HCA415: Community & Public Health-10 Essential Services of Public Health

Overview of Community Health Learning Objectives After reading this chapter, you should be able to: •Identify the important terms used in the community health field, givin\ g examples of each term.

•Discuss the three key elements of public health.

•Discuss historical landmarks in the field of community health.

•Describe the current health status of the United States.

•Evaluate trends in the current health status of the United States.

•Identify funding sources for public and community health.

•Describe and give examples of determinants of community health.

•Describe three governmental and other organizations that support community health and public health. Chapter 1 Fancy Collection/SuperStock fri80977_01_c01.indd 1 8/30/13 12:46 PM CHAPTER 1 Section 1.2 Definitions of Key Terms Used in This Chapter 1.1 Introduction to the Field This textbook covers the topics of community health and public health; c\ ommunity health, which refers to the overall health status of a community, is related to a society’s ability to achieve its goals. The field of public health makes an essential contrib\ ution to community health by improving the overall quality of life and helping people live longer, more pro- ductive lives. In addition, public health helps children stay healthy and grow into healthy adults. Finally, public health is crucial for minimizing human suffering from the effects of adverse health outcomes and from the effects of disasters such as Hurricane Sandy, which devastated the East Coast of the United States in late 2012. Two important characteris- tics of public health are the concern with disease prevention and focus on health promo - tion among populations of people. These concerns of public health have contributed to remarkable achievements during the past century. Not only have there been great reduc - tions in infectious disease mortality rates in the United States, but al\ so life expectancy has increased from about 49 years in 1900 to 78 years in 2008. In order to introduce you to the fields of community health and public health, Chapter 1 commences by defining impor - tant terms such as health, community health, and community. In addition, the next section provides more detailed information on the distinctions between community health and \ public health. 1.2 Definitions of Key Terms Used in This Chapter The meaning of health is complex and can be interpreted in several different ways, depend - ing upon the context in which it is used. First, let’s consider the word as it is used com - monly. The origin of the term health is the old English word hal, “meaning whole, sound in mind and limb” (Porta, 2008, p. 110). The Oxford College Dictionary defines health as “the state of being free from illness or injury” (Oxford College Dictionary, 2007, p. 627). A criti - cism of this definition is that it defines health in terms of the absenc\ e of illness but does not consider the positive dimensions of health. fri80977_01_c01.indd 2 8/30/13 12:46 PM CHAPTER 1 Section 1.2 Definitions of Key Terms Used in This Chapter Figure 1.1: What is health? World Health Organization (WHO) definition of health Health is a state of complete physical, mental, and social well-beingand not merely the absence of disease or infirmity. Source: Adapted from University of Pittsburgh, Super Course http://www.pitt.edu/~super1/globalhealth/WhatisHealth.pdf .

The World Health Organization (WHO) provides one of the most widely cited and influ - ential definitions of health, and one that affords recognition to the positive aspects of health. WHO defines health as “a state of complete physical, mental, and social well- being and not merely the absence of disease or infirmity” (World Health Organization [WHO], 2003; see Figure 1.1.). In 1948, WHO formally adopted this definition, which is in the preamble to WHO’s constitution. According to WHO, the definition has not been amended since 1948.

Although WHO’s definition represented a new idea because of its emphasis upon the positive aspects of health, it poses a challenge when researchers attempt to study and understand health under this definition. For one, it is difficult to develop reliable and valid measurements of health’s positive dimensions—for example, mental, physic\ al, and social well-being. At present, the principal measurements of health indicate either the absence of ill health or the presence of disease and symptoms of ill health. Thus, given cur - rently available tools, measuring the existence of adverse health outcome\ s is more feasible than assessing dimensions of good health (Susser & Stein, 2009).

Another limitation of the definition of health proposed by WHO is that it does not take into account recent biomedical advances. Examples are those involving molecular and fri80977_01_c01.indd 3 8/30/13 12:46 PM CHAPTER 1 Section 1.2 Definitions of Key Terms Used in This Chapter genetic markers (genes associated with certain diseases); these develo\ pments affect our knowledge about both the positive and negative dimensions of health. Per\ haps, in the future, progress in the development of molecular and genetic markers will enable furt\ her specification of the meaning of good health (Susser & Stein, 2009).

An editorial in the influential British medical journal The Lancet also questioned the ade- quacy of WHO’s definition of health. The editorial suggested that the\ definition no longer be upheld, given scientists’ much greater knowledge of disease at the molecular, individ- ual, and societal levels: “Given that we now know the important influence of the genome in disease, even the most optimistic health advocate surely has to accept the impossibility of risk-free well-being” (The Lancet, 2009, p. 781). According to the editorial in The Lancet, a more realistic definition of health is “the ability to adapt to one’s environment.” WHO’s definition of health is currently among the most enduring definitions in use since the mid-20th century. However, it has been criticized for not accounting for recent behav - ioral science, genetic, and medical knowledge. In addition, the term health can mean dif- ferent things to different people, sometimes connoting physical health and other times mental health, which is discussed in more detail in Chapter 9. Neither is health a black- and-white term. Psychiatrists and psychologists think of mental health a\ s a continuum, with good mental health on one end and mental illness on the other. Similarly, physical health can represent a continuum, with the ability to function at an optimal level at o\ ne end. Nevertheless, persons who have chronic diseases and disabilities are still capable of performing at high levels, so this definition is not entirely satisfactory. Regardless, the word health, as defined in this section, is part of the terms public health and community health, so for the purposes of the following sections, we will defer to this d\ efinition.

The Definition and Mission of Public Health The term public health is not easily defined and, perhaps, we can best express it in terms of its mission, governmental functions, and basic services. C. E. A. Winslow, a highly regarded public health expert who founded the Yale University Department of Public Health, proposed one of the most widely quoted and influential definitions of publ\ ic health. According to Winslow, public health is the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort for the sanita - tion of the environment, the control of communicable infections, the educa - tion of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of dis - ease, and for the development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his [or her] birthright of health and longevity. (as cited in Turnock, 2004, p. 10) As implied by the foregoing definition, the central mission of public health is to achieve social justice, which has been described both as the foundation and the core value of the field (Golstin & Powers, 2006; Krieger & Birn, 1998). Examples of public health’s c\ oncern fri80977_01_c01.indd 4 8/30/13 12:46 PM CHAPTER 1 Section 1.2 Definitions of Key Terms Used in This Chapter with social justice include improvements in sanitation in England during the mid-1800s to improve the conditions of the poor and the more recent efforts during the present century to address health disadvantages and disparities in the United States. (We will discuss this topic in more depth later in this chapter.) Social justice “stresses the fair disbursement of common advantages and the sharing of common burdens. It captures the twin moral impulses that animate public health: to advance human well-being by impr\ oving health and to do so particularly by focusing on the needs of the most disadvant\ aged” (Gostin & Powers, 2006, p. 1054).

One of the distinguishing features of public health is its mission to protect the health of an entire population (WhatisPublicHealth.org, n.d.). This focus on the population contrasts with that of clinical medicine, which is concerned with the health of individual patients.

The Institute of Medicine (IOM) summarized the mission of public healt\ h in its widely regarded 1988 report, The Future of Public Health, which stated that public health is “what we, as a society, do collectively to assure the conditions in which people can be healthy” (IOM, 1988, p. 19). The report noted that public health encompasses activities that are beyond the capabilities of individual health care providers. In addition, the IOM stressed the role of public health in early intervention and prevention of disease (health promo- tion). These types of public health activities are known as primary prevention and include immunizations and programs for control of communicable diseases.

Public health departments in the United States are tasked with implementing and over - seeing programs that protect the health of the populations in their jurisdictions. Some examples are programs for tuberculosis control, environmental protection, maintaining food safety, and prevention of the spread of communicable diseases. Other examples include immunizations for children and families; clinics for child health, HIV testing, and family planning; and birth and death certificates.

In its 1988 report, the IOM identified the three core functions of public health as assess - ment, policy development, and assurance. These core functions are defined as follows: • Assessment: “[E]very public health agency [should] regularly and systematically collect, assemble, analyze, and make available information on the health\ of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems” (IOM, 1988, p. 7). • Policy development: “[E]very public health agency [should] exercise its respon-sibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision- making about public health, and by leading in developing public health p\ oli - cies. Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process” (IOM, 1988, p. 8). • Assurance: “[P]ublic health agencies [should] assure their constituents that ser - vices necessary to achieve agreed-upon goals are provided, either by encourag- ing actions by other entities (private or public sector), by requiring such action through regulation, or by providing services directly. . . . Each public health agency [should] involve key policymakers and the general public in deter\ min - ing a set of high-priority personal and communitywide health services th\ at governments will guarantee to every member of the community. This guarantee should include subsidization or direct provision of high-priority health care fri80977_01_c01.indd 5 8/30/13 12:46 PM CHAPTER 1 Section 1.2 Definitions of Key Terms Used in This Chapter services for those unable to afford them” (IOM, 1988, p. 8).

Examples of these core public health functions include the col- lection and analysis of data that show the occurrence of infec - tious diseases, identify signifi - cant health problems in a community, and illustrate prog- ress in meeting programmatic goals. Public health depart - ments should lead in the cre - ation of health policies such as those related to tobacco control and maintenance of sanitary conditions in restaurants. In many cases, local health depart - ments provide direct health care services to people who are unable to afford health care. Community Health McKenzie, Pinger, and Kotecki (2012, p. 7) state that community health “refers to the health status of a defined group of people and conditions to promote, protect, and pre - serve their health.” An example of community health is the level of health in a specific city\ such as Ann Arbor, Michigan; Berkeley, California; or New Orleans, Louisiana. Included within the definition of community health are activities carried out to safeguard, main - tain, and promote the health of the residents of a community.

The term community refers to “[a] group of people, often living in a defined geographi - cal area, who may share a common culture, values and norms, and arranged in the social structure according to relationships, which the community has developed over a period of time” (WHO, 2004, p. 16). Often community members identify with \ this set of shared norms that reflect their beliefs and values and reinforce group awareness. In many cases, the members of the community are committed to preserving these beliefs and values.

Furthermore, race, ethnicity, and religion are related to the health characteristics of the community. There is a high prevalence of sickle cell anemia among communities that have high percentages of Blacks. Diabetes mellitus tends to occur more frequently among pre- dominantly Latino communities. Communities that have large numbers of residents who are members of certain religious groups tend to have disease rates that are a consequence of their religious practices. For examples, a community of Seventh-Day Adventists might have low chronic disease rates that result from abstinence from alcohol and avoidance of meat consumption.

Regarding the international perspective, WHO describes community health as “\ [t]he com - bination of sciences, skills and beliefs directed towards the maintenance and improvement Everett Collection/SuperStock Public health departments are tasked with creating programs that help to protect the citizens at the state and local levels.

This engraving from 1873 depicts an inspector from the New York Board of Health examining the stock of a grocery store in one of the city’s poorer neighborhoods. fri80977_01_c01.indd 6 8/30/13 12:46 PM CHAPTER 1 Section 1.2 Definitions of Key Terms Used in This Chapter of health of all the people through collective or social actions” (WHO, 2004, p. 16). The World Health Organization indicates that community health empha- sizes disease prevention that is directed to the needs of an entire population. Although the activi- ties and programs may change with the times, the goals of com - munity health remain constant.

Well-Being and Wellness Most discussions of health bring up the issues of well-being and wellness; moreover, well-being is an aspect of some defini - tions of health. Also, wellness is linked to both community health and public health. For example, the WHO definition of health indicates that health is a state of well-being. Well-being can be defined as “the state of being comfortable, healthy, or happy” ( Oxford College Dictionary, 2007), while wellness is “the optimal state of health of individuals\ and groups” (WHO, 2006, p. 5). According to the WHO, “[t]here are two focal concerns: the realization of the fullest potential of an individual physically, psychologically, socially, spiritually, and eco - nomically, and the fulfillment of one’s role expectations in the family, community, place of worship, workplace, and other settings” (WHO, 2006, p. 5). As noted previously, one of the overarching goals of community health is the promotion of well-being (or wellness), one of the key components of the WHO definition of health. Wellness is one of the outcomes related to a healthy community.

