01CH Community Bell

1 Overview of Community
and Public Health
Natali_Mis/iStock/Thinkstock
Learning Outcomes
After reading this chapter, you should be able to
• Define community and public health.
• Describe the most important public health concerns and how social factors can influence them.
• Summarize the history of community and public health.
• Identify the roles and responsibilities of different community and public health agencies.
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What Is Public and Community Health? Section 1.1
• A massive hurricane strikes the coastal states, and millions of people are without
adequate food or water. Who is responsible for providing those resources?
• Hundreds of people across the country are sickened by listeria found in onions that
were served at a major restaurant chain across the country. Whose job is it to moni-
tor our food systems?
• Millions of people fall ill from seasonal influenza because no one received the annual
influenza vaccine. Who should ensure the public is safe from a preventable disease?
The answers to all three scenarios will be provided in this text, but the brief answer is that
different agencies within the community and public health system are responsible for all
three situations. Community health, which refers to the overall health status of a community,
is crucial because it is related to a society’s ability to achieve its goals. Healthy communities
are successful communities. The health of any community is supported by the field of public
health, which is focused on improving overall quality of life and helping people live longer,
more productive lives.
Disease prevention and a focus on health promotion among populations are two important
characteristics of public health. In fact, public health has been responsible for remarkable
achievements in both of these areas during the past century. Besides great reductions in
infectious disease mortality rates in the United States, life expectancy has also increased from
about 46 years in 1900 to 79 years in 2015 (Berkeley Demography, n.d.; Centers for Disease
Control and Prevention, 2017k). An introduction to the fields of community health and public
health starts by defining important terms and exploring the distinctions between community
health and public health, public health versus health care (aka medical services), and the vari-
ous agencies within community and public health services.
1.1 What Is Public and Community Health?

Evaluate the following scenarios and consider where each action falls: public health or indi-
vidual health care.
Scenario 1: Your infant runs a high fever, and he is treated in the emergency
room by the pediatrician on call.
Scenario 2: You take your kindergartener to the health department’s clinic to

obtain her immunizations before she attends school.
Scenario 3: Your family is sheltered in temporary housing after massive floods

destroyed your neighborhood.
Scenario 4: Your doctor is about to begin gastric bypass surgery on you because
your obesity has compromised your overall health.
Once you understand the differences among community health, public health, and health
care, the answers to these scenarios are clear.
The Definition of Health

The World Health Organization (WHO) in 1948 defined health as “a state of complete physi-
cal, mental, and social well-being and not merely the absence of disease or infirmity” (para. 2).
This definition, with its emphasis on the positive

aspects of being well, represented at the time a new
approach to health. However, researchers attempt-
ing to study and understand health under this defi-
nition have found it challenging for several reasons.
First, it is difficult to develop reliable and valid mea-
surements of the positive dimensions of health, such
as mental, physical, and social well-being. This is
because the principal measurements of health indi-
cate either the absence of ill health or the presence Danuta Hyniewska/age fotostock/SuperStock
of a disease and symptoms of ill health. Given cur- The World Health Organization has a
rently available diagnostic tools, measuring the exis- definition of health that encompasses
tence of poor health is easier than assessing dimen- physical, mental, and social well-being
sions of good health (Susser & Stein, 2009). in addition to the absence of disease.
Another limitation of this definition of health is that it does not account for recent biomedi-
cal advances, such as the identification of molecular and genetic markers associated with
diseases. For example, individuals with a history of cardiovascular disease are more likely
to pass on that genetic marker to their offspring and that offspring to theirs and so on. Does
that mean this entire family line is considered unhealthy? Not necessarily. Genetics can point
toward cause, but they can also help identify ways to prevent the onset of a disease.
Today, health researchers and professionals also commonly use two other definitions to fully
describe the concept of health. The first is that health is “the absence of any disease or impair-
ment,” and the second is that “health is a state that allows the individual to adequately cope
with all demands of daily life” (Sartorius, 2006, para. 2). Keep in mind that, despite the variety
of definitions out there, many researchers, communities, organizations, and groups will iden-
tify one as the only true definition. When reviewing a viewpoint, whether in research, online,
or at an organization, we as public health professionals must understand the definition of
health being used. There is not one sole definition that covers the meaning of health entirely.
Therefore, the WHO’s definition of health will be the one referred to in this text.
Public Health Versus Community Health

Health can refer to more than just an individual’s well-being. Public health is a discipline that
focuses on the health of a population of individuals. The field focuses on monitoring, regulat-
ing, and promoting health within a defined population. For example, in the United States, all
residents make up the “population” of concern. This means that public health in the United
States involves monitoring and regulating the health of more than 320 million people: a Her-
culean task!
As with the definition of health, there are numerous variations on the definition of public
health. These key, but different, definitions help us understand how various agencies approach
their roles in maintaining population well-being. Here are three of the more popular defini-
tions used in the public health realm today:
• “Public health is concerned with protecting the health of entire populations. These
populations can be as small as a local neighborhood, or as big as an entire country or
region of the world” (Centers for Disease Control and Prevention Foundation, 2017).
• “Public health promotes and protects the health of people and the communities
where they live, learn, work, and play” (American Public Health Association, 2017).
• “Public health protects and improves the health of individuals, families, communi-
ties, and populations, locally and globally” (Association of Schools & Programs of
Public Health, 2017).
Community health is also a discipline that focuses on population well-being; however, it

defines its “population” at a different level—the community. A community is defined as a
population in a certain geographical area. A healthy community is one whose belief system
focuses on the elements required for optimal health and wellness.
So, a community health intervention might be tailored toward people with diabetes who live
in the Midwest. A public health initiative on the same issue would target everyone in the
United States who has diabetes. While both community and public health focus on popula-
tions, the population group is differentiated—that is the main difference (Table 1.1). Public
health is focused on group characteristics within a larger scope. Community health is typi-
cally geographically driven. In other words, community health is nested within public health.
Table 1.1: Community versus public health

Population Community health Public health
Louisiana Focuses on all health concerns Does not focus specifically on Louisiana unless all
residents of the residents of Louisiana residents suffer from one key public health problem that
is not in any other state
Example 1: Aiming to reduce
pollution from specific Example 1: Addressing obesity concerns nationwide,
industrial sites in Louisiana which would include residents of Louisiana but would
and mitigate asthma rates in not be exclusive to the state
the state
Example 2: Addressing obesity concerns in Louisiana if
Louisiana were the ONLY state with obese residents
Residents Does not focus on all coastal Focuses on all coastal states and affected cities
of East states but instead on individual
Coast states states or communities Example 1: Preparing to secure and provide safe
drinking water to those in need after a hurricane strikes,
Example 1: Providing which could include an indefinite number of states
hurricane safety tips tailored to
the Florida coast Example 2: Working with the coastal cities of Miami,
Florida; Jacksonville, Florida; Savannah, Georgia;
Example 2: Providing safety Charleston, South Carolina; Myrtle Beach, South
procedures to Key West Carolina; Wilmington, North Carolina; and Virginia
residents in preparation for the Beach, Virginia, to ensure safe evacuation routes inland
upcoming hurricane season in the event of a hurricane
Public Health Versus Health Care

While it is easy to confuse public health and health care, they are actually two separate fields.
Public health treats a population of people through education, interventions, and other
means. On the other hand, health care is defined as maintaining, treating, and improving an
individual’s physical, mental, and/or spiritual health. The key term here is “individual.” Public
health focuses on populations, while health care focuses on individuals.
Let’s dig deeper into the two realms using the subject of immunizations, or vaccines that can
protect against certain diseases, in public health versus health care. Consider the following
two examples:
Yolanda is a middle-class working mother who needs to have her two chil-
dren vaccinated before they can attend public school (a public health initia-
tive). She goes to her children’s pediatrician for the vaccinations (a health care
initiative).
Benjamin is an unemployed single father

who also needs to have his young daughter
vaccinated before she attends public school
(a public health initiative). He cannot afford
a doctor, so he goes to the local public health
department to obtain his daughter’s vacci-
nations (a public health initiative).
While Benjamin and Yolanda both need the same Weedezign/iStock/Thinkstock

thing, they obtained the service in different realms. School vaccinations are a public
Yolanda is following the public health policy of initiative but can be acquired in either
school vaccination requirements. She seeks out the the health care realm, via a private
services of her personal physician, who resides in physician, or through the public sector,
the health care realm and takes care of individual via public health services.
needs. Benjamin is in a population of low-income
single-parent families who cannot afford a private physician. He seeks assistance through
the public health realm and receives his daughter’s vaccination from the public sector, which
serves the community’s needs.
With this in mind, let’s go back to the scenarios from the beginning of the chapter.
Scenario 1: Your infant runs a high fever, and he is treated in the emergency
room by the pediatrician on call. Is this action part of community and public
health?
Scenario 4: Your doctor is about to begin gastric bypass surgery because your
obesity has compromised your overall health. Is this action part of community
and public health?
Both of these scenarios involve health care, or medical care, as they both involve individual
treatment. Although obesity is a public health concern, the public health perspective focuses
on population obesity issues—not one-on-one care such as surgeries. What about the last
two scenarios?
Public Health Issues and the Social Environment Section 1.2
Scenario 2: You take your kindergartener to the health department’s clinic

to obtain her immunizations before she attends school. Is this action part of
community and public health?
Scenario 3: Your family is sheltered in temporary housing after massive floods

destroyed your neighborhood. Is this action part of community and public
health?
Scenarios 2 and 3 are within the community and public health realm, as both focus on the
safety and health of the broader population. School entrance immunizations are part of a
public health policy required by federal law to ensure certain diseases do not spread. A health
clinic helps to ensure all children receive vaccinations so they can attend school, rather than
only the individuals on a private physician’s regular patient roster. You can use this formula to
remember the key differential between the two realms:
public health = population focus
health care = individual focus
Table 1.2 takes a brief look at the various careers within the public health realm versus the
health care realm.
Table 1.2: Top careers within public health and health care
Public health Health care
Epidemiologist Medical director

