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David L. Streiner Douglas W. MacPherson Brian D. Gushulak
David L. Streiner, Douglas W. MacPherson, and Brian D. Gushulak
Like sausage-making, the process of making and delivering public health policy and programs may be a mystery we’d prefer to ignore. Even so, when done well the results can be very good indeed – much like this book. Its description of the history of public health and its importance in the present is often humorous, but never fails to deliver the essential information. Outbreaks of infectious, and often deadly, transmissible diseases are clearly still very much with us, so it’s as important as it ever was to understand basic information about the role of public health. The goal of this book is to provide the reader with an understanding of public health, complete with due attention to the necessary details and also the ironies in how public health tools have evolved. Be prepared to laugh your way through the matters of life and death that are addressed in the book; bear in mind the proven health benefits of laughter, which helps stave off the degenerative and lifestyle diseases that we are prone to acquiring these days. Covers the three phases of the epidemiological transition: the Age of Pestilence and Famine, the Age of Receding Pandemics, and the Age of Degenerative and Man-Made Disease. Provides a comprehensive list of acronyms and abbreviations (and defines the difference) in common use in public health, along with some that are just in common use. Enhances the concepts presented with germane, and usually humorous, quotes.
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ISBN-13: 978-1-60795-044-8 ISBN-10: 1-60795-044-8
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ACKERMANN PDQ PHYSIOLOGY BAKER, MURRAY PDQ BIOCHEMISTRY CASSILETH et al. PDQ INTEGRATIVE ONCOLOGY CORMACK PDQ HISTOLOGY DAVIDSON PDQ MEDICAL GENETICS INGLE PDQ ENDODONTICS, 2/e JOHNSON PDQ PHARMACOLOGY, 2/e KERN PDQ HEMATOLOGY McKIBBON, WILCZYNSKI PDQ EVIDENCE-BASED PRINCIPLES AND PRACTICE, 2/e NORMAN, STREINER PDQ STATISTICS, 3/e STREINER, NORMAN PDQ EPIDEMIOLOGY, 3/e SCHLAGENHAUF-LAWLOR, FUNK-BAUMANN PDQ TRAVELERS’ MALARIA SCIUBBA PDQ ORAL DISEASE
*PDQ (PRETTY DARNED QUICK)
Pretty Darned Quick
David L. Streiner, Ph.D., C.Psych.
Professor of Clinical Epidemiology and Biostatistics and of Psychiatry McMaster University Faculty of Health Sciences Hamilton, Ontario, Canada
Douglas W. MacPherson, M.D., M.Sc.
Professor of Pathology and Molecular Medicine McMaster University Faculty of Health Sciences Hamilton, Ontario, Canada Migration Health Consultants, Inc. Cheltenham, Ontario, Canada
Brian D. Gushulak, M.D.
Migration Health Consultants, Inc. Cheltenham, Ontario, Canada
2011 PEOPLE’S MEDICAL PUBLISHING HOUSE–USA SHELTON, CONNECTICUT
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Library of Congress Cataloging-in-Publication Data
Streiner, David L. PDQ public health / David L. Streiner, Douglas W. MacPherson, Brian D. Gushulak. p. ; cm. — (PDQ) Other title: Public Health Includes bibliographical references and index. ISBN-13: 978-1-60795-044-8 (alk. paper) ISBN-10: 1-60795-044-8 (alk. paper) 1. Public health. I. MacPherson, Douglas W. II. Gushulak, Brian D. III. Title. IV. Title: Public Health. V. Series: PDQ series. [DNLM: 1. Public Health. WA 100] RA425.S77 2011 362.1—dc22 2010031836
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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.
TABLE OF CONTENTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 1: What Is Public Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Brief History of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dogma and Disease —The Sociology of Public Health . . . . . . . . . . . Bad Smells, Bodies, and Boards of Health: Controlling Disease Becomes a Legislative Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . We Can See You Now—Germs Identified as the Enemy . . . . . . . . . . Better Sanitation Through Cleaning the Gene Pool—Eugenics and Social Engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Why Modern Schools of Public Health Owe Their Origin to an Alpine Railway Tunnel—The Medical Science of Social and Economic Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . It’s Easier to Prevent It Than Treat It—Mid-20th Century Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Public Health and Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Taking Care of It Yourself—The Ascent of Health Promotion . . . . Meetings and Definitions—Making Sure Everyone Is on the Same Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 2: Classical Key Concepts In Public Health . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some Basic Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communicable Diseases, Vectors, Hosts, and Environments . . . . Person, Place, and Time—The Determinants of Health . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 3: Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Uses of Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods of Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sources of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spectrum of Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attributes of Surveillance Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi 1 1 5 10 17 22
24 27 30 32 33 41 41 42 50 57 66 69 69 70 77 85 91 91 96
Chapter 4: Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Counting the Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Measures of Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Measures of Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 DALYs, QALYs, and Other Outcome Measures That Don’t End in “LY” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Chapter 5: Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 On the Varieties of Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Risk Perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Communicating Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Risk Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Chapter 6: Mitigation and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Changing the Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Making a Difference—Modern Public Health Interventions . . . . . . 174 The Origin of Population Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Chapter 7: Globalization of Public Health and the Influence of Population Mobility: A Selective History of Human Disease Outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Globalization and Public Health Over the Ages . . . . . . . . . . . . . . . . . . . 188 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Chapter 8: The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Changing Management of Threats, Risks, and the Perception of Risk in Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Interconnectivity and Globalization of Public Health . . . . . . . . . . . . . 227 Integration of Health and Public Health Capacities— Coordination and Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Population Mobility and International Diversity and Disparity . . 236 Moving From Stakeholders to Stewardship: Integration of Health, Public Health With Other Nonhealth Sectors . . . . . . . . . . 237 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
What can be said about public health that has not been said before, particularly in the context of what will drive you unerringly to buy this book? From the perspective of the authors, and as presented in this book, making and delivering public health policy and programs is very similar to the process of making sausages—no one really wants to know how it’s done, but when it is done properly the results can be very good, even if you are a vegetarian…or a politician, a member of the public, or a student or practitioner of the subject. With painstaking attention to (some of) the details and (much of) the irony in how the tools of public health have evolved and are applied for the detection, measurement, and intervention in public health threats and risks, the goal of this book is to firmly place an understanding of public health in your hands…but be sure to wash carefully afterwards. For many years now, we’ve heard that we’re in the third phase of the epidemiological transition. First, there was the Age of Pestilence and Famine, when the major health threats were infectious diseases. This phase of what was to become public health started long before anyone knew what an infectious disease was, or how diseases were transmitted, or what the Germ Theory is (or indeed, what germs are). These threats were expressed as the risk for things like the plague (The Black Death), cholera (the flux), and tuberculosis (TB, consumption). Note that the lack of knowledge did not hamper really good names being given to things they did not understand. Then, with the introduction of better sanitation and the discovery of antibiotics, we thought that we had either eliminated most infectious diseases (e.g., smallpox) or brought them under some degree of control (such as polio and TB), and we entered the Age of Receding Pandemics. But, one reality of life is that none of us gets out of it alive, and if we don’t die of one thing, we’ll die of something else. So,
viii PDQ: PUBLIC HEALTH
“conquering” the infectious diseases that knocked our ancestors off at an earlier age has led to the third phase, the Age of Degenerative and Man-Made Diseases, like cancer, Alzheimer’s Disease, and stroke. Another note, “degenerate diseases” or those of “lewd and lascivious” behaviors and those associated with persons of “low moral turpitude” often crept into public health jurisdiction in all three of these phases. For a while, it seemed as if the only place students of public health could learn about the field was in the History department, rather than in a Faculty of Medicine (or “Health Sciences,” to use the current jargon). Then a funny thing happened—as attention was being turned to non-contagious diseases of interest to the public (such as hypertension, hypercholesterol, some cancers, obesity, and others) it turned out that outbreaks of infectious, and often deadly, transmissible diseases of public health significance weren’t just a thing of past; they were with us all the time, and we just weren’t paying too much or perhaps enough attention. Some of the diseases were new (e.g., HIV/AIDS, Viral Hemorrhagic Fevers, Severe Acute Respiratory Syndrome), but many were ones we thought we had all but wiped out, particularly in economically advanced regions such as North America, Europe, Australia, and New Zealand. Due to a confluence of many factors, issues continue to arise in public health. For example, fears that the mumps, measles, and rubella (MMR) vaccine may cause autism, combined with religious opposition to vaccination, and people who were too old to have received the MMR vaccine as children but were not old enough to have developed a natural immunity through exposure, resulted in epidemics of these diseases in affected countries, such as the U.S., Canada, and the Netherlands between 2004 and 2009. In the U.K., up to 70,000 people may have contracted one of these diseases (Gupta et al., 2005). Furthermore, although the Pure Food and Drug Act and the Meat Inspection Act were passed in reaction to Upton Sinclair’s muck-raking novel, The Jungle (1906), hardly a week goes by that we don’t read about some outbreak of E. coli or Salmonella infection, due to contaminated meat, vegetable produce, or even peanuts. Dying from the foods we eat is hardly a phenomenon only of developing countries or our distant past; nor is succumbing to the water we drink. In May of 2000, half the residents of the
• P RE FAC E
town of Walkerton, Ontario, developed serious gastrointestinal problems from E. coli O157:H7 from farm run-off in the drinking water, and seven people likely died of the poisoning. Another factor in the public health equation has been the access, availability, and affordability of international air flights. People may not be able to bring knives, guns, or hair spray with them onto the plane, but nothing stops them from carrying infectious diseases. Although malaria and dengue fever were effectively wiped out in the U.S. in the 1950s, in 2001 alone, there were 107 cases of dengue infections (Beatty et al., 2005), and 1,383 cases of malaria (Filler et al., 2003), all courtesy of people coming as tourists, immigrants, or some other category of international traveler from areas where these diseases are endemic. Population mobility and globalization of public health threats and risks has always been a characteristic of public health, it is just getting really big now. So, while we discuss the history of public health and the application of the essential tools in disease identification and control, this book is intended for people who want to learn about the topic as something relevant for today, not just for the history books. One last word. Each section in every chapter opens with a quote. Sometimes, these are germane and serious. Whenever we could find an appropriate one, though, we’ve used a quote that’s germane and humorous. But, given the choice between appropriateness and humor, we always opted for the latter. Matters of life and death aren’t to be taken too seriously. References
Beatty, M. E., Vorndam, V., Hunsperger, E. A., Muñoz, J. L., & Clark, G. G. 2005. Travel-associated dengue infections—United States, 2001–2004. MMWR 54: 556–558. Filler, S., Causer, L. M., Newman, R. D., Barber, A. M., Roberts, J. M., MacArthur, J., et al. 2003. Malaria surveillance—United States, 2001. MMWR 52: 1–14. Gupta, R. K., Best, J., & MacMahon, E. 2005. Mumps and the UK epidemic 2005. BMJ 330: 1132–1135. Sinclair, U. 1906. The jungle. New York: Doubleday.
—David L. Streiner —Douglas W. MacPherson —Brian D. Gushulak
as an aid to what follows. —G. If you can pronounce it—like SARS or AIDS—it’s an acronym.ACRONYMS AND ABBREVIATIONS Like other occult techniques of divination. the social science. if it can’t be pronounced—FDA. which is designed to foster communication with other insiders. (Yes.) So. and to dazzle the rest of the world with our erudition. O. we just like them. has its own jargon. But. some of them you won’t see in the book. Ashley The world of public health. (Actually. statistics. as with every specialty. there is a difference. and government. the statistical method has a private jargon deliberately contrived to obscure its methods from non-practitioners. public health has a surfeit of acronyms and abbreviations.) AIDS—Acquired Immunodeficiency Syndrome AR—Attributable Risk ARR—Absolute Risk Reduction AR%—Attributable Risk Percent BCG—Bacillus Calmette-Guérin BRFSS—Behavioral Risk Factor Surveillance System xi . herewith is a list of the abbreviations and acronyms you’ll encounter in this book. being at the intersection of medicine. epidemiology. HIV—it’s an abbreviation.
DC. H2. Neuraminidase 1 (two surface proteins on Influenza viruses. Switzerland IPV—Injectable. as in Influenza (2009) H1N1. killed Polio Vaccine ISID—International Society for Infectious Diseases ISTM—International Society for Travel Medicine LDL—Low-Density Lipoprotein LOL—Laughing Out Loud LOL—Little Old Lady MDR—Multiple-Drug Resistant (organism). Washington.xii PDQ: PUBLIC HEALTH BSE—Bovine Spongiform Encephalopathy CDC—Centers for Disease Control and Prevention. Atlanta. and N1 or N2 commonly affect humans) HALE—Healthy Life Expectancy HCV—Hepatitis C Virus HDL—High-Density Lipoprotein HIV—Human Immunodeficiency Virus IATA—International Air Transport Association IOM—Institute of Medicine. USA (see USFDA) FEAR—F**k Everything And Run FUBAR—F**ked Up Beyond All Recognition (WW II slang) GACD—Global Alliance for Chronic Diseases GAVI—Global Alliance for Vaccines and Immunization GOMER—Get Out of My Emergency Room! GYAT—Get Your Act Together H1N1—Hemagglutinin 1. Georgia. as in MDR-TB (See XDR-TB) . USA CIHI—Canadian Institute for Health Information CRP—C-reactive Protein CVD—Cardiovascular Disease DALY—Disability Adjusted Life-Year DHS—Department of Homeland Security FDA—Food and Drug Administration. Geneva. there are 16 H and 9 N subtypes in influenza. of which only H1. USA IOM—International Organization for Migration. or H3.
also known as tuberculin PPV—Positive Predictive Value ProMED—Program for Monitoring Emerging Diseases QALY—Quality Adjusted Life-Year RCT—Randomized Controlled Trial RR—Relative Risk RRR—Relative Risk Reduction SARS—Severe Acute Respiratory Syndrome SIV—Simian Immunodeficiency Virus SMR—Standardized Mortality Rate SNAFU—Situation Normal – All F**ked Up (WW II slang) TB—Tuberculosis TropNetEurop—European Network on Imported Infectious Disease Surveillance TST—Tuberculin Skin Test .• AC R O NYM S A N D A B B R E V I AT I O N S xiii MMR—Mumps. Rubella vaccine MRSA—Methicillin-Resistant Staphylococcus Aureus NAMCS—National Ambulatory Medical Care Survey NHANES—National Health and Nutrition Examination Survey NHAMCS—National Hospital Ambulatory Medical Care Survey NIOSH—National Institute of Occupational Health and Safety NMFS—National Mortality Feedback Survey NOEL—No Observable Effect Level NPV—Negative Predictive Value (see PPV) NNT—Number Needed to Treat NVSS—National Vital Statistics System OPV—Oral Polio Vaccine OR—Odds Ratio PAHO—Pan-American Health Organization PAR—Population Attributable Risk PAR%—Population Attributable Risk Percent PMR—Proportional Mortality Rate PPD—Purified Protein Derivative (see TST). Measles.
xiv PDQ: PUBLIC HEALTH UN—United Nations UNAIDS—Joint United Nations Programme on HIV/AIDS US—United States of America—don’t know why the “A” gets dropped. USFDA—United States Food and Drug Administration USPSTF—United States Preventive Services Task Force VOA—Voice of America WHO—World Health Organization XDR-TB—Extensively Drug Resistant TB (sometimes referred to as “extremely” but only by those who want to make a different point in public health) YLD—Years Lost to Disability YLL—Years of Life Lost YPLL—Years of Potential Life Lost .
What is Public Health?
Again and again in our planning we ponder the increasing scope of public health demands, the rapidity of change, the mounting pressures of new and growing health problems, the shortages of qualified personnel, the need to obtain more knowledge through research, and above all the increasing difficulty of coordination in the planning and execution of activities. —Roy J. Morton (1958)
A BRIEF HISTORY OF PUBLIC HEALTH
Those who don't study the past will repeat its errors; those who do study it will find other ways to err.
—Charles Wolf, Jr. quoted in the Wall Street Journal, Feb. 26, 1976
Like the weather, everyone seems to be talking about public health, and similarly, no one seems to be doing anything about it. Television, print media, and the Internet are replete with stories, articles, and commentaries about various threats and risks to public health, and discussing the political, policy, and programmatic challenges and what society and individuals can do. Taking a historical perspective, it has always been thus. Society
2 PDQ: PUBLIC HEALTH
is concerned with its collective health and well-being. While the explosion of modern media sources provides more outlets and therefore greater volume commenting on school closures and H1N1 influenza, a reader of newspapers or a viewer of news reels in the last century would have seen the same messages about polio in the 1950s (Oshinsky, 2005) and virtually every other disease outbreaks since the dawn of mass communication. Similarly, newspapers of the 19th century would have carried stories about cholera or yellow fever, and accounts of plague graced the news media of the century before that. These examples represent one view of public health. This public view focuses on the social, community, and organizational
FIGURE 1-1. Public health poster from Spanish flu era. 'Prevent Disease. Careless Spitting,
Coughing, Sneezing, Spread Influenza and Tuberculosis'. Image courtesy Rensselaer County Tuberculosis Association, Troy, New York (Wiki Commons)
C h a p ter 1 • WHAT IS PUBLIC HEALTH?
FIGURE 1-2. Example of a public health poster from World War I.
responses to perceived threats and real disease risks. It’s like a history of public health made up of a scrapbook of oral instructions, religious and social guidance, pamphlets, broadsheets, news headlines, posters, notices and signs on trains, streetcars and buildings, and now television, YouTube videos, blogs, and Twittering (see Figures 1-1 and 1-2). Behind the “public” history of public health there is another, parallel, history reflecting three basic factors. The first factor that has played an important role in developing what we know as public health derives from the observational skills of individuals who were able to look at specific situations or events and ask questions that made a difference. The story of public health is marked by the impact of such people, many of whom were not physicians but hat makers, lawyers, soldiers, mathematicians, and other strange beasts. A second important factor has been the science and technology of the time. Medicine’s and the public’s responses to leprosy and polio, for example, have changed dramatically (and not always for the better) as our understanding of them improved and new interventions became available. Finally,
4 PDQ: PUBLIC HEALTH
public health has been shaped by the long, tedious, and unglamorous process of standardizing definitions, classifications, and actions. Over time, these three factors have supported each other in developing public health, and that process continues today. Many of the important aspects of public health began with observation and example during human history and predate written history. Linking survival to safety and health was an essential part of our evolutionary learning curve, as evidenced by the fact that we’re here to write this book (and you to read it). As children, when we wanted to put some unknown plant or a berry into our mouths, a parent would say “Don’t eat that, it will make you sick!” (Often followed by the injunction, “If you kill yourself, you won’t get dessert tonight!”). While the ancient societies that developed these food taboos did not leave written records, we can assume that learning what was harmful to eat came from the gained knowledge of those who had boldly gone where no one had gone before and gotten sick or died as a consequence. This is easy for items that cause immediate illness, but one can only imagine how much sickness and death occurred as humanity learned to process foods that are palatable, such as cassava or akee (Dufour, 1994), but can subsequently be very toxic. Early public health observations and practice extended far beyond dietary activities. One of the first described smallpox control practices is attributed to a Buddhist nun in the 1700’s, who scraped up and dried flakes of smallpox-encrusted pustules, pulverized them to dust, and blew the powder up susceptible people’s noses. This technique of stimulating protective immunity, known as variolation after the virus that causes smallpox, Variola major, was adopted in many centers in China, India, Turkey, and later in Europe. Voltaire said that Circassian women deliberately gave smallpox to their children, especially daughters, to protect their skin from disfiguring pox marks (Voltaire, 1733/ 2004). The wife of the British Ambassador to Istanbul, Mary Wortley Montagu(e), who herself had suffered from smallpox, had her children inoculated in this way. As could be expected, there were a few “postmarketing” complications among the nasal recipients of smallpox dust. One was full-blown smallpox with death occurring in about 2 to 3% of the recipients. This was an improvement over the 20 to 30% mortality rate associated with the disease itself (Gross & Sepkowitz,
C h a p ter 1 • WHAT IS PUBLIC HEALTH?
1998). With the variolation technique, the overall smallpox disease case-fatality rate is said to have fallen by 90%. Variolation, of course, is not the only example of communitybased disease management practices of its time that had public health overtones. For hundreds of years, mothers throughout Asia were scraping the leading edges of the weeping ulcers of cutaneous leishmaniasis to inoculate their children’s buttocks to protect them against the cosmetically debilitating facial scarring of Oriental Ulcer. The next major step in smallpox control came from England and a physician named Edward Jenner (Riedel, 2005). Jenner observed that milkmaids rarely got smallpox or, if they did, it was very mild. He had also noted that milkmaids often had blisters on their hands similar to the skin lesions of smallpox. This was cowpox, or vaccinia (from the Latin for cow or vaca), acquired from the teats of the cows. In 1796, much as had been done previously by the Buddhist nun with Variola major and the mothers in Asia with Leishmania tropica, Jenner took the weeping, pusladen fluid from a cow’s teat blisters and “vaccinated” a young boy. Although the medical community resisted the technique of vaccination early on (starting a pattern of resistance to vaccination that persisted well into the 20th century), it rapidly achieved favor over variolation. The challenge was to maintain fresh vaccinia lesions to use as a source of inoculum material. In areas where the vaccinia virus was not available for protection against smallpox, such as in some areas of Africa and the Americas, the indigenous people suffered horribly from smallpox disease that had been introduced by Europeans during their periods of exploration, colonization, and conquest.
DOGMA AND DISEASE —THE SOCIOLOGY OF PUBLIC HEALTH
Many fledgling moralists in those days were going about our town proclaiming there was nothing to be done about it and we should bow to the inevitable.
—Albert Camus, The Plague
Arab. pork products (Trichinella). are forbidden to touch a corpse or even to enter a cemetery. these principles were passed orally from one generation to the next. As social structures and religion evolved. While some beliefs may have served to maintain social exclusion and positions of power for the wealthy who could afford to live in cleaner or “unfouled” environments. 2008) was often seen as the gods favoring the righteous or devoted. hungry. . members of the tribe of the high priests (the Kohanim). Similar codes of conduct were developed to deal with which animals can and cannot be eaten (e. decay. and the instructions of teachers. It has been hypothesized by some (e. In Judaism. When disease did strike the penitent. Before people could record their history. Jewish. who are to remain pure so that they can bless others. Beliefs about the positive health aspects of diet and exercise. the lessons learned by observations. it was often blamed on drifts from dogma. 1953) that these and other prohibited foods are more likely to carry disease.. Rules of behavior in early human societies often included edicts that can be seen to have implications for public health. and poorly housed (what in public health would now be called “health inequalities”) (Commission on Social Determinants of Health. and elders were codified. what is kosher in Judaism or halal in Islam). many societies developed faith-based linkages between diet. and scavengers (everything else). bad experiences. Over generations. they also provided a philosophy and examples that health could be affected by ones’ actions and environment.. prophets. explaining the risks of certain behaviors and activities. behaviors.g. and disease occurred more often among the poor. and many aboriginal populations. The fact that plagues. Indian.6 PDQ: PUBLIC HEALTH The basis of public health is trying to prevent or reduce future harm.g. both ancient and modern. including protocols on dealing with the dead and cadavers. pestilence. and the approach to eating or using animals that were found dead or who died on their own (forbidden). such as shellfish (Vibrio). overcrowded. including the ancient Greeks and Egyptians. and decomposition and either health or social status. as well as the antiquarian and current Chinese. or objects exist many cultures. Macht. and from the avoidance of some activities. cleanliness. for example.
Larger mobile communities can manage waste and garbage simply by moving to new hunting or gathering grounds. particularly disfiguring. Instructions regarding aspects of sanitation were provided by early religious texts. The development of static towns and cities. or entire states. and practices that needed to be done after “contamination” or contact with evil. cities. and religion have had a great impact on the sociological approaches to disease and illness. Deuteronomy 23:13 provides instructions on covering excreta: and you shall have a spade among your tools. however. and some of those connections influenced how communities respond to sanitation and the risks—both real and perceived—posed by some infections. which often included the diseases they came down with (at least those they survived). Cleanliness was often associated with religious activities and could involve ritual preparations for devotion or rites. required methods to avoid being swamped in the detritus of human and animal existence. physical fitness. ritual. Greek cities had regulations dealing with keeping streets and fountains clean (Arnaoutoglou. Sewers and drains have been seen in early cities such as Minoan society in Crete (Corrigan. and it shall be when you sit down outside.. 2008). and sport were activities and attributes of wealthy Greek and Roman cultures. Waste and sanitation for small groups of people usually do not exceed the capacity of the environment to absorb or degrade it. 1948). 1932). Descriptions of plagues and epidemics. Bathing. either in thought or deed (Oldenberg. Clerical principles of cleanliness and purity could easily become transformed into an organized societal response to illness. The relationships between health.C h a p ter 1 • WHAT IS PUBLIC HEALTH? 7 The development of writing allowed people to record their history. 1998). 1993). because they affected large populations. Public health themes are frequent and recurrent components of those records (Pack & Grand. you shall dig with it and shall turn to cover up your excrement. . recur in ancient and classical history and these historical events continue to be referred to even in the modern public health literature (Morens et al.
. Some of these refuges for the sick also became involved in assisting those afflicted with a long-feared disease. Lepers were isolated. leprosy. 2005). 2007). The latter term FIGURE 1-3. 1999). or “dirty” diseases (Porter. 1997). was based on the concept of risk of transmission of adverse outcomes (Laungani. Because of its mistaken biblical associations (see Chapter 3). Not only did religious guidance recommend how some diseases were to be dealt with. or caste. status. Linking religious practice and dogma to disease control are historically related to many aspects of modern disease control. the belief that purity or religious status could be contaminated by contact with others of a particular occupation. known in Europe as leprosaria or lazarettos (Figure 1-3). prevented from social contact. the care of the ill by religious orders became associated with the development of what later became hospitals and hospices (Lewis. leprosy triggered a series of community actions sanctioned by the Christian church in an attempt to control the disease (Watts.8 PDQ: PUBLIC HEALTH loathsome. resulting in clerical institutions becoming involved in health care. Over time. but many religions also recommend or required duty to the poor and sick. Even before people understood the Germ Theory of disease. A leprosarium (from Wellcome Trust). and housed or detained in specific institutions.
With the exception of a small number of infectious diseases of serious public health importance for which quarantine and isolation may be required. Thus the process of “quarantine” was as both named and developed. marginalization. Experiments in timing. 1929). led to determining that most commonly 40 days of isolation was sufficient (Clemow. Public health activities and policies are now more focused on eliminating the economic. As people reflexively turn to the tools and practices that they know. .C h a p ter 1 • WHAT IS PUBLIC HEALTH? 9 FIGURE 1-4. some leprosaria even issued their own currency. with Britain alone having more than 100 (Brothwell. the sociological nature of public health has turned full circle. and lack of social contact actually create more problems than they solve. and environmental disparities that are now known to affect health. who it was believed suffered from leprosy (Luke 16: 19–31). social. Coins issued by a leprosarium in Colombia. As seen in Figure 1-4. owes its origin to Lazarus the Beggar. which we assume involved waiting until everyone who was going to get sick and die had done so.1300’s that isolation and separation of the sick and the exposed were used to try to control the disease. 1958). it is not surprising that when Europe was faced with the plague in the mid. Many modern population-based public health principles recognize that isolation. By the 13th and 14th centuries there were thousands of leprosaria in Europe. Lazarettos and leprosaria provided the model—and in some cases the facilities—in which those arriving from plague-affected regions were detained.
Although many of the principles we recognize as core to public health were developed in Africa. states. but on an examination more strictly by the justices of peace. you wouldn’t want to send out sick men to be killed. European scientific advances. BODIES. provided much of the canvas on which the public health as we know it today was painted. as did agriculture and other labor sectors. and Europe. —Daniel Dafoe A Journal of the Plague Year The end of the medieval period was associated with many changes that affected the history of public health. and in some cases entire nations. such as the plague. hungry. it was a civic necessity. The number of cadavers that needed to be dealt with during the 17th century bubonic plague in Europe challenged existing capacities in many locations (Byrne. To maintain local services. But the burials in St Giles's were fifty-three—a frightful number!—of whom they set down but nine of the plague. when the number of the plague was seventeen. 2006). as a king. Much of the written history of public health has a European focus. besides others concealed.10 PDQ: PUBLIC HEALTH BAD SMELLS. and unhoused people posed risks of social unrest that could threaten the political system (so much for charity as a noble endeavor). Military forces required large contingents of men with at least a modicum of good health (after all. became involved in assisting the poor and sick. The relative political stability of Britain. coupled with imperial and colonial connections. it was found there were twenty more who were really dead of the plague in that parish. combined with . and at the Lord Mayor's request. AND BOARDS OF HEALTH: CONTROLLING DISEASE BECOMES A LEGISLATIVE PROCESS The next bill was from the 23rd of May to the 30th. Asia. Widespread poverty and illness were closely related to the development of social support systems. many municipalities. The ruling classes also knew that large numbers of sick. and shared among these regions. Maintaining economic and military services and capacities became more than a religious duty. would you?). but had been set down of the spottedfever or other distempers. exceeded the abilities of religious orders to provide for the ill and destitute (see Figure 1-5). Major epidemics.
resulted in several important developments in public health to be first observed. Column in Vienna commemorating victims of the plague of 1605. . recorded. and greater edu- FIGURE 1-5. with their large populations. At the same time. had expanding linkages with other locations. increasing both the frequency and consequences of epidemic diseases. Cities. Urbanization changed the character of many nations.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 11 the growth of scientific methods. the development of the printing press. the introduction of paper making. and then exported from there.
Parish death records. The addition of some talented and inquisitive individuals who began to examine these relationships in more detail led to one of the major developments in public health—statistical analysis (although many students would not see this as a positive development). Yale University.12 PDQ: PUBLIC HEALTH cational opportunities provided tools that could be used to study health and the factors that affected it. . managing debts and estates. and deaths. known in Britain as Bills of Mortality (Fig. the more complex issues of taxation. marriages. served as an early epidemiologic FIGURE 1-6. 1-7). and social support for the poor required additional methods of keeping track of who was where and how many of them there were. However. Church records routinely recorded births. Plague doctor. Harvey Cushing/John Hay Whitney Medical Library.
His work. record of the impact of plague and other epidemics. entitled The Observations upon the Bills of Mortality and published in 1662. Presidential elections) and discussed it with Graunt and others.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 13 FIGURE 1-7. He called this “political arithmetic” (which is to be differentiated from what happened in Florida in the 2000 U.S. Sir William Petty. Yale University. it can be seen that together. was also interested in how quantitative measures could be used to study economic and social activity. December 1664. The collected Bills of Mortality from London. In England. A physician colleague of Graunt. is recognized as one of the earliest applications of statistical analysis in the field of health. Harvey Cushing/John Hay Whitney Medical Library. a scientifically inclined clothing merchant named John Graunt examined local Bills of Mortality to try to understand the deaths of children and the nature of epidemics like the plague. England. Looking backwards. the work of Graunt and Petty represent one of the important beginnings of .