Healthy Communities A healthy community is one that “embraces the belief that health is more than merely an absence of disease; a healthy community includes those elements that ena\ ble people to maintain a high quality of life and productivity” (United States Department of Health and Human Services [USDHHS], 2001, p. 1). Consequently, a healthy community provides a setting that is conducive for comfortable living and playing and also offers resources for employment, education, and cultural activities. Spotlight: Healthy Communities explains why healthy communities are important to the individual and the society. FogStock/Thinkstock Most community health activities target smaller units, whereas public health efforts target entire populations. This sign promoting AIDS protection by the National AIDS Commission and Youth Department, however, is an example of a community health effort that targets the population level. fri80977_01_c01.indd 7 8/30/13 12:46 PM CHAPTER 1 Section 1.2 Definitions of Key Terms Used in This Chapter Spotlight: Healthy Communities What Is a Healthy Community?

A healthy community has leaders in organizations of all types (e.g., businesses, health agencies and centers, schools, faith-based organizations) who are committed to solving today’s and tomorrow’s critical public health problems. These leaders make needed changes in living conditions (e.g., structural and opportunity changes) to make the community an inviting place in which to live, work, learn, worship, and play.Why Are Healthy Communities Important?

With today’s financial challenges, including the rising cost of health care, it is more important than ever that communities and organizations make the most of their available resources to prevent chronic diseases and conditions, such as cancer, heart disease, stroke, obesity, diabe- tes, and arthritis. Since the majority (70%) of these diseases and conditions are caused by preventable risk factors (e.g., tobacco use, physical inactivity, unhealthful eating), commu- nities can effectively impact chronic disease by making changes in systems and environments to support healthful lifestyles. (We will describe some examples of how chronic diseases and conditions affect the health of Americans in the next section.) Chronic diseases pose a major health challenge in the United States in terms of death, illness, and disability: • Heart disease and stroke remain the first and fourth leading causes of death in the United States.

Together heart disease and stroke account for approximately 30% of all mortality.

•Cancer claims more than half a million lives in the United States each year and remains the nation’s second leading cause of death.

•Nearly 24 million Americans have diabetes. An estimated 57 million U.S. adults have pre-diabetes, which places them at increased risk of developing diabetes.

•Each year, an estimated 443,000 people in the United States die prematurely from smoking or exposure to secondhand smoke (death caused by smoking-related lung disease, heart disease, or cancer).

•In the United States, 50 million (22%) adults have doctor-diagnosed arthritis, making it the most common cause of disability.

Many Americans still engage in behaviors that significantly elevate their risk for chronic disease. For instance:

• Approximately 46 million U.S. adults smoke cigarettes.

•In 2007, almost two-thirds (65%) of high school students and more than one-third (36%) of all adults did not meet national recommendations for aerobic physical activity (Centers for Disease Control and Prevention [CDC], 2011a). (These findings are according to the 2008 Physical Activity Guidelines for Americans [USDHHS, 2008]. Note: In 2009, the percentages increased to 80% and 56%, respectively [CDC, 2011a].) (continued) iStockphoto/Thinkstock With the rising cost of health care in the United States, it has become increasingly important for communities to make the most of their available resources to improve community health. fri80977_01_c01.indd 8 8/30/13 12:46 PM CHAPTER 1 Section 1.2 Definitions of Key Terms Used in This Chapter One of the activities of community health is to actively promote community health, through “[a] comprehensive, systematic, coordinated approach to affecting long-term health behavior change by influencing the community (cultural) norms t\ hrough educa- tion and community organization” (Minnesota Department of Health, n.d.). At present, several federal government agencies as well as private organizations have developed community health promotion programs. For example, the Centers for Disease Control and Prevention (CDC) support funding for development of healthy communities.\ Repre - sentative examples of CDC’s activities are programs for reduction of disease risk factors— for example, tobacco use, physical inactivity, and poor nutrition, as well as support for equity in health (CDC, 2013c). The California Endowment sponsors a 10-\ year, $1 billion program called Building Healthy Communities, which seeks to produce healthier living conditions in 14 California communities (The California Endowment, 2011). This innova - tive and comprehensive activity takes a multifaceted approach to advancing community health by activities such as increasing employment opportunities, reducing unhealthy environmental conditions, and making healthy foods available.

The goals of achieving healthy communities and community health promotion can be accomplished by strengthening and enabling community leaders and community mem - bers to take actions in support of their own health, or community empowerment. As the WHO notes, “community empowerment is an important goal in community action for health” (WHO, 2004, p. 16).

Two types of key players are involved with a community’s efforts to improve its overall health status as well as the health of individuals: community health wor\ kers and commu - nity health nurses. Community health workers are trained to be the first point of contact between the individual and the health system. These workers typically wo\ rk in teams and are often from the community in which they work, but their roles can vary depending on the community’s needs and available resources (The California Endowment, 2011). Com - munity health nurses, according to Mosby’s Medical Dictionary, combine “primary health care and nursing practice with public health nursing,” adhering to the philosophy that “is based on the belief that care directed to the individual, the family, and the group con - tributes to the health care of the population as a whole” (as cited in Free Dictionary, 2009, para. 1). These nurses develop comprehensive health programs and activities to educate the community about good health, which often requires special attention to social and ecologic factors and at-risk populations. • In 2007, only 32% of high school students ate at least two servings of fruit each day, and only 13% ate at least three servings of vegetables daily. Only 24% of U.S. adults ate five or more servings of fruits and vegetables each day. (Note: In 2009, the respective percentages were 34%, 14%, and 23% [CDC, 2011a].) Source: Adapted from CDC’s Healthy Communities Program. Discover the Leadership Challenge. Center\ s for Disease Control and Prevention (2011b).

Spotlight: Healthy Communities (continued) fri80977_01_c01.indd 9 8/30/13 12:46 PM CHAPTER 1 Section 1.3 History of Community and Public Health 1.3 History of Community and Public Health This section will touch upon some of the most significant historical milestones in the extensive history of community and public health (see Table 1.1). An overview of these developments is given in the next paragraph; then each of these developm\ ents is covered in more detail.

Public health concerns first arose with the clustering of humans into settlements and with the domestication of animals that lived in proximity to humans. Human settlements increased the possibility of the spread of communicable diseases. In antiquity, people attributed disease to magical forces. Much later, during the classical period of history, Greek philosophers speculated about the causes and nature of disease and wrote about environmental influences as causes of disease. As a means of preventing infectious dis- eases, the ancient Romans recognized the importance of sanitary sewers and water that was safe for drinking. Subsequent to the fall of the Roman Empire, medical knowledge returned to earlier mystical theories of disease and magical treatments that had been pop- ular during antiquity. Soon after the advent of the Middle Ages, Europe was swept by recurring mass outbreaks of disease, such as the Black Death, which happened in the 14th century. The Renaissance and Baroque periods witnessed advances in the recognition of causes of disease and the beginnings of vital statistics. In London duri\ ng the mid-1600s, John Graunt developed methods for compiling mortality statistics. His in\ novations helped to form the underpinnings of modern vital statistics and to ident\ ify trends in births and deaths due to specific causes. As a result of his work, Graunt became known as the Columbus of biostatistics. The field of public health blossomed duri\ ng the Industrial Revolution, when further refinements in knowledge of disease etiology were obtained.

During the 1870s, Edward Jen - ner invented a successful vacci - nation for smallpox. One of the most significant events during this period was John Snow’s investigation of an outbreak of cholera in London, which will be discussed further in this chapter, in Spotlight: John Snow (1813–1858). Also, the Industrial Revolution marked the begin- ning of a phase of public health known as the sanitary reform movement, discussed later in this section. The 20th and 21st centuries have benefited from further, snowballing advances in medical knowledge and efforts to stem chronic and degenerative conditions. Table 1.1 details some of these and other historic community health milestones. Christopher Herwig/Getty Images As early human civilizations started living closely with animals and other people, the first public health concerns began to form. The close proximity of a number of individuals to each other, as well as to domesticated animals, allowed infectious diseases to spread rapidly. Public health threats are heightened in overcrowded cities such as the one shown in this photograph (Dhaka) in Bangladesh. fri80977_01_c01.indd 10 8/30/13 12:46 PM CHAPTER 1 Section 1.3 History of Community and Public Health Table 1.1: Historical time periods and community health landmarks Historical time periodApproximate datesCommunity health landmarks Early human civilizations Pre-500 BCEZoonotic diseases from increased contact between humans and animals; recognition of health hazards from human wastes Classical period 500 BCE to 500 CEAge of Hippocrates; Romans install public sewer systems and aqueducts Dark Ages 500 to 1100 CERecurrence of superstitious and magical beliefs regarding disease Middle Ages (in Europe) Medieval period 1100 to 1453 The Black Death kills nearly one-third of Europe’s population Renaissance 1300 through 1500Discoveries in human anatomy; hypotheses regarding microbial organisms and disease Baroque period 1600 through 1700John Graunt compiles vital statistics Industrial Revolution Late 1700s through mid-1800sEdward Jenner invents a successful smallpox vaccine; John Snow’s investigation of London cholera outbreak, 1849; development of public works in the United Kingdom; bacteriology 20th century 1900 to 1999The great influenza pandemic of 1918; invention of antibiotics; focus on control of chronic diseases 21st century 2000+Policies for prevention of secondhand smoke exposure; labeling of menus for nutrition content; development of vaccine for human papilloma virus; rapid population growth Era of Early Human Civilizations (pre-500 BCE) The formation of ancient societies generated early concerns about public\ health. Our early human ancestors were responsible for clearing forests for lumber and for agriculture; these activities damaged the land and caused rivers to fill up with silt\ from erosion. Ani - mals became domesticated and were raised in proximity to human beings. This contact promoted the transmission of parasitic infections from animals; human settlements also increased the possibility of transmission of diseases via human wastes (Porter, 1999). In Ancient Mesopotamia, now present-day Iraq, people developed herbal medicines; the earliest prescriptions from Mesopotamia are estimated to have been written in about 2000 BCE (Biggs, 2005). Biblical references to careful disposal of human waste, isolation of per - sons who had infections, and proper handling of dead bodies suggested ancient civiliza - tions’ awareness of public health measures. fri80977_01_c01.indd 11 8/30/13 12:46 PM CHAPTER 1 Section 1.3 History of Community and Public Health Classical Period (About 500 BCE to 500 CE) The classical period of history covers dates that range from 500 BCE (and somewhat ear- lier) to about 500 CE. During the classical period, important historica\ l developments for health and public health included the writings of the ancient Greeks, contributions of the Romans, and the writings of the Chinese philosopher Confucius.

Ancient Greece (About 500 BCE to 200 CE) During this time period, the Greek physician Hippocrates wrote about the linkage between the environment and health, suggesting that health was affected by: (1) environmental and climatic factors; (2) the quality of air, water, and food; and (3) geography (elevated versus low-lying areas) (Friis, 2012). Also, the Greek physician Galen advanced the field of human anatomy through his detailed illustrations of the human body.

Romans/Roman Empire (About 27 BCE to Late 400 CE) Contributions of the Romans to public health included design of water tr\ ansport systems that supplied adequate amounts of water to cities in the Roman Empire. The Romans also created sewage systems, public toilets, and public baths. Vestiges of Roman sanitary installations such as aqueducts and public baths can be found throughout former Roman settlements in Europe and the former Roman Empire (Friis, 2012).

Influence of Confucianism (551 to 479 BCE) The ideas of distinguished philosopher Confucius (551–479 BCE) have\ been a major influence in China and other Asian countries. One of the important contributions of Confucianism was the articulation of guiding principles of medical ethics. Stressing the value of life, these principles advocated healing patients who were afflicted with dis - eases, expending maximal efforts to save dying persons, showing integrity in the practice of medicine, and advancing one’s medical knowledge by exercise of personal diligence (Zhaojiang, 1995).

Dark Ages (500 to 1100) The era of the Dark Ages is believed to have commenced with the fall of Rome to the Goths about 476 CE (healthguidance.org, 2013). Superstitious and magical beliefs regard - ing the nature of disease became prominent. Folk medicine and healers attended to the sick. The medieval church became a base for the practice of medicine.

