What Is Public Health? 1 YORK DISTRICT PUBLIC HEALTH COUNCIL QUARTERLY MEETING

What Is Public Health?1
YORK DISTRICT PUBLIC HEALTH COUNCIL
QUARTERLY MEETING
January 21, 2009
Marc D. Hiller, DrPH
College of Health and Human Services, University of New Hampshire
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Sources: Bernard J. Turnock. 2009. Public Health – What It Is and How It Works, Fourth
Edition. (chapter 1, pp. 1-28, “What is Public Health?”) and Institute of Medicine, National
Academy of Sciences. 1988. The Future of Public Health. (“Summary and
Recommendations”).
Public Perceptions of Public Health
(or, What the Person in the Street Thinks Public Health Is?)
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General ignorance (no clue); “I don’t know, I never thought about it.”
“Abstract;” hard to pin down or define
Surrounded by uncertainty and confusion (“well….ummmm, I’m not
sure”)
Vague/obtuse understanding (oh, well, “it’s the health of the public”)
Considered simply another branch of medicine
When Does Public Health Come to the Forefront?
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Seldom, when it is working or doing what is supposed to; typically, it
is simply assumed; going unnoticed or appearing to be “invisible”
most of the time... EXCEPT
When its absence is recognized when there is a problem
When a crisis is at hand
When “the system” seems to fail
Health Care (Medicine) and Public Health
“Health care is vital to all of us some of the time, but
public health is vital to all of us all of the time.”
Source: Former U.S. Surgeon General C. EVERETT KOOP, MD
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Public Health vs. Medicine
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Public Health
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Population
Disease Prevention
Health Promotion
Interventions
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Environment
Human behavior
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Medicine
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Individual
Diagnosis
Treatment
Intervention
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Medical care
Private (Some public)
Government (Some private)
Source: Brandt, AM and Gardner, M. 2000. American Journal Public Health. 90:707-715 .
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A Dictionary’s Definition of Public Health
“the science and practice of protecting and improving the health of
the community, as by preventive medicine, health education, control
of communicable diseases, application of sanitary measures, and
monitoring of environmental hazards.”
Source: The American Heritage Dictionary, Public Health Institute. PUBLIC HEALTH 101.
CEA Winslow’s Definition of Public Health, 1920
(short version)
“the science and art of preventing disease, prolonging life and
promoting health and efficiency through organized community
effort.”
Source: CEA Winslow, 1920.
CEA Winslow’s “Classic” Definition of Public Health, 1920
(expanded version)
“… the science and art of preventing disease. Prolonging life and
promoting health and efficiency through organized community effort
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for the sanitation of the environment,
the control of communicable infections,
the education of the individual in personal hygiene,
the organization of medical and nursing services for the early diagnosis
and preventive treatment of disease, and for
the development of the social machinery to ensure everyone a standard
of living adequate for the maintenance of health,
so organizing these benefits as to enable every citizen to realize his
birthright of health and longevity.”
John Last’s Definition of Public Health, 1980
“… efforts organized by society to protect, promote, and restore the
people’s health … combination of sciences, skills, and beliefs
directed to maintenance and improvement of health of all people
through collective or social actions … emphasis on prevention of
disease … activities change with changing technology & social
values, but goals remain the same.”
Source: John Last, 1980
Public Health Defined, 1988
“Public health is what we, as a society, do collectively to
assure the conditions in which people can be healthy.”
Source: Institute of Medicine Report (IOM).
THE FUTURE OF PUBLIC HEALTH. Washington DC:
National Academy Press. 1988.
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Characteristics of Public Health
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“A broad social enterprise or system.”
“A body of knowledge and techniques that can be applied to healthrelated problems.”
“Public health is literally the health of the public as measured in
terms of health and illness.”
“Social justice is said to be the cornerstone of public health.”
Source: Turnock B. PUBLIC HEALTH – WHAT IT IS AND
HOW IT WORKS, FOURTH EDITION. 2009.
Sudbury MA: Jones and Bartlett Publishers.
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Images of Public Health
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The System and Social Enterprise (Including the Nation’s Public
Health Infrastructure)
The Profession (Professionals and the Workforce)
The Methods (Knowledge and Techniques Applied to Health-related
Problems)
Governmental Services (Especially Medical Care for the Poor)
The Health of the Public (the Intended Results of Public Health
Endeavors, as Measured by the Levels of Health and Illness in the
Population)
Source: Turnock B. PUBLIC HEALTH – WHAT IT IS AND
HOW IT WORKS, FOURTH EDITION. 2009.