France. Against this background of services and support systems that were less and less able to provide for those in dire need. The results were urban congestion. In the 1830’s. as larger and larger numbers of people moved to rapidly expanding urban areas.) In 1842. who began to appreciate the relationships among and social consequences of poor sanitation and poverty. (There’s nothing like a few beheadings to clarify one’s mind. This document represents one of the earliest national analyses of the relationships among poverty. as the poor remained fodder for the sweatshops. he published The Report from the Poor Law Commissioners on an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain. However. cities became larger and industry moved from the cottage or guild to the factory. sanitation. and health. remained ever-present in the minds of those who governed. In Europe. and bad social outcomes. and is considered a milestone in the development of public health. and their allies also released large numbers of soldiers into a society that did not have jobs for many of them. Edwin Chadwick.3% of lawyers who are given a bad name by the other 97. The report was delivered at a time when the Germ Theory of disease was not yet widely accepted in Europe. further exacerbating the stress on existing social programs and services. particularly those of the rich. economic development. they quickly overwhelmed municipal services that were built for smaller populations.14 PDQ: PUBLIC HEALTH the science of statistical analysis. as exemplified by the French Revolution.7%. (He must have been one of the 2. frequent poor health. One of those involved in this process was the lawyer.) Reducing the social and economic consequences of poverty and disease assumed increasing importance as the industrial revolution continued to change the face of many nations. and poverty provided tools that governments and individuals could use in their political and commercial activities. Much . the examples of what a disenfranchised population could do. Greater urbanization and industrialization generated wealth that improved many lives. Using public records to quantify the impact of death. The end of the long-standing worldwide conflict among England. Britain began to look at what would be now called social assistance programs through a review of the Poor Laws that had existed in one form or another since Elizabethan times. health.
were based on principles that were often incorrect. Villermé established a prototypical medical journal dealing with public health . The frequent reference to British activities in public health does not mean that they were alone in the field. Change had to await election of a new government in Britain. the first national legislation of its type (except for the U. As such. such as that health could be improved through better sanitation. improvements sometimes did occur. including New York City. but we are being Euro-centric for the moment). were common.S. both the political and social implications of Chadwick’s report were too much for the government of the time to deal with. when a period of drought reduced the flow of the Thames River and its ability to clear sewage from the city. some of the assumptions. As students of history know. was reduced nonetheless by the construction of effective sewers.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 15 of the scientific and medical thought of the time associated the presence of many diseases with miasmas. and poor social graces (which many parents still believe accounts for the behavior of their children). while not a consequence of the bad odors and gases resulting from the lack of sewerage systems. studied and wrote about the health of the disadvantaged. began to build London’s sewer system (Haliday. that the opposite of progress is Congress. In France. London suffered through what was called the “Great Stink.” Quickly. Joseph Bazalgette.S. 1848 was a period of great unrest and revolution in much of Europe. His actions were copied in many places. and those who worked in unsafe environments. The passage of legislation however. funds were allocated and an engineer. and attempts to improve the lot of the poor so that they would not threaten the status quo of the wealthy. real attention to cleaning up the sanitation of London did not start until a decade later. incarcerated. Cholera. does not necessarily lead to action. In spite of the Public Health Act. In a situation that frequently recurs in the history of public health. reinforcing the belief in the U. Despite this. British legislation became a model of governance for many other nations and many of the principles can be seen today in national approaches to dealing with public health…and stand-up comedy. legislation 50 years earlier. 1999). following which a Public Health Act was enacted in 1848. bad smells. Alexandre Parent-Duchâtelet and Louis-René Villermé.
A personal interest in his family’s history led him to note gaps in the state’s births and deaths records. Winslow. and the collection of demographic data. This cornerstone report laid out some 50 recommendations regarding sanitation and provided a concrete model for state public health law. uniform disease definitions. In the United States. like Chadwick in Britain. C.S. the American Statistical Association recommended that Massachusetts conduct a sanitary survey of the state. especially with regard to using the person as the unit of enumeration. 1949). and regulation. began his professional life as a teacher. Lemuel Shattuck. Shattuck made recommendations about sanitation. regular sanitary surveys. On both sides of the Atlantic. This was followed by a detailed report on the Census of the City of Boston in 1845 ( Shattuck.K. another icon of public health. civic engineering. There he became involved in civic affairs and became a member of the city council. He successfully lobbied the State of Massachusetts to pass a Vital Statistics Act in 1842 that became a model for other jurisdictions. which came out in 1850 (Smillie. rather than the family. which he strove to correct. another non-medically trained icon of public health. The report recommended boards of health.-E. civic planning and the teaching of preventive medicine in medical schools. Shattuck was the chair and recorder for the Commission that wrote the Report of a General Plan for the Promotion of Public and Personal Health. In 1848. described civic demography in both social and economic terms. . Like Chadwick’s in Britain. vital statistics. In 1948. 2003). Shattuck’s work was seminal in terms of establishing public health legislation and regulation in the United States.16 PDQ: PUBLIC HEALTH (Annales d’hygiène publique et de médécine légale) that continues today (Szreter. these reports defined the nature. could move as slowly on public health recommendations as the U. demonstrating that the U. in which he. later moving to Boston where he worked as a bookseller and publisher. 1850). Shattuck was aware of Chadwick’s work and applied similar analytic descriptions to human conditions. it encompassed aspects of public health that included sanitation. noted that 36 of Shattuck’s recommendations had been universally accepted while a further 10 were in the process of being established (Winslow. 1949).
wasn’t an apple). an accomplished physician and anesthetist. “I will greatly increase your suffering and your childbearing. since Genesis 3:16 quotes God as saying. including Francis Galton and William Osler. The primacy of sanitation would remain until the advances in microbiology. Many at the time. WE CAN SEE YOU NOW—GERMS IDENTIFIED AS THE ENEMY In science the credit goes to the man who convinces the world. and vector control later in the 20th century. Back in Britain. he . Their application would influence the nature and practice of public health during this period when sanitation and public health engineering was the primary focus of public health. making him the father of obstetric analgesia. by the way. What was good enough for the Queen became good enough for the rest of the childbearing population. and organization of public health in the Englishspeaking world as the 20th century dawned. the second pandemic of Asiatic cholera was more successful. It was proving to be an exception to the rule that “the pen is mightier than the sword or disease” as it reached London by the fall of 1848. John Snow. the development of antibiotics. In 1848. As an anesthetist and respirologist. he was a physician of other talents as well. —Sir Francis Darwin. while the continental revolutions of 1848 had failed to reach the Island. Eugenics Review. Snow was keen observer and scientist and had become recognized as an expert in the use of ether and chloroform anesthesia. Snow’s reputation was such that he would later be asked to administer inhalation anesthesia for the birth of two of Queen Victoria’s children. not the man to whom the idea first occurs. While students of public health know of him for his work on cholera. in pain you shall bring forth children” as punishment for eating the fruit of the tree (which.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 17 administration. April 1914 This quotation serves as a metaphor for itself. too. including religious teachers. felt that the use of anesthesia during childbirth was improper. lived in the city at that time. as it is attributed to several other authors. he turned his mind to considering the nature and transmission of cholera.
Snow hypothesized that. He published his landmark epidemiologic study on the Mode of Communication of Cholera in 1849. not breathe it in. Studies of the residence of cholera patients and the source of their drinking water led him to speculate that water contaminated with sewage was responsible for the disease. Needless to say. and interventions to interrupt transmission. In 1853. suggested to him that one had to consume the transmissible material. as it was believed by many at the time to be a malady transmitted through the air. the analysis of cases and location data. is now regarded as one of the fathers of investigative epidemiology (Henry Whitehead is largely forgotten. While Snow anticipated the nature of transmissible agents spread through the contamination of water with sewage. workers in those occupations should be the most affected. People had known that small creatures could be . Be that as it may. It was not until 1866 that the waterborne theory of cholera transmission was widely accepted (Ramsay. but we’re not sure what it is). They also hypothesized a link in Germany to the first (index) case in Soho. They concluded that water drawn from a specific well was associated with the spread of disease. and work in proximity to offal and waste. John Snow.18 PDQ: PUBLIC HEALTH was well placed to explore the disease. 2006). as cholera was devastating the people of Soho in London. The most likely suspects then were the bad smells and foul air associated with the tanners and butchers. however. they were ridiculed despite the good outcomes. The disease returned to London as part of the Third Pandemic of Cholera (1852–1860). through the use of observation. the parish priest Henry Whitehead was working with Snow mapping out the cases and deaths due to cholera. there’s a lesson there. As the Germ Theory of disease became more accepted. Of course. if the disease were airborne. it took considerably longer until science was able verify those assumptions. physicians and scientists increasingly studied how infections were transmitted. His studies. This was the origin of modern epidemiology. his ideas were not accepted and folks who believed that cholera was transmitted by the odors of decomposition (miasmas) continued to hold primacy (at least until they died of cholera). Together they were able to convince the parish fathers to remove the handle from the Broad Street pump (see Figure 1-8) and in doing so stopped the cholera outbreak in Soho.
While convinced that the microbes were . mouths. and disease. However. and beverages since Anton van Leeuwenhoek invented the microscope and saw what he called animalcules. food spoilage. food. found in their water. The Broad Street Pump.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 19 FIGURE 1-8. in France. while studying fermentation. noted that preventing microbial access could delay and prevent bad outcomes. it was some time later that Louis Pasteur.
He presented his work in 1873 and it was published in 1874. The solution was left to a German physician and microbiologist. When the pathogen from step (2) is introduced into a healthy organism. 4. Gerhard Hansen. The pathogen should be able to be isolated from the organism in step (3). he was convinced that the microbe was responsible for leprosy. Although he could not demonstrate transmission of the disease either in animals or humans (he lost his hospital position for attempting to inoculate the disease into a patient without consent [Kato. or chemicals in the air or water. who was able to identify the cause of anthrax (he used solid media) and through an elegant series of experiments developed the principles that define the nature of infectious diseases (see Table 1-1).20 PDQ: PUBLIC HEALTH involved. a meticulous pathologist. in Bergen. The official party line at this time was that leprosy was a congenital disease. . The pathogen must be found in every organism that has the disease. Norway. Koch’s postulates 1.1. 3. the principles of immunization were applied. Pasteur introduced vaccination using attenuated anthrax organisms in 1881. A few hundred kilometers to the north of Pasteur and Koch. Robert Koch. His critics suggested that without the absolute proof that microbial agents caused disease or spoilage. deliberately administering infectious material to induce immunity for prevention of disease was already known. it must become ill. when following the recognition of the microbial cause of anthrax. He was quick to apply the process to other diseases such as rabies. 1973]). making it difficult to obtain pure cultures. was noticing the presence of a particular rod-shaped bacterium in every specimen of leprosy he studied. he was unable to isolate and identify individual organisms. it was possible that the effects were due to compounds. More than a century later. His difficulties in that regard related to his use of broth media for growth. extending the lessons of Jenner from the previous century. 2. toxins. Hansen not only gave his name to the disease but was the TABLE 1. The pathogen must be able to be isolated from a organism person and grown in a culture. As we’ve seen.
who now applied the Germ Theory of infection to his principles of antisepsis and disinfection (and gave us the name for a mouthwash. Semmelweis’s increasing psychosis and eventual early death in an asylum did little to strengthen his reputation. Disease and ill health were again associated with dirt. He was born in Hungary and while working as a physician in 1847 in Vienna (since they were both part of the Austro-Hungarian empire) demonstrated that having medical students disinfect their hands after leaving postmortem theaters and before attending deliveries could reduce the incidence of puerperal fever. and contamination. One of those listening was Joseph Lister in Britain. Pasteur. and others were widely disseminated and for those who believed in the Germ Theory of disease.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 21 first to suggest that a chronic disease could be caused by microbes (Vogelsang. which limited their appreciation of the science. 2005)—an unfortunate example of publish and perish. probably not the best way to be immortalized). Cleanliness and sterilization became routine components of health care and the principles were extended to other aspects of daily life. 1965). The extension of public health into the workplace had begun with . while containing the basic elements of his observations. His publication. It did not take long for these sanitary principles to be applied to industrial and occupational situations. but now it was known that the reasons were biological and not chemical. and his reputation and importance in the history of sanitation were both developed and recognized only after his death (Loudon. One of the other interesting stories of the sanitary period of public health is that of Ignaz Semmelweis. filth. The scientific discoveries of Koch. the impact of his work was actually limited at the time. 2005). who is often cited as the physician who reduced much of the impact of puerperal or childbed fever. While the document is frequently referred to as a milestone in public health history. shoes began to drop as it became possible to more clearly explain and understand the infectious cause of disease. It took him a few years to publish his findings and by that time he was beginning a long spiral into mental disorder. The Germ Theory of disease explained a great deal and supported sanitary movements. airborne. or moral. also included aggressive and bellicose attacks on his critics (Dunn.
packaging. pasteurization. on June 30. Standardization and uniformity were required to ensure market retention. The end of the 19th century was a period of profound social. is often credited with raising public demand for better inspection and regulation to ensure food safety.22 PDQ: PUBLIC HEALTH the earlier associations of poverty. Simultaneously. and dietary supplements. The health risks of unsafe working conditions. 1906). political. including inspecting. Old orders in Europe were under great pressure . medications. but occupational health now began to include sanitary and biological components. the food manufacturing and preparation industry was going through a technological revolution. a graphic description of the meat packing industry published in 1906 (Sinclair.S. squalor.. Modern occupational health. foods. and monitoring foodstuffs. this led to the passage of the Pure Food and Drug Act and its companion bill. In addition to the public media. 1985). Public media also began to focus on the real and perceived health risks of industry. the Meat Inspection Act. Since 1810. The Jungle. —David Gerrold. scientific study of the content and quality of food and medicinal products demonstrated the need for systems to ensure that ingredients were not harmful and that consumers were getting what they were paying for. became easy for the public to understand. regulating. American writer The social and economic aspects of health have been interpreted as both a cause and an effect over time. In the U. the United States Pharmacopeia has been involved in this area related to pharmaceuticals. 1906 (Barkan. BETTER SANITATION THROUGH CLEANING THE GENE POOL— EUGENICS AND SOCIAL ENGINEERING The problem with the gene pool is that there’s no lifeguard. and railway distribution supported a more centralized food and beverage industry. and disease. and scientific change. and manufacturing in general. particularly when they were also dirty or loathsome. is a continuation of these practices. Canning.
and consequences of these differences. and physical factors. large numbers of poor Eastern and Southern Europeans became migrants. If the nature of the problem was biologic. Such principles were presented as a component of public health. took place during a period of social and political change. while at the same time increasing the need for labor manufacturing capacity. and what we now see as results of poverty were postulated as its causes. Just after the turn of the 20th century. Increasing demands for labor and capital alternated with periods of recession. Through this lens. at the time the picture was not that clear. 1904).C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 23 from an increasingly aware and politically motivated population. Although issues of class and status had always been components of immigration when migrants came primarily from Western Europe. Sir Francis Galton. he suggested that by supporting “positive” traits. the arrival of large numbers of migrants who were more culturally diverse coincided with debates about the origin. Science and technology were providing new and wonderful things to those who could afford them. Driven by politics. repression. poverty. it was suggested that some of the social and medical ills seen among the poor were due to unfavorable biologic. health implications. in some cases. Further. mental. it would be possible to improve society in general by encouraging those with the best ones to have more children. These movements. might not the solution be similar? It was suggested that some of the social and health issues of the day might have biologic origins and thus be amenable to scientific solutions. proposed that society could benefit from the study of heredity (Galton. and. an English scientist who was familiar with both the science of genetics and the principles of evolution. beginning in the latter 1800s. was limiting the number of those with less positive attributes. The impact of . of course. The converse. which had severe impacts on the poor in places where social and welfare services were limited. While it is now clear that it was the social and health consequences of poverty that created marginalized communities. 2003). and used to restrict or limit reproduction by those with “inferior” or “undesirable” characteristics (Wilson. accompanied by cycles of economic expansion and contraction. it was reasoned. The expanding economies of America and Western Europe provided opportunities for many people in the rest of Europe.
forced sterilization of convicts and the mentally or physically impaired. The full impact of eugenics on immigration peaked in the early 1920s. and to reduce the importation of what were seen as old world social problems. and for those suffering with disease. 1913. The importance of eugenic principles in public health practices was frequently noted in the early part of the 20th century. 848). The object of the medical supervision of immigration is to exclude the physically and mentally unfit. Unfortunately. Public Health Services noted: On arrival at domestic ports. thereby bringing about the further increase of insanity in the United States (Anderson. ultimately. WHY MODERN SCHOOLS OF PUBLIC HEALTH OWE THEIR ORIGIN TO AN ALPINE RAILWAY TUNNEL— THE MEDICAL SCIENCE OF SOCIAL AND ECONOMIC DEVELOPMENT Education is that which remains when one has forgotten everything he learned in school. eugenic principles began to be applied by those nations experiencing large flows of immigration. They were applied to better the “race.24 PDQ: PUBLIC HEALTH eugenics can be seen in early 20th century marriage laws. hospitals are maintained. immigration restrictions. 2010). p.S. —Albert Einstein . eugenics is not simply a relic of a less-enlightened age. In 1913. and. the former Prime Minister (now the “Minister Mentor”) strongly encouraged college graduates to marry only other college graduates. who will endow their offspring with an unstable mentality. The quasi-scientific nature of eugenics was used to influence the legislative approach to the medical management of immigration. In Singapore. the Director of the Hygienic Laboratory of the U. in the race purification atrocities of Nazi Germany. all aliens are required to undergo medical inspection. in order to “uplift the national stock” (Jacobson.” to prevent degeneration. and especially the latter. In the early part of the 20th century.
shoeless. Italian physicians correctly deduced that. Rockefeller established the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease. The success of the campaign .C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 25 While some were laboring to improve the gene pool through the principles of eugenics. sponsored treatment. he studied the hookworm infections and became convinced that a part of the problem of worker productivity was due to the extensive prevalence of hookworm and its complications. people who were barefoot were more likely to become infected with hookworm. One clue to that development came from Europe. In the United States. 1981) and was aware of the impact that the disease had on the Gotthard Tunnel workers.S. The Commission was to determine the extent of the disease and then reduce its prevalence.S.. which affected labor output in the southern U. and epidemiology to directly improve health outcomes. the northern stereotype of the lazy. Extending expanding U. due to the length of the tunnel.S. southern farm worker was partially correct. industry to the south would require social development in the region and that became a goal of many in the commercial sector. a railway tunnel was built between Switzerland and Italy at the Gotthard Pass. thus contaminating others due to poor footwear. statistics. particularly the building of pit toilets designed to reduce larval contamination of the soil (Link. An American zoologist named Charles W. It developed a large campaign that trained local practitioners. supported laboratories to identify the parasite. had an interest in hookworm (Ettling. 1988). During its construction. much of the former Confederacy had been slow to develop and advance after the Civil War and by the early part of the 20th century. the workmen had defecated near where they were working. Stiles.) He presented his findings to the General Educational Board created earlier by John D. (Interesting. and educated the public in sanitation. others were using the expanding sciences of microbiology. The “laziness” could be explained by profound anemia. On his return to the U. who had studied under Pasteur. Stiles’s message was heard and in 1909. industrial capacity and the overall economy were far lower than in the north-eastern states. Rockefeller to support and improve rural communities through education and development. Decades earlier. In 1880. many workers suffered from diarrhea and anemia. particularly anemia.
while still others felt that there was no need for new schools if existing universities could be expanded. Some argued that it should be part of clinical medicine. was not quite collaborative. the Dean of the Johns Hopkins School of Medicine. began to exceed the capacities of traditional universities. others supported the concept of linked courses at different universities and institutions. as well as the earlier fields of statistics and epidemiology. In America. after a meeting of Rockefeller’s General Educational Board in 1914.26 PDQ: PUBLIC HEALTH was a force in the creation of the Rockefeller Foundation and its International Health Board that later supported hookworm elimination and prevention programs in the Caribbean and Latin America. who became involved in public health and became the director of the Rockefeller Hookworm Commission. the University of London established a School of Tropical Medicine in 1905. and advocated centralized schools of public health in each state that would turn out armies of practical workers. the tensions underlying the definitions of who should lead the way in public health. there were diverse opinions regarding what was best. Insightful organizations. Not surprisingly. The Board asked for a report on how to teach public health and two figureheads of the profession were asked to prepare it. 2009). The two versions of the report actually recommended conflicting designs. Welch. as the initial draft prepared by Rose was modified by Welch and submitted to the Board without being reviewed by Rose. The report. however. In Britain. This conflict mirrored. a teacher and professor of philosophy. Some wanted separate schools. individuals. a School for Health Officers was jointly established by MIT and Harvard University in 1913. One was Wickliffe Rose. The other was William Welch. on the other . and universities established what would now be called “centers of excellence” to focus on public health (Evans. Rose differentiated the “science of hygiene” from medicine. Things really took off. while others argued just as vociferously that public health must include sanitary engineers and social scientists. Acquiring the skills and training to manage the expanding role of public health that now included biology and microbiology. much like the agricultural extension workers (a program also funded by the Rockefeller Foundation). in a way. submitted in 1915.
” which would be centers of research. 1991). if I had it written down: but I can't quite follow it as you say it. antibiotics were becoming available and vaccine science was expanding. including Harvard University. and public health was very effective in dealing with some of international health threats of the “not very united” world of the early 20th century. At the same time. The Rockefeller Foundation’s work in hookworm in Brazil. Later. IT’S EASIER TO PREVENT IT THAN TREAT IT— MID-20TH CENTURY PUBLIC HEALTH I think I should understand that better. and displaced persons. although they still occurred in less developed . meant that another talented individual. not headquarters for field workers (Fee & Acheson. the University of Michigan.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 27 hand. for example. refugees. By the middle of the 20th century. public health had begun to lean towards prevention activities that extended beyond hygiene and sanitation. and the University of London. and were integrated into faculties of medicine where those schools were not as dominant. advocated “Institutes of Hygiene. the Foundation supported the establishment of schools of public health at other places. separate schools of public health were set up where medical schools were powerful. Fred Soper. Alice’s Adventures in Wonderland The Second World War turned public health activities towards protecting military forces from disease and managing epidemics among prisoners. The increased ability to treat infections with antibiotics while preventing other diseases through vaccination decreased the global impact of epidemics. was in the country when it faced epidemics of both yellow fever and malaria resulting from Anopheles gambiae mosquitoes imported from Africa. The mixture of philanthropy. To a large degree. —Lewis Carroll. with the support of the Rockefeller Foundation. The Welch-Rose Report led to the creation of the School of Hygiene and Public Health in 1916 at the Johns Hopkins University. science.
1950. epidemiology increased our understanding of risk and showed where we could intervene. many of the repressive aspects associated with the misguided attempts to improve the gene pool. p. water.28 PDQ: PUBLIC HEALTH regions of the world. Control of many pediatric infections and improved obstetrical care now meant that greater attention could be given to other pediatric problems. over time. lifespan increased and chronic diseases began to replace infections and acute illnesses in physicians’ offices. state and national health departments. as exemplified by identifying the health risks of tobacco (Doll & Hill. In many countries. and disease registries developed in the early part of the century. Better diagnosis and treatment for many diseases were accompanied by greater attention to their natural history and progression. increased knowledge about the nature and biology of genetics made possible by the burgeoning science of molecular biology ended the unhappy existence of eugenics and. and soil pollution assumed public health importance in the industrialized world as we began to discover the etiologies of . 470). Hammond et al. coupled with improved understanding of psychiatric and mental illness. At the same time. 2009). Better laboratory and microbiological techniques provided new insights into previously obscure infections such as viral hepatitis.. The role of the environment and the consequences of air. Public health interventions aimed at improving maternal-child care became mainstream. At the same time. and conditions associated with genetic disorders. 1954. The development of medications to manage psychiatric symptoms (none existed prior to the mid-1950’s). The treatment and impact of mental disorders were also evolving. led to a more humane and treatment-oriented approach to mental disorders. Public health organizations delivered food guides and extolled the benefits of appropriate nutrition (we’ll ignore. for the moment. and similar advances were made in the area of nutrition and diet. An editorial in American Journal of Public Health noted: “It is an encouraging sign of the alertness of leaders in medicine and public health that interest in the problems of chronic illness is growing with leaps and bounds” (Anonymous. that these guides seem to change more often than the seasons). A growing number of epidemiologists were beginning to take advantage of the vital statistics and standardized data collection that resulted from the creation of boards of health.
there is no question about the benefit of removing a virulent infectious disease from the world. One of the most outstanding examples of international cooperation was the global strategy to eliminate smallpox.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 29 diseases caused by exposure to contaminants. (In Chapter 6. However.) Statistics also provided the capacity to measure and evaluate these interventions. Screening and surveillance became technically possible through new medical advances.. and an effective vaccine. although the smallpox virus remains stored in two secure (we hope!) national laboratories. even before the disease itself occurred. Much of this occurred in the epidemiological analysis of cancer registries and vital statistics repositories created earlier. we’ll discuss why this is not always a positive development. or an animal that could be a source of human infections) or environmental niche. This resulted in the virtual elimination of quarantine stations. for those with pre-existing biological or genetic risk factors. ethical. a distinctive clinical diagnosis. A coordinated international collaboration allowed Donald Henderson and many colleagues to actually eliminate an endemic human disease for the first time. Canada. The growth of international travel and a post-war immigration boom in many countries. Prevention could now begin before some diseases showed any symptoms and. an animal that is a natural host and functions as a bridge between the infection in the wild and humans. but the greater amount of data and increasing sophistication of the analyses allowed for more elegant interpretations of the information. coupled with the shift from ships to jet travel. but the medical selection of immigrants moved to screening people before they left home. and biological questions. Disease elimination (locally) or eradication (globally) poses many moral. (Unfortunately. rapidly exceed the ability to medical screen and assess migrants at port-of-entry health services. This was due in part to the characteristics of the disease itself—the absence of a zoonotic host (that is. and the U. some of which remain under discussion. Immigration medical screening was kept by nations with long-standing immigration policies. The principles of analysis were not that much different than those Graunt used in his studies of the Bills of Mortality. “reality” and “idol” shows on TV are .S. such as Australia. The last natural case of smallpox disease occurred in 1977.
means that images of need and suffering are brought immediately to the attention of those able to help. The change from print film to live video. and the epidemic of them is likely to grow. and the earthquake in Haiti in 2010. help me get up. such as services for tuberculosis. we have the tragedies associated with the tsunami that devastated parts of the southern hemisphere in 2004. As nations began to consider health in the broader context of more than just the absence of disease. we now become aware of emergencies and disasters much earlier than previously. The need for humanitarian health and medical assistance associated with those events were responsible for the creation of Médecins Sans Frontières (Aeberhard. and are now an important . PUBLIC HEALTH AND EMERGENCIES Dear God. I can fall down by myself. or limited to specific groups. In Europe.. —Jewish proverb With our modern technology. such as the U.30 PDQ: PUBLIC HEALTH not susceptible to such interventions. many emergencies had already moved into the recovery phase by the time we became aware of them. and the ubiquity of the Internet. where its aftermath was witnessed in real time by the entire world. public health aspects of health care delivery remain disease–based. public health’s role in relief. defining the boundaries of medicine and public health became increasing difficult. recovery. More recently. We saw an early example of this with the conflict in the Nigerian enclave of Biafra in the late 1960’s and early 1970’s. When news traveled more slowly.) Mid-20th century public health focus was not limited to prevention. Over the past 40 years. The classic example is the formation of the British National Health Service in 1949. and redevelopment efforts related to complex emergencies and disasters have been defined.S. 1996). In other nations. such as Native Americans or veterans. public health also began to include providing basic medical services to all or some segments of the population.
responsibility. 2007]) can represent major hindrances when nations are unable to deal with emergencies without international assistance. It is composed of scientific.. both for the providers and those affected.. Added to the complexity are issues related to legality. These include: • Awareness of the epidemiology and statistics of health outcomes in crisis situations to better and more effectively intervene or direct relief efforts and resources (Burkle. monitoring. mission goals. and managing the complex sociological and psychosocial/mental health aspects of emergencies. 2004). and moral/ethical elements that are specific to relief and post-event rehabilitation and development. communicable disease control. • Applying public health principles of sanitation. social. can be significant and can affect the planning and delivery of services. the desire and intent to help can result in the influx of large numbers of providers with diverse skills. Coordinating the logistics and activities of what can be a massive operation involving thousands of providers and in some cases more than 100 agencies. and nutrition to prevent and mitigate the impact of preventable death and disease. water supply. In events of great international importance. and authority which. experience. and groups has become a science unto itself. The public health role in complex emergencies and disasters is a continuously evolving and dynamic one. and capacities. Issues of protection and security. An . While the causes and nature of humanitarian emergencies and crises differ. 2006).C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 31 component in its spectrum of activities (Noji. Providing public health services in the acute phase of complex emergencies often entails different challenges than those present in other aspects of development assistance. organizations. while ensuring recovery and post-event recovery activities include sustained public health components (Salama et al. states and not the national government may be responsible for the public health aspects of disasters [Gionis et al. • Recognizing. 1997). while challenging enough at the national level (in some countries. there are public health issues present in one form or another across the spectrum of events.
and . 1998). there is growing awareness that the interrelated nature of modern health threats makes all solutions spread beyond the boundaries of any one social or technological sector. international standardization. American baseball player As the 20th century ended. At the same time. economic. TAKING CARE OF IT YOURSELF— THE ASCENT OF HEALTH PROMOTION If I knew I was going to live this long. economic. which is more often becoming involved in the decisions and policy directions dealing with public health. and capacity to make healthy choice about their lives and by increasing their control over their health. is the importance of ensuring that public health principles and practice are integrated elements of the response to emergencies and crises at both the acute. and evaluation of outcomes (Brown et al. public health was addressing new health aspects of advocacy and promotion.32 PDQ: PUBLIC HEALTH example of this is seen in the discussions about the role of the military in humanitarian relief operations (Pugh.. however. The philosophy is that health can be improved by giving people the education. and it increasingly involves the public. Fundamental in that latter regard. knowledge. I'd have taken better care of myself. and extending into the subsequent rehabilitation and development programs (Checchi et al. initial phase. 2007). where both the responsibility for and the actions necessary to improve health outcomes extend beyond the health and medical sectors and into the educational. 1986). social. environmental. This shift was based on a broader definition of health.. The Ottawa Charter spelled out the strategy of health promotion in 1986 (World Health Organization. social. —Mickey Mantle. Public health needs are generated through the interplay of biological. and political spheres. 2008) that affect other components of global health. The role of public health is shaped by the nature and location of the events themselves and involves some of the complex aspects of globalization. Health promotion remains one of the major goals of public health.
By the 19th century. and we can only speculate about it. Director of the International Health Division. and strategies to meet these needs will likewise need to be multi-sectoral. Many of these practices—in terms of both methods and rationale—varied in application from one place to another. the history of public health shows that it has often been so. solutions. the world was becoming more economically integrated. —Wilbur A. If this sounds similar to messages appearing on television today. you shouldn’t be surprised: cycles of human social activities are repetitive. sanitation. Today it is jet aircraft and the Internet. and while the driving factors of technology. Sawyer. communication. although the rapidity of change may be introducing greater variability. The Rockefeller Foundation (1944) Municipalities. and even entire nations responded to health and disease threats through activities and practices that evolved with medical science. While individualism is fine (within limits) in static environments. from isolation and quarantine to vaccination. Rarely have advances in public health not been associated with these components. Policies. and transportation may change. in the mid-19th century it was steamships. The diversity of regional and national approaches to public health proved to be increasingly costly for those who did business in several places. MEETINGS AND DEFINITIONS— MAKING SURE EVERYONE IS ON THE SAME PAGE The fourth stage is in the future. and drugs.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 33 political factors. different ways of doing the same thing can be a challenge to those who travel from one place to another. the principles remain the same. There will probably be still less reliance on conventional quarantine and more on the control of disease wherever it is discovered. History often provides directions and examples that can inform future policy and program activities. cities. so that the past cannot be relied upon to completely determine the future. railways. and the telegraph (and likely some of our prehistoric ancestors . religious organizations. But this is not new.
