Future of Public Health 2 pages in length
1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . C hapte r 9 F utu re C halle n ges f o r P ublic H ea lt h i n A m eric a O BJE C TIV ES A fte r c o m ple tin g C hap te r 9 , l e arn ers w ill b e p ro fic ie n t i n d esc rib in g t h e p ast a ch ie v em en ts , c u rre n t i s su es, a n d f u tu re c h alle n ges f o r p ublic h ealth a n d t h eir i m plic atio ns f o r i m pro vin g p opula tio n h ealth s ta tu s a n d q uality o f l if e . K ey a sp ects o f t h is c o m pete n cy e x pecta tio n i n clu de t h e f o llo w in g: • I d en tif y in g a n d d is c u ssin g a t l e ast t h re e l e sso ns f ro m p ublic h ealth ’s a ch ie v em en ts i n t h e 2 0th c en tu ry • I d en tif y in g a n d d is c u ssin g a t l e ast t h re e c u rre n t i s su es a n d c h alle n ges f a cin g p ublic h ealth a n d p ublic h ealth p ra ctitio ners i n t h e f ir s t d ecad e o f t h e 2 1st c en tu ry T his t e x t a p pro ach es w hat p ublic h ealth i s a n d h ow i t w ork s f ro m a u nif ie d c o ncep tu al f ra m ew ork . K ey d im en sio ns o f t h e p ublic h ealth s y ste m a re e x am in ed , i n clu din g i ts p urp ose , f u nctio ns, c ap acity , p ro cesse s, a n d o utc o m es. A lth ough a s im ple f ra m ew ork , m an y o f t h e c o ncep ts a d dre sse d a re a n yth in g b ut s im ple . A s a r e su lt, m uch h as b een l e ft u nsa id , a n d m an y i m porta n t i s su es a n d p ro ble m s f a cin g t h e p ublic h ealth s y ste m h av e b een a d dre sse d o nly i n p assin g. T his m ay s e rv e t o w het t h e a p petite o f t h ose e ag er t o m ove b ey ond t h e b asic s a n d r e ad y t o t a ck le e m erg in g a n d m ore c o m ple x i s su es i n g re ate r d ep th . T he b asic c o ncep ts i n clu ded i n t h is t e x t s e ek t o f a cilita te t h at p ro cess a n d e n co ura g e t h in kin g “ o uts id e t h e b ook.” D elv in g i n to t h ese o th er i s su es w ith out t h e b en efit o f a b ro ad u nders ta n din g o f t h e f ie ld a n d h ow i t w ork s, h ow ev er, c an b e a n o ccu patio nal h azard i n a n y f ie ld o f e n deav or. F or p ublic h ealth w ork ers , c o ntin uously f ig htin g o ff a llig ato rs r e m ain s t h e m ajo r d ete rre n t t o d ra in in g t h e s w am p i n o rd er t o a v ert t h e a llig ato r p ro ble m i n t h e f ir s t p la ce.
E ach o f t h e e ig ht i n itia l c h ap te rs s p otlig hts o ne o r m ore p ublic h ealth a ch ie v em en ts o f t h e 2 0th c en tu ry , t e llin g t h e s to ry o f h ow w e g ot w here w e a re t o day. T ogeth er, t h ese s to rie s d em onstr a te t h at t h e p ro ble m s f a cin g p ublic h ealth h av e c h an ged o ver t h e p ast c en tu ry a n d a rg ue t h at w e c an e x pect t h em t o c o ntin ue t o c h an ge t h ro ughout t h e c u rre n t c en tu ry . I n r e tr o sp ect, m an y p ast p ro ble m s a p pear r e la tiv ely e asy t o s o lv e i n c o m paris o n w ith t h ose o n t h e p ublic h ealth a g en da a t t h e b eg in nin g o f t h e 2 1st c en tu ry ; h ow ev er, w e o fte n f o rg et t h at t h e l a st c en tu ry ’s p ro ble m s a p peare d t o b e q uite f o rm id ab le t o p ublic h ealth a d vocate s b ack i n 1 910. A lth ough f o rm id ab le , t h ey w ere e v en tu ally d eem ed u naccep ta b le , i n itia tin g t h e c h ain o f e v en ts t h at r e su lte d i n t h e i m pre ssiv e c ata lo g o f a cco m plis h m en ts c h ro nic le d i n e arlie r c h ap te rs .
E ach o f t h ese a ch ie v em en ts p ro vid es v alu ab le l e sso ns a n d i n sig hts i n to t h e o bsta cle s t o a ch ie v in g e v en f u rth er g ain s t h at l ie a h ead . C halle n ges r e sid e a t m an y l e v els , e sp ecia lly a t t h e l e v el o f p re p are d ness f o r u nfo re se en a n d p re v io usly u nan tic ip ate d t h re ats t o t h e p ublic ’s h ealth . M eld in g t h e e x pecta tio ns f o r a d dre ssin g o ngoin g h ealth p ro ble m s i n t h e c o m munity w ith t h ose f o r p re p arin g a n d r e sp ondin g t o n ew t h re ats l e ad s u s t o t h e t h re e k ey q uestio ns a d dre sse d i n t h is c h ap te r: • W hat a re t h e l e sso ns l e arn ed f ro m t h e t h re ats a n d c h alle n ges f a ced b y p ublic h ealth i n 2 0th c en tu ry A m eric a?
• W hat a re t h e l im ita tio ns a n d c h alle n ges f a cin g p ublic h ealth i n t h e 2 1st c en tu ry ?
• H ow c an t h ese l im ita tio ns a n d c h alle n ges b e o verc o m e? L ESSO NS F R O M A C EN TU RY O F P R O GRESS I N P U BLIC H EA LT H T he r e m ark ab le a ch ie v em en ts o f t h e 2 0th c en tu ry d id n ot c o m ple te ly e ra d ic ate t h e p ublic h ealth p ro ble m s f a ced i n 1 910. M an y o f t h ese c o ntin ue t o t h re ate n t h e h ealth o f A m eric an s a n d i m ped e p ro gre ss t o w ard r e aliz in g t h e l if e s p an p ro je ctio ns p re se n te d i n F ig ure 9 1 . N ew f a ces f o r o ld e n em ie s h av e a p peare d i n t h e f o rm o f c h alle n ges a n d o bsta cle s t o b e o verc o m e i n t h e e arly d ecad es o f t h e 2 1st c en tu ry . I n fe ctio us d is e ase s, t o bacco , m ate rn al a n d i n fa n t m orta lity , e n vir o nm en ta l a n d o ccu patio nal h ealth , f o od s a fe ty , c ard io vasc u la r d is e ase , i n ju rie s, a n d o ra l h ealth r e m ain h ig h o n t h e l is t o f l e ad in g t h re ats t o t h e p ublic ’s h ealth . E ach p re se n ts s p ecia l c h alle n ges. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 2 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . I n fe ctio u s D is e a se s T he c o ntin uin g b attle a g ain st i n fe ctio us d is e ase s w ill b e f o ught o n s e v era l f ro nts b ecau se o f t h e e m erg en ce o f n ew i n fe ctio us d is e ase s a n d t h e r e e m erg en ce o f o ld e n em ie s, o fte n i n d ru gre sis ta n t f o rm s. F or e x am ple , i n fe ctio ns c au se d b y E sc h eric h ia c o li O 157:H 7 h av e e m erg ed a s a f re q uen t a n d f rig hte n in g r is k t o t h e p ublic . I n itia lly i d en tif ie d a s t h e c au se o f h em orrh ag ic c o nditio ns i n t h e e arly 1 980s, t h is p ath ogen w as i n cre asin gly a sso cia te d w ith f o odb orn e i lln ess o utb re ak s i n t h e 1 990s, i n clu din g a m ajo r o utb re ak i n t h e P acif ic N orth w est r e la te d t o E . c o li c o nta m in ate d h am burg ers d is tr ib ute d t h ro ugh a n atio nal f a st f o od c h ain . 1 T he s o urc e o f t h e E . c o li w as c attle . O th er o utb re ak s o f t h is p ath ogen i n volv ed s w im mers i n l a k e w ate r c o nta m in ate d b y b ath ers i n fe cte d w ith t h e o rg an is m ( F ig ure 9 2 ) . B ecau se m an y o f t h e i lln esse s a re m in or a n d b oth m ed ic al a n d p ublic h ealth p ra ctitio ners f a il t o p erfo rm t h e t e sts n ecessa ry t o d ia g nose E . c o li i n fe ctio ns p ro perly , c u rre n t s u rv eilla n ce e ff o rts g re atly u nderre p ort t h e e x te n t o f t h is c o nditio n. M ultid ru gre sis ta n t p ath ogen s r e p re se n t a n oth er e m erg in g i n fe ctio us d is e ase p ro ble m f o r t h e p ublic h ealth s y ste m . T he w id esp re ad a n d, a t t im es, i n dis c rim in ate u se o f a n tib io tic s i n a g ric u ltu ra l a n d h ealth care s e ttin gs p ro duces s tr a in s o f b acte ria t h at a re r e sis ta n t t o t h ese d ru gs. A ntim ic ro bia l a g en ts h av e b een i n cre asin gly d ep lo yed t h ro ughout t h e s e co nd h alf o f t h e 2 0th c en tu ry . S lo w ly , o ver t h is p erio d, t h e c o nse q uen ces o f t h ese “ m ir a cle d ru gs” h av e b een e x perie n ced i n t h e c o m munity , a s w ell a s i n h ealth f a cilitie s. T he e m erg en ce o f d ru gre sis ta n t s tr a in s h as r e d uced t h e e ff e ctiv en ess o f t r e atm en t f o r s e v era l c o m mon i n fe ctio ns, i n clu din g t u berc u lo sis , g onorrh ea, p neu m oco ccal i n fe ctio ns, a n d h osp ita l a cq uir e d s ta p hylo co ccal a n d e n te ro co ccal i n fe ctio ns. F or t u berc u lo sis , d ru g r e sis ta n ce a n d d em ogra p hic t r e n ds, i n clu din g i m mig ra tio n p olic ie s, p la y ed s u bsta n tia l r o le s i n t h is d is e ase ’s r e su rg en ce i n t h e e arly 1 990s. T he c h an gin g d em ogra p hic s o f t u berc u lo sis i n fe ctio ns a re i llu str a te d i n F ig ure 9 3 . F ig u re 9 1 P ast a n d p ro je cte d f e m ale a n d m ale l if e e x p ecta n cy a t b ir th , U nit e d S ta te s, 1 900–2050.
S ourc e: F ro m U .S . D ep t. o f H ealth a n d H um an S erv ic es, O ff ic e o f D is e ase P re v en tio n a n d H ealth P ro m otio n. H ea lth y P eo ple 2 010: U ndersta ndin g a nd I m pro vin g H ea lth . R ock ville , M D: O DPH P; 2 000. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 3 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . F ig u re 9 2 E m erg en ce o f a p ublic h ea lt h t h re a t: t h e E sc h eric h ia c o li O 157:H 7 t im e l in e.
S ourc e: F ro m A ddre ssin g E m erg in g I n fe ctio us D is e a se T hre a ts : A P re ven tio n S tr a te g y f o r t h e U nite d S ta te s , 1 994, U .S . C en te rs f o r D is e ase C ontro l a n d P re v en tio n, A tla n ta , G A.
P ath ogen s, b oth o ld a n d n ew , h av e d ev is e d i n gen io us w ay s o f a d ap tin g t o a n d t h w artin g t h e w eap ons u se d t o c o ntr o l t h em . M an y f a cto rs i n s o cie ty , t h e e n vir o nm en t, a n d g lo bal i n te rc o nnecte d ness c o ntin ue t o i n cre ase t h e r is k o f e m erg en ce a n d s p re ad o f i n fe ctio us d is e ase s. A n o utb re ak o f m onkey pox v ir u s a ff e ctin g s e v era l s ta te s i n t h e U nite d S ta te s i n 2 003 d em onstr a te s h ow u nusu al d is e ase s i n r e m ote p arts o f t h e w orld c an a ff e ct A m eric an s v ir tu ally o vern ig ht ( F ig ure 9 4 ) . T he p ote n tia l f o r g lo bal o utb re ak s a n d m assiv e p an dem ic s i s n ow o n t h e p ublic h ealth r a d ar s c re en . A n o utb re ak o f s e v ere a cu te r e sp ir a to ry s y ndro m e h it m ore t h an t w o d ozen c o untr ie s i n N orth A m eric a, S outh A m eric a, E uro pe, a n d A sia i n 2 003 b efo re i t w as c o nta in ed , b ut n ot b efo re t a k in g n early 8 00 l iv es. T he p ossib ility o f a g lo bal p an dem ic o f i n flu en za v ir u s l o om s a s e v en m ore f rig hte n in g b ecau se i t i s i m possib le t o p re d ic t w hen t h e n ex t i n flu en za p an dem ic w ill o ccu r o r h ow s e v ere i t w ill b e. W here v er a n d w hen ev er a p an dem ic s ta rts , e v ery one e v ery w here i n t h e w orld i s a t 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 4 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . r is k . C ountr ie s m ig ht, t h ro ugh m easu re s s u ch a s b ord er c lo su re s a n d t r a v el r e str ic tio ns, d ela y a rriv al o f t h e v ir u s, b ut c an not s to p i t.
F ig u re 9 3 N um ber a n d r a te o f t u berc u lo sis c a se s a m on g U .S . b orn a n d f o re ig n b orn p erso n s * b y y ea r r e p orte d , U nit e d S ta te s, 1 993–2008. * p er 1 00,0 00 p opula tio n S ourc e: F ro m C en te rs f o r D is e ase C ontro l a n d P re v en tio n. T re n ds i n t u berc u lo sis , U nite d S ta te s, 2 008. M MWR. 2 009;5 8(1 0):2 49–253. F ig u re 9 4 M ovem en t o f i m porte d A fr ic a n r o d en ts t o a n im al d is tr ib uto rs a n d d is tr ib utio n o f p ra ir ie d ogs f r o m a n a n im al d is tr ib uto r a sso cia te d w it h h um an c a se s o f m on key p ox, 1 1 s ta te s, 2 003. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 5 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . S ourc e: F ro m C en te rs f o r D is e ase C ontro l a n d P re v en tio n. U pdate : m ultis ta te o utb re ak o f m onkey pox— Illin ois , I n dia n a, K an sa s, M is so uri, O hio , a n d W is c o nsin , 2 003. M MWR. 2 003:5 2(2 7):6 42–646. T he H 1N 1 i n flu en za p an dem ic i n 2 009 s e rv ed t o t e st p an dem ic p re p are d ness a n d r e sp onse p la n s i n t h e U nite d S ta te s a n d i n te rn atio nally . A lth ough n ev er a ch ie v in g t h e i m pact i n itia lly f e are d , t h e s u dden e m erg en ce a n d r a p id g lo bal s p re es l e ft a n i m prin t o n p ublic h ealth s y ste m s e v ery w here . H ealth p ro fe ssio nals r e m ain c o ncern ed t h at t h e p ossib le s p re ad o f a h ig hly p ath ogen ic a v ia n H 5N 1 v ir u s a cro ss e aste rn A sia a n d o th er c o untr ie s r e p re se n ts a s ig nif ic an t t h re at t o h um an h ealth . T he H 5N 1 v ir u s h as r a is e d c o ncern s a b out a p ote n tia l h um an p an dem ic b ecau se • I t i s e sp ecia lly v ir u le n t.
