Introduction to public health

By: Assefa Andargie (BSc, MPH)

assefaand@gmail.com

1
 Learning objectives
➢ Define health, population, community and public health.
➢ Compare and contrast public health and clinical medicine.
➢ Identify and describe the three hallmarks of public health:
philosophy of social justice, focus on prevention, and focus
on populations.
➢ List and distinguish the three core functions and ten
essential public health services.
➢ Describe major historical milestones in the development of
public health.

2
3
 Definition of concepts
Health
▪ WHO definition: ‘a state of complete physical,
mental, and social well-being and not merely the
absence of disease, or infirmity’
▪ “Health is a resource for everyday life, not the
object of living, and is a positive concept
emphasizing social and personal resources as well
as physical capabilities.”
WHO, 1948

4
 Definitions … Health
Physical health is the overall condition of a living organism at a
given time, the soundness of the body, freedom from disease or
abnormality, and the condition of optimal well-being.
Mental health - WHO defines 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 productively and fruitfully, and
◦ is able to make a contribution to his or her community

5
 Definitions … health
Social health- refers
◦ how people reacts with other people and how he interacts with
social institutions and societal mores.
◦ those who are well integrated into their communities tend to live
longer and recover faster from disease.
◦ Conversely, social isolation has been shown to be a risk factor for
illness.
A society is healthy when there is:
◦ equal opportunity for all and
◦ access by all to the goods and services essential to full
functioning as a citizen.

6
 Critics of the WHO definition of health
▪The word "complete“ is absolute, and difficult to
measure.
▪Not taking other dimensions into account, namely the
emotional, spiritual and societal aspects of health.
▪Viewing health as a state or product rather than as a
dynamic relationship, a capacity, a potential or a
process
▪Specifying an idealistic state that is impossible to attain

7
Health…
▪Others have stated that health cannot be defined
as a state because it is ever changing.
▪Health is a dynamic state or condition of the
human organism that is multidimensional in
nature, a resource for living, and results from a
person’s interactions with and adaptations to his
or her environment;
▪therefore, it can exist in varying degrees and is
specific to each individual and his or her situation.

8
Health…
▪Therefore, health is:
▪‘a resource for everyday living’,
▪‘a fundamental human right’, and
▪‘an essential component of development’.

9
Definitions … Population
POPULATION: All the inhabitants of a given country or
area considered together; the number of inhabitants of
a given country or area.
POPULATION HEALTH
➢The prevailing or aspired level of health in the
population of a specified country or region or in a
defined subset of that population.

10
 Definitions … Community
➢ COMMUNITY: A group of individuals organized into a unit or
manifesting some unifying trait or common interest; loosely,
the locality or catchment area population for which a
service is provided or, more broadly, the state, nation, or
body politic.
➢ WHO defines community as “a group of people, often living
in a defined geographical area who share a common
culture, values, and norms.

11
 Community …
▪Communities are characterized by the following elements:
1) membership—a sense of identity and belonging;
2) common symbol systems—similar language, rituals, and
ceremonies;
3) shared values and norms;
4) mutual influence—community members have influence
and are influenced by each other;
5) shared needs and commitment to meeting them; and
6) shared emotional connection—members share common
history, experiences, and mutual support.

12
 Public health
1. ‘The science and art of preventing disease, prolonging life
and promoting health through the organized efforts and
informed choices of society, organizations, public and
private, communities and individuals’ (Winslow, 1920).
2. ‘the science and art of preventing disease, prolonging life,
and promoting health through the organized efforts of
society’ (Sir Donald Acheson, 1988)
3. “Efforts organized by society to protect, promote and
restore the peoples health”. (John Last,

13
CEA Winslow’s “Classic” Definition of Public Health,
1920 (expanded version)

“… the science and art of preventing disease.