Given the initial focus on the Middle East. Industrialization provided expanded opportunities for trade and commerce among countries. the number of people traveling internationally was growing. Those physicians would provide notification to that effect to departing ships. the meetings had produced an international Sanitary Convention. Cholera was an important influence in this process. The importance of the Middle East in the history . allowing them to avoid quarantine on arrival (Cabell. provided that the local French government physicians said that there was no evidence of an epidemic.34 PDQ: PUBLIC HEALTH bemoaned the pace of progress when walking on two feet became popular). became increasingly challenging for transportation and trade sectors. By 1892. The variety of procedures and practices put in place at different ports of entry or by different nations. quarantined. Looking at current problems in arriving at international agreements on issues such as climate change. and as we have seen. or denied admission. In Europe. as there was still confusion regarding the nature of its transmission. and events such as the spread of cholera from Asia to Europe in the mid-1800’s required control measures. While some bilateral international agreements were undertaken during the intervening years. Starting in 1851. particularly as they related to goods and cargo. Nations tried to control these epidemics with the tools they had at hand. Western European nations made up the majority of the participants. Once one nation had begun to change the rules of the game. some had begun to question the blanket use of quarantine and other precautions that were not empirically based (see. it looks like some things haven’t changed. Ships and goods were held up at ports. a series of international conferences dealing with sanitation. many of those tools had been around for a very long time. a formal international sanitary convention took some time to negotiate. international trade. At the same time. evidence-based practice is not such a new phenomenon). it became necessary to see if others would follow suit. and travel were organized by the major powers of the time. the French had begun to reduce or eliminate periods of quarantine from some nations such as Turkey and Egypt. It took several meetings to obtain international agreement on sanitary measures. 1881). In 1847. Epidemic diseases continued to follow trade and travel routes.
The health and wellbeing of the colonials and the indigenous population had direct impact on the costs of maintaining an empire. (and sometimes the people) they carried could now be disinfected. The Bureau was the progenitor of the Pan-American Health Organization (PAHO) and was further defined by the first Pan-American Sanitary Conference of the American Republics in 1902.S. The understanding that yellow fever was a mosquito-borne disease became more accepted and by the time the second convention was held in Washington in 1905. and provided information on infectious diseases to the 50 countries that signed the 1926 International Sanitary Convention. had also led to the rise of the “age of disinfection. it was nearly under control . primarily due to yellow fever affecting the workers. where it was stated that: It shall be the duty of the International Sanitary Bureau.” Ships and the goods. President Theodore Roosevelt. In the Americas. in order that disease may be eliminated and that commerce between said Republics may be facilitated. an international conference dealing with health met in 1901 and created the Pan-American Sanitary Bureau. The important relationships between commerce and public health were clearly noted in the final resolution of the conference. to lend its best aid and experience toward the widest possible protection of the public health of each of the said Republics. The International Office of Public Hygiene was created in Paris after another convention in Rome in 1907. That conference. Second. attended by 11 nations and addressed by U. the public health aspects of the large pilgrimages (the hajj to Mecca) that brought the devout from regions of the world with different endemic diseases into contact with one another and then returned them home have influenced health in the area for some time. but standardized methods and practices were needed. in the 19th century.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 35 of public health regulation is two-fold. That office was involved in preventing the spread of cholera during the hajj. The understanding the Germ Theory of disease. First. much of the region was under the influence or control of the major European powers. while clarifying the natural history of many infections. Infectious diseases had seriously delayed the construction of the Panama Canal. looked at the control of yellow fever and other epidemic diseases in region. which was still unfinished at the time.
The second conference considered differences in practices in the Americas and Europe and they were part of the discussions: Even in our own countries when complaint is made of the stringency of quarantine measures. and assisting the International Red Cross in humanitarian activities (Buchanan. 1921). WHO was active in infectious disease control and developing international standards. a World Health Conference was held in 1946 at the same time as the United Nations was being formed. and a forum for international agreements for health interventions (World Health Organization. and the WHO has provided the focus for many meetings and processes intended to improve global health.36 PDQ: PUBLIC HEALTH in Panama. 1958). Controlling epidemic diseases and managing the public health consequences of the Second World War was WHO’s first order of business. Many of the objectives of the International Health Organization remain valid today. and the detention of passengers for observation. International public health retreated to the sidelines until the United Nations and a post-war world grew out of the ashes of conflict. 1912). the League of Nations created after that conflict established first an Epidemic Commission to deal with serious outbreaks of infectious diseases. The Great War of 1914-1918 (now known as the First World War) interrupted the development of an international public health organization. a liaison among countries. The World Health Organization (WHO) as we know it today was established and defined. the more liberal practice of some European countries. in contrast. The health impacts of the Great Depression and the Second World War were global in scope. Building on the lessons of the Paris Office. the Health Organization of the League of Nations. and second. and the Pan-American Bureau. some are apt to bring forth. However. and the canal was completed some nine years later. It has later moved on to the broader aspects of primary health care and . During the years following the Second World War. specially England (Guiteras. such as organizing the rapid exchange of information during epidemics. That organization was an international source of information. protecting the health of workers. the International Health Organization of the League of Nations in 1921. Having a global forum to discuss health has supported collaborative efforts to guide public health.
F. Burkle. G. and the movement of medical professionals in all part of the current panoply of public health. WHO has been involved in modern issues of health and development. e89. More recently. E. 2006. 1881. The rise and progress of international hygiene. Anderson. Complex humanitarian emergencies: A review of epidemiological and response models. C. D. 1842. I. Research in complex humanitarian emergencies: The Médecins Sans Frontières/Epicentre experience. British Medical Journal 1: 331–335.1371%2Fjournal. 1985.pmed. S. London: . B. F. Journal of Postgraduate Medicine 52: 110–115.Y) 3: 845–852. Ancient Greek laws: A sourcebook. Health and Human Rights 2 (1): 30–44. American Journal of Public Health (N. Public Health Papers and Reports 7: 16–31. An address on international organization and public health.. D. At the same time. Paquet. D. Medical History 2: 287–291. —David Thelen. Anonymous. and duties of the United States Public Health Service today. 1996. Arnaoutoglou. R. 2008. The challenge of history is to recover the past and introduce it to the present.plosmedicine. Legros. global health. Retrieved 1/20/2009 from http://www. J. Not surprisingly. Barkan. I. 1921. Pécoul. Buchanan. Guerin. The report from the Poor Law Commissioners on an inquiry into the sanitary conditions of the labouring population of Great Britain. Chadwick. Brothwell. Daily life during the Black Death. PLoS Medicine 15. 0050089.. Santa Barbara. Cabell. American Journal of Public Health 40:470–472. American Journal of Public Health 75: 18–26.. P. Evidence of leprosy in British archaeological material. 1913. and agreements. L. 1998. Byrne. Chronic disease as a public health problem.org/article/ nfo:doi%2F10. & Moren. it is not difficult to discover the threads of history in the modern approaches and activities. 1958. Industry invites regulation: The passage of the Pure Food and Drug Act of 1906. J. M.C h a p ter 1 • W H AT I S P U B L I C H E A LT H ? 37 health promotion. Brown. powers. New York: Routledge Press.. 1950. P. each of those tasks has come with its own collection of meetings. 2006. P. J. V. A. resolutions. conventions. CA: Greenwood Press. Organization. health equity. J.. Historian References Aeberhard. 5 (4). A historical survey of humanitarian action.
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unpredictable. natural disasters. local authorities responsible for the safety of the citizens could only go by the stacking-up of bodies in the streets to know that there was something wrong.. and other ne’er-do41 . prior to the understanding of “germs” as a cause of disease and death. the origins of public health and interventions to protect the health of the public had a great deal to do with the unknown. malfeasance). and uncontrolled events associated with transmissible or communicable infectious diseases that were also virulent.g. social circumstances. and the study of epidemics (epidemiology) pointing to causations (e. That is. germs. brigands. The typical problems for officials in those days tended to be marauding warriors.2 CLASSICAL KEY CONCEPTS IN PUBLIC HEALTH “Bring out your dead! Bring out your dead!” —Monty Python and the Holy Grail INTRODUCTION As we said in Chapter 1.
prevalence gaps. flux. the pox. and time. neurology. and “drippy willy” to mention a few. —Blind Lemon Jefferson. cities built on hills. scrapie. physical approaches to public safety. American blues singer and guitarist • Microbes include viruses. food safety. and the determinants of health as applied to populations. • Some microbes cause infections. but prions and the diseases they cause are certainly are of public health concern. It went by other names: the Black Death. Where prions (i. and kuru) fit into “microbial life” isn’t quite clear. nor in which medical domain they belong (infectious diseases. and other similar civil defense. and arthropods (multi-legged animals including insects and the spider group. bacteria. It just wasn’t called “public health concerns” at the time. moats. used to diagnose Mycobacterium . place. In this chapter. and environments. replicating and transmissible proteins that cause diseases like bovine spongiform encephalopathy [BSE or mad cow disease]. we’ll address some key concepts in public health: communicable diseases. so they will be kept in this chapter for the purpose of conceptual inclusion and completeness.e. But first. SOME BASIC TERMINOLOGY Knowin’ all the words in the dictionary ain’t gonna help if you got nuthin’ to say. These types of threats to the health and security of the village could be addressed by walled cities. where the affected host mounts a defensive immunological response that can be detected by antibodies or a cellular immune test such as a tuberculin skin test (TST). disparity and diversity. a pause for clarity in terminology to be used in this chapter. vectors. consumption (also known as the galloping consumption). parasites. But public health concerns were also lurking in the wings and often were not deterred by these physical barriers (some things never change).. vulnerability. or public health). fungi.42 PDQ: PUBLIC HEALTH wells. person. hosts. the scourge. especially ticks and mites).
usually evidenced by fever. and Helicobacter pylori (gastric).g. other flies. and viruses. due to immunization with influenza vaccine. and cancers associated with chronic hepatitis C infection or schistosomiasis (liver or bladder). parasites. and anyone who is interested in such arcane topics should read some standard reference text for that information. fungi. lice) or our clothing and hair may produce an allergic immune response due to their excretions of saliva or feces.. usually seen as an inflammatory disease or a malignant progression. • Some microbial infections result in infectious diseases that are the clinical manifestation of an infection: the interaction between the pathogen causing the infection and host immune response. much less commonly. human papillomavirus (cervical-uterine). Reiter’s syndrome following gastrointestinal bacterial infections or a number of sexually-acquired infections. bacteria. the skin burrowing scabies mite). but it is possible to have intermediary hosts or vectors. Communicable and contagious are not exactly the same thing.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 43 tuberculosis infection (note: not tuberculosis disease itself). to mention just a few. mosquitoes. • Some infectious diseases have noninfectious conse- quences. redness. and death. That would be called an infestation. A complete discussion of infectious diseases and immunology is beyond the intent of this book.g. including tissue damage. and other signs of inflammation. • Some infectious diseases are communicable or conta- gious. Examples are Guillain-Barré syndrome following a bowel infection with Campylolbacter jejuni or. etc. as with some arthropods (e.) or live on us (e. Contagions are generally directly . pain. necrosis. mites.. that is definitely an infection. When they are in us and we are reacting to them immunologically. Those things that feed upon us (ticks. swelling. but their presence on our clothing or hair is not an infection. Communicable (also can be used interchangeably with transmissible) means that the pathogen moves from person to person.
after the night on the town. Influenza is both communicable and contagious. There are some important nuances here for clinicians. Just to make life more complex. The importance of this interval is that many microbial agents (such as influenza. not all microbes are infectious on detection in the host. which is the time interval between being infected and developing clinical symptoms.g. the football team was highly contagious…). For example. Contagion is often used to convey the degree of transmissibility (e. for example through unscreened blood transfusion or intravenous drug use.” The importance of this is that they may still be able to transmit the infectious agent during the asymptomatic but infected period. Malaria can be contagious if a person infected with malaria shares blood directly to another person. public health officials. which can be days or years before the development of clinical symptoms or signs of disease (incubation period). Some contagious or communicable infectious diseases can be virulent (see below). but to a violent confrontation or divorce or both). Some (such as soil-living roundworms. The interval from infection to the time when the infectious agent is detectable in the host is called the prepatent period. inanimate objects like clothing (which are called fomites). malaria is a communicable infectious disease and requires a mosquito vector for the completion of the full lifecycle between person-to-person transmissions. Some people with some infectious diseases may have no symptoms or have such mild symptoms to be considered “subclinical. • An important concept in communicable diseases is the incubation period. due to the ease of moving the virus between susceptible hosts by direct physical contact. or sneezing in someone’s face (which can lead not only to the flu. or geo-helminths such as ascaris and whipworm) require development outside the host or need an intermediary . and hepatitis C) are transmissible at the end of the prepatent period.. human immunodeficiency virus [HIV].44 PDQ: PUBLIC HEALTH transmitted by near or direct physical contact between people without intermediaries or vectors. and patients.
it will not be discussed further. such as pandemic or endemic. SARS was certainly bad enough for those who had it. including microbial virulence factors (such as invasive or toxin-producing organisms). malaria. • Demics—epi. this just does not match the nearly 100% mortality due to rabies disease. and since it cannot be rationalized. host factors (including immune status. • Virulence is a measure of the morbidity (illness—sometimes difficult to quantify) and mortality (death—epidemiologically an easier outcome to measure. This public health legislative use of the term “virulence” just is not right clinically. Some public health authorities have legislatively defined certain conditions or microbial organisms as virulent outside of any consideration of morbidity or mortality. or differentiating it from similar terms. in human hosts). We’ve been tossing around the term epidemic without really defining it. and for the just under 10% of the global cases reported with SARS who died. But from a public health perspective. let’s take care of that. An endemic event (which is derived from the Greek. So. or the 70% mortality associated with most of the viral hemorrhagic fevers. Virulence is an outcome measurement but is related to many potential factors that can be interdependent. access to quality health care services. meaning “within the people”) is . nor does it really make any sense from a public health programmatic perspective. where it is defined in the Health Protection and Promotion Act as a “virulent” condition. under most circumstances. intercurrent diseases). and en. it was really bad. the giant tapeworms and.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 45 vector for its own development (for example. Canada. and the environment (for example. particularly if the dead person agrees to fall down somewhere noticeable and not move for a while) associated with an infectious disease. pan. This is the case with severe acute respiratory syndrome (SARS) in Ontario. But it is similar to the mortality seen with meningococcal disease or with serious vehicular trauma for that matter. effective public health programs for prevention).
Why “on average”? The reason is that some infected people just aren’t that good at infecting others. on average. respiratory syncytial virus infections in kids during the winter. large numbers aren’t necessary. or was more virulent than usual. this would not be considered an epidemic unless there were a new strain of the virus. If an infectious endemic condition is at a steady state. are defined epidemiologically as a (statistically) significant increase in the number of observed cases over the expected number of cases. then we have an epidemic. Even if the .46 PDQ: PUBLIC HEALTH a condition that occurs naturally within a circumscribed time or place at an expected frequency. If the epidemic spreads beyond its local region and affects people in other areas of the world through personto-person transmission. a single case of non-laboratory acquired smallpox is more than expected and would be considered to be an epidemic (as well as a global public health emergency). If the average number of people infected by one person drops below one. or a naturally occurring one where the number of cases in a population is greater than what’s expected. Using their criteria. every year. swine flu [Influenza (H1N1) 2009] would be a pandemic. which can be a new condition. so the others have to work overtime to compensate for the slackers. or the old strain affected more people than anticipated. So. and hypertension among auto manufacturer CEOs. in 1976. we have an expected outbreak of the flu. But. • Outbreaks of transmissible infectious diseases. If the average number of infected people is greater than one. but the usage isn’t limited to them. we are dealing with a pandemic. It’s often used within the context of infectious diseases. then each affected person will infect one other person. The existing WHO definition does not include any criteria for morbidity or mortality associated with a pandemic. much as what happened with the outbreak of Ebola hemorrhagic fever in Zaire. whether virulent or not. it can be applied to Plasmodium falciparum malaria or river blindness (Onchocerciasis) in subSaharan Africa. then the infection will die out.
and that reliable and valid measurements to detect. plants. nations with established public health systems defined in law often have a mandatory requirement for reporting certain infectious diseases.” We generally do not talk about outbreaks of good health. Also note that in this usage. and analyze data exist. tetanus. requires that someone knows what normal is. Rare or imported diseases also make most lists. and polio. viral hemorrhagic fevers. Depending on the level and ease of transmissibility and the potential virulence of the animal or plant disease.” • Outbreaks of diseases of public health significance are defined epidemiologically and sometimes within legislation and regulations. gonorrhea. a measured and appropriate response can be implemented to mitigate. The usual suspects will be on this list of notifiable conditions: tuberculosis. or other positive things—we could from an epidemiological perspective. in an ideal world. Public health has traditionally addressed human case events but clearly other animals. Then once we have an outbreak. or prevent more undesired outcomes. This. some of these events will be considered to be of “public health importance or significance. diphtheria. syphilis. That is the way it is in medicine. Diseases that are controlled in the region of that public health authority are also often on the list and usually include diseases under publicly funded preventable infectious diseases programs like measles. report. we could consider it to be an outbreak if the virulence is worse than expected or what is normal. or happiness. rubella. too. Certainly the animal and plant health folk would point out that domestic or wild animal diseases (known as zoonotic diseases) and plant or botanical related events are important to human public health. chlamydia. For the latter. and others of that nature. but we just don’t. mumps. and potentially other things can also be infected and sometimes this is of public health concern. an “outbreak” is in the direction of “bad outcomes. such as malaria.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 47 number of cases is what we expect it to be. . of course. tularemia. control.
an event can become both complex and complicated very quickly. tuberculosis. yellow fever. the WHO country office. WHO. Seems we are still trying to find that balance in health with economics and trade. such as establishment of transmission in the new international location. SARS. polio. has potential for international spread. and others. and many others. Generally these events would be outbreaks of diseases occurring with sustained transmission and virulence outside of endemic zones or at least involving international spread.48 PDQ: PUBLIC HEALTH plague. leprosy. malaria. or at least . WHO now has its member states focus on events that may lead to public health emergencies of international concern. As you can see. on Surveillance. The latter is one of the original concerns linking health and the international community that was expressed in the Maritime Sanitation Regulations (in which the discussions began circa 1851 but were not concluded until 40 years later). the process of using disease lists changed with the new International Health Regulations (WHO. from that perspective. In terms of epidemics and health emergencies. “No one expects the Spanish Inquisition”).) Historically. can declare an event a public health emergency of international concern. such as plague. in consultation with the Regional WHO offices. is unusual or unexpected (as in. cholera. smallpox. e. and the event managers in the countries involved. with the guidance of expert committees.g. the World Health Organization (WHO) used lists of diseases to guide the management of internationally important disease outbreaks.. 1969). WHO still supports and assists in coordinating the response to several globally important diseases. (We discuss this in more detail in the next chapter. Depending on those factors and their outcomes. 2005). Important factors include if the event has serious public health impact. (Note that virulence will become. and whether or not a coordinated international response may be required. Some things seem to never change. and/or could interfere with international travel or trade. and yellow fever (WHO.
or other declared pandemic influenza events. natural or industrial heavy metal contamination such as lead or mercury). for example. against influenza. Emergency measures can be put in place. media hype. and national—can define an outbreak based on epidemiologic data. and pandemic influenza outbreaks if certain defined criteria are met. it can also include hypertension. diabetes. . an “event” without death or dying just isn’t much of an event. As we now know. food safety…well. obesity. sexually-transmitted infectious disease. states or provinces. 2009 was an important year for WHO in declaring a global pandemic for influenza H1N1.) Public health officers need to be aware of their responsibilities and liabilities regarding reporting requirements under both local legislation and international agreements.) An “all hazards of public health concern” approach goes beyond transmissible infectious diseases. and political manipulation in declaring health emergencies is less often appreciated. While this outbreak definition is most frequently considered in the context of transmissible infectious diseases. toxic exposures (e. or any other measurable health condition or disease outcome. These conditions have been a significant public health focus for a number of years. heart disease. cancer. All levels of public health jurisdiction—cities. stroke. and includes events such as natural or man-made disasters (just ask the CEO of British Petroleum about the 2010 ultra-deep oil spill in the Gulf of Mexico. literally ALL hazards. ask President Barack Obama). expected outcomes with influenza.. or even better.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 49 should become. We are still waiting for final assessments and reports on how the global virulence for this pandemic influenza compares to seasonal. public health fear mongering. environmental risks (e.. mass mushroom poisoning). The role of public concern. (Sure sounds like life itself is a high-risk.g. an increasingly important measurement of outcome in public health. the public health consequences of conflict. avian influenza. including any and all causes of morbidity and mortality.g.
epidemiology. is not enough. ultimately resulting in a mitigating response or at least a policy . wherever it came from. VECTORS. the Israelites spent 40 years searching for Canaan (Numbers 13:25. analyzed. microbes. So. former American Secretary of Defense Back to the unknown. the most evident outcome during events of public health significance was death. there are known knowns. microbial-host lifecycles. Moses was 40 days on the mount (Exodus 19:18). HOSTS. 40 days is the period of time things were set aside. what they will be in the future. there are things we know we know. public deaths were generally something that was easy to detect by civic authorities. unpredictable. though. But there are also unknown unknowns—the ones we don't know we don't know. Surveillance on its own. COMMUNICABLE DISEASES. The Great Flood lasted 40 days (Genesis 7:17).50 PDQ: PUBLIC HEALTH • The source of the term quarantine has many explanations. and communicated. AND ENVIRONMENTS As we know. One is the use of the French (diplomatic language of the day) term quarantaine. Jesus fasted in the wilderness for 40 days tempted by Satan (Mark 1:13). The maximum number of strokes to be inflicted on a malefactor was also 40 (Deuteronomy 25:3). and before there were effective interventions. it is hoped. or the Italian quarantine which. that is to say we know there are some things we do not know. and the neighborhood is still known as Mount Quarantana or Jebel Kuruntul. to allow contagious. interpreted. There are also some who believe that the choice of 40 had a religious influence. not surprisingly. We also know there are known unknowns. Surveillance systems were not then what they are today. and uncontrollable. Before people knew about germs. means the same thing. Generating data requires that information be extracted. Deuteronomy 7:2). virulent diseases to run their courses before the people or goods were allowed to enter general society. like ships. —Donald Rumsfeld. That is. which merely means a group of 40. nor.
in the absence of the sciences of microbiology and epidemiology. Defining the mosquito’s role in malaria transmission came very much later. But. parasites. The concept of disease transmissibility was difficult to rationalize in ancient civilization. preparedness. Some of the first perceptions of disease/ causality and transmission related to public health have became entrenched in our language: Miasmas.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 51 to make a plan to respond with something that might mitigate the event. Perceptions of risk. or the noxious exhalations from putrescent organic matter. Once an event was detected (and ideally confirmed). (It has been rumored that the word “politics” comes from the Greek “poly. it’s just a rumor. especially if they sicken or kill lots of people. Before the plethora of instant communication devices.” meaning bloodsucking parasites. relatively large-scale population die-offs were most easily detected if they occurred in or around large urban centers (yet another benefit of urbanization). and response to public health events. Diseases that are communicable from person-to-person and from place-to-place are characteristics of diseases of public health importance. These steps are complementary and can occur concurrently with planning. “Nitpicking” was the useless pulling of empty lice egg casings off of hair shafts and has come to mean any inutile activity not just related to public health interventions. it could be communicated to others by inter-regional foot mail (or hoof or sail) hence carrying the bad news—and sometimes the pathogen itself—from city to city. The word malaria [mal + aria = bad air (Italian)] reflected the belief that the swamp gases were responsible for the fevers caused by Plasmodium sp.” meaning “many.” and “tics. were often linked to what could be detected by the human senses—very often there was both an olfactory and a visual accounting of death if the bodies were actually stacking up in the streets under the hot summer sun. came into popular use around the time of the Black Death (plague due to Yersinia pestis) in 17th century Europe.) . poisonous effluvia or germs polluting the atmosphere. Being a “nitwit” or “feeling lousy” were terms describing the dullness of being anemic due to the blood-sucking lice that infested clothing (the body louse—Pediculus humanus humanus or Pedicululus humanus corporis) or head hair (Pediculus humanus capitus) and occasionally transmitted other diseases.
Poor personal or environmental Fecal contamination usually of food waste management. Africa. such as sexually. ovale venous drug needle or blood transfusion transmitted Dengue (virus) Mosquito (several culicine species: i. and environments—examples of diseases of public health importance Usual host Intermediate or other hosts Environment Pathogen Vector Traditional concepts of vectors Human beings are the definitive Mosquito (asexual reproductive hosts in whom sexual phase) reproduction occurs for these malaria parasites Humans are the clinical and public health host of interest but the concept of definitive and intermediate hosts do not apply. Oceania. Nontraditional concepts of vectors Human beings None. Africa. In rural disease other primates maintain the virus cycle in nature with humans inadvertently being infected. Hepatitis C virus may be asymptomatic Human beings only. . Asia. rarely intramalariae. hosts. An infected human host who Hepatitis B virus.e. except during outbreaks. Salmonella typhi (bacterial cause Asymptomatic human carrier of typhoid fever) (“Typhoid Mary”) Human Immune Deficiency Virus. endemic in or water with oral transmission India and other parts of Asia. Tropical regions of Asia and Latin America predominantly. Blood and body fluid transmitted. All three viruses have become global in distribution with some endemic foci of genetically or behaviorally at-risk populations. Latin America and the Southwest of the USA. The Black Norwegian rat is the usual rodent host. many species). Latin and South America.. Pathogens. vectors. occurring in India and other parts of Asia. Mexico and Latin America. Humans generally inadvertently and sporadically affected. Can be imported by mobile populations. Sub-Saharan. although other hosts can occur including domestic cats and dogs. tropical Africa and humans may be the host that the Amazon drainage basin in maintains the cycle of transmission. Tropical areas of Africa. shared needle use (tattooing. vivax. Aedes) Plague (bacterium) Yersinia pestis Flea (specifically the rat flea Xenopsylla cheopis) Yellow Fever (virus) Mosquito (Aedes aegypti) In urban outbreaks of yellow fever. (malaria parasite) Mosquito (always an anopheline.TABLE 2-1. drugs) and unscreened blood transfusion. (species: falciparum. South America. Plague is rare. 52 PDQ: PUBLIC HEALTH Plasmodium sp.
.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 53 FIGURE 2-1. The evolution of transmissible diseases.
but especially cholera due to Vibrio cholerae). At a later movement of zoonosis to humans. such as kuru. smallpox (viral agent Variola major). hosts. a vector is an organism that acts as a carrier and transmitter of a pathogenic microbe between two or more hosts or inter-regionally between environments. and ship fever (epidemic typhus due to Rickettsia prowazeki and transmitted by the human body louse).54 PDQ: PUBLIC HEALTH Prior to understanding the etiology and pathogenesis of diseases of public health significance.g. mange) remain at the level of animal-to-animal transmission and don’t affect humans. Examples of the colorful naming of diseases include the Black Death or the plague (transmitted from host to host by the rat flea Xenopsyllya cheopis).. yellow fever due to the Yellow Fever virus transmitted by the bite of a mosquito (often Aedes aegypti) that causes your liver to turn to pâté and you to become jaundiced (a sickly yellow-orange color) and then frequently die. some of these diseases (e. and SARS (caused by an animal coronavirus). So what about vectors. the flux (any form of severe diarrhea. Some of the relationships in these lifecycles are very complex (see Table 2-1). non-B hepatitis (now known to be caused by hepatitis C virus). The same syndromic approach to naming diseases is still used today when unknown. such as the Ebola virus. The next step in pathogen adaptation to the naked ape is that humans can become infected from animals (BSE. environmental reservoirs. The complexities are often important in understanding transmission. In the third example. As shown in Figure 2-1. humans can infect one another with fairly virulent diseases. and the disease doesn’t have much chance to spread very far. or mad cow disease). acquired immune deficiency syndrome ([AIDS]. but can’t easily transmit the disease to other humans (for some prion diseases. and seemingly uncontrollable events are detected. Many human infectious diseases got their start in animals. for example non-A. caused by human immunodeficiency virus [HIV]). diseases were often described by their clinical presentation. the pathogen is . and management and control approaches for both clinical and public health purposes. eating your neighbor’s brain is associated with transmission). and environments? In the infectious diseases and public health sense. but these kill their hosts off quickly. unpredictable.
or their conveyances being the vectors of disease and pestilence. this is not true for all vector-borne diseases. a potential outcome will be the emerging and re-emerging of diseases. among others. molluscs. and crusaders beyond wall cities. and others). Canada) were public health measures implemented to reduce the *In many urbanizing cultures. trans-stadial (egg to larva or nymph to adult) or transovarian (adult to egg to larva or nymph to adult). . on Ellis Island in New York and Pier 21 in Nova Scotia. Much of public health has evolved around human beings themselves. their belongings. Then there are the diseases where a nonhuman animal host does not exist or. For some public health control measures. where they play both a mechanical and a biologic role in passing the infection between hosts. In the biologic sense.* Some vectors are an essential component of the lifecycle and transmission of microbial pathogens.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 55 well-adapted to the new host and becomes less virulent (HIV). Isolation of returning traders. vectors include arthropods. filariasis. Children are sometimes considered vectors in this context (for example. and the screening of newcomers for disease (for example. and other lower. allowing people to spread it to others at their leisure. A plethora of urban breeding sites for arbo-virus transmitting mosquitoes (particularly the Aedes and Culex mosquitoes) has been associated with dengue. annelids (segmented worms and leeches). plague. and the viral encephaliditis in cities around the world. schistosomiasis. if it did exist. rats. nonhuman life forms carrying pathogens for which humans are either an essential component or an inadvertent host. is no longer affected by the pathogen. Microbial replication but without physical change in the pathogen is typical of all of the arthropod-borne viral infections (eastern equine encephalitis. When a lot of people who are susceptible to infection or are vulnerable to communicable diseases are living near one anther. it is important to know if the pathogen can move across developmental stages of the vector—that is. yellow fever. (See. pollution isn’t all bad. warriors. the standing offshore of ships for 40 days (quarantine—see variations on this theme above). polio and the mumps are examples. St. Louis encephalitis. and other vermin or pests has been associated with a reduction in the risk of urban malaria. West Nile virus. Biologic roles involve the lifecycle maturation of the pathogen within the vector as is seen with malaria. the environmental changes associated with cities are barriers to the classical vector-borne diseases: the active or passive control of mosquitoes. and human giant tapeworm infections. parents tend to develop psychiatric disorders because of their children).) Unfortunately. and other diseases in many cities of the world.
