Public Health I

An Introduction

Outline

• Aim of the Course • Learning Outcomes: Knowledge, Skills, Responsibility and

autonomy and Field competencies• Lecture: themes of Public Health I• Class work

Distribution of Hours

ECTS 4 credits – 100 hr. (4X25)

Lecture 14 hr.

Seminar 26 hr.

Presentation 2 hr.

Miterm and final exams 3 hr.

Total contact 45 hr.

Independent work 55 hr.

Distribution of Hours

Evaluation components

1 Activity at seminars (Oral quiz) 33 points

2 Presentation 7 points

3 Midterm exam (MCQs) 20 points

4 Final exam (MCQs) 40 points

Total scores of interim evaluation and final examinations 100 points

Theme: Public Health I (1)

• The population health approach • Evidence based public health • Public health data and communications • Social and behavioral science in public health • Health law, policy and ethics • Non communicable disease • Communicable diseases

Theme: Public Health I (2)• Environmental Health and safety • Health professionals, Healthcare institutions and

Healthcare systems • Health care institutions • Health insurance and healthcare system • Public health institutions and systems • Food and drugs as public health issues • Systems Thinking: From single solutions to one health

Class work Activities

• Explanation, • Group work,• Discussion, • Analysis, • Synthesis • Oral assessment • Presentations• Quiz

Final Evaluation

• Mid-term Exam - IX Week • Final Exam - XVIII /XIX/ XX Week

Lecture 1 The population health approach

• identify multiple ways that public health affects daily life.• define eras of public health from ancient times to the present.• 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 and how this affects

health.

Public Health

Global challenges • Climate change and ongoing environmental deterioration territory for • Zika• Dengue• Ebola • Malaria• Overuse if antibiotics and resistant bacteria• The epidemic of obesity• Heart disease• Cigarette smoking • Drug abuse• Cancer• Food and product safety• COVID 19

What do we mean by “public health”?

“Public health is the science and art of preventing disease, prolonging life and promoting health through organized community effort”

Winslow CEA. The untilled field of public health. Modernizing Medicine. 1920;920(2):183–191.

“Public health is organized community efforts aimed at the preventionof disease and the promotion of health.”

Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988:41.

What do we mean by “public health”?

Public Health is one of the efforts organized by society to protect, promote, and restore the people’s health. It is the combination of sciences, skills, and beliefs that is directed to the maintenance and the improvement of the health of the people through collective or social actions.’

Last 1988

A new 21st century definition of public health

The totality of all evidence-based public and private efforts throughout the life cycle that preserve and promote health and prevent disease, disability, and death

Public Health: the population health approach

• Population health considers the full range of options forintervention to address health problems, from communitycontrol of communicable disease and environmentalhealth, to healthcare delivery systems, to public policiessuch as taxation and laws designed to reduce cigarettesmoking.

The population health approach

• Population health takes a life cycle approach, considering how risks to health affect the population throughout the life span:

• How populations are changing • Aging • Three important transitions (the demographic, epidemiological, and

nutritional transitions) that affect population health today and will continue to do so for years to come.

Public health vs. Medical care

• Public Health considers medical care as one of the means of protecting and improving the health of the people

• Public Health is especially concerned about the interplay between costs and financing, access, quality and equity of the care

• No artificial separation between the two disciplines!

A brief history of ideas about health

• Health as a God given blessing • Health from a sanitary environment• Health as a result of medical science• Health as a consequence of lifestyle• Health from socioeconomic strength• Health is created in the context of everyday life where

people live, love, work and play; health as a resource for development

How Has the Approach of PublicHealth Changed Over Time?• Health Protection (Antiquity—1830s)Prohibitions against specific foodsfood preparationProhibitions against alcoholProhibition of cannibalismsexual practices and health consequences: male circumcision,premarital abstinence, marital fidelityQuarantine or isolation of individuals with disease

History of public health (continue)