Sudbury MA: Jones and Bartlett Publishers.
Selected Unique Features of Public Health
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Basis in social justice philosophy
Inherently political nature
Dynamic, ever-expanding agenda
Link with government
Grounding in the sciences
Use of prevention as a prime strategy
Uncommon culture and bond
Source: Turnock B. PUBLIC HEALTH – WHAT IT IS AND
HOW IT WORKS, FOURTH EDITION. 2009.
Sudbury MA: Jones and Bartlett Publishers.
20th Century’s Top Ten Achievements
in Public Health
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Fluoridation of drinking water
Control of infectious diseases
Motor vehicle safety
Safer workplaces
Safer and healthier foods
Healthier mothers and babies
Recognition of tobacco use as a health hazard
Family planning
Decline in deaths from coronary heart disease and stroke
Immunizations
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Identified “Themes” Associated with Public Health Issues
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Uneasy tension between science and politics, and practice?
What should the role of government be in public health?
Newly emerging concern: preparedness
The role (and use) of incentives in public health
Integral connection between environmental issues and public health
Public health is global in nature (e.g., communicable disease
transmission/travel; global warming), and broad in scope
Ethical issues arise in conducting public health research –
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Risks?
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do the subjects of research also reap the benefits/rewards;
should U.S. standards (protections) apply universally in other (developing)
nations
Risks associated with pandemic flu; avian flu
Risks associated with HIV/AIDS
Vaccinations/immunizations
The “Tragedy of the Commons”
Public Health Fundamentals
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5 Ps of Public Health (expansion from the 3 Ps)
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Prevention (individual and community-focused)
Promotion (voluntary, education, advocacy)
Protection (policies/regulations; enforcement)
Population-based (communities, groups)
New 5th P: Preparedness (e.g., bioterrorism, natural disasters,
pandemics)
Closely linked to Environmental Health
Major Eras in U.S. Public Health History
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Prior to 1850
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1850-1949
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1950-1999
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2000-
Influence of superstition, religion, miasma
theory; battling epidemics/pandemics:
avoidance and acceptance;
advent of bacteriological era
Sanitary reform through state and local
infrastructure (state and local health
departments); development of public health
infrastructure
Filling gaps in medical care and expanding the
health agenda; Major advances in medicine;
AIDS; control of infectious disease, growth of
chronic disease (largely behaviorally-related)
Community public health practice; evolving
public health infrastructure development;
preparing for and responding to community
health threats
The Future of Public Health – IOM Selected Findings
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“The current state of our abilities for effective public health
action… is cause for national concern and for the development
of a plan of action for needed improvement … we have
slackened our public health vigilance nationally, and the health
of the public is unnecessarily threatened as a result.”
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Clearly defined public health is basic terms
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Stated that neither the general public or policymakers understood
public health or its importance
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Urged those working in public health to reach out to educate the
public about what public health is
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Source: Institute of Medicine (IOM), National Academy of Sciences. 1988.
IOM Selected Findings - 2
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Throughout the history of public health, two major factors have
determined how problems were solved:
1. The level of scientific and technical knowledge
2. The content of public values and popular opinions (and ultimately
political will)
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Overtime, public health measures have changed with important
advances in understanding the causes and control of disease (i.e.,
epidemiology)
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Public health practices have been affected by:
1. popular beliefs about illness and
2. by public views of appropriate governmental action
IOM Selected Findings - 3
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As poverty and disease came to be seen as both a societal as well
as a personal problem, and as governmental involvement in societal
concerns increased, collective action against disease became
gradually accepted… Health became a social as well as an
individual responsibility.
Selected Findings - 4
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Knowledge and values today remain decisive elements in the
shaping of public health practice… but they blend less harmoniously
than they once did. On the surface, there appears to be
widespread agreement on the overall mission of public health,
as reflected in comments heard by the Committee…
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Public health does things that benefit everybody
Public health prevents illness and educates the population
Selected Findings - 5
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But, when it comes to translating broad statements into effective
action, little consensus can be found…
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There is little agreement as to what services should be provided or
to what intensity they should be provided (in some states the state health
department was a major provider of prenatal care for poor women; in
another, women who could not pay got no care).