HIV/AIDS. was one of the first known asymptomatic excretor of Salmonella typhi in the United States.56 PDQ: PUBLIC HEALTH risk of entry of external vectors and exposure to the local population. In the past. ship. It did not always work out that way: Mary Mallon. She acquired a considerable amount of media attention during her life.g. tuberculosis. She spent most of the last three decades of her life on North Brother Island in enforced isolation from the general population due to her refusal to not work preparing food. This has greatly facilitated our ability to spread pathogens from high.to low-prevalence areas. New means of travel have diminished the protective effects of long journeys. Hepatitis B. Yet again.” an Irish domestic servant and cook working in New York in the early 1900’s. persistent. for example. Humans with chronic. or latent infections that are both transmissible and potentially virulent remain a concern to public health officials. There have other more prolific “Typhoid Mary’s” in history in terms of numbers of persons sickened or who died because of a human playing the role of a disease vector. modern technology has made many of the prevention strategies obsolete. technology has reared up and bitten us on the leg (or some area of the anatomy just north of it). the clinical symptoms and signs of a disease may not appear until long after the plane. travel between countries was slow. Changing from sails to steam. changed the patterns . and South American trypanosomiasis (Chagas’ disease) are a few of the infectious diseases for which current screening programs exist (e. syphilis. or train has unloaded. She was associated with several outbreaks of acute typhoid fever in families she worked for in New York. better known as “Typhoid Mary. An interesting footnote too is that she remained a Salmonella carrier and excretor until her death. However. truck. and for the host and pathogen to survive the voyage itself. explaining her public legacy. but Mary Mallon will forever be stuck with the moniker of Typhoid Mary. meaning that only diseases with a long incubation period could remain asymptomatic in their hosts to evade border inspections.. immigration and blood and tissue donation) on public health principles and are applied to identified risk populations by some national jurisdictions. Now that people and goods and the vehicles carrying them can move around the world in a matter of hours or days. hepatitis C.
avian.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 57 of international measles transmission in the 19th century by allowing infections to be sustained during the entire voyage (Cliff & Haggett. as was intended in the past. The movement of influenza (seasonal. As a result. thus in essence reinstituting a quarantine. —Martha W.. where after decades of environmental abuse.) PERSON. drink. Taft In some places in the world. and other . or any other liquids. The only one I can ever remember is that if all the people who go to sleep in church were laid end to end they would be a lot more comfortable. the pandemic swine flu H1N1). it will soon take 40 days to get from the ticket counter to the gate. At the present rate of increase. AND TIME—THE DETERMINANTS OF HEALTH I always find that statistics are hard to swallow and impossible to digest. goods. an efficient vector of arboviruses arrived from Asia to North America) will become more common community-based occurrences. events of “public health significance” will become more common everywhere in the world. 2004). existing policies and practices based on screening and quarantine to control the spread of infectious diseases have become much less effective (Bitar et al. tuberculosis. Aedes albopictus. many of our leaders want all nations—especially the economically developing countries such as India and China—to curtail their environmental dumping of greenhouse gases. with high volume and rapid international movement of people. This may also help counter the epidemic of obesity. but without the ability for exclusionary screening. and new vectors (for example. there is increasing concern about the environment and the sustainability of human life on this planet. and other multiple-drug resistant organisms. Combined with enhanced surveillance and reporting systems. This is occurring mostly in economically advanced western nations. airlines seem to be responding by making us spend longer and longer times in line. PLACE. Taft. wife of Senator Robert A. These trends are continuing. and in the spring of 2009. 2009). and conveyances. albeit one without food. waiting to be screened. (However.
This is a good thing if you are a population demographer or a social anthropologist because you will have a job for life. we just mentioned it. okay. Graphically. agreements.” So. (Other species may contest this. making sure that we focus on the important things first is. 2008) are being expressed at the level of international discussion leading to conventions. (We won’t comment on the fact that the developed countries objected to pollution only after they were past their peak as manufacturing centers. or getting sick or being healthy. and uncontrolled. “Who cares about low flush toilets if there is not going to be anyone around to flush them?” When a large proportion of the world’s population don’t have toilets of any sort. Well.58 PDQ: PUBLIC HEALTH effluents and toxins that support greater economic growth but is perhaps not so good for living and breathing human beings. unpredictable. but they don’t attend international meetings and issue accords. all of this change is a challenge as the “numerator” and “denominator” of literally anything we may want to measure will also be changing (see Table 2-2). first are people. (As an aside. it is an interesting observation that at the international level “accords” can generate so much discord resulting in the need for more meetings—and always in exotic locales when it is freezing at home. and accords. well.” The problem with “us” is that we are constantly changing at both the individual and societal level. such as the Framework Convention on Climate Change (United Nations. one picture of the importance of global population change is shown in Figure 2-2.) To paraphrase another unnamed source (it is debated to be either Socrates or Osler). or that there are more of us getting older or being born (getting younger). This goes well beyond that fact that there are more of us. As the shift in focus in health and public health moves back toward people from pathogens or technology (again). For the rest of us. On the list of important things. it’s all about us.d. the complexity of public health management will have to address the complicated nature of humans that includes the “unknown. “Knowing what sort of person has a disease is more important than knowing what disease a person has.) Mounting fears over climate change. . extreme weather events and the adverse impact on human health (Institute of Medicine. n.) But an unnamed colleague in environmental public health once quipped. important.).
770 (1.798 (-0.424 (3.975 41.21) *Source: World Resources Institute (2009).561 157.980 (1. we have heavily invested in the concept of the “determinants of health” as a measure and predictor of what our health will be.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 59 TA BL E 2.607 3.351.05) 250. The core to the challenge of changing global population demographics is that we hardly know anything about ourselves now.99) 202.787 (0.294.59) 1.995 12.801 (1.82) 7.1) 210.687 (-0.532 (-0.752 (0.13) 31.13) 272.06) 683.813 102.01) 383. these can be expressed as those factors that influence the risk of good or bad health and the resulting outcomes.760 357.775 171.345.695 (4.25) 1.936.157.495 6.538 (1.534 (3.549 (1.519.34) 174.68) 288.3) 120.741 (1. Country and region population with rate of growth* Current top 10 countries by population size China India USA Russia Japan Indonesia Brazil Bangladesh Pakistan Nigeria 1950 Population in thousands 554.530 (1. For the lumpers of the world.706 (4.281 (2.56) 1.041.144 (3.62) 683. East) Europe Sub-Saharan Africa North America South America Oceania 1.822 (0.020 (1.847 (3.678 (0.52) 319.047 (5.790 2002 Population in thousands (% growth/year) 1.8) 2025 Population in thousands— projected (% growth/year) 1.925 (1.365 112.377 (2.77) 127.625 79.331.493.702 83.2. As large lumps.28) 40.957 (3) Selected regions Asia (excl.01) 217.85) 4.659 29.1) 218.21) World 2.721 (5.3) 346.68) 148. The determinants of health are functional at both the individual and societal levels.12) 725.124 (0.911 (1.206 176. the determinants of health are socio- .823 (2.082 (2.783 39.55) 123.636 548. Mid.59) 143.211.470.364 (4.88) 125.87) 460.782 (5.981 (2.3) 143. so what is it going to be like in the future? In allopathic medical and academic environments.538 53.67) 355.
) . the world’s population has nearly tripled and virtually all of this population growth has occurred in the less economically advanced countries in Africa. again. or for that matter a fourth world or beyond and it is just not politically correct anymore (much like some other statements in this book for which we sincerely apologize to all those we have offended. The determinants of health can be predictive of health and disease outcomes. are robust within a defined population. FIGURE 2-2. and can vary in their relative importance over time and place.60 PDQ: PUBLIC HEALTH Reprinted with permission from Population Reference Bureau. Another wonderful thing about them is that they are interdependent among themselves and this too is variable. Asia. and Latin America. 1750–2150. behavior. genetics and biology. Those are the places previously known as the Third World. Globalization: The Determinants of Health Within the last 60 years. economic status. World population growth. and the environment (see Table 2-3). second. Third World is not a term used any more largely because we don’t really recognize a first.
Population-based disability previous hepatitis A adjusted life years (trauma.3. seismic events. and China for example. storms. food and air quality Publicly funded social disease rates. floods. While socio-economic status is not . Chile. etc. occupational housing. Determinants of health—examples of individual and societal measures Determinants of Health Socio-economic status Individual Annual disposable income (individual or family) Highest educational attainment Language literacy – written. Some are. transportation. mud slides. cold. multi-linguistic capability Single or dual parent family Societal Gross National and Domestic Product Educational attainments Literacy levels Female employment rates Fecundity and fertility rates Maternal-child mortality rates Immunization coverage rates Genetics-biology Innate or acquired Population diversity immunity—Hemoglobin Life expectancy at birth S trait and malaria.) Now. safety and security. spoken. programs for economically disadvantaged. Extreme weather or environmental events (heat. drought. Water. comprehension. food and water. some of those countries are doing quite well in the field of economics and trade—India. education. but a lot of people—the poorest of the poor—are getting even poorer. Societal political stability. That does not mean that everyone is getting rich or richer in those areas. domestic.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 61 TABLE 2. infection chronic disease) Risk acceptance/taking Smoking Diet and exercise Smoking rates Acceptance of immunizations Societal and cultural norms Behavior Environment Home ownership Social infrastructure for Toxins exposures.
injuries and risk factors in causing premature . but other manifestations of disparity are more difficult to demonstrate. and so forth. safest = nonsmoking. validating. heterosexual/homosexual/bisexual/asexual. language. things are not going to turn out well for you. and getting an education). analysing and disseminating such information as needed to assess the comparative importance of diseases. wonderful environment (social infrastructure and natural). we can look at the global burden of disease for evidence of disparity. In this context. On the international scale. Statistically. safer sex. Occasionally. 1948). not going to jail. nonsmoker/smoker/smoker of really weird crap. what does this disparity or disadvantage really look like? On the local scale. these indicators can be directly and visibly linked to adverse personal health or public health events in our communities. Diversity adds to our culture. we can gather information on income or education as indicators of disparity. no teenage pregnancies. and choices of restaurants. Diversity enriches our lives. Some elements of diversity may contribute to differentials in the determinants of health and the health outcomes resulting in disparities. art.” So. educational attainments) in determining health and health outcomes. male/female/transgender. hemoglobin S trait/hemoglobin S disease/no hemoglobin S gene at all. good behavior (safe driving. no drugs. diversity is used to merely indicate that there is a difference: taller/shorter. pale/darker/darkest skin color. all are linked together with socioeconomics (access to food and water. it really doesn’t matter how well adapted your genes are or how good your behavior is. faithful/ not so faithful/without faith. We “celebrate” diversity and we try to protect it through respect for human rights (United Nations. if you have no food or clean water. The Global Burden of Disease Project is a multi-center collaborative effort to provide “a framework for integrating. Disparities in this context are “diversities with a disadvantage. This is also true at the population level in determining health and health outcomes: a good gene pool (basically the absence of bad genes predisposing to infections or cancer).62 PDQ: PUBLIC HEALTH the only determinant of health. under-housing and homelessness is a visible manifestation of a disparity as we see (or don’t see) people living on the street. But there is diversity within the global population.
To summarize this very important and periodically updated body of work (and at the same time to under-represent the complexity of the data by grossly oversimplifying it): in low income countries. ~ 2. loss of health and disability in different populations” (WHO. to say that in another way. 2007) death. 2008). This is particularly true of communicable infectious diseases in poor regions. 2007) International Students Migrant workers Refugees Asylum seekers or refugee claimants Temporary—recreational or business travel 900 million per year (2007) (United Nations. Or.000 per year (2006) (US Department of State. people who die are the old to very old and are dying of vascular diseases (heart attacks and strokes) and cancers (see Table 25). 2001).1 Million (stock in 2003) (Böhm et al. 2004. or cardio-vascular and stroke syndromes in rich regions. in high-income countries. 2006c). 2004). Some diseases or causes of ill-health are more common in certain areas of the world compared to others.000 (stock in 2007) (United Nations. 2007) 650. Global Burden of Disease. 16 million (stock in 2007) (United Nations. the poor lose decades of life .4. infectious diseases. The differentials in diseases shown in the global burden of disease report reflect the prevalence gaps of diseases between regions (MacPherson & Gushulak. 2009).4 million (2005) with a stock of ~ 200 million (United Nations. Global estimates of migrant populations Category of migrant Regular immigrants Population estimates Annual flow of ~2.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 63 TABL E 2. 2004) ~ 86 Million (stock in 2005) (International Labour Organization. people who die are the very young to young who are dying of preventable. 2008) 51 million (stock in 2007) includes those displaced by natural disasters and conflict. Trafficked (across international borders) Internally displaced Estimated 800. (United Nations.
2 2.18 3.76 0. lung cancers Road traffic accidents Hypertensive heart disease Stomach cancer Tuberculosis Diabetes mellitus Coronary heart disease Stroke and other cerebro-vascular diseases Trachea.8 2.16 0.86 0.5 2.7 5.27 1. lung cancers Road traffic accidents Prematurity and low birth weight .5 2.22 0.4 3.81 1.40 1.31 0.14 7.8 3.8 2.18 11.2 9.29 0.20 5.91 0.62 0.1 3.5.33 0.47 1.80 0.48 0.5 3.48 0. bronchus.71 4.52 1.94 0.32 1.7 3.3 2.9 2.9 7.02 2. Global burden of disease: The 10 leading causes of death by broad income group (2004) Cause Death in Millions Low-Income Countries Lower respiratory infections Coronary heart disease Diarrheal diseases HIV/AIDS Stroke and other cerebro-vascular diseases Chronic obstructive pulmonary disease Tuberculosis Neonatal infections Malaria Prematurity and low birth weight Stroke and other cerebro-vascular disease Coronary heart disease Chronic obstructive pulmonary disease Lower respiratory infection Trachea.1 5.2 9.2 13.3 2. bronchus.9 3.2 14.1 16.84 3.5 3.16 2.4 3.3 9.4 3.67 0.6 3.54 0.51 1.46 1.9 5.7 7.5 2.94 2. lung cancers Lower respiratory infections Chronic obstructive pulmonary disease Alzheimer and other dementias Colon and rectum cancers Diabetes mellitus Breast cancer Stomach cancer 2.04 1.8 2. bronchus.55 0.6 3.0 1.8 12.27 0.0 % of deaths Middle-income countries High-income countries World Coronary heart disease Stroke and other cerebro-vascular diseases Lower respiratory infections Chronic obstructive pulmonary disease Diarrheal diseases HIV/AIDS Tuberculosis Trachea.47 3.2 2.69 0.92 0.3 3.64 PDQ: PUBLIC HEALTH TABLE 2.4 6.28 0.2 2.3 5.90 0.
In 1950’s. and a functional public health infrastructure. Current estimates of international migrants are at nearly 200 million individuals—or roughly 1 in 33 people in the world today are living in a place outside of their country of birth. Transportation authorities report that 831 million passengers flew internationally and 1. migrants constituted at least 20% of the total population of 41 nations. If these people were considered as a national population.. intercontinental migration was accomplished primarily by ship or rail.. Journeys that previously required days of ocean or land travel could now be made in a few hours (New York Times. clean water. the world’s population was estimated at approximately 2. 60% of international migrants lived in countries with high-income economies. The introduction of commercial jet aircraft in 1958 triggered an abrupt shift in the mode of travel (IATA. 1960). This means that the number of people making international journeys today pretty much equals the entire population of the world in 1800.6 billion people. International Population Mobility as a Determinant of Health.g. 30% of migrants moved from a developing to another developing nation.C h a p ter 2 • C L A S S I C A L K E Y CO N C E P T S I N P U B L I C H E A LT H 65 very early to diseases linked to their poverty including the lack of access to nutritious food. 2009). they would qualify it as the world’s fifth largest nation. smoking and other toxins). and the rich lose months of life and die late of diseases linked to behavioral and environmental risk factors such as excessive access to food (e. So what is it with all these people in the world and international migration? Part of the growth in migration is a reflection of the increase in human population over the last 60 years. 2009). the world population estimate is 6. obesity and diabetes) and carcinogens (e. Until the 1950’s. 2004). effective vaccines and antibiotics. and 30% of migrants moved from a developing nation to . there were about 76 million international migrants (United Nations.249 billion flew within their own country of residence in 2007 (IATA. A report from the United Nations (2006b) stated that 75% of all migrants resided in 30 nations. 2007). The World Tourism Organization estimated 924 million international tourist arrivals in 2008 (United Nations. 2006a). In 1960. For 2008.7 billion (United Nations.g.
and other diseases showed us in the past. SUMMARY The classical key concepts in public health originated in the attempts to prevent or control the introduction of virulent. as cholera. These migrations across lines of diversity and disparity and can be associated with significant demographic impacts on both the source and destination countries. The quality of the data for irregular migrants decreases as the process becomes more irregular. back for a moment to Table 2-2 and Figure 2-2. These are migrants who travel without permission to do so and who live unofficially in a host country. The clandestine nature of these irregular migration flows. detention. 2004) and pandemic swine influenza 2009 (Khan et al. Further. Then there are those migrant populations for whom the statistics are less clear. This creates challenges in classical public health where the existing tools are increasingly ineffective in preventing and controlling transmissible diseases. people who are vulnerable to communicable diseases because of their determinants of health also show differences in their risk for noncommunicable diseases. And. about 20% arrived in the U. Extending public health into other realms of diseases exponentially ups that challenge. But now people are far more mobile.S. leprosy. including smuggling and trafficking. No moat or walled city is going to work as a public health intervention in the modern world of global population mobility. communicable infectious diseases through measures of inspection..66 PDQ: PUBLIC HEALTH a developed nation. influenza. plague. Can you see the emerging issue? Not only do we have to deal with our own health disparities in a regional or national context. . 2009) have shown us recently. So. and they and their belongings move easily from areas with a high prevalence of transmissible diseases to those with a low prevalence. but also the whole world is lurking in the wings from a public health perspective. as both SARS (Campbell. Of the nearly 200 million international migrants reported by the UN in 2005. and exclusion. makes determining their numbers inexact. yellow fever.
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Retrieved 12/30/2009 from: http://esa. The international health regulations 1969 (3rd annotated ed. 2006b.int/ publications/1983/9241580070. New York: High Commission for Refugees. United Nations.68 PDQ: PUBLIC HEALTH United Nations.gov/g/tip/rls/tiprpt/2008/. WHO. Global burden of disease—2004 update. Retrieved 12/30/2009 from: http://www. Document A/60/871. 2006c. WHO.unwto. International tourism challenged by deteriorating global economy.pdf. Earth trends—the environmental information portal.org/esa/policy/wess/wess2004files/part2web/ wess04p2prel.). The international health regulations 2005 (2nd ed.pdf. United Nations.org/ statistics/STATISTICS/4852366f2. and Human Well-being.php?id=1665. 2008.html.un. United Nations. 2009. Retrieved 12/30/2009 from: http:// www.htm. Country Profiles. . World population prospects: The 2006 revision. Retrieved 12/30/2009 from: http://www. Press release: World tourism exceeds expectations in 2007: Arrivals grow from 800 million to 900 million in two years. D. 2009 from: http://earthtrends. asylum-seekers.un. Retrieved 12/ 30/2009 from: http://unfccc. US Department of State.un. WHO.org/media/news/en/press_det. United Nations.wri.who.php?theme=4. Geneva. November 29. 2007 .).org/doc/UNDOC/ GEN/N06/353/54/PDF/N0635354. Retrieved 12/28/2009 from: http://www. United Nations. Retrieved 12/30/2009 from: http://unwto. United Nations. Retrieved December 30. 2008.int/2860.pdf?OpenElement.org/unpp. Population.org/facts/eng/pdf/barometer/ UNWTO_Barom09_1_en_excerpt.who.state.int/ihr/ 9789241596664/ en/index. New York: Department of Economic and Social Affairs. Retrieved 12/30/2009 from: http://www. Report of the Secretary-General. Health. Geneva: WHO.) Framework convention on climate change.php. WHO. internally displaced and stateless persons.d.int/healthinfo/global_burden_disease/ GBD_report_2004update_full.pdf.pdf.org/esa/population/ publications/2006Migration_Chart/2006IttMig_chart. International migration (2006). 2006a.pdf. New York: United Nations. 1969. Global trends: Refugees. 2009. Trafficking in persons report. (n.un. United Nations. United Nations. Retrieved 12/30/2009 from: http://www.who.C: Office to Monitor and Combat Trafficking in Persons. United Nations. 2004. United Nations.org/ country_profiles/ index. New York: World Tourism Organization. 2004. Washington. World Tourism Barometer 7(1). 2004. 2005. Population Division. June 4. Retrieved 12/30/2009 from: http://www.unhcr. Retrieved 12/30/2009 from: http://daccessdds. Department of Economic and Social Affairs press release: International migration. returnees. World Resources Institute. International migration and development. 2008. Retrieved 12/28/2009 from: http://whqlibdoc.
led the CDC to focus on diseases rather 69 .3 SURVEILLANCE You can observe a lot by just watching. Alexander Langmuir. so it’s necessary to know what the risks to the population are at any given time. the chief epidemiologist at the Centers for Disease Control ([CDC]. tracking health risks and isolating potentially infectious people was the responsibility of local municipalities. and that means surveillance. and foreign quarantine stations. but they never got around to tacking the P onto the end). such as the bubonic plague. —Yogi Berra. Initially.. First. this later became the Centers for Disease Control and Prevention. smallpox. Until the middle of the 20th century in the U. these responsibilities were transferred to the federal government. American baseball player INTRODUCTION One of the goals of public health is to prevent disease rather than to cure it. This changed in the middle of the 20th century in three ways. Second. states.S. and yellow fever. That implies that we (or at least somebody) are keeping an eye out for them. surveillance meant watching and isolating people who had communicable diseases.
let’s delve into the world of surveillance. implementation. 1999). 1986). So. According to the World Health Organization (WHO. The current CDC definition of surveillance now defines it as: …the ongoing systematic collection. Needless to say. and interpretation of health data essential to the planning. analysis. clinical) • Collection of data • Analysis and interpretation of data • Feedback and dissemination of results • Public health response So.70 PDQ: PUBLIC HEALTH than solely on people (Thacker & Birkhead. laboratory. there’s quite a bit of overlap among the reasons. . its primary purpose is to simply describe what. The final link in the surveillance chain is the application of these data to prevention and control (CDC. Second. and evaluation of public health practice. although surveillance data can at times be used for research. we can distinguish public health surveillance from epidemiology in two ways. 2008). with that as background. there are six key elements in a surveillance system: • Detection and notification of a health event • Investigation and confirmation (epidemiological. if anything. but not the focus (Garcia-Abreu et al. very few survive. because data gathered for one purpose can serve a number of aims. surveillance leads to actions based on the findings. 2002). Any hypotheses or conclusions that stem from the data are an added bonus. The third change in the definition involved taking some public health action to prevent or ameliorate outbreaks of disease. is happening. closely integrated with the timely dissemination of these data to those who need to know. First. —Attributed to George Bernard Shaw and to Wallace Irwin Surveillance is used for a variety of purposes.. THE USES OF SURVEILLANCE Statistics show that of those who contract the habit of eating. and we’ll go over a few of them here.
2001). (Other epidemics. Detect Epidemics or Define a Problem One of the most primary uses of surveillance is to determine if there is an epidemic of some disorder. or will it be like the swine flu “epidemic” at Fort . where it’s obvious that there was an outbreak starting in the beginning of September and lasting until the end of the year. Estimate the Magnitude of a Problem After determining that an outbreak of something has occurred. These outbreaks can be either short-lived (e.g. salmonella poisoning traceable to a single restaurant or food processing plant) or of a longer duration. 2001 FIGURE 3-1.C h a pte r 3 • S U R VE I L L A N C E 71 Adapted from World Health Organization. counting bodies is not quite an exact science). Number of new cases of Ebola in Uganda in 2000. the next question is.. such as the avian flu (H5N1) pandemic which began in 2003 and still lingers on. as they’re not tracked by most public health agencies. such as of purple Barney dolls.) Figure 3-1 shows the number of cases of Ebola hemorrhagic fever in Uganda in 2000 (WHO. “How bad is it?” Is the latest flu (influenza [H1N1] 2009) going to be a repeat of the Spanish flu pandemic of 1918–1920 that killed anywhere between 5 and 100 million people (as you can see. can be ignored.
. in 2007. Obesity in the U.) FIGURE 3-2. n.d. a.72 PDQ: PUBLIC HEALTH Adapted from: Centers for Disease Control and Prevention..S.
But. and found that countries with the highest prevalence rates also had the highest estimated rates of fat intake. Similarly. On the other hand. underestimate the magnitude. For example. Fort Dix. is an example of an early and totally inappropriate action that was taken because the assessment of the magnitude of the problem was completely wrong. again pointing to a possible causal agent. where there are high concentrations of copper in the soil. if anything.C h a pte r 3 • S U R VE I L L A N C E 73 Dix. in 2007. Figure 3-2 shows the distribution of obesity in the U. in 1976 that killed one person (which was a lot fewer than the influenza vaccine killed or injured that year)? Obviously. The geographic distribution of a disease may also provide some clues regarding its etiology. The primary one is for planning services—where should resources be put in order to deal with the consequences of the illness? Done over time. which is discussed in Chapter 5. it also tracks the natural history of an extremely virulent infection—it kills many people in a short period of time and then quickly runs out of available hosts (how’s that for a lovely euphemism—who invites Ebola in for a visit?). and northern Minnesota and Wisconsin. with any type of epidemic or pandemic. Japan. it can show whether it is confined to one area (i. planners need to know as early as possible so that appropriate action can be taken. most of the time. New Jersey.e. Although this doesn’t rule out other causes (such as diet or genetics). Cohen’s (1987) study compared rates of breast cancer around the world. Matthews (1990) reported that the incidence of stomach cancer is highest in Iceland. When overlaid against a map showing US voting preferences. it does point to a possible etiological factor. milder infections often take a longer .. it suggests the obvious hypothesis that the causal agent is voting Republican. an epidemic) or is spreading and may become a pandemic. Show the Natural History of a Disease Figure 3-1 shows more than the magnitude of the Ebola outbreak in one country. the counters get it right or. Determine the Geographic Distribution of the Problem Mapping out the distribution of a disorder serves many purposes.S. at least initially.
led to) the increased number of suicides over the weekend. why Wednesday? At this point. show a spike on Wednesday.) Evaluate Control Measures In 1998. Generate Hypotheses In 1941. time to run their course. But. These data. which was a completely unexpected finding. following on the earlier success of the program to wipe out smallpox (or as public health officials term it. written by Reszö Seress and László Jávor. 2009. who can then go on to infect other people.000 suicides in the U. Percent of suicides by day of the week. until newer data implicate a different day of the week. Billy Holliday popularized the song Gloomy Sunday.S. but it’s guaranteed to lead to a large number of articles over the next few years (at least. summarized in Figure 3-3. nobody knows. the WHO began its global vaccination program to eliminate polio from the world by the year . told a different story. FIGURE 3-3. recent data based on roughly 162.74 PDQ: PUBLIC HEALTH Adapted from Kposowa & D’Auria. the next question is. because they spare their hosts. “eradicate” smallpox) in the late 1970s. according to urban legend. So. that purportedly epitomized (or.
and in turn.C h a pte r 3 • S U R VE I L L A N C E 75 Adapted from World Health Organization. a funny thing happened. sometimes you get something else. Newer antimicrobial agents were then thrown into the fray. everything was under control. and not wanting to keep a good thing to itself. Then as a consequence of the burden of disease and antimicrobial pressures in hospitals. hospital-based methicillin-resistant S. S. an orange fizzy drink. all you get as presents are some chocolates and a few bouquets of flowers. 2000. Monitor Changes in Infectious Agents Most people think that. or if you are really lucky or British. the goal hasn’t been totally achieved by 2009 (there were 174 new cases reported in 2008). As can be seen in Figure 3-4. Well. when you enter hospital for an operation. aureus began producing penicillinase. But soon. Number of new cases of polio by year. FIGURE 3-4. in particular to defeat nosocomial or hospital-acquired infections. not really. multiple-drug resistant organisms arose from the oozing swamps of high-risk environments such as hospitals and their intensive care units. However. like a Staphylococcus aureus infection. which did unto penicillin what penicillin was to do unto S. 2009a. aureus (MRSA) ventured outside. but the program certainly has been effective at significantly reducing the global burden of new cases of ascending paralytic neuritis due to the polio viruses. and became community-acquired MRSA or CA-MRSA (some will . when penicillin came into wide-spread use after World War II. aureus—sort of the reverse of the Golden Rule.
how well do we listen to this advice (accepting for the moment that the advice is good and should be followed)? If we can believe self-reported data (and that’s a very big “if.” given the ubiquitous presence of the social desirability bias). Prevalence rates for hospital. but the picture for lipid screening is a bit more mixed. Nataranjan and Nietert (2003) found that compliance is improving for that test. 2001. but we are going to keep the story simple and let those debates carry on).and community-based S. aureus are now resistant to methicillin and a large group of related antimicrobial drugs used in clinical medicine. want to debate the source of CA-MRSA as coming from animal health.76 PDQ: PUBLIC HEALTH Adapted from: Chambers. ain’t medicine marvelous? Detect Changes in Health Practices In addition to flossing our teeth and eating our broccoli. we’re instructed to have our blood pressure and cholesterol checked on a regular basis. FIGURE 3-5. Based on annual national surveys. The results are seen in Figure 3-5: most cultures of S. . we’re doing OK when it comes to blood pressure. aureus cases. So. agri-food or other non-hospital sources and they may be right. As we’ll say many times in this book. but is still only about 70% (see Figure 3-6).
Percent of people screened for hypertension and cholesterol. the same data can be used to help plan for the future—“Where do we expect the next threat to health will occur?” “How bad might it be?”. “Is there anything we can do to prevent it or mitigate its impact?” METHODS OF SURVEILLANCE Evidence is never enough. 2003. . “What works and doesn’t work trying to manage it?” And perhaps most important. and the other is passive versus active surveillance. Facilitate Planning Most of the uses of surveillance mentioned so far have been reactive—gathering information about risks to the health of the population after they have occurred. One is case versus statistical surveillance. FIGURE 3-6. —Hodgson & Rollnick (1996) We can differentiate the various types of surveillance in two different ways.C h a pte r 3 • S U R VE I L L A N C E 77 Adapted from: Nataranjan & Nietert. But.
which referred to skin diseases with flaking or scaly lesions. and cholera (Thacker. Currently. viruses such as rubella. however.S.78 PDQ: PUBLIC HEALTH Case Surveillance As the name implies. sexually transmitted diseases. The bubonic plague in the 14th century led many communities. the adjectival form of lepra ( ). Leviticus 13:2 charges the priests with identifying people (as well as houses. The historical roots of case surveillance go quite deep. case surveillance is still required for 75 to 100 conditions by many national health authorities. and others. especially the Republic of Venice. “leprosy. Rhode Island required tavern keepers to report any cases of contagious disease among their patrons (we presume drunkenness was not considered to be contagious). At the end of that time. It was (mis)translated into the Greek word leprosum. Even before the founding of the U. and mumps. mildew. often for a period of 40 days (quarantena.” and in Numbers 5:2. it was this association between the historic religious rules and leprosy that resulted in some of the approaches to those afflicted with the disease in Europe (Hastings & Opromolla. case surveillance involves a public health agency monitoring individual people or small groups of people.. In the U. and clothing) suffering from “leprosy. the suspected carriers were dead. The purpose is to identify those with certain diseases—most often communicable ones—in order to prevent the disease from spreading and endangering a larger group of people. and even a spiritual failing—the outward manifestation of inner corruption. 2000). thus sparing the inhabitants of the city (if only quarantine had actually worked out that way!). However. 1994. or cured. and this was later broadened to include the reporting of smallpox. including respiratory diseases such as tuberculosis.” especially in the Old Testament. in the local dialect). because it was the basis for the application of the prescribed purification and exclusion activities outlined in Leviticus. was not what we today call Hansen’s disease caused by an infection with Mycobacterium leprae.S. yellow fever. measles. 1946). recovered. The Hebrew word tsara’at ( ) could have meant any number of disfiguring skin diseases. .. leather goods. those with leprosy were banished from the community. Rogers & Muir. to prevent those with the disease from entering. This translation error was very important. As we mentioned in Chapter 1.
and the difficulty is compounded by the problem that many of the intervention programs to prevent obesity. such as smoking? What about not cooking your hamburgers enough to kill all possible germs (and taste)? Not arranging your home according to the principles of feng shui? Stoto (2008) outlines five criteria that should be considered when balancing the aims of public health against individual privacy rights: (1) the extent to which the disorder is transmissible. Arkansas public schools began measuring students’ body-mass index. toward the end of 2005. will they at some point be reported on for other unhealthy behaviors. As long as mandatory reporting with identifying information was restricted to communicable diseases. but are vestiges of the “loathsome and vile” diseases and moralities of days gone by. and raise the specter of Big Brother or the “Nanny State” that legislates that you take care of yourself (and not have any fun along the way)? If people are put on a register for overeating. for example. the justification of preventing the spread of a disease does not apply to these conditions (unless lack of exercise and dietary habits can be transmitted person-to-person as in. so do the children. 2008). which includes the .C h a pte r 3 • S U R VE I L L A N C E 79 the list of notifiable diseases is revised yearly by the Council of State and Territorial Epidemiologists (Silk et al. as well as the name of the patient and the physician who ordered the test. 2007). (2) the reliability of the screening method. not only do the wallets of those running the programs get fatter. and sending annual reports to parents whose children are obese or at risk for obesity. Clearly. Case surveillance raises important issues regarding privacy and the release of confidential personal health information. in 2003. have been dismal failures. (3) the degree to which the screening and reporting benefits the individual. the loss of privacy could be rationalized on the basis of the greater good of protecting the population at large (Stoto. Similarly. “Can I supersize that for you?”). there are moves to broaden case surveillance to non-communicable diseases as well. to the Department of Health and Mental Hygiene (Gostin. 2008). Many of the diseases on these lists do not pose significant public health risks today.. However. For example. At what point does the surveillance of an individual for his or her own good violate the principles of privacy and confidentiality. New York City began a diabetes surveillance program that mandated reporting blood sugar levels.