• I t i s b ein g s p re ad b y m ig ra to ry b ir d s.
• I t c an b e t r a n sm itte d f ro m b ir d s t o m am mals a n d i n s o m e l im ite d c ir c u m sta n ces t o h um an s.
• L ik e o th er i n flu en za v ir u se s, i t c o ntin ues t o e v olv e. S in ce 2 003, a g ro w in g n um ber o f h um an H 5N 1 c ase s h av e b een r e p orte d i n A sia , A fric a, a n d E uro pe. M ore t h an h alf o f t h e p eo ple i n fe cte d w ith t h e H 5N 1 v ir u s h av e d ie d . M ost o f t h ese c ase s a re a ll b elie v ed t o h av e b een c au se d b y e x posu re t o i n fe cte d p oultr y . T here h as b een n o s u sta in ed h um an to h um an t r a n sm is sio n o f t h e d is e ase , b ut t h e c o ncern i s t h at H 5N 1 w ill e v olv e i n to a v ir u s c ap ab le o f h um an to h um an t r a n sm is sio n.
H eig hte n ed c o ncern s o ver t h e r is k o f a cts o f b io te rro ris m a d d a n ew t w is t t o t h e t h re ats p ose d b y i n fe ctio us d is e ase s.
A s n ote d i n C hap te r 8 , t h ese c o ncern s h av e r a is e d e x pecta tio ns f o r p ublic h ealth t o s e rv e b oth n atio nal s e cu rity a n d p ers o nal s a fe ty r o le s.
T he r o le o f i n fe ctio us d is e ase s i n t h e d ev elo pm en t o f c h ro nic d is e ase s s u ch a s d ia b ete s, h eart d is e ase , a n d s o m e c an cers f u rth er a rg ues t h at i n fe ctio us d is e ase s w ill c o ntin ue a s i m porta n t h ealth r is k s i n t h e n ew c en tu ry . T o b attle i n fe ctio us d is e ase s, t h e d ev elo pm en t a n d d ep lo ym en t o f n ew m eth ods, b oth i n l a b ora to ry a n d e p id em io lo gic s c ie n ces, a re n eed ed t o u nders ta n d b ette r t h e i n te ra ctio ns a m ong e n vir o nm en ta l f a cto rs a s c o ntr ib uto rs t o t h e e m erg en ce a n d r e e m erg en ce o f i n fe ctio us d is e ase p ro cesse s. A ls o , d esp ite t h e s u ccesse s r e aliz ed i n t h e d ev elo pm en t a n d u se o f v accin es o ver t h e p ast c en tu ry , s u bsta n tia l g ap s p ers is t i n t h e i n fra str u ctu re o f t h e v accin e d eliv ery s y ste m , i n clu din g p are n ts , 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 6 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . p ro vid ers , i n fo rm atio n t e ch nolo gy, a n d b io te ch a n d p harm aceu tic al c o m pan ie s. I m pro vin g t h e c o ord in atio n o f t h ese e le m en ts h old s t h e p ro m is e o f r e d ucin g t h e t o ll f ro m i n fe ctio us d is e ase s i n t h e 2 1st c en tu ry .
T ob acco U se T he p ote n tia l g ain s t o b e r e aliz ed f ro m f u rth er r e d uctio n o f t o bacco u sa g e a re a ls o a p pare n t. D esp ite t h e o vera ll d eclin e i n t o bacco u se a m ong a d ults o ver t h e s e co nd h alf o f t h e 2 0th c en tu ry , a n a la rm in gly h ig h p re v ale n ce o f t o bacco u se a m ong t e en s p ers is ts , a n d r a te s a m ong a d ults a re n o l o nger d eclin in g, a s t h ey d id b efo re 1 980. T hese t r e n ds s u ggest t h at c o ncern s o ver r is k s r e la te d t o e x posu re t o e n vir o nm en ta l t o bacco s m oke w ill c o ntin ue f o r m an y y ears t o c o m e. D is p aritie s i n t o bacco u se b y r a ce a n d e th nic ity , t o geth er w ith t h e g ro w th o f d em ogra p hic g ro ups w ith h ig h u se r a te s, a d d y et a n oth er d im en sio n t o t h e w ar a g ain st t o bacco . N ew a p pro ach es a n d n ew p ro ducts w ill r a is e n ew i s su es o f s a fe ty , w here as t h e i n cre ase i n t o bacco u se a cro ss t h e g lo be w ill t r a n sp ort o ld a n d n ew c h alle n ges a ro und t h e w orld .
M ate rn al a n d C hild H ea lt h E ven a s m ate rn al a n d c h ild h ealth o utc o m es h av e i m pro ved d ra m atic ally , t h ere h as b een l ittle c h an ge i n t h e p rim e d ete rm in an ts o f p erin ata l o utc o m es— th e r a te o f l o w b ir th w eig ht a n d p re te rm d eliv erie s. T his s itu atio n m ust b e a d dre sse d t o e v en p artia lly r e p lic ate t h e g ain s r e aliz ed i n t h e 2 0th c en tu ry . A noth er i m porta n t r is k f a cto r m ovin g i n t h e w ro ng d ir e ctio n i s t h e r a te o f u nin te n ded p re g nan cie s. T ogeth er, t h ese c h alle n ges c all f o r i m pro ved u nders ta n din g o f t h e b io lo gic , s o cia l, e co nom ic , p sy ch olo gic al, a n d e n vir o nm en ta l f a cto rs t h at i n flu en ce m ate rn al a n d i n fa n t h ealth o utc o m es a n d i n t h e e ff e ctiv en ess o f i n te rv en tio n s tr a te g ie s d esig ned t o a d dre ss t h ese c au sa tiv e f a cto rs .
W ork pla ce S afe ty W ork pla ces a re n ow s a fe r t h an e v er b efo re , y et c h alle n ges r e m ain o n t h is f ro nt a s w ell. I m pro ved s u rv eilla n ce o f w ork re la te d i n ju rie s a n d i lln esse s a n d b ette r m eth ods o f c o nductin g f ie ld i n vestig atio ns i n h ig hris k o ccu patio ns a n d i n dustr ie s r e m ain f o rm id ab le c h alle n ges. A pply in g n ew m eth ods o f r is k a sse ssm en t t o i m pro ve a sse ssm en t o f i n ju ry e x posu re s a n d i n te rv en tio n o utc o m es, a s w ell a s i m pro ved r e se arc h i n to i n te rv en tio n e ff e ctiv en ess, s u rv eilla n ce m eth ods, a n d o rg an iz atio n o f w ork r e p re se n t a d ditio nal c h alle n ges f o r p ublic h ealth p ra ctic e i n t h e 2 1st c en tu ry .
C ard io vasc u la r D is e a se A n a g in g p opula tio n l e ss t h re ate n ed b y i n fe ctio us d is e ase a n d i n ju ry w ill p la ce e v en m ore p eo ple a t r is k o f i ll h ealth r e la te d t o c ard io vasc u la r d is e ase s. G re ate r a tte n tio n t o r e se arc h t o u nders ta n d t h e v ario us s o cia l, p sy ch olo gic al, e n vir o nm en ta l, p hysio lo gic , a n d g en etic d ete rm in an ts o f c ard io vasc u la r d is e ase s i s n eed ed i n t h e n ew c en tu ry .
R ed ucin g d is p aritie s t h at e x is t i n t e rm s o f b urd en o f d is e ase , p re v ale n ce o f r is k f a cto rs , a n d a b ility t o r e ach h ig hris k p opula tio ns r e p re se n ts a n oth er m eg ach alle n ge. I d en tif y in g n ew a n d e m erg in g r is k f a cto rs a n d t h eir r e la tio nsh ip s, i n clu din g g en etic a n d i n fe ctio us d is e ase f a cto rs , w ill b e n ecessa ry i n b oth d ev elo ped a n d d ev elo pin g p arts o f t h e w orld .
F ood S afe ty O ur u nders ta n din g o f f o od s a fe ty a n d n utr itio n m ad e g re at s tr id es i n t h e 1 900s, b ut b oth o ld a n d n ew r is k s w ill n eed t o b e a d dre sse d i n t h e n ew c en tu ry . I ro n a n d f o la te d efic ie n cie s c o ntin ue, a n d m an y o f t h e a d van ta g es r e la te d t o b re astf e ed in g r e m ain u nre aliz ed . T he e m erg en ce o f o besity a s a n i n cre asin gly p re v ale n t c o nditio n t h ro ughout t h e p opula tio n i s o ne o f t h e m ost s ta rtlin g d ev elo pm en ts o f t h e l a te t w en tie th c en tu ry . P ers is te n t c h alle n ges i n clu de a p ply in g n ew i n fo rm atio n a b out n utr itio n, d ie ta ry p atte rn s, a n d b eh av io r t h at p ro m ote h ealth a n d r e d uce t h e r is k o f c h ro nic d is e ase s.
I n ju rie s 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 7 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . T he i m pre ssiv e g ain s r e aliz ed i n r e d ucin g m oto r v eh ic le i n ju rie s h av e u nco vere d g ap s i n o ur u nders ta n din g o f c o m pre h en siv e p re v en tio n. C halle n ges i n clu de e x pan din g s u rv eilla n ce t o m onito r n onfa ta l i n ju rie s, d ete ct n ew p ro ble m s, a n d s e t p rio ritie s. G re ate r r e se arc h i n to e m erg in g a n d p rio rity p ro ble m s, a s w ell a s i n te rv en tio n e ff e ctiv en ess, i s a ls o n eed ed , a s a re m ore e ff e ctiv e c o lla b ora tio ns a n d i n te ra g en cy p artn ers h ip s. I n ju rie s t o p ed estr ia n s a n d f ro m v eh ic le s o th er t h an a u to m obile s w ill a ls o c h alle n ge p ublic h ealth i n t h e 2 1st c en tu ry . T he e ff e cts o f a g e, a lc o hol u se , s e at b elt u se , a n d i n te rv en tio ns t a rg etin g t h ese r is k s w ill r e q uir e g re ate r a tte n tio n f o r p ro gre ss t o c o ntin ue i n t h e b attle a g ain st m oto r v eh ic le i n ju rie s.
O ra l H ea lt h O ne o f t h e m ost o verlo oked a ch ie v em en ts o f p ublic h ealth i n t h e 2 0th c en tu ry w as t h e d ra m atic d eclin e i n d en ta l c arie s d ue t o f lu orid atio n o f d rin kin g w ate r s u pplie s. I ro nic ally , t h ese a d van ces i n o ra l h ealth h av e c o ntr ib ute d t o t h e p erc ep tio n t h at d en ta l c arie s a re n o l o nger a s ig nif ic an t p ublic h ealth p ro ble m a n d t h at f lu orid atio n i s n o l o nger n eed ed . T hese b attle s a re l ik ely t o b e f o ught i n p olitic al, r a th er t h an s c ie n tif ic , a re n as, p re se n tin g a s u bsta n tia l c h alle n ge t o p ublic h ealth i n t h e 2 1st c en tu ry .
U nfin is h ed A gen da F or t h e s e co nd d ecad e o f t h e 2 1st c en tu ry , H ealth y P eo ple 2 020 a rtic u la te s t h e u nfin is h ed a g en da b y i d en tif y in g i m porta n t t a rg ets a n d l e ad in g i n dic ato rs o f h ealth s ta tu s f o r t h e U nite d S ta te s. 2 V ario us c h ap te rs o f t h is t e x t s p otlig ht t h ese l e ad in g i n dic ato rs a n d t a rg ets , i n clu din g i m muniz atio ns ( C hap te r 1 ) , t o bacco u se ( C hap te r 2 ) , a ccess t o c are ( C hap te r 3 ) , w ork pla ce h ealth a n d s a fe ty ( C hap te r 4 ) , p hysic al a ctiv ity ( C hap te r 5 ) , o verw eig ht a n d o besity ( C hap te r 6 ) , i n ju rie s ( C hap te r 7 ) , a n d o ra l h ealth ( C hap te r 8 ) . T arg ets f o r t h e n atio n’s l e ad in g h ealth i n dic ato rs a re e x am in ed i n t h ese c h ap te rs a s w ell. E vid en ce a n d p opula tio nb ase d p re v en tiv e i n te rv en tio ns, b ase d o n t h e w ork o f t h e C om munity P re v en tiv e S erv ic es T ask F orc e, a re h ig hlig hte d f o r e ach l e ad in g i n dic ato r.
K ey a sp ects o f t h ese h ealth p ro ble m s a re n ew t o t h e p ublic h ealth a g en da. O ver t h e c o urs e o f r e cen t d ecad es, t h e p ublic h ealth a g en da h as e x pan ded t o i n clu de n ew i s su es r e la te d t o m ed ic al c are , s u bsta n ce a b use , m en ta l h ealth , l o ng t e rm c are , a n d v io le n ce. T hese a re n ow c ate g oriz ed a s p ublic h ealth p ro ble m s a n d h av e t a k en t h eir r ig htf u l p la ce o n t h e p ublic h ealth a g en da. S ev era l o f t h ese d ese rv e t o b e s p otlig hte d h ere b ecau se t h ey a re i n clu ded i n H ealth y P eo ple ’s p an el o f l e ad in g h ealth i n dic ato rs .
S potlig h t o n B eh avio ra l H ea lt h 3 A m ong t h e H ealth y P eo ple 2 010 l e ad in g h ealth i n dic ato rs w ere m en ta l h ealth , s u bsta n ce a b use , a lc o hol a b use a n d m is u se , a n d r e sp onsib le s e x ual b eh av io r. A lth ough n one o f t h ese d ir e ctly r e la te s t o t h e p ublic h ealth a ch ie v em en ts o f t h e 2 0th c en tu ry s p otlig hte d i n p re v io us c h ap te rs , t h ese s to od a m ong t h e m ost i m porta n t p ublic h ealth i s su es a t t h e e n d o f t h e 2 0th c en tu ry a n d r e m ain l e ad in g c au se s o f p oor h ealth s ta tu s i n t h e e arly 2 1st c en tu ry . F ig ure 9 5 r e fle cts p ro gre ss t o w ard m eetin g t h e y ear 2 010 t a rg ets e sta b lis h ed i n H ealth y P eo ple 2 010 f o r t h ese l e ad in g i n dic ato rs .
N ota b ly , d esp ite s o m e p ro gre ss, t h e y ear 2 010 t a rg ets f o r e ach o f t h ese m easu re s o f b eh av io ra l h ealth w ere n ot a ch ie v ed .
