An Introduction to Prevention & the Public Health System A.H. Strelnick, M.D. Professor, Family...

An Introduction to An Introduction to Prevention &Prevention &the Public Health Systemthe Public Health System

A.H. Strelnick, M.D.A.H. Strelnick, M.D.

Professor, Family MedicineProfessor, Family Medicine

Albert Einstein College of Albert Einstein College of MedicineMedicine

Prevention & Public HealthPrevention & Public Health

““Health care is vital to all of us Health care is vital to all of us some of the time, but public health some of the time, but public health is vital to all of us all of the time.”is vital to all of us all of the time.”

– Former U.S. Surgeon GeneralFormer U.S. Surgeon General– C. Everett Koop, M.D.C. Everett Koop, M.D.

Public Health in AmericaPublic Health in America

Vision: Vision: Healthy People in Healthy CommunitiesHealthy People in Healthy Communities

Mission: Mission: Promote Physical and Mental Health Promote Physical and Mental Health and Prevent Disease, Injury, and Disabilityand Prevent Disease, Injury, and Disability

Public HealthPublic Health– Prevents epidemics & spread of diseasePrevents epidemics & spread of disease– Protects against environmental health hazardsProtects against environmental health hazards– Prevents injuriesPrevents injuries– Promotes & encourages healthy behaviorsPromotes & encourages healthy behaviors– Responds to disasters & assists in recoveryResponds to disasters & assists in recovery– Assures quality & accessibility of health Assures quality & accessibility of health

servicesservices

Essential Public Health Essential Public Health ServicesServices

1. Monitor health status to identify 1. Monitor health status to identify community health problemscommunity health problems

2. Diagnose & investigate health 2. Diagnose & investigate health problems & health hazards in the problems & health hazards in the communitycommunity

3. Inform, educate & empower people 3. Inform, educate & empower people about health issuesabout health issues

4. Mobilize community partnerships to 4. Mobilize community partnerships to identify & solve health problems identify & solve health problems


5. Develop policies & plans that support 5. Develop policies & plans that support individual & community health effortsindividual & community health efforts

6. Enforce laws & regulations that protect 6. Enforce laws & regulations that protect health & ensure safetyhealth & ensure safety

7. Link people to needed personal health 7. Link people to needed personal health services & assure the provision of health services & assure the provision of health care when otherwise unavailablecare when otherwise unavailable


8. Assure a competent public health & 8. Assure a competent public health & personal health care workforcepersonal health care workforce

9. Evaluate effectiveness, accessibility & 9. Evaluate effectiveness, accessibility & quality of personal & population-based quality of personal & population-based health serviceshealth services

10. Research for new insights & 10. Research for new insights & innovative solutions to health problemsinnovative solutions to health problems

Definitions of Public HealthDefinitions of Public Health

• C.E.A. Winslow (1923)C.E.A. Winslow (1923)– Public health is the science and the art of (1) Public health is the science and the art of (1)

preventing disease, (2) prolonging life, and (3) preventing disease, (2) prolonging life, and (3) organized community efforts for (a) the sanitation organized community efforts for (a) the sanitation of the environment, (b) the control of of the environment, (b) the control of communicable diseases, (c) the education of the communicable diseases, (c) the education of the individual in personal hygiene, (d) the organization individual in personal hygiene, (d) the organization of medical and nursing services for the early of medical and nursing services for the early diagnosis & preventive treatment of disease, and diagnosis & preventive treatment of disease, and (e) the development of the social machinery to (e) the development of the social machinery to ensure everyone a standard of living adequate for ensure everyone a standard of living adequate for the maintenance of health, so organizing these the maintenance of health, so organizing these benefits as to enable every citizen to realize his benefits as to enable every citizen to realize his birthright of health and longevity.birthright of health and longevity.


