Fluent Essays

Assignment Content For the next newsletter, you have been asked to provide information about the role of government in public health. Choose a health issue prevalent in your community. Research national, state, and local government health agency websites for information on your chosen health issue. Write a 700- to 1,050-word summary of your findings. Your summary should: Analyze the structure and function of public health at national, state, and local levels. In your analysis, include: What type of structure you see between levels of government What functions you see at each level of government How the levels of government work together Use specific examples from your research to validate your points. Include at least 3 references. Format your assignment according to APA guidelines. 1114237 - Jones & Bartlett Learning © © Elena Elisseeva/ShutterStock, Inc. 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.   © kak2s/ShutterStock, Inc. 1114237 - Jones & Bartlett Learning © 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 centuries. 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 defibrillators. 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 public 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 unnoticed, from the regulation of microwave ovens to the reduction 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. 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 progress 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 achievements 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 healthcare 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 populations, 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 applicable 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 1114237 - Jones & Bartlett Learning © range: from food and drug safety to controlling air pollution, from measures to prevent the spread of tuberculosis to vaccinating against childhood diseases, 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 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 preventing 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 important 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 redefining “community,” as well as offering us new ways to communicate. •   The enormous expansion in the options for intervention, 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 private 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: •   An examination of the full range of environmental, social, and economic determinants of health —not just those traditionally addressed by public health and clinical health care. •    An examination of the full range of interventions to address health issues, including the structure and function 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 infections 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 1114237 - Jones & Bartlett Learning © 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 seafood—plus customs for food preparation, including officially 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 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 prevention 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 developed 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 vaccinations 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 consequence 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 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 contamination 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 foundation, the hygiene movement made major strides in controlling communicable diseases, such as tuberculosis, cholera, and waterborne diseases, largely through alteration of the physical environment. The fundamental concepts of epidemiology also developed 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 effectiveness. 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. 1114237 - Jones & Bartlett Learning © 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 puerperal 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. The mid-1800s in England also saw the development of birth and death records, or vital statistics, which formed the basis of population-wide assessment of health status. From the beginning of this type of data collection, there was controversy over how to define the cause of death. Two key figures in the early history of organized public health took opposing positions that reflect this continuing controversy. Edwin Chadwick argued that specific pathological conditions or diseases should be the basis for the cause of death. William Farr argued that underlying factors, including what we would today call risk factors and social conditions, should be seen as the actual causes of death. Thus, the methods of public health were already being established before the development of the germ theory of disease by Louis Pasteur and his European colleagues in the mid-1800s. The revolutions in biology that they ignited ushered in a new era in public health. U.S. physicians and public health leaders often went to Europe to study new techniques and approaches and brought them back to the United States to use at home. After the Civil War, U.S. public health began to produce its own advances and organizations. In 1872, the American Public Health Association (APHA) was formed. According to its own historical account, “the APHA’s founders recognized that two of the association’s most important functions were advocacy for adoption by the government of the most current scientific advances relevant to public health, and public education on how to improve community health.”8 The biological revolution of the late 1800s and early 1900s that resulted from the germ theory of disease laid the groundwork for the modern era of public health. An understanding of the contributions of bacteria and other organisms to disease produced novel diagnostic testing capabilities. For example, scientists could now identify tuberculosis cases through skin testing, bacterial culture, and the newly discovered chest X ray. Concepts of vaccination advanced with the development of new vaccines against toxins produced by tetanus- and diphtheria-causing bacteria. Without antibiotics or other effective cures, much of public health in this era relied on prevention, isolation of those with disease, and case-finding methods to prevent further exposure. In the early years of the 1900s, epidemiology methods continued to contribute to the understanding of disease. The investigations of pellagra by Goldberger and the United States Public Health Service overthrew the assumption of the day that pellagra was an infectious disease and established that it was a nutritional deficiency that could be prevented or easily cured with vitamin B-6 (niacin) or a balanced diet. Understanding the role of nutrition was central to public health’s emerging focus on prenatal care and childhood growth and development. Incorporating key scientific advances, these efforts matured in the 1920s and 1930s and introduced a growing alphabet of vitamins and nutrients to the U.S. vocabulary. A new era of effective medical intervention against active disease began in force after World War II. The discovery of penicillin and its often miraculous early successes convinced scientists, public health practitioners, and the general public that a new era in medicine and public health had arrived. During this era, public health’s focus was on filling the holes in the healthcare system. In this period, the role of public health was often seen as assisting clinicians to effectively deliver clinical services to those without the benefits of private medical care and helping to integrate preventive efforts into the practice of medicine. Thus, the great public health success of organized campaigns for the eradication of polio was mistakenly seen solely as a victory for medicine. Likewise, the successful passage of Medicaid and Medicare, outgrowths of public health’s commitment to social justice, was simply viewed as efforts to expand the private practice of medicine. This period, however, did lay the foundations for the emergence of a new era in public health. Epidemiological methods designed for the study of noncommunicable diseases demonstrated the major role that cigarette smoking plays in lung cancer and a variety of other diseases. The emergence of the randomized controlled trial and the regulation of drugs, vaccines, and other