Big gems public health

Public Health 101 Healthy People–Healthy Populations

Second Edition

Richard Riegelman, MD, MPH, PhD Professor and Founding Dean

The George Washington University

School of Public Health and Health Services

Washington, DC

Brenda Kirkwood, MPH, DrPH University at Albany, State University of New York

School of Public Health

Albany, NY

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To Nancy Alfred Persily, whose enthusiasm for teaching public health to undergraduates inspired Public Health 101:

Healthy People–Healthy Populations.

Dedication

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Acknowledgments xv Preface: What Is Public Health 101: Healthy People–Healthy Populations All About? xvii About the Authors xix

Section I Principles of Population Health 1

Chapter 1 Public Health: The Population Health Approach 3 Learning Objectives 3 What Do We Mean by “Public Health”? 4 How Has the Approach of Public Health Changed Over Time? 5 What Is Meant by “Population Health”? 9 What Are the Implications of Each of the Four Components of Public Health? 9 Should We Focus on Everyone or on Vulnerable Groups? 10 What Are the Approaches Available to Protect and Promote Health? 11 What Factors Determine the Occurrence of Disease, Disability, and Death? 11 What Changes in Populations Over Time Can Affect Health? 14 Key Words 17 Discussion Question 18 References 19

Chapter 2 Evidence-Based Public Health 21 Learning Objectives 21 How Can We Describe a Health Problem? 22 How Can Understanding the Distribution of Disease Help Us Generate

Ideas or Hypotheses about the Cause of Disease? 24

Contents

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Contentsvi

How Do Epidemiologists Investigate Whether There Is Another Explanation for the Difference or Changes in the Distribution of Disease? 25

What Is the Implication of a Group Association? 26 Etiology: How Do We Establish Contributory Cause? 27 What Can We Do if We Cannot Demonstrate All Three Requirements

To Definitively Establish Contributory Cause? 28 What Does Contributory Cause Imply? 31 Recommendations: What Works To Reduce the Health Impact? 32 Implementation: How Do We Get the Job Done? 35 Evaluation: How Do We Evaluate Results? 36 Key Words 39 Discussion Questions 42 References 43

Section I Cases and Discussion Questions 44 HIV/AIDS Determinants and Control of the Epidemic 45 Smoking and Adolescents—The Continuing Problem 45 Reye’s Syndrome: A Public Health Success Story 46 Sudden Infant Death Syndrome (SIDS) 47 Oxygen Use in Premature Infants and Blindness 48

Section II Tools of Population Health 51

Chapter 3 Public Health Data and Communications 53 Learning Objectives 53 What Is the Scope of Health Communications? 54 Where Does Public Health Data Come From? 55 How Is Public Health Information Compiled To Measure the

Health of a Population? 55 How Can We Evaluate the Quality of the Presentation of Health Information? 58 What Factors Affect How We Perceive Public Health Information? 60 What Types of Information Needs To Be Combined To Make Health Decisions? 61 What Other Data Needs To Be Included in Decision Making? 63 How Do We Utilize Information To Make Health Decisions? 67 How Can We Use Health Information To Make Healthcare Decisions? 67 Key Words 70 Discussion Questions 71 References 72

Chapter 4 Social and Behavioral Sciences and Public Health 73 Learning Objectives 73 How Is Public Health Related to the Social and Behavioral Sciences? 74

Contents vii

How Are Social Systems Related to Health? 75 Complex Interactions 75 Influencing Behavior 76

How Do Socioeconomic Status, Culture, and Religion Affect Health? 76 Socioeconomic Status 76 Culture 78 Religion 79

What Are Social Determinants of Health? 79 10 Key Categories of Social Determinants of Health 80

How Do Social Determinants Affect Health? 81 Can Health Behavior Be Changed? 82 Why Are Some Individual Health Behaviors Easier To Change than Others? 83 How Can Individual Behavior Be Changed? 83 How Can Health Behavior Be Explained and Predicted? 84 What Are Some Key Theories and Models Used to Address Health Behavior? 84

Intrapersonal Level 84 Interpersonal Level 85 Population and Community Level 88

How Can Theories Be Applied in Practice? 90 Choosing a Theory/Model 90 Planning Frameworks 90

Key Words 93 Discussion Questions 94 References 95

Chapter 5 Health Law, Policy, and Ethics 97 Learning Objectives 97 What Is the Scope of Health Law, Policy, and Ethics? 98 What Legal Principles Underlie Public Health and Health Care? 99 What Do We Mean by “Health Policy”? 100 How Are Public Health Policy Priorities Established? 101 How Do Philosophies Toward the Role of Government Affect Health Policies? 101 Is There a Right to Health Care? 103 How Does Public Health Attempt To Balance the Rights of

