Public Health

Public health is "the science and art of preventing disease, prolonging life and promoting healththrough the organized efforts and informed choices of society, organizations, public and private, communities and individuals" (1920, C.E.A. Winslow).^[1] It is concerned with threats to health based on population health analysis. The population in question can be as small as a handful of people or as large as all the inhabitants of several continents (for instance, in the case of apandemic). The dimensions of health can encompass "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity", as defined by the United Nations' World Health Organization.^[2] Public health incorporates the interdisciplinary approaches of epidemiology, biostatistics and health services. Environmental health, community health,behavioral health, and occupational health are other important subfields.

The focus of public health intervention is to improve health and quality of life through the prevention and treatment of disease and other physical and mental health conditions, through surveillance of cases and the promotion of healthy behaviors. Promotion of hand washing and breastfeeding, delivery of vaccinations, and distribution of condoms to control the spread of sexually transmitted diseases are examples of common public health measures.

Modern public health practice requires multidisciplinary teams of professionals includingphysicians specialising in public health/community medicine/infectious disease, epidemiologists,biostatisticians, public health nurses, medical microbiologists, environmental health officers,dental hygienists, dietitians and nutritionists, health inspectors, veterinarians, public health engineers, public health lawyers, sociologists, community development workers, communications officers, and others.^[3]

Objectives

The focus of a public health intervention is to prevent and manage diseases, injuries and other health conditions through surveillance of cases and the promotion of healthy behaviors, communities and environments. Many diseases are preventable through simple, non-medical methods. For example, research has shown that the simple act of hand washing with soap can prevent many contagious diseases.^[4] In other cases, treating a disease or controlling a pathogen can be vital to preventing its spread to others, such as during an outbreak of infectious disease, or contamination of food or water supplies. Public health communications programs, vaccination programs, and distribution ofcondoms are examples of common public health measures.

Public health plays an important role in disease prevention efforts in both the developing world and in developed countries, through local health systems and non-governmental organizations. The World Health Organization (WHO) is the international agency that coordinates and acts on global public health issues. Most countries have their own government public health agencies, sometimes known as ministries of health, to respond to domestic health issues. For example in the United States, the front line of public health initiatives are state and localhealth departments. The United States Public Health Service (PHS), led by the Surgeon General of the United States, and the Centers for Disease Control and Prevention, headquartered in Atlanta, are involved with several international health activities, in addition to their national duties. In Canada, the Public Health Agency of Canada is the national agency responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. In India, the Public Health Foundation of India was launched in 2006 as a response to growing concern over the emerging public health challenges in that country.

There is a vast discrepancy in access to health care and public health initiatives between developed nations and developing nations. In the developing world, public health infrastructures are still forming. There may not be enough trained health workers or monetary resources to provide even a basic level of medical care and disease prevention.^[5] As a result, a large majority of disease and mortality in the developing world results from and contributes to extreme poverty. For example, many African governments spend less than USD$10 per person per year on health care, while, in the United States, the federal government spent approximately USD$4,500 per capita in 2000.

History of public health

In some ways, public health is a modern concept of human development in science , although it has roots in antiquity. From the beginnings of human civilization, it was recognized that polluted water and lack of proper waste disposal spread communicable diseases (theory ofmiasma). Early religions attempted to regulate behavior that specifically related to health, from types of food eaten, to regulating certain indulgent behaviors, such as drinking alcohol or sexual relations. The establishment of governments placed responsibility on leaders to develop public health policies and programs in order to gain some understanding of the causes of disease and thus ensure social stabilityprosperity, and maintain order.

The term "healthy city" used by today's public health advocates reflects this ongoing challenge to collective physical well-being that results from crowded conditions and urbanization.