Community health worker Physician—all specialties
Public health nurse Registered nurse
Environmental health specialist Dentist
Health educator Physical therapist
Health and safety engineer Anesthesiologist
Health care executive (health department) Health care executive (hospitals, clinics, doctor’s offices)
Public health professor Psychiatrist
Public health statistician Health information management professional
Public health research scientist Medical services researcher
1.2 Public Health Issues and the Social Environment

While the focus of public health issues is broad, it has been segmented to tackle each issue at
its root causes. The Centers for Disease Control and Prevention (CDC) is at the helm of most
of the work that identifies and mitigates population health concerns—from the national
down to the community level. The top public health concerns include alcohol abuse and
harm, food safety, health care–associated infections (HAI), heart disease and stroke, human
immunodeficiency virus, motor vehicle accidents, obesity, prescription drug abuse, teen
pregnancy, and tobacco use.
Furthermore, the health of the public is not necessarily all related to human behaviors. The
social environment—formed by the collective influences of a group of people upon one
individual—plays a key role in health outcomes. Factors such as race, gender, education, reli-
gion, health literacy, culture, and socioeconomic status can also influence health outcomes.
Top Public and Community Health Concerns

The CDC annually reports on the biggest public health concerns for all 50 states and the Dis-
trict of Columbia (CDC, 2016i). The agency’s most recent report identified the top 10 prob-
lems and concerns within public and community health. The CDC’s Prevention Status Reports
are a set of web-based, state-level reports that examine the extent to which states are using
evidence-based policies and practices to address these top 10 concerns. Each report follows
the same framework: Describe the problem, identify the solutions, and report the status of
the problem. Public health leaders use these reports to assess their state’s status and iden-
tify areas for improvement (CDC, 2016i). The following is a brief look at those concerns and
potential resolutions.
Alcohol-Related Harms
Problem: Alcohol is the third leading cause of preventable deaths in the United States (Alco-
hol Justice, 2014; National Institute on Alcohol Abuse and Alcoholism, 2017). According to
Alcohol Justice (2014), most people believe alcohol-related harm is just another name for
“drunk driving,” but that is a misnomer. Alcohol plays a role in various activities that lead to
injury and/or death, including assault, violent crimes, low birth weight, infant mortality, and
high-risk behaviors such as overdose and other substance abuse. In 2005 alone, there were
1.6 million hospitalizations and 4 million emergency room visits due to alcohol (Alcohol Jus-
tice, 2014). More recent numbers show that 88,000 people die annually from alcohol-related
causes, with nearly 10,000 of those deaths due to driving fatalities. But alcohol is not damag-
ing only to people’s health. Alcohol-related harms are a significant economic burden as well,
costing the United States about $250 billion annually in lost production, care, emergency per-
sonnel, and so much more.
Potential Solution: Adopt policies to reduce the incidence of alcohol-related harms, including
increasing state excise taxes on beer, distilled spirits, and wine and holding establishments
that serve intoxicated or underage customers liable for injuries caused by the customers.
Food Safety
Problem: The CDC (2016i) has noted that one in every six Americans gets sick from eating con-
taminated food each year. The agency monitors outbreaks annually through its surveillance
system, the National Outbreak Reporting System (NORS). In 2015, 902 foodborne disease
outbreaks were reported, and they caused 15,202 illnesses, 950 hospitalizations, 15 deaths,
and 20 food product recalls (CDC, 2015j). Norovirus, Salmonella, and Escherichia coli (E. coli)
were the top three outbreaks in the nation.
Solution: Improve surveillance, detection, and prevention methods, including increasing the
speed of DNA fingerprinting to test for all cases of Shiga-toxin-producing E. coli 0157. Addi-
tionally, a CDC Prevention Status Report suggested that the FDA Food Code be adopted into
state food safety regulations.
Health Care–Associated Infections

Problem: The CDC’s most recent report in 2014 showed a 50% decrease in some infections
as a result of a hospital stay, but only a 13% decrease in methicillin-resistant Staphylococcus
aureus (MRSA), which is an infection caused by bacteria that does not respond to many anti-
biotic treatments (CDC, 2016c). While the results did show improvement, the report noted
that 1 out of every 25 patients contracts an infection during a hospital stay (CDC, 2016c). This
shows why infection control remains a priority.
Solution: Two key practices were recently introduced: implementing state activities to build
capacity for HAI infections and implementing stewardship programs to reduce the overuse of
antibiotics in the acute care setting.
Heart Disease and Stroke

Problem: The American Heart Association (2017a) released an updated report on cardiovas-
cular disease (CVD) that showed a significant decrease in the CVD incidence rate over the
10-year span of 2004 to 2014. It also reported a rate drop for every race/ethnic group for
which it collects data: White, Black, Asian/Pacific Islander, Hispanic, and American Indian/
Alaska Native. While this is good news, it does not necessarily mean the health issue is no
longer a problem. Because the prevailing causes of heart disease and stroke, which include
risk behaviors such as smoking and a sedentary lifestyle, remain significant factors, there is
still more work to be done.
Solution: Heart disease and stroke have remained key national problems for several decades.
Policies have been developed to decrease the incidence rate; however, more scientific stud-
ies have shown critical areas that could improve effectiveness in managing heart disease
and stroke risk. These include implementing meaningful use of electronic health records
and establishing collaborative drug therapy management policies at the state level that will
authorize pharmacists to provide certain patient services.
Human Immunodeficiency Virus (HIV)

Problem: Human immunodeficiency virus (HIV), once labeled the “gay man’s disease,” is wide-
spread now in the United States. Data collected between 2010 and 2014 have shown that the
rate of diagnosis of HIV infection has dropped overall, yet certain races show higher rates
than the population at large. For example, in 2015, the national rate of HIV infections was
12.3 per 100,000 people (CDC, 2015c). The rate for Blacks/African Americans was 44.3 in the
same year (CDC, 2015c). This suggests that the interventions and actions taken to reduce the
rate are having little to no effect on certain populations.
Solution: Recent advances in HIV prevention and medical care have prompted the adoption
of several state policies. These include facilitating state Medicaid reimbursement for HIV
screening and making the state HIV testing laws compatible with the national testing recom-
mendations from the 2006 CDC and 2013 U.S. Preventive Services Task Force.
Motor Vehicle Injuries

Problem: The more than 32,000 deaths as a result
of motor vehicle accidents cost the health care sys-
tem a whopping $380 million in direct medical care
(CDC, 2016g). A lack of child car seats and booster
seat use as well as not buckling up accounted for
9,500 of those deaths. Drunk driving accounted for
more than 10,000 of those deaths.
Solution: While motor vehicle injuries have been

Yaoinlove/iStock/Thinkstock
Laws that mandate the use of child car reduced thanks to the inclusion of seat belts and air-
seats help further reduce the number bags in vehicles, there is still much that can be done
of motor vehicle injuries. to reduce crash-related injuries and deaths. Recom-
mendations include implementing primary enforce-
ment of seat belt laws that cover all occupants in the vehicle and not just the driver, mandating
the use of car seats and booster seats for all passengers through at least age 8, and requiring
the use of ignition interlock devices for everyone convicted of alcohol-impaired driving.
Nutrition, Physical Activity, and Obesity

Problem: Schoolchildren have a variety of options at their disposal for food during the school
day. Story, Nanney, and Schwartz (2009) reported that 33% of elementary schools, 71% of
middle schools, and 89% of high schools had a vending machine or some sort of snack area
where foods could be purchased. Most of those foods consisted of soft drinks, sports drinks,
and high-fat, salty snacks such as potato chips. While the number of vending machines and
other outlets selling these foods is decreasing, many are still available to children.
Solution: Scientific studies support implementing certain recommendations across the nation.
First, limit the availability of minimally nutritious foods/drinks in schools, and second, enact
obesity prevention standards in licensed childcare facilities. These initiatives should be com-
bined with maintaining or adding physical education within the school system and designing
features in communities to support physical activities, such as playgrounds and walking paths.
Prescription Drug Overdose

Problem: The U.S. Department of Health and Human Services (HHS) (2018c) found that 11.5
million people misused prescription opioids in 2016, and that number appears to be rising. In
2016, 116 people died daily from alleged opioid abuse and misuse (U.S. Department of Health
and Human Services, 2018c). In 2017, the department declared a public health emergency in
hopes of halting the crisis.
Solution: Implementing stricter monitoring programs to track the dispensing of controlled

substances would include requiring timely submission of data to the state’s prescription drug
monitoring program and universal monitoring programs to be used by all prescribers. This
involves quite a bit of health information technology expertise and funding, but having one
all-encompassing monitoring program could profoundly reduce prescription drug overdoses.
Teen Pregnancy
Problem: The health policy and research organization known as the Guttmacher Institute
(2016) reported a decline in teen pregnancy due to the increased use of contraception meth-
ods. Guttmacher’s research found that teen sexual activity remained the same, but preg-
nancy rates (as well as potential abortions) dropped, thanks to the use of contraceptives.
In its 2016 report, Guttmacher indicated that policy needs to be expanded to focus on teen
contraceptive use.
Solution: Enact a policy to increase access to contraceptive counseling and services by expand-
ing the age and income eligibility levels for Medicaid coverage of family planning services. This,
in turn, will increase teens’ access to contraceptives as well as other preventive measures.
Tobacco Use
Problem: Smoking overall has declined since former Surgeon General Luther Terry embarked
on his campaign to warn people about the dangers of cigarette smoking in the mid-1960s.
However, the issue remains a large public health concern, as more than 480,000 deaths occur
annually from direct smoking as well as exposure to secondhand smoke (CDC, 2016k).
Solution: Because the connection between smoking and cancer is well established, the next
steps are to assist people in quitting the habit. Smoking rates have dropped over the decades,
but smoking and smoking-related illnesses remain a major health problem. Policy recommen-
dations include increasing the price of tobacco products, especially a larger state-based tax, and
establishing stronger and more widespread smoke-free policies in public and private establish-
ments to protect nonsmokers, especially children, from exposure to secondhand smoke.
The Role of Social Influences