• 1740s, British naval commander James Lind demonstrated thatlemons and other citrus fruit could prevent and treat scurvy, athen-common disease among sailors, whose daily nourishment wasdevoid of citrus fruit, the best source of vitamin C

Hygiene Movement (1840–1870s)

Public health awareness • Europe and the United States in the mid-1800s. • Concepts of disease as the consequence of social conditions - 1830s

and 1840s.• Social justice• 1850s- John Snow,• Ignaz Semmelweis-puerperal fever—or fever of childbirth• Vital statistics

Contagion Control (1880–1940s)

• The germ theory of disease - Louis Pasteur• 1872 -the American Public Health Association (APHA)• Chest X-ray• vaccines against toxins produced• Tetanus -bacteria• Diphtheria-bacteria• Pellagra by Goldberger - nutritional deficiency-vitamin B-6

(niacin)

History of public health• 19th century: focus on sanitation, clean water, sewerage and waste

disposal, isolation of cases; improved public housing, food safety; prevention through immunizations;

• from middle 20th century: ncd’s; focus on biomedicine and provision & access of services; increasing costs…Bismarck: social security; Beveridge: NHS

• 1974: Lalonde; 1986: Ottawa charter: Health promotion; focus onlifestyle changes, enabling people to gain control over and to improvetheir health, social justice & equity; creating supportive environments forpeople to live healthy lives; explicit concern for health in all areas ofpolicy

John Snow: 1813-1858 Father of Field Epidemiology

• Physician in London

• London, slums due to industrialized revolution , ravaged by cholera epidemics

• First classical studies in epidemiology.

From analysis of community data to preventive action

Death and disease due to cholera in Europe

• Cholera periodically swept across Europe during the nineteenth century, causing considerable social disruption and high mortality.

• After a severe epidemic in 1832, the disease next appeared in London in 1848.

Cause of cholera?• Miasma – bad air ? – (Farr)

• Through “morbid matter” through person- to –person? (Snow)

Then in 1854…

• "The most terrible outbreak of cholera which ever occurred in this kingdom, is probably that which took place in Broad Street, Golden Square, and the adjoining streets, a few weeks ago.“

• - John Snow, September 1854

Descriptive stage: obtain informationdescribe illness by time, place, person

Eras of Public Health

Eras of Public Health Focus of attention/paradigm

Action framework Notable events and movements in publichealth and epidemiology

Health protection(Antiquity–1830s)

Authority-based control of individual and communitybehaviors

Religious and cultural practices and prohibited behaviors

Quarantine for epidemics; sexualprohibitions to reduce disease transmission;dietary restrictions to reduce foodbornedisease

Hygiene movement(1840–1870s)

Sanitary conditions asbasis for improved health

Environmental action on a community-wide basis distinct from health care

Snow on cholera; Semmelweis and puerperalfever; collection of vital statistics asempirical foundation for public health andepidemiology

Contagion control(1880–1940s)

Germ theory: demonstration ofinfectious origins of disease

Communicable disease control through environmental control, vaccination, sanatoriums, and outbreak investigation in general population

Linkage of epidemiology, bacteriology, andimmunology to form tuberculosis (TB)sanatoriums; outbreak investigation, e.g.,Goldberger and pellagra

Health promotion/ Disease prevention(Mid-1980s–2000)

Focus on individual behavior and disease detection in vulnerable and general populations

Clinical and population oriented prevention with focus on individual control of decision-making and multiple interventions

AIDS epidemic and need for multipleinterventions to reduce risk; reductions incoronary heart disease through multipleinterventions

Population health(2000s)

Coordination of public health and healthcare delivery based upon shared evidence-basedsystems thinking

Evidence-based recommendations and information management, focus on harms and costs as well as benefits of interventions, globalization

Evidence-based medicine and public health;information technology; antibioticresistance; global collaboration, e.g., onehealth; tobacco control; climate change, anda full life cycleapproach to improving community health