Some state health departments are active and well equipped and
funded; others perform minimal functions and have little support
In some states, there are large and sophisticated local health
departments; in many localities, there is no health department
IOM’s Three Basic Recommendations
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The mission of public health
The government role in fulfilling the mission
The responsibilities unique to each level of government
Other recommendations made by the committee were instrumental
in implementing the basic recommendations for the future of public
health, e.g., statutory frameworks, structural and organization steps,
strategies to build the fundamental capacities of public health
agencies – technical, political, managerial, programmatic, fiscal,
educational
1. The Mission of Public Health
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Fulfilling society’s interest in assuring conditions in which
people can be healthy.
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Generate organized community effort to address the public interest in
health by applying scientific and technical knowledge to prevent disease
and promote health
The mission is addressed by both private organizations and individuals
as well as by public agencies
Unique function of the governmental public health agency: to see that
vital elements are in place and that the mission is adequately addressed
2. The Governmental Role in Public Health
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The “core functions” of governmental agencies at ALL levels of
government are (a) assessment, (b) policy development, and
(c) assurance.
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a. What is Assessment?
Every public health agency regularly and systematically collect,
assemble, analyze, and make sensible information on the health
of the community, including statistics on health status, community
health needs, and epidemiologic and other studies of health
problems
2. The Governmental Role in Public Health (continued)
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b. What is Policy Development?
Every public health agency has the responsibility t oserve the
public interest in the development of comprehensive public health
policies (a) by promoting use of its scientific knowledge base in
decision making about public health and (b) by leading in the
development of public health policy. Agencies must take a
strategic approach, developed on the basis of a positive
appreciation for the democratic political process.
c. What is Assurance?
Public health agencies must assure their constituents that
services necessary to achieve agreed upon goals are provided,
either by encouraging actions by other entities (private or public),
by requiring such action through regulation, or by providing
services directly.
3. Levels of Responsibility
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Each level of government bears its unique set of responsibilities.
a. States
Must be the central force in public health, playing the primary
public sector responsibility for health.
State duties should include:
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Assessing state health needs; statewide data collection
Assuring an adequate state statutory base for health activities
Establishing statewide health objectives, delegating power to
localities as appropriate and hold them accountable
Assuring an organized statewide effort to develop and maintain
essential personnel, educational, and environmental health services,
provision of access to necessary services, and solving health-related
problems
Guaranteeing a minimum set of essential health services
Supporting local service capacity, particularly when disparities exist
3. Levels of Responsibility (continued)
b. Federal
The following were viewed as federal public health obligations.
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Support of knowledge development and dissemination through data
gathering, research, and information exchange
Establishing nationwide health objectives and priorities, and
stimulating debate on interstate and national public health issues
Providing technical assistance to help states and localities determine
their own objectives and to carry out action on national and regional
objectives
Providing funds to states to strengthen state capacity for service,
especially to achieve an adequate minimum capacity, and to achieve
national objectives
Assurance of actions and services that are in the public interest of
the entire nation such as control of AIDS and similar communicable
diseases, interstate environmental actions, and food and drug
inspection
3. Levels of Responsibility (continued)
c. Localities
Because of the great diversity in size, powers, and capacities of local
governments, generalizations must be made with caution. Nevertheless,
no citizen from any community, no matter how small or remote, should
be without identifiable and realistic access to the benefits of public health
protection, which is possible only through a local component of the
public health delivery system
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Assessment, monitoring, and surveillance of local health problems and needs
and of resources for dealing with them
Policy development and leadership that foster local involvement and a sense
of ownership, that emphasize local needs, and that advocate equitable
distribution of public resources and complementary private activities
Assurance that high quality services, including personal health services,
needed for the protection of public health in the community are available ans
accessible to all persons; that the community receives proper consideration in
the allocation of federal and state public health funds, and that the community
is informed about how to obtain public health services or to comply with public
heath requirements
What (Who) Comprise Public Health?