Middle Ages (1100 to 1500) Waves of recurrent and serious pandemics of cholera, leprosy, and plague beset Europe and other regions of the world during the Middle Ages (Sciencemuseum.org, n.d.). One of the most remarkable pandemics was the Black Death. Note that an epidemic denotes fri80977_01_c01.indd 12 8/30/13 12:46 PM CHAPTER 1 Section 1.3 History of Community and Public Health “[t]he occurrence of disease within a specific geographical area or population that is in excess of what is normally expected” (CDC, 2012h). A pandemic is “[a]n epidemic occur- ring over a very large geographic area” (CDC, 2012h).

Black Death (1346 to 1352) The Black Death describes a devastating outbreak of a “new and terrifying illness” from 1346 to 1352 (McEvedy, 1988. p. 118). In 1346, the estimated combined populations of Europe, northern Africa, and the Middle East totaled 100 million people. The Black Death killed one-quarter of this population—20 million people in Europe alone. His - torians attribute the cause of the deadly pandemic to bubonic plague tra\ nsmitted by fleas from infected rats that infested medieval cities. The European pandemic is thought to have been heralded by the arrival of 12 Genovese trading ships that d\ ocked at the Sicilian port of Messina in October 1347 (History.com, 2013). Many of the ships’ crew members were already dead from the plague or suffering from plague symptoms when the trading vessels docked. Following its introduction into Sicily, the plague spread throughout Europe.

One of the consequences of the medieval plague epidemic was expansion of\ the public health measure known as quarantine, which involved the isolation of persons with com - municable diseases from the community. Quarantine is believed to have begun early in the medieval period as a measure to protect the population from lepers (persons with leprosy) by expelling them from the community (Rosen, 1968). Isolation of the sick is a procedure related to quarantine. According to the CDC, Isolation and quarantine are public health practices used to stop or limit the spread of disease. Isolation is used to separate ill persons who have a communicable disease from those who are healthy. Quarantine is used to separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill. (CDC, 2013d) Renaissance (1300 to 1500) and Baroque (1600 to 1700) Periods During the Renaissance and Baroque periods, numerous discoveries in anatomy and physiology improved the classification and recognition of diseases. Also developing dur - ing this time was the awareness that microbial organisms cause infectious diseases (Bri - tannica Online Encyclopedia, n.d.). Two of several historically important writers during this era were Paracelsus (1493–1541) and John Graunt (1620–1674). Paracels\ us advanced knowledge regarding occupational diseases. Likewise, John Graunt’s compilation of vi\ tal statistics records was a pioneering contribution to biostatistics. Graunt’s work was \ pub - lished in Natural and Political Observations Made Upon the Bills of Mortality (1662). Based on his analysis of vital statistics data, Graunt produced several innovative demographic findings, including seasonal variations in infant mortality and an exces\ s of male deaths in comparison with female deaths. fri80977_01_c01.indd 13 8/30/13 12:46 PM CHAPTER 1 Section 1.3 History of Community and Public Health Industrial Revolution (About the Late 1700s to mid-1800s) Numerous developments relevant to community health, including the conceptualization of the field of public health and the creation of the first public health department in 1799, occurred dur- ing the Industrial Revolution. Some important developments included the following: • Establishment of the first public men- tal health hospital in colonial America (1773) (Coy, 2006). • Edward Jenner ’s (1749–1823) develop- ment of a successful vaccine against smallpox (1790s) (Riedel, 2005). • John Snow’s (1813–1858) investigation of a cholera outbreak in the Soho district of London in 1849: Snow introduced several innovations (e.g., the method of natural experiments, collection of out- break data, and mapping of the loca- tion of cholera victims). These methods remain valid today (Friis & Sellers, 2009), and many regard Snow as the father of epidemiology. Photo 12/Universal Images Group/Getty Images English physician Edward Jenner first developed a successful vaccine against smallpox during the Industrial Revolution.

The first of many public health efforts to fight the disease, Jenner’s contribution paved the way to the worldwide eradication of the disease in 1978.

Spotlight: John Snow (1813–1858) John Snow was an English anesthesiologist who is also remembered for making one of the most impor - tant historical contributions to epidemiology by using a “natural experiment.” His work, which took place during the mid-1800s, demonstrated that contaminated water was associated with a cholera out - break in several London districts. At the time of his work, microbes had not yet been confirmed as the cause of cholera. Snow observed that cholera rates during an 1849 outbreak were high in London districts whose water was supplied by the Lambeth Company and by the Southwark and Vauxhall Com - pany. Snow hypothesized that the occurrence of cholera was associated with contaminated water. This hypothesis seemed plausible, as these two companies drew water from highly contaminated sections of the Thames River. By 1854, the Lambeth Company’s water source had been relocated to a cleaner section of the river. Snow was able to test his hypothesis regarding cholera and water contamination by comparing the incidence of cholera among residents who used the two different water companies.

Snow demonstrated that the incidence of cholera in areas supplied by the cleaner Lambeth water was lower than the incidence in areas supplied by the Southwark and Vauxhall Company. The relocation of the water supply became known as a natural experiment, which Snow used to test his keen powers of reasoning and observation regarding the relationship between cholera and water contamination. fri80977_01_c01.indd 14 8/30/13 12:46 PM CHAPTER 1 Section 1.3 History of Community and Public Health • Bacteriology and public health: Robert Koch (1843–1910) verified th\ at a human disease was caused by a living microorganism, and he published his findings in 1882 (Jordan, 1921). • Sanitary reform movement began in England (19th century). In 1842 Edwin Chadwick published a report that linked communicable diseases with squalid urban environments (Rosen, 1968). • Passage of the Public Health Act of 1848 (Great Britain), called an important public health milestone: “For the first time, the state became the guarantor of standards of health and environmental quality and provided resources to local units of government to make the necessary changes to achieve those stand\ ards” (Fee & Brown, 2005, p. 866). • Publication of Report on the Sanitary Conditions of Massachusetts by Lemuel Shat- tuck (1850). The Shattuck report argued for the creation of a state health depart- ment and local health boards (Shattuck, 1850; Wilcox, 2005). Recent History: 20th and 21st Centuries Several additional milestones that occurred during recent history contributed to the evo - lution of community health. The first is the development of health educa\ tion, a field that is an essential activity for community health promotion. Health education is defined as “any combination of learning experiences designed to help individuals\ and communi - ties improve their health, by increasing their knowledge or influencing their attitudes” (WHO, 2013b, para. 1). Another key development was a growing emphasis on lifestyle changes, especially in the context of community health. Lifestyle change\ s include efforts to improve people’s diets, increase exercise levels, and encourage smoking cessation. These efforts stem from a growing recognition of the adverse impacts of chronic diseases such as heart disease, cancer, diabetes, and conditions like obesity. Other developments include: • 1918–1919: Spanish flu pandemic, responsible for 50 million deaths worldwide (Taubenberger & Morens, 2006). The 1918 influenza pandemic could portend future devastating influenza outbreaks. Since 1918, several global influenza pan- demics have transpired, although these pandemics have been much less severe. • 1945: Penicillin made available. • 1948: The Framingham Heart Study began a community investigation of risk\ factors for coronary heart disease. (Refer to Case Study: The Framingham Heart Study for additional details.) • 1955: Salk polio vaccine announced. • 1964: The Surgeon General’s report Smoking and Health identified smoking as a cause of lung cancer. • 1965: Medicare and Medicaid bills passed by Congress. • 1974: LaLonde Report pointed out the importance of the social, economic,\ and political determinants of health and suggested the importance of health \ promo - tion in limiting Canadian health expenditures (MacDougall, 2007). • 1978: Smallpox eradicated worldwide. • 1981: First case of acquired immunodeficiency syndrome (AIDS) reported. • 1990: Healthy People 2000 released by the Department of Health and Human Ser - vices. (Refer to the next section for a discussion of Healthy People.) fri80977_01_c01.indd 15 8/30/13 12:46 PM CHAPTER 1 Section 1.4 Current Health Status of the United States • 2001: Anthrax spores intentionally distributed in the U.S. mail, causing 21 anthrax poisoning cases. This was one of the events that raised awareness of bioterrorism. • 2003: Completion of the Human Genome Project (HGP). The HGP and research in the field of genetics will contribute to public health through improved screen- ing programs; these programs can use genetic testing to identify individuals who are at high risk of genetic diseases (Bobrow & Grimbaldeston, 2000). • 2007: Gardasil™ vaccine against the human papilloma virus introduced. • 2009: Influenza pandemic caused by (H1N1) 2009 influenza virus. This pan- demic heightened concerns about the possible recurrence of the devastation caused by influenza nearly a century earlier. Case Study: The Framingham Heart Study Since [its] beginning in 1948, the Framingham Heart Study, under the direction of the National Heart, Lung and Blood Institute (NHLBI) . . . has been committed to identifying the common factors or char - acteristics that contribute to cardiovascular disease (CVD). [The Study has] followed CVD development over a long period of time in three generations of participants.

[The] Study began in 1948 by recruiting an Original Cohort of 5,209 men and women between the ages of 30 and 62 from the town of Framingham, Massachusetts, who had not yet developed overt symptoms of cardiovascular disease or suffered a heart attack or stroke. Since that time the Study has added an Offspring Cohort in 1971, the Omni Cohort in 1994, a Third Generation Cohort in 2002, a New Offspring Spouse Cohort in 2003, and a Second Generation Omni Cohort in 2003.

Over the years, careful monitoring of the Framingham Study population has led to the identification of major CVD risk factors, as well as valuable information on the effects of these factors such as blood pressure, blood triglyceride and cholesterol levels, age, gender, and psychosocial issues. Risk factors for other physiological conditions such as dementia have been and continue to be investigated. In addition, the relationships between physical traits and genetic patterns are being studied.

Source: Adapted from the Framingham Heart Study (2013). 1.4 Current Health Status of the United States The health status of the United States as measured by life expectancy has shown dra - matic improvements since 1900. Nevertheless, life expectancy in the United States \ lags behind that of other wealthy, developed countries. In addition to the lower life expectancy reported for the United States, numerous challenges from chronic conditions affect the health of American communities. The government initiative known as Healthy People formulates a science-based strategy for improving our nation’s health by the end of the 21st century.

Life Expectancy Since 1900, the life expectancy of Americans has increased from an average of 49.2 years (47.9 and 50.7 years for males and females, respectively) to 78.0 years (75.5 and 80.5 years fri80977_01_c01.indd 16 8/30/13 12:46 PM CHAPTER 1 Section 1.4 Current Health Status of the United States for males and females, respectively) (Arias, 2011; United States Census Bureau, 2012).

Since the turn of the 20th century, infectious diseases—the leading causes of death at that time—have become much less frequent causes of mortality. As a result of the improve- ments in the health status of Americans, demographers predict that by 2020, U.S. life expectancy will increase to 79.5 years (77.1 and 81.9 years for males and females, respec - tively) (United States Census Bureau, 2012). The Institute of Medicine points out that “the health of the American people at the beginning of the 21st century would astonish thos\ e living in 1900” (2003, p. 2). We can attribute much of this success story to the achievements of public health, community health, and advances in medicine.

However, the IOM also states that “despite leading the world in health expenditures, the United States is not fully meeting its potential health status and lags \ behind many of its peers” (2003, p. 2). For example, life expectancy in the United Sta\ tes trails behind that of other countries: In 2012, estimated life expectancy in the United States\ was in 50th posi - tion among countries listed in The World Factbook (Central Intelligence Agency, 2012). In comparison, Monaco, the Chinese administrative district of Macau, and Ja\ pan led the world with the three highest life expectancies: 89.7, 84.4, and 83.9 years, respectively. Can - ada, America’s adjacent northern neighbor, had an estimated life expectancy of 81.5 years (12th highest).