T he l a n dm ark s tu dy “ G lo bal B urd en o f D is e ase ” i d en tif ie s m en ta l d is o rd ers a s t h e s e co nd l e ad in g s o urc e o f d is e ase b urd en i n e sta b lis h ed m ark et e co nom ie s. 4 C hie f a m ong m en ta l d is o rd ers a s a l e ad in g c au se o f d is a b ility i n t h ese c o untr ie s i s m ajo r d ep re ssio n, w hic h t a k es a n e n orm ous t o ll o n f u nctio nal s ta tu s, p ro ductiv ity , a n d q uality o f l if e a n d i s a sso cia te d w ith e le v ate d r is k o f h eart d is e ase a n d s u ic id e. I n cre asin gly , a t l e ast i n t h e U nite d S ta te s, t h e r a te o f t r e atm en t f o r d ep re ssio n i s i n cre asin g d ra m atic ally . F ig ure s 9 6 a n d 9 7 p ro vid e e v id en ce o f t h e h ealth b urd en o f m en ta l d is o rd ers i n t h e U nite d S ta te s a n d o f t h e d if f e re n ces a m ong v ario us r a cia l a n d e th nic p opula tio ns. T he a n nual e co nom ic b urd en o f d ep re ssio n i n t h e U nite d S ta te s ( in clu din g d ir e ct c are , m orta lity , a n d m orb id ity c o sts ) h as b een e stim ate d t o t o ta l a lm ost $ 44 b illio n. T his c o m bin atio n o f i n cre asin g b urd en a n d c o st h as s tim ula te d n um ero us i n vestig atio ns i n to p opula tio nb ase d s tr a te g ie s t o p re v en t t h e o ccu rre n ce o f m ajo r d ep re ssio n a n d t o e n co ura g e m ore e ff e ctiv e t r e atm en t o f d ep re ssio n, t h ere b y l im itin g i ts c o urs e a n d p re v en tin g i ts r e cu rre n ce. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 8 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . F ig u re 9 5 S co re ca rd f o r s e le cte d H ea lt h y P eo p le 2 010 l e a d in g i n dic a to rs f o r b eh avio ra l h ea lt h c o m parin g 2 008 l e v els w it h 2 010 t a rg ets .
S ourc e: D ata f ro m D ata 2 010, H ealth y P eo ple 2 010 d ata b ase . h ttp ://w onder.c d c.g ov/d ata 2 010/ftp se le c.h tm . A ccesse d M ay 3 1, 2 010. I n t h e l ig ht o f t h is g ro w in g b ody o f l ite ra tu re a ro und p opula tio nb ase d s tr a te g ie s t o i m pro ve t h e p rim ary , s e co ndary , a n d t e rtia ry p re v en tio n o f d ep re ssio n a n d t h e i n cre asin g b urd en o f t h is d eb ilita tin g c h ro nic c o nditio n, t h e T ask F orc e o n C om munity P re v en tiv e S erv ic es h as i d en tif ie d s e v era l e ff e ctiv e i n te rv en tio ns. F or i n div id uals i n a ll a g e g ro ups 1 8 y ears o f a g e a n d o ld er, t h e t a sk f o rc e f o und c o lla b ora tiv e c are f o r t h e m an ag em en t o f d ep re ssiv e d is o rd ers t o b e e ff e ctiv e i n i m pro vin g s h ort te rm d ep re ssio n o utc o m es. D ep re ssio n o utc o m es i n clu de r e sp onse r a te s ( 5 0% r e d uctio n i n d ep re ssio n s c o re s), r e m is sio n ( n o l o nger m eetin g d ia g nostic c rite ria ), a n d c h an ges i n d ep re ssio n s c ale s c o re s. T his i n te rv en tio n a im s t o i n cre ase p rim ary c are p ro vid ers ’ k now le d ge a n d s k ills , i m pro ve c lie n t u nders ta n din g a n d a w are n ess o f d ep re ssiv e d is o rd ers , a n d t o r e o rg an iz e t h e s y ste m o f c are i n to a n o ptim al e n vir o nm en t f o r m an ag em en t o f d ep re ssio n a n d d ep re ssiv e d is o rd ers t h at i s s y ste m atic , m ultif a cete d , a n d t e am b ase d . T his i n te rv en tio n c re ate s a c o lla b ora tio n o f p rim ary c are p ro vid ers ( s u ch a s p hysic ia n s, n urs e p ra ctitio ners , a n d p hysic ia n a ssis ta n ts ), m en ta l h ealth s p ecia lis ts ( s u ch a s p sy ch ia tr is ts , p sy ch olo gis ts , a n d p sy ch ia tr ic m en ta l h ealth n urs e s), a n d o th er p ro vid ers ( s u ch a s s o cia l w ork ers a n d n urs e s) t o i m pro ve t h e e ff e ctiv en ess o f t h eir e n gag em en t w ith c lie n ts i n t h e m an ag em en t o f d ep re ssio n. M ultic o m ponen t i n te rv en tio ns o fte n i n clu de c lie n t e d ucatio n, p ro vid er f e ed back , c ase m an ag em en t, p ro vis io n o f i n fo rm atio n o n t r e atm en t g uid elin es/p ro to co ls t o p ro vid ers , a n d u se o f i n fo rm atio n t e ch nolo gy. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 9 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . F ig u re 9 6 P erc en ta ge o f p erso n s a ged > 12 y ea rs w it h d ep re ssio n , * b y r a ce/e th nic it y a n d p overty s ta tu s † , N atio n al H ea lt h a n d N utr it io n E xam in atio n S urv ey , U nit e d S ta te s, 2 005–2006.
* D ep re ssio n w as m easu re d u sin g t h e P atie n t H ealth Q uestio nnaire ( P H Q9 ), a n in eite m s c re en in g i n stru m en t t h at a sk s q uestio ns a b out t h e f re q uen cy o f s y m pto m s o f d ep re ssio n d urin g t h e p re ced in g 2 w eek s. R esp onse c ate g orie s “ n ot a t a ll,” “ se v era l d ay s,” “ m ore t h an h alf t h e d ay s,” a n d “ n early e v ery d ay ” w ere g iv en a s c o re r a n gin g f ro m 0 t o 3 . D ep re ssio n w as d efin ed a s a t o ta l s c o re o f 1 0 o r h ig her o n t h e P H Q9 .
T his c u t p oin t h as b een w ell v alid ate d a n d i s c o m monly u se d i n c lin ic al s tu die s t h at m easu re d ep re ssio n w ith t h e P H Q9 .
† P overty s ta tu s w as d efin ed u sin g t h e p overty i n co m e r a tio ( P IR ), a n i n dex c alc u la te d b y d iv id in g t h e f a m ily i n co m e b y a p overty t h re sh old t h at i s b ase d o n t h e s iz e o f t h e f a m ily . A P IR o f l e ss t h an 1 w as u se d a s t h e c u t p oin t f o r b elo w t h e p overty l e v el.
§ 9 5% c o nfid en ce i n te rv al.
S ourc es: F ro m C en te rs f o r D is e ase C ontro l a n d P re v en tio n. P erc en ta g e o f p ers o ns a g ed > 12 y ears w ith d ep re ssio n, b y r a ce/e th nic ity a n d p overty s ta tu s, N atio nal H ealth a n d N utritio n E xam in atio n S urv ey , U nite d S ta te s, 2 005–2006. M MWR. 2 008;5 7(3 9):1 082. D ata f ro m N atio nal H ealth a n d N utritio n E xam in atio n S urv ey d ata , 2 005–2006. h ttp ://w ww.c d c.g ov/n ch s/n han es.h tm . A ccesse d M ay 3 1, 2 010. P ra tt L A , B ro dy D J. D ep re ssio n i n t h e U nite d S ta te s h ouse h old p opula tio n, 2 005–2006. N CH S d ata b rie f n o. 7 . H yatts v ille , M D: U S D ep artm en t o f H ealth a n d H um an S erv ic es, C D C, N atio nal C en te r f o r H ealth S ta tis tic s; 2 008. A vaila b le a t h ttp ://w ww.c d c.g ov/n ch s/d ata /d ata b rie fs /d b07.h tm . A ccesse d M ay 3 1, 2 010. F ig u re 9 7 P erc en ta ge o f a d ult s w it h 1 4 o r m ore m en ta lly u nhea lt h y d ays ( fr e q uen t m en ta l d is tr e ss), b y r a ce, U nit e d S ta te s, 1 993–2005. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 0/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . S ourc e: F ro m C en te rs f o r D is e ase C ontro l a n d P re v en tio n, N atio nal C en te r f o r H ealth S ta tis tic s, N atio nal H ouse h old I n te rv ie w S urv ey D ata . F or a d ults 6 0 y ears o f a g e a n d o ld er w ith d ep re ssio n, t h e t a sk f o rc e r a te d b oth h om eb ase d a n d c lin ic b ase d d ep re ssio n c are m an ag em en t a s e ff e ctiv e i n te rv en tio ns. H om eb ase d d ep re ssio n c are m an ag em en t i n co rp ora te s a ctiv e s c re en in g f o r d ep re ssio n, m easu re m en t b ase d o utc o m es, t r a in ed d ep re ssio n c are m an ag ers , c ase m an ag em en t, p atie n t e d ucatio n, a n d a s u perv is in g p sy ch ia tr is t. C lin ic b ase d d ep re ssio n c are m an ag em en t i n volv es a ll o f t h e c o m ponen ts i n clu ded i n h om eb ase d m an ag em en t p lu s p rim ary c are p ro vid er e d ucatio n, a n tid ep re ssa n t t r e atm en t, a n d/o r p sy ch oth era p y.
T he t a sk f o rc e a ls o a sse sse d t h e e ff e ctiv en ess o f c o m munity b ase d e x erc is e i n te rv en tio ns t h at p ro vid e i n div id ual o r g ro up e x erc is e c la sse s f o r o ld er a d ults . T hese c la sse s m ay f o cu s o n s tr e n gth en in g, e n dura n ce, a n d/o r f u nctio nal t r a in in g. T he t a sk f o rc e f o und i n su ff ic ie n t e v id en ce t o d ete rm in e t h e e ff e ctiv en ess o f e x erc is e i n te rv en tio ns f o r r e d ucin g d ep re ssio n i n o ld er a d ults . A lth ough t h e s tu die s r e v ie w ed g en era lly f o und t h at e x erc is e i n te rv en tio ns w ere a sso cia te d w ith i m pro ved s c o re s o n d ep re ssio n s y m pto m s c ale s, n one o f t h e s tu die s r e v ie w ed r e p orte d r e su lts f o r d ep re sse d s u bje cts , s o i t i s u ncle ar w heth er c lin ic ally s ig nif ic an t c h an ges c an b e e x pecte d i n t h ese p opula tio ns.
S ubsta n ce a b use i s a p rio rity t o pic f o r f u tu re a tte n tio n b y t h e T ask F orc e o n C om munity P re v en tiv e S erv ic es. I n a d ditio n t o s y ste m atic r e v ie w s a lr e ad y c o m ple te d o r i n p ro gre ss o n r e d ucin g t h e u se o f t o bacco a n d p re v en tin g a lc o hol a b use a n d m is u se , o th er a d dic tiv e d ru gs w ill b e t h e s u bje ct o f f u tu re s y ste m atic r e v ie w s. T hese r e v ie w s e x plo re t h e e v id en ce o n e ff e ctiv en ess o f s e le cte d p opula tio nb ase d i n te rv en tio ns t o p re v en t o r r e d uce t h e a b use o f d ru gs o th er t h an t o bacco a n d a lc o hol. T he c rite ria u se d t o s e le ct t h is t o pic i n clu ded t h e b urd en o f d is e ase , i n ju ry , i m pair m en t, o r e x posu re , a s w ell a s p re v en ta b ility a n d r e la te d i n itia tiv es s u ch a s t h e H ealth y P eo ple p ro cess. A s o f m id 2 010, w ork h ad n ot y et b eg un o n t h is s y ste m atic r e v ie w .
T he T ask F orc e o n C om munity P re v en tiv e S erv ic es s e le cte d a lc o hol u se a n d a b use a s a p rio rity f o r s y ste m atic r e v ie w b ase d o n t h e s a m e c rite ria d esc rib ed a b ove f o r s u bsta n ce a b use . F ig ure 9 8 p re se n ts r e cen t d ata o n e x cessiv e a lc o hol c o nsu m ptio n, o fte n r e fe rre d t o a s b in ge d rin kin g. S ev era l i n te rv en tio ns w ere i d en tif ie d a s e ff e ctiv e i n p re v en tin g e x cessiv e a lc o hol u se . T hese i n clu de a lc o hol o utle t d en sity r e g ula tio ns, l a w s l im itin g t h e d ay s a n d h ours w hen a lc o hol c an b e s o ld , e x cis e t a x es o n a lc o hol, a n d e n han ced e n fo rc em en t o f l a w s p ro hib itin g t h e s a le o f a lc o hol t o m in ors .
A lc o hol o utle t d en sity r e g ula tio n i s d efin ed a s a p ply in g r e g ula to ry a u th ority t o r e d uce a lc o holic b ev era g e o utle t d en sity o r t o l im it t h e i n cre ase o f a lc o holic b ev era g e o utle t d en sity . R eg ula tio n i s o fte n i m ple m en te d t h ro ugh l ic en sin g o r z o nin g p ro cesse s. A n a lc o hol o utle t i s a p la ce w here a lc o hol m ay b e l e g ally s o ld f o r t h e b uyer t o d rin k t h ere ( o n p re m is e s) o r e ls e w here ( o ff p re m is e s). D en sity r e fe rs t o t h e n um ber o f a lc o hol o utle ts i n a g iv en a re a. T he t a sk f o rc e r e co m men ds t h e u se o f r e g ula to ry a u th ority ( e .g ., t h ro ugh l ic en sin g a n d z o nin g) t o l im it a lc o hol o utle t d en sity o n t h e b asis o f s u ff ic ie n t e v id en ce o f a p ositiv e a sso cia tio n b etw een o utle t d en sity a n d e x cessiv e a lc o hol c o nsu m ptio n a n d r e la te d h arm s. T he t a sk f o rc e a ls o r e co m men ds m ain ta in in g e x is tin g l im its o n t h e d ay s a n d h ours w hen a lc o hol c an b e s o ld i n o rd er t o p re v en t e x cessiv e a lc o hol c o nsu m ptio n a n d r e la te d h arm s. M ost p olic ie s l im itin g d ay s o f s a le t a rg et w eek en d d ay s ( u su ally S unday s). T hey m ay a p ply t o a lc o hol o utle ts i n w hic h a lc o hol m ay b e l e g ally s o ld f o r t h e 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 1 /2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . w eek en d d ay s ( u su ally S unday s). T hey m ay a p ply t o a lc o hol o utle ts i n w hic h a lc o hol m ay b e l e g ally s o ld f o r t h e b uyer t o d rin k a t t h e p la ce o f p urc h ase ( o np re m is e s o utle ts ) o r e ls e w here ( o ff p re m is e s o utle ts ). I n t h e U nite d S ta te s, p olic ie s m ay b e m ad e a t t h e s ta te l e v el a n d, w here n ot p ro hib ite d b y s ta te p re em ptio n l a w s, a t l o cal l e v els . A lc o hol e x cis e t a x es a ff e ct t h e p ric e o f a lc o hol a n d a re i n te n ded t o r e d uce a lc o hol re la te d h arm s, r a is e r e v en ue, o r b oth .
A lc o hol t a x es a re i m ple m en te d a t t h e s ta te a n d f e d era l l e v el a n d a re b ev era g e s p ecif ic ( i.e ., t h ey d if f e r f o r b eer, w in e, a n d s p ir its ). T hese t a x es a re u su ally b ase d o n t h e a m ount o f b ev era g e p urc h ase d ( n ot o n t h e s a le s p ric e), s o t h eir e ff e cts c an e ro de o ver t im e d ue t o i n fla tio n i f t h ey a re n ot a d ju ste d r e g ula rly . T he t a sk f o rc e r e co m men ds i n cre asin g t h e u nit p ric e o f a lc o hol b y r a is in g t a x es b ase d o n s tr o ng e v id en ce o f e ff e ctiv en ess f o r r e d ucin g e x cessiv e a lc o hol c o nsu m ptio n a n d r e la te d h arm s. P ublic h ealth e ff e cts a re e x pecte d t o b e p ro portio nal t o t h e s iz e o f t h e t a x i n cre ase .