It’s obvious that tobacco use and alcohol consumption affect health. It is also easy to under-
stand how sedentary lifestyles and poor nutrition choices increase a person’s risk for various
diseases. But there are also social influences that affect health status. These can be summed
up in three categories: race and ethnicity, socioeconomic status and education, and religion
and culture.
Race and Ethnicity

In the United States, the key public health issue related to race and ethnicity involves poor
health outcomes for Blacks/African Americans, Asian Americans, and Native Americans.
For example, life expectancies are far lower for Black men and women than for their White
counterparts (Table 1.3 and Figure 1.1). In 2013, the average life expectancy for a Black male
was 71.9 years, compared with a White male at 76.5 (Arias, Heron, & Xu, 2017). A similar dis-
crepancy exists for Black women, whose life expectancy is 78.1 years, versus 81.2 years for a
White female (Arias et al., 2017).
Table 1.3: Life expectancy at birth by race/ethnicity in the United States, 2009*
Race/ethnicity Life expectancy
White 78.9
African American 74.6
Latino 82.8
Asian American 86.5
Native American 76.9
*Most recent data available
Source: Data from “Life Expectancy at Birth (in Year), by Race/Ethnicity,” by Kaiser Family Foundation, 2018 (https://www.kff.org
/other/state-indicator/life-expectancy-by-re/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort
%22:%22asc%22%7D).
Figure 1.1: Black, White, and Hispanic life expectancy rates, 2006, 2013
Life expectancies for women are higher than for men of the same race. However, life expectancies for
Black women and men are lower than those of their White and Hispanic counterparts.
2006 2013
100
90 84.2
80.6 81.2 82.9
78.1 79.2
80 75.7 76.5 76.4 77.5
71.9
69.5
70
Age (years)
60
50
40
30
20
10
0
White White Black Black Hispanic Hispanic
males females males females males females
Race/gender
Sources: Data from “United States Life Tables, 2007,” by E. Arias, 2011, National Vital Statistics Reports, 59(9), 48, retrieved from
https://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_09.pdf; and “United States Life Tables, 2013,” by E. Arias, M. Heron, and J. Xu,
2017, National Vital Statistics, 66(3), retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_03.pdf.
Of interest, Hispanic/Latino populations had the highest life expectancy in 2013, with the
average age for males being 79.2 and females being 84.2 (Arias et al., 2017). This has become
known as the “Hispanic paradox.” Empirical studies have shown that Hispanics have strong
protective instincts that focus on taking care of each other (Franzini, Ribble, & Keddie, 2001).
The Hispanic population lives longer because of this cultural support, despite many members
of this ethnic group living in poverty with less education, factors more commonly associated
with higher mortality.
Those numbers fluctuate significantly in the United States depending on where a person
resides. For example, a Latino living in New Mexico has a life expectancy of only 78.8 years,
whereas the same Latino in Minnesota has a life expectancy of 87.3 years (Kaiser Family
Foundation, 2018). A Native American in Minnesota has a life expectancy of only 70.2 years
(Kaiser Family Foundation, 2018). The disparity can be viewed as rather alarming; however,
these figures are influenced by multiple factors, such as community, access to health care, and
educational level.
Much of the research on Blacks versus Whites points toward discrimination, whether real or
perceived. Studies have shown that 55% of the 32.3 million nonelderly uninsured are people
of color (Artiga, Foutz, Cornachione, & Garfield, 2016). Furthermore, Black men and women
live sicker and die sooner than their White counterparts, with heart disease as the top killer
(Williams, 2017). Research has also suggested that the stress brought on by discrimination
may be contributing to these higher rates of heart disease (Mays, Cochran, & Barnes, 2007).
In other words, Blacks are aging faster thanks to the physiological response to stress caused
by racial discrimination (Williams, 2017).
Socioeconomic Status (SES) and Education

Importantly, one study found that education levels and salary were irrelevant—discrimi-
nation causes poorer health outcomes for Blacks more than for any other race (Williams,
2017). Socioeconomic status (SES) is a measure of a person’s work experiences and social
position based on income, education, and occupation in relation to others. The World Health
Organization (2017j) stated that approximately 1.2 billion people around the world live in
extreme poverty, meaning that they live on less than $1 per day. The Institute for Research on
Poverty (n.d.), based out of the University of Wisconsin, Madison, reported that 18.5% of non-
elderly people live without health insurance, 70% of whom are poor or near poor. Research
has shown that those without insurance also tend to go without preventive care, waiting until
an illness is severe before seeking medical attention. Children are especially vulnerable to
diseases, and if they live in poverty-stricken families, they often do not receive care.
Individuals in higher SES groups are better educated than those in lower SES groups. Zimmer-
man, Woolf, and Haley (2015) noted that adults without a high school diploma will live about
10 years fewer than those who graduated from college. Those with only a bachelor’s degree
were 26% more likely to die earlier than those who had a professional degree. Adults without
a high school education were more likely to suffer from diabetes than those with a degree. Of
course, educational and SES status are two factors that are highly correlated, or related. Typi-
cally, the more education individuals have, the more money they make. The inverse is also
true: People who have more money are more likely to also have resources to pursue more
education. Education is truly a driving force, not only to reduce the poverty rate, but also to
reduce disease risk.
Religion and Culture

An individual’s belief system also has a strong cor-
relation to health. For example, some religions teach
that illness is a direct punishment from their god
and that there should be no intervention to allevi-
ate that punishment. Other religions seek aid from
their internal community when someone is ill. In
some cases, religion and medicine collide when reli-
gious beliefs cause people to reject modern medical
care. For example, members of religious sects that
do not believe in immunization may not have their
Stock Connection/SuperStock
children vaccinated. The Dutch Reformed Church
Religious belief systems can influence
teaches that vaccinations interfere with individuals’
a population’s health behaviors,
relationship with God by making them less depen-
perspectives, and comprehensions.
dent on God in the event they get sick (Krule, 2015).
Educational practices in Amish
communities, for example, affect this
Alberta Health Services (n.d.), in Canada, recognizes
population’s health literacy.
that health care actions and beliefs differ greatly
across religions and published a book that focuses on how to approach families and people
with specific beliefs. As public health professionals, we can only recommend but not force
people to seek help. This certainly results in ethical considerations, which will be discussed
later in this course.
Culture—the shared meanings, values, and ideas within a community—can also play a role
in health and public health interventions and potentially result in poorer health outcomes.
The Amish population is a good example of when a strong culture collides with health inter-
ventions. In fact, a study of health literacy among Amish people showed that this population
was unable to comprehend basic information on managing chronic disease (Katz, Ferketich,
Paskett, & Bloomfield, 2013). The Amish have a cultural practice of providing formal educa-
tion only up through eighth grade, and as a result, their general literacy levels are low, which
affects their level of health literacy (Katz et al., 2013).
Health Literacy
Health literacy is the comprehension of health-related materials, such as the ability to under-
stand a doctor’s directions, prescriptions, and how to manage diseases and maintain health.
Research has shown that health literacy may be “a contributing factor to lower health knowl-
edge, poor health status, and improper use of health services” (Katz et al., 2013, para. 2).
It is difficult to explain to an individual without an understanding of health terminology, much

less a population, what problems exist and why. Health literacy is highly dependent upon
a group of systemic factors, including communication skills of the individuals/population,
knowledge of health topics in general, culture, and demands for health care (U.S. Department
of Health and Human Services, n.d.-b). A lack of health literacy makes it difficult for communi-
ties to navigate the health care system, share meaningful health histories, or engage in self-
care and/or self-management of a chronic disease such as diabetes.
History of Community and Public Health Section 1.3
1.3 History of Community and Public Health

Public health concerns first arose thousands of years ago when human settlements increased
the possibility of the spread of communicable diseases. In antiquity, people attributed disease
to magical forces. Much later, during the classical period of history, Greek philosophers specu-
lated that environmental influences were causes of disease. From the Industrial Revolution to
the 20th and 21st centuries, we have benefited from snowballing advances in medical knowl-
edge and efforts to stem chronic and degenerative conditions. Table 1.4 details some of these
and other historic community health milestones.
Table 1.4: Community health landmarks