A brief history of health promotion

• Lalonde Report and Health Field Concept, 1974• McKeown’s search for influences on health, 1979• Achieving Health for All, PHC: 1978• The Ottawa Charter, 1986• Move to healthy communities• More determinants with complex interaction, WHR 2002;

Commission on Social Determinants of Health 2007;

Lalonde model

The Health Field conceptLalonde, 1974: A New Perspective on the Health of Canadians

Principles of PHC• Universal accessibility and coverage in relation to need:

Equity• Accent on health promotion and prevention• Community and individual involvement and self-

reliance• Multisectoral approach to health• Appropriate technology and cost-effectiveness in

relation to available resources

PHC: the 8 essential elements- Education concerning prevailing health problems and methods to

prevent them- Promotion of food supply and proper nutrition- Adequate supply of safe water and basic sanitation- Maternal and child health care, including family planning- Immunization against major infectious diseases - Prevention and control of local endemic diseases- Treatment of common diseases and injuries- Provision of essential drugs

Ottawa Charter for Health Promotion, 1986

• Build Healthy Public Policy• Create Supportive Environments• Strengthen Community Actions• Develop Personal Skills• Reorient Health Services

Determinants of health

7. Social Environments8. Healthy Child Development 9. Biology and Genetic

Endowment 10. Health Services Access &

Quality11. Gender 12. Culture

1. Income and Social Status 2. Social Support Networks 3. Education 4. Employment/ Working

Conditions 5. Physical Environment6. Personal Health Practices and

Coping Skills

Core functions of Public Health• Surveillance, Monitoring (diseases, health status, access, quality &

efficiency of health services; prevention of epidemics)

• Legislation, regulation (stronger when State withdraws more from direct provision of goods and services)

• Provision of essential public goods (clean water, sanitation, health prevention & promotion, respond to disasters and assist communities in recovery : high externalities)

• Protection of the environment (macro, micro)

• Provision of information to the public to educate, allow for choice and appreciation of risk, including advocacy to decision makers; promote healthy behaviours

• Globalisation: international coordinated action

How does public health fulfill these responsibilities?(Essential services that should be undertaken in all communities: APHA, 1995)

1. Monitor health status to identify and solve health problems2. Diagnose and investigate health problems and health hazards in the community3. Inform, educate and empower people about health issues4. Mobilize community partnership and action to identify and solve health

problems5. Develop policies and plans that support individual and community efforts6. Enforce laws and regulations that protect health and ensure safety7. Link people to needed personal health services and assure the provision of health

care when otherwise unavailable8. Assure a competent public and personal health care workforce9. Evaluate effectiveness, accessibility and quality of personal and population-based

health services10. Research for new insights and innovative solutions to health problems

Where do public health people work?• Vaccination programs• Environmental health• Occupational health• Accident prevention and safety• Child health clinics• Screening programs• Health education and promotion• Organization and management of health services• Health policy• Research (epidemiology, health systems research)

A Population Health Framework

Addressing DOH: issues & challenges

• ‘The urgent drives out the important’: bias towards acute hospital care;

• No incentive for investments for long term: short electoral cycles;• Lifestyle choices: often putting the blame on people; what about

global food industry, transport, smoking…

Health Status of the Population( Mortality, morbidity, quality of life,

healthy life expectancy, DALY / DALE ….)

Health care delivery system / Health Sector

Health Policy-Intersectoral policies (Health protection, health promotion, primary prevention): Healthy public policies-Organisation of health care delivery -Allocation and planning of resources -Global aspects: Monitoring & research, Target groups, International aspects, Institutional framework

Primaryprevention

Secundaryprevention

Curative care

Rehabilitation Instit. care of

elderly

Financing of health

care system

Determinantsof health

(Culture, lifestyle, socioeconomic factors,

gender, genetics, employment, social

networks,…)

Components of Population HealthHealth Population Examples of

society-wide concernsExamples ofvulnerable groups

Historical Physical Geographicallylimited

Communicable disease High-riskmaternaland child, high-riskoccupations

Current Physical andmental

Local, state,national, global,governmentallydefined

Toxic substances, productand transportation safety,communicable diseases,costs of health care

