INTRODUCTION TO

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 OBJECTIVES

• Define public health (PH) and list its core areas

• Describe conditions that existed before the advent of
modern public health
• Trace the development of USA PH system
• Name some PH achievements in the 20th Century
• Describe the epidemiological transition and name the top 3
leading causes of death
• Understand the “PH in America” vision, mission and
essential services and the unique features of PH 2
DEFINITIONS
& CORE AREAS

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 IMAGES OF PUBLIC HEALTH

Public Health
 The system
 The profession
 The health of the public
 The methods – knowledge and techniques
 Governmental services – especially medical care for the poor 4
 DEFINITIONS OF PH
 The science and art of preventing disease, prolonging life and promoting
health and efficiency through organized community effort… (Winslow,
1920)

 Public Health refers to all organized measures (whether public or private) to

prevent disease, promote health, and prolong life among the population as
a whole. Its activities aim to provide conditions in which people can be
healthy and focus on entire populations, not on individual patients or
diseases. Thus, public health is concerned with the total system and not only
the eradication of a particular disease. (WHO, 2014)

Prevent disease. Prolong life. Promote health.

Organized measures/interventions 5

Targets population.
 5 CORE AREAS

Epidemiology

Health Policy
& Management Biostatistics

Public
Health

Environmental & Social &

Occupational Behavioural
Health Sciences Sciences
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DEVELOPMENT OF
THE US PH SYSTEM

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 Major Eras in PH History in USA

>1999 Preparing for and responding

to community health threats

Filling gaps in
Medical Care
Delivery 1950-1999

Building State and

Local Infrastructure
Battling
Epidemics
1850-1949
<1850
BATTLING EPIDEMICS

• Dense populations in industrial seaports lived in unsanitary

conditions and worked long hours
• Outbreaks of infectious diseases - cholera, smallpox, typhoid,
tuberculosis, yellow fever, etc.
• Collective attempt to confront disease - Local boards
comprising of distinguished citizens
• Primary tactic was avoidance - evacuation and
isolation/quarantine
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 PH PIONEERS

Edward Jenner
 Developed and used vaccination to prevent smallpox (1796)
 Global eradication (1977)

John Snow
 Traced outbreak of cholera to well water drawn from Broad Street
Pump in London (1854)
 Collected and analysed data to determine causation
 Widely considered the Father of Epidemiology

Edwin Chadwick
 Report on sanitary conditions in London
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 Major part in structuring government’s role and responsibilities

for protecting the publics health
 BUILDING STATE & LOCAL
INFRASTRUCTURE
• Lemuel Shattuck’s “Report of the Sanitary Commission of
Masschusetts” outlined existing and future PH needs (1850)
• America’s blueprint for development of a PH system
• Establishment of state and local health departments
• Sanitary inspections
• Water and sewage control
• Communicable disease control – garbage collection, street cleaning,
landfills
• Food sanitation
• Vital statistics 11

• Services for infants and children

INCREASE IN SCIENTIFIC
KNOWLEDGE
 Louis Pasteur
 1862 - Germ Theory of Disease: germs caused many
diseases
 1888 - First public health lab
 Milk pasteurization eliminated a substantial number of food
borne disease

 Robert Koch
 1883 - identified the vibrio that causes cholera, 20 years
after Snow’s intervention
 Discovered the tuberculosis bacterium
 1884 - Koch’s postulates (causation)
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INCREASE IN SCIENTIFIC
KNOWLEDGE
 Ignaz Semmelweis
 Father of infection control
 1847 – Observes that women delivered by
physicians and medical students had a much higher
rate (13–18%) of post-delivery mortality (called
puerperal fever or childbed fever) than women
delivered by midwife trainees or midwives (2%).
 Demonstrated that hand washing could prevent
infections
 Initiated mandatory hand washing policy for
physicians & medical students

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 FILLING GAPS IN MEDICAL CARE
DELIVERY
• Health became a power exercised by states (Health does not
appear in the constitution)
• Federal government established Marine Hospital Service (later
Public Health Service)
• Ratification of 16th amendment authorized national income tax
(1916)
• Expectation of Federal government involvement during Great Depression
(1930s)
• Federal Grant-in-aid programs for medical service provision (≥1960s)
• Grants for substance abuse prevention, mental health, community 14
prevention services (≥1960s)
PREPARING FOR AND RESPONDING TO
COMMUNITY HEALTH THREATS

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REDEFINING THE UNACCEPTABLE
In the next 5 minutes:
Brainstorm and record a list of “things”
affecting the public’s health that have
passed from tolerable (accepted) to
intolerable (unaccepted).
Include items that you wish would
become unacceptable.
 PUBLIC HEALTH
ACHIEVEMENTS IN THE
20TH CENTURY

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 IMPROVEMENT IN LIFE
EXPECTANCY
U.S. Mortality Rate: 1900-2001
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Deaths per 1,000