Early public health interventions

By Roman times, it was well understood that proper diversion of human waste was a necessary tenet of public health in urban areas. The Chinese developed the practice of variolation following a smallpoxepidemic around 1000 BC. An individual without the disease could gain some measure of immunity against it by inhaling the dried crusts that formed around lesions of infected individuals. Also, children were protected by inoculating a scratch on their forearms with the pus from a lesion. This practice was not documented in the West until the early-18th century, and was used on a very limited basis. The practice of vaccination did not become prevalent until the 1820s, following the work of Edward Jenner to treat smallpox.During the 14th century Black Death in Europe, it was believed that removing bodies of the dead would further prevent the spread of the bacterial infection. This did little to stem the plague, however, which was most likely spread by rodent-borne fleas. Burning parts of cities resulted in much greater benefit, since it destroyed the rodent infestations. The development of quarantine in the medieval period helped mitigate the effects of other infectious diseases. However, according to Michel Foucault, the plague model of governmentalitywas later controverted by the cholera model. A Cholera pandemic devastated Europe between 1829 and 1851, and was first fought by the use of what Foucault called "social medicine", which focused on flux, circulation of air, location of cemeteries, etc. All those concerns, born of themiasma theory of disease, were mixed with urbanistic concerns for the management of populations, which Foucault designated as the concept of "biopower". The German conceptualized this in the Polizeiwissenschaft ("Science of police").

The science of epidemiology was founded by John Snow's identification of a polluted public water well as the source of an 1854 choleraoutbreak in London. Dr. Snow believed in the germ theory of disease as opposed to the prevailing miasma theory. Although miasma theory correctly teaches that disease is a result of poor sanitation, it was based upon the prevailing theory of spontaneous generation. Germ theory developed slowly: despite Anton van Leeuwenhoek's observations of Microorganisms, (which are now known to cause many of the most common infectious diseases) in the year 1680, the modern era of public health did not begin until the 1880s, with Louis Pasteur's germ theory and production of artificial vaccines.

Other public health interventions include latrinization, the building of sewers, the regular collection of garbage followed by incineration or disposal in a landfill, providing clean water and draining standing water to prevent the breeding of mosquitoes. This contribution was made by Edwin Chadwick in 1843 who published a report on the sanitation of the working class population in Great Britain at the time. So began the inception of the modern public health. The industrial revolution had initially caused the spread of disease through large conurbations around workhouses and factories. These settlements were cramped and primitive and there was no organised sanitation. Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants.... in east africa the public

Modern public health

With the onset of the epidemiological transition and as the prevalence of infectious diseases decreased through the 20th century, public health began to put more focus on chronic diseases such as cancer and heart disease. Previous efforts in many developed countries had already led to dramatic reductions in the infant mortality rate using preventative methods. For instance in the United States, public health worker Dr. Sara Josephine Baker established many programs to help the poor in New York City keep their infants healthy, leading teams of nurses into the crowded neighborhoods of Hell's Kitchen and teaching mothers how to dress, feed, and bathe their babies.

During the 20th century and early in the next, the dramatic increase in average life span is widely credited to public health achievements, such as vaccination programs and control of many infectious diseases including polio, diphtheria, yellow fever and smallpox; effective health and safety policies such as road traffic safety and occupational safety; improved family planning; tobacco control measures; and programs designed to decrease non-communicable diseases by acting on known risk factors such as a person's background, lifestyle and environment. One of the major sources of the increase in average life span in the early 20th century was the decline in the "urban penalty" brought on by improvements in sanitation. These improvements included chlorination of drinking water, filtration and sewage treatment which led to the decline in deaths caused by infectious waterborne diseases such as cholera and intestinal diseases. In Cutler and Miller's, "The Role of Public Health Improvements in Health Advances", they display evidence of the decline in typhoid fever deaths in Chicago, Baltimore, Cincinnati, and Cleveland after these American cities adopted chlorination, filtration, or a sewage improvement.^[6]

Front-page headlines continue to present society with public health issues on a daily basis: emerging infectious diseases such as SARS, rapidly making its way from China (see Public health in China) to Canada, the United States and other geographically distant countries; reducinginequities in health care access through publicly funded health insurance programs; the HIV/AIDS pandemic and its spread from certain high-risk groups to the general population in many countries, such as in South Africa; the increase of childhood obesity and the concomitant increase in type II diabetes among children; the social, economic and health impacts of adolescent pregnancy; and the ongoing public health challenges related to natural disasters such as the 2004 Indian Ocean tsunami, 2005's Hurricane Katrina in the United States and the 2010 Haiti earthquake.

Meanwhile, large parts of the developing world remained plagued by largely preventable/treatable infectious diseases and poor maternal and child health outcomes, exacerbated by malnutrition and poverty. The WHO reports that a lack of exclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year.^[7] Intermittent preventive therapyaimed at treating and preventing malaria episodes among pregnant women and young children is one public health measure in endemic countries.

