information on birth control. In 1921, Sanger founded the
American Birth Control League, the organization that eventually became Planned
Parenthood.
In 1922, Sanger married J. Noah Slee. The millionaire president of Three-in-One
Oil Company and a conservative church leader, Slee was an unlikely match for the
headstrong, adventurous younger woman. The relationship did not deter Marga-
ret’s activities. In 1923, she opened a birth control clinic with Dr. Hannah Stone.
Stone worked without pay and used the opportunity to collect data. Stone discov-
ered that out of 1,655 clinic patients, 1,434 (87 percent) had self-aborted, and one
woman reported self-aborting 40 times (Gray, 1979). The finding that nearly 9 out
of 10 w omen reported self-aborting was eye-opening to the medical establishment.
As information on birth control became accessible, demand for birth control meth-
ods increased. Yet, there w ere no suppliers in the United States. Sanger arranged
for diaphragms to be shipped from Germany to Canada and smuggled them across
the U.S. border in Three-in-One Oil boxes. In 1929, the police raided Sanger’s clinic,
collected the names and addresses of patients, and confiscated medical records. This
time, the medical establishment stepped in, criticizing the police for violating doctor-
patient confidentiality.
After World War II, the major opponent of birth control was the Catholic Church.
The public generally accepted birth control. However, the cost of a diaphragm was
prohibitive, and the device was awkward for some w omen. Sanger envisioned an
inexpensive pill. The major pharmaceutical companies did not believe that women
would take a pill every day of their lives for something that was not related to dis-
ease. With the financial support of Katharine Dexter McCormick (1875 II, the major
opponent of birist capable of developing an oral contraceptive. Dr. Gregory Pincus
was a struggling chemist who was denied tenure at Harvard for his controversial
experiments with in vitro fertilization. Using a formula by G. D. Searle Pharmaceu
tical Company, Pincus developed and tested the pill. The U.S. Federal Drug Admin-
istration approved the pill for use in 1960.
Margaret Sanger was a pioneer in women’s reproductive health. Contrary to fed-
eral laws that viewed sex education as crude and vulgar, Sanger embraced h uman
S C HOOL HEALTH 559
sexuality and worked to empower both men and w omen to control reproduction.
Sanger’s investment in health education, contraception, and w omen’s rights created
a system of care that prevents 1.9 million pregnancies per year and reduces the
demand for elective abortions (Guttmacher Institute, 2016). The ability to control
reproduction improves women’s health, frees women to pursue career and volun-
teer opportunities, and interrupts the poverty and stress of disadvantaged families.
Sally Kuykendall
See also: Dunham, Ethel Collins; Family Planning; Healthy People 2020; Infant Mor-
tality; Maternal Health; Planned Parenthood; Prevention; Social Determinants of
Health; Upstream Public Health Practices; W omen’s Health; Controversies in Public
Further Reading
Centers for Disease Control and Prevention (CDC). (1999). Achievements in public health,
1900–1999: Family planning. Morbidity and Mortality Weekly Report, 48(47), 1073.
Centers for Disease Control and Prevention (CDC). (2017). Maternal and infant health.
Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/.
Coigney, V. (1969). Margaret Sanger: Rebel with a cause. Garden City, NY: Doubleday.
Gray, M. (1979). Margaret Sanger: A biography of the champion of birth control. New York:
Richard Marek.
Guttmacher Institute. (2016). Publicly funded family planning services in the United States.
Retrieved from https://www.guttmacher.org/fact-sheet/publicly-funded-family-planning
-services-united-states.
Jacobs, E. (n.d.). Places that matter: Margaret Sanger Clinic (former). Retrieved from http://
www.placematters.net/node/1329.
New York University. (n.d.). The Margaret Sanger Papers Project. Retrieved from http://www
.nyu.edu/projects/sanger/.
Sanger, M. (1931). My fight for birth control. New York: Farrar & Rinehart.
Wardell, D. (1980). Margaret Sanger: Birth control’s successful revolutionary. American Jour-
nal of Public Health, 70(7), 736.
SCHOOL HEALTH
School health is an important topic in the United States and has been a special part
of public health for over the past 100 years. More recently, there has been much
discussion of the establishment of comprehensive school health programs (CSHPs).
A push for CSHPs has emphasized both the public health and the educational advan-
tages of such programs. From an educational standpoint, CSHPs improve students’
academic performance and thus the employability and productivity of future citi-
zens. From the public health perspective, CSHPs are an important way to decrease
morbidity and mortality in school age populations and also to impact health care
560 SC HOOL HEALTH
expenditures. One important aspect of school health programs is that one-third of

the objectives in public health approaches such as the Healthy People projects are
either directly attained or significantly influenced through schools (Institute of
Medicine, 1997). T here are often three different aspects of school health programs:
traditional provision of limited health care services to children during the school
day often through the services of a school nurse, health education provided to
children through the school setting (sometimes with the help of a school nurse or
through the efforts of classroom teachers), and, more recently, school-based com-
prehensive clinics.
Some of the same arguments in support of the importance of general child health
programs also relate to school health. If c hildren are healthy, they are more likely
to be ready and able to learn and, as adults, to be healthy and able to contribute to
the workforce and the overall vitality of society. In earlier eras, disease and death in
children were due largely to infections. During this time period, childhood deaths
were common, and there was concern over the spread of infectious disease within
a school setting. Over the past century, both childhood mortality and infectious
disease rates in the United States have been drastically lowered, so it is now uncom-
mon for a child to die in childhood, whereas 150 years ago many families experi-
enced the death of at least one child. In addition, in the United States, at least from
age five on, children spend a large proportion of their waking hours in a school
setting. Participation in public schools is one of the most commonly shared experi-
ences in society.
One of the founders of modern nursing in the United States, Lillian Wald (1867–
1940), was also recognized as the first school nurse in the United States. She worked
in New York City in the poorer sections of the city. New York City was one of the
first cities with mandatory school attendance laws and also had a large number of
immigrant c hildren with health care problems. From their efforts, the idea of gen-
eral physical evaluations of c hildren became more common, and New Jersey was
the first state to require this by law in 1910. The poor health of some Americans
had become evident during World War II (1939–1940) with high rejection rates of
recruits into the military service due to health problems. In 1946, partially as a
response to this, the National School Lunch Act was passed to promote better
childhood nutrition and thus improve child health.
As immunizations became a more important part of the health of c hildren, laws
for mandatory immunization for school entrance became important, and often the
school nurse had to help enforce these requirements. By the 1950s, often school
nurses w ere very busy with school health examinations, including screening for
vision and hearing deficits, and keeping immunization records. Another major role
of school nurses is first aid and the evaluation of sick children. As concern about
child abuse has grown, identification of violence-related injuries treated in the school
setting has become another important task for school nurses (Igoe, 1994).
Another part of school health is a comprehensive health education program.
Such programs are an important part of the curriculum in most school districts.
Classroom teachers in lower grades have always included some health content in
S C HOOL HEALTH 561
their teaching throughout the year. Programs generally start in kindergarten and
continue through high school, and focus on providing an introduction to the
human body and to factors that prevent illness and promote or damage health.
National standards for such programs were established in the 1990s and have
helped school districts create better curriculum content in the area of health.
There has been a growth in evidence-based programs and evaluation of the con-
tent of educational programs in school health. In recent decades, more of the focus
has been on elementary and middle schools, as the emphasis on more advanced
courses has become one focus of changes in high school education in the United
States.
Beginning in the 1980s and increasing in the 1990s, there was a move to pro-
vide more comprehensive school-based clinics in some schools. Groups such as the
American Public Health Association created a Center for School, Health and Edu-
cation in 2010 to advocate for and help organize school-based health care as a com-
prehensive strategy for preventing school dropouts and improving graduation
rates for K–12 students. School-based health clinics grew from 31 in 1984 to 327 in
1991 to over 500 in 1992 (Kronenfeld, 2000). In 2004, the W. K. Kellogg Founda-
tion launched a six-year initiative to expand school-based health care. Such clinics
were included as a safety net provider in the 2009 Child Health Insurance Reau-
thorization Program, formerly SCHIP. The expansion of health care insurance cov-
erage for children with the passage of the Affordable Care Act (ACA) u nder President
Barack Obama made school-based clinics less important, especially in states that
adopted the Medicaid expansions. The future of the ACA is currently uncertain, as
are issues related to comprehensive school-based clinics.
Another area of uncertainty and problems in school health is the decline in school
nurses, especially those with training at the registered nurse (RN) level. Since the
early 2000s, and even more so since the G reat Recession (roughly 2007–2012), the
number of school nurses has been declining. Less than half of the country’s public
schools employ a full-time nurse, and in some of the worst cases—largely in poor,
urban school systems—there’s only one school nurse for e very 4,000 students (Cam-
era, 2016). This is another area of concern for the future in the school health area.
See also: C
hildren’s Health; Community Health; Evidence-Based Programs and Prac-
tices; Health Education; Wald, Lillian; Controversies in Public Health: Controversy 5
Further Reading
Camera, L. (2016, March 23). Many schools don’t have enough school nurses. U.S. News &
World Report online. Retrieved June 30, 2017, from https://www.usnews.com/news
/articles/2016-03-23/the-school-nurse-scourge.
Centers for Disease Control and Prevention. Healthy Schools. Retrieved from https://www
.cdc.gov/healthyschools.
Centers for Disease Control and Prevention. (2011). School health guidelines to promote
healthy eating and physical activity. Morbidity and Mortality Weekly Report, 60(5), 1–78.
562 SEL F-E FFIC ACY
Igoe, J. B. (1994). School nursing. Nursing Clinics of North America, 29, 443–458.
Institute of Medicine. (1997). 6 Challenges in school health research and evaluation. Schools
and health: Our nation’s investment. Washington, DC: The National Academies Press.
doi:10.17226/5153
Kronenfeld, J. J. (2000). Schools and the health of children: Protecting our future. Thousand
Oaks, CA: Sage.
SELF-E FFICACY
Self-efficacy is the personal belief that one is capable of performing the tasks
necessary to attain a desired goal (Bandura, 1977, pp. 191–215). Self-efficacy is
an important principle in public health because public health practitioners are
constantly striving toward teaching p eople new skills and behaviors that w ill
promote and maintain health. The concept of self-efficacy focuses less on the
actual behavioral objective and centers on the individual’s beliefs regarding his or
her own ability to both meet and accomplish the challenges associated with
attaining that objective. In the case of teaching individuals who are newly diag-
nosed with diabetes to measure and inject their own dose of the drug insulin, the
patients must believe that they have the ability to perform the skill. High self-
efficacy is related to a range of positive outcomes, including overall well-being
and approaching tasks with interest and commitment. In contrast, individuals
with low self-efficacy are more likely to avoid difficult challenges b ecause they
do not believe that they are capable of successfully accomplishing the necessary
task. In order to encourage healthy behaviors and treatment compliance, public
health professionals must understand, gauge, and promote self-efficacy among
the patients who they serve.
Self-efficacy is developed in three primary ways: through mastery experiences,
observing others who model the behavior, and persuasion (Bandura, 1986, pp. 359–
373). Mastery experiences are challenges that take moderate to high levels of per-
severance to accomplish a task. As a diabetic person is being taught to self-inject
insulin, it is common to practice inserting the syringe into an orange or other model.
In these situations, maintaining effort, even in the face of adversity, acts as evidence
and allows the person to realize that he or she can effectively accomplish the task.
A second pathway to develop self-efficacy is through observing o thers—social
models who maintain effort. The most effective model is someone who is similar to
the observers. Physical similarities suggest that they can also be successful in com-
pleting the task. This means that a child learning to self-inject insulin may be more
successful when the behavior is modeled by another child rather than an adult. A
third method to develop self-efficacy is through social persuasion. Social persuasion
occurs when the communicator attempts to change another person’s thoughts or
behaviors. In this instance, the public health professional attempts to convince some-
one that he or she is capable of performing the behavior. Persuasive messages are
most effective when they are realistic. Improbable messages are quickly discounted,
SEL F - EF F I C A CY 563
especially if the person attempts and fails in the task. Persuasive messages can
come from public health practitioners, medical professionals, and family members
and ultimately increase the person’s self-efficacy.
Perceived self-efficacy is appraised in three areas: magnitude and strength (van
der Bijl & Shortridge-Baggett, 2001, pp. 189–207) and generality (Lunenburg, 2011,
pp. 1–6). Magnitude is an external appraisal in which a person judges the level of
difficulty of the task. For example, a student might evaluate his or her psychology
exam to be moderately challenging. This assumed level of difficulty w ill accord-
ingly influence his or her perception of self-efficacy regarding studying for the test.
Strength is an internal appraisal referring to the level of confidence a person has
about his or her ability to successfully complete a task. For example, a student is
likely to judge his or her ability to effectively accomplish a goal-related task, such
as putting in the long hours to study for an exam. Generality is a global perception
of self-efficacy in which a person generalizes his or her expectations of self-efficacy
across situations. In this instance, generality refers to the expectation of a level of
self-efficacy in a range of tasks, not just one task. Together and individually, these
characteristics influence how one perceives one’s level of self-efficacy.
An important aspect of public health is empowering p eople to care for their own
bodies, minds, and spirits. This may include engaging in regular physical activity,
following a healthy diet, stopping smoking, or controlling anger and frustration.
Public health professionals can use the concepts of self-efficacy to ensure that the
patient realizes and appreciates the advantages of learning and practicing a specific
health behavior, that the behavior is appropriately modeled, and by encouraging
healthy behaviors through a variety of sources. Self-efficacy is an important princi
ple in determining and guiding self-care and healthy lifestyles.
Stephen K. Trapp
See also: Children’s Health; Diabetes Mellitus; Health Education; Locus of Control;
Social Cognitive Theory
Further Reading
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psycho-
logical Review, 84(2), 191–215.
Bandura, A. (1986). The explanatory and predictive scope of self-efficacy theory. Journal of
Social and Clinical Psychology, 4(3), 359–373.
Bandura, A. (1994). Self-efficacy. Hoboken, NJ: Wiley.
Bandura, A. (2012). On the functional properties of perceived self-efficacy revisited. Jour-
nal of Management, 38(1), 9–44.
Lunenburg, F. C. (2011). Self-efficacy in the workplace: Implications for motivation and
performance. International Journal of Management, Business, and Administration, 14(1),
1–6.
van der Bijl, J. J., & Shortridge-Baggett, L. M. (2001). The theory and measurement of the
self-efficacy construct. Research and Theory for Nursing Practice, 15(3), 189–207.
564 SHATTUC K , LEMUEL
SHATTUCK, LEMUEL (1793–1859)

By today’s standards, Lemuel Shattuck was a brilliant public health epidemiologist
with incredible stamina and vision. At the time that Shattuck lived, however, pub-
lic health was in its infancy, and official records of births, deaths, and diseases were
nonexistent or haphazard. A self-educated man, Shattuck nurtured and developed
many talents. He was a teacher, bookseller, publisher, researcher, and statistician.
He served as a member of the Massachusetts State Legislature, a member of the
Massachusetts Historical Society, and founder of the American Statistical Society.
In public health, he is recognized as the main researcher and author of the Report
of the Sanitary Commission of Massachusetts of 1850. Also known as The Shattuck
Report, the document collected statistics on the living conditions of Massachusetts
state residents and proposed ways to improve health through sanitation, regula-
tions on the quality of food and drugs, and community planning. Shattuck is con-
sidered the architect of the public health system in the United States. He designed
a framework for public health that was later a dopted by many states and towns.
C. E. A. Winslow described The Shattuck Report as “perhaps the most significant
single document in the history of public health.”
Lemuel Shattuck was born on October 15, 1793, in Ashby, Massachusetts. He
was the fifth of six children of Betsey (Miles) and John Shattuck. In 1794, the Shat-
tuck family relocated to southern New Hampshire where they purchased a farm.
The land was rocky and poor. The f amily labored to survive. The c hildren worked on
the farm, attending school only five or six weeks per year. John Shattuck worked
the farm during the day and as a shoemaker in the evening. Betsey Shattuck died
of consumption (tuberculosis) in 1798, and John remarried the following year. The
Shattuck children w ere self-taught, studying together as a group. Lemuel attended
Appleton Academy for only two quarters, enough for him to qualify as a teacher
and supplement the family income.
The summer of 1816 was particularly bad for farmers. Unseasonably cold weather
wrecked crops and forced many to migrate westward, including Shattuck. On his
travels, Shattuck worked as teacher, first in New York and then in Detroit. In Mich-
igan, he founded the first Sunday school. Direct interactions with students and their
families plus an insatiable curiosity gave him insights into the living and working
conditions of residents in the various places he lived. By 1823, Shattuck returned
to Massachusetts to help his brother manage a general store in Concord. Two years
later, he married Clarissa Baxter, and the c ouple eventually had five children. Man-
aging the store in Concord allowed Shattuck to pursue his passion of reading, studying,
and learning. He researched and wrote his first book, A History of Concord, Middle-
sex County Massachusetts, from the Earliest Settlement to 1832; and the Adjoining
Towns, Bedford, Acton, Lincoln and Carlisle; Containing Various Notices of County and
State History Not before Published, which was published in 1835. At the time, a book
on the history of Concord was not novel. T here w
ere several existing books on the
history of Concord. These works primarily reported church or town records. What
was novel about Shattuck’s book was the extent that he went to in order to gather
SHATTU C K , LE M UEL 565
information. Shattuck visited the towns and p eople of the area, gathered stories,
and documented interesting bits of information, which brought the tedious rec
ords to life. He did what is now known as field research or an oral history project.
In addition to compiling personal stories, Shattuck gave recommendations to
improve the living conditions of local residents. His research was concurrent with
serving on Concord’s school committee and gave him insights into improving the
school system. He is credited with organizing school finances and developing poli-
cies, including a plan for teachers to record and report academic lessons to the town
committee each year.
In 1834, the Shattuck family moved to Cambridge, Massachusetts, where he man-
aged a store. The following year, they moved to Boston where Shattuck worked as
a bookseller and publisher. He served on the City Council and the Massachusetts
General Court. Colleagues recalled that Shattuck was extremely conscientious in
his public duties. Whenever he was assigned to a committee or a project, he gave
it all of his effort. He firmly believed that data could be used to identify social prob
lems and to appropriately guide wise government policy. His pursuit of data led to
the creation of the American Statistical Association in 1839. Shattuck’s reputation
as a hard worker came at a price. Other members on a committee with Shattuck
would sit back and not work as hard. Shattuck often carried the weight of public
responsibilities.
Although the study of genealogy was frowned upon at the time, Shattuck enjoyed
researching his heritage. He traced his ancestors back to the original emigration to
America. This research was an enormous task because of the lack of official records
and high degree of population movement. And yet, Shattuck took the genealogical
research one step further by presenting stories of each of the six to eight genera-
tions. He created a system of genealogical research that became a model for o thers.
In 1841, he published A Complete System of Family Registration. In 1855, he pub-
lished Memorials of the Descendants of William Shattuck, the Progenitor of the Families
in America That Have Borne His Name; Including an Introduction and an Appendix Con-
taining Collateral Information. The following year, Shattuck published Blank Book
Forms for Family Registers, Devised and Constructed upon a New, Simple, and Compre-
hensive Plan; Containing Suggestions and Directions for an Improved System of Family
Registration, Designed for General Use in Every Family. Shattuck’s genealogical research
was not simply focused on recording f amily births and deaths. He cared deeply about
people. He believed that in presenting births, marriages, deaths, residences, illnesses,
social conditions, income, and anecdotes, he was giving evidence of h uman con-
nectedness and brotherly affection. His Memorial of the Descendants of William Shat-
tuck (1855) became a model for the preservation of family histories. His genealogical
research also impressed on him the need for a formal census.
In Boston, Shattuck successfully advocated for and organized a town census. In
1849, the Massachusetts governor and council requested that Shattuck, N. P. Banks,
and Jehiel Abbott prepare a census report on the sanitary conditions of the state.
Shattuck did most of the research and writing. The Report of the Sanitary Commission
566 SHATTUC K , LEMUEL
of Massachusetts of 1850 is considered one of the greatest documents in the history

of public health. In introducing the purpose of the report, Shattuck wrote:
We believe that the conditions of perfect health, e ither public or personal, are seldom
or never attained, though attainable; that the average length of human life may be
greatly extended, and its physical power greatly augmented; that in e very year within
this Commonwealth, thousands of lives are lost which might have been prevented; that
a vast amount of unnecessarily impaired health, and physical debility exists among
those not actually confined by sickness; that these preventable evils require an enor-
mous expenditure and loss of money, and impose upon the people unnumbered and
immeasurable calamities pecuniary, social, physical, m
ental, and moral, which might be
avoided; that means exist, within reach, for their mitigation or removal; and that mea
sures for prevention w
ill effect infinitely more than remedies for the cure of disease.
The report was divided into four parts. The first two sections presented the history
of the sanitary movement in France, Germany, England, and colonial America, with
a review of major epidemics. The third section presented statistical analyses of mor-
tality data by place, season, occupation, and cause followed by 50 recommenda-
tions for public health. The recommendations reflected a combination of thoughtful
long-range planning and common sense. The final section gave support for the rec-
ommendations and offered suggestions for state policies to support public health.
Prior to The Shattuck Report, boards of health w
ere small organizations that dealt
with acute epidemics and public nuisances. The Shattuck Report recommended:
• Establishing formal state and local boards of health.
• Sanitary surveys of other cities and towns.
• Uniform nomenclature for c auses of death.
• Collection of data on diseases including research of malaria and tuberculosis.
• Control of nuisances that affect health.
• Supervision of the construction of new buildings for safety.
• Sanitary requirements for schools and lodging h ouses.
• Periodic vaccinations for smallpox.
• Control of the sale of spoiled food, drink, and medicine.
• Quarantine measures.
The report recommended using civil engineering to promote health. Communities
should be planned with trees and green spaces for recreation, public walkways, and
access to clean air and water. Shattuck expressed concerns for the use of the crimi-
nal justice system in controlling mentally ill p
eople. He argued that p eople suffer-
ing from m ental illness should be turned over to the boards of health for care rather
than be put in jail. He also called for the education of nurses and specialty train-
ing in sanitary science. To put this in perspective, Shattuck’s report was pub-
lished in 1850. Florence Nightingale did not establish the first nursing school
until 1860. Finally, the report advocated for public health education. He envi-
sioned that clergy should speak to their congregations on public health issues at
least once a year. Shattuck estimated the annual cost of reducing preventable
S K IN C AN C E R 567
diseases in Massachusetts was $7,512,000 and requested $3,000 for the state board
of health. Despite the effort, foresight, and economic benefits, the recommendations
were initially disregarded. Dr. Henry Ingersoll Bowditch described Shattuck’s report
as falling “stillborn from the hands of the State printer.”
In 1869, Massachusetts established the first state board of health. Other states
quickly followed suit, and The Shattuck Report served as a valuable guide in defin-
ing roles and responsibilities of the new agencies.
Shattuck was a self-educated man, a teacher, an enthusiastic and focused vision-
ary, and man of high faith and morals. He believed in the value of data in defining
and charting social progress. His hard work helped to design a plan for arranging
and preserving public documents and f amily records. More importantly, he had the
wisdom and courage to call attention to social problems, filthy living conditions,
and disease, and the stamina to work t oward a vision of prosperity for all. The sani-
tary report increased awareness and helped to implement measures to provide clean
water and adequate ventilation, to safely dispose of sewage, and to restrict the sale
of unsafe food and drink. The Shattuck Report not only describes life in 1850 but
also provides the infrastructure for public health t oday.
Sally Kuykendall
See also: American Journal of Public Health; Bowditch, Henry Ingersoll; Food Safety;
Social Determinants of Health; State, Local, and Territorial Health Departments;
Winslow, Charles-Edward Amory
Further Reading
Shattuck, L. (1850). Report of the Sanitary Commission of Massachusetts. Cambridge, MA: Har-
vard University Press. Retrieved from https://archive.org/details/b21359131.
Smillie, W. G. (1949). Lemuel Shattuck, still a prophet. American Journal of Public Health,
39, 135–144.
Winklestein, W. (2008). Lemuel Shattuck: Architect of American public health. Epidemiol-
ogy, 19(4), 634.
SKIN CANCER
Prolonged exposure to the sun damages the skin and can result in tumors, disfig-
urement, and death. Over the past 50 years, skin cancer has steadily increased, espe-
cially in Australia, North America, and Northern Europe. An estimated one in five
Americans will develop some form of skin cancer in their lifetime. There are more
skin cancers in the U.S. population than all other cancers combined. Annual treat-
ment costs are estimated at $8.1 billion. In many areas of the country, there is lim-
ited access to dermatologists for treatment. To prevent skin cancer, the surgeon
general of the U.S. Public Health Service appealed to businesses, schools, commu-
nities, and federal, state, tribal, local, and territorial governments to increase public
awareness of skin cancer and to promote skin cancer prevention.
568 SK IN CANC ER
Skin cancer is classified into two main categories: nonmelanoma skin cancer
(NMSC), which includes basal cell carcinoma (BCC) and squamous cell carcinoma
(SCC), and melanoma, which is less common than NMSC representing less than
2 percent of all skin cancers, but is responsible for the majority of skin cancer–related
deaths. Of the NMSCs, 75 percent are BCC and the remaining 25 percent are SCC.
There are several well identified risk f actors for skin cancer. The most important
risk factor is the average annual ultraviolet (UV) radiation exposure received from
the sun or tanning beds. Most UV exposure occurs during childhood, before the
age of eight. Other known risk factors include occupational hazards and genetics.
Pilots, sailors, and farmworkers are just a few of the at-risk occupations due to pro-
longed exposure outdoors. Certain genetic phenotypes are at greater risk. P eople
with light complexion, blue eyes, and blonde or red hair have higher risk. Both
SCC and BCC are found more often in males than females. SCC and BCC are com-
monly found on the head, neck, and upper extremities.
Skin cancer is detected by a dermatologist performing a full body skin examina-
tion (FBSE). For every 400 patients screened, approximately one melanoma is
detected. Diagnosis is made by biopsy and pathological examination. The “ABCDEs”
guide is used to identify which lesions require biopsy. Asymmetry, irregular Bor-
ders, Color changes, Diameter greater than 6 mm, and Evolving or changing in
appearance suggests the need for biopsy. Several biopsy types are possible includ-
ing excisional, incisional, and shave. Excisional biopsies remove the entire lesion
in one section with margins. It results in a larger specimen for examination, but
also results in a larger scar. Incisional biopsies include punch biopsies that only
remove a piece of the lesion. Although this limits the scar, it also limits the amount
of material for exam. Shave biopsies are done for superficial lesions where the entire
lesion is removed by slicing u nder the lesion. It does not require suturing.
Skin cancer is treated by surgical excision, electrodessication, topical chemother-
apy, laser, radiation, or chemotherapy. NMSC are easily treated with local treatments.
Melanoma treatment requires precise diagnosis, staging, and excision. An excisional
biopsy is used to measure the depth of invasion, known as Breslow thickness. A
wide excision with 2-cm margins ensures the entire tumor is removed with a border
of adjoining healthy tissue. The five-year survival rate for early localized disease is
91 percent whereas advanced, metastatic disease has a poor prognosis. Advanced
melanoma is relatively resistant to chemotherapy, radiation, and immunotherapy.
Diagnosis and treatment should be performed by a board certified dermatologist,
surgeon, or primary care physician. In areas with poor access to medical care, doc-
tors use telemedicine, communicating through electronic means, including video, to
help diagnose and treat a suspected lesion.
Skin cancer is easily preventable. Unfortunately, in a large study of teenagers,
less than 40 percent regularly used sunscreen, 83 percent experienced sunburn in
the last year, and 33 percent experienced more than three sunburns. Only a minor-
ity of the survey respondents knew the correct amount of sunscreen to apply, the
need for reapplication, or the need to apply 30 minutes before g oing outdoors
S K IN C AN C E R 569
(Federman, Kirsner, & Viola, 2013). Regular daily sunscreen use is better at reduc-
ing skin cancer than discretionary application—only using sunscreen when the indi-
vidual feels it is needed (Green, Williams, Logan, & Strutton, 2011). Furthermore,
although sunscreen helps prevent SCC, it has little effect on BCC. The Surgeon Gen-
eral’s Call to Action to Prevent Skin Cancer recommends:
• Educating people about skin cancer so that they may take action to protect
their skin.
• Providing more opportunities for shade or sun protection in outdoor settings.
• Reducing the dangers of indoor tanning.
• Developing policies to advance skin cancer prevention.
• Advancing the science of skin cancer prevention through research, surveil-
lance, and evidence-based programs. (U.S. Department of Health and Human
Services, 2014)
A number of nonprofit, government, and professional organizations support pub-
lic service announcements (PSAs) to educate the public about the dangers of skin
cancer. Impact Melanoma, formerly the Melanoma Foundation of New England,
created PSAs, Tanning Is Out, Your Skin Is In, to highlight the dangers of tanning beds.
Practice Safe Skin: Skin Cancer Prevention Project provides brightly colored sunscreen
dispensers in convenient, high-traffic outdoor spaces, such as at beaches, parks,
day care centers, zoos, and golf courses. Skin cancer prevention is also integrated
into schools, workplaces, parks, and recreational facilities through policies that dis-
courage tanning and by providing adequate shaded areas.
Skin cancers are increasing in the United States and worldwide. Regular screen-
ing with early diagnosis and treatment can effectively take care of many of these
cases. However, not all cases are easily treated, and treatment can be expensive and
time consuming. To prevent skin cancer, physicians, dermatologists, and public
health professionals recommend regular application of sunscreen before g oing
outside, reapplication e very half an hour and after swimming or sweating, and min-
imizing overall exposure to UV radiation.
Erin Mathews and Neil Mathews
See also: Cancer; Intervention; Logic Model; National Cancer Institute
Further Reading
American Academy of Dermatology. Retrieved from https://www.aad.org.
Centers for Disease Control and Prevention. Skin cancer. Retrieved from https://www.cdc
.gov/cancer/skin/index.htm.
Federman, D. G., Kirsner, R. S., & Viola, K. V. (2013). Skin cancer screening and primary
prevention: Facts and controversies. Clinics in Dermatology, 31, 666–670. doi:10.1016/j
.clindermatol.2013.05.002
Geller, A. C., Oliveria, S. A., Bishop, M., Buckminster, M., Brooks, K. R., & Halpern, A. C.
(2007). Study of health outcomes in school c hildren: Key challenges and lessons learned
570 SM ALLPOX
from the Framingham Schools’ Natural History of Nevi Study. Journal of School Health,
77(6), 312–318.
Green, A.C., Williams, G. M., Logan, V., & Strutton, G.M. (2011). Reduced melanoma after
regular sunscreen use: Randomized trial follow-up. Journal of Clinical Oncology, 29(3),
257–263.
Impact Melanoma. Retrieved from http://mfne.org.
Kimbrough, C. W., et al. (2017). Melanoma and cutaneous malignant neoplasms. In C. M.
Townsend, Jr., R. D. Beauchamp, B. M. Evers, & K. L. Mattox (Eds.), Sabiston textbook
of surgery: The biological basis of modern surgical practice (20th ed., pp. 724–753). Phila-
delphia: Elsevier.
Kimbrough, C. W., McMasters, K. M., & Davis, E. G. (2014). Principles of surgical treat-
ment of malignant melanoma. Surgical Clinics of North America, 94(5), 973–988.
doi:10.1016/j.suc.2014.07.002
Soyer, H. P., Rigel, D. S., & Wurm, E. M. (2012). Actinic keratosis, basal cell carcinoma,
and squamous cell carcinoma. In J. L. Bolognia, J. J. Jorizzo, & J. V. Schaffer (Eds.),
Dermatology (pp. 1773–1793). Philadelphia: Elsevier.
U.S. Department of Health and H uman Services. (2014). The Surgeon General’s call to action
to prevent skin cancer. Retrieved from https://www.surgeongeneral.gov/library/calls
/prevent-skin-cancer.
SMALLPOX
Smallpox is a viral infection caused by one of two varieties of a virus subdivided as
Variola major and Variola minor. This microorganism takes a horrific toll on the
human body, first manifesting as a high fever followed by a distinctive, bumpy rash
with blistering of the skin, mouth, and throat. Mortality can range from 1 percent
in cases of Variola minor to more than 33 percent with Variola major. Death occurs
roughly a week and a half to two weeks a fter initial infection from a combination
of viremia (overabundance of virulent matter in the bloodstream), immune system
collapse, and heart failure. Historically, smallpox caused millions of deaths around
the world and decimated entire populations. Those who survived were often left
with permanent facial scars, blindness, or limb deformity. The discovery of small-
pox inoculation in the 18th century and later innovations in vaccination science
significantly decreased the number of cases, with a few notable exceptions. In 1950,
the Pan American Health Organization developed the goal of eradicating smallpox
in North, South, and Central America. Initial efforts w
ere promising, and effective
public health strategies were extended throughout the world. By 1979, the World
Health Organization (WHO) officially declared smallpox eradication. The eradica-
tion of smallpox is one of the leading public health accomplishments of all time.
This incredible feat was accomplished by all countries working together and using
thoughtful public health measures.
The variola virus is part of a family of orthopox viruses that characteristically
replicate in the cell’s cytoplasm instead of the nucleus. The f amily includes variola,
vaccinia, cowpox, and monkeypox. Although variola only infects h umans, vaccinia,
cowpox, and monkeypox are animal diseases that can also attack h umans. The
S M ALLPO X 571
majority of cases of smallpox are classified as ordinary, where the entire body begin-
ning with the forehead and face is covered by distinctive pustules that harden,
burst, and leave pockmarks on the skin. Less than 10 percent of cases are malignant
with softened, flat lesions that produce a high fever and toxemia, a profusion of
toxins in the bloodstream. Malignant cases nearly all result in fatality. Less than
3 percent of cases are hemorrhagic and characterized by lesions that bleed beneath
the skin, giving the body a black appearance, hence its common name black pox.
Hemorrhagic cases, like malignant ones, are nearly always fatal.
Smallpox is contracted in the same manner one catches other highly contagious
human-contact diseases. The virus is primarily transmitted through airborne inha-
lation or face-to-face contact with an infected person. Exposure to infected bodily
fluids or contaminated objects, such as clothing or blankets, can also act as a means
of transmission. Infected persons are highly contagious from the first appearance
of rash and blisters u ntil the last one disappears, a period lasting many weeks. In
order to eradicate smallpox, public health professionals had to break the chain of
transmission from the carrier or reservoir to other susceptible hosts. This interrup-
tion was achieved through disease surveillance. Public health epidemiologists stud-
ied the patterns of past smallpox epidemics and predicted where future outbreaks
were most likely to occur. Health professionals around the world and specifically
in high-risk areas w ere vigilant for patients with symptoms of smallpox. In 90 to
100 percent of cases, early, preeruptive (before the rash appears) symptoms are high
fever, headache, and backache. The classic smallpox rash starts as macules, small
red spots on the tongue and mouth. T hese spots turn into lesions that break open,
releasing viral particles into the mouth. The challenge for health professionals was
to quickly and accurately differentiate the macules from other childhood rashes,
such as chickenpox. Once potential cases were identified, the case was immedi-
ately reported for epidemiological tracking, the patient was isolated, and everyone
who came in contact with the infected individual was vaccinated, a strategy known
as ring vaccination. Normally, public health practices herd immunity where immu-
nizing a certain threshold of individuals effectively prevents the spread of that dis-
ease. With smallpox, 83 to 85 percent of individuals would have to be immunized
for effective herd immunity. With ring vaccination, 100 percent of individuals sur-
rounding the infected person are immunized. Ring vaccination provides a complete
blockade. The virus can no longer move from one host to the next. All bed linens
or other materials that came in contact with the patient’s open wounds are destroyed.
Smallpox could be either epidemic, striking in a particular area with a burst of
fatalities, or endemic, in which the disease reoccurs each year as part of everyday
life. The earliest historical cases of smallpox can be traced to the Indian subconti-
nent in 1500 BCE, China in 1122 BCE, and Egypt in 1145 BCE, where the disease
was endemic to t hese populations. It is less clear when smallpox arrived in Europe.
Some speculate about outbreaks in ancient Greece or Rome. The first direct refer-
ences date from the early M iddle Ages. By the 16th century, smallpox was endemic
in Western civilization. European explorers and settlers carried smallpox to the New
572 SM ALLPOX
World and Australia, causing great loss of life in native communities. The Native
Americans w ere especially hard hit, decimating many tribes until widespread gov-
ernment immunizations in 1833. By the 18th century, smallpox was wreaking havoc
in Europe. In the later part of the c entury, an estimated 400,000 Europeans died
each year from the disease. C hildren w ere the hardest hit.
The ancient Chinese were the first to practice and perfect methods to prevent
the spread of smallpox. Methods of inhaling the dried powder of smallpox pus-
tules or in-grafting, rubbing a strain of the virus into a scratch on the skin, success-
fully controlled the spread and reduced mortality. As people migrated or traded
between countries, in-grafting practices spread across India, Persia, Turkey, and
Africa, eventually gaining the attention of physicians at the Royal Society of Lon-
don. European doctors were initially reluctant. There was the potential of spread-
ing smallpox even more or rejection by peers and society. Lady Mary Wortley
Montagu (1689–1762), the wife of the British ambassador to the Ottoman Empire
(modern-day Turkey), is credited with changing attitudes toward in-grafting or vari-
olation. Lady Montagu had contracted smallpox as a young adult and was left with
permanent scarring. Her brother died from smallpox. While living in Turkey, she
noticed a distinct absence of the disease and curiously investigated variolation prac-
tice. She arranged for her six-year-old son to be variolated but not her infant
daughter. A fter returning to E ngland and facing another smallpox epidemic, she
arranged for variolation of her three-year-old daughter, the first recorded in Lon-
don. Very learned and persuasive, Lady Montagu encouraged her friends in the royal
court to get variolated. Now that the practice was commonplace among the influ-
ential aristocracy, British physicians felt more comfortable with the technique.
Although variolation helped lower smallpox mortality, there w ere still consider-
able risks to introducing c hildren to viral strains. Inoculation remained a great con-
troversy and was not universally accepted. In 1796, a British physician named
Edward Jenner noticed that milkmaids caught the benign cowpox disease but rarely
contracted the deadly smallpox. He hypothesized that inoculating material from the
pustules of cowpox could provide immunity against smallpox. He named the cow-
pox material “vaccina” from the Latin word for cow, vacca. Later, during the
19th century, vaccinia, a relative of variola, was substituted as a means for vaccination,
and the riskier method of smallpox inoculation was banned in many countries.
A number of nations, including the United States and Russia, continue to main-
tain specimens of the smallpox virus for current and f uture laboratory experiments.
The general population is no longer routinely vaccinated against smallpox. The only
people who are vaccinated are military personnel who could be exposed to small-
pox through bioterrorism or scientists who work with the virus. Should an out-
break occur, smallpox can be diagnosed in a laboratory environment through
electron microscope replication and observation. Upon diagnosis, the physician
would gauge the time elapsed from initial infection to determine w hether vaccina-
tion will be helpful. Vaccination accomplished within three days of the infection
greatly alleviates symptoms in the majority of cases. Administered between the
S MITH , J A MES M C C UNE 573
fourth and seventh days carries less effectiveness. T here are no drugs approved
within the last 50 years for the treatment of smallpox, meaning medical facilities
can only provide supportive care such as hydration and dressing of wounds.
Smallpox was once one of the greatest scourges to mankind. Millions of p eople
infected by the variola virus suffered permanent disability or early death. The first
public health measures to stop the transmission of smallpox started in ancient China
as in-grafting. Chinese medical practitioners purposely introduced small amounts
of dried viral particles through breaks in the skin. This strange, but effective prac-
tice was passed along trade routes through India and Turkey. In Europe, the prac-
tice was met with controversy, interest, rejection, and fear. In an act of informed
desperation, members of the British aristocracy started opting for variolation. Early
results w ere mixed, and British physicians and scientists eventually improved the
technique to develop safe and effective vaccinations. Armed with effective vaccines
and new techniques in disease surveillance, global health organizations realized the
potential to completely eliminate smallpox, and in 1979 smallpox was officially
eradicated. The techniques used to control smallpox may be effective in eradicat-
ing other infectious diseases plaguing mankind.
Sean P. Phillips
See also: Bioterrorism; Epidemic; Immigrant Health; Indian Health Service; Infec-
tious Diseases; Jenner, Edward; Modern Era, Public Health in the; Public Health in
the United States, History of; Quarantine; Renaissance, Public Health in the; Vac-
cines; World Health Organization; Controversies in Public Health: Controversy 3
Further Reading
Behbehani, A. M. (1983). The smallpox story: Life and death of an old disease. Microbiologi-
cal Reviews, 47(4), 455–509.
Fenn, E. A. (2002). Pox americana: The g reat smallpox epidemic of 1775–82. New York: Hill
and Wang.
Hopkins, D. (2002). The greatest killer: Smallpox in history. Chicago: University of Chicago
Press.
Williams, G. (2011). Angel of death: The story of smallpox. London: Palgrave Macmillan.
SMITH, JAMES MCCUNE (1813–1865)

Physician, pharmacist, and abolitionist James McCune Smith was the first African
American to obtain a medical degree and to publish in an American medical jour-
nal. His staunch opposition to the recolonization of blacks back to Africa and his
advocacy for abolitionism are indicative of the issues that concerned free black activ-
ists in the North in the mid-18th century. Smith advanced public health by decon-
structing ideas of the day and harmful stereotypes against blacks. A prolific and
eloquent writer, Smith countered Thomas Jefferson’s Notes on Virginia, which pre-
sented and validated slave-owner fears of violent retaliation by former slaves.
574 SM ITH, JAM ES MCCUNE
Smith was born on April 18, 1813, in New York City to parents who had success-
fully obtained their freedom. As a young boy, he was educated in the African Free
Schools, where he established lifelong relationships with others who would also
become significant activists, including Henry Highland Garnet and George Down-
ing. Even as a child, Smith’s intelligence singled him out for special recognition. At
the age of 11, he was selected by the African Free School teachers to prepare a speech
in honor of a visit from Revolutionary War hero general Marquis de Lafayette.
When he was 14, Smith witnessed one of the most historic occasions in New
York City’s free black community, the Emancipation Day celebration. Despite his
young age, Smith later wrote one of the most revealing accounts of the commemo-
rative activities, which included a parade complete with drums, dancing, and m usic.
Smith was denied admission to American medical schools on the basis of race. Sorely
disappointed, he sought assistance from activist Peter Williams Jr., who arranged
for Smith to enroll at the University of Glasgow in Scotland. Thus, in 1832, Smith
sailed for Scotland, where he spent the next five years earning three degrees: a bach-
elor’s degree (1835), a master’s degree (1836), and a medical degree (1837).
In 1837, Smith returned to his home in New York City and opened a successful
medical practice and two pharmacies. His political activism began almost immedi-
ately; he fought openly against slavery and helped to create the Young Men’s Anti-
Slavery Society shortly a fter his return home. Yet he soon found that most of his
associates were obsessed with another political issue: the emergence of the Ameri-
can Colonization Society, an organization that they feared would forcibly remove
free blacks from the United States. Smith responded to the call by joining the anti-
colonization struggle.
On January 8, 1839, African American New Yorkers convened the “Great Anti-
Colonization Meeting” in order to protest against the “scheme” of African coloniza-
tion. Smith was among the strongest leaders who addressed the crowd, offering an
unequivocal manifesto on colonization. Describing the notion as antirepublican and
un-Christian, they asserted the United States as the only logical home for free blacks.
Smith’s reputation as an orator also led him to deliver two additional addresses in
the 1840s: “A Lecture on the Haitian Revolution” in 1841 and “The Destiny of the
People of Color” in 1843.
Smith’s determination to eradicate racism and claim U.S. citizenship for African
Americans often caused him to assume rather controversial positions. During the
1840s, for example, he was extremely outspoken in his opposition to separate Afri-
can American organizations. He believed that, given racial conflict in the United
States, it was necessary to form successful biracial coalitions. As a result, he opposed
the call for a statewide colored convention in New York on the grounds that inde
pendent African American action was a form of racial exclusivity that threatened
the cause of racial advancement. A fter considerable debate and conflict, Smith was
finally convinced to attend the New York State colored conventions, but he never
relinquished his concerns about potential racial divisiveness. Instead, he increased
his public activities on a wide range of political issues locally and nationally.
S M ITH, JA M ES M C C UNE 575
On the local level, Smith demonstrated his growing concern with the plight of
working-class African Americans. In 1843, he became the physician for the Col-
ored Orphan Asylum and diligently worked for more than a decade on behalf of
these children. In 1850, Smith also assisted in the establishment of a new organ
ization to address the needs of African American workers, the American League of
Colored Laborers, which advocated for education and training in mechanical skills
as a method to improve conditions.
In the following year, he convened a gathering of African American New Yorkers
to assess the state of their community. Smith prepared a rather elaborate statement
on the socioeconomic status of the African American community, outlining the vice
plaguing their people and the economic problems that drove p eople to desperation.
He revealed that African Americans had been denied equal access to education and
skilled training and had therefore been reduced to the lowest occupations. In
response, Smith developed a solution. Although similar plans had not been success-
ful, Smith suggested that African Americans should abandon the city en masse and
relocate back to the country. Through this project, Smith developed a friendship
with white abolitionist Gerrit Smith, and the two men collaborated for many years
thereafter. The plan never fully took shape, but Smith’s plan for a return to an agri-
cultural lifestyle demonstrated both his desperation and his dedication to improv-
ing conditions for the African American community.
Smith’s national activism manifested itself in a wide range of issues during
the 1850s. At the opening of the decade, he became particularly active following
the passage of the Fugitive Slave Act. Outraged by this legislation, Smith joined the
Committee of Thirteen, an organization designed to protect and defend fugitives.
He became particularly famous for a public confrontation with his white pastor at
St. Phillip’s Church, during which Smith chastised him for not opposing the Fugi-
tive Slave Act. A fter the minister declared that they must uphold the laws of the
United States, Smith confronted him and reportedly “raised the Devil” with his anger.
His activism with the Committee of Thirteen eventually caused Smith to refocus
his energies on the cause of anticolonization. In January 1852, the Committee of
Thirteen convened the African American community in Abyssinian Baptist Church
to declare their opposition to colonization and assert their rights as American citi-
zens. They were particularly concerned because New York governor Hunt had
endorsed colonization and was apparently considering a plan to provide funds to
finance forced removal of the African American population. Smith was elected as a
delegate to a meeting with the governor and ultimately convinced Hunt to reverse
his position.
During this period, Smith also gained a reputation within the national African
American leadership. He was a regular contributor to Frederick Douglass’s news-
papers under the pseudonym Communipaw. He also represented New York City
at the 1853 Colored Convention and played a critical role in attempting to create
a national African American organization, the National Council of the Colored People
(NCCP). The idea for the NCCP was to implement the success of local associations
576 SM ITH, JAM ES MCCUNE
on the national level and create a power base of African American leaders across
the North. However, the NCCP was plagued by disorganization from its inception,
and the organization never fully developed. Unable to reproduce their local effec-
tiveness on the national level, activists abandoned the NCCP in 1855, only two years
after it commenced.
Despite the failure of the NCCP, however, Smith remained nationally active. In
particular, in 1855, he became the first African American to chair a national politi
cal convention. The Radical Abolition Party, formerly the Liberty Party, held its inau-
gural convention in Syracuse, New York, in June 1855 and hoped to gain the
endorsement of African American voters by selecting Smith as its chair. However,
Smith had opposed the Liberty Party in the 1840s because he believed the organ
ization had not sufficiently advocated on behalf of the f ree black population. How-
ever, the reorganized political party made a concerted effort to incorporate African
American men, and Smith had been convinced to provide his support to the strug-
gling organization. Smith was rewarded for his loyalty, for they selected him as the
nominee for secretary of state in 1857. Yet despite their best efforts, the Radical
Abolition Party did not make major inroads with e ither the African American com-
munity or the American political system. As a result, by 1858, most African Ameri-
can leaders, including Smith, had abandoned the organization.
Even with all of Smith’s political activism, perhaps his most well known activity
was his very public conflict with Garnet beginning in 1858. Garnet had recently
founded the African Civilization Society, an organization designed to spread religion
and establish business relationships in Africa. In particular, the society was inter-
ested in exploring the possibility of cotton production in West Africa, an endeavor
it hoped would provide competition for southern cotton and destroy the system of
slavery. However, the controversial portion of the plans lay in the idea that free blacks
should migrate from the United States and assist in the development of Liberia.
Although Garnet insisted that emigration should be entirely voluntary, both Smith
and fellow activists Downing and Douglass denounced Garnet and his society. T here
was, in particular, a very public confrontation between Smith and Garnet that played
out in the pages of the Anglo-African Magazine. Smith challenged Garnet to focus
his energy on the condition of African Americans in the United States, instead of
other countries throughout the world. According to Smith, he and Garnet had made
a pledge 25 years earlier that they would devote their lives to uplift the black race,
fight for abolition, and gain the suffrage. Smith maintained that because they had
not yet achieved their goals, Garnet was obligated to honor his agreement. For
months, the two men exchanged ugly words about each other and the colonization
issue. Smith and Garnet remained at odds until 1862 when they reunited over the
cause of slaves during the Civil War.
Up until his death, Smith remained active in the African American community.
In 1861, he helped finance the creation of the African American newspaper the
Anglo-African Magazine and, in 1863, was appointed as a professor of anthropology
at Wilberforce College. However, a continuing heart problem prevented Smith from
SNO W, J OHN 577
actually joining the faculty, a condition that eventually took his life in Novem-
ber 1865. His final major contribution was authoring an introduction to Garnet’s
address before Congress in February 1865. His ideas on social indicators of health
provide a critical foundation to today’s public health practice. Smith died on Novem-
ber 17, 1865, just weeks after the passage of the Thirteenth Amendment.
Leslie M. Alexander
See also: Bousfield, Midian Othello; Bowditch, Henry Ingersoll; Health Disparities;
Kelley, Florence; Social Determinants of Health; Tubman, Harriet
Further Reading
Alexander, L. M. (2008). African or American? Black identity and political activism in New York
City, 1784–1861. Champaign: University of Illinois Press.
Blight, D. W. (1985). In search of learning, liberty, and self-definition: James McCune Smith
and the ordeal of the antebellum black intellectual. Afro-Americans in New York Life &
History, 9(2), 7–25.
Harris, L. (2003). In the shadow of slavery: African Americans in New York City, 1626–1863.
Chicago: University of Chicago Press.
Houston, H. R. (2009). Smith, James McCune (1813–1865). In J. C. Smith & L. T. Wynn
(Eds.), Freedom facts and firsts: 400 Years of the African American civil rights experience.
Canton, MI: Visib le Ink Press. Retrieved from https://ezproxy.sju.edu/login?url=http://
search.credoreference.com/content/entry/vipfff/smith_james_mccune_1813_1865/0
?institutionId=4
73.
Stauffer, J. (2000). The black hearts of men: Radical abolitionists and the transformation of race.
Cambridge, MA: Harvard University Press.
SNOW, JOHN (1813–1858)

Dr. John Snow was a British physician who worked to improve the unsanitary liv-
ing conditions existing in industrialized cities during the 19th century. Snow pio-
neered the early use of anesthesia and advocated for public hygiene reforms. He is
best remembered for his ingenuity and tenacity in tracing the source of contamina-
tion of a virulent outbreak of cholera in London in 1854. To accomplish this feat,
Snow developed a theory of how cholera was spread, tested his theory by mapping
the outbreak of the disease, and traced the problem to one specific source. Snow’s
ideas and vision spurred the development of public works and city planning, creat-
ing sanitary reform within urban areas.
Snow was born as the oldest of nine c hildren of a working-class family living in
York, E
ngland. At the age of 14, he apprenticed with a surgeon and went on to assist
other medical practitioners in the Durham and Yorkshire region from 1833 to
1836. In 1836, Snow enrolled in London’s Hunterian School of Medicine. He l ater
earned his doctorate from the University of London (1844) and joined the Acad
emy of Physicians (1850). Snow was one of the first physicians in G reat Britain
to study the administration of anesthetic agents. He believed that chloroform and
578 SNO W, JOHN
ether might be used as a way to alleviate pain during surgery. This was a dangerous
endeavor because anesthesia slows the body systems, and incorrect or reckless
administration can cause death. To support patients u nder anesthesia, Snow
invented a rudimentary artificial respirator and identified five characteristic stages
of anesthesia. The equipment and knowledge allowed physicians to administer
anesthesia with greater accuracy and safety. Snow published a number of articles
advocating the use of anesthetics during medical procedures and childbirth. His
ideas on the use of chloroform gained public attention and acceptance in 1853 and
1857 when Queen Victoria and her husband employed Snow to administer
anesthesia during the childbirth of her youngest two children.
Snow was a founding member of the Epidemiological Society of London, and
his greatest legacy remains in epidemiology. Throughout the early 1800s, the world
had experienced several major outbreaks of cholera. More than 1 million people
died during these epidemics and pandemics. A new outbreak occurred in London in
1854. Snow, who was working as
a doctor in the area of the out-
break, performed a geographical
analysis of deaths. He drew a map
of London, noting where the
infected people lived. Through
this map, he was able to pinpoint
the place of origin, tracing it to a
single water pump at Broad Street
in London’s Soho District. Snow’s
report provided sufficient evi-
dence to convince civil officials
to act. The pump handle was
removed, causing the pump to
be nonfunctional and stemming
further transmission of the dis-
ease. Snow conducted a further
analy sis comparing the w ater
supplies of the Lambeth and the
Southwark and Vauxhall compa-
nies. This investigation revealed
that deaths by cholera may be
related to the water source of the
household. Southwark and Vaux-
hall water had eight to nine times
Memorial pump honors Dr. John Snow’s contribu-
tion to public health. Snow traced London’s 1854 greater instances of disease com-
cholera cases to the water pump on Broad Street. pared to the Lambeth company.
Removing the pump handle stopped the epidemic. The difference appeared to be
(Betsy Weber) that the Lambeth company had
SO C IAL C O G NITI V E THEO RY ( SC T ) 579
recently moved its w ater supply to a cleaner source outside of London. Although
Snow’s advances in epidemiology w ere groundbreaking, many of his findings on
the transmission of disease were not fully appreciated until the 20th century.
Snow suffered from poor health throughout his life. An early teetotaler and veg-
etarian, declining health prompted him to abandon these practices. In June 1858,
while writing a new work on anesthetics, Snow suffered a stroke and died from
complications. Snow’s discovery of water as a means for the transmission of cholera
had a profound impact on the development of public health medicine and urban
planning. Geographic mapping is a valuable tool used by epidemiologists today to
track patterns in disease transmission and to identify sources of an infection and
at-risk populations. Snow was also instrumental in demonstrating the intersect
between public health and social responsibility. By identifying a health problem
among a disadvantaged population and working to alleviate that problem, Snow
developed strategies to prevent further spread of the disease.
Sean P. Phillips
See also: Cholera; Epidemic; Epidemiology; Infectious Diseases; Intervention; Pan-

demic; Waterborne Diseases
Further Reading
Friis, R. H., & Sellers, T. (2015). Epidemiology for public health practice (5th ed.). Burlington,
MA: Jones & Bartlett.
Hamlin, C. (2007). Cholera: The biography. Biographies of diseases 2. Oxford, UK; New York:
Oxford University Press.
Hempel, S. (2007). The strange case of the broad street pump: John Snow and the mystery of
cholera. Berkeley: University of California Press.
Kudlick, C. J. (1996). Cholera in post-revolutionary Paris: A cultural history. Studies on the
history of society and culture 25. Berkeley: University of California Press.
Rosenberg, C. E. (1987). The cholera years: The United States in 1832, 1849, and 1866. Chi-
cago: University of Chicago Press.
Vinten-Johansen, P., et al. (2003). Cholera, chloroform, and the science of medicine: A life of
John Snow. New York: Oxford University Press.
SOCIAL COGNITIVE THEORY (SCT)

Social cognitive theory (SCT) is a theory that describes how individuals watch and
assess other p
eople in order to learn new skills or behavior (Bandura, 1986). Pub-
lic health professionals use the theory to understand, investigate, and change nega-
tive health behaviors and to promote health-enhancing behaviors. SCT applies to
numerous health topics such as violence, medication compliance, parents’ inten-
tion to vaccinate c hildren, maternal nutrition, weight loss, and adolescent pregnancy.
Although SCT developed from social research, recent discoveries suggest that biol-
ogy may also play a role in observational learning. The theory presents multiple
constructs that are highly relevant to public health practice.
580 SO CIAL COG NITIVE THEORY (SCT)
In early 1962, Canadian American psychologist Dr. Albert Bandura conducted

a series of experiments investigating aggressive behavior. Bandura believed that
children learn aggression by watching others act aggressively. To test his hypothe-
sis, he created eight different scenarios or skits. All of the scenes featured an adult
in a room with toys. Some of the scenes featured the adult attacking an inflatable
clown while other scenes showed nonaggressive play. Young study participants were
divided by gender. Half of the male c hildren observed a male actor while the other
half observed a female actor. Female children w ere similarly assigned to either same
gender or different gender role models. Bandura found that the c hildren who
observed the aggressive play were 16 to 17 times more likely to act aggressively,
and the c hildren who observed an adult of the same gender displayed aggression
more than children who observed aggression by someone of the different gender.
A higher number of males exhibited violent behavior in comparison to females. Ban-
dura was alarmed to see that the children’s aggression was not limited to imitation.
The children created their own novel forms of violence, substituting toys as weap-
ons to attack the clown. Bandura’s studies provided overwhelming evidence that
children learn violence by watching others.
Constructs are the building blocks or concepts that combine to create a theory
or model. The constructs of SCT are observational learning, behavioral capability,
self-efficacy, expectations, expectancies, reinforcements, emotional coping, environ-
ment, situation, and reciprocal determinism. Observational learning is the idea that
people learn by watching other people. If someone wants to learn how to snow-
board, she starts by watching other p eople snowboard. Self-efficacy is the degree of
confidence that the observer has in her ability to perform the observed behavior.
Behavioral capability is the physical or cognitive aptitude to perform the desired
action. Snowboarding requires leg strength, power, agility, flexibility, core strength,
and the ability to navigate geographic situations. Expectations are the consequences
or outcomes that observers believe may occur b ecause of the behavior. If the observer
is unsure of what might happen after performing the behavior or fears injury or
punishment, she may be less likely to try the behavior. If the expected outcome is
positive, a concept known as expectancies, the observer w ill be more willing to try
the behavior. Reinforcements are material or psychosocial rewards that affirm the
behavior. The beginner snowboarder will feel some sense of pride in successfully
navigating a difficult slope. Emotional coping refers to how the individual deals with
any psychological or physical arousal that results from the action. If the snowboarder
falls, how does she cope with the fall? Does she get up and try again, or is she embar-
rassed and wanting to leave the slope? Environment is the physical or social sur-
roundings that promote or inhibit the specific behavior. How do experienced
snowboarders respond to the novice snowboarder? Are they friendly and supportive,
or do they dismiss or belittle efforts? Situations refer to how the individual interprets
the environmental conditions. Are environmental obstacles simply challenges to be
overcome, or do they block learning? Reciprocal determinism describes mutuality
SO C IAL C O G NITI V E THEO RY ( SC T ) 581
between the individual and the environment. The novice snowboarder learns by
watching others, and within a few months other novice snowboarders will be
watching her. She w ill create the environment for o thers. The SCT constructs out-
line the underlying factors that influence learning and explain how p eople acquire
new behaviors.
Although SCT was envisioned over half a c entury ago, the theory continues to
evolve. Scientists have identified specialized nerve cells in primates and birds. T hese
cells, known as mirror neurons, become active when the animal observes another
animal performing an interesting behavior (Dipellegrino, Fadiga, Fogassi, Gallese, &
Rizzolatti, 1992). Mirror neurons may play a significant role in helping p eople to
learn social rules and to accurately interpret the emotions of o thers. Such skills are
important when people move to a new region, join a social group, or start a new
job. Some experts speculate that defects in the mirror neurons may be associated
with social- emotional disturbances such as autistic spectrum disorders or
schizophrenia.
Social cognitive theory is used extensively to study a wide range of health issues.
For example, Hasking and Rose (2016) used social cognitive theory to study nonsui-
cidal self-injury (NSSI). The researchers found that individuals who were aware of
peers who self-injured were more likely to self-injure. The findings suggest that
health educators focus on negative expectancies, such as infection, nerve damage,
hair loss, shame, and depression, to reduce NSSIs and also raise questions about how
media portrays harmful behaviors. In describing the psychosocial factors that influ-
ence learning, SCT is a valuable tool for public health researchers and practitioners.
Sally Kuykendall
See also: Diffusion of Innovations Theory; Health Communication; Health Educa-

tion; Locus of Control; Reciprocal Determinism; Self-Efficacy
Further Reading
Bandura, A. (1962). Social learning through imitation. In M. R. Jones (Eds.), Nebraska sym-
posium on motivation, 1962 (pp. 211–274). Lincoln: University of Nebraska Press.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Engle-
Dipellegrino, G., Fadiga, L., Fogassi, L., Gallese, V., & Rizzolatti, G. (1992). Under-
standing motor events—A neurophysiological study. Experimental Brain Research,
91(1), 176–180.
Hasking, P., & Rose, A. (2016). A preliminary application of social cognitive theory to
nonsuicidal self-injury. Journal of Youth and Adolescence, 45(8), 1560–1574. doi:10.1007
/s10964-016-0449-7
Kuykendall, S. (2012). Bullying: Health and medical issues today. Santa Barbara, CA:
Greenwood.
582 SO CIAL DETERMINANTS OF HEALTH (SDOH )
SOCIAL DETERMINANTS OF HEALTH (SDOH)

The social determinants of health (SDOH) are the causes underlying the major health
problems and diseases in the United States and around the world. SDOH are referred
to as the causes of the causes or the actual causes of death. Currently, deaths are clas-
sified by biological cause, the disease or problem that resulted in fatality. In the
United States, the leading biological c auses of death are heart disease, cancer, respi-
ratory diseases, injuries, cerebrovascular disease, Alzheimer’s disease, and diabetes
mellitus. T hese diseases are all related to common risk factors of poor nutrition,
lack of physical activity, smoking, substance abuse, and poor mental health. Dig-
ging deeper, major health risk factors are created by social, environmental, and mate-
rial resources. For example, the person who lives alone in an impoverished
neighborhood, lacks the means for fresh fruits and vegetables, and lacks access to
safe places for exercise is at greater risk for heart disease, diabetes mellitus, vio
lence, and cancer than the person who lives in a comfortable home, in an area with
walking paths, farmers’ markets and grocery stores, and a wide selection of fresh
fruits and vegetables. Thus, the cultural, social, economic, wellness opportunities,
and environmental conditions that surround us—individually and collectively—
impact health. Public health epidemiologists decided to calculate deaths by social
determinants, rather than biological causes. An estimated 245,000 people die every
year in the United States as a result of lack of education, 176,000 p eople die from
racial segregation, 162,000 p eople die from limited social support, 133,000 p eople
die due to individual-level poverty, 119,000 people die due to income inequality,
and 39,000 p eople die due to area-level poverty (Galea, Tracy, Hoggatt, Dimaggio, &
Karpati, 2011). This means that more people die every year as a result of racial
segregation than from Alzheimer’s disease (93,541 deaths/year) and diabetes mel-
litus (76,488 deaths/year), combined. Analyzing deaths and health from the social
determinants standpoint offers a deeper understanding of the leading c auses of
death, revealing the existence of unnatural causes and providing opportunity to
improve health beyond disease-based approaches.
Social determinants of health result from social structures. Economic and politi
cal systems determine how power and resources are distributed, creating unnatu-
ral systems that impact health. Socially disadvantaged and marginalized groups are
often segregated to noxious environments and hazardous, low-paying jobs with lim-
ited access to resources, further education, and other opportunities to improve
living conditions. Social conditions, particularly race and socioeconomic status, are
among the fundamental causes of health disparities. The landmark Whitehall stud-
ies tracked the health status of thousands of civil servants in the United Kingdom.
These cohort studies consistently found that the mortality rate was three times higher
among low paid workers in comparison to workers in the highest pay grades (Marmot
& Brunner, 2005). The Healthcare Cost and Utilization Project studied earning
and preventable hospitalizations in the United States. To compensate for regional
cost of living differences, participants were divided into four groups based on
pay. Quartile 1 was p eople earning in the lowest 25 percent. Quartile 2 was
SOC IAL DETE R M INANTS O F HEALTH ( SDOH) 583
eople earning in the m

p iddle to lower percentiles (25–50 percent). Quartile 3
was people earning in the m iddle to higher percentiles of 50–75 percent, and Quar-
tile 4 was people earning in the highest percentiles of 75 percent and above. In com-
parison to people in Quartile 4, p eople in Quartile 1 reported an additional 500,000
hospitalizations, people in Quartile 2 reported an additional 220,000 hospitaliza-
tions, and people in Quartile 3 reported an additional 90,000 hospitalizations.
Income disparity accounted for an additional $6 billion in preventable hospitaliza-
tions (Centers for Disease Control and Prevention [CDC], 2014). Statistic after
statistic demonstrates substantial differences in health status based on the color of
a person’s skin. Infant mortality rate is 5.5 deaths per 1,000 live births among
infants of white m others and 12.7 deaths per 1,000 live births among infants of
black and African American mothers (CDC, 2014). The five-year breast cancer
survival rate is 91.4 percent for white w omen and 77.4 percent for black w omen
(National Center for Health Statistics, 2012). The homicide rate of men, aged
15–29 years, is 4.3 per 100,000 for white males and 75.3 per 100,000 for black
males (CDC, 2014). Community resources dictate quality of life, and quality of life
influences health. Depriving people of community resources condemns that group to
poorer health status. Although the impact of social conditions may be greatest in early
life, health effects often last and accumulate over time and across generations.
Absolute and relative measures of social conditions are important in understand-
ing health disparities between and within countries. Among less developed nations,
higher country-level income (i.e., GDP) is associated with health gains. The life
expectancy of the Polynesian Island of Tuvalu, the country with lowest GDP of
approximately $37 million, is 65 years old, while the life expectancy of the United
States with a GDP of approximately $18 trillion is 79 years old. A fter a country
attains a certain standard of living, the extent of social inequality within the coun-
try is more important in explaining between-country variations in health and
well-being. Among rich, developed countries, health and well-being are better in
countries with low inequality as measured by comparing the gap between the top
20 percent and lowest 20 percent of society or using the Gini coefficient. Denmark
has a low income inequality (Gini coefficient = 0.25), an infant mortality rate of 3.8
deaths per 1,000 live births and 1.01 homicides/100,000 people. The United States,
with a high income inequality (Gini coefficient = 0.40) has an infant mortality rate
of 6.9 deaths per 1,000 live births and 5 homicides/100,000 people. In countries
with greater inequality, the health outcomes for all groups—even for the best-off—
are worse compared to countries with lower inequality. Social inequality also explains
some within-country health disparities. In the United States, states with lower
inequality have better health indicators on average compared to states with greater
inequality.
A large body of research evidences a strong and consistent link between the envi-
ronment and health and well-being indicators, including disability, chronic condi-
tions, mental health, birth outcomes, and domestic violence. Although behaviors
are proximate determinants of these health outcomes, a key understanding in the
584 SO CIAL DETERMINANTS OF HEALTH (SDOH )
social determinants of health perspective is that health behaviors and other down-
stream health determinants are substantially impacted by upstream factors. The
environment, both physical and social, influences health by shaping the choices
available to individuals as well as the choices they are likely to make regarding health
behaviors and other life experiences that impact health, such as whether they attend
college—one of the factors most strongly associated with morbidity and mortality
in developed countries. Cigarette smoking, the leading cause of preventable death
worldwide, is a useful example of how the environment impacts health. Who
smokes, and why smoking is more common among certain population groups, may
be linked to multiple f actors—the availability of cigarette retailers, social norms sur-
rounding smoking in one’s social networks, stress, and occupation and work envi-
ronment. T here is some evidence that a greater availability of cigarettes in proximity
to one’s home (measured through the density of cigarette retailers) and greater expo-
sure to tobacco advertising, which may be regulated by governments, are associ-
ated with a greater likelihood of smoking. However, cigarette retailers and tobacco
marketing are often concentrated in low income and predominantly minority neigh-
borhoods in the United States; it is therefore not surprising that smoking is more
common among low income and minority groups in the United States. T hese con-
ditions do not occur by chance, but are shaped by the political economy.
The physical environment encompasses both the natural and built environments.
Aspects of the natural environment that influence health include air quality, which
affects respiratory health. Features of the built environment, including sewage and
sanitation infrastructure, parks, buildings, streets and other man-made features, may
also promote or hinder healthy behaviors. For instance, access to usable parks and
supermarkets (which provide fresh produce) near one’s home is associated with
lower obesity, whereas a lack of parks and greater access to convenience stores are
associated with greater obesity. Researchers have questioned whether the association
between neighborhoods and health is causal—that is, whether neighborhood envi-
ronment impacts health or whether individuals with characteristics that predispose
them to illness elect to live in the same neighborhoods. The Moving to Opportu-
nity program, initiated in the United States in 1994, was a randomized experiment
in which very low income families w ere given vouchers to move to more advan-
taged neighborhoods. This permitted the examination of the effects of the condi-
tions in which p eople live on their quality of life and outcomes. Although earlier
studies found null results, recent longitudinal research finds that moving to a better-
off neighborhood in childhood is associated with several improved outcomes later
in life compared to those who continue living in poor areas (Chetty et al., 2016).
This Moving to Opportunity program provides evidence of the causal impact of
neighborhood on health and suggests that changing the environment may change
health. Future research should leverage longitudinal data to better understand the
mechanisms by which the environment influences health.
In terms of the social environment, a large body of literature finds that positive
social ties are crucial to health. Since Emile Durkheim’s studies of social integration,
SO C IAL DETE R M INANTS O F HEALTH ( SDOH ) 585
social scientists have documented the salubrious effects of positive social relation-
ships, which can buffer against the harmful health effects of stressors. Conversely,
strained relationships and interactions are deleterious to health. Racial discrimina-
tion, for example, has been linked with poor m ental health and greater risk of obe-
sity and cardiovascular disease. Moreover, the physical and social aspects of the
environment are interrelated, often having cascading effects. For example, deteriora-
tions in the physical environment (e.g., more abandoned buildings) can change the
social environment (e.g., increased crime), and vice versa.
Recognizing the critical importance of physical and social environments on health,
many organizations have adopted formal strategies that incorporate the social deter-
minants of health into their approaches to improving population health. The Com-
mission on Social Determinants of Health, initiated by the World Health Organization
(WHO), proposed three overarching principles of action: (1) improving daily liv-
ing conditions; (2) tackling inequitable distribution of power, money, and resources;
and (3) measuring the problem and evaluating the impact of action. To achieve this,
an increasing number of public health organizations are promoting a “health in all
policies” strategy that addresses how all social policies can affect individual and com-
munity health. This approach advocates for the use of health impact assessments
to understand how policies in diverse areas—ranging from community planning,
education, transportation, and agriculture, to housing and law—impact health.
Through cross-sector collaboration, organizations can strategically target neighbor-
hood conditions that contribute to poor health to efficiently and effectively amelio-
rate vari ous social determinants si mul ta
neously. For instance, planners and
developers can work together to create safe, affordable housing that maximizes
health by enhancing access to recreational space and facilitating neighborhood cohe-
sion through innovative design.
Social determinants of health range from basic physiological requirements for
food and safety to psychosocial needs for living wages, supportive relationships,
quality education, and justice. Economics, housing, community, policy, environ-
ment, social support, and material resources influence people psychologically and
behaviorally. Social determinants explain many public health disparities and offer
ways to improve the health of disadvantaged groups. Ultimately, the social deter-
minants of health are pivotal to improving population health because they address
the root c auses of morbidity, mortality, and health disparities.
Georgiana Bostean and Sally Kuykendall
See also: Adverse Childhood Experiences; Anderson, Elizabeth Milbank; Care, Access
to; Chadwick, Edwin; Children’s Health; Cornely, Paul B.; Cultural Competence;
Disability; Disability Movement; Health; Health Disparities; Healthy Places; Infant
Mortality; Leading Health Indicators; Lesbian, Gay, Bisexual, and Transgender
Health; Population Health; Shattuck, Lemuel; Smith, James McCune; Social Eco-
logical Model; Spiritual Health
586 SO CIAL EC OLOGICAL MODEL
Further Reading
Braveman, P., Egerter, S., & Williams, D. R. (2011). The social determinants of health: Com-
ing of age. Annual Review of Public Health, 32, 381–398. doi:10.1146/annurev-publhealth
-031210-101218
Chetty, R., Hendren, N., & Katz, L. F. (2016). The effects of exposure to better neighbor-
hoods on c hildren: New evidence from the Moving to Opportunity experiment. Ameri-
can Economic Review, 106(4), 855–902. doi:http://dx.doi.org.ezproxy.sju.edu/10.1257
/aer.106.4.855
Centers for Disease Control and Prevention. (2014). Centers for Disease Control and Pre-
vention Health Disparities and Inequalities Report—United States, 2013. Morbidity and
Mortality Weekly Report, 62(Suppl. 3). Retrieved from http://www.cdc.gov/mmwr/pdf
/other/su6203.pdf.
Durkheim, E. (1951). Suicide: A study in sociology. New York: The F ree Press.
Galea, S., Tracy, M., Hoggatt, K. J., Dimaggio, C., & Karpati, A. (2011). Estimated deaths
attributable to social factors in the United States. American Journal of Public Health,
101(8), 1456–1465. doi:10.2105/AJPH.2010.300086
Link, B. G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal
of Health and Social Behavior, 80–94.
Marmot, M., & Brunner, E. (2005). Cohort profile: The Whitehall II study. International
Journal of Epidemiology, 34(2), 251–256.
Marmot, M., Friel, S., Bell, R., Houweling, T. A., & Taylor, S. (2008). Public health: Clos-
ing the gap in a generation: Health equity through action on the social determinants of
health. The Lancet, 372, 1661–1669. doi:10.1016/S0140-6736(08)61690-6
on socioeconomic status and health. Hyattsville, MD. Retrieved from http://www.cdc.gov
/nchs/data/hus/hus11.pdf.
Wilkinson, R. G., & Pickett, K. (2009). The spirit level: Why greater equality makes societies
stronger. New York: Bloomsbury Press.
Williams, D. R., & Sternthal, M. (2010). Understanding racial-ethnic disparities in health:
Sociological contributions. Journal of Health and Social Behavior, 51(Suppl.), S15–S27.
World Health Organization. (2008). Closing the gap in a generation: Health equity through action
on the social determinants of health. Commission on Social Determinants of Health final
report.
SOCIAL ECOLOGICAL MODEL