Other epidemics that were first brought to light through passive surveillance include the hantavirus outbreak in the Four Corners region of the southwest U. and (5) the vulnerability of those affected. Statistical surveillance can be either passive or active.80 PDQ: PUBLIC HEALTH effectiveness of any intervention. oddly enough. How other disorders fare often depends on criteria 3 and 4 and. First. Statistical Surveillance Unlike case surveillance. There are two reasons why the reports are sent in. in 1974. West Nile virus encephalitis in the northeast U.S. and similar conditions satisfies these conditions. those sending reports to some central agency are astute physicians: in private office practice or based in hospitals who have noticed something odd in their clinical practices. 1978) presaged a short-lived epidemic exacerbated by ultra-absorbent tampons and which was resolved when the Rely® brand was taken off the market and other brands reduced their absorbency. in Lyme. and Lyme disease. (4) the ability of the reporting to control the outbreak in the population. everyone affected by the condition. which was the first harbinger of the AIDS epidemic in North America. (1981) reported a number of cases of a rare form of pneumonia due to Pneumocystis carinii (now renamed to P. would likely be relegated to the dust heap. measles. even on a national or global level—and most often consists of anonymized data. seven cases of toxic shock syndrome in adolescents (Todd et al. Passive surveillance is just what the name implies: you just sit back in your chair and wait for the data to trickle (or flood) in. in 1999. So who sends the data in and why? For the most part. . with no identifying information at the person level. obesity and lack of exercise (and feng shui) does not. tuberculosis. Needless to say..S. given the current state of our technology. For example. somebody may notice an unusual occurrence of something. in 1994. that is. and that something useful is done on the basis of the reports. statistical surveillance is concerned with larger groups of people—ideally. and Gottlieb et al. Connecticut. this implies that surveillance is more than just reporting. Mandatory reporting of HIV/ AIDS. jiroveci just to confuse everyone and keep infectious disease specialists gainfully employed for a few more years).
(That’s right. venereal diseases. other people are doing all the work for them. the main ones being that they are relatively cheap and easy to operate by health departments. There are a number of positive features of passive surveillance systems. These are likely the reasons that passive surveillance is the norm at the local and state level (Birkhead . consulates and embassies on cholera. 2009b). rather. Additionally. The “new” regulations now no longer require automatic notification of these diseases. and responsibility for collecting and reporting data for nationally reportable diseases has rested with the CDC since 1961. The list of mandated reporters is slightly longer in most local health jurisdictions and often includes physicians. such as cancer. In 1893. At an international level. and injuries—selected by the governments’ ability to take remedial public health measures. 2000). 2007). and cases of human influenza caused by a new subtype (WHO. Congress authorized the Marine Hospital Service (which later became the Public Health Service) to collect data at overseas U. after all. and school principals.S. a model state statute covered 53 conditions that should be reported to state health departments and then forwarded to the Surgeon General. In addition to these disorders. and yellow fever (Lee. WHO member states had to report all cases of three diseases: plague. This changed in 2005. At the current time. for which reporting is required (Table 3-1). there are nearly 100 conditions in the U. though. pesticide poisoning. this was expanded to include data from the individual states about communicable diseases. smallpox. and yellow fever. laboratory directors. cholera. These conditions were divided into four categories—infectious diseases. In 1913.S. poliomyelitis due to wild-type poliovirus. all cases of four diseases must be automatically notified to WHO: smallpox. the U. Your school principal could rat you out to the authorities!) In 1878. SARS. but compliance by the states was voluntary (Birkhead & Maylahn.C h a pte r 3 • S U R VE I L L A N C E 81 The other reason that reports are sent in is because they’re mandated by state or federal law or legislation.S. some jurisdictions may require other conditions to be reported. 2007). or gunshot wounds. with the adoption of the International Health Regulations. plague. occupational diseases. countries must report any “event that may constitute a public health emergency of international concern” (WHO.
invasive. chronic Hepatitis B virus. congenital Tetanus Toxic-shock syndrome (other than streptococcal) Trichinellosis Tuberculosis Tularemia Typhoid fever Vancomycin-intermediate Staphylococcus aureus infection (VISA) Vancomycin-resistant Staphylococcus aureus infection (VRSA) Varicella infection (morbidity) Varicella (mortality) Vibriosis (noncholera Vibrio infections) Yellow fever . acute Hepatitis B. congenital syndrome Salmonellosis Severe acute respiratory syndrome–associated coronavirus (SARS-CoV) disease Shiga toxin-producing Escherichia coli (STEC) Shigellosis Smallpox Streptococcal disease. invasive disease Hansen disease (leprosy) Hantavirus pulmonary syndrome Hemolytic uremic syndrome. paralytic Poliovirus infection. acute Hepatitis C virus infection (past or present) Human immunodeficiency virus (HIV) infection adult (age >13 yrs) pediatric (age <13 yrs) Influenza-associated pediatric mortality Legionellosis Listeriosis Lyme disease Malaria Measles Meningococcal disease Mumps Novel influenza A virus infections Pertussis Plague Poliomyelitis. perinatal infection Hepatitis C. all ages age <5 years. acute Hepatitis B. postdiarrheal Hepatitis A. genital infection Cholera Coccidioidomycosis Cryptosporidiosis Cyclosporiasis Diphtheria Ehrlichiosis human granulocytic human monocytic human. other or unspecified agent Giardiasis Gonorrhea Haemophilus influenzae. invasive disease drug resistant. nonparalytic Psittacosis Q fever Rabies animal human Rocky Mountain spotted fever Rubella Rubella. Louis encephalitis virus disease West Nile virus disease Western equine encephalitis virus disease Botulism food-borne infant other (wound and unspecified) Brucellosis Chancroid Chlamydia trachomatis. group A Streptococcal toxic-shock syndrome Streptococcus pneumoniae.82 PDQ: PUBLIC HEALTH TABLE 3-1. Notifiable conditions in the USA Acquired immunodeficiency syndrome (AIDS) Anthrax Domestic arboviral diseases California serogroup virus disease Eastern equine encephalitis virus disease Powassan virus disease St. nondrug resistant Syphilis Syphilis.
. Example of a Notifiable Disease reporting form.C h a pte r 3 • S U R VE I L L A N C E 83 FIGURE 3-7.
. with no clear dividing line. for example. For example. nearer the research end of the continuum. folate. which can be an issue when something really big is emerging as a public health event. albumin. which uses random-digit dialing to regularly contact people in the U.S. It falls somewhere between pure research on the one side and following individual patients with. in order to interview them about their health-related behaviors . It began in the early 1960s. Active surveillance requires actually going out and collecting the necessary information itself. and a host of other variables. 2000). the world’s largest telephone survey is the Behavioral Risk Factor Surveillance System (BRFSS). But. Another form of active surveillance involves surveys addressing specific topics. and is still gathering data on a yearly basis. which uses what are essentially mobile clinics to conduct physical examinations in areas ranging from audiometry to vitamin intake. FoodNet. and a range of lab tests for calcium. which is a collaborative effort among the Emerging Infections Program of the CDC and other local and federal agencies. they generally result in substantial under-counting of most reportable conditions (Thacker & Birkhead. (2006) estimated the prevalence of candidemia in Australia through blood culture surveillance from nearly all of the laboratories.S. n. interviews covering areas such as mental health and food habits.. enlarged prostates. One of many examples is the National Health and Nutrition Examination Survey (NHANES).84 PDQ: PUBLIC HEALTH & Maylahn. collects information about nine food-borne pathogens (Centers for Disease Control. focusing on communicable and contagious diseases. 2003). and effective and timely interventions. confirmation. depending on the size of the lab).d. as it tends to delay detection. On the other hand. Many health agencies have programs to gather data in specific areas. the Society for Healthcare Epidemiology of America has advocated screening all hospital patients for MRSA (Muto et al. b). It uses a sentinel surveillance system (which we’ll define a bit later). though. contacting each of the 600+ clinical labs on a regular basis (weekly or monthly. Chen et al.. for clinical purposes on the other. what epitomizes active surveillance is that it is not designed to discover new truths. There are literally hundreds of similar programs in nearly all developed countries. Toward the clinical end of the spectrum. 2008). in the U. Similarly. but to monitor health situations.
or you are famous and have a personal physician. we’ve mentioned various sources of data—surveys. prevention of injury and substance abuse. if you want to be clinical about it). But. rabies. But you must never forget that every one of these figures comes in the first instance from the village watchman. reproductive health. emerging trends. The content consists of a “core component” that stays the same over the years. and go through them one by one. vaccine-preventable diseases. the local Boards of Health are mandated to conduct “epidemiological analysis of surveillance data. n. and these data are usually available at a local level within a matter of days (although if there are multiple causes of death. exposure to ultraviolet radiation). physical activity. 2008)—obviously enough work to keep epidemiologists employed for many years (not to mention policy wonks and public health program bureaucrats). including monitoring trends over time. tuberculosis.C h a pte r 3 • S U R VE I L L A N C E 85 (Centers for Disease Control.. —Josiah Stamp. plus questions that are changed from one survey to the next. c).and long-term trends regarding who is dying of what. Fur- . and priority populations” in a variety of different areas: chronic disease prevention (e. Head of the U. the data may not be available for months). add them. In the Canadian province of Ontario. raise them to the nth power. food and water safety.g. take the cube root and prepare wonderful diagrams. Inland Revenue Department In discussing the different types of surveillance. SOURCES OF DATA The government are very keen on amassing statistics. all deaths have to be recorded. healthy eating. and so on. let’s be a bit more systematic (or obsessive. and sexually transmitted diseases (Ontario Ministry of Health and Long-Term Care.d. who just puts down what he damn pleases.K.. lab data. child health. They collect them. By law or statute. Mortality Data Data about mortality—the numbers of deaths and the reasons—are an excellent source of information about short. infectious diseases.
000 people who died within the year (NMFS. in most developed countries. With all these things going for it.C. well. n. A similar survey. this has been supplemented by the National Mortality Feedback Survey. In addition to being centralized. and there is. and New York City because. While the data regarding the numbers of deaths are fairly accurate.). Winkler et al.) Washington. The additional information that is gathered varies from year to year. the data are also sent to a central registry. who described the behavior of the village watchman. has been done every year since 1991 (Wilkins et al. but the physician whose data are suspect. In the U. and may include health care expenditures during the last year of life. physicians. or whatever else is of interest that year.. Since 1961. the data set (like most these days) is computerized and freely available via the World Wide Web (NVSS. Bet you forgot about the Commonwealth of the North Mariana Islands.). We began this section with a quote from Sir Josiah Stamp. there is little standardization in determining and listing the cause of death. which elicits information from the next of kin for a sample of about 25.d. the National Vital Statistics System (NVSS) gathers these data from all 50 states and the five territories. Despite efforts by the NVSS.S. just don’t believe what they say. Morbidity Data As we mentioned. called the Canadian Census Mortality Follow-Up Study. go ahead and use the data.d. (For bonus points. So. it’s New York City. and health care agencies are required to file reports on anywhere from 50 to 150 notifi- . and New York City send in their data separately: Washington because it doesn’t belong to any state. smoking. there must be a drawback somewhere. labs. With death records. access to care. Comparing two official coding centers in Germany. D. 2008).86 PDQ: PUBLIC HEALTH thermore. so did we. and information about the circumstances of death (external causes) is very limited (Thacker & Birkhead. Gittelsohn and Senning (1979) compared simply the coding of cause of death between the hospital discharge abstracts and the death record and found disagreements 28% of the time. health insurance. name the five territories.. the cause of death is another matter. 2008). (2009) found only 56% of deaths used the same three-digit ICD code. it’s not the village watchman. n.
Diseases that require lab tests to make or confirm a diagnosis are more accurately captured. botulism) are fairly good.) has a number of databases derived from both in. as it’s the lab. for example. the National Hospital Ambulatory Medical Care Survey (NHAMCS). However. because these surveys require the physicians and hospitals to volunteer to take part. while the data for rare and severe diseases (e. for disorders such birth defects. and always will be). and others are voluntary and so may be prone to a host of biases. The quality of the registers is highly variable. For a 1-week period each year. However. Gaucher’s disease. because then the data would be forwarded automatically to the central registry. and so on. An example of such a form is shown in Figure 3-7. diabetes. is carried out in about 500 randomly selected hospital emergency rooms and outpatient clinics. sending the report (see the next section). n. physicians—especially those in private practice—tend to under-report more common infections. How accurate are school principals in reporting on health conditions? We don’t know and we are pretty sure we don’t want to know. In Canada. the National Ambulatory Medical Care Survey (NAMCS. Since 1973. anesthesiologists. n. and so forth. and these reports are also a rich source of information. hospitals send discharge data to a central data registry.C h a pte r 3 • S U R VE I L L A N C E 87 able diseases or conditions. if the push to computerize all medical records ever achieves its goal (a prospect that seems to be 10 years in the future.. including registers of discharge diagnoses. and medications ordered or provided from about 3. . which report data for a 4-week period. it’s not known if there are any biases regarding who participates and who doesn’t. The CDC also uses a number of active surveillance methods to gather morbidity data. data for a random sample of about 30 visits are recorded and sent to the NAMCS. because some are mandated by legislation and thus are relatively complete. the Canadian Institute for Health Information (CIHI. not pathologists.d. drug utilization. not the physician.d. hospital morbidity. or radiologists).g.000 office-based physicians offering direct patient care (that is. This may improve in the future. There are also a multitude of disease-specific registers.) has collected data patients' symptoms. A similar survey. In many jurisdictions.and out-patient admissions. diagnoses.
2000). usually weekly. surveillance based on laboratory test reports may underestimate the actual disease activity in the community. such as outbreaks of salmonella poisoning or E. If there is one positive aspect to this. especially as the data are often available within hours or days of testing. clinics. Sentinel Systems There are times when it isn’t necessary or feasible to count every case of a disorder in order to figure out what. as the labs accumulate data.88 PDQ: PUBLIC HEALTH Laboratory Data The new trend in hospital administration is “re-engineering. and test a specimen. they can be used to look at trends in areas such as lead poisoning from house paint and imported toys. is that someone has to actually order. of course. say. This makes lab data an excellent source of information for active surveillance. This is also possible because the public health system is not required in these instances to take any action in response to individual cases (Birkhead & Maylahn. coli. For very common conditions. it is that lab services are becoming more and more centralized and computerized. transport. or physicians who agree to perform certain tests (if necessary) and report to some central agency on a regular basis. such as the annual outbreak of the flu during winter. This usually means a physician starts the laboratory process (see above for accuracy of cause of death reporting). As mentioned. if anything. in contrast to. Because this moni- . The limitation here. then create a test report and submit it to a data collection system to potentially generate the surveillance reports. collect. though. labs. Sentinel systems consist of a selected number of hospitals. except for rare and exotic diseases that require a laboratory test for diagnosis and confirmation. This is extremely useful for monitoring short-term trends. a reported case of HIV/AIDS or tuberculosis.” which is a fancy term for firing front-line staff and hiring more administrators. Over time. who are in charge of firing yet more front-line staff to pay for the administrators’ salaries. it is sufficient to randomly sample from selected sites in order to determine the timing and to estimate the magnitude of the problem. The biggest problem is selecting the sentinel sites so that they are representative of the general population. is going on.
S. in which even one occurrence of a disorder (e. but don’t work well if the outbreak is very localized. how many people are affected. or when there’s precious little that can be done at an individual level.g.g. and thus under-represent less affluent parts of the country. or some other type of intervention. 1992). there’s a danger that if any action is taken on the basis of the information. What is done instead is that some central agency becomes responsible for trying to document where outbreaks are occurring and.g. 1983). when a woman who was participating in a “drum circle event. or when the disease is poorly reported. death (e.” which is meant to promote “well-being” and “healing. it is not effective for detecting early cases. Since drum skins are not a usual source of food. sentinel systems are fine for estimating the magnitude of common disease outbreaks. A variant of sentinel surveillance is sentinel health reporting. Moreover. it is possible that sites and practices that volunteer are the affluent ones or whose computer systems are more comprehensive.. it is oftentimes impractical and a waste of time to try to document every occurrence of it. polio). making those sites even less representative of the general population (Sandiford et al. which could be an issue if the problem must be dealt with quickly by vaccination. they can tell public health workers where to intervene and whether their efforts are having . Also. it’s suspected that the spores were aerosolized by the drumming (Goodnough. While these data won’t be of much use for research or scientific purposes. a branch of the CDC. An ironic case happened recently. if possible. good health can kill you. or unnecessary disability (e. it will be done most vigorously in the sentinel sites where the problem was identified.. So. See. isolation. This is used most widely by the National Institute of Occupational Safety and Health (NIOSH)..” contracted the first known case in the U. in childbirth). Epidemic Reporting When a disease is very common. 2009).C h a pte r 3 • S U R VE I L L A N C E 89 toring is time-consuming and adds an additional expense. of digestive anthrax.. in the workforce) is a signal that the system has failed and some form of intervention is necessary (Rutstein et al.
varicella. subclinical cases in the community (Thacker & Birkhead. . or where the symptoms or actual cause of the illness weren’t reported to the central agency.90 PDQ: PUBLIC HEALTH any effect. This is illustrated in Figure 3-8. the cases reported to some central registry are only a small fraction of the number of people who have been exposed.d. b. reports of a single case may signal a wider. rubeola. The reason is that any one case may reflect hundreds of unreported. According to Thacker and Birkhead (2008). or in whom the symptoms were not recognized for what they were and an incorrect diagnosis was made. FIGURE 3-8. this approach has been used quite successfully with rubella. though. dengue fever. 2008). we’ve been discussing relatively large numbers of cases in databases that can be scrutinized to see if there are increases or decreases in the number of people with a disease. and for the 1970s program in West Africa to eliminate smallpox.. Individual Case Reports So far. but did not develop severe symptoms. n. One reported case of salmonella or lead poisoning may indicate that there are a much larger number of people in the population who have been similarly exposed. Sometimes. Adapted from: Centers for Disease Control and Prevention. Under-reporting of exposure. underlying problem.
surveillance can look at any step along the chain of causation (Garcia-Abreu et al. ATTRIBUTES OF SURVEILLANCE SYSTEMS Programming today is a race between engineers striving to build bigger and better idiot-proof programs. American author From what we’ve discussed so far. though. So what are the hallmarks of a good surveillance system? Hatzell et al. using condoms when having sex with new partners. .C h a pte r 3 • S U R VE I L L A N C E 91 SPECTRUM OF OUTCOMES Smoking is one of the leading causes of statistics. we can assess (a) how many people have died from it. the universe is winning. looking at behavioral risk factors that may predispose people to or help prevent them from contracting some disorder. Most of these have proven to be quite helpful. it may seem as if the only outcome that surveillance focuses on is counting the number of people with a specific disease or condition—HIV/AIDS. and so on. So far. and so on.. Surveillance can also come at a problem from the opposite direction. if we were interested in the latest outbreak of some flu graced with an animal’s or a foreign country’s name. lead poisoning. the bad ones don’t last long enough for them to get noticed. 2002). (b) how many people contracted it. (2008) and others generally agree that there are about seven or eight attributes to consider in assessing the utility of such systems. stopping smoking. we’ve mentioned a number of different surveillance systems. For example. —Rick Cook. (c) how many people were vaccinated. This could include actions such as having regular mammograms or Pap tests. and (d) how many vaccinated people came down with it (“vaccine failures”). —Fletcher Knebel. Actually. The Wizardry Compiled In the last couple of sections. using sunscreen lotions. and the universe trying to produce bigger and better idiots.
or is attending a training course). and so on. The more steps. stupid” (KISS). and so on the user has to navigate. mouse clicks. the system must be one that is accepted by the users. Those who design Web pages use the rule of thumb that people are willing to click on three links to get where they want to go. more important. the less the system will be used. Similarly. Not only must it be simple. This usually means that the information that we thought we’d need is useless. not just by the people managing the database. passwords. equally bad news. It should use the language (or jargon) that the front line staff use. Flexibility Another universal law of nature—things never work out as we expect them to. It must be flexible to allow for changes to be made quickly and. what they don’t like about it. it should be easy to enter data into the system and just as easy to get the data back. then the system is useless. to determine what they like about it and. it can be done only by a database specialist (who is always tied up with another job. pages. Only after we set up a system do we realize that there are key elements that we should have captured and didn’t. have a graphics interface that is neither daunting nor insulting to their intelligence. ideally. This requires extensive pre-testing with the potential users. by the people overseeing the system. If the system cannot be easily modified or. applies as much to surveillance systems as to all other aspects of life. paper forms that ask for unnecessary or irrelevant information (as perceived by the person filling out the form) won’t be forms that are filled in.92 PDQ: PUBLIC HEALTH Simplicity The engineer’s old adage. “Keep it simple. be available at weird hours when they have time to enter data or ask questions of it. and other data are required. Ideally. Acceptability A system that is not accepted by the users is a system that soon will have no users. The worst systems are usually those . or that the nature of the epidemic itself has changed. more than that and they’ll just give up.
” and tried out using only other database experts. that the diagnoses given are accurate ones. It also means that people with a disorder seek medical help. we can simply close our eyes and label every sample of blood we test as positive. but it bears only a passing resemblance to English.. we’d pay a penalty for this. say hepatitis C. What we mean is that it must be capable of detecting actual cases. What’s the difference? If we want to be sure that we’ll pick up all of the people who have a given disorder.C h a pte r 3 • S U R VE I L L A N C E 93 designed by database “experts. 2009).000 B 855 857 95 Total 143 . But. let’s take a look at Table 3-2. Hypothetical results of a test for hepatitis C Have Hepatitis C Do not have Hepatitis C Test Positive Test Negative Total 48 A 2 C 50 D 950 1. it must also have good predictive power. The two columns represent people who actually do and do not have TABLE 3-2. Our experience is that they speak and write in some language. all those people who don’t have hepatitis C. Positive Predictive Value It isn’t sufficient for a test to be sensitive. 2000). This is guaranteed to correctly identify everyone who has it. This is the epidemiological definition of sensitivity—the ability of a test to correctly identify those who have the condition of interest (Streiner & Norman. and that the physician or agency reports the cases (Romaguera et al. The implication is that the data that are collected are relevant for establishing the diagnosis of the condition. which is a very large number of false-positive results. Sensitivity When we say that a surveillance system must be sensitive. That means that the test has very poor positive predictive value (PPV). To illustrate this. we are not lapsing into New Age psychobabble. but whom we’ve labeled as positive.
= ------------Number of True Positives + Number of False Positives A+B [3-2] then the PPV in this (fictitious) example is 48/143 = 0. So. This is a universal law of nature. the poorer the PPV. see Streiner and Norman . Translated into English. in other words. such as sentinel ones. Streiner and Norman . but we have to recognize the fact that it will happen. But not only did the test pick up true HCV cases (cell A). for example. to repeat what we said in the previous paragraph. sensitivity is: A Sensitivity = ------------- A+C [3-1] which in this case is a very impressive 98%. the lower the prevalence of the disorder in the population. it can’t be appealed.34. if we define the PPV as: PPV = Number of True Positives A ---------------------------------------------------------------------------------------------------------------------------------------------------------------------. or both. this means that nearly two-thirds of all tests that come back positive from the lab are actually false-positive. (For more about sensitivity. this is called shameless self-promotion. many surveillance systems. it can’t be annulled. PPV. it also erroneously identified 95 people (cell B). a surveillance system must represent the general population. Making matters worse. . are voluntary.94 PDQ: PUBLIC HEALTH hepatitis C. the surveillance system should not erroneously identify too many healthy people as ill. Sensitivity. realizing that most of the disorders we’re interested in are low-prevalence ones. it can’t be overturned—all we can do is live with it. must participate. to the extent possible. However.) Representativeness In order to be accurate and effective. and other properties of diagnostic tests. and require buy-in from the hospital. or if a survey uses some form of random sampling (and assuming most people agree to be interviewed). So. and the rows reflect our test results—the test shows they have it or don’t have it. This isn’t an issue if every lab. is the ability of the test to detect someone with the disorder.
C h a pte r 3 • S U R VE I L L A N C E 95 clinic. or private practitioner. Another factor is its utility. and on time. needless to say. There are a number of factors that affect sustainability. who know the cost of everything and the value of nothing. Sustainability It’s of no use to set up a surveillance system if it won’t last very long. Needless to say. too. or solo practices in small communities may find that participation has a low priority when compared with dealing with the madding horde clamoring at the gates. is cost–expensive systems are the first to draw the attention of bean counters. The first. and it is possible that these factors may bias who does and doesn’t take part. Timeliness To be useful. We have had too many experiences with “write only” systems. the data have to reflect what’s happening as it happens. then the program will likely fail after a short time. usually government mandated—we have to send in the data. 2000). You can guess how motivated people were to ensure that the data were accurate and timely. the total amount of time from the initial occurrence of an outbreak until the results are available in a useful form should not exceed the incubation period of the disease. Hospitals that have a large number of uninsured patients. That means that the information needs to be entered into the database almost as soon as it is gathered. in addition to the ones we’ve already mentioned. then the databases may not be representative of the general population. As we’ve said. Timeliness also implies that you can get back data that you (and others) fed in. or when the cycle of secondary transmission can be interrupted (Parrish & McDonnell. and the results in the form of a report fed back to health care workers in time for them to act on it. If this is the case. analysis and interpretation must occur. agency. and will raise a storm if the costcutters want to shelve it? If the data aren’t used much. are there a lot of people who depend on the data. participation takes time and resources. . but getting anything back in terms of summary reports is another matter.
Comprehensive plan for epidemiologic surveillance. Canadian Institute for Health Information. though. Churchill. obesity trends: Trends by state 1985– 2008. it will always run up against Finagle’s three laws (which have also been attributed to the equally prolific and mythical Murphy): 1..gov/obesity/data/ trends. From a purely scientific perspective this would seem to be the easy part but many pages of journals have been filled with letters to the editors disputing and debating the results of sound scientific studies. Analysis and interpretation are essential components that follow information gathering and data generation. S.jsp?cw_page=home_e.d. you have to know whether or not your intervention had any effect. it is a vital aspect of public health. Retrieved 1/20/2010 from: http://www. The information you want is not what you need.S. New York: Oxford University Press. S. 3. 2. (n. E. More on that in other chapters. Atlanta: Centers for Disease Control. you’re Dustin Hoffman). G.). & Maylahn. from: http://secure. and it is the backbone that supports many of the other activities of public health. Retrieved 9/22/2009. All of these fall within the realm of surveillance. Centers for Disease Control. where it’s located. 253–286 in Principles and practice of public health surveillance (2nd ed. that no matter how good a surveillance system is.cihi. However. The information you have is not what you want. Realize. in some instances). it’s first necessary to know that there is a problem. (n. References Birkhead. of course. Centers for Disease Control.d. M. C. 1986. nobody is going to make a Hollywood film showing the intrepid hero counting cases of sick people and diligently entering the data into a computer (unless. Teutsch & R. and how big it is.cdc. U.html. 2000. M.. Pp. At the end of the day (or decade. a). State and local public health surveillance. In order to mount successful interventions. . ed.ca/ cihiweb/dispPage. The information you need is not what you can obtain. But. surveillance alone is not enough.). like backbones themselves.SUMMARY Surveillance is not the most glamorous aspect of public health.
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we’ll start introducing some more sophisticated ways of looking at outcomes so that we can sound scientific and feel justified in wearing a white lab coat. University of Groningen In previous chapters. Les Oiseaux de Lune 101 . Statistics show that those people who celebrate the most birthdays become the oldest. Although to be fair to the lab coat. we’ve alluded to various outcomes that are related to public health interventions (or their absence). —Marcel Aymé. public health people see themselves as scientists. In this chapter. den Hartog. and scientists like numbers. —S. COUNTING THE BODIES Life always comes to a bad end. Ph D. such as the number of bodies piling up in the streets following the plague. it can be said with utmost confidence that most public health practitioners are found closer to the political flame than the Bunsen burner (the famous Bunsen burner having been phased out of laboratories before the end of the last century). Thesis. But.4 OUTCOMES It is proven that the celebration of birthdays is healthy.
We also think that this malady can be fatal for some people. it’s easy to discriminate between these states. as evidenced by the number of people who posthumously receive the Darwin Award for removing their contributions from the gene pool in incredibly stupid ways. it’s safe to assume the person is either dead or a politician. imagine that we want to know the number of people who suffer from that dreaded scourge of mankind. To set the scene. so on January 2nd. Usually.” then that’s the end of the questioning. such as dead or alive. As we’ll see shortly. If the person says “Yes. such as cancer. which results in not knowing your ass from your elbow.102 P DQ : P U BLI C H E A LT H Most of the time. Because such people rarely appear in hospital. and so. It’s often more appropriate to ask. we are dealing with a dichotomous outcome.) However. and at what point a cellular abnormality (a dysplasia) is advanced enough to say it is cancerous is somewhat arbitrary and may vary from one clinician to the next. Anconal-Nates Confusion (ANC). if the cadaver’s heart and brain are sitting in jars of formaldehyde. we’ll assume for now that we can dichotomize the outcome relatively accurately. and there are two ways of doing this—by looking at the total number of people who have the disorder at any given time. physicians go to medical school for four years or more in order to learn how to tell if someone is dead or not. The first job is to simply count the number of cases. or by counting only the number of new cases. neither of whom needs either organ to function. when we are discussing the result of some public health intervention. both numbers are important and are used for different purposes. we send a survey team door to door to elicit the necessary information from a sample of 500 people. Each person is asked a series of questions: (1) Within the past year. we’ll try to get this information from . a positive or a negative test result. sometimes the dichotomy is artificial. one that has only two states. (Pathologists have an easier time of it. Many diseases. we can’t use administrative data bases. “How much of disease X does the person have?” or “How severe is disease Y in this person?” rather than if it is present or absent. after all. having a disease or not having it.” we ask three more questions: (2) When did it begin? (3) Do you still have it? (4) If not. have you ever had ANC? If the person answers “No. when was the problem resolved? Because we’ll miss people who died during the year. exist along a continuum. However.