Rene Dubos (1968)Rene Dubos (1968)• Social organization and ways of life that Social organization and ways of life that

promote & support the survival of the grouppromote & support the survival of the group Dan Beauchamp (1976)Dan Beauchamp (1976)

• Means to achieve social justice & protect all Means to achieve social justice & protect all human lifehuman life

Avi Ellencweig & Ruthellen Yoshpe (1984)Avi Ellencweig & Ruthellen Yoshpe (1984)• Protection of the community against the Protection of the community against the

hazards engendered by group lifehazards engendered by group life


Institute of Medicine, The Future of Institute of Medicine, The Future of Public Health, 1988Public Health, 1988• The mission of public health is the fulfillment The mission of public health is the fulfillment

of society’s interest in assuring the of society’s interest in assuring the conditions in which people can be healthyconditions in which people can be healthy

• Its aim is generating organized community Its aim is generating organized community efforts to address the public interest in efforts to address the public interest in health by applying scientific & technical health by applying scientific & technical knowledge to prevent disease & promote knowledge to prevent disease & promote healthhealth

Core Functions of Public Core Functions of Public Health Agencies & Health Agencies & OrganizationsOrganizations

AssessmentAssessment– Regular & systematic collection, assembly, analysis Regular & systematic collection, assembly, analysis

& distribution of information on health of the & distribution of information on health of the community, including statistics on health status, community, including statistics on health status, community health needs & epidemiologycommunity health needs & epidemiology

Policy DevelopmentPolicy Development– Apply scientific knowledge in decision-making Apply scientific knowledge in decision-making

about public’s health through democratic processabout public’s health through democratic process

AssuranceAssurance– Guarantee necessary services through regulation, Guarantee necessary services through regulation,

incentives, and/or direct provisionincentives, and/or direct provision

Public Health vs. Clinical Public Health vs. Clinical Medicine TraditionsMedicine Traditions

AsclepiusAsclepius• Greek hero/god of Greek hero/god of

medicine, medicine, concerned as the concerned as the healer with the healer with the individual, the individual, the functioning of the functioning of the body, diseases body, diseases within the body & within the body & treatments to alter treatments to alter the course of disease the course of disease within the individualwithin the individual

HygeiaHygeia• Greek goddess of Greek goddess of

health, daughter health, daughter of Asclepius, of Asclepius, concerned with concerned with environment & environment & interaction interaction between societies between societies & their & their environments environments (human ecology)(human ecology)

Selected History of Public Selected History of Public HealthHealth

1348--Venice appoints sanitary council 1348--Venice appoints sanitary council to quarantine ships, goods & people to to quarantine ships, goods & people to prevent plague & contagionprevent plague & contagion

1485--Venetian Council of Health 1485--Venetian Council of Health established to regulate all established to regulate all Mediterranean ports & harbors to Mediterranean ports & harbors to prevent spread of plague, leprosy, prevent spread of plague, leprosy, yellow fever & cholera yellow fever & cholera


1601--English Poor Law enacted, 1601--English Poor Law enacted, establishing general hospitals for establishing general hospitals for physically ill & asylums for mentally illphysically ill & asylums for mentally ill

1701--Massachusetts passed laws to 1701--Massachusetts passed laws to isolate smallpox patients & quarantine isolate smallpox patients & quarantine shipsships

1721--Inoculation for smallpox 1721--Inoculation for smallpox accepted as effective means to contain accepted as effective means to contain diseasedisease


1847--AMA founded1847--AMA founded 1848--John Griscom’s “The Sanitary 1848--John Griscom’s “The Sanitary

Condition of the Labouring Population in Condition of the Labouring Population in New York”New York”

1849--John Snow removed handle from 1849--John Snow removed handle from Broad Street Pump, London, ending Broad Street Pump, London, ending cholera epidemic & founding epidemiologycholera epidemic & founding epidemiology

1850--Lemuel Shattuck’s “Report of the 1850--Lemuel Shattuck’s “Report of the Massachusetts Sanitary Commission”Massachusetts Sanitary Commission”


1906--Federal Pure Food & Drug Act 1906--Federal Pure Food & Drug Act restricts narcotics & patent medicinesrestricts narcotics & patent medicines

1907--First reportable disease law 1907--First reportable disease law (Massachusetts)(Massachusetts)

1908--First Children’s Bureau in 1908--First Children’s Bureau in NYCDOHNYCDOH

1912--Marine Hospital Service becomes 1912--Marine Hospital Service becomes U.S. Public Health Service; federal U.S. Public Health Service; federal Children’s BureauChildren’s Bureau