Individuals and the Needs of Society? 104 What Bioethical Principles Are Used to Address Public Health Issues? 104 How Can Bioethical Principles Be Applied to Protecting Individuals

Who Participate in Research? 106 Key Words 108 Discussion Questions 109 References 110

Contentsviii

Section II Cases and Discussion Questions 111 Don’s Diabetes 112 A New Disease Called SADS—A Decision Analysis 113 José and Jorge—Identical Twins without Identical Lives 113 The Obesity Epidemic in the United States—The Tip of an Iceberg 114 Changing Behavior—Cigarette Smoking 115 The Elderly Driver 116

Section III Preventing Disease, Disability, and Death 117

Chapter 6 Noncommunicable Diseases 119 Learning Objectives 119 What Is the Burden of Noncommunicable Disease? 120 How Can Screening for Disease

Address the Burden of Noncommunicable Diseases? 120 How Can Identification and Treatment of Multiple Risk

Factors Be Used To Address the Burden of Noncommunicable Disease? 124 How Can Cost-Effective Interventions Help Us Address the Burden of

Noncommunicable Diseases? 127 How Can Genetic Counseling and Intervention Be Used To Address

the Burden of Chronic Diseases? 129 What Can We Do When Highly Effective Interventions Do Not Exist? 130 How Can We Combine Strategies To Address Complex Problems of

Noncommunicable Diseases? 131 Key Words 132 Discussion Questions 133 References 134

Chapter 7 Communicable Diseases 135 Learning Objectives 135 What Is the Burden of Disease Caused by Communicable Diseases? 136 How Do We Establish that an Organism Is a Contributory Cause of

a Communicable Disease? 138 What Factors Affect the Ease with which a Communicable Disease

is Transmitted? 138 Route of Transmission 138 Asymptomatic Transmission 138 Reproduction Ratio 139

What Public Health Tools Are Available To Address the Burden of Communicable Diseases? 139

How Can Barriers Against Disease Be Used To Address the Burden of Communicable Diseases? 139

Contents ix

How Can Immunizations Be Used To Address the Burden of Communicable Disease? 140

How Can Screening and Case Finding Be Used To Address the Burden of Communicable Disease? 140

How Can Treatment of Those Diagnosed and Their Contacts Help To Address the Burden of Communicable Disease? 141

How Can Public Health Efforts Maximize Effectiveness of Treatment and Prevent Resistance? 141

How Can Public Health Strategies Be Used To Eliminate Specific Communicable Diseases? 141

What Options Are Available for the Control of HIV/AIDS? 143 What Options Are Available for the Control of Influenza? 146 What Options Are Available for the Control of Rabies? 147 Key Words 148 Discussion Questions 149 References 150

Chapter 8 Environmental Health and Safety 151 Learning Objectives 151 What Is Meant by “Environment”? 152 What Is the Burden of Disease Due to the Physical Environment? 153 How Do We Interact with Our Physical Environment? 155 How Does Risk Assessment Address the Impacts of

the Physical Environment? 156 What Is a Public Health Assessment? 158 What Is an Ecological Risk Assessment? 158 What Is an Interaction Analysis Approach to Environmental Diseases? 160 What Do We Mean by “Intentional and Unintentional Injuries”? 162 What Is Being Done To Keep the Population Safe? 162 Key Words 165 Discussion Questions 166 References 167

Section III Cases and Discussion Questions 168 High Blood Pressure: A Public Health and Healthcare Success 169 Testing and Screening 169 H. pylori and Peptic Ulcers 170 What to do about Lyme Disease? 171 Sharma’s Village 172 Legal Drugs that Kill—Death from Prescription Drug Overdoses 172

Contentsx

Section IV Health Professionals, Healthcare Institutions, and Healthcare Systems 175

Chapter 9 Health Professionals and the Health Workforce 177 Learning Objectives 177 What Do We Mean by a “Health Professional”? 178 How Do Education and Training Serve To Define Health Professions? 179 What Are the Educational Options within Public Health? 179 What Is the Education and Training Process for Physicians? 181 What Is the Education and Training Process for Nursing? 184 What Roles Do Physicians, Nurses, and Other Clinical Health

Professions Play in Public Health? 185 What Is Meant by “Primary, Secondary, and Tertiary Care”? 185 How Are Clinical Health Profesionals Rewarded and

Compensated for Their Services? 186 How Can We Ensure the System has the Right Number of

Healthcare Professionals? 188 Key Words 189 Discussion Questions 190 References 191

Chapter 10 Healthcare Institutions 193 Learning Objectives 193 What Institutions Make up the Healthcare System? 194 What Types of Inpatient Facilities Exist in the United States? 194 What Types of Outpatient Facilities Exist in the United States? 196 What Do We Mean by the “Quality of Healthcare Services?” 196 How Can Health Care Be Coordinated Among the Multiple