Since the 1980s, the growing field of population health has broadened the focus of public health from individual behaviors and risk factors to population-level issues such as inequality, poverty, and education. Modern public health is often concerned with addressing determinants of health across a population. There is a recognition that our health is affected by many factors including where we live, genetics, our income, our educational status and our social relationships - these are known as "social determinants of health." A social gradient in health runs through society, with those that are poorest generally suffering the worst health. However even those in the middle classes will generally have worse health outcomes than those of a higher social stratum.^[8] The new public health seeks to address these health inequalities by advocating for population-based policies that improve health in an equitable manner.

Public Health 2.0

Public Health 2.0 is the term given to a movement within public health that aims to make the field more accessible to the general public and more user-driven. There are three senses in which the term "Public Health 2.0" is used. In the first sense, "Public Health 2.0" is similar to the term "Health 2.0" and is used to describe the ways in which traditional public health practitioners and institutions are reaching out (or could reach out) to the public through social media.^[9][10] In the second sense, "Public Health 2.0" is used to describe public health research that uses data gathered from social networking sites, search engine queries, cell phones, or other technologies.^[11] In the third sense, "Public Health 2.0" is used to describe public health activities that are completely user-driven.^[12] An example this type of Public Health 2.0 is the collection and sharing of information about environmental radiation levels following the March 2011 tsunami in Japan.^[13] In all cases, Public Health 2.0 draws on ideas from Web 2.0, such as crowdsourcing, information sharing, and user-centred design.^[14]

Education and training

Education and training of public health professionals is available throughout the world in Medical Schools, Veterinary Schools, Schools of Nursing, Schools of Public Health, and Schools of Public Affairs. The training typically requires a university degree with a focus on core disciplines of biostatistics, epidemiology, health services administration, health policy, health education, behavioral science andenvironmental health.^[15][16]

[edit]Schools of public health

In the United States, the Welch-Rose Report of 1915 has been viewed as the basis for the critical movement in the history of the institutional schism between public health and medicine because it led to the establishment of schools of public health supported by the Rockefeller Foundation.^[17][18] The report was authored by William Welch, founding dean of the Johns Hopkins Bloomberg School of Public Health, and Wycliffe Rose of the Rockefeller Foundation. The report focused more on research than practical education.^[17][19] Some have blamed the Rockefeller Foundation's 1916 decision to support the establishment of schools of public health for creating the schism between public health and medicine and legitimizing the rift between medicine's laboratory investigation of the mechanisms of disease and public health's nonclinical concern with environmental and social influences on health and wellness.^[17][20]

Even though schools of public health had already been established in Canada, Europe and North Africa, the US had still maintained the traditional system of housing faculties of public health within their medical institutions. However, a year following the Welch-Rose report, theJohns Hopkins School of Hygiene and Public Health was founded in 1916. By 1922, schools of public health were established in Columbia,Harvard and Yale universities. By 1999 there were twenty nine schools of public health in the US, enrolling around fifteen thousand students.^[17][15]

Over the years, the types of students and training provided have also changed. In the beginning, students who enrolled in public health schools typically had already obtained a medical degree; public health school training was largely a second degree for medical professionals. However, in 1978, 69% of American students enrolled in public health schools had only a bachelor's degree.^[15]

Degrees in public health

Main article: Professional degrees of public health

Schools of public health offer a variety of degrees which generally fall into two categories: professional or academic.^[21] The two major postgraduate professional degrees are the Master of Public Health (MPH) or the Master of Science in Public Health (MSPH). Doctoral studies in this field include Doctor of Public Health (DrPH) and Doctor of Philosophy (PhD) in a subspeciality of greater Public Health disciplines. DrPH is regarded as a professional leadership degree and PhD is more an academic degree.

Professional degrees are oriented towards practice in public health settings. The Master of Public Health, Doctor of Public Health, Doctor of Health Science (DHSc) and the Master of Health Care Administration are examples of degrees which are geared towards people who want careers as practitioners of public health in health departments, managed care and community-based organizations, hospitals and consulting firms among others. Master of Public Health degrees broadly fall into two categories, those that put more emphasis on an understanding of epidemiology and statistics as the scientific basis of public health practice and those that include a more eclectic range of methodologies. A Master of Science of Public Health is similar to an MPH but is considered an academic degree (as opposed to a professional degree) and places more emphasis on quantitative methods and research. The same distinction can be made between the DrPH and the DHSc. The DrPH is considered a professional degree and the DHSc is an academic degree.