Prolonging life and promoting health and efficiency
through organized community effort
◦ for the sanitation of the environment,
◦ the control of communicable infections,
◦ the education of the individual in personal hygiene,
◦ the organization of medical and nursing services for the early
diagnosis and preventive treatment of disease, and for
◦ the development of the social machinery to ensure everyone a
standard of living adequate for the maintenance of health,
so organizing these benefits as to enable every citizen
to realize his birthright of health and longevity.”

14
 Definitions … public health
❑Public health is a science: it requires scientific
knowledge to understand diseases causation,
prevention and health promotion.
❑Public health is an art: the application of scientific
knowledge indicates an art, such as purification of
water, environmental sanitation and etc.

15
 Public Health …
Public Health encompasses:
1. The health of a whole society. It can be measured and assessed through
quantitative and qualitative indicators and analytic processes.
2. The specific policies, services, programs and other essential efforts agreed,
organized, structured, financed, monitored, and evaluated by society to
collectively protect, promote, and restore the people’s health and its
determinants.
3. The institutions, public and private organizations—including private and public
companies—, and other citizens organizations, that plan, develop, fund, and
implement such efforts, and which are thus an integral part of local, national,
regional, and global public health systems.
4. The scientific disciplines and professions, knowledge, methods, art, and craft
essential to positively influence health determinants, and thus prevent disease
and disability, prolong life, and promote health through the organized and
collective efforts of society.

16
Definitions … Health promotion
Health promotion: is the process of enabling
people to increase control over, and to improve,
their health.
➢ Health promotion is not just the responsibility
of the health sector, but goes beyond healthy
lifestyles to well-being. (Ottowa Charter 1986)
➢ Health promotion is much wider than individual
issues and individual actions.

17
Definitions … Health promotion
➢ Health promotion is concerned with global warming,
food preservation, crop production, engineering
investment to achieve less pollution, transport
policies, allocation of resources to different sectors
of health care services.
➢ The message is health promotion combines a wide
number of issues which complement each other to
assist with the achievement of better levels of
health.

18
Definitions … Prevention
PREVENTION:
➢ Actions that prevent disease occurrence.
➢ Actions aimed at eradicating, eliminating, or
minimizing the impact of disease and disability, or if
none of these is feasible, retarding the progress of
disease and disability.
➢ Can be primary, secondary or tertiary level.

19
 Definitions … Prevention
❖ Primary prevention intends to prevent the
development of disease and the occurrence of
injury, and thus, to reduce their incidence in the
population.
❖ Secondary prevention is concerned with treating
disease after it has developed so that there are no
permanent adverse consequences; early detection
is emphasized.
✓ Secondary prevention activities are intended to identify the
existence of disease early so that treatments that might not
be as effective when applied later can be of benefit.

20
Definitions … Prevention
❖Tertiary prevention focuses on the optimum
treatment of clinically apparent and clearly
identified disease to reduce complications to
the greatest possible degree.
✓ Tertiary prevention often involves limiting
disability that occurs if disease and injury are
not effectively treated.

21
 Public health Vs clinical medicine
➢ The central focus of clinical professions is to restore
health or prevent exacerbation of health problems.
➢ Thus, health care is primarily concerned with
secondary and tertiary prevention:
➢ The health care system undoubtedly has its smallest
impact on primary prevention, once again that group
of interventions that focus on preventing disease,
illness, and injury from occurring.

22
 Public Health vs. Medicine

Public Health Medicine

◦ Population ◦ Individual
◦ Disease Prevention ◦ Diagnosis
◦ Health Promotion ◦ Treatment
◦ Interventions ◦ Intervention
◦ Environment ◦ Medical care
◦ Human behavior ◦ Private (Some public)
◦ Government (Some
private)

Source: Brandt, AM and Gardner, M. 2000. American Journal Public Health. 90:707-715 .