Institutions that Provide Healthcare Services? 198 What Types of Coordination of Care Are Needed and What

Purposes Do They Serve? 198 What Types of Healthcare Delivery Systems Are Being Developed

and How Can They Help Ensure Coordination of Health Care? 198 How Can Electronic Medical Records Be Used To Facilitate

Coordination of Care and Improve Quality? 200 How Is Technology Being Used To Improve the Quality of Care? 202 What Mechanisms Are Being Used To Monitor and Ensure the Quality

of Health Care in the United States? 203 Can Disclosing Medical Errors Contribute to Quality of Care

and Serve as an Alternative to Malpractice? 203 Key Words 205 Discussion Questions 206 References 207

Contents xi

Chapter 11 Health Insurance and Healthcare Systems 209 Learning Objectives 209 How Much Money Does the United States Spend on Health Care? 210 What Types of Government-Supported Health Insurance Are Available? 211

Medicare 211 Medicaid 212

What Types of Employment-Based Health Insurance Are Available? 213 What Are the Key Health Insurance Changes Incorporated into

the ACA Legislation? 215 What Might the United States Health Insurance System Look Like

When the ACA Phase-In Is Completed? 216 How Can We Describe Heathcare Systems in General

and the United States Healthcare System in Particular? 217 How Can We Describe the Healthcare Systems in Canada

and the United Kingdom? 217 What Conclusions Can We Reach from These Descriptions of the Healthcare

Systems in the United States, Canada, and the United Kingdom? 217 How Can a Healthcare System Be Scored? 219 Using the National Scorecard, How Does the United States’ Healthcare

System Perform Compared to Those of Other Developed Countries? 219 How Can the Costs of Health Care Be Controlled in the United States? 220 Key Words 223 Discussion Questions 224 References 225

Section IV Cases and Discussion Questions 226 When Nursing Meets Medicine 227 Jack and Continuity of Care 227 Donna’s Doctor—To Err Is Human 228 Health Care in the United States—For Better or Worse? 229 Excess Costs—How Much Can Be Saved? 230

Section V Public Health Institutions and Systems 231

Chapter 12 Public Health Institutions and Systems 233 Learning Objectives 233 What Are the Goals and Roles of Governmental Public Health Agencies? 234 What Are the 10 Essential Public Health Services? 235 What Are the Roles of Local and State Public Health Agencies? 237 What Are the Roles of Federal Public Health Agencies? 239 What Are the Roles of Global Health Organizations and Agencies? 242 How Can Public Health Agencies Work Together? 243 What Other Government Agencies Are Involved in Health Issues? 243

Contentsxii

What Roles Do Nongovernmental Organizations Play in Public Health? 244 How Can Public Health Agencies Partner with Health Care To

Improve the Response to Health Problems? 244 How Can Public Health Take the Lead in Mobilizing Community

Partnerships To Identify and Solve Health Problems? 245 Key Words 247 Discussion Questions 248 References 249

Chapter 13 Food and Drugs as Public Health Issues 251 Learning Objectives 251 What Are Important Milestones in the History of Food

and Drugs as Public Health Issues in the United States? 252 Food and Food Safety 253

What Ways Can Food Affect Health and Disease? 253 How Important Is Foodborne Communicable Disease

as a Cause of Morbidity and Mortality? 255 What Are the Steps in Foodborne Outbreak Investigation? 255 What Is Being Done To Prevent Foodborne Diseases? 256 In the United States, What Other Programs Aim to

Prevent Food-Related Disease and Disability? 257 Drugs and Drug Safety 258

Why Is Drug Safety Considered an Important 21st Century Public Health Issue? 258

What Do We Mean By “Preclinical Research” on Drugs? 259 What Is Phase 1? 259 What Are Phase 2 and Phase 3? 260 What Are the Implications of FDA Approval of a Drug? 260 How Are Adverse Effects of a Drug Monitored in Phase 4,

after FDA Approval? 262 What Else Can Be Done? 262 Do All FDA-Regulated Products Receive the Same Effectiveness

and Safety Assessment as Prescription and Nonprescription Drugs? 264 What Other Products Does the FDA Regulate? 264

Key Words 264 Discussion Questions 265 References 266

Chapter 14 From Single Solutions to Systems Thinking—The Future of Population Health 267 Learning Objectives 267 What Makes Systems Thinking Different? 268 What Is a System? 269

Contents xiii

How Can Systems Analysis Be Used To Understand the Health Research Process? 269

What Are the Initial Steps in Systems Analysis? 270 What Additional Steps Are Needed To Complete a Systems Analysis? 271 How Can We Use a Systems Analysis To Better Understand a Problem

such as Coronary Artery Disease? 272 How Can We Use Systems Diagrams To Display the Workings of a System? 273 How Can We Apply Systems Thinking to Population Health Issues? 278 How Can Systems Thinking Help Us Incorporate Interactions