Ecological models consider the many psychosocial, environmental, political, and
regulatory f actors that influence individual and community well-being. The idea
that the social and political environment influences health applies to numerous pub-
lic health concerns. Community violence, obesity, oral health, suicides, substance
abuse, and occupational health and safety are influenced by family, peers, commu-
nity, and the regulatory environment. The ecological perspective is used to plan
multilevel public health research, programs, interventions, and media campaigns.
The models differentiate levels of influence, suggesting opportune points for inter-
ventions. Key principles to understanding the ecological perspective are (1) an
individual’s health behaviors are influenced by intrapersonal, interpersonal,
SOC IAL E C OLO G I C AL M ODEL 587
organizational, community and, public policy circumstances; (2) in addition to

influencing the individual, ecological factors also interact across systems to accen-
tuate or inhibit behavior; (3) effective interventions work on multiple levels; and
(4) programs that focus on behavioral change (as opposed to systems-level change)
offer greater impact (Glanz, Lewis, & Rimer, 1997).
Charles Darwin was the first to suggest that the environment influences living
beings. The theory of evolution states that some species adapt novel physical or
behavioral traits as a way to enhance survival, and this process results in natural
selection. Dr. Sigmund Freud applied Darwin’s theory to h uman beings. Freud pro-
posed that the ego develops to mediate between the instinctual id and the moral-
istic superego. Thus, the human psyche develops because of interactions with
parents, f amily, peers, and society. Sociologist George Herbert Meade expanded the
idea of human-environmental influence to sociology. M eade noted that people
observe the world around them, interpret the world, and interact with others based
on their interpretation. He used the term symbolic interactionism to describe how
individuals communicate, interpret, and adjust to social groups and the term social
behaviorism to describe how social interactions influence the mind and behaviors.
Meade’s work was advanced by his mentee Herbert Blumer. Blumer noted that inter-
actions are dynamic, occurring as ongoing processes. Although a person interprets
the social world based on previous experiences, that interpretation can change
through continued experiences and interactions. Dr. Kurt Lewin (1935) furthered
Blumer’s work by introducing the idea of group dynamics. Group dynamics describe
how individuals and groups interact, react, and adapt to changing circumstances.
The expert most often associated with ecological systems theories is develop-
mental psychologist Dr. Urie Bronfenbrenner. In 1973, Bronfenbrenner noted that
children’s emotional and social development is dependent on interactions with other
people. Bronfenbrenner proposed four subsystems, presented as concentric circles
with the individual at the center. The individual is encircled by the microsystem of
family, peers, close neighbors, school, and other close social network. The micro-
system is encircled by the mesosystem, which represents connections between parts
of the microsystems, such as relationships between parent and teacher. The meso-
system is encircled by the exosystem, social institutions that indirectly impact the
child, such as the parent’s workplace, social services, adult neighbors, the media,
or political systems. The exosystem is encircled by the macrosystem. The macrosys-
tem is the predominant culture to which the child is exposed, that is, socioeco-
nomic status, ethnic identity, or social norms and values. Each system influences
the individual and other systems, and the effects occur over time, an idea referred
to as chronosystem. Bronfenbrenner’s model has many different applications. Research-
ers in Australia used the model to understand community resilience during natural
disasters (Boon et al., 2012). Individual characteristics include past experiences with
disaster (bushfire, flood, or cyclone), personal health, gender, or indigenous vul-
nerability or resilience. The microsystem consists of concerns for and by f amily and
friends. The mesosystem reflects warnings, by word of mouth, phone, or Internet.
588 SO C IAL EC OLO G IC AL M ODEL
The exosystem consists of relief centers, insurance, emergency management agen-

cies, charities, and other disaster relief agencies. The chronosystem covers initial
response and capacity as well as recovery after the event. Each level influences one
another, and effective disaster management must address all levels. The advantage
of Bronfenbrenner’s model, as well as other ecological models, is that they point
out the many factors outside of individual control that influence behaviors. They
do not blame the victim for the problem. One limitation is that the models explain
behavior; they do not advise how to alter the behavior.
Using Bronfenbrenner’s model, public health experts developed the social
ecological model (McLeroy, Bibeau, Steckler, & Glanz, 1988). Under the social eco-
logical model, influencing factors are presented as individual, interpersonal,
institutions and organizations, community, and structures and systems. The model
is used to examine and suggest multilevel interventions for complex health issues,
such as obesity. For example, the individual factors for obesity include gender, abil-
ity or disability, genetics, epigenetics, and knowledge or attitudes toward physical
activity and diet. Interpersonal factors include food traditions, preferences, and
choices, which are heavily influenced by f amily, friends, and culture. Institutions
and organizations include school, workplaces, or faith-based institutions, which also
influence dietary choices and food access. Community factors include neighbor-
hood walkability and safety, access to physical activity facilities or programs, and
access to fresh fruits and vegetables. Policy level factors are zoning for recreational
areas, access to bike paths or trails, public transportation, housing, and other health
or social policies. Local programs to reduce obesity must consider multiple levels
for intervention activities. Experts suggest that future directions for the use of eco-
logical models are to place greater emphasis on the relationships between systems.
In the interrelationship design, influencing f actors are presented as a series of over-
lapping, roulette curves rather than in the traditional nested arrangement.
The social ecological model tailors well known ecological theories to public health
practice. The model presents the individual as a center point, influenced by mul-
tiple social, community, institutional, and government factors. Ecological models
are widely used and critical to public health practice. They are listed within the
public health core competencies and as curricular frameworks in schools of public
health. Advantages of the models are that they highlight the many factors that initi-
ate and maintain health behaviors and suggest points of intervention. Ecological
models also demonstrate the complexity of health behaviors and the need for sophis-
ticated, multifactorial approaches in health promotion.
Sally Kuykendall
See also: Care, Access to; Cultural Competence; Disability; Disability Movement;
Environmental Health; Healthy Places; Infant Mortality; Leading Health Indicators;
Reciprocal Determinism; Social Determinants of Health; Spiritual Health
SOC IAL SEC U R ITY A C T ( SSA ) 589
Further Reading
Boon, H., Cottrell, A., King, D., Stevenson, R., & Millar, J. (2012). Bronfenbrenner’s bio-
ecological theory for modelling community resilience to natural disasters. Natural Haz-
ards, 60(2), 381–408. doi:10.1007/s11069-011-0021-4
Bronfenbrenner, U. (1973, February 26–March 1). An emerging theoretical perspective for
research in h uman development. Paper presented at the annual meeting of the American
Educational Research Association, New Orleans, LA.
Bronfenbrenner, U., Alvarez, W. F., & Henderson, C. R. (1984). Working and watching:
Maternal employment status and parents’ perceptions of their three-year-old children.
Child Development, 55(4), 1362–1378. doi:10.2307/1130006
Centers for Disease Control and Prevention. (2013). Addressing obesity disparities. Retrieved
from https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health-equity/framing
-the-issue.html.
Lewin, K. (1935). A dynamic theory of personality. New York: McGraw-Hill.
McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective
on health promotion programs. Health Education & Behavior, 15(4), 351. doi:10.1177
/109019818801500401
Trickett, E., Beehler, S., Deutsch, C., Green, L., Hawe, P., McLeroy, K., & . . . Trimble, J. (n.d.).
Advancing the science of community-level interventions. American Journal of Public
Health, 101(8), 1410–1419.
SOCIAL SECURITY ACT (SSA)

During the Great Depression of the 1930s, p eople in the United States grew their
own vegetables for food, walked rather than rode, and avoided the unnecessary
expense of cigarettes or alcohol. As a result, life expectancy increased. However,
the state-run pension plans did not take into account America’s increasing elderly
population or inflation. Pension payments fell short on providing a reasonable
income to the aging population. Many elderly who had worked their entire lives
were starving or unable to pay for basic health care. The Social Security Act (SSA)
of 1935 is a federal program enacted in response to the vast number of the aging
workforce who could not support themselves. With the intention of providing social
insurance, Franklin D. Roosevelt signed the SSA into law on August 14, 1935. The
concept of social insurance was built on the philosophy of a government-sponsored
subsidy to benefit senior citizens. The program and system have been expanded to
provide assistance to c hildren, elderly, or the disabled who cannot or do not earn
enough to support themselves. Every feature of the SSA is related directly or indi-
rectly to public health. Providing economic security supports m ental health, proper
nutrition, and means to medical care.
The original intent of the SSA was to provide guaranteed income for retired per-
sons aged 65 or older. According to SSA.gov, “benefits w ere to be based on payroll
tax contributions that the worker made during their working life” (SSA.gov, 2017).
590 SO CIAL SE C URITY ACT (SSA)
President Franklin D. Roosevelt signs the Social Security Act into law on August 14, 1935.
The program supports children, elderly, and disabled people who cannot earn enough to
support themselves. (Social Security Administration)
hese contributions would be placed into a joint fund where workers actively saved
T
for their retirement. The fund would be overseen by the government. The Social
Security Board (SSB) was established to oversee the system. Initially, the board com-
pensated for the lack of bank funding by borrowing money from other federal
agencies. The SSB acted as an independent entity until it was eliminated in 1946
and replaced by the present Social Security Administration (SSA) u nder the direc-
tion of a single administrator.
In order to allocate benefits, the United States Postal Service was given the task
of assigning and distributing Social Security numbers. The USPS then forwarded
the applications to satellite Social Security offices where the Social Security cards
were issued. Federal Insurance Contributions Act (FICA) taxes w ere withdrawn
from an employee’s earnings and the monies forwarded to the Social Security Trust
Fund. The fund dispersed payments as a one-time payout to individuals who were
not able to fully contribute to the program. The monthly payments that are known
today were not implemented u ntil 1940.
In 1939 several amendments w ere made to the original act. Two additional sec-
tions were added to provide benefits for spouses and c hildren of qualified workers
as well as “survivors’ benefits paid to the family in the event of the premature death
of a covered worker” (SSA.gov, 2017). The inclusion ultimately changed the act from
SOC IAL SEC U R ITY A C T ( SSA ) 591
one of individual retirement plan to that of a family income protection plan. The
amendment also allowed an increased payment amount. No further changes w ere
made to the program u ntil 1950.
In response to the inefficiencies of act, the Social Security Administration
announced major changes. The first change was to increase the monetary payments
for those enrolled in the plan as well as providing additional incentives for the cur-
rent workforce that would utilize the system at a later time. The increases w ere
named cost-of-living allowances (COLAs) and would be completed in two phases,
in 1950 and 1952. These increases accounted for inflation.
In 1954 the Social Security Administration began the disability insurance pro-
gram for disabled workers aged 50–64 as well disabled minor children (SSA.gov,
2017). This program provides those with documented disabilities income to pre-
vent economic uncertainty. In 1960 this was changed to include disabled workers
of any age and their dependents.
In 1960 t here w ere substantial changes to the Social Security program. The first
modification was to adjust the age that men could apply for benefits to age 62. By
decreasing the age at which benefits w ere granted, it decreased the allowance paid
out. This resulted in substantially more beneficiaries being enrolled at the time. By
far the most powerful change was launching the health insurer, Medicare, in 1966.
The implementation of Medicare meant that recipients w ere now eligible to receive
health insurance funded by the Social Security Administration. The Medicare pro-
gram provided two forms of coverage, Part A covering hospital service and Part B
covering physicians’ services.
The 1970s brought about additional changes for the Social Security Administra-
tion. Although the initial act of 1935 provided benefits for the elderly, the poor,
and the blind, and in 1950 the disabled w ere added, t hese groups w
ere considered
“adult categories” (SSA.gov, 2017). T hese categories were not managed by the SSA
but instead by the state and local administrations that w ere given monetary fund-
ing from the federal government. Due to the state and local government inability
to properly manage and distribute benefits, the Secretary of Health, Education and
Welfare determined that the benefits should be managed by the Supplemental Secu-
rity Income (SSI), which is supervised by the SSA.
Medicare benefits w ere extended to individuals that received disability payments
for a minimum of two years and those ill with chronic renal disease. The provisions
also “liberalized the retirement earnings test” as well as allowed for deferred retire-
ment credits and increased allowances for individuals that chose to postpone their
benefits a fter the age of 65 (SSA.gov, 2017). Automatic COLAs’ increases w ere also
implemented. This resulted in increases of the Social Security tax additionally mod-
ifying the wage-base assessment that is used to determine allowance amounts.
COLA specifically regulates prices whereas wage-based assessment regulates wages.
These modifications were done to preserve the future of the Social Security system,
but the ramifications of the current system meant that benefit payments would
exceed the salary contributions made. Due to the problematic impact of future
592 SO C IETY O F PU B LI C HEALTH EDU C ATION ( SOPHE )
benefits, these modifications were not successful and thereby had to be changed,
which resulted in modification in the 1980s that included an increase in the retire-
ment age and the collection of taxes on benefits.
In the years since there have been changes but none greater than that as previ-
ously discussed. The SSI program has been modified to eliminate previous health
conditions that w ere believed to be considered a disability, such as alcoholism and
drug addiction. Legislation has been established to combat fraud, determine immi-
grant eligibility, establish employment incentives for disabled workers, eliminate
the retirement earnings test, add health insurance coverage for prescription drugs,
and eliminate potential benefits for incarcerated individuals. Overall, the program
functions to support members of the community who are unable to support them-
selves due to age or disability.
See also: Centers for Medicare and Medicaid Services; Medicaid; Medicare; Public
Health Law; Roosevelt, Eleanor; Roosevelt, Franklin Delano
Further Reading
Coffey, E. R. (1941). Public health expands its facilities under Title VI, federal Social Secu-
rity Act. American Journal of Public Health, 31, 297–304.
Eliot, M. M. (1936). Progress in maternal and child welfare under the Social Security Act.
American Journal of Public Health, 26, 1155–1162.
Hood, R. C. (1940). Services for crippled children under the Social Security Act. American
Journal of Public Health, 30, 935–937.
Social Security Administration. (2017). Social Security history: Historical background and devel-
opment of Social Security. Retrieved from https://www.ssa.gov/history/briefhistory3
.html.
Waller, C. E. (1935). Social Security Act in its relation to public health. American Journal of
Public Health, 25, 1186–1194.
SOCIETY OF PUBLIC HEALTH EDUCATION (SOPHE)

The Society of Public Health Education (SOPHE) is the primary professional asso-
ciation of public health educators. The organization’s main purpose is to improve
public health education practice by identifying and addressing the challenges and
needs of community-based and clinical health professionals. Founded in 1950, this
international organization brings together practitioners, academics, researchers,
administrators, grant funders, nonprofit agencies, policy makers, and students to
share best practices, innovations, and tools. Membership benefits include access to
SOPHE publications and newsletters, continuing education opportunities, discounts
on conferences and SOPHE health education and c areer resources. In addition to
offering professional education, SOPHE also offers awards, scholarships, and fel-
lowships to members. SOPHE is a good way to build a professional network and
SO CIETY O F PU B LIC HEALTH EDU C ATION ( SOPHE) 593
to stay current in the field of health education. Students are eligible for discounted
memberships.
Knowledge of the h uman body and diseases advances quickly, and professional
health educators are responsible for keeping up to date with scientific progress and
refuting false information while planning, managing, and advancing the health of
those whom they serve. Professional organizations such as SOPHE help health edu-
cators to stay current in the field by offering annual conferences, newsletters, and
quality, peer-reviewed journals. Attendees of SOPHE’s annual meeting learn new
techniques in health education, current information, best practices, and can earn
continuing education to maintain professional certifications. Electronic newsletters
provide information on upcoming events of interest to health educators, workshops,
advocacy information, brief research reports, and news on the achievements and
efforts of current members.
SOPHE publishes three quality, peer-reviewed professional journals, Health Pro-
motion Practice, Health Education & Behavior, and Pedagogy in Health Promotion: The
Scholarship of Teaching and Learning. The journals are published by Sage journals
and adhere to the Committee on Publication Ethics (COPE) guidelines. This means
that the journal articles are checked by experts to ensure that the information pre-
sented is accurate, honest, and original. Health Promotion Practice examines practi-
cal strategies and applications in health education and health promotion programs.
Articles on community interventions, worksite wellness, school health, and inter-
national settings share best practices, suggestions for improvement, and problem-
solving strategies. This journal is for readers interested in the practical application
of health promotion programs. Health Education & Behavior examines the theory
and process of planning, implementing, and evaluating health behavior and health
education programs. The journal publishes empirical research studies, case reports,
evaluation research, literature reviews, and articles on health behavior models and
theories. This journal is appropriate for the reader who is interested in theoretical
concepts of how people learn or how people change or adapt health behaviors. Peda-
gogy in Health Promotion focuses on best practices in training future generations of
health care practitioners and educators. The primary audience is faculty members
and instructors of continuing education courses or t hose who are interested in teach-
ing health educators. All three journals offer self-study articles providing continu-
ing education contact hours for Certified Health Education Specialists (CHES).
SOPHE advances health of the general public by partnering efforts with
community-based organizations, federal government agencies, decision makers, and
members. For example, the ACHIEVE program (Action Communities for Health,
Innovation & EnVironmental ChangE) is a national network of organizations work-
ing together to create healthy places to live, work, and play. ACHIEVE organizations
offer a number of resources and tools to help community members develop health
programs within their own communities. SOPHE also advocates for effective health
policies by educating local and national decision makers on current health issues and
by keeping members informed on current policies u nder consideration.
594 SPI R ITUAL HEALTH
SOPHE supports health educators in communities, workplaces, and health cen-

ters by keeping them informed of best practices, by ensuring access to accurate
health information, and by promoting health policies and systems that support indi-
vidual efforts of members.
Sally Kuykendall
Health Education; Health Policy; School Health
Further Reading
ACHIEVE Healthy Communities. (2017). Retrieved from http://www.achievecommunities
.org/.
Committee on Publication Ethics. (2017). Retrieved from http://publicationethics.org/.
Society of Public Health Education. (2017). Retrieved from http://www.sophe.org/.
SPIRITUAL HEALTH
In earlier views of health, especially in the ancient world, there was a recognized
and even unquestioned connection between physical well-being and religious prac-
tices and beliefs. Beginning with Hippocrates (ca. 460–370 BCE), health and med-
icine began to focus on natural, biological determinants and causes, gradually
developing into a science that eventually led to better treatment, research, and out-
comes. However, as modern medical science became more prominent and main-
stream, the medicalization of health care became dominant, and the connection
between health and spiritual aspects of a person’s life and makeup was lost or dimin-
ished. It has been a relatively recent phenomenon for health to be viewed again as
something broader than the physical or biological well-being. Such a shift has
impacted both medical and public health treatments and interventions.
Health care today is typically seen in the context of holistic health, which takes
into account the physical, emotional, social, psychological, and spiritual needs of
the person. Public health research and practice also follows this comprehensive view.
For example, in studies regarding population health and health-related quality of
life, the Centers for Disease Control and Prevention (CDC) defines and measures
health broadly. Quality of life surveys take into account f actors of culture, employ-
ment, availability of schools, nature of community or neighborhood, values, and
spirituality (Taylor, 2000). Spirituality and considering spiritual needs, then, are
key components to understanding a person’s overall health and important to con-
sider in the prevention and treatment of disease or injury.
There are no standard definitions for spirituality or spiritual well-being, although
there are common characteristics among the various definitions. One of the better
definitions of spirituality comes from the Consensus Conference, a group of over
SPI R ITUAL HEALTH 595
40 health care providers that included chaplains, physicians, nurses, social workers,
psychologists, and pastors: “Spirituality is the aspect of humanity that refers to the
way individuals seek and express meaning and purpose and the way they experi-
ence their connectedness to the moment, to self, to o thers, to nature, and to the
significant or sacred” (Puchalski et al., 2009, p. 887). The “significant” referred to
in this definition could be God or other supreme being, or it could also be family,
a particular social cause, organization, or vocation. Spiritual health, then, can be
described as integrating, or finding a balance, regarding purpose and meaning in
light of one’s connections to self, others, and to the significant or sacred.
When assessing spiritual health, it is essential to consider a number of related
matters and concerns. Besides purpose and meaning, it is helpful to address other
areas of life, such as love and belonging, guilt and forgiveness, acceptance, grati-
tude, and a sense of hope or hopelessness. It is also critical to understand that spiri-
tual health is less about a cure than it is about healing. For instance, individuals who
are dealing with a life-limiting illness like cancer can experience spiritual health and
healing even though there may be no cure for their illness.
Another aspect of spiritual health is knowing and recognizing the difference
between spirituality and religion or being religious. Religion can be viewed as “a
group’s enculturation of an organized system of beliefs, texts, roles and practices
related to spirituality” (Robinson, Thiel, Backus, & Meyer, 2006, p. 720). The reli-
gious focuses on the corporate and communal nature of spirituality, while spiritu-
ality concerns the individual and personal search for meaning. Religion has to do
with codifying rituals and beliefs, whereas spirituality involves what meaning the
person gives to a particular ritual, how they internally experience a practice like
prayer or Eucharist. The religious is more external, while spirituality deals with one’s
inner beliefs. Everyone can be considered spiritual, but not everyone is religious.
This difference is critical to public health practice and research, especially regard-
ing outcomes or the way information is analyzed. For example, a researcher may
want to study the direct link between a religious ritual, like prayer, and positive
medical outcomes. However, such a study may fail to recognize that personal spiri-
tuality and faith experience help a patient to know that God is with them whatever
the medical outcome. If the investigation examines only the connection between
the ritual and positive medical outcomes, and not the meaning behind the ritual,
critical information and connection may be missed.
Spirituality or attending to spiritual well-being can be seen as one of a cluster of
needs when addressing overall health. Attending to the spiritual health of a patient
may involve singing a hymn or saying a prayer at the bedside, a conversation about
life’s meaning, or addressing a deep hurt. Dealing well with a person’s spiritual health
may or may not affect their physical health or outcomes. However, discovering
the effect of spirituality on physical or overall health is also important to consider.
In spite of the differences between science and religion, or biology and spirituality,
many have insisted that there is a definite relationship between spirituality, or
596 SPI R ITUAL HEALTH
religious practices, and overall health (especially mental and medical health). For
example, one might think it is plausible that the more at peace p eople feel, the bet-
ter their health, or the more able they will be to cope with a serious illness.
The first known study investigating spirituality and health was performed in 1872
(Harrington, 2010). Further research has only gained momentum over the past
30 years. Numerous studies have been conducted investigating relationships between
prayer and health, attending religious services and mortality, spirituality and end
of life issues, spiritual practices and stress reduction, the impact of faith and belief
on recovery from serious illness, forgiveness and health, as well as the role of the
physician and other health care workers regarding spiritual care. Many have
attempted to discover a deeper, definitive relationship between spirituality or being
religious and positive health outcomes, especially physical ones. Although a num-
ber of investigations have indicated a positive relationship between religious prac-
tices or rituals and positive health outcomes, there are others that have shown the
opposite.
Although there have been nearly 1,600 studies regarding religion or spirituality
and health, more research needs to be done to discover what relationship there is
and how to make the most of t hese connections to improve health (Koenig, King, &
Carson, 2012). Even though more study needs to be accomplished, it is impor
tant to understand that spiritual issues and spirituality impact how a patient
approaches health-related behaviors, treatment, end of life decisions, or how they
cope with the disease. Such insights can be integrated into public health ensuring
optimal health.
Louis Kuykendall Jr.
See also: Behavioral Health; Disease; Health; Healthy Places; Indian Health Service;
Mental Health; Social Determinants of Health
Further Reading
Harrington, A. (2010). God and health: What more is t here to say? [e-book]. Templeton Founda-
tion Press. Available from Digital Access to Scholarship at Harvard (DASH), Ipswich, MA.
Idler, E. (2014). Religion as a social determinant of public health. New York: Oxford University
Press.
Koenig, H. G., King, D. E., & Carson, V. B. (2012). Handbook of religion and health (2nd ed.).
New York: Oxford University Press.
Meanley, S., Pingel, E. S., & Bauermeister, J. A. (2016). Psychological well-being among
religious and spiritual-identified young gay and bisexual men. Sexuality Research & Social
Policy: A Journal of the NSRC, 13(1), 35–45. doi:10.1007/s13178-015-0199-4
Musgrave, C. F., Allen, C. E., & Allen, G. J. (2002). Spirituality and health for w omen of
color. American Journal of Public Health, 92(4), 557.
Puchalski, C., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., Bull, J., & . . . Sulmasy, D. (2009).
Improving the quality of spiritual care as a dimension of palliative care: The report of the
Consensus Conference. Journal of Palliative Medicine, 12(10), 885–904. doi:10.1089
/jpm.2009.0142
SPO RTS -R ELATED C ON C USSIONS ( S R C s) 597
Robinson, M. R., Thiel, M. M., Backus, M. M., & Meyer, E. C. (2006). Matters of spiritual-
ity at the end of life in the pediatric intensive care unit. Pediatrics, 118(3), 719–729.
Stone, R. T., Whitbeck, L. B., Chen, X., Johnson, K., & Olson, D. M. (2006). Traditional
practices, traditional spirituality, and alcohol cessation among American Indians. Jour-
nal of Studies on Alcohol, 67(2), 236–244. doi:10.15288/jsa.2006.67.236
Taylor, V. R. (2000). Measuring healthy days: Population assessment of health-related quality of
life [Electronic resource]. Atlanta: U.S. Department of Health and Human Services, Cen-
ters for Disease Control and Prevention, National Center for Chronic Disease Preven-
tion and Health Promotion, Division of Adult and Community Health.
SPORTS-R ELATED CONCUSSIONS (SRCs)

Sports-related concussions (SRCs) are defined as a traumatic brain injury induced
by biomechanical forces. They are a common public health problem in the United
States with estimates ranging between 1.6 and 3.8 million cases per year. Due to
underreporting, t hese figures might underestimate the actual incidence. Football has
the highest incidence, and females have a greater incidence than males. SRCs account
for approximately 9 percent of all high school sports injuries. T here has been an
increase in the number of concussions over the past decades, likely due to several
factors, including greater involvement in team sports and an increased awareness
of concussions along with better diagnostic techniques (Sprouse, Harris, Sprouse,
Humerick, & Miller, 2016). Public health efforts to prevent SRCs focus on educat-
ing parents, youth, coaches, health care providers, and the general public.
SRCs share some common features. They are caused by either a direct blow to
the head, neck, face, or elsewhere on the body with the impulse force being
transmitted to the head. Suffering an SRC does not need an impact directly to the
head to occur. Typically, this force results in rapid onset of short-lived impairment of
neurological function that resolves spontaneously, but some symptoms may
develop over minutes to hours. An SRC may result in neuropathologic changes,
but signs and symptoms are of functional disturbances, not structural injury, which
would be shown on standard neuroimaging like computed tomography (CT) or
magnetic resonance imaging (MRI). Finally, the diagnosis may or may not include
loss of consciousness.
Athletes suspected of having an SRC may exhibit signs and symptoms across
many domains. Symptoms may include somatic (headache, dizziness, blurred vision,
photophobia, phonophobia), cognitive (decreased attention, feeling in a fog, dis-
tractibility), or emotional (lability, depression, personality changes). Physical signs
encompass loss of consciousness, blank or vacant look, seizure, amnesia, or neu-
rologic deficits. Other helpful aspects for diagnosis include balance impairment (gait
unsteadiness, ataxia), behavioral changes (anger, irritability), cognitive impairments
(slow reaction times, attention deficit), and sleep disturbances (somnolence, drows-
iness, hypersomnia).
The hallmark of diagnosis of an SRC is a thorough history and physical exam.
The history should include the mechanism of injury, history of prior concussions,
598 SPO RTS -R ELATED CON CUSSIONS (SRC s)
and symptom inventory. A graded

symptom checklist, such as the
Standardized Assessment of Con-
cussion (SCAT), can aid in review-
ing pertinent symptoms and be
followed over several visits. Phys-
ical exam should include a detailed
neurologic exam covering m ental
status, cognitive function, ocular
function, vestibular function, gait,
and balance. Brain imaging is
reserved for those patients sus-
pected of having more severe
injuries, such as skull fractures
or intracranial bleeding. Wors-
ening symptoms over time would
also be an indication for advanced
imaging.
Most SRCs resolve in 7–10
days; children and adolescents
usually recover more slowly due to
Athletic trainer Brandon Nolt and Director of Sports the developing, immature brain.
Medicine Rennie Sacco check Kutztown University Numerous studies have demon-
defensive back Corey Harris for neurological deficits strated longer recovery times for
after injury. (Shutterstock.com) younger athletes compared to
college and professional athletes.
Most consensus statements agree that the initial treatment should be rest until the
patient is symptom f ree. This includes both physical and cognitive rest to allow the
brain to heal. Activities such as video games, cell phone use, reading, school-
work, and exercise need to be limited until symptoms have abated. Once symp-
toms at rest have resolved, a graded, stepwise rehabilitation strategy is employed to
return the athlete to sports and academics. Athletes are started on very low exer-
tion exercise and observed for reemergence of symptoms, then progressed e very
day to the next level if symptoms do not reappear. Typically, this progression takes
a minimum of five days to complete. These programs and exercises should be super-
vised by a certified athletic trainer or other professional. Certain strategies may
have to be employed to support academic success, such as shortened school days,
extra time for tests, help with note taking, and restrictions on classes that induce
symptoms (e.g., computer science or music).
A serious but rare event is the second impact syndrome. This occurs in a young
athlete who suffers a second concussion when he or she has not recovered from the
first. The proposed hypothesis is uncontrolled brain swelling from the second insult
and carries a 50 percent mortality rate. This situation has only been described in
athletes u nder 20 years old.
SPO RTS -R ELATED CON CUSSIONS ( S R C s) 599
Unfortunately, 10–15 percent of SRCs do not improve in the first couple weeks

and may develop post-concussive syndrome (PCS). It is not a prolonged concus-
sion, but a separate clinical entity characterized by headache, dizziness, nausea,
memory disturbance, confusion, fatigue, sleep disturbance, concentration problems,
and fogginess. Although data are limited, treatments are directed at symptoms and
include medications and various forms of physical and occupational therapy such
as cognitive, visual, and vestibular therapy. Medications are aimed at specific symp-
toms such as analgesics for headaches, stimulants for fatigue, or antidepressants for
anxiety and depression.
A recent concern has been the possible connection between repeated SRCs and
the development of chronic traumatic encephalopathy (CTE) first described by
Nigerian American physician Bennet Omalu in 2004. CTE is clinically associated
with mood disorders, neuropsychiatric disturbances, and cognitive impairments.
To date, there are no epidemiological, prospective, or cross-sectional studies that
demonstrate a cause and effect relationship between SRC and CTE.
Public health efforts directed toward decreasing the incidence and severity of
SRCs focus on education of athletes, coaches, parents, and health care providers in
the signs and symptoms of SRC; instruction of proper fit and use of equipment;
teaching proper athletic technique (tackling in football, heading in soccer, e tc.);
encouraging athletes to report concussive symptoms; and developing better meth-
ods to diagnose SRC such as biomarkers and advanced imaging. Equipment modi-
fications have demonstrated mixed results. Football helmets, for example, have
greatly reduced some injuries, like skull fractures, but have not impacted concus-
sions to the same degree. However, headgear in rugby has had a protective effect.
Use of mouth guards has not shown any reductions in SRCs. Rules changes in some
sports have had a more dramatic effect. In junior ice hockey, the rule change to
prohibit body-checking before age 13 has markedly reduced concussion rates in
this sport. Heads Up is a resource center provided by the Centers for Disease Con-
trol and Prevention that provides information on best practices in preventing SRCs.
Future efforts seek to change the culture of sports to one which emphasizes the
safety and wellness of the athlete over the outcome of the game.
Neil Mathews
See also: Injuries; National Center for Injury Prevention and Control; School
Health
Further Reading
Almeida, A. A., & Kutcher, J. S. (2016). Sports and performance concussion. In R. B. Daroff,
J. J. Jankovic, J. C. Mazziotta, & S. L. Pomeroy (Eds.), Bradley’s neurology in clinical prac-
tice (7th ed.). Maryland Heights, MO: Elsevier Saunders.
Centers for Disease Control and Prevention. (2017). HeadsUp. Retrieved from https://www
.cdc.gov/headsup/index.html.
Dashnaw, M. L. (2017). Mild traumatic brain injury in adults and concussion in sports.
In H. R. Winn (Ed.), Youmans and Winn neurological surgery. London, UK: Elsevier.
600 STA R K LAW
Giza, C. C., Kutcher, J. S., Ashwal, S., Barth, J., Getchius, T. D., Gioia, G. A., & . . . Zafonte,
R. (2013). Summary of evidence-based guideline update: Evaluation and management
of concussion in sports: Report of the Guideline Development Subcommittee of the
American Academy of Neurology. Neurology, 80(24), 2250–2257. doi:10.1212/WNL
.0b013e31828d57dd
Halstead, M. E., & Walter, K. D. (2010). Sport-related concussion in c hildren and adoles-
cents. Pediatrics, 126(3), 597–615. doi:10.1542/peds.2010-2005
McCrory, P., Meeuwisse, W., Dvořák, J., Aubry, M., Bailes, J., Broglio, S., & . . . Johnston,
K. M. (2017). Consensus statement on concussion in sport: The 5th international con-
ference on concussion in sport held in Berlin, October 2016. British Journal of Sports
Medicine, 51(11), 838. doi:10.1136/bjsports-2017-097699
Omalu B. (2004). Chronic traumatic encephalopathy and the National Football League. Jour-
nal of Neuropathology & Experimental Neurology, 63(5), 535.
Sprouse, R. A., Harris, G. D., Sprouse, G. E., Humerick, M., & Miller, R. T. (2016). Sport-
related concussion: How best to help young athletes. Journal of Family Practice, 65(8),
538–546.
STARK LAW
The Stark law prohibits physician self-referral—a practice in which doctors refer
patients to health services where the physician or a physician’s family member has
a financial interest. Doctors have a lot of power in prescribing medical tests or treat-
ments and where patients go for such services. Ethical conflicts arise when doctors
are directly or indirectly compensated by a business related to their practice. The
physician may prescribe unnecessary services or f avor certain organizations, block-
ing competition and increasing regional health care costs. In Sumter, South Caro-
lina, Tuomey Healthcare System administrators engaged in such practices. Hospital
administrators were concerned with a new freestanding surgicenter, which was being
built nearby. The administrators feared that Tuomey would lose revenue if doctors
performed minor surgeries in the doctor’s office or the ambulatory service center
rather than in the hospital’s facility. To c ounter losses, the health care system con-
tracted 19 area specialists to exclusively use Tuomey’s outpatient surgicenter. The
contracts w ere unusual in that they allowed the physicians to continue as indepen
dent practitioners and focused on number of surgeries rather than number of hours
worked at Tuomey’s facility. The 10-year contracts prohibited the physicians from
performing surgeries within a 30-mile radius of the hospital for another two years
after the end of the contract. In the case against Tuomey, the U.S. Department of
Justice alleged the contract payments w ere higher than market rate for specialist
services, and the hospital was padding the Medicare bills to compensate the physi-
cians (U.S. Department of Justice, 2015). Tuomey was found guilty and fined $237
million for improper financial relationships. The case eventually settled for $72.4
million, and Tuomey was taken over by Palmetta Health.
Named after the bill’s sponsor, U.S. Congressman Pete Stark, the Stark law became
effective in 1992 and has gone through several modifications. Stark I was origi-
nally a provision of the Omnibus Budget Reconciliation Act (OBRA) of 1989. The
STA R K LAW 601
regulation applied to self-referrals to clinical laboratory services. OBRA 1993 created

Stark II, expanding the law to cover designated health services such as inpatient and
outpatient treatment or rehabilitation services, radiology, medical equipment, and
prescription drugs. The law has been criticized. In communities with limited access
to health resources, the Stark law could conceivably block physicians from creating
needed treatment centers. Oftentimes, physician-created services are less expen-
sive b ecause they do not carry the overhead expenses of hospitals. The Stark law
could also block physicians from participating in managed care networks where
the physicians might act as advocates for their patients. The Stark law does allow
some exceptions. Hospitals and physicians may enter into contracts if the proposed
payment amounts are reasonable in comparison to market value, the payment
amount is identified in advance and not based on volume, and the physician ser
vices are clearly named. Contracts should last longer than one year to avoid preda-
tory agreements that take advantage of a natural disaster or regional epidemic.
Examples of acceptable contracts are bona fide employment, incidental benefits
(such as free parking or meals while on call), and renting medical office space.
Penalties for violation of the Stark law start with denial of Medicare or Medicaid
payment for the services in question, fines of up to $15,000 per incident, and pos
sible expulsion from federally financed health programs. This is why we see a hos-
pital such as Tuomey, bought out by a neighboring institution. If a hospital cannot
bill for Medicare services, the organization is essentially out of business. The loss
not only affects the hospital but also hurts the community who needs t hose medi-
cal services. A violation must meet four main criteria: (1) physician; (2) referral for
designated health services; (3) entity that bills Medicare; and (4) financial relation-
ship between the organization and the physician or the physician’s immediate f amily
member (Fredricksen & Egan, 2015). For the purposes of the law, “physician” refers
to any medical or osteopathic doctor, podiatrist, dentist, optometrist, or chiroprac-
tor. “Designated health services” include clinical laboratory services, physical ther-
apy, occupational therapy of speech therapy, radiological services, home health
services, medical equipment, and outpatient prescription drugs or hospital services,
both inpatient and outpatient. “Financial relationship” is defined as direct or indi-
rect ownership or investment interest or direct or indirect compensation arrange-
ment. Although Stark was designed primarily to avoid Medicare fraud, the law has
been used to settle fraudulent Medicaid claims. The final amendment from the
Patient Protection and Affordable Care Act (PPACA) states that the Centers for Medi-
care and Medicaid Services will allow providers to initiate a process of self-reporting
for possible or actual breaches of the act. Physicians, who try to circumvent the
Stark law by putting ownership in another person’s name or through other contriv-
ance, can be fined up to $100,000 per scheme.
The Stark law is related but not the same as the False Claims Act and the federal
Anti-Kickback law. The Stark law is intended to protect patients and prevent cor-
ruption and abuse of the Medicare program by physicians and health care–related
businesses. The law safeguards medical care by ensuring that the doctor is acting
602 STATE , LO C AL , AND TE RR ITO R IAL HEALTH DEPA RT MENTS
in the patient’s best interests and that prescribed treatments and tests are not finan-
cially motivated.
See also: Administration, Health; Affordable Care Act; False Claims Act; Medicare;
Public Health Law
Further Reading
Frederiksen, M., & Egan Weaver, E. (2015). Understanding the federal physician self-referral
statute: “Stark law.” Journal of Health Care Compliance, 17(2), 47–65.
U.S. Department of Justice. (2015, October 16). United States resolves $237 million false claims
act judgment against South Carolina hospital that made illegal payments to referring physi-
cians. Washington, DC. Retrieved from https://www.justice.gov/opa/pr/united-states
-resolves-237-million-false-claims-act-judgment-against-s outh-carolina-h
ospital.
STATE, LOCAL, AND TERRITORIAL

HEALTH DEPARTMENTS
State, local, and territorial health departments are government agencies responsi-
ble for preventing diseases and promoting the health of p eople living within the
respective jurisdiction. The agencies w ere originally organized as a way to prevent
and control epidemic diseases. Over time, functions, scope, and regulatory author-
ity extended to other areas of health. Organizational structures varied based on the
area, state governance, or population served. Generally, health departments are
responsible for (1) developing policies to protect, promote, and improve public
health; (2) ensuring adequate resources for essential public health services; (3) ensur-
ing compliance with federal, state, and local laws and regulations related to public
health; (4) organizing and leading public health efforts; (5) collaborating with com-
munity partners to promote health; and (6) ensuring continuous quality improve-
ment (Public Health Law Center and William Mitchell College of Law). Services
tend to cover certifying agencies for federal reimbursement for health services,
mental health care, tuberculosis control, medical examiner services, health plan-
ning, minority health services, and rural health services. These services may be per-
formed directly by the health department or indirectly through contracts with
for-profit or nonprofit agencies. Public health departments are also responsible for
responding to emerging health issues. In the past few decades, public health depart-
ments have assumed leading roles in bioterrorism preparedness, emergency response,
toxicology prevention, chronic disease epidemiology, cancer screenings, state health
insurance programs, and h uman participant protections review boards.
The first state board of health was founded in 1869 by Massachusetts physician
and social reformer Henry Ingersoll Bowditch. Bowditch envisioned an organization,
supported by the government, which used science to provide medical and social care
to disadvantaged people. Within a few years, other states and large cities created
their own departments of health. These early public health departments focused on
STATE , LO C AL , AND TE R R ITO R IAL HEALTH DEPA RT MENTS 603
sanitation and hygiene, maintaining disease registries, immunizations, and treatment.

During World War I (1914–1918), many draftees were rejected due to poor physical
or m ental health. It became apparent that success as a nation depended on healthy
citizens. Health departments expanded efforts to provide health education, visiting
nurses to support new m others, infants, and children, and community health clinics.
Through the mid-20th century federal activities in disease research, prevention, and
control grew with the establishment of the National Institutes of Health, the Public
Health Service, and the Centers for Disease Control and Prevention. The roles of state
and local boards of health changed to keep relevant with federal activities and fund-
ing opportunities. For example, maternal and child health services, family planning
services, sexually transmitted disease control, and tuberculosis control became stan-
dard services within state and local health departments when the federal government
offered financial and technical assistance for such services.
Today, there are approximately 2,600 local health departments in the United
States (Yeager, Ferdinand, Beitsch, & Menachemi, 2015). Primary health depart-
ment functions are to identify community health needs, investigate health hazards,
communicate health matters to the general public, engage with the community in
health promotion activities, develop public health policies and strategic plans,
enforce public health laws, promote access to quality health care, maintain a com-
petent workforce, employ evidence-based programs and practices, collaborate with
the governing entity, and ensure ongoing quality improvement. The Public Health
Accreditation Board (PHAB) offers a voluntary review of health departments to
ensure quality services. A growing challenge for all health departments is the sky-
rocketing cost of medical services. Despite scientific advances in the prevention of
infectious diseases, improved nutrition, and evidence-based practices in behavioral
health, the nation still struggles with political, economic, and social values that con-
tradict public health, and this leaves public health departments in the difficult
position of justifying the need for care and services to disadvantaged populations.
Sally Kuykendall
See also: Association of State and Territorial Health Officials; Bowditch, Henry Inger-
soll; Community Health Centers; National Association of County and City Health
Officials; U.S. Public Health Service; Controversies in Public Health: Controversy 4
Further Reading
Association of State and Territorial Health Officials. (2016). Retrieved from http://www.astho
.org.
_508.pdf/.
Hyde, J. K., & Shortell, S. M. (2012). The structure and organization of local and state pub-
lic health agencies in the U.S.: A systematic review. American Journal of Preventive Medi-
cine, 42(5, Suppl. 1), S29–S41. doi:10.1016/j.amepre.2012.01.021
604 SU BSTAN CE ABUSE AND M
ENTAL HEALTH SER VI C ES AD M INIST R ATION ( SA M HSA )
Institute of Medicine. (2003). The future of the public’s health in the 21st century. Washington,
DC: The National Academies Press.
Miller, C. A. (1977). Statutory authorizations for the work of local health departments. Amer-
ican Journal of Public Health, 67, 940–945.
Miller, C. A. (1977). Survey of local public health departments and their directors. Ameri-
can Journal of Public Health, 67, 931–939.
Public Health Accreditation Board. Retrieved from http://www.phaboard.org.
Public Health Law Center and William Mitchell College of Law. Retrieved from http://www
.publichealthlawcenter.org/sites/default/files/resources/phlc-fs-state-local-reg-authority
-publichealth-2015_0.pdf.
Shipley, A. E. (1917). Health administration on the district plan. American Journal of Public
Health, 7, 248–259.
The state health department—Services and responsibilities. (1954). American Journal of Pub-
lic Health, 44, 235–252.
Yeager, V. A., Ferdinand, A. O., Beitsch, L. M., & Menachemi, N. (2015). Local public health
department characteristics associated with likelihood to participate in national
accreditation. American Journal of Public Health, 105(8), 1653–1659. doi:10.2105
/AJPH.2014.302503
SUBSTANCE ABUSE AND M ENTAL HEALTH SERVICES

ADMINISTRATION (SAMHSA)
An estimated 22.7 million Americans need treatment for substance abuse, yet only
2.5 million p eople actually receive treatment from qualified facilities (National Insti-
tute on Drug Abuse [NIDA], 2015). The Substance Abuse and Mental Health Services
Administration (SAMHSA) is the federal agency responsible for leading national
efforts in prevention, treatment, and recovery of substance abuse, mental illness, and
behavioral health problems. SAMHSA’s mission is to “reduce the impact of substance
abuse and mental illness on America’s communities” (SAMHSA). To carry out this
mission, SAMHSA creates and disseminates information through public awareness
campaigns, offers research and community grants, analyzes and develops national
policies, advocates for evidence-based programs, and works to improve access to
quality services for people suffering from substance abuse and m ental illness. The
agency is one of the eight operating divisions of the Department of Health and Human
Services (DHHS). Current initiatives address substance abuse, suicide, trauma and
violence, workforce wellness, veterans’ health, homelessness, mental illness, prescrip-
tion drug misuse, disaster preparedness and response, HIV/AIDS, and criminal and
juvenile justice. SAMHSA serves members of the general population and popula-
tions vulnerable to socioemotional trauma, such as lesbian, gay, bisexual, trans-
gender, and queer (LGBTQ) individuals, ethnic minorities, veterans and their
families, and college students and youth in transitional stages. SAMHSA studies
and encourages best programs and practices in substance abuse prevention and
promotion of m ental health.
Federal organizing against the problem of substance abuse prevention traces back
to 1935 when a research facility was established for addiction research within the
Public Health Service hospital in Lexington, Kentucky. The facility eventually became
SU BSTAN C E ABUSE AND M
ENTAL HEALTH SER V I C ES AD M INIST R ATION ( SA M HSA ) 605
the Addiction Research Center (ARC) and later the National Institute on Drug Abuse
(NIDA). Before the science of addictions or m ental illness was realized, p
eople with
neurological disorders, addictions, or m ental illness were housed in mental institu-
tions and isolated from the rest of society. Mental asylums struggled with overcrowd-
ing, underfunding, seriously ill patients, and unqualified staff. The popular opinion
was that p eople with m ental illness w
ere morally defective and did not deserve
humanity or compassion. The field of medicine was complicit in the problem. Few
doctors chose to go into psychiatry, and little was known (or even cared to be known)
about effective treatments. As veterans returned from World War II, the nation was
confronted by an epidemic of post-traumatic stress disorder, anxiety, depression,
and paranoia. Witnessing the trauma of war, death, torture, destruction, and fear
took a toll on the sons, brothers, uncles, and fathers who served the nation. Over
one million service men and women were admitted to military hospitals for neuro-
psychiatric problems (Appel, Beebe, & Hilger, 1946). The nation could no longer
depersonalize, blame, or stereotype the mentally ill as morally defective. T here was a
moral obligation to care for the nation’s veterans. In 1946, President Harry S. Truman
signed the National M ental Health Act. The law called for research into m ental health
disorders, prevention and treatment programs, training in care of the mentally ill
for medical professionals, and the creation of the National Advisory Mental Health
Council. The obligation to care for the nation’s veterans helped to stimulate research,
training, and programs in m ental health.
In 1970, President Richard M. Nixon signed the Comprehensive Alcohol Abuse
and Alcoholism Prevention, Treatment, and Rehabilitation Act, also known as the
Hughes Act after recovering alcoholic senator Harold Hughes. The act supported
research, prevention, and treatment of alcohol abuse and led to the creation of the
National Institute on Alcohol Abuse and Alcoholism (NIAA). The NIAA was respon-
sible for many new discoveries in treatment of alcohol addiction, fetal alcohol syn-
drome, and underage drinking as well as advocating for effective policies, programs,
and treatments. The public started to recognize alcoholism as a disease in need of
medical treatment, rather than a moral deficit. The Alcohol, Drug Abuse, and Mental
Health Administration (ADAMHA) was established to take NIAA’s discoveries and
apply the information to addiction treatment. ADAMHA was quickly replaced by
SAMHSA. Whereas ADAMHA focused on the treatment of addictions, SAMHSA
focused on promoting m ental health among all people. Thus, SAMHSA’s focus is
holistic, geared t oward disease prevention and health promotion.
SAMHSA serves as the nation’s leading authority on behavioral health. The organ
ization provides accurate resources and information to states, territories, tribes,
communities, local organizations, health professionals, and individuals. SAMHSA
is a clearinghouse for quality information on alcohol, tobacco and other drugs,
behavioral health treatment, mental disorders, school and campus health, suicide
prevention, trauma and violence, and vulnerable populations. Mentalhealth.gov is
a resource for individuals experiencing mental health problems, concerned friends
looking to help a loved one, parents and caregivers, teachers, and faith and com-
munity leaders. The site describes attributes of m ental health, warning signs of
606 SU B STAN C E A B USE AND M
ENTAL HEALTH SER V I C ES AD MINIST RATION (SA M HSA)
ental health problems, ways to promote positive mental health, and recovery
m
from m ental illness. The website links directly to the National Suicide Preven-
tion Lifeline, 1-800-273-TALK (8255), for those who need someone to connect
with. SAMHSA News is a national newsletter providing the latest information in
substance use and mental disorder prevention, treatment, and recovery. Article
topics include building trauma-informed resilient communities, self-care for
health care professionals, and partnering with faith-based organizations. Stop-
bullying.gov is where experts in bullying turn for the latest information, news,
and updates in bullying prevention research. Written for all audiences, the site
defines bullying, risk factors, effective strategies for prevention, and constructive
responses. Stopbullying.g ov deconstructs many of the myths and misperceptions
regarding bullying in order to bring accurate information into homes, schools,
and communities. SAMHSA provides a wealth of current and accurate informa-
tion to support mental health.
The nation has come a long way in recognizing mental illness and addictions as
chronic diseases in need of medical treatment. Much of the progress can be attrib-
uted to federal partners working with communities to study and understand behav-
ioral health problems. SAMHSA focuses specifically on increasing public awareness
and understanding of m ental disorders and substance use, promoting m ental health
among all people in the nation, preventing substance abuse and mental illness, sup-
porting recovery, and increasing access to evidence-based programs and treatments.
Over the next several years, the organization will focus on building a competent,
qualified behavioral health workforce, integrating behavioral health services into
existing health systems, exposing the connections between trauma and antisocial
behaviors, preventing substance abuse and mental illness, and strengthening the
systems that support people in recovery by partnering with education and employ-
ment services. A major challenge will be confronting and controlling the opioid
epidemic, as this may divert resources from current needs.
Sally Kuykendall
See also: Addictions; Alcohol; Beers, Clifford Whittingham; Centers for Disease Con-
trol and Prevention; Dix, Dorothea Lynde; Emergency Preparedness and Response;
Evidence-Based Programs and Practices; Food and Drug Administration; M ental
Health; Mental Illness; Prescription Drugs; U.S. Department of Agriculture; U.S.
Department of Health and H uman Services; Veterans’ Health; Violence; Controver-
Further Reading
Appel, J. W., Beebe, G. W., & Hilger, D. W. (1946). Comparative incidence of neuropsychi-
atric casualties in World War I and World War II. The American Journal of Psychiatry,
103, 196–199. doi:10.1176/ajp.103.2.196
National Institute on Drug Abuse. (2015). Drug facts, nationwide trends. Retrieved from
https://www.drugabuse.gov/publications/drugfacts/nationwide-trends.
SUR G EON G ENE R AL 607
Pols, H., & Oak, S. (2007). War & military m ental health: The US psychiatric response in
the 20th century. American Journal of Public Health, 97(12), 2132–2142.
Substance Abuse and Mental Health Services Administration. Retrieved from https://www
.samhsa.gov.
SURGEON GENERAL
The surgeon general is the country’s senior medical officer responsible for commu-
nicating important health information to the nation and managing the U.S. Public
Health Service. Only one surgeon general serves at a time. To qualify for the posi-
tion, the candidate must have experience in public health, and be a member of the
U.S. Public Health Service, nominated by the president of the United States, and
confirmed by the Senate. The position of surgeon general was founded in 1870 when
President Ulysses S. Grant appointed Dr. John Maynard Woodworth as supervising
surgeon of the Marine Hospital Service, a national health system for sick, injured,
and disabled seamen. Over the years, the role of the surgeon general evolved from
treating and preventing communicable diseases to treating and preventing acute
and chronic health issues. Today, the Office of the Surgeon General reviews the lat-
est scientific advances in health and makes recommendations for the nation’s
health. As a public health professional, the surgeon general is bound by ethical
principles of honesty, integrity, respect for persons, beneficence, and justice. This
means that the surgeon general must act in the best interests of the nation and the
people in the nation and cannot selectively review scientific information in order
to support or oppose political ideology.
The Office of the Surgeon General traces back to 1798 when President John
Adams signed the Act for the Relief of Sick and Disabled Seamen. The act was
designed to hold shipping merchants and crews accountable for compensating local
hospitals caring for sick or injured sailors. As shipping trade developed and the
system grew, the Marine Hospital Service (MHS) was created to supervise and coor-
dinate services. In 1871, Dr. John M. Woodworth was appointed as the first super-
vising surgeon. Woodworth created a uniformed federal workforce responsible for
examining sailors and immigrants, investigating outbreaks of infectious diseases,
and regulating local sanitation. The Commissioned Corps of the U.S. Public Health
Service is a nonmilitary organization composed of public health professionals
responsible for protecting, promoting, and advancing the health and safety of the
United States. In 1873, the position of supervising surgeon became supervising sur-
geon general and was later changed to surgeon general.
The surgeon general holds the rank of a two-star rear admiral (RADM) or three-
star vice admiral (VADM). The surgeon generals and acting surgeon generals who
have served the nation are:
• John M. Woodworth (1871–1879)
• RADM John B. Hamilton (1879–1891)
• RADM Walter Wyman (1891–1911)
608 SU R G EON G ENE RAL
• RADM Rupert Blue (1912–1920)

• RADM Hugh S. Cumming (1920–1936)
• RADM Thomas Parran Jr. (1936–1948)
• RADM Leonard Scheele (1948–1956)
• RADM Leroy E. Burney (1956–1961)
• RADM Luther L. Terry (1961–1965)
• VADM William H. Stewart (1965–1969)
• RADM Richard A. Prindle (acting surgeon general, 1969)
• RADM Jesse L. Steinfeld (1969–1973)
• RADM S. Paul Ehrlich (acting surgeon general, 1973–1977)
• VADM Julius B. Richmond (1977–1981)
• Edward Brandt, Jr. (acting surgeon general, 1981–1982)
• VADM C. Everett Koop (1982–1989)
• ADM James O. Mason (acting surgeon general, 1989–1990)
• VADM Antonia C. Novella (1990–1993)
• RADM Robert A. Whitney (acting surgeon general, 1993)
• VADM M. Joycelyn Elders (1993–1994)
• RADM Audrey F. Manley (acting surgeon general, 1995–1997)
• ADM/ VADM David Satcher (1998–2002)
• RADM Kenneth P. Moritsugu (acting surgeon general, 2002)
• VADM Richard H. Carmona (2002–2006)
• RADM Kenneth P. Moritsugu (acting surgeon general, 2006–2007)
• RADM Steven K. Galson (acting surgeon general, 2007–2009)
• RADM Donald L. Weaver (acting surgeon general, 2009)
• VADM Regina M. Benjamin (2009–2013)
• RADM Boris D. Lushniak (acting surgeon general, 2013–2014)
• VADM Vivek H. Murthy (2014–2017)
• RADM Sylvia Trent-Adams (acting surgeon general, 2017)
The surgeon general is the chief authority for public health issues in the nation. For
example, u nder President John F. Kennedy, Surgeon General Luther L. Terry led a
committee of experts to investigate the health effects of smoking. Mounting evi-
dence contradicted the popular belief that cigarettes cleared the lungs and aided
breathing. The committee reviewed more than 7,000 research articles and Surgeon
General Terry concluded that cigarette smoking is a health hazard. From the sur-
geon general’s report, Congress passed the Federal Cigarette Labeling and Adver-
tising Act of 1965 requiring the surgeon general’s warning label on all cigarette
packages and banning cigarette advertising on television.
Although the surgeon general is responsible for ensuring and promoting the health
of people in the nation, political pressures often strain the person and the role. In
1968, the position of Assistant Secretary of Health (ASH) was created to oversee the
surgeon general’s office. Whereas the Office of the Surgeon General is a service posi-
tion, legally and ethically forbidden from engaging in political activities, the Assistant
SY R IN G E SE R V I CE P RO G R A M S 609
Secretary of Health is a political position. This means that the surgeon general has
a responsibility to promote public health while the surgeon general’s boss has a
responsibility to promote the current administration’s political agenda. This creates
problems. Such as when the Reagan administration attempted to pressure Surgeon
General C. Everett Koop, MD, into saying that abortion was psychologically harm-
ful to w
omen. Fortunately, members of Congress accepted and supported the con-
clusions from Terry’s smoking and health advisory committee. If members had
acted in the best interest of tobacco companies, cigarette advertising companies, or
small shopkeepers, more people would have died from cancer and smoking-related
diseases.
The surgeon general is the nation’s top doctor or nurse, responsible for identify-
ing pressing health concerns, investigating the latest science, and developing rec-
ommendations. Overall, the system works. The surgeon general’s office is cautious
knowing that announcements could make or break a business. Unfortunately, the
current system of oversight is based on politics, and this can become a problem if
the current political regimen has an agenda that conflicts with public health.
Sally Kuykendall
See also: Association of State and Territorial Health Officials; Cancer; Centers for
Disease Control and Prevention (CDC); Cutter Incident, The; Elders, Joycelyn;
Health Policy; Healthy People 2020; National Heart, Lung, and Blood Institute
(NHLBI); Obesity; Research; Tuskegee Syphilis Study; U.S. Department of Health
and Human Services; U.S. Public Health Service; Skin Cancer; Violence; Wynder,
Ernst Ludwig; Controversies in Public Health: Controversy 2; Controversy 4
Further Reading
Carmona, R. (2017). Instant admirals and the plague of politics in the United States Public
Health Service: Back to the future. Military Medicine, 182(5), 1582–1583. doi:10.7205
/MILMED-D-17-00039
Furman, B. (1973). A profile of the United States Public Health Service, 1798–1948. Washing-
ton, DC: U.S. Department of Health, Education, and Welfare.
Mullan, F. (1989). Plagues and politics: The story of the United States Public Health Service.
New York: Basic Books.
Surgeon General. Retrieved from https://www.surgeongeneral.gov.
SYRINGE SERVICE PROGRAMS

When injection drug users (IDUs) inject heroin, cocaine, methamphetamine, or
other substance, they draw a tiny amount of blood from the vein into the syringe
to check that the needle is properly positioned. If the blood is infected with HIV,
hepatitis B, hepatitis C, or other blood borne disease, the pathogen can be transmitted
to other p
eople who use the syringe. As the AIDS epidemic advanced, one-quarter to
one-third of all new cases were due to needle sharing (HIV/AIDS surveillance
610 SY R IN G E SE RVICE PROGRAMS
report, 1993). Half of all heterosexually acquired AIDS cases traced to unprotected
sex with an IDU, carrying the infection to newborns and nursing infants. Improperly
discarded syringes risk injury and infection to children, sanitation workers, and
members of a community. Needle exchange programs (NEPs) reduce blood borne
infections by offering injection drug users (IDUs) free sterile syringes in exchange
for used, potentially contaminated n eedles. Syringe service programs (SSPs) are
comprehensive public health programs offering needle exchange, alcohol swabs,
bleach, safe needle disposal bins, condoms, health education on safe injection prac-
tices and wound care, overdose prevention, counseling, testing for HIV and hepati-
tis, and referral to drug treatment programs or other m ental health services. NEPs,
SSPs, and syringe exchange programs (SEPs) are also called harm reduction programs
because the programs focus on reducing the harm of injection drug use, rather than
treating the addiction. Multiple evaluation studies show that SSPs effectively reduce
the transmission of HIV, hepatitis, and other blood borne diseases among at-risk
populations (Des Jarlais, Sloboda, Friedman, Tempalski, McKnight, & Braine,
2006; Kaplan & O’Keefe, 1993; Wodak & Cooney, 2006). However, since incep-
tion NEPs have been highly controversial, criticized as promoting illegal and self-
destructive behavior. The Consolidated Appropriations Act of 2016 limits the use
of federal funds to support NEPs. The federal government provides partial support
to state, local, tribal, and territorial health departments that demonstrate the need
for SSPs. To qualify, the organization must present strong epidemiological evidence
of increased cases or risk of HIV and hepatitis due to injection drug use. Taxpayer
dollars may not be used to support illegal drug activities. From a public health
perspective, SSPs are effective in reducing HIV and hepatitis among IDUs and
sexual partners of IDUs. An added benefit is that they provide access to closed,
hard to reach communities. This access will become increasingly important as the
United States grapples with the emerging opioid and heroin epidemics.
Needle exchange programs started in Edinburgh, Scotland, when a pharmacist
distributed sterile syringes to IDUs in order to stop an epidemic of hepatitis B and
hepatitis C. In 1983, a large, centrally located pharmacy in Amsterdam stopped
selling syringes to IDUs after an outbreak of hepatitis B. Junkiebond, a community
of IDUs, partnered with the local health department to establish a program of nee-
dle exchange. The onset of AIDS prompted other NEPs in major cities of the Neth-
erlands, the United Kingdom, and Australia. In the United States, NEPs started as
underground movements. Yale student and former heroin addict Jon Stuen-Parker
created the Boston AIDS Brigade and the Yale AIDS Brigade, which evolved into
the National AIDS Brigade. Working out of his home or car along the northeastern
corridor of the United States, Stuen-Parker was arrested 27 times in seven states for
the possession and delivery of drug paraphernalia (McLean, 2011). Despite evidence
supporting the effectiveness of SSPs, the United States lagged well b ehind other
nations (Wodak & Cooney, 2006). America’s War on Drugs and other national drug
policies focused on crime and punishment at the expense of public health. With-
out effective prevention or intervention mechanisms, the United States developed
SYR ING E SER V I C E P R O G R A M S 611
the highest HIV/AIDS incidence rates of any non–third world country (Wodak &
Cooney, 2006).
The first legal NEP in the United States was established in Tacoma, Washington,
in 1988. In 1994, 55 SEPs exchanged approximately 8 million syringes (Syringe
Exchange Programs—United States, 1995). By 2002, 119 SEPs exchanged almost
25 million syringes as well as offering referrals for substance abuse treatment, on-
site HIV and hepatitis counseling, tuberculosis and sexually transmitted disease
(STD) screening, and on-site medical care (Update: Syringe Exchange Programs—
United States, 2005). Early evaluation of SSPs showed limited efficacy in reducing
HIV transmission. Critics argued that SSPs encouraged drug use and increased blood
borne diseases. Experts responded that study results may have been confounded
by the fact that SSPs attract chronic IDUs. SSP participants have higher risk of HIV
than nonparticipants. Researchers concluded that programs may be most effective
during early drug use and suggested expanding services to include STD prevention
and addiction treatment services.
Multiple studies refute the arguments used to oppose SSPs and SSP funding. From
1991 to 2001, the U.S. government sponsored seven evaluation studies (Wodak &
Cooney, 2006). All seven studies showed that SSPs reduced HIV transmission
among IDUs, their partners, and c hildren. Researchers in New Haven, Connecti-
cut, estimated a 33 percent reduction in HIV infection rate among program users
(Kaplan & O’Keefe, 1993). The World Health Organization (2004) analyzed over
200 reports from around the world and concluded that SSPs:
1. Substantially reduce HIV.