E nhan ced e n fo rc em en t p ro gra m s t h at i n itia te o r i n cre ase t h e f re q uen cy o f r e ta ile r c o m plia n ce c h eck s f o r l a w s a g ain st t h e s a le o f a lc o hol t o m in ors w ere a ls o f o und t o b e e ff e ctiv e i n te rv en tio ns.
W ith r e sp ect t o r e sp onsib le s e x ual b eh av io rs , p re v en tio n o f H IV , s e x ually t r a n sm itte d i n fe ctio ns, a n d p re g nan cy, t h e t a sk f o rc e r e co m men ds g ro upb ase d c o m pre h en siv e r is k r e d uctio n ( C RR) d eliv ere d t o a d ole sc en ts a s a n e ff e ctiv e i n te rv en tio n. T he r e co m men datio n i s b ase d o n s u ff ic ie n t e v id en ce o f e ff e ctiv en ess i n r e d ucin g t h e n um ber o f s e lf r e p orte d r is k b eh av io rs , i n clu din g e n gag in g i n a n y s e x ual a ctiv ity , f re q uen cy o f s e x ual a ctiv ity , n um ber o f p artn ers , a n d f re q uen cy o f u npro te cte d s e x ual a ctiv ity . C RR a ls o i n cre ase s s e lf re p orte d u se o f p ro te ctio n a g ain st p re g nan cy a n d s e x ually t r a n sm itte d i n fe ctio ns ( S T Is ) a n d r e d uces t h e i n cid en ce o f s e lf re p orte d o r c lin ic ally d ocu m en te d S IT I.
T here i s l im ite d d ir e ct e v id en ce o f e ff e ctiv en ess, h ow ev er, f o r r e d ucin g p re g nan cy a n d h um an i m munodefic ie n cy v ir u s ( H IV ). T he t a sk f o rc e’s r e v ie w e v alu ate d C RR i n te rv en tio ns d eliv ere d i n s c h ool o r c o m munity s e ttin gs t o g ro ups o f a d ole sc en ts ( 1 0–19 y ears o ld ). T hese i n te rv en tio ns m ay a ls o i n clu de o th er c o m ponen ts s u ch a s c o ndom d is tr ib utio n a n d S T I t e stin g.
F ig u re 9 8 P erc en ta ge o f a d ult s a ged > 18 y ea rs w ho c o n su m ed f iv e o r m ore a lc o h olic d rin ks i n 1 d ay a t l e a st o n ce i n t h e p re ced in g y ea r, * b y s e x a n d a ge g ro u p, N atio n al H ea lt h I n te rv ie w S urv ey , U nit e d S ta te s, 2 007 † . 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 2/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . * B ase d o n r e sp onse s t o t h e f o llo w in g q uestio ns: “ In y our e n tire l ife , h av e y ou h ad a t l e ast 1 2 d rin ks o f a n y t y pe o f a lc o holic b ev era g e?” a n d i f “ y es,” “ In t h e p ast y ear, o n h ow m an y d ay s d id y ou h av e f iv e o r m ore d rin ks o f a n y a lc o h olic b ev era g e?” † E stim ate s a re b ase d o n h ouse h old i n te rv ie w s o f a s a m ple o f t h e c iv ilia n n onin stitu tio naliz ed U .S . p opula tio n.
§ 9 5% c o nfid en ce i n te rv al.
S ourc es: F ro m C en te rs f o r D is e ase C ontro l a n d P re v en tio n. P erc en ta g e o f a d ults a g ed > 18 y ears w ho c o nsu m ed f iv e o r m ore a lc o holic d rin ks i n 1 d ay a t l e ast o nce i n t h e p re ced in g y ear, b y s e x a n d a g e g ro up, N atio nal H ealth I n te rv ie w S u rv ey , U nite d S ta te s, 2 007. M MWR. 2 008; 5 7(4 9):1 333. D ata f ro m H ey m an K M , S ch ille r J S , B arn es P . E arly r e le ase o f s e le cte d e stim ate s b ase d o n d ata f ro m t h e 2 007 N atio nal H ealth I n te rv ie w S urv ey . h ttp ://w ww.c d c.g ov/n ch s/a b out/m ajo r/n his /re le ase d 200806.h tm . A ccesse d M ay 3 1, 2 010. C RR p ro m ote s b eh av io rs t h at p re v en t o r r e d uce t h e r is k o f p re g nan cy, H IV , a n d o th er S T Is . T hese i n te rv en tio ns m ay s u ggest a h ie ra rc h y o f r e co m men ded b eh av io rs , i d en tif y in g a b stin en ce a s t h e b est o r p re fe rre d m eth od b ut a ls o p ro vid in g i n fo rm atio n a b out s e x ual r is k r e d uctio n s tr a te g ie s. C RR m ay p ro m ote a b stin en ce a n d s e x ual r is k r e d uctio n w ith out p la cin g o ne a p pro ach a b ove a n oth er, o r p rim arily o r s o le ly p ro m ote s e x ual r is k re d uctio n s tr a te g ie s. T he t a sk f o rc e c o nclu ded t h at t h ere i s i n su ff ic ie n t e v id en ce t o d ete rm in e t h e e ff e ctiv en ess o f g ro upb ase d a b stin en ce e d ucatio n d eliv ere d t o a d ole sc en ts t o p re v en t p re g nan cy, H IV , a n d o th er S T Is . E vid en ce w as c o nsid ere d i n su ff ic ie n t b ecau se o f i n co nsis te n t r e su lts a cro ss s tu die s.
A lth ough m uch h as b een a ch ie v ed , m uch r e m ain s t o b e d one. T he p ublic h ealth c h alle n ges o f t h e 2 1st c en tu ry a p pear d au ntin g, b ut t h ose o f t h e p re ced in g c en tu ry m ust h av e s e em ed e v en m ore s o . N ev erth ele ss, s te ad y p ro gre ss c am e t h ro ugh c o nsis te n t a p plic atio n o f p ublic h ealth a p pro ach es a n d m eth ods, s u ch a s t h ose r e co unte d b y t h e p ublic h ealth p hysic ia n i n T ab le 9 1 . A pply in g t h e l e sso ns l e arn ed f ro m t h e r e cen t c en tu ry o f p ro gre ss i n p ublic h ealth t o b oth n ew a n d p ers is tin g h ealth t h re ats w ill b e n ecessa ry t o i n cre ase t h e s p an o f h ealth y l if e a n d e lim in ate t h e h uge d is p aritie s i n h ealth o utc o m es t h at a re t h e o vera rc h in g g oals o f t h e y ear 2 020 n atio nal h ealth o bje ctiv es. T he p ublic h ealth c h alle n ges o f b oth c en tu rie s c all f o r t h e a p plic atio n o f s o und s c ie n ce i n a n e n vir o nm en t t h at s u pports s o cia l j u stic e i n h ealth . T his r e m ain s t h e m ost f o rm id ab le c h alle n ge f a cin g p ublic h ealth p ra ctic e i n t h e 2 1st c en tu ry .
L IM IT A T IO NS O F 2 1S T C EN TU RY P U BLIC H EA LT H D esp ite t h e r e m ark ab le a ch ie v em en ts o f t h e 2 0th c en tu ry , t h ere i s m uch f o r p ublic h ealth t o d o i n t h e e arly y ears o f t h e n ew c en tu ry . C ontin ued p ro gre ss i s b y n o m ean s a ssu re d b ecau se o f a n ew c o nste lla tio n o f p ro ble m s a n d i m porta n t l im ita tio ns o f c o nven tio nal p ublic h ealth e ff o rts . G lo bal e n vir o nm en ta l t h re ats , t h e d is ru ptio n o f v ita l e co sy ste m s, g lo bal p opula tio n o verlo ad , p ers is te n t a n d w id en in g s o cia l i n ju stic e a n d h ealth i n eq ualitie s, a n d l a ck o f a ccess t o e ff e ctiv e c are a d d t o t h e l is t o f h ealth p ro ble m s l e ft o ver f ro m t h e 2 0th c en tu ry . 5 C onsid er, f o r e x am ple , t h e i m plic atio ns o f F ig ure s 9 9 a n d 9 1 0 i n t e rm s o f t h e l in k b etw een i n co m e, e d ucatio nal a tta in m en t, a n d h ealth , a n d a n atio n g ro w in g m ore a n d m ore d iv ers e , w ith a d is p ro portio nate b urd en o f p overty f a llin g o n c h ild re n , m in oritie s, a n d o nep are n t f a m ilie s. F urth er g ain s i n h ealth s ta tu s m ay b e l e ss r e la te d t o s c ie n ce t h an t o s o cia l p olic ie s. F or s o m e p ublic h ealth p ro fe ssio nals , t h e l im ita tio ns o f c o nven tio nal p ublic h ealth a re d if f ic u lt t o a ccep t b ecau se , i n l a rg e p art, t h ey r e p re se n t t h e s u pportin g p illa rs o f t h e p ublic h ealth e n te rp ris e . T his r e lu cta n ce t o c ritic ally s e lf a sse ss m ak es f u tu re p ro gre ss l e ss c erta in . I t i s u se fu l t o e x am in e t h ese l im ita tio ns i n t e rm s o f t h eir r e la tio nsh ip t o t h e t w o m ajo r f o rc es s h ap in g p ublic h ealth r e sp onse s— sc ie n ce a n d s o cia l v alu es.
D esp ite t h e i m pre ssiv e g ain s i n h ealth s ta tu s a ch ie v ed i n t h e 2 0th c en tu ry , a n d t h e c o ntin uin g r e d uctio ns i n m orta lity r a te s i n t h e e arly 2 1st c en tu ry , n ot a ll i n dic ato rs a re m ovin g i n t h e r ig ht d ir e ctio n. E arlie r c h ap te rs c h ro nic le d t h e m odern e p id em ic o f o besity a n d m in im al p ro gre ss i n i n cre asin g p hysic al a ctiv ity f o r m an y A m eric an s. F ig ure s 9 1 1 a n d 9 1 2 t r a ck e v en s u btle r t r e n ds i n o vera ll h ealth s ta tu s i n t h e U nite d S ta te s. F ig ure 9 1 1 s h ow s a n i n cre asin g p erc en ta g e o f a d ults r e p ortin g f a ir o r p oor h ealth s ta tu s. F ig ure 9 1 2 b ols te rs t h is c o nte n tio n i n t e rm s o f t h e p erc en ta g e o f a d ults r e p ortin g 1 4 o r m ore d ay s o f a ctiv ity l im ita tio n d urin g t h e p ast y ear. T hese t r e n ds s u ggest t h at m uch m ore i s n eed ed t o u nders ta n d a n d i m pro ve h ealth a n d q uality o f l if e i n t h e f ir s t d ecad e o f t h e 2 1st c en tu ry .
T ab le 9 1 A Y ou ng P ublic H ea lt h P hysic ia n ’s S to ry 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 3/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . I n 1 940, I l e ft p riv ate p ra ctic e t o a ccep t a p ositio n a s a l o cal h ealth o ff ic er i n K en tu ck y. A fte r a 3 m onth c o urs e a t t h e U niv ers ity o f K en tu ck y, w hic h i n clu ded t h e p rin cip le s o f e p id em io lo gy a n d l a w , I w as a ssig ned t o B re ck en rid ge, H an co ck , a n d M ead e c o untie s— th re e r u ra l c o untie s w ith a c o unty s e at a s t h e o nly t o w n i n e ach a n d a c o m bin ed p opula tio n o f a p pro xim ate ly 4 5,0 00. T he s ta ff i n e ach c o unty c o nsis te d o f a p ublic h ealth n urs e , a s a n ita ria n , a n d a c le rk .
D urin g m y 2 y ears i n t h is a ssig nm en t, t h ere w ere o utb re ak s o f p olio m yelitis , s m allp ox, t y phoid f e v er, d ip hth eria , s c arle t f e v er, m easle s, a n d w hoopin g c o ugh. T uberc u lo sis , s y philis , a n d g onorrh ea w ere w id ely p re v ale n t. R ab ie s w as e n dem ic i n t h e w ild a n im al a n d d og p opula tio ns. V ery f e w w om en r e ceiv ed p re n ata l c are a n d m ost w ere d eliv ere d i n t h e h om e. M ost o f t h e w ells w ere p ollu te d . D is p osa l o f h um an w aste w as h ap hazard , a n d p riv ie s w ere u nsa n ita ry .
P ra ctic ally a ll o f t h e m ilk c o nsu m ed w as r a w , a n d r e sta u ra n ts w ere n ot i n sp ecte d .
T o r a is e i m munity l e v els q uic k ly , t h e n urs e s a n d I v is ite d e v ery s c h ool i n t h e t h re e c o untie s a n d v accin ate d e v ery c h ild w e c o uld h old s till l o ng e n ough t o g iv e t h e i m muniz atio ns. I f y ou w ere t o d o t o day w hat w e d id t h en , y ou w ould b e s u ed . A ls o , I a m s u re t h e F ood a n d D ru g A dm in is tr a tio n w ould n ot a p pro ve t h e a n tig en s w e u se d .
W eek ly v en ere al d is e ase c lin ic s w ere s e t u p i n e ach c o unty . T re atm en t w as a y ear o f w eek ly i n je ctio ns o f a rs e n ic als i n tr a v en ously a n d b is m uth i n tr a m usc u la rly . K eep in g p atie n ts i n t r e atm en t w as a p ro ble m , a n d I f re q uen tly s e n t t h e s h erif f t o b rin g i n p atie n ts w ho m is se d t r e atm en ts .
F or t u berc u lo sis p atie n ts , w e s e t u p t h e b est i s o la tio n w e c o uld a ch ie v e i n t h eir o w n h om es. P re g nan t w om en w ere r e fe rre d b y t h eir p hysic ia n s t o t h e n urs e s f o r p re n ata l n urs in g c are . A s te rile p ack o f s h eets a n d i n str u m en ts w as d ev elo ped ; t h e n urs e s a cco m pan ie d t h e d octo rs t o a ssis t i n h om e d eliv erie s.
W ell d efic ie n cie s w ere c o rre cte d a n d a s y ste m o f b acte ria l t e stin g o f w ell w ate r w as i n stitu te d . T he p riv y p ro gra m w as a p ro ble m b ecau se t h e c o unty c o urt h ad t o s e t u p a p ro ced ure t o c o lle ct f o r b uild in g t h e p riv ie s. I n stitu tin g t h e u se o f p aste u riz ed m ilk w as a p ro ble m b ecau se a v ocal m in ority p re d ic te d a ll m an ner o f m ed ic al p ro ble m s t h at w ould r e su lt f ro m t h e u se o f p ro cesse d m ilk . T hey e x hib ite d t h e s a m e m in dse t w e s e e t o day i n t h ose w ho r a il a g ain st t h e r a d ia tio n o f f o ods a n d f lu orid atio n o f w ate r s u pplie s.
R esta u ra n t i n sp ectio n a n d f o od h an dle r i n str u ctio n p ose d f e w p ro ble m s. T he t r a n sfe r o f v ita l r e co rd s f ro m t h e c o unty c le rk t o t h e h ealth d ep artm en t r e q uir e d a h ig h o rd er o f d ip lo m acy, b ut w as a ch ie v ed a n d w e w ere a b le t o h an d t a b ula te a r e p ort o f b ir th s a n d d eath s.