Growing Impact of Chronic Health Conditions Between the early and mid-1900s, chronic diseases replaced infectious diseases as the most significant causes of morbidity—illness in a population—mortality, and disability. Since the mid-1900s, this trend has continued. Refer to Table 1.2 for data on the leading causes of death in the United States for 1900 and 2008. The three leading causes of mortality in 1900 were the category of influenza and pneumonia; tuberculosis; and the category of diarrhea and enteritis. (Note that even though influenza and pneumonia are two different causes of death, they are grouped as a single category of mortality for purposes of vital statistics reports; similarly, diarrhea and enteritis are combined.) In 2008, the three leading causes of mortality were heart disease, cancer, and chronic lower respiratory diseases. Other major causes of mortality were unintentional injuries, Alzheimer ’s disease, and suicide. Diabe - tes, a prevalent condition in the United States and the seventh leading cause of \ death in 2008, is a risk factor for several other chronic illnesses. Many of the foregoing causes of death are linked to adverse lifestyle practices (e.g., sedentary lifestyle, tob\ acco use, risk taking, and consumption of a high-fat diet). Consequently, they are likely to continue to impact the health of communities negatively. fri80977_01_c01.indd 17 8/30/13 12:46 PM CHAPTER 1 Section 1.4 Current Health Status of the United States Table 1.2: The 10 leading causes of death in 1900 and 2008 19002008 RankCause RankCause 1 Influenza and pneumonia 1Diseases of heart (heart disease) 2 Tuberculosis 2Malignant neoplasms (cancer) 3 Diarrhea and enteritis 3Chronic lower respiratory diseases 4 Diseases of heart (heart disease) 4Cerebrovascular diseases (stroke) 5 Cerebrovascular diseases (stroke) 5Accidents (unintentional injuries) 6 Nephritis (kidney disease) 6Alzheimer’s disease 7 Accidents (unintentional injuries) 7Diabetes mellitus (diabetes) 8 Malignant neoplasms (cancer) 8Influenza and pneumonia 9 Senility 9Nephritis, nephrotic syndrome and nephrosis (kidney disease) 10 Diphtheria 10Intentional self-harm (suicide) Sources: Data from U.S. Bureau of the Census. (1957). Statistical abstract\ of the United States, p. 69; Miniño, Murphy, Xu, & Kochanek (2011).

Deaths for two of the four leading causes of death (heart disease and s\ troke) peaked in the 1960s and have declined substantially since then (Remington & Brownson, 2011). This outcome in part may be a reflection of the success of health promotion and risk modifica - tion programs. Death rates from cancer, the second leading cause of death, have tended to remain constant since the 1960s. fri80977_01_c01.indd 18 8/30/13 12:46 PM CHAPTER 1 Section 1.4 Current Health Status of the United States Figure 1.2: Trends in age-adjusted death rates for the leading chronic diseases—United States, 1960–2007 Rate per 100,000 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Year 600 500 400 300 200 10 0 0 Heart disease Cancer Stroke Source: Adapted from the National Center for Health Statistics. (2011). He\ alth, United States, 2010. Hyattsville, MD: U.S. Department of Health and Human Services. Available at www.cdc.gov/nchs/data/hus/hus10.pdf .

While cancer death rates have remained relatively stable over the last 50 years, both heart disease and stroke rates have declined.

According to the CDC, almost half of U.S. adults aged 20 years and older during 2009 through 2010 exhibited at least one of three risk factors—smoking, ele- vated low density lipoproteins cholesterol (LDL-C), and hyper - tension—for cardiovascular dis- ease and stroke (Fryar, Chen, & Li, 2012). Approximately one- quarter of U.S. adults were smok - ers, a similar percentage had uncontrolled high levels of LDL cholesterol, and more than one- eighth had uncontrolled high blood pressure. These risk factors were most pronounced among older men and women, non- Hispanic Blacks, and individuals Yellow Dog Productions/Getty Images An inviting environment, like a health club, encourages individuals to improve their health. Community health is impacted by the setting that community creates for itself. fri80977_01_c01.indd 19 8/30/13 12:46 PM CHAPTER 1 Section 1.4 Current Health Status of the United States who have lower income levels. Although the status of U.S. adults with respect to these three risk factors has shown an improving trend in recent years, much work needs to be carried out to encourage the avoidance of tobacco use, maintenance of a healthy \ diet, participation in exercise, and other ways of controlling physiological risk factors for cardiovascular dis- ease and stroke.

Healthy People’s Strategy for Improving America’s Health Healthy People formulates a science-based strategy for improving our nation’s health by the end of the 21st century. It “provides science-based, national goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States” (CDC, 2013b, para. 1).

Healthy People goals have been adapted to meet the specific needs of the U.S. population and changing public health priorities. During the three decades since the beginning of Healthy People, three major publications have presented goals for improving Americans’ health. These documents are as follows: • Healthy People 2000: National Health Promotion and Disease Prevention Objectives, released in September 1990. This publication listed 319 objectives organized according to 22 priority areas related to health promotion, health protection, preventive services, and surveillance and data systems (CDC, 2009). • Healthy People 2010, released in January 2010. This publication listed 467 objec-tives, which would provide a framework for improving the nation’s health.

Healthy People 2010 further organized these objectives into 28 focus areas that corresponded to crucial public health areas. A subset of the objectives was called sentinel measures of public health: “These indicators were chosen based on their ability to motivate action, the availability of data to measure their progress, and their relevance to broad public health issues” (CDC, 2011c, para. 2). • Healthy People 2020 was launched in December 2010 (CDC, 2011d). Building upon the foundation established by Healthy People documents for 1990 and 2000, Healthy People 2020 reflects an expanded focus on reducing health disparities in the nation to “achieve health equity” and “improve the health of all groups.” (HealthyPeople.gov, 2012b, para. 5). These activities will be informed by apply- ing an ecological approach to disease prevention and health promotion. (The term ecological approach is explained further later in this chapter.) Healthy People 2020’s four Foundation Health Measures are the following: General Health Status, Health-Related Quality of Life and Well-Being, Determinants of Health, and Disparities. These measures will be used to monitor the progress of the nation’s overarching goals with respect to reducing health disparities. Healthy People 2020 fosters collaborations across all United States Department of Health and Human Services agencies, national organizations, state agencies, and com- munities, and motivates individuals to take a proactive role in their health.

Examples of goals and topic areas in Healthy People 2020 are provided in Table 1.3 (HealthyPeople.gov, 2012b; HealthyPeople.gov, 2013). fri80977_01_c01.indd 20 8/30/13 12:46 PM CHAPTER 1 Section 1.5 Trends That Impact Community Health in the United States Table 1.3: Healthy People 2020 overarching goals •Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

•Achieve health equity, eliminate disparities, and improve the health of all groups.

•Create social and physical environments that promote good health for all.

•Promote quality of life, healthy development, and healthy behaviors across all life stages.

Healthy People 2020 Topic Areas * New topic areas for Healthy People 2020 1. Access to Health Services 2. Adolescent Health* 3. Arthritis, Osteoporosis, and Chronic Back Conditions 4. Blood Disorders and Blood Safety* 5. Cancer 6. Chronic Kidney Disease 7. Dementias, Including Alzheimer’s Disease* 8. Diabetes 9. Disability and Health 10. Early and Middle Childhood* 11. Educational and Community-Based Programs 12. Environmental Health 13. Family Planning 14. Food Safety 15. Genomics* 16. Global Health* 17. Health Communication and Health Information Technology 18. Health care-Associated Infections* 19. Health-Related Quality of Life & Well-Being* 20. Hearing and Other Sensory or Communication Disorders 21. Heart Disease and Stroke 22. HIV 23. Immunization and Infectious Diseases 24. Injury and Violence Prevention 25. Lesbian, Gay, Bisexual, and Transgender Health* 26. Maternal, Infant, and Child Health 27. Medical Product Safety 28. Mental Health and Mental Disorders 29. Nutrition and Weight Status 30. Occupational Safety and Health 31. Older Adults* 32. Oral Health 33. Physical Activity 34. Preparedness* 35. Public Health Infrastructure 36. Respiratory Diseases 37. Sexually Transmitted Diseases 38. Sleep Health* 39. Social Determinants of Health* 40. Substance Abuse 41. Tobacco Use 42. Vision Source: Reprinted from HealthyPeople.gov (2012b) About Healthy People. Retrieved from http://www.healthypeople.gov/2020/about/ default.aspx and HealthyPeople.gov (2013) 2020 Topics & objectives—objectives A-Z. Retrieved from http://www.healthypeople.gov/ 2020/topicsobjectives2020/default.aspx .

Healthy People has made a vital contribution to community health and public health by identifying goals for the improvement of health and setting forth measures of progress toward attaining these goals. Also, Healthy People has increased attention to health dispari - ties that exist in some American populations. Finally, Healthy People goals can be used to track the effectiveness of federal public health activities.

1.5 Trends That Impact Community Health in the United States Worldwide trends in health and those in the United States demonstrate how the world’\ s inhabitants are increasingly interconnected. Many of the patterns of disease found in one geographic area mirror those in other areas. Globally, infectious and communicable fri80977_01_c01.indd 21 8/30/13 12:46 PM CHAPTER 1 Section 1.5 Trends That Impact Community Health in the United States diseases have diminished as the leading causes of morbidity and mortality, with a corresponding increase in the importance of chronic conditions such as heart disease and cancer. The term epidemiologic transition is used to describe the change from infectious diseases as the princi - pal causes of morbidity and mortality to chronic, degenera- tive diseases as the leading causes. This shift has accompa - nied urbanization and improve - ment in economic conditions in less developed areas of the world and is a global phenomenon. Figure 1.3 shows the 10 leading causes of the burden of disease globally in 2004 and projected changes by 2030. Lower respiratory infections will move from rank one to rank six. Diarrhoeal diseases, HIV/AIDS, and neonatal infections will also diminish in importance. Figure 1.3: Ten leading causes of the burden of disease—world, 2004 and 2030 2004 Disease or injury Disease or injury Lower respiratory infections Diarrhoeal diseases Unipolar depressive disorders Ischaemic heart disease HIV/AIDS Cerebrovascular disease Prematurity and low birth weight Birth asphyxia and birth trauma Road traffic accidents Neonatal infections and other COPD Refractive errors Hearing loss, adult onset Diabetes mellitus 6.2 4.8 4.3 4.1 3.8 3.1 2.9 2.7 2.7 2.7 2.0 1. 8 1. 8 1. 3 1 2 3 4 5 6 7 8 9 10 13 14 15 19 As % of total DALYs Rank 2030 6.2 5.5 4.9 4.3 3.8 3.2 2.9 2.7 2.5 2.3 1. 9 1. 9 1. 9 1. 6 1 2 3 4 5 6 7 8 9 10 11 12 15 18 As % of total DALYs Rank Unipolar depressive disorders Ischaemic heart diseaseRoad traffic accidents Cerebrovascular disease COPD Lower respiratory infections Hearing loss, adult onset Refractive errorsHIV/AIDS Diabetes mellitus Neonatal infections and other Prematurity and low birth weight Birth asphyxia and birth trauma Diarrhoeal diseases Source: Adapted from World Health Organization. (2008). Global burden of disease: 2004 updat\ e. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf .

What inferences can you make about the types of disease burdens that will increase in frequency over the next generation? Why might unipolar depressive disorders increase, while diarrhoeal diseases and HIV/AIDS incidences decrease? iStockphoto/Thinkstock Tobacco is the single leading—and preventable—cause of disease, disability, and death in the United States. fri80977_01_c01.indd 22 8/30/13 12:46 PM CHAPTER 1 Section 1.5 Trends That Impact Community Health in the United States Another implication of worldwide interconnectedness—for example, through rapid, long- distance travel—is the growing recognition that many dangerous communicable diseases are no longer confined to a limited geographic area. An infectious disease epidemic that originates in one corner of the world can easily spread to another part of the world.

With respect to the United States, several trends that affect community health are evident.

(Refer to Table 1.4.) The trends represent continuing challenges to public health and are likely to be pertinent in the future.