2. Are more effective than bleach or other forms of disinfection.
3. Do not increase illicit drug use.
4. Are cost effective.
5. Provide opportunity for referral to drug treatment programs and other health
services.
International experts noted that NEPs combined with other HIV prevention programs
are an appropriate public health response to HIV transmission. They also cautioned
that U.S. laws against drug paraphernalia impeded public health efforts. Despite over-
whelming evidence in support of SSPs, it is illegal to buy or own syringes without a
prescription, and federal regulations heavily restrict the use of federal funds for NEPs.
SSPs are public health programs that protect against HIV transmission and sero-
conversion. Studies show that the programs work in at least 10 countries and are
cost effective (Wodak & Cooney, 2006). However, simply exchanging n eedles is
not enough to control HIV or hepatitis among IDUs. Programs that target transmis-
sion of pathogens to sexual partners and children or assist with treatment and
recovery provide an umbrella of services that can have greater public health impact.
Sally Kuykendall
612 SY R IN GE SE RV I C E P R O GR AM S
See also: Addictions; Evidence-Based Programs and Practices; Hepatitis; Infectious

Diseases; Mental Illness; Risk-Benefit Analysis; Controversies in Public Health: Con-
troversy 2
Further Reading
Burris, S., Finucane, D., Gallagher, H., & Grace, J. (1996). The legal strategies used in oper-
ating syringe exchange programs in the United States. American Journal of Public Health,
86(8), 1161–1166.
Centers for Disease Control and Prevention. (2016). Syringe service programs. Retrieved from
https://www.cdc.gov/hiv/risk/ssps.html.
Des Jarlais, D., Sloboda, Z., Friedman, S. R., Tempalski, B., McKnight, C., & Braine, N.
(2006). Diffusion of the D.A.R.E and syringe exchange programs. American Journal of
Public Health, 96(8), 1354–1358.
Harm Reduction Coalition. Retrieved from http://harmreduction.org.
HIV/AIDS surveillance report. (1993). Atlanta, GA: U.S. Department of Health and H uman
Services, Public Health Service, Centers for Disease Control and Prevention, National
Center for Infectious Diseases, Division of HIV/AIDS; Rockville, MD: CDC National
AIDS Clearinghouse [distributor].
Kaplan, E. H., & O’Keefe, E. (1993). Let the n eedles do the talking! Evaluating the New
Haven needle exchange. Interfaces, 23(1), 7–26.
McLean, K. (2011). The biopolitics of needle exchange in the United States. Critical Public
Health, 21(1), 71–79. doi:10.1080/09581591003653124
North American Syringe Exchange Network. Retrieved from https://nasen.org.
Syringe Exchange Programs—United States, 1994–1995. (1995). Morbidity and Mortality
Weekly Report, 44(37), 684.
Update: Syringe Exchange Programs—United States, 2002. (2005). Morbidity and Mortality
Weekly Report, 54(27), 673–676.
van Ameijden, E., van den Hoek, J., van Haastrecht, H., & Coutinho, R. (1992). The harm
reduction approach and risk factors for human immunodeficiency virus (HIV) sero-
conversion in injecting drug users, Amsterdam. American Journal of Epidemiology, 136(2),
236. Retrieved from https://doi.org/10.1093/oxfordjournals.aje.a116489.
Wodak, A., & Cooney, A. (2006). Do needle syringe programs reduce HIV infection among
injecting drug users: A comprehensive review of the international evidence. Substance
Use & Misuse, 41(6–7), 777–813. doi:10.1080/10826080600669579
World Health Organization. (2004). Effectiveness of sterile needle and syringe programming in
reducing HIV/AIDS among injecting drug users. Geneva, Switzerland: Author. Retrieved
from http://www.who.int/hiv/pub/idu/pubidu/en.
T
TRANSTHEORETICAL MODEL (TTM)
The transtheoretical model (TTM) was developed in 1983 by two researchers,
Dr. James O. Prochaska and Dr. Carlo C. DiClemente, while investigating how people
successfully stopped cigarette smoking. The model presents the cognitive stages that
people go through when they are intentionally changing health behaviors. Also
known as “stages of change,” TTM describes both adopting a positive health
behavior, such as increasing exercise, and stopping a negative behavior, such as
substance abuse. Originally applied to addictive disorders, the model has been
found to relate to many other behaviors such as intimate partner violence, bully-
ing, physical activity, mammography screening, safe sexual practices, diet, and sun-
screen use. TTM depicts multiple concepts that play a role in intentional behavioral
change. The main constructs or building blocks of the model are the stages of change,
cognitive and emotional factors that influence the ability and decision to change, and
activities that help p
eople to progress through the specific stages. It is an important
tool for public health professionals to use for dealing with issues that can affect
health,
The core constructs of TTM are the actual stages of behavioral change: precon-
templation, contemplation, preparation, action, maintenance, and termination. The pre-
contemplation stage describes the phase when the person engages in the negative
health behavior or, if moving t oward a healthy behavior, has yet to adopt the posi-
tive behavior. For example, when a person is in an unhealthy relationship, one that
includes intimate partner violence (IPV), the victim in precontemplation is fully
immersed in relationship with the aggressor and has no intention or need to escape
the abusive relationship. The victim either denies or avoids discussing the abuse
and may even make excuses for the perpetrator. In the contemplation stage, the
individual recognizes the problems of continuing the behavior. Normally, contem-
plation lasts approximately six months. P eople can easily get stuck in this stage, a
problem that the model’s authors refer to as chronic contemplation or behavioral
procrastination. In the contemplation stage, the victim of an abusive relationship
might start to question the perpetrator’s actions and motives. The victim might com-
pare the current relationship to positive interpersonal relationships of friends and
family members. In identifying and recognizing acts of disrespect, intimidation, or
abuse, the victim becomes more aware of the problem. During preparation, the indi-
vidual weighs available support systems or options and thinks about using these
systems within the next month. The victim of IPV may gather information on dif
ferent types of counseling services or local domestic violence resources. The action
614 TR ANSTHEORETICAL MODEL (TT M)
phase is the most obvious and observable of the stages. The action phase is the stage
when the individual is actively engaged in stopping the negative behavior or adopt-
ing the positive behavior. The person in a violent relationship may break off the
relationship, move, change telephone numbers, or terminate social networking sites.
The action stage is the most dangerous for victims of IPV b ecause the perpetrator
will become more aggressive in order to maintain control. Violence may escalate to
physical assault. The maintenance phase occurs when the person has successfully
stopped the unhealthy behavior and has few temptations to relapse to the former
lifestyle. Although stages are presented in temporal order, TTM is not linear. Indi-
viduals can easily become stuck in a stage or relapse to former behaviors. Most
importantly, TTM tells us that behaviors rarely stop or start without thought, plan-
ning, and awareness. People go through stages to change behavior. This is an impor
tant concept because public health programs are often measured by the number of
people who take action. The number of p eople who change behavior is not always
an accurate representation of program success. It is just as valuable to move a pro-
gram participant from precontemplation to contemplation as it is to move some-
one from preparation to action.
TTM includes ideas from prior research on decision making by Janis and Mann
(1977). Decisional balance depicts how p eople think about and weigh the pros
and cons of an intended action. W omen in abusive relationships often stay b ecause
they do not believe that they have the economic power to support themselves and
their children, or the victim may believe that the perpetrator w ill recognize the
hurt and pain and self-correct ways of relating. Physicians and health professionals
can help p eople in the early stages of decisional balance by providing health infor-
mation and lists of available resources. In many cases, victims of domestic vio
lence, often m others, w
ill not seek help for themselves but will seek help when
they realize the impact of exposure to abuse on their c hildren. Knowing what
information will enable healthy decision making can help public health profession-
als to empower people to make decisions and change behavior. As individuals move
through the stages, the advantages of changing the behavior outweigh the concerns
or disadvantages.
TTM also provides individuals undergoing behavioral change and the public
health educators supporting those individuals with a toolbox of educational and
support strategies, known as the “processes of change.” The processes of change
are techniques that support p eople through the specific stages. The person in the
precontemplation-contemplation stage needs accurate and specific information. Dur-
ing this time, the public health educator might use consciousness raising, dramatic
relief, environmental reevaluation, or self-reevaluation to support the individual in
decision making. The person in the preparation stage needs help in making a plan
or commitment to stop smoking. This is the stage where pledges, contracts, or reso-
lutions are most useful. The person in the action and early maintenance stages needs
active and strong support. Controlling situations and events that might cause a
relapse, using a reward system, supportive relationships, and substituting the
T RUTH C A M PAI GN , THE 615
negative behaviors with positive behaviors are ways that people in the action phase
succeed in changing the behavior.
TTM is a highly relevant and useful model for today’s health issues. Understand-
ing how p eople consider and change behaviors helps public health professionals to
work with communities and individuals to prevent and reduce many chronic
diseases.
Sally Kuykendall
See also: Addictions; Behavioral Health; Health Communication; Health Education;

Intervention; Self-Efficacy; Substance Abuse and M ental Health Services Adminis-
tration; Controversies in Public Health: Controversy 4
Further Reading
Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health educa-
tion: Theory, research, and practice. San Franscisco: Jossey-Bass.
Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice,
and commitment. New York: F ree Press.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smok-
ing: Toward an integrative model of change. Journal of Consulting and Clinical Psychol
ogy, 51, 390–395.
Transtheoretical Model. (2015, July 9). Cancer Prevention Research Center, University of
Rhode Island. Retrieved from http://web.uri.edu/cprc/transtheoretical-model/.
TRUTH CAMPAIGN, THE

A national tobacco counter marketing campaign branded as Truth was launched by
the American Legacy Foundation (ALF) in February 2000. The ALF was founded
only a few years earlier as a result of the 1998 Master Settlement Agreement between
the tobacco industry, 46 states, and five U.S. territories. Among other provisions, this
agreement set standards for, and imposed restrictions on, the sale and marketing of
cigarettes to youth (Schroeder, 2004). The resulting Truth campaign, the largest
national youth smoking prevention campaign, targets an audience that is primarily
adolescents aged 12 to 17 years who are susceptible to tobacco use. From the
onset, Truth sought to capitalize on the desire of adolescents to be rebellious and
independent by exposing them to the tobacco industry’s deceptive marketing prac-
tices toward teens (Holtgrave, Wunderink, Vallone, & Healton, 2009). The Truth
campaign exposed teens to easily digestible truths about the detrimental effects of
tobacco use and encouraged them to make their own decisions about smoking.
By marketing an anti-smoking message as a brand, the campaign was able to
appeal to adolescents who were at risk for tobacco use. TV and print commercials
in line with the latest trends, along with street marketing and a website, allowed
Truth to reach a large portion of its target audience (Farrelly et al., 2002). Rather than
simply telling youths to “just say no” to smoking, similar to previous anti-smoking
616 TR UTH C AM PAIGN, THE
campaigns, Truth delivered straightforward facts about the tobacco industry’s

motives and marketing practices toward teens. The Truth campaign often used
direct, and often sobering, quotes from the tobacco companies themselves that
revealed their youth-centric marketing and their denial of the negative health effects
caused by tobacco (Biener & Siegel, 2000). Truth advertisements showed teens tak-
ing on the tobacco industry and tearing down the attractiveness of smoking that
tobacco companies tried to establish in their marketing to youths. For example,
one Truth commercial known as “The Real Cost” features a young teenage girl try-
ing to buy a pack of cigarettes. The cashier tells her that she will need to give a little
more beyond the cash value of the cigarettes, so the girl pulls off a piece of skin
from her face and puts it alongside the money. The commercial fades out with a
message asking what the real cost of cigarettes is, and then ends by saying that smok-
ing causes wrinkles that age you prematurely. These hard-hitting commercials are
meant to catch the attention of adolescents and portray information about the neg-
ative effects of smoking in a shocking manner.
The national Truth campaign was modeled a fter the highly successful Truth pro-
gram in Florida. Within two years of the 1998 launch, the prevalence of smoking
by Florida m iddle and high school students dropped by 40 percent and 18 percent,
respectively (Bauer, Johnson, Hopkins, & Brooks, 2000). The decline was deter-
mined to be related to exposure to the Florida counter advertising program (Sly,
Hopkins, Trapido, & Ray, 2001). After the nationwide launch, youth smoking
decreased 22 percent between 1999 and 2002 (Farrelly, Davis, Haviland, Messeri, &
Healton, 2005). The decline was directly attributable to the national Truth cam-
paign. Smoking rates among youth were 1.6 percent lower than they would have
been in the absence of the campaign; an estimated 300,000 fewer youth smoked as
a result of Truth. Further study found that from 2000 to 2004, Truth prevented
450,000 adolescents from initiating the habit of smoking (Farrelly, Nonnemaker,
Davis, & Hussin, 2009). Truth not only reduced the number of youth who were
smoking, but the program also changed attitudes toward smoking. Among young
people aged 12–17 years, exposure to the Truth campaign was associated with an
increase in anti-tobacco attitudes and beliefs, and this effect increased at higher doses
of the Truth exposure (Farrelly et al., 2005). More importantly, t hese effects w ere
sustained over three years, indicating that c ounter marketing campaigns can success-
fully sustain young p eople’s attitudes and beliefs in a positive way (Farrelly, Davis,
Duke, & Messeri, 2009). The Truth campaign is associated with substantial declines
in the youth smoking and has accelerated the recent decline in youth smoking preva-
lence (Farrelly et al., 2005). T here is also evidence that youth-focused anti-smoking
campaigns do not just impact youth, but they also promote attitudinal and behav-
ioral changes in young adults not (Richardson, Green, Xiao, Sokol, & Vallone, 2010).
Despite having nationwide reach and markedly improving the public’s health with
a substantial decrease in youth smoking, this public health campaign did not impose
a large economic burden. Expenditures for Truth totaled just over $324 million to
T RUTH C A M PAI GN , THE 617
develop, deliver, evaluate, and litigate the campaign (Holtgrave et al., 2009). Even
when using conservative estimates of the campaign’s positive health impacts, Holt-
grave and colleagues found that Truth resulted in a savings of approximately $1.9
billion in shared medical costs in just its first two years. An optimistic estimate
speculates that this savings was upwards of $5.4 billion. Ultimately, the cam-
paign recouped its expenditures and was extremely cost effective.
The ALF was able to fund the highly successful Truth campaign due to a settle-
ment from litigation between state attorney generals and the tobacco industry.
According to the Master Settlement Agreement, ALF funding was dependent on the
collective total market share of the four participating tobacco manufacturers, reach-
ing 99.05 or higher (extremely unlikely) (Holtgrave et al., 2009). Due to this stipu-
lation, the ALF has been slowly reducing its expenditures on the Truth campaign
in recent years, and it is only being funded by income generated from its reserve
fund. In 2014, Truth launched the Finish It campaign targeted at the next genera-
tion of youth. This campaign encourages upcoming youth to step up to the chal-
lenge of becoming the generation that ends smoking for good.
Salini Inaganti
See also: Addictions; Birth Defects; Children’s Health; Evaluation; Master Settlement
Agreement; RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Main-
tenance); Risk-Benefit Analysis; Rural Health; Surgeon General; Wynder, Ernst
Ludwig
Further Reading
Bauer, U. E., Johnson, T. M., Hopkins, R. S., & Brooks, R. G. (2000). Changes in youth ciga-
rette use and intentions following implementation of a tobacco control program: Find-
ings from the Florida youth tobacco survey, 1998–2000. Journal of the American Medical
Association, 284, 723–728. Retrieved from http://doi.org/10.1001/jama.284.6. 723.
Biener, L., & Siegel, M. (2000). Tobacco marketing and adolescent smoking: More support
for a causal inference. American Journal of Public Health, 90, 407–411. Retrieved from
http://doi.org/10.2105/AJPH.90.3. 407.
Farrelly, M. C., Davis, K. C., Duke, J., & Messeri, P. (2009). Sustaining “truth”: Changes in
youth tobacco attitudes and smoking intentions after 3 years of a national antismoking
campaign. Health Education Research, 24, 42–48. Retrieved from http://doi.o rg/1 0.1093
/her/cym087.
Farrelly, M. C., Davis, K. C., Haviland, M. L., Messeri, P., & Healton, C. G. (2005). Evi-
dence of a dose-response relationship between “truth” antismoking ads and youth smok-
ing prevalence. American Journal of Public Health. Retrieved from http://doi.org/10
.2105/AJPH.2004.049692.
Farrelly, M. C., Healton, C. G., Davis, K. C., Messeri, P., Hersey, J. C., & Haviland, M. L.
(2002). Getting to the truth: Evaluating national tobacco countermarketing campaigns.
American Journal of Public Health, 92, 901–907. Retrieved from http://doi.org/10.2105
/AJPH.92.6. 901.
618 TUBM AN, HARRIET
Farrelly, M. C., Nonnemaker, J., Davis, K. C., & Hussin, A. (2009). The influence of the
national truth campaign on smoking initiation. American Journal of Preventive Medicine,
36, 379–384.
Holtgrave, D. R., Wunderink, K. A., Vallone, D. M., & Healton, C. G. (2009). Cost-utility
analysis of the national Truth® campaign to prevent youth smoking. American Journal
of Preventive Medicine, 36, 385–388. Retrieved from http://doi.org/10.1016/j.amepre
.2009.01.020.
Richardson, A. K., Green, M., Xiao, H., Sokol, N., & Vallone, D. (2010). Evidence for truth?
The young adult response to a youth-focused anti-smoking media campaign. American
Journal of Preventive Medicine, 39, 500–506. Retrieved from http://doi.org/10.1016/j
.amepre.2010.08.007.
Schroeder, S. A. (2004). Tobacco control in the wake of the 1998 Master Settlement Agree-
ment. New England Journal of Medicine, 350, 293–301. Retrieved from http://doi.org/10
.1056/NEJMsr031421.
Sly, D. F., Hopkins, R. S., Trapido, E., & Ray, S. (2001). Influence of a counteradvertising
media campaign on initiation of smoking: The Florida “truth” campaign. American
Journal of Public Health, 91, 233–238. Retrieved from http://doi.org/10.2105/AJPH
.91.2.233.
TUBMAN, HARRIET (1822–1913)

The enslavement of African people is one of the darkest moments of American history.
Deprived of the basic h uman rights of health, liberty, and the pursuit of happiness,
millions of p
eople lived in squalid confinement. At risk for violence, injuries, malnu-
trition, and infection, slaves had an average life expectancy of 21 or 22 years. Harriet
Tubman was a fugitive slave who is best known for helping slaves escape to freedom
on the Underground Railroad. Historians estimate that Tubman rescued approxi-
mately 70 people making 13 trips across the Mason-Dixon Line. She was also one
of 20,000 w omen who worked as nurses, cooks, laundry workers, and cleaners,
caring for soldiers during the Civil War (1861–1865). A fter the war, she continued
to work actively for the rights of African Americans, w omen, the elderly, and the
disabled. She opened a nursing home for the elderly and ill in New York. Hailed as
“the Moses of her p eople” because of her courageous leadership on the Under-
ground Railroad, Tubman was a living symbol of human rights activism in the for-
mation of the United States.
Tubman was born as Araminta “Minty” Ross in 1822, one of eight c hildren of
Harriet “Rit” (Green) and Ben Ross. Her parents were enslaved on the Anthony
Thompson plantation in Dorchester County, Maryland, and Tubman was born into
slavery. She began working as a field hand when she was seven years old. She received
no schooling and never learned to read or write. Despite the subordination of slav-
ery, Tubman grew up strong-willed and independent. When she was 13, an abu-
sive overseer threw a two-pound dry goods weight at another young slave. Tubman
jumped to protect the lad and the weight struck her in the head causing permanent
neurological damage. Throughout her life, she suffered seizures, headaches, sleeping
TUB M AN, HAR R IET 619
spells, and visions. In 1844, she married John Tubman, a free African American,
and changed her name to Harriet Tubman.
Five years later, when the plantation where she lived was sold, Tubman escaped
to the North. Her husband did not accompany her, so Tubman traveled by herself
on the Underground Railroad. She eventually returned for John Tubman, but he
had remarried. Not long after her safe arrival in Philadelphia, Tubman began mak-
ing trips to the Eastern Shore to help free other slaves. In December 1850, she
brought out her sister and two children from Maryland, and later she helped her
brother and two other slaves. Tubman’s most daring exploit occurred in 1857, when
she hired a wagon and brought from Maryland her elderly parents. Armed with a
small pistol, Tubman brought out not only her family, but other slaves as well. By
her own accounts, Tubman rescued approximately 70 African Americans. The num-
ber was later inflated by biographer Sara Bradford.
Deeply religious, Tubman thought all her actions w ere guided by God. Tubman
sang two songs during her rescue operations, “Go Down Moses” and “Bound for
the Promised Land.” She changed the tempo of the song to signal to t hose in hiding
whether it was safe to come out. Fellow abolitionists extolled her virtues, and in
the late 1850s, she began speaking at abolitionist meetings. In 1858, Tubman met
radical abolitionist John Brown in St. Catherines, Ontario, where she and her par-
ents w ere then residing. She became a coconspirator in planning his raid on Harp-
ers Ferry, Virginia, in 1859. She had initially planned to participate in the raid herself
but was compelled by illness to miss the opportunity; the raid resulted in Brown’s
capture and death.
During the first year of the Civil War, Tubman continued her rescue work across
enemy lines into the South. In early 1862, she joined the Union forces at Beaufort,
South Carolina, serving as a scout and spy. She also worked as a nurse and helped
slaves who sought refuge with the Union Army. In 1863, Tubman led an army expe-
dition to free over 700 slaves.
After the war, Tubman returned to Auburn, New York, where she had resettled
her parents on a farm in the late 1850s. In 1869, she married Nelson Davis, a dis-
abled veteran. She also cared for a number of African American orphans and elderly
former slaves. Part of the money that enabled her to do this came from royalties
turned over to her from Sarah Bradford, who wrote two biographies: Scenes in the
Life of Harriet Tubman (1869) and Harriet, the Moses of Her P eople (1886). Although
Tubman repeatedly applied to the federal government for compensation for her war
time services, the only money she received was a small pension as the widow of
Nelson Davis, who had died in 1888.
In the last years of her life, Tubman raised money for freedmen’s schools and
helped spur the growth of the African Methodist Episcopal Church in upstate New
York. In 1903, she donated 25 acres of land to the church for the establishment
of a shelter for poor and homeless African Americans. Tubman died of pneumo-
nia on March 10, 1913. The importance of Tubman’s work as an abolitionist was
620 TUS KE G EE SYPHILIS STUDY
acknowledged in 2013, when President Barack Obama designated a portion of

Maryland’s Eastern Shore as the Harriet Tubman Underground Railroad National
Monument, the first national monument to honor an African American w oman.
On April 20, 2016, Secretary of the Treasury Jack Lew announced a plan to recog-
nize Tubman by putting her image on the front of the $20 bill, making her the first
African American to appear on the front of U.S. paper currency.
Tubman’s life demonstrates the struggles and successes of African Americans in
securing basic human rights and the most basic level of health.
William McGuire, Leslie Wheeler, and Sally Kuykendall
See also: Bousfield, Midian Othello; Bowditch, Henry Ingersoll; Health Disparities;
Kelley, Florence; Smith, James McCune
Further Reading
Bradford, S. H. (2012). Harriet, the Moses of her p eople. Chapel Hill: University of North
Carolina Press.
Daniel, S. I. (1932). Women builders. Washington, DC: Associated Publishers.
Harriet Tubman Underground Railroad Byway. (2017). About Harriet Tubman. Retrieved from
http://harriettubmanbyway.org.
Heidish, M. (1976). A w oman called Moses: A novel based on the life of Harriet Tubman. Ips-
wich, MA: Houghton.
Quarles, B. (1969). Black abolitionists. New York: Oxford University Press.
Schultz, J. E. (2004). Women at the front: Hospital workers in Civil War America. Chapel Hill:
University of North Carolina Press.
TUSKEGEE SYPHILIS STUDY

The Tuskegee Syphilis Study was a 40-year observational study of the health con-
sequences of untreated syphilis among black men. The U.S. Public Health Service
(USPHS) initiated the study in 1932. Six hundred men participated, 399 with syph-
ilis and 201 without the sexually transmitted disease. After the discovery of peni-
cillin, local doctors were instructed not to treat study participants with the antibiotic.
Thus, there was a concerted effort to obstruct treatment. The study not only threat-
ened the men’s health, but it also exposed sexual partners and unborn children to
the deadly pathogen. The study stopped a fter media reports raised public outcry.
The Tuskegee Syphilis Study is of historical significance for several reasons. The
study stands as the longest unethical study in the history of the United States. It
brought disgrace to public health, medicine, and research. Many African Ameri-
cans hold a deep distrust of t hese systems t oday because of what happened to t hese
vulnerable families at the hands of people who were obligated to provide care. The
case is also a reminder of how professional arrogance and social values can adversely
affect science and medicine. Scientists must maintain constant vigilance in the pro-
tection of human research participants.
TUSK E G EE SYPHILIS STUDY 621
To understand the Tuskegee Syphilis Study, one must understand the fascinating
and deadly disease of syphilis and the history of racism in medicine. The bacte-
rium Treponema pallidum is spread through sexual contact. Without treatment, dis-
ease symptoms progress through four unique stages. In the primary stage, painless
sores develop at the sight of entry to the body. The sores may go undetected and
will disappear in three to six weeks regardless of treatment. During the secondary
stage, the victim has signs of infection—fever, sore throat, muscle aches, fatigue,
and rashes. Some rashes appear on the mucous membranes—mouth, vagina, or
anus. The classic syphilitic rash is red or reddish brown spots on the palms of the
hand or the soles of the feet. Again, the rash will go away regardless of treatment.
At this point, the infection is internalized. The person shows no outward signs or
symptoms. The latent stage can last for 10–30 years. During the tertiary stage, the
disease attacks the brain, nervous system, and eyes. The victim suffers from diffi-
culty with muscle movements, paralysis, dementia, or blindness. Syphilis can be
transmitted from mother to unborn baby, causing low birth weight, premature birth,
or stillbirth. The origin of syphilis is unknown. The disease was first recorded in
Europe in 1494, believed to be carried from the new world by Columbus’s sailors.
Syphilitic symptoms quickly became associated with prostitution and immorality.
Curious doctors performed many early experiments in syphilization and cures. Mer-
cury emerged as one early treatment. However, mercury had nasty side effects
causing neurological damage and death. From 1891 to 1910, Caesar Boeck, pro-
fessor of dermatology at the University of Oslo, studied 2,000 cases of untreated
syphilis. Boeck believed that mercury interfered with the body’s natural healing,
and he forbid treatment of his hospital patients. When Salvarsan was created in
1910, Boeck’s patients w ere offered treatment even though Salvarsan contained arse-
nic and also had harmful side effects. In 1925, E. Bruusgaard followed up with
patients from the earlier study. The Boeck-Bruusgaard Oslo Study of Untreated
Syphilis became a classic study on the natural course of untreated syphilis. The
investigators concluded that all cases of syphilis, no matter what stage, should be
treated. Although the Oslo Study provided detailed information on the clinical
course of syphilis, the study participants w ere all white. European American
anthropologists, biologists, doctors, and scientists believed that African Ameri-
cans were primitive people who were uneducable, oversexed, and subordinate.
Physical, mental, and moral differences were due to evolution, not socioeco-
nomic conditions. Black people were considered naturally inferior and inherently
at greater risk of death and disease.
In 1929, the Julius Rosenwald Fund provided the U.S. Public Health Service
(USPHS) with a grant to identify the prevalence of syphilis and potential for treat-
ment of black p eople in the rural South. Prevalence data w ere collected from six
counties. Treatment was never given due to the financial collapse of the economic
depression. In 1932, Dr. Taliaferro Clark, chief of the USPHS Venereal Disease Divi-
sion and author of the Rosenwald report, determined that Macon County, Ala-
bama, could provide a “study in nature.” With a large, stable black population and
622 TUS K EG EE SYPHILIS STUDY
syphilis rates of 39.8 percent, Macon County was as an ideal location for longitu-
dinal research (Olansky, Simpson, & Schuman, 1954). Many former plantation
slaves settled in the area, working small tracts of degraded agricultural land. The
community was geographically, economically, socially, and culturally isolated. Few
people moved out of the area. Medical services were limited to one black and nine
white physicians, the John A. Andrew Memorial Hospital on the campus of the pres-
tigious Tuskegee Institute, the Veterans Administration Hospital, and the Macon
County Health Department. Even t hese services were limited. The physicians w ere
located in wealthier areas of the county, difficult to access from the poorer regions.
Costs at Andrew Memorial Hospital were prohibitive for low income patients. The
VA hospital only treated veterans. It was generally concluded that black residents
of Macon County with syphilis did not have access to effective, affordable treat-
ment. Surgeon General H. S. Cummings contacted the director of the Tuskegee Insti-
tute requesting cooperation with “an unparalleled opportunity” for scientific research
that could not “be duplicated anywhere else in the world.”
The USPHS partnered with physicians at the Tuskegee Institute, providing funds,
resources, and training internships. Six hundred men were enrolled in the USPHS
Dr. Walter Edmondson draws blood from an unidentified man enrolled in the Tuskegee
Syphilis Study. U.S. Public Health Service doctors exploited black residents of Macon
County, Alabama, in a study of syphilis. Study participants were purposefully blocked from
getting treatment when penicillin became available. (National Archives)
TUSK E G EE SYPHILIS STUDY 623
study. Over 80 percent of the study participants were married. Infected participants
had a median age of 60, and uninfected participants had a median age of 61. The
researchers hired black staff so that participants would feel more comfortable and
less likely to question or resist. A predominant figure was nurse Eunice Rivers. Rivers
was a product of her time period. A black woman from the South, Rivers did not
question the white doctors. She developed close relationships with the men, ensur-
ing that the men continued in the study despite demands on time and painful proce-
dures. The men w ere enticed with free medical exams, treatment for disorders not
related to syphilis, free meals, certificates of participation, and the promise of burial
payment. The men were never given informed consent. They were told that they had
“bad blood.” The first study report was published in 1936. Interim reports were
issued every four to six years. By 1953, Rivers appeared as the principal coauthor on
the report, suggesting her growing importance as a member of the study team.
The study was intended to last six months. As funding was renewed, the study
continued. By 1947, penicillin became the drug of choice for syphilis. The men
were not offered treatment. Their names were sent to local doctors who w ere asked
to refer the patient back to the Tuskegee Institute for care. In 1968, the USPHS social
worker and epidemiologist Peter Buxton learned of the study and filed an official
protest with the Division of Venereal Diseases. His concerns were dismissed as irrel-
evant. The following year, the CDC reviewed the study and concluded that it
should continue. In 1972, Buxton leaked the story to the Washington Post. The next
day, it was front page news. Senator Edward Kennedy called for congressional inves-
tigation and the study was terminated. By the end of the study, 74 participants
were still alive. Over 100 had died from advanced syphilis. The U.S. government
settled a class action lawsuit out of court for $10 million and medical care for the
surviving men and their wives, w idows, and offspring. On May 16, 1997, Presi-
dent Clinton officially apologized to the surviving men and their families on behalf
of the nation. The USPHS has taken full responsibility for the civil rights violations.
Reviews of the Tuskegee Syphilis Study determined that the study was unethical.
The Oslo study already provided a detailed account of the clinical progression of
syphilis. The idea that people with dark skin experience different symptoms or pro-
gression was not based in science. The men were never told the purpose of the study
or that they had syphilis. Coming from an impoverished minority group, the men
were a vulnerable population, easily enticed by minor inducements. The lack of
treatment a fter penicillin was available was maleficent. The risks of study participa-
tion did not outweigh the benefits. The Tuskegee Study forced public health and
medical scientists to develop a set of guidelines for human participants in research.
In 2014, the descendants of the research participants organized to form the Voices of
Our Fathers Legacy Foundation. The purpose of the foundation is to remember the
men who participated in the study, to preserve the history, and to educate others on
the human rights violations resulting from the Tuskegee Syphilis Study.
Sally Kuykendall
624 TUS KE G EE SYPHILIS STUDY
See also: Belmont Report, The; Centers for Disease Control and Prevention; Ethics in
Public Health and Population Health; Hinton, William Augustus; Public Health in
the United States, History of; Research; Surgeon General; U.S. Public Health Service
Further Reading
Associated Press (Producer). (1997). USA: President Clinton apologises for syphilis experi-
ment [Streaming video]. Retrieved from Associated Press Video Collection database.
Brandt, A. M. (1978). Racism and research: The case of the Tuskegee Syphilis Study. The Hast-
ings Center report. Retrieved from http://nrs.harvard.edu/urn-3:HUL.InstRepos:3372911.
Centers for Disease Control and Prevention. (2016). U.S. Public Health Service Syphilis Study
at Tuskegee. Retrieved from https://www.cdc.gov/tuskegee/timeline.htm.
Centers for Disease Control and Prevention. (2017). Syphilis: CDC fact sheet. Retrieved from
https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm.
Final report of the Tuskegee Syphilis Study Ad Hoc Advisory Panel [Microform]. (1973). Wash-
ington, DC: U.S. Department of Health, Education, and Welfare, Public Health Service.
Jones, J. H. (1981). Bad blood: The Tuskegee syphilis experiment. New York: Free Press; Lon-
don: Collier Macmillan.
A Matter of Morality. (1972). Time, 100(6), 56.
Michigan State University. (n.d.). Faces of Tuskegee. Retrieved from https://msu.edu/course
/hm/546/tuskegee.htm.
National Center for Bioethics in Research and Health Care. (2017). Voices of Our F athers
Legacy Foundation. Retrieved from http://tuskegeebioethics.org/about/voices-for-our
-fathers-legacy-foundation.
Olansky, S., Simpson, L., & Schuman, S.H. (1954). Environmental factors in the Tuskegee
Study of untreated syphilis: Untreated syphilis in the male Negro. Public Health Reports
(1896–1970), 69(7), 691. doi:10.2307/4588864
Reverby, S. (2009). Examining Tuskegee: The infamous syphilis study and its legacy. Chapel Hill:
The University of North Carolina Press.
U
UPSTREAM PUBLIC HEALTH PRACTICES
Upstream public health practices are programs or efforts designed to stop a prob
lem before it starts. Public health offers the story of a fisherman who sees a person
drowning in the river. He pulls the person out and resuscitates him. Soon, another
person is carried by in the rapids, struggling and gasping for air. The fisherman
rescues the second victim. The process continues until the water is filled with drown-
ing p eople. Villagers arrive to help the drowning victims. Exasperated, one rescuer
walks away and the remaining rescuers shout, “Where are you going? We have to
help these people!” The frustrated rescuer replies, “I’m going upstream to stop people
from falling in the river.” While some villagers stay to retrieve victims from the river,
others walk upstream, identify the area where p eople are falling in the w ater, build
a fence, and post warning signs.
The parable demonstrates important principles in public health practice. Stop-
ping a problem before it starts saves valuable resources and lives. Efforts must occur
simultaneously upstream and downstream, and neither effort is more important than
the other. Success requires multiple people, pooling resources, and working together
to address the identified problem.
Paton (1987) credits Dr. Alan Clark, dean and professor of surgery at the Uni-
versity of Otago in Dunedin, New Zealand, with introducing the term upstream med-
icine. Throughout most of his medical c areer, Dr. Clark found himself performing
surgery on tumors that were not diagnosed u ntil late. His training, skill, and efforts
were palliative rather than curative. Rather than performing surgery on end-stage
cancer, Dr. Clark advocated for screening. He agreed that screening for breast, cer-
vical, and intestinal cancers could be expensive and inconvenient and required per-
sonal responsibility. However, he felt prevention was more beneficial and effective.
Although many of the screening services have been assumed by technicians, doc-
tors and clinical practitioners use the principle of upstream practices in anticipa-
tory care. Anticipatory care anticipates potential health problems and engages the
patient as partner in care. An example of anticipatory care is the pediatrician who
examines and identifies the physical and emotional development of an infant and
counsels the young parent on upcoming developmental milestones. If the health
care professional notices that the infant is sitting up and preparing to crawl, she
might discuss potential hazards in the home and ways to provide a safe environ-
ment for the curious, young explorer. Both upstream and anticipatory care are pro-
active, foreseeing problems before they occur. Anticipatory care focuses on the
patient-provider relationship, envisioning health care as a long-term relationship.
626 U .S . DEPA RTMENT OF AGR IC ULTUR E (USDA)
Every effort, e very practice, and e very program in public health is intended to
prevent exposures, experiences, behaviors, and contacts that may result in physi-
cal, emotional, mental, social, or spiritual harm. The idea has widespread applica-
tion to pressing health problems, such as smoking, obesity, opioid abuse, and youth
violence. Public health uses the principles of upstream medicine to examine c auses
and risk f actors, effective ways to stop the problem, and methods to prevent f uture
cases.
Sally Kuykendall
See also: Medicine; Precaution Adoption Process Model; Prevention; Risk-Benefit

Analysis; Social Determinants of Health; Controversies in Public Health: Controversy 4
Further Reading
Bower, E. M. (1978). Pathways upstream: Risks and realities of early screening efforts. Ameri-
can Journal of Orthopsychiatry, 48(1), 131–139. doi:10.1111/j.1939-0025.1978.tb01294.x
Compton, W. M., Boyle, M., & Wargo, E. (2015). Prescription opioid abuse: Problems and
responses. Preventive Medicine: An International Journal Devoted to Practice and Theory,
80, 5–9. doi:10.1016/j.ypmed.2015.04.003
Paton, A. (1987). Upstream medicine. Postgraduate Medical Journal, 63(744), 915–916.
U.S. DEPARTMENT OF AGRICULTURE (USDA)

The United States Department of Agriculture (USDA) is a group of 29 federal agen-
cies and offices that provide “leadership on food, agriculture, natural resources, rural
development, nutrition, and related issues based on public policy, the best avail-
able science, and effective management” (USDA, 2017). The USDA protects and
promotes the health of farmworkers, the public, and the environment through food
safety, nutrition education, food policies, land management, rural development,
research, and education. USDA agencies and offices directly related to public health
are the Animal and Plant Health Inspection Service, Center for Nutrition Policy and
Promotion, Farm Service Agency (FSA), Food and Nutrition Services, Food Safety
and Inspection Service (FSIS), Forest Service (FS), National Agricultural Library
(NAL), National Institute of Food and Agriculture (NIFA), Natural Resources Con-
servation Services (NRCS), Rural Development (RD), Office of Advocacy and Out-
reach (OAO), Office of the Assistant Secretary for Civil Rights (OASCR), faith-based
and neighborhood partnerships (FBNP), and Office of Tribal Relationships (OTR).
The roles and responsibilities of each agency are described on the USDA website.
The USDA communicates with stakeholders through multiple venues, such as
news releases, reports, radio, television, blogs, and live feeds.
In 1906, Upton Sinclair published The Jungle, a novel describing the life of a
poor Lithuanian immigrant in Chicago. Although the book was intended to expose
the harsh and exploitive living and working conditions of recent immigrants,
readers w ere horrified by the descriptions of rats, unsanitary conditions, and
U.S. DEPA RT M ENT O F A G R I C ULTUR E ( USDA ) 627
health violations in the nation’s meatpacking industry. Sinclair later pointed out,
“I aimed for the public’s heart, and by accident I hit it in the stomach.” The book
raised public outcry forcing Congress and President Theodore Roosevelt to create
the Federal Meat Inspection Act of 1906.
Foodborne illnesses are a serious threat to public health. Approximately 48 mil-
lion people suffer from foodborne illness each year, resulting in 128,000 hospital-
izations and 3,000 deaths (CDC, 2016). Estimated cost of foodborne illnesses is as
high as $152 billion per year (Scharff, 2012). The Food Safety and Inspection Ser
vice (FSIS) is responsible for ensuring the safety and accurate labeling of meat,
poultry, and processed eggs (USDA, 2013). FSIS staff inspects food for bacterial con-
tamination, allergens, mislabeled products, illegal chemical residues, and foreign
materials; provides public education and outreach; builds partnerships between
public and private sectors to promote food safety; studies foodborne illnesses in
order to identify emerging risks; and develops policies to protect the public from
foodborne illnesses. The FSIS also ensures that animals are handled humanely at
slaughter. Within FSIS is the Office of Public Health Service, an interdisciplinary
scientific team of microbiologists, chemists, toxicologists, epidemiologists, and
public health professionals who work to identify, manage, and prevent foodborne
pathogens and chemical contamination in meat, poultry, and egg products. The Ani-
mal and Plant Health Inspection Service (APHIS) ensures the health and care of
animals and plants. APHIS’s Plant Protection and Quarantine (PPQ) program pro-
tects the nation’s plants and animals by safeguarding against the entry and spread
of nonnative pests.
One in seven U.S. households suffers from food insecurity, not having enough
food to nourish all members of the h ousehold, or not knowing when safe food can
be secured for the next meal (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2016).
Food insecurity increases risk for obesity and obesity-related diseases. When p eople
are unsure of how and when they w ill be able to attain food again, they compen-
sate by overeating or eating unhealthy foods. Food insecurity is particularly harm-
ful to infants and c hildren who need regular nutrition for healthy physical, social,
and emotional development. The Food, Nutrition, and Consumer Services (FNS)
agency provides c hildren and families in need with access to nutritious foods. FNS
programs include W omen, Infant and C hildren (WIC) Program, Supplemental
Nutrition Assistance Program, school meals, food distribution programs, disaster
assistance, child and adult care food program, summer food service program, farm-
ers’ markets nutrition programs, and nutrition education. It is not enough to sim-
ply feed people; these programs ensure that families in need are attaining healthy
foods that promote health and wellness and prevent disease.
The USDA indirectly combats food insecurity through loans promoting quality
of life in rural communities. The agency offers low interest loans for small businesses,
home purchases, and rural development. For example, in 2008, the USDA Rural
Development partnered with the city of Manistique, Michigan, to upgrade the city’s
drinking water, sewage, and storm water management systems. In 2012, the USDA
628 U .S . DEPA RTMENT OF HEALTH AND HUM AN SE R VI CES (HHS )
Rural Development invested $28.75 million with Box Butte General Hospital in Alli-
ance, Nebraska. The hospital is using the funds to update services. Local residents no
longer need to travel for hours to attain quality health care. Grants and loans are also
used to purchase homes, build business spaces for new entrepreneurs, and develop
community restaurants. Loans are not limited to rural areas. The USDA also supports
microloans for urban farmers and programs, such as Square Roots in New York City,
which creates vertical farms using shipping containers.
For 150 years, the U.S. Department of Agriculture has been responsible for ensur-
ing a safe and nutritious food supply for p eople in the nation and for p
eople import-
ing food products from the United States into other countries. The agency does this
through many different mechanisms, such as nutrition education, food safety inspec-
tion and monitoring, addressing food insecurity, and investing in human resources
by providing loans for home buyers and small businesses in rural communities.
Sally Kuykendall
See also: Agricultural Safety; Environmental Protection Agency; Food and Drug
Administration; Food Insecurity; Food Safety; Nutrition; Rural Health; U.S. Depart-
ment of Health and Human Services
Further Reading
Centers for Disease Control and Prevention. (2016). Foodborne germs and illnesses. Retrieved
from https://www.cdc.gov/foodsafety/foodborne-germs.html.
Coleman-Jensen, A., Rabbitt, M., Gregory, C., & Singh, A. (2016). Household food secu-
rity in the United States in 2015. Economic Research Report No. ERR-215. Retrieved
from https://www.ers.usda.gov/publications/pub-details/?pubid=79760.
Scharff, R. (2012). Economic burden from health losses due to foodborne illness in the
United States. Journal of Food Protection, 75(1), 123–131.
U.S. Department of Agriculture (USDA). (2013). One team, one purpose. Food Safety Inspec-
tion Service: Protecting public health and preventing foodborne illness. Retrieved from https://
www.fsis.usda.gov/wps/wcm/connect/7a35776b-4717-43b5-b0ce-aeec64489fbd
/mission-book.pdf?MOD=A JPERES.
U.S. Department of Agriculture (USDA). (2017). Retrieved from https://www.usda.gov/wps
U. S . DEPARTMENT OF HEALTH AND H UMAN

SERVICES (HHS)
The U.S. Department of Health and Human Services (HHS) is the federal agency
responsible for managing medical, public health, and social services. The mission of
HHS is help Americans achieve healthy and productive lives. The strategic plan to
achieve this mission is to strengthen health care; advance scientific knowledge and
innovation; advance health, safety, and well-being of Americans; and ensure agency
efficiency, transparency, accountability, and effectiveness. Given the wide scope
U . S . DEPA RTMENT OF HEALTH AND HU M AN SE R VI CES (HHS ) 629
of HHS, the current priorities are to achieve affordable health care, ensure safe food
and medical products, provide job assistance, promote access to affordable quality
child care, support biomedical research, and address obligations to disadvantaged
communities, including tribal communities. Public health falls within the purview
of many of HHS agencies.
HHS operations are carried out by 11 divisions, 8 agencies within the U.S. Public
Health Service (USPHS) and 3 human service agencies. The operating divisions are
Administration for Children and Families (ACF), Administration for Community
Living (ACL), Agency for Healthcare Research and Quality (AHRQ), Agency for Toxic
Substances and Disease Registry (ATSDR), Centers for Disease Control and Preven-
tion (CDC), Centers for Medicare and Medicaid Services (CMS), Food and Drug
Administration (FDA), Health Resources and Services Administration (HRSA), Indian
Health Service (IHS), National Institutes of Health (NIH), and Substance Abuse and
Mental Health Services Administration (SAMHSA). Much of the day-to-day work is
done at the state and local levels or through partnerships with private and nongov-
ernment organizations. Although the divisions may appear to represent separate and
distinct responsibilities, in practice, functions are often interdependent. The divisions
work with each other to address emerging and reemerging health issues.
A limitation of the agency is that individual and community health are influ-
enced by many economic, demographic, social, and environmental f actors outside
the scope of the operating divisions. Health issues, such as climate change, com-
munity water fluoridation, gun violence, healthy housing, prescription drug over-
doses, reproductive and sexual health, and tobacco are influenced by businesses,
politics, and personal beliefs. HHS must balance keeping children, adults, families,
and communities safe and healthy within the current system of politics and power.
Throughout history, ensuring and promoting the health of the nation has come in
conflict with politics and economy. Such controversies continue t oday with gun vio
lence, reproductive health, health disparities, and climate change.
HHS is a complex government agency that oversees and administers programs
supporting the health of Americans. Most of the HHS operating divisions address
some aspect of public health, w hether it is physical, m
ental, environmental, social,
or medical. Challenges emerge when political rights and beliefs conflict with the
mission of the agency.
Sally Kuykendall
See also: Affordable Care Act; Centers for Disease Control and Prevention; Centers
for Medicare and Medicaid Services; Food and Drug Administration; Indian Health
Service; Medicaid; Medicare; National Cancer Institute; National Heart, Lung, and
Blood Institute; National Institute on Drug Abuse; National Institutes of Health;
Substance Abuse and M ental Health Services Administration; Surgeon General; U.S.
Department of Agriculture; U.S. Public Health Service; Controversies in Public Health:
Controversy 2
630 U.S. PU BLI C HEALTH SERVICE (PHS)
Further Reading
U.S. Department of Health and H uman Services. (2017). About HHS. Retrieved from https://
www.hhs.gov/about/index.html.
U. S . PUBLIC HEALTH SERVICE (PHS)

The Commissioned Corps of the United States Public Health Service (PHS) is one
of the seven uniformed services under the direction of the executive branch of the
federal government. Commissioned by presidential appointment, physicians, den-
tists, nurses, therapists, pharmacists, environmental health specialists, dietitians,
health administrators, veterinarians, scientists, and other public health profession-
als work to promote health, prevent disease, and advance public health science
throughout the nation. Corps members work in biomedical research, novel drug
development and approval, safe use of medical devices, design of healthy build-
ings, and counterterrorism. They also provide needed medical care to underserved,
disadvantaged communities. The surgeon general directs the PHS. Corps members
wear military uniforms, are assigned to active duty stations, and may be deployed
in national and international emergencies. Core values are leadership, service, integ-
rity, and excellence. Commissioned Corps members engage in nonmilitary service.
Active duty positions include jobs within the Centers for Disease Control and Pre-
vention, the Food and Drug Administration, Indian Health Service, National Insti-
tutes of Health, or other operating divisions of the Department of Health and H
uman
Services (DHHS). Although the Commissioned Corps carries the responsibility to
protect and defend the nation’s health, this responsibility, many times, has been
undermined by politics. Former surgeon general Dr. Richard Carmona (2017) warns
that undermining the credibility of the Office of the Surgeon General erodes PHS
morale, making it difficult to recruit and retain talented professionals. Given that
Commissioned Corps members are highly trained public health professionals who
could easily work in more lucrative industry positions, supporting PHS personnel
at all ranks is an important step in protecting the health of the nation.
In 1798, President John Adams signed the Act for the Relief of Sick and Disabled
Seamen. The act authorized port authorities to collect money for the medical care
of merchant seamen at local hospitals. The intent was to subsidize local hospitals
when ships abandoned sick sailors in port and to halt the transmission of commu-
nicable diseases along shipping routes. Each sailor paid the ship’s accounting offi-
cer twenty cents per month. The funds were given to the port official when the
ship docked. Failure to pay resulted in a one hundred dollar fine, and the ship was
banned from renewing its shipping license. The nation’s first system of national
health insurance was highly successful. The fund enabled new hospitals to be built
in Boston; Newport, Rhode Island; New Orleans; Charleston; and Washington Point,
Virginia. As the system expanded, the need for oversight and coordination of ser
vices increased. In 1870, the Marine Hospital Service (MHS) was created, and
Dr. John M. Woodworth was appointed as the first supervising surgeon. Woodworth
U . S . PU B LIC HEALTH SER VI C E ( PHS ) 631
created a workforce that reflected his experiences in the Union Army. Applicants
were required to undergo rigorous physical examination. Personnel wore uniforms
and could be deployed as needed. When Congress passed the National Quarantine
Act in 1878, the PHS gained the responsibility of inspecting and clearing ships
as they arrived in port. The PHS Commission Corps was officially created in 1889,
and responsibilities expanded to include examining new immigrants, investigating
infectious diseases, and regulating local sanitation.
Currently 6,800 USPHS Commissioned Corps members serve in underserved,
hard to recruit areas, such as the prison system, Indian Health Services, disaster
areas, and military bases. Without t hese committed professionals, many disadvan-
taged populations would lack health care services. In 2014–2015, when the deadly
Ebola epidemic struck West Africa, PHS personnel w ere deployed to the area to
contain and control the epidemic. With a mortality rate of 51 percent, the virus
devastated regional health care workers and disabled local health care systems.
The U.S. government mobilized forces. The Army’s 101st Airborne Division built
Ebola treatment units in West Africa. The U.S. Agency for International Develop-
ment (USAID) provided logistical support. The Centers for Disease Prevention and
Control (CDC) provided training and expertise in infectious diseases. The PHS Com-
missioned Corps gave direct care. To prepare for treating Ebola-infected health
workers in Monrovia, Liberia, PHS doctors, nurses, laboratory staff, and support
personnel w ere specially trained in Ebola, epidemiology, infection control, and cur-
rent and experimental treatments (Mosquera, Braun, Hulett, & Ryszka, 2015). On
October 26, 2014, the first team arrived to staff Monrovia’s 25-bed hospital unit.
The goal was to treat infected patients and stop transmission. However, typical health
care practices encouraging patient-provider interaction had to be set aside for this
deadly pathogen. To limit exposure, staff wore heavy personal protective equipment.
Patient care was performed by task-specific teams. One team measured vital signs.
A second team drew laboratory specimens. A third team provided fluids, nutrition,
and hygiene. Over six months, PHS personnel worked 12-hour shifts under hot,
stifling conditions. Of the 300 PHS corps members working in Monrovia, none
contracted Ebola, the disease was successfully contained, and Liberia was declared
Ebola-free in May 2015.
Commissioned Corps members are deployed to many humanitarian crises at
home and around the world. PHS members served in New Orleans after Hurricane
Katrina (2005), Haiti after the earthquake (2010), Newtown, Connecticut, after the
school shooting (2012), Boston a fter the Marathon bombings (2013), and New Jer-
sey after Hurricane Sandy (2013). Commissioned Corps members risk their lives
to work with victims of man-made and natural disasters. In addition to health dan-
gers, PHS efforts are increasingly threatened by political agendas.
In 1968, a new position, the Assistant Secretary of Health, was created to over-
see the surgeon general’s office. Whereas the Office of the Surgeon General is a ser
vice position and forbidden from engaging in political activities, the Assistant
Secretary of Health is a political position. This means that the surgeon general has
632 U .S . PU B LI C HEALTH SE RV I C E ( PHS )
a responsibility to promote public health while the surgeon general’s boss has a
responsibility to promote the current administration’s political agenda. This creates
problems. For example, the Reagan administration attempted to pressure Surgeon
General Dr. C. Everett Koop into saying that abortion was psychologically harmful to
women. There is no evidence to support that abortion is psychologically harmful
to women. Former surgeon general Dr. Richard Carmona (2017) notes that politics
undermines the integrity, service, and values of the corps and diminishes morale,
making it harder to recruit and retain qualified personnel.
The Commissioned Corps of the PHS is responsible for protecting the health and
safety of the nation. Members share a greater sense of purpose and camaraderie
knowing that they are making a difference and helping underserved communities.
Public health professionals say that schools of public health can do much more to
prepare and encourage students to commit part of their public health expertise and
knowledge to government service (Kolb, 2016). Corps members gain professional
training, education, and technical skills that can provide a wonderful springboard
to a career in public health.
Sally Kuykendall
See also: Centers for Disease Control and Prevention; Dean, Henry Trendley; National
Heart, Lung, and Blood Institute; National Institutes of Health; Quarantine; Roo
sevelt, Franklin Delano; State, Local, and Territorial Health Departments; Surgeon
General; Tuskegee Syphilis Study; U.S. Department of Health and H uman Services
Further Reading
Carmona, R. (2017). Instant admirals and the plague of politics in the United States Public
Health Service: Back to the future. Military Medicine, 182(5), 1582–1583. doi:10.7205
/MILMED-D-17-00039
Commissioned Corps of the U.S. Public Health Service. (2017). Retrieved from https://usphs
.gov.
Furman, B. (1973). A profile of the United States Public Health Service, 1798–1948. Washing-
ton, DC: U.S. Department of Health, Education and Welfare.
Koh, H. K. (2016). Strengthening the U.S. Public Health Service Commissioned Corps:
A view from the Assistant Secretary for Health. Military Medicine, 181(1), 12–15.
doi:10.7205/MILMED-D-15-00204
Kolb, L. J. (2016). Federal public health service: In retrospect and prospects. Health Educa-
tion & Behavior, 43(5), 509–517.
Mosquera, A., Braun, M., Hulett, M., & Ryszka, L. (2015). U.S. Public Health Service
response to the 2014–2015 Ebola epidemic in West Africa: A nursing perspective. Pub-
lic Health Nursing, 32(5), 550–554. doi:10.1111/phn.12217
Mullan, F. (1989). Plagues and politics: The story of the United States Public Health Service. New
York: Basic Books.
Williams, R. C. (1951). The United States Public Health Service, 1798–1950. Washington, DC:
Commissioned Officers Association of the United States Public Health Service. Retrieved
from https://archive.org/details/unitedstatespubl00will.
V
VACCINES
Vaccines are biological agents introduced into a human or animal body with the
intention of creating immunity to an infectious agent. Vaccines introduce weakened
or dead disease matter that can be easily destroyed and, most importantly, stimu-
late and aid the body in recognizing and confronting future full-strength instances
of the disease. Vaccines can be applied in preventative situations to inhibit the devel-
opment of a disease in an individual or group, or in therapeutic situations where
vaccines are applied to weaken or ameliorate the conditions of an illness that already
exists within the patient. Despite vaccines being originally developed to combat
smallpox at the end of the 18th century, vaccines over the last two centuries have
proliferated to cure a variety of diseases and conditions. They can also be adminis-
tered in different ways and in various environments, depending on the particular
disease being combatted. The influence of the basic immunological concept b ehind
vaccination on public health policy and globalization ensures that new vaccines w ill
continue to be developed well into the 21st century.
All vaccines stimulate immune system activity and prevent future occurrences
of the disease for a period of time. This is achieved by introducing weakened or
dead disease matter into the body, whereupon the body recognizes it as foreign and
can easily subdue it. This experience allows the immune system to better combat
the disease should it enter the body in a strengthened state. Henceforward the per-
son is deemed “immune,” meaning his or her body can recognize the protein coat-
ing of the pathogen and prevent it from implanting itself into healthy cells. Vaccination
(and the immunological concepts that underlie the process) requires an individual
and a community commitment. The more people who are vaccinated, the more
individuals cease being incubators for particular diseases and fewer people are
exposed. This phenomenon is called “herd immunity,” and it is a crucial concept
in public health, which is the coordination of medical methods and public struc-
tures such as hospitals or clinics to improve the health conditions of communities.
There are different types of vaccines available based largely on the biological sta-
tus of the pathogen used in creating that vaccine. The oldest are heterotypic or
“Jennerian” vaccines, which use a related animal disease that only mildly impacts
humans. This group includes the smallpox vaccine, the first vaccine. A number of
vaccines known as “inactivated” are made from previously virulent material ren-
dered innocuous by heat, chemicals, or radiation. Polio, bubonic plague, influenza,
and cholera are vaccinated in this fashion. “Attenuated” vaccines use specially grown
versions of the virus whose active, disease-causing attributes are not expressed. This
634 VACC INES
group includes vaccines for measles, mumps, rubella, and typhoid fever. “Subunit”
vaccines use fragments of the disease microorganism and are part of vaccinations
for hepatitis B. Further experimental vaccines continue to be developed, including
ones that make use of DNA material from an infectious agent or the targeting of
T-cell receptor peptides, among many elements.
The manner whereby vaccines are introduced into the body has evolved over
centuries and has allowed for a variety of methods to be available to medical pro-
fessionals by the 21st century. Before the widespread introduction of smallpox
vaccination at the turn of the 19th century, the West was already familiar with
inoculation as a means of disease prevention. Inoculation—later called variolation
to differentiate it from vaccination—was an immunological method brought to
Europe from Asia during the 18th century that involved the introduction of mate-
rial from smallpox pustules into the body. This was administered by making a small
cut into the skin using a bladed instrument called a lancet and then rubbing the
disease material into the wound. A mild case of smallpox would soon develop which,
in time, would pass away and leave the patient immune from future instances of
the disease. Although helpful in decreasing instances of smallpox, inoculation had
great medical and social risks that made its public health application sporadic at
best. In using the actual smallpox microorganism, there was a risk the individual
might contract the full disease and thus expose himself or herself to disfigurement
or even death. It was fears that the medical community was far from introducing a
saving method but rather actually exposing p eople to unnecessary risks that spurred
religious and political authorities in Britain and throughout Europe to approach
the method with caution and seek out newer, safer methods of disease control.
The development of the smallpox vaccine by the British physician Edward Jen-
ner in 1796 marked the ascendency of vaccination in disease prevention. After
observing that milkmaids who contracted cowpox (a nonlethal cousin of smallpox
found in cows) w ere subsequently immune to smallpox, Jenner took material from
cowpox pustules on the hand of a milkmaid named Sarah Nelmes and tested his
immunological observations on James Phelps, a local boy. Weeks later the boy did
not develop smallpox despite being directly exposed to it by Jenner. He named this
breakthrough vaccinia from the Latin word for cow (vacca), which has come to rep-
resent both the material (vaccine) and process (vaccination) in many languages.
Originally this word applied only to smallpox vaccination; however, by the end of
the 19th century the term came to be applied to a succession of immunological
advances developed to combat other diseases.
In the 1880s French scientist Louis Pasteur initiated the second generation of
vaccines by developing medicines for anthrax and chicken cholera. He advocated
the use of “vaccination” to honor these new creations. In 1885 Pasteur also suc-
cessfully prevented rabies in a patient bitten by a rabid animal in a method called
postexposure vaccination. The 20th century witnessed further advances in vacci-
nations against pressing epidemic diseases. T hese advances led to treatments for
diphtheria, typhoid, whooping cough, and tetanus. The 20th century witnessed a
VA C C INES 635
number of landmark vaccines developed in laboratory environments. South Afri-

can born virologist Max Theiler developed a yellow fever vaccine in 1935 while
director of the Rockefeller Institute in New York. In 1955 Jonas Salk developed the
first injectable vaccine for poliomyelitis (commonly called polio). Since 1960, vac-
cines have been developed for measles, mumps, rubella, hepatitis B, and human
papillomavirus.
In 1980 the World Health Organization (WHO) declared that increased world-
wide access to vaccination and sanitation resulted in the eradication of natural cases
of smallpox. Despite great hopes among the medical community for the elimina-
tion of other ailments through the development of vaccines, no other human dis-
ease has yet been eliminated through vaccination. Vaccines continue to be developed
in the hopes of eradicating other diseases, and particular attention has been given
to the relationship between vaccines and cells that cause cancer. T here remain no
vaccines for malaria, herpes simplex, or HIV. The WHO remains confident that polio
will be the second human disease to be eradicated, with the disease having dis
appeared from the Americas in 1994, Europe in 2002, and India in 2014.
The earliest vaccinations w ere delivered by means of a blade or lancet used to
cut or “scarificate” (scrape) the skin and insert the vaccine material into the blood-
stream. The first use of a hypodermic needle was by Francis Rynde, an Irish physi-
cian, in 1844, and later glass syringes w
ere developed that rapidly replaced the lancet
as the primary tool for vaccination even to this day. The development of oral vac-
cines occurred in the 20th century, including a variety of the polio vaccine in the
1950s. Oral vaccines could be administered by persons with minimal medical train-
ing and required less temperature and environment controls than those required to
preserve liquid vaccines. Developments in vaccine transmission are allied closely
to improvements in creating and distributing vaccines. In the earliest days of vac-
cination, supply relied on the expertise of individual doctors and the limits of avail-
able transportation. Some vaccines were retrieved directly from infected humans
and others from animals. By the late 19th century the development of laboratory
science streamlined the creation and preservation of vaccine material. The inter-
vention of government oversight of medical materials, such as the 1906 “Wiley Act”
that created the Food and Drug Administration in the United States, minimized
irresponsible or haphazard medicines. In modern times, vaccines are typically cul-
tivated in laboratory environments from bacteria or virus cultures grown from envi-
ronments ranging from chicken egg cells to h uman cells.
The employment of vaccination as a public health tool has remained a matter of
contention in the public sphere, particularly a fter the middle of the 19th century
when many governments made certain vaccinations compulsory for entry into
schools or occupations. Some dispute the immunological validity of certain vac-
cines, o thers contend they pose adverse health effects, and still o thers claim that
not enough clinical study goes into vaccines before they enter the market. Some
protest compulsory vaccination on the grounds of religious belief or advocacy of
individual liberty. The refusal of part of the population to submit to vaccination
636 V ETE R ANS ’ HEALTH
could have adverse effects on society as a w hole (their “herd immunity”), and pub-
lic health professionals are dedicated to greater dissemination and education about
these issues in the 21st century.
Sean P. Phillips
See also: Cutter Incident, The; Food and Drug Administration; Global Health; Hep-
atitis; Infectious Diseases; Influenza; Jenner, Edward; Measles; Meningitis; Modern
Era, Public Health in the; Pasteur, Louis; Polio; Roosevelt, Franklin Delano; Salk,
Jonas; Smallpox; Controversies in Public Health: Controversy 3
Further Reading
Bazin, H. (2000). The eradication of smallpox: Edward Jenner and the first and only eradication
of a human infectious disease. San Diego: Academic Press.
Bliss, M. (2011). The making of modern medicine. Chicago: University of Chicago Press.
Largent, M. (2012). Vaccines: The debate in modern America. Baltimore: Johns Hopkins Uni-
versity Press.
VETERANS’ HEALTH
From a public health perspective, there are several reasons why military veterans
should be a population of greater interest. First, veterans with a health condition
that resulted from their military service are legally entitled to care. The United States
has a moral obligation to provide needed medical care to t hose who have defended
its freedom. Additionally, there are more than 20 million veterans (U.S. Census
Bureau, 2017). As a demographic group they are similar in size to other popula-
tions of public health interest, such as those with smoking-related diseases or veg-
etarians. Finally, public health endeavors focused on veterans provide insights into
the long-term risks and benefits of military service, many components of which are
similar to civilian jobs. Such information can inform t oday’s policy makers and health
care leaders.
Generally, a veteran is thought of as someone who has fought in a war. The defi-
nition is actually much broader: anyone “who served in the active military, naval,
or air service, and who was discharged or released therefrom u nder conditions other
than dishonorable” (Pensions, Bonuses, and Veterans’ Relief, 38 C.F.R. § 101. 2008,
p. 783). So while many p eople believe all veterans have fought in combat, few actu-
ally have. For the purposes of receiving health benefits paid for with federal tax
dollars, to be considered a veteran the illness or injury must occur in the line of
duty. This means in pursuit of a legitimate, authorized endeavor, such as the per-
son’s actual job or training for that job. Health-related consequences of criminal
acts or other unauthorized activity are not covered. For example, someone who
gets into a motor vehicle crash while under the influence of alcohol likely will not
have their medical care paid for by the government.
V ETE R ANS’ HEALTH 637
Many veterans are legally entitled to public health interventions as compensa-

tion for service in the military. Upon entry into military service, all veterans take
an oath to defend the U.S. Constitution. The implicit agreement is that veterans are
willing to risk their life for the sake of their country. In return, Congress—on behalf
of the American p eople—in essence promises vets that if their health is compro-
mised by some aspect of their military service they w ill get f ree or affordable health
care for the rest of their life. The details of which vets are eligible for what medical
care is determined by various legislative acts. For example, the Veterans Health Care
Act of 1992 (H.R. 5193) stipulates that psychological counseling is to be provided
to all veterans who w ere sexually assaulted while on active duty.
Actually, Congress has a long history of legislating the medical care of veterans,
especially those disabled during wars and conflicts. In 1798 a system of hospitals
and domiciliaries was created that served disabled veterans. Eventually known as
the Public Health Service, all veterans’ medical care was transferred to it in 1919 at
the end of World War I. In 1930 Congress established the Veterans Health Admin-
istration (VHA), in part, to provide medical care to all eligible veterans. Today the
VHA serves nearly 6 million veterans annually through a network of more than
1,000 outpatient clinics and more than 150 hospitals (VHA, 2017).
Based on the most recent census data, t here are approximately 18.8 million vet-
erans, of whom 8.5 percent are women, 11.6 percent are African American, and
6.4 percent are Hispanic (U.S. Census Bureau, 2016). Around 20 percent of all vet-
erans have a medical condition that has been officially deemed to be disabling (to
some extent), the most common of which are tinnitus/hearing loss, post-traumatic
stress disorder (PTSD), back pain, scars, and knee pain (VHA, 2016).
With millions of veterans needing some type of health care, costs are a concern.
Congress does not write a blank check to the VHA each year. The total dollars that
can be spent on veterans’ health is limited. Veterans deemed eligible for VA services
are prioritized into several groups. Ideally, the neediest are seen first. In any given
year, those lower on the priority list might have to obtain the care they need out-
side of the VHA system, and pay for it themselves.
Medical care for veterans in the VHA system costs around $65 billion per year,
roughly $11,000 per unique patient (VHA, 2016b). As such, any public health
efforts to improve veterans’ health status or make their care more efficient could
likely generate huge savings. For example, studies suggest that it is less expensive
in the long run to treat all veterans with any trace of hepatitis C, as opposed to only
treating those in advanced stages of the disease. If just 10 percent of all veterans
have hepatitis C, the lifetime costs savings for treating all of them would be well
over $670 million (Chidi et al., 2016).
Attending to the public health needs of all veterans generates information that
is beneficial—not only to the participants themselves—but also to other veterans
and civilians who might one day face similar circumstances. However, some in the
public health community might argue that investigations of the veteran population
are irrelevant to the rest of society. They could say that due to unique exposures
638 VETER ANS ’ HEALTH
Vietnam veteran Jim Alderman is haunted by the fear, chaos, and odors he experienced as a
19-year-old soldier. Alderman is a patient at Bay Pines Veterans Affairs Medical Center in Bay
Pines, Florida, where therapists work with veterans to recognize psychological triggers and
to respond with positive coping mechanisms. (E. J. Hersom/Department of Defense)
(combat environments) or various health-related rules and regulations vets had to

endure while on active duty, such as having to maintain certain weight standards
or mandatory vaccination programs, the findings might not be useful when applied
to other populations. It is true that approximately 28 percent of military occupa-
tional specialties (i.e., jobs) do not have a civilian equivalent (Sulsky, 2003). T hese
mostly have to do with weapons systems not used by civilians. However, that leaves
about three out of every four veterans having been employed in a job with a civil-
ian equivalent. For example, there are military police whose job is very similar to
civilian police. And many veterans occupied managerial positions with all of the
same stressors and benefits as their civilian counterparts.
One of the most important aspects of public health service that could benefit
future generations pertains to the long-term effects of military service. This is true
for both health risks and benefits. An example of a health risk is exposure to com-
bat environments. Even though a small minority of veterans has fought in combat,
many more have been exposed to combat environments, locations where the threat
of attack is possible. This can be very stressful and carries certain health effects such
as PTSD. But we d on’t know how long these effects last. In contrast, a benefit of
military service is free and easy access to medical care. What are the long-term effects
VIOLEN C E 639
of this? Perhaps veterans are healthier than their civilian counterparts who did not
have health insurance during their early years of employment. T hese are just some
of the questions that could be answered by greater public health interest in the
veteran population, something that is owed to them by law, and would likely gar-
ner many benefits for a worthy and sizable group many consider heroes.
David J. Reynolds
See also: Bousfield, Midian Othello; Dean, Henry Trendley; Hepatitis; Mental Health;
Substance Abuse and Mental Health Services Administration; Controversies in Pub-
lic Health: Controversy 2
Further Reading
Chidi, A. P., Rogal, S., Bryce, C. L., Fine, M. J., Good, C. B., Myaskovsky, L., & . . . Smith,
K. J. (2016). Cost-effectiveness of new antiviral regimens for treatment-naïve U.S. vet-
erans with hepatitis C. Hepatology, 63(2), 428–436. doi:10.1002/hep.28327
Gordon, S., & Kizer, K. W. (2017). The b attle for veterans’ healthcare: Dispatches from the front-
lines of policy making and patient care. Cornell, NY: Cornell.
Powers, R. (2009). Veterans benefits for dummies. Hoboken, NJ: Wiley.
Sulsky, S. I. (2003). On occupational health and safety research in the US Army: Compa-
rability with civilian employee cohorts. Journal of Occupational and Environmental Medi-
cine, 45(3), 220–221.
Title 38—Pensions, bonuses and veterans’ relief, 38 C.F.R. § 101. 2008. Washington, DC:
U.S. Government Printing Office. Retrieved from https://www.gpo.gov/fdsys/pkg/CFR
-2012-title38-vol1/pdf/CFR-2012-title38-vol1-chapI.pdf.
U.S. Census Bureau. (2016). Facts for features: Veterans’ day 2016. Retrieved from https://
www.census.gov/newsroom/facts-for-features/2016/cb16-ff21.html.
U.S. Census Bureau. (2017). 2011–2015 American community survey 5-year profiles. Retrieved
from https://www.census.gov/programs-surveys/acs.
U.S. Department of Veterans Affairs. (2014). Federal benefits for veterans, dependents, and sur-
vivors (Updated ed.). New York: Skyhorse.
Veterans Healthcare Administration. (2016a). VBA annual benefits report fiscal year 2015.
Retrieved from http://www.benefits.va.gov/REPORTS/abr.
Veterans Healthcare Administration. (2016b). Expenditures: 2015. Retrieved from https://
www.va.gov/vetdata/expenditures.asp.
Veterans Healthcare Administration. (2017). About VHA. Retrieved from https://www.va.gov
/health/aboutvha.asp.
VIOL ENCE
Violence presents in many forms with serious public health implications. Homi
cide cuts short 17,000 deaths per year while suicide claims another 44,000 (Cen-
ters for Disease Control and Prevention [CDC], 2017). Over half a million people
seek treatment in emergency rooms for injuries due to child maltreatment, elder
abuse, intimate partner violence (IPV), youth violence, sexual violence, or suicide
attempts. Many more injuries are treated in doctor’s offices, emergent care centers,
640 VIOLENCE
or at home. The estimated cost in medical care and lost productivity for violence-
related injuries totaled $70 billion in 2000 (Corso, Mercy, Simon, Finkelstein, &
Miller, 2007). Public health aims to reduce and prevent violence through univer-
sal, selected, and indicated prevention. Applicable Healthy P eople 2020 goals are to
reduce homicides from 6.1 per 100,000 p eople to 5.5 per 100,000 p eople and to
reduce suicides from 11.3 suicides per 100,000 p eople to 10.2 per 100,000 p eople.
The National Center for Injury Prevention and Control (NCIPC) serves as the nation’s
leading authority on violence prevention research. The NCIPC monitors the prob
lem, conducts research, and recommends the most effective solutions in violence
prevention.
As deaths due to infectious diseases declined, public health officials turned atten-
tion to other leading causes of death and disability. Violence was formally acknowl-
edged as a major public health problem in Healthy People (1979). This first edition
set the goals of reducing suicides, homicides, access to handguns, and child mal-
treatment. In 1981, CDC staff became formally involved in violence prevention
when they assisted Atlanta police investigating the abduction and murder of 28
children and young adults. The CDC used epidemiological tools in the case known
as the Atlanta Child Murders (1979–1981). Two years later, the CDC established
the Violence Epidemiology Branch to investigate violence-related behaviors and the
prevention of violence. Epidemiological data revealed that young black men
were dying at significantly higher rates than w omen and whites. Surgeon General C.
Everett Koop (1916–2013; in office 1982–1989) encouraged politicians to invest
in youth violence research, which would identify causes, risk and protective
factors, and solutions. Guns emerged as one of the leading causes of homicide and
suicide in the United States. The National R ifle Association responded by persuad-
ing Congress to ban any further CDC-funded research into gun violence. The
research ban lasted 17 years and was finally lifted a fter the Sandy Hook Elementary
School shooting in Newtown, Connecticut (2012).
Between 1983 and 1993, politicians realized that they could garner votes by
promising to take a hard line on crime. Voters were programmed to fear a new breed
of superpredator, represented as a young African American or Latino American male.
The costs for housing chronic offenders skyrocketed with estimates totaling $1.7
to $2.3 million per offender in 1997 U.S. dollars (Cohen, 1998). Public health used
the tools of epidemiology to investigate the problem and find effective, affordable
solutions. In 2001, the Department of Health and Human Services (DHHS) issued
Youth Violence: Report of the Surgeon General. This comprehensive report described
the scope of the problem, presented reliable data, identified risk and protective
factors, and reviewed research into existing youth violence prevention programs.
Out of hundreds of programs, experts only found a small number of effective pro-
grams. Notable programs w ere home visitation by nurses, multisystemic therapy,
Families and Schools Acting Together (FAST), Promoting Alternative Thinking Strat-
egies (PATHS), and Life Skills Training. Even more worrisome was the fact that
many of the most popular programs, boot camps, peer mediation, gun buyback
V IOLEN C E 641
programs, and waivers to adult court were found ineffective and, in some cases,
exacerbated violence-related behaviors. The surgeon general’s report recommended
identifying and using evidence-based programs that w ere proven to work.
Public health addresses a problem by reducing known risk factors. Risk factors
for violence-related behavior are categorized as individual level, family level, and
community level (DHHS, 2001). Individual-level risk factors are low IQ, antisocial
beliefs, exposure to violence, involvement with drugs, alcohol, or tobacco, atten-
tion deficit, hyperactivity, and impaired ability to process information. Risk factors
at the family level are harsh, negligent, or overbearing parenting practices, poor
emotional attachments between parent and child, low income and educational level,
dysfunctional communication, and parental substance abuse or criminality. Peer and
social factors that promote violence are association with antisocial peers and poor
connections to the school. Community-level risk factors are lack of jobs, limited
resources, crowded living conditions, lack of community structure, and transient
populations with little financial or emotional investment in the neighborhood. In
most cases, there is not one specific factor that causes violence. Aggression results
from multiple factors working in combination. Thus, solutions require multifac-
eted approaches.
The CDC, Department of Education (DoE), Office of Justice and Delinquency
Prevention (OJJDP), and Substance Abuse and Mental Health Services Administra-
tion (SAMHSA) promote evidence-based programs in violence prevention. Programs
are categorized as universal, selected, or indicated prevention. Universal prevention
programs aim to prevent violence-related behaviors before they emerge. Participants
represent varying levels of risk. Examples of universal programs in youth violence
prevention are skill building and problem solving, positive youth development, par-
ent training, or bullying prevention programs. Selected prevention programs aim
to reduce the risk of violence by working with at-risk populations. Home visita-
tion, academic tutoring, behavioral management, mentoring, and case management
work promote protective factors and minimize risk factors. Indicated prevention
programs are for populations who have already demonstrated seriously delinquent
behavior or violence. Indicated programs focus on skill building, behavioral man-
agement, family therapy, or individual therapy. Examples of evidence-based programs
in youth violence prevention are Big Brothers Big Sisters Mentoring Program, Chi-
cago Parent Program, cognitive therapy, Early Risers “Skills for Success,” Familias
Unidas Prevention Intervention, Families and Schools Together (FAST), Life Skills
Training, Partners in Parenting, Peacebuilders, and Positive Action Pre–K. The
National Registry of Evidence-based Programs and Practices maintains a searchable
database of programs that have been reviewed by experts and proven to work.
Violence is one of the leading public health issues in the nation. Although the
problem affects all ages, young people, those who offer the most valuable human
resource of any society, are at highest risk for injury and death. Using careful epi-
demiological investigation, public health researchers have been able to identify the
risk and protective factors for violence. Program planners developed and tested
642 V IOLEN C E
programs to determine effectiveness. Federal and nonprofit agencies reviewed pro-