Disabled, frailelderly,individuals withpain, uninsured

Emerging Cosmetic,genetic, socialfunctioning

Defined by local,national, andglobalcommunications

Disasters, climate change,technology hazards,emerging infectiousdiseases

Immunosuppressed,geneticvulnerability

Leading Causes of Death and Disability by Age Groups in the United StatesAge Group(Age)

Age GroupName

Unique features of the age group and death rates per 1,000 in the US

Major causes of death and disability in the US

Birth to 28 days Neonatal Highest death rate of any age groupuntil over 50. Approximately 4/1,000.Nearly two-thirds of deaths duringfirst year of life occur in this period

Most deaths due to conditions present at birth including premature birth, lowbirthweight, and birth defects.

Birth to 1 year Infancy Infant mortality rates approximately6/1,000 live births withapproximately 2/1,000 after 1 month

Sudden infant death syndrome and infectious diseases are important causes of death after 1 month.

1–5 years Earlychildhood

Death rates fall dramatically in the US and developed countries where infectious disease and malnutrition deaths are low. Rates approximately 0.2–0.4/1,000 per year

Unintentional injuries are the leading cause of death and disability.

5–14 years Adolescentsand Youth

Increasing death rates with nearly1/1,000 deaths per year by age 24

Dramatic increase in unintentional injuries and intentional injuries with homicide and suicide as the second and third leading causes of death. Behavior and mental disorders are the single largest cause of disability, and remain sountil after age 65.

Leading Causes of Death and Disability by Age Groups in the United States

Age Group(Age)

Age GroupName

Unique features of the age group and death rates per 1,000 in the US

Major causes of death and disability in the US

15–24 years Adolescentsand Youth

Increasing death rates with nearly1/1,000 deaths per year by age 24

Dramatic increase in unintentional injuries and intentional injuries with homicide and suicide as the second and third leading causes of death. Behavior and mental disorders are the single largest cause of disability, and remain so until after age 65.

25–65 years Working age Rates gradually increase fromapproximately 1/1,000 at age 30to 1.5/1,000 at age 40 to 3/1,000at age 50 to 8/1,000 at age 60 to12/10,000 at age 65

Causes of death change with increases in cancer and heart disease as the first and second leading causes of death by age 45 and remaining so through age 65. Chronic obstructive pulmonarydisease is the third leading cause of death by age 55 and remains so until age 85. Muscular-skeletal diseases are the greatest cause of disability during this period.

66–85 years Youngelderly/Seniorcitizens

Rates gradually increase fromapproximately 20/10,000 at age 70 to 30/1,000 at age 75 to 50/1,000 at age 80

Cancer remains the leading cause of death until age 80 when it is exceeded by heart disease. Strokes and Alzheimer’s increase as cause of death and disabilityafter age 75.

85+years Old elderly/Frail elderly

Rates rapidly increase fromapproximately 80/1,000 at age 85 to 140/1,000 at age 90 to 225/1,000 at age 95 to 300 per 1,000 at age 100

Heart disease and cancer remain the first and second leading causes of death followed by Alzheimer’s and strokes until age 95 when Alzheimer’s becomes thesecond leading cause of death. Alzheimer’s becomes the leading cause of disability in this age group.

Approaches to Population Health

Characteristics Examples

Health care Systems for delivering one-on-oneindividual health services, includingthose aimed at prevention, cure,palliation, and rehabilitation

Clinical preventive services, including vaccinations, behavioral counseling, screening for disease, and preventive medications

Traditional public health Group- and community-basedinterventions directed at healthpromotion and disease prevention

Communicable disease control, control of environmental hazards, food and drug safety, reduction in risk factors for disease

Social interventions Interventions with anothernon-health-related purpose, whichhave secondary impacts on health

Interventions that improve the built environment, increase education, alter nutrition, or address socioeconomic disparities through changes in tax laws;globalization and mobility of goods and populations