Table 1.4: Ten current trends that impact community health and public health NumberTrend 1. Aging of the U.S. population 2. Economic issues such as food insecurity and unemployment, which threaten community health 3. Reduced funding for public health and community health 4. Infectious/communicable diseases and their continuing challenges 5. Occurrence of health disparities (e.g., HIV disparities) 6. Population dynamics (e.g., immigration) 7. Preventable chronic illnesses 8. Substance abuse (e.g., among students and other segments of the community) 9. The obesity epidemic 10. Unintentional injuries, societal violence, and gun violence The Aging U.S. Population The population of the United States is growing older over time, and this trend will have many implications for community health. Estimates suggest that in 2030 about 20% of the population will be aged 65 and older. An increasingly elderly population will pose many challenges for living arrangements in the community and for the provision of health care, both direct care and supportive services. Adequate funding for health care services and skilled nursing facilities will need to be made available to the increasing numbers of elderly individuals so that, ideally, they can function independently.

Economic Deprivation In recent years, median household income in the United States has declined, \ and the pov - erty rate has increased (DeNavas-Walt, Proctor, & Smith, 2011). According to the 2010 United States Census Bureau statistics, the official poverty rate was 15.1%, with 46.2 mil - lion people living in poverty. Associated with poverty is growing income inequality, which refers to “[a] measurement of the distribution of income that highlights the gap between individuals or households making most of the income in a given country a\ nd those mak - ing very little” (BusinessDictionary.com, n.d.). An example of income inequality in the fri80977_01_c01.indd 23 8/30/13 12:46 PM CHAPTER 1 Section 1.5 Trends That Impact Community Health in the United States United States is the growing discrepancy between the salaries of workers employed in many service and blue collar jobs and the salaries of company executives\ .

The causes of poverty include lack of employment opportunities or, for employed persons, lack of employment that provides enough income to meet living expenses. For many occu- pations, income levels have not kept up with continuing increases in the cost of living and inflation. Poverty and unemployment contribute to the inability to obtain health care and also are associated with increased levels of morbidity and mortality. Significant propor - tions of the population are underinsured or do not have health insurance. An additional consequence of poverty is food insecurity—the inability to purchase adequate supplies of nutritious food. Food insecurity and nutritionally inadequate diets t\ hreaten the health of young children in particular and burden many U.S. families, especially single-parent families in which women are the head of household (Equal Rights Advocates, 2013).

Declines in Federal Funding for Community and Public Health During the present decade (2010–2019), federal government funding priorities hav\ e reduced monies available for many community and public health activities.\ In order to gain an appreciation of the current situation, it is important to review the historical evolu - tion of federal involvement in public health.

Public health activities originated at the state and local levels beginning approximately with the 18th century; these first efforts began with improvements in sanitation and meth - ods to control infectious diseases. Subsequently, during the late 19th and early 20th centu - ries, the federal government’s involvement in public health increased. Examples of federal involvement include the establishment of the National Hygienic Laborator\ y in 1887, the Food and Drug Act in 1906, the Public Health Service in 1912, the National Institute o\ f Health in 1937, and the Centers for Disease Control and Prevention in 1946.

With respect to funding of public health programs, Congress passed the Social Security Act in 1935. One of the provisions of the act was inclusion of funding for grants to states for public health services. The National Mental Health Act (1946) financed training programs, mental health research, and community mental health services. In 1965, the establishment of the Medicare and Medicaid programs funded health care services for the elderly and economically disadvantaged. The mechanism of Medicaid funding is the award of federal dollars to the states for financing health care. Another federal program for funding state activities was the Partnership in Health Act (1966); this program awarded grants (called block grants) for various health programs at the state and county levels.

The adverse financial impact of expanded federal financial contributions\ to public health programs became apparent with their increasing costs to the federal budget. The high costs of public health programs have been a cause for continuing debate since the 1970s.

As of 2013, drastic cuts in federal funding for public health services h\ ave resulted from across-the-board budget cuts (called sequestration). Federal support will be reduced for the CDC and Health Resources and Services Administration (HRSA). As a result, these agencies’ public health activities (in addition to the public health\ programs offered by other federal agencies) will be cut back. fri80977_01_c01.indd 24 8/30/13 12:46 PM CHAPTER 1 Section 1.5 Trends That Impact Community Health in the United States Finally, some significant changes to the U.S. government’s role in public health are under way due to the Patient Protection and Affordable Care Act, the health care reform bill Pres- ident Barack Obama signed into law in 2010. Perhaps the most immediate and apparent change will be in the area of health insurance. Adequate health insurance is a vital compo - nent of maintaining community health. However, almost one-fifth (16.3%) of the American population was without health insurance coverage in 2010, and the number\ of uninsured persons was close to 50 million (DeNavas-Walt et al., 2011). In the past, employers usu - ally provided health insurance coverage for their employees. Currently, some employers are discontinuing this practice as a result of the rising costs of insurance coverage for workers and economic challenges facing many firms, which must reduce expenditures in order to remain in business. In 2010, about one half of employers (55.3%) provided health insurance coverage to their workers. This percentage represented a decline from 56.1% in 2009. Obtaining health insurance coverage at reasonable rates is particularly difficult for persons who have preexisting conditions and disabilities. However, the Affordable Care Act will ensure access to health insurance coverage for persons who have such conditio\ ns (HealthCare.gov, 2013). Still, many individuals are now unable to obtain health insurance coverage even when available due to its high cost; another provision of the Affordable Care Act aims to improve this situation.

Challenges in Controlling Infectious and Communicable Diseases Some types of infectious and communicable diseases that can threaten the health of a com - munity are sexually transmitted diseases, vaccine-preventable diseases, and foodborne illnesses. Although chronic diseases are among the leading causes of death in the United States, infectious diseases continue to be important causes of morbidity\ and mortality.

For example, the category representing influenza and pneumonia was the eighth leading cause of death in 2008.

Sexually Transmitted Infections and Their Complications Sexually transmitted infections (STIs) such as HIV infections, syphili\ s, and chlamydia can also challenge community health by increasing morbidity and complications among newborn children. As the name suggests, STIs—also called sexually transmitted dis - eases (STDs)—are usually acquired via sexual contact. However, because the organisms involved are passed from person to person through bodily fluids, STIs can also be trans - mitted nonsexually: Newborns, for example, can contract these infections\ through their mother ’s blood or when they are delivered vaginally (Mayo Clinic, 2013). Possible com - plications of STIs include tertiary syphilis syndrome, sterility, and harm to fetuses and newborn infants. Effective interventions that are available include encouraging sexually active youth to use condoms (which are effective for reducing the risk of STIs) and to avoid risky sexual behavior. Nevertheless, often these types of prevention are not taught broadly, and sex education may be hindered in some school districts. Consequently, youth tend to not adopt these preventive measures.

Declining Immunization Rates Immunizations (also called vaccinations or inoculations) are defined as “[t]he process by which a person or animal becomes protected against a disease” (CDC, 2012h). Because of fri80977_01_c01.indd 25 8/30/13 12:46 PM CHAPTER 1 Section 1.5 Trends That Impact Community Health in the United States parental concerns about the safety and number of immuni- zations for children, as well as parents’ religious beliefs, immu - nization rates for common com- municable diseases have declined, particularly in some groups of the population. This decline is thought to have con - tributed to a resurgence of vaccine-preventable diseases such as whooping cough.

Unvaccinated, nonimmune per - sons in the United States are at risk of uncommon vaccine- preventable conditions such as measles and polio should these diseases be imported by travel- ers from endemic areas—regions where diseases are habitually present—in foreign countries.

Other Infectious Diseases Other infectious disease threats arise from use of microbial agents (for example, Bacillus anthracis), during bioterrorism attacks and emerging/reemerging infectious diseases like Hantavirus pulmonary syndrome. A growing concern for public health officials is the increasing resistance of some strains of bacteria, due to clinicians’ indiscrimin\ ate use of antibiotics.

Foodborne Illness The CDC states that “[e]ach year, 1 in 6 Americans gets sick by consuming contaminated foods or beverages. Many different disease-causing microbes, or pathogens, can con - taminate foods, so there are many different foodborne infections. In addition, poisonous chemicals, or other harmful substances can cause foodborne diseases if t\ hey are present in food” (CDC, 2012e, para. 1). Continuing examples of foodborne il\ lnesses include out - breaks on cruise ships, E. coli infections transmitted by ground hamburger, and geograph - ically dispersed Salmonella infections from poultry and contaminated vegetables. These costly events—which often dominate the attention of the media—can \ produce severe ill - nesses and even deaths, yet they are highly preventable.

Health Disparities The influential document Healthy People 2020 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environ - mental disadvantage. Health disparities adversely affect groups of people who have sys - tematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, se\ nsory, or physical Science Photo Library/Getty Images Even though chronic diseases have overtaken infectious diseases as the leading causes of death, declining immunization rates have given rise to a resurgence in some infectious diseases—such as whooping cough—in the U.S. fri80977_01_c01.indd 26 8/30/13 12:46 PM CHAPTER 1 Section 1.5 Trends That Impact Community Health in the United States disability; sexual orientation or gender identity; geographic location; \ or other characteris- tics historically linked to discrimination or exclusion” (HealthyPeo\ ple.gov, 2010, para. 5).

Two groups that consistently experience health disparities are Native Americans (Jones, 2006) and Blacks.

Population Dynamics Population dynamics comprise factors that influence the growth and decline in the size of populations. These factors, which include immigration, migration, the nu\ mber of births, and the number of deaths, hold a close connection with community health.\ Over time, the U.S. population has increased, as have the populations of many states and cities, such as the coastal areas of California. At the same time, other geographic areas have remained sparsely populated or witnessed population declines. Communities with low, widely dis - persed populations, for example, in rural areas, may have challenges in accessing health care because of distance from services and unavailability of providers. Communities that have a significant number of immigrants and high birth rates face unique\ challenges in meeting the social and health-related needs of the burgeoning population.

Preventable Chronic Diseases As noted previously, the United States has not achieved equality in health status in com - parison with similarly advanced nations, despite having the highest annual per person expenditure on health care. Preventable chronic diseases—such as hypertension, diabe - tes, and obesity—are associated with the leading causes of death in the United States. In many American communities, a substantial proportion of the population suffers from the burden of uncontrolled and unrecognized treatable conditions. The field of community health needs to sharpen its focus on reduction and prevention of such conditions in order to bring the health status of the American people up to the level reported for the citizens of other wealthy nations.

Substance Abuse Substance abuse affects all sectors of the community, from the young to the elderly. Sub - stance abuse involves the intake of psychoactive chemicals and may take \ the form of the abuse of alcohol, illicit drugs, or prescription drugs. Examples of illicit drugs are heroin and cocaine; abused prescription drugs include sedatives and narcotics. According to the WHO, Psychoactive substance use can lead to dependence syndrome—a cluster of [behavioral], cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state. (2013a, para. 1) Prescription drug abuse involves the ingestion of a prescription drug for nonprescribed purposes or in nonprescribed dosages. After marijuana and alcohol, prescription and fri80977_01_c01.indd 27 8/30/13 12:46 PM CHAPTER 1 Section 1.5 Trends That Impact Community Health in the United States over-the-counter (OTC) drugs are the third most commonly abused drugs among Amer- icans who are age 14 and older (National Institute on Drug Abuse [NIDA], 2012). The classes of commonly abused prescription drugs include opioids, such as Vicodin or Oxy - contin (for pain); central nervous system depressants, such as Valium (for anxiety and sleep disorders); and stimulants, such as Adderall or Ritalin (for attention deficit hyper - activity disorder). Cough and cold remedies containing dextromethorphan (a drug that suppresses coughs) are the most commonly abused over-the-counter medications. The abuse of prescription and OTC drugs can become addictive, placing abusers at risk for adverse health effects such as overdosing.

According to an article pub- lished in The Daily Collegian , data from the Substance Abuse and Mental Health Services Admin - istration (SAMHSA) show that “[t]he non-medical use of Adder - all among full-time students rose from 6.3 percent in 2006 to 8.3 percent in 2011” (Huangpu, 2012, para. 2). The article also pointed out that sharing Adder - all, which is a controlled sub - stance, constitutes a felony.

Students who share Adderall are placing themselves at risk of being arrested and indicted by undercover officers enrolled at colleges and universities.