grams and promote implementation of evidence-based programs. Despite progress,
obstacles remain. Too many times, individuals and communities respond to vio
lence with greater violence. Harsh, punitive, and unforgiving policies can aggra-
vate the problem. Long-term solutions are to invest in youth before violence-related
behaviors take hold and are transmitted throughout the community.
Sally Kuykendall
See also: Adverse Childhood Experiences; Centers for Disease Control and Preven-
tion; Child Maltreatment; Community Health; Evidence-Based Programs and Prac-
tices; Grants; Healthy People 2020; H
uman Trafficking; Immigrant Health; Indian
Health Service; Injuries; Intimate Partner Violence; Leading Health Indicators;
Mental Health; National Center for Injury Prevention and Control; Prevention;
School Health; Substance Abuse and Mental Health Services Administration; U.S.
Department of Health and Human Services; Controversies in Public Health: Contro-
versy 2
Further Reading
Centers for Disease Control and Prevention. (2017). Violence prevention at CDC. Retrieved
from https://www.cdc.gov/violenceprevention/overview/index.html.
Cohen, M. A. (1998). The monetary value of saving a high-risk youth. Journal of Quantita-
tive Criminology, 14(1), 5–33.
Corso, P. S., Mercy, J. A., Simon, T. R., Finkelstein, E. A., & Miller, T. R. (2007). Medical
costs and productivity losses due to interpersonal and self-directed violence in the
United States. American Journal of Preventive Medicine, 32(6), 474–482. doi:10.1016/j
.amepre.2007.02.010
Dahlberg, L. L., & Mercy, J. A. (2009). History of violence as a public health issue. AMA
Virtual Mentor, 11(2), 167–172. Retrieved from http://virtualmentor.ama-assn.org/2009
/02/mhst1-0902.html.
Department of Health and Human Services. (2001). Youth violence: A report of the Surgeon
General. Rockville, MD: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Injury Prevention and Control;
Substance Abuse and Mental Health Services Administration, Center for Mental Health
Services; and National Institutes of Health, National Institute of M ental Health. Retrieved
from https://www.ncbi.nlm.nih.gov/books/NBK44294.
Kuykendall, S. (2012). Bullying: Health and medical issues today. Santa Barbara, CA: ABC-
CLIO Greenwood Press.
National Center for Injury Prevention and Control. Retrieved from https://www.cdc.gov
/injury/index.html.
National Registry of Evidence-based Programs and Practices. Retrieved from http://nrepp
.samhsa.gov/landing.aspx.
W
WALD, LILLIAN (1867–1940)
Lillian Wald was one of the most famous social reformers of the Progressive Era.
Wald advanced the welfare of c hildren, developed public health nursing into a pro-
fession, and influenced many other social reformers of the era through the Henry
Street Settlement in New York City.
Born on March 10, 1867, in Cincinnati, Ohio, into a prosperous family, Lillian D.
Wald grew up in Rochester, New York, where she attended Miss Cruttenden’s
English-French Boarding and Day School. At age 16, she applied to Vassar College
but was rejected b ecause she was considered to be too young. A fter several years
spent enjoying an active social life, Wald decided she wanted serious work and
entered the New York Hospital training school for nurses. Graduating in 1891, she
worked for a year as a nurse at the New York Juvenile Asylum. This experience
proving unsatisfactory, Wald enrolled in the W oman’s Medical College in New York
to obtain additional training. At the same time, she began teaching home-nursing
classes for immigrant families.
The turning point in Wald’s life occurred in March 1893, when she was called
from the classroom to help a sick woman in a run-down tenement building. Hor-
rified by the wretched living conditions, Wald decided to devote herself to public
health nursing. Together with Mary Brewster, Wald set up an office first at the Col-
lege Settlement on the Lower East Side and then on the top floor of a tenement
on Jefferson Street. With the financial help of Mrs. Solomon Loeb and her banker/
philanthropist son-in-law, Jacob H. Schiff, Wald and Brewster were able to move to
a permanent home on Henry Street, where in 1895 they established the Nurses’
Settlement.
The Nurses’ Settlement was the only social settlement to emphasize nursing,
which in Wald’s view extended beyond caring for the sick to include education
aimed at preventing disease. By 1896, the settlement had 11 residents, 9 of whom
were trained nurses, and was known as the Henry Street Visiting Nurses Service.
By 1913, there w ere nine such h
ouses in Manhattan and the Bronx, with a total
residential staff of 92 nurses, who made more than 200,000 visits a year. The idea
of public health nursing had been born and spread rapidly.
Wald also established the country’s first public-school nursing program in New
York City. She was instrumental in setting up a department of nursing at Columbia
University in 1910, and two years l ater, she helped the Red Cross establish the Town
and Country Nursing Service. Having played a prominent role in the creation of
the National Organization for Public Health Nursing, Wald was elected president
of the organization in 1912.
644 WALD, LILLIAN
A public health nurse climbs across a roof while visiting patients in the tenements of New
York’s lower east side, 1920. Lillian Wald envisioned specially trained nurses who possessed
a fundamental understanding of life in the inner city. (MPI/Getty Images)
The Nurses’ Settlement, meanwhile, soon outgrew its nursing focus and became
known as the Henry Street Settlement, providing a full complement of community
programs. A system of scholarships was started for c hildren from poor families, and
career guidance and vocational training w ere offered. In addition, the Henry Street
Settlement was involved in efforts to provide better education for c hildren with intel-
lectual disabilities, to improve housing, to establish more parks and playgrounds,
and to eradicate tuberculosis. Henry Street was always dependent on donations,
and Wald proved to be a good fund-raiser.
Wald also became active in the child welfare movement. She pushed for legisla-
tion prohibiting child labor, and in 1904, she and Florence Kelley, who was also a
Henry Street resident, founded the National Child Labor Committee. Wald’s sug-
gestion to President Theodore Roosevelt of the need for a government agency to
protect the rights of c hildren led in 1912 to the establishment of the Federal Children’s
Bureau, headed by Julia Lathrop.
The outbreak of World War I in 1914 was a blow to Wald’s pacifist convictions.
Together with Kelley and Jane Addams, she helped found the American Union
Against Militarism, which had as its goal ending the war by mediation. When the
WATER B O RNE DISEASES 645
United States did enter the war, Wald served as head of the Council of National
Defense’s committee on home nursing. She also chaired the Nurses’ Emergency
Council, recruiting volunteer nurses and coordinating nursing agencies during the
influenza epidemic of 1918.
The war over, Wald helped found the League of F ree Nations Association, a fore-
runner of the Foreign Policy Association. She had expanded the Henry Street Set-
tlement to include a neighborhood playhouse in 1915, and in the 1920s, she added
an experimental theater and a playground. Her health deteriorating, Wald stepped
down as head of the settlement in 1933. She retired to Westport, Connecticut, where
after a long illness she died at the age of 73 on September 1, 1940.
James M. McPherson and Gary Gerstle
See also: Anderson, Elizabeth Milbank; Baker, Sara Josephine; Children’s Health;
Immigrant Health; Kelley, Florence; Maternal Health; Controversies in Public Health:
Controversy 5
Further Reading
Buhler-Wilkerson, K. (1993). Bringing care to the p eople: Lillian Wald’s legacy to public
health nursing. American Journal of Public Health, 83(12), 1778.
Eisemann, A., (1976). Rebels and reformers: Biographies of four Jewish Americans: Uriah Phil-
lips Levy, Ernesteine L. Rose, Louis D. Brandeis, Lillian Wald. New York: Doubleday.
Miss Wald and Henry Street settlement have birthdays. (1933). American Journal of Public
Health, 23(5), 521–522.
Reverby, S. M. (1993, December). From Lillian Wald to Hillary Rodham Clinton: What will
happen to public health nursing? American Journal of Public Health, 83(12), 1662.
Wald, L. (1915). The house on Henry Street. New York: Henry Holt & Co.
Wald, L. D. (1934). Windows on Henry Street. Boston: Little, Brown, and Company.
Williams, B. (1948). Lillian Wald: Angel of Henry Street. New York: Julian Messner.
WATERBORNE DISEASES
Waterborne diseases are physical problems and diseases caused by bacterial, viral, or
parasitic agents in drinking or recreational w ater. The pathogens often originate from
animal or h uman waste, which is ingested by drinking, food preparation, washing
utensils, household cleaning, or during recreational activities, such as swimming.
Examples include campylobacter, Vibrio cholera, hepatitis A and E, Legionella, Salmo-
nella, and Shigella. The body attempts to rid itself of the pathogen through vomiting
or diarrhea. However, this response can be life threatening to infants, children,
elderly, and p
eople with preexisting health conditions. Severe diarrhea can result in
dehydration or malnutrition. Diarrhea is the second leading cause of death among
children exposed to waterborne disease, and the World Health Organization esti-
mates more than 1.7 billion cases of diarrhea each year (WHO, 2013). Waterborne
diseases are distinct from water-related illnesses.
646 WATER BOR NE DISEASES
Water-related illnesses, such as malaria, yellow fever, West Nile fever, and
encephalitis occur in areas where stagnant w ater provides a good breeding place
for mosquitoes and the mosquitoes transmit the pathogenic organisms to humans.
To control water-related illnesses, health officers recommend reducing sources
of standing w ater or chemicals to reduce mosquito breeding (Moeller, 2005).
Waterborne diseases are controlled by protecting sources of drinking w ater from
contamination and following good sanitary practices during food storage, prepa-
ration, and serving. Compared to other areas of the world, the United States has
low levels of waterborne diseases. Storms, heavy rain fall, and floods increase
risk of waterborne diseases. Federal, state, and local public health systems are
designed to identify pathogens and take preventive action. The Centers for Dis-
ease Control and Prevention (CDC) relies on collaboration of local public health
agencies and state agencies to investigate and report cases of bacterial, viral, or
parasitic contamination.
Campylobacter is a bacterial pathogen found in contaminated surface and rain
water, infected c attle, contaminated foods, meat, and unpasteurized milk. Contami-
nation occurs when fecal droplets from wild birds enters drinking water sources
and water treatments fail to adequately clean the w ater. Campylobacter jejuni
(C. jejuni) is the most infective species. H uman transmission occurs by ingestion of
contaminated food or drink. Symptoms include abdominal pain and acute diarrhea.
In severe situations, the symptoms may progress to vomiting, chills, fever, arthritis,
meningitis, or Guillain-Barre syndrome, a demyelinating disease of the peripheral
nerves. C. jejuni infection is prevented by protecting drinking and surface w ater from
contamination, and adequate w ater purification and treatment is essential.
Escherichia coli (E. coli) is a gram-negative bacteria. Different strains are classified
by virulence. The most common strains are Enterohaemorrhagic E. coli, Enterotoxi-
genic E. coli, Enteropathogenic E. coli, and Enteroinvasive E. coli. The microorganism
is found in drinking and recreational water contaminated by animal or human feces.
Infection c auses abdominal discomfort, cramps, nausea, and mild diarrhea. Severe
infection could progress to bloody diarrhea, vomiting, headache, fever, hemolytic
colitis, hemolytic anemia, or acute renal failure. In 1999, E. coli serotype 0157:H7
contaminated w ater at a New York county fair sickened 16,000 people, including
10 c hildren who w ere hospitalized (Moeller, 2005). Exposure to E. coli can be pre-
vented by protecting drinking w ater from animal and h uman waste and by effec-
tive treatment and protection of w ater prior to distribution for human use.
Legionella bacteria are found in a variety of w ater sources that include rivers,
streams, ponds, recreational w ater systems, and man-made w ater environments such
as cooling and heating systems or spas. The species L. pneumophila is associated
with legionellosis, a respiratory disease with two clinical manifestations in h umans:
Legionnaire’s disease and Pontiac fever. Legionnaire’s disease can result in severe
pneumonia. Pontiac fever is a mild illness with influenza-like symptoms, such as
coughing, muscles ache, headache, nausea, and vomiting. Prevention of Legionella
pathogens focuses on eliminating an environment where bacteria thrive. Reducing
WATER B O RNE DISEASES 647
cold water systems to less than 20°C and raising hot w ater systems above 50°C
effectively kills Legionella. Other strategies to control human exposure include use
of disinfections in recreational water systems, preventing the accumulation of
standing water, preventing biofilm development on w ater systems, and creating
water distribution systems that are free of dead-end loops.
Waterborne viral pathogens include hepatitis A and Norwalk-like viruses (NLVs).
Hepatitis A is an infectious disease that primarily affects school-aged c hildren and
young adults (Moeller, 2005). The route of entry is oral-fecal. The virus is found in
contaminated salads, sandwiches, lettuce, strawberries, and drinking water. Symp-
toms range from abdominal pain to jaundice. Prevention efforts focus on protect-
ing food from fecal contamination, disinfection, and chlorination of w ater. NLVs
are the major cause of gastroenteritis outbreaks in the United States. An estimated
23 million cases occur annually, resulting in 50,000 hospitalizations and 300 deaths
(Moeller, 2005). Outbreaks occur easily in crowded and unsanitary environments.
Passenger cruise ships take special precautions to avoid outbreaks (National Cen-
ter for Environmental Health Vessel Sanitation program, 2013).
Waterborne parasites include Giardia and Cryptosporidium. Giardia is the most
common drinking water parasite in the United States and is often seen in summer
camps and day care centers due to contaminated w ater, shallow wells, or untreated
water (Moeller, 2005). H uman exposure c auses giardiasis, a disease characterized
by diarrhea, abdominal pain, and bloating. Prevention includes protecting water
sources, such as groundwater, ponds, shallow wells, rivers, and streams from ani-
mal or h uman wastes. Water purification treatments also reduce infection. Crypto-
sporidium parvum is a waterborne parasite transmitted by swimming pools, water
parks, fountains, hot tubs, or spas. The pathogen is transmitted through feces in the
water. Preventive measures include protecting the w ater, boiling w
ater, or filtration
(National Center for Environmental Health Vessel Sanitation Program, 2013). The
CDC also recommends clearing everyone out of the water when solid feces is
observed in a pool, water park, or hot tub (Moeller, 2005).
Waterborne diseases are very common health problems, which can be particu-
larly fatal for the very young, very old, or incapacitated. Fortunately, such diseases
are easily preventable through individual and public health surveillance with rapid
response.
Victor Okparaeke
See also: Association of Public Health Laboratories; Bioterrorism; Centers for Dis-
ease Control and Prevention; Cholera; Epidemic; Food Insecurity; Food Safety;
Infectious Diseases; Snow, John; World Health Organization
Further Reading
Moeller, D. W. (2005). Environmental health (3rd ed.). Cambridge, MA: Harvard University
Press.
648 WEG M AN, MYRON EZ RA
National Center for Environmental Health Vessel Sanitation program. (2013). Health prac-
tices on cruise ships: Training for employees. Centers for Disease Control and Prevention.
Retrieved from https://www.cdc.gov/nceh/vsp/training/videos/transcripts/water.pdf.
Weiss, T. C. (2015). Water-borne diseases: Types and information. Retrieved from https://www
.disabled-world.com/health/water-diseases.php.
World Health Organization. (2017). Microbial fact sheets. Retrieved from http://www.who
.int/mediacentre/factsheets/en/.
WEGMAN, MYRON EZRA (1908–2004)

Through his work as the secretary general of the Pan-American Health Organization
(1956–1960) and as dean of the School of Public Health at the University of Michi-
gan (1960–1974), Dr. Myron Ezra Wegman navigated the field of maternal and child
health into a scientific discipline that uses biostatistics and social indexes to reduce
deaths and improve health and well-being for infants, children, and mothers in
developing and advanced countries. Myron Wegman was born in Brooklyn, New
York, to Nettie (Finkelstein) and Max Wegman. The Polish/Lithuanian c ouple had
six children, two of which died during infancy. Myron earned a BA in classics from
the City College of New York in 1928. While deciding on a career, he was influ-
enced by Upton Sinclair’s 1925 novel, Arrowsmith. The book follows the main char-
acter, Dr. Martin Arrowsmith, through medical training, clinical practice, and a
career in scientific research. The novel was highly acclaimed for its accuracy and
for shedding light on scientific misconduct, institutional pressure, professional
jealousy, greed, ignorance, and negligence in research and medicine. The concerns
raised by Sinclair highlight the need for qualified, ethical practitioners in medicine
and health care.
In 1932, Wegman graduated cum laude from Yale University School of Medicine.
He intended to go into pediatrics. Pediatric care was shifting from treating deadly
infectious diseases, such as smallpox and diphtheria, to tackling complex social and
behavioral health issues. Wegman’s first job was as a circuit rider for the state of
Maryland. Circuit riders provided on-site technical advice and medical expertise
to doctors practicing in isolated areas. Wegman covered the Eastern Shore of Mary
land where he shared the latest advancements in prenatal and pediatric care. He
continued his own studies by earning a master of public health degree at Johns
Hopkins University and was invited to teach courses at Hopkins.
In 1940, Wegman moved to develop maternal child health in Puerto Rico. He
did not stay long as the outbreak of World War II (1939–1945) increased the demand
for doctors in the states. He returned to New York and accepted a position as direc-
tor of school health while also teaching at Columbia University and Cornell Uni-
versity. In 1946, Wegman moved to Louisiana where he became chief of pediatrics
at Louisiana State University and New Orleans Charity Hospital. The South was
not a good fit for him. He protested the segregation of black and white infants in
the neonatal ward and resisted the paranoid efforts of the McCarthy Era. In 1949,
Wegman started publishing the first Annual Review of Vital Statistics in Pediatrics.
W E G M AN , M Y R ON E Z R A 649
The report summarized national statistics on births, fertility rates, infant mortality
rates, and other vital data. He translated complex, difficult to understand statistics
into an understandable format. These reports were published every year in the
December issue of Pediatrics. The data helped pediatricians to guide practices based
on national data and patient needs. Wegman was a stickler for grammar. He con-
tinued to author the annual report for the next 40 years. In 1952, Wegman moved
to the Pan American Sanitary Bureau, working to improve care of c hildren and
mothers in Latin America. Eight years later, he returned to education as the dean of
the University of Michigan, School of Public Health.
Throughout his lifetime, Wegman published more than 200 articles. His work
encompassed pediatrics, health policy, public health and nursing, international
health, biomedical research, occupational lung disease, school health, and his vision
for a national system of health. In 1972, Wegman served as president of the Ameri-
can Public Health Association (APHA). He guided the professional organization
through its 100th annual meeting, focusing on the need for a national health pol-
icy. In his presidential address, Wegman said:
The country has many accomplishments that are a source of pride, yet in other
areas t here are gaps, duplication, confusion or protection of special interest. Some
say we have no health policy, w hether it is explicit or, more often, implicit in
the sum total of national action, or inaction, related to the health of its citizens. The
United States clearly falls into the latter category; what we have lacks coordination,
often lacks rationality and frequently has shortcomings of performance. (Wegman,
1973, p. 98)
He called on APHA members to influence policy makers by expressing the need for
a national health policy that would create life, liberty, and the pursuit of happiness.
In 1974, Wegman was awarded the Sedgwick Memorial Medal for distinguished
service in public health. He died on April 14, 2004, at the age of 95.
Myron Ezra Wegman was a pediatrician, faculty member, and public health leader
who helped move maternal and child health from infectious disease treatment to
evidence-based practices in behavioral and social health. As an academic, he was
known for supporting the success of students and junior faculty members, and he
helped to kick-start the careers of many notable public health leaders. His ideas of
using data and statistics to develop policies and practices are applicable to public
health in all countries.
Sally Kuykendall
See also: American Public Health Association; Biostatistics; Children’s Health; Eliot,
Martha May; Infant Mortality; Maternal Health; School Health
Further Reading
Brown, V. J. (2005). Myron Ezra Wegman. American Journal of Public Health, 95(8), 1309–
1311. doi:10.2105/AJPH.2005.066555
650 WINSLO W, CHA RLES-EDWARD AMORY
Wallis, A. B., & Guyer, B. (2006). Myron Wegman: Early days, lasting influence. Maternal &
Child Health Journal, 10(1), 5–11. doi:10.1007/s10995-005–0033-3
Wegman, M. E. (1973). Centennial presidential address policy, priority, and the power to
act. American Journal of Public Health, 63(2), 98–101.
Wegman, M. E. (1996). Infant mortality: Some international comparisons. Pediatrics, 98(6),
1020.
Wegman, M. E. (1999). Foreign aid, international organizations, and the world’s c hildren.
Pediatrics, 103(3), 646.
WINSLOW, CHARLES-E DWARD AMORY (1877–1957)

Charles-Edward Amory (C.-E. A.) Winslow is a historical figure in American pub-
lic health for numerous reasons. As an academic, administrator, and social activist,
he advanced the fields of bacteriology, industrial hygiene, home health, public health
nursing, and health education. Throughout his lifetime, he wrote over 600 articles
and books. Topics ranged widely with articles on garbage disposal in urban inner
cities, sex education for teachers and parents, and the influence of odor on appetite.
Students of public health recognize him as the author of the commonly cited and
all-encompassing definition of public health. Winslow’s drive, determination, and
vision for public health is best captured by his description of Lemuel Shattuck, “If
we pursue our vocation with Shattuck’s zeal and courage and vision and faith, the
second hundred years of public health may be even harder than the first; but they
will certainly be even more glorious” (Winslow, 1949). Winslow created a niche for
public health as a multidisciplinary profession that uses natural science, social
science, political science, and clinical practice to improve the human condition (Ros-
ner & Markowitz, 1998).
C.-E. A. Winslow was born in 1877 in Boston as the only child of Catherine Mary
(Reignolds) and Erving Winslow. At the time, the nation was changing from an agri-
cultural society to an industrial power. Thousands of farmworkers moved to the
inner cities in search of employment, joining millions of non-English-speaking
immigrants. The poor working class toiled long hours in coal mines, steel mills,
assembly lines, and arduous trades. The massive population movement, overcrowd-
ing, and poor living conditions bred frequent outbreaks of cholera, typhus, small-
pox, and tuberculosis. Industrial toxins of lead, mercury, arsenic, and silica dust
silently poisoned workers and their families. Young c hildren worked in dangerous
occupations, attaining calories from beer because it was less contaminated than milk.
Health professionals debated the underlying causes and solutions to the problems
of the inner cities. Some blamed the poor and immigrant workers, purporting that
communicable diseases w ere due to immorality and ignorance. O thers emerged as
social reformers working to reduce the exploitation of low income workers and edu-
cate the public on sanitation and hygiene. Winslow’s m other was an English actress
who acted in plays featuring social controversies. His father was a vocal anti-
imperialist who opposed U.S. expansion. Young Winslow was privileged to attend
Boston’s English High School and the Massachusetts Institute of Technology (MIT).
WINSLO W, C HAR LES -ED WA R D A M O RY 651
He planned to study biology and ultimately pursue a career in medicine until he

encountered Professor William H. Sedgwick. Sedgwick stood on the side of social
reform, studying the relationships between contaminated w ater, sewage, and dis-
ease. However, he did live in an ivory tower of simply studying the problem. He
used research to identify sanitary measures and prevent w ater pollution. Sedgwick
introduced his students to the field of practical biology, inspiring Winslow to
change majors from medicine to public health. A fter graduation with a bachelor’s
degree in 1898, Winslow continued at MIT as a graduate student. He conducted
research on sewage and sanitary practices where he met Anne Rogers, his future
wife and scientific partner. As a student, Winslow coauthored the first textbook
on water bacteriology. In 1905, he offered the first university course on industrial
hygiene. The course explored factory ventilation, industrial toxins, working condi-
tions, and the need for factory inspections. The course would have been very con-
troversial for the time period, confronting and seeking to control powerful private
industries.
After graduation, Winslow worked for the New York State Department of Health
establishing health education services. In 1914, the family of Anna M. Lauder, wife
of George Lauder, donated $400,000 to Yale University Medical School to fund a
Department of Public Health. George Lauder was the cousin and adviser of Andrew
Carnegie. A condition of the funding was that the new chair should be a physician
with experience in sanitary medicine. Yale disregarded the family’s request for a phy-
sician and instead hired Winslow. From the start, Winslow embraced the opportu-
nity to inspire o thers. He taught undergraduates, graduate students, nursing students,
and medical students. A highlight of the semester was evening lectures at Winslow’s
home where faculty and students discussed international cultures and philoso-
phies. Despite his blueblood upbringing and prestigious position as chair, Win-
slow held firmly to his sense of empathy. Former student A. Pharo Gagge recalls
attending his first Sunday dinner at Winslow’s house. Dressed in a sports coat and
slacks, Gagge arrived to find the other male guests and Winslow in formal dinner
jackets. As Mrs. Winslow introduced the new graduate student to other guests,
Winslow changed into a sports coat and slacks and reappeared among his guests
(Kemper, 2015).
Winslow’s influence extended beyond Yale. He advocated for public health edu-
cation, serving as a consultant for the Accreditation of Schools of Public Health. To
this end, he created the definition of public health, which is still used today:
The science and art of preventing disease, prolonging life, and promoting health and
efficiency through organized community efforts 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 organ
izing these benefits as to enable every citizen to realize his birthright of health and
longevity. (Winslow, 1920, p. 183)
652 W INSLO W, C HA R LES - ED WAR D AMO RY
The definition reflects Winslow’s belief and experiences in public health. The phrase
“science and art of preventing disease” refers to public health’s role and partnership
in medicine. “Organized community efforts” reflects public health as a collabora-
tive practice with many different facets. Ending with the phrase “to enable every
citizen to realize his birthright” highlights the mission of public health in social
justice.
Winslow was a prolific writer, active in the American Public Health Association
(APHA) and public health education. Among his numerous accomplishments are:
• Editor of the Journal of Bacteriology (1916–1944)
• Chair of the New Haven Demonstration Health Center (1919–1923)
• Helped establish the Connecticut Department of Public Health
• Chairman of the APHA Laboratory Section (1920–1935)
• Helped establish Yale University School of Nursing (1923)
• Vice-chairman of the Committee on the Costs of Medical Care (1928–1932)
• Chairman of the APHA Committee on Hygiene of Housing (1936–1956)
• Helped establish the APHA Public Health Nursing Section
• Helped establish the APHA Medical Care Section
• Editor of the American Journal of Public Health (1944–1954)
Throughout all of his accomplishments, Winslow maintained direct and honest
communication and staunch advocacy for public health. On numerous occasions,
he was pressured to withhold research findings, particularly information on occu-
pational hazards. Winslow refused to bow to political pressure and stood by objec-
tive scientific data.
Winslow helped to define public health as a professional field unique from but
in partnership with medicine, nursing, biology, sanitation, public policy, and mental
health. He helped to craft public health practice and responsibilities.
Sally Kuykendall
See also: American Public Health Association; Council on Education for Public
Health; Kelley, Florence; Nation’s Health, The; Shattuck, Lemuel
Further Reading
Fulton, J. F. (1957). C.-E. A. Winslow, leader in public health. Science, 125(3260), 1236.
Kemper, S. (2015). C-E.A. Winslow, who launched public health at Yale a c entury ago, still influ-
ential today. Retrieved from https://news.yale.edu/2015/06/02/public-health-g iant-c-e a
-winslow-who-launched-public-health-yale-century-ago-s till-influe.
Rosner, D., & Markowitz, G. (1998). C.-E. A. Winslow: Scientist, activist, and theoretician
of the American public health movement throughout the first half of the twentieth
century: Commentaries. Journal of Public Health Policy, 19(2), 147. doi:10.2307/3343295
Terris, M. (1998). C.-E. A. Winslow: Scientist, activist, and theoretician of the American pub-
lic health movement throughout the first half of the twentieth c entury. Journal of Public
Health Policy, 19(2), 135. doi:10.2307/3343294
WOMEN’S HEALT 653
Winslow, C. (1951). International co-operation in the service of health. Annals of the

American Academy of Political & Social Science, 273(1), 192. doi:10.1177/000271625127
300126
Winslow, C.-E. A. (1920). The untilled field of public health. Modern Medicine, 2, 183–191.
Winslow, C.-E. A. (1944). Who killed Cock Robin? American Journal of Public Health, 34,
658–659.
Winslow, C.-E. A. (1949). Lemuel Shattuck: Still a prophet. American Journal of Public Health,
39, 156–162.
Winslow, C.-E. A. (1952). The cost of sickness and the price of health. World Health Organ
ization monograph series. Tubercle, 33, 119. doi:10.1016/S0041-3879(52)80053-4
W OMEN’S HEALTH
Women’s health refers to the physical and mental state of a woman, regardless of
the presence of disease. The women’s health movement started in the early 1900s
with a focus on reproductive freedom. The field now covers issues that are unique
to women, such as menstruation, menopause, and gynecological wellness, as well
as how certain diseases or health issues affect women differently than men. In the
United States, the leading causes of death for both genders are heart disease, can-
cer, lower respiratory diseases, stroke, Alzheimer’s disease, injuries, and diabetes.
Although the diseases are similar, the level of risk, symptoms, or social implications
may be vastly different for females. For example, the classic sign of heart attack is
chest pain that radiates to the neck, jaw, shoulder, or arm. Although men tend to
report the discomfort as a dull ache concentrated on the right side, w omen report
the discomfort as a pressing sensation affecting the throat. Men are much more likely
to recognize the symptoms of a heart attack and seek immediate treatment whereas
women will go home, make dinner for their family, help the children with home-
work, and pack their suitcase before heading to the emergency room. This delay in
recognition and treatment costs lives. Other disorders, such as depression, eating
disorders, and some types of cancer are more prevalent among females. W omen are
more likely to be diagnosed with depression and anxiety than men and are more
likely to attempt suicide. Reproductive health, sexually transmitted infections, and
sexual violence are also major public health concerns. W omen in developing coun-
tries are more likely to die from childbirth or pregnancy complications than women
in developed countries and also are at a greater risk for HIV/AIDS. Women’s health
is examined across the life stages of adolescence (aged 10–19), m iddle adulthood
(aged 20–59), and older adulthood (aged 60 and older). Each stage presents unique
health needs for public health services.
The major health concerns of adolescent girls in the United States are m ental
health, injuries, successful transition to adulthood, adolescent pregnancy, and nutri-
tion. Half of all mental health conditions develop by age 14. The most common brain
disorders among girls are depressive disorders, schizophrenia, mood disorders, anxi-
ety disorders, eating disorders, ADHD, and autism. The period of puberty marks
the transition from childhood to womanhood. Onset can occur as young as 7 years
654 WOMEN’S HEALT
old or as late as 17. During this time, breasts and pubic hair develop, changes in fat
distribution create curves in the body frame, skin becomes oily, and menstruation
begins. Regular hormonal cycles produce the menstrual period with regular shed-
ding of blood and other materials from the lining of the uterus. Except during preg-
nancy or during times of starvation or severe stress, this process occurs at regular
intervals starting about one lunar month from puberty until menopause. Before and
during menstruation, the female may experience mood swings, headaches, cramps,
difficulty concentrating, or upset stomach. As soon as puberty begins, females are
able to become pregnant. Adolescents who become pregnant are at greater risk
for complications during the pregnancy or birth. Internationally, more than 15
million live births every year are by girls between the ages of 15 to 19 (WHO,
2013). Complications from pregnancy and childbirth are a leading cause of death in
adolescent girls in developing countries. Adolescent girls are also more likely to have
unsafe abortions, which can lead to health problems such as hemorrhage, infertility,
infections, and death.
Adequate nutrition is another special consideration during adolescence. Approx-
imately one out of five adolescent girls in the United States is obese (Fryer, Carroll, &
Ogden, 2012). Overweight and obesity are related to premature puberty, asthma,
heart disease, breast cancer, social and emotional problems, and increased wear and
tear on joints leading to total knee or hip replacements as young adults. The
Nurse practitioner Rachel Eisenberg checks Natalia Reyes’s heart during a routine physical
exam at Planned Parenthood in West Palm Beach, Florida. Heart disease is the leading
cause of death for women in America. ( Joe Raedle/Getty Images)
WOMEN’S HEALT 655
physical and psychological events of adolescence generate unique nutritional

needs in females. Young girls need macronutrients and micronutrients to com-
pensate for growth spurts and blood loss during menstruation. Pregnancy further
complicates the demand for a healthy diet. More than one-third of adolescent girls
worldwide are anemic (WHO, 2013). Approximately 17 percent of adolescent girls
in the United States are considered obese (Fryer, Carroll, & Ogden, 2012).
In middle adulthood, women’s health encompasses maternal health, cardiovas-
cular disease, cancer, sexually transmitted diseases, mental health, violence, and
disabilities. Maternal health is the period of time from before a woman is pregnant
to the postpartum period. T here are several complications that can occur during
pregnancy. T hese can range from mild discomfort to life-threatening. Common com-
plications are hypertension, urinary tract infections, postpartum depression, gesta-
tional diabetes mellitus, infections, and hyperemesis gravidarum, a condition where
the mother suffers from severe nausea and vomiting. Postpartum depression, which
occurs after giving birth, affects 8 to 19 percent of w
omen (Centers for Disease Con-
trol and Prevention Division of Reproductive Health, 2017). Symptoms include
trouble sleeping, not feeling connected to the baby, exaggerated or excessive con-
cerns for the safety of the baby, and worrying that the mother could harm the baby.
The female anatomy and physiology predisposes w omen who have unprotected
sex with men to sexually transmitted diseases. In the United States, one in four
people with HIV are female (CDC, 2017). W omen account for 19 percent of new
HIV infections (CDC, 2017). African American women carry a disproportionate
share of the disease. African American w omen account for 60 percent of females
living with HIV. White and Hispanic/Latina w omen account for 17 percent each
(CDC, 2017). Sexually transmitted diseases weaken the body’s protection against
other infections and related diseases. Cervical cancer, the second most common
type of cancer for women, is linked to the sexually transmitted disease human pap-
illomavirus (HPV) (WHO, 2013).
Power imbalances promote the physical, sexual, psychological, and economic
abuse of females in some societies. Worldwide, 38 percent of female murders are
committed by intimate partners (WHO, 2013). Thirty-five percent of women have
experienced physical or sexual violence at some point in their life (WHO, 2013).
In some areas of the world, sexual violence is used as a weapon of war and ethnic
elimination. In the United States, 44 percent of women have experienced sexual
violence (Breiding, 2015). Victims are more likely to experience depression, sexu-
ally transmitted diseases, asthma, irritable bowel syndrome, headaches, chronic
pain, and insomnia. Economic violence presents as a spectrum of abuse and is char-
acterized by someone with power taking advantage of those with lesser power. For
women, this could take the form of human trafficking or as less noticeable gender
disparities in pay. W
omen are more likely to live longer than men. The world popu-
lation above 90 years of age is 70 percent w omen (WHO, 2013). The primary
causes of death in women over 60 is cardiovascular disease and cancer. Senior
women may experience disabilities, chronic diseases, and decreased physical and
656 WOMEN’S HEALT
cognitive functioning. Disabilities are more common among women. If a woman

has a disability, she is less likely to have positive health outcomes, educational
achievements, and high income compared to able-bodied women. One of the rea-
sons women may be more likely to have a disability than men is due to the partner
violence they are more likely to experience. Age-related issues may include loss of
vision or hearing, arthritis, depression, and dementia. In many countries, w omen
are less likely to receive treatment than men. W omen begin menopause in their for-
ties or fifties and become postmenopausal in their sixties. W omen g oing through
menopause may experience irregular periods, vaginal dryness, hot flashes, night
sweats, sleeping problems, mood changes, weight gain, thinning hair, and loss of
breast fullness. W omen may go into early menopause if they have a hysterectomy
(surgery that removes both the uterus and ovaries), chemotherapy and radiation,
or primary ovarian insufficiency (a condition where ovaries fail to produce normal
levels of reproductive hormones).
Research into women’s health problems lags behind men. In 1977, the Food and
Drug Administration (FDA) refused to allow women of child-bearing age to par-
ticipate in early phases of clinical research. W omen were not included in many large-
scale studies such as how aspirin affects cardiovascular health. Furthermore, many
researchers believed that women’s health was similar to men’s health. Women’s health
advocates worked for a more extensive definition of w omen’s health. In 1983, the
United States Public Health Service expanded the definition of w omen’s health to
include social issues and the biological differences between men and w omen. In
1993, the National Institutes of Health created a mandate that stated w omen and
other minority groups should be included in all h uman participant research. In
2001, the FDA began monitoring how sex differences may account for drug safety
and effectiveness. F uture directions of research in w
omen’s health contain six goals
(NIH, 2010). The first goal is to increase gender differences in basic scientific stud-
ies. This goal includes, but is not limited to, genetic and epigenetic studies, gender
differences in the structure of male and female cells, and increasing basic research
on gender differences in the prevention and treatment of diseases. The second goal
is to use t hese findings to influence the design and application of new devices and
medication such as the development of computational models and developing min-
imally invasive technologies for accurate screening, diagnosis, and treatment of
diseases. The third goal is to personalize prevention, diagnostics, and therapies for
females. This means studying gender differences in the aging process and expand-
ing research on pregnancy-related conditions. The fourth goal is to create global
alliances to increase the impact of women’s health research. This includes reaching
out to world class scientists in many different fields to create a plan for implement-
ing strategies for w omen’s health research. The fifth goal is to create and put in place
new social networking media to further understanding and appreciation of w omen’s
health. This includes serving as a central resource for information for federal and
state agencies, elected officials, media, health organizations, and the public on
women’s health research issues. The sixth goal is to utilize creative strategies to recruit
W O R LD HEALTH OR G ANI Z ATION ( W HO ) 657
an impressive women’s health research workforce. Addressing the many different

factors that affect women’s advancement in the sciences, including organizational,
institutional, and systemic factors can enhance the well-being of women, children,
men, families, and communities throughout the globe.
Alison C. Walensky and Sally Kuykendall
See also: Addictions; Cancer; Eating Disorders; Ellertson, Charlotte Ehrengard;

Family Planning; Heart Truth® (Red Dress) Campaign, The; Human Immunodefi-
ciency Virus and Acquired Immune Deficiency Syndrome; Human Trafficking; Inti-
mate Partner Violence; Kelley, Florence; Lesbian, Gay, Bisexual, and Transgender
Health; Maternal Health; M ental Health; Nutrition; Planned Parenthood; Sanger,
Margaret Louise Higgins
Further Reading
Breiding, M. J. (2015). Prevalence and characteristics of sexual violence, stalking, and inti-
mate partner violence victimization: National Intimate Partner and Sexual Violence Sur-
vey, United States, 2011. American Journal of Public Health, 105(4), e11–e12.
Centers for Disease Control and Prevention. (2017). HIV among women. Retrieved from
https://www.cdc.gov/hiv/group/gender/women/index.html.
Centers for Disease Control and Prevention Division of Reproductive Health. (2017). Depres-
sion among w omen of reproductive age. Retrieved from http://www.cdc.gov/reproductive
health/depression/.
Centers for Disease Control and Prevention Office of Women’s Health. (2017). Women’s
health. Retrieved from https://www.cdc.gov/women/index.htm.
Fryer, C. D., Carroll, M. D., & Ogden, C. L. (2012, September 12). Prevalence of obesity among
children and adolescents: United States, trends 1963–1965 through 2009–2010. Centers for
Disease Control. Retrieved from http://www.cdc.gov/nchs/data/hestat/obesity_child_07
_08/obesity_child_07_08.htm.
HIV among women. (2015, June 23). Centers for Disease Control and Prevention. Retrieved
from http://www.cdc.gov/hiv/group/gender/women/.
Menopause. (2015). Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases
-conditions/menopause/basics/definition/con-20019726.
National Institutes of Health. (2010). Moving into the future with new dimensions and strat-
egies: A vision for 2020 for women’s health research. Retrieved from http://orwh.od
.nih.gov/research/strategicplan/ORWH_StrategicPlan2020_Vol1.pdf.
Women’s health. (2013, September 1). World Health Organization. Retrieved from http://
www.who.int/topics/womens_health/en/.
WORLD HEALTH ORGANI ZATION (WHO)

The World Health Organization (WHO) is an international humanitarian agency
with the mission of promoting health for all p
eople throughout the globe. The WHO
is an agency of the United Nations (UN) supported and managed by UN member
governments. The agency collects global health data and shares the information
658 WOR LD HEALTH ORGANIZ ATION (WHO )
through their website and special reports. Examples of WHO work includes pub-
lishing the World Health Report, working to control sexually transmitted diseases,
environmental problems, epidemic and endemic diseases, and promoting maternal
and child health and equitable access to care. Major health achievements are the
eradication of smallpox and the control of measles, yellow fever, cholera, tubercu-
losis, and malaria.
The first international effort to coordinate national public health started in 1851
with the International Sanitary Conference in Paris. The conference focused on pre-
venting the transmission of cholera and the high costs of fighting infectious dis-
eases by standardizing rules for quarantine and minimizing redundant efforts at
ports of entry. The International Sanitary Conference continued to meet annually,
evolving into the Office International d’Hygiène Publique (OIHP), a permanent
committee of health officials headquartered in Paris. World War I (1914–1918) dis-
rupted OIHP’s work. A fter the war, the agency was supposed to join the League of
Nations. However, the United States objected and the League of Nations established
a new international health organization. The Health Organization of the League of
Nations, OIHP, the Pan American Sanitary Organization, and other agencies worked
together to promote world health u ntil efforts w
ere again stymied by world war. A
fter
World War II, officials met to establish the UN. Delegates from Brazil and China
advocated for combining the multinational health organizations into one agency.
Fifty-one UN members and delegates from 10 nations drafted a Constitution of the
WHO. U.S. surgeon general Thomas Parran (serving from 1936 to 1948) referred to
the WHO Constitution as the “Magna Carta for world health.” The Constitution was
formally ratified by 26 members of the UN on April 7, 1948, a date that is now cel-
ebrated as World Health Day. The first director general was Canadian psychiatrist
Dr. Brock Chisholm, a highly respected doctor and a World War I veteran.
The WHO currently employs over 7,000 p eople from 150 countries. Public health
objectives are:
• Providing public health leadership and engaging partners.
• Identifying areas for research and translating research findings into public
health practice.
• Defining standards for public health practice.
• Determining evidence-based policies that adhere to ethical principles.
• Building institutional capacity.
• Disease surveillance and monitoring.
Staff include public health professionals, medical doctors, scientists, epidemiolo-
gists, health administrators, biostatisticians, financial experts, and health economists.
The organization is headquartered in Geneva, Switzerland, with regional offices in
Africa, the Americas, South-East Asia, Europe, Eastern Mediterranean, and the West-
ern Pacific. The Global Service Centre is located in Malaysia. Offices are multilin-
gual to ensure that information is clearly communicated and effectively addresses
pressing health issues. The WHO is governed by the World Health Assembly, which
is composed of health ministers from member states.
W O R LD HEALTH O R G ANI Z ATION ( WHO ) 659
Toddler Rahima Banu shows classic signs of smallpox infection with a distinctive, bumpy
rash, and blistering of the skin, mouth, and throat. World Health Organization workers
responded to the outbreak by vaccinating all people who came in contact with Rahima and
cared for the little girl until she recovered physically. (National Library of Medicine)
Major efforts involve monitoring trends in diseases and health problems and
sharing information and best practices with nations. The WHO sends emergency
responders to manage disease outbreaks at the source, containing and controlling
deadly diseases, such as Ebola; manages mass immunization campaigns to ensure
the safety of c hildren around the world; ensures that prescription medicines have
a single international name so that people traveling abroad can attain the drug that
their doctor prescribed; and sets standards for environmental health issues, such
as air pollution. Major achievements include the control of the disabling disease
yaws (1952–1964), eradication of smallpox (1979), identification of the virus that
causes AIDS (1983), control of severe acute respiratory syndrome (2003), the global
public health treaty to reduce tobacco-related deaths (2003), and a 99 percent reduc-
tion in cases of polio (1988–2006). The Health Action in Crisis team manages
responses to man-made and natural disasters, helping communities to strengthen
internal capacity and to recover from disasters while minimizing threats to public
health. Future priorities are global eradication of polio, advocating for disadvan-
taged groups living in poverty, and reducing the 500,000 maternal deaths each year
caused by complications of pregnancy. The WHO works with partners around the
world addressing the most pressing emerging and remerging health issues.
Sally Kuykendall
660 W YNDE R , E R NST LUD W I G
See also: Air Pollution; Alcohol; Bioterrorism; Child Maltreatment; Cholera; Disability;
Disability Movement; Dunham, Ethel Collins; Eliot, Martha May; Environmental
Health; Epidemic; Family Planning; Global Health; Health; Healthy Places; Immi-
grant Health; Infant Mortality; Intimate Partner Violence; Maternal Health; Mea-
sles; Mental Health; Pandemic; Polio; Salk, Jonas; Smallpox; Social Determinants
of Health; Vaccines; Waterborne Diseases; Winslow, Charles-Edward Amory; Con-
Further Reading
Parran, T., & Boudreau, F. G. (1946). World Health Organization. American Journal of Public
Health, 36, 1267–1272.
World Health Organization. (2007). Working for health: An introduction to the World Health
Organization. Retrieved from http://www.who.int/about/brochure_en.pdf.
World Health Organization. (2017). Retrieved from http://www.who.int/en.
The World Health Organization and Its Work. (2008). American Journal of Public Health,
98(9), 1594–1597.
WYNDER, ERNST LUDWIG (1922–1999)

Ernst Ludwig Wynder was a German American physician, surgeon, researcher, and
public health advocate who worked diligently to create awareness of smoking as a
health hazard. Between 1850 and 1900, lung cancer increased over fourfold in the
United States, from 9 cases per 100,000 people to 43 cases per 100,000 (Adler,
1912). Similar increases w ere seen throughout the world. Some scientists suspected
air pollution. Few suspected smoking b ecause cigarettes were marketed as health
enhancing. Doctors, famous athletes, and movie stars featured prominently in adver-
tisements claiming that smoking cleared the lungs, soothed the throat, or relieved
asthma. As lung cancer cases increased, medical researchers focused on treatments.
Wynder focused on naming and preventing the cause. His body of research and
public advocacy is a model of interdisciplinary, translational research in public
health. Wynder combined aspects of epidemiology, biology, pathology, biochemis-
try, and health behavior to study smoking and cancer. Despite dismissal by col-
leagues and pressure from tobacco companies, Wynder persevered and his research
saved and continues to save many lives.
Ernst Ludwig Wynder was born on April 30, 1922, in Herford, Germany, the
son of Therese (Godfrey) and Alfred Wynder. In 1938, the family fled Nazi perse-
cution to the United States. Ernst earned a bachelor of arts degree from New York
University. In 1943, he became a naturalized citizen and joined the U.S. Army Intel-
ligence Corps. After two years of army service, he attended Washington University
Medical School in St. Louis, Missouri. During a summer internship at New York
University, Ernst observed an autopsy of a 42-year-old man. The man died of lung
cancer a fter smoking two packages of cigarettes per day over 30 years. A fter the
autopsy, Wynder questioned patients about their smoking. Noticing that many
WYNDE R , E R NST LUDWI G 661
patients smoked, Wynder devised a study. He returned to Washington University

and convinced faculty mentor Dr. Evarts Graham to allow him to interview Gra-
ham’s patients.
The idea that smoking was harmful to health was not new. In 1912, Dr. Isaac A.
Adler of the New York Polyclinic and the German, Beth-Israel, Har Moriah, and
Peoples Hospitals and the Montefiore Home and Hospital published the landmark
report Primary Malignant Growths of the Lung and Bronchi. The report summarized
worldwide increases in lung cancer. Much of the data came from doctors in Europe.
In the 1920s, cancer specialist and director of the Instituto de Medicina Experi-
mental in Buenos Aires, Argentina, Dr. Ángel Roffo tested the effects of tobacco tar
on rabbits. Dr. Roffo concluded that “this product is highly carcinogenic; it c auses
carcinomas which are invasive, metastatic and aggressive” (Roffo, 2006, p. 502).
Roffo recommended an aggressive public campaign against smoking. The Nazi Party
was the first to organize national anti-smoking efforts. Posters discouraged smok-
ing. Cigarettes w
ere rationed. Smoking was banned on public transportation. Adolf
Hitler, a former smoker himself, encouraged friends and colleagues to quit the habit.
The campaign was consistent with the Nazi goal of creating a physically perfect and
genetically pure race (Proctor, 1996). German doctors believed that smoking caused
birth defects. Messages and rationing w ere frequently aimed at German w omen in
an effort to promote fertility and children’s health. Roffo died in 1947, and the anti-
smoking movement was dismissed as Nazi propaganda.
In May 1950, Wynder published his first study on smoking and health while in
his fourth year as a medical student. Gathering the smoking histories of 605 men
with bronchiogenic carcinoma and 780 men with other diseases, Wynder and Gra-
ham (1950) discovered that patients with lung cancer reported higher rates of
smoking, longer smoking histories, and heavier smoking than patients with other
diseases. The study provided epidemiological analysis by mathematicians at the Uni-
versity of Washington. The statisticians rejected the null hypothesis that smoking
was not related to lung cancer. The odds that the differences in smoking between
the two groups was due to chance alone was less than one in 10,000. Wynder and
Graham surmised that smoking was related to lung cancer and, based on patient
report, cigarette smoking posed higher risk than pipes or cigars. Experts criticized
the study because it only proved that the two variables, smoking and lung cancer,
existed together (a cross-sectional, correlational study). The study did not prove
that smoking caused lung cancer. Dr. Charles S. Cameron, medical director of the
American Cancer Society, told the press:
The evidence that has been adduced does not justify an indictment of smoking as a
cause of lung cancer, in our opinion. We believe that the methods of collecting this
evidence have all had certain inadequacies, and we are now initiating another study
which we hope will put us in a better position to answer this question in five years.
(Spencer, 1950, p. 136)
Cameron believed that cancer was due to hormonal factors.

662 WYNDER , ERNST LUDWIG
Meanwhile, in E ngland and Wales, deaths due to lung cancer increased from
612 in 1922 to 9,287 in 1947 (Doll & Hill, 1950). Within several months of Wyn-
der and Graham’s report, Drs. Richard Doll and Bradford Hill of the British Medical
Council published a similar hospital-based study. Doll’s 1,732 patients with carci-
noma and 743 general medical and surgical patients confirmed Wynder’s analysis.
By 1954, Doll and Hill published their landmark study “The Mortality of Doctors
in Relation to Their Smoking Habits” in the British Medical Journal. The study fol-
lowed 40,564 male and female physicians over 29 months. All deaths due to lung
cancer w ere among smokers and the more one smoked, the greater the risk of lung
cancer. This prospective study of a highly reliable, healthy population was a critical
step in showing that smoking causes lung cancer.
Wynder completed his medical internship at Georgetown University Hospital in
Washington, DC, and residency at the Memorial Hospital for Cancer and Allied Dis-
eases. He continued his quest to discover the cause of lung cancer at Sloan-Kettering
Institute in New York. His research was stymied by big tobacco, office politics, and
comparisons with bench science. Tobacco companies pressured Sloan-Kettering
director Frank Horsfall financially. They asked him to stop Wynder’s research and
his anti-tobacco press announcements. Wynder’s research was saved by world
famous virologist Dr. Peyton Rous. Rous cautioned Horsfall against interfering with
science. Inside and outside of Sloan-Kettering, Wynder’s frequent requests for press
interviews aroused professional jealousy. He was the target of criticism for the qual-
ity of his work and his personal life as a bachelor.
In 1960, Clarence Cook L ittle, an expert in tumors in mice, held a public debate
with Wynder. L ittle argued that cancer was caused by viruses, and Wynder’s research
simply showed a correlation between smoking and lung cancer, not that smoking
caused lung cancer. By the standards of bench science, Little was correct. To prove
that smoking caused lung cancer, Wynder would have to take a group of healthy
nonsmokers, randomly assign them to smoking or nonsmoking groups and then
follow them over a period of time to see if lung cancer developed. Of course, such
a study would be highly unethical. Retrospective studies (comparing past smoking
history with disease) or quasi-experimental studies (using nonrandomized groups)
were scientifically weak but ethical. Wynder’s hands were tied by the limitations of
translational research. Wynder recruited Dietrich Hoffmann from the Max Planck
Institute of Biochemistry in Munich, Germany. The researchers used animal testing
to discover the carcinogenic ingredients in tobacco tar, benzo(a)pyrene, and poly-
nuclear aromatic hydrocarbons. Although tobacco companies dismissed the science,
few experts dared disagree with the idea that smoking c auses cancer. In 1969, the
new director of Sloan-Kettering admonished Wynder. He claimed that Wynder’s
research was irresponsible, and all future publications had to be reviewed and cleared
by the director’s office (Doll, 1999). Again, Rous came to Wynder’s defense. The
reprieve was only temporary. Wynder’s research budget was cut.
In Framingham, Massachusetts, 5,209 men and women were participating
in a large cohort study investigating lifestyle and cardiovascular disease. With
W YNDE R , E R NST LUD WI G 663
motivation from the Framingham Heart Study and the philosophy that “common
diseases have common c auses,” Wynder established the American Health Founda-
tion (AHF) as a research institute (Stellman, 2006, p. 14). Knowing that the fed-
eral government would provide limited support for nontraditional, interdisciplinary,
translational research, Wynder developed funding partnerships with the American
Cancer Society, Eastman Kodak Co., Northwestern Mutual Life Insurance Co., Time,
Inc., and several other large benefactors. The AHF researchers studied novel topics,
such as saccharin and bladder cancer; cell phones and brain cancer; low fat diet and
low incidence of breast cancer in Japan; and rye bread and low incidence of intestinal
cancer in Finland. The organization recruited participants for the Multiple Risk
Factor Intervention Trial (MRFIT, pronounced Mr. Fit). Male participants of MRFIT
received counseling on cigarette smoking, diet, and health care in the community.
Wynder was very active in prevention medicine, setting public policies against smok-
ing, and advocating for comprehensive school health education programs. In 1972,
he started Preventive Medicine, the peer-reviewed, quality research journal.
Dr. Ernst L. Wynder died on July 14, 1999, at the age of 77. Throughout his
lifetime, he made landmark discoveries in cancer research. He noticed characteris-
tics and patterns among patients that suggested common causal factors and devel-
oped the best possible ways to study the issue and test his hypotheses. Colleagues
describe Wynder as someone who was always one step ahead, able to predict the
next area of research. However, Wynder was not content with novel discoveries.
He was very clear in his responsibility as a doctor and a scientist. He worked to get
the message out that smoking c auses cancer. He stood solidly against public opin-
ion, big business, and ivory tower politics to ensure that the public understood the
real price of cigarette smoking. Even as the field of oncology evolved, Wynder con-
tinued to look for ways to enhance human health.
Sally Kuykendall
See also: Addictions; Birth Defects; Cancer; Causality; Epidemiology; Men’s Health;
Surgeon General; Truth Campaign, The; Controversies in Public Health: Controversy 2;
Controversy 4
Further Reading
Adler, I. A. (1912). Primary malignant growths of the lung and bronchi. New York: Longmans,
Green and Company. Retrieved from https://archive.org/details/primarymalignant00adle.
Doll, R. (1999, December). Ernst Wynder, 1923–1999. American Journal of Public Health,
89(12), 1798–1799.
Doll, R., & Hill, A. B. (1950). Smoking and carcinoma of the lung. British Medical Journal,
2(4682), 739.
Doll, R., & Hill, A. B. (1954). The mortality of doctors in relation to their smoking habits.
British Medical Journal, 1(4877), 1451.
Johnson, J. A. (1998). Ernst Wynder, M.D., president, American Health Foundation. Jour-
nal of Healthcare Management, 43(2), 107.
664 WYNDER , ERNST LUDWIG
Proctor, R. N. (1996). The anti-tobacco campaign of the Nazis: A little known aspect of
public health in Germany, 1933–45. British Medical Journal, 313(7070), 1450–1453.
Roffo, A. H. (2006). The carcinogenic effects of tobacco. Bulletin of the World Health Organ
ization, 84(6), 500–502.
Spencer, S. M. (1950). Can we check the rising toll of lung cancer? Saturday Evening Post,
222(41), 36–136.
Stellman, S. D. (2006). Ernst Wynder: A remembrance. Preventive Medicine: An International
Journal Devoted to Practice and Theory, 43(4), 239–245. doi:10.1016/j.ypmed.2006.08.007
Weinberg, R. (1999). Ernst Ludwig Wynder, 1922–99. Nature, 401(6752), 442.
Wynder, E. L. (1959). Laboratory contributions to the tobacco-cancer problem. British Med
ical Journal, 1(5118), 317.
Wynder, E. L., & Graham, E. A. (1950). Tobacco smoking as a possible etiologic factor in
bronchogenic carcinoma. Journal of the American Medical Association, 143(4), 329–336.
Z
ZOMBIE PREPAREDNESS
In 2011, the Centers for Disease Control and Prevention (CDC) surprised pop cul-
ture fans by publishing a blog entitled Preparedness 101: Zombie Apocalypse. What
began as a tongue-in-cheek campaign to educate the public on emergency prepared-
ness has become one of the CDC’s most amusing and popular public health pro-
grams. The blog post uses the example of a zombie apocalypse to expound on the
CDC’s preparedness strategies and outline specific ways readers could prepare
for an emergency. The website provides a list of items to keep available in case of
natural, man-made, or supernatural disasters and offers suggestions for a person-
alized safety plan.
The idea of the dead returning to life traces back to the earliest civilizations. In
the Epic of Gilgamesh, King Gilgamesh searches for the secret to eternal life in hope
of bringing his friend Enkidu back to life. The word “zombie” derives from the
West African words nzambi (god) and zumbi (fetish). The term was brought to
Haiti and the new world by enslaved Africans and would have embodied the spirit
of enslaved p eople as lifeless, apathetic, emaciated corpse-like figures. According
to Haitain folklore, the dead are reanimated by a voodoo god. Those who please
the god are taken to heaven while others are enslaved for eternity. Over time, hor-
ror genre adopted the image of the zombie as mindless and soulless and reani-
mated by magic, virus, or radiation. George Romero’s 1968 hit movie Night of
the Living Dead is credited with introducing zombies into pop culture. In 2011,
Dr. Stephen Schlozman, Harvard medical school physician and professor, appeared
on a late night weekend radio show mimicking the famous H. G. Wells War of the
Worlds radio show dramatic adaptation. Schlozman described the transmission
and physiology of the (fictional) disease ataxic neurodegenerative satiety defi-
ciency syndrome (ANSD). Public reaction was stunning. Some p eople continued
the hoax by submitting medical questions on how to prevent zombie infection.
Over 1,000 people complained to the network about the “irresponsible” jour-
nalism. The F.C.C. received more than 600 letters of complaint, and Schlozman
reports that Harvard administrators w ere not amused by the hoax. One complain-
ant expressed concerns that the doctor violated the Hippocratic Oath. Regardless
of what one thinks of Schlozman’s interview, it is clear that people are fascinated by
outlandish stories.
In 2011, Ali S. Kahn created a blog for the CDC that applies the basic concepts
of public health response and emergency preparedness to a zombie apocalypse.
Zombie Preparedness guidelines describe essential supplies needed to survive man-made,
natural, or supernatural disasters. (Centers for Disease Control and Prevention)
Z O M B IE P R EPA R EDNESS 667
The blog provides a comprehensive list for items necessary for a public health
emergency:
• Water
• Medications and health supplies
• Food
• Tools
• Cleaning and personal care items
• Safety supplies
• Clothing
• Copies of important documents
• Electronics
Specific sections describe additional supplies for c hildren and pets. The CDC also
published a digital graphic novella, detailing the events of a zombie outbreak, avail-
able as a PDF on the CDC’s website. In case of an emergency, the CDC would conduct
an investigation, provide technical assistance, consult with local authorities, manage
cases, and control spread. Disease surveillance, investigation, and control are part of
the typical CDC responsibilities with any critical disease outbreak or public health
emergency. What makes the zombie preparedness campaign so special is the public’s
response. Normally, people don’t get too excited over preparing for a hurricane,
tornado, or snowstorm. A zombie apocalypse draws p eople’s attention. “Lisa” com-
mented “That is soooooo awesome!!!! Thanks, CDC.” Shelabella writes:
I think this is an excellent campaign for the CDC to breathe life back into disaster
preparedness. I love the zombie theme & think it’s timely, unique, and has plenty of
shock factor to make it memorable and highly effective.
The levity behind this is something that will interest my teenage boys . . . some-
thing that is so hard to do in this day and age (unless y ou’re a pixel, perhaps). Any-
way, I r eally like this campaign, because it presents a disaster in a manner that I can
actually entice my family into discussion; and it will provide some assistance for any
potential disaster as well. Awesome job!
Solega of the Zombie Outbreak Response Team (ZORT) of Helena, MT, responds
to the conversation of adding a weapon to the emergency response kit:
I notice quite a few people posting about the usefulness of a baseball bat in the event
of a zombie apocalypse. If you read the Zombie Survival Guide, it explains with grue-
some detail exactly what happens to the guy with the baseball bat. It wasn’t pretty
and now there’s a zombie with a baseball bat. In all seriousness, though, I think the
biggest reason that weapons w eren’t addressed in this particular post was largely
because it’s designed to be an all encompassing emergency plan, not JUST for zombies.
You’re not g oing to need a shotgun in a hurricane. You specifically. Yea, you, I see you
reading this post. You definitely d on’t need a shotgun. Ever.
Some comments complain about the public resources used to develop and main-
tain the website. One reader notes that garnering this amount of interest and atten-
tion would be very expensive and saves significant advertising dollars.
668 Z OM B IE PR EPA R EDNESS
The CDC’s Zombie Preparedness campaign highlights how health educators strive
to create imaginative and informative programs to prevent health crises and to pro-
mote well-being. As public health educators compete with big businesses for pub-
lic attention, campaigns such as the Zombie Preparedness campaign will become a
model for other public health programs.
Mark Black
See also: Bioterrorism; Centers for Disease Control and Prevention; Emergency Pre-
paredness and Response; Epidemic; Health Communication; Influenza; Pandemic;
State, Local, and Territorial Health Departments
Further Reading
Centers for Disease Control and Prevention. Zombie preparedness. Retrieved from https://
www.cdc.gov/phpr/zombies.htm.
Preparedness 101: Zombie pandemic. Retrieved from https://www.cdc.gov/phpr/zombies
_novella.htm.
Schlozman, S. (2013). The Harvard doctor who accidentally unleashed a zombie invasion.
The New York Times. Retrieved from http://www.nytimes.com/2013/10/27/magazine/the
-harvard-doctor-who-accidentally-unleashed-a-zombie-invasion.html.
Controversies in Public Health
CONTROVERSY 1: SHOULD DRUG PRICES BE