T hese w ere p rim itiv e p ro gra m s, b ut t h at w as p ublic h ealth i n t h e e arly 1 940s. P ro bab ly m ore i m porta n t t h an t h e s p ecif ic p ro gra m a ctiv itie s w as t h e p ublic h ealth p ro cess. T he s ta ff g ath ere d i n fo rm atio n a n d t h en m ad e d ecis io ns a s t o w hat w as n eed ed , g av e p rio ritie s t o t h e p ro ble m s, a n d p la n ned t h e v ario us p ro gra m s. T his i s s till a h allm ark o f t h e p ublic h ealth m eth od.
S ourc e: F ro m P ete rs o n P Q . P ublic H ea lth : I ts P ro gra m E vo lu tio n a nd F utu re C halle n ges. C onvo ca tio n A ddre ss . C hic ag o, I L : S ch ool o f P ublic H ealth , U niv ers ity o f I llin ois a t C hic ag o; M ay 1 994.
F ig u re 9 9 L ow i n co m e b y a ge, r a ce, a n d H is p an ic o rig in , U nit e d S ta te s, 2 007. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 4/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . S ourc e: F ro m C en te rs f o r D is e ase C ontr o l a n d P re v en tio n, C en te r f o r H ealth S ta tis tic s. H ea lth U nite d S ta te s, 2 009 , F ig ure 5 . D ata f ro m U .S . C en su s B ure au .
T hese f in din gs a ls o h ig hlig ht a r a n ge o f l im ita tio ns f a cin g m odern p ublic h ealth p ra ctic e. A m ong t h e l im ita tio ns a ff e ctin g t h e s c ie n tif ic f o undatio ns o f p ublic h ealth p ra ctic e i s a n u ndue e m phasis o n r e d uctio nis t t h in kin g t h at s e ek s m ole cu la r le v el e x pla n atio ns f o r s o cia l a n d s tr u ctu ra l p hen om en a. I d en tif ic atio n o f r is k f a cto rs h as b een u se fu l f o r p ublic h ealth e ff o rts , b ut t h e e m phasis o n i n div id ual r is k f a cto rs o fte n o bsc u re s p atte rn s t h at c all f o r m ultile v el r e sp onse s w ith in a n e co lo gic al p ers p ectiv e o f h ealth a n d i lln ess. T he p ers is te n t i d en tif ic atio n o f t h e a sso cia tio n o f s o cia l d ep riv atio n w ith m an y o f t h e i m porta n t h ealth p ro ble m s o f t h e l a st c en tu ry i s a c ase i n p oin t. A ppro ach es f o r r e d ucin g c o ro nary h eart d is e ase p ro vid e a n oth er e x am ple . H ealth i n te rv en tio ns t a rg etin g a r e d uctio n i n c o ro nary h eart d is e ase f re q uen tly f o cu s o n r is k f a cto rs a t t h e p hysio lo gic l e v el, s u ch a s b lo od p re ssu re c o ntr o l, c h ole ste ro l, a n d o besity a n d o n l if e sty le f a cto rs a t t h e i n div id ual l e v el, i n clu din g s m okin g, n utr itio n, p hysic al a ctiv ity , a n d p sy ch oso cia l f a cto rs ; h ow ev er, t h ere a re a ls o e n vir o nm en ta l i n flu en ces, s u ch a s g eo gra p hic l o catio n, h ousin g c o nditio ns, o ccu patio nal r is k s, a n d s o cia l s tr u ctu re i n flu en ces, s u ch a s s o cia l c la ss, a g e, g en der, a n d r a ce/e th nic ity . I n t h is m ultile v el v ie w o f c o ro nary h eart d is e ase , i n te rv en tio ns t h at f o cu s o n p rim ary a n d s e co ndary p re v en tio n ( th ose a d dre ssin g t h e p hysio lo gic a n d i n div id ual l e v els ) n eed t o b e s u pple m en te d b y o rg an iz atio n a n d c o m munity le v el i n te rv en tio ns ( a d dre ssin g e n vir o nm en ta l i n flu en ces) a n d h ealth y p ublic p olic y ( a d dre ssin g t h e s o cia l s tr u ctu re l e v el) .
F ig u re 9 1 0 H ea lt h s ta tu s * a m on g p erso n s a ged > 25 y ea rs, b y e d uca tio n l e v el, N atio n al H ea lt h I n te rv ie w S urv ey , U nit e d S ta te s, 2 007 † . 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 5/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . * H ealth s ta tu s d ata w ere o bta in ed b y a sk in g r e sp onden ts t o a sse ss t h eir o w n h ealth a n d t h at o f f a m ily m em bers l iv in g i n t h e s a m e h ouse h old a s e x celle n t, v ery g ood, g ood, f a ir , o r p oor. D ata a re p re se n te d o nly f o r f a m ily m em bers a g ed > 25 y ears .
† E stim ate s a re b ase d o n h ouse h old i n te rv ie w s o f a s a m ple o f t h e n onin stitu tio naliz ed , U .S . c iv ilia n p opula tio n.
D en om in ato rs f o r e ach c ate g ory e x clu de p ers o ns f o r w hom d ata w ere m is sin g. E stim ate s a re a g e a d ju ste d u sin g t h e p ro je cte d 2 000 U .S . p opula tio n a s t h e s ta n dard p opula tio n a n d u sin g f o ur a g e g ro ups: 2 5–44 y ears , 4 5–64 y ears , 6 5– 7 4 y ears , a n d > 75 y ears .
§ G en era l E ducatio nal D ev elo pm en t.
S ourc es: F ro m C en te rs f o r D is e ase C ontr o l a n d P re v en tio n. H ealth s ta tu s a m ong p ers o ns a g ed > 25 y ears , b y e d ucatio n l e v el, N atio nal H ealth I n te rv ie w S urv ey, U nite d S ta te s, 2 007. M MWR. 2 008;5 7(4 7):1 282. D ata f ro m N atio nal H ealth I n te rv ie w S urv ey 2 007. h ttp ://w ww.c d c.g ov/n ch s/n his .h tm . A ccesse d M ay 3 1, 2 010. A dam s P F, B arn es P M , V ic k erie J L . S um mary h ealth s ta tis tic s f o r t h e U .S . p opula tio n: N atio nal H ealth I n te rv ie w S urv ey, 2 007. V ita l H ea lth S ta t. 2 008;1 0(2 38).
N ev erth ele ss, a n oth er l im ita tio n o f p ublic h ealth ’s s c ie n tif ic h erita g e i s t h e p en ch an t f o r d ic h oto m ous t h in kin g a n d t h e f a ilu re t o v ie w h ealth p hen om en a a s c o ntin uous. A gain u sin g c o ro nary h eart d is e ase a s a n e x am ple , d ic h oto m ous t h in kin g d ra w s a tte n tio n t o i n div id ual a n d p hysio lo gic l e v el f a cto rs , w here as v ie w in g t h is c o nditio n a s c o ntin uous e n co ura g es a p opula tio nw id e v ie w a n d d ev elo pm en t o f i n te rv en tio ns t h at r e d uce o vera ll i n cid en ce a n d p re v ale n ce b y a ff e ctin g f re q uen cy d is tr ib utio ns i n t h e e n tir e p opula tio n. A v ie w o f h ealth p ro ble m s a s c o ntin uous p hen om en a s u ggests t h at e ff o rts b e m ad e t h ro ughout t h e p opula tio n t o m ove t h e e n tir e f re q uen cy d is tr ib utio n f o r c o ro nary h eart d is e ase “ to t h e l e ft,” r a th er t h an t o r e d uce d is e ase b urd en o nly a m ong t h ose g ro ups m ost h eav ily i m pacte d . H ere i t i s a p pare n t t h at s c ie n ce a n d s o cia l v alu es a re n eith er p ure n or m utu ally e x clu siv e f o rc es. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 6/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . F ig u re 9 1 1 P erc en ta ge o f a d ult s w it h f a ir o r p oor s e lf r a te d h ea lt h , U nit e d S ta te s, 1 993–2005.
S ourc e: F ro m C en te rs f o r D is e ase C ontr o l a n d P re v en tio n, N atio nal C en te r f o r H ealth S ta tis tic s, N atio nal B eh av io ra l R is k F acto r S urv eilla n ce S yste m D ata 1 993–2005.
F ig u re 9 1 2 P erc en ta ge o f a d ult s w it h 1 4 o r m ore a ctiv it y l im it a tio n d ays, U nit e d S ta te s, 1 993–2005. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 7/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . S ourc e: F ro m C en te rs f o r D is e ase C ontr o l a n d P re v en tio n, N atio nal C en te r f o r H ealth S ta tis tic s, N atio nal B eh av io ra l R is k F acto r S urv eilla n ce S yste m D ata , 1 993–2005.
D is c u ssio n a n d d eb ate o ver s c ie n tif ic a p pro ach es t o p ublic h ealth p ro ble m s a re n ot, h ow ev er, p ure ly s c ie n tif ic i n n atu re . A t t h e h eart o f c o lle ctiv e a ctio ns a re c o lle ctiv e v alu es a s t o w heth er i s su es a ff e ctin g i n div id uals a re m ore i m porta n t t h an i s su es a ff e ctin g c o m munitie s o f i n div id uals a n d a s t o t h e m ean in g o f h ealth i ts e lf . S hould p ublic h ealth e m phasiz e t h e h ealth o f i n div id uals o r t h e h ealth o f c o m munitie s? I n p art, t h ese r e fle ct t h e d if f e re n t p ers p ectiv es o f h ealth d esc rib ed i n p re v io us c h ap te rs . O n o ne h an d i s a m ech an is tic v ie w o f h ealth a s t h e a b se n ce o f d is e ase , p ro m otin g h ealth i n te rv en tio ns t h at e m phasiz e c u ra tiv e t r e atm en t f o r a ff lic te d i n div id uals . O n t h e o th er h an d i s a m ore h olis tic v ie w o f h ealth t h at s e es h ealth a s a c o m ple x e q uilib riu m o f f o rc es a n d f a cto rs n ecessa ry f o r o ptim al f u nctio nin g o f t h at i n div id ual. T his l a tte r v ie w e m phasiz es h ealth m ain te n an ce a n d h ealth p ro m otio n, o fte n t h ro ugh b ro ad s o cia l p olic ie s a ff e ctin g t h e e n tir e c o m munity . D if f e re n ces i n p ublic h ealth s y ste m s a m ong s o cie tie s a re l a rg ely d esc rib ed b y t h ese d if f e re n ces. S om e s o cie tie s, s u ch a s t h e U nite d S ta te s, f o cu s o n i n div id uals u sin g a l a rg ely m ed ic al t r e atm en t a p pro ach . O th ers a re m ore h eav ily i n flu en ced b y c o lle ctiv is m a n d a h olis tic v ie w o f h ealth . A t t h e c o re o f w hat c an b e a cco m plis h ed , h ow ev er, a re b asic v alu es a n d s o cia l p hilo so phie s t h at g uid e t h e u se o f t h e s c ie n tif ic k now le d ge a v aila b le a t a n y t im e.
T hese d if f e re n ces i n s o cia l v alu es a ls o a ff e ct p erc ep tio ns a s t o w hat i s e x pecte d o f g overn m en t a n d, a s a r e su lt, t h e f o rm a n d l e ad ers h ip o f p ublic h ealth e ff o rts . T o a l a rg e e x te n t, t h ese f o rc es h av e h aste n ed t h e d ev elo pm en t o f c o m munity p ublic h ealth p ra ctic e i n t h e U nite d S ta te s, a p hen om en on p re v io usly d esc rib ed i n s e v era l c h ap te rs o f t h is t e x t.
T H E F U TU RE O F P U BLIC H EA LT H I N 1 988 A ND T W O D EC ADES L AT ER I n m an y r e sp ects , t h e l im ita tio ns o f m odern p ublic h ealth a re a s a p pare n t a s i ts a ch ie v em en ts . P ers is tin g, e m erg in g, r e e m erg in g, a n d n ew ly a ssig ned p ro ble m s w ill f o re v er c h alle n ge p ublic h ealth a s a s o cia l e n te rp ris e . S uccess w ill d ep en d o n b oth t h e s tr u ctu re a n d t h e c o nte n t o f t h e p ublic h ealth r e sp onse . A c o ntin uous, c ritic al, a n d c o m pre h en siv e s e lf e x am in atio n o f t h e p ublic h ealth e n te rp ris e o ff e rs t h e g re ate st c h an ce f o r c o ntin ued s u ccess. A s e rie s o f s u ch s e lf e x am in atio ns b eg an w ith t h e 1 988 r e p ort o f t h e I n stitu te o f M ed ic in e ( IO M ), T he F utu re o f P ublic H ea lth .
6 A c o m pre h en siv e r e ex am in atio n, T he F utu re o f t h e P ublic ’s H ea lth i n t h e 2 1st C en tu ry , w as p ublis h ed i n 2 003. 7 A c o m pan io n s tu dy o f i s su es r e la te d t o e d ucatin g p ublic h ealth p ro fe ssio nals w as a ls o p ublis h ed b y t h e I O M i n 2 003. 8 T hese e x am in atio ns o utlin ed t h e l im ita tio ns o f p ublic h ealth e ff o rts i n t h e 2 0th c en tu ry b ut c ast t h ese f a ilin gs a s l e sso ns, c h alle n ges, a n d o pportu nitie s f o r p ublic h ealth i n t h e 2 1st c en tu ry .
T he F utu re o f P ublic H ea lt h , 1 988 T he I O M ’s l a n dm ark r e p ort, c o m ple te d i n 1 988, f o und m uch o f v alu e i n t h e n atio n’s p ublic h ealth e ff o rts , b ut i t a ls o i d en tif ie d a l o ng l is t o f p ro ble m s. T he m ost s e rio us p ro ble m o f a ll w as t h at A m eric an s w ere t a k in g t h eir p ublic h ealth s y ste m f o r g ra n te d . T he n atio n h ad c o m e t o b elie v e t h at e p id em ic s o f c o m munic ab le d is e ase s w ere a t h in g o f t h e p ast a n d t h at f o od a n d w ate r w ould f o re v er b e f re e o f i n fe ctio us a n d t o xic a g en ts . A m eric an s a ssu m ed t h at w ork pla ces, r e sta u ra n ts , a n d h om es w ere s a fe a n d t h at e v ery one h ad a ccess t o t h e i n fo rm atio n a n d s k ills n eed ed t o l e ad h ealth y l iv es. T hey a ls o a ssu m ed t h at a ll o f t h is c o uld o ccu r e v en w hile p ublic h ealth a g en cie s w ere b ein g i n cre asin gly c alle d o n t o p ro vid e h ealth s e rv ic es t o m ore t h an 4 0 m illio n A m eric an s w ho h ad n o h ealth i n su ra n ce o r w ere u nderin su re d ; h ow ev er, a cro ss t h e n atio n, s ta te s a n d l o calitie s w ere f a ilin g t o p ro vid e t h e r e so urc es t h at w ould a llo w b oth t h e t r a d itio nal p ublic h ealth a n d m ore r e cen t h ealth s e rv ic e r o le s t o b e c arrie d o ut s u ccessfu lly . W hen f u tu re b en efits c o m pete w ith i m med ia te n eed s, t h e r e su lts a re p re d ic ta b le .