interventions by the 1114237 - Jones & Bartlett Learning © Food and Drug Administration developed the foundations for what we now call evidence-based public health and evidence-based medicine. The 1980s and much of the 1990s were characterized by a focus on individual responsibility for health and interventions at the individual level. Often referred to as health promotion and disease prevention, these interventions targeted individuals to effect behavioral change and combat the risk factors for diseases. As an example, to help prevent coronary artery disease, efforts were made to help individuals address high blood pressure and cholesterol, cigarette smoking, and obesity. Behavioral change strategies were also used to help prevent the spread of the newly emerging HIV/AIDS epidemic. Efforts aimed at individual prevention and early detection as part of medical practice began to bear some fruit with the widespread introduction of mammography for detection of breast cancer and the worldwide use of Pap smears for the detection of cervical cancer. Newborn screening for genetic disease became a widespread and often legally mandated program, combining individual and community components. Major public health advances during this era resulted from the environmental movement, which brought public awareness of the health dangers of lead in gasoline and paint. The environmental movement also focused on reducing cancer by controlling radiation exposure from a range of sources, including sunlight and radon, both naturally occurring radiation sources. In a triumph of global cooperation, governments worked together to address the newly discovered hole in the ozone layer. In the United States, reductions in air pollution levels and smoking rates during this era had an impact on the frequency of chronic lung disease, asthma, and most likely coronary artery disease. The heavy reliance on individual interventions that characterized much of the last half of the 1900s changed rapidly in the beginning of the 2000s. A new era in public health that is often called “population health” has begun to transform professional and public thought about health. From the potential for bioterrorism to the high costs of health care to the control of pandemic influenza and AIDS, the need for community-wide or population-wide public health efforts have become increasingly evident. This new era is characterized by a global perspective and the need to address international health issues. It includes a focus on the potential impacts of climate change, emerging and reemerging infectious diseases, and the consequences of trade in potentially contaminated or dangerous products, ranging from food to toys. Table 1-1 outlines these eras of public health, identifies their key defining elements, and highlights important events that symbolize each era.9 1114237 - Jones & Bartlett Learning © TABLE 1-1 Eras of Public Health Data from Awofeso N. What’s New About the “New Public Health”? American Journal of Public Health. 2004;94(5):705–709. Thus, today we have entered an era in which a focus on the individual is increasingly coupled with a focus on what needs to be done at the community and population level. This era of public health can be viewed as “the era of population health.” WHAT IS MEANT BY “POPULATION HEALTH”? The concept of population health has emerged in recent years as a broader concept of public health that includes all the ways that society as a whole or communities within society are affected by health issues and how they respond to these issues. Population health provides an intellectual umbrella for thinking about the wide spectrum of factors that can and do affect the health of individuals and the population as a whole. Figure 1-1 provides an overview of what falls under the umbrella of population health. Population health also provides strategies for considering the broad range of potential interventions to address these issues. By “intervention” we mean the full range of strategies designed to protect health and prevent disease, disability, and death. Interventions include preventive efforts, 1114237 - Jones & Bartlett Learning © such as nutrition and vaccination; curative efforts, such as antibiotics and cancer surgery; and efforts to prevent complications and restore function—from chemotherapy to physical therapy. Thus, population health is about healthy people and healthy populations. The concept of population health can be seen as a comprehensive way of thinking about the modern scope of public health. It utilizes an evidence-based approach to analyze the determinants of health and disease and the options for intervention to preserve and improve health. Population health requires us to define what we mean by “health issues” and what we mean by “population(s).” It also requires us to define what we mean by “society’s shared health concerns,” as well as “society’s vulnerable groups.” FIGURE 1-1 The Full Spectrum of Population Health   To understand population health, we therefore need to define what we mean by each of these four components: •   Health issues •   Population(s) •   Society’s shared health concerns •   Society’s vulnerable groups WHAT ARE THE IMPLICATIONS OF EACH OF THE FOUR COMPONENTS OF PUBLIC HEALTH? All four of the key components of public health have changed in recent years. Let us take a look at the historical, current, and emerging scopes of each component and consider their implications. For most of the history of public health, the term “health” focused solely on physical health. Mental health has now been recognized as an important part of the definition; conditions such as depression and substance abuse make enormous contributions to disability in populations throughout the world. The boundaries of what we mean by “health” continue to expand, and the limits of health are not clear. Many novel medical interventions—including modification of genes and treatments to increase height, improve cosmetic appearance, and improve sexual performance—confront us with the question: Are these health issues? The definition of “population,” likewise, is undergoing fundamental change. For most of recorded history, a population was defined geographically. Geographic communities, such as cities, states, and countries, defined the structure and functions of public health. The current definition of “population” has expanded to include the idea of a global community, recognizing the increasingly interconnected issues of global health. The definition of “population” is also focusing more on nongeographic communities. Universities now include the distance-learning community, health care is delivered to members of a health plan community, and the Internet is creating new social media communities. All of these new definitions of “population” are affecting the thinking and approaches needed to address public health issues. What about the meaning of society-wide concerns—have they changed as well? Historically, public health and communicable disease were nearly synonymous, as symbolized by the field of epidemiology, 1114237 - Jones & Bartlett Learning © which actually derives its name from the study of communicable disease epidemics. In recent decades, the focus of society-wide concerns has greatly expanded to include toxic exposures from the physical environment, transportation safety, and the costs of health care. However, communicable disease never went away as a focus of public health, and the 2000s are seeing a resurgence in concern over emerging infectious diseases, including HIV/AIDS, pandemic flu, and newly drug-resistant diseases, such as staph infections and tuberculosis. Additional concerns, ranging from the impact of climate change to the harms and benefits of new technologies, are altering the meaning of society-wide concerns. TABLE 1-2 Components of Population Health Finally, the meaning of “vulnerable populations” continues to transform. For most of the 1900s, public health focused on maternal and child health and high-risk occupations as the operational definition of “vulnerable populations.” While these groups remain important to public health, additional groups now receive more attention, including the disabled, the frail elderly, and those without health insurance. Attention is also beginning to focus on the immunosuppressed among those living with HIV/AIDS, who are at higher risk of infection and illness, …