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Broad and interdisciplinary in nature
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Epidemiologists and biostatisticians
Biomedical scientists (e.g., biologists, microbiologists, bacteriologists,
virologists, chemists, physicians)
Environmental health specialists (including environmental health specialists,
toxicologists, sanitarians)
Social and behavioral scientists (e.g., health educators, psychologists, social
workers)
Health policy makers and administrators (e.g., administrators, elected officials,
program managers)
“Non-public health” professionals who are involved in public health activities
and programs (e.g., engineers, lawyers, nutritionists, teachers)
Other workers and occupations whose “work” constitutes activities that protect
and promote the public health, but who never think of themselves as playing a
role in public health (e.g., plumbers, rubbish collectors, contractors)
In sum, people practicing skills aimed at protecting and promoting
the health of the public
The Public Health System
Police
EMS
Community
Centers
MCOs
Health
Department
Home Health
Churches Corrections
Parks
Schools
Elected
Hospitals
Officials Nursing Mass Transit
Doctors
Philanthropist
Homes
Environmental
Civic Groups
Health
CHCs
Fire
Tribal Health
Economic
Laboratory
Employers
Drug
Mental
Development
Facilities
Treatment
Health
Source: Centers for Disease Control and Prevention
Dimensions of the Public Health System
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Capacity (Inputs): the resources and relationships necessary to
carry out the core functions and essential services of public health
(e.g., human resources, information resources, fiscal and physical
resources, and appropriate relationships among system
components).
Processes (Practices and Outputs): those collective practices or
processes that are necessary and sufficient to assure that the core
functions and essential services of public health are being carried
out effectively (including the key processes that identify and address
health problems and their causative factors and the interventions
intended to prevent death, disease, disability, and to promote quality
of life).
Outcomes (Results): indicators of health status, risk reduction, and
quality of life enhancement outcomes are long-term objectives that
define optimal, measurable future levels of health status; maximum
acceptable levels of disease, injury, or dysfunction; or prevalence of
risk factors.
Source: Adapted from Public Health Practice Program Office. 1990.
the Centers for Disease Control and Prevention.
Public Health
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Prevents epidemics and the spread of disease
Protects against environmental hazards
Prevents injuries
Promotes and encourages healthy behaviors
Responds to disasters and assists communities in recoveries
Assures the quality and accessibility of health services
The 10 Essential (Public Health) Services1
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Monitor health status to identify community health problems
Diagnose and investigate health problems and health hazards in
the community
Inform, educate, and empower people about health issues
Mobilize community partnerships to identify and solve health
problems
Develop policies and plans that support individual and community
health efforts
Enforce laws and regulations that protect health and ensure safety
Link people with needed personal health services and assure the
provision of health care when otherwise unavailable
Assure a competent public health and personal health care work
force
Evaluate effectiveness, accessibility, and quality of personal and
population-based health services
Research for new insights and innovative solutions to health
problems
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1 Source:
U.S. Public Health Service, 1994.
Ten Essential Services of Public Health
Source: Centers for Disease Control and Prevention
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Levels of Disease Prevention
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Primary Prevention: activities intended to prevent future onset of
disease, e.g., immunizations, seatbelt use, avoidance of tobacco,
reduced alcohol consumption, “safe sex,” exercise, air pollution
control, restaurant inspections, health education programs
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Secondary Prevention: early detection of health
problems/disease, to promote further recommended testing and the
early intervention of treatment or the risk that communicable
diseases transmission to others, e.g., hypertension screening,
cholesterol screening, HIV/STD testing, mammograms, pap smears,
colonoscopies.
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Tertiary Prevention: rehabilitation activities designed to prevent
subsequent worsening or reoccurrence of disease, disability, or
injury, e.g., cardiac rehab, adhering to strict dietary restrictions, relearning to walk after an orthopedic injury or stroke.
Health Promotion and Disease Prevention
Encompasses a Broad Array of Functions and Expertise
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Assess and monitor the health of communities and populations
at risk to identify health problems and priorities
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In collaboration with community and government leaders,
formulate public policies to solve identified local, state, and
national problems and priorities
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Assure that all populations have access to appropriate,
effective, and cost-effective health promotion and disease
prevention services
A Day in Your Life with Public Health
An Exercise
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In thinking about your activities that typically occur on a daily basis,
let’s try to make a list of how public health touches or impacts you
(i.e., the ways in which you interface with public health)...
Let’s add to the list events or activities that you periodically
encounter but not necessarily on a daily, or even weekly, basis …
Think practically and creatively …
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From the moment you arise in the morning, e.g., 6:30am
Going to work or to school, e.g., 8:00am
Mid-day, e.g., noon
End of the work day or school day, e.g., 4:30pm
Evening, e.g., 6:00pm
Retiring for the night, 11:00pm
A Day in Your Life with Public Health
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In reviewing the above list(s), what do you realize?
What does this illustrate to you?
Public Health At Work in Maine
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