Historical time period Approximate dates Community health landmarks
Early human Pre-500 BCE Zoonotic diseases from increased contact

civilizations between humans and animals; recognition of
health hazards from human waste
Classical period 500 BCE to 500 CE Age of Hippocrates; Romans install public sewer
systems and aqueducts
Dark Ages 500 BCE to 1100 CE Recurrence of superstitious and magical beliefs
regarding disease
Middle Ages/medieval 1100 to 1453 Black Death kills nearly one third of Europe’s
period (in Europe) population
Renaissance 1300 to 1500 Discoveries in human anatomy; hypotheses

regarding microbial organisms and disease
Baroque period 1600 to 1700 John Graunt analyzes vital statistics
Industrial Revolution Late 1700s to mid-1800s Edward Jenner invents a successful smallpox
vaccine; John Snow investigates London cholera
outbreak in 1849; development of public works in
the United Kingdom; bacteriology
20th century 1900 to 1999 Great influenza pandemic of 1918; invention of

antibiotics; focus on control of chronic diseases;
Healthy People begins with the first iteration
stemming from the 1979 Surgeon General’s
Report on Health Promotion and Disease
Prevention, and Healthy People 1990 is launched
in 1980
First decade of the 21st 2000 to 2009 Policies for prevention of secondhand smoke
century exposure; labeling of menus for nutrition
content; development of vaccine for human
papilloma virus; rapid population growth; obesity
recognized as an epidemic
Second decade of the 2010 to present Acceleration of gun control stemming from
21st century increasing violence; intent focus on climate
change; improved access to health care
Early History
The formation of ancient societies generated early concerns about public health. Early humans
cleared forests for lumber and for agriculture, which damaged the land and caused rivers to
fill up with silt from erosion. These humans also domesticated animals and began raising
them near their own dwellings. This contact promoted the transmission of parasitic infec-
tions from animals; human settlements also increased the possibility of transmission of dis-
eases via human waste (Porter, 1999). In ancient Mesopotamia, now present-day Iraq, people
developed herbal medicines; the earliest prescriptions from Mesopotamia are estimated to
have been written in about 2000 BCE (Biggs, 2005). Biblical references to careful disposal of
human waste, isolation of persons who had infections, and proper handling of dead bodies
suggested ancient civilizations’ awareness of public health measures.
As a means of preventing infectious diseases, the

ancient Romans recognized the importance of
sanitary sewers and water that was safe for drink-
ing. Contributions of the Romans to public health
included the design of water transport systems that
supplied adequate amounts of water to cities in the
Roman Empire. Vestiges of Roman sanitary instal-
lations such as aqueducts and public baths can be
found throughout former Roman settlements in
Europe and the former Roman Empire (Friis, 2012).
Oliviero Olivieri/robertharding/SuperStock
Aqueducts contributed to public health After the fall of the Roman Empire, medical knowl-
in the Roman Empire. These networks edge returned to earlier mystical theories of dis-
of pipes, bridges, and channels ease and magical treatments that had been popu-
transported water. lar during antiquity. Soon after, Europe was swept
by recurring mass outbreaks of disease. Waves of
serious cholera, leprosy, and plague pandemics beset Europe and other regions of the world
during the Middle Ages (Sciencemuseum.org, n.d.). One of the most remarkable pandemics
was the Black Death in the 14th century. Note that an epidemic denotes “the occurrence of
disease within a specific geographical area or population that is in excess of what is normally
expected” (CDC, 2016l). A pandemic is “an epidemic occurring over a very large geographic
area” (CDC, 2016l).
The Renaissance and Baroque periods witnessed advances in the recognition of causes of
disease and the beginnings of vital statistics. In London during the mid-1600s, John Graunt
developed methods for analyzing mortality statistics. His innovations helped to form the
underpinnings of modern vital statistics and to identify trends in births and deaths due to
specific causes. Because of his work, Graunt became known as the Columbus of biostatistics.
Industrial Revolution Period

The field of public health blossomed during the Industrial Revolution, when there were fur-
ther refinements in knowledge of disease etiology, or the cause of diseases. The field of pub-
lic health was conceptualized, and the first public health department was created in 1799.
Other important developments included
• Edward Jenner’s (1749–1823) development of a successful vaccine against smallpox

(1790s) (Riedel, 2005).
• John Snow’s (1813–1858) investigation of a cholera outbreak in the Soho district of
London in 1849. Snow introduced several innovations (e.g., the method of natural
experiments, collection of outbreak data, and mapping of the location of cholera
victims). These methods remain valid today (Friis & Sellers, 2009), and many regard
Snow as the father of epidemiology. (See Spotlight on Public Health Figures.)
• Robert Koch’s (1843–1910) verification that a human disease was caused by a living
microorganism. Koch published his findings in 1882 (Jordan, 1921).
• The sanitary reform movement in England (19th century). In 1842, Edwin Chadwick
published a report that linked communicable diseases with squalid urban environ-
ments (Rosen, 1968).
• Passage of the Public Health Act of 1848 (Great Britain). This was the first time in
Britain’s history that the government guaranteed resources for improving the health
of its people (Fee & Brown, 2005, p. 866).
Spotlight on Public Health Figures:

John Snow (1813–1858)
Who is John Snow?

John Snow was born in 1813 in York, England. He
was the son of a coal-yard laborer, but his mother
believed her son could go much further. She used
a small inheritance to send him to private school,
and he eventually earned his medical degree.
He was only 18 when the first major cholera
epidemic struck London, while he was serving
as a medical apprentice to the only doctor in the
area, Dr. William Hardcastle. The epidemic had
killed thousands of people, and Hardcastle could
not keep up with the need and relied on Snow
for help. Snow had a sense that cholera was not Anthony Upton/EMPPL PA Wire/Associated Press
an airborne disease, as was traditionally thought, John Snow investigated the causes of
and it was here that he began his public health cholera and, ultimately, discovered
discoveries. how the disease was transmitted. His
methodological investigation techniques
became the foundation of modern-day
epidemiology.
(continued)
Spotlight on Public Health Figures: John Snow (1813–1858)

(continued)
What was the political climate at the time?

Change is always a difficult concept, especially when there is a prevailing thought process
that is widely accepted. This was the case during Snow’s time as a physician. The cholera
outbreak was alleged to be caused by “miasmas,” which were poisonous gases emanating
from sewers, swamps, garbage, and open graves. The foul smells were thought to cause all
kinds of illnesses, including cholera. Snow believed that poisonous gases could not explain
many diseases such as cholera, but when he suggested that a fecal-oral route of transmission
caused cholera instead, he was nearly laughed at. This particular mode of transmission was so
unpleasant that most of the public and educated physicians refused to consider it. And so the
battle between Snow’s theories and the generally accepted theories of the time began.
What was his contribution to public health?

Snow was the first to begin a methodological investigation into the cause of cholera for two
reasons: to prove his theory of fecal-oral transmission and to end the cholera epidemic. He
mapped out the locations of people who became ill and cross-referenced their locations with
where they obtained their water. The famous mapping that Snow performed became the
foundation of modern-day epidemiology. It was his mapping that led to the source: the Broad
Street Pump, where many of the sick had acquired their water. The water from that pump
had been contaminated with human waste and other toxins that people were ingesting—
causing cholera.
What motivated him?

As a child, Snow was always motivated to improve his knowledge, find answers, and resolve
issues. His mind was so analytical that he thrived on digging into the details of why and how.
This deep-rooted mannerism compelled him to continue pushing for answers to the cholera
epidemic. It was also what gave him the name “the father of epidemiology.”
Sources: Vachon, D. (2005). Part one: Doctor John Snow blames water pollution for cholera epidemic. Old News, 16(8), 8–10. Retrieved
from http://www.ph.ucla.edu/epi/snow/fatherofepidemiology.html
Tuthill, K. (2003). John Snow and the Broad Street pump: On the trail of an epidemic. Cricket, 31(3), 23–31. Retrieved from http://www
.ph.ucla.edu/epi/snow/snowcricketarticle.html
Contemporary History: 20th and 21st Century

Several additional milestones in recent history have contributed to the evolution of commu-
nity health (Table 1.5). It is important to note that public health and health care were on
equal footing in terms of funding and national acceptance until the advent of penicillin. With
this medical breakthrough in treating bacterial infections, more funding was given to medical
research for additional breakthroughs. This started the complete separation of public health
endeavors from health care treatment (or medical science).
The next major milestone was the development of health education, a field that is an essential
activity for community health promotion. Health education is “any combination of learning
experiences designed to help individuals and communities improve their health, by increas-
ing their knowledge or influencing their attitudes” (WHO, 2017h, para. 1). A third key devel-
opment was a growing emphasis on lifestyle changes, especially in the context of community
health. Lifestyle changes include efforts to improve people’s diets, increase exercise levels, and
encourage smoking cessation. These efforts stem from a growing recognition of the adverse
impacts of chronic diseases such as heart disease, cancer, and diabetes and conditions such as
obesity. (See Case Study: The Framingham Heart Study for an example.)
Table 1.5: Contemporary history events in public health

Time Event
1918–1919 The Spanish flu pandemic caused 50 million deaths worldwide (Taubenberger
& Morens, 2006). Since 1918, several global influenza pandemics have occurred,
although they have been much less severe.
1948 The Framingham Heart Study began a community investigation of risk factors
for coronary heart disease. (Refer to Case Study: The Framingham Heart Study for
additional details.)
1955 The Salk polio vaccine was announced.
1964 The surgeon general’s report Smoking and Health identified smoking as a cause of
lung cancer.
1978 Smallpox was eradicated worldwide.
1981 The first case of acquired immunodeficiency syndrome (AIDS) was reported.
1990 Healthy People 2000 was released by the Department of Health and Human Services.
2010 The Affordable Care Act was signed into law by President Barack Obama on March 23.
2015 The Environmental Protection Agency finalized new standards to reduce carbon
emissions from power plants for the first time. These standards were outlined in the
Clean Air Act, one of the major pieces of legislation to tackle climate change.
Case Study: The Framingham Heart Study