Among the consequences of substance abuse are increased crime rates and adolescent delin - quency and truancy in the community. In addition, methamphetamine abuse has resulted in the creation of meth labs that are toxic to the environment and can harm people by caus - ing explosions and fires when the drug is cooked. Drinking alcoholic beverages and binge drinking can cause serious health impairments (e.g., liver diseases and\ cancer). Adverse behavioral effects include injuries, deadly automobile crashes, risky behavior, and violence.

Car crashes caused by drivers who are under the influence of alcohol and other drugs are a particularly troubling phenomenon. In the United States, alcohol-related causes including motor vehicle injuries account for approximately 79,000 deaths each year (CDC, 2012d).

Obesity From 2009 through 2010, slightly more than one-third of adults were classified as obese in the United States. Overweight and obesity are calculated by using body mass index (BMI). “An adult who has a BMI between 25.0 and 29.9 is considered overweight” (CDC, 2012f). Obesity is linked with many preventable causes of death, such as some forms of cancer, type 2 diabe - tes, heart disease, and stroke. It also contributes greatly to medical costs in the United States.

Figure 1.4 demonstrates that the percentage of obesity in the United States has increased between 1960 and 2010 at the same time that the percentage of smoking has declined. RelaXimages/SuperStock Alcohol abuse and other substance abuse has an impact on every age group within a community. Beyond the chronic health conditions brought on by excessive drinking, the community is affected by an increase in resultant crime, accidents, and other risky behaviors. fri80977_01_c01.indd 28 8/30/13 12:46 PM CHAPTER 1 Section 1.6 Multiple Determinants of Community Health Figure 1.4: Trends in the prevalence of smoking and obesity—United States, 1960–2010 Percentage of population 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2 010 Year 45 40 35 30 25 20 1510 5 0 Obesity Smoking Source: Adapted from obesity data taken from the National Center for Health \ Statistics and smoking data from the Centers for Disease Control and Prevention. National Center for Health Statistics. (2011).\ Health, United States, 2010. Hyattsville, MD: U.S. Department of Health and Human Services. Retrieved from www.cdc.gov/nchs/data/hus/hus10.pdf . Centers for Disease Control. (2011). Vital signs:

Current cigarette smoking among adults aged $ 18 years—United States, 2005–2010. Morbidity and Mortality Weekly Report (MMWR), 60(35), 1207–1212. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6035a5.htm .

What factors may have contributed to the increase in U.S. obesity? In the reduction of cigarette consumption?

Unintentional Injuries In the United States, unintentional injuries (accidents) were the fifth leading cause of death in 2008 and the leading cause of death among persons aged 1 to 44 years \ (Kochanek, Xu, Murphy, Miniño, & Kung, 2011). Unintentional injuries include motor vehicle crashes, falls, accidental poisonings, firearm injuries, recreational injuries, and industrial injuries.

Many unintentional injuries are highly preventable through appropriate community health interventions. Yet preventive programs have not been implemented effectively. 1.6 Multiple Determinants of Community Health A determinant is “[a]ny factor that brings about a change in a health condition or\ other defined characteristics” (Porta, 2008, p. 65). The theory of multiple determinants of health proposes that the health status and health-related characteristics of the community have multifactorial precursors. This theoretical perspective differs from earlier models such as Koch’s postulates, which restricted disease causality to a single overwhelming agent or factor (e.g., a bacterium) (Friis & Sellers, 2009). Robert Koch was a microbiologist who in the late 1880s developed a set of criteria (or postulates) used to dem\ onstrate that bacteria fri80977_01_c01.indd 29 8/30/13 12:47 PM CHAPTER 1 Section 1.6 Multiple Determinants of Community Health were the causes of diseases such as tuberculosis. For example, one of his postulates stated that a microorganism needs to be observed in every case of a disease caused by the mic\ ro- organism. Further, this microorganism could be cultured and transferred to a susceptible animal that would then get the infection.

Currently, the major determinants of health outcomes are considered to be part of a broader view called the ecological approach to health. The ecological approach includes the categories of environmental influences (social and physical), individual behavior, and health services. For example, the Healthy People 2020 framework indicates that “health and health behaviors are determined by influences at multiple levels[.] . . . Because significant and dynamic inter-relationships exist among these different levels of health determinants, interventions are most likely to be effective when they address determinants at all levels” (HealthyPeople.gov, n.d.). Figure 1.5 illustrates these multiple determinants and how they interact in their relationship with health outcomes. The determinants are covered in more detail in the following sections.

Figure 1.5: The ecological approach to health used in Healthy People 2020 Determinants Health Outcomes Social Environment Health Services Individual Behavior Biology &Genetics Physical Environment Source: Adapted from Healthy People 2020, HealthyPeople.gov .

The five determinants of health outcomes combine to determine the health of both communities and the public at large.

Social Determinants of Community Health Social determinants are intimately connected with the social environment, which is defined as the collective influences of a group of people upon the individual. Social deter - minants embody a wide range of variables, including race and ethnic group membership, level of education, and cultural/religious factors. Other examples of social determinants fri80977_01_c01.indd 30 8/30/13 12:47 PM CHAPTER 1 Section 1.6 Multiple Determinants of Community Health are social norms and attitudes (e.g., discrimination and residential segregation), social dis- ruptions such as crime and violence, social support, and socioeconomic st\ atus (Healthy People.gov, 2012a). These determinants may act upon the individual in both positive and deleterious ways by influencing life expectancy, morbidity from chronic diseases, disabil - ity levels, and culturally related health practices. We now discuss several examples of major social determinants.

Race and Ethnicity Racial and ethnic groups in the United States vary in their profiles of morbidity and mortal- ity (e.g., infant mortality; homicide rates; mortality from HIV disease; and mortality from heart disease, cancer, and other chronic diseases). For example, Blacks have an age-adjusted death rate that is higher than that of the White population. In comparis\ on with White males and females or Black females, Black males have the lowest life expectanc\ y at birth. Other racial and ethnic groups that show unique patterns of morbidity and mortality are Ameri - can Indians/Alaska natives, Asians/Pacific Islanders, and Hispanics/Latinos. As the United States continues to become more and more diverse, health-related differences with respect to race and ethnicity will become increasingly important for community health.

Socioeconomic Status and Education The health status of individuals varies according to their socioeconomic status and edu - cation levels. Socioeconomic status (SES)—sometimes called social c\ lass—is defined in terms of a person’s level of education, type of occupation, and incom\ e. For example, numerous empirical studies have documented that SES is inversely related to adverse health outcomes and mortality. An inverse relationship between two variables is one in which a decrease in one variable is associated with an increase in the other variable; an inverse relationship also is called a negative association. In their classic research, Leonard Syme and Lisa Berkman reported that low social class standing is associated with excesses in morbidity, mortality, and disability (Syme & Berkman, 1976). With respect to education, the United States Census Bureau reported that “households with householders who have lower levels of education were more likely to remain in poverty or move into a lower quintile [of income] than households whose householders had higher level\ s of education” (DeNavas-Walt et al., 2011, p. 4). Consequently, persons with lower education levels tend to be locked in a cycle that perpetuates numerous adverse health outcomes. The health of a community (e.g., the number of persons afflicted with preventable chronic illnesses) tends to correspond with the level of socioeconomic status within that community.

Religion and Cultural Beliefs Religion tends to be associated with cultural norms and beliefs that hav\ e implications for community health. Sometimes members of a religious denomination are concentrated in particular geographic areas and form cultural groups as in the example of the Mormons in Utah or the Amish in Pennsylvania.

Research has suggested that adherence to religious-based practices is related to health outcomes such as risk of cancer, heart disease, infectious diseases, and other conditions.

For example, some religious groups encourage their membership to restrict intake of pork products, a practice that might have implications for health. Members of t\ he Seventh-Day fri80977_01_c01.indd 31 8/30/13 12:47 PM CHAPTER 1 Section 1.6 Multiple Determinants of Community Health Adventist Church advocate a lacto-ovo-vegetarian diet that limits consumption of meat,\ poultry, and fish. Studies have demonstrated that Seventh-Day Adventists have low rates of coronary heart disease (CHD) in comparison with the general population (Friis & Sell- ers, 2009).

Social Support, Discrimination, and Segregation Social support refers to the availability of help and assistance (including emotional s\ up - port) from friends and family members. Persons who have social support tend to h\ ave greater physical and emotional resources for coping with life’s difficulties than persons who are isolated. Availability of social support bears a particularly strong positive influ - ence upon the health of certain groups in the community—for example, the elderly. By definition, residents of communities that encourage residential stability, development of strong family and community ties, and participation in community activities are likely to have higher levels of social support than those who live in communiti\ es where people tend to be more isolated.

Discrimination, an important determinant of health inequities, refers to an individual or members of a social group being treated differently because of their association with a par - ticular group. Community residents subject to discrimination are more likely than others to live in areas affected by environmental pollution, adverse lifestyle factors, and lower socioeconomic situations (Agudelo-Suarez et al., 2011). Segregation refers to the physical separation of the races in various contexts. One of the fundamental caus\ es of differences in health status among racial and ethnic groups, segregation shapes socioeconomic condi - tions at the individual and community levels (Kramer & Hogue, 2009).

The Impact of the Physical Environment on Community Health Meaningful aspects of the physical environment for community health include the qual - ity of the natural environment, presence of industrial and agricultural chemicals (many of which are toxic to living beings), air pollution, and urban crowding. As a result, the physi - cal environment is a major determinant of the health of the community. The original says, “An estimated 24% of the global disease burden and 23% of all deaths can be attributed to environmental factors.” (Prüss-Üstün & Corvalán, 2006, p. 9). This observation points \ to the role of a healthy environment in optimizing both the quality of life and length of people’s healthy lives.

The Natural Environment Flora, fauna, and climatic conditions (e.g., amount of rainfall and temperature) form the natural environment. The term green space denotes zones set aside for growing ornamen - tal landscaping plants, urban forests, small lakes, parks, nature conservation areas, and green paths that encourage walking. Well-known urban green spaces are Central Park in New York City and Golden Gate Park in San Francisco. These natural areas (urban green spaces) promote exercise, physical activity, and an opportunity to escape from the pres - sures of urban life. Researchers have reported a positive association between the amount of available green space in one’s place of residence and perceived general health (Maas et al., 2012). fri80977_01_c01.indd 32 8/30/13 12:47 PM CHAPTER 1 Section 1.6 Multiple Determinants of Community Health Toxic Chemicals and Metals Toxic chemicals include industrial solvents, pesticides, and substances called dioxins and polychlorinated biphenyls (PCBs). These substances can come from factories, farms, and disposal sites that are improperly designed. Poorly engineered disposal sites such as land- fills are unsightly and smelly and can produce toxic chemicals that may get into the ground - water. Chemicals such as these can persist in the environment for many years and become more potent as they move up the food chain. When animals higher on the food chain consume animals that are lower on the food chain, toxins can become more concentrated, which is called bioaccumulation (increasing concentration of substances in the bodies of liv - ing organisms). Toxic chemicals known as endocrine disruptors can interfere with animals’ hormone systems, causing adverse biological outcomes. They can pose a ha\ zard to humans who consume fish and other animals. Industrial facilities located in residential neighbor - hoods may release toxic chemicals that endanger community members who live nearby.

Pesticides used in agriculture are examples of chemicals that have potentially adverse health effects among farm workers who apply them. Also, residents who live near fields may be exposed to pesticide drift. An additional concern is that residues from pesticides can remain on fruits and vegetables. The United States Environmental Protection Agency (EPA) sets limits on the amounts of pesticides that are permissible in foods in order to protect consumers from harmful pesticide levels. However, some companies manufac - ture pesticides that are not registered for use in this country and have not been tested for tolerance limits in foods. These pesticides are sold to foreign countries where they can be used in agriculture. Then, agricultural products grown with these unregistered pes - ticides might be exported to the United States. Some individuals believe\ these imported foods might pose health hazards to consumers and have used the term “circle of poison” to refer to importation of foods treated with U.S.-manufactured unregistered pesticides.

Toxic chemicals and metals will be discussed in more detail in Chapter 7.