Between Factors To Better Understand the Etiology of Disease? 278 How Can Systems Thinking Help Take into Account

the Interactions Between Diseases? 279 How Can Systems Thinking Help Us Understand the Impact of

a Disease over the Life Span? 279 How Can Systems Thinking Help Identify Bottlenecks and Leverage Points

that Can Be Used To Improve Population Health? 280 How Can Systems Thinking Help Us Develop Strategies

For Multiple Simultaneous Interventions? 280 How Can Systems Thinking Help Us Look at Processes as a Whole To

Plan Short-Term and Long-Term Intervention Strategies? 281 How Can Systems Thinking Help Us Predict the Future Frequency

of Diseases? 282 What Can Systems Thinking Contribute to Public Health,

and What Are Its Limitations? 283 Key Words 283 Discussion Questions 284 References 285

Section V Cases and Discussion Questions 286 Public Health Departments—Getting the Lead Out 287 Community-Oriented Primary Care (COPC) 287 Hurricane Karl and the Public Health Success in Old Orleans 288 Lung Cancer: Old Disease, New Approaches 289 Restorital—How Do We Establish Safety? 290 The Future of HIV/AIDS 291

Glossary 293

Index 305

Acknowledgments

Public Health 101: Healthy People–Healthy Populations, Second Edition, is the culmination of 15 years of effort aimed at introducing public health to undergraduates. The effort originated with the teaching of an introductory course in public health in 1998 at the then newly created The George Washington University School of Public Health and Health Services. The new course, organized by associate dean Nancy Alfred Persily, inspired efforts to teach and to learn from a new generation. The approach was designed as part of a liberal arts education, stimulating the movement that came to be called the Educated Citizen and Public Health.

Efforts to think through the content of an introductory course in public health have involved a large number of people throughout the United States. Public health, arts and sciences, and clinical educators all participated in the 2006 Consensus Conference on Public Health Education, which put forward the framework for Public Health 101 upon which this book is based. Among those who led and continue to lead this effort is Susan Albertine, whose insights into the relationship between public health and liberal education have formed the basis for much of the Educated Citizen and Public Health movement.

I have taught Public Health 101 since 2002, which has provided me with an opportunity to teach and to learn from over 400 undergraduate students at The George Washington University. Their feedback and input has been central to writing and rewriting this book. Madison Hardee and Katie Harter deserve special recognition for their extensive feedback on many chapters of the first edition. Yifen Liu provided important feedback for the second edition. I would also like to thank Alan Greenberg and Dante Verme, the chair and vice chair of the Department of Epidemiology and Biostatistics at The George Washington University School of Public Health and Health Services, for their support of my efforts to expand the audience for undergraduate public health.

A key change in the second edition is the addition of a second author. I am pleased to welcome and acknowledge the contributions of Brenda Kirkwood, MPH, DrPH. I first had the opportunity to work with Brenda while she was a DrPH student at The George Washington University. Dr. Kirkwood has made extraordinary contributions to the sec- ond edition. She has taken the primary responsibilities for writing and rewriting several chapters. Her careful reviews and dedication to getting the details right have been key to the quality of this edition. Brenda is truly exceptional and a pleasure to work with, as will be confirmed by all who work with her.

The draft of the second edition went through extensive review and feedback. I am grateful to all those who read chapters and provided constructive input. Mike Brown, Publisher of the Public Health and Health Administration line of products for Jones & Bartlett Learning, has made special contributions to this book and the series as a whole. His vision has helped craft the series, and his publishing expertise made it happen. The production, marketing, and editorial staff of Jones & Bartlett Learning deserve special recognition. Their commitment to this book and the entire Essential Public Health series has gone well beyond the expectations of their jobs.

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Acknowledgmentsxvi

Last, but by no means least, is my wife, Linda Riegelman, who encouraged this book and the Essential Public Health series from the beginning. She saw the need to reach out to students and make real the roles that public health plays in their everyday lives. Linda went the extra mile by reading and rereading both the first and the second edition. She deserves the credit for what works, but the blame for what fails is all mine.

Confronting the challenge of putting together Public Health 101 has been one of the great joys of my professional life. I hope it will bring both joy and challenge to you as you enter into the important and engaging world of public health.

Richard Riegelman, MD, MPH, PhD

Public health is more than a profession; it is a way of thinking. Public Health 101: Healthy People–Healthy Populations introduces you to the profession and also the way of thinking that we will call population health. Population health is an important way of looking at the world, whether you are going into public health as a profession, a clinically oriented health profession, business, law, international affairs, or a range of other professions.

Population health is also a key way of thinking, which prepares you for the challenges of citizenship in a democ- racy. Many of the issues that come before us as a society stem from or benefit from a population health perspective. Whether we are dealing with AIDS, the impact of aging, climate change, or the costs of health care, the population perspective can help us frame the issues and analyze the options to intervene.