REGULATED IN THE UNITED STATES?
Introduction
In 2015, U.S. pharmaceutical companies spent over $58 billion on drug discovery,
research, and development (R&D). To protect pharmaceutical industry investment,
the federal government awards exclusive rights of marketing the drug for a period
of up to seven years. Drug patents allow the company time to recover the cost of
R&D from the consumer. However, recent cases of extraordinarily high price
increases well a fter product development raise concerns of price gouging by phar
maceutical companies. A study published in the Journal of the American Medical
Association compared the cost of R&D to drug prices and concluded, “Although
prices are often justified by the high cost of drug development, t here is no evidence
of an association between research and development costs and prices; rather, pre-
scription drugs are priced in the United States primarily on the basis of what the
market will bear” (Kesselheim, Avorn, & Sarpatwari, 2016). People with chronic or
acute illnesses are highly vulnerable to price gouging. Prescription medications
account for up to 17 percent of all health care costs. A significant portion of Medi-
care and Medicaid expenses are prescription medications. To protect consumers
and government-funded health care programs, many other countries regulate drug
prices. The United States is one of the only nations that does not regulate prices. This
raises the question of whether drug prices should be regulated in the United States.
The Tufts Center for the Study of Drug Development estimates that pharmaceu
tical R&D can cost up to $2.6 billion per drug. Yet, recent cases suggest that devel-
opment does not always justify price. In 2001, Questcor purchased the rights to
Acthar Gel, an adrenocorticotrophic hormone analogue used to treat infantile
spasms, systemic lupus erythematosus, and multiple sclerosis in relapse. The drug
was developed by researchers at the Mayo Clinic in 1950. Questcor increased the
price from $40 to $23,000. In 2015, Valeant acquired rights to the drug Isuprel, a
drug used to support blood pressure in patients with heart problems. Valeant raised
the price from $440 per vial to $2,700 per vial. The explanation given for the increase
was to maximize shareholder profit. Hospitals had to remove the life-saving drug
from crash carts because they could no longer afford it. Before Turing Pharma
ceuticals bought the rights to Daraprim, a drug used to treat parasitic infections
670 C on trove rs ies in Public Healt h
among p eople with immunosuppression due to AIDS or cancer, the drug cost
$13.50 per pill. Turing increased the price 5,000 percent to $750 per pill. In 2016,
Mylan Pharmaceuticals increased the cost of EpiPen from $57 (in 2007) to over
$500. Unexplainable price increases are particularly common with drugs used
to treat rare diseases. When Marathon Pharmaceuticals received approval to sell
deflazacort, a drug to alleviate the symptoms of Duchenne muscular dystrophy, the
drug price increased from $1,200 per year to $89,000 per year. Not all increases
are so egregious. Pfizer and Allergan employed a different strategy by raising the
price of almost all of their drugs by 10 percent. Pharmaceutical companies argue
that price increases are absorbed by insurance companies and patients rarely have
to pay the a ctual cost of the drug.
Some experts argue that the culprit b ehind higher drug prices is a business model
that values profit over p eople. Money clouds one’s ability to discriminate between
right and wrong. In short, money corrupts ethics. The case of Johnson and John-
son and Massachusetts General Hospital and Harvard University professor Dr. Joseph
Beiderman demonstrates the dangers of applying the business model to pharma
ceutical research and marketing. In 2002, Johnson and Johnson donated $700,000
to Biederman’s Center for the Study of Pediatric Psychopathology. The highly
regarded child psychologist performed a research study comparing Johnson and
Johnson’s drug Risperdal to placebo. The study found no difference in treatment
effectiveness. Johnson and Johnson executive Dr. Gahan Padina substituted the orig-
inal report with a new report indicating that Risperdal was significantly better than
placebo. Beiderman agreed to “support the safety and effectiveness of risperidone
[Risperdal].” L ater investigation by Congress revealed that Beiderman failed to report
$1.4 million in consulting fees from Johnson and Johnson (Gardner, 2008). The
Alliance for H uman Research Protection explains:
The real scandal perpetrated by Biederman has nothing to do with his consulting fee
shenanigans and everything to do with the real life (and death) consequences . . . Many
remember Rebecca Riley, the Hull, MA, toddler whose death in 2004 made headlines.
But she is merely the tip of the iceberg. According to the New York Times from 1993
through 2008, 1,207 c hildren who w ere given Risperdal suffered serious problems,
including 31 who died. Among the deaths was a nine-year-old who suffered a fatal
stroke 12 days a fter starting therapy with Risperdal. (Azerrad, 2011)
The case shows that higher drug prices do not necessarily mean better research or
better health care. In fact, higher drug prices mean that people on limited incomes
will look for ways to reduce costs. Fourteen percent of Americans skip doses, take
less medicine than prescribed, or delay filling prescriptions in order to reduce drug
costs (CDC, n.d.).
Drug patents protect the company’s intellectual property. By providing exclusive
rights to manufacturing and marketing, drug companies are able to recoup the costs
of R&D from consumers. Drug companies also employ strategies of evergreening
C o ntr o v er s i es i n P ub l i c H ea lth 671
or hard switching to extend market exclusivity. Evergreening is patenting a slightly

different version of the medicine by making minor, insignificant changes to the
drug. Hard switching is removing a drug that is about to go generic and replacing it
with a higher priced product. Orphan drugs present a special challenge to drug com-
panies and therefore consumers. Orphan diseases are diseases that are not related to
other, more common diseases and affect less than 200,000 Americans. To encourage
R&D into the treatment of orphan diseases, the federal government passed the
Orphan Drug Act of 1983. The law offers special incentives, tax breaks, and exclu-
sive rights to market in exchange for the development and manufacture of orphan
drugs. Despite additional incentives, the cost of orphan drugs is extraordinarily high.
The average annual cost of a nonorphan drug is $27,756 per patient. The average
cost of an orphan drug is $140,443 per patient.
Discovering and developing new drugs is an expensive business, driven by high
patient demand and aggressive market competition. Unfortunately, high prices can
make drugs unaffordable and inaccessible to many p eople who need the medicine
to survive. Furthermore, the federal government may be paying twice for the drug,
the first time through grants or subsidies for R&D and a second time through pub-
licly funded health care services. Salini Iniganti and Alex Black debate w
hether drug
prices should be regulated in the United States.
Sally Kuykendall
Further Reading
Azerrad, J. (2011). The real Beiderman scandal. Alliance for Human Research Protection.
Retrieved from http://ahrp.org/the-real-biederman-scandal.
CDC. (n.d.). Percentage of U.S. adults not taking medication as prescribed to reduce prescription
drug costs in 2013, by age group. In Statista—The Statistics Portal. Retrieved July 19,
2017, from https://www-statista-com.ezproxy.sju.edu/statistics/397724/adults-not
-taking-medication-as-prescribed-to-lower-prescription-drug-costs-by-age.
Daniel, H. (2016). Stemming the escalating cost of prescription drugs: A position
paper of the American College of Physicians. Annals of Internal Medicine, 165(1),
50–52. doi:10.7326/M15-2768. Retrieved from http://annals.org/aim/article/2506848
/s temming-e scalating-c ost-p rescription-d rugs-p osition-p aper-a merican-c ollege
-physicians.
Gardner, H. (2008, November 25). In documents, ties between child psychiatry center and
drug maker. The New York Times, p. 22.
Kesselheim, A. S., Avorn, J., & Sarpatwari, A. (2016). The high cost of prescription drugs
in the United States: Origins and prospects for reform. Journal of the American Medical
Association, 316(8), 858. doi:10.1001/jama.2016.11237
PhRMA. (n.d.). Spending of the U.S. pharmaceutical industry on research and development at
home and abroad from 1990 to 2015 (in million U.S. dollars). In Statista—The Statistics
Portal. Retrieved July 19, 2017, from https://www-statista-com.ezproxy.sju.edu/statistics
/265090/us-pharmaceutical-industry-spending-on-research-and-development.
Smith, A. G. (2016). Price gouging and the dangerous new breed of pharma companies.
Harvard Business Review Digital Articles, 2.
Yes, Drug Prices Should Be Regulated by the Government
The United States spends more per capita on health care than any other developed
nation. National spending on health care exceeded $10,000 per person in 2016. In
comparison, Canada’s national health care spending was estimated to be $4,608
per person, and the United Kingdom’s spending was only $4,003 per person in 2015
(OECD, 2015). One of the major factors that is increasing U.S. health care spend-
ing is the rising cost of prescription drugs. It is estimated that prescription drug
spending will increase by 4 to 7 percent through 2021, creating a $580 billion to
$610 billion market (Aitken et al., 2016). In 2013, per capita spending on pre-
scription drugs was $858 compared with an average of $400 for 19 other industri-
alized nations (Kesselheim, Avorn, & Sarpatwari, 2016). Part of the reason that
consumers in the United States pay a much higher price for their drugs is b ecause
pharmaceutical companies are free to establish their own prices without regulation.
American consumers have no bargaining power when it comes to prescription
drugs. There is no single entity that can bargain on behalf of consumers due to the
complexity of the health care system with its various insurers, employers, and fed-
eral/state programs. All of these different entities negotiate their own contracts and
drug prices for their individual consumers. Due to a lack of regulation in pricing,
Americans pay anywhere from two to six times more than the rest of the world for
brand-name prescription drugs according to the International Federation of Health
Plans. In other countries with national health care systems, the government is the
main purchaser of prescription drugs. As such, they are able to effectively negotiate
with drug companies to get the lowest drug prices possible for consumers.
Despite being one of the largest providers of health care in the United States,
Medicare cannot negotiate with pharmaceutical companies. In 2003, Congress
expanded the program to include Part D prescription drug coverage but prohibited
Medicare, the largest single-payer health care system in the United States, from set-
ting drug prices. In the same expansion, Congress required eligible Medicare Part
D plans to cover all drugs in certain disease categories (e.g. cancer, depression).
This left the determination of drug prices u nder these categories at the discretion
of the pharmaceutical manufacturing companies, who are free to establish what
ever price that they believe the market will bear. If Medicare were able to negotiate
with pharmaceutical companies directly, the price of drugs for everyone could be
driven down. Since this is not the case, American consumers are left without much
bargaining power and much higher drug prices.
Americans also deal with the effects of direct-to-consumer marking of prescrip-
tion drugs. Unlike most Western nations, the U.S. has not banned the direct advertis-
ing of pharmaceuticals to consumers. Many suggest that this type of marketing
encourages consumers to take medications unnecessarily, or choose more expensive
brand-name drugs. When drugs that are newly on the market are advertised to con-
sumers, the purchase and use of those drugs accelerate despite unknown long-term
outcomes for the drug (Lyles, 2002). Due to the lack of regulation in advertising,
many drug commercials contain emotional testimonials but lack actual scientific
data (Woloshin, Schwartz, Tremmel, & Welch, 2001). In addition to potentially mis-
leading drug consumers, the added costs of production for advertising (e.g, televi
sion commercials, magazines, billboards) are ultimately passed on to the consumer.
At this time, the government is trying to find a balance between (1) giving phar
maceutical companies financial incentives to innovate and produce breakthrough
drugs and (2) keeping drug prices as low as possible. The current system for incen-
tivizing drug research involves patents that cover an innovative drug for approxi-
mately 20 years. In addition to patents, the Food and Drug Administration (FDA)
can grant temporarily market exclusivity rights, which would ensure that the FDA
would not approve a generic version of a particular drug for a set amount of time.
Together, the patents and market exclusivity rights guarantee that new, brand-name
drugs get an average of 13 years of sales before a generic, more affordable, alterna-
tive medication enters the market (Grabowski, Long, & Mortimer, 2014). Once a
generic drug is able to be introduced to the drug market, there is an increase in
competition and a decrease in costs for both the brand-name and generic versions
of the drug.
Unfortunately, many people do not have the ability to wait for an affordable
generic to come to market when they are dealing with a life-threatening illness, and
they cannot afford what is available. According to a survey by Consumer Reports,
many respondents took “potentially dangerous” steps due to high drug costs: not
filling a prescription (17 percent), skipping a scheduled dose (14 percent), or tak-
ing an expired medication (14 percent). The survey also found that 19 percent of
respondents spent less on groceries, and 15 percent postponed paying other bills
so they could afford their prescription drugs (Consumer Reports, 2014).
Unchecked by the government, pharmaceutical companies are making large prof-
its at the expense of Americans’ health and well-being. Drug companies attempt to
justify the high prices they set by arguing that they need to offset the high costs of
research and development (R&D). However, drug companies spend much more
on marketing their drugs to consumers than they spend on R&D. For example,
Johnson and Johnson spent $17.5 billion on sales and marketing, but spent a mere
$8.2 billion on R&D while making $71.3 billion in revenue in 2016. Furthermore,
the premiums that pharmaceutical companies earn from charging substantially
higher prices for their medications in the United States compared to other Western
countries generate substantially more than they spend globally on their R&D (Yu,
Helms, & Bach, 2017).
Without government regulation of drug prices, an increasing number of Ameri-
cans w ill be unable to access the medications that they need to maintain their qual-
ity of life. This will lead to poorer health outcomes and higher health care costs.
Higher spending on prescriptions drugs is not only a burden for t hose who are sick
or needing medication. These costs are ultimately passed on to everyone who has
health coverage in the form of premiums, deductibles, and other forms of cost
sharing. Furthermore, drug spending increases costs for taxpayer-funded programs
like Medicare and Medicaid, resulting in higher taxes and cuts to public funding.
There needs to be some form of government regulation of drug prices so that the
financial and physical health and well-being of Americans is not at the mercy of
pharmaceutical companies’ bottom line.
Salini Inaganti
Further Reading
Aitken, M., Kleinrock, M., Pennente, K., Lyle, J., Nass, D., & Caskey, L. (2016). Medicines
use and spending in the US: A review of 2015 and outlook to 2020. Parsippany, NJ:
IMS Institute for Healthcare Informatics.
Grabowski, H., Long, G., & Mortimer, R. (2014). Recent trends in brand-name and generic
drug competition. Journal of Medical Economics, 17(3), 207–214.
Kesselheim, A. S., Avorn, J., & Sarpatwari, A. (2016). The high cost of prescription drugs
in the United States: Origins and prospects for reform. Journal of the American Medical
Association, 316(8), 858–871. Retrieved from http://doi.org/10.1001/jama.2016.11237.
Lyles, A. (2002). Direct marketing of pharmaceuticals to consumers. Annual Review of Pub-
lic Health, 23(1), 73–91.
OECD. (2015). Health at a glance 2015. OECD Publishing. Retrieved from http://doi.org/10
.1787/health_glance-2015-en.
Some Americans take risks with needed drugs due to high costs. (2014). Consumer Reports.
Retrieved from http://www.consumerreports.org/cro/2014/09/some-americans-take
-risks-with-needed-drugs-due-to-high-costs/index.htm.
Woloshin, S., Schwartz, L. M., Tremmel, J., & Welch, H. G. (2001). Direct-to-consumer
advertisements for prescription drugs: What are Americans being sold? The Lancet,
358(9288), 1141–1146.
Yu, N., Helms, Z., & Bach, P. (2017). R&D costs for pharmaceutical companies do not explain
elevated US drug prices. Health Affairs. Retrieved from http://www.healthaffairs.org/do
/10.1377/hblog20170307.059036/full/.
No, Drug Prices Should Not Be Regulated by the Government
The federal government should not regulate drug prices. In order to develop a drug,
pharmaceutical companies must discover, develop, manufacture, and market
products. The costs of t hese processes are much higher than other consumer prod-
ucts. After discovering a drug, the company has exclusive rights to market. In many
cases, consumers do not actually pay the listed drug price. Many p eople are cov-
ered by insurance or health maintenance organizations who barter for discounted
drug prices. Members pay copay or reduced price, not the full price of the drug.
Once the drug goes off patent or exclusive rights to market, it can be manufactured
by a generic drug company. The generic company does not have to pay for research
and development (R&D). Generic drugs actually drive up prices. Customers have no
loyalty to the original manufacturer. Consumers w ill opt for less expensive generic
brands. The pharmaceutical industry is a high-risk business with responsibility to
shareholders. If shareholders do not benefit from their financial investment, they
ill find other businesses to invest in. Restricting drug prices would limit future
w
R&D and impair the discovery of new pharmaceutical treatments.
Pharmaceutical R&D is a risky investment. Many potential formulations fail either
in the laboratory or when tested in h umans. Clinical t rials for novel drugs are large,
complex operations that follow strict study protocols. Paid study participants are
closely monitored by highly trained medical professionals and scientists using
advanced medical technology. In order to obtain Food and Drug Administration
(FDA) approval, the pharmaceutical company must test the formulation, dosages,
and regimens and monitor adverse effects and long-term consequences. The pro
cess of discovering a new drug begins with researching the basic physiological pro
cess causing the disease. Potential treatments are selected by either studying current
therapies or by random selection of biological products. The new formula may be
extracted from plants, minerals, or animals or may be artificially synthesized. Vari-
ations of the compound of interest are tested through computer models, on cells
or tissues, or on animals to determine pharmacologic activity, therapeutic value,
and potentially harmful effects. The preferred compound is then formulated into a
pill, capsule, ointment, liquid, spray, or patch. Chemists, pharmacists, doctors, and
other scientists determine and test possible dosages and forms of administration.
Other compounds may be added to delay absorption or to stabilize the compound
to prevent it from deteriorating too quickly. Before the drug is tested in h umans, it
must undergo toxicology testing on animals, cells, or tissues. When the drug is con-
sidered safe for human consumption, the pharmaceutical company files an Inves-
tigational New Drug (IND) Application. The IND describes all of the results of the
research to date and provides a detailed plan for testing the drug in h umans. U
nless
the FDA decides to stop the clinical evaluation, drugs are automatically approved
for the next stages of testing. Phase I clinical evaluations investigate how the healthy
body absorbs, metabolizes, and excretes different amounts of the drug. Phase II stud-
ies investigate effectiveness and adverse effects in the healthy body. Phase III stud-
ies investigate safety and effectiveness among the intended consumer, hospital
patients, or outpatients. A fter Phase III studies, the pharmaceutical company must
determine the most effective way to manufacture large batches of the drug without
altering the formulation. The product may be tested again in bioavailability studies
to ensure that the manufactured product matches the original compound. The phar
maceutical company will then file a New Drug Application (NDA) with the FDA.
The NDA summarizes all of the research from laboratory and clinical testing. After
the drug is approved for marketing, the pharmaceutical company will continue to
study the long-term effects of the drug or effects of the drug in special populations
such as children or pregnant women. Bringing one new drug to market is a 10-to
12-year process costing approximately $2.6 billion (Tufts Center for the Study of
Drug Development, 2014). Pharmaceutical R&D costs more than other industries.
In 2009, the pharmaceutical industry spent $32,610 million on R&D while medi-
cal technology companies spent $9,047 million (Research!America, n.d.). The good
news is that this level of expenditure allows pharmaceutical companies to develop
over 1,000 new drugs each year, advancing treatments for cancer, heart disease,
and other c auses of death and disability. Price control would restrict new drug
development.
A second factor that drives up drug prices is the pressure to recoup expenses
before exclusive rights to market end. Pharmaceutical companies can patent a novel
drug for 14 years from the NDA approval date. A fter that time, the drug may be
manufactured and sold in generic form. Generic drugs are drugs that are chemically
the same as the branded drug but less expensive because the generic company does
not have to pay for R&D. Generic drugs are very attractive to consumers paying
out of pocket, insurance companies, and pharmacy benefit programs. With limited
time before a drug goes off patent, pharmaceutical companies are u nder pressure
to market the drug and recoup expenses. In 1997, the FDA permitted pharmaceuti
cal companies to advertise directly to consumers. Direct-to-consumer marketing
further drives up costs. In 2016, the pharmaceutical industry spent $23,333.95 mil-
lion on advertising (Schonfeld & Associates, n.d.). Among the top 10 pharmaceutical
companies, marketing accounts for 17.9 percent (Roche) to 28.4 percent (Astra-
Zeneca) of sales (BBC, n.d.). In addition to consumer marketing, pharmaceutical
companies must educate prescribing physicians. One-on-one physician educa-
tion, journal publications, and conference presentations add to drug cost.
A third factor that increases drug prices is consumer demand. Drugs improve
quality of life and keep people in the workforce and functioning in communities.
The average person over age 65 fills 9 to 12 prescriptions per year (Burton, 1998).
Half of all drug expenditures are by people with chronic disease. As baby boomers
age, demand for pharmaceuticals increase. More p eople are taking drugs for longer
periods of time, and managed care has made prescription drugs more affordable.
Drugs also offer an affordable alternative to other treatments. For example, phar
maceutical treatment for hepatitis C is less expensive than liver transplant surgery.
Health insurance increases demand by making drugs more affordable. Insurance
companies develop lists of drug formularies, medications that have been shown to
be effective in treating a disease and medications that are cost effective. Pharma
ceutical companies give large discounts to pharmacy benefit plans in order to
ensure that their drug is listed on the formulary. Consumers on pharmacy benefit
plans only pay the copay. Patients and insurance companies rarely pay the list price
of a drug.
There are other solutions to the rising cost of pharmaceutical products other than
government price regulation. Pharmaceutical companies take a major risk in devel-
oping new drugs. To minimize risk, the government could subsidize pharmaceuti
cal research. Alternatively, allowing pharmaceutical companies longer periods of
time to recoup R&D costs or requiring insurance companies to pay what the drug
is worth to develop and market are a few ways to reduce price while still ensuring
that pharmaceutical companies produce novel drugs to treat disease.
Alex Black
Further Reading
BBC. (n.d.). Top pharmaceutical companies’ expenditure on marketing as a percentage of sales in
2013. In Statista—The Statistics Portal. Retrieved August 7, 2017, from https://www
-statista-com.ezproxy.sju.edu/statistics/271784/marketing-expenditure-of-pharmaceutical
-companies-in-2009.
Burton, T. M. (1998, November 16). Hard to swallow: America’s soaring drug costs, Wall
Street Journal, p. A1.
Consumer Reports. (2014). Some Americans take risks with needed drugs due to high costs
but they remain leery of low-cost generics, Consumer Reports poll finds. Retrieved from
https://www.c onsumerreports .o rg /c ro /2 014 /0 9 /s ome -a mericans -t ake -r isks -with
-needed-drugs-due-to-high-costs/index.htm.
Paul, D. P., III, Chandra, A., & Lambrinos, F. (2006). Global pharmaceutical costs: Evalu-
ating the American approach. Journal of Medical Marketing, 6(1), 38–48.
Pharmaceutical R&D [microform]: Costs, risks, and rewards. (1993). Washington, DC: Office
of Technology Assessment, Congress of the U.S. For sale by the U.S. Government Print-
ing Office, Superintendent of Documents.
Research!America. (n.d.). Expenditure on research and development in U.S. health care 2009 by
industry (in million U.S. dollars). In Statista—The Statistics Portal. Retrieved August 7,
2017, from https://www-statista-com.ezproxy.sju.edu/statistics/272020/research-and
-development-expenditure-by-health-care-industry.
Schonfeld & Associates. (n.d.). Advertising spending in the pharmaceutical preparations indus-
try in the United States from 2010 to 2017 (in million U.S. dollars). In Statista—The Sta-
tistics Portal. Retrieved August 7, 2017, from https://www-statista-com.ezproxy.sju.edu
/statistics/470460/pharmaceutical-preparations-industry-ad-spend-usa.
Sloan, F. A., & Hsieh, C. (2007). Pharmaceutical innovation: Incentives, competition, and cost-
benefit analysis in international perspective. Cambridge, UK; New York: Cambridge Uni-
versity Press.
Statista Survey. (n.d.). How high do you think the pressure on physicians is from the pharma indus-
try to prescribe certain drugs? In Statista—The Statistics Portal. Retrieved August 7,
2017, from https://www-statista-com.ezproxy.sju.edu/statistics/694566/us-adults-that
-believe-physicians-are-under-pressure-from-pharma.
Tufts Center for the Study of Drug Development. (2014). Cost to develop and win marketing
approval for a new drug is $2.6 billion. Retrieved from http://csdd.tufts.edu/news/complete
_story/pr_tufts_csdd_2014_cost_study.
CONTROVERSY 2: SHOULD THE FEDERAL

GOVERNMENT RESTRICT ADVERTISING OF PRODUCTS
THAT HAVE AN IMPACT ON PUBLIC HEALTH?
Introduction
The history of cigarette advertising, fast food advertising, and prescription drug mar-
keting shows how business competition for consumer dollars presents challenges for
public health and raises questions regarding the federal government’s role and
responsibility in policing advertising of products that impact public health. Tensions
between product marketing, public health, and personal responsibility garnered

popular interest with the tobacco industry Master Settlement Agreement. The mul-
tibillion dollar lawsuit uncovered incriminating internal documents from big tobacco
companies. Despite an earlier agreement that restricted marketing to young people,
tobacco companies were intentionally targeting 14-to 18-year-olds with cigarette
advertising. Middle-aged and older smokers w ere d
ying, and cigarette makers needed
new customers. Young smokers promised high returns on advertising expendi-
tures. Using brand imprinting, tobacco companies hoped to establish a new genera-
tion of smokers with the public health programs of Medicare and Medicaid picking
up the bill.
The classic example of the conflict between advertising and public health is Joe
Camel, the cartoon character developed by the marketing team of R. J. Reynolds
Tobacco (RJR-T). For many decades, cigarettes were advertised as health enhanc-
ing. Doctors, nurses, and dentists endorsed cigarettes as an effective treatment for
relieving tension, asthma, hay fever, or bronchial irritation. Popular sports figures
pronounced that smoking helped to clear the throat, improving athletic perfor
mance. Movie and radio stars presented smoking as fashionable, dignified, and
sexually attractive. When studies showed that smoking was actually harmful to
health, tobacco companies entered a voluntary agreement to self-regulate market-
ing. The Cigarette Advertising Code of 1964 banned advertising to young p eople
and prohibited false health claims. By the early 1970s, RJR-T executives w ere look-
ing for ways to compete with Marlboro and Winston cigarettes. Secret planning doc-
uments reported that young people offered the greatest opportunity for long-term
cigarette sales growth:
The brands which these beginning smokers accept and use will become the domi-
nant brands in future years. Evidence is now available to indicate that the 14 to 18
year old group is an increasing segment of the smoking population. RJR-T must soon
establish a successful new brand in this market if our position in the industry is to be
maintained over the long term. (R. J. Reynolds Research Department, 1976)
One executive suggested using a comic strip–type character, and a plan was devel-
oped “to contemporize the Brand [Camel cigarettes] thus making it more relevant
and appealing.” The “Heroic Camel Mascot” Joe Camel was developed to “generate
excitement, awareness and appeal for the Brand” (Macfarlane, 1988). With a devel-
opment cost of $4,500 and advertising budget of $5.6 million, Joe Camel was rolled
out in 1988. Within three years, nearly as many children recognized Joe Camel as
recognized Mickey Mouse. The campaign to brand imprint was extremely success-
ful. Among a sample of six-year-old preschool c hildren, 91 percent recognized the
mascot’s association with cigarettes (Fischer et al., 1991). Before the Joe Camel cam-
paign, teenage smokers accounted for $6 million of Camel cigarette sales. By 1992,
teenage smokers accounted for $476 million of Camel cigarette sales. With smoking-
related medical expenditures reaching $50 billion per year, Medicare and Medicaid
bore most of the brunt of the cost. State governments successfully sued the tobacco
industry and were awarded complex settlement payments through the Master Set-
tlement Agreement. The agreement strictly prohibits tobacco advertising to youth.
The fast food industry faced similar accusations of advertising unhealthy prod-
ucts. In 2003, two youth sued McDonald’s alleging that eating McDonald’s fast food
made them overweight. The plaintiffs lost the lawsuit. However, their concerns were
examined through the film Super Size Me (2004). The documentary follows direc-
tor and producer Morgan Spurlock over a 30-day period in which he only eats at
McDonald’s restaurants and investigates the fast food industry. The film points out
that in 2001 McDonald’s spent $1.4 billion on worldwide advertising, Pepsi spent
over one billion dollars, and Hershey Foods spent $200 million. The highest annual
budget for the public health program, Five-a-Day, was $2 million, one one-hundredth
of Hershey Foods. In 2004, Congress passed H. R. 339 Personal Responsibility in
Food Consumption Act, making it illegal to sue any food manufacturer or business
on the grounds of causing obesity or obesity-related diseases. Nevertheless, the film
had an impact. Within six weeks, McDonald’s started offering healthier food items
and stopped supersized servings.
In 1998, Purdue Pharma distributed 15,000 copies of a video advertising
OxyContin. Intended for use as patient education in the doctors’ waiting rooms,
the video advertised that opioids do not have serious side effects and should be
prescribed more often. Within a year, the number of opioid prescriptions increased
by 11 million. By 2010, doctors wrote enough prescriptions to medicate every adult
in the United States for one month. Today, over 4 million p eople abuse pain killers.
The estimated cost of prescription drug abuse in the United States in 2006 was
$53.4 billion, including $42 billion in lost productivity (Hansen, Oster, Edelsberg,
Woody, & S ullivan, 2011).
The United States believes in a free market economy where the federal govern-
ment does not interfere with business in any way. Toward this end, businesses spend
$183 billion each year on product advertising. In 2015, McDonald’s spent $802.1
billion on advertising, cigarette companies spent $763.1 million, and Perdue Pharma
spent $3.9 million. In the same year, the Centers for Disease Prevention and Con-
trol were allocated $1.1 billion for chronic disease prevention and health promo-
tion, a decrease of $110 million from 2014.
In the following arguments, Dr. Shayan Waseh and A. J. Smuskiewicz explore the
issues of federal government restrictions on advertising for two industries that impact
public health: advertising for the tobacco industry and pharmaceutical advertising.
Sally Kuykendall
Further Reading
Campaign for Tobacco-Free Kids. (2013). Camel cigarettes: A long history of targeting kids.
Retrieved from https://www.tobaccofreekids.org/microsites/camel/Camel_History.pdf.
Fischer, P. M., Schwartz, M. P., Richards, J. W., Goldstein, A. O., & Rojas, T. H. (1991). Brand
logo recognition by children aged 3 to 6 years. Journal of the American Medical Association,
266(22), 3145.
Hansen, R. N., Oster, G., Edelsberg, J., Woody, G. E., & Sullivan, S. D. (2011). Economic
costs of nonmedical use of prescription opioids. The Clinical Journal of Pain, 27,
194–202.
Macfarlane, H. B. (1988). Camel mascot. Truth tobacco industry documents. Retrieved from
https://www.industrydocumentslibrary.ucsf.edu/tobacco/docs/#id=q xhv0090.
R. J. Reynolds Research Department. (1976). Planning assumptions and forecast for the
period 1977–1986+ for R. J. Reynolds Tobacco Company. Retrieved from https://www
.industrydocumentslibrary.ucsf.edu/tobacco/docs/#id=fl dw0098.
Schonfeld & Associates. (n.d.). Advertising spending in the cigarettes industry in the United States
from 2010 to 2016 (in million U.S. dollars). In Statista—The Statistics Portal. Retrieved
July 8, 2017, from https://www-statista-com.ezproxy.sju.edu/statistics/470438/cigarettes
-industry-ad-spend-usa.
Statista. (n.d.). Food advertising in the United States. Retrieved from https://www.statista.com.
Yes, the Federal Government Should Restrict Advertising
Pharmaceutical advertising in the United States has become a topic of great public
health interest in contemporary times. Pharmaceutical companies, which are respon-
sible for discovering, developing, and manufacturing many of the medications that
are in common usage today, spend a large proportion of their expenditures on adver-
tising. This marketing of medications can have a significant impact on the decision-
making process that patients and physicians use when choosing which medication
to use. Therefore, t here are a series of ethical and public health considerations that
necessitate the restriction of such pharmaceutical advertising.
Pharmaceutical companies utilize a diverse range of marketing strategies to inform
physicians, pharmacists, and patients about their medications. Some of these dif
ferent approaches include hosting educational and promotional meetings, distrib-
uting free samples for patients to physician’s offices, sending promotional mailings,
and publishing print advertisements.
There are, however, two main forms of pharmaceutical advertising that form the
bulk of pharmaceutical marketing expenditures. The first is direct-to-physician
detailing, which is face-to-face promotion with physicians. This type of advertising
constitutes over $15 billion of annual pharmaceutical marketing expenditure (Mack,
2013). Pharmaceutical sales representatives meet with physicians to encourage them
to prescribe more of a certain medication, through sales techniques or by giving
incentives to the prescribers.
The second main form of pharmaceutical marketing is direct-to-consumer adver-
tising. This kind of advertising is often seen on billboards or television and radio
advertisements, and is meant to raise awareness of name-brand medications in
patients to encourage them to ask their physician for certain medications. The costs
of direct-to-consumer advertising are more than $3 billion of annual pharmaceuti
cal marketing expenditure (Mack, 2013).
These two forms of pharmaceutical advertising have significant effects on the
choices that physicians and patients make when deciding what medication regimes
to begin. Physicians that receive more money from pharmaceutical companies are
also more likely to prescribe that company’s brand of medication. For example, oph-
thalmologists who received more than $5,000 in payments from pharmaceutical
companies prescribed almost 20 percent more name-brand prescriptions than their
colleagues who did not receive any money from pharmaceutical companies (Orn-
stein et al., 2016). A similar trend was seen across fields and specialties. This increase
of name-brand prescribing is significant because name-brand medications often
carry a much higher cost than equally effective generic medications. Additionally,
direct-to-consumer advertising has similar negative effects by causing patients to
ask for medications that are inappropriate or even harmful (Mintzes et al., 2003).
This can lead to medication overutilization or suboptimal patient management.
Although pharmaceutical advertising is an important and effective form of mar-
keting for pharmaceutical companies, the potential harmful impacts of such mar-
keting warrant governmental restrictions and regulations. Pharmaceutical advertising
must be restricted in order to avoid inappropriate prescribing habits, reduce mis-
information, and prevent the promotion of new drugs before their safety is fully
determined.
A 2006 study found that while over 80 percent of direct-to-consumer advertise-
ments made factual claims and arguments supporting the use of their advertised
drug, only a quarter of such advertisements mentioned any relevant risk factors or
disease prevalence (Almasi et al., 2006). By omitting such information, pharma
ceutical companies misinform patients and may encourage them to ask for medi
cations that they are not eligible for or are unlikely to need. The federal government
can restrict this practice by mandating that pharmaceutical advertisements include
disease prevalence or risk factor information. This regulatory strategy is likely
to face opposition and be considered as overly burdensome by pharmaceutical
companies.
Additionally, due to the expensive investments required to develop novel classes
of medications, many new drugs receive heavy direct-to-consumer promotion early
in their life cycle, even prior to the medication’s full safety profile being known.
Vioxx, a brand-name medication marketed by Merck, is an example of the detri-
mental impact that this can have on patients. Merck invested over $500 million to
advertise Vioxx, leading to over $1 billion in annual sales in the United States (Ven-
tola, 2011). By extensive advertising, patients were led to believe that taking Vioxx
was better for their health. However, it was not revealed until later that Vioxx ele-
vated the risk for myocardial infarctions and stroke in many of these patients. It
was only after five years of being advertised and sold on the market that Vioxx was
voluntarily withdrawn b ecause of its negative health effects.
Although the claim by pharmaceutical companies that such extensive advertis-
ing is required to maximize profits to offset their large research and development
costs, it would be dangerous to leave their advertising strategies unregulated or unre-
stricted. In this regard, the United States is one of only three countries in the
world, along with New Zealand and Brazil, to permit pharmaceutical companies to
advertise directly to consumers. In e very other country in the world, this practice
is banned. Therefore, extensive experience around the world has been generated
showing that the restriction of pharmaceutical advertising practices does not overly
interfere with the functioning of the pharmaceutical industry and the overall health
care system. In fact, it allows physicians greater opportunity to exercise their exper-
tise in prescribing the appropriate medications for their patients, while protecting
patients from the challenges and negative health effects of misinformation and inap-
propriate medication use.
The government should carry out its regulatory functions and restrict the adver-
tising employed by the pharmaceutical industry for marketing its medications. It is
particularly important that certain forms of pharmaceutical advertising that have
the greatest opportunity for negative health ramifications, such as direct-to-physician
and direct-to-consumer advertising, be regulated and restricted for the benefit of
patients. The United States should change its policies to reflect the worldwide con-
sensus regarding direct-to-consumer advertising. This will serve to protect patients,
empower physicians, and ensure that the decision-making process behind patient
medication regimes is ethical and effective.
Shayan Waseh
Further Reading
Almasi, E. A., Stafford, R. S., Kravitz, R. L. & Mansfield, P. R. (2006). PLOS Medicine, 3(3),
e145.
Mack, J. (2013). Pharma promotional spending in 2013. Pharma Marketing News, 13(5),
1–6.
Mintzes, B., Barer, M. L., Kravitz, R. L., Bassett, K., Joel, L., Kazanjian, A. . . . Marion, S. A.
(2003). How does direct-to-consumer advertising (DTCA) affect prescribing? A survey
in primary care environments with and without l egal DTCA. Canadian Medical Associa-
tion Journal, 169(5), 405–412.
Ornstein, C., Groeger, L., Tigas, M., & Jones, R. G. (2016). Dollars for docs. New York: Pro-
Publica. Retrieved from https://projects.propublica.org/docdollars.
Ventola, C. L. (2011). Direct-to-consumer pharmaceutical advertising: Therapeutic or toxic?
Pharmacy and Therapeutics, 36(10), 669–684.
No, the Federal Government Should Not Restrict Advertising
The federal government’s main stated goal in restricting the advertising of tobacco
products is to prevent people, especially c hildren and adolescents, from purchas-
ing and using these products, thereby protecting public health. Related goals are
to help tobacco users quit using these products and to generally reduce the harm-
ful effects of tobacco (BeTobaccoFree.g ov, 2017). It is the intention of the present
essay to argue that tobacco advertising restrictions are not only an infringement
on personal freedom by the government, but also supremely hypocritical of the
government.
Arguments against restrictions
Standard arguments that are made against tobacco ad restrictions include the fol-
lowing (Debate.org, 2017):
• Restrictions violate the First Amendment, b ecause they restrict the f ree speech
of tobacco product manufacturers (Langvardt, 2014).
• Restrictions violate the F ourteenth Amendment, because they abridge the
rights of thousands of tobacco farmers, cigarette factory workers, and other
people in the tobacco industry.
• Since tobacco is a legal product for p eople above a certain age, banning its
advertisement is unreasonable.
• Advertisements for alcohol, an addictive substance with adverse health con-
sequences, are ubiquitous on television, so it is unfair to discriminate against
tobacco products that are associated with comparable health problems.
• Advertisements do not force anyone to smoke. They merely help make p eople
aware of particular brands of a product that they are g oing to use anyway.
• Advertisements are not as important in influencing the smoking behavior of
young people as are their parents, other family members, teachers, friends,
and other people in their lives. Thus, the focus of anti-tobacco efforts should
be on t hose people rather than ads.
Each of t hese points has been widely debated in the public realm (Debate.org, 2017).
However, to better understand this controversial issue, it is beneficial to review the
history of government restrictions on tobacco ads.
Ever-expanding restrictions
The road to the government’s advertising restrictions on tobacco began in 1964,

when the U.S. surgeon general declared smoking to be a cause of increased mortality,
followed the next year by the first required health warning on cigarette packages
(BeTobaccoFree.gov, 2017). This warning gave official sanction to something that
had long been common knowledge—cigarettes are bad for smokers’ health. Many
decades before the surgeon general’s proclamation, people had referred to cigarettes
as “coffin nails”—as is evident in a 1906 short story by O. Henry titled “The Higher
Abdication,” in which a character asks, “Say, sport, have you got a coffin nail on
you?” (Will, 1999)
The first U.S. law targeting advertising was the 1970 Public Health Cigarette
Smoking Act, which prohibited the advertising of cigarettes on television and radio
(Be Tobacco Free.gov, 2017). No longer could the Marlboro Man, the iconic repre
sentation of American smoking and freedom developed by the Leo Burnett agency
in 1955, be seen riding across TV screens (The Marlboro Man, 1999). But he would
still frequently be found in magazines, on signs in convenience stores and gas sta-
tions, and on highway billboards.
Further, broader, and stricter restrictions w ere instituted over subsequent

decades—with each new law expanding government power over citizens in the
names of “public health” and “children.” In 1986, smokeless tobacco advertisements
on television and radio were banned. In 1992, Congress passed the Synar Amend-
ment to force states to restrict cigarette sales to people aged 18 and older. The 1998
Master Settlement Agreement between most states and the four largest tobacco com-
panies led to several new restrictions, including limits on billboard ads and public
transit ads (BeTobaccoFree.gov, 2017).
Several new regulations w ere included in the F amily Smoking Prevention and
Tobacco Control Act of 2009. This act gave the Food and Drug Administration (FDA)
the authority to regulate the manufacture, distribution, and marketing of tobacco
products, similar the way the FDA has long regulated pharmaceuticals. After the
act went into effect in June 2010, tobacco companies could no longer sponsor sports,
music, or other entertainment events, nor could they display their logos on hats,
shirts, or other apparel (BeTobaccoFree.gov, 2017; Tobacco Control L egal Consor-
tium, 2009). The act also prohibited the use of “light,” “low,” “mild,” and other mod-
erating adjectives in ads and labels; banned outdoor ads within 1,000 feet of schools;
limited ads in publications with “significant teen readership” to s imple black text on
white backgrounds; and required disturbing graphics to be added to label warn-
ings (BeTobaccoFree.g ov, 2017). Moreover, the act gave the FDA broad authority to
impose additional restrictions on marketing as it deemed appropriate to “promote
overall public health” (Tobacco Control L egal Consortium, 2009).
The few remaining permitted venues for cigarette ads as of 2017 include the Inter-
net, magazines, and signs inside stores. A number of tobacco restrictions have been
legally challenged, usually on grounds that they violate the First Amendment, but
few have been overturned by the courts.
Increasing tax revenues
This history review shows how U.S. government restrictions and regulations over
tobacco advertising and marketing have expanded enormously for more than half
a century. The motivation for these laws has apparently been an attempt to hide
two facts from Americans that all cognitive and sentient citizens already know—
that cigarettes exist and that they are bad for your health. As cigarette ads have
become rarer, government pronouncements about the evils of smoking have become
louder. Simultaneously, taxes on cigarettes have become higher (Face the Facts,
2012). In 2015, federal tax revenues from tobacco sales in the United States totaled
about $14 billion, compared with about $7 billion in 2000. State and local tax
revenues from tobacco sales were even higher. Annual federal tobacco tax reve-
nues are projected to spike to more than $30 billion by the 2020s (Statista, 2016).
Tax revenues increased despite a decline in U.S. cigarette and tobacco sales in
the early 2000s, and they continued to increase as sales began to rise again in 2015
(Yang & Rosenberg, 2015), when 36.5 million American adults were cigarette
smokers (CDC, 2016a). About 25 percent of U.S. m iddle and high school students
used tobacco products in 2015—roughly the same percentage as in 2011 (CDC,
2017). It is obvious that vast numbers of p
eople still want to smoke even without
seeing advertisements, and that they are willing to pay higher taxes, which now
make up more than 40 percent of the price of a pack of cigarettes (CDC, 2017).
Hypocrisy
In summary, the government is demonizing a product that Americans already know

is bad for their health, but they continue to want it anyway, for whatever reasons
they may have for wanting it . . . it makes them happy, it satisfies a craving or addic-
tion, it calms them down, it helps them focus, whatever the case may be. Each
individual has his or her own reasons for smoking tobacco, just as he or she does
for smoking marijuana, drinking alcohol, eating tasty but fatty foods, gambling, text
ing all day on cell phones, driving fast cars, having multiple sexual relations, or
engaging in any other behaviors that can be described as satisfying in some ways
and risky in other ways. In a “free country,” citizens should be allowed to engage
in risky behaviors, and they should be expected to deal with the consequences. And,
although tobacco products are demonized by the government, t hese products and
the massive amount of tax revenue generated by their sales remain legal. Thus, it is
clear to any thinking citizen that, despite the ad bans and the scary warnings, the
government really does not want them to stop smoking! The money is too good to give
up. The hypocrisy of the government’s advertising and marketing restrictions is
obvious.
It is time to stop the charade. If people are going to smoke anyway and if smok-
ing is going to remain legal, manufacturers should be allowed the same freedom to
promote and sell their products that manufacturers of other legal products have.
And public health officials should respect the rights and the intelligence of citizens
to weigh the adverse consequences of smoking against the perceived benefits by
allowing them to view ads for t hese products, just as they can view ads for any other
legal product they may want to purchase.
A. J. Smuskiewicz
Further Reading
BeTobaccoFree.gov. (2017). U.S. Department of Health & H uman Services. Laws/policies.
Retrieved from https://betobaccofree.hhs.gov/laws.
Centers for Disease Control and Prevention (CDC). (2016a). Smoking & tobacco use: Current
cigarette smoking among adults in the United States. Retrieved from https://www.cdc.gov
/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking.
Centers for Disease Control and Prevention (CDC). (2016b). Tobacco use among m iddle and
high school students—United States, 2011–2015. Retrieved from https://www.cdc.gov
/t obacco /i nfographics /y outh /p dfs /y outh -t obacco -u se .p df ?s _c id= b b -o sh -y outh
-graphic-008.
Centers for Disease Control and Prevention (CDC). (2017). Smoking & tobacco use: Economic
trends in tobacco. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets
/economics/econ_facts.
Debate.org. (2017). Should advertising tobacco products be banned in all forms? Retrieved from
http://www.debate.org/opinions/should-advertising-tobacco-products-be-banned-in
-all-forms.
Face the Facts. (2012, September 23). A tax revenue source that’s just smokin’. Retrieved from
http://www.facethefactsusa.org/facts/a-tax-revenue-source-thats-just-smokin.
Langvardt, A. W. (2014). Tobacco advertising and the First Amendment: Striking the right
balance. William & Mary Business Law Review, 5(2). Retrieved from http://scholarship
.law.wm.edu/wmblr/vol5/iss2/2.
The Marlboro Man. (1999, March 29). Advertising Age. Retrieved from http://adage.com
/article/special-report-the-advertising-century/marlboro-man/140170.
Statista. (2016). Tobacco tax revenue and forecast in the United States from 2000 to 2021 (in
billion U.S. dollars). Retrieved from https://www.statista.com/statistics/248964/revenues
-from-tobacco-tax-and-forecast-in-the-us.
Tobacco Control L egal Consortium. (2009). Fact sheet 5: Tobacco product marketing restric-
tions. Retrieved from http://www.publichealthlawcenter.org/sites/default/files/fda-5.pdf.
Will, G. (1999, October 3). From “coffin nails” of old days: Cigarettes’ health threat well-
known. Sun Sentinel. Retrieved from http://articles.sun-sentinel.com/1999-10-03
/features/9910010840_1_tobacco-companies-tobacco-industry-coffin-nail.
Yang, S., & Rosenberg, A. (2015, October 7). Why cigarette sales are rising in America. CNBC.
Retrieved from http://www.cnbc.com/2015/10/06/why-cigarette-sales-are-rising-in
-america.html.
CONTROVERSY 3: SHOULD PARENTS HAVE THE RIGHT

TO REFUSE VACCINATIONS FOR THEIR C
HILDREN?
Introduction
Vaccinations are one of the greatest public health accomplishments of the

20th century, saving millions of children from premature death or disability. Despite
overwhelming medical evidence in support of childhood immunizations, a public
debate continues of whether parents should have the right to refuse vaccinations
for their children. At the heart of the controversy is the question of individual rights
versus common good. Individual rights are the ability to think, act, and behave with-
out retribution by the government. The right to life, liberty, and the pursuit of
happiness are the principles on which the original 13 colonies were founded. Com-
mon good is a concept from political science, economics, philosophy, and ethics
that holds several meanings. One meaning of common good refers to a resource
that is owned by all members of the community, such as public roads or parks. The
second meaning refers to social justice. Common good considers the needs of indi-
vidual members of a group and acts according to what is best for most or all of the
members. Common good is also one of the founding principles of the nation. “We
hold these truths to be self-evident, that all men are created equal” assumes that
the desires or needs of one person do not supersede the rights of o thers. Thus,
we have a nation founded on the right to individual freedoms (the right to refuse
vaccinations) and the right to common good (the right to ensure health within
the community). Controversies arise when t hese two rights come in conflict with
each other.
Until the advent of the sanitation movement, microbiology, immunology, and
antibiotics, infectious diseases were the leading cause of death. The most notable
example of destruction and devastation due to infectious disease was the Black Death
pandemic of 1346–1353. An estimated 100 million people died. The bacterium
Yersinia pestis wreaked havoc with death rates of up to 80 percent in heavily popu-
lated areas. The plague permanently impacted social structures and economies. Early
Americans constantly struggled against infectious diseases. In 1837, smallpox spread
across the G reat Plains. T hose who had been vaccinated, primarily white people,
were immune. Over 15,000 Native Americans died. Entire tribes were wiped out
along with valuable early American history and culture. Into the 20th century, small-
pox, measles, diphtheria, typhoid, polio, and pertussis claimed thousands of lives
each year. In 1900, there w ere 21,064 cases of smallpox resulting in 894 deaths. In
1920, there w ere 469,924 cases of measles with 7,575 deaths and 147,991 cases
of diphtheria with 13,170 deaths. In 1922, there were 107,473 cases of pertussis
with 5,099 deaths (U.S. Department of Health, Education, and Welfare, 1953). By
1998, vaccination was routinely practiced. The annual number of deaths due to
smallpox was zero; measles caused 89 deaths; diphtheria accounted for 1 death;
and 6,279 p eople died of pertussis (Impact of Vaccines Universally Recommended
for Children—United States, 1999). Many of the infectious diseases that killed
thousands of young children are almost unheard of t oday.
There are many different public health methods of preventing the spread of infec-
tious diseases. Good handwashing, sanitation, antivirals, and antibiotics reduce
transmission and therefore infectious diseases. Immunizations work by triggering
the body to create immunity to the pathogen. Weakened or dead bacteria or viruses
are introduced into the body. T hese antigens stimulate the immune system to cre-
ate antibodies. When and if the immunized person comes in contact with the patho-
gen again, the body uses the antibodies to fight the infection. Vaccines do have adverse
effects. Very few p eople enjoy getting stuck with a needle. Side effects include red-
ness, pain, or irritation at the injection site. To ensure that vaccines are given at the
appropriate time and spacing, the American Academy of Pediatrics developed an
immunization schedule for children. Public health and medical professionals
administer vaccines according to the schedule. Most parents agree that vaccines are
necessary and safe. Only 3 percent of parents believe that vaccines are not neces-
sary and not safe (Gust et al., 2005).
From a public health perspective, vaccinations work in two ways. They protect
immunized individuals and they protect unimmunized individuals. When the
majority of p eople are vaccinated against a disease, it is harder for the micro
organism to spread and infect. Based on past epidemics and mathematical
modeling, scientists can predict the percentage of a population that must be vac-
cinated in order to inhibit transmission. Measles, an airborne disease, is effectively
inhibited when over 92 to 95 percent of individuals are immunized. The more
people who are immunized, the harder it is for the germ to move from person to
person. This concept, known as herd immunity, is particularly important because
not every individual is able to get vaccinated. Some people may be allergic to vac-
cine ingredients. Other people have compromised immunity and rather than devel-
oping antibodies, they become infected with the pathogen. Some vaccines are
contraindicated during pregnancy or among the very young. Herd immunity pro-
tects people who are unable to be vaccinated. The concept also creates opportunity
for parents not to immunize believing that if everyone else’s child is immunized,
their child does not need immunizations.
The threat of losing loved ones to cholera, smallpox, polio, pneumonia, influ-
enza, or typhoid is unfamiliar to today’s generation of parents and children. In the
following essays, A.J. Smuskiewicz discusses why parents should be able to opt out
of vaccinations for their c hildren, and Dr. Nooshin Asadpour discusses why par-
ents should not be able to opt out.
Sally Kuykendall
Further Reading
American Academy of Pediatrics. Immunizations. Retrieved from https://www.aap.org/en-us
/advocacy-and-policy/aap-health-initiatives/immunizations/Pages/Immunizations
-home.aspx.
Centers for Disease Control and Prevention. Vaccines and immunizations. Retrieved from
https://www.cdc.gov/vaccines/index.html.
Gust, D., Brown, C., Sheedy, K., Hibbs, B., Weaver, D., & Nowak, G. (2005). Immuniza-
tion attitudes and beliefs among parents: Beyond a dichotomous perspective. American
Journal of Health Behavior, 29(1), 81–92.
Impact of Vaccines Universally Recommended for C hildren—United States, 1990–1998.
(1999). Morbidity and Mortality Weekly Report, 48(12), 243.
U.S. Department of Health, Education, and Welfare. (1953). Vital statistics—special report,
national summaries: Reported incidence of selected notifiable diseases. United States, each
division and state, 1920–50 (p. 37). Washington, DC: U.S. Department of Health, Edu-
cation, and Welfare, Public Health Service, National Office of Vital Statistics.
World Health Organization. Immunization. Retrieved from http://www.who.int/topics
/immunization/en.
Yes, Parents Should Have the Right to Refuse Vaccinations for Their C
hildren
Approximately two centuries of clinical experience and scientific research have

proven that vaccinations have generally been beneficial to the health of individuals
and the public as a w
hole. They are responsible for dramatic progress in fighting some
of the world’s most disabling and deadly diseases, perhaps most notably the eradica-
tion of smallpox and the prevention of poliomyelitis. Ongoing research continues
to develop new vaccines to slow the spread of newly emerging diseases, as well as
to battle long-known but ever-evolving pathologic viruses.
Despite the g reat advances in h uman health that are widely attributed to vac-
cines, controversy continues to surround these prophylactic substances—and, in
fact, public resistance in the United States is increasingly pushing back against gov-
ernment, medical, and media demands to vaccinate (Blaszczak-Boxe, 2016; Hotez,
2017; W. W., 2015). A survey conducted by the Pew Research Center in 2014 found
that 30 percent of Americans believed that the vaccination of children should be a
matter for parents to decide rather than being required by government. Among poll
respondents aged 18 to 29, 41 percent believed that parents should have the right
to make vaccination decisions (Mackey, 2017).
The reasons for this substantial public resistance are multiple, including rebel-
lion against what some view as the increasingly excessive power of government,
doubts about the honesty and integrity of the medical and scientific establishment,
the influence of popular anti-vaccine celebrities, religious motivations, libertarian
political motivations, and other f actors. And it d
oesn’t m
atter what respected medi-
cal experts and powerful government officials say—some Americans simply do not
believe t hese authorities. Rather, they prefer to follow their own instincts and beliefs
and to put trust in their own experiences or in anecdotal evidence that they may
have heard from friends, family, or famous p eople.
So the question arises, should individuals have the right to opt out of medi-
cally recommended and legally required vaccination regimens for themselves
and their c hildren—for whatever reasons they may have for d oing so? Should they
be allowed to refuse vaccinations for their children even when to do so might
reduce the effectiveness of efforts to protect the overall public health, including the
health of other children in school? Moreover, should they be allowed to reject vac-
cinations even if their rejections are based on scientifically incorrect or question-
able ideas?
People opposed to vaccinating their c hildren are widely ridiculed as ignorant
“anti-vaxxers.” Yet, various legitimate arguments can be put forth that the answers
to the above questions are “Yes.” The goal of the present essay is to argue that such
a position can be viewed as legitimate, logical, reasonable, and respectable—not
necessarily that it is the “correct” position. One can personally support the use of
vaccines, while also supporting the rights of other people to decide if they want to
use vaccines for themselves and their children. Such is the stated position of Sena-
tor (and ophthalmologist) Rand Paul (W. W., 2015).
Freedom of choice, Freedom from risk
Perhaps the most important arguments in favor of the right to refuse vaccinations
are based on the concept of individual freedom of choice concerning life, liberty,
and the pursuit of happiness—a concept enshrined in the U.S. Declaration of Inde
pendence. Part of freedom of choice is freedom to avoid potential risks for oneself
and one’s children—no matter how vanishingly small those risks may apparently
be. Each of us has a different tolerance for risk. Some people jump out of airplanes
wearing artificial wings on their arms and legs; other p eople refuse to even get into
an airplane. The risk of flying on a five-mile-high jumbo jet might be easier for an
individual to judge than the risk of an invisible microbe and the mysterious sub-
stance injected into the body to fight it. Nevertheless, pharmaceutical companies
must admit that any vaccine and any other pharmaceutical product does indeed
carry some risk of adverse health effects, though they usually make those admis-
sions in tiny lettering or rapidly spoken dialogue. It is not entirely illogical for a
mother to decide she does not want to take a chance that her child will be one of
those tiny statistics of serious adverse effects.
Adding to the logic and legitimacy of such a decision is the fact that government
officials recommend about twice as many vaccines today, in 2017, as they did three
decades ago. The greater number of vaccines means a greater chance of rare, adverse
vaccine reactions actually happening. The recommended childhood vaccine sched-
ule advocated by the U.S. Centers for Disease Control and Prevention (CDC) in
2017 includes 16 different vaccines administered in 69 doses through age 18 (Par-
pia, 2016). More shots are surely to come eventually. No physician or scientist can
predict with accuracy which individual will be the unlucky rarity who becomes
harmed by a vaccine, so how can an individual legitimately give his or her informed
consent to turn his or her child over to the state for vaccination?
The risk-to-benefit ratio of vaccines is diluted if vaccines are not 100 percent
effective, which they are not. No vaccine can be fully guaranteed to prevent the
designated disease, because vaccines are imperfect products as soon as they leave
the pharmaceutical manufacturing facility. Furthermore, research published in the
Journal of the American Medical Association in 2012 found an association between
reduced childhood vaccine efficacy and exposure to the environmental chemicals
known as perfluorinated compounds (PFCs), which are in nonstick pans, water-
proof clothing, stain-proof carpeting, and many other commonly encountered mate-
rials (Grandjean et al., 2012). The efficacy of vaccines is also weakened by their
widespread use, because the more they are used, the more evolutionary pressure is
placed on the targeted viruses to develop genetic mutations that render the vac-
cines useless and possibly make the microbes more dangerous. This situation is simi-
lar to the antibiotic resistance currently creating serious problems for the medical
community (Mercola.com, 2014).
Personal experience versus scientific evidence
Although it is quite reasonable that all people deserve to exercise their freedom of
choice regarding manufactured chemical combinations that are put into their bod-
ies and their children’s bodies, perhaps the most deserving of having their views
respected are parents who have observed their children experiencing adverse effects
after vaccination. No amount of expert testimony denying any link between
the diphtheria, tetanus, and pertussis (DPT) vaccine and encephalopathy or the
measles, mumps, and rubella (MMR) vaccine and autism is g oing to convince a
mother who personally observed such a link that it didn’t happen. It doesn’t help
the medical establishment’s argument that numerous pharmaceuticals approved for
use by the government later had to be withdrawn from the market because of safety
or efficacy problems that ultimately became apparent during clinical use. Examples
of vaccines withdrawn from the U.S. market include Wyeth Laboratories’ rotavirus
vaccine in 1999 and GlaxoSmithKline’s Lyme disease vaccine in 2002 (CDC, 1999;
Nigrovic & Thompson, 2007).
The CDC acknowledges vaccine withdrawals with the following wording, which
is probably not g oing to reassure many vaccine skeptics:
There have been only a few vaccine recalls or withdrawals due to concerns about
e ither how well the vaccine was working or about its safety. Several vaccine lots have
been recalled in recent years because of a possible safety concern before anyone
reported any injury. (Centers for Disease Control and Prevention, 2015)
Although vaccine advocates frequently belittle parents who are outspoken vac-
cine skeptics, such as actress and activist Jenny McCarthy (Frontline, 2015), what
is more logical and understandable for a m other to believe? Her own eyes and her
own personal experience, or profit-conscious pharmaceutical companies and gov-
ernment regulators who have been proven wrong before?
Solution to dilemma?
The most obvious argument against allowing personal choice on childhood vac-
cines is that the threat to other students’ health is increased when unvaccinated
children are present in school. Surgeon Jeffrey A. Singer, who supports parent choice,
has proposed a solution to this dilemma:
. . . allow a public school to require that parents keep their c hildren out of school in
the event of an outbreak of a contagious disease for which they refused vaccination,
and not allow the children back into school until the threat has been deemed to have
ended by public health authorities. (Singer, 2015)
That idea would strike a reasonable balance between protecting public health and
preserving freedom of choice.
Populist rebellion
The current popular rebellion against vaccines might be viewed as part of the gen-
eral populist trend against big government, big business, big media, big authority,
and big establishment, which has been evident in such developments as the United
Kingdom’s Brexit referendum in June 2016 and the U.S. election of Donald Trump
as president in November 2016. Trump himself has often expressed skepticism
about vaccines (Mackey, 2017). T hese developments seem to be reactions against

giant government establishments that are always expanding their own power and
that of their corporate donors, while reducing the personal choices of regular, com-
mon people. Authorities in Brussels set economic rules that p eople in England had
to follow even though they had no say about it. Authorities in Washington ruled
that all Americans had to purchase certain types of health insurance and use only
certain doctors or else pay a tax penalty.
State laws requiring Americans to inject numerous laboratory-made chemicals
into their c hildren in order for their c hildren to attend school—and recent moves
by states to clamp down on personal belief waivers to those requirements (Fisher,
2017; Mercola.com, 2014)—are seen by many p eople as yet more excessive,
undemocratic, and even tyrannical rules. They resent these rules being foisted on
them by faceless and distant bureaucrats, so-called “experts,” and corporate profi-
teers who they feel cannot be trusted. In the times we live in today, such a view is
not illogical.
The rejection of vaccines might also be considered part of another trend—that
of seizing control of one’s own health and body, rather than automatically obeying
establishment medical dogma. Other aspects of this trend include moves to drink
raw milk, remove fluoride from public drinking w ater, eat GMO-free foods, and
use drug-free holistic and alternative modes of health care. All such efforts to increase
personal health care freedom are deserving of respect rather than ridicule.
A. J. Smuskiewicz
Further Reading
Blaszczak-Boxe, A. (2016, August 29). More parents are refusing vaccinations, but their rea-
sons are changing. LiveScience. Retrieved from http://www.livescience.com/about.
CBS News. (2015, January 23). Should parents be allowed to choose whether to vaccinate their
kids? Retrieved from http://www.cbsnews.com/news/should-parents-be-allowed-to
-choose-whether-to-vaccinate-their-kids.
Centers for Disease Control and Prevention (CDC). (1999, November 5). Withdrawal of
rotavirus vaccine recommendation. Morbidity and Mortality Weekly Report, 48(43), 1007.
Centers for Disease Control and Prevention (CDC). (2015). Vaccine recalls. Retrieved from
https://www.cdc.gov/vaccinesafety/concerns/recalls.html.
Fisher, B. L. (2017, February 8). Take action in 2017 to protect vaccine freedom of choice. National
Vaccine Information Center. Retrieved from http://www.nvic.org/nvic-vaccine-news
/february-2017/take-action-2017-protect-vaccine-freedom-of-choice.aspx.
Frontline. (2015, March 23). Jenny McCarthy: We’re not an anti-vaccine movement . . . we’re
pro-safe vaccine. Public Broadcasting Service. Retrieved from http://www.pbs.org/wgbh
/frontline/article/jenny-mccarthy-were-not-an-anti-vaccine-movement-were-pro-safe
-vaccine.
Grandjean, P., Andersen, E. W., & Budtz-Jorgensen, E. (2012). Serum vaccine antibody con-
centrations in c hildren exposed to perfluorinated compounds. Journal of the American
Medical Association, 307(4), 391–397. doi:10.1001/jama.2011.2034. Retrieved from
http://jamanetwork.com/journals/jama/fullarticle/1104903.
Hotez, P. J. (2017, February 8). How the anti-vaxxers are winning. New York Times. Retrieved
from https://www.nytimes.com/2017/02/08/opinion/how-the-anti-vaxxers-are-winning
.html?_r=0
.
Mackey, R. (2017, January 10). Trump asks anti-vaccine activist Robert Kennedy Jr. to lead
panel on vaccine safety. The Intercept. Retrieved from https://theintercept.com/2017/01
/10/trump-names-anti-vaccine-activist-robert-kennedy-jr-lead-panel-vaccine-safety.
Mercola.com. (2014, April 29). Should parents be allowed to decide about vaccines? Retrieved
from http://articles.mercola.com/sites/articles/archive/2014/04/29/children-vaccines
.aspx.
Nigrovic, L. E., & Thompson, K. M. (2007). The Lyme vaccine: A cautionary tale. Epidemi-
ology and Infection, 135(1), 1–8. doi:10.1017/S0950268806007096. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870557.
Parpia, R. (2016, February 17). Questioning the safety of the CDC’s childhood vaccine sched-
ule. Vaccine Impact. Retrieved from https://vaccineimpact.com/2016/questioning-the
-cdcs-childhood-vaccine-schedule-vaccine-combinations-never-tested-for-safety.
Singer, J. A. (2015). Seeking balance in vaccination laws. CATO Institute. Originally published
by Reason.c om. Retrieved from https://www.cato.org/publications/commentary/seeking
-balance-vaccination-laws.
W. W. (2015, February 4). Resorting to freedom. The Economist. Retrieved from http://www
.economist.com/blogs/democracyinamerica/2015/02/rand-paul-vaccination.
No, Parents Should Not Have the Right to Refuse Vaccinations for Their Children
The choice to vaccinate a child is one of the first important decisions that a parent
makes. This decision can be particularly challenging in a world with conflicting
messages about the benefits and risks of vaccination. It is therefore imperative that
all parents are armed with the information they need to appreciate fully the impor-
tance of vaccination.
Prior to the advent of immunization, many children from around the world died
from diseases that are easily preventable t oday, such as polio, smallpox, whooping
cough, and measles. The immunization of c hildren against childhood infectious
diseases represents one of the greatest public health achievements of the 20th century
(Diekema, 2005). The Centers for Disease Control and Prevention (CDC) estimated
that over 300 million illnesses and 700,000 deaths w ere prevented between 1994
and 2013 in the United States due to vaccination alone (Whitney et al., 2014). The
World Health Organization (WHO) reports that vaccinations save about 2.5 million
lives each year. However, this success has also led to many young parents never hav-
ing seen or heard of the detrimental effects that vaccine-preventable diseases can have
on a family or community (CDC, 2016). It is important that parents remain aware
that these diseases do exist and that not vaccinating puts their children, as well as
others, at risk for illness and death. It is estimated that more than 3 million people die
each year from diseases that are preventable through vaccination (WHO, 2016). It
is thus evident that children all over the world, including in the United States, can
be and still are susceptible to these diseases. Therefore, parents should not have
the right to refuse the most well-established form of protection against serious
infectious diseases.
The role that vaccination can play in the development of a healthy immune sys-
tem is another fundamental reason it should be mandated. When a child becomes
infected with a given disease, the child’s immune system produces antibodies against
it. However, it takes time for the immune system to stop the disease from causing
illness, so the child still gets sick. After this initial encounter, the immune system
“remembers” the disease, and if it ever enters the body again, the body can produce
antibodies fast enough to prevent a second illness. Vaccines are a safer substitute
for a child’s first exposure to a disease, since vaccines contain a tiny amount of a
weakened or killed germ, thereby imitating a given infection without causing ill-
ness (CDC, 2014). The vaccination schedule is thus designed to protect young
children before they are likely to be exposed to potentially serious diseases, par-
ticularly when they are most vulnerable to infections (CDC, 2017). Although some
parents view illnesses as a natural part of the development of a child’s immune
system, subjecting a child to a vaccine-preventable disease that is known to cause
significant suffering and even death, places both the child and those around him
or her at far greater risk.
The risks of not vaccinating, in fact, outweigh the potential side effects of vaccinat-
ing. For example, measles vaccinations decreased deaths due to measles 79 percent
worldwide, preventing an estimated 20.3 million deaths (WHO, 2017). The most
common side effects of vaccination are mild and include redness, soreness, and
swelling where the shot was administered. Serious side effects, such as severe
allergic reaction, are very rare. The ingredients contained within a given vaccine,
such as preservatives, stabilizers, and residual substances, are safe in the amounts
used, and each play a necessary role in e ither making the vaccine or ensuring that
it is safe and effective (CDC, 2017). Safety monitoring continues a fter a vaccine
has been approved through a vaccine safety system that serves to assess the fre-
quency and severity of these effects while considering the epidemiology of natural
disease. The rates of adverse outcomes following natural measles infection are
high, with encephalitis in 1 in 1,000 and death in 1 in 1,000. In comparison,
the risk of MMR-associated immune thrombocytopenia purpura is 1 in 40,000
doses and is transient (Smith, 2015). Therefore, compared to the significant
risks associated with natural infection, vaccines appear to be the obvious choice.
Physicians can serve to educate parents about the risks of vaccination in a prop-
erly contextualized way that stresses the fundamental value of vaccination.
Although there are many evidence-based resources available for both physicians
and parents, distinguishing between reliable and unreliable information is a chal-
lenge. This is yet another reason to mandate universal vaccination, thereby preventing
misinformation from negatively affecting parental decision making. For example,
the belief that vaccines are linked to autism is a classic fear of parents and one that
often leads them to choose not to vaccinate their child. This concern arose from a
controversial and significantly flawed 1998 case series that provided weak proof of
causal association. In fact, the study was later discredited when it was discov-
ered that the results w ere fraudulent. Over the years, several large epidemiologic
studies have found no association between MMR and autism, which has been
repeatedly affirmed by the Institute of Medicine (IOM) in 2001, 2004, and 2011.
Yet, many parents continue to believe that vaccination c auses more harm than good.
Requiring parents to vaccinate their child can allow health care providers who are
better informed and more up to date on the scientific literature to drive the decision-
making process.
Even when parents appreciate the tremendous benefits of vaccination, care must
be taken to avoid allowing parents to dictate the approach to vaccination. This is
particularly important with regard to adherence to the current immunization sched-
ule. This schedule is designed to protect c hildren against diseases when they are
most susceptible, and thus any delay in the schedule may increase risk for infec-
tion. Parents may also find it difficult to watch their children receive a shot, but they
must remember that the short-term pain does not even begin to compare to the
suffering that may result from contracting a potentially deadly disease such as mea-
sles, pertussis, or diphtheria. Requiring parents to follow the standardized and
evidence-based immunization schedule can contribute to the more effective pro-
tection of all children.
Vaccinations are vital in protecting c hildren from potentially deadly infectious
diseases and maintaining generations of healthy c hildren. It is important to remem-
ber that one parent’s choice not to vaccinate their child does not only put their own
child at a greater risk for illness and even death, but also increases the susceptibil-
ity of other children to a host of diseases. Keeping all children safe and healthy is
the primary goal of vaccination, a fact that lies at the heart of why vaccination should
be a mandatory part of children’s health care.
Nooshin Asadpour
Further Reading
Ben-Joseph, E. P. (2015). Frequently asked questions about immunizations. Johns Hopkins All
Children’s Hospital. KidsHealth®. Retrieved from https://www.hopkinsallchildrens.org
/p atients -f amilies /h ealth -l ibrary /h ealthdoc /f requently -a sked -q uestions -a bout
-immunizations?id=20785.
Centers for Disease Control and Prevention. (2014). Why are childhood vaccines so impor
tant? Vaccines and immunizations. National Center for Immunization and Respiratory
Diseases. Retrieved from https://www.cdc.gov/vaccines/vac-gen/howvpd.htm.
Centers for Disease Control and Prevention. (2016). What are the reasons to vaccinate my
baby? CDC features. National Center for Immunizations and Respiratory Diseases.
Retrieved from https://www.cdc.gov/features/reasonstovaccinate/index.html.
Centers for Disease Control and Prevention. (2017). Making the vaccine decision. For parents:
vaccines for your children. National Center for Immunizations and Respiratory Diseases.
Retrieved from https://www.cdc.gov/vaccines/parents/vaccine-decision/index.html.
Diekema, D. S. (2005). Responding to parental refusals of immunization of children. Pedi-
atrics, 115(5), 1428–1431. doi:10.1542/peds.2005-0316
Smith, M. (2015). Vaccine safety: Medical contraindications, myths, and risk communica-
tion. Pediatrics in Review, 36(6), 227–238. doi:10.1542/pir.36-6-227
Whitney, C. G., Zhou, F., Singleton, J., & Schuchat, A. (2014). Benefits from immunization
during the vaccines for children program era—United States, 1994–2013. Morbidity
and Mortality Weekly Report, 63(16), 352–355.
World Health Organization (WHO). (2016). Children: Reducing mortality. Fact sheet. WHO
Media Centre. Retrieved from http://www.who.int/mediacentre/factsheets/fs178/en.
World Health Organization (WHO). (2017). Measles. Fact sheet. WHO Media Centre.
Retrieved from http://www.who.int/mediacentre/factsheets/fs286/en.
CONTROVERSY 4: SHOULD PUBLIC HEALTH