T hese c ir c u m sta n ces f o ste re d t h e i m ag e o f a p ublic h ealth s y ste m i n d is a rra y. W ith in t h is s y ste m , n eith er t h e p ublic n or t h ose i n volv ed i n t h e w ork o f p ublic h ealth a p pre cia te d t h e s c o pe a n d c o nte n t o f p ublic h ealth i n m odern A m eric a.
T here w as l ittle c o nse n su s a s t o t h e s p ecif ic r e sp onsib ilitie s t o b e e x pecte d f ro m t h e v ario us l e v els o f g overn m en t a n d e v en l e ss i n te re st i n s e cu rin g s u ch c o nse n su s. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 8/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . P re v io us c h ap te rs d ocu m en t t h at s e v era l f o rm ula tio ns i n t h e I O M r e p ort h av e b een w id ely e m bra ced b y t h e p ublic h ealth c o m munity . T hese i n clu de s ta te m en ts o f t h e m is sio n, s u bsta n ce, a n d c o re f u nctio ns o f p ublic h ealth . T he m is sio n h as b een d esc rib ed s im ply a s e n su rin g c o nditio ns i n w hic h p eo ple c an b e h ealth y. T he s u bsta n ce c o nsis ts l a rg ely o f o rg an iz ed c o m munity e ff o rts t o p ro m ote h ealth a n d p re v en t d is e ase . T he I O M r e p ort i d en tif ie d a n e sse n tia l r o le f o r g overn m en t i n p ublic h ealth i n o rg an iz in g a n d e n su rin g t h at t h e m is sio n g ets a d dre sse d . A n e x pan ded v ie w o f t h e f u ndam en ta l f u nctio ns o f g overn m en ta l p ublic h ealth w as a rtic u la te d i n t h e t h re e c o re f u nctio ns o f a sse ssm en t, p olic y d ev elo pm en t, a n d a ssu ra n ce. T hese r e p re se n t a m ore c o m pre h en siv e v ie w o f p ublic h ealth e ff o rts t h an t h at c o nvey ed b y e arlie r v ie w s t h at p ublic h ealth p rim arily f u rn is h ed s e rv ic es a n d e n fo rc ed s ta tu te s. T he n ew p ublic h ealth d if f e re d i n i ts e m phasis o n p ro ble m i d en tif ic atio n a n d r e so lu tio n a s t h e b asis o f r a tio nal i n te rv en tio ns a n d o n w ork in g w ith a n d t h ro ugh o th er s ta k eh old ers , r a th er t h an i n te rv en in g u nila te ra lly .
P erh ap s t h e m ost m otiv atin g a sp ect o f t h e I O M r e p ort, h ow ev er, w as i ts c h ara cte riz atio n o f t h e d is a rra y o f p ublic h ealth a n d t h e s ig nif ic an ce o f t h at d is a rra y. T he I O M r e p ort p ain te d a p ic tu re o f d is jo in te d e ff o rts i n t h e 1 980s t o d eal w ith i m med ia te c ris e s, s u ch a s t h e e p id em ic o f H IV i n fe ctio ns a n d a n i n cre asin g l a ck o f a ccess t o h ealth s e rv ic es a n d e n durin g p ro ble m s w ith s ig nif ic an t s o cia l i m pacts , s u ch a s i n ju rie s, t e en p re g nan cy, h yperte n sio n, d ep re ssio n, a n d t o bacco a n d d ru g u se . W ith i m pen din g c ris e s o n t h e h oriz o n i n t h e f o rm o f t o xic s u bsta n ces, A lz h eim er’s d is e ase , a n d p ublic h ealth c ap acity , t h e I O M r e p ort f o und t h e s itu atio n t o b e g rim mer s till.
T he r e p ort f o und a w id e g ap b etw een t h e c ap ab ilitie s o f t h e p ublic h ealth s y ste m o f t h e 1 980s a n d t h ose o f a p ublic h ealth s y ste m c ap ab le o f r is in g t o m odern c h alle n ges. I t c h arte d a c o urs e t o m ove e v er c lo se r t o a n o ptim ally f u nctio nin g s y ste m . S ev era l e n ab lin g s te p s w ere i d en tif ie d 6 : • I m pro vin g t h e s ta tu to ry b ase o f p ublic h ealth • S tr e n gth en in g t h e s tr u ctu ra l a n d o rg an iz atio nal f ra m ew ork • I m pro vin g t h e c ap acity f o r a ctio n, i n clu din g t e ch nic al, p olitic al, m an ag em en t, p ro gra m matic , a n d f is c al c o m pete n cie s o f p ublic h ealth p ro fe ssio nals • S tr e n gth en in g l in kag es b etw een a cad em ia a n d p ra ctic e I n t h e e n d, t h e r e p ort c o nclu ded t h at w ork in g t h ro ugh a m ultitu de o f s o cie ty ’s i n stitu tio ns, r a th er t h an t h ro ugh o nly t r a d itio nal p ublic h ealth o rg an iz atio ns, i s t h e k ey t o i m pro vin g t h e p ublic h ealth s y ste m . I t i s a ls o a d au ntin g t a sk , c allin g f o r e n te rin g i n to p artn ers h ip s w ith s e cto rs s u ch a s e d ucatio n, l a w e n fo rc em en t, m ed ia , f a ith , c o rre ctio ns, a n d b usin ess, a n d f o ste rin g c h an ge t h ro ugh l e ad ers h ip a n d i n flu en ce, r a th er t h an t h ro ugh c o m man d a n d c o ntr o l. T he b arrie rs t o e ff e ctin g t h ese c o lla b ora tio ns a re t h e m ajo r o bsta cle s t o a ch ie v in g t h e a sp ir a tio ns o utlin ed i n H ealth y P eo ple 2 010’s n atio nal h ealth o bje ctiv es. T hese b arrie rs c o m e i n a ll s iz es a n d s h ap es a n d f ro m m an y d if f e re n t s o urc es.
S om e a re p erc eiv ed a s e x te rn al b arrie rs ; o th ers a p pear t o b e m ore i n te rn al.
T he I O M r e p ort i d en tif ie d i m porta n t b arrie rs i n hib itin g e ff e ctiv e p ublic h ealth a ctio n 6 : • L ack o f c o nse n su s o n t h e c o nte n t o f t h e p ublic h ealth m is sio n • I n ad eq uate c ap acity t o c arry o ut t h e e sse n tia l p ublic h ealth f u nctio ns o f a sse ssm en t, p olic y d ev elo pm en t, a n d a ssu ra n ce o f s e rv ic es • D is jo in te d d ecis io n m ak in g w ith out n ecessa ry d ata a n d k now le d ge • I n eq uitie s i n t h e d is tr ib utio n o f s e rv ic es a n d t h e b en efits o f p ublic h ealth • L im its o n e ff e ctiv e l e ad ers h ip , i n clu din g p oor i n te ra ctio n a m ong t h e t e ch nic al a n d p olitic al a sp ects o f d ecis io ns, r a p id t u rn over o f l e ad ers , a n d i n ad eq uate r e la tio nsh ip s w ith t h e m ed ic al p ro fe ssio n • O rg an iz atio nal f ra g m en ta tio n o r s u bm ers io n • P ro ble m s i n r e la tio nsh ip s a m ong t h e s e v era l l e v els o f g overn m en t • I n ad eq uate d ev elo pm en t o f n ecessa ry k now le d ge a cro ss t h e f u ll a rra y o f p ublic h ealth n eed s • P oor p ublic i m ag e o f p ublic h ealth , i n hib itin g n ecessa ry s u pport • S pecia l p ro ble m s t h at u nduly l im it t h e f in an cia l r e so urc es a v aila b le t o p ublic h ealth T he F utu re o f P ublic H ea lt h , T w o D eca d es L ate r T he I O M a d van ced t h ese t h em es t h ro ugh s e v era l o th er r e p orts p ublis h ed i n t h e 1 990s a n d e arly y ears o f t h e n ew c en tu ry . A b rie f s ta tu s r e p ort o n p ro gre ss i n i m ple m en tin g t h e 1 988 r e p ort’s m ajo r r e co m men datio ns w as c o m ple te d i n 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 1 9/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . t h e m id 1 990s, a n d a r e p ort p ro m otin g c o m munity h ealth i m pro vem en t p ro cesse s ( s e e C hap te r 5 ) a p peare d l a te r i n t h e d ecad e. A f u ll s c ale r e ex am in atio n o f t h e p ublic h ealth e n te rp ris e , t itle d T he F utu re o f t h e P ublic ’s H ea lth i n t h e 2 1st C en tu ry , w as u nderta k en a fte r t h e t u rn o f t h e c en tu ry a n d c o m ple te d i n l a te 2 002. T hat r e p ort f o cu se d m ore e x te n siv ely o n m ulti s e cto ra l p artn ers h ip s w ith g overn m en t t h an h ad t h e 1 988 r e p ort, w hic h e m phasiz ed g overn m en t’s r o le i n a ch ie v in g p ublic h ealth g oals .
T he 2 002 I O M r e p ort ( a lth ough n ot p ublis h ed u ntil 2 003) r e sta te d t h e u niq ue r e sp onsib ility t h at g overn m en t h as f o r p ro m otin g a n d p ro te ctin g t h e h ealth o f i ts p eo ple . I t n ote d , h ow ev er, t h at f o ur f a cto rs a rg ue t h at g overn m en t a lo ne s h ould n ot b ear f u ll r e sp onsib ility f o r t h e h ealth o f t h e p ublic 7 : • P ublic r e so urc es a re l im ite d , a n d p ublic h ealth s p en din g m ust c o m pete w ith o th er v alid c au se s.
• D em ocra tic s o cie tie s e x pre ssly l im it t h e p ow ers o f g overn m en t a n d r e se rv e m an y a ctiv itie s f o r p riv ate i n stitu tio ns.
• D ete rm in an ts a ff e ctin g h ealth d eriv e f ro m m ultip le s o urc es a n d s e cto rs , i n clu din g m an y s o cia l d ete rm in an ts t h at c an not b e a d dre sse d b y g overn m en t a lo ne.
• T here i s g ro w in g e v id en ce t h at m ulti s e cto ra l c o lla b ora tio ns a re m ore p ow erfu l a n d e ff e ctiv e t h an g overn m en t a ctin g a lo ne. I n l ig ht o f t h ese f a cto rs , t h e 2 002 I O M r e p ort e x am in ed b oth t h e g overn m en ta l c o ntr ib utio ns t o t h e p ublic ’s h ealth a n d t h ose f ro m o th er s e cto rs o f A m eric an s o cie ty . R eco m men datio ns f o r t h e g overn m en ta l e n te rp ris e w ere c o m ple m en te d b y r e co m men datio ns f o r h ealth care p ro vid ers , b usin ess, m ed ia , t h e f a ith c o m munity , a n d a cad em ia . T he r e p ort p ro pose d s ix m ajo r a re as f o r a ctio n 7 : • A doptin g a p opula tio n h ealth a p pro ach t h at c o nsid ers t h e m ultip le d ete rm in an ts o f h ealth w ith in a n e co lo gic al f ra m ew ork • S tr e n gth en in g t h e g overn m en ta l p ublic h ealth i n fra str u ctu re , w hic h f o rm s t h e b ack bone o f t h e p ublic h ealth s y ste m • B uild in g a n ew g en era tio n o f i n te rs e cto ra l p artn ers h ip s t h at a ls o d ra w o n t h e p ers p ectiv es a n d r e so urc es o f d iv ers e c o m munitie s a n d a ctiv ely e n gag es t h em i n h ealth a ctio ns • D ev elo pin g s y ste m s o f a cco unta b ility t o e n su re t h e q uality a n d a v aila b ility o f p ublic h ealth s e rv ic es • M ak in g e v id en ce t h e f o undatio n o f d ecis io n m ak in g a n d t h e m easu re o f s u ccess • E nhan cin g a n d f a cilita tin g c o m munic atio n w ith in t h e p ublic h ealth s y ste m ( e .g ., a m ong a ll l e v els o f t h e g overn m en ta l p ublic h ealth i n fra str u ctu re , b etw een p ublic h ealth p ro fe ssio nals a n d c o m munity m em bers ) T he b arrie rs t o f u tu re p ro gre ss a re a p pare n t i n b oth m ajo r I O M r e p orts . F ore m ost h as b een t h e l a ck o f a n e co lo gic al v ie w o f h ealth t h at a tte m pts t o u nders ta n d g ood a n d p oor h ealth i n t e rm s o f t h e m ultip le f a cto rs t h at i n te ra ct w ith e ach o th er a t t h e p ers o nal, f a m ily , c o m munity , a n d p opula tio n l e v el. A noth er s e t o f i m porta n t b arrie rs a ff e ctin g p ublic h ealth i s t h e p re v ailin g v alu es o f t h e A m eric an p ublic — in p artic u la r, t h ose r e str ic tin g t h e a b ility o f g overn m en t t o i d en tif y a n d a d dre ss f a cto rs t h at i n flu en ce h ealth . S ocia l v alu es d ete rm in e t h e e x te n t t o w hic h g overn m en t c an r e g ula te h um an b eh av io r, s u ch a s t h ro ugh c o ntr o llin g t h e p ro ductio n a n d u se o f t o bacco p ro ducts o r r e q uir in g b ic y cle o r m oto rc y cle h elm et u se . T hese v alu es a ls o d ete rm in e w heth er a n d t o w hat e x te n t f a m ily p la n nin g o r s c h ool b ase d c lin ic s e rv ic es a re p ro vid ed i n a c o m munity a n d d ete rm in e t h e c o nte n t o f s c h ool h ealth e d ucatio n c u rric u la . S om e o f t h ese s o cia l v alu es f in d s tr a n ge b ed fe llo w s. F or e x am ple , m an y A m eric an s o ppose c o ntr o l o f f ir e arm s o n t h e b asis o f p rin cip le s o f s e lf p ro te ctio n e m bodie d i n t h e U .S . C onstitu tio n; g un c o m pan ie s a ls o o ppose c o ntr o l, a lth ough o n t h e b asis o f m ore d ir e ct e co nom ic c o nsid era tio ns.
E co nom ic a n d r e so urc e c o nsid era tio ns a re c o m mon t h em es, a s w ell. O ne o bvio us i s su e i s t h at m ost p ublic h ealth a ctiv itie s r e m ain f u nded f ro m t h e d is c re tio nary b udgets o f l o cal, s ta te , a n d f e d era l g overn m en t. A t a ll l e v els , d is c re tio nary p ro gra m s h av e b een s q ueezed b y t r u e e n title m en t p ro gra m s, s u ch a s M ed ic aid a n d M ed ic are , a s w ell a s b y s o m e g overn m en ta l r e sp onsib ilitie s t h at h av e b eco m e n ear e n title m en ts , s u ch a s p ublic s a fe ty , l a w e n fo rc em en t, c o rre ctio ns, a n d e d ucatio n. T he B ush A dm in is tr a tio n’s w ar o n t e rro ris m w ith m ilita ry c am paig ns i n I ra q a n d A fg han is ta n f u rth er s q ueezed t h e n atio nal b udget a n d a n y c h an ce o f s ig nif ic an t h ealth o r h um an s e rv ic e i n itia tiv es a t h om e. F undin g o ne s e t o f h ealth re la te d s e rv ic es f ro m g overn m en ta l d is c re tio nary f u nds w hile o th er h ealth s e rv ic es a re f in an ced t h ro ugh a c o m petitiv e m ark etp la ce w id en s t h e i m bala n ce b etw een t r e atm en t a n d p re v en tio n a s i n vestm en t s tr a te g ie s f o r i m pro ved h ealth s ta tu s. T here a re p ow erfu l e co nom ic i n te re sts a m ong h ealth s e cto r i n dustr ie s, a s w ell a s a m ong i n dustr ie s w hose p ro ducts a ff e ct h ealth , s u ch a s t h e t o bacco , a lc o hol, p estic id e, a n d 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 2 0/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . f ir e arm s i n dustr ie s. O ne c an o nly d re am t h at e q ually p ow erfu l l o bbie s, o th er t h an p harm aceu tic al c o m pan ie s, m ig ht d ev elo p f o r h ep atitis o r d ru gre sis ta n t t u berc u lo sis .