1922--Sheppard-Towner Act creates 1922--Sheppard-Towner Act creates Federal Board of Maternity & Infant Federal Board of Maternity & Infant Hygiene & makes grants to state for Hygiene & makes grants to state for maternal & child health; first federal funds maternal & child health; first federal funds for personal health services & federal for personal health services & federal guidelines for state implementationguidelines for state implementation

1930--Hygienic Laboratory moves from 1930--Hygienic Laboratory moves from Staten Island to Washington, D.C., to Staten Island to Washington, D.C., to become the National Institute of Healthbecome the National Institute of Health


1960--Kerr-Mills Amendments to Social 1960--Kerr-Mills Amendments to Social Security Act provides state grants for Security Act provides state grants for care of elderlycare of elderly

1962--Kefauver-Harris Amendments to 1962--Kefauver-Harris Amendments to FDA establishes drug efficacy FDA establishes drug efficacy standards; first Vaccination Assistance standards; first Vaccination Assistance ActAct

1964--U.S. Surgeon General’s “Report 1964--U.S. Surgeon General’s “Report on Smoking and Health”on Smoking and Health”


1965--Medicare (Title XVIII) & 1965--Medicare (Title XVIII) & Medicaid (Title XIX) Amendments Medicaid (Title XIX) Amendments to Social Security Actto Social Security Act

1969--Coal Mine Safety & Health 1969--Coal Mine Safety & Health ActAct

1970--Occupational Safety & 1970--Occupational Safety & Health ActHealth Act

Public Health by the Public Health by the NumbersNumbers

Schools of Public Health = 35Schools of Public Health = 35 Public Health Disciplines > 50Public Health Disciplines > 50 Public Health Professionals > 50,000Public Health Professionals > 50,000 State & Territorial Departments of State & Territorial Departments of

Health=55Health=55 County & Local Departments of County & Local Departments of

Health=3000Health=3000

Public Health by the Public Health by the NumbersNumbers

Expenditures for Essential Public Health Expenditures for Essential Public Health Services (1995)Services (1995)• U.S Public Health Service = $7.1 billion U.S Public Health Service = $7.1 billion

– Research = $2.4 billion (34%)Research = $2.4 billion (34%)– Personal health services = $2.0 billion (29%) Personal health services = $2.0 billion (29%)

• States = $8.8 billionStates = $8.8 billion– Personal health services = $6.1 billion (69%)Personal health services = $6.1 billion (69%)

• Per capita health care costs = $3,342Per capita health care costs = $3,342• Per capita population-based services=$36Per capita population-based services=$36

» Source: Public Health Foundation, 1996Source: Public Health Foundation, 1996

State Public Health State Public Health WorkforceWorkforce

Nurses (20%); Engineers & Sanitarians (7%)Nurses (20%); Engineers & Sanitarians (7%) Laboratory Technicians (6%)Laboratory Technicians (6%) Administrators (5%); Physicians (3%) Administrators (5%); Physicians (3%) Planners & Program Analysts (2%)Planners & Program Analysts (2%) Social Workers (2%); Nutritionists (1%)Social Workers (2%); Nutritionists (1%) Dentists (0.5%); Health Educators (0.5%)Dentists (0.5%); Health Educators (0.5%) Clerical & Support Staff (41%); Other (12%)Clerical & Support Staff (41%); Other (12%)

» IOM Report, 1988IOM Report, 1988

State Public Health State Public Health Assessment ActivitiesAssessment Activities

Data CollectionData Collection• Vital Records & Statistics (96%)Vital Records & Statistics (96%)• Health Facilities (85%)Health Facilities (85%)• Health Manpower (83%)Health Manpower (83%)• Health Trends Analysis (76%)Health Trends Analysis (76%)• Hospital Care (70%)Hospital Care (70%)• Population Forecast (67%)Population Forecast (67%)• Long Term Care (61%)Long Term Care (61%)• Morbidity (54%)Morbidity (54%)

State Public Health State Public Health Assessment ActivitiesAssessment Activities

EpidemiologyEpidemiology• Communicable Disease Control Communicable Disease Control

(100%)(100%)• Health Screening (100%)Health Screening (100%)• Laboratory Analyses (98%)Laboratory Analyses (98%)