The second decision is how wide to make the interval in which we count the cases. died. Cases of Anconal-Nates Confusion in a Sample of 500 individuals. However. and whether they were cured. For disorders that aren’t related to the time of year. (We’ll also gather the data if the relative isn’t all that bereaved. hay fever or the common cold. though. The first one is to decide when to count them. we have to make a couple of decisions. The only exception is if the disorder is related to the time of the year.Chapter 4 • OUTCOMES 103 FIGURE 4-1. bereaved relatives. say. we should sample when the condition is most likely to occur. depending on whether we sample in the summer or the winter. and any differences just reflect random fluctuations around some “real” value. this is an arbitrary choice. for many conditions. But. the numbers we find in January will be different from those we get in November. we pick a time that doesn’t interfere with our summer vacation or other important obligations. The answer is a very definite. That is. for conditions like these. “It all . we’d get wildly different estimates for the number of people with. Needless to say. or still had it. before we can start counting the bodies.) Figure 4-1 shows what we found from the 10 people who had ANC at some time during the year.
other times. Some of them. advanced math tells us they’re all the same.000 people. it is: Number of people with the disorder Prevalance = ----------------------------------------------------------------------------------------------------------------Number people at risk [4-1] In this case. For other conditions.016. or to need medications. or 1. or even per 1. For disorders like this. The prevalence is a very useful number for people who have to manage (or mismanage) resources—hospital administrators. say 1 or 6 months. say a day or a week. and the like. like tuberculosis. and we counted eight who had ANC. They want to know how many people are expected to fill their offices or wards. or 16 cases per 1. it’s due to the fact that knowledge of the disorder depends on some lab test—it may show that the condition is now present or absent. again like the common cold. When the prevalence is low. The first number we can look at is the number of people with the disorder.104 P DQ : P U BLI C H E A LT H depends. it would make more sense to have a wider interval. Sometimes this is due to the nature of the symptoms themselves. we can now go on to counting people.000 or per 100. or many psychiatric disorders. HIV. Prevalence So let’s say that we’ll use a 1-month interval (the “window”) in April.6%. the onset and (in some cases) the remission are much more gradual.016 500 [4-2] We would report this as 0.” What it depends on is the nature of the condition. the window can be very narrow. there are 500 people at risk. . drug manufacturers.= 0. More formally. or the prevalence.000. family doctors. we often report it as the number of cases per 10.000. In these cases. so its prevalence is: 8 Prevalance = --------. Having made these decisions. have a very acute onset and remission.000 when dealing with a very rare disorder. which get better or worse very slowly. but we don’t know the actual dates when it started or was resolved. we can often say exactly what day it started and when it was over.
That’s why researchers prefer a different number. either through treatment or because it resolves on its own. if we think that once a person contracts the disorder. rarely has any firm empirical basis.” Bear in mind. the prevalence doesn’t tell us too much about the natural history of the disorder. but rather an exacerbation of a pre-existing condition.” Now what it depends on is our knowledge or theory of the natural history of the disorder. But. he had it before. and may be the case with some psychiatric disorders. In these situations. On the other hand. with a waxing and waning of symptoms. for instance. and an existing case if it occurred less than X months after. This is what happens in arthritis and multiple sclerosis. is “It all depends. Is Case H in Figure 4-1 a new case or not? On the one hand. then this would not be considered a new case. and determining the number of people at risk (the denominator). for example. However. that the choice of X months. researchers may arbitrarily say. such as schizophrenia. How we resolve whether or not to include people who have had the disease in the past naturally affects the numerator of Equation 4-3. which is the proportion of new cases: Number of new cases within an interval Incidence = ------------------------------------------------------------------------------------------------------------------------------Number people at risk [4-3] Here we run into two problems: whom to count as a new case (the numerator). There are times when we just don’t know—it’s a definitional issue whether a person is ever cured of major depression. then this would be considered a new (incident) case. only to suffer from it again some months or years later. he or she has it for an extended period of time. “It’s a new episode if it occurred at least X months after the end of the last one. If we state that a new episode is one that starts more than six months after a .Chapter 4 • OUTCOMES 105 Incidence However. yet again. so is this episode really new? The answer. though. or how long a person must be free from malaria before we say she contracted it again. because it consists of a mix of new cases and old ones. it also affects the denominator. If we believe that a person can be cured of the disorder. he developed ANC during the interval. as opposed to Y months. called the incidence.
. hepatitis B. I. I.2% = 2 per 1000 494 [4-4] If we want to know the number of new cases in a year. such as systemic lupus erythematosus (or lupus. D. but the prevalence will be high.014. Incidence. F. but the incidence is high. and Duration If we know the incidence and prevalence of a disorder. Conversely. because his previous episode ended only one month ago. then person H in Figure 4-1 cannot be considered to be at risk of a new episode. In a similar manner. because they already have it. for short). for acute. people A. the prevalence at any given time may be low. brief conditions like the common cold. or 0. so that now the prevalence of chronic conditions and their duration is increasing.106 P DQ : P U BLI C H E A LT H previous one ended. One of the major “advances” of modern medicine and public health is to keep sick people alive (or sick) longer. it’s a simple matter to figure out its duration: Prevalence Duration = -------------------------------Incidence [4-5] By simple math. Prevalence. D. or many forms of arthritis. E. B. and J) over 497 (because cases A. meaning that the one-month incidence is: 1 Incidence 1 month = --------. Consequently. let’s translate these equations into English. this tells us that: Prevalence Incidence = -------------------------------Duration [4-6] and Prevalence = Incidence × Duration [4-7] So. not 500. the annual incidence may be low. Also. For disorders that have a very long duration. the denominator of Equation 4-3 is 494. and J can’t be “at risk” of developing ANC. Indeed. because it’s possible to catch a cold many times during the year. H.002 = 0. and G are not at risk). we would say that the one-year incidence is 7 (cases B.= 0. it’s quite possible for the incidence to exceed 1. C.
Is 0. By itself. three people with ANC died out of the 500. But just how dangerous is it? We can quantify the risk in a number of ways. except that the denominator contains only people who have the disorder: Case fatality rate = Number of deaths from the disease in a given time -------------------------------------------------------------------------------------------------------------------------------------------------------------------Number people with the disease [4-9] .Chapter 4 • OUTCOMES 107 because we can now treat diseases. —Woody Allen. or comparing different regions of a country or the world. such as type I diabetes. this doesn’t tell us very much. meaning that the annual mortality rate was 3/500 = 0. we have raised the prevalence of such disorders and affected the genetics of evolution. or looking at trends over time. American humorist and director As we mentioned. such as those from different disorders. that previously knocked people off before they were old enough to have kids.6%. not knowing your ass from your elbow can be hazardous to your life. Mortality Rate The mortality rate is: Mortality rate = Number of deaths from the disease in a given time -------------------------------------------------------------------------------------------------------------------------------------------------------------------Number people at risk [4-8] For the year shown in Figure 4-1. Case Fatality Rate The case fatality rate is similar to the mortality rate. Ain’t medicine wonderful? MEASURES OF MORTALITY I don’t want to achieve immortality through my work.000 people. I want to achieve immortality through not dying. The mortality rate is useful only in comparison to other mortality rates. or 6 per 1.6% per year high or low? We really don’t know.
this is not a disorder that’s congenial to a long life. a larger number of people are dying each year from a variety of causes related to old age—cancer. this is called the proportional mortality rate. the number is hard to interpret.681 = 0.022% in 2004. Proportional Mortality Rate Because the population is aging.959. What we’ll look at are deaths from Alzheimer’s disease in the U. P.0004% in 1980. to get a better handle on these and other indices of disease impact. Some of that increase is likely due to the fact that there is an increasing proportion of people in the U.0004% 2004 65.490 0.037 / 227.224.022% Now we have three deaths (same people) among the 10. and part is due to improved methods for detecting Alzheimer’s. in proportion to all deaths in the population. (and most of the developed world) who are over 70.S.108 P DQ : P U BLI C H E A LT H TABLE 4-1.959. So.037 227.. However.490 = 0. in 1980 and 200* 1980 Deaths from Alzheimer’s Disease Total population Annual mortality rate *Adapted from: National Center for Health Statistics.S. 1.829 / 293. So. or the PMR: Proportional mortality rate ( PMR ) = Number of deaths from a specific cause ------------------------------------------------------------------------------------------------------------------------------Total number of deaths [4-10] . and 65.681 0. we have the same problem as with the mortality rate. and others. what happened to Alzheimer’s disease over that quarter of a century? Needless to say. Deaths from Alzheimer’s Disease in the U. the annual mortality rate was 1. let’s change the example and use real data. which is nearly a 50-fold increase. comparing 1980 with 2004.S. But let’s see what else we can do to get a better idea about what’s going on. So. 2006.30 or 30%. FROG effect (Just Plain Friggin’ Run Outta Gas). so the case fatality rate is 0.224. for a change. by itself. The relevant information is in Table 4-1. the J.829 293. coronary heart disease.
or be different in two locations. at least some of the difference in mortality rate is due to the fact that the aging population is resulting in more deaths from all causes.74%—still considerably higher. Deaths from Alzheimer’s Disease and All Causes in the U. (If you don’t remember that we said . the population as a whole in developed countries is getting older. if we wait long enough..S.037.077% 2004 65.037 1. were attributed to Alzheimer’s disease. cardiac disease. the PMR is usually easy to determine for most conditions. The better we become in preventing deaths from pneumonia. In 2004.829 2.848 0. and the data are published by the census bureau of most countries every year.Chapter 4 • OUTCOMES 109 TABLE 4-2. the case fatality rate is 100%.74% The numbers we need to figure this out are in Table 4-2.365 2. in 1980 and 2004* 1980 Deaths from Alzheimer’s Disease Total number of deaths Proportional mortality rate *Adapted from: National Center for Health Statistics.848 deaths in the U. the PMR was 2. and eating “organic” foods merely postpones the inevitable—life is a time-limited condition. The sad reality is that. 1. 2006. we’ll die from something else. and if we don’t die from one thing.S. In 1980. But.341. the greater the proportion of people who will die from whatever is left. They may change over time. simply because the rates for other diseases change. ANC. 1. Age-Specific Mortality Rate As we’ve mentioned.398. Cause of death is recorded for all people (although the accuracy of this information is another story). This highlights one of the difficulties in interpreting PMRs. but the 50-fold difference in mortality rate has been reduced to a 35-fold difference.341.077%. and other maladies. All that jogging. of the 1. So. or 0. on a positive note. arranging the house according to the principles of feng shui. drinking of bottled water.
It allows us to compare differences over time or between places that differ with respect to the proportion of people in one specific age group.19% in 2004. 2006. Under these conditions.19% and the data for this are shown in Table 4-3.) So.110 P DQ : P U BLI C H E A LT H this. Standardized Mortality Rate Using age-specific mortality rates is a very useful technique.829 34.037 25. and 0. there is a greater proportion of people in the older age range. This is fine if the disorder affects mainly people in that age range but isn’t too helpful when the risk of a disorder or an outcome varies with age. In essence. The age-specific mortality rate in 1980 for those over 65 years of age was 0.004% 2004 65. 1.000 0. perhaps you should skip the whole section on Alzheimer’s disease.300 0. so an aging population is likely not an explanation of the difference (as evidenced by the fact that none of the authors aged more than 5 years over that 24-year interval). one possible reason for the increase in both the annual mortality rate and the PMR may be this. reflecting a 47-fold increase. In essence. we will calculate an age-specific mortality rate: Age-specific MR = Number of deaths in a specific age group for cause X ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------Total number of deaths in that age group [4-11] TABLE 4-3. what we do is use a common age . So.004%. we use standardized mortality rates in order to compare two (or more) times or regions.544.205. Deaths from Alzheimer’s Disease for Those Over Age 65* 1980 Deaths from Alzheimer’s Disease Total population age 65+ Age-specific mortality rate * Adapted from: National Center for Health Statistics. This is similar to what we found for the mortality rate. let’s restrict our analyses to only those over 65 years of age.
0026 (column D).353 . for a mortality rate of 0. . this can be due to one of two reasons—either the prevalence of CVD is higher in one region than the other. 2006.000 1.000 (C) (D) (E) 29. of group Population deaths Europe and Central Asia Death rate Weighted no.000027 . If we look at Table 4-4. but the age distribution is different in the two areas (or both conditions may apply).0001478 50 194 512 1.219. or the availability of treatment.000 (F) 2 2 17 99 351 651 (G) .016275 .000476 .096.28 49. The risk of dying from CVD is directly related to a person’s age.318 13. reporting.000 1.295 Total 5.000 260. we see that in LMIs there were 13.09 1. We’ll ignore other possible reasons. So.24 88.002559 26.and middle-income countries (LMIs).000 74. Data from Lopez et al. Deaths from cardiovascular disease in two regions of the world* Low & middle income countries Age No.042731 .011469 .082950 .000 *All numbers in thousands.000 40.000961 .000 (bottom of column B).353.46 458.06 226.000 cardiac deaths in 2001 (bottom of column C) out of a total population of 5.000 1.394. In Europe and Central Asian countries (ECA).075.006937 (H) 4.000 103.28 3. the corresponding rate is 0. or it may be the same. of rate Population deaths (A) 0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+ (B) 562. such as that the systems may differ in terms of diagnosis.321 3.000046 .654.000145 . To see how it’s done.132750 .77 808.000 117.000 1.Chapter 4 • OUTCOMES 111 distribution for all of them.000139 .062 475.56 83 .000069 . you are TABLE 4-4.219.031086 .000 139. Let’s see how that applies here.000 1.893 2. we’ll use the example of deaths from cardiovascular disease (CVD) in two regions of the world—Europe and Central Asia compared with low..982 4.002903 . If two places (or times) differ with respect to the proportion of people who die from CVD.0069 (column G).000 40.004500 .000 652.000 78.111 8.000. it seems that if you live in ECA countries.000 3.38 16. of deaths Death No.
In this example. by working out what the data would look like if both regions had the same age distribution. It really doesn’t matter which region we use as the standard.) What we can do to account for this age discrepancy is to agestandardize the mortality rate. and see how many deaths there would be at each age if the ECA countries had the same age distribution. The problem is that the distribution of people at various ages is quite different in the two regions. we could explore this by looking at the PMRs for other diseases. but we won’t. So. . perhaps part of the difference is due to the fact that a higher proportion of people are at risk of CVD in ECA countries. the banking industry is ensuring that everyone in Europe and North American will have the same standard of living as those in LMI countries. Should we all immediately move to an LMI country? (Actually. 2. as seen in Figure 4-2. maybe not so fast. (Another possibility is that people in LMI countries don’t live long enough to develop CVD.7 times more likely to die of CVD than if you live in LMI countries.) Well. as we write this. You can trust us on this. and a smaller proportion of older people. we are doctors.112 P DQ : P U BLI C H E A LT H FIGURE 4-2. LMI countries have a larger proportion of young people.and MiddleIncome countries. than do ECA countries. Distribution of Ages in Europe and Central Asia Versus Low. we’ll use the LMI countries as the standard. the final numbers will come out the same.
not the song of the same name by the Tragically Hip). This is done for each of the age categories. if both regions were comparable.00348—still 1.280 deaths (column H).295.000 kids aged 0-4 in ECA countries (column E). but there are several ways to calculate life expectancy. and we find that. and services where the people live. and for looking at changes over time.560 cardiac deaths instead of 3. and we find that we would expect there to be 4.000. Sounds simple. life expectancy has been used to both set and measure priorities. In public health terms this usually involves the concept of life expectancy. in order to prevent early deaths. the most common of which is life expectancy at birth. It can also be of immense assistance to those who plan and allocate humanitarian assistance. so the mortality rate (column D) is 0. we can’t actually prevent it. This table can be a great help if you are looking at investing in Old Folk’s Homes.654. the best we can do is to delay the inevitable. there would have been 1.000. and international development assistance. 2009). if ECA countries had the same age distribution as LMI countries. But.Chapter 4 • OUTCOMES 113 In LMI countries. and objectives. We now multiply that age-specific mortality rate by the 29. rather than the 2. Life Expectancy Given the inevitability of death (the process.000 kids (column B). for those in the age range of 0 to 4. the age-standardized mortality rate in ECA countries is 0. Some examples of recent life expectancy at birth are given in Table 4-5 (Central Intelligence Agency. So. a goal is a fairly broad statement of .000 deaths (column C) out of a total population of 562.4 times higher than in LMI countries. In public health work. (For those who are interested. Life expectancy at birth is often used as an indication of the overall quality of the environment. you can unpack your bags now. but half of what we found when we didn’t age-standardize. goals. based on their present age and the demographic characteristics of the reference population in which they live. we have to know what “early” means.0001478. Life expectancy is the average number of years that people are anticipated to live.000 that actually occurred (column F). Thus. investment in health care.000. society. there were 83.
5 76. That is. the intervention to be used. it may not necessarily mean that the average person lives to age 50 and then joins the choir invisible.0 60.1 81. you must have reliable birth and death information and accurate knowledge of the size of the population. In order to calculate life expectancy. These definitions apply even if for those who aren’t really interested.) However. As such. he or she will live for another 60 years.0 78.0 38.2 80. but you already know this.5 69. 2009 estimates* Country Macau Japan Canada Norway USA Cuba Mexico China India Russia Haiti South Africa Angola *Adapted from Central Intelligence Agency. other measures are often used to account for the impact of some agerelated influences. It could reflect a very high infant mortality rate. Life Expectancy at Birth 84. it is influenced by all mortality in the population. 2009.2 a desirable state of affairs.8 66. an objective is a narrower. quantitative statement that sets out a target population. because it’s an aggregate measure. an individual’s life expectancy at birth may be less than that for an adult in the same location who has survived the risks of early death. which .1 77.114 P DQ : P U BLI C H E A LT H TABLE 4-5.1 73. For example.8 49. but if the person survives to the age of 5. having just read the section on standardized mortality rates. and the indicator to be measured. say. National life expectancies at birth.4 82. if the average life expectancy is 50 years. and a target is a specific statement of the amount of improvement to be achieved and the date by which it is to be achieved. and may be misleading.
when I call for statistics about the rate of infant mortality. all this talk about mortality rates. The results after the third year are summarized in Table 4-6. D 1. and so forth. and used another village as a control. Don’t public health researchers ever look at the bright side of life? Actually. The first lesson that you must learn is. As an example. what I want is proof that fewer babies died when I was Prime Minister than when anyone else was Prime Minister. MEASURES OF IMPACT I gather. and they have the numbers to prove it. ineffective) public health interventions are. 2001. Alzheimer’s disease. young man. Relative Risk Yadav et al..Chapter 4 • OUTCOMES 115 is why the development of accurate vital statistics has been such a necessary component of the development of public health. That is a political statistic. that you wish to be a Member of Parliament. we’ll use bed nets treated with deltamethrin to control malaria.914 B 590 814 Number without Malaria 953 Total 1. we will look at some of the numbers used to express how effective (and. Number of cases of malaria among those using or not using treated bed nets* Number with Malaria Treated nets No nets Total 147 A 224 C 371 *Adapted from: Yadav et al. British Prime Minister The discussion so far has been pretty morbid and pessimistic. In this section.543 1. case fatality rates. cardiovascular disease.100 . (2001) distributed deltamethrin-treated bed nets in two villages in India. —Winston Churchill. TABLE 4-6. they do. ANC. at times.
in other words. but found that the number of cases of malaria stayed the same. That is. Assume we did the study again. and may lead us to support the use of treated nets in high-risk countries.134. and used 10 times the number of people in each group. we would have found the results shown in Table 4-7. even though 13.134/0. resulting in RR = 0. for this study.275. or .= -----------------------C C(A + B) Risk Control -------------C+D [4-14] So. the RR is identical.0. The benefit for the treated group is 953/1100.0134. just looking at the RR hides as much information as it provides. before we get too carried away. But.275 = 0. There’s a second problem with RR. the RR is 0. rather than the risk of getting malaria.49. but only 1.4% of people were helped in the first case. then the RR would be 1.116 P DQ : P U BLI C H E A LT H Among those with treated nets. let’s look at some problems with the RR. If the nets had no effect. the risk of contracting malaria is: A Risk Treated group = ------------A+B [4-12] which in this group is 147/1100 = 0. This looks very impressive. but ran the calculations in terms of the benefit of the netting (that is.000 = 0.3% of the people were in the second case. The risk in the treated group is 147/11.49. What this means in English is that using nets reduced the risk of malaria by slightly more than half. not getting malaria). In the control group. Let’s say we used the data in Table 4-6. the risk is: C Risk Control group = -------------C+D [4-13] or 224/814 = 0. That means that the relative risk (RR) of malaria in the experimental group is: A ------------Risk Treated A(C + D) A+B Relative risk = -------------------------------.= ----------------. and in the comparison group it is 224/8140 = 0. Obviously.0275.
In fact. so the relative benefit is 0. though.515.725. we show two RRRs of 50%. that would be 2. but express the results in terms of the RRR. So.04. or 51½%.49. and it’s obvious that the amount of change is quite different in the two situations.853 Total 11.Chapter 4 • OUTCOMES 117 TABLE 4-7. relative to the risk in the comparison or control group. we find an identical number for the RRR. that works out to 0.769 19. It’s defined as: Risk Treat ment – Risk Control Relative risk reduction ( RRR ) = --------------------------------------------------------------------------Risk Control [4-15] For the data in Table 4-6. which is the amount the risk changes. this doesn’t help us too much more than the RR.140 Number without Malaria 10. This is not the reciprocal of the relative risk. let’s look for some other indices and see if they will give us a better handle on what’s going on.725 = 1.916 8. So. If we do the same calculations for the data in Table 4-7. 0.866/0. In Figure 4-3. Relative Risk Reduction One index is the relative risk reduction (RRR). . This means that whether we express the results in terms of how many are helped as opposed to how many are harmed gives us very different results.19.140 B 7.000 0. and the benefit in the comparison group is 590/814 = 0.866.275 = 0. which isn’t too reassuring. Number of cases of malaria among those using or not using treated bed nets in a hypothetical study using 10 times the sample size Number with Malaria Treated nets No nets Total 147 A 224 C 371 D 18. it’s a marvelous way for drug companies to sell their wares—make a product that reduces a tiny risk to an infinitesimal one.1415/0.
1415 = 7.1415.118 P DQ : P U BLI C H E A LT H FIGURE 4-3. or about 1. the ARR was 0.134. we find that the ARR is 0. the absolute risk of dying from malaria when there are no bed screens is 0. Computationally. but we can use the ARR in an even more informative index.0142. Sackett.275 – 0.4%. The absolute risk reduction is simply the difference between the two: Absolute risk reduction ( ARR ) = Risk Treat ment – Risk Control [4-16] which in this case is 0. and the risk with the screens is 0. This means that we’ve reduced the risk of contracting malaria and dying because of it by about 14%. so the NNT is 1/0. In the first case. These are better reflections about the effectiveness of the screens in the two situations.07. Doing the same thing for the fictitious example in Table 4-7. and Roberts (1988) introduced an index called the number needed to treat (NNT). it’s the essence of simplicity: 1 Number needed to treat = ----------ARR [4-17] Let’s work those out for the examples in Tables 4-6 and 4-7. The Same Relative Risk Reductions for Two Situations. the ARR was 0. while in the second case. Absolute Risk Reduction In Table 4-6.134 = 0. Number Needed to Treat Laupacis.275. so the NNT .0142.1415.
“What proportion of new cases within a given time frame are due to exposure to some risk factor?” Other ways of putting it are. results of drug trials always report RRs. for no particular reason. we’ll use the first term. Even more crucially. “What proportion of the cases would be eliminated in a given time if people were not exposed to the risk factor?” or “What is the excess risk due to the risk factor?” Dehghan et al. even some people who were given the bed nets developed malaria. .000. if we can bring everyone’s CRP under control. we would have to hand out 8 treated bed nets to prevent one case of malaria. we’d have to hand out 71 to prevent one case. First. will we eliminate diabetes? The answer is obviously No. but—especially for drugs that treat “lifestyle” disorders like hypertension or hypercholesterolemia—rarely report NNTs.) It attempts to answer the question.) That means that for the data in Table 4-6. That’s probably because the manufacturers don’t like numbers pretty close to 1. (A point of etiquette—we always round the numbers up to be conservative. Attributable Risk and Attributable Risk Percent C-reactive protein (CRP) has been implicated in type 2 diabetes (as well as a host of other disorders. So we can ask the question. And that’s why the NNTs for most drugs are so high—the vast majority of people who don’t take them won’t have an adverse event. Table 4-8 summarizes what they found for those in the lowest and highest quartiles of CRP levels. (2007) looked at the prevalence of diabetes in people with various levels of CRP.6. while for the data in Table 4-7. such as hypertension and cardiovascular disease). it also goes by the names of attributable fraction and excess fraction. To keep life simple. Now we have an index that more accurately reflects the results. rather than relying on just the RR. (Just to confuse you. the majority of people who did not have treated bed nets didn’t develop malaria. Interestingly.0? There are two reasons. because diabetes has many other causes.Chapter 4 • OUTCOMES 119 is 70. despite the dire warnings we see on TV. Here’s where the attributable risk (AR) comes in. so we’ll call those NNTs 8 and 71. though. Why isn’t the NNT 1.
2007.463 No Diabetes 1.053 = 0. The formula for AR% can be written in a number of ways.478 *Adapted from: Dehghan et al. Conversely. it’s 77/ 1463 = 0.. more than half the cases of diabetes can be attributed to elevated CRP. it means that even if we eliminate elevated CRP as a risk factor. at least for people with the highest CRP levels.386 1.053 AR% = ----------------------------------. albeit not as prevalent. is 0.941 B 1. One is: ( Risk for exp osed ) – ( Risk for un exp o sed ) AR% = -------------------------------------------------------------------------------------------------------------------------------Risk for exp osed [4-19] which in this case is: 0. the AR.117 – 0. Number of cases of diabetes for those in the lowest and highest quartiles of C-reactive protein* Diabetes Highest quartile Lowest quartile Total 173 A 77 C 250 D 2. The AR is simply the difference in the risks for the two groups: AR = Risk Exposed – Risk Un exp osed [4-18] The risk of those exposed to the highest level of CRP is 173/ 1478 = 0.117 – 0. To be consistent.053. diabetes will still be around.305 Total 1. We can also express this as a percentage. in which case it is known (for obvious reasons) as the attributable risk percent (AR%) or the etiologic fraction (EF).117.547 0.064.= 0.117 [4-20] meaning that. So. we’ll use AR%. .120 P DQ : P U BLI C H E A LT H TABLE 4-8. or risk difference.691 2. while for the lowest (unexposed) group.
the AR is 0. the RR is 2. . The number is slightly different from what we got using Equation 4-19. But. let’s assume that the people in the lowest quartile in Table 4-8 reflect the unexposed population. meaning that we’d reduce the overall prevalence of diabetes by about 3¼ percent.2. One way to write the formula for the PAR is: PAR = Incidence Population – Incidence Un exp osed [4-22] To simplify our lives. amazingly. Population Attributable Risk and Population Attributable Risk Percent The AR and AR% show how much the outcome can be averted among exposed individuals. In this example. If we plug those numbers in to Equation 4-23.Chapter 4 • OUTCOMES 121 Another way of expressing the AR% is: RR – 1 AR% = ---------------. we’ll come up with the same answer.× 100 RR [4-21] and. Another way of calculating the PAR is: PAR = AR × P Exposed [4-23] where AR is the attributable risk. we can use the odds ratio (OR). so what would be the effect at the population level if we brought CRP levels down? This is referred to as the population attributable risk (PAR) which. from a public health perspective.4%. in this case. and some people with normal CRP have diabetes. but that’s just rounding error. the incidence of diabetes in the unexposed group is 77/1463 = 0. if we can’t get the RR (as with case-control studies) and if the prevalence is lower than about 10%. So. we are also interested in how great an effect this will have on the entire population. Not everyone in the population has elevated CRP.5026.0850. so Equation 4-21 gives us 54. which we’ll describe in the next section. has no other names.064 (we got that from Equation 4-18) and PExposed = 1478/2941 = 0. which.0526 and in the total population it is 250/2941 = 0. Here. means people who have high levels of CRP. and PExposed is the proportion of people exposed to the risk factor.
for one reason or another. there are situations in which we can calculate the OR. in which the investigator determined who got the intervention and who got the comparison condition. and then measure what proportion of people had the outcome of interest. because they’re related to the effectiveness of the nets. Another widely used index of this is the odds ratio (OR). we do (or don’t do) something to a group of people.× 100 Incidence Population [4-24] and can also be written as: P Exposed × ( RR – 1 ) PAR% = --------------------------------------------------------------. meaning that we’ve reduced the incidence in the population by about 38%. Why two indices of the same thing? There are two reasons: first. Let’s start off with the second reason. Here. which is also called the relative odds. Thus. they’re not quite the same. . As with an RCT. and C to D are meaningful representations of how effective (or ineffective) the intervention was. Another way the study could have been done is called a cohort design. in which case it’s referred to as the population attributable risk percent (PAR%). which is an index of how much more likely an outcome is in one group rather than another. In this case. we get a PAR% of 38. we would find one group (or cohort) of people who. and then look at the prevalence of malaria in both. the ratios of cells A to B. were using the treated bed nets and another group who weren’t.× 100 P Exposed × ( RR – 1 ) + 1 [4-25] Plugging the numbers into the equation. Odds Ratio We started this section by talking about the relative risk (RR). The type of study that led to the data in Table 4-6 was a randomized controlled trial (RCT).122 P DQ : P U BLI C H E A LT H We can express the PAR as a percentage of the population incidence. and second.1%. the ratios of the numbers in the cells are meaningful. but not the RR. which is simply: Incidence Population – Incidence Un exp osed PAR% = ---------------------------------------------------------------------------------------------------------------------.
we’d have to sample so many people in order to find enough who had the outcome that the cost would be astronomical (although this doesn’t prevent drug companies from launching massive trials of marginally effective cardiac medications. the ratios are determined by the researchers. though. (2000) didn’t look directly at this. for statistical reasons. to definitively determine if smoking leads to lung cancer). the ratios of cell A to cell B. in a case-control study. “And then I go. but at brain cancer. Muscat et al.” it’s been hypothesized that cell phone use leads to brain death.) In a casecontrol study. and C to D. and then find a group of people (the controls) who are as similar to the cases as possible. they found 469 cases of cancer. are not determined by the exposure (cell phones).) Their results are shown in Table 4-9. we begin by drawing a sample of people who have the outcome of interest (the cases). but it’s not always possible to do an RCT or cohort study. they tried to recruit about equal numbers of cases and controls. or whatever. but by the researchers. and recruited 422 people. For example. In this case. So why can’t we use the RR? The reason is that. like ‘duh’. or five controls. 2009. perhaps based on overhearing teenagers on cell phones saying. We can’t do the former when we’re looking at adverse events (ethics boards would frown on randomly assigning 500 adolescents to smoke for the next 20 years and 500 kids to abstain. is to figure out the odds of having used a cell phone for . Then we either ask them or search company or medical records to determine if they were exposed or not to the putative causal agent. the design of choice is the case-control study. When we’re dealing with rare outcomes. (For more about the advantages and disadvantages of each of these designs. except that they don’t have the outcome. since there are only seven people in the world who don’t use them. but here it’s the consumer who’ll pay in the end). Using medical records. but. Cohort studies are extremely difficult when we’re dealing with relatively rare outcomes. So. they could have recruited two controls for every case. and they’re all in nursing homes in Uzbekistan. (This study would be impossible to do now. matched on a number of demographic variables. What we can do. although it’s a relatively weak design. see Streiner & Norman. and determined how many used cell phones.Chapter 4 • OUTCOMES 123 RCTs and cohort studies are powerful designs for examining effectiveness.