23
Dimensions of public health

24
 Dimensions …
PREVENTIVE MEDICINE
◦ It differentiates public health from the clinical disciplines
that are primarily involved with the care of the sick, whilst
public health emphasizes the avoidance of illness.
◦ Cover the early diagnosis and treatment of sick persons
with the aim of preventing advanced diseases and in the
case of communicable diseases, in preventing the spread
within the community.
◦ A further extension of the definition covers the treatment of
sick individuals aimed at reversing damage and restoring
function.

25
 Dimension….
SOCIAL MEDICINE- ‘The poor die young’
◦ Statistical analyses of mortality and morbidity data show
strong correlation between the social stratification in society
and the pattern of health and disease.
◦ The objective of social medicine is to identify the social
determinants of health and disease in the community and to
devise mechanisms for alleviating suffering and ill health
through social policies and actions.

26
Dimensions ….
Assumptions of social medicine
◦ Health as a birthright
◦ The responsibility of the state.
◦ Development and health are inter-related
◦ Education promotes health
◦ Health begins at home
◦ Poverty is a major underlying cause of ill health
The overall goal is to achieve equity in health.

27
Dimensions…
COMMUNITY HEALTH
◦ Community health deals with the services that aim
at protecting the health of the community.

◦ It includes an important diagnostic element –

‘community diagnosis’ – aimed at surveying and
monitoring community health needs and assessing
the impact of interventions.

28
Dimensions ….
COMMUNITY MEDICINE
◦ This usually refers to services that are provided
at the community level and is now often
encompassed in the new term primary care.
◦ Community physicians, nurses and other
health-care personnel are involved in providing
care at clinics, health centers and in people’s
homes.

29
 MODERN PUBLIC HEALTH
The modern concept of public health includes all
these elements.
Important features of modern public health include
the following characteristic features.
◦ Multidisciplinary
◦ multi-sectoral
◦ evidence-based- decision making
◦ equity-oriented.

30
 The key elements of modern
public health are seen to be:
▪having a population perspective
▪recognizing the role of governments in tackling
underlying socio-economic causes of ill health
▪working in partnership with local communities to
ensure their involvement in all stages of service
development and planning
▪working in partnerships with other agencies and the
public to develop health improvement strategies
▪developing the capacity of communities, professionals
and organizations to work in this way.
31
 The Mission of Public Health
Fulfilling society’s interest in assuring conditions in
which people can be healthy.
◦ Generate organized community effort to address the public
interest in health by applying scientific and technical
knowledge to prevent disease and promote health
◦ The mission is addressed by both private organizations and
individuals as well as by public agencies
◦ Unique function of the governmental public health agency: to
see that vital elements are in place and that the mission is
adequately addressed

32
 Purpose of PH
The purpose of modern public health is to protect and
promote health by:
▪ improving people’s life circumstances (e.g. housing,
employment, education, environment)
▪ improving people’s lifestyles
▪ improving health services
▪ protecting the public from communicable diseases and
environmental hazards
▪ developing the capacity of individuals and communities
to protect their health.

33
 Philosophy of public health
➢ "Philosophy" means how and what people think about
basic and longstanding human concerns such as
knowledge, reasoning, free will, morality, objectivity and
rationality, facts and values, and freedom.
➢ Knowledge is generated in the form of objective evidence
from studies in biology, epidemiology, and social science;
➢ these facts provide a rational basis for undertaking
interventions designed to prevent disease, injury, or death;
➢ these actions also reflect community values—some communities
constrain an individual's freedom in the name of the common good.

34
 Philosophy cont …
➢ How do empirical and normative issues relate to
each other?
➢ Controversial ethical, political and social issues,
including those relating to vaccinations, the threat of
pandemics and possible restrictions to individual
liberties, public health research, screening and
obesity policy should also be considered.
➢ The success of public health depends on adhering to
the basic rules of equity, partnerships, and social
justice, as well as the mobilization of local, national,
and international resources.