Academic degrees are more oriented towards those with interests in the scientific basis of public health and preventive medicine who wish to pursue careers in research, university teaching in graduate programs, policy analysis and development, and other high-level public health positions. Examples of academic degrees are the Master of Science, Doctor of Philosophy, Doctor of Science (ScD), and Doctor of Health Science (DHSc). The doctoral programs are distinct from the MPH and other professional programs by the addition of advanced coursework and the nature and scope of a dissertation research project.

In the United States, the Association of Schools of Public Health^[22] represents Council on Education for Public Health (CEPH) accredited schools of public health.^[23] Delta Omega is the honorary society for graduate studies in public health. The society was founded in 1924 at the Johns Hopkins School of Hygiene and Public Health. Currently, there are approximately 68 chapters throughout the United States and Puerto Rico.^[24]

Public health programs

Today, most governments recognize the importance of public health programs in reducing the incidence disease, disability, and the effects of aging and other physical and mental health conditions, although public health generally receives significantly less government funding compared with medicine.^[25] In recent years, public health programs providing vaccinations have made incredible strides in promoting health, including the eradication of smallpox, a disease that plagued humanity for thousands of years.

The World Health Organization (WHO) identifies core functions of public health programs including:^[26]

• providing leadership on matters critical to health and engaging in partnerships where joint action is needed;
• shaping a research agenda and stimulating the generation, translation and dissemination of valuable knowledge;
• setting norms and standards and promoting and monitoring their implementation;
• articulating ethical and evidence-based policy options;
• monitoring the health situation and assessing health trends.

In particular, public health surveillance programs can:^[27]

• serve as an early warning system for impending public health emergencies;
• document the impact of an intervention, or track progress towards specified goals; and
• monitor and clarify the epidemiology of health problems, allow priorities to be set, and inform health policy and strategies.

Public health surveillance has led to the identification and prioritization of many public health issues facing the world today, includingHIV/AIDS, diabetes, waterborne diseases, zoonotic diseases, and antibiotic resistance leading to the reemergence of infectious diseases such as tuberculosis. Antibiotic resistance, also known as drug resistance, was the theme of World Health Day 2011.

For example, the WHO reports that at least 220 million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is projected that the number of diabetes deaths will double by the year 2030.^[28] In a June 2010 editorial in the medical journal The Lancet, the authors opined that "The fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation."^[29] The risk of type 2 diabetes is closely linked with the growing problem of obesity. The WHO’s latest estimates highlighted that globally approximately 1.5 billion adults were overweight in 2008, and nearly 43 million children under the age of five were overweight in 2010.^[30] The United States is the leading country with 30.6% of its population being obese. Mexico follows behind with 24.2% and the United Kingdom with 23%. Once considered a problem in high-income countries, it is now on the rise in low-income countries, especially in urban settings. Many public health programs are increasingly dedicating attention and resources to the issue of obesity, with objectives to address the underlying causes including healthy diet and physical exercise.

Some programs and policies associated with public health promotion and prevention can be controversial. One such example is programs focusing on the prevention of HIV transmission through safe sex campaigns and needle-exchange programmes. Another is the control oftobacco smoking. Changing smoking behavior requires long term strategies, unlike the fight against communicable diseases which usually takes a shorter period for effects to be observed. Many nations have implemented major initiatives to cut smoking, such as increased taxation and bans on smoking in some or all public places. Proponents argue by presenting evidence that smoking is one of the major killers, and that therefore governments have a duty to reduce the death rate, both through limiting passive (second-hand) smoking and by providing fewer opportunities for people to smoke. Opponents say that this undermines individual freedom and personal responsibility, and worry that the state may be emboldened to remove more and more choice in the name of better population health overall.

Simultaneously, while communicable diseases have historically ranged uppermost as a global health priority, non-communicable diseasesand the underlying behavior-related risk factors have been at the bottom. This is changing however, as illustrated by the United Nationshosting its first General Assembly Special Summit on the issue of non-communicable diseases in September 2011.^[31]

Applications in healthcare

As well as seeking to improve population health through the implementation of specific population-level interventions, public health contributes to medical care by identifying and assessing population needs for health care services, including:

• Assessing current services and evaluating whether they are meeting the objectives of the health care system
• Ascertaining requirements as expressed by health professionals, the public and other stakeholders
• Identifying the most appropriate interventions
• Considering the effect on resources for proposed interventions and assessing their cost-effectiveness
• Supporting decision making in health care and planning health services including any necessary changes.