Since its beginning in 1948 under the direction of the National Heart, Lung, and Blood
Institute (NHLBI), the Framingham Heart Study has been committed to identifying the
common factors or characteristics that contribute to cardiovascular disease (CVD). The study
has monitored cardiovascular disease over three generations of participants.
This intensive study on the risk factors for heart disease began in 1948 with 5,209 men
and women between the ages of 30 and 62 from the town of Framingham, Massachusetts.
At the time, none of these individuals had developed symptoms of cardiovascular disease
or suffered a heart attack or stroke. The study later added an Offspring Cohort in 1971, the
Omni Cohort in 1994, a Third Generation Cohort in 2002, a New Offspring Spouse Cohort in
2003, and a Second Generation Omni Cohort in 2003.
(continued)
Case Study: The Framingham Heart Study (continued)

Over the years, careful monitoring of the Framingham study population has led to the
identification of major CVD risk factors, such as blood pressure, blood triglyceride and
cholesterol levels, age, gender, and psychosocial issues, as well as valuable information on the
effects of these factors. Risk factors for other physiological conditions such as dementia have
been and continue to be investigated. In addition, the relationships between physical traits
and genetic patterns are being studied.
The heart study is still going on today, as thousands of people continue to report potential
symptoms and risks associated with heart disease.
Source: Adapted from the Framingham Heart Study (2017). About the Framingham Heart Study. Retrieved from
http://www.framinghamheartstudy.org/about-fhs/index.php
Important Public Health Achievements

In addition to the eradication of many deadly infectious diseases, public health initiatives
have also led to an increase in overall life expectancies. In the 19th century, life expectancy
was between 30 and 40 years, and today, it is now between 75 and 85 for men and women
combined (all races) (Berkeley Demography, n.d.; Roser, n.d.). According to the CDC, the great-
est achievements in public health from 1900 to 1999 were vaccination, motor vehicle safety,
safer workplaces, control of infectious diseases, a decline in deaths from coronary heart dis-
ease and stroke, safer and healthier foods, healthier mothers and babies, family planning,
water fluoridation, and recognition of tobacco as a health hazard (CDC, 1999c). In 2011, the
agency released another top 10 list of achievements from 2001 to 2010, some of which are
still having a significant impact on the population: vaccinations, control of infectious diseases,
tobacco control, maternal and child health, motor vehicle safety, cardiovascular disease pre-
vention, occupational safety, cancer prevention, childhood lead poisoning prevention, and
public health preparedness and response (CDC, 2011).
While public health has made a significant impact on population well-being in the United
States, it still has significant work ahead. The following sections provide more information
on four of the achievements that made the top 10 achievement lists for both 1900–1999 and
2001–2010.
Immunizations
Thanks to breakthroughs in vaccine development, four key infectious diseases have been
eliminated: smallpox, polio, measles, and Hib (Haemophilus influenzae, which can cause men-
ingitis, epiglottitis, pneumonia, arthritis, and cellulitis in infants and children under age 6).
While these diseases were wholly eradicated, they are making a comeback due to recent con-
cerns that vaccines cause autism and other issues. Though a long study (CDC, 2015l) proved
this concern unfounded, some people have still opted not to vaccinate. As a result, there has
been a resurgence of many formerly rare diseases. For example, there have been more cases
of polio, measles, mumps, rubella, and pertussis because of the lack of vaccination (Brady,
2015). Worldwide, there were 40,761 cases of measles, 7,660 cases of mumps, and 2,124
cases of pertussis (whooping cough) in 2017 (Vaccines Work, 2017). In North America alone,
cases of these five diseases exceeded 6,500 (Vaccines Work, 2017). Almost all of these inci-
dences would likely have been prevented by vaccination.
Motor Vehicle Safety

While awareness of issues such as driving while intoxicated and child safety seat use has
decreased driving-related deaths, the biggest impact has come from the installation of safety
belts in all motor vehicles. After 1984 legislation required safety belt use and public health
education emphasized the “why” of the legislation, safety belt use nationwide increased from
11% in 1981 to 68% in 1997 and then to 87% in 2015 (CDC, 1999b; U.S. Department of Trans-
portation, 2015). However, motor vehicle crashes are the leading cause of death among those
ages 1 to 54, and more than half of adults who died in a motor vehicle crash in 2015 were not
wearing a seat belt.
Family Planning and Maternal and Child Health

Margaret Sanger, who opened the first birth control clinic in the United States in 1916, played
a key role in advocating for birth control and women’s rights. That clinic was the start of
the national organization now known as Planned Parenthood. The organization, along with
Sanger’s work, promoted the legal distribution of contraception and contraceptive devices to
women, allowing women and/or couples to choose when to have children and decide how
many children they wanted. (See Spotlight on Public Health Figures.) In 1900, six to nine of
every 1,000 women died in childbirth, and one in five children died within the first 5 years of
life because of over-reproduction (CDC, 1999a). Today, 1.3 million unintended pregnancies are
prevented annually through the use of contraception provided by publicly supported services.
That means there are fewer abandoned children and fewer large families without adequate
resources who become sick from lack of adequate care. Furthermore, improved reproductive
care has reduced the number of mother and child deaths caused by the childbirth process.
Recent political actions have led to the potential defunding of Planned Parenthood, which cur-
rently receives Medicaid reimbursements for patient treatments. New legislation under the
Trump administration is trying to remove all funding from the organization, noting that the
federal government should not underwrite the costs of abortion services. While Planned Par-
enthood does perform such services, it also provides significant preventive care for women in
low socioeconomic communities, and defunding could cut off needed care for many individu-
als. The key issue revolves around abortion. The big question in the debate is, Whose respon-
sibility is it to underwrite such a procedure?
Spotlight on Public Health Figures:

Margaret Sanger (1879–1966)
Who is Margaret Sanger?

Born in September 1879, Sanger was the daughter of
a lower-class family in Corning, New York. Because of
her interest in helping other women, she began her
career as a nurse working in a women’s ward at a local
hospital. She had a general interest in women’s health
as well as sex education. She became an advocate
of women’s rights and birth control, and her efforts
eventually morphed into the well-known organization
Planned Parenthood.
What was the political climate at the time?

A bohemian culture, including radical activism, was
taking root in New York. Women were still viewed as
lesser individuals than men and were meant to birth
children at the pleasure of men. There was also a lack
Underwood Photo Archives/SuperStock
of solid care for those in poverty—including those
Margaret Sanger was an advocate
who could not afford multiple children. In addition,
for women’s rights and family
maternal care was nonexistent at the time, and women
planning. She established the
frequently died during childbirth. Women often sought
organization that eventually became
or even performed illegal abortions to avoid having
Planned Parenthood.
children. Furthermore, women could not even share
publicly information on abortion or birth control methods thanks to the Comstock Law of
1873, which made the distribution of materials on those subjects a federal crime punishable
by imprisonment.
What was her contribution to public health?

Sanger’s primary contribution to public health was promoting women’s health rights and
family planning. She believed that a woman should be able to make her own choices as to how
many children she will birth, and she pushed for nationwide contraceptive use. In 1946, she
established an international organization of family planning advocates called the International
Planned Parenthood Federation. Eventually, this organization became Planned Parenthood.
What motivated her?

She was extremely influenced by her father’s iconoclasm, the act of assertively rejecting
common practices or beliefs. She also witnessed her mother’s premature death, which
haunted her for the rest of her life. Her mother’s death was attributed to too many
childbirths and poverty. During her work as a nurse, Sanger saw numerous examples of
women who died from frequent childbirth, miscarriage, and self-induced abortion. Inspired
by her mother and these female patients, she turned her attention toward educating women
about contraceptives, regardless of the Comstock Law. Taking on her father’s attitude and
persisting toward gaining ground in women’s rights, she focused on educating as many
women as possible on contraception and abortion.
Sources: American National Biography. (2018). Sanger, Margaret. Retrieved from http://www.anb.org/view/10.1093
/anb/9780198606697.001.0001/anb-9780198606697-e-1500598
Free Legal Encyclopedia. (2018). Comstock Law of 1873. Retrieved from http://law.jrank.org/pages/5508/Comstock-Law-1873.html
Public and Community Health Structure Section 1.4
Water Fluoridation
Fluoride is a natural mineral found in nature that protects teeth against decay. If decaying
teeth are not managed through dental work or removal, infection can spread to the rest of
the body, causing serious illness. Investigations of water consumption and dental caries, the
scientific term for cavities and tooth decay, across various regions in the United States led to
the 1962 development of a recommended range for fluoride-to-water concentration. That
specific amount of fluoride was then added to water systems across the nation. Dental caries
drastically declined over the next decade. Since the early 2000s, there have been continual
concerns that fluoride causes thyroid, kidney, heart, and other organ damage (Oppel, 2006).
However, extensive research over the past 50 years has found no evidence that fluoridated
water is unsafe (Oppel, 2006). Some published reports have shown that too much fluoride in
general can cause the aforementioned issues; however, the amount of fluoride in water sys-
tems is well below the recommended levels of 0.7 to 1.2 parts per million—an extremely low
dose (Oppel, 2006). Fluoride is also found in bottled teas, sports drinks, toothpaste, Teflon
pans, and mechanically deboned meat such as chicken fingers/nuggets, among other sources
(Fluoride Action Network, 2017). The problem of ingesting too much fluoride is unlikely to be
caused by water fluoridation alone but may be a result of a combination of various sources.
1.4 Public and Community Health Structure