To say that the odds of Beetlebaum winning in the 4th race are 1:4 means he’s definitely not a favorite—there’s only a 20% chance he’ll win. you can also get the OR by: (66 ×346) / (76 × 403) = 0. and for the controls. and the odds of cell phone use for those without cancer.= ------B⁄D BC [4-28] In this example. .164.75. “Odds” are a familiar term for those who frequent race tracks or bet on other sporting events. it is 76/346 = 0. meaning that the OR is 0..220 = 0.124 P DQ : P U BLI C H E A LT H TABLE 4-9. algebra actually does work. those who have cancer. As equation 4-28 indicates.164/0.75—you’re less at risk of brain cancer if you use a cell phone (probably because you’ll die in a car crash caused by your lack of attention to driving). 2000. The odds of exposure among the cases is: A Odds Cases = --C [4-26] and the odds among the controls is: B Odds Controls = --D [4-27] so that the odds ratio is simply: A⁄C AD Odds ratio = ----------. the odds of cell phone use among those with brain cancer is 66/403 = 0. and an 80% chance that he won’t. The number of cases of brain cancer among people who did or did not use cell phones* Number with Brain CA Cell phone users Non-users Total 66 A 76 C 142 D 749 891 B 346 422 Number without Brain CA 403 Total 469 *Adapted from: Muscat et al.220.
When the RR is greater than 1. loneliness. 2000) argue that the OR is a perfectly good index in its own right. then it becomes Equation 4-28. Second. Walter. and suffering—and it’s all over much too soon. Preventing life-ending events in 100 25-year-olds will result in greater aggregate survival than preventing life-ending events in 100 75year-olds simply because the youngsters should live longer than . algebra works. But a few brave souls (e. With the OR. Yet again. doesn’t suffer from the problem that plagues the RR and that we mentioned earlier— the fact that we get different results depending on whether we use the good outcome or the bad one as our outcome measure. the OR and the RR are very close to each other when the prevalence of an outcome is low. So. Many epidemiologists say that the RR is the “gold standard. say 10% or less. and moreover. the OR is always larger than the RR. and set A and C equal to zero. This points out a couple of things.86.” and the OR is a poor cousin—nothing but a rough approximation which we use when we can’t figure out the RR. the results with one outcome is merely the reciprocal of the results with the other. —Woody Allen. interventions to prevent death in younger populations have a greater impact on aggregate life expectancy..g. the RR is more conservative than the OR. we’d find it is 0. DALYS. reflecting a very low prevalence. the choice between the RR and the OR is not as black and white as some people advocate. Because everyone eventually dies. AND OTHER OUTCOME MEASURES THAT DON’T END IN “LY” Life is full of misery. the OR is always smaller. American humorist and director While preventing early death is a desirable goal for everyone on a personal level. and become more different as the prevalence increases. when it is less than 1. The reason is that if we take the equation for the RR (Equation 4-14). the societal consequences of extending life expectancy can vary. QALYS. depending on the outcome. First.Chapter 4 • OUTCOMES 125 If we ignored our advice and figured out the RR.
. YPLL offers a measure of where you get the greatest return on life expectancy when you’re comparing preventive or mitigating programs. This age could be the life expectancy of the reference population. YPLL isn’t the only abbreviation used in public health to try to provide some quantifiable measure of the impact of disease. but more often. Years of potential life lost in New Jersey.126 P DQ : P U BLI C H E A LT H the old fogies. YPLL was developed in the late 1940s in order to reflect the amount of time not lived by those dying before a predetermined age (Haenszel. deaths in younger groups have a greater impact than in those who are nearer the predetermined cut-off. and deaths among people over the cut-off have no impact at all. and death on “what might have been. Decisions in this context can assist high level.. 1950). 1996). Trying to measure this sort of impact led to the concept of years of potential life lost (YPLL). Figure 4-4 shows the causes and amounts of YPLL in New Jersey in 1966 (New Jersey Department of Health and Senior Services . 1996. With YPLL. it has a set value such as 65 or 75 years of age. disability.” While it’s clear that early death results in a loss of productive life (as well as Adapted from: New Jersey Department of Health and Senior Services. It is not clear from the literature. health policy development by providing a quantitative estimate of the benefits of interventions or services designed to improve health outcomes. but we assume that those responsible for YPLL were young when the concept was developed. 1996 FIGURE 4-4. These tools can be useful in developing public health programs to reduce or prevent early death if effective interventions are put into place.
such economic measures. The common thread here as we’ve said often is the concept of health being more than the absence of disease. people who are ill or injured but remain alive can also have less favorable outcomes than those who remain healthy. or injury led to the creation of a measure combining what was historically referred to as morbidity and mortality. While YPLLs and DALYs quantify the impact of poor health on longevity and disability. When compared to other indicators. as seen in Figure 4-5 (Reidpath & Allotey. The size of this indicator reflects the disparity between the theoretical potential of a population free from injury. There are also situations in which an intervention may prolong life and move the YPLL yardstick. When all of the DALYs for a population are considered together. they provide useful insight into how health. can create situations where people do less well than their healthier counterparts. disease. 2007). whether through disease or from other reasons. and disability and their present status. and the distribution of resources are related. Unfavorable health states. disability. At the same time. Getting a quantitative handle on these sorts of issues which describe not the length of life but rather its quality is important for those who have to .Chapter 4 • OUTCOMES 127 unproductive life. wealth.. This metric is the disability adjusted life years or DALYs.g. DALYs are often used to quantify global disparities and inequities in health. 1994). but the simple extension of life may not always be seen by the patient or society to be totally beneficial. they provide a quantitative assessment of the burden of illness and disease (Murray. a lot of effort and money go into interventions that don’t always affect YPLLs or DALYs. Extending the principle of potential years of life lost by death to situations where years of good health are lost due to disease. DALYs are defined as: DALY = YLL + YLD [4-29] where YLL means years of life lost and YLD stands for years lost to disability—what used to be called morbidity (Murray. hip replacements and cataract surgery). but it’s not politically correct to mention that). 1996). other interventions or treatments may neither prolong life nor extend YPLLs but may improve life (e.
many of those living . Healthy people almost always assign lower values to less than perfect health states than do people actually living in them. As we said. Disease burden for various risk factors. and they come with ethical and moral considerations that are more complicated than simply measuring survival (Macran & Kind. FIGURE 4-5.5 means that five years of perfect health is equivalent to 10 years of living in a given health state (Prieto & Sacristán. who have limited or no experience with condition itself (Hirskyj. 2003). 2001). such as quadriplegia or writing “mission statements” for organizations).128 P DQ : P U BLI C H E A LT H Adapted from World Health Organization. This is the least empirical of the indicators. A QALY of 0. the QALY. The challenges here are obvious. The method is based on the principle of assigning perfect health a score of 1 and death a score of 0 (we’ll ignore for the moment conditions that some healthy people say are worse than death. This has resulted in yet another “LY” indicator. as it requires estimates and assumptions regarding what a “quality” year of life really is.d. such as mechanically sustained biological activity in the absence of higher motor neuron function. An example is congenital deafness. However. the decisions about the QALY assigned to certain outcomes are often made by healthy people. allocate health care resources or chose among several therapeutic alternatives. or quality adjusted life years. Any situation that results in less than perfect health has a QALY less than 1. 2007). n. some people feel that some states could be worse than death.
QALYs and DALYs are also used in another way to express outcomes. particularly if they have the condition being assessed. he wrote: Screening mammography for women in their 40s is clearly effective. 2009). as compared with a proposed alternative costing only $35. when all the costs that are associated with gaining a quality of life-year or avoiding a year of life with a disability are known. Health economists love devising “league tables” of the QALYs associated with different interventions so that they can be rank-ordered. 2009). and sometimes irrational arguments (Allhoff. another measure can be created: the cost/ QALY or cost/DALY. or the medicalindustrial complex that makes money out of the disease. In part. The point here on cost per outcome is not that human life can have a value assigned to it. or clinicians who bill for this service. The problem is that the benefit is tiny and expensive. 2005) . or politicians whose constituents lobby for patients with the disease. and not funding procedures that were too low on the list. Well. or are researchers whose grants depend on the disease. 2007). Statistician Donald Berry has calculated that for a woman in her 40s. the program was scuttled because of ethical.Chapter 4 • OUTCOMES 129 with this condition do not consider their life to be adversely affected. a decade’s worth of mammograms would increase her lifespan by an average of 5 days — and this survival advantage would be lost if she rode a bicycle for 15 hours without a helmet (or 50 hours with a helmet) (Crewdson.. and the recommendations of an expert panel on breast cancer screening in women. QALYs are often used to provide a quantifiable indicator of the expected benefits of some intervention because they include aspects of both longevity and the quality associated with that longevity. That is. the state of Oregon proposed doing just this in 1989.000 per QALY (Ahern & Shen.000 per quality-adjusted life-year (QALY) gained. but that individuals should not be left alone to play with cost/QALY. However. Technical knowledge is not always . you see the dilemma. Truog (2009) wonderfully expressed this concept of cost and outcome in an editorial on health care rationing in the U. political.S. while a hearing intact person could weigh deafness as having a great impact on quality of life. A recent cost–benefit analysis showed that adherence to the current guidelines from the American Cancer Society costs more than $680. In fact. and they are often used in cost-effectiveness studies (Cox et al.
and as such. health inequality and HALEs are worthy of brief mention here. is a little harder to wrap .130 P DQ : P U BLI C H E A LT H helpful in making easy social decisions in health care or public health. or even interventions between different disease conditions. public health officials. By systematically collecting mortality data and disease surveys from different countries on levels of ill-health allows. It is all about accountability and rational use of public financing and where allocations can be technically ranked on the “bang for the buck” scale. data can be adjusted where necessary. Health and health inequalities are measures that describe how well the systems are improving overall levels of health and reducing inequalities in health indicators at the population level. QALYs and DALYs are useful measures of outcomes relevant to people and applied by health system planners. As noted above. and others interested in health. large scale population estimates of health inequality could be fraught with interpretative error and bias.. That said. In some situations it is important to have health outcome measurements (and performance indicators) for public health systems (translation: governments and international health agencies). Fortunately for technical experts who know their place in the scheme of things. using standard techniques to correct for under-reporting or lack of cross-population comparability (Murray et al.” particularly as it relates to good health or the absence of disease. Health and equity … not too much in terms of being concrete. The HALE combines age-specific mortality with estimates of age-specific prevalence of ill-health. In this concept there are two terms that are frequently used: health inequality and health equity. In the WHO framework. researchers. those are issues of social policy and are best left to politicians. weighted by severity. 2002). in an effort to advise where society could invest limited health care and public health resources for an expected outcome. Program designers and health policy analysts may use these assessments to compare two interventions for a disease condition. “equal” and “not equal” are fairly concrete and understandable concepts. population health is measured according to the estimate of Healthy Life Expectancy (HALE). Equity. You can see immediately that with more adjustments than you get at a chiropractor’s office. when used to mean “fairness.
cardiovascular disease. let’s consider a fictitious country with an annual national health expenditure budget of $168 billion. if this same fictitious country actually had a definition of poverty and knew how many poor people that there were for which this $16. You may well ask. There will also be an equity gain related to her not developing facial wrinkles (cosmetic surgery). or approximately the cost of her cell phone bill for a year. and stroke (health systems costs). emphysema. and living a healthy life longer (only to be the victim of a drunk text-messaging driver at the age of 80 while she is out jogging because—remember—she still has to die of something). These scenarios on measurement in health equity are currently fictitious as well. “How does one measure social justice?” Good question (note that there is no answer here). as in how much equity do you have in your home (the re-sale value less unpaid mortgage and other debts).800. WHO is establishing a scientific advisory panel on measurements in health equity. For example. the equity per poor person could be calculated ($16. There may be more to come (we have to dangle something for a second edition of this book). if a teen-aged girl chooses to not smoke (behavioral determinant of health) she will accumulate an equity of $10 per week (approximate cost of one package of cigarettes) for her life time (start with life expectancy at birth of 80 years): $10 × 52 weeks per year × 65 years of not smoking = $33. and programs to address poverty. and take vacations in the south to avoid the bitter winter cold and snow in this fictitious country. cancer. health equity is usually discussed in the context of social justice (Commission on Social Determinants of Health. But if equity is used in the sense of free and clear ownership. salaries.8 billion/number of poor people) as a socio-economic benefit for all the employed people supporting poverty who could then buy homes. with 10% of expenditures for infrastructure.Chapter 4 • OUTCOMES 131 one’s fingers around. So. cars.8 billion for the poor (socio-economic determinant of health). And.00. 2008). then health equity as applied across all the determinants of health may make more sense and actually be measurable at both societal and individual levels. . hold this thought. refrigerators. or $16. Continuing in the vein of health equity. As a consequence.8 billion was dedicated.
M. Shen Y. I. 2009. Uitterlinden. A. Critical Care Medicine 35: 1918–1927.theatlantic. Genetic variation.. Dehghan. These are often presented as raw numbers. CSDH. J. Health inequality and heath equity are conceptual constructs applied for accountability in national and international organizations for health systems as indicators of health improvement. 2009. 2008. Central Intelligence Agency. The Oregon plan and QALYs. Cox. E. Sijbrands. Final Report of the Commission on Social Determinants of Health. Carson.gov/library/publications/the-world-factbook/ rankorder/2102rank. Retrieved 12/26/2009 from: http://www. et al. Diabetes 56: 872–878... An economic evaluation of prolonged mechanical ventilation. Retrieved 12/9/2009 from: http://virtualmentor. S. A. E. 2005. There is also recognition that the quality of life is as important as the quantity. F. how many succumbed.htm. W. but it’s often more informative to present risks and rates. References Ahern C. 7.. Geneva: World Health Organization. Retrieved 12/18/ 2009 from: https://www. such as DALYs and QALYs. de Maat.cia. A. A. P. 18: 718–725.ama-assn...int/publications/2008/ 9789241563703_eng.who. J. 2007. The Atlantic. to reflect this. Crewdson. Chelluri. . G. Closing the gap in a generation: Health equity through action on the social determinants of health. The Virtual Mentor. Allhoff. D. J. 1950.com/doc/ 200911u/ mammograms. html. and incidence of diabetes. & Sanders. G..pdf. American Journal of Public Health 40: 17–26..org/2005/02/ pfor2-0502. Nov. Retrieved 12/ 21/2009 from: http://whqlibdoc. and how many survived. 2007. S. Haenszel. 2009.. The world fact book 2009.. H. and to adjust them for local conditions. H. M. 2009. C. L.. G. and there have been various indices. 19. Bootsma. Kardys. Govert. Cancer Epidemiol Biomarkers & Prevention.132 P DQ : P U BLI C H E A LT H SUMMARY Much of public health involves counting—how many people were affected by some disease. Standardized rate for mortality defined in units of lost years of life. Rethinking the mammogram guidelines. C-reactive protein levels. A. Cost-effectiveness analysis of mammography and clinical breast examination strategies: A comparison with current guidelines.
& Lopez. J. D.gov/nchs/data/hus/hus06. C. Retrieved 10/14/2009 from: www. Laupacis. doi: 10. PDQ Epidemiology (3rd ed. P. Malkin.nejm.htm. L.cdc. & Norman. A.int/pub/smph/en/index.. Handheld cellular telephone use and risk of brain cancer. An assessment of clinically useful measures of the consequences of treatment. International Journal of Equity in Health 6: 16. L.state. McRee. 1.. “Death" and the valuation of health-related quality of life. L. 2007. 2000.Chapter 4 • OUTCOMES 133 Hirskyj. 2006. Retrieved 8/5/2009 from: http:// www. J.1056/NEJMp0911447. et al.. New England Journal of Medicine. D. R. Murray. Jamison. Published online 12/19/2003. Murray. Retrieved 12/26/2009 from: http://healthcarereform.html. G. L. C. T. measurements and applications.us/health/chs/stats96/ mort15. New Jersey Department of Health and Senior Services. R. Problems and solutions in calculating quality-adjusted life years (QALYs). P.. Geneva: World Health Organization. Hyattsville MD: National Center for Health Statistics. Thompson. ed. L. 2009. Retrieved 12/20/2009 from: http://www. A. Lopez. JAMA 284: 3001–3007. M. Muscat. United States. Global burden of disease and risk factors. MA: Harvard School of Public Health. E. C. C. Streiner. D. Murray & A. D. Truog. J.. eds. Health. Macran.1186/1477-7525-1-80 Reidpath. G. Medical Care 39: 212–227. D.. and risk factors in 1990 and projected to 2020. & Allotey. M. Rethinking DALYs. (Eds. Salomon.nj. ethics. & Sacristán. Mortality 1996.. R. J. L. D. injuries. Summary measures of population health: Concepts. S. doi: 10. 1996. 2006. S. & Kind. & Murray. CT: PMPH US. Stellman. 2003 ... National Center for Health Statistics. D. doi: 10.. Murray. 1988.1186/1475-9276-6-16. Shore. P. Mathers..D. Cambridge. New England Journal of Medicine 318: 1728–1733.). A. 2002. New Jersey Health Statistics 1996. Washington: The World Bank. Published online 10/30/2007. Shelton. J. Pp 1–98 in The global burden of disease: A comprehensive assessment of mortality and disability from diseases. J.pdf. C.. 2009. C. Lopez. Screening mammography and the “R” word. Bulletin of the World Health Organization 72: 429–445. Nursing Ethics. Sackett. 2007. Ezzati. 1994... with chartbook on trends in the health of Americans. Quantifying the burden of disease: The technical basis for disability-adjusted life years. 14: 72–82. D. A. Prieto. Measuring global health inequity. 2006. ... Volume 1.). QALY: An ethical issue that dare not speak its name. J. C. D. J.D. 1996. R. E. S. A. 80. Mathers.org/?p=2439&query=TOC... 2001 . D. S. Years of potential life lost to age 65.. Health and Quality of Life Outcomes. D.who. & Roberts.
2000. S. R. D. R. & Sharma.html. P. Choice of effect measure for epidemiological data.. (n.who.). Sampath. Journal of Medical Entomology 38: 613–622. R.d. Reported crime in United States. The top 10 causes of death.usdoj. Deltamethrin treated bednets for control of malaria transmitted by Anopheles culicifacies (Diptera: Culicidae) in India. cfm?stateid=52.int/mediacentre/factsheets/fs310/en/ index..134 P DQ : P U BLI C H E A LT H U.).d.gov/dataonline/ Search/Crime/State/statebystaterun. 2001. (n. . Department of Justice. Retrieved 8/3/2009 from: http://bjsdata.S. World Health Organization. V. Retrieved 8/3/ 2009 from: http://www. Yadav. S. Walter.ojp. Journal of Clinical Epidemiology 53: 931–939.
or that there’s an increased risk of one bad outcome or another if migration patterns change (or don’t change). or the decreased risk of bad outcomes associated with a “Mediterranean diet” (wine. vegetables. wine. 135 . to describe the spectrum of outcomes related to various factors— people are at greater risk for certain diseases if they’ve been exposed to one thing or another. Dear Me INTRODUCTION In previous chapters. and wine). we used the term “risk. olive oil. wine. and discuss factors that influence our perceptions of risk. fish. In this chapter. but evidently he owed his unusual longevity to the fact that in those days there were no doctors competent to warn him of the dangers of obesity.” in general terms.5 RISK That he was overweight was certain. we’ll define it a bit more rigorously. —Peter Ustinov.
and doesn’t imply that the relationship is necessarily causal. The interesting point about this second definition is that it uses the term “association” in describing the relationship between a risk factor and an outcome. A risk marker is some attribute or exposure that is related to a higher prevalence of the outcome. should we mount a large-scale . or an inborn or inherited characteristic which on the basis of epidemiological evidence is known to be associated with health-related condition(s) considered important to prevent (p. e. feel it’s important to differentiate among various types of risk. argue that causality is irrelevant. we concur with Burt. a nontechnical term encompassing a variety of measures of the probability of a (generally) unfavorable outcome (p. for example. that an individual will become ill or die within a stated period of time or age. 160). Judging from the blind alleys many have gone down because of the mix-up. such as Gerstein (2002). 160). American comedian In A Dictionary of Epidemiology. So.136 P DQ : P U BLI C H E A LT H ON THE VARIETIES OF RISK Health nuts are going to feel stupid someday. A risk determinant is a factor that is causally related to the outcome. all that counts is whether removing the risk factor consistently reduces the risk. some authors. Last (2001) gives the definition of risk as: The probability that an event will occur. tend to have lower birth weight children. —Redd Foxx. but may or may not be causally related to it. exposure to asbestos vastly increases the risk of developing mesothelioma. there are almost no cases of people who have mesothelioma who haven’t been exposed.g. Indeed. Almost everyone who has been diagnosed with this disease has been exposed. Also. lying in hospitals dying of nothing. such as Burt (2001). Others.. an environmental exposure. and a risk factor as: An aspect of personal behavior or lifestyle. as opposed to “designer” bottled water. because mixing them up has led a lot of people astray. Pregnant women who drink tap water.
they won’t die of heart attacks.C h a p ter 5 • RIS K 137 intervention to supply all pregnant women with bottled water? We can.g. and there is mounting evidence that low-density lipoprotein (LDL) and highdensity lipoprotein (HDL) cholesterol may be only markers for hypercholesterolemia. not causal factors (Ravnskov. reducing them didn’t affect disease progression at all (e. 1993).” Aha! The culprit must be estrogen. Stott et al. this isn’t the only example of a risk marker being mistaken for a modifiable risk factor. Sadly.. but it won’t affect neonatal weight in the slightest.. Finally. and this difference declines in the “golden years. All of this would be mere semantics if it weren’t for the fact that confusing them has led to some amazing failures in medicine. —Albert Einstein . let’s move on to things we can really count on—numbers.. lower the person’s pressure. 2005). reducing the probability of the disorder. reducing plaque levels in the brain didn’t slow Alzheimer’s disease (Green et al. and the risk goes down (but lower it too much and the risk starts to increase again). Similarly. 1973). RISK ASSESSMENT Whoever undertakes to set himself up as a judge of Truth and Knowledge is shipwrecked by the laughter of the gods. Perhaps the prime example is blood pressure and the risk of stroke and heart attacks. so if we give it to men. 2009). Well. Who can afford to pay 10 times the price of gasoline for a product that’s (literally) freely available? Only those with enough disposable income to indulge in such frivolity. they didn’t— they died of cancer and strokes (Coronary Drug Research Group. the type of water you drink is simply a marker for something else—socioeconomic status (SES)—and it is this that affects birth weight. a modifiable risk factor is a determinant of an outcome that can be ameliorated. In their 40s and 50s. Although homocystine levels are elevated in dementia and cardiovascular disease. men stand a much greater risk than women of having a heart attack. Obviously. On that cheery note.
in the public health arena. and so forth. was thought to be unlike previous such outbreaks. we can calculate relative risks. It involves first identifying exactly what is going on (although this may take some time because of limitations of technology) and then determining whether it is a credible but as yet undocumented event (that is. we try to determine what are the risks involved—who’s most at risk. This is the (relatively) easy step. etiologic fractions. After the data are in. or the contamination of a water supply system? This is a necessary precondition for taking or not taking some action. a threat) or a quantified problem (a risk). Identification of the hazard. such as the outbreak of a new and possibly lethal virus. based on our knowledge of previous such incidents. This is one of the areas in which public health differs from epidemiology—epidemiology tells us whether past exposure has increased the risk of some outcome for a group of people. quite unlike other influenza viral attacks. Sometimes. whereas most such epidemics are winter phenomena. we can find ourselves over-reacting to minor threats or not responding in an appropriate and timely manner to major ones. in that early in the outbreak the median age of the people who died was 22. First of all. which may have begun in Mexico.138 P DQ : P U BLI C H E A LT H What we discussed in the previous chapter on outcomes—the quantification of risk—assumes that we have accurate data. Usually. what are the consequences. it occurred in the summer. . which affect primarily the elderly. and all of the other fancy stuff we just covered. nature can rear up and smack us in the face. influenza surveillance isn’t even normally done in the summer months in the northern hemisphere. (Indeed. risk assessment is used to estimate whether current or future exposure will affect a city or community. though. The H1N1 influenza outbreak in 2009 (the swine flu). standardized mortality ratios.) It was atypical in another way. we have a different type of problem to confront: how do we assess the risk of a potential hazard. whether they derive from epidemiologic studies or trials of interventions. Then. the process of risk assessment is broken down into a number of steps: 1. However. Without an accurate assessment.
000. When possible. We could have just as rationally divided by the weight of a Volkswagen engine. pesticides sprayed on fruits and vegetables.C h a p ter 5 • RIS K 139 2. In many areas. which bear only a passing resemblance to most people we know. so we just draw a “best-fitting” line. or 1. if we assume that there is a threshold. 3. Do we simply continue the line downward to figure out the exposure below which nothing untoward will happen. This is of particular concern for environmental hazards. or the effect of the level of air pollution on asthma. there are few data points. Many purported carcinogens. are deemed as such because of their effects on lab mice. for example. and then divide that by 100 or 1. Furthermore. Risk estimation.000. and how severely? Risk management types often use formulae such as: Risk = Severity × Number of people affected or: Probability × Expected loss Risk = ---------------------------------------------------------------------------------Preparedness .000. This is the bottom line—just how bad is it going to be? How many people will be affected. or do we assume that there’s no such threshold and any exposure is bad (see Figure 5-1)? Second.000 just to be safe. But we have to guess what the shape of the relationship is beyond the measured data points. or any other arbitrary amount? The answer is. recommendations regarding the maximum acceptable level of exposure are often flawed for a number of reasons. though. exposure to bright sunlight. the actual dose chosen is somewhat arbitrary. This involves estimating the relationship between exposure and the risk of an adverse event. Dose-response assessment. because we don’t know. or 10. But why 100. we find a “NOEL” dose (the highest dose or exposure that produces No Observable Effect Level). the necessary data just do not exist. at least in humans. and then extrapolate to determine the possible effects at reasonable levels of exposure. Very often. such as radon seeping through the basement floor. or even 10.
the response to these different situations is often very different and requires different sets of priorities. rough guides. very often the estimates are nothing more than informed or uninformed guesses about severity.140 P DQ : P U BLI C H E A LT H FIGURE 5-1. The result of this type of analysis is supposed to give us an estimate of the nature and degree of each of these components of the overall risk. Samuelson. if anything. these estimates are often way off the mark. As neat as this framework looks. at best. those at highest risk. The equations mean that a very severe illness affecting only a few people is given the same weight as a very mild one affecting many. the number of people who will be involved. allowing us to make decisions about what. to do. so these equations are. Newsweek. and in face of the purported accuracy of the estimates. and so on. 1994 . —Robert J. As we’ll see in the next section. May 9. though. However. despite the expertise of the people. The dangers are often low and falling. But these lead to some problems. while the fears are high and rising. Extrapolation of a Dose-Response Curve. RISK PERCEPTION We live in a world of real dangers and imagined fears.
which is expected to kill 600 people. they drive their car to the store. we laugh at people who won’t fly because of the risk of the airplane crashing (it’s about 1 in 13 million for any flight on a major North American or European airline). n. A poll conducted toward the end of 2007 showed that 56% of people thought that the incidence of crime was going up. and you’re the Medical Officer of Health. but who run out and buy lottery tickets. S.S. 2008).d. let’s consider the following situation. There’s an outbreak of a new strain of the flu virus. from 1960 to 2007. The actual trends over the past 47 years are shown in Figure 5-2. Which of these two options would you choose? .000. Why is there this marked discrepancy between the actual risk of crime and the perception of what’s happening? Don’t people know what the risk is of being the victim of some crime? Similarly. FIGURE 5-2. where the chance of winning is often less than one in 14 million. or is it more universal? Well.C h a p ter 5 • RIS K 141 Adapted from: U. Department of Justice. and the risk of having a fatal car crash going to the lottery store is about 1 in 5. is it only people who buy lottery tickets (which can be seen as a tax on the statistically challenged) and people concerned with crime who have trouble assessing risk. even worse. Crime Statistics in the U. versus 11% who thought it was the same or decreasing (Third Wave. So.
If you’re like the vast majority of people (nearly 75%). simply “framing” the issue differently—saving lives versus losing lives—completely alters how we evaluate a situation. Heuristics and Biases At a deeper level. but you have two different options: Option C 400 people will die. and risk-taking when losses are involved (there’s a chance. but at the risk of saving no one. Option D There’s a one-third chance that nobody will die. albeit small. Would you want an operation in which there’s a 1% chance of dying on the table? If not. whether it’s getting consent for an operation. findings. mathematically the same outcome but different reactions.. Options A and C are identical. that’s the same as 400 people dying (Option C). Most people in this case are risk-averse: they want the assurance of saving 200 people. and disturbing. Similarly. Options B and D are exactly the same: a one-third chance of saving everybody (Option B) is the same as a two-thirds chance of saving nobody (Option D). The only thing that differs is how the options are framed—in terms of lives saved or lives lost. One conclusion from this now-classic study by Tversky and Kahneman (1981) is that people are often risk-averse in choices that involve gains (they want to be sure of holding on to their winnings). Consider the same situation. Now the same proportion of people choose Option D. and two-thirds chance that nobody will be saved. and two-thirds that everyone will die. rather than a gamble of saving everyone. If 200 of the 600 people are saved (Option A). So. they are taking a risk because the one-third probability of saving everyone is more palatable than the certainty that 400 people will die. Option B There’s a one-third chance that everyone will be saved. let’s go through the numbers. participating in a research . That is.142 P DQ : P U BLI C H E A LT H Option A 200 people will be saved. it points to more profound. of averting the loss). But. then how about one in which there’s a 99% probability that everything will be fine? Again. you’d go for Option A. First.
when in fact the correct answer is (b). but finding new ones has become a growth industry. such as stomach cancer.C h a p ter 5 • RIS K 143 study. let’s use another example: (a) are there more words that start with the letter R. or (b) that have R as the third letter? Again. 2008). framing the outcome differently changes how people appraise it and what they opt to do. Thus. since being regularly subjected to minor hazards results in people treating them as an upper bound on the size of the risk (Yudkowsky. and these frequently lead us astray. we use rules of thumb (called “heuristics”) to influence our decision making. 1991. words that begin with R are more available for recall. In a way. always). the morning paper likely had a number of news stories about people who were shot the day before or who died in car accidents. In other words. . assessing the risks of a mass immunization program. What is responsible for more deaths: (a) accidents or (b) diseases? What about (a) homicides or (b) stomach cancer? Most people choose option (a) in both cases.g. Another implication from this work is that while we would like to think of ourselves as rational human beings who make decisions based on the facts. Availability Bias. like the pandemic of 1918 that purportedly killed between 50 and 100 million people worldwide (Patterson & Pyle. these reported options are more available to us when we try to think of causes of death. We can’t possibly list them all. but probably none about people who died of some disease. Another implication of the availability bias is that we have difficulty extrapolating from small hazards (e. Similarly. where to build a nuclear reactor. but it’s much more difficult to think of those where R is the third letter. although that number—and indeed. any estimate of its impact—is open to question). successful vaccines have inoculated people against more than the flu.. an outbreak of a mild flu) to the possibility of more extreme ones. The reason is that you can easily think of many words starting with R. or whatever. they’ve prevented people from contemplating more dangerous outbreaks. although most respondents say (a). Tversky and Kahneman (1974) originally listed 12 such heuristics. but we’ll discuss a few of the major ones. the correct answer is (b). To see why people make this mistake. the fact is that under conditions of uncertainty (that is.