Air Pollution Air pollution—a mixture of par - ticles, gases, and other airborne substances—is emitted by mobile and stationary sources in the community. The former include motor vehicles (particularly cars and trucks), trains, aircraft, and ships. Stationary sources of air pollution are electric power plants, factories, and port facili- ties where pollution is generated by ships waiting to be off-loaded and by vehicles used for goods transport. Communities that are situated close to heavily traveled highways and major express - ways may expose their residents to high levels of traffic-related air pollution. Air pollution can Zoonar/Thinkstock Air pollution is one of the many factors negatively impacting the physical environment. Air pollutants emitted from power plants, factories, and ports can contribute to worsening asthma and other lung diseases, as well as adverse cardiovascular events. fri80977_01_c01.indd 33 8/30/13 12:47 PM CHAPTER 1 Section 1.6 Multiple Determinants of Community Health cause a plethora of damaging health effects, among them worsening of asthma, some other types of serious lung diseases, and adverse cardiovascular events. Because of their develop- ing bodies, children who live, play, and attend school near sources of air pollution are par - ticularly at risk of adverse health effects. Urbanization and the Built Environment The world is becoming increasingly urbanized as a result of population growth and the movement of persons to cities, which provide improved eco- nomic opportunities. In addition to causing rising levels of air pollution, the world’s crowded cities increase the possibility of the spread of communi - cable and infectious diseases through person-to- person contact and by disease vectors. Examples of disease vectors—living insects or animals involved with the transmission of disease agents—are mosquitoes, flies, and rats.

The structures and configurations found in cities form the built environment. City planners and public health officials use the term built environ - ment to denote “human-made (versus natural) resources and infrastructure designed to sup - port human activity, such as buildings, roads, parks, restaurants, grocery stores and other ame - nities” (CountyHealthRankings.org, 2013, para.

1). Increasingly, community health experts have recognized that thoughtful design of the built environment can affect human activity levels (for example, by encouraging people to walk instead of driving), promote personal interaction, and aid in the availability of healthful food choices and recreational opportunities. Quality of Housing Poor housing quality can have a significant impact on the well-being and\ health of a community—causing asthma exacerbations and increasing risk of cancer—and holds the potential to cause widespread harm to the majority of the population in some communi - ties: People spend up to 90% of their lives in indoor environments (Wu, Jacobs, Mitcheel, Miller, & Karol, 2007). Unsafe indoor household environments might conceal contami - nants from biological and chemical materials, lead-based paint, and rodent and vector infestations. Particularly worrisome are homes that contain lead, which is known to impact children’s learning. The presence of lead-based paint in homes is also an example of health disparities: Low-income groups, particularly people of color, are more likely than higher income groups to live in substandard housing. Unintentional injuries may result from structural defects, overloaded electrical circuits, fire hazards, and carbon monoxide poisoning from faulty heating systems. Inadequate heating, ventilation, and CACCHIA/BSIP/SuperStock With the rise of urbanization, the leading causes of death have shifted away from infectious diseases toward chronic diseases like heart disease, respiratory disease, and cancer. This shift is happening worldwide. fri80977_01_c01.indd 34 8/30/13 12:47 PM CHAPTER 1 Section 1.6 Multiple Determinants of Community Health sanitation can promote the growth of mold and increase indoor air pollution levels. Sick building syndrome refers to a condition caused by exposure of persons residing or work - ing in a “sick building” (i.e., one that exposes them to various \ potentially toxic agents that are affecting their health).

Global Warming Scientists believe that global warming may be the reason behind the northward movement of disease vectors (e.g., mosquitos that transmit Dengue fever and other viruses) over recent decades, as areas that were previously too cold for these vectors experience average tem - perature increases. Also, global warming may be contributing to extreme weather events such as fatal heat waves (within in the last few years, heat waves in C\ hicago, Moscow, and Paris have caused numerous heat-related fatalities), increasingly frequent and catastrophic floods, and droughts associated with food shortages in some parts of the world.

The Relationship Between Personal Behavior and Community Health Personal behavior is associated closely with the health of individuals a\ nd is related to the health of the community. Examples of behaviorally related health determinants are substance abuse (described earlier in the chapter), dietary choices, cigarette smoking and use of other forms of tobacco, exercise levels and physical activity, and youth and societal violence. Many of these behaviorally related determinants are linked to personality fac - tors, cultural influences, and the prevailing social climate. Adverse behavioral and life - style choices in the United States are implicated in chronic diseases heart such as disease, cancer, diabetes, obesity, and many other conditions. Some examples are described in the following sections.

Dietary Choices The dietary choices of individuals and households have obvious impacts o\ n their health and well-being. The consequences of poor dietary choices are expected to contribute to an increase in chronic health conditions, such as obesity, coronary disease, cancer, stroke, diabetes, and hypertension. Having changed significantly in recent decades, the typical American diet now contains fewer fresh vegetables and fruits and more prepared meals.

According to the United States Department of Agriculture (USDA), Americans consume too many calories, sugars, and saturated fats, and insufficient amounts of whole grains, fruits, and vegetables (USDA, 2013). Another favorite category of foods that have less nutri - tion are refined carbohydrates such as white bread and white rice. These foods have been treated to give them a softer texture. Americans’ preferences for less nutritious foods may be the result of increased availability of tasty, affordable, and convenient selections from fast food restaurants and grocery stores—which are now selling a growing selection of prepackaged and frozen meals. Nutritionists report that many of these convenience meals tend to be energy dense (have large amounts of calories) and low in nutritional value.

Tobacco and Health Tobacco use has been identified as the single most preventable cause of disease, disability, and death in the United States. Each year, roughly 440,000 Americans die prematurely fri80977_01_c01.indd 35 8/30/13 12:47 PM CHAPTER 1 Section 1.7 Organizations That Support Community and Public Health due to smoking or exposure to secondhand smoke. Even though they may be aware of the health hazards associated with the habit, approximately 46.6 million U.S. adults smoke cigarettes (CDC, 2012a). Tobacco and tobacco smoke contain more than 7,000 different sub- stances, more than 60 of which are known to be carcinogenic, or cancer causing (American Cancer Society, 2012). An extensive body of research has documented that tobacco affects nearly every part of the human body adversely. Whether tobacco is smoked, chewed, or snuffed, its consumption is hazardous.

Exercise and Sedentary Lifestyle Unfortunately, most Americans are not achieving a sufficient amount of physical activity, which is defined as 2.5 hours per week, according to 2008 Physical Activity Guidelines. Only about 48% of adults met this standard in 2008 (CDC, 2012c). In general, exercise refers to physical activity, which can be any type of repetitive body movement (CDC, 2011e). The benefits of physical activity are both physical and mental and aid in relieving depres - sion, reducing the risk of cardiovascular diseases, and building bone strength. Sedentary lifestyles place individuals at increased risk for early mortality and morbidity from heart disease, stroke, diabetes, and some types of cancer. Technological advances have made our lives increasingly sedentary: We ride escalators, drive cars, watch television, and play video games. Consequently, we have very little incentive to exercise.

Youth Violence Violence is the act of using physical force with the intent to cause harm, injury, or death to an individual. Violence among youth involves dangerous behaviors that begin in ado - lescence and may continue into young adulthood. Violent acts, such as bullying, hitting, robbery, and assault, can lead to serious injury or death. In the United States\ , widespread youth violence is the second leading cause of death for young persons who are 10 years to 24 years of age. Among the prominent examples of deadly violence are the 1999 Col - umbine High School massacre and the 2012 mass murder at Sandy Hook Elementary School in Newtown, Connecticut. In addition to causing injuries and death, violence has an impact on the health of communities by contributing to rising health \ care costs, lower - ing property values, and disrupting social services (CDC, 2012g). 1.7 Organizations That Support Community and Public Health This section covers the roles of federal governmental, nongovernmental, and international organizations that support community and public health. One of the primary\ federal gov - ernmental organizations in this respect is the United States Department of Health and Human Services, or USDHHS. Other organizations include the Environmental Protection Agency, the Institute of Medicine, and various international groups, including the World Health Organization. fri80977_01_c01.indd 36 8/30/13 12:47 PM CHAPTER 1 Section 1.7 Organizations That Support Community and Public Health United States Department of Health and Human Services (USDHHS) A unit of the USDHHS is the Office of Public Health and Science, which comprises 14 offices, including the Office of Disease Prevention and Health Promotion, the Office of Minority Health, and the Office of the Surgeon General (USDHHS, n.d.). The USDHHS contains 11 operating divisions, which report directly to the Secretary of Health and Human Services. These operating divisions include the following units: • Administration for Children and Families (ACF)—promotes the economic and social well-being of families, children, individuals, and communities. • Administration for Community Living (ACL)—maximizes the independence, well-being, and health of older adults, people with disabilities across the lifes - pan, and their families and caregivers. (The ACL now includes the Admin- istration on Aging, the Administration on Intellectual and Developmental Disabilities, and the USHHS Office on Disability.) • Agency for Health care Research and Quality (AHRQ)—improves the quality, safety, efficiency, and effectiveness of health care for all Americans. • Agency for Toxic Substances and Disease Registry (ATSDR)—serves the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and diseases related to toxic substances. • Centers for Disease Control and Prevention (CDC)—Refer to detailed informa-tion in the following section. • Centers for Medicare & Medicaid Services (CMS)—responsible for the admin-istration of federal health care programs such as Medicare (insurance program for the elderly) and Medicaid (need-based insurance program). • Food and Drug Administration (FDA)—protects the public’s health by assuring that foods are safe, wholesome, sanitary, and properly labeled; and that drugs, vaccines and other biological products and medical devices intended for human use are safe and effective. Also, the FDA regulates veterinary drugs. • Health Resources and Services Administration (HRSA)—improves access to health care services for people who are uninsured, isolated, or medically vulnerable. • Indian Health Service (IHS)—responsible for providing federal health services to American Indians and Alaska Natives. • National Institutes of Health (NIH)—Refer to detailed information in the fol-lowing sections. • Substance Abuse and Mental Health Services Administration (SAMHSA)— specializes in reducing the effects of mental and substance use disorders. SAM - HSA offers contracts and grants, programs, statistical information, and literature, as well as support of policy development with respect to behavioral health. Centers for Disease Control and Prevention (CDC) The CDC, the leading federal agency for public health, “is recognized as the nation’s pre - miere [sic] health promotion, prevention, and preparedness agenc[y]” (CDC, 2013a, para.

3). Founded in 1946, and now an operating component of the USDHHS, the \ CDC is based in Atlanta, Georgia. As of 2012, the CDC employed about 15,000 workers and operated on a budget of $6.9 billion. CDC staff members work in all 50 U.S. states and in over 50 countries, where they aid in control of infectious diseases and related issues (CDC, n.d.). fri80977_01_c01.indd 37 8/30/13 12:47 PM CHAPTER 1 Section 1.7 Organizations That Support Community and Public Health The director of the CDC is appointed by the U.S. president and oversees seven offices: • Office of Public Health Preparedness and Response • Office for State, Tribal, Local, and Territorial Support • National Institute for Occupational Safety and Health • Office of Surveillance, Epidemiology, and Laboratory Services • Office of Non-Communicable Diseases, Injury, and Environmental Health • Office of Infectious Diseases • Center for Global Health.

When it was founded, CDC’s original function was control of malaria (CDC, 2013a). How - ever, since the founding of the CDC, its activities have expanded greatly and now encom - pass eight areas, including controlling unintentional injuries, responding to emergency health threats, investigating disease outbreaks in the United States and globally, detecting foodborne disease outbreaks, creating health-related data, and implementing disease pre - vention strategies (CDC, 2010).