Public and community health is composed of organizations from large federal agencies to
small community-based nonprofit organizations. There are three types of organizations
within the community and public health structure: governmental, nongovernmental, and
quasi-governmental.
Governmental Agencies
From international organizations to state-level health agencies, governmental agencies are
funded by tax dollars and managed by government officials.
The United States Department of Health and Human Services (HHS)

The U.S. Department of Health and Human Services (HHS) is the primary federal governmen-
tal organization with oversight over all national functions of public health. Within HHS lies a
plethora of agencies and offices—also collectively known as the Public Health Service—each
of which focuses on a specific aspect of the health, safety, and well-being of the nation. The
Public Health Service is composed of individuals who carry out the bulk of public health work
across the nation in different offices and agencies (Table 1.6).
Table 1.6: Offices and agencies of the Public Health Service

Office of Public Health and Science (the operating agency of HHS)
National Institutes of Health*
Centers for Disease Control and Prevention*
Food and Drug Administration*
Substance Abuse and Mental Health Services Administration*
Health Resources and Services Administration*
Agency for Healthcare Research and Quality*
Agency for Toxic Substances and Disease Registry*
Indian Health Service*
Office of Regional Health Administrators
*Among the 11 operating divisions of HHS
Sources: U.S. Department of Health and Human Services. (2011). Commissioned Corps of the U.S. Public Health Service: HHS offices
and agencies. Retrieved from https://www.usphs.gov/aboutus/agencies/hhs.aspx
Centers for Disease Control and Prevention. (2017). Official mission statements and organizational charts. Retrieved from
https://www.cdc.gov/maso/officialmissionstatementscharts.html
HHS administers the various services it provides through 11 different operating divisions:
Administration for Children and Families (ACF). This agency promotes the economic and social
well-being of families, children, individuals, and communities. While the agency has multiple
aims, two critical goals within the ACF programs include improving access to services and
addressing the needs of vulnerable populations, including those with developmental disabili-
ties, refugees, and migrants.
Administration for Community Living (ACL). The ACL maximizes the independence, well-being,
and health of older adults, people with disabilities across the lifespan, and their families and
caregivers. The ACL provides important advocacy work to keep older people as independent
as possible within their own communities and focuses on ensuring older adults maintain the
right to make their own choices about their home, work, and other lifestyle preferences.
Agency for Healthcare Research and Quality (AHRQ). The AHRQ improves the quality, safety,
efficiency, and effectiveness of health care for all Americans through knowledge and data. It
invests in research projects that improve the health care system and the profession itself and
provide solid evidence of needed policy changes for making informed health decisions.
Agency for Toxic Substances and Disease Registry (ATSDR). This agency serves the public by
using the best science, taking responsive public health actions, and providing trusted health
information to prevent harmful exposure and diseases related to toxic substances. The ATSDR
focuses on response efforts in relation to environmental health emergencies, investigating
emerging environmental threats, and researching ways to build capacity for greater preven-
tion across all 50 states.
Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention is
the largest public health–focused organization in the United States. It works 24 hours a day,
7 days a week, to protect the United States from health, safety, and security threats. The CDC’s
structure is complex, encompassing a significant number of offices responsible for keeping
the country safe. Its mission reads,
The Centers for Disease Control and Prevention serves as the national focus
for developing and applying disease prevention and control, environmen-
tal health, and health promotion and health education activities designed to
improve the health of the people of the United States. (CDC, 2017u, para. 1)
The agency is made up of centers, institutes, and offices known as CIOs, which allow the
agency to respond to a wide variety of public health concerns (Table 1.7). Each center, insti-
tute, and office has its own mission statement. All of these can be found at the CDC website.
Table 1.7: CIOs of the CDC

CDC Washington Office
Center for Global Health
National Institute for Occupational Safety and Health
Office for State, Tribal, Local, and Territorial Support
Office of Equal Employment Opportunity
Office of Infectious Diseases

• National Center for Emerging and Zoonotic Infectious Diseases
• National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
• National Center for Immunization and Respiratory Diseases
Office of Minority Health and Health Equity
Office of Noncommunicable Diseases, Injury and Environmental Health

• National Center for Chronic Disease Prevention and Health Promotion
• National Center for Environmental Health/Agency for Toxic Substances and Disease Registry
• National Center for Injury Prevention and Control
• National Center on Birth Defects and Developmental Disabilities
Office of Public Health Preparedness and Response
Office of Public Health Scientific Services

• Center for Surveillance, Epidemiology and Laboratory Services
• National Center for Health Statistics
Office of the Associate Director for Communication
Office of the Associate Director for Laboratory Science and Safety
Office of the Associate Director for Policy
Office of the Associate Director for Science
Office of the Chief of Staff
Office of the Chief Operating Officer
Source: From “Official Mission Statements and Organizational Charts,” by Centers for Disease Control and Prevention, 2017
(https://www.cdc.gov/maso/officialmissionstatementscharts.html).
Centers for Medicare and Medicaid Services (CMS). The CMS is responsible for the administra-
tion of federal health care programs such as Medicare, which is an insurance program for the
elderly, and Medicaid, which is a need-based insurance program. The CMS provides a plethora
of services to those who hold Medicare or Medicaid, including services information, emer-
gency needs, and advice on individual rights.
Food and Drug Administration (FDA). The FDA protects the public’s health by ensuring that
foods are safe, wholesome, sanitary, and properly labeled and that drugs, vaccines, and other
biological products and medical devices intended for human use are safe and effective. This
organization also regulates the manufacturing, marketing, and distribution of tobacco prod-
ucts and plays a role in the nation’s counterterrorism capability by monitoring the food sup-
ply. Additionally, the FDA regulates veterinary drugs.
Health Resources and Services Administration (HRSA). This agency improves access to health
care services for people who are uninsured, isolated, or medically vulnerable. It is the pri-
mary agency responsible for improving health care to people who are geographically isolated
and/or economically depressed. It also oversees organ, bone marrow, and cord blood dona-
tions. Its main focus is health equity.
Indian Health Service (IHS). The IHS is responsible for providing federal health services
to American Indians and Alaska Natives. This agency was established due to the special
government-to-government relationship between the U.S. federal government and federally
recognized tribal governments. It ensures that these two populations receive comprehensive,
culturally acceptable personal and public health services.
National Institutes of Health (NIH). The NIH seeks

fundamental knowledge about the nature and
behavior of living systems and the application
of that knowledge to increase healthy living and
reduce illness. The National Institutes of Health
comprises 30 different institutes. The institutes
are the stewards of biomedical and behavioral
research for the United States. The NIH’s four
goals are to 1) foster innovative research strate-
gies and their applications to protect and improve
Jia He/iStock/Thinkstock health; 2) develop, maintain, and renew human
The NIH labs conduct biomedical and and physical resources that assist in prevent-
behavioral research. ing disease and promoting health—all toward
enhancing the quality of life for all Americans;
3) expand the knowledge base in biomedical and associated science to improve overall well-
being in the nation; and 4) promote the highest level of scientific integrity, public account-
ability, and social responsibility in research.
Substance Abuse and Mental Health Services Administration (SAMHSA). This agency special-
izes in reducing the effects of mental health and substance use disorders by offering contracts
and grants, programs, statistical information, literature, research, and policy development
with respect to behavioral health. SAMHSA’s sole focus is to provide education and services to
those who suffer from substance abuse and mental health disorders.
Aside from these 11 operating divisions is the Office of Public Health and Science, the operat-
ing agency of HHS that oversees several smaller offices within the public health realm:
• Office of the Surgeon General—provides the best scientific information on how to

improve health and reduce the risk of injury and illness
• Public Health Service Commissioned Corps—protects, promotes, and advances the
health and safety of the nation in a variety of settings (see A Closer Look)
• Office of Population Affairs—advises on a wide range of reproductive health topics,
including adolescent pregnancy, family planning, and sterilization
• Office of HIV/AIDS and Infectious Disease Policy—advises on health policy and
program issues related to HIV/AIDS, viral hepatitis, and other infectious diseases as
well as blood and tissue safety and availability in the United States
• Office of Minority Health—works to improve the health of racial and ethnic minority
populations through the development of health policies and programs that eliminate
health disparities
• Office of Women’s Health—addresses women’s health issues by informing and
advancing policies and educating health care professionals and consumers
• President’s Council on Sports, Fitness & Nutrition—engages, educates, and empow-
ers Americans to adopt a healthy lifestyle that includes regular physical activity and
appropriate nutrition
• National Vaccine Program Office—works to carry out the goals of the National Vac-
cine Plan
• Office of Research Integrity—oversees and directs the Public Health Service research
activities, with the exception of the Food and Drug Administration work
A Closer Look: Public Health Service Commissioned Corps

One of the lesser-known uniformed forces in the United States is the U.S. Public Health
Service Commissioned Corps. Its mission is simple: “to protect, promote, and advance the
health and safety of our nation” (U.S. Department of Health and Human Services, 2014,
para. 1). It is one of the smallest uniformed forces in the United States, with approximately
6,500 public health professionals serving the corps. However, for public health professionals,
it’s one of the most important uniformed forces for the country.
Officers are commissioned by the surgeon general in various community and public health
roles to fight disease, conduct research, and care for underserved populations. Those who
have been commissioned to the U.S. Public Health Service work full time in various health
field positions, such as physicians, dentists, behavioral health counselors, therapists,
dietitians, pharmacists, nurses, and veterinarians. While those careers may seem obvious
for serving in the U.S. Public Health Service Commissioned Corps, there are a few unusual
service members.
(continued)
A Closer Look: Public Health Service Commissioned Corps