PROFESSIONALS ADVISE P EOPLE OF A HEALTH RISK
WHEN THEY ARE UNCERTAIN ABOUT THE LEVEL OF
THE RISK?
Introduction
Threats to public health occur frequently and communicating such risks is a core
responsibility of public health. Unfortunately, in many cases, time is of the essence
and public health departments must decide w hether to warn people of a potential
risk before the cause, mode of transmission, or treatment is known. The problem
is that communicating partial information, inaccurate information, or inadequately
communicating information can cause confusion or undermine public trust in the
profession. For example, the myth that vaccines cause autism came from a poorly
devised but highly publicized study. Although the doctor who did the study lost
his medical license and numerous subsequent studies have discredited the origi-
nal research findings, the myth continues. The controversy—should public health
professionals advise p eople of a health risk when they are uncertain about the level
of risk?—more often pits the individual’s right to know against business interests.
The two main public health principles underlying this controversy are the precau-
tionary principle and health risk communication. The precautionary principle states
that if an action is suspected of causing harm, the burden of proof that it does not
cause harm is on the person, organization, or government committing the action,
rather than the person or community being acted on. This means that if a business
is exhausting chemicals into air and residents believe that the chemicals are caus-
ing breathing problems, the business is responsible for proving that the chemicals
are safe. The precautionary principle is standard practice in many countries around
the world. The controversy becomes more complicated in the United States where
personal injury law has different rules. Toxic torts require the injured party to
provide the burden of proof. With the potential for hundreds of millions of dol-
lars in legal settlements, the stakes are very high and tend to overshadow public
health practices.
The precautionary principle was created as the result of several large-scale envi-
ronmental disasters. Love Canal, Times Beach, Seveso, Minamata, and Chernobyl
helped people to realize that prevention or early control of environmental disasters
is easier than cleanup. The precautionary principle originated in Germany and was
adopted by the United Nations General Assembly in the 1982 World Charter for
Nature. The principle puts the burden of proof on the person or organization d oing
the action. This means that the person or organization must stop the action and
prove that the action does not cause harm before proceeding with the action. The
most common uses are in occupational and environmental health. The U.S. Cham-
ber of Commerce objects to the precautionary principle on the grounds that the
assumption of risk limits businesses and restricts the economy. Any government
regulation on business should be based in science, not suspicions of harm. Instead,
businesses propose using a more detailed risk-benefit analysis, which weighs the
potential risks of the action against social and economic benefits. Thus, using the
precautionary principle, warning people of potential risks could unnecessarily
restrict businesses.
Risk communication is a branch of public health that constructs and transmits
thoughtfully managed messages to citizens so that they may take action to protect
their health. The basic steps of risk communication are gathering accurate infor-
mation from reliable sources; identifying the goals or objectives of the communica-
tion; identifying the target audience; identifying the channel or medium to transmit
the message; creating and piloting the message; developing a plan for promotion;
implementing the strategy; and evaluating the process, impact, or outcome. Dur-
ing health emergencies, this process must be done very quickly, effectively, and accu-
rately. A good example of risk communication in action is the evacuation warnings
prior to Hurricane Katrina (2005). The health communicator needs to tailor the
message to the audience, be honest and open, empower the public with informa-
tion, use credible and reputable sources of information, work with the media, lis-
ten carefully to the audience’s response and concerns, and avoid dismissing or
minimizing the listener’s concerns (Covello & Allen, 1988). It is important to rec-
ognize that not every health warning will result in action. After a message is com-
municated, the listener judges the risk and decides whether to take action. Many
people stayed in their homes during Hurricane Katrina because they had stayed
through previous hurricanes. F actors that influence risk perception are the nature
of the risk, level of control, possible benefits from the risk, and type of risk. P
eople
are more likely to accept risks if the risk is voluntary, natural (as opposed to man-
made), within their control, or has some perceived benefits. They are less likely
to take risks if the risk is catastrophic, unfamiliar, or affects children (Fischhoff
et al., 1981). Health communication is a very complex practice, and the health
communicator must anticipate reactions and respond appropriately. After the
devastation of Hurricane Katrina, many changes were made in subsequent disas-
ter warnings, such as alerting people as to where to go for safe shelter and which
shelters allowed pets.
Knowing what to announce and when is critical. Many more lives could have
been saved if the warnings used prior to Hurricane Sandy had been used prior to
Hurricane Katrina. On the other hand, there are times when public health warn-
ings may be misguided or misinformed. Announcements regarding cell phone use
and brain cancer, vaccines and autism, or saccharin and cancer create a loss of trust
in scientists and health professionals. In the following essays, Dr. Dave Reynolds and
Dr. Shayan Waseh explore whether public health professionals should advise p
eople
of a health risk when they are unsure of the level of risk.
Sally Kuykendall
Further Reading
Berthoud, B. (2015). The precautionary principle in EU risk regulation: A matter of priorities.
Hamburg, Germany: Diplomica Publishing GmbH. Retrieved from https://www.anchor
-publishing.com/document/277346.
Centers for Disease Control and Prevention. Risk communication. Retrieved from https://www
.cdc.gov/healthcommunication/risks/index.html.
Covello, V., & Allen, F. (1988). Seven cardinal rules of risk communication. Washington, DC:
U.S. Environmental Protection Agency, Office of Policy Analysis.
Elder, K., Xirasagar, S., Miller, N., Bowen, S.A., Glover, S., & Piper, C. (2007). African Amer-
icans’ decision not to evacuate New Orleans before Hurricane Katrina: A qualitative
study. American Journal of Public Health, 97(1), S124–S129.
Fentiman, L. C. (2014). Are m others hazardous to their c hildren’s health? Law, culture, and
the framing of risk. Virginia Journal of Social Policy & the Law, 21(2), 295–340.
Fischhoff, B., Lichtenstein, S., Slovic, P., & Keeney, D. (1981). Acceptable risk. Cambridge,
UK: Cambridge University Press.
Goldstein, B. D. (2001). The precautionary principle also applies to public health actions.
American Journal of Public Health, 91(9), 1358–1361.
Goldstein, B. D. (2005). Advances in risk assessment and communication. Annual Review
of Public Health, 26, 141–163. doi:10.1146/annurev.publhealth.26.021304.144410
Myers, N. (2004). The rise of the precautionary principle. Multinational Monitor, 25(9), 9–15.
Rosner, D., & Markowitz, G. (2002). Industry challenges to the principle of prevention in
public health: The precautionary principle in historical perspective. Public Health Reports,
117(6), 501–512.
Wiedemann, P. M., & Schütz, H. (2005). The precautionary principle and risk perception:
Experimental studies in the EMF area. Environmental Health Perspectives, 113(4), 402–
405. doi:10.1289/chp.7538
Yes, Public Health Professionals Should Advise P

eople of a Health Risk When They
Are Uncertain about the Level of the Risk
Public health officials should advise p

eople of health risks, regardless of the degree
of uncertainty. The primary reasons to support informing the public are as follows:
it is what the public wants and expects; it is what ethical guidelines require; failure
to do so may be punishable by law; and the uncertainty inherent in e very risk assess-
ment can be clearly communicated, empowering individuals to make their own
decisions. Concerns that the public w ill become confused and panic in the midst
of uncertain risk levels are largely unjustified.
The American public expects local, state, and federal authorities to protect them
from health hazards, such as air and w ater pollution, by frequently testing numer-
ous samples to ensure they are safe. If they cannot be protected, then the public
wants information about how they can protect themselves, such as by staying indoors
or drinking only bottled w ater. Surveys have shown that half of all Americans want
more information, including what they can do to protect themselves (Princeton Sur-
vey Research, 2000). Ninety p ercent said it would be “somewhat” or “very impor
tant” to them that information on hazards be made public. Indeed, to protect and
inform are among the duties of the Environmental Protection Agency, and the Cen-
ters for Disease Control and Prevention, two of the most well-recognized federal
agencies involved in public health risk assessment and reduction.
Public health institutions and officials must adhere to ethical principles and guide-
lines. This includes valuing the community. According to the Public Health Leader-
ship Society (PHLS), corresponding ethical actions include: “communication; truth
telling; transparency (i.e., not concealing information); accountability; reliability; and
reciprocity” (PHLS, 2002, p. 5). The society considers it an essential public health
service, “to inform, educate, and empower p eople about health issues” (PHLS, 2002,
p. 12), and states, “there is a moral obligation in some instances to share what is
known” (PHLS, 2002, p. 6). The only exception would be when such information
is confidential or could, “bring harm to an individual or community if made public
(Thomas, 2004, p. 11). An example might be that a given individual or community
has been the source of a sexually transmitted disease outbreak. Public health ethics
also address uncertainty: “Action is not based on information alone. In many instances,
action is required in the absence of all the information one would like” (PHLS, 2002).
Although the ethical principles are intended primarily for institutions with a
decidedly public health mission, individual public health personnel are bound to
the society’s core competencies (Thomas, 2004). Specific to providing communities
with information, an ethical core competency is listed as, “Effectively presents accu-
rate demographic, statistical, programmatic, and scientific information for profes-
sionals and lay audiences” (Thomas, 2004, p. 10). Since the mid-1970s, numerous
states have enacted laws that require companies that could expose the public to
hazards to disclose this information. Other laws allow those who might be put at
risk, such as through employment, use of a product, or living in proximity to the
known hazard, to obtain health risk information, even if this information is pri-
vately held (Baram, 1984). Failure to abide by such “duty-to-disclose” or “right-
to-know” laws has resulted in class action lawsuits and large payouts to injured
parties. Some states’ right-to-know laws apply to every company and organization
that collects—or should collect—“hazard information” relevant to employees, pol-
iticians, and citizens, in general (Baram, 1984). Colorado’s regulations on epidem-
ics are but one example (see Codes 1009-1 and 1009-5). American society places
a high value on the public’s need-to-know health and safety risk information, even
when privately held, and many state and local laws support this view. Withholding
health risk information simply b ecause a public health professional believes the
degree of uncertainty about the finding is too great, likely would subject the indi-
vidual or his or her employer to punitive damages resulting from personal injury.
And applicable laws do not appear to include any exemption to disclose health risk
information simply due to a high degree of uncertainty.
Every health risk assessment conducted involves some degree of statistical uncer-
tainty due to such things as measurement error. This is true whether measuring
opinions, behaviors, or the physical properties of things. Uncertainty is also a
component of risk levels obtained through modeling or estimation. For example,
the health risks associated with pesticide exposure involves uncertainty b ecause lab
animals serve as surrogates (stand-ins) for humans. The risk to h umans is estimated
based on what happens to the exposed animals. It is standard practice in many sci-
entific fields to report potential sources of error for any given result, along with the
degree of uncertainty.
One objection to health officials publicizing uncertain health risk information is
that people will not modify their behavior due to a lack of confidence. However,
research from the field of risk communication suggests that several other factors
influence the adoption of protective health behaviors. These include anxiety, risk
severity, susceptibility, duration, trust of source, degree of individual control over
risk, degree to which advised behaviors are deemed actionable, and likelihood they
will be effective (Rubin et al., 2009). Furthermore, the public recognizes the exis-
tence of uncertainties and incomplete information within health risk messaging,
such as in the early stages of a disease outbreak.
Although the perception among many public health professionals may be that
the public will panic during a health crisis, in actuality, the public is more likely to
respond with skepticism and apathy, regardless of the level of uncertainty reported
(Rubin et al., 2015). For example, in the face of bovine spongiform encephalopa-
thy (mad cow disease), which had contaminated some of the beef supply, even in
the face of unknowns and uncertainty, of which the public was readily aware, they
did not panic (Millstone et al., 2006). In fact, the general public held more sophis-
ticated assumptions about health risks than e ither public policy makers or the
general media outlets gave them credit. For example, whereas it was assumed the
public would see the risk in all-or-none terms, they instead took a nuanced approach
to the crisis.
The field of public health risk communication (Bennett et al., 2010), as well as
guidance from the World Health Organization (2013), suggests that the question is
not whether public health officials should communicate health risk levels of which
they are uncertain, but rather how to communicate this information. The degree of
uncertainty can be accurately conveyed to both expert and lay audiences, along with
various recommendations so as to motivate health protective behaviors, the ulti-
mate goal.
David J. Reynolds
Further Reading
Baram, M. S. (1984). The right to know and the duty to disclose hazard information. Ameri-
can Journal of Public Health, 74(4), 385–390.
Bennett, P., Calman, K., Curtis, S., and Fishbacher-Smith, D. (Eds.). (2010). Risk communi-
cation and public health (2nd ed.). Oxford, UK: Oxford University Press.
Colorado Department of Public Health and Environment, Disease Control and Environmen-
tal Epidemiology Division. (2007). State board of health rules and regulations pertaining
to preparations for a bioterrorist event, pandemic influenza, or an outbreak by a novel and
highly fatal infectious agent or biological toxin, CO Code Regs. § 1009-5, reg. 1. Retrieved
from https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=1
588.
Colorado Department of Public Health and Environment, Disease Control and Environmen-
tal Epidemiology Division. (2017). Epidemic and communicable disease control, CO Code
Regs. § 1009-1, reg. 6. Retrieved from http://www.sos.state.co.us/CCR/GenerateRulePdf
.do?ruleVersionId=7134&fileName=6 %20CCR%201009-1.
EPA. (2017). About EPA: Our mission and what we do. Retrieved from https://www.epa.gov
/aboutepa/our-mission-and-what-we-do.
Millstone, E., van Zwanenberg, P., Bauer, M., Dora, C., Dowler, E., Draper, A., Dressel, K.,
Gasperoni, G., Green, J., Koivusalo, M., & Ollila, E. (2006). Improving communica-
tion strategies and engaging with public concerns. In C. Dora (Ed.), Health, hazards
and public debate: Lessons for risk communication from the BSE/CJD saga. Copenhagen,
Denmark: World Health Organization Regional Office for Europe.
Princeton Survey Research Associates. (2000). National survey of public perceptions of environ-
mental health risks. Princeton, NJ: Topline Results. Retrieved from http://healthyamericans
.org/reports/files/survey0620.pdf.
Public Health Leadership Society. (2002). The principles of the ethical practice of public health
(Version 2.2). Retrieved July 4, 2017, from https://www.apha.org/~/media/files/pdf
/membergroups/ethics_brochure.ashx.
Rubin, G., Finn, Y., Potts, H., & Michie, S. (2015). Who is sceptical about emerging public
health threats? Results from 39 national surveys in the United Kingdom. Public Health,
129(12), 1553–1562. doi:10.1016/j.puhe.2015.09.004
Rubin, G. J., Amlôt, R., Page, L., & Wessely, S. (2009). Public perceptions, anxiety, and behav-
iour change in relation to the swine flu outbreak: Cross sectional telephone survey.
British Medical Journal, 339(7713), 156.
Thomas, J. (2004). Skills for the ethical practice of public health. Public Health Leadership Soci-
ety. Retrieved from https://nnphi.org/wp-content/uploads/2015/08/ph-code-of-ethics
-skills-and-competencies-booklet.original.pdf.
Wester, M. (2011). Fight, flight or freeze: Assumed reactions of the public during a crisis.
Journal of Contingencies & Crisis Management, 19(4), 207–214. doi:10.1111/j.1468
-5973.2011.00646.x
World Health Organization, Regional Office for Europe. (2013). Health and environment:
Communicating the risks. Copenhagen, Denmark: WHO. Retrieved from http://www.euro
.who.int/en/publications/abstracts/health-and-environment-communicating-the-risks
-2013.
No, Public Health Professionals Should Not Advise P

eople of a Health Risk When
They Are Uncertain about the Level of Risk
The purpose of public health is to contribute to the health and well-being of entire
populations. This broad aim is accomplished through a variety of mechanisms, such
as promotion of healthy lifestyles, infectious disease control, biomedical research,
injury prevention, and environmental health. Public health professionals are
responsible for creating and maintaining systems that promote the health of the
population in a multitude of ways. They are likewise responsible for protecting and
safeguarding the population from a variety of harmful influences, w hether it be nega-
tive lifestyle behaviors, dangerous toxins and pollutants, or contagious diseases.
Many times, however, public health professionals are faced with situations where
the risk to the population is uncertain and the decision to act or not act becomes
of paramount importance. An example of a circumstance where public health pro-
fessionals are forced to act on limited evidence to make highly impactful decisions
can be seen in hydrofracturing in the United States, particularly in states like Penn-
sylvania that rely heavily on hydrofracturing.
Hydrofracturing is the use of high-pressure w ater to cause cracks in the ground
to release natural gas. This process provides an immense amount of natural gas to
the nation and is responsible for many tens of billions of dollars of energy, busi-
ness, and jobs (Dows, 2015). However, environmental impact analysis has shown
that the chemicals used in hydrofracturing can sometimes find their way into the
drinking water of nearby towns and localities (Howarth, Ingraffea, & Engelder,
2011). Many of t hese chemicals have unknown effects on h uman health and h uman
reproduction. Therefore, public health professionals are forced to balance the real
and immense socioeconomic benefits of hydrofracturing with the potential for a
yet to be determined level of risk to people’s health.
By showing precaution about the risk of harm to human health and recommend-
ing that hydrofracturing be halted u ntil further research is carried out, many p eople
would lose their jobs, and the price of consumer gas and goods would increase
across the nation. This would harm many p eople who require their income from
working in the hydrofracturing industry to support their families. Additionally,
households across the United States would have to spend more on their gas bills
and for products that rely on cheap natural gas to be affordable. This would pre-
vent people from being able to save more money and spend money on things like
healthy food, exercise, and recreation—all of which are definitively associated with
better health. Thus, acting on an uncertain level of risk, public health professionals
can often hastily make decisions that cause real and measurable harms to society.
They can cause harm to the public health in order to possibly prevent a f uture harm.
Although the prevailing view in the public health field is that of the “precaution-
ary principle,” it is clear that the precautionary principle has many serious draw-
backs that warrant further consideration. The precautionary principle states that
when there is the risk for a serious and irreversible harm, regulatory action and
preventative measures should be undertaken even if the exact level or potential for
risk is not fully understood (Applegate, 2000). Simply stated, the precautionary
principle recommends that public health professionals err on the safe side of con-
cern and act on any potentials for risk. Although this is an effective paradigm for
preventing major public health problems, it does have serious drawbacks.
One example is with genetically modified organisms, also known as GMOs. Plant
GMOs are engineered by agricultural scientists by inserting different codes into their
DNA. This allows the plant GMOs to show a variety of very desirable traits such as
exhibiting pest resistance, having a longer shelf life, holding more nutrients, and
producing much larger yields. Overall, the creation of plant GMOs has been a tre-
mendous benefit for humanity and has prevented many p eople from starvation and
allowed better access to higher nutrient foods for many others.
Due to the man-made nature of genetic engineering in plant GMOs, however,
some public health professionals are concerned about the potential for health side
effects from eating GMO foods. T here has been a recent push for state and federal
governments to mandate that different food companies label their packaging to indi-
cate w hether or not their food contains any GMOs. They pose that such labeling
would allow consumers to decide whether or not they want to expose themselves
to the risk of whatever unknown health effects GMOs may have. However, the agri-
cultural and food industries have fought against these regulations by stating that
such labeling would unnecessarily cause consumers to think that GMOs might be
unhealthy and therefore not purchase GMO products. Additionally, evidence shows
that GMO products for the most part are not associated with any evidence of harm
to human health (Panchin & Tuzhikov, 2016).
Therefore, the question becomes: should public health advise p eople about the
health risk of GMOs through food package labeling, even when the likelihood of
the health risk of GMOs is unknown or minute? If the decision is guided by the
precautionary principle, then a public health professional may recommend pack-
age labeling, at least until further and more extensive research concludes that GMOs
are fully safe. This would be more harmful, however, because doing so would cause
an immediate harm. For example, while labeling GMO foods may reduce the amount
of GMOs ingested, it is unclear how beneficial this would actually be. On the other
hand, many of the affordable fruits and vegetables in supermarkets and grocery
stores are GMOs, and p eople may eat less of t hese healthy foods. Unlike the health
risk of GMOs, having a poor diet is strongly and definitively associated with the
risk of harm to health. Additionally, GMOs allow for foods to be more affordable
and accessible to people. Requiring package labeling may cause the price of foods
to increase, also leading to less healthy eating habits. Therefore, by informing the
public about potential (and unlikely) health risks, they may be driven by fear to act
in even more unhealthy ways. Therefore, it is important that public health profes-
sionals show wisdom and consideration in making decisions to inform the public
regarding potential and unknown health risks.
Shayan Waseh
Further Reading
Applegate, J. S. (2000). The precautionary preference: An American perspective on the
precautionary principle. Human & Ecological Risk Assessment, 6(3), 413. doi:10.1080
/10807030091124554
Dows, F. (2015). The economic benefit of fracking. Washington, DC: Brookings Institution.
Retrieved from https://www.brookings.edu/blog/brookings-now/2015/03/23/the-eco
nomic-benefits-of-fracking.
Howarth, R. W., Ingraffea, A., & Engelder, T. (2011). Natural gas: Should fracking stop?
Nature, 477, 271–275.
Panchin, A. Y., & Tuzhikov, A. I. (2017). Published GMO studies find no evidence of harm
when corrected for multiple comparisons. Critical Reviews in Biotechnology, 37(2),
213–217. doi:10.3109/07388551.2015.1130684
Sandin, P., Peterson, M., Hansson, S. O., Ruden, C., & Juthe, A. Five charges against the
precautionary principle. Journal of Risk Research, 5(4), 287–299.
CONTROVERSY 5: SHOULD UNDOCUMENTED

IMMIGRANTS HAVE ACCESS TO HEALTH CARE?
Introduction
Soon after I moved to England, I developed a urinary tract infection. It was the
weekend. It was painful and I did not know what to do. When I could no longer
take the discomfort, I went to the local emergency room. The nurses and doctors
were rude. I felt like a second class citizen, abusing national health resources on a
nonemergent problem. Thankfully, they did treat me and gave me instructions on
how to register with the National Health Service. For the next five years, I worked
as a nurse and paid taxes in the United Kingdom. I don’t know what it is like to be
an undocumented immigrant in need of health care. I know what it is like to
become suddenly and unexpectedly ill in a foreign country where one does not
know how to navigate the health care system. An estimated 12 million undocu-
mented immigrants live in the United States. Many do not seek care due to lan-
guage barriers, documentation status, or other fears. Failure to seek medical care
jeopardizes individual and public health. Tuberculosis or HIV/AIDS may be trans-
mitted to others. Untreated m ental health problems can impact coworkers, neigh-
bors, and communities. T hese issues raise the question of w
hether undocumented
immigrants should have access to health care.
People immigrate for a wide variety of reasons, seeking better opportunities, love,
adventure, or escape from violence. The United States is a nation of immigrants,
people who were searching for a better life. Yet, the country’s health care system
cannot sustain unrestricted immigration and access to care. The United States spends
more on health care than many other countries, $9,403 per person per year (World
Bank Group, 2017). The Affordable Care Act restricts undocumented immigrants
from seeking health care. Beyond this legal restriction, undocumented immigrants
are less likely to seek health care. Reasons given are fears of inability to pay for care,
discrimination, language barriers, bureaucracy, deportation, shame and stigma, and
inability to navigate the health care system. Safety net services, such as emergent care
centers, free clinics, food banks, and maternal and child health care organizations,
provide short-term care but are typically insufficient for demand. As a result,
undocumented immigrants are at increased risk for serious complications or
putting o thers at risk.
As the world becomes a global community, migration is likely to increase and

infectious diseases do not discriminate by nativity. Those who migrate will be at
greater risk for endemic diseases or may transmit endemic diseases from their
country of origin to the new country. Experts from the University of Pittsburgh and
Harvard University recommend expanding access for undocumented immigrants,
education and outreach to undocumented immigrants, and enhancing safety net
services as well as developing novel insurance programs for immigrant popula-
tions. A comprehensive approach to immigrant care (documented or undocu-
mented) trains health care providers on how to work with diverse populations and
teaches immigrants how to navigate the U.S. health care system (Hacker, Anies,
Folb, & Zallman, 2015). In the following essays, Matthew Black and Dr. Shayan
Waseh present the controversy of should undocumented immigrants have access
to health care.
Sally Kuykendall
Further Reading
Hacker, K., Anies, M., Folb, B., & Zallman, L. (2015). Barriers to health care for undocu-
mented immigrants: A literature review. Risk Management and Healthcare Policy, 8,
175–183.
Philbin, M. M., Flake, M., Hatzenbuehler, M. L., & Hirsch, J. S. (2017). State-level immi-
gration and immigrant-focused policies as drivers of Latino health disparities in the
United States. Social Science & Medicine. doi:10.1016/j.socscimed.2017.04.007
Torres, J. M., & Waldinger, R. (2015). Civic stratification and the exclusion of undocumented
immigrants from cross-border health care. Journal of Health & Social Behavior, 56(4),
438–459. doi:10.1177/0022146515610617
data.w orldbank.o rg/i ndicator/S H.X PD.P CAP?e nd= 2
014&start= 1
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Yes, Undocumented Immigrants Should Have Access to Health Care
Undocumented immigrants should have access to health care in the United States.
Although the Affordable Care Act brought health insurance coverage to millions of
uninsured Americans, undocumented immigrants w ere excluded from federal
requirements. Undocumented immigrants do not currently have access to publicly
funded health care. This is done to protect public resources and to deter illegal immi-
gration. The problem is that when a large population inside the country goes unmon-
itored and untreated by health officials, problems arise. Preventative care such as
STD testing or vaccinations are not available to unauthorized immigrants, risking
disease outbreak among legal residents. Unauthorized immigrants are in constant
contact with other U.S. residents and citizens. Many unauthorized immigrants work
in the agricultural and food service industries (Kullgren, 2003). Any infection or
disease can potentially spread to o thers, regardless of passport or immigration status.
Such an outbreak could potentially lead to massive spending on treatment for U.S.
citizens. Unauthorized immigrants may turn to self-medication or unlicensed medi-

cal care. Partial treatment or mistreatment could lead to drug-resistant disease.
Many public health professionals advocate for health care for unauthorized immi-
grants from a prevention standpoint and from a human rights perspective. By not
treating p eople who require help, the United States is turning a blind eye to people
in need, including c hildren (Biswas, Toebes, Hjern, Ascher, & Norredam, 2012). If
the CDC and NHS are expected to protect the country from illnesses, it is in the
best interests of everyone in the country that unauthorized immigrants have access
to public health care.
People migrate for numerous reasons. Some flee political or religious persecu-
tion, o thers migrate voluntarily. Human population movement through air, sea, and
land travel helped to shape world culture, the global economy, health, and lifestyle.
Despite the many benefits of global travel, historically, h uman migration created
opportunities for pathogens to spread from one area to another. Migrants carried
communicable diseases endemic in their country of origin to new areas, as the early
European settlers brought smallpox to Native Americans. Conversely, migrants new
to an area may be susceptible to communicable diseases common in the arriving
country. Today, screenings, vaccinations, food safety, and border protection regula-
tions provide a high level of biosecurity. Tourists and business travelers are just as
likely to transmit communicable diseases as migrants. In fact, the World Health
Organization lists the most frequent health problems of new refugees and migrants
as unintentional injuries, hypothermia, burns, gastrointestinal illnesses, cardiovas-
cular diseases, birth and pregnancy complications, diabetes and hypertension, sim-
ilar problems as might be seen among ordinary U.S. citizens. Infectious diseases
are actually associated with poverty, inadequate sanitation, and limited access to
vaccinations or health care. The underlying problem is not the migrants but the
conditions that they are leaving. The risk of exotic illnesses being brought into the
country by migrants or refugees is fairly low.
Traumatic, forced migration creates monumental health problems of m ental
disorders, high infant mortality, substance abuse, malnutrition, post-traumatic
stress disorder, and vulnerability to infection and higher risk of noncommunica-
ble diseases. Diseases are further compounded by overcrowded living conditions,
limited access to personal hygiene facilities, malnutrition, conflict, or economic
crisis. Female refugees and migrants may have experienced physical or sexual
violence leading to emotional and reproductive health problems. Children, espe-
cially, are prone to respiratory and gastrointestinal infections. From a humanitar-
ian perspective, depriving vulnerable populations of health care is malicious and
uncivilized.
The public arguments against providing health care to unauthorized immigrants
purport that the cost would be prohibitive and that the nation should not support
illegal immigration. The Pew Research Center estimates that t here are currently 11
million unauthorized immigrants in the United States (Passel & Cohn, 2016).
The majority of unauthorized immigrants are from countries other than Mexico,
primarily from Asian and Central American countries. Many of these are middle to
high income countries. In the United States, 8 million undocumented immigrants
are employed. At least two-thirds have lived in the United States for at least a decade.
The Center for Immigration Studies estimates that the cost of treating undocumented
immigrants is approximately $4.3 billion per year. The American Hospital Associa-
tion reports losses due to all uninsured patients are approximately $41.1 billion
per year. Providing health care for undocumented immigrants may not significantly
reduce unreimbursed costs to hospitals. However, it would divert undocumented
patients from seeking the expensive care of emergency rooms or untreated, com-
plicated illnesses, to more preventive services.
Beyond economics, there is a social benefit to providing health care to undocu-
mented immigrants. For many years, the United States enjoyed the status of a world
power, respected as the world’s social conscience. The plaque at the base of the Statue
of Liberty welcomed struggling immigrants with the message, “Give me your tired,
your poor, your huddled masses yearning to breathe free, the wretched refuse of
your teeming shore. Send these the homeless, tempest-tossed to me, I lift my lamp
beside the golden door.” The United States is a nation of immigrants. To dismiss or
diminish people in need contradicts the values on which the nation was established.
Consistent with American values, undocumented immigrants should have access
to health care services.
Matthew Black
Further Reading
Biswas, D., Toebes, B., Hjern, A., Ascher, H., & Norredam, M. (2012). Access to health care
for undocumented migrants from a h uman rights perspective: A comparative study of
Denmark, Sweden, and the Netherlands. Health & Human Rights, 14(2), 49–60.
Johns, K. A. (1998). The tuberculosis crisis: The deadly consequence of immigration poli-
cies and welfare reform. Journal of Contemporary Health Law & Policy, 15, 101.
Krogstad, J. M., Passel, J. S., & Cohn, D. (2017). 5 facts about illegal immigration in the U.S.
Retrieved from http://www.pewresearch.org/fact-tank/2017/04/27/5-facts-about-illegal
-immigration-in-the-u-s.
Kullgren, J. T. (2003). Restrictions on undocumented immigrants’ access to health services:
The public health implications of welfare reform. American Journal of Public Health,
93(10), 1630–1633.
Passel, J. S., & Cohn, D. (2016, September). Overall number of U.S. unauthorized immigrants
holds steady since 2009. Pew Research Center. Retrieved from http://assets.pewresearch
.org/wp-content/uploads/sites/7/2016/09/31170303/PH_2016.09.20_Unauthorized
_FINAL.pdf.
Portes, A., Fernández-Kelly, P., & Light, D. (2012). Life on the edge: Immigrants confront
the American health system. Ethnic & Racial Studies, 35(1), 3–22. doi:10.1080/01419
870.2011.594173
Sanchez, G. R., Sanchez-Youngman, S., Murphy, A. A., Goodin, A. S., Santos, R., & Val-
dez, R. B. (2011). Explaining public support (or lack thereof) for extending health
coverage to undocumented immigrants. Journal of Health Care for the Poor and Under-
served, 22(2), 683.
World Health Organization. (2017). Migration and health: Key issues. Retrieved from http://
www.e uro .w ho .i nt /e n /h ealth -t opics /h ealth -d eterminants /m igration -a nd -h ealth
/migrant-health-in-the-european-region/migration-and-health-key-issues.
No, Undocumented Immigrants Should Not Have Access to Health Care
The flow of undocumented immigrants into the United States rapidly increased
throughout the 1990s and reached a plateau over the past decade. T here are
currently an estimated 11 million unauthorized immigrants in the United States.
Although half of these undocumented immigrants originate from Mexico, immi-
gration from Asia and Central America has constituted a rising share of the
undocumented immigrant population throughout the last 10 years. Although
many of t hese undocumented immigrants live throughout the nation, t here are
a group of six states that host the concentrated majority of unauthorized immi-
grants: California, Texas, Florida, New York, New Jersey, and Illinois account
for 59 percent of all unauthorized immigrants in the United States (Krogstad,
Passel, & Cohn, 2017).
The emergence of undocumented immigration, also referred to as illegal immi-
gration, has been responsible for significant cultural, financial, and labor contribu-
tions between the United States and Mexico as well as other countries. Over 8 million
unauthorized immigrants are in the U.S. civilian workforce, and 1 out of every
20 people working or looking for work is an undocumented immigrant (Krogstad
et al., 2017). Although the policy and approach that is being taken toward undocu-
mented immigration is a highly polarized political topic, the impact and cost of
undocumented immigration are well studied.
Undocumented immigrants and their families, similar to any average American
family, rely on the federal and state governments for a variety of services and sup-
port in accessing health care, enrolling in education and university, and utilizing
public works in their communities. Since many undocumented immigrants are
forced to work in occupations that do not report their incomes to the Internal Rev-
enue Service, they are often unable to pay income tax to offset their usage of gov-
ernment services and funding.
Therefore, the question of whether or not to allow undocumented immigrants
to have access to health care is a vital one. A study carried out by RAND was able
to extrapolate that the total medical spending for the adult undocumented immi-
grant population across the nation was likely to be more than $6 billion a year (Gold-
man, Smith, & Sood, 2006). At least $1 billion of this was paid for by state and
federal government funds.
The United States already spends more than any other country in the world on
health care by a large margin. In 2015 alone, U.S. health care spending exceeded
$3 trillion and accounted for almost $10,000 per person. Although the cost of health
care for undocumented immigrants may not seem like a large expenditure, it would
be one more additional cost to drive up runaway health care spending.
Additionally, studies have shown that undocumented immigrants currently uti-

lize significantly less health care than their counterparts who have legal status in
the United States (Pourat, Wallace, Hadler, & Ponce, 2014). This is often attrib-
uted to lack of insurance coverage and fear regarding their illegal immigration
status. By expanding health coverage to include health care for undocumented
immigrants, health care utilization would likely increase and lead to exponentially
higher health care costs, which would then be an added burden on taxpayers and
the government. Although annual per capita expenses for health care were 86 percent
lower for uninsured immigrant c hildren than for uninsured U.S-born children (pre-
sumably because of lack of coverage and fear of their illegal immigration status),
their emergency department utilization rates were nearly three times as high
(Mohanty, Woolhandler, Himmelstein, Pati, Carrasquillo, & Bor, 2005). Emergency
departments are likely more utilized because they are prohibited from asking about
income, insurance, or citizenship status before rendering care. If access to non-
emergency department care w ere opened to all undocumented immigrants, then
those health care costs might show similar patterns of use as the currently highly
utilized emergency departments.
Another issue that is vital to considering whether or not undocumented immi-
grants should have access to health care is that implementing subsidized health care
for undocumented immigrants would create incentives for citizens of other coun-
tries such as Mexico to illegally immigrate into the United States. Many people
already illegally immigrate into the United States seeking opportunities to work and
sustain a f amily. Adding the ability to receive health care would create an even more
enticing attraction to coming to the United States. The legal immigration process
exists to serve the function of facilitating legal and regulated immigration into the
United States, but by incentivizing illegal immigration through the expansion of
services offered to undocumented immigrants, the function and efficacy of the l egal
immigration system would be undermined.
If health care is accessible by undocumented immigrants in the United States,
then there may also be a surge of illegal immigration for the purpose of receiving
health care in the United States. Since immigrants who would enter the United States
for the purpose of receiving health care would often be sick, this would drive up
health care costs in the United States and add an increased tax burden on U.S. citi-
zens as well as on immigrants who followed legal processes to enter the country
and find jobs.
A final consideration is that many fully legal U.S. citizens already suffer from a
lack of insurance or suffer from underinsurance. Even with the expansion of Med-
icaid through the Affordable Care Act, many p eople in the United States still are
effectively unable to access non-emergency health care services in an affordable and
timely manner. A study in 2017 showed that 10 percent of primary care visits in
community health centers in states that chose to expand Medicaid coverage were
still uninsured (Huguet, Hoopes, Angier, Marino, Holderness, & DeVoe, 2017).
There would therefore be an ethical concern in providing health care access to
immigrants who illegally enter the country before providing health care for all
American citizens and legal immigrants. Therefore, undocumented immigrants
should not receive access to health care u
nless they are able to follow the legal and
regulated immigration process when entering the country.
Shayan Waseh
Further Reading
Center for Medicare and Medicaid Services. (2016). National health expenditures 2015 high-
lights. Washington, DC: Author. Retrieved from https://www.cms.gov/Research-Statistics
-D ata -a nd -S ystems /S tatistics -Trends -a nd -R eports /N ationalHealthExpendData
/downloads/highlights.pdf.
Goldman, D. P., Smith, J. P., & Sood, N. (2006). Immigrants and the cost of medical care.
Health Affairs, 25(6), 1700–1711.
Huguet, N., Hoopes, M. J, Angier, H., Marino, M., Holderness, H., & DeVoe, J. E. (2017).
Medicaid expansion produces long-term impact on insurance coverage rates in com-
munity health centers. Journal of Primary Care & Community Health. Retrieved from
http://journals.sagepub.com/doi/abs/10.1177/2150131917709403?url_ver=Z39.88
-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed.
Krogstad, J. M., Passel J. S., & Cohn, D. (2017). 5 facts about illegal immigration in the U.S.
Pew Research Center. Retrieved from http://www.pewresearch.org/fact-tank/2017/04/27
/5-facts-about-illegal-immigration-in-the-u-s.
Mohanty, S. A., Woolhandler, S., Himmelstein, D. U., Pati, S., Carrasquillo, O., & Bor, D. H.
(2005). Health care expenditures of immigrants in the United States: A nationally repre-
sentative analysis. American Journal of Public Health, 5(8), 1431–1438.
Pourat, N., Wallace, S. P., Hadler, M. W., & Ponce, N. (2014). Assessing health care services
used by California’s undocumented immigrant population in 2010. Health Affairs, 33(5),
840–847.
Directory of Organizations
American Public Health Association (APHA)

800 I Street, NW
Washington, DC 20001
202-777-2742
https://apha.org
The APHA is the primary professional organization of public health practitioners,
administrators, researchers, and educators in the United States.
Association of Public Health Laboratories (APHL)

8515 Georgia Avenue, Suite 700
Silver Spring, MD 20910
240-485-2745
https://www.aphl.org
The APHL is the national organization networking state and local government health
laboratories, companies, laboratory professionals, and students interested in the lab-
oratory sciences.
Association of State and Territorial Health Officials (ASTHO)

2231 Crystal Drive, Suite 450
Arlington, VA 22202
202-371-9090
http://www.astho.org
The ASTHO is a national nonprofit network of current and past public health offi-
cers in the United States, U.S. territories, District of Columbia, Mexico, and
Canada.
Centers for Disease Control and Prevention (CDC)

1600 Clifton Road
Atlanta, GA 30329-4027
800-CDC-INFO (800-232-4636), TTY: 888-232-6348
https://www.cdc.gov
The CDC is a unit of the U.S. Department of Health and Human Services (DHHS)
responsible for disease surveillance, treatment, and prevention and response to man-
made and natural disasters.
712 Dire ctory of Organi zat ions
Centers for Medicare and Medicaid Services (CMS)

7500 Security Boulevard
Baltimore, MD 21244
https://www.cms.gov
The CMS is a division of the DHHS responsible for managing programs that finance
health services for the elderly, p
eople with special health needs, people with lim-
ited income, and t hose who are not covered by employer-sponsored health plans.
Council on Education for Public Health (CEPH)

1010 Wayne Avenue, Suite 220
https://ceph.org
The CEPH is an agency that reviews the teaching, research, and service efforts of
schools and programs in public health and accredits those schools and programs
that meet the documented standards.
Health and Medicine Division of the National Academies of Sciences, Engineering,

and Medicine
2101 Constitution Avenue, NW
202-334-2352
http://www.nationalacademies.org/hmd
Formerly known as the Institute of Medicine (IOM), the Health and Medicine Divi-
sion (HMD) of the National Academies of Sciences, Engineering, and Medicine (the
National Academies) provides independent, nonpartisan advice to Congress and
the White House to ensure that each new or revised policy has a valid scientific
basis.
Health Resources and Services Administration (HRSA)

5600 Fishers Lane
Rockville, MD 20857
https://www.hrsa.gov
The HRSA is the federal agency responsible for ensuring that p eople who are geo
graphic ally isolated, economically disadvantaged, or medically vulnerable are able
to access quality health care.
Indian Health Service

5600 Fishers Lane
Rockville, MD 20857
https://www.ihs.gov
The IHS is an agency within the DHHS responsible for fulfilling the nation’s obliga-
tion to provide community health services and primary health care to 2.2 million
indigenous Americans from 567 tribes.
D i r ec to ry o f Orga ni z ati o ns 713
National Association of County and City Health Officials (NACCHO)

1201 Eye Street, NW
4th Floor
202-783-5550
http://www.naccho.org
The NACCHO is a nonprofit organization serving local health departments, health
department administrators, and practitioners by providing professional skill-building
resources and networking opportunities.
National Cancer Institute (NCI)

BG 9609 MSC 9760
9609 Medical Center Drive
Bethesda, MD 20892-9760
800-4-CANCER (800-422-6237)
https://www.cancer.gov
The NCI is an institute within the National Institutes of Health (NIH) responsible
for coordinating and supporting cancer research and treatment.
National Heart, Lung, and Blood Institute (NHLBI)

P.O. Box 30105
Bethesda, MD 20824-0105
301-592-8573
https://www.nhlbi.nih.gov
The NHLBI is a federal agency responsible for advancing knowledge of the c auses,
treatment, and prevention of heart, lung, and blood disorders.
National Institute on Drug Abuse (NIDA)

Office of Science Policy and Communications
Public Information and Liaison Branch
6001 Executive Boulevard
Room 5213, MSC 9561
Bethesda, MD 20892
301-443-1124
https://www.drugabuse.gov
The NIDA conducts and supports research on the c auses and consequences of addic-
tive substance use and translates this science into practical advice for policies,
programs, and practices in public health.
National Institutes of Health (NIH)

9000 Rockville Pike
Bethesda, MD 20892
301-496-4000, TTY: 301-402-9612
714 Dire ctory of Organi zat ions
https://www.nih.gov
The NIH is the federal agency responsible for advancing scientific knowledge of
the causes, treatment, and prevention of h
uman diseases in order to promote well-
being of the nation.
Office of the Surgeon General

200 Independence Avenue, SW
https://www.surgeongeneral.gov
The surgeon general is the country’s senior medical officer responsible for commu-
nicating important health information to the nation and managing the U.S. Public
Health Service.
Society of Public Health Educators (SOPHE)

10 G Street NE, Suite 605
202-408-9804
http://www.sophe.org
The SOPHE is the primary professional association of public health educators with
the mission of identifying and addressing the challenges and needs of community-
based and clinical health professionals.
Substance Abuse and M ental Health Services Administration (SAMHSA)

5600 Fishers Lane
Rockville, MD 20857
877-SAMHSA-7 (877-726-4727)
https://www.samhsa.gov
The SAMHSA is the federal agency responsible for leading national efforts in pre-
vention, treatment, and recovery of substance abuse, m ental illness, and behavioral
health problems.
U.S. Department of Agriculture (USDA)

1400 Independence Ave., SW
202-720-2791
https://www.usda.gov
The USDA is a federal agency that protects and promotes the health of farmwork-
ers, the public, and the environment through food safety, nutrition education, food
policies, land management, rural development, research, and education.
U.S. Department of Health and Human Services (DHHS)

200 Independence Avenue, SW
D i r ec to ry o f Orga ni z ati o ns 715
877-696-6775
https://www.hhs.gov
The DHHS is the federal agency responsible for managing medical, public health,
and social services.
U.S. Environmental Protection Agency (EPA)

1200 Pennsylvania Avenue, NW
202-564-4700
https://www.epa.gov
The EPA is the federal agency responsible for supporting public health by protect-
ing the air, w
ater, and land.
U.S. Food and Drug Administration (FDA)

10903 New Hampshire Avenue
888-INFO-FDA (888-463-6332)
https://www.fda.gov
The FDA is an agency of the DHHS responsible for protecting and promoting pub-
lic health through the regulation and supervision of a variety of types of food and
drug products.
U.S. Public Health Service (USPHS)

800-279-1605
https://www.usphs.gov
The USPHS is one of the seven uniformed services u nder the direction of the exec-
utive branch of the federal government composed of health professionals serving
throughout the nation to promote health, prevent disease, and advance public health
science.
World Health Organization (WHO)

http://www.who.int/en
The WHO is an international humanitarian agency of the United Nations (UN) with
the mission of promoting health for all p
eople throughout the globe.
Glossary
Access to health care: The ability to locate and use medical services in a timely
manner in order to promote the best possible health outcomes.
Acute illness: A temporary health problem that comes on suddenly and resolves
within a few days to weeks.
Anatomy: The science of the structure of the body parts and organ systems.
Anticipatory guidance: A form of pediatric counseling that predicts the next stage
of physical or social development of a child in order to educate and advise parents
in effective parenting techniques.
Beneficence: Acting with goodness or kindness.
Best practices: Actions, programs, or treatments that are accepted and recom-
mended by the majority of experts in the field.
Biopsychosocial: A perspective of care and prevention that considers the role and
interaction of biological, psychological, and social factors in disease occurrence or
prevention.
Biostatistics: A field of statistics applied to biological or health data.
Birth defect: A physical, structural, or functional abnormality present at birth.
Case study: A type of research study that details the life experiences of one person
or group of p
eople.
Causal factor: A factor or condition that determines w
hether a specific disease,
event, or outcome will occur.
Causality: An action, condition, or factor that brings about a specific outcome.
Chronic illness: A long-term or permanent health problem.
Cohort study: A type of research study that follows the diet or activities of a large
group of p
eople for a long period of time, in some cases for their entire life.
Collaboration: A style of working with other p eople that brings together p
eople of
different strengths and backgrounds in order to achieve a common goal.
Communicable disease: An illness that spreads from one person to another through
direct or indirect contact.
718 G lossa ry
Community: A geographic area or a group of people with shared characteristics or

interests.
Comorbid: An additional disease or diseases that are commonly seen at the same
time as a primary disorder. For example, cardiovascular disease and diabetes mel-
litus are comorbid diseases, often seen with obesity.
Construct: Conceptual elements that interface to form a health theory.
Copayment: A nominal fee charged to customers of health insurance for medical
services or prescription medication.
Data: Ideas or numbers that provide information.
Demographics: Data that describes a specific population.
Diagnosis: The act of investigating signs or symptoms in order to identify the cause
or disease.
Disease: A condition that interferes with normal functioning of the human body.
Efficacy: The power to achieve the intended outcome.
Emerging disease: A disease that appears in a population for the first time.
Empowerment: To give power or authority to someone who traditionally lacks or
is deprived of such power.
Endemic: Native or natural to a particular geographic region or group of p
eople.
Epidemic: Rapid outbreak or growth of a health condition in a specific geographic
area or within a specific group of p
eople.
Epidemiology: The study of the distribution and determinants of disease within
human populations.
Eradicate: To put an end to or destroy.
Evidence-based: Actions, programs, or treatments that have been proven to work
through rigorous research.
Health promotion: Any planned set of educational, political, or regulatory activi-
ties intended to support individual or population health.
Hemorrhage: A life-threatening emergency of profuse, uncontrolled bleeding.
Herd immunity: A strategy of preventing communicable disease by increasing the
immunity of enough individuals so that pathogens cannot infect susceptible hosts
and achieve transmission to others.
Homicide: The death of a human being caused by the action or inaction of another
person.
Host: A person, animal, or plant on which a pathogen lives.
G l o s s a ry 719
Hygiene: A set of practices to prevent the spread of communicable diseases and

promote health.
Hypertension: High blood pressure.
Hypochondriac: A person who is overly anxious about disease.
Iatrogenic: Illness caused by medical procedures.
Incidence: The number of new cases of disease in a given population at a given
time period.
Infectious disease: Illness caused by a microorganism.
Injury: Damage to the human body caused by exposure to mechanical, thermal,
electrical, chemical, or radiant energy.
Intentional injury: Purposeful damage to the body.
Intervene: To alter a problem, condition, or disease while it is occurring in order
to minimize the adverse outcomes.
Intervention: Actions, programs, strategies, or behaviors that alleviate a health
problem after it has started.
Jaundice: A yellowish tinge of the skin or whites of the eyes caused by excess bili-
rubin in the blood, a telltale sign of liver problems.
Justice: To treat fairly and equally.
Key stakeholder: An influential person or group with an interest in the project or
problem.
Life expectancy: The number of years of life anticipated at a specific age.
Means of transmission: How an agent or pathogen moves from one host to another
host.
Metabolite: An intermediate product of metabolism.
Metabolize: The chemical process of changing food, medication, or chemicals
brought into the body into a form that can be used by the body.
Model: A symbol representing a larger or more complex idea.
Moderating factor: A factor or condition that affects an individual’s potential for
disease.
Morbidity: Illness or disease.
Mortality: Death.
Needs assessment: A systematic investigation of a health problem within a spe-
cific population. Needs assessments are used to identify the next steps t oward alle-
viating the problem.
720 G lossa ry
Pandemic: A rapid, widespread outbreak of an infectious disease, affecting multiple

human populations across geographic al countries or continents at a particular point
in time.
Paradigm: A clear example, pattern, or model that represents a larger concept.
Pathogen: A bacterium, virus, helminth, or other microorganism that causes
disease.
Pathology: A branch of medicine that deals with how a disease causes structural
or functional abnormality.
Pediatrics: A branch of medicine that deals with c hildren and diseases of c hildren.
Physiology: The study of normal functions of cells, organs, tissues, or body systems
and related chemical activities.
Positive reinforcement: Giving a reward in order to increase the likelihood of a
certain behavior.
Postpartum: After childbirth.
Post-Traumatic Stress Disorder: A m
ental health disorder that is triggered by a
traumatic or stressful event.
Practice: The application of ideas or methods to perform a particular function.
Prevalence: The number of p eople affected by a disease or condition in a particu
lar population at a given point in time.
Prevention: Programs, p eople, or behaviors that stop an anticipated event, condi-
tion, or disease from occurring.
Process: A series of actions or operations in order to achieve a particular outcome.
Program planning: A field of public health that plans, develops, implements, and
evaluates health promotion or disease prevention activities.
Protective factor: A condition that promotes optimal health.
Protocol: A set of rules that outlines procedures and conduct of scientific research
or medical care.
Public: Ordinary people living or working in the community.
Quality of life: A standard of health, comfort, and satisfaction of an individual or
population.
Racial segregation: The practice of restricting certain people from public facilities
or benefits on the basis of race or perceived race.
Racism: Prejudice or discrimination against someone due to the misconception that
one race is superior to another.
G l o s s a ry 721
Reassortant virus: The mixing of genetic material from two or more viruses to cre-
ate a new virus with properties of each of the parent viruses.
Reemerging disease: A disease that was once a major health problem, declined,
and is becoming a major health problem again.
Research: A planned, systematic investigation.
Research participant: A person who participates in an experiment or study trial.
Respect for persons: The bioethical principle that describes treating o thers with
dignity, kindness, and honor.
Reward: An incentive, praise, or gift that is given in return for desired behavior.
Ring vaccination: A strategy of preventing communicable disease by building a buf-
fer against transmission by vaccinating a circle of individuals around the infected
person.
Risk factor: A condition that increases the potential for injury or disease.
Sanitation: A term in public health that refers to cleanliness, adequate sewage dis-
posal, and ensuring a safe water and food supply.
Screening: A medical strategy that checks for disease regardless of the presence of
symptoms.
Shoe leather epidemiology: Epidemiological investigation that involves direct
inquiries with the affected individuals.
Socioeconomic status: The combination of education, income, and occupation that
determine one’s standing in society.
Sociologist: A scientist who studies the nature and behaviors of people in
groups.
Stillborn: An infant born dead.
Suicide: The intentional act of killing oneself.
Surveillance: Close and continuous observation.
Symptom: A sign that indicates disease or disorder of the body.
Teratogen: An agent that c auses malformation of the embryo.
Theory: A hypothetical set of concepts that provide an explanation of complex
behaviors, events, or situations.
Toxin: A substance that is harmful to the body.
Treatment: The pharmaceutical, medical, or surgical remedy of a disease or health
problem.
722 G lossa ry
Unintentional injury: Unexpected hurt or damage to the body resulting from

neglect or carelessness.
Universal population: People who are unaffected or marginally affected by a health
problem.
Universal prevention: A form of treatment that targets all p eople in the popula-
tion, including t hose who do not suffer from a health problem, and aim to prevent
the problem in the population.
Violence: The use of physical force or power that either results in physical or emo-
tional injury or has a high likelihood of resulting in injury, death, or psychological
harm.
About the Editor and Contributors
Editor
Sally Kuykendall, RN, PhD (CHES), is a professor in health services and a pro-
gram evaluator of community-based public health programs. She earned a diploma
in nursing, a BSc (hons) in chemistry and biology, an MS in health education, and
a PhD in health sciences. Kuykendall worked as a critical care nurse in E ngland
and the United States before authoring numerous articles and reports on bully-
ing and violence prevention. She wrote the book Bullying: Health and Medical Issues
Today and served as content consultant on the public television movie Beyond the
Bully (2014) by KSMQ in Rochester, MN. Her current research investigates scien-
tific and scholarly misconduct.
Contributors
Nadav Antebi-Gruszka, MA, MPhil, is a doctoral candidate in the departments of

Sociomedical Sciences and Psychology at Columbia University. His research focuses
on LGBT health, HIV and substance use prevention, and technology.
Nooshin Asadpour, MD, is a pediatric resident physician at St. Christopher’s Hos-

pital for C
hildren in Philadelphia, PA. Dr. Asadpour earned her bachelor’s degree
in biochemistry from Temple University and her medical degree from the Lewis
Katz School of Medicine. Her love of children has led her to pursue a career in pedi-
atric medicine. She plans to work as a general pediatrician in an urban setting where
she can empower children and youth to build a strong foundation for a healthy exis-
tence in all domains of their life.
Elizabeth Y. Barnett is a postdoctoral fellow at Harvard Medical School and Brigham

and Women’s Hospital. She specializes in the development, implementation, and
evaluation of health promotion programs, particularly in workplaces, communi-
ties, and schools.
Diana Bertorelli graduated from Saint Joseph’s University with a master of health
administration. Her research interests include the prevention and management of
chronic diseases, particularly diabetes.
724 About th e Ed it o r and Cont ribut o rs
Alex Black holds a bachelor’s degree in computer science and is studying for a mas-
ter of business administration. His research interests include automotive mainte-
nance and safety.
Mark Black is a consultant with Center City Film & Video and volunteer with
EvoXLabs. Black designs digital images for medical continuing education and
assistive technologies for p
eople with disabilities.
Matthew Black holds a dual bachelor’s degree in mathematics and chemistry and
a master’s degree in education. His area of expertise is math education for inner-
city youth. He is currently pursuing a PhD in mathematics education at Pennsylva-
nia State University.
Georgiana Bostean, PhD, is an assistant professor of sociology and environmental

science and policy at Chapman University. Her research focuses on the social deter-
minants of health and has been published in journals including the American Jour-
nal of Public Health, Social Science and Medicine, and Journal of Immigrant and Minority
Health.
Rochelle Caviness is an independent scholar whose main area of interest is the

history of science, technology, and medicine.
George W. Dowdall, PhD, is professor emeritus of sociology at Saint Joseph’s Uni-

versity and an adjunct fellow at the Center for Public Health Initiatives of the Uni-
versity of Pennsylvania. His most recent book is College Drinking: Reframing a Social
Problem/Changing the Culture (Sterling, VA: Stylus, 2013).
Leapolda Figueroa is a graduate of the College of Professional and Liberal Studies,

majoring in healthcare administration at Saint Joseph’s University. Ms. Figueroa
works as a health administrator and is currently applying to law school to work in
healthcare law.
Ariel A. Friedman, BA, is an MEd candidate in the Department of Clinical and

Counseling Psychology at Teacher’s College, Columbia University. Her research
interests include LGBT health, sex positivity, gender nonconformity, and alterna-
tive family planning methods.
Sarah R. Green, MD, is a pediatric resident at Saint Christopher’s Hospital for

Children in Philadelphia. She plans to pursue a c areer in adolescent medicine. Her
current research focuses on depression screening in adolescents.
Julia Hanes, LSW, MSW, is the intimate partner violence (IPV) specialist at St. Chris-
topher’s Hospital for Children through Lutheran Settlement House (LSH). Through
this work, Julia responds to crisis consults for victims and survivors of IPV and
Abo ut th e E d i to r a nd C o ntr i b uto r s 725
trafficking. In addition, Julia trains the hospital staff about IPV and trafficking
and how to talk to caregivers and patients about those topics. Outside of the
hospital system Julia has presented at the Trans Health Conference on IPV and
trans-related issues. Julia received a master’s degree in social Work from New York
University.
Salini Inaganti is project manager at Public Health Management Corporation

(PHMC). Her research interests include health communication, decision making,
organ donation, and health disparities.
Amy Jessop, PhD, MPH, is founder and director of Hepatitis Treatment, Research
and Education Center (HepTREC). Dr. Jessop’s work focuses on the prevention,
screening, and treatment of infectious diseases, particularly vaccine-preventable
infections and viral hepatitis.
Jennie Jacobs Kronenfeld is professor emerita in the Sociology Program, Sanford

School of Social and F amily Dynamics, Arizona State University. Her research areas
are medical sociology and aging and the life course with special focus on health
policy, health care utilization, and health behavior. She serves as editor of the annual
Research in the Sociology of Health Care published each year by Emerald Press. She
is coeditor of Health and associate editor in chief of the American Journal of Health
Promotion. She has served in many roles with the American Sociological Associa-
tion (ASA) including as chair of the Medical Sociology Section and other positions
in this group. She is currently serving as a council member with the Retired Soci-
ologist Interest Group of the ASA. She has served as secretary-treasurer of the Med-
ical Care section of the American Public Health Association. She is a past president
of Sociologists for Women in Society.
Louis Kuykendall Jr., DMin, is an ordained clergyperson in the United Church of

Christ (UCC) and a volunteer hospice chaplain. His research focuses on the spiritual
care of hospice patients. He is pastor and teacher in a local UCC parish and trains
hospice and church volunteers regarding end-of-life issues and spiritual care.
Marvin J. H. Lee, PhD, is editor of The Journal of Healthcare Ethics & Administra-
tion, published by The Institute of Clinical Bioethics at Saint Joseph’s University.
He is also a bioethics consultant at the institute. His research primarily focuses
on ethical issues concerning medicine, culture/tradition, and health administra-
tion. Dr. Lee majored in philosophy as an undergraduate, and took his interest
in medical ethics and health care administration during his graduate years; he
earned his master’s at Yale University and completed a PhD at Cambridge Univer-
sity, England.
Susana Leong earned her doctorate and master’s degrees in health and behavior
studies from Columbia University, and her bachelor’s degree from the University of
California, Berkeley. Dr. Leong is an adjunct assistant professor in the Department

of Physiological Nursing at the University of California, San Francisco.
Kristie Lowery is a health care professional with more than 40 years of experience
in the industry. Half of her c areer has been focused on quality, risk management,
regulations, and patient safety. She has participated in the development of 12 pro-
fessional posters on patient safety interventions and contributed multiple articles
on patient safety concerns. She has experienced the evolution of patient safety since
the Institute of Medicine issued the “To Err is H uman” report in 1999. She contin-
ues to communicate with consumers to inform them of patient safety concerns and
their role and responsibilities while navigating the health care system.
Noora F. Majid is a master of public health graduate from the Mailman School of
Public Health at Columbia University. Her interests include intervention design,
evaluation, and health communication, specifically related to the prevention and
management of chronic diseases.
Erin Mathews is a premed student at Ursinus College in Collegeville, PA, majoring

in biology and French. She intends to pursue a c areer in dermatology.
Neil Mathews, MD, is a f amily and sports medicine physician at Lehigh Valley Hos-
pital in Allentown, PA, and assistant professor in the Department of Family Medi-
cine. He also serves as head team physician for a professional hockey team and has
extensive experience in the diagnosis and management of concussions.
Maria DiGiorgio McColgan, MD, MSEd, FAAP, is a board certified child abuse
pediatrician, medical director of the Child Protection Program at St. Christopher’s
Hospital for C hildren, and an associate professor at Drexel University College of
Medicine. Dr. McColgan is the founding advisory board chair and pediatric advisor
of Prevent Child Abuse Pennsylvania.
Caitlin Monahan is a BA candidate in the psychology department in the College

of Arts and Sciences at New York University. Her research focuses on intersection-
ality, power relations, and stigma of marginalized social groups.
Autumn Nanassy, MA, is the trauma research coordinator for St. Christopher’s Hos-
pital for C
hildren. Her research primarily focuses on pediatric trauma and burns.
Kim L. Nguyen earned her bachelor of science in biology with minors in health
care ethics and business administration from Saint Joseph’s University. She explored
the topic of telemedicine in her publication titled “Obstacles and Solutions in the
Implementation Telestroke: Billing, Licensing, and Legislation.” She is currently an
MD candidate at Drexel University College of Medicine pursuing pediatrics.
Abo ut th e E d i to r a nd C o ntr i b uto r s 727
Victor Okparaeke, PhD, is a graduate of Walden University School of Public Health,

and the University of Health Sciences, School of Medicine, Antigua, WI. His inter-
ests include community and environmental health issues, as well as the prevention
and management of hypertensive disease and diabetes in rural communities.
Godyson Orji, DHA, is a visiting assistant professor of Health Services at Saint Joseph
University. Dr. Orji’s research and interest are in health informatics, health informa-
tion management, health care analytics, and health economics and outcome research.
Sean P. Phillips is a doctoral candidate in modern European history at the Univer-

sity of Notre Dame, where he is a past Annese fellow of the Nanovic Institute for
European Studies. He is a recipient of the Francis A. Countway Library Fellowship
in the history of medicine and a Wood Institute Grant from The College of Physi-
cians of Philadelphia. His dissertation explores the role of Catholic clergy in the
propagation of the smallpox vaccine in 19th-century France.
David J. Reynolds, PhD, health psychologist at Joint Base Andrews, trains and
supervises residents in behavioral medicine. His main interests are PTSD, chronic
pain, and insomnia. He is a veteran of the Persian Gulf War and Operation Endur-
ing Freedom, having served 4 years in the Marines and 16 years in the Air Force.
Staceyann Smith is a pediatric resident at Saint Christopher’s Hospital for Children

in Philadelphia, PA. She earned her BS in h
uman science from Georgetown Univer-
sity. In 2015, she earned a dual MD/MPH degree from the University of Connecti-
cut School of Medicine and School of Public Health. Her professional interests
include childhood obesity and child advocacy.
A. J. Smuskiewicz is a freelance writer and editor with more than 25 years of pro-
fessional experience. He specializes in science, health and medicine, sexuality issues,
music, and current events.
Timur Suhail-Sindhu, MD, is currently a resident in psychiatry at Dartmouth

Hitchcock Medical Center. His clinical and research interests include addiction,
trauma-related disorders, and psychotherapy.
Eileen L. Sullivan is licensed pharmacist and an assistant professor in the Depart-

ment of Health Services at Saint Joseph’s University. Sullivan teaches courses in
chronic illness, health and society, medical terminology, and global health initia-
tives. Her research focuses on nonpharmacologic interventions to improve quality
of life for p
eople living with Alzheimer’s disease.
Christine M. Thomas completed a bachelor’s degree in Interdisciplinary Health Ser

vices at Saint Joseph’s University in Philadelphia, PA. Christine intends to expand her
knowledge of the health care field in the branch of physical therapy, specializing in
neurology. Throughout her studies, Christine focused on prenatal care, developing
a promotional video on public health for Mercy Health System clients.
Rochelle Thompson, MS, is the injury prevention coordinator at St. Christopher’s

Hospital for C
hildren. Her primary focus is providing education and tools to help
save lives and reduce preventable unintentional injuries.
Tenille J. Torres is a health researcher particularly interested in the development

of community-based participatory research to eliminate racial gaps in health and
equity. She received her MPH at Boston University School of Public Health in mater-
nal and child health.
Stephen K. Trapp, PhD, is a research associate at the University of South Florida.

He has a particular interest in positive psychology constructs as they relate to chronic
health conditions and physical rehabilitation.
Jason S. Ulsperger is an associate professor of sociology at Arkansas Tech University,

where he teaches gerontology. He has published on a wide variety of elder care top-
ics, including aging, nursing home reform, and abuse in long-term care facilities. He
is currently studying ritualized practices related to volunteerism among the aged.
Catherine van de Ruit, PhD, is an assistant professor of health and exercise physi-
ology at Ursinus College. Her scholarship focuses on public health responses to the
AIDS epidemic in Southern Africa and on quality improvement in clinical settings
in South Africa and the United States.
Simon Waldbaum, PhD, has spent over a decade conducting biomedical science
research, most recently at the University of Colorado Anschutz Medical Campus.
His primary research focus and areas of publication have been in the field of neu-
rology, illuminating the link between neuronal mitochondrial oxidative stress and
the development of acquired epilepsy.
Alison C. Walensky is an independent scholar with a master of special education,

grades 1–6. She has taught over 500 students in her past three years of teaching,
including 125 students with Individualized Education Plans.
Shayan Waseh is an MD/MPH candidate at Thomas Jefferson University in Phila-

delphia, PA. His past research has included telemedicine training curricula and diag-
nostic tools for detecting Alzheimer’s disease. He is interested in applying population
health approaches to solving contemporary health care challenges in patient access,
health care quality, and medical costs.
Index
Page locators in boldface indicate main entries in the encyclopedia.
A1C blood test, 166 investigation of, 106, 187

abandonment (defined), 114 pandemic, 473
Abbott, Jehiel, 565 preventing, 189, 252
“ABCDEs,” 568 services for people with, 189
ability (defined), 171, 270 syringe service programs and, 609–610
ableism, 174 transmission of, 188, 189, 220
abortion treatment in, 252
botched, 234–235 Across the Line, 489
dangers of, 63 Act for the Relief of Sick and Disabled
demand, reducing, 234 Seamen, 511, 607, 630
restrictions on, 127 action
rights, 199 as collaboration phase, 130, 131, 132
spontaneous, 32 in community organizing, 140
statistics on, 235 Action Plan to Reduce Racial and Ethnic
support for, 203 Health Disparities, 2011, 279
abstinence, 236 active living, promoting, 135
abuse, 69, 133, 368, 655. See also intimate active TB disease, 274
partner violence (IPV) activities in logic model, 390–391
Abyssinian Baptist Church, 575 activities of daily living, 20, 171
acceptability of services, 99, 100–101 activity limitation as disability level, 171
accessible physical infrastructure, 174 activity theory, aging and, 21
accident (term), 326, 359 acute hepatitis, 317
accreditation, 150–151, 152, 162–163, acute illness, 1–2
508–511 acute necrotizing ulcerative gingivitis
acetylcholinesterase inhibitors (AchEIs), (ANUG), 159
35 Ad Council, 165
achievable (defined), 256 Addams, Jane, 264, 266, 374, 644
Acinetobacter, multidrug-resistant, 51 Addiction Research Center (ARC), 447,
A Complete System of Family Registration 604–605
(Shattuck), 565 addictions, 3–7
acquired immune deficiency syndrome cause of, 176
(AIDS). See also human horrors of, 61
immunodeficiency virus (HIV)/ origin, 4–5
acquired immune deficiency prevention, 5
syndrome (AIDS) recognition of, 606
immunocompromised condition due to, research into, 604–605
51 treatment, 5–6
730 INDEX
additives, hazardous, 246 aerobic activities, 485–486

Address on the Medical Education of Women Affirmative Action, 174
(Blackwell), 84 affordability as care access component,
adipose tissue, 87 99–100
administration, health, 7–11, 8–9, 162, Affordable Care Act (ACA), 15–18
163 care access and costs regulated
Administration for Children and Families by, 100
(ACF), 629 children’s coverage under, 117
Administration for Community Living False Claims Act (FCA) refined by, 233
(ACL), 629 health care disparities, reducing
adolescents through, 279
addiction in, 176 health insurance access as goal of, 166
ADHD in, 58 health literacy as defined by, 298
brain structure and development, 176 Medicaid expansion under, 407, 709
disordered eating in, 256 Medicare and Medicaid anti-fraud
drug abuse among, 5 measures in, 601
eating disorders in, 193 obesity addressed in, 302
goals for, 256 prescription drugs and, 502–503
growth, 87 restrictions on immigrants, 704
health concerns, 653–654 school-based clinics and, 561
mental health issues, 418–419, 653 Africa, health challenges in, 252
nutrition, 654–655 Africa American adolescents, birth rates
obesity and, 466 for, 117
physical activity guidelines, 486–487 African Americans
pregnancy (see teen pregnancy) diabetes risks, 165
risky behaviors in, 13 education, 90, 147–148
smoking cessation and reduction for, experiments performed on, 71, 72
226, 383 health care for, 88, 90, 93, 148,
sports-related concussions, 598 277–279, 287
substance dependence in, 4 health challenges, 153
Adolescent Smoking Cessation: Escaping heart disease in, 289, 311
Nicotine and Tobacco Program HIV/AIDS in, 333
(ASCENT), 228 hypertension in, 340
adopters of new product or idea, 168–169 income, 89
adulthood, child health effects impacting, labor unions, 89
116 life expectancy, 307
Adult Protective Services (APS), 197 living and working conditions, 146,
adult relationships, child maltreatment 147–148
impact on, 115 medical education and training, 88, 90,
adults, Attention-Deficit/Hyperactivity 94, 146–150
Disorder (ADHD) in, 58 obesity in, 301
adults, physical activity guidelines for, physicians, 88–90, 183–186, 198–199,
486–487 321–323
adult sex work, 336 rights of, 373
adverse childhood experiences (ACEs), 3, sexually transmitted diseases among,
11–15 278
advertising, 284, 302, 447, 677–686 socioeconomic conditions, 90
advocacy for community health, 134 stroke in, 313
INDEX 731
African American women, cortisol levels, in moderation, 341, 342

12–13 during pregnancy, 79, 80
African Brazilians, 88 in utero exposure to, 170
African Civilization Society, 576 Alcohol, Drug Abuse, and Mental Health
African Free Schools, 574 Administration (ADAMHA), 605
African Methodist Episcopal Church, 619 alcohol abuse
agar, 378 ADA coverage for persons engaged in,
age, 87 43
Agency for Healthcare Research and behavioral genetic theories applied to,
Quality (AHRQ), 629 250
Agency for Toxic Substances and Disease as birth defect risk factor, 350
Registry (ATSDR), 629 food insecurity associated with, 243
age-related sarcopenia, 87 health effects of, 70
aging, 18–22, 165 as heart disease risk factor, 311
agrarian societies, health conditions in, 44 heterosexual/cisgender and LGBT
Agricultural Adjustment Administration individuals compared, 386, 387
(AAA), 539 as hypertension risk factor, 340
agricultural safety, 22–25 as injury risk factor, 359
A History of Concord, Middlesex County, as liver disease risk factor, 30, 70, 317
Massachusetts (Shattuck), 564 parent incapacity due to, 114
AIDS. See acquired immune deficiency stress in home due to, 114
syndrome (AIDS); human alcohol abuse and dependence (concept),
immunodeficiency virus (HIV)/ 31
acquired immune deficiency Alcoholics Anonymous, 31
syndrome (AIDS) alcoholism, 3, 24, 31, 249
air, foul, 261 alcohol-related products, regulation of,
airborne diseases, 473 242
air contaminants, 22 alcohol use disorder (AUD), 31
AirNow, 28 Alcott, Bronson, 94
air pollution, 25–30 Alibekov, Kanatijian, 77
cancer risks of, 97 Alinsky, Saul David, 139
impact of, 210–211, 213 allergens
interventions for, 28–29 as air pollution source, 25
motor vehicle traffic as factor in, 308 contamination by, 246
reducing, 309 potential consumption of, 245
Air Pollution and Respiratory Health allergic diseases, 271
Branch (CDC), 28, 177 allergic reactions, 482–483
Air Pollution Control Act, 27 Allstate Foundation, 533
air quality, 28, 210, 211 all-terrain vehicles, 432
Air Quality Index (AQI), 25, 28 Aluminum Company of America
air toxics, 27 (ALCOA), 160, 238, 239
air travel, 252 Alzheimer, Aloysius “Alois,” 33–34
Alaskan Natives, 311, 346, 348 Alzheimer’s disease (AD), 33–37, 249
alcohol, 30–33 ambulance corps, 94
advertising, 683 amebic dysentery, 104–105
dependency rate, 3 amenorrhea, 270
diabetes management challenge due American Academy of Pediatrics, 235, 329
to, 166 American Birth Control League, 558
732 INDEX
American Civil War divisions, 283

law and legislation during, 233 health education role of, 293
medicine during, 94 materials used by, 274–275
mentally ill, advocacy during, 182 The Nation’s Health, 451
milk supply during, 47 presidents, 649
women in, 84, 618 publications, 37
American College of Surgeons, 185, 186 school-based clinics, 561
American Colonization Society, 574 women presidents, 201
American Dental Association, 239, 275, American Public Welfare Association, 506
469, 470 American Red Cross Blood Bank, 185
American Diabetes Association, 165 American School Health Association
American Health Foundation (AHF), 663 (ASHA), 293
American Health Information American Society of Addiction Medicine
Management Association, 295 (ASAM), 3
American Heart Association, 341, 469 American Society of Hypertension (ASH),
American Hospital Association, 506 342
American Hospital Association (AHA), American Statistical Association, 565
707 Americans with Disabilities Act (ADA),
American Journal of Public Health (AJPH), 41–44, 174
37–38, 41, 451, 540–541, 544 Americans with Disabilities Act
American League of Colored Laborers, Accessibility Guidelines (ADAAG),
575 270
American Legacy Foundation (ALF), 5, American Union Against Militarism,
284, 615 644–645
American Lung Association, 28 America’s War on Drugs, 610–611
American Medical Association (AMA), Amherst, Jeffrey, 76
38–40, 506 amino acids, 461
African Americans barred from, 185 amoebic dysentery, 187
Code of Medical Ethics (AMA), 39, 94 amoxicillin, 483
diabetes involvement, 166 ampicillin, 483
health insurance concerns of, 17 amputations of lower extremities, 164,
prediabetes awareness role of, 165 165–166
social medicine, position on, 63 amyotrophic lateral sclerosis (ALS), 172
American Planning Association, 309 anal sex (males), 12
American Psychiatric Association, analytical thinking skills and assessment,
58, 177 142, 144
American Public Health Association An Atlas of the Medulla and Mid-Brain
(APHA), 40–41 (Sabin), 551
African American issues brought before, Anatomical, Pathological and Therapeutic
89 Researches upon the Disease Known
African American presidents, 146, 149 under the Name of Gasto-Enterite
alcoholism identified as treatable by, 3 (Louis), 92
Charles-Edward Amory Winslow and, anatomy, ancient Greek knowledge of,
652 325
code of ethics adopted by, 127–128 ancient world, public health in, 44–47
Commission on Chronic Illness Anderson, Abraham Archibald, 47, 48
co-founded by, 506 Anderson, Elizabeth Milbank, 47–49
dentists recognized by, 161 Anderson, Marian, 536
INDEX 733
anesthetic agents, 577–578 anti-vaccine movement, 689

aneurysm, 342 antivirals, 56, 357, 358
anger, 176 anxiety
Angina pectoris, 371 ADHD accompanied by, 57
Anglo-African Magazine, 576–577 attacks, 65
Animal and Plant Health Inspection behaviors related to, 69
Service, 626, 627 exercise, excessive associated with, 270
animal control officer, 141 in persons with adverse childhood
animals experiences (ACEs), 14
antibiotic resistance spread from, 50–51 socioemotional state of, 243
bacterial infections among, 50 anxiety disorders, 421
bites, 1 Apgar, 213
as reservoirs, 353 ACHIEVE program, 593
sacrifice of, 44 Army Medical Corps, 90
Annual Review of Vital Statistics in Army Medical School, 458
Pediatrics, 648 Arnott, Neil, 111
anorexia nervosa, 193 arrhythmias, 311, 312–313
antenatal care, 402 Arrowsmith (Sinclair), 648
anthrax arteriosclerosis, 340
bioterrorism role in, 75, 76, 77, 107, artery-opening treatment, 307
207 Arthur, Chester A., 94
emergency response to, 208–209 artificial sweeteners, 102
origin of, 378, 379 Ashurbanipal, Assyrian king, 46
study of, 377, 378 Asian Americans
vaccine, 477 diabetes risks, 165
anthropogenic activities, 253 health care for, 287
anthropology degree, 162 health challenges, 153, 279
anti-Asian sentiment, 185 heart disease in, 311
antibiotic resistance, 50–53, 482–483 Assistant Secretary of Health (ASH), 608,
antibiotic-resistant microorganisms, 51, 631–632
271 assistive technology, 172
antibiotics Association for Improving Conditions of
categories of, 50 the Poor, 49
developing and testing, 50 Association of Public Health Laboratories
development of, 123 (APHL), 53–54
good stewardship of, 52 Association of Schools and Programs of
limitations of, 56 Public Health (ASPPH), 163
penicillin, 50, 278, 481–484 Association of State and Territorial Health
anticipatory care, 625 Officials (ASTHO), 54–56
antifluoridationist groups, 239 Assyrians, 75
antihypertensive medication, 341 asthma
Anti-Kickback law, 601–602 as air pollution health effect, 25
Anti-Man-Hunting League, 94 attacks, reducing, 28
antioxidants, 19 incidence, factors affecting, 271
antiretroviral therapy (ART), 334 management and control, 177
anti-Semitism, 185 pollutant exposure, association with, 27
anti-smoking laws, 362–363 prevalence of, 118
antisocial behavior, 230 symptoms, 177
734 INDEX
astronomy, 92 basal cell carcinoma (BCC), 568

ataxic neurodegenerative satiety deficiency baseline data (defined), 227
syndrome (ANSD), 665 Bates, Mrs. J. F., 185–186
Atharva Veda, 46 bathhouses in New York City, 47, 48
atherosclerosis, 165–166, 312, 340 bathing, ancient world practices, 44–45
atrial fibrillation (AFib), 312 Bauxite, 160, 238, 239
at-risk groups Beattie, John, 184
for child maltreatment, 114 Beaumont, William, 543
identifying, 102, 208, 221, 249, 304 Beck, Lewis Caleb, 241
police dealings with, 229 Bedloe’s Island, 520
predicting, 221 bedroom communities, 139
protecting, 358 Beers, Clifford Whittingham, 64–68
screening focusing on, 250 Beers, George Merwin, 66, 68
attention deficit disorder, 118 Beers, Samuel, 65
Attention-Deficit/Hyperactivity Disorder Beethoven, Ludwig van, 270
(ADHD), 57–60, 69, 118 behavior
attitudes, interventions aimed at changing, cancer risks posed by, 97
362 defined, 271
attitudinal barriers for people with interventions aimed at changing, 362
disabilities, 174 risk factors for violence, 641
Aum Shinrikyo, 77 self-efficacy and, 562
Australian penal colonies, 111 behavioral capability, 580
authoritarian abusers, 196 behavioral change, 70, 342, 389–390
author rights and restrictions, 37–38 behavioral diagnoses, 501
autoimmune hepatitis, 317 behavioral genetics, 250
availability of services, 99, 100 behavioral health, 16, 69–71, 162, 163,
avian influenza, 251, 356, 357 389, 605
behavioral health sciences, 108–109, 151
baby-boomer population, 18, 21, 33, 197, behavioral human research, 71–73
214 behavioral problems, 13, 231
bachelor’s degree in public health, 151, Behavioral Risk Factor Surveillance
163 System (BRFSS), 34, 134
back injuries, 24 behavioral therapy, 6
bacteria, 50, 245, 377, 378 behavior management, 58, 69
bacterial infections, 50 beliefs, respecting diverse, 128
bacterial meningitis, 414 The Belmont Report, 71–73, 127, 532
bacterial-resistant illnesses, 50 beneficence, 71, 72, 127, 224, 225
bactericidal antibiotics, 50 Bengal, India, cholera outbreak in, 121
bacteriology, 380 benign neoplasms, 97
bacteriostatic antibiotics, 50 Benjamin, Regina M., 608
Baker, Josephine, 394 Bentham, Jeremy, 110
Baker, Sara Josephine, 61–64 Berle, Adolph, Jr., 539
Bandura, Albert, 525, 580 Berlin University, 542
Banks, N. P., 565 beta amyloid proteins, 34
Ban Non Wat, Thailand, 45 beverage industry, 221, 284, 301
bariatric surgery, 466–467 Biafran War, 106
Barnaby, Ruth, 398 bicycle paths, 308
Barry, Katherine “Kitty,” 85 bicycle routes, 310
INDEX 735
The Big Boys (Nadar), 437 B-lactamase, 483