The largest allocation ($2.2 billion) of CDC’s budget in fiscal year 2012 \ was for protec - tion against infectious diseases such as HIV/AIDS, respiratory disease, and tuberculo - sis (CDC, n.d.). Two key functions of CDC are surveillance (continuous monitoring) of infectious diseases such as influenza and foodborne illness and compilin\ g statistics on the occurrence of infectious and other diseases. One of the programs operated by CDC is the Epidemic Intelligence Service (EIS), a 2-year postgraduate training program. Trainees, called EIS officers, provide assistance at the local level with respect to outbreak investiga - tions and surveillance of infectious diseases (CDC, 2012b). The CDC pu\ blishes Morbidity and Mortality Weekly Reports, which presents accounts of infectious and other diseases. National Institutes of Health (NIH) The mission of the National Institutes of Health (NIH) “is to seek \ fundamental knowledge about the nature of behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce the burdens of illness and disability” (NIH, n.d., para. 1). This mission is supported by conducting and supporting \ research on the causes and prevention of diseases (mental, addictive, and physical) in humans, stud\ ying the effects of environmental contaminants, and disseminating information about health and medicine. The NIH is a very complex organization that comprises 27 institutes and centers plus several programs (for example, the Office of AIDS Research) housed in the Office of the Director. The NIH institutes are as follows: • National Cancer Institute (NCI) • National Eye Institute (NEI) • National Heart, Lung, and Blood Institute (NHLBI) • National Human Genome Research Institute (NHGRI) • National Institute on Aging (NIA) • National Institute on Alcohol Abuse and Alcoholism (NIAAA) • National Institute of Allergy and Infectious Diseases (NIAID) • National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) • National Institute of Biomedical Imaging and Bioengineering (NIBIB) fri80977_01_c01.indd 38 8/30/13 12:47 PM CHAPTER 1 Section 1.7 Organizations That Support Community and Public Health • Eunice Kennedy Shriver National Institute of Child Health and Human Devel-opment (NICHD) • National Institute on Deafness and Other Communication Disorders (NIDCD) • National Institute of Dental and Craniofacial Research (NIDCR) • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK\ ) • National Institute on Drug Abuse (NIDA) • National Institute of Environmental Health Sciences (NIEHS) • National Institute of General Medical Sciences (NIGMS) • National Institute of Mental Health (NIMH) • National Institute on Minority Health and Health Disparities (NIMHD) • National Institute of Neurological Disorders and Stroke (NINDS) • National Institute of Nursing Research (NINR) • National Library of Medicine (NLM) United States Environmental Protection Agency (EPA) The United States Environmental Protection Agency (EPA), a federal government agency, has the mission “to protect health and the environment” (EPA, 2013a). In order to imple - ment this mission, one of the EPA’s responsibilities is to formulate and enforce environ - mental regulations. The EPA is involved with implementing congressional environmental laws and setting national environmental standards. An important aspect of the EPA’s work is educating the public about environmental issues and publishing reports about the environment. The EPA administrator is appointed by the president of the United States.

Headquartered in Washington, D.C., the EPA has 12 headquarters offices as well as 10 regional offices that address local concerns. Among the headquarters offices are the Office of Air and Radiation, Office of Research and Development, Office of Solid Waste and Emergency Response, and the Office of Water. The EPA has more than 17,000 employees and a proposed budget of $8.344 billion for fiscal year 2013.

Institute of Medicine (IOM) Not affiliated with the federal government, the Institute of Medicine plays an\ important role in advising members of government and individuals in the private sec\ tor regard - ing crucial health issues. One of the branches of the National Academies, the IOM “is an independent, nonprofit organization that works outside of government to provide unbi - ased and authoritative advice to decision makers and the public” (IO\ M, 2013, para. 1). In addition to the IOM, the National Academics include National Academy of Sciences, the National Academy of Engineering, and the National Research Council.

In 2002, the IOM published a groundbreaking report on health disparities. The report highlighted the lower quality of health care that persons from ethnic and minority groups receive in comparison with White individuals. This report has been instrumental in turn - ing the attention of the public and community leaders to the urgent need to improve the quality of clinical and related services for minority groups. The words of the IOM were quite compelling: “[M]inorities are less likely than whites to receive needed services, including clinically necessary procedures. These disparities exist in a number of disease areas, including cancer, cardiovascular disease, HIV/AIDS, diabetes, and mental illness, fri80977_01_c01.indd 39 8/30/13 12:47 PM CHAPTER 1 Section 1.7 Organizations That Support Community and Public Health and are found across a range of procedures, including routine treatments for common health problems” (IOM, 2002, p. 2).

As a follow-up to the 1988 IOM report (discussed earlier in the chapter), the IOM released For the Public’s Health: Investing in a Healthier Future in April 2012. For the Public’s Health argued that “[t]he poor performance of the United States compared with its global peers in life expectancy and other major health outcomes . . . reflects what this nation chooses to purchase; clinical care has far greater spending priority than population-based prevention and, more broadly, than social investments, such as child well-being” (IOM, 2012, p. 101). The report proposed transformation of the way the nation invests in health to pay mor\ e attention to population-based prevention efforts. The introduction to the IOM’s report is provided in Spotlight: For the Public’s Health: Investing in a Healthier Future.

Spotlight: Introduction to For the Public’s Health: Investing in a Healthier Future Debate over America’s place at the top of economic superpowers aside, it is clear that it is not a super - power in health. In fact, this Institute of Medicine (IOM) Committee on Public Health Strategies to Improve Health asserts that merely reaching the average of comparable high-income countries in health status would require considerable national effort. Despite spending far more on medical care than any other nation, and despite having seen a century of unparalleled improvement in population health and longevity, the United States is now falling behind many of its global counterparts and competitors in such health outcomes as overall life expectancy and the incidence of preventable diseases and inju - ries. A fundamental but often overlooked driver of the imbalance between spending and outcomes is the nation’s inadequate investment in strategies that promote health and prevent disease and injury population-wide. Strategies that are often summarized by the set of Essential Public Health Services include monitoring and reporting on community health status; investigating and controlling disease out - breaks; educating the public about health risks and prevention strategies; implementing community- wide health improvement initiatives (including the social and physical environment); developing and enforcing laws and regulations to protect health; and assuring the safety and quality of water, food, air, and other resources necessary for health. All of these services require coordinated action at the local, state, and national levels, and public health departments have essential roles in informing and mobiliz - ing public- and private-sector efforts.

Source: Reprinted from IOM (2012, pp. 13–14). The complete report may b\ e retrieved from http://www.nap.edu/catalog.

php?record_id=13268 .

In conclusion, the IOM reports have been used to set policy and are far reaching in the United States with respect to health care services and delivery. The reports have served as an impetus to improve services to minority populations and to target health domains in which the United States trails other developed countries. An important implication of the 2012 report is the need for the health care system to increase emphasis on prevention of disease. The health status of Americans will be enhanced through greater investments in social and medical services, more support of the educational system, and larger financial contributions to society by giant corporations, many of which benefit fr\ om government subsidies. fri80977_01_c01.indd 40 8/30/13 12:47 PM CHAPTER 1 Section 1.7 Organizations That Support Community and Public Health International Organizations That Support Public Health Numerous international organi- zations are involved with the support of public health. One example of the types of support provided is programs for improvement of water and sani- tation in the developing world.

Another example is technical assistance for the operation of health data systems such as the design of epidemiologic surveil- lance systems and health pro- gram evaluation. Among the international organizations that support public health are WHO, the European Commission, and the Organization for Economic Cooperation and Development.

Headquartered in Geneva, Switzerland, WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. In the 21 st century, health is a shared responsibility, involving equitable access to essential care and collective defense against transnational threats. (WHO, 2013c, p. 2) WHO was founded on April 7, 1948; each year April 7 is celebrated as World Health Day.

About 8,000 people from 150 countries are WHO employees. A total of six regional offices assist in meeting the health-related needs of specific areas—for example, Europe. Dur - ing 2006–2007, the total budget of WHO was about $3.3 billion. Health-related activities include interventions for communicable and noncommunicable diseases, hea\ lth policy, and health promotion.

The European Commission sponsors the Second Program for European Action in the Field of Health. The objectives of the program are to improve health security, promote health, reduce health inequalities, and disseminate information about health.

The OECD is an organization made up of 34 countries. The organization is involved with numerous health-related activities germane to community health and regularly publishes an extensive compilation of data on health and health systems among OECD\ member states. See h t t p://w w w. o e c d . o r g/e l s/ h e a lt h - s y s t e m s/ for more information. Danuta Hyniewska/age fotostock/SuperStock The World Health Organization (WHO) is a public health body for the global community. The WHO includes representatives from 150 countries. On a smaller scale, the Department of Health and Human Services is the public health body responsible for the U.S. community. fri80977_01_c01.indd 41 8/30/13 12:47 PM CHAPTER 1 Summary Summary Community health refers to the overall health status of a community. Positive health sta- tus of a community is essential for providing a setting in which individuals can thrive and lead productive lives. Public health is a science and art that stresses health promotion and disease prevention at the population level and thus contributes to optimal community health. The core functions of public health are assessment, policy development, and assur - ance. The chapter gave examples of these functions.

In the United States, community health has shown dramatic improvements during the past century. Currently, life expectancy is estimated at 79.5 years. Nevertheless, the nation lags behind other developed peer countries with respect to life expectancy and other health indices. Also, many preventable risk factors, such as tobacco use, and chronic con - ditions, such as diabetes and hypertension, are prevalent among Americans.

In this chapter, we reviewed trends in and determinants of community health in the United States and in the world. We viewed community health from the perspective of the ecologi - cal approach, which encompasses influences from the social environment and the physi - cal environment, as well as from individual behavior. We traced the history of community health from its origins in the classical period to the present. An overview of the roles of federal agencies (and the funding they provide for public health), the IOM, and interna - tional organizations that promote community and public health was provided. Finally, we examined goal-setting documents from Healthy People (for example, Healthy People 2020).

Study Questions and Exercises 1. Give two definitions for the term health. What limitations are there for the World Health Organization’s definition of health? 2. In what ways is the health of the community significant for the health o\ f the indi - vidual and vice versa? 3. In your opinion, how do health disparities, discrimination, and segregation impact community health? 4. Define the term multiple determinants of community health. 5. Give three examples of social influences upon the health of the community. 6. Provide an argument for the roles of social environmental, physical environmen- tal, and lifestyle factors in the health of the community. 7. Give two examples of health-related developments that occurred during each of the following historical time periods: classical era, Middle Ages, the Industrial Revolution, and recent history (e.g., 20th and 21st centuries). 8. Describe the functions of the CDC and the USDHHS with respect to community health. 9. In your own words, state how the poor health status of Americans as described in the Institute of Medicine’s 2012 report For the Public’s Health: Investing in a Healthier Future came about. 10. In what ways does Healthy People 2020 set an agenda for community health in the United States? Be sure to give some examples. fri80977_01_c01.indd 42 8/30/13 12:47 PM CHAPTER 1 Key Terms Key Terms built environment All manmade resources and infrastructure that supports human actions such as roads, parks, build- ings, and similar facilities. community A group of people living within a defined geographical space or region; they may also share common val- ues, norms, cultures and social structure. community empowerment The art of groups working collectively to control and improve the health factors within their community. community health The health status of a group of people within one specific community. determinant Any element or factor that can influence a person’s health status. endemic Indicates that a condition is habitually present in a particular geo- graphic area. epidemic The occurrence of a disease that affects a specific geographic region (i.e.

community, state, nation). epidemiologic transition A change in the leading cause of mortality and morbidity (in the United States, this transition went from infectious diseases to chronic diseases as the leading cause). health As defined by the World Health Organization, health is a state of complete physical, mental, and social well-being and not just the absence of disease. healthy community A community whose belief system focuses on the elements required for optimal health and wellness. Healthy People 2020 A national strategic health initiative to prevent and reduce a plethora of diseases and health conditions; it formulates science-based strategies to improve the nation’s health by the end of the 21st Century. health education Programs, campaigns, and classes that promote health and awareness of health risks. immunizations Vaccines that can protect against certain diseases. pandemic An epidemic that spans beyond one specific geographic region, such as to include several countries, or continents. public health The science and art of preventing disease, prolonging life and promoting the health of populations. morbidity A state of disease or symptoms. sick building syndrome A condition caused by exposure of potentially toxic agents trapped within a building that affects the health of a person or persons working or residing therein. social environment Collective influences of a group of people upon one individual. social support The availability of help and assistance (including emotional support) from friends and family members as well as the community. wellness The state of optimal health for an individual or group. World Health Organization (WHO) An international organization headquar - tered in Geneva, Switzerland that directs and coordinates all global health matters within the United Nations system. fri80977_01_c01.indd 43 8/30/13 12:47 PM fri80977_01_c01.indd 44 8/30/13 12:47 PM