35
 Functions of public health
➢ Public health is a multidisciplinary field that
combines and applies techniques from both
social and natural science to assess the health
state of a population, to promote health, and to
prevent diseases.
➢ Additionally, public health policy is central for
adequate reactions to current and predicted
future health threats.

36
Functions …
The “core functions” of governmental agencies at
ALL levels of government are
1. Assessment
2. Policy development
3. Assurance

37
Assessment
All the activities involved in community diagnosis:
➢ Surveillance
➢ Needs assessment
➢ Analysis of cause of problems
➢ Collection and interpretation of data
➢ Case-finding
➢ Monitoring and forecasting trends
➢ Research and evaluation

38
Policy Development

➢ Scientific information
➢ Data from the assessment process
➢ Information from concerned citizens &
providers

39
Assurance
➢ Maintenance of a level of service needed to
attain an intended impact or outcome that is
achievable given the resources and techniques
available
➢ Administer quality assurance
➢ Help recruit & retain health care practitioners
➢ Maintain administrative capacity

40
The 11 Essential (Public Health) Services

41
Core functions and essential
services of public health

42
The ten organizational practices of
public health
Assessment 1. Assess the health needs of
the community
2. Investigate the occurrence
of health effects and health
hazards in the community
3. Analyze the determinants
of identified health needs

43
The ten organizational practices of
public health
Policy 4. Advocate for public health,
build constituencies, and
Development
identify resources in the
community
5. Set priorities among health
needs
6. Develop plans and policies
to address priority health
needs

44
The ten organizational practices of
public health
Assurance 7. Manage resources and
develop organizational
structure
8. Implement programs
9. Evaluate programs and
provide quality assurance
10. Inform and educate the
public

45
Serving all functions
➢ Research for new insights
and innovative solutions
to health problems

46
History of public health:
➢ History provides a perspective to develop an
understanding of health problems of communities and
how to cope with them.
➢ All societies must face the realities of disease and
death, and develop concepts and methods to manage
them.
➢ The history of public health is a story of the search for
effective means of securing health and preventing
disease in the population.
➢ The history of public health is the story of man's
endeavors to protect himself and his fellows against the
hazards to health entailed by group life.
47
➢ Public health is as old as the man
itself.
➢ In primitive time, since the
knowledge was limited, man
attributed disease to the wrath of
gods, the invasion of body by evil
spirits and the malevolent
influence of stars and planets.

48
➢ There was nomadic existence of
men
➢ Magic and spells were prevalent
➢ Sanitation of camp sites was
there but it was due to mythical
reasons
➢ Clothing, shelter, fire for warmth
and cooking of food for use and
storage, burial of the dead, and
removal of waste products from
living areas.
49
◦ Supernatural theory of disease

◦ Disease and human sufferings

& calamities were attributed to
the wrath of god

◦ Influence of evil spirits, stars &

planets

50
 Indian medicine
• Has been practiced in india for more than 5000 years
• Hindu god of medicine born as a result of churning of oceans
during tug of war between gods & demons
• Lord of healing in ayurveda
• Father of Indian science of medicine and ayurveda

51
 Indian medicine

➢Ayurveda emphasizes on
▪Importance of hygiene
▪Modification of diet
➢ Important source of medical
relief to rural population even
today

52
 Pioneer of
◦ Immunization
◦ Barefoot doctors which is the
basis of recent concept of
community participation
◦ Acupuncture
◦ Cultivation of plants & use of
herbs

Acupuncture
53
Mesopotamian medicine-

Babylonian Code of Hammurabi

(2000BC)
➢ High degree of social
organization
➢ Governed the conduct of
physicians & health practices
➢ Penalties for harmful therapy

54
➢ Physiotherapy, tramping on
patient’s body and counter-
irritant mixtures were
common therapeutic
measures
➢ Importance of worms,
insects & other parasites in
pathology of diseases
depicted in their paintings

55
➢ Circumcision was started
in 4000 B.C.