A ll t o o o fte n , t h e c o m ple x p ro ble m s a n d i s su es o f p ublic h ealth , w ith c au se s a n d c o ntr ib utin g f a cto rs p erc eiv ed t o l ie o uts id e i ts b oundarie s, l e ad p ublic h ealth p ro fe ssio nals t o b elie v e t h at t h ey s h ould n ot b e h eld a cco unta b le f o r f a ilu re o r s u ccess; h ow ev er, m an y f a cets o f p ublic h ealth p ra ctic e i ts e lf c o uld b e f u rth er i m pro ved . T hese i n clu de r e la tio nsh ip s w ith t h e p riv ate s e cto r a n d m ed ic al p ra ctic e a n d s o m e i n te rn al r e e n gin eerin g o f p ublic h ealth p ro cesse s.
F ear a n d s u sp ic io n o f t h e p riv ate s e cto r c an l e ad t o m an y m is se d o pportu nitie s. J u st a s t h e t h re e m ost i m porta n t f a cto rs d ete rm in in g r e al e sta te v alu es a re l o catio n, l o catio n, a n d l o catio n, i t c an b e a rg ued t h at t h e t h re e m ost i m porta n t f a cto rs f o r h ealth a re j o bs, j o bs, a n d j o bs. I f t h is i s a n yw here n ear t r u e, s u sp ic io ns o f t h e p riv ate s e cto r n eed t o b e p ut t o r e st. T here i s l ittle q uestio n t h at e m plo ym en t i s a p ow erfu l p re v en tiv e h ealth i n te rv en tio n, i n t e rm s o f b oth i n div id ual a n d c o m munity h ealth s ta tu s. C om munity d ev elo pm en t a ctiv itie s t h at b rin g n ew b usin esse s a n d j o bs t o a c o m munity c an a ff e ct h ealth s ta tu s m ore p ositiv ely t h an a p ublic h ealth c lin ic o n e v ery c o rn er. F urth erm ore , b usin esse s h av e b een m ajo r f o rc es b eh in d t h e g ro w th o f m an ag ed c are s y ste m s i n t h e U nite d S ta te s. T heir p artn ers h ip w ith p ublic h ealth i n te re sts w ill b e e sse n tia l t o s e cu re n ew r e so urc es o r t o s h if t t h e b ala n ce b etw een t r e atm en t a n d p re v en tio n s tr a te g ie s. I n cre ase d p artn ers h ip s w ith m ed ic al c are i n te re sts w ill a ls o b e n ecessa ry . U nfo rtu nate ly , t h ere i s w id esp re ad i g nora n ce o f t h e m ed ic al c are s e cto r a m ong p ublic h ealth w ork ers .
A m ong b arrie rs i n te rn al t o p ublic h ealth a g en cie s i s o ne t h at o fte n g oes u nnotic ed — th e w id esp re ad u se o f c ate g oric al a p pro ach es t o p ro gra m m an ag em en t, w hic h o fte n f ra g m en ts a n d i s o la te s i n div id ual p ro gra m s, o ne f ro m a n oth er. I n a d ditio n t o t h e u nnecessa ry p ro lif e ra tio n o f i n fo rm atio n, m an ag em en t, a n d o th er a d m in is tr a tiv e p ro cesse s, e ach p ro gra m t e n ds t o d ev elo p i ts o w n a sso rtm en t o f i n te re st a n d c o nstitu en cy g ro ups, i n clu din g t h ose i n volv in g p ro gra m s ta ff m em bers , w ho o fte n w ork t o o ppose m ean in gfu l c o nso lid atio n a n d i n te g ra tio n o f p ro gra m s.
A noth er l im itin g f a cto r i s t h e g en era liz ed i n ab ility t o p rio ritiz e a n d f o cu s p ublic h ealth e ff o rts , d esp ite t h e w ealth o f i n fo rm atio n a s t o w hic h f a cto rs m ost a ff e ct h ealth a t t h e n atio nal, s ta te , o r e v en l o cal l e v els . T im e a n d t im e a g ain , t o bacco , a lc o hol, d ie t, a n d v io le n ce h av e b een s h ow n t o l ie a t t h e r o ot o f m ost p re v en ta b le m orta lity a n d y ears o f p ote n tia l l if e l o st. I d eally , r e so urc e a llo catio n d ecis io ns w ould b e m ad e o n t h e b asis o f t h e m ost i m porta n t a ttr ib uta b le r is k s, r a th er t h an b ein g s p re ad a ro und t o a d dre ss, i n eff e ctiv ely , r is k s b oth l a rg e a n d s m all. W ith s c o re s o f p rio ritie s, t h ere a re r e ally n one, a n d w ith out c le ar p rio ritie s, a cco unta b ility i s s e ld om e x pecte d . P ublic h ealth h as a lw ay s o pera te d a t t h e c o nflu en ce o f s c ie n ce a n d p olitic s; p olitic al i s su es a n d c o m pro m is e s a re n atu ra l. S till, i n co nsis te n cie s b etw een s ta te d p ublic h ealth p rio ritie s a n d a ctu al p ro gra m p rio ritie s, a s d em onstr a te d t h ro ugh f u ndin g, a re t h em se lv es b arrie rs t o p ublic u nders ta n din g a n d s u pport f o r p ublic h ealth w ork . C om pre h en siv e a n d s y ste m atic a p pro ach es m ust r e p la ce c u rre n t s ilo s tr a te g ie s.
O th er f a cto rs t h at i n flu en ce p ublic u nders ta n din g a n d s u pport f o r p ublic h ealth r e la te t o t h e t r a n sitio n f ro m c o nditio ns c au se d b y m ic ro org an is m s t o t h ose c au se d b y h um an b eh av io rs . I t i s m ore d if f ic u lt f o r t h e p ublic t o a p pre cia te t h e s c ie n tif ic b asis f o r p ublic h ealth i n te rv en tio ns w hen s o cia l, r a th er t h an p hysic al s c ie n ces, g uid e s tr a te g ie s. T his o ccu rs a t a t im e w hen g overn m en t i s i n cre asin gly p ortr a y ed a s b oth i n co m pete n t a n d o verly i n tr u siv e. L arg ely b ecau se g overn m en ta l p ro cesse s a re c o nsid ere d b y t h e p ublic t o b e i n te n se ly p olitic al, t h e p ublic v ie w o f p ublic h ealth p ro cesse s, i n clu din g p ro gra m s a n d r e g ula tio ns, i s t h at o f h ig hly p olitic iz ed a n d p artly s c ie n tif ic e x erc is e s.
T here h as b een c o nsid era b le d eb ate a s t o w heth er t h e 1 988 I O M r e p ort a ccu ra te ly c ap tu re d t h e p ro ble m s a n d n eed s o f t h e A m eric an p ublic h ealth s y ste m . I n m an y r e sp ects , t h e r e p ort r e sta te d t h e f u ndam en ta l v alu es a n d c o ncep ts u nderly in g p ublic h ealth i n t e rm s o f i ts e m phasis o n p re v en tio n, p ro fe ssio nal d iv ers ity , c o lla b ora tiv e n atu re , c o m munity p ro ble m s o lv in g, l o ose ly a tta ch ed c o nstitu en cie s, a ssu ra n ce f u nctio ns, n eed t o d ra w o th er s e cto rs i n to t h e s o lu tio n o f p ublic h ealth p ro ble m s, a n d l a ck o f a n i d en tif ia b le c o nstitu en cy. T ak en t o geth er, t h ese f e atu re s a p pear t o r e p re se n t d is a rra y ; h ow ev er, t h e c au se o f t h is d is a rra y m ay n ot l ie w ith p ublic h ealth b ut r a th er w ith o ur s o cia l a n d g overn m en ta l i n stitu tio ns, m ore g en era lly . P osin g s o lu tio ns t h at r e str u ctu re t h e s y ste m ’s c o m ponen ts m ay d o l ittle m ore t h an r e arra n gin g t h e d eck c h air s o n t h e T ita n ic .
I t m ay b e n ecessa ry t o m ore b ro ad ly r e str u ctu re t h e t a sk s a n d f u nctio ns o f p ublic h ealth t o d eal w ith m odern p ublic h ealth p ro ble m s. T he l a rg er w ork o f p ublic h ealth i s t o g et t h e t h re at p ro te ctio n, d is e ase p re v en tio n, a n d h ealth p ro m otio n j o b d one r ig ht, r a th er t h an t o g et i t d one t h ro ugh a t r a d itio nal s tr u ctu rin g o f r o le s a n d r e sp onsib ilitie s.
P re v en tin g d is e ase a n d p ro m otin g h ealth m ust b e e m bra ced t h ro ughout s o cie ty a n d i ts h ealth i n stitu tio ns, r a th er t h an e x is tin g i n a p ara lle l s u bsy ste m . T here i s n o e v id en ce t o s u pport t h e c o nte n tio n t h at p ublic h ealth a ctiv itie s a re b est 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 2 1/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . o rg an iz ed t h ro ugh p ublic h ealth a g en cie s o f g overn m en t. I t i s t h e m is sio n a n d t h e e ff o rt t h at a re i m porta n t a n d n ot n ecessa rily t h e o rg an iz atio n f ro m w hic h t h ose e ff o rts a re g en era te d .
C O NCLU SIO N: T H E N EED F O R A M ORE E FFE C TIV E P U BLIC H EA LT H S Y ST EM T he p erp etu al f ru str a tio n f o r p ublic h ealth i s t h e g ap b etw een w hat h as b een a ch ie v ed a n d w hat c o uld h av e b een a ch ie v ed . T he u nfu lf ille d p ro m is e o f p ublic h ealth s h ould n ot b e v ie w ed a s s o m e u nfo rtu nate a ccid en t b ut a s a d ir e ct r e su lt o f a s e rie s o f p ast d ecis io ns a n d a ctio ns u nderta k en q uite p urp ose fu lly . S ad ly , t h ey r e fle ct b oth a h is to ry o f d is re g ard a n d t h e c o nse q uen ces o f b attle s o ver t h e l e g itim acy, s c o pe, p ro fe ssio nal a u th ority , a n d p olitic al r e ach o f p ublic h ealth . 9 A r e cen t e x am ple i s t h e u se o f t o bacco s e ttle m en t f u nds. T he v ario us s e ttle m en ts i n 1 998 w ith a g ro up o f t h e m ajo r t o bacco c o m pan ie s w ill p ro vid e $ 250 b illio n t o t h e s ta te s o ver a 2 5y ear p erio d. T hese s e ttle m en ts w ere i n itia lly v ie w ed a s a c o lo ssa l s u ccess f o r p ublic h ealth o ver o ne o f i ts m ost i m porta n t e n em ie s. A lth ough s till i n t h e e arly y ears o f t h is p ossib le q uarte r c en tu ry w in dfa ll, s ta te l e g is la tiv e a n d e x ecu tiv e b ra n ch l e ad ers h av e o pte d t o u se t h ese f u nds f o r a v arie ty o f p urp ose s, s o m e f o r h ealth p urp ose s b ut m uch f o r o th er e n ds. I t w as e x pecte d t h at a p pro ach es w ould v ary f ro m s ta te t o s ta te , w ith m ost u sin g s o m e p ortio n o f t h e m oney t o s u pport t o bacco c essa tio n a n d p re v en tio n i n te rv en tio ns. E arly i n dic atio ns, h ow ev er, a re t h at a s l ittle a s o ne t h ir d o f t h e s e ttle m en t f u nds w ere e arm ark ed f o r h ealth p ro gra m s t h ro ugh 2 002 a n d t h at t h e h ealth s h are d eclin ed r a p id ly i n t h e f a ce o f s ta te b udget d efic its a fte r 2 002.
T he t o bacco c o m pan y s e ttle m en t c an b e v ie w ed a s a s u ccess s to ry o r a s p art o f a f u ll a cco untin g o f t h e m assiv e f a ilu re o f p ublic h ealth e ff o rts i n t h e b attle a g ain st t o bacco u se . W hy d id i t t a k e 3 d ecad es t o c h an ge p ublic p erc ep tio ns a n d v alu es t o t h e p oin t t h at s e ttle m en t b ecam e i n ev ita b le ? W ith out a tte n tio n t o t h e l e sso ns o f t h is s a g a a n d t o s tr e n gth en in g t h e p ublic h ealth s y ste m , t o bacco w ill b e t h e f ir s t o f m an y h ealth h azard s t h at a re i n ad eq uate ly a d dre sse d a n d f o r w hic h a n eg otia te d s e ttle m en t w ill e v en tu ally o ccu r. I f w e l o ok a t t h e t o bacco s e ttle m en t a s a s ig nal o f t h e f a ilu re o f p ublic h ealth a n d e v id en ce o f a w eak p ublic h ealth i n fra str u ctu re , t h is w in dfa ll b eco m es, a t b est, a b itte rs w eet v ic to ry . P erh ap s t h e t o bacco s e ttle m en t w in dfa ll w ould b est b e d ir e cte d t o w ard a v ertin g t h e n ex t t o bacco l ik e s e ttle m en t. D if f ic u lt q uestio ns a ris e , e v en i n o th erw is e g ood t im es!
I n a n y e v en t, t h e s e ttle m en t o ff e re d t h e p ossib ility o f a s u sta in ed i n cre ase i n p ublic h ealth r e so urc es t o t h e t u ne o f a b out $ 10 b illio n a n nually f o r 2 5 y ears . C onsid erin g t h at o nly a p pro xim ate ly $ 17 b illio n w as e x pen ded f o r g overn m en ta l p ublic h ealth a ctiv itie s i n 2 000, t h e t o bacco f u nds r e p re se n te d a p ossib le 7 0% i n cre ase . A dditio nal f u ndin g t o g overn m en ta l p ublic h ealth a g en cie s f o r b io te rro ris m p re p are d ness o n t o p o f t h e t o bacco s e ttle m en t f u nds p ro vid ed f o r a p ossib le d oublin g o f g overn m en ta l p ublic h ealth a ctiv itie s i n t h e e arly y ears o f t h e 2 1st c en tu ry . A s w e h av e s e en , h ow ev er, t h is w as a n i llu sio n t h at n ev er m ate ria liz ed .