ResearchResearch• Collaborative Projects (91%)Collaborative Projects (91%)• Laboratory Research (28%)Laboratory Research (28%)

State Public HealthState Public HealthPolicy Development Policy Development ActivitiesActivities

Health Planning (65%)Health Planning (65%) Categorical Plans (98%)Categorical Plans (98%)

• Emergency Medical Services (89%)Emergency Medical Services (89%)• Health Facilities (52%)Health Facilities (52%)• Health Services (46%)Health Services (46%)• Health Manpower (33%)Health Manpower (33%)• Environmental Health (9%)Environmental Health (9%)

Standards for Local Health Agencies (80%)Standards for Local Health Agencies (80%) Population-Based Health Goals (35%)Population-Based Health Goals (35%)

State Public Health State Public Health Assurance ActivitiesAssurance Activities

InspectionInspection• Food & Milk Control (93%), Housing Safety Food & Milk Control (93%), Housing Safety

(91%), Health Facility Safety (89%), Institutional (91%), Health Facility Safety (89%), Institutional Safety (80%) & Product Safety (63%)Safety (80%) & Product Safety (63%)

LicensingLicensing• Health Services (93%), Health Facilities (89%) & Health Services (93%), Health Facilities (89%) &

Health Manpower (87%)Health Manpower (87%) Health EducationHealth Education

• Health Education (100%) & Health Health Education (100%) & Health Promotion/Disease Prevention (67%)Promotion/Disease Prevention (67%)

State Public HealthState Public HealthAssurance ActivitiesAssurance Activities

Environmental ServicesEnvironmental Services• Sewage Disposal Systems (83%)Sewage Disposal Systems (83%)• Public & Individual Water Supply Safety (80%)Public & Individual Water Supply Safety (80%)• Radiation Control (78%)Radiation Control (78%)• Hazardous Waste Management (54%)Hazardous Waste Management (54%)• Water Pollution (54%)Water Pollution (54%)• Occupational Safety & Health (50%)Occupational Safety & Health (50%)• Solid Waste Management (48%)Solid Waste Management (48%)• Air Quality (46%) & Noise Pollution (33%)Air Quality (46%) & Noise Pollution (33%)

State Public HealthState Public HealthAssurance ActivitiesAssurance Activities

Personal Health ServicesPersonal Health Services• Maternal & Child Health (100%), Prenatal Care Maternal & Child Health (100%), Prenatal Care

(100%), Family Planning (100%) & Obstetrics (100%), Family Planning (100%) & Obstetrics (61%)(61%)

• Immunizations (100%) & Dental Health (100%)Immunizations (100%) & Dental Health (100%)• Chronic Disease (98%), Inpatient Services Chronic Disease (98%), Inpatient Services

(91%) & Facilities (41%) & Home Care (83%)(91%) & Facilities (41%) & Home Care (83%)• Handicapped Children (78%)Handicapped Children (78%)• Mental Health (63%) & Retardation (59%), Mental Health (63%) & Retardation (59%),

Alcoholism (52%) & Drug Abuse (43%)Alcoholism (52%) & Drug Abuse (43%)

Responding to Leading Responding to Leading Health Indicators--Healthy Health Indicators--Healthy People 2010People 2010

Tobacco UseTobacco Use• Department of JusticeDepartment of Justice

– Alcohol, Tobacco & Firearms AgencyAlcohol, Tobacco & Firearms Agency

• Department of Health & Human ServicesDepartment of Health & Human Services– Food & Drug AdministrationFood & Drug Administration– Office of Smoking & HealthOffice of Smoking & Health– National Institutes of HealthNational Institutes of Health

– National Cancer InstituteNational Cancer Institute– National Heart, Lung & Blood InstituteNational Heart, Lung & Blood Institute


Substance AbuseSubstance Abuse• Department of JusticeDepartment of Justice

– Drug Enforcement AdministrationDrug Enforcement Administration– Alcohol, Tobacco & Firearms AgencyAlcohol, Tobacco & Firearms Agency

• Department of Health & Human ServicesDepartment of Health & Human Services– Alcohol, Drug Abuse & Mental Health Alcohol, Drug Abuse & Mental Health

AdministrationAdministration– National Institute of Alcoholism & Alcohol National Institute of Alcoholism & Alcohol