➢ Meanwhile they started

realizing importance of
hygiene & sanitation

56
 ➢Well-established community systems:
✓ Public baths
✓ Drains collecting rain water
➢Importance of hygiene & clean
dwellings
➢Punishment for artificial abortions
➢Care of infants
➢Use of Knife & cautery
➢Value of mosquito nets
Public bath ➢Association of plague with rats
58
Hippocrates
59
➢Appointed health officers
were to advise the Govt on
Epidemics
➢Like other Greek pioneers of
science, the doctors were
prone to think that much more
could be discovered by mere
reflection and argument than
by practice and experiment

60
Aesculapius (1200 BC)

• An early leader in Greek

medicine
• Had two daughters : Hygiea &
Panacea
• Hygiea: goddess of health
(preventive medicine)
• Panacea: goddess of medicine
(curative medicine)

61
Greeks emphasized the value of exercise, a
nutritious diet, and clean air in healing the body.

Disease prognosis and case histories were

introduced in the 5th century, and medical
schools were established.

62
Romans borrowed their medicine from Greeks whom
they had conquered

They were more practical

The first doctor to come to Rome was Arcagathus who

arrived from Greece.

63
➢ Public health was born in
Rome
➢ They developed drained
marshes for Malaria control
➢ Development of public baths,
sewers:
◦ mark of cleanliness & hygiene
➢Establishment of hospitals

64
Sewers & Rain Sanitary awareness
water drains A Roman health officer
stated on sanitary aspects

“My office concerns not only

the usefulness of such a
system, but also the very
health & safety of Rome”

65
 EUROPE
➢ Dark Ages of Medicine: medicine reverted
back to primitive medicine dominated by
superstition & dogma
➢ When Europe was passing through dark
ages, Arabians translated Graeco-Roman
medical literature into Arabic
➢ They developed Unani system of medicine
➢ Schools of medicine & hospitals in
Baghdad, Cairo were established by them

66
 ➢ This is one of the
indigenous system of
medicine nowadays

Unani medicine
67
➢After the fall of Rome,
Christian faith entered the
world
➢Implicit faith on Christ was
the only method of
treatment of disease
➢Christ was the supreme
healer, the savior of body &
soul

68
➢ Because of this the enquiry into the diseases
became unnecessary & even culpable.
➢ A doctor curing patients by rational methods was
considered to be committing sin & using medicine
was seemed to be lack of faith in God.
➢ The scientific medicine suffered greatly & was fully
dormant.
➢ All classes of people were treated alike.

69
➢ These institutions provided
efforts to cope with
epidemic and endemic
diseases
➢ Most physicians were
monks guided by church
doctrine and ethics
➢ Medical scholarship was
based primarily on the
teachings of Galen

70
➢ Crowding, poor nutrition and sanitation, lack of
water sources and drainage, unpaved streets,
keeping of animals in towns, and lack of organized
waste disposal created conditions for widespread
infectious diseases.
➢ All these were threat for the public health
➢ Although physicians provided services for those
able to pay but medical knowledge was a mix of
pragmatism, mysticism and sheer lack of scientific
knowledge.

71
ENLIGHTENMENT, SCIENCE, AND
REVOLUTION (1750–1830)

➢ Edward Jenner’s
experiment in 1796
brought hope that the
disease could be
controlled.
He carried out the first
vaccination with cowpox
virus in 1796

72
 SOCIAL REFORM AND THE SANITARY
MOVEMENT (1830–1875)
A milestone in the history of public health is great Sanitary
awakening which took place in England in mid-nineteenth century
and gradually spread to other countries.
Industrial revolution of the 18th century sparked of numerous
problems, i.e. creation of slums, overcrowding with all its ill effects.
◦ Germ Versus Miasma Theories-Pasteur, Cohn, Koch, and Lister
◦ Hospital reforms
◦ Vector born diseases
◦ Nutrition in public health
◦ Internationalization of health
◦ Cholera outbreak

73
➢ Preventive medicine really dates back to the 18th
century.