(continued)
For one, engineers are common in the Commissioned Corps. According to the Corps,
“Being an engineer officer . . . means you’re serving on the front lines of public health”
(Commissioned Corps of the U.S. Public Health Service, n.d.-a, para. 2). The engineers of this
group design and implement initiatives that serve the public, such as water and sewer lines
for underserved populations, responding to natural disasters, conducting workplace safety
programs, and overseeing the construction of health-related projects (e.g., hospitals and
schools). Second, public health officers may conduct research in the fields of epidemiology,
chemistry, biology, entomology, and toxicology, just to name a few. Third, students have
an excellent opportunity to join the force while completing their education. There are two
routes that students can take: Junior or Senior Commissioned Officer Training (JRCOSTEP
and SRCOSTEP).
Junior Commissioned Officer Student Training and Extern Program
(JRCOSTEP)
Students can apply for internships or practicums in their own communities while serving in
the Junior Corps through an application process that can be found on the JRCOSTEP website.
Assignments usually vary between 1 to 3 months in length and take place during official
school breaks. The specific fields of interest for Junior Corps members are engineering,
environmental health, pharmacy, and nursing. There is a paycheck, which is based on any
prior service in another uniformed service office (Navy, Air Force, Army, Marines, Coast
Guard, National Oceanic and Atmospheric Administration, Commissioned Corps for the
Department of Commerce, or the Commissioned Corps for the Department of Health and
Human Services).
To be eligible, an individual must have at least 2 years of undergraduate study in one of the
following disciplines: environmental health, engineering, nursing, physician assistant studies,
dental hygiene, dietetics, medical laboratory technology, medical record administration, or
therapy.
For graduate programs, individuals must be in at least their first year of a program in a
specific field, including social work, public health, or health care administration.
Senior Commissioned Officer Student Training and Extern Program
(SRCOSTEP)
This is a highly competitive program open only to students who are about to begin their
final year of academic study. They should be in one of the following areas/roles: nursing,
pharmacy, nurse practitioner, or physician assistant.
Source: U.S. Department of Health and Human Services. (2014). Retrieved from https://www.usphs.gov/
The Environmental Protection Agency (EPA)

Besides HHS, there are other national agencies that also play a role in maintaining and pro-
moting health in the United States. The U.S. Environmental Protection Agency (EPA), a federal
government agency, seeks to protect health and the environment (U.S. EPA, 2017a). One of
the EPA’s responsibilities is to formulate and enforce environmental regulations. The EPA
is involved with implementing congressional environmental laws and setting national envi-
ronmental standards. An important aspect of the EPA’s work is educating the public about
environmental issues and publishing reports about the environment. The EPA administrator
is appointed by the president of the United States. Based in Washington, DC, the EPA has 12
headquarters offices as well as 10 regional offices that address local concerns. Among the
headquarters offices are the Office of Air and Radiation, Office of Research and Development,
Office of Solid Waste and Emergency Response, and Office of Water.
International Organizations
Numerous international organizations also support public health, including the World Health
Organization (WHO), the European Commission, and the Organization for Economic Coop-
eration and Development (OECD).
Headquartered in Geneva, Switzerland, the World Health Organization is the directing and
coordinating authority for health within the United Nations system. Founded on April 7,
1948, the WHO comprises 150 countries employing about 8,000 people. It is responsible for
providing leadership on global health matters, shaping the health research agenda, setting
norms and standards, articulating evidence-based policy options, providing technical sup-
port to countries, and monitoring and assessing health trends. In the 21st century, health is a
shared responsibility, involving both equitable access to essential care and collective defense
against transnational threats (WHO, 2017m).
The European Commission sponsors the Second Programme of Community Action in the
Field of Health. The objectives of the program are to improve health security, promote health,
reduce health inequalities, and disseminate information about health.
The OECD is an organization made up of 34 countries. The organization is involved with

numerous health-related activities germane to community health and regularly publishes an
extensive compilation of data on health and health systems among OECD member states.
Nongovernmental Agencies
Nongovernmental agencies are also known as nongovernmental organizations (NGOs) or
nonprofit organizations. More than 1.5 million nonprofit organizations are registered in the
United States (Foundation Center, 2017). These include public charities, chambers of com-
merce, fraternal organizations, and nonprofit organizations. Many are affiliated with public
health, health care, and medical services.
National-Level Organizations
Some nonprofits are large foundations and organizations that reach all 50 states and even
beyond. The following are two examples of nationwide nonprofits:
Make-A-Wish Foundation—While not directly

public health related, this organization aids
children with life-threatening medical condi-
tions. It is solely operated by donations from
the community, individuals, and grants. It
has no ties to the government and functions
through independent staff and volunteers.
It has representation in all 50 states and the
United States’ territories.
Jeff Chiu/Associated Press
American Lung Association—This nonprofit In November 2013, the Make-A-Wish
focuses its efforts on healthy lungs and Foundation partnered with the San
healthy air. It seeks to prevent lung disease Francisco Police Department to turn
through research, education, and advocacy. the streets into Gotham City for a
Part of the public health realm due to its day to fulfill one child’s wish to be a
national population focus, it is represented in superhero.
all 50 states.
State and Local Organizations

Nonprofits can also be found at the regional and state levels. Smaller nonprofit organizations
generally focus on helping those in their community, town, or city. The best examples of non-
profit organizations come at the community level. One such regional organization is Connec-
tions for Abused Women and their Children (CAWC) in the Chicago area. CAWC focuses on
ending domestic violence by providing a shelter for women and their children along with
various counseling efforts. Here are two additional examples:
“I Have a Dream” Foundation—This nonprofit in Colorado helps impoverished

youth obtain academic success. The foundation works closely with local offi-
cials and schools to assist those in need so they can be successful in their aca-
demic careers from elementary school through college. From a public health
standpoint, this is helping to break the cycle of poverty and teach young peo-
ple that they can achieve their goals, as improved financial situations are asso-
ciated with improved health (“I Have a Dream” Foundation, 2017).
Mercy Center for Women—This nonprofit provides shelter for homeless

women and their children from the Erie, Pennsylvania, area. The center offers
programming to help these women refrain from drugs and alcohol, learn how
to interview for and maintain a job, and connect with resources for improved
health and well-being.
Quasi-Governmental Agencies
Quasi-governmental organizations reside in the private sector but receive support in vari-
ous ways from government, such as funding or personnel. Most quasi-governmental agencies
began as government but became independent agencies.
American Red Cross

The largest nonfederal government agency that focuses on the health and well-being of the
nation’s population, the American Red Cross provides care in five key public health areas:
• People affected by disasters in the United States (such as hurricanes, tornadoes, and
blizzards)
• Support for members of the military and their families
• Blood collection, processing, and distribution
• Health and safety education and training (such as CPR/AED training and HIV/AIDS
education, first aid, babysitting, and lifeguarding)
• International relief and development
This quasi-governmental agency works for and with

the government on a variety of public health tasks.
One of the nation’s longest-standing humanitar-
ian organizations, it is dedicated to helping people
throughout the United States and the world.
The American Red Cross was founded in Washington,

DC, on May 21, 1881, by a nurse, Clara Barton, and a
handful of other humanitarian-focused people. Prior
to World War I (1914–1918), the Red Cross intro-
duced its first aid, water safety, and public health
nursing programs to the public. The Red Cross grew
from 107 chapters at the start of the war to 3,864 by
the war’s end. Overall total membership grew from
17,000 in 1914 to more than 20 million adults and 11
million junior members by 1918.
During World War II, the Red Cross enrolled more Stocktrek Images/Stocktrek Images/SuperStock
than 104,000 nurses for military service and pre- In the organization’s earliest days,
pared 27 million packages for American and Allied American Red Cross volunteers
prisoners of war in addition to shipping more than provided aid during both World
300,000 tons of supplies overseas. It was during this War I and World War II. Today, the
war that the military requested the organization ini- organization continues to provide
tiate a national blood program to collect blood for the medical and disaster relief services at
military armed forces hospitals. home and abroad.
The American Red Cross also helped to combat the 1918 influenza epidemic, the 1927 Mis-
sissippi River floods, and the severe drought and Great Depression of the 1930s. Today, the
American Red Cross still operates its blood donation program and supplies more than 40%
of all blood and blood products needed for hospitals and emergencies in the United States.
Summary & Resources
AmeriCorps
AmeriCorps volunteers dedicate their time to various humanitarian efforts. For example, they
assist people in obtaining affordable housing, mentor students to help them prepare for col-
lege or get through high school, assist affected communities in their disaster recovery efforts,
and clean up the environment through trash removal. Members serve from 3 months to 1 year
by volunteering with a nonprofit or as an individual.
Independent Living Research Utilization

The Independent Living Research Utilization was established in 1977 with the main purpose
of educating people on how to live with a disability. It has made significant strides in working
with this special population, and it has been funded through governmental grants to provide
education, training, and research for disabled populations living independently.
National Science Foundation

The National Science Foundation is an independent federal agency operating as a nonprofit
with federal funds. For this reason, it is considered quasi-governmental. It focuses on promot-
ing the progress of science; advancing national health, prosperity, and welfare; and securing
national defense. About one quarter of its funding is spent on health-related research con-
ducted at U.S. colleges and universities.
National Academy of Sciences