In addition, the population perspective leads us to look broadly at the way issues intertwine and interact with each other. We call this systems thinking. In population health, systems thinking is taking center stage as we increas- ingly struggle with complex problems that require us to look beyond the traditional boundaries of health and disease.

Until recently, public health was considered a discipline taught only at the graduate level. Today, undergraduate public health is booming at four-year colleges and is beginning to take hold at community colleges as well. Its roots in general and liberal education go back to the 1980s, when David Fraser, the president of Swarthmore and an epi- demiologist who led the investigation of Legionnaires’ disease, wrote a now classic article called “Epidemiology as a Liberal Art.”1

In 2003, the Institute of Medicine of the National Academies of Sciences recommended that “all undergraduates should have access to education in public health.”2 That recommendation encouraged the development of the Edu- cated Citizen and Public Health initiative, a collaboration of undergraduate educators and public health educators to define and stimulate public health curricula for all undergraduates. Public Health 101 was written to implement the recommendations that came out of this initiative and continue to form the basis for undergraduate education in public health.

This second edition of Public Health 101 has been thoroughly updated and expanded. Each chapter includes new material designed to expand your understanding of public health. Two new chapters have been added, one on food and drugs as public health issues and the other on systems thinking as the future of population health. These chapters are designed to keep Public Health 101 at the cutting edge of new developments and ways of thinking. In addition, each of the five sections includes new case studies challenging you to apply what you have learned.

Public Health 101: Healthy People–Healthy Populations will not try to overload your mind with facts. It is about providing you with frameworks for thinking, and applying these frameworks to real situations and thought-provoking scenarios. Each chapter begins and ends with vignettes designed to show you the types of situations you will confront in public health. After each section, there are cases studies that relate to one or more chapters in the section. They

Preface: What Is Public Health 101: Healthy People–Healthy Populations All About?

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Preface: What Is Public Health 101: Healthy People–Healthy Populations All About?xviii

provide realistic, engaging exercises and open-ended questions to help you think through the application of the key concepts presented in each section.

Public Health 101 is designed as a gateway to the world of public health. It provides an introduction to the Essential Public Health series, a comprehensive series designed primarily for undergraduate public health education. You should take advantage of the Essential Public Health series’ website at www.essentialpublichealth.com. It provides information on all the books in the series.

Hopefully, you will come away from reading Public Health 101 with an appreciation of how the health of the public is influenced by and can be improved by efforts directed at the population level, as well as at the individual level. Let us begin in Chapter 1 by exploring the ways that public health affects everyone’s daily life.

RefeRences 1. Fraser DW. Epidemiology as a liberal art. N Engl J Med. 1987;316:309–314. 2. Gebbie K, Rosenstock L, Hernandez LM. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington DC:

National Academy Press; 2003.

Richard Riegelman, MD, MPH, PhD, is professor of epidemiology–biostatistics, medicine, and health policy, and founding dean of The George Washington University School of Public Health and Health Services. His education includes an MD from the University of Wisconsin, plus an MPH and PhD in epidemiology from The Johns Hopkins University. Dr. Riegelman practiced primary care internal medicine for over 20 years.

Dr. Riegelman has over 70 publications, including 6 books for students and practitioners of medicine and public health. He is editor of the Jones & Bartlett Learning Essential Public Health series. The series provides books and ancil- lary materials for the full spectrum of curricula for undergraduate public health education.

Dr. Riegelman has spearheaded efforts to fulfill the Institute of Medicine’s recommendation that “all undergradu- ates should have access to education in public health.” His work with national public health and arts and sciences orga- nizations has developed into the Educated Citizen and Public Health movement. This movement now includes efforts by the Association of Schools and Programs of Public Health (ASPPH) and the Association of American Colleges and Universities (AAC&U) to implement undergraduate public health education. He also co-chairs the Community Col- lege and Public Health project, which aims to incorporate public health education into community colleges as part of the continuum of public health education.

Richard Riegelman teaches medical school, undergraduate, and graduate public health courses, which include Public Health 101 and Epidemiology 101.

Brenda Kirkwood, MPH, DrPH, has experience in higher education spanning public and private institutions on the associate, baccalaureate, and graduate levels, including development and teaching of undergraduate and graduate public health courses, development and management of public health academic programs, student mentorship, and contributions to national educational initiatives. She has held faculty and administrative positions at the University at Albany, State University of New York, School of Public Health, The George Washington University School of Public Health and Health Services, American University College of Arts and Sciences, and George Mason University Col- lege of Health and Human Services. She currently works in academic administration at the University at Albany, State University of New York, School of Public Health.