➢ It developed as a branch of medicine distinct from

Public Health.

➢ Preventive Medicine got a firm foundation after the

discovery of causative agents of disease and
establishment of the Germ Theory of disease.

74
Modern Preventive Medicine:
defined as…
“ the art and science of
health promotion, disease
prevention, disability limitation
and rehabilitation”

75
Term Public Health came in to general use around
1840’s

It arose from need to protect the public from the

spread of communicable diseases

In1848 the Public Health Act in England crystallized

the efforts organized by the society to protect,
promote & restore the public health

76
 Ten Great Achievements in
Public Health, 1900-1999
1. Vaccination.
2. Motor-vehicle safety.
3. Safer workplaces.
4. Control of infectious diseases.
5. Decline in deaths from coronary heart disease and stroke.
6. Safer and healthier foods.
CDC, Morbidity and Mortality
7. Healthier mothers and babies. Weekly Report, December 24, 1999
/ 48(50); 1141.
8. Family planning. Available at:
http://www.cdc.gov/mmwr/preview/
9. Fluoridation of drinking water. mmwrhtml/mm4850bx.htm

10. Recognition of tobacco use as a health hazard.

77
 Summary
➢ First Public Health Era — the control of
communicable diseases
➢ Second Public Health Era — the rise and fall of
chronic diseases
➢ Third Public Health Era — the development of
long and high-quality life

78
 Disciplines of public health
Discipline Description
Epidemiology Frequency, distribution, and determinants of diseases
and other related states or events
Biostatistics collection, storage, retrieval, analysis and interpretation
of health data; design and analysis of health-related
surveys and experiments; and concepts and practice of
statistical data analysis
Nutrition science of food, the nutrients and other substances
therein, their action, interaction and balance in relation
to health and disease.
Health services mgt planning, organization, administration, management,
evaluation and policy analysis of health and public health
programs (includes policy making, public health law)
Reproductive health Health in relation to reproductive system and to its
functions and processes.
79
 Disciplines of public health
Discipline Description
Health Promotion Process of enabling people to increase control over and
improve their health.
Environmental Health Concerned with environmental factors including
biological, physical and chemical factors that affect the
health of a community.
Health Economics Alternative uses of resources in the health services
sector and with the efficient utilization of economic
resources such as manpower, material and financial
resources.

80
 What (Who) Comprise Public Health?
Broad and interdisciplinary in nature
◦ Epidemiologists and biostatisticians
◦ Biomedical scientists (e.g., biologists, microbiologists, bacteriologists,
virologists, chemists, physicians)
◦ Environmental health specialists (including environmental health specialists,
toxicologists, sanitarians)
◦ Social and behavioral scientists (e.g., health educators, psychologists, social
workers)
◦ Health policy makers and administrators (e.g., administrators, elected
officials, program managers)
◦ “Non-public health” professionals who are involved in public health activities
and programs (e.g., engineers, lawyers, nutritionists, teachers)
◦ Other workers and occupations whose “work” constitutes activities that
protect and promote the public health, but who never think of themselves as
playing a role in public health (e.g., plumbers, rubbish collectors, contractors)

81
 References
1. Hodder Arnold. SHORT TEXTBOOK OF PUBLIC HEALTH MEDICINE FOR THE
TROPICS, 4th edition: 2003.
2. Angus Dawson. The Philosophy of Public Health. 2009.
3. Wilhelm Kirch. Encyclopedia of Public Health: vol.1. 2008.
4. Theodore H. Tulchinsky, Elena A. Varavikova, John Last. The New Public
Health. Ed. 2nd. 2009.
5. Raymond L. Goldsteen, Karen Goldsteen, David G. Graham. Introduction to
Public Health. 2011.
6. Miquel Porta. A Dictionary of Epidemiology. 6th ed. 2008.

82
Thank you!

83