BIG GEMS (Behavior, Infection, Genetics, B-lactams, 481
Geography, Environment, Medical bladder cancer, 102–103
care, and Socioeconomic-cultural Blank Book Forms for Family Registers
status), 271 (Shattuck), 565
Bill and Melinda Gates Foundation, 254, blindness, 63, 164, 165–166
492 Blockley Almshouse, Philadelphia, 83
Bills of Mortality, 527–528 blood diseases, 444–446
binge drinking, 30, 31, 104 Blood for Britain program, 185
binge eating disorder, 193, 194 bloodletting, 55, 92
bioethics, 127 bloodmobiles, 185
biological aging, 18, 19 blood pressure, 227, 341. See also
Biological Weapons Convention, 77, 78 hypertension (HTN)
biomedical human research, 71–73 blood products, 183, 184, 186
biopharmaceuticals, 240–241 blood storage, 184
biopsychosocial model of disease, 4 blood sugar, 165, 166
biopsychosocial well-being (concept), blood thinning drugs, 312–313
269–270 Blood Transfusion Betterment Association,
biostatistics, 73–75, 108–109, 151, 162, 185
163 blood transfusions, 240–241
bioterrorism, 75–79, 212 blood vessels, diseases affecting, 311–312
bipolar disorder, 65, 66 Blue, Rupert, 608
birth control blue zones, 21
benefits of, 203 Blulmer, Herbert, 587
campaign for, 554–559 bodily fluids, balance between, 98
clinics, 235 body composition, 87
conditions prior to, 63 body fat, 87
education in, 235 body mass index (BMI), 86–88, 227, 341,
legalization of, 235 465
maternal health and, 400–401 The Body Project (program), 194
pelvic examination prior to, 204 Boeck, Caesar, 621
teen access to, 199 Boeck-Bruusgaard Oslo Study of
birth control movement, 234–235 Untreated Syphilis, 621
birth defects, 25, 79–81, 217, 349–350 bone, activities strengthening, 486
birth injuries, 349 bone tissue weight, 87
birth records, 512 books, 37
births outside of marriage, 117 Borden Condensed Milk Company, 47
birth weight, low, 32, 279, 350 Bordetella pertussis, 217
Black, Alex, 671 Boston AIDS Brigade, 610
Black, Green Vardiman, 160, 237–238 botulism, 75, 77
black carbon emissions, 27 Bousfield, Maude Tanner (Brown), 88,
Black Caucus of Health Workers, 148 89–90
Black Death, 76, 352 Bousfield, Midian Othello, 88–91
Black Death pandemic, 426–427, 526 Bowditch, Henry Ingersoll, 91–95, 567,
black pox, 571 602
Blackwell, Elizabeth, 61, 81–85 Bowditch, Nathaniel, 94
Blackwell, Emily, 61, 83, 84–85 Bracebridge, Charles, 456
Blackwell, Samuel, 81, 82 Bracebridge, Selina, 456
736 INDEX
Bradford, Sara, 619 Bureau of Child Hygiene, 62–63

Brady Campaign to End Gun Violence, Bureau of Health Workforce (BHW), 304
329 Bureau of Labor, 265
brain Bureau of Labor Standards, 23
Alzheimer’s disease impact on, 34 Bureau of Labor Statistics (BLS), 136, 212
ancient Greek knowledge of, 325 Bureau of Primary Health Care (BPHC),
damage, 54 304
development, 4, 11, 13, 114, 176 Burney, Leroy E., 608
function, drug impact on, 4 burns, 326, 328, 360
structure, 176 Burns, Anthony, 93
traumatic brain injury, 223, 359, Bush, George H. W., 41, 174
597–599 business, competition with, 284
Brandeis Brief, 376 business administration, 8
brand medications, 503–504 business degree, 162
Brandt, Edward, Jr., 608 business operation and planning, 8
breast cancer business psychology, 255
alcohol linked to, 30 business travelers, 706
in ancient world, 97 Byrne, Ethel, 488, 557
as genetic disorder, 249
high BMI associated with, 86 caduceus (medical symbol), 352–353
races compared, 279 calcium, 461
screening for, 98, 124, 169, 234 calcium supplements, 360
survival rates, 583 California Department of Rehabilitation,
treating, 250–521 173–174
breastfeeding, 62, 351 caloric restriction, 19
breast self-examination, 124 Cameron, Charles S., 661
breathing problems, 86 Campbell Collaboration, 230
breath testing, random, 31 Camp Devenus, Boston, MA, 356
Breslow thicknesses, 568 Campylobacter jejuni, 245, 646
Brewster, Mary, 643 Canada, health insurance in, 16
A Brief Plea for an Ambulance System for the cancer, 97–99
Army of the United States (Bowditch), as air pollution health effect, 25
94 alcohol linked to, 30
Brigham, Amariah, 181 behaviors linked to, 70
British health care system, 98, 111 cells, 98
bronchitis, 91 as global health issue, 253
Bronfenbrenner, Urie, 587–588 immunocompromised condition due to,
Brotherhood of Sleeping Car Porters 51
(BSCP), 89 National Cancer Institute (NCI),
Brown, John, 619 439–441
Bryan, William Lowe, 255 people with and without disabilities
bubonic plague, 380 compared, 171
building materials, 25 reduction attempts, 125
built environment, 271 research funding, 439–440, 449
Built Environment and Health Initiative risks, lowering for, 165, 341
(Healthy Places), 308–311 studies, 71
bulimia nervosa, 193 survivors, 133
bullying, 174, 176, 231, 385, 387 treatment, 51
INDEX 737
The Canon of Internal Medicine (Huangdi Carnegie, Andrew, 48

neijing) (Huang Di), 46 carrier screening, 249, 250
capitalist health and health care economy, Carroll, James, 429
224–225 Carson, Rachel, 214
capitalist-liberal democratic country, case control studies, 222
health system in, 225 causality, 102–104
Caplan, Gerald, 507 causal relationships, confirming, 222
Carbapenem, 51 cause-effect relationships, 102
carbohydrates, 460 cavities, 160–161, 275
carbon monoxide poisoning cell growth, 97, 98
as air pollution health effect, 25 cellular aging theory, 19
among immigrants, 264 Center for Food Safety and Applied
as chemical injury, 360 Nutrition, 242
as farm work hazard, 23 Center for Immigration Studies, 707
public health education about, 326, Center for Independent Living, 173
329–330 Center for Nutrition Policy and
cardiac arrest, 315 Promotion, 626
cardiac death, 30, 312, 315 Center for School, Health and Education,
cardiac ischemia, 312 561
cardiopulmonary resuscitation, 307 Center for the Study and Prevention of
cardiovascular disease Violence, 230
causes of, 70 Center for the Study of Pediatric
chronic stress associated with, 269 Psychopathology, 670
death due to, 210, 341 Centers for Disease Control and
defined, 175, 311 Prevention (CDC), 104–107
as global health issue, 253 ADHD treatment recommended by, 58
as pandemic, 216 agricultural safety initiatives by, 22–23
risks, lowering for, 165, 341 Air Pollution and Respiratory Health
care, access to, 99–102 Branch (see Air Pollution and
broadening, 17–18 Respiratory Health Branch (CDC))
children’s health, 114, 117 Association of Public Health
community health, 134 Laboratories (APHL) work with, 53
community organizing to address, 139 Association of State and Territorial
diabetes and, 164, 166 Health Officials (ASTHO) work with,
disparities, 137, 276–281, 285, 55
286–287, 387 bacterial-resistant illnesses reported by,
facilitating, 209 50
health literacy relationship to, 298–299 BMI data collected by, 87–88
helping people with limited, 136 child maltreatment addressed by, 113,
improving, 304 115
as leading health indicator, 383 collaboration with, 646
undocumented immigrants, 704–710 Commissioned Corps members in, 630
care, alleviating barriers to, 100 Community Health Program, 134–135
Career Development Center, 41 diabetes involvement, 166
care facilities, elder maltreatment in, 195, disability as defined by, 170
196–197 duties of, 699
caregivers, 33, 35–36 Emergency Operations Center (EOC),
Carmona, Richard H., 608, 630 207
738 INDEX
Centers for Disease Control (continued ) CFTR (cystic fibrosis transmembrane

emergency response role of, 208–209 conductance regular) gene, 249
expenditures, 284 Chadwick, Edwin, 109–112, 428–429
fluoridation studied by, 239 Chadwick’s Report, 110
flu protection measures recommended Chain, Ernst B., 482
by, 357, 358 change, resistance to, 302
food safety information disseminated change, stages in, 614
by, 246 channel as communication element,
foundation of, 512 281–282
handwashing recommendations charities and foundations, 253
by, 268 Charles II, King of England, 251
health as defined by, 594 Charles X, King of France, 121
health disparities reported by, 278 chemical injuries, 360
health education role of, 293–294 chemical residues, 246
healthy places information disseminated chemicals, harsh, 22
by, 308 Cherokee Nation v. Georgia, 346
HHS and, 629 Chicago, conditions in, 374
immigrant health regulated by, 344 Chicago World’s Fair, 1933, 104–105
immigrant service guidelines provided Child Abuse Prevention and Treatment
by, 343 Act (CAPTA), 113
information role of, 169 child behavior, 69, 243
injuries, combating by, 361 childbirth, 267, 397–404, 578, 654
pneumocystis carinii pneumonia (PCC) Childhelp National Child Abuse Hotline,
reported by, 188 115
polio eradication programs, 492 childhood, mental illness in, 421–422
prediabetes awareness role of, 165 childhood development, 63, 64, 243
public health emergency response, role childhood diseases, vaccinations against,
in, 78 353
quarantines, 520 childhood education, early, behavioral
on vaccinations, 691 health and, 70
violence prevention studies, 640 childhood experiences, intimate partner
waterborne diseases and, 646 violence linked to, 368
zombie preparedness, 665–668 childhood exposure to violence, 367
Centers for Medicare and Medicaid childhood mortality, decline in, 116
Services (CMS), 108, 406–407, childhood obesity
408–410, 629 beverages contributing to, 221
Center to Reduce Cancer Health causes of, 103–104
Disparities (CRCHD), 440 collaborations addressing, 130,
Central Board of Health (Great Britain), 131–132
112 community organizing to address, 139
central nervous system, 412–416 health policy impact on, 300–301
cephalosporins, 483 impact of, 123–124
cerebrospinal fluid (CSF), 413 investigating, 221
Certified Health Education Specialists prevalence of, 118
(CHES), 593 childhood screenings, early, increase in,
Certified in Public Health (CPH), 198
108–109 child labor, 373, 375, 376, 644
cervical cancer, 13, 153, 234, 279, 655 law and legislation, 113, 201, 375, 376
INDEX 739
child maltreatment, 113–116, 195–196, dental health, 160–161

336, 359, 639 early efforts in, 49
Child Protective Services (CPS), 113 free care programs, 100
children health care disparities, 286–287
air pollution impact on, 29 hygiene, 63
behavior, managing, 58 immunization and screenings, 198
diarrheal diseases, 645 law and legislation affecting, 201
with disabilities, 174 maternal health and, 163
emergency response, teaching about, oral health, 238–239
208 school health, 559–562
farm-associated dangers, exposure to, systems of care, 61
22 and welfare, 62–63, 64
farm work, involvement in, 23 Children’s Health Insurance Plan (CHIP),
food insecurity in, 243 15, 108
growth, 87 child sexual abuse, 113, 114, 336
handwashing benefits to, 268 Child Welfare Information Gateway
health education, 194, 293, 298, 299 website, 115
health insurance, 17 child welfare movement, 644
immigrant, 48, 63 chilling food, 246, 247
injuries to, 113–114, 116, 118, 326, chimpanzees, HIV/AIDS spread through,
327, 328 332
mortality, 327 China, medicine in, 45–46
obesity in, 465 Chinese physicians, code of ethics for, 127
physical activity guidelines, 486–487 Chisholm, Brock, 658
poisoning, 327 chlorination, 429
raising, cost of, 235 cholera, 119–123
respiratory infections in, 27 battling, 61–62
sex trafficking of, 336, 338 causal agents of, 377
as SNAP recipients, 244 epidemics, 47, 110, 112, 188, 213,
sports-related concussions, 598 428–429
tooth decay in, 471 epidemiology, 578–579
undocumented immigrants, 706 global warming role in, 253
vaccination pros and cons, 686–696 goal of eradicating, 122
vaccination rates for, 306 intervention, 362
war impact on, 201 mapping, 221–222
Women, Infant and Children (WIC) outbreaks, 55, 111
program, 627 as point source outbreak, 217
Children’s Aid Society, 48 resistance to, 271
Children’s Bureau spread of, 577
Child and Maternal Health Division, transmission of, 218, 252
200–201 choleragen toxin, 120
child maltreatment prevalence Chopin, Frédéric, 251
according to, 113 Christians, early, 176–177
neonatal studies, 190–191 Christie, Chris, 517
children’s health, 116–119 chromosomal disorders, 170
addressing, 273 chronic, degenerative diseases, caring for
behavioral health, 69 people with, 33, 36
challenges, 123–124 chronic bronchitis, 27
740 INDEX
chronic disease circadian rhythm, 340

defined, 123, 177 cirrhosis of liver, 19, 30, 70, 317
diabetes Type 2 overlapping with, 167 Citua, Inca purification festival of, 44–45
failure to diagnose or treat, 299 Civil Defense Measures for the Protection of
managing, 137 Children (Eliot), 201
preventing, 135, 284 Civilian Conservation Corps (CCC), 214,
rise in, 118 539
substance addiction impact on, 4 civil liberties, 127
chronic food insecurity, 243 civil rights, advancing, 139
chronic health problems, 171 Civil Rights Act, 1964, 41, 148, 174
chronic hepatitis, 317 civil rights movement, 89, 147, 148, 278,
chronic illness, 123–126 348
acute illness relationship to, 1 Civil Works Administration, 539
behavioral issues related to, 69 Clar, Alan, 625
as child maltreatment risk factor, 114 Clark, Taliaferro, 621
defined, 123 class action lawsuits, 699
depression in persons with, 124 Clean Air Act, 513
in Greek and Roman times, 260 Clean Air Acts, 27
management and adapting to, 125 clean energy, 212
as public health specialty, 163 Clean Indoor Air Act, 515
chronic obstructive pulmonary disease cleaning food, 246
(COPD) cleaning products, environmentally safe,
as air pollution-related disease, 27 28
causes of, 70 cleanliness in Judaism, 46
contributing factors, 210 clean water, 211, 213
defined, 175–176 Clean Water Act, 513
risks, lowering for, 341 Clifford Beers Clinic, 68
chronic respiratory diseases, 253 climate change
chronic stress, 269 cause of, 25
chronic traumatic encephalopathy (CTE), challenge presented by, 212
599 conditions leading to, 252
chronosystems, 587 health effects of, 27–28
Churchill, Harry Van Osdall, 160, 238 interventions for, 28–29, 211
Cigarette Advertising Code of 1964, 678 clinical ethics (defined), 127
cigarettes Clinton, Bill, 198, 199
advertising, 677–686, 683 Clinton Foundation, 254
deaths related to, 584 Clostridium botulinum, 246, 353
Master Settlement Agreement (MSA), Clostridium dificile, 51, 217
396–397 Clostridium perfringens, 245
tax revenues, 684–685 closure or maintenance (collaboration
cigarette smoking phase), 130, 131
by adolescents, 117–118, 226, 383 Cobb, William Montague, 148
adverse effects of, 226 cocaine, 4
e-cigarettes replacing, 229 Cochrane Collaboration, Office of Juvenile
heterosexual/cisgender and LGBT Justice and Delinquency Prevention
individuals compared, 386 (OJJDP), 230
prevention of, 5 code of ethics, 126–129. See also
reducing, 383–384 Hippocratic Oath
INDEX 741
Code of Medical Ethics (AMA), 39, 94 anthropogenic activity role in, 253
codes of medical ethics, 127, 224, 261, conquering, 354
323–324, 325 control, attempts at, 343–344
cod liver oil, 200 epidemics, 110, 219
cognition, 70 historic and current conditions, 252
cognitive behavioral therapy (CBT), 58, investigation of, 188
422 preventing transmission of, 213
cognitive theory, 275 risk factors, 1
cohort studies, 222 spread and transmission of, 55, 252,
colds, 1, 177, 268 354
Cold War, 239 surveillance of, 77
Cholera morbus (defined), 120–121 transmission, 706
collaborations, 130–133 workplace conditions role in, 375
challenges of, 143 communicable pathogens, 211
childhood obesity, addressing through, communication
302–303 competencies of, 151
developing, 273 degree in, 162
in disease prevention and health elements of, 281–282
promotion, 307–308 of health risks, 696–704
in global health, 252, 254 during military operations, 159
grants supporting, 258–259 patient safety and, 479–480
health care disparities addressed as public health core competency, 142,
through, 279 143
collaborative project, implementing and Communipaw, 575
evaluating, 131, 132 communities
college cafeterias, 147–148 advocacy for, 254
colon cancer, 19, 86, 249 defined, 133–134
colonial America, communicable disease empowering, 133
control in, 343–344 public health professional role in, 145
Colorado brown stain, 159–160, 237 rights of, 129
Colored Orphan Asylum, 575 community-based treatment or prevention
Columbia University, 185 programs, 100, 278
combustion emissions, 27 Community Clinical Oncology Program
comfort foods, 243 (CCOP), 440
Commissioned Corps of the U.S. Public community design and planning, 308,
Health Service, 607, 630–632 309, 310
Commission on Chronic Illness, 506 community dimensions of practice, 142,
Commission on Social Determinants of 143
Health, 585 community health, 133–136
Committee of Thirteen, 575 achieving, 127
committee on home nursing, 645 improving, 361
Committee on Publication Ethics (COPE), NHANES surveys, 443–444
593 practice, 162
common cold, 1, 177 as public health specialty, 163
common source outbreak, 217 community health centers (CHCs),
Commonwealth Foundation, 288 136–139
communicable diseases Community Health Initiatives, 135
as acute health problem, 2 community health partnerships, 135–136
742 INDEX
community health practices, 135 contagious illnesses, 46

community health profile, 309 continuity theory, 21
community health promotion programs, continuous source outbreak, 217
279 contraceptives. See also emergency
community initiatives, 226 contraception
community organizing, 139–141 access to, 234
Community Organizing for Obesity FDA-approved, 558
Prevention in Humboldt Park options, expanding, 236
(Co-Op HP), 140 pregnancies prevented by, 234
community violence, preventing, prescribing, 203–204
133–134 school distribution of, 198, 199
compassion, sense of, 387 contribution-based theory, 224–225
Comprehensive Alcohol Abuse and control as epidemic management tool,
Alcoholism Prevention, Treatment, 218, 219
and Rehabilitation Act, 605 cooking food, 246, 247
Comprehensive Environmental Response, cooperation, 130
Compensation, and Liability Act, 513 Cooperative Safety Congress, First
comprehensive school health programs (Milwaukee, Wis.), 23
(CSHPs), 559 coordinated approach, 140
Comstock Law, 556 coordination, 130
concern, identifying, 139 copepods, 354
conclusions, drawing, 220 copyright, 37
concussions, 598 core competencies in public health,
Condition of the Working Class in England in 141–146, 150, 162–163
1844 (Engels), 374 Cornely, Paul Bertau, 146–150
condoms, 203, 334 coronary artery disease, 311–312
conduct disorder, 57, 69 coronary heart disease (CHD), 289, 307
conference presentations, 258 corporate for-profit health organizations, 9
confidential health information, 296, 297 Corpus Hippocraticum, 325
confidentiality of information, 128, 250 cortisol levels, 12–13
congenital disorders or malformations, 25, cost effectiveness, 532–534
79–81, 217, 349–350 cost-of-living allowances (COLAs), 591
Connecticut Society for Mental Hygiene, cough etiquette, 354
68 coughing, germs spread through, 267
Consensus Conference, 594–595 Council for Higher Education
conservationism, 213–214 Accreditation (CHEA), 150–151
consistency with other research as Council of National Defense, 645
causality condition, 103 Council on Education for Public Health
Consolidated Appropriations Act of 2016, (CEPH), 109, 150–152, 162–163
610 Council on Linkages between Academia
Consolidated Omnibus Reconciliation Act and Public Health Practice, 142
(COBRA), 206 Council on Medical Education and
consumer goods, regulation of, 241 Hospitals (National Medical
consumer leagues, 376 Association), 148
Consumer Product Safety Commission, counseling, 6, 134
437 covariation between two factors, 103
Consumer Reports, 673 cowpox, 371, 572
consumer safety, 241–242 Cragin, Edward B., 395
INDEX 743
credibility, accreditation and, 510–511 Davis, Nathan Smith, 38–39

Crete, plumbing in, 45 DDT, 106
Crichton, Sir Alexander, 57 Dean, Henry Trendley, 159–162, 237, 238
crime, 32, 142–143 death, causes of
Crimean fever, 457 AIDS, 331
Crimean War, 1853–1856, 84 alcohol, 30, 31
criminal activity, child exposure to, 114 Alzheimer’s disease, 33
criminal investigations, 242 cancer, 97, 99
criminality, 250 carbon emissions, 27
Crisis & Emergency Risk Communication cardiovascular disease, 210, 341
(CERC), 78, 208, 209 chronic diseases, 123, 125
cross-cultural situations, 152 combustion emissions, xxx
cross-sectional studies, 222–223 communicable diseases, 306, 406
cryptosporidiosis (water diarrhea), 218 diabetes, 164
Cryptosporidium spp. (C. parvum), 647 diphtheria, 47
crystallized intelligence, 20 environmental factors, 210
cues to action, 275 global health challenges, 252–253
cultural competence, 101, 142, 143–144, hand hygiene, poor, 267–268
152–154 heart disease, 311, 312, 314, 315, 316
cultural practices, disease transmission home injuries, 326, 327
and, 217 improving, 125
cultural sensitivity training, 149 infants, 349, 350
cultural values, 100–101, 271 infections, 182
culture (defined), 153 infectious diseases, 352
cultures, diverse, 128, 151, 152 injuries, 259
Cumming, Hugh S., 608, 622 lifestyle and culture relationship to, 153
Cutter incident, 106, 154–157 liver disease, 317
Cutter Laboratories, Berkeley, CA, maternal and infant deaths, 399
155–156, 553 premature births, 191
Cuyahoga River, fires on, 214 sexually transmitted diseases, 322
cyberbullying, 231 sleep-related, 329
cystic fibrosis, 120, 249–250, 272 smallpox, 687
stroke, 313
dairy foods, 461, 469–470 tobacco use, 383
Daraprim, 669–670 violence-related, 329
Dartmouth Atlas Project, 288 women, 314
Darwin, Charles, 587 work-related, 361
DASH (dietary approaches to stop young Americans, 31
hypertension) eating plan, 341, 342 death of loved ones, 65–66, 68, 69
data death of spouse, 21
collecting, 74–75, 135, 221, 222, 227, death records, 512
453, 531 decayed, missing, or filled teeth (DMFT),
constructing, analyzing, and 159, 161
interpreting, 74–75, 220 decisional balance, 275
conversion of, 531 decision making, balance in, 614
Davies, John, 322 Declaration of Helsinki (1964), 516
Davies-Hinton test, 322 Declaration of Human Rights (U.N.), 536
Davis, Miles, 251 deflazacort, 670
744 INDEX
deforestation, 218, 253, 353 desert, justice as, 224

degrees in public health, 146, 151, destination as communication element,
162–164 282
dehydroepiandrosterone (DHEA), 20 Deter, Frau Auguste, 33–34
de-identified data, 297 detoxification, 6
delivery activities, 391 developed countries, 53, 254
Delta Omega Honorary Society in Public developing countries, 53, 252, 254
Health, 163 development activities, 390–391
delusions, 65, 66 developmental disabilities, 25
dementia, 21, 69, 196 developmental disorders, 170
dengue, 77, 253 diabetes
dental care, 137 causes of, 70
dental fluorosis, 238 in children, 118
dental health, 163 complications of, 124, 170
dentistry, 159–161 cystic fibrosis-related, 249–250
Department of Agriculture, 241, 242 failure to diagnose or treat, 299
Department of Health, Education and as global health issue, 253
Welfare (HEW), 241 as heart disease risk factor, 311
Department of Health and Human as heat-related illness risk factor, 24
Services (DHHS), 241, 297, 640 lifestyle changes for persons with, 124
Department of Health and Human managing, 137
Services, Office of Minority Health, people with and without disabilities
153, 278, 279 compared, 171
Department of Homeland Security, 78, prevalence of, 118, 124–125
209, 343 reducing, 165
Department of Justice, 43, 233 risk factors for, 124, 165, 340
Department of Transportation, 43 risks, lowering for, 341
dependency theory, 196 uncontrolled, health complications of,
dependent abusers, 196 165–166
dependent children, health insurance for, diabetes mellitus, 164–167
17 diabetes Type 1, 118, 164–165, 167
depression diabetes Type 2, 86, 118, 124, 164–165,
ADHD accompanied by, 57 167
in ancient Greek medicine, 324 diagnosis, 261, 323, 324
behaviors related to, 69 Diagnostic and Statistical Manual of Mental
chronic illness leading to, 124, 125 Disorders (DSM), 57–58, 177,
examples of, 65–66 385–386, 421
exercise, excessive associated with, diarrhea
270 as acute illness, 1
in Greek and Roman times, 260 in cholera, 119, 120
HIV/AIDS as factor in, 333 deaths due to, 645
LGBT individuals at risk for, 385, 386 reducing, 51–52, 268
people with and without disabilities diastolic pressure, 339–340, 341
compared, 170–171 DiClemente, Carlo C., 613
in persons with adverse childhood diet
experiences (ACEs), 14 diabetes management through, 166
depression, worldwide economic, 185 diabetes risks, reducing through, 165
depressive disorders, 421 heart disease and, 311
INDEX 745
hypertension and, 340, 341 prevention of, 62, 92, 104, 107,
obesity and, 466 141–142, 260, 274, 275
Dietary and Supplement Health and protection during, 100
Education Act, 1994, 242 reducing, 135
dietary supplements, 242 resistance against, 271
diffusion of innovations theory, 167–170, risk factors for, 102, 104
283, 294 screening, 153, 169
diphtheria, 47, 61–62, 123, 156, 380 spread of, 218, 261
direct contact (defined), 354 surveillance and mitigation, 254, 571
disability, 170–172 transmission, 217, 706
defined, 170, 174 treatment of, 99, 153, 154
obesity and, 465 disease-carrying vectors, 27, 213
prevalence of, 171 disenfranchised people, 128, 187
prevention of, 92, 326 disengagement theory, 21
protection during, 100 disordered eating, 243, 245, 256
as socially constructed condition, Disproportionate Share Hospitals (DSHs),
270–271 407
stroke as cause of, 313 dissection, 325
women with, 656 dissemination as collaboration phase, 130,
disability movement, 173–175 131, 132
disabled person (defined), 42. See also distributive justice, 224–225
people with disabilities (PWD) diversity, 172
disabled workers and widows, 111–112 diversity and culture, 128, 151, 152
disaster, recovery after, 209 Divine Husbandman’s Materia Medica (Ben
disaster assistance, 243–244 cao jing ji zhu) (Shennong), 46
Disaster Distress Helpline, 209 Division of Global Migration and
disaster preparedness, 107, 212 Quarantine, Centers for Disease
disaster response, 106, 207, 208 Control and Prevention (CDC), 344
discrimination, 63, 69, 149, 278, 585 Division of Strategic National Stockpile,
disease, 175–178 75, 207
in ancient world, 44 divorce, 21
campaigns, 274–275 Dix, Dorothea Lynde, 64, 178–183
categories of, 177 DNA damage, 98
causes of, 104, 127, 222, 260 doctoral degrees in public health, 146,
classification as, 176, 177–178 163
contagion theory of, 527 Doctors Without Borders, 520
defined, 176 Doll, Richard, 662
detection of, 99, 153 domestic violence (DV), 13, 366,
disparities, reducing, 137 368–369
early diagnosis of, 154 donepezil, 35
factors influencing, 271 “do no harm” (Greek maxim), 72
germ theory of, 378 Donora, Pa. smog incident, 1948, 26
management, 275 dopamine, 4
mapping, 220, 221–222 dose-response relationship, 103
outbreaks, 220 Downing, George, 574
pathogen association with, 377, Down syndrome, 80–81
378–379 dracunculiasis medinensis, 353
predisposition to, 249 Drew, Charles Richard, 183–187
746 INDEX
drinking, 69 Earth Day, 214

drinking water, 211, 213, 237, 429 eating
Dritz, Selma Kaderman, 187–190 disordered, 243, 245, 256
driver licensing, 533 promoting healthy, 135, 169, 302
driving, 33 Eating, Aesthetic Feminine Models and the
driving under the influence, 31 Media (program), 194
drought, 29 eating disorders, 166, 193–195, 270
drug legalization, 198, 199 ebola epidemic, 631
drug paraphernalia, 611 Ebola virus
drug poisoning, 503 bioterrorism role in, 77
drug price regulation, 669–671, 672–677 as global health issue, 251
drug resistance, 56, 352 outbreaks, 107
drug-resistant (MDR) bacteria, 50, 51 pandemic, 473
drugs response to, 516–517
marketing of, 673 spread of, 217, 252
regulation of, 241, 242 e-cigarettes, 118, 229
in utero exposure to, 170 ecogenetics, 249
drug screens, random, 6 E. coli
drug testing, laws concerning, 43 bioterrorism role in, 77
drug use as pathogenic contaminant, 245
as birth defect risk factor, 350 transmission of, 218, 646
child exposure to, 114 ecological model, social, 586–589
consequences of, 13 ecology, 214
heterosexual/cisgender and LGBT economic abuse, 655
individuals compared, 387 economic disparity, 111, 149
illegal, 43 economic problems, 24
prevalence of, 3 Edison, Thomas, 131
psychological and social aspects of, 6 education, oral health and, 471
stress in home due to, 114 educational attainment, 299
drunk driving penalties, 31 educational diagnosis, 501
dual degree programs, 163 educational neglect (defined), 114
Du Bois, W. E. B., 89 education programs, 134, 254
Dunham, Ethel Collins, 190–192, 200, Egypt, ancient, 46, 97
202 Ehrlich, Paul, 380
Dunn, William, 482 Ehrlich, S. Paul, 608
Durkheim, Emile, 584–585 eight-hour workday, 375, 376
“duty to disclose,” 699 Eijkman, Christian, 380
dysentery, 61, 218 Einstein, Albert, 270
elderly
ear infections, 1, 50 behaviors, managing, 69
early adopters (in diffusion of innovations burns, 328
theory), 168 disability in, 171
Early and Periodic Screening, Diagnosis, diseases of, 19
and Treatment (EPSDT) program, falls, 327, 360, 361, 442
407 health care disparities, 287
early majority adopters (in diffusion of health services for, 108
innovations theory), 168–169 home health care for, 18
early neonatal mortality (defined), 349 home injuries to, 326
INDEX 747
life disruptions experienced by, 21 encephalitis (inflammation of the brain),

memory improvement techniques for, 355
20 endemic (defined), 216
elder maltreatment, 195–197, 639 endemic diseases, 252
Elders, Joycelyn, 198–199, 608 end-of-life care, 273, 286–287
electrical injuries, 360 Engels, Frederick, 374
electric shock, heart attack treatment with, Enterobacteriaceae, 51
307 enteroviruses, 491
electrolytes environment
balance, 184 defined, 271
cholera impact on, 120, 122 definition of, 580
eating disorder impact on, 193, 194 embryo and fetal development affected
therapy, 122 by, 79–80
electromagnetic drugs, 240–241 health impact of, 26
electronic cigarettes, 118, 229 monitoring, 25
electronic devices, disposal of, 212 natural and built, 584
Electronic Health Record (EHR), 100 social ecological model, 586–589
Eliot, Martha May, 190, 191, 199–202 environmental barriers, 174
Eliot, T. S., 200 environmental change, 342
Ellertson, Charlotte Ehrengard, 203–205 environmental contaminants, 116
El Mirador, Guatemala, urban planning environmental degradation, 213
for, 45 environmental hazards, 54, 209, 350
Emancipation Day celebrations, 574 environmental health, 163, 210–212,
embryo development, 79–8 246, 271
emergency contraception, 203, 204 environmental health sciences, 108–109,
emergency departments, 205, 206 151
Emergency Maternity and Infant Care environmental movement, 213, 214
Program (EMIC), 201, 278 Environmental Protection Agency (EPA),
emergency medical condition, 206 213–216
Emergency Medical Treatment and Association of Public Health
Labor Act (EMTALA), 205–207, Laboratories (APHL) work with, 53
279, 344 creation of, 437
Emergency Operations Center (EOC), 207 duties of, 699
emergency preparedness and response, food safety role of, 246
163, 207–210, 208 greenhouse gas emissions monitored by,
emergency rooms, 639, 709 211
emergency services, 17, 299 mold spore prevention guidelines
emerging diseases, 221, 306 provided by, 177
emotional abuse, 113, 114, 195, 197 enzyme therapy, 19
emotional coping, 580 epidemic, 216–220
emotional health (defined), 269 controlling, 55
emotional neglect, 114 defined, 216
empathy, sense of, 387 as global challenge, 252
emphysema, 27 horrors of, 61
employees, motivation of, 255–256 tracking, 512
employers of persons with disabilities, urban, 47
42–43 epidemiological diagnosis, 501
enactment of policy, 301–302 epidemiologic study, 220, 222, 238
748 INDEX
epidemiology, 220–223 of parks and trails, 309

CDC involvement in, 106 of policy, 302
collaborations in, 187 PRECEDE-PROCEED planning model,
courses in, 151 501–502
creation of, 353 evergreening, 670–671
defined, 220 evidence-based medicine, 230
expertise in, 162 evidence-based principles, 135
knowledge required in, 108–109 evidence-based programs and practices,
as public health specialty, 163 230–232
purpose of, 141 addiction, combating through, 5
in the Renaissance, 526 for ADHD, 58–59
shoe leather, 183, 187, 265 community health, promoting through,
start of, 92, 121–122 134
violence studies, 640 creating, 142
epilepsy, 65, 124, 260, 324 databases of, 293–294
EpiPen, 670 diabetes, combating through, 165, 166
Equal Employment Opportunity eating disorder prevention through,
Commission (EEOC), 43 194
Escherichia coli evaluation of, 280
bioterrorism role in, 77 in family planning, 204
as pathogenic contaminant, 245 in health education, 292
transmission of, 218, 646 injuries, combating through, 360, 361
estrogen, 20 in intervention, 363–364, 365
Etaples military base, France, 356 in maternal and infant care, 351
ethical dilemmas, 127, 128–129, 239–240 promoting, 163
ethical misconduct, 73 in public communication, 208
ethical practice, 128 exercise. See physical activity
ethical standards, 292 exosystems, 587
ethics, 128, 533–534 expectancies (defined), 580
ethics in public health, 127, 223–226 Experiences and Impressions (Anderson), 48
ethnic groups, 153 experimental study design, 222
ethnic minorities extended spectrum ant Candida, 51
government institution treatment of, extreme weather events, 27, 29, 243
149 eye exams, 360
health care disparities, 285–286
as vulnerable groups, 225 factory, time and motion in, 255
ethnography, 183 factory inspections, 241
etiology, 102 fact sheets, online, 208
eugenics, 63, 251 Fahlberg, Constantin, 102
European immigrants, 48, 346, 348 failed diffusion, 169
euthanasia, 127 failures, communicating, 131, 144–145
evacuation warnings, 697 Fair Labor Standards Act (FLSA), 113,
evaluation, 226–229 201, 515, 536
of evidence-based programs, 230–231, faith-based neighborhood partnerships
280 (FBNP), 626
of health communications, 283 falls
in health education, 291, 292–293 alcohol role in, 30–31
of intervention, 363, 364–365 prevalence of, 359
INDEX 749
preventing, 326, 327 Federal Trade Commission (FTC), 43

rate of (for farm workers), 24 fee-for-service payment structures, 125,
reducing risk of, 360–361 126
False Claims Act (FCA), 233–234, 601 female-headed households, 243
Families and Schools Acting together fermentation, 476
(FAST), 640 fetal alcohol syndrome (FAS), 32, 80, 170
families below poverty line, financial fetus development, 30, 79–80
assistance to, 243–244 fever, causes and prevention measures,
Family and Medical Leave Act (FMLA), 111
401 fidelity of implementation, 228
family discord, behavioral issues related Fighting for Life (Baker), 61
to, 69 financial abuse, 195
family history as diabetes risk factor, 165 financial planning and management, 142,
Family Limitation (Sanger), 235, 236, 557 145
family planning, 203, 204, 234–237, 252, Finish It campaign, 618
400–401 fire, 326, 328
Family Planning Services and Population firearm injury prevention research, 259
Act, 1970, 235 fireworks safety, 296
family relationship dynamics, 196 First Amendment, 683
family size, change in, 235 fishers, 22
Family Smoking Prevention and Tobacco Fleming, Alexander, 482
Control Act, 684 Flexnor, Simon, 263
family violence, 130, 234–235 Flint, Mich. water supply, lead
famine, 44 contamination in, 107
famine relief, 106 floods, cleaning up after, 177
farmers, 22, 23 Flory, Howard, 482
farm fatalities, 23 flossing, 275, 470
farm safety, 22–25 fluid intelligence, 20
Farm Service Agency (FSA), 626 fluids, 184, 193, 194
farm workers, 24 fluoridation, 159, 171, 237–240, 362
fast food, 103–104, 301, 302 fluoride, 161, 239
fast food industry, 679 fluoride treatment, 469–470
Fatality Analysis Reporting System fluorosis (term), 161
(FARS), 433 Fluorosis Index, 161
Federal Child Abuse Prevention and flu pandemic, 1918, 356
Treatment Act (CAPTA), 113 flush toilets, 45, 110
Federal Children’s Bureau, 376, 644 folic acid supplementation, 80
Federal Cigarette Labeling and Advertising food, contaminated, recall of, 253
Act, 608 Food, Drug, and Cosmetic Act, 1938, 241
Federal Drug Administration, 50, 558 Food, Nutrition, and Consumer Services
Federal Emergency Relief Administration, (FNS), 627
539 Food and Drug Administration (FDA),
Federal Insurance Contributions Act 240–242
(FICA) taxes, 590 Association of Public Health
Federal Meat Inspection Act, 512, 627 Laboratories (APHL) work with, 53
Federal Office of Rural Health Policy Commissioned Corps members in, 630
(FORHP), 305, 545 drugs approved or refused by, 80
Federal Security Agency, 241 food, contaminated recalled by, 253
750 INDEX
Food and Drug Administration (continued ) formation, 130, 132, 139

food safety information disseminated formative evaluations, 227–228
by, 246 fossil fuels, 25, 253
health information shared with, 297 4H chapters, 23
HHS and, 629 fracture, reducing risk of, 360
prescription drugs, 503 Framingham Heart Study, 513, 662–663
tobacco products and, 684 fraud, reporting, 233
Wiley Act, 635 Freedman’s Hospital, 184, 185
Food and Nutrition Services, 626 freedom of choice, vaccinations and,
Food-A-Pedia website, 462 689–690
food borne illnesses free radical theory, 19
conditions leading to, 252 free radical therapy, 19
cost of, 246 free speech, 683
as global health challenge, 253 French and Indian War, 76
preventing, 245 Freud, Sigmund, 587
preventive measures, 627 Fugitive Slave Act, 1850, 93, 575
study of, 246 full body skin examination (FBSE), 568
food chemistry, 102 Fuller, Bridget Lee, 398
food distribution programs functional activity, 272
pros and cons, 243–245 functional disability, 193, 194
food hazards, protection from, 54 fungal meningitis, 414
food industry, advertising by, 284 Future Farmers of America (FFA), 23
food insecurity, 44, 243–245, 256, 627 The Future of Public Health (IOM), 172
food poisoning, 1, 217, 245 The Future of Public’s Health in the
food preparation, 51, 147–148 21st Century (IOM), 172, 273–274,
foods, healthy 509
access to, 302
food safety, 245–247 Gagge, A. Pharo, 651
as global health challenge, 253 galactosemia, 250
inspections, 141–142, 146, 246 galantamine, 35
as public health specialty, 163 gallstones, 86
Food Safety and Inspection Service (FSIS), Galson, Steven K., 608
246, 626, 627 gametes, cell division errors in, 80–81
food stamps, 243–244, 245, 278, 546, Ganges River delta, cholera in, 120
627 garment industry, 374–376
food storage, 247 Garnet, Henry Highland, 574
Food Tracker website, 462 Garrison, William Lloyd, 93
football, 597 gastrointestinal problems, 249–250
football players, 223 gays
forced termination, 347, 348 health education for, 189
forceful and repetitive motions, 24 HIV/AIDS and risks to, 333, 334
forecasting as epidemic management tool, in San Francisco, 187, 188
218, 219 sexual practices of, 188
foreign language interpreter services, 153 G.D. Searle Pharmaceutical Company, 558
Foreign Policy Association, 645 gender
Forest Service (FS), 626 barriers, breaking, 82–83, 85, 202
forgetfulness, normal, 33 BMI standardized to, 87
formal evaluations, 227 body fat variation by, 87
INDEX 751
hypertension and, 340 Global Polio Eradication Initiative, 492,

life expectancy differences by, 416 553
sensitivity to, 101 Global Programme on AIDS, 189
gender discrimination, 63 Global Service Centre, 658
“gender dysphoria” (term), 386 global warming
gender identity, 388 challenge presented by, 212
gender violence, eliminating, 203 diseases related to, 25
general information, 208 global health threatened by, 253
generalist health administrators, 9–10 impact of, 29, 211, 213
General Motors (GM), 436 motor vehicle traffic as factor in, 308
generational forgetting, 447 reducing, 309
generic drugs, 242, 674–675 response to, 211
generic medications, 503–504 glucose, 164–165, 166
genes, mutations in, 97 goals (defined), 255, 292
gene therapy, 169 goals, achieving, 390
genetically modified organisms (GMOs), goals, setting, 291, 300, 306
702–703 goals and objectives, 255–257, 283, 292,
genetic disorders, 170, 271 306
genetic hazards, protection from, 54 goal setting theory (GST), 256
genetic mutations, disorders due to, 249 gonorrhea, 188
genetics, 163, 249–251, 271 Good Behavior Game, 228
genetic screening, 250, 251 Gordon, Robert S., Jr., 507
Geneva Medical College, 82 The Gospel of Wealth (Carnegie), 48
geographic and place factors in health Gottsdanker Anne, 156
disparities, 288–289 government, public health role of, 49
geographic isolation, 136 government, suit on behalf of, 233
geography, diseases influenced by, 217, government grants, public announcement
271 of, 258
Georgia Warm Springs Foundation, government-owned health system, 9
537–538 graduate degree in public health, 163
germs, 267, 268, 357, 378 Graham, Evarts, 661
germ theory, 213 grains, 460
gestational diabetes, 145, 165 granaries, 45
Get Real (Planned Parenthood), 489 grants, 258–260
Giardia, 647 Graunt, John, 528
giardiasis, 647 Gray, James B., 93
Gin, Chick, 520 Great Britain, economic conditions in,
gingivitis, 161 109–112
Gini coefficients, 583 Great Depression
GLAMA! (Girls! Lead! Achieve! Mentor! academic disciplines in wake of, 269
Activate!), 524 government programs spurred by, 278,
global disease prevention, 104 539–540
global environment, 214 immigrant-African American relations
Global Fund, 252 during, 147
global health, 54, 163, 251–255, 273, life expectancy during, 408–409
305 Social Security Act and, 589
Global Health Security Agenda, 252 Great Famine of 1315–1322, 426
globalization, 218, 353 Great Famine of Ireland, 1845–1852, 83
752 INDEX
Great Plains smallpox epidemic, 218 Harriet, the Moses of Her People (Bradford),
Greco-Roman era, public health in, 619
260–262 Hartner, Noble, 255
greed, 176 Harvard Injury Control Research Center,
Greeks, ancient 329
homosexuality, attitudes concerning, Harvard School of Medicine, 200,
176 265–266, 321, 322
humor imbalance, beliefs concerning, Harvard School of Public Health, 201
120–121 “have-nots,” economic opportunities for,
medicine, 323–326 139
philosopher-physicians, 260–261, Hawking, Stephen, 172
324–325 Haymarket massacre, 1886, 374
public health started by, 324–325 Haynie, James A., 277–278
rickets knowledge in, 200 hazardous biological materials, 207, 208
greenhouse gas (GHG) emissions, 211 hazardous substances, 53, 210
Green Party USA, 437 hazardous wastes (defined), 211
green vehicles, 28 hazards, exposure to, 212
grocery stores, inspections of, 246 Heads Up center, 599
ground and surface water, 211 HEADS UP series, 442
group dynamics, 587 HEAL (Healthy Eating, Active Living)
group health, preserving, 133 program, 135
groups, at-risk. See at-risk groups health, 269–272
group therapy, 230 attitudes toward, 152
growth hormone therapy, 19–20 defined, 176
Guillain-barre syndrome, 646 improving, 135
guinea worm disease (GWD), 352–353, measuring, challenge of, 271–272
354 people with and without disabilities
gum disease, 469–471 compared, 173
guns, 259, 640 requirements for, 127
gun safety, 326, 329 social determinants of, 250
socioeconomic-cultural determinants
H1N1 aviation influenza A, 356, 357 of, 271
H1N1 virus pandemic, 473 studies of prayer and, 596
H3N2 aviation influenza A, 357 Health Action in Crisis team, 659
Haddon, William, Jr., 431 health administration, 7–11, 8–9, 162, 163
Haemophilus influenza, 414 health advancements, 167–168
Haitian earthquake, 631 health advisories (warnings), 208
Hamilton, Alice, 263–266, 374 Health Alert Network (HAM), 77–78, 208
Hamilton, John B., 607 health alerts (high priority), 208
Hammurabi, Law Code of, 46, 127 Health and Medicine Division, National
hand hygiene, 267–268 Academies of Sciences, Engineering,
handicapped. See people with disabilities and Medicine, 272–274. See also
(PWD) Institute of Medicine (IOM)
handwashing, 51–52, 267–269, 354, 355 health behaviors
Hansen, Gerhard, 380 changing, 227, 306, 363–364, 365,
Harappan civilization, 45, 46 613–615
hardship (defined), 42 culture influence on, 152
Harlem Legal Aid Society, 49 factors influencing, 226, 294
INDEX 753
health behavior theory, 314 health-conscious culture, 224

health belief model, 274–276, 283, 294, health department accreditation, 508–511
314, 364 health departments, 602–604
health care health disparities, 285–291
access to (see care, access to) defined, 276, 285
child well-being connection to, 114 dental health, 239
disparities, 137, 276–281, 285, health care disparities relationship to,
286–287, 387 276–277
employer provision of, 344 for people with disabilities, 171–172
federal funds for, 373, 376 race and ethnicity based, 153, 301
racial discrimination in, 148, 149 reducing, 135, 137, 224, 305
health care-associated infections (HAI), sexual orientation-based, 386–387
55–56, 480 health education, 291–295
Healthcare Cost and Utilization Project, 581 advocacy of, 298
health care costs biostatistics in, 73–74
alcohol use impact on, 31–32 as cue to action, 275
health literacy association with, 299 early efforts in, 62–63
payment structures, 125, 126 eating disorder prevention through, 1
reducing, 64 94
United States and other countries health literacy incorporated into, 299
compared, 307 as public health specialty, 163
health care decisions, 100–101, 274, 298 school-based, 560–561
health care delivery models, 125 Health Education Curriculum Analysis
health care facilities, patient information Tool (HECAT), 294
maintained by, 297 health equity (defined), 288
Health Care Financing Administration health impact assessment (HIA),
(HCFA), 108 309–310
health care operations and services, health indicators (defined), 383
managing, 9 health inequalities (term), 286
health care organizations, patient safety health information
and, 481 acting on, 298
health care practitioners, management CDC publications, 107
skills of, 8–9 disseminating, 299
health care professionals in ancient world, journals and books compared, 37
45 law and legislation, 295–297
health care programs, federally sponsored, reading, understanding, and critiquing,
108 143
health care reform, 39. See also Affordable risks, communication about, 696–704
Care Act (ACA) health information management, 163,
Healthcare Research and Quality, 1999, 295
286 health information managers, 10–11
health care services, 10, 273 health insurance. See also Affordable Care
Healthcare Systems Bureau (HSB), 304 Act (ACA)
health communication, 162, 208, 281–285, for children, 15, 108, 117
299 coverage, social determinants of, 351
Health Communication Division, industry, 17
American Public Health Association subsidies, 100
(APHA), 283 universal, 17
754 INDEX
Health Insurance for the Aged (Medicare) health topics, reviewing previous studies
Act, 406 on, 220
Health Insurance Marketplace programs, health updates, 208
108 healthy behaviors, engaging in, 342
Health Insurance Portability and Healthy People, 468, 560, 640
Accountability Act (HIPAA), 11, Healthy People, 1979, 302, 306
295–297 Healthy People 2000, 306
health insurance programs, employer- Healthy People 2010, 283, 287, 288, 306
sponsored, 100 Healthy People 2020, 306–308
health literacy, 39, 270, 291, 298, chronic disease prevention in, 125
298–300 diabetes addressed in, 164, 166
health opinions, changes in, 391 family planning objectives, 235–236
Health Organization of the League of flu vaccines covered in, 358
Nations, 658 goals and objectives, challenge of
health plan communications, 298 meeting, 145
health policy, 300–304 grants covered in, 258
biostatistics applied to, 73–74 health care disparity elimination as goal
career in, 162 of, 287–288
defined, 300 leading health indicators described in,
health promotion including, 291 383
and management, 109 LGBT health addressed in, 385
reform, 15–18 (see also Affordable Care Objective SH-4, 445
Act (ACA)) ten-year objectives, 256–257
health problems healthy places, 308–311
adverse childhood experiences (ACEs) heart attack
associated with, 11, 12, 13 causes of, 312
collaboration to address, 133 early warning signs, 307
health professionals, information sources filtered tunnel impact on, 310
for, 38 risk factors for, 342
health program, aims of, 257 treatment, 307
Health Promoters, 279–280 heart damage, 1
health promotion, 107, 291 heart defects, 311
Health Promotion Practice (SOPHE), 593 heart disease, 311–314
health records, computerization of, 295 as air pollution health effect, 25
health-related behaviors, 443 alcohol linked to, 30
Health Resources and Services defined, 311
Administration (HRSA), 53, 137, diabetes as factor in, 164, 165–166
304–306, 629 failure to diagnose or treat, 299
health risk information, 700 goals and objectives concerning, 307
health services administration, 151 high BMI associated with, 86
health system lifestyle changes for persons with, 124
improving, 224, 225 NHLBI and, 444–446
policy impact on, 300 nutrition and, 461
strengthening, 252, 254 people with and without disabilities
in United States, 15–18 (see also compared, 171
Affordable Care Act (ACA)) preventing and reducing, 125, 314–316
health threats, monitoring and detecting, races compared, 289
53 risk factors for, 124
INDEX 755
risks, lowering for, 103, 341 high blood sugar level, 165
weight connection to, 86 high-density lipoprotein (HDL) levels,
heart palpitations, 315 465
heart rhythm problems (arrhythmias), high-risk communities, programs for, 88
311, 312–313 high-risk sexuality, 13
Heart Truth® Campaign, 445 high school students, tobacco use by,
Heart Truth® (Red Dress) Campaign, 118
314–316 Highway Safety Act, 515
heat exposure, 23–24 Hill, Bradford, 662
Heath Education & Behavior (SOPHE), 593 Hill-Burton Act, 551
heat-related illnesses, 24 Hindu physicians, code of ethics for,
heat stress, 25 127
Hebrew Oath of Asaph, 127 Hinton, William Augustus, 321–323
Hell’s Kitchen, New York, 61–62 Hippocrates, 323–326
hemochromatosis, 249 cancer references, 97, 98
hemophilia, 249 as Father of Western Medicine, 261,
hemorrhagic fevers, 473 324
hemorrhagic stroke, 30, 313 on illness causes, 25–26, 389
Henderson, Charles, 265 medical science and, 594
Henle, Friedrich Gustgav Jakob, 378 meningitis described by, 413
Henry Street Settlement, 49, 376, 643 Hippocratic Corpus, 325
Henry Street Visiting Nurses Service, Hippocratic Oath, 127, 224, 261,
643 323–324, 325
hepatitis, 13, 70, 279, 317–320 Hippocratic principles of medicine, 262
hepatitis A virus (HAV) Hispanic adolescents, birth rates for, 117
bioterrorism role in, 77 Hispanics
overview of, 317 demographic trends, 280
prevention of, 318 diabetes risks, 165
sources of, 647 health care for, 287
untreated resolution of, 319 heart disease, 311
vaccination against, 320 obesity in, 301
hepatitis B virus (HBV), 317, 318, 319, The History of Miners’ Diseases (Rosen),
320, 609–610 543
hepatitis C virus (HCV), 252, 317, 318, Hitler, Adolf, 177
319, 609–610 HIV/AIDS. See human immunodeficiency
hepatitis D, 319 virus (HIV)/acquired immune
HER-2-positive genetic profile, 250–251 deficiency syndrome (AIDS)
Herbert, Sidney, 456 HIV/AIDS Bureau (HAB), 305
herd immunity (defined), 218–219, 633 Hoffmann, Dietrich, 662
heroic treatment of mental illness, 180 holistic care, 1–2
heroin, 4, 130 holistic health, 594
Hess, Fannie, 378 Holmes, Oliver Wendell, Sr., 92, 267
Hess, Walther, 378 home energy use, reducing, 28
heterosexual biases, 202 home health care, 18
heterosexual/cisgender individuals, LGBT homelessness, 136, 422
individuals compared to, 386 home nursing, 645
Hickox, Kaci, 516, 520 Home Owners’ Loan Corporation, 539
high blood pressure, 124, 137, 165, 311 home safety, 326–331
756 INDEX
homicides human immunodeficiency virus (HIV)/

alcohol role in, 31 acquired immune deficiency
decrease in, 306 syndrome (AIDS), 331–336
guns and, 329, 640 in Africa, 252–253
health disparities reported by, birth defects caused by, 350
278–279 cause of, 103
by intimate partners, 367 discrimination against people with,
rates, 583, 640 296, 333–334
homosexuality heterosexual/cisgender and LGBT
attitudes concerning, 176–177, individuals compared, 387
385–386 investigation of, 187
disease classification, 176, 177–178, as pandemic, 216
385–386 protection against, 203
honeymoon periods, 447 races compared, 278–279
hookahs, 118 risk factors, 13
Hoover, J. Edgar, 535 testing and counseling, 199
Hoover Commission, 347 transmission of, 187, 252
Horsfall, Frank, 662 treatment, 100, 137
hospital-acquired infections, 56 vulnerable populations, 386
hospital business operation and humanitarian crises, 631
administration, 10 human papillomavirus (HPV), 655
hospitalization, 299, 581 human papillomavirus (HPV) vaccine,
host, entry and exit from, 354 124
host, susceptibility of, 216–217 human participants in research, rights of,
hostile abusers, 196 71
hotlines (for intimate partner violence), human research, ethical guidelines for,
368–369 71–73
household plumbing, 45 human resources for people with
household pollutants, 210–211 disabilities, 172
household products, 25 human resources management, 100
housing, 109–110, 114 human rights, 127
housing support services, 137 human sacrifices, 44
Howard University, 147 human trafficking, 336–339
Howard University School of Medicine, Humboldt Park community, 140
184, 185 humidity, increased, impact of, 29
Howe, Samuel Gridley, 94, 179, 180, humoral theory, 260, 324
181 humors, imbalance of, 120
Howland, John, 190 Humphrey, Hubert, 409
HPV, 655 hunger-obesity paradox, 243
HPV vaccine, 124 Hunter, John, 371
Huang Di, Chinese Emperor, 46 Hunter, William, 399–400
Hughes Act, 605 hunter-gatherer societies, 44
Hull House, 263–264, 266, 374 hunters, work-related deaths among, 22
human growth hormone (HGH), 20 Huntington’s disease, 249
human immunodeficiency virus (HIV), Hurricane Katrina, 2005, 78, 631, 697
473 hurricanes, cleaning up after, 177
rates in women, 655–656 Hurricane Sandy, 2012, 78, 631
syringe service programs and, 609 Hussein, Saddam, 77
INDE X 757
hybrid seed corn, adoption of new, immune system

168 compromised, 51, 354
hydration, 340, 470 development, 114
hydrofracturing, 702 diseases affecting (see acquired immune
hygiene deficiency syndrome (AIDS); human
for African Americans, 148 immunodeficiency virus (HIV)/
in ancient Rome, 260, 261 acquired immune deficiency
benefits of, 355 syndrome (AIDS))
better, 123 enhancing, 354
education in, 219 handwashing for people with, 268
during food preparation, 51 optimizing, 358
hand hygiene, 267–268 vaccine impact on, 633
hypothesis, 271 immunization
pathogen interruption through, 354 advances in, 219
hyperglycemia, 166 at community health centers, 137
hyperkinetic disease of infancy, 57 as global health intervention, 254
hyperkinetic reaction of childhood (or monitoring rates of, 218–219
adolescence), 57–58 rise of, 198
hypertension (HTN), 339–342 immunocompromised patients, antibiotic
causes of, 70 resistance in, 51, 56
chronic stress associated with, 269 immunology, 380
high BMI associated with, 86 impact evaluation, 228, 501
people with and without disabilities Impact Melanoma, 569
compared, 171 impairment as disability level, 171
risk factors for, 340, 341 impetigo, 51
screening for, 234 implementation
hypertensive crisis (defined), 340 in health education, 291, 292
hypochondria, 65, 66 of intervention, 363, 364
hypoglycemia, 166 of policy, 302
hypothyroidism, congenital, 250 inability (defined), 171, 270
inactivated poliovirus vaccine (IPV), 493
Ibis Reproductive Health, 204 Inca purification festival, 44–45
illegal drug use, 43 incontinence, 69
illness prevention, 141–142 Incredible Years, 58–59
Imhotep National Conference on Hospital independence for people with disabilities,
Integration, 147, 148 171
immigrant health, 343–345 independent living movement, 173
immigrants Indian Health Care Improvement Act,
children of, 48, 63 1976, 348
diseases and ailments, 264–265 Indian Health Service (IHS), 16, 345–349,
as labor trafficking victims, 337 629, 630
living conditions, 61–62, 374 Indian Self-Determination and Education
screening, intervention and services for, Assistance Act, 1975, 348
343, 344 indicated addiction prevention programs, 5
statistics, 343 indicated prevention mechanisms, 13–14
support for, 263–264 indirect contact (defined), 354
undocumented (see undocumented individuals, rights of, 127, 129
immigrants) indoor bathrooms, 45
758 INDEX
indoor toilets, earliest, 45 preventing, 209, 377

Indus River Valley, 45, 46 protection from, 54
industrial chemicals, 253 as public health specialty, 163
industrialization, 577 reporting, 106
Industrial Revolution, 109–110, 113, 179, response to, 53
213 spread of, 121, 220
industrial toxins, 265 tracking, 52
industrial waste products, 213 treatment of, 377
infanticide, laws against, 113 infertility services, 234
infant morbidity, decline in, 116 influenza (flu), 355–359
infant mortality, 349–352 bioterrorism role in, 77
analysis of, 191 pandemics, 356
decline in, 63, 116, 117, 201, 202, 236 seasonal epidemics of, 218
racial breakdown, 234 transmission of, 218, 252
rate (IMR), 349, 583 influenza A virus, 357
reducing, 204, 350–351 influenza B virus, 357
sleep-related deaths, 329 informal evaluations, 227
infants informatics, competencies of, 151
abandoned, care of, 63 information processing, 57, 59, 69
AIDS in, 188 information source as communication
costs related to, 401 element, 281
health care for, 61 information theory, 282
medical care of, 190–191 informed consent, 72, 250
syphilis in, 63 Iniganti, Salini, 671
victimization of, 114 injection drug users (IDUs), 609
Women, Infant and Children (WIC) injuries, 359–362
program, 243–244, 278, 627 as acute health problem, 2
infections alcohol role in, 30–31, 32
chain of, 353–354 to children, 113–114, 116, 118
controlling, 353, 354 controlling, 209
death due to, 182 disability caused by, 170
defined, 271 in Greek and Roman times, 260
geography role in spread of, 217 in home, 326–329
health care acquired, 480 in intimate partner violence, 367
monitoring, 56 prevalence of, 1
spread, stopping, 51 preventing, 326
susceptibility to, 165–166, 269 inner-city children, physical activity for,
infectious diseases, 352–355 131–132
CDC expertise, 631 inner-city public health clinics, 279
of children, 116 innovation, response to, 167–168
controlling, 219, 377 innovators (in diffusion of innovations
death due to, 50 theory), 168
decline, 118, 123, 306 inputs in logic model, 390
defined, 175–176 An Inquiry into the Effects of Ardent Spirits
as global challenge, 252–253 upon the Human Body and Mind
in Greek and Roman times, 260 (Rush), 447
outbreaks of, 297 An Inquiry into the Nature and Origin of
postulates of, 213, 377, 378–379 Mental Derangement (Crichton), 57
INDEX 759
insects, 353 interpersonal relationships, 6

Inside Public Health, 41 interpreters, 153
insomnia, 445 interstate travel, 241
Institute for Health Improvement (IHI), intervention, 6, 139, 362–366
495 intestinal tract, 120
Institute for Infectious Diseases, 380 intimate partner violence (IPV), 366–370
Institute of Medicine (IOM) ER treatment for, 639
addiction prevention programs LGBT individuals at risk for, 385
organized through, 5 research on, 204
children’s health, work on, 116, 118 screening for, 234
disjointed services noted by, 143 transtheoretical model applicable to,
Health and Medicine Division, National 613–614
Academies of Sciences, Engineering, intravenous drug use, 12
and Medicine, 272–274 inventory assessment as collaboration
health care disparities as defined by, component, 130
285 Investigational New Drug (IND)
publications, 172, 272, 273–274, 287, application, 503–504, 675
478, 509 investigation as epidemic management
public health issues cited by, 142 tool, 218
institutionalization as community Irish immigrants, 83, 182
organizing step, 139, 140 Irish Potato Famine, 182
institutionalized elder maltreatment, irrigation systems, 45
196–197 ischemic heart disease, 27, 219
institutional review boards (IRBs), 532 ischemic hepatitis, 317
Institution of Protestant Deaconesses, 456 ischemic strokes, 313
instruments, 227, 272 islet cells, 167
insulin, 164–165, 166 isolation, 219
integrity, mental health and, 418 isolation theory, 196
intellectual disability, 114 Isuprel, 669
intellectual health (defined), 269–270 itching, 1
intellectual/sensory disabilities, places Ivacaftor (Kalydeco), 250
inaccessible to those with, 174 Ivins, Bruce Edwards, 77
intelligence, 20, 281
intermittent source outbreak, 217 Jackson, Andrew, 346
International Communication Association James, William, 67
(ICA), 282 Japanese physicians, code of ethics for,
International Conference on Population 127
and Development, 204 Jenner, Edward, 78, 371–372, 477
International Congress on Mental Health, Jennerian Society, 371–372
68 Jex-Blake, Sophia, 85
International Convention for the Suppression job loss, 367
of Traffic in Women and Children Joe Camel, 678–679
(League of Nations), 337–338 Johns Hopkins University, 190
International Health Regulations, 516 Johns Hopkins University School of
International Planned Parenthood, 235 Medicine, 200
International Sanitary Conference, 658 Johnson, Lyndon B., 148, 214, 406–407,
Internet, 334 409
interpersonal communication, 282 Johnson and Johnson, 670
760 INDEX
Joint Commission International, 510 Laboratory Response Network (LRN), 209

Joint Principles of the Patient-Centered labor trafficking, 336, 337
Medical Home (PC-MH), 411 labor unions, 376
Journal of the American Medical Association laggards in diffusion of innovations theory,
(JAMA), 38–39 168, 169
Journal of the History of Medicine and Allied La Matérnité, Paris, 83
Sciences, 543 land pollution, 213, 308
journals, 37 land preservation, 214
Judaism, prohibited foods in, 46 Langmuir, Alexander, 106
Judson Health Center, 48 language barriers, 152, 153, 344
Julius Rosenwald Fund, 621 Lasker Award, 549
Junkiebond, 610 late majority adopters in diffusion of
justice, 72–73, 127, 224–225 innovations theory, 169
Justinian plague, 216 late majority in diffusion of innovations
Just Say No, 447 theory, 168
juvenile justice system, 12 latent (noninfectious) TB infection, 274
Lathrop, Julia, 374, 644
Kaffa, Crimea, 75–76 Latimer, George, 93
Kahn, Ali S., 665 Latino Community Investment Grants,
Kaiser Permanente Community Health 490
Initiatives, 135 Latinos
Kalydeco, 250 diabetes risks, 165
Kaposi’s sarcoma, 187, 188 health challenges, 153, 279
Kassite physicians, 46 HIV/AIDS in, 333
Kaufman, Roger, 453 living and working conditions, 146
Kay, James, 111 obesity in, 301
Kelley, Florence, 373–377, 644 Lauffer, Max, 552
Kempf, Grover, 160 laundry detergent, 327
Kennedy, Edward, 623 Law Code of Hammurabi, 46
Kennedy, John F., 214, 251 LDL cholesterol, 311, 465
Kennedy-Kassebaum Act, 11, 295–297 lead, reduction in levels of, 116, 117
Keys, Ancel, 86 leadership, 142, 145, 151
kidney disease, 260, 324 leading health indicators, 383–384
kidney failure, 164, 165–166, 342 lead poisoning, 216, 264, 265
kidneys, blood sugar excess impact on, League of Free Nations Association, 645
165 League of Nations, 337–338
Kindig, David, 495 learning activities, 292
kinetic energy, 360 learning disorders, 57
Kitasato, Shibasaburo, 380 Legionella pneumophilia, 353–354
Knossos, Crete, plumbing in, 45 Legionella spp., 646–647
knowledge, interventions aimed at Legionnaire’s disease, 646
changing, 362 Lenroot, Katharine Frederica, 200–201
Koch, Heinrich Hermann Robert, 122, Leo Burnett agency, 683
213, 377–381, 477 leprosy, 519
Koop, C. Everett, 608, 609, 640 leprosy bacillus, 380
Krafft-Ebing, Richard von, 177 lesbians, 190–191, 199–202
Kramer, Franz, 57 Let’s Move Campaign, 302
kwashiorkor, 461 letter of intent, 258
INDEX 761
Lew, Jack, 620 Lincoln, Abraham, 251, 273, 373