The National Academy of Sciences is a private, nonprofit organization composed of the coun-
try’s leading researchers in the fields of science, engineering, and medicine. While these fields
are not fully aligned with public health, some of the key advances made in them support pub-
lic health efforts. The National Academy of Sciences was established by President Abraham
Lincoln in 1863 and has focused on the same mission of advancing scientific research since
its inception.
Summary & Resources
Chapter Summary
Community health refers to the overall health status of a community. Public health is a science
and art that stresses health promotion and disease prevention at the population level and
thus contributes to optimal community health. Community health is part of public health,
but it is implemented at the local level. In the United States, community health has shown
dramatic improvements during the past century. Nevertheless, the nation lags behind peer
countries with respect to life expectancy and other health indices. Also, many preventable
risk factors, such as tobacco use, and chronic conditions, such as diabetes and hypertension,
are prevalent among Americans. Public health began as part of the medical realm and split off
after the elimination of many infectious diseases thanks to the advent of vaccinations. Today,
the medical realm of treatment and the public health arena of prevention seem worlds apart,
and they both struggle for funding to stay afloat. But both focus on improving health—public
health at the national level, and medical care at the individual level.
Summary & Resources
Community health and public health have their origins in the classical period. Early human
civilizations before 500 BCE saw an increase in zoonotic diseases from human and animal
contact. During the classical period, from 500 BCE to 500 CE, public water and sewer systems
were installed. But it wasn’t until the Industrial Period that modern public health began to
form. The invention of vaccines and preventing infectious diseases came to the forefront of
mitigating poor health outcomes. Today, public health officials concentrate on chronic dis-
eases, especially those that can be influenced by lifestyle choices, such as substance abuse
and obesity.
The structure of public health has grown exponentially since the Industrial Revolution and
now includes a variety of governmental and nongovernmental agencies. At the top level
is the Office of Public Health and Science, the operating agency of the U.S. Department of
Health and Human Services. Supporting agencies include the National Institutes of Health,
the Centers for Disease Control and Prevention, the Food and Drug Administration, the
Substance Abuse and Mental Health Services Administration, the Health Resources and
Services Administration, the Agency for Healthcare Research and Quality, the Agency for
Toxic Substances and Disease Registry, the Indian Health Service, and the Office of Regional
Health Administrators—to name a few.
These agencies within the community and public health system can be governmental, quasi-
governmental, or nongovernmental. Governmental agencies are operated by the government
at any level (local, state, federal); quasi-governmental agencies typically started as a govern-
mental agency but operate independently now, usually with some federal funding; and non-
governmental agencies are purely nonprofit organizations that focus on a public health issue.
Critical Thinking and Review Questions

1. Supply two definitions of the term health. What limitations are there for the World
Health Organization’s definition of health?
2. What is the difference between public health and community health? Why do we
make that distinction?
3. Describe the functions of health care and how they differ from the role of community
and public health.
4. Investigate one of the top public health careers and provide an argument for its role
in population wellness.
5. Explain how race, religion, culture, socioeconomic status, and education affect health
outcomes.
6. What is health literacy, and why is it important in public health?
7. Describe at least one development that took place in the early periods of public
health and how it shaped the field.
8. Describe one of the 10 public health achievements and explain how it has made an
impact on the health of the population.
9. Refer to A Closer Look: Public Health Service Commissioned Corps, and name a few
advantages of membership.
10. What is the difference between governmental agencies, quasi-governmental agen-
cies, and nongovernmental agencies?
Summary & Resources
Additional Resources
Centers for Disease Control and Prevention’s Official Mission
Statements and Organizational Charts
https://www.cdc.gov/maso/officialmissionstatementscharts.html
Learn more about the different centers, institutes, and offices (CIOs) of the CDC. Each group
has separate mission statements and organizational structures to best support its area of
focus.
A History of Public Health in the United States

http://sphweb.bumc.bu.edu/otlt/mph-modules/ph/publichealthhistory
/publichealthhistory8.html
Review a century-by-century overview of the foundations of public health, and get a better
understanding of how it morphed into the entity it is today.
The National Institutes of Health’s Institutes

https://oma.od.nih.gov/DMS/Pages/Organizational-Changes-Org-Chart-Function.aspx
Learn about the 30 different institutes that make up the National Institutes of Health.
The U.S. Public Health Service

https://usphs.gov/student/jrcostep.aspx
https://usphs.gov/student/srcostep.aspx
https://usphs.gov/apply/apply.aspx
Learn about the U.S. Public Health Service, one of the lesser-known uniformed services in
the United States. For more details about the application process, email corpsrecruitment@
hhs.gov.
The Organization for Economic Cooperation and Development (OECD)

http://www.oecd.org/els/health-systems/
Learn about the OECD, which is an organization made up of 34 countries. The organization
is involved with numerous activities related to community health and regularly publishes an
extensive compilation of data on health and health systems among OECD member states.
Examples of nongovernmental organizations that work within the public health realm
http://wish.org/
http://www.lung.org/
https://www.ihaveadreamfoundation.org/
https://www.mcwerie.org/
Visit these links to find out more about four nonprofit organizations: Make-A-Wish Founda-
tion, American Lung Association, “I Have a Dream” Foundation, and Mercy Center for Women.
These organizations focus on health and well-being. Take a moment to consider how these
organizations help members at local or state levels.
Summary & Resources
Examples of quasi-governmental organizations that work within the public health realm
http://www.redcross.org/
https://www.nationalservice.gov/programs/americorps
http://www.ilru.org/
https://www.nsf.gov/
http://www.nasonline.org/
Visit these links to learn more about these five quasi-governmental organizations: American
Red Cross, AmeriCorps, Independent Living Research Utilization, National Science Founda-
tion, and National Academy of Sciences. Take a moment to think about how these organiza-
tions contribute to the health and well-being of the communities that they help.
Key Terms
community A group of people living within health literacy The comprehension of
a defined geographical space or region; they health-related materials, such as the ability
may also share common values, norms, cul- to understand a doctor’s directions, pre-
tures, and social structures. scriptions, and how to manage diseases and
maintain health.
community health A specific discipline
that studies the health characteristics within healthy community A community whose
communities. belief system focuses on the elements
required for optimal health and wellness.
disease etiology The manner in which a
disease is developed; it determines cause immunizations Vaccines that can protect
and origin. against certain diseases.
governmental agency An organization in nongovernmental organization (NGO) A

the federal realm, funded by taxpayer dollars voluntary group of individuals not affiliated
to oversee and administer specific functions with any government that provides service
as outlined by their constituents. according to its charter and mission.
health Defined by the WHO as a positive public health A discipline that focuses
state of complete physical, mental, and social on promoting the health of a population of
well-being (not simply being free of disease). individuals.
health care Maintaining, treating, and quasi-governmental organization A type

improving a person’s physical, mental, and/ of corporation typically in the private sector
or spiritual health. that is supported by government but oper-
ated as a nongovernmental entity providing
health education Programs, campaigns, some type of public service.
and classes that promote health and aware-
ness of health risks. social environment Collective influences
of a group of people upon one individual.

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1 Overview of Community

and Public Health

1.1 What Is Public and Community Health?

Scenario 2: You take your kindergartener to the health department’s clinic to

Scenario 3: Your family is sheltered in temporary housing after massive floods

The Definition of Health

This definition, with its emphasis on the positive

Public Health Versus Community Health

Community health is also a discipline that focuses on population well-being; however, it

Table 1.1: Community versus public health

Public Health Versus Health Care

Benjamin is an unemployed single father

While Benjamin and Yolanda both need the same Weedezign/iStock/Thinkstock

Scenario 2: You take your kindergartener to the health department’s clinic

Scenario 3: Your family is sheltered in temporary housing after massive floods

public health = population focus

health care = individual focus

Epidemiologist Medical director

1.2 Public Health Issues and the Social Environment

Top Public and Community Health Concerns

Health Care–Associated Infections

Heart Disease and Stroke

Human Immunodeficiency Virus (HIV)

Motor Vehicle Injuries

Solution: While motor vehicle injuries have been

Nutrition, Physical Activity, and Obesity

Prescription Drug Overdose

Solution: Implementing stricter monitoring programs to track the dispensing of controlled

The Role of Social Influences

Race and Ethnicity

African American 74.6

Asian American 86.5

Native American 76.9

*Most recent data available

Socioeconomic Status (SES) and Education

Religion and Culture

It is difficult to explain to an individual without an understanding of health terminology, much

1.3 History of Community and Public Health

Table 1.4: Community health landmarks

Early human Pre-500 BCE Zoonotic diseases from increased contact

Renaissance 1300 to 1500 Discoveries in human anatomy; hypotheses

Baroque period 1600 to 1700 John Graunt analyzes vital statistics

20th century 1900 to 1999 Great influenza pandemic of 1918; invention of

As a means of preventing infectious diseases, the

Industrial Revolution Period

• Edward Jenner’s (1749–1823) development of a successful vaccine against smallpox

Spotlight on Public Health Figures:

Who is John Snow?

Spotlight on Public Health Figures: John Snow (1813–1858)

What was the political climate at the time?

What was his contribution to public health?

What motivated him?

Contemporary History: 20th and 21st Century

Table 1.5: Contemporary history events in public health

1955 The Salk polio vaccine was announced.

1978 Smallpox was eradicated worldwide.

Case Study: The Framingham Heart Study

Case Study: The Framingham Heart Study (continued)

Important Public Health Achievements

Motor Vehicle Safety

Family Planning and Maternal and Child Health

Spotlight on Public Health Figures:

Who is Margaret Sanger?