AbuseAbuse– National Institute of Drug AbuseNational Institute of Drug Abuse


Responsible Sexual BehaviorResponsible Sexual Behavior• Department of Health & Human ServicesDepartment of Health & Human Services

– Centers for Disease Control & PreventionCenters for Disease Control & Prevention– Office of Adolescent Pregnancy ProgramOffice of Adolescent Pregnancy Program– Administration for Children, Youth & FamiliesAdministration for Children, Youth & Families– Health Resources & Services AdministrationHealth Resources & Services Administration

– Bureau of Community Health ServicesBureau of Community Health Services– Office of AIDS Services (Ryan White CARE Program)Office of AIDS Services (Ryan White CARE Program)

– National Institute of Allergy & Infectious DiseasesNational Institute of Allergy & Infectious Diseases

• Department of EducationDepartment of Education– Office of Comprehensive School HealthOffice of Comprehensive School Health


Mental HealthMental Health• Department of Health & Human ServicesDepartment of Health & Human Services

– Alcoholism, Drug Abuse & Mental Health Alcoholism, Drug Abuse & Mental Health AdministrationAdministration

– National Institute of Mental HealthNational Institute of Mental Health– Health Resources & Services AdministrationHealth Resources & Services Administration

– Bureau of Community Health ServicesBureau of Community Health Services

• Department of EducationDepartment of Education– Office of Comprehensive School HealthOffice of Comprehensive School Health


Injury & ViolenceInjury & Violence• Department of JusticeDepartment of Justice

– Alcohol, Tobacco & Firearms AgencyAlcohol, Tobacco & Firearms Agency– Drug Enforcement AdministrationDrug Enforcement Administration

• Department of CommerceDepartment of Commerce– Consumer Product Safety CommissionConsumer Product Safety Commission

• Department of Health & Human ServicesDepartment of Health & Human Services– Centers for Disease Control & PreventionCenters for Disease Control & Prevention

• Department of TransportationDepartment of Transportation– National Traffic Safety CommissionNational Traffic Safety Commission


Environmental QualityEnvironmental Quality• Environmental Protection AgencyEnvironmental Protection Agency• Department of Health & Human ServicesDepartment of Health & Human Services

– National Institute of Environmental Health SciencesNational Institute of Environmental Health Sciences– Food & Drug AdministrationFood & Drug Administration

– National Center for Toxicology ResearchNational Center for Toxicology Research

– Centers for Disease Control & PreventionCenters for Disease Control & Prevention– National Institute of Occupational Safety & HealthNational Institute of Occupational Safety & Health

• Department of Labor (also Injury Prevention)Department of Labor (also Injury Prevention)– Occupational Safety & Health AdministrationOccupational Safety & Health Administration– Mine Safety & Health AdministrationMine Safety & Health Administration


ImmunizationImmunization• Department of EducationDepartment of Education

– Office of Comprehensive School HealthOffice of Comprehensive School Health

• Department of Health & Human ServicesDepartment of Health & Human Services– Centers for Disease Control & PreventionCenters for Disease Control & Prevention– Health Care Finance AdministrationHealth Care Finance Administration– Office of Disease Prevention & Health PromotionOffice of Disease Prevention & Health Promotion– Health Resources & Services AdministrationHealth Resources & Services Administration

– Bureau of Community Health ServicesBureau of Community Health Services

– Administration for Children, Youth & FamiliesAdministration for Children, Youth & Families


Access to Health CareAccess to Health Care• Department of Health & Human ServicesDepartment of Health & Human Services

– Health Care Finance Administration Health Care Finance Administration – Medicaid Medicaid – MedicareMedicare– Office of Special Programs (Early Periodic Screening, Office of Special Programs (Early Periodic Screening,

Diagnosis & Treatment Program)Diagnosis & Treatment Program)

– Health Resources & Services AdministrationHealth Resources & Services Administration– Bureau of Community Health ServicesBureau of Community Health Services– Bureau of Medical Services (Indian Health Service)Bureau of Medical Services (Indian Health Service)

– Agency for Healthcare Research & QualityAgency for Healthcare Research & Quality

An Introduction to Prevention & the Public Health System A.H. Strelnick, M.D. Professor, Family...

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