Lewin, Kurt, 587 “Lincoln Law,” 233
LGBT health, 385–389 Lindemann, Eric, 507
LGBTQ individuals lipid disorders, screening for, 234
of color, 387 Listeria monocytogenes, 245, 414
HIV/AIDS risks to, 333 Little, Clarence Cook, 662
as human trafficking victims, 336 Little Ice Age, 426
ostracizing of, 177 Little Mothers League, 63
in public health, 64, 190–191, liver, 317, 318, 319
199–202 liver cancer, 30, 317
resilience of, 387 liver disease, 19, 30, 70, 317–320
risky behavior by, 385 Liverpool Workhouse Infirmary, 458–459
liability without fault, 156 local economies, 137
Liberty Life Insurance, 89 local politics, 139
life expectancy Locke, Edwin A., 256
flu pandemic impact on, 356 locus of control, 389–390
gender breakdown, 306–307 logical inferences, drawing, 74
increase in, 50, 123, 306–307, 352 logic model, 364, 390–392
racial breakdown, 90, 306–307 London, epidemics in, 188
threats to, 123–124 London School of Medicine for Women,
lifeguards, training and employing, 85
363–364 long-term care, people needing,
life span 286–287
economic disparity in, 111 long-term memory, aging impact on, 20
Framingham Heart Study, 513 long-term outcomes in logic model, 391
in Greek and Roman times, 260 Lou Gehrig’s disease, 172
increase in, 18, 19, 306 Louis, Pierre Charles Alexandre, 92
Middle Ages, 425 low density lipoprotein (LDL), 311,
obesity and, 465 465
physical activity and, 484–485 low income people, health care for,
predetermined, 19 279–280, 288
racial breakdown, 89 low-sodium, low-fat diet, 341
women’s, 655–656 lung cancer
lifestyle after smoking, 103
behavioral health and, 70 as air pollution-related disease, 27
cancer risks posed by, 97 causes of, 70, 310–311
culture influence on, 152 mortality, 310
death, causes related to, 153 pollutant exposure, association with, 27
diabetes and, 165 smoking and, 661
encouraging healthy, 81, 135 lung conditions, 28
stroke and, 313 lung disease, 28, 444–446
life-threatening diseases, genetic Lushniak, Boris D., 608
mutations causing, 249 Lymphocytic choriomeningitis, 414
lifetime health insurance limits, ban on, lymph theory, 98
17
life transitions, 69 Mace, Cecil Alec, 255–256
limbic brain structures, childhood macro-level air pollution interventions, 28
maltreatment effect on, 13 macrosystems, 587
762 INDEX
magicians, health care role of, 45 Massachusetts Department of Public

magnetic resonance imaging (MRI), 176 Health Laboratory, 322, 323
Mahoney serotype poliovirus, 155 Massachusetts State Board of Health, 94
maintenance, 130, 131 mass media campaigns, 291
maintenance as community organizing master of health administration (MHA),
step, 139, 140 163
major depressive disorder (MDD), master of health sciences (MHS), 163
422–423 master of public health (MPH), 163
majority stress model, 386–387 master of science (MS), 163
malaria Master Settlement Agreement (MSA),
addressing, 273 396–397, 615, 678, 684
in Africa, 252–253 Maternal and Child Health Bureau
carrier of, 429 (MCHB), 305
global warming role in, 253 maternal and children’s health
races compared, 277–278 advances in, 200–201, 201
resistance to, 271 in Africa, 252
study of, 377 care, improving, 351
treatment and prevention of, 252 family planning role in, 236
Malaria Control in War Areas (MCWA) as public health specialty, 163
program, 105–106 services in, 252
malignant neoplasms, 97 maternal care, free, 100
Mall, Franklin, 549 maternal complications, 350
Mallon, Mary (Typhoid Mary), 62, maternal folate deficiency, 80
128–129, 393–396, 520 maternal health, 397–404
malnutrition, 86, 252, 461 maternal mortality
maltreatment, recognizing signs of, 197. decline in, 201, 202
See also child maltreatment; elder factors affecting, 203
maltreatment racial breakdown, 234
mammograms, 124 reducing, 204, 350–351
management sciences, 8 Maternity and Infancy Care Act, 401
mania, 66–67 math degree, 162
manic depression, 66 Matrimonial Causes Act, 1878, 366
Manley, Audrey F., 608 Maya, 45, 46
man-made disasters, 78, 219 Mayo Clinic, 669
Mann, Horace, 180, 181 M. Carey Thomas prize, 551
Mann, Jonathan, 189 McCormick, Katharine Dexter, 558
Marathon bombings, 631 McGill University, 184
Marathon Pharmaceuticals, 670 McKay, Frederick S., 159–160, 237,
Marburg, 77 238
March of Dimes, 538 Meade, George Herbert, 587
March on Washington, 1963, 148 means of transmission (defined), 354
Marfan syndrome, 249 measles, 61–62, 252, 404–406
marijuana, 3, 4 measurable (defined), 256
Mari letters, 46 meat, 51, 247
Marine Hospital Service (MHS), 607, 630 meatpacking, 512, 626–627
market distributive justice, 224–225 meat products, regulation of, 242
Marxist/Communist ideology, 224 Medicaid, 406–407
Mason, James O., 608 ACA expansion of, 15
INDEX 763
Canadian health care model compared geographic data provided by, 288
to, 16 health care disparities, addressing
costs, 137 through, 278
expansion of, 709 health literacy of people on, 299
false claims, 233 implementation of, 591
federal agencies involved with, 108 Native Americans on, 348
health literacy of people on, 299 overview of, 16
Medicaid and CHIP Payment and Access padded bills to, 600
Commission (MACPAC), 407 participation in, 206
medical advances patients on, 205
care opportunities available through, medication
108 instructions, understanding, 298
health care access challenges in wake “off label” and “on label,” 504
of, 16 poisoning from, 328
health literacy and, 298 side effects reviewing for, 360
life span increase due to, 19 medication events, 479–480, 504
world war role in, 278 Medicine, 410–412
medical breakthroughs, 169 medicine
medical care, 44, 271 advances in, 85, 306, 307
medical countermeasures (MCMs), biostatistics applied to, 73
stockpiling, 209 creation of field, 260
medical devices, regulation and genetics application to, 249
supervision of, 240–241 racism in, 185
medical education and training, 38, 39 as science, 261, 323, 324
medical errors, 273, 504 segregation in, 147, 185
medical ethics, 127, 261–262 textbooks, 321, 322
medical histories, patient safety and, 479 Medicine as a Profession for Women
medical home, 125, 136 (Blackwell), 84
medical interpreters, 153 medicine men, 45
medical model of disability, 170 Medico-Chirugical Society of the District
medical model of mental illness, 181 of Columbia, 148
medical neglect of children, 114 medium-term outcomes, 391
medical practice, 125, 176 Meharry Medical College, 147, 321
medical professionals, quality care Meister, Joseph, 477
by, 100 melanoma, 568
medical questions by employers, 43 memantine, 35
medical records managers, 10–11 Memorial Fund Association, 48, 49
medical science, 273 Memorial of Descendants of William
medical screening, 206 Shattuck, 565
medical technology, 100 Memorial to the Legislature of Massachusetts
Medicare, 408–410 (Dix), 180
American Medical Association position memory, 20, 34, 35–36
on, 39 memory aids, 20
Anti-Kickback law, 601–602 meningitis, 50, 218, 412–416
care affordability under, 100 men’s health, 416–418
drug costs and, 672 heart disease, 311, 314, 315
false claims, 233 HIV/AIDS, 333
federal agencies involved with, 108 life expectancy, 416
764 INDEX
mental, behavioral, or developmental Mexican American agricultural workers,

disorders (MBDDs), 69, 70 149
mental health, 418–420 Meyer, Adolf, 67
adolescents, 653 microbial adaptations, 252
climate change-related trauma impact microbial deprivation hypothesis, 271
on, 28 microbiology, 219, 353
defined, 269, 423 micro-level air pollution interventions,
focus on, 187 28–29
heterosexual and LGBT individuals micronutrients, 460
compared, 388 micropolitan (defined), 545
HIV/AIDS and, 333, 334 microscopes, 527
promotion of, 68, 309 microsystems, 587
racial discrimination and, 585 Middle Ages, 98, 113
rural populations, 546–547 Middle Ages, public health in, 425–428
SAMSHA and, 604–607 Middle East respiratory syndrome
mental health clinic, outpatient, first, 68 (MERS), 77
mental health disorders, 57, 118 midwifery, 398–399, 425
Mentalhealth.gov, 605 midwives, 45, 62, 402–403
mental health problems, 6, 114, 386 migrant farmworkers, 23, 136, 343, 344
mental health system reform, 64–68 migrant health, 344
mental hospitals and institutions Milbank, Albert G., 48, 49
conditions, 67, 181 Milbank Memorial Fund, 48
creation of, 64–65 Milbank Public Baths, 48
establishment of, 181–182 military families, health care for, 278
reform of, 68 milk, 62
mental illness, 420–424 milk, condensed, 47
preventing, 68 Mill, John Stuart, 110
recognition of, 606 mind-altering substances, 6
stigma of, 270–271 Mindell, Fania, 557
stress in home due to, 114 A Mind That Found Itself (Beers), 67–68
treatment, 180 minerals, nutrition and, 460
mentally ill miners, occupational safety for, 23
attitudes concerning, 64–65, 67 miners’ diseases, 543
biographies, 64–68 minimum wage, 244, 376
living conditions, 178, 179–181 ministrokes, 313
mental status, gauging, 272 minorities
Merck, 681 health care for, 288
meso-level air pollution interventions, 28 hypertension and, 340
Mesopotamia, health care in, 45, 46 obesity and, 466
mesosystems, 587 oppression of, 185
mesothelioma, 216 social and economic burdens carried by,
metabolism, inborn error of, 53–54 149
methamphetamine, 4 minority groups
Methicillin-resistant Staphylococcus aureus health and health care for, 280,
(MRSA), 51 286–287, 289
methylenedioxypyrovalerone (bath salts), health disparities, eliminating for,
448 288
metropolitan (defined), 545 tobacco control measures for, 279
INDEX 765
Minority Health and Health Disparities multiple chronic conditions (MCC), 123,
Research and Education Act, 2000, 124
279 Multiple Risk Factor Intervention Trial
minority patients, dumping of, 205 (MRFIT), 663
minority women, 235, 315, 316 multiple source outbreak, 217–218
minors, prohibiting alcohol sales to, 31 multisystem organ failure, 355
Model Adolescent Suicide Prevention municipal wastes (defined), 211
Program (MASPP), 5 Murthy, Vivek H., 608
Modern Era, public health in the, muscles, 87, 484–486
428–430 musculoskeletal disorders, work-related,
Mohenjo-Daro, urban planning for, 45 24
mold, 25, 27–28, 177, 213 Muslim soldiers, 75–76
Moley, Raymond, 539 myasthenia gravis, 271
monitoring of parks and trails, 309 Mycobacterium tuberculosis, 274
Monitoring the Future Survey, 447 Mylan Pharmaceuticals, 670
mononucleosis, 317 myocardial infarction. See heart attack
Montagu, Mary Wortley, 572 myocarditis (inflammation of the heart
mopeds, 432 muscle), 355
moral codes, 127 My Plate tool, 460
moral treatment of mental illness, 180,
181 Nader, Ralph, 435–438
morbidity, measuring, 271–272 Nader’s Raiders, 436
The Morbidity Mortality Weekly Report Naegleria fowleri, 414–415
(MMWR), 107 Narcotic Addict Rehabilitation Act, 1966,
Moritsugu, Kenneth P., 608 3
Morse code, 281 Nash, John Forbes, Jr., 270
mortality, measuring, 271–272 Natioinal Suicide Prevention Lifeline,
mosquito-borne diseases, 217 606
mosquitoes, 105–106, 646 National Academies of Sciences,
mothers, health education for, 62–63, 351 Engineering, and Medicine, 272–273
motivation, 256, 274 National Academies of Sciences,
motorcycles, 432 Engineering, and Medicine, Health
motor vehicle crashes (MVCs), 430–433 and Medicine Division, 272–274
alcohol in, 30–31, 32 National Academy of Engineering (NAE),
costs related to, 430 273
deaths related to, 430 National Academy of Medicine (NAM),
prevalence of, 359 273
safety advances, 437 National Academy of Sciences (NAS), 273,
sleep deprivation and, 445 551
trends, 515 National Advisory Mental Health Council,
motor vehicle injuries, minimizing, 309 605
motor vehicle safety, 430–433 National Agricultural Library (NAL), 626
motor vehicle traffic, 308 National AIDS Brigade, 610
mottled tooth enamel, 159–161, 238 National Assessment of Adult Literacy,
Moving to Opportunity program, 584 298, 299
Muller, Johannes Peter, 98 National Association for the Advancement
multidrug-resistant (MDR) bacteria, 50 of Colored People (NAACP), 148,
multidrug resistant tuberculosis, 77 185, 322, 376
766 INDEX
National Association of Alcoholism and National Foundation for Infantile Paralysis

Drug Abuse Counselors, 3 (NFIP), 155, 552–553
National Association of County and City National Health and Nutrition
Heath Officials (NACCHO), Examination Survey (NHANES),
438–439 134, 443–444
National Board of Public Health National Healthcare Disparities Report,
Examiners (NBPHE), 109 2004, 287
National Cancer Institute (NCI), 169, 283, National Health Committee (NAACP),
439–441 148
National Center for Chronic Disease National Health Education Standards
Prevention and Health Promotion (NHES), 293
(NCCDPHP), 167 National Health Interview Survey,
National Center for Emerging and 170–171
Zoonotic Infectious Diseases, 344, National Health Literacy Act, 298
520 National Health Service Corps, 304
National Center for Health Statistics, National Health Survey Act of 1956, 443
87–88 National Heart, Lung, and Blood Institute
National Center for Injury Prevention, (NHLBI), 340, 341–342, 444–446
259 National Highway Safety Act, 533
National Center for Injury Prevention and National Highway Traffic Safety
Control (NCIPC), 441–443, 640 Administration (NHTSA), 361, 431
National Center for the Prevention and National Human Trafficking Resource
Control of Alcoholism, 3 Center (NHTRC), 338
National Center on Minority Health and National Institute for Occupational Safety
Health Disparities (NCMHD), 279 and Health (NIOSH), 22–23
National Child Labor Committee, 49, 644 National Institute of Dental and
National Children’s Center for Rural Craniofacial Research (NIDCR),
Agricultural Health and Safety, 23 470–471
National Clearinghouse on Child Abuse National Institute of Dental Research, 161
and Neglect (NCCAN), 113 National Institute of Environmental
National Colorectal Cancer (CRC) Action Health Sciences (NIEHS), 28, 266
Campaign, 284 National Institute of Food and Agriculture
National Commission for the Protection of (NIFA), 626
Biomedical and Behavioral Research, National Institute of Mental Health, 65, 68
71 National Institute of Occupational Safety
National Committee for Mental Hygiene, and Health (NIOSH), 361
49 National Institute on Alcohol Abuse and
National Conference on Social Welfare, Alcoholism (NIAA), 605
201 National Institute on Drug Abuse (NIDA),
National Council of the Colored People 3, 169, 446–449, 605
(NCCP), 575–576 National Institute on Minority Health and
National Council on Disability, 174 Health Disparities (NIMHD), 279
National Diabetes Prevention Program National Institutes of Health (NIH),
(DPP), 165 449–451
national disasters, 211 Commissioned Corps members in, 630
National Environmental Health dentists hired by, 160, 238
Association Committee (NEHA) food safety information disseminated
environmental health as defined by, 210 by, 246
INDEX 767
HHS and, 629 Native Hawaiian Health Scholarship

institutes under, 341–342 Program, 304
National Labor Relations Act, 536 natural disasters
National Labor Relations Board, 539 advance knowledge and planning for,
National Medical Association (NMA), 90, 208
148 epidemics following, 219
National Mental Health Act, 605 information issued during, 78
National Negro Insurance Association, 89 response to, 53
National Notifiable Disease Surveillance natural healing, supporting, 260–261, 324
System (NNDSS), 2 naturalistic practices
National Organization for Public Health Greek and Roman practices compared,
Nursing, 643–644 261
National Park Service, 214, 309 naturalistic practices, Greek and Roman
National Recovery Administration (NRA), compared, 326
539 natural resources, preservation of, 214
National Registry of Evidence-Based Natural Resources Conservation Services
Programs and Practices (NREPP), (NRCS), 626
230 navigation, 92
National Research Council, 116, 118 Nazi Germany, 251, 266
National Rifle Association, 640 necrotizing fascitis (“flesh-eating” disease),
National Safety Council, 23 51
National School Lunch Act, 560 needle exchange programs (NEPs),
National School Lunch program, 610–611
243–244 needle sharing, 609–610
National Suicide Prevention Lifeline, 448 needs (defined), 452
National Traffic and Motor Vehicle Safety needs assessment, 452–455
Act, 431, 515 as collaboration component, 130
National Vaccine Establishment, 372 in health education, 291, 292
National Vaccine Injury Compensation intervention following, 362, 363
Program, 155, 156 needs-based theory of justice, 224
National Wear Red Day, 445 neglect
Nation’s Health, The, 41, 451–452 of children, 113, 114, 359
Native Americans of elderly, 195, 197
benefits for, 149 neighborhood violence and crime, 114
childbirth beliefs, 398 neighbors, relationships between, 114,
diabetes risks, 165 139
health care for, 16, 287, 345, 346, 347, Neisseria gonorrhoeae, drug-resistant, 51
348 Neisseria meningitidis, 414
heart disease in, 311 Nelmes, Sarah, 634
historic conditions, 345–346 Nelson, Gaylord, 214
homosexuality, attitudes concerning, neonatal mortality, 349
176 neonatal mortality rate (defined), 349
legal status, 346–347 neoplasm (term defined), 97
living and working conditions, 146 nervous system development, 114
medicine versus Western medicine, 347 networking, 130
self-determination, 345–348 Nuremberg Code, 530
smallpox among, 76, 218 neurodevelopmental disorders, 59
suicide prevention, 5 neuropathy, 165–166
768 INDEX
neurotransmitters, 4 noxious gases, 25

newborns numerical method, 92
abandonment of, 63 NURSE Corps, 304
care of, 191 nurses, 560, 561, 643
screening, 53–54, 249 Nurses’ Health Study, 222
New Century Guild for Working Women Nurses’ Settlement, 643–644
in Philadelphia, 373 nursing
New Drug Applications, 675 advances in, 85
new drugs, approval of, 241, 242 during Civil War, 182
New Forest Parenting Programme, 58–59 history of, 455–459, 566
New Moves (program), 194 in pediatrics, 191
new policy, improving, 226 shortage of, 273
New Poor Law, 110 training, 85
Newton, Connecticut school shooting, nursing care, 10
631 nursing home administrators, 10
New York City, conditions in, 47, 61–62 nursing home residents, 69
New York Condensed Milk Company, 47 nursing homes, 197, 246
New York State Lunatic Asylum of Utica, nutrient deprivation, 246
181 nutrition, 460–463
NIDA for Teens, 447 addressing, 273
Nightingale, Florence, 84, 182, 455–459 adolescent, 654–655
Nightingale School for Nurses, 458 counseling, 193, 194
Night of the Living Dead, 665 education programs, 627
911, dialing, 208 Framingham Heart Study, 513
Nixon, Richard M., 77, 214, 348, 605 immunity enhancement through, 354
N-methyl-D-aspartate (NMDA) nerve cell management, 250
receptor, 35 oral health and, 469–471
Nobel Prizes, 482 as public health specialty, 163
noise (defined), 282 services in, 252
noises, loud, exposure to, 22 Women, Infant and Children (WIC)
noncommunicable diseases, 2, 123, 253 program, 627
nonemerging diseases, 221 nutritional deficiencies, 44
nongovernmental organizations (NGOs), nutritional supplements, 80
253 nutritious foods, 302, 309
nonhazardous wastes (defined), 211 Nyquist, Harry, 281
noninfectious epidemics, 216, 219
nonmaleficence, 224 Oath of Sun Simiao, 127
nonmelanoma skin cancer (NMSC), 568 Obama, Barack, 17, 259, 298
nonprofit health organizations, 9 Obama, Michelle, 302
nonprofit organizations, 258 Obamacare. See Affordable Care Act
nonresident visitors, 343 (ACA)
normal blood pressure (defined), 340 obesity, 465–468. See also childhood
norovirus, 77, 218 obesity
Norovirus, 245 addressing, 302
Norwalk-like viruses (NLVs), 647 adolescent girls, 654–655
Notes on Nursing (Nightingale), 458 chronic stress associated with, 269
Not On Tobacco (N-O-T), 228 community organizing to address, 140
Novella, Antonia C., 608 as diabetes risk factor, 164, 165
INDEX 769
as epidemic, 219 Office of Legislation, 305

food insecurity and, 627 Office of Minority Health, 153, 278, 279
health complications due to, 300–301 Office of Operations, 305
as heart disease risk factor, 311 Office of Planning, Analysis, and
heterosexual/cisgender and LGBT Evaluation (OPAE), 305
individuals compared, 386 Office of Public Health Preparedness and
as hypertension risk factor, 340 Response, 78, 209
multilevel interventions, 587 Office of Rare Diseases Research (ORDR),
needs assessment and, 452 450
as pandemic, 216 Office of Regional Operations (ORO), 305
pregnancy risk and, 402 Office of Regulatory Affairs (ORA),
prevention of, 301, 302 241–242
risk factors for, 301, 340 Office of Smoking and Health’s Tips from
trends in, 87–88 Former Smokers, 384
obesity-related diseases, 86–87, 165 Office of the Assistant Secretary for Civil
obesogenic environments, 302 Rights (OASCR), 626
obesogenic factors, 465 Office of Tribal Relationships (OTR), 626
objectives (defined), 255, 292 Office of Women’s Health (OWH), 305
objectives, identifying, 306 Omalu, Bennet, 599
observational learning, 580 Omnibus Budget Reconciliation Act
observational studies, 222–223 (OBRA), 1987, 196–197, 600–601
obstetrics, 191, 201 Omran, Abdel, 429
occupational health and safety Online Health Services (OHS) Program, 489
agricultural safety, 22–24 open spaces, preserving, 310
creation of field, 263, 265 oppositional defiant disorder (ODD), 57,
law and legislation, 266, 373 69
as public health specialty, 163 options, identifying, 301
work-related fatalities, reducing, 361 oral contraceptive use, 222
Occupational Safety and Health Act, oral health, 468–471
1970, 266, 435 oral hygiene, 275, 469
Occupational Safety and Health organ damage, 165
Administration (OSHA), 360, 437, organ failure, 355
515 organisms, 75, 353
Office International d’Hygiène Publique organizational diagnosis, 501
(OIPH), 658 Orphan Drug Act of 1983, 670–671
Office of Advocacy and Outreach (OAO), orthopox viruses, 570–572
626 osteoarthritis, 86
Office of Civil Rights, Diversity, and osteoporosis, 1, 176, 234
Inclusion, 305 outbreak, identifying impact of, 219
Office of Communications, 305 outcome evaluation, 228, 302, 501–502
Office of Criminal Investigation (OCI), outcome/impact in logic model, 390, 391
241, 242 out-of-pocket payments, 100
Office of Disease Prevention and Health outputs in logic model, 390, 391
Promotion (ODPHP), 306, 383, 487 outreach programs, 134
Office of Federal Assistance Management, overcrowding, 218, 353
305 overeating, 69, 70, 243
Office of Global Health (OGH), 305 overscheduling, 139
Office of Health Equity, 305 over-the-counter drugs, 240–241, 242
770 INDEX
overweight Pasteur Institute, 477

defined, 86–87 path dependence, 302
as diabetes risk factor, 165 pathogens
as heart disease risk factor, 311 disease, association with, 377, 378–379
as hypertension risk factor, 340 emerging and reemerging, 354–355
investigating, 221 mutations in, 352, 354–355
OxyContin, 679 reservoirs supporting, 353–354
ozone, 25, 26, 27–28 transmission of, 216–217
patient antidumping law, 206
pacemaker, 312, 313 Patient Bill of Rights, 153–154
Pacific Islanders, 153, 165, 279, 311 patient care, factors affecting, 39
Packard, Elizabeth Parsons Ware, 182 Patient-Centered Medical Home (PCMH),
Padina, Gahan, 670 125
Paganini, Niccolò, 251 patient dumping, 205
Paget, James, 83 patient examination, 261, 323, 324
pain killers, 679 patient information, 153–154, 297
pain relievers, addiction to, 3 patient outcomes, 137
pain scale, 272 Patient Placement Criteria for the Treatment
paints, environmentally safe, 28 of Psychoactive Substance Use Disorders
Pan American Health Organization, 78, (American Society of Addiction
648 Medicine (ASAM)), 3
Pan American Sanitary Bureau, 649 patient population, personnel from same
Pan American Sanitary Organization, 658 culture as, 154
pancreas, transplantation of, 167 Patient Protection and Affordable Care
pancreatic problems, 249 Act. See Affordable Care Act (ACA)
pancreatitis, 70 patient-provider relationship, 137
pandemics, 121, 216, 473–475 patient rights, 205–206
paralysis patient safety, 478–481
amyotrophic lateral sclerosis (ALS) as patient screening and stabilizing, 205, 206
cause of, 172 patient transfer or discharge, 205, 206
polio-related, 154–155, 156, 173, 492 Pearce, Louise, 64
paranoia, 65, 66, 68 Pedagogy in Health Promotion (SOPHE),
parasitic meningitis, 414 593
Parent-Child Interaction Therapy, 58–59 pedestrian injuries, minimizing, 309
parent education pediatrics, 190–191, 200–202
infant health, promoting through, 201 peer pressure, mental health and, 419
parents, child maltreatment risk factors peer review, 104
for, 114 pelvic examinations, 203–204
parents, student motivation and, 420 penicillin, 481–484
parent therapy for ADHD, 58–59 allergic reaction to, 482–483
parent training classes, 70, 144 classification of, 50
Parks, Edwards A., 200 discovery of, 278
Parks, Trails, and Health Workbook (CDC syphilis treatment with, 623
and National Park Service), 309 Pentateuch (Five Books of Moses), 46
parks and trail system planning, 309 people of color
Parran, Thomas, Jr., 608, 658 demographic trends, 280
participation restriction, 171, 172 HIV/AIDS and risks to, 333, 334
Pasteur, Louis, 379, 475–478, 634 medical training for, 149
INDEX 771
people with disabilities (PWD) physical abuse

attitudes toward, 174 of children, 113–114
burns, 328 of elderly, 195, 197
contributions, 172 history of, 13
defined, 42 of women, 655
discrimination against, 174 physical accessibility, 99, 101
education, 173 physical activity, 484–488
employment, 42–43, 173–174 blood pressure affected by, 340, 341
health behaviors and outcomes, diabetes management through, 166
170–171 diabetes risks, reducing through, 165
health care disparities, 286–287 encouraging, 301, 302, 306, 309
health care for, 225 excessive, 270
health of, 173 level as birth defect risk factor, 79
legislation affecting, 41–43 obesity and, 466
recommendations concerning, 175 place influence on, 308
perceived barriers, 275 places for, 308
perceived benefits, 275 promoting, 169
perceived severity, 275 recommendations, 341, 342
perceived susceptibility, 275, 364 strength and balance, improving
Perkins, Frances, 536 through, 360
perpetration (intimate partner violence), urban and suburban infrastructures for,
367 308–309
personal funds, managing, 196–197 Physical Activity Guidelines for Americans,
Personal Liberty Act, 1843, 93–94 485, 487
personal relationships, elder maltreatment physical ailments (in intimate partner
within, 195, 196 violence), 367–368
pertussis (whooping cough), 216, 217, physical disability
218, 252 as child maltreatment risk factor, 114
pesticides, 22, 214, 245, 246 communities identifying with, 133
Petri, Julius Richard, 213, 378 places inaccessible to those with, 174
pets, products for, 241 psychological impact of, 21
Pew Charitable Trusts, 310 physical exam, annual, 137
pharmaceutical companies, 225, 233 physical fitness, encouraging, 302
pharmaceutical product supply, 254 physical health (defined), 269
pharmaceutical sales representatives physical inactivity
patient care influenced by, 39 as behavioral issue, 69
pharmaceuticals in ancient China, 46 as diabetes risk factor, 165
pharmacogenetics, 249 health effects of, 70
pharmacology, 73 as heart disease risk factor, 311
pharmacy, Special Interest Groups (SIGs) as hypertension risk factor, 340
in, 39 physical maturation, bodily changes after,
Phelps, James, 634 18
phenylketonuria (PKU), 54, 249, 250 physical violence, 367
Philadelphia, PA, health care in, 83 physical well-being, life disruption impact
Philadelphia Female Anti-Slavery Society on, 21
(PFASS), 373 physicians, malpractice by, 46
Phillips, Robert Allen, 122 physicians in ancient world, 45, 46
photography in bacteria studies, 378 Pierre-Paul, Jason, 296
772 INDEX
Pincus, Gregory, 558 policy debates, 301

pitted tooth enamel, 160, 237 policy development, 142, 143
place, focus of, 220 polio, 491–494
place factors in health disparities, elimination of, 107, 156
286–287, 288–289 eradication of, 688–689
plague long-term effects of, 187
bacillus, 380 people with, 173
bioterrorism role in, 75, 76, 77 reduction in, 659
defined, 216 transmission, 491
pandemic, 426–427 vaccination, 154–156
study of, 377 vaccine for, 635
Planet Health (program), 194 poliovirus type 1 (Mahoney), 553
Planned Parenthood, 236, 401, 488–491, Polish Americans, 147
558 political and social injustices, 243
Planned Parenthood Action Fund, 490 political science degree, 162
planning politics, grants influenced by, 259
in health education, 291, 292 Polk, James K., 121
of intervention, 363 pollen, 25, 27–28, 213
mega- and micro-levels, 453 Pollnow, Hans, 57
needs assessment and, 453 pollutants, 27, 51
PRECEDE-PROCEED model, 500–502 Pontiac fever, 646
program, 73–74, 142, 151, 363 poor. See also low income people; working
plant allergens, 27–28, 213 poor
plaques in Alzheimer’s brain, 34, 35 health care for, 225, 287
plasma, 184, 185 hygiene for, 47, 48
plastic, 212 policies regarding, 110–111
Plato, 176, 324 sanitation, 112
plausible causes, other ruled out as stereotyping of, 110–111, 112
causality condition, 103 Poor Law commission, 110
playground, establishing, 131–132 poor women, pregnancy, unintended in,
pneumocystis carinii pneumonia (PCC), 235
187, 188 population (defined), 220
pneumonia population, intervention targeting, 362
among immigrants, 264 population-based behavioral change, 70
contributing factors, 219 Population Council, 203
diagnosis and treatment, 91 population growth, urban, 110
as influenza complication, 355 population health, 87–88, 163, 223–225,
Streptococcus pneumoniae as agent for, 50 494–498
pneumonitis, 27 population migration, disease spread
pneumothorax through, 55, 218, 343, 356
diagnosis and treatment, 91 populations, general health of, 87–88
Points of Dispensing (PODs), 209 portal of entry (defined), 354
point source outbreak, 217 portal of exit (defined), 354
Poison Control Center, 305 post-concussive syndrome (PCS), 599
poisoning, education about, 326, 327–328, postmortem examinations, 92
360 postnatal mortality (defined), 349
Polaris, 338 postnatal mortality rate (PNMR or PMR)
police as health educators, 228–229 (defined), 349
INDEX 773
postnatal services, 349 women’s health and, 653

post-traumatic stress disorder (PTSD), pregnant women, 12–13, 368
216, 367, 637–639 prehypertension (defined), 340
poverty premature births, 32, 187, 191, 349
collaborations addressing, 130, premature infants, 190, 191, 234
142–143 prenatal services, 349
disability and, 171 preplanning of evaluation, 226–227
geographic variations based on, 289 prescription drugs, 502–505
health care access limited due to, 136 advertising, 677, 679, 680–682
horrors of, 61 overdoses, 359
impact of, 69 over-the-counter drugs as former, 242
organizing challenges due to, 139 regulation and supervision of, 240–241
preventing, 111 President’s Council on Fitness, Sports, and
reducing, 64 Nutrition, 487
reduction, 254 President’s Emergency Plan for AIDS Relief
socioemotional state of, 243 (PEDFAR), 252
stress of, 114, 271 President’s Malaria Initiative (PMI), 252
power generation, 27 presyptomatic or preclinical phase of
PPFA’s Generation (PPGen), 490 Alzheimer’s disease, 34
practices, improving, 226 pretest data (defined), 227
Practice Safe Skin, 569 preventable diseases, 154, 236
prayer, studies of health and, 596 Prevent Diabetes STAT Screen/Test/Act
precaution adoption process model Today Program, 166
(PAPM), 498–500 prevention, 218, 219, 505–508
precautionary principle, 697 prevention efforts, 102
PRECEDE-PROCEED planning model, preventive actions, 275
500–502 preventive care, 17, 62
precision medicine, 250–251 Preventive Medicine, 663
preconception care, 236 preventive services, 138
predementia phase of Alzheimer’s disease, primary data collection, 221
34–35 Primary Malignant Growths of the Lung and
prediabetes, 164, 165, 167 Bronchi, 661
preexisting conditions, 17, 100, 296 Prince v. the Commonwealth of
preformation as collaboration phase, 130, Massachusetts, 1944, 113
131 Principles of the Ethical Practice of Public
pregnancy Health, 2002, 127–128
complications of, 236, 654 Prindle, Richard A., 608
drinking during, 30, 31, 32, 80 prisoners, 111, 181, 348, 422
excess, 234–235 privacy notices, 153–154
gestational diabetes risks during, 145 Privacy Rule (Health Insurance Portability
nutritional supplements during, 80 and Accountability Act), 295, 296,
outcomes, 236 297
planning and counseling, 236 private donors, 253
preventing, 235, 236 private health system, 16
risks, 401–402 problem, identifying, 139, 300–301
unintended, 203, 235, 236, 400–401 process evaluation, 227–228, 501
weight gain in, 402 Prochaska, James O., 613
women’s control over, 234 professional journals, 38, 258
774 INDEX
prognosis, 261, 323, 324, 325 public health education, 163

program activities, 257 public health emergencies, international,
program evaluations, 226, 292–293 343
program impact, measuring, 228 public health emergencies, response to,
program implementation, 229 78, 208–209
program objectives, 226, 230–231, 257 public health ethics, 127, 223–225, 326
program outcomes, 230–231, 258 public health in the United States, history
program planning, 73–74, 142, 151, 363 of, 511–515
Progressive Era, 47–48 public health laboratories, 207, 209, 353
prohibited foods, 46 public health law, 515–518
Project EX, 228 Public Health Leadership Institute,
Promoting Alternative Thinking Strategies 127–128
(PATHS), 640 Public Health Leadership Society (PHLS),
Promoting Health/Preventing Disease, 306 699
propagated outbreak, 217 public health nurse, 141, 145
prostate cancer, 220, 249 public health policies, 273, 391
protection equipment, 219 public health practices in ancient world,
protective factors (of LGBT individuals), 44–46
387 public health preparedness and response,
protein-energy malnutrition (PEM), 243 75, 273
proteins, 461, 470 public health projects in ancient world, 45
Provident Hospital, Infantile Paralysis public health research, 162, 163
Unit, 90 public health sciences, 142, 144
psychiatric care, 137 Public Health Service, 241
psychological abuse, 655 Public Health Service Act, 137, 235
psychological aging, 18, 20–21 public health warnings, 208, 298,
psychological neglect, 114 696–704
psychological well-being, 21, 272 Public Interest Research Group (PIRG),
psychology, 73, 269 436
psychology degree, 162 Public Law 106–129, 286
Psychopathia Sexualis (Krafft-Ebing), 177 public participation, 500–501
puberty, 653–654 Public Progress Administration, 539
public, information sources for, 38 public service announcements, 153–154
Public Citizen, Inc., 437 public works, 45
public health (defined), 224 Public Works Administration, 539
Public Health (Rosen), 543 puerperal fever, 267–268
Public Health Accreditation Board Pugh, Sarah, 373
(PHAB), 509, 603 pulmonary diseases, 91
Public Health Act (Great Britain), 1848, Purdue Pharma, 679
112, 429 Pure Food and Drugs Act, 1906, 241,
public health advancements, 307 512–513
public health biology, 151 purification, bathing as form of, 44–45
Public Health CareerMart, 41 Puritans, 176–177
public health care system, earliest, 261
Public Health Cigarette Smoking Act, 683 Quain, Sir Richard, 315
public health department accreditation, quality of life, 171–172, 272, 306
508–511 quarantine, 55, 219, 343, 344, 519–521
public health departments, 602–604 Quarantine Act, 1893, 213
INDEX 775
Quarterly Journal of Inebriety, 431 refugees, 343, 344

Questcor, 669 regional accreditation, 15
Quetelet, Lambert Adolphe Jacques, 86 Rehabilitation Act, 1973, section 504, 41
Quetelet index. See body mass index rehabilitation care, 10
(BMI) rehabilitation services, 171
Qui tam (legal term), 233 rehydration therapy, 122
reinforcements (defined), 580
rabies, 77, 271, 353 relationships
race assessing, 197
health care disparities based on, behavior changes and, 613–615
285–286 interactions and, 587
health disparities based on, 153, mental health and, 419
277–279 mental illness and, 422
HIV/AIDS and, 332, 333 sleep deprivation and, 445
hypertension and, 340 relevant (defined), 256
and income, 277 reliability (defined), 227
mental illness and, 422 religion, 595
smoking and, 384 religious beliefs, health care and,
racial discrimination, 146, 585 100–101
racial minorities, 146, 225 Remarks on Prisons and Prison Discipline in
racism, 149, 176, 185–186 the United States (Dix), 181
Radical Abolition Party, 576 Renaissance, public health in, 525–529
radioactive materials, 253 Report of the Sanitary Commission of
railroad workers, 23 Massachusetts, 564, 565–566
Railway Men’s International Benevolent Report on the Poor Law (Chadwick and
Industrial Association, 89 Senior), 110
randomized controlled trial design, 365 Report on the Result of a Special Inquiry into
rape, 31, 204 the Practice of Internment in Towns
Raspail, François-Vincent, 428–429 (Chadwick), 110
Rathbone, William, 458 Report on the Sanitary Conditions of the
rats, bladder cancer in, 102, 103 Labouring Population of Great Britain
Rawls, John, 225 (Chadwick), 110
Reagan, Ronald, 3, 332 reproduction, education in, 235
Reagan’s Ruling Class (Nader), 437 reproductive health, 236, 252, 653
RE-AIM (reach, effectiveness, adoption, reproductive problems, 25
implementation, and maintenance), reproductive rights, 203
523–525 reproductive services, 137
real-world practices, models and theories reproductive systems, 249
applied to, 228–229 reputation, accreditation and, 510–511
reasonable accommodations for employees research, 529–532, 656, 669–671
with disabilities, 174 research ethics, 71–73, 127
recall bias, 222 research findings, dissemination of, 258
reciprocal determinism, 525, 580–581 research hypothesis, 74, 220, 222
recreational areas, 302, 309 research studies, funding, 273
Red Cross, 643 reservoirs, 353–354
red wine, 103 resilience, 3, 387
Reed, Walter, 429 Resource Conservation and Recovery Act
referrals, 600 (RCRA), 1976, 211
776 INDEX
respect for persons disability, 270

defined, 224 National Cancer Institute (NCI)
as medical code of ethics component, established by, 440
127 National Foundation for Infantile
research participants, 71, 72, 127, 129, Paralysis founded by, 155
224 poliomyelitis suffered by, 492
respiratory system, 27, 29, 354 Social Security Act and, 409, 589
rest, immunity enhancement through, 354 Roosevelt, Theodore, 48, 214
restaurants, food safety inspections, Rosen, George, 541–545
141–142, 146, 246 Ross, Araminta “Minty” (Harriet Tubman),
retirement, 21 618–620
Reynolds, Dave, 697 Ross, Ronald, 429
rhabdomyolysis (muscle injury), 355 Rotary, 492
rheumatic fever, 1, 51 Rotter, Julian B., 389
rheumatism, 264 Rous, Peyton, 662
Richards, Cecil, 488–489 Royal Society of Medicine, 372
Richmond, Julius B., 608 RU-486, 204
ricin toxin, 75, 77 Rubinow, Isaac Max, 539–540
rickets, 200 rural (defined), 545
“right-to-know” laws, 699 rural areas, health care in, 286–287, 288,
rinderpest, 380 305
Ringland Project, 309–310 Rural Development (RD), 626, 627–628
risk-benefit analyses, 532–534 rural health, 545–547
risk communication, 696–704 Rush, Benjamin, 447
risk management, 478 Russell, William Howard, 457
risky behavior, 13, 114, 385 rye ergot fungus, 75
Risperdal, 670 Rynde, Francis, 635
ritualistic cures, 44
rivastigmine, 35 Sabin, Albert, 155, 538
Rivers, Eunice, 623 Sabin, Florence Rena, 549–552
Roberts, Ed, 173–174 saccharin, 102–103
Robertson, F. L., 160, 238 Safe Drinking Water Act of 1974, 435, 513
Robert Wood Johnson Foundation, 310 safe sex, education on, 188, 189
robotic limbs, 169 safe sleep, 326, 329
Roche, James M., 436 safety, patient, 478–481
Rockefeller Institute, 550 safety equipment for farm work, 23, 24
Rocky Mountain spotted fever, 216 Salk, Jonas, 155, 493, 538, 552–554, 635
rodent-borne diseases, 473 Salk Institute, 554
Roffo, Angel, 661 salmonella
Rogers, Anne, 651 diagnosis and treatment, 146
Rogers, Everett “Ev” M., 168, 169 prevalence or, 253
Rome, ancient, 224, 260, 261, 262, Salmonella
325–326 bioterrorism role in, 75, 77
Romero, George, 665 as pathogenic contaminant, 245
Roosevelt, Eleanor, 534–536 physiological effects of, 246
Roosevelt, Franklin Delano, 536–541 Salmonella typhi, 128–129, 393
Civilian Conservation Corps founded salt sensitivity, 340
by, 214 Salvarsan, 621
INDEX 777
sanctuary cities, 344 Scotland, indoor plumbing in, 45

sandwich generation, 315 Screen for Life, 284
Sandy Hook Elementary School shooting, Scudder, John, 184
259, 640 seafood, bacteria from, 247
San Francisco, HIV/AIDS in, 187 sea levels, elevated, 27–28, 29, 211, 213,
Sanger, Margaret Louise Higgins, 234–235, 253
236, 400–401, 488, 554–559 seasonal outbreak, 217
sanitation secondary data collection, 221
in ancient Rome, 260, 262 secondhand smoke
cholera prevention through, 122 deaths due to, 210
in Great Britain, 110 effects of, 384
improved, 123 exposure to, reducing, 306
sanitoriums, 66 laws combating, 362–363
sarin gas, 77 reducing, 383
Satcher, David, 608 Sudden Infant Death Syndrome caused
satisfactory accommodation for persons by, 350
with disabilities, 42–43 second impact syndrome, 598
scalds, 326, 328 Sedgwick, William H., 651
scarlet fever, 51 Sedgwick Memorial Medal, 649
Scenes in the Life of Harriet Tubman segregation
(Bradford), 619 ban on, 278
Scheele, Leonard, 608 in medicine, 147, 185, 277, 321
Scheffer, Adam, 296 of people with disabilities, 173, 174
schizophrenia, 13, 270–271 seizures, 54
schizophrenia spectrum, 421 selected addiction prevention programs, 5
scholarly literature, reviewing, 301 selected prevention mechanisms, 13–14
school absences, illness-related, decline in, self-care, 35, 315
117 self-efficacy, 562–563, 580
school admissions, 151 self-harm, 69
school attendance laws, 560 self-identity, 418
school cafeteria inspections, 246 self-inflicted injuries, 31
school health, 559–562 self-medication, 4–5, 13
school health education, 194, 293, 298, Semmelweis, Ignaz Philipp, 267–268
299 Senior, Nassau, 110
School Health Policies and Practices Study, senior citizens, 16, 18–20, 21
294 separating food, 246–247
school lunches, free, 243–244, 245 sepsis (blood infection), 50, 200, 324,
school nurses, 62, 560 355
school shootings, 259, 631, 640 settlement houses, 263–264
Schools of Public Health, 274–275 severe acute respiratory syndrome (SARS)
school violence, 231 bioterrorism role in, 77
Schulman, Henry, 543 control of, 659
sciatica, 260, 324 death due to, 310
science, 176, 306, 307 as global health issue, 251
scientific credibility as causality condition, spread and transmission of, 252
103 severe maternal morbidity (SMM), 398
scientific method, 74 severe weather events. See extreme
scientific reasoning in medicine, 91 weather events
778 INDEX
sewage, 44, 45, 110, 261 sickle cell disease, 250, 276
sex education, 199, 236, 556 sickness, faith and, 425
sex trafficking of children, 336, 338 sick-role behaviors, 275
sexual abuse Sigerist, Hery Ernest, 543
of children, 113, 114, 336 sign language interpreter services, 153
of elderly, 195 Silent Spring (Carson), 214
history of, 13 silver nitrate, 63
sexual acts, decriminalization of, 187–188 silver staining, 34
sexual assault, 31 Sinclair, Upton, 512, 626, 648
sexual freedom, health issues and, 188, Singer, Jeffrey A., 691
189 single-payer health care model, 16, 100
sexuality, high-risk, 243, 387 site assessment, 309
sexually active people, 236 site planning, 309
sexually transmitted diseases. See also situations, 580
acquired immune deficiency Skara Brae, indoor plumbing in, 45
syndrome (AIDS); human skin cancer, 567–570
immunodeficiency virus (HIV)/ intervention against, 363–364, 365,
acquired immune deficiency 391
syndrome (AIDS) preventing, 362
alcohol role in, 32 risk factors, 360
human trafficking role in, 336 screening for, 234
investigation of, 188 Slavery Abolition Act, 1833, 93
LGBT individuals at risk for, 385 slavery and slave trade
preventing, 199, 203, 236 antislavery movement, 82, 91, 93–94,
research on, 204, 278 373
screening and treatment, 137, 234, 278 in Brazil, 88
in women, 653 British involvement in, 82
sexually transmitted infections, 12 Civil War and, 182
sexual orientation human trafficking, 336–339
education concerning, 388 slave escapes, 618–619
HIV/AIDS and, 332, 333 in West Indies, 178
prevalence rates of, 385 sleep, recommended hours of, 445
sexual violence, 203, 367, 368, 639 sleep apnea, 86
shamans, 45 sleep deprivation, 445
Shannon, Claude E., 281–282 sleep disorders, 445
Shannon-Weaver model of sleeping sickness, 377
communication, 282, 283 sleep-related deaths, 329
Shattuck, Lemuel, 564–567, 650 smallpox, 570–573
Shattuck Report, 564 attempts to control, 343–344
Shennong, Chinese Emperor, 46 battling, 61–62
Sheppard-Towner Maternity and Infancy bioterrorism role in, 75, 76, 77
Protection Act, 1921, 373, 376 epidemics, 213
Shigella, 51 eradication of, 78, 106, 123, 156, 512,
shock, treatment, 184 519, 635, 658, 659, 688–689
short-term outcomes, 391 immunity to, 371
sibling care programs, 62, 63 outbreaks of, 55
sickle cell anemia, 249 quarantine for, 519–520
sickle cell carriers, 271 spread of, 218, 343, 687, 706
INDEX 779
vaccinations, 62, 78, 346, 371 Snow, John, 121, 188, 213, 221–222,
vaccines, 428, 429, 512, 515, 633, 634 362, 577–579
SMART (Specific, Measurable, Achievable, snowmobiles, 432
Relevant, and Time-bound), social and behavioral programs, 230
256–257 social barriers, reducing, 171
SMART (specific, measurable, accurate, social behaviorism, 587
realistic, timely) objectives, 501 social changes, 391
Smellie, William, 399–400 social cognitive theory, 283, 294
Smith, James McCune, 573–577 social cognitive theory (SCT), 579–581
Smith, Kevin, 37, 38 social determinants of health (SDOH),
Smith, Thomas Southwood, 111 582–586
Smith Gerrit, 575 social development, 11
smog, 26 social diagnosis, 500
smoking social ecological approaches, 454
abstention from, 342 social ecological model, 363, 586–589
by adolescents, 117–118, 226 social ecological theory, 288
attitudes toward, 228 social functioning, 272
avoiding, 28 social health (defined), 269
as behavioral issue, 69 social health sciences, 108–109, 151
as birth defect risk factor, 79 social injustice, addressing, 139
cancer risks of, 97 social interactions, medications to
deaths related to, 584 improve, 59
decreasing attraction of, 226 social justice, 146–147, 172, 276–277,
defined, 228 280
health effects of, 70 social learning theory, 195–196
as heart disease risk factor, 311 socially unacceptable behaviors, masking,
heterosexual/cisgender and LGBT 69
individuals compared, 387 social marketing, 314
lung cancer and, 103, 661 social media, 169, 229, 291
Master Settlement Agreement (MSA), social medicine, 62, 63, 200, 542
396–397 social model of disability, 170, 173, 174
misinformation concerning, 169 social networks, 169
people with and without disabilities social norms, 271
compared, 170–171 social reform, 82, 91
prevention of, 230–231, 383 in Progressive Era, 47–48
racial breakdown of, 384 Social Security Act (SSA), 589–592
reducing, 226, 383 amendment to, 108
respiratory effects of, 27 as Depression countermeasure, 278
respiratory system impaired by, 354 elderly insurance through, 539
rural rates, 546 E. Roosevelt role in passing, 536
stopping, 70 health policy and program expansion
technology, new affecting, 229 under, 55
smoking cessation programs maternal and child health provisions of,
evaluation of, 283–284 201
evidence-based, 228 Title XIX, 406–407, 409
hypothetical, 226, 227–228 Social Security Administration (SSA), 590,
life stories presented through, 384 591
smoking prevention campaign, 615 Social Security Board (SSB), 590
780 INDEX
social workers, 68 sports-related concussions (SRCs),

Society of Health and Physical Educators 597–600
(SHAPE), 293 sprains, 1
Society of Public Health Education Spurlock, Morgan, 679
(SOPHE), 291–292, 592–594 stabilization, 206
socioeconomic status (SES) staining techniques in bacteria studies,
geographic and place factors combined 378
with, 288 stalking victims, 367
health care disparities related to, Standards and Recommendations for the
285–286, 287, 289 Hospital Care of Newborn Infants
HIV/AIDS and, 332, 333 (Dunham), 191
sociological aging, 18, 21 Stanton, Edwin, 182
sociology Staphylococcus aureus, Vancomycin-
biostatistics applied to, 73 resistant, 51
as emerging discipline, 269 Stark, Peter, 600–601
sociology degree, 162 Stark law, 517, 600–602
soda tax, 221 Starr, Ellen Gates, 264
soldiers state, local, and territorial health
in ancient Rome, 261 departments, 602–604
oral health and hygiene, 159, 238 state board of health, first, 91, 94
sexually transmitted diseases among, state mental hospitals
278 conditions, 67
solid waste creation of, 64–65
as classification, 211 reform of, 68
Soper, George, 393–394 St. Bartholomew’s Hospital, London, 84
Sorano of Ephesus, 200 STEADI (Stopping Elderly Accidents,
Spanish-speaking youth Deaths, and Injuries) program, 360,
beverages advertised to, 302 361, 442
Speak Up program, 480–481 steatosis, 317
special health needs steelworkers
health services for people with, 108, occupational safety for, 23
286–287 Steinfeld, Jesse L., 608
specialist health administrators stereotypes, 153
overview of, 9, 10–11 stethoscope, 91, 92
special populations Stewart, William H., 608
meeting needs of, 254 Still, Sir George Frederic, 57
special schools for people with disabilities, stillbirths, 351
173 Stoddart, Greg, 495
Special Supplemental Nutrition Program Stone, Hannah, 558
for Women, Infants and Children storm runoff
(WIC), 401 in ancient world, 45
specialties strains
medical, 411 as acute illness, 1
specificity, examples of, 256 strategic planning
Speizer, Frank, 222 as collaboration phase, 130–131,
spina bifida, 80 132
spiritual health, 270, 594–597 street cleaning
spirituality (defined), 270, 594–595 advocacy of, 110
INDEX 781
strep throat, 1, 51 HIV/AIDS as factor in, 333

Streptococcus, Group A, Erythromycin- injuries resulting from, 359
resistant, 51 intimate partner violence and, 367
Streptococcus, Group B, Clindamycin- as leading health indicator, 383
resistant, 51 LGBT individuals at risk for, 385
Streptococcus pneumoniae, 50, 414 parent incapacity due to, 114
stress people with and without disabilities
diabetes management challenge due to, compared, 170–171
166 reducing, 64, 231
health problems associated with, 269 SAMSHA and, 604–607
healthy management of, 341 treatment, 6
heterosexual/cisgender and LGBT unacceptable behaviors, masking
individuals compared, 386–387 through, 69
mental health and, 418–419 Substance Abuse and Mental Health
violence as response to, 196 Services Administration, 230
stressed caregiver theory helpline, 209
elder maltreatment according to, 196 information role of, 169, 293–294
stress in the home Substance Abuse and Mental Health
as child maltreatment risk factor, 114 Services Administration (SAMHSA),
stroke 604–607, 629
as air pollution-related disease, 27 Substance Abuse Treatment Facility
alcohol linked to, 30 Locator, 448
causes of, 1 substance use issues
contributing factors, 219 mental illness and, 422
diabetes as factor in, 164 success
goals and objectives concerning, 307 communicating, 144–145
high BMI associated with, 86 dissemination of, 131
mortality, 289 evaluating, 140
overview of, 313 sudden infant death syndrome (SIDS),
people with and without disabilities 236, 329, 349, 350
compared, 171 sudden unexpected infant death (SIUD),
preventing, 313 329, 350
races compared, 289 sugar-sweetened beverage tax, 302
risk factors for, 124, 312, 342 suicide
risks, lowering for, 165, 341 alcohol role in, 31
Student Bodies (program), 194 attempted, 65–66
Stuen-Parker Jon, 610 firearm role in, 259, 329
“subjective cognitive decline” (term), 35 LGBT individuals at risk for, 385, 386,
substance abuse 387
addressing, 142–143 suicide attempts
chronic stress associated with, 269 ER treatment for, 639
consequences of, 3 suicides
development of, 4–5 guns and, 640
education on, 359–360 Sumeria, 45, 46
as epidemic, 219 summative evaluations, 228
food insecurity associated with, 243 Sumner, Charles, 179, 180, 181
heterosexual/cisgender and LGBT sun exposure, unprotected
individuals compared, 387 cancer risks of, 97
782 INDEX
sunlight tacrine, 35
rickets prevention with, 200 “talk test,” 486
sunscreen, 391 tangles, 34, 35
Supplemental Nutrition Assistance Tanner, Elizabeth Milbank, 48
Program (SNAP), 243–244, 546, Tanner, John Stewart, 48
627 Tanning Is Out, Your Skin Is In, 569
Supplemental Security Income (SSI), Tarde, Jean-Gabriel De, 168
591–592 tartaric acid, 476
Supreme Life Insurance Company, 89 task force
surgeon generals organizing, 139
women and minorities as, 198, 199 task performance
Surgeon General’s Call to Action to Prevent goals, aims and, 256
Skin Cancer, 569 tau proteins, 34
surgeons general, 607–609 tax revenues, 684–685
surgery Taylor, Frederick Winslow, 255
patient safety and, 480–481 Tay-Sachs disease
surgical care ethnic groups affected by, 276
coordinating and managing, 10 as genetic disorder, 249
Surveillance, Epidemiology, and End tuberculosis resistance in people with,
Results (SEER) program, 440 271
surveillance systems Tchaikovsky, Pyotr, 121
advances in, 219 technology, 176
survey teenage brain, 4
patient knowledge, attitudes, teenage mothers and fathers, parenting
and behaviors, measuring through, classes for, 144
227 teen pregnancy
sweatshops, 374–375 adverse childhood experiences (ACEs)
symbolic interactionism, 587 correlation to, 12
Symposium (Plato), 176 collaborations addressing, 130,
Synar Amendment, 684 142–143
syphilis decline in, 117
birth defects caused by, 350 gestational diabetes and, 145
detecting, 321–322 preventing, 144
epidemic of, 188 reducing, 198–199
studies, 71, 72, 514, 532, 620–624 research on, 204
transmission, 621 unintended, 235
syphilis, congenital teen sexuality, 198
blindness prevention in, 63 teixobactin, 52
transmission of, 322 telecommunication, 281, 282
Syphilis and Its Treatment (Hinton), 322 telegraph code-writing, 255
syringe service programs, 609–612 telemedicine, 100
systems thinking telomere theory, 19
coursework on, 151 Temporary Assistance to Needy Families
intervention, approach to developing, (TANF), 244
363 10-hour workday, 376
as public health core competency, 142, Ten Essential Public Health Services, 509
145 Ten Leading Causes of Death and Injury
systolic pressure, 339, 340, 341 charts (NCIPC), 442
INDEX 783
Tennessee Valley Authority, 539 as hypertension risk factor, 340

ten-year goals, 306 as leading health indicator, 383
teratogens, 79–80 messages countering, 615–618
terrorist attacks, response to, 53 Tobacco Use among U.S. Racial/Ethnic
Terry, Luther L., 608 Minority Groups (Surgeon General),
testicular self-examination, 124 279
testosterone, 20 To Err Is Human (IOM), 478
tetanus toilets, earliest, 45
in ancient Greek medicine, 324 Tokyo subway, sarin gas released in, 77
antitoxin for, 380 toothbrush, 159
Texas City Disaster, 1947, 106 tooth disease, 469–471
Thai villages, ancient tooth enamel, 470
moats around, 45 tooth loss, 161
Thalidomide Toulouse-Lautrec, Henri de, 251
birth defects due to, 79–80 tourists, disease transmission to, 706
Theiler, Max, 635 Town and Country Nursing Service, 643
The Joint Commission, 480–481 toxic chemicals, 97
The Jungle (Sinclair), 626–627 toxic shock syndrome, 51
“The Mortality of Doctors in Relation to toxic substances, 51, 245
Their Smoking Habits,” 662 toxin-induced hepatitis, 317
Therapeutic Communication interest toxins, 210, 265
group, 282–283 trade routes, communicable disease
thermal energy, 360 occurrence along, 55
The Woman Rebel (Sanger), 557 traditional healers, coordinating care with,
time, measuring, 220 153
time-bound (defined), 256–257 trafficking victims, 337
time sequence, 103 Trafficking Victims Protection Act, 336
Title X funding, 489 trail bikes, 432
tobacco trails, planning, 309
advertising restrictions, 682–683 transgender communities, HIV/AIDS risks
deaths-related to, 659 to, 333, 334
tax revenues, 684–685 transient ischemic attacks (TIAs), 313
tobacco industry translational research, 228–229
advertising, 284 transmission, chain of, 353–354
Master Settlement Agreement (MSA), transmitter as communication element,
396–397 281–282
misinformation spread by, 169 transplantation, 167
social media use by, 229 transplantation programs, 305
tobacco products, 240–241 transportation, clean forms of, 28
tobacco smoke as air pollution transsexualism, 386
source, 25 transtheoretical model (TTM), 227, 283,
tobacco use 294, 613–615
abstention from, 341 trash and refuse, disposal of, 110
by adolescents, 117–118 trastuzumab (Herceptin), 250–251
cancer risks of, 97 trauma, physical, 98
deaths caused by, 383 traumatic brain injury, 223, 359, 597–599
food insecurity associated with, 243 traumatic events, response to, 13, 209
health risks associated with, 383 traumatic injuries, 1
784 INDEX
travelers, disease transmission by, 706 underweight (defined), 86

Treatise on the Theory and Practice of Underwood, Michael, 492
Midwifery (Smellie), 400 undocumented immigrants
treatment, 153, 222, 261, 323, 324 health care for, 277, 279, 344, 704–710
trench mouth, 159, 160, 238 as labor trafficking survivors, 337
Trent-Adams, Sylva, 608 statistics, 343
Treponema pallidum, 321 unemployed patients, dumping of, 205
Triple Aim scholars, 495 unemployment, 114
Triple P (Positive Parenting Program), Unequal Treatment (IOM), 287
58–59 UNIAIDS, 253
trips, reducing, 29 uninsured populations
Trudeau Medal, 551 ACA impact on, 17
Truman, Harry S., 409, 540, 605 health care for, 279
Trust Black Women, 490 health insurance to, 16–17
Truth Campaign, 5, 284, 615–618 health literacy of, 299
tuberculosis unintentional injuries, 359
diagnosis, 91 United Nations, 338, 657
drug-resistant, 51, 77 United Nations agencies, 253
epidemics, 47 United Nations Children’s Fund
origin of, 377, 379 (UNICEF), 201, 253
prevention, 252 The United Nations Convention for the
races compared, 277, 279 Suppression of the Traffic in Persons and
resistance to, 271 of the Exploitation of the Prostitution of
screening for, 274–275 Others, 338
spread and transmission of, 252 United States Agency International
treatment, 91, 252 Development (USAID), 252
Tubman, Harriet, 618–620 United States Postal Service, 590
Tufts Center for the Study of Drug universal addiction prevention, 5
Development, 669 universal health insurance, 17
Tugwell, Rexford, 539 universal prevention mechanisms, 13–14
tularemia, 77 Unsafe at Any Speed (Nader), 436
Tuomey Healthcare System, 600 upper respiratory infections, 51–52
Tuskegee Institute, 49, 90, 186 upstream public health practices,
Tuskegee Syphilis Study, 71, 72, 514, 532, 625–626
620–624 urban planning, 45, 308
2005 Surgeon General’s Call to Action to urban sanitation, 49
Improve the Health and Wellness of urban sprawl, 308, 310
Persons with Disabilities, 175 urine cotinine levels, 227
typhoid fever U.S. Agency for International
battling, 61–62 Development (USAID), 203,
carriers, 393–396 253–254
epidemics, 110, 213 U.S. Chamber of Commerce, 697
outbreaks and spread of, 128–129 U.S. Department of Agriculture (USDA),
Typhoid Mary, 62, 128–129, 393–396, 23, 626–628
520 U.S. Department of Education, 150–151
typhus, 47 U.S. Department of Health and Human
tyrosine, 54 Services (HHS), 628–630
tyrosinemia, 250 agencies within, 345–349
INDE X 785
food safety information disseminated validity (defined), 227

by, 246 values, 128, 176, 177–178
units and divisions, 104, 383 (see also Van Buren, Martin, 346
specific division, e.g.: Children’s Vancomycin, 51
Bureau) van Gogh, Vincent, 251
U.S. Department of Labor, 22–23 van Leeuwenhoek, Anton, 353
U.S. Environmental Protection Agency Variola major, 570
(EPA), 28 Variola minor, 570
U.S. Fire Administration (USFA), 328 vector-borne diseases, 253, 473
U.S. Marine Hospital Service, 511–512 vector-borne outbreak, 217–218
U.S. Public Health Service (PHS), vectors, 217, 354
630–632 vegetables, 460
dental health, involvement with, 159, vehicle borne outbreak, 217, 218
238 vehicle greenhouse gas rules, 211
disease campaigns conducted by, vehicles, refueling, 29
274–275 Venereal Disease Division, USPHS, 621
Indian Health Services (IHS) established venereal diseases. See sexually transmitted
within, 347 diseases
Venereal Disease Division, 621 veterans
U.S. Sanitary Commission, 84 health care for, 16, 273
utilitarianism, 110, 225 mental health issues, 605
post-traumatic stress, 637–639
vaccines, 633–636 Veterans Affairs, 16
against childhood diseases, 353 veterans’ health, 636–639
compulsory, 635–636 Veterans Health Administration (VHA),
development of, 123, 371 637
epidemic control through, 219 Veterans Health Care Act of 1992, 637
flu prevention with, 357–358 veterinary medicine, 163
as global health intervention, 254 veterinary public health, 39
guidelines for, 51 Vibrio cholera, 119
immunity enhancement through, 354 victimization (intimate partner violence),
increased rate of, 306 factors associated with, 367
Louis Pasteur and, 475–476 victimology theory, 196, 197
mandatory, 515 Victoria, Queen of England, 251
manufacture and safety testing, 156 violence, 639–642
measles, 404–405 addressing, 142–143
mechanism of action, 687–688 attitudes concerning, 367
meningitis, 413 behavioral genetic theories applied to,
parental refusal pros and cons, 250
686–696 childhood exposure to, 367
polio, 492–493, 553 as epidemic, 219
postexposure, 634 injuries resulting from, 359
regulation and supervision of, 240–241 as learned behavior, 195–196
safety of, 273 school, 231
small pox, 571 stress in home due to, 114
vaccines, new, 169, 187 against women, 366
Vaidya’s Oath, 127 women’s issues, 653
Valeant, 669 youth, 139, 230, 231
786 INDEX
Violence Epidemiology Branch, CDC, 640 water systems, public, 110

Vioxx, 681 water usage by poor, 112
viral gastroenteritis (stomach flu), 218, wealth inequality, 277
253 weaponized organisms, 75
viral hemorrhagic fevers, 77 weapons of mass destruction, 77
viral hepatitis, 317 wearable health sensors, 169
Virchow, Rudolf, 98 weather emergencies, 208
visiting nurses Weaver, Donald L., 608
for children, 62, 64, 70 Weaver, Warren, 282
for elderly, 18 websites, 107
vitamin B, 461 Wegman, Myron Ezra, 648–650
vitamin D, 360, 461 weight
vitamins, 380 as birth defect risk factor, 79
vitamin supplements, regulation of, 241 controlling, 256
vocational training for people with heart disease connection to, 86
disabilities, 171 maintaining healthy, 171, 341
Voices of Our Fathers Legacy Foundation, promoting healthy, 88
623–624 weight loss, 465
vomiting, 119, 120, 193 The Weight to Eat (program), 194
von Behring, Emil Adolf, 380 Welch, William Henry, 380
vulnerable groups, 225, 254 well baby care, 62
well-being, promoting, 209
waist circumference, 466 wellness, 135, 152
Wald, Lillian, 560, 643–645 Wells, H. G., 665
walking paths, integrating, 310 wells, poisoning, 75
War of the Worlds, 665 Wesley, John, 110
War on Drugs, 3, 447 West Africa, ebola in, 107
Wasserman, August von, 321, 380 west migration, 55
Wasserman Laboratory, 321 West Nile Virus, 77, 354
waste disposal, 44, 213 Wetherill, Charles L., 241
waste products, 211 whistleblowers reporting fraud,
waste systems, 110 compensating, 233
water, contaminated, 44 white labels, 376
in ancient Rome, 261 white plague (term), 274
causes of, 211 white superiority, 185
cholera transmitted through, 120, 122, white women, life expectancy of, 307
218, 252, 362 Whitney, Robert A., 608
historic conditions, 213 Wholesome Meat Act of 1974, 435, 436
in New York City, 47 Why Are Some People Healthy and Others
pathogens in, 353–354 Not? (Evans, Barer, Marmor),
water, hydration and, 470 494–495
water and drainage systems, 45, 110 Whytt, Robert, 413
waterborne diseases, 473, 645–648 Wilberforce, William, 93
waterborne illnesses, 119–120, 253 Wiley Act, 635
water filtration, 122 Willkie, Wendell, 540
Waterhouse, Benjamin, 512 Willowbrook Hepatitis Studies, 71, 532
water pollution, 213, 253, 308, 309 Wilson, Woodrow, 214
water quality, 246 Winslow, C. E. A., 451
INDEX 787
Winslow, Charles-Edward Amory, workplace

650–653 alcohol, excessive in, 31
WISQARS (Web-based Injury Statistics injuries, sleep deprivation and, 445
Query and Reporting System), respect within, 152
441–442 safety programs, 367
W.K. Kellogg Foundation, 561 toxins in, 265
Woman’s Central Relief Association, 84 work-related injuries, 515
women World Bank, 171–172
alcohol health hazards for, 30 World Charter for Nature, 696–697
death, causes of, 314, 653 World Health Assembly (WHA), 350, 351
disability in, 171 World Health Organization (WHO),
education, 49, 83–85, 91, 94 657–660
as elder maltreatment victims, 196 child maltreatment addressed by, 113,
food insecurity in, 243 115
health insurance for, 17 Commission on Social Determinants of
heart disease in, 314–316 Health, 585
as homicide victims, 367 on diarrhea, 645
life expectancy, 307 environmental health information
in medicine, 61–64, 81–85, 91, 94, provided by, 210, 271
101, 187–189, 190–191, 198–199, establishment of, 201
200–202, 263–266 global health challenges addressed by,
risk behaviors for, 12 253
violence against, 366, 368, 655 Global Programme on AIDS, 189
in workplace, 373, 375, 376 health as defined by, 176, 269, 270
Women, Infants and Children (WIC) intimate partner violence survey
program, 243–244, 278, 627 conducted by, 366–367
women’s health, 653–657 pandemic classification, 473–475
advancing care, 85 persons with disabilities,
agencies supporting, 305 recommendations concerning,
early efforts in, 49 171–172, 174
education in, 235 polio eradication programs, 492
female medical professional role in, 101 premature birth prevention measures,
global, 201 191
health care disparities, 286–287 Quality of Care Framework, 351
promoting, 204 smallpox declared eradicated by, 78,
as public health specialty, 163 570
self-care, 315 on syringe service programs, 611
workplace issues, 376 vaccination access and, 635
Woodruff, Robert W., 106 World Trade Center attacks, 2001, 107,
Woodworth, John Maynard, 55, 607, 207
630–631 World War I
workers, safety measures for, 111–112, American Union Against Militarism,
265 644–645
worker strikes, 374 children, aid programs during, 48
workforce development, 145–146 dentistry during, 238
working class, 110, 111, 265, 374 draft, 159
working memory, 20 flu pandemic at end of, 356
working poor, 110 health of draftees in, 603
788 INDEX
World War II Young, T. Kue, 497

African Americans in, 90, 185 young adults, goals for, 256
bioterrorism during, 76–77 young Americans, causes of death for, 31
blood preservation and transport Young Men’s Anti-Slavery Society, 574
during, 185 The Young Stethoscopist (Bowditch), 92
economic boom after, 214 youth
Franklin Delano Roosevelt and, beverages advertised to, 302
540–541 drinking among, 30
infant and maternity care during, 191 drugs, perception about, 6
oral hygiene during, 159 elders, contact with, 19
racism in, 185 farm-associated injuries among,
returning veterans, 605 22, 23
school attendance laws, 560 HIV/AIDS risks to, 331
U.S. participation in, 266 as human trafficking victims, 336
wounded soldiers, treating, 91 obesity in, 301
Wylie, Ida, 64 violence, 139, 230, 231
Wyman, Walter, 607 Youth Risk Behavior Survey (YRBS), 134
Wynder, Ernst Ludwig, 660–664 Youth Violence (DHHS), 640
Youth Violence: Report of the Surgeon
Yale AIDS Brigade, 610 General, 230
yaws, 659 Yuzpe, Albert, 204
yellow fever
attempts to control, 344 Zakrzewska, Marie, 84
bioterrorism role in, 77 Zika virus, 217–218, 251
epidemics, 213 Zombie Outbreak Response Team (ZORT),
global warming role in, 253 667
spread of, 55 zombie preparedness, 665–668
vaccines, 635 zoonotic diseases, 473
Yersinia pestis, 352, 353, 426–427 zoonotic infections, 22

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Encyclopedia of

SALLY KUYKENDALL, EDITOR

Library of Congress Cataloging in ­Publication Control Number: 2017045280

ISBN: 978-1-61069-982-2 (set)

This book is also available as an eBook.

This book is printed on acid-­free paper

Manufactured in the United States of Amer­i­ca

Guide to Related Topics xv

Attention-­Deficit/Hyperactivity Disorder (ADHD) 57

Cornely, Paul Bertau (1906–2002) 146

False Claims Act (FCA) 233

Heart Truth® (Red Dress) Campaign, The 314

Planned Parenthood 488

Snow, John (1813–1858) 577

­Women’s Health 653

Diseases, Health Prob­lems, and Hepatitis

Centers for Medicare and Medicaid Public Health Law

Beers, Clifford Whittingham Wald, Lillian (1867–1940)

Maternal Health Council on Education for Public

Indian Health Ser­vice (IHS) ­Children’s Health

Public health encompasses a broad array of programs, princi­ples, and professional

the control of communicable infections, the education of the individual in personal

c. 1754 BCE Code of Hammurabi states laws of Mesopotamia including

1783 American Revolutionary War ends with an estimated 4,435 U.S.

1877 Louis Pasteur proves germ theory

1949 Florence Sabin reorganizes Colorado State Board of Health

1979 First edition of Healthy ­People published

2012 Ebola epidemic in West Africa

How Addictions Begin

Public health uses the biopsychosocial model as a framework to understand dis-

are used as a way to self-­medicate for ­those living in harsh or disadvantaged

Interventions by ­family members or court mandates can be just as effective as vol-

See also: Alcohol; Cancer; Collaborations; Epidemic; Hepatitis; ­Human Trafficking;

leadership coordination, operational pro­cesses, and implementation of policies

Basic Courses for Discipline and Degree

A health administration degree prepares prospective health care administrators to

management skills in their specialties. At the gradu­ate level, such concentrations

Generalists and Specialists

A generalist health administrator is a business-­oriented man­ag­er with technical

as medical rec­ords man­ag­ers or health information man­ag­ers secure patient health

ADVERSE CHILDHOOD EXPERIENCES (ACEs)

See also: Behavioral Health; Child Maltreatment; Intimate Partner Vio­lence; M

AFFORDABLE CARE ACT (ACA)

programs, grants, and publications to gather information on the dangers of farm-

• ­Don’t smoke or allow o­ thers to smoke in your home or workplace.

• Reduce trips by planning shopping routes and combining errands.

L. Jantarasami, D. M. Mills, S. Saha, M. C. Sarofim, J. Trtanj, & L. Ziska (Eds.). U.S.

plays a significant role in unintentional injury, including motor vehicle accidents,

gastrointestinal organs. Alcohol impairs decision making, which increases risk of

See also: Addictions; Adverse Childhood Experiences; Behavioral Health; Birth

ALZHEIMER’S DISEASE (AD)

See also: Aging; Chronic Illness; Ge­ne­tics; M

AMERICAN JOURNAL OF PUBLIC HEALTH (AJPH)

AMERICAN MEDICAL ASSOCIATION (AMA)

AMERICAN PUBLIC HEALTH ASSOCIATION (APHA)

AMERICANS WITH DISABILITIES ACT (ADA)

ser­vices” (Department of Justice, 2017). The ADA is relevant to public health in

ANCIENT WORLD, PUBLIC HEALTH IN THE

Lawler, A. (2009, February). Bodies of evidence in Southeast Asia. Smithsonian Magazine,

ANDERSON, ELIZABETH MILBANK (1850–1921)

Elizabeth Milbank Anderson died of pernicious anemia on February 22, 1921.

ASSOCIATION OF PUBLIC HEALTH

by-­products build up and can cause a variety of health or developmental prob­lems.

Library of Congress Cataloging in Publication Control Number: 2017045280

This book is printed on acid-free paper

Manufactured in the United States of America

Attention-Deficit/Hyperactivity Disorder (ADHD) 57

Women’s Health 653

Diseases, Health Problems, and Hepatitis

Indian Health Service (IHS) Children’s Health

Public health encompasses a broad array of programs, principles, and professional

1979 First edition of Healthy People published

are used as a way to self-medicate for those living in harsh or disadvantaged

Interventions by family members or court mandates can be just as effective as vol-

See also: Alcohol; Cancer; Collaborations; Epidemic; Hepatitis; Human Trafficking;

leadership coordination, operational processes, and implementation of policies

management skills in their specialties. At the graduate level, such concentrations

A generalist health administrator is a business-oriented manager with technical

as medical records managers or health information managers secure patient health

See also: Behavioral Health; Child Maltreatment; Intimate Partner Violence; M

• Don’t smoke or allow o thers to smoke in your home or workplace.

See also: Aging; Chronic Illness; Genetics; M

services” (Department of Justice, 2017). The ADA is relevant to public health in

by-products build up and can cause a variety of health or developmental problems.

See also: Administration, Health; Antibiotic Resistance; Core Competencies in Public

ATTENTION-D EFICIT/H YPERACTIVITY

Parenting Program), Incredible Years, Parent-Child Interaction Therapy, and

See also: Adverse Childhood Experiences; Attention-Deficit/Hyperactivity Disorder;

Departments; Substance Abuse and Mental Health Services Administration; Social

The Wampanoag p eople of Massachusetts are stricken by smallpox. Millions of indigenous

distribution by geography or other factors. Through such large-scale BMI studies,

1186. Retrieved from http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2009

voluntarily implemented training and safety programs. In a study of w ater usage,

Kudlick, C. J. (1996). Cholera in post-revolutionary Paris: A cultural history. Studies on the

1. Public health should address principally the fundamental c auses of disease

See also: Community Health; Community Organizing; Evaluation; Intervention;

See also: Collaborations; Community Organizing; Cultural Competence; Evidence-

COMMUNITY ORGANI ZING

communities. And although community organizing can be challenging, juggling

competency advocates and empowers p eople regardless of gender, ethnicity, lan-

c hildren participated in a demonstration against hunger. In California, Mexican

Culture is defined as a “structure of behaviors, ideas, attitudes, values, habits,

the program, engagement of students in learning and community service, support

History provides numerous examples of people who, with appropriate support,

See also: Americans with Disabilities Act; Attention-Deficit/Hyperactivity Disorder;

Charles was awarded a partial college scholarship to Amherst College in Massa