Prior to her career in higher education, Dr. Kirkwood held positions with the New York State Cancer Registry and the Bureaus of Sexually Transmitted Disease Control and Injury Prevention within the New York State Department of Health. She received a bachelor of science from Ithaca College, master of public health from the University at Albany, State University of New York, and doctor of public health degree from The George Washington University.

About the Authors

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pson/ShutterStock, Inc.

About the Authorsxx

Dr. Kirkwood has been actively involved in national efforts to expand public health education and strengthen the public health workforce. As a researcher and educator, she has collaborated with a number of academic and public health workforce organizations. Her recent research explored the adoption of public health curricula in community colleges, contributing to Healthy People 2020, a collaborative initiative of the U.S. Department of Health and Human Services. Her publications and pre- sentations at numerous national professional conferences have focused on undergraduate public health education, contributing to the Educated Citizen and Public Health movement.

Principles of Population Health

section I

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S ection I of Public Health 101: Healthy People—Healthy Populations introduces you to the ways that public health affects your every waking moment, from the food you eat, to the water you drink, to the car you

drive. Even sleep matters. In public health, we use bed nets to prevent malaria, we use beds that prevent back pain, and we put infants to sleep on their backs to prevent sudden infant death syndrome (SIDS).

In Section I, we will examine a range of approaches to public health that have been used over the centuries. Then we will focus on a 21st century approach known as population health. Population health includes the full range of options for intervention to address health problems, from community control of communicable disease and environmental health, to healthcare delivery systems, to public policies such as taxation and laws designed to reduce cigarette smoking. We will also look at how populations are changing by examining

three important transitions that are affecting population health today and will continue to do so for years to come.

In this section, we will also examine an evidence-based approach to population health that focuses on defining the problem, establishing the etiology, making evidence-based recommendations, implementing these recommendations into practice, and evaluating the impacts of interventions. The population health and evidence-based approaches introduced in Section I provide an underpinning for all that follows.

At the end of Section I, as with each section, there are cases with discussion questions that draw on chapters from the section. Each case is designed as a realistic description of the types of problems we face as we seek to achieve healthy people and healthy populations.

So with no further ado, let us take a look at how public health can and does affect all of our daily lives.

SEcTIon I Principles of Population Health2

Public Health: The Population Health Approach

Learning objectives By the end of this chapter, the student will be able to:

• identify multiple ways that public health affects daily life.

• define eras of public health from ancient times to the early 2000s.

• define the meaning of “population health.”

• illustrate the uses of health care, traditional public health, and social interventions in population health.

• identify a range of determinants of disease.

• identify ways that populations change over time, which affects health.

I woke up this morning, got out of bed, and went to the bathroom, where I used the toilet, washed my hands, brushed and flossed my teeth, drank a glass of water, and took my blood pressure medicine, cholesterol medication, and an aspirin. Then I did my exercises and took a shower.

On the way to the kitchen, I didn’t even notice the smoke detector I passed or the old ashtrays in the closet. I took a low-fat yogurt out of the refrigerator and prepared hot cereal in the microwave oven for my breakfast.

Then I walked out my door into the crisp clean air and got in my car. I put on my seat belt, saw the light go on for the airbag, and safely drove to work. I got to my office, where I paid

little attention to the new defibrillator at the entrance, the “no smoking” signs, or the absence of asbestos. I arrived safely in my well-ventilated office and got ready to teach Public Health 101.

It wasn’t a very eventful morning, but then it’s all in a morning’s work when it comes to public health.

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chapter 1

However, the challenges continue. Globalization increases the potential for the spread of existing and emerging diseases and raises concerns about the safety of the products we use. Climate change and ongoing environmental deterioration continue to produce new territory for “old” diseases, such as malaria and dengue fever. Overuse of technologies, such as antibiotics, has encouraged the emergence of resistant bacteria.

The 1900s saw an increase in life expectancy of almost 30 years in most developed countries, much of it due to the successes of public health initiatives.2 We cannot assume that these trends will continue indefinitely. The epidemic of obesity already threatens to slow down or reverse the prog- ress we have been making. The challenges of 21st century public health include the protection of health and continued improvement in quality of life, not just quantity of years individuals are living.

To understand the role of public health in these achieve- ments and ongoing challenges, let us start at the beginning and ask: What do we mean by “public health”?

WHaT dO We mean By “PuBlIc HealTH”? Ask your parents what “public health” means and they might say, “Health care for the poor.” Well, they are right that public health has always been about providing services for those with special vulnerabilities, either directly or through the health- care system. But that is only one of the ways that public health serves the most needy and vulnerable in our population. Public health efforts often focus on the most vulnerable popu- lations, from reducing exposure to lead paint in deteriorating buildings to food supplementation to prevent birth defects and goiters. Addressing the needs of vulnerable populations has always been a cornerstone of public health. As we will see, however, the definition of “vulnerable populations” continues to change, as do the challenges of addressing their needs.