16

14

12

10

8
00
15
30
33
36
39
42
45
48
51
54
57
60
64
67
70
73
76
79
82
85
88
91
94
97
00
Year
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
Source: www.infoplease.com

• 30 year increase in life expectancy at birth since 1900

(McKeown, 1965)
• 25/30 years due to PH prevention efforts 18

• 5 years due to medical care (1.5 – clinical preventive services e.g.

vaccination, screening)
TEN GREAT PH ACHIEVEMENTS
(US 1900-1999)
1. Immunization
2. Motor-vehicle safety
3. Safer workplaces
4. Control of infectious diseases
5. Decline in deaths from coronary heart disease and
stroke
6. Safer and healthier foods
7. Healthier mothers and babies
8. Family planning
Read more
9. Fluoridation of drinking water 19

10. Recognition of tobacco use as a health hazard

 1. VACCINATION

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 Virtual elimination of Smallpox, Diphtheria, Pertussis, Tetanus,
Polio, Measles, Rubella
 5. DECLINE IN DEATHS FROM CORONARY
HEART DISEASE & STROKE

 CHD is the leading cause of death despite 60% decrease in mortality rate since
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1950
 10. RECOGNITION OF TOBACCO USE AS A
HEALTH HAZARD

The decline in cigarette consumption is due to education, prevention and

cessation programs; campaigns for non-smokers' rights; restrictions on cigarette
advertising; counter-advertising; policy changes - enforcement of minors' access22
laws, restricting smoking in public places, and increased taxation
EPIDEMIOLOGIC TRANSITION
& LEADING CAUSES OF DEATH

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EPIDEMIOLOGIC TRANSITION

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DEMOGRAPHIC TRANSITION

2012

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 10 LEADING CAUSES OF DEATH – UNITED
STATES, 2010

Heart Disease
Cancer
Chronic LRD
Cause of Death

Stroke
Unintentiona Injuries
Alzheimer's Disease
Diabetes
Influenza and pneumonia
Nephritis, nephrotic syndrome, &
nephrosis
Suicide

0 100 200 300 400 500 600 700

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Number of Deaths (in thousands)
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 CHALLENGES AHEAD

NEW AND PERSISTENT PROBLEMS

IN PUBLIC HEALTH
 CAUSE OF DEATH (U.S. 1990)

 Tobacco 19%
 Diet/Activity 14%
 Alcohol 5%
 Microbial agents 4%
 Toxic Agents 3%
 Firearms 2% Tobacco
 Sexual Behavior 1% 38%

 Motor Vehicles 1% Diet/Activity

 Illicit Drug Use <1% 28%

McGinnis & Foege, JAMA, 1993

 WORLD POPULATION GROWTH
8000 2010
Population (in millions)

7000

6000

5000

4000

3000
1850
2000

1000

Year
 HEALTH DISPARITIES

Access and Outcomes

 Infant Mortality
 Cancer Screening and Management
 Cardiovascular Disease
 Diabetes
 HIV Infection/ AIDS
 Immunizations
MULTIPLE DETERMINANTS OF HEALTH

Policies and Interventions

Behavior

Physical Social
Individual
Environment Environment

Biology

Access to Quality Health Care

Source: U.S. Department of Health and Human Services, Health People 2010
GLOBALIZATION

• Emerging infectious diseases

• Reemerging infectious diseases
• Health disparities between
industrial and nonindustrial
countries
http://www.healthypeople.gov
 HEALTHY PEOPLE 2020

 Healthy People provides science-based, national goals and objectives

with 10-year targets designed to guide national health promotion and
disease prevention efforts to improve the health of all people in the
United States. For three decades, Healthy People has established
benchmarks and monitored progress over time in order to:
 Identify nationwide health improvement priorities.
 Increase public awareness and understanding of the determinants of
health, disease, and disability and the opportunities for progress.

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 HEALTHY PEOPLE 2020
 Provide measurable objectives and goals that are applicable at the national,
State, and local levels.
 Engage multiple sectors to take actions to strengthen policies and improve
practices that are driven by the best available evidence and knowledge.
 Identify critical research, evaluation, and data collection needs.
 Healthy People 2020 contains about 1,200 objectives in 42 Topic Areas
designed to serve as this decades framework for improving the health of all
people in the United States.

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* PUBLIC HEALTH IN
AMERICA
* UNIQUE FEATURES

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 PUBLIC HEALTH IN AMERICA
 National working group assembled by US PH Service (1994)
developed a consensus statement on core PH functions –
“Public Health in America”
 Vision
 Healthy people in healthy communities
 Mission
 Promote physical and mental health and prevent disease,
injury and disability
 Core Functions (1988 IOM Report)
 Assessment, Policy Development and Assurance 40
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 UNIQUE FEATURES OF PH

 Basis in social justice philosophy

 Inherently political nature
 Dynamic, ever expanding agenda
 Link with government
 Grounding in the sciences
 Use of prevention as prime strategy
 Uncommon culture and bond
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