T hese c ir c u m sta n ces a n d o th er k ey i s su es a n d c h alle n ges f a cin g t h e f u tu re o f p ublic h ealth d efy s im ple s u m mariz atio n. T his c h ap te r h as e x am in ed s e v era l, i n clu din g t h ose o ff e re d b y t h e a ch ie v em en ts a n d l im ita tio ns o f p ublic h ealth p ra ctic e i n t h e 2 0th c en tu ry a n d o th ers o ff e re d b y t h e I O M r e p orts ; e arlie r c h ap te rs p re se n te d m an y m ore . W hic h o f t h ese a re m ost i m porta n t r e m ain s a p oin t o f c o nte n tio n. I t w ould b e u se fu l t o h av e a n o ff ic ia l l is t t h at r e p re se n ts t h e c o nse n su s o f p olic y m ak ers a n d t h e p ublic a lik e; h ow ev er, b ecau se a n o ff ic ia l l is t i s l a ck in g, s e v era l g en era l c o nclu sio ns a s t o t h e c ritic al c h alle n ges a n d o bsta cle s f a cin g t h e f u tu re o f p ublic h ealth i n t h e U nite d S ta te s a re p re se n te d . T hey s u m mariz e s o m e o f t h e i m porta n t t h em es o f t h is t e x t i n d esc rib in g w hy w e n eed m ore e ff e ctiv e p ublic h ealth e ff o rts .
T he E asy P ro b le m s H ave A lr e a d y B een S olv ed M ajo r s u ccesse s h av e b een a ch ie v ed t h ro ugh p ublic h ealth e ff o rts o ver t h e p ast 1 50 y ears , l a rg ely r e la te d t o m assiv e r e d uctio ns i n i n fe ctio us d is e ase s b ut a ls o i n volv in g s u bsta n tia l d eclin es i n d eath r a te s f o r i n ju rie s a n d s e v era l m ajo r c h ro nic d is e ase s s in ce a b out 1 960. T he l is t o f c u rre n t p ro ble m s f o r p ublic h ealth i n clu des t h e m ore d if f ic u lt c h ro nic d is e ase s, n ew a n d e m erg in g c o nditio ns, i n clu din g b io te rro ris m , a n d b ro ad er s o cia l p ro ble m s w ith h ealth e ff e cts ( te en p re g nan cy a n d v io le n ce a re g ood e x am ple s) t h at h av e i d en tif ia b le r is k a n d c o ntr ib utin g f a cto rs t h at c an b e a d dre sse d o nly t h ro ugh c o lle ctiv e a ctio n. T he d ay s o f c o m man da n dc o ntr o l a p pro ach es t o r e la tiv ely s im ple i n fe ctio us r is k s a re 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 2 2/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . b eh in d u s. I n t h e p ast, e n vir o nm en ta l s a n ita tio n a n d e n gin eerin g c o uld c o lla b ora te w ith c o m munic ab le d is e ase c o ntr o l e x pertis e t o a d dre ss i m porta n t p ublic h ealth p ro ble m s. T he c o lla b ora tio ns n eed ed f o r v io le n ce p re v en tio n o r b io te rro ris m p re p are d ness r e q uir e v ery d if f e re n t s k ills a n d r e la tio nsh ip s.
T o a H am mer, t h e E ntir e W orld L ook s L ik e a N ail B eh in d t h is a p horis m i s t h e p erc ep tio n t h at c o m mon e d ucatio n a n d w ork e x perie n ces f o ste r c o m mon p ro fe ssio nal p ers p ectiv es. T he d an ger l ie s i n b elie v in g t h at o ne’s o w n p ro fe ssio nal t o ols a re a d eq uate t o t h e t a sk o f d ealin g w ith a ll o f t h e p ro ble m s a n d n eed s t h at a re s e rv ed b y t h e p ro fe ssio n. E ach p ro fe ssio n h as i ts o w n s c ie n tif ic b ase a n d j a rg on.
P ro ble m s a re g iv en l a b els o r d ia g nose s, u sin g t h e p ro fe ssio n’s s p ecia liz ed l a n guag e, s o t h at t h e t o ols o f t h e p ro fe ssio n c an b e b ro ught t o b ear o n t h ose p ro ble m s. A ll t o o o fte n , h ow ev er, t h e p ro ble m s c o m e t o b e c o nsid ere d a s t h e d om ain o f t h at p ro fe ssio n, a n d t h e p ote n tia l c o ntr ib utio ns o f o th er p ro fe ssio ns a n d d is c ip lin es a re u ndera p pre cia te d . A lth ough p ublic h ealth p ro fe ssio nals a re r e m ark ab ly d iv ers e i n t e rm s o f t h eir e d ucatio nal a n d e x perie n tia l b ack gro unds, w e c an a ls o f a ll i n to t h is t r a p . W hen w e d o, b rid ges t o o th er p artn ers a re n ot b uilt, a n d c o lla b ora tio ns d o n ot t a k e p la ce. A s a r e su lt, p ro ble m s t h at c an b e a d dre sse d o nly t h ro ugh c o lla b ora tiv e i n te rs e cto ra l a p pro ach es f lo uris h u nab ate d .
A F rie n d i n N eed I s a F rie n d I n deed F in din g m ean s t o b uild s u ch b rid ges c an b e d if f ic u lt, b ut s o m e k ey c o lla b ora tio ns a p pear t o b e a b so lu te ly e sse n tia l f o r t h e w ork o f p ublic h ealth t o s u cceed . C erta in ly , l in ks b etw een p ublic h ealth a n d m ed ic al c are m ust b e i m pro ved f o r b oth t o p ro sp er i n a r e fo rm in g h ealth s y ste m . L in ks w ith b usin esse s a ls o r e p re se n t a n oth er a v en ue f o r m utu ally s u ccessfu l c o lla b ora tio ns. T he k ey i s t o f in d m ajo r a re as o f c o m mon p urp ose . F or m ed ic al c are i n te re sts , t h e c o m mon d en om in ato r i s t h at p re v en tio n s a v es m oney a n d r e w ard s t h ose w ho u se i t a s a n i n vestm en t s tr a te g y. F or b usin ess i n te re sts , t h e b otto m l in e h as t o b e i m pro ved , a n d b usin esse s m ust a ccep t t h e p re m is e t h at i m pro vin g h ealth s ta tu s i n t h e c o m munity s e rv es t h eir b otto m l in es t h ro ugh h ealth ie r, m ore p ro ductiv e w ork ers a n d h ealth ie r a n d w ealth ie r c o nsu m ers .
Y ou G et W hat Y ou P ay F or T here i s g ood c au se t o q uestio n t h e c u rre n t n atio nal i n vestm en t s tr a te g y a s i t r e la te s t o h ealth . T he e x cess c ap acity t h at h as b een e sta b lis h ed i n t h e A m eric an h ealth s y ste m i s b eco m in g i n cre asin gly u naff o rd ab le , a n d t h e r e su lts a re n oth in g t o w rite h om e a b out. S till, t h e c o m petitio n f o r a d ditio nal d olla rs i s i n te n se a m ong t h e m ajo r i n te re sts t h at d om in ate t h e h ealth i n dustr y , a n d t h ere i s l ittle m ovem en t t o a lte r t h e c u rre n t b ala n ce b etw een t r e atm en t a n d p re v en tio n s tr a te g ie s. W ith l e ss t h an 5 % o f a ll h ealth e x pen ditu re s s u pportin g p ublic h ealth ’s c o re f u nctio ns a n d e sse n tia l s e rv ic es a n d o nly a b out o ne p erc en t s u pportin g p opula tio nb ase d p re v en tio n, e v en s m all s h if ts c o uld r e ap s u bsta n tia l r e w ard s. T he a rg um en t t h at r e so urc es a re l im ite d a n d t h at t h ere s im ply a re n ot a d eq uate r e so urc es t o m eet t r e atm en t, a s w ell a s p re v en tio n p urp ose s, i s u niq uely A m eric an a n d q uite i n im ic al t o t h e p ublic ’s h ealth . M ore d is c o ncertin g y et a re t h e l o st o pportu nitie s i n s e cu rin g a n d u sin g r e cen t t o bacco s e ttle m en t a n d b io te rro ris m p re p are d ness f u ndin g t o s h ore u p a s a g gin g p ublic h ealth i n fra str u ctu re .
I t’s N ot M y J ob ?
T he j o b d esc rip tio n o f p ublic h ealth h as n ev er b een c le ar. A s a r e su lt, p ublic h ealth h as b eco m e q uite p ro fic ie n t i n d eliv erin g s p ecif ic s e rv ic es, w ith l e ss a tte n tio n p aid t o m obiliz in g a ctio n t o w ard t h ose f a cto rs t h at m ost s e rio usly a ff e ct c o m munity h ealth s ta tu s. A m ong t r a d itio nal h ealth re la te d f a cto rs , t o bacco , a lc o hol, a n d d ie t a re f a cto rs r e sp onsib le f o r m uch o f m odern A m eric a’s m orta lity a n d m orb id ity . N oneth ele ss, t h e r e so urc es s u pportin g i n te rv en tio ns d ir e cte d t o w ard t h ese f a cto rs a re m in usc u le . S im ila rly , t h e p rim ary c au se o f A m eric a’s r e la tiv ely p oor h ealth o utc o m es, i n c o m paris o n w ith o th er d ev elo ped n atio ns, a s w ell a s t h e m ost l ik ely s o urc e f o r f u rth er h ealth g ain s i n t h e U nite d S ta te s, r e sid es i n t h e h uge a n d i n cre asin g g ap s b etw een r a cia l a n d e th nic g ro ups. T he p ublic h ealth s y ste m , f ro m n atio nal t o s ta te a n d l o cal l e v els , m ust r e co gniz e t h ese c ir c u m sta n ces a n d m ove b ey ond t h em t o a d vocate a n d b uild c o nstitu en cie s a g gre ssiv ely f o r e ff o rts t h at t a rg et t h e m ost i m porta n t o f t h e t r a d itio nal h ealth r is k f a cto rs a n d t h at p ro m ote s o cia l p olic ie s t h at w ill b oth m in im iz e a n d e q ualiz e r is k s t h ro ughout t h e p opula tio n. T he t a sk i s a s s im ple a s f o llo w in g t h e G old en R ule a n d d oin g f o r o th ers w hat w e w an t d one f o r o urs e lv es b ecau se e ff o rts t o 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 2 3/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . i m pro ve t h e h ealth o f o th ers m ak e e v ery one h ealth ie r. T his d oes n ot c o nstitu te a n ew j o b d esc rip tio n f o r p ublic h ealth i n t h e U nite d S ta te s, b ut r a th er a r e co m mitm en t t o a n o ld , s u ccessfu l, a n d n ecessa ry o ne.
D IS C USSIO N Q UEST IO NS A ND E X ER CIS E S 1 . W hat w as t h e m ost i m porta n t a ch ie v em en t o f p ublic h ealth i n t h e 2 0th c en tu ry ? W hy? 2 . W hat w ill b e t h e m ost i m porta n t a ch ie v em en t o f p ublic h ealth i n t h e 2 1st c en tu ry ? W hy? 3 . I f r a n dom iz ed c lin ic al t r ia ls a re c o nsid ere d t h e g old s ta n dard o f r e se arc h , w hy i s t h ere n ot m ore e m phasis o n t h is a p pro ach i n a sse ssin g c o m munity b ase d i n te rv en tio ns?
4 . U sin g a s c ale f ro m 1 t o 1 0, h ow e ff e ctiv e i s t h e p ublic h ealth s y ste m i n t h e U nite d S ta te s? H ow d id y ou a rriv e a t t h is r a tin g?
5 . D o y ou a g re e w ith t h e I O M a sse rtio n t h at p ublic h ealth i s i n d is a rra y o r w ith t h e c o unte ra sse rtio n t h at i t i s g overn m en t, n ot p ublic h ealth , t h at i s i n d is a rra y ?
6 . W hat i m pact h as T he F utu re o f P ublic H ea lth h ad o n t h e p ublic h ealth c o m munity s in ce 1 990? 7 . W hat i m pact h as T he F utu re o f t h e P ublic ’s H ea lth i n t h e 2 1st C en tu ry h ad o n t h e p ublic h ealth c o m munity s in ce 2 003?
8 . W hat d o y ou t h in k a re t h e m ost i m porta n t n ew o r e x pan ded r o le s f o r p ublic h ealth i n t h e 2 1st c en tu ry ? 9 . Y our s ta te h as $ 100 m illio n f ro m t o bacco s e ttle m en t f u nds. W hat s tr a te g ie s a n d p ro gra m s s h ould r e ceiv e f u ndin g? W hy?
1 0. H ow h as y our u nders ta n din g o f w hat p ublic h ealth i s a n d h ow i t w ork s c h an ged a fte r e x am in in g t h e t o pic s i n t h is b ook? R EFE R EN CES 1 .
C en te rs f o r D is e ase C ontr o l a n d P re v en tio n. A ddre ssin g E m erg in g I n fe ctio us D is e a se T hre a ts : A P re ven tio n S tr a te g y f o r t h e U nite d S ta te s . A tla n ta , G A: U .S . P ublic H ealth S erv ic e; 1 994. 2 .
U .S . D ep artm en t o f H ealth a n d H um an S erv ic es. H ea lth y P eo ple 2 010: U ndersta ndin g a nd I m pro vin g H ea lth . W ash in gto n, D C: U .S . D ep artm en t o f H ealth a n d H um an S erv ic esP ublic H ealth S erv ic e; 2 000.
3 .
T ask F orc e o n C om munity P re v en tiv e S erv ic es. T he C om munity G uid e. h ttp ://w ww.t h eco m munity guid e.o rg . A ccesse d M ay 3 1, 2 007.
4 .
M urra y C JL , L opez A D, e d s. T he G lo bal B urd en o f D is e a se : A C om pre h en siv e A sse ssm en t o f M orta lity a nd D is a bility f r o m D is e a se s, I n ju rie s, a nd R is k F acto rs i n 1 990 a nd P ro je cte d t o 2 020 . C am brid ge, M A: H arv ard S ch ool o f P ublic H ealth ; 1 996.
5 .
M cK in la y J B , M arc eau L D . T o b old ly g o. . . . A m J P ublic H ea lth . 2 000;9 0:2 5–33. 6 .
I n stitu te o f M ed ic in e. T he F utu re o f P ublic H ea lth . W ash in gto n, D C: N atio nal A cad em y P re ss; 1 988. 7 . 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 2 4/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d . I n stitu te o f M ed ic in e. T he F utu re o f t h e P ublic ’s H ea lth i n t h e 2 1st C en tu ry . W ash in gto n, D C: N atio nal A cad em y P re ss; 2 003.
8 .
I n stitu te o f M ed ic in e. W ho W ill K eep t h e P ublic H ea lth y? E duca tin g P ublic H ea lth P ro fe ssio nals f o r t h e 2 1st C en tu ry . W ash in gto n, D C: N atio nal A cad em y P re ss; 2 003. 9 .
F ee E , B ro w n T M . T he u nfu lf ille d p ro m is e o f p ublic h ealth : d éjà v u a ll o ver a g ain . H ea lth A ffa ir s . 2 002;2 1:3 1–43. 1 /2 1/2 017 P ublic H ealth : W hat It Is a nd H ow It W ork s h ttp s://b ookshelf.v ita ls ourc e.c om /# /b ooks/9 781284046342/c fi/1 8!/4 /2 /2 @ 0:0 2 5/2 5 P R IN TED B Y: j o n ath an j1 988@ yah oo.c o m . P rin tin g i s f o r p erso n al, p riv ate u se o n ly . N o p art o f t h is b ook m ay b e r e p ro d uced o r t r a n sm it te d w it h ou t p ublis h er's p rio r p erm is sio n . V io la to rs w ill b e p ro se cu te d .