Ask your grandparents what “public health” means and they might say, “Washing your hands.” Well, they are right too—public health has always been about determining risks to health and providing successful interventions that are appli- cable to everyone. But hand washing is only the tip of the iceberg. The types of interventions that apply to everyone and benefit everyone span an enormous range: from food and drug safety to controlling air pollution, from measures to prevent the spread of tuberculosis to vaccinating against childhood dis- eases, from prevention and response to disasters to detection of contaminants in our water.

The concerns of society as a whole are always in the forefront of public health. These concerns keep changing and the methods for addressing them keep expanding. New

This rather mundane morning is made possible by a long list of achievements that reflect the often-ignored history of public health.1 We take for granted the fact that water chlorination, hand washing, and indoor plumbing largely eliminated the transmission of common bacterial diseases, which so often killed the young and not-so-young for cen- turies. Do not overlook the impact of prevention on our teeth and gums. Teeth brushing, flossing, and fluoridation of water have made a dramatic impact on the dental health of children and adults.

The more recent advances in the prevention of heart disease have been a major public health achievement. Preventive successes include the reduction of blood pressure and cholesterol, cigarette smoking prevention and cessation efforts, the use of low-dose aspirin, an understanding of the role of exercise, and the widespread availability of defibril- lators. These can be credited with at least half the dramatic reductions in heart disease that have reduced the death rate from coronary artery disease by approximately 50% in the United States and most other developed countries in the last half century.

The refrigerator was one of the most important advances in food safety, which illustrates the impact of social change and innovation not necessarily intended to improve health. Food and product safety are public health achievements that require continued attention. It was pub- lic pressure for food safety that in large part brought about the creation of the U.S. Food and Drug Administration. The work of this public health agency continues to affect all of our lives from the safety of the foods we eat to the drugs and cosmetics we use.

Radiation safety, like radiation itself, usually goes unno- ticed, from the regulation of microwave ovens to the reduc- tion of radon in buildings. We rarely notice when disease does not occur.

Highway safety illustrates the wide scope of activities required to protect the public’s health. From seat belts, child restraints, and airbags to safer cars, highways, designated driver programs, and enforcement of drunk driving laws, public health efforts require collaboration with professionals not usually thought of as having a health focus.

The physical environment too has been made safer by the efforts of public health. Improvement in the quality of the air we breathe both outdoors and indoors has been an ongoing accomplishment of what we will call “population health.” Our lives are safer today because of interventions ranging from installation of smoke detectors to removal of asbestos from buildings.

cHAPTER 1 Public Health: The Population Health Approach4

•• An examination of the full range of environmental, social, and economic determinants of health—not just those traditionally addressed by public health and clini- cal health care.

•• An examination of the full range of interventions to address health issues, including the structure and func- tion of healthcare delivery systems, plus the role of public policies that affect health even when health is not their intended effect.

If your children ask you what public health is, you might respond: “It is about the big picture issues that affect our own health and the health of our community every day of our lives. It is about protecting health in the face of disasters, preventing disease from addictions such as cigarettes, controlling infec- tions such as the human immunodeficiency virus (HIV), and developing systems to ensure the safety of the food we eat and the water we drink.”

A variety of terms have been used to describe this big picture perspective that takes into account the full range of factors that affect health and considers their interactions.5 A variation of this approach has been called the social- ecological model, systems thinking, or the population health approach. We will use the latter term. Before exploring what we mean by the population health approach (also known as the ecological approach or socioecological approach), let us examine how the approaches to public health have changed over time.a

HOW Has THe aPPrOacH Of PuBlIc HealTH cHanged Over TIme? Organized community efforts to promote health and prevent disease go back to ancient times.6, 7 The earliest human civilizations integrated concepts of prevention into their culture, their religion, and their laws. Prohibitions against specific foods—including pork, beef, and sea- food—plus customs for food preparation, including offi- cially designated methods of killing cattle and methods of cooking, were part of the earliest practices of ancient societies. Prohibitions against alcohol or its limited use for religious ceremony have long been part of societies’ efforts to control behavior, as well as prevent disease. Prohibition

a Turnock2 has described several meanings of “public health.” These include the system and social enterprise, the profession, the methods, the government services, and the health of the public. The population health approach used in this text may be thought of as subsuming all of these different perspectives on public health.

technologies and global, local, and national interventions are becoming a necessary part of public health. To understand what public health has been and what it is becoming, let us look at some definitions of “public health.” The following are two definitions of “public health”—one from the early 1900s and one from more recent years.

Public health is “the science and art of prevent- ing disease, prolonging life and promoting health through organized community effort.”3

The substance of public health is the “organized community efforts aimed at the prevention of disease and the promotion of health.”4

These definitions show how little the concept of public health changed throughout the 1900s; however, the concept of public health in the 2000s is beginning to undergo impor- tant changes in a number of ways, including:

•• The goal of prolonging life is being complemented by an emphasis on the quality of life.

•• Protection of health when it already exists is becoming a focus along with promoting health when it is at risk.

•• Use of new technologies, such as the Internet, are rede- fining “community,” as well as offering us new ways to communicate.

•• The enormous expansion in the options for interven- tion, as well as the increasing awareness of potential harms and costs of intervention programs, require a new science of “evidence-based” public health.

•• Public health and clinical care, as well as public and private partnerships, are coming together in new ways to produce collaborative efforts rarely seen in the 1900s.

•• Complex public health problems need to be viewed as part of larger health and social systems, which require efforts to simultaneously examine multiple problems and multiple solutions rather than one problem or one solution at a time.

Thus, a new 21st century definition of public health is needed. One such definition might read as follows:

The totality of all evidence-based public and pri- vate efforts that preserve and promote health and prevent disease, disability, and death.

This broad definition recognizes public health as the umbrella for a range of approaches that need to be viewed as a part of a big picture or population perspective. Specifically, this definition enlarges the traditional scope of public health to include:

How Has the Approach of Public Health changed over Time? 5

of cannibalism, the most universal of food taboos, has strong grounding in the protection of health.b

The earliest civilizations have viewed sexual practices as having health consequences. Male circumcision, premarital abstinence, and marital fidelity have all been shown to have impacts on health.

Quarantine or isolation of individuals with disease or exposed to disease has likewise been practiced for thousands of years. The intuitive notion that isolating individuals with disease could protect individuals and societies led to some of the earliest organized efforts to prevent the spread of disease. At times, they were successful, but without a solid scientific basis. Efforts to separate individuals and communities from epidemics sometimes led to misguided efforts, such as the unsuccessful attempts to control the black plague by barring outsiders from walled towns and not recognizing that it was the rats and fleas that transmitted the disease.

During the 1700s and first half of the 1800s, individuals occasionally produced important insights into the preven- tion of disease. In the 1740s, British naval commander James Lind demonstrated that lemons and other citrus fruit could prevent and treat scurvy, a then-common disease among sailors, whose daily nourishment was devoid of citrus fruit, the best source of vitamin C.

In the last years of the 1700s, English physician Edward Jenner recognized that cowpox, a common mild ailment of those who milked cows, protected those who developed it against life-threatening smallpox. He devel- oped what came to be called a vaccine—derived from the Latin vacca, meaning “cow.” He placed fluid from cowpox sores under the skin of recipients, including his son, and exposed them to smallpox. Despite the success of these smallpox prevention efforts, widespread use of vaccina- tions was slow to develop, partially because at that time, there was not an adequate scientific basis to explain the reason for its success.

All of these approaches to disease prevention were known before organized public health existed. Public health awareness began to emerge in Europe and the United States in the mid-1800s. The U.S. public health movement has its origins in Europe, where concepts of disease as the con- sequence of social conditions took root in the 1830s and 1840s. This movement, which put forth the idea that disease emerges from social conditions of inequality, produced the

b In recent years, this prohibition has been indirectly violated by feeding beef products containing bones and brain matter to other cattle. The development of “mad cow” disease and its transmission to humans has been traced to this practice, which can be viewed as analogous to human cannibalism.

concept of social justice. Many attribute public health’s focus on vulnerable populations to this tradition.

While early organized public health efforts paid special attention to vulnerable members of society, they also focused on the hazards that affected everyone, such as contamina- tion of the environment. This focus on sanitation and public health was often called the hygiene movement, although it began even before the development of the germ theory of disease. Despite the absence of an adequate scientific founda- tion, the hygiene movement made major strides in control- ling communicable diseases, such as tuberculosis, cholera, and waterborne diseases, largely through alteration of the physical environment.

The fundamental concepts of epidemiology also devel- oped during this era. In the 1850s, John Snow, often called the father of epidemiology, helped establish the importance of careful data collection and documentation of rates of disease before and after an intervention in order to evaluate effective- ness. He is known for his efforts to close down the Broad Street pump, which supplied water contaminated by cholera to a district of London. His actions quickly terminated that epidemic of cholera. John Snow’s approach has become a symbol of the earliest formal epidemiological thinking.

Ignaz Semmelweis, an Austrian physician, used much the same approach in the mid-1800s to control puerperal fever—or fever of childbirth—then a major cause of maternal mortality. Noting that physicians frequently went from the autopsy room to the delivery room without washing their hands, he instituted a hand-washing procedure and was able to document a dramatic reduction in the frequency of puer- peral fever. Unfortunately, he was unable to convince many of his contemporaries to accept this intervention without a clear mechanism of action. Until the acceptance of the germ theory of disease, puerperal fever continued to be the major cause of maternal deaths in Europe and North America.