144 P DQ : P U BLI C H E A LT H Hindsight Bias. and all of the negative aspects of the rival cars you didn’t buy. to pay no attention to hindsight) changed the 57% to 56%. “I knew it all along. Before the incident. people’s reaction is. Telling a third group to ignore their knowledge of the flood (that is. According to Karl Popper (1959). Hindsight bias is different from increased confidence based on new information. it will be all of the positive features of your vehicle.” and those in the heuristics game as the confirmation bias—we look for information that confirms our choices. Sadly. After nearly every situation that resulted in tragedy—the global outbreak of SARS (severe acute respiratory syndrome) that significantly affected Toronto and other areas of the world in 2003. Just after it exploded. before the Challenger disaster. transfusions with HIV-infected blood. Afterwards. the hallmark of science is that . 57% said that the city was negligent. the destruction of the Challenger shuttle in 1986—some agency or other was deemed negligent for failing to foresee the potential hazard. Confirmation Bias. rather than that which refutes or falsifies it. because the person believes that the outcome information did not affect his or her judgment (Hawkins & Hastie. estimates of a major problem occurring were usually within the area of one per 50. Both were instructed to find the city remiss if the probability of flooding was greater than 10%. which is always 20/20. we just can’t ignore hindsight. the Three Mile Island accident in 1979. over three-quarters of the people said that a flood was too unlikely for the city to take precautions. Kamin and Rachlinski (1995) gave one group of people the information that was known to city officials before a flood actually occurred. another group was given the same information. What will you focus on? Most likely. Try as we might. by the way) are not immune to it.000 flights. these are examples of the hindsight bias. the assessment of the risk involved was extremely low (albeit possibly influenced by the availability bias). In most cases. Based on an actual case. Just after you’ve bought a new car. researchers (and physicians. the annual automotive issue of Consumers’ Reports comes in the mail. one person in the industry said that he knew for certain it was doomed. though. In the first group. but was also told that a flood had happened.” Indeed. Psychologists refer to this effect as “cognitive dissonance. while in the second group. 1990).
The first group guessed 45.200. we constantly look for information that confirms our hypothesis (or diagnosis).g. You have five seconds—estimate the answers to these two series of numbers: [A] and [B] 1×2×3×4×5×6×7×8×9=? According to Dawes (1988). and the second guessed 25. 1992). The confirmation bias manifests itself in other ways. but it did. a disorder later found to be caused by the Helicobacter pylori (H. this hasn’t prevented meta-analyses coming to completely opposing conclusions (e. too. 1992. This initial anchor should not have affected the results. and Stress-Related Stomach Disorders (Monroe.. though. and it is 500 for [B]. versus Nurmohamed et al. a totally irrelevant “anchor” influences estimates. the average estimate for [A] is 4. pylori) bacterium. and almost never look for data that would refute it. by including or excluding articles based only on methodological criteria and not on their results. this was one of the motivations behind systematic reviews and meta-analyses.C h a p ter 5 • RIS K 145 hypotheses can be falsified. hasn’t stopped the publication of books such as Coping with Ulcers.880). They then asked people to guess the number of countries there are in Africa. their 9×8×7×6×5×4×3×2×1=? . How many years of research were wasted “proving” the link between stress (or spicy foods) and ulcers. Heartburn. Even though the people saw that the initial numbers were randomly generated and bore no relationship to how many countries there actually are. We are far more critical of the methodology of articles that refute our pet theory and more accepting of those that support it. Leizorovicz et al. However.. This finding. Tversky and Kahneman (1974) first spun a wheel which landed on the number 65 with one group of people and 15 with a second group. Even more disturbingly. reviews were supposed to be more objective and free from the confirmation bias. why was there almost a nine-fold difference in the guesses? It’s perhaps no coincidence that the first number in [A] is nine times that of [B]. 2000). Indeed. Although both answers seriously underestimate the true total (the actual answer is 362. However. Anchoring. in our day-to-day work.
S. this leads to adjustments in the estimate that are too small. not much has changed in the interim. or how many million eggs are produced in the U. Overconfidence Bias. In a classic study. Garrison Keillor describes Lake Wobegon as the place where “all the women are strong.” So you say. and no fewer than 10. all the men are good-looking. Seven “internationally known” engineers were asked to estimate how high an embankment had to be to cause the foundation to fail. 80% of drivers in Texas thought they were above average (Svenson.” “Do you think it could go up to 500. “experts” are similarly (or perhaps even more) overly confident.” says he. 2008). Alpert and Raiffa (1982) asked people 1.146 P DQ : P U BLI C H E A LT H responses were influenced by the anchor. worldwide. “250. This overconfidence in one’s estimates doesn’t apply just to the lay public. The number who got it right? Zero! Physicians’ estimates of the proportion of over 1. Notice what was done. Compounding the problem that many estimates of risk are just plain wrong is the fact that people are overly confident of their “knowledge. “Probably? Can you put a confidence interval around that?” He may reply. If the estimates were accurate. Over 2000 years ago.000 tops. “Probably 50. and confidence intervals that are too narrow.” Similarly.000.000. 1981). Almost universally. then 20 of them should have fallen outside the CIs. and then anchored his confidence interval around this.000 general knowledge questions.” Overconfidence is the systematic overestimation of the accuracy of one’s decisions and the precision of one’s knowledge. and to put CIs around the estimate wide enough to have a 50% chance of bracketing the true height (Hynes & Vanmarke. over 43% did.500 patients . cited in Yudkowsky. each year. such as how many physicians and surgeons are listed in the Boston Yellow Pages. in fact.000?” “Absolutely not. Thucydides said that “Their judgment was based more on wishful thinking than on sound calculations of probabilities. he made an estimate based on little or no knowledge of the true extent. This would seem like a purely academic exercise were it not for the fact that experts are asked to provide estimates of uncertain outcomes all the time: “How many people are going to be affected by this latest outbreak of Kyrgyzstan Python flu?” The expert may answer. and all the children are above average.” Sadly. and to put 98% confidence intervals (CI) around their estimates.
Scope Neglect. As Senator Everett Dirkson may (or may not) have said. even when made by experts. would pay only 28% more to preserve all 57 wilderness areas than they would to protect just one of them (McFadden & Leonard. people living in the U. Similarly.or 100-fold. .” Tacking one or two zeros at the end of a large number doesn’t change our impression of it—it was larger than we can comprehend to begin with. It takes exponential increases in risk to change our assessments by linear amounts. what’s the bottom line? It’s not encouraging.g. The issue here is called scope neglect or scope insensitivity. One is that we have a fixed amount of money we’re willing to spend to give us a “warm glow” (e. 1995). 27). this is called “Weber’s law. (For those of you who suffered through psychophysics in undergraduate experimental psychology classes.S. and saving 10 times as many lives didn’t change the dollar amount at all (Baron & Green. $78. a billion there. and the number of birds we save is of secondary importance.”) So. Estimates of risk. and remains larger than our ability to grasp when it increases 10. increasing the supposed risk of chlorinated water by a factor of 600 affected people’s willingness to pay to ameliorate the problem only by a factor of 4 (Carson & Mitchell. This isn’t a problem with saving only birds and trees. despite unwarranted confidence in those assessments. the actual magnitude of the problem has little effect on the amount of money or effort we are willing to spend to fix or prevent it. Be wary of any estimates that are not based solidly on facts. There are a number of possible explanations for this. (1993) asked this of a group of people. and few estimates ever are.C h a p ter 5 • RIS K 147 who may have pneumonia after being examined for a cough were close to 90%.000 birds? When Desvousges et al. the actual proportion was under 20% (Christensen-Szalanski & Bushyhead (1981). and pretty soon you're talking real money. about $80 to save birds). and $88.000 birds? How about 20. Another possibility is that we have difficulty grasping large numbers. 1996). That’s probably why O’Donnell (1997) defines “experience” as “making the same mistakes with increasing confidence over an impressive number of years” (p. the answers were $80. respectively. “A billion here. 1993).000 birds? What about 200. are often wrong. How much would you be willing to spend to save 2..
2006). DHS’s review concluded that “at its best. and the system was amended and “clarified. resulting in about 2. something should have been done sooner to warn the people and fix the problem. Some of the threats are very real. This is seen in the “color alerts” put out by the Department of Homeland Security (DHS) in the U. the credibility of the entire system was further diminished. Obviously.” Despite this. the threat was never really there. contaminated food from a restaurant or food processing plant. an outbreak of a new strain of the flu. For example.500 people becoming ill and at least seven dying. the vaccination program implemented to counter this non-existent threat resulted in about 500 cases of Guillain-Barré syndrome and 13 deaths (Sencer & Millar. and on and on.000 people. the effects from drinking too much (or is it too little?) red wine. and immediate action must be taken by those in authority and by the public.148 P DQ : P U BLI C H E A LT H COMMUNICATING RISK “The sky is falling! The sky is falling!” —Chicken Little It seems that we cannot open a newspaper or watch a news program on TV without hearing about some risk to our health— chemicals sprayed on fruit (go to Wikipedia and check out alar).S. and the reactions caused more harm than good. an “outbreak” of the swine flu at Fort Dix in 1976 killed one person and hospitalized 13 others. at worst. Each time the alert level was raised to orange (“High”) or red (“Severe”) and nothing happened. Ontario. Other times. coli. until some day the wolf will actually show up at the door and no one will be prepared. after 9/11. being exposed too much to the sun (melanoma) or not being exposed enough (vitamin D deficiency). in a town of 5. However. This leaves people who must declare an emergency in a quandary. the water supply in Walkerton. there is a . side effects of some drug. became contaminated with a highly dangerous strain of E. though. If one is called each time an outbreak is suspected. In 2000. until it was recognized that people were ignoring it completely. then it will be like the boy who cried “wolf”—the public will discount future warnings. there is currently indifference to the Homeland Security Advisory System and.
then we can show them the numbers and they’ll see that our course of action was correct. .C h a p ter 5 • RIS K 149 disturbing lack of public confidence in the system” (Homeland Security Advisory Council. they must see the benefits as well as the risks. All we have to do is tell them the numbers. if an emergency isn’t declared. we can tell them that they accepted situation X in the past. or if the risk level is acceptable. those in authority will be accused of ignoring “obvious” signs of a problem and leaving the public unprepared. and public health workers warning (or not) of potential epidemics. 6. It’s obvious then for the public to accept situation X. then. 7. All we have to do is get the numbers right. if the public demands to know. If we can manage the risk. All we have to do is show them that they’ve accepted similar risks in the past. When it became obvious that the explanations aren’t sufficient. that had a similar level of risk. because that protects the rest of society. When stage 2 was perceived as not caring about the public’s perspective. with the advantage of the hindsight bias. All we have to do is make them partners. The first six stages treat people as passive recipients of risk communications. 2009). 4. All we have to do is treat them nicely. we will show people that we respect them and give them all the necessary information. So. Fischoff (1995) outlines seven “historic stages” in risk communication: 1. All we have to do is explain what the numbers mean. then we’ll explain the numbers. because the public doesn’t have a good grasp of scientific uncertainty. This is a dilemma faced by weathercasters warning (or not) of impending tornados and hurricanes. It’s OK to hospitalize people with SARS. then why bother to tell people about it? 2. On the other hand. Well. All we have to do is show that it’s a good deal for them. or if there’s nothing we can do about it. 3. 5. It’s obvious that the way the message is delivered is as important as the message itself. seismologists warning (or not) of possible earthquakes.
(As Yogi Berra.. So. the better. As long as the probability of canceling the threat is high. 4. making vaccines against an epidemic). wearing face masks) should be as time-limited as possible. . getting out of the path of a tornado. Requests to take protective action (e. but Breznitz recommends even more. and the higher the level of the threat when it is cancelled. This must be balanced against the fact that the longer the warning is delayed.g.”) The more the warning system tries to appear infallible beforehand. it means that at least they can’t complain that they weren’t consulted about the situation. The high levels of threat routinely announced by the DHS were seen as self-serving. 2. or perhaps it was Niels Bohr. once said. the more foolish it appears afterwards. 3. there must be enough time allowed to take preventative action (e. We have no idea what the next stage will be. especially about the future.150 P DQ : P U BLI C H E A LT H This stage makes them partners and gives them a seat at the table. it should be done as soon as possible. The lower the announced probability of the threat. the more false alarms will have been averted. the less credibility is lost when it is cancelled.. The more discrete stages there are. 5. “Prediction is very difficult. allowing the magnitude of the threat to be better communicated to the public and the policy makers. From a cynical perspective. false alarms are inevitable. The longer the warning is in place. The DHS had four stages (although they rarely seemed to use the lower two). The warning should be delayed as long as possible. what can be done to minimize the “cry wolf” effect? Breznitz (1984) offers a number of suggestions: 1. When a threat warning has to be cancelled. Needless to say. 6. the more the credibility of the warning system is jeopardized. and ultimately were self-defeating. people should also be told about the difficulty in making accurate predictions. Despite making the public partners in communicating risk.g.
—Robert J. he replied. the more people who are exposed to a given risk.000 times more accepting of risks that accompany voluntary activities like hunting. the risk tolerated for voluntary activities is about the .” One of the first to look at what it depends on was Chauncey Starr (1969). such as natural or man-made disasters (for example. decreasing the risk 30-fold increases the perceived benefit by only slightly more than three. The ugly reality is that life itself is a risky proposition. May 9. in fatalities per hour. “See. Conversely. as compared with involuntary events. a doubling in benefit translates into an eight-fold increase in the level of acceptable risk. Second. he said. at what point does some potential threat become a risk? The answer is.” First.”) RISK TOLERANCE We act as if there's a constitutional right to immortality and that anything that raises risk should be outlawed. who assumed that. measured by the annual amount spent on the activity). This allowed him to use “revealed preferences. Asked why. Third.” based on economic data (plotting costs. society has reached an “essential optimum” balance between the risks and benefits associated with any activity. to come up with four “laws of acceptable risk. the amount of risk the public is willing to tolerate is roughly proportion to the cube of the benefit of that activity. earthquakes or exposure to chemical spills or food preservatives). and driving. it is impossible to live in a completely risk-free environment. (This is like the man who keeps shredding paper into small pieces. “To keep the alligators away. the lower the acceptable level of it. through trial and error over the years. people are about 1. Finally. it works. “It all depends. against benefit.C h a p ter 5 • RIS K 151 To this we can probably add the “Dick Cheney defense”—claim that the danger was averted because of the preventative actions you took. So. Samuelson. Newsweek.” When told that there are no alligators in this part of the world. smoking. 1994 One of the major problems confronting people who must communicate risk to the public is determining how much risk is acceptable or tolerable.
such as Alzheimer’s disease or stroke. We are less concerned now with infectious diseases like polio. all sorts of biases affect our judgment. cancer).g. there are now new. and that people would behave in a rational manner if they had all the facts.. Krewski et al. people are anything but rational decisionmakers. and the left side . people in the Netherlands accepted massive flooding every few decades as simply reflecting the fragility of existence. 1982) took the revolutionary step of actually asking people directly what they find tolerable and what they don’t. and modern civilization itself has bred new risks—the carcinogen-of-the-week. Because of these limitations. (1980) found two factors that affect risk tolerance (Figure 5-3). Another thing Starr did not take into account is that the nature of risk has been changing over time. global in scope. technological risks with low probabilities but that would involve large numbers of people. are not easily reduced. Further. and are involuntary. that the death rate from disease serves as a psychological yardstick for evaluating other activities. 88). and global climate change. such as melting nuclear reactors in Chernobyl and Three Mile Island. To begin with. Basically. perceived with dread (e. there are some indications that we are becoming more risk-averse over the years. in automobiles and on the ski slopes. cognitive psychologists such as Paul Slovic (1987) and Baruch Fischoff (Fischoff et al. as we saw when we looked at heuristics. “Successful invasions of the land by the hostile water are now more likely to provoke an aggressive response” (p. Starr’s methods assumed that the tolerance for risk has been constant over the years. though. ozone depletion. two assumptions that are questionable at best. that number increased to 54%.. 12 years later. people seem to become less tolerant of those that remain. have fatal consequences. Van der Horst (2006) states that before the massive dike-building program. are not equitably distributed. Slovic et al. (1995) found that 38% of respondents in 1992 thought that a risk-free environment is not an attainable goal in Canada. As we get better at minimizing risks. and more worried about chronic ones. severe accidents in Dickensian factories and mines have been replaced by those caused outside the workplace.152 P DQ : P U BLI C H E A LT H same as that for disease. After the program. are catastrophic in nature. The right end of Factor 1 are events that are uncontrollable.
(vi) be statistical (e. and involve risks that are new and unknown to science. reflects their opposites. Activities. FIGURE 5-3. 1980. At one level. events. Factors Affecting the Tolerance for Risk. have delayed effects. and the desire for regulation increases as we move into the upper right quadrant. and (viii) affect mainly adults as opposed to children. (vii) be familiar rather than exotic..C h a p ter 5 • RIS K 153 Adapted from: Slovik et al.. (v) be natural as opposed to manmade. it refers to measuring and quantifying the probability of some . (iii) have clear benefits. and exposures in the lower left quadrant have the most tolerated risks. are unknown to those affected. SUMMARY The concept of risk is ubiquitous in public health. “smokers”) rather than identifiable (specific people killed in a plane crash). hazards are more tolerated if they are seen to: (i) be voluntary versus imposed.g. So in summary. (iv) be fairly and equitably distributed. The top of Factor 2 has events that are not observable. (ii) be under personal control rather than controlled by others.
250. mitigation and control efforts.000 influenza deaths are estimated to occur globally. reporting. Tversky. 294–305 in Judgment under uncertainty: Heuristics and biases. one is labeled a pandemic of global public health significance requiring nations to divert effort and resources to surveillance. and public health risk versus political risk will undoubtedly be components raised in evaluating how the world did in the risk management of a pandemic event. this is the easy part.154 P DQ : P U BLI C H E A LT H event. “Guns don’t kill people. 1982. National Rifle Association References Alpert. more difficult because humans are involved. & Raiffa. D. and the other is normal background noise. At the end of 2009. Slovic. A progress report on the training of probability assessors. H. In a normal seasonal influenza year. The more difficult aspect of risk involves how it’s perceived by the public and by experts. people kill people”. Personal risk versus public health risk. ed. If you are confused on risk just imagine how the politicians feel! Go back and read this chapter again…to a politician. An example of the dichotomies in risk and communications will be the emerging discussions on pandemic influenza (2009) H1N1. “Dichotomies” is perhaps not the best word to describe these discussions—confusing is better. the World Health Organization announced that they had received reports of 10. such as dying from a specific cause or contracting some disorder. Pp. P. Yet. Numbers don’t lie. Cambridge: Cambridge University Press..000 H1N1 deaths globally. & A. The two events don’t seem to be in the same ballpark of risk. Kahneman. .000 to 500. because numbers are rational and can be manipulated with ease. The World Health Organization (2009) explains the differences in statistical approaches to global estimation of seasonal excess mortality due to influenza versus the use of selected. Although some counting and math is involved. validated laboratory confirmed H1N1 death reports. M. and the public is rarely as rational as numbers (although politicians feel they can be manipulated more easily).
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Modern considerations of ‘public health’ extend well beyond epidemics and infections and now include pretty much all of the factors that affect our lives. How we deal with the impact of public health risks reflects the science of the times. Getting to this point required advances in a number of areas: at the molecular. and outcomes. ecological. microbiological. —Mark Twain. understanding the relationships 159 .6 MITIGATION AND PREVENTION Giving up smoking is easy. Molecular biology and genetics provided knowledge of the mechanisms of disease pathogenesis..I've done it hundreds of times. At the same time.. susceptibility. In this context. and population levels. public health approaches towards reducing adverse health outcomes have grown from the traditional quarantine. and hygienic focus to encompass policies and strategies to minimize the impact of these adverse events. so have its activities. American author and humorist INTRODUCTION As the nature and science of public health have evolved. sanitation.
public health strategies now include efforts to reduce the impact of those influences. as public health grew to encompass the broader definitions of health and concepts of population-based determinants of health (in particular. the media fire blips of unrelated information at us. Now that modern public health goals are presented in terms of improved or sustained health through measures of disease prevention and health promotion. Historically.or epidemic-based. (Or. they had no statistics. We now recognize that economic. Experts bury us under mountains of . Because most of these strategies are complex and expensive. so they had to fall back on lies. and disease at the population level were quantified through advances in statistics and epidemiology. or whether they occurred at all. influences (van der Maesena & Nijhuisb. when the focus of public health was disease. 2000). those who have to decide whether or not to act on them need to show that they are effective. “In earlier times. and cultural factors can be some of the most important population-based influences on health outcomes and disparities. often related. how they occurred.160 P DQ : P U BLI C H E A LT H among exposures. the process has become more complex. Improving the public’s health and preventing adverse outcomes are clear and obvious goals of public health. “money” is a very powerful political force).” Statistics and epidemiology can give us the means to empirically measure the outcomes. social. We came to appreciate outcomes as being much more than the product of the interaction between a host and a pathogen.”) CHANGING THE OUTCOMES In describing today's accelerating changes. as Stephen Leacock said. The dynamics of those interactions. However. how the interactions affected both individuals and populations. That can be a challenge all on its own. goals and outcomes were easy to define and measure. risk. outcomes can be challenging to measure and quantify. socioeconomics. as opposed simply to the absence of disease. This is particularly true when the desired outcome is “nothing happened. As a result. or the person and a risk factor. and what happens as a result of those interactions are now understood to be the product of multiple.
more immunization = fewer cases of mumps). Popular forecasters present lists of unrelated trends. Because of their nature. without any model to show us their interconnections or the forces likely to reverse them. The effect was easily demonstrated. However. HiB vaccine became available in 1993 and was added to the childhood immunization schedule in January 1994. As a result. In New Zealand for example. or immunization on outcomes that are directly linked to them is relatively uncomplicated (e. A conjugated vaccine (that is. sanitation. when one moves to the more complex issues involving the interaction of several related and sometimes . Just as it was relatively easy to count bodies using bills of mortality in the 17th century. Haemophilus influenzae type B (HiB) infections have been responsible for many serious infectious diseases in children. In some developed nations. was developed in 1985. It became widely used and was responsible for a dramatic reduction in HiB infections in children. responsible for death and severe sequelae even in those who survived. polysaccharide vaccines don’t elicit a strong protective immune response in children less than two years of age. a vaccine made of at least two parts: the target antigen and another antigen that stimulates a better immune response to the target) that overcame those technical issues followed later in the 1980’s. 2002). as seen in Figure 6-1 (Wilson et al. it was the leading cause of bacterial meningitis and other invasive bacterial disease such as epiglottitis among children under five. These were life-threatening infections.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 161 narrowly specialized monographs. change itself comes to be seen as anarchic. No problems there in demonstrating the benefit of the intervention. a polysaccharide-based version. Preventing the disease and its outcomes was a public health goal of the end of the 20th century. The first vaccine against HiB. it has been easy to demonstrate the impact of some medical interventions when we know what outcomes to look for. reducing their effectiveness. American writer and futurist The Search for Benefit Measuring the benefits of traditional interventions such as providing clean water. cleaner water = less cholera. For example..g. —Alvin Toffler. even lunatic.
they were able to measure the effects of interventions such as the vaccination example we just discussed. Hospitalizations and laboratory-reported cases attributed to HiB disease in New Zealand. careful observation had revealed the association between certain behaviors and exposures and the development of malignancies. disease. But what if one could detect problems earlier? If a condition. competing determinants of health. Cancer researchers provided some of the earliest and clearest examples related to early detection.162 P DQ : P U BLI C H E A LT H Adapted from Wilson et al. Pogo. 2002 . how do you demonstrate benefit or efficacy? Moving the Yardsticks of Prevention—Screening Di-agnostic?…Lessee…agnostic means “one what don’t know”…an’ di is a Greek prefix denotin’ two-fold—so the di-agnostic team don’t know twice as much as an ordinary agnostic…right? —Walt Kelly. the questions about early detection became more practical. or risk factor could be identified sooner than it usually was. FIGURE 6-1. could it be better or more easily managed or treated? As medical science and technology evolved and people began to study the natural history and pathogenesis of disease and illness. Long before science understood carcinogenesis. .. 1966 Once people had the epidemiologic tools to quantify outcomes and had agreed on things like risk and benefit (Chapter 4). August 11. New York Post.
Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 163 In 1775. Once the process had been described at the cellular and molecular level. Opportunities for prevention and control increased as improving science and epidemiologic analysis revealed the association between a risk event and a bad outcome. and developments in organic chemistry allowed for the isolation of benzopyrene as the causative carcinogen (Doll. Following Pott’s report. Looking at clinical disease and searching for subsequent risk factors was important. as shown in Figure 6-2. The early recognition and identification of risk factors or existing conditions provides an opportunity to intervene and improve the ultimate outcome. Percival Pott. The study of malignancies provided important advances in this regard. Medical science. others noticed similar situations in those working with oils and products extracted from coal. This is one of the bases of public health disease prevention programs. it became possible to identify some of the early effects of some of the risks before they presented themselves as more advanced disease. The first was the obvious conclusion that taking away the risk could prevent the disease. noticed an association of scrotal cancer and being a chimney sweeper. Programs to reduce exposure to disease-causing agents are now integral components of public health practice. The process was driven by people with a disease that may have been too advanced to treat by the time it was discovered. When the threads of long-time developing “eureka” moments of this type came together. One could potentially move the diagnosis earlier and earlier from the actual presentation of clinical disease. they provided the foundation for two basic public health approaches intended to improve health. a surgeon in Britain. researchers in Japan had induced cancers by painting rabbits’ ears with coal tar. Exposure to soot and products of combustion was associated with this cancer. pathology. This is the fundamental concept underlying screening. The ongoing attempts to reduce exposure to tobacco represents one of these programs that have been under way for decades. 1975). the assumption is . By the early 20th century. The second approach involved trying to detect existing problems earlier. and the understanding of cellular and molecular biology markedly changed the way in which the origin and development of malignancies were understood. but it worked backwards from the disease.
at what point is some finding deemed “pathological?” This brings in the concepts of the prevalence of the disorder. To be effective. sensitivity. and positive and negative predictive values. One of the fundamental principles of screening was that the earlier that a disease is detected the better it would be for the individual (Malm. As we’ll see. The purported benefits of early screening. Some of the earliest standardized screening tests included radiologic . • The capacity to determine thresholds. easily done. preferably. that is.164 P DQ : P U BLI C H E A LT H FIGURE 6-2. These elements began to become available in the early 20th century. 1999). screening practices require certain factors to be present (Rose & Barker. The screening test must be readily available. and. that doing something early will restore the person to normal functioning. • The ability to treat or mange the condition. 2004). specificity. though. and it has been since then that the science of public health screening began to develop (Morabia & Zhang. 1978) including: • An appropriate level of technical ability to reliably and accurately identify a condition or disease. inexpensive. this assumption isn’t always true.
and screening for sugar in the urine and diabetes (chemical laboratory capacities). This was related in part to the limited validity of some screening tests. screening tests for syphilis infection (microbiologic and serologic techniques). Screening tests developed later during the last century have included cytology to detect cervical and uterine malignancies. maternal blood screening for Rh incompatibility. cardiovascular risk factors by cholesterol and lipid blood profiles. and lung). screening for colonic malignancies with fecal occult blood or colonoscopy. or may in fact actually result in some adverse effects? This is why the first question about screening that should be considered is. 2009). psychiatric evaluations for military inductees (standardized classification of mental health disorders and validated scales to detect them).Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 165 screening for pulmonary tuberculosis (widely available inexpensive radiology). and chemical and radiologic screening for a number of other solid tumors (such as those of the prostate. This is where screening comes back to the lessons on risk in Chapter 4. Screening generates considerable discussion and sometimes confusion in both the health care field and the general public. as we’ve seen recently with the recommendation in the U. Historically. breast. This raises questions about what happens if the early detection of disease does not really improve an individual’s health. screening tests were not routinely intended to diagnose the stage and presence of disease. which we’ll discuss in more detail later in this section. Some of this debate is scientific and epidemiologic and results from situations where belief may be stronger than evidence (which. is most of the time). Remember that relative risk is expressed as a proportion of the difference in outcomes between an intervention and a . to discontinue routine mammography for women under 50. we might not want to start (Kramer & Croswell. prenatal and newborn blood and urine screening for congenital disorders (both metabolic and physical). They were to be first line indicators of the presence of a condition that required more detailed assessment and follow-up. “What are we going to do with the results of the test?” If we don’t know that answer. where we discussed the concepts of relative and absolute risk. where false-positive tests needed to be confirmed or when the nature and significance of the results required more direct involvement with the individual.S. it seems.
that 20% increase doesn’t look quite so impressive. on the other hand. Some people might even think that 20% more individuals would potentially benefit from the new test. Are There Any Risks Associated With the New Test? Any new or additional risk of the test (exposure to radiation. This is where screening and health care decisions come together (and often clash). In a perfect world. In the real world of actual health care. Let’s assume we have a disease that occurs at a rate of 50 per 10. An average person and even those with advanced education can be forgiven for thinking that this necessarily means that the test is obviously worth doing. Now we develop a new test that increases that by 20%. where resources were infinite and we could request a health care genie to do anything we wanted.667 people screened. It was recently estimated that CT scans performed in the U. however. absolute risk. that 30% of those now detected represents only 1 person for every 1.000.166 P DQ : P U BLI C H E A LT H control group. in 2007 could be related to .000 of the population. where there are no genies to do the heavy lifting. when absolute risk is considered. this is often the way things are announced in the media. this screening example creates a whole series of questions and considerations that have to be considered in the context of public health (Keen & Keen. For example. But. we would throw out the old test and embrace the new one. the sensitivity is 30/50 = 0. even for the same condition (Black & Welch. Those considerations are: 1. or 60%).60. Screening usually improves the relative risk. is the difference between the outcomes (Barratt. But in actual terms. having blood drawn. it all depends. which is 30% of those missed by the old technology. and that existing screening technology routinely finds 30 of those 50 cases (for those with an epidemiologic bent. 2009). In screening. Let’s say that a new screening test finds 20% more disease than routine methods. as with many things. Suddenly. 1997). we would now find 36 cases per 10.S. having a biopsy or some other procedure) should be less than the benefit of finding one new case. If we introduced the new test. 2004). radiologic screening for malignancies or other disorders exposes large numbers of people to the risks of radiation. the benefits of screening may be less impressive. it usually depends on how common the disease is.
As we know.. Also. n.d. 2009). some screening tests require a second diagnostic intervention to confirm the findings. and depending on what we are screening for. . Finally. injury. the benefits have to be weighed against the negative consequences of the process. FIGURE 6-3.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 167 29. 2009). Lead-time bias. 2. While that may be an acceptable level of risk for CT scans when used to diagnose people with a suspected disease. These risks are often small but present. Screening doesn’t really extend survival of the patients. each invasive procedure comes with some risks (including increased costs. such as tissue biopsy that may follow mammography or an elevated prostate specific antigen. there are psychological effects that can result from a person being told he or she has abnormalities of uncertain significance (Sawaya. and even death). a situation called lead time bias. With some malignancies.000 future cancers. misdiagnosis. it just means that they know about the dis- Adapted from NCI. Does The Earlier Identification of the Condition Have Any Impact on the Long-Term Outcome? Sometimes the early detection of condition may not affect the outcome for the individual. the ultimate outcome is the same whether diagnosis takes place before or after the disease is clinically present. it raises serious questions about the risks of CT scanning used for screening asymptomatic individuals (Berrington de González et al.
While the age at death is the same. . ranging from aggressive and lethal. and shows up when there is a broad spectrum of outcomes due to the disorder. When longterm outcomes for screened individuals are compared with outcomes for people who weren’t screened. 2005). In fact. Length-time bias.168 P DQ : P U BLI C H E A LT H ease for a longer period of time. In other situations.d. screening is more likely to detect greater numbers of slow grow- Adapted from Bhatnagar & Kaplan.) is shown in Figure 6-3. An example of lead-time bias from the U. down to indolent and relatively benign. widespread screening can find indolent or less aggressive stages of disease that would otherwise not be detected and where the person would be dead for many years from other causes before the disease had any impact. 2005. it looks like we have extended survival time. the only thing that’s been extended is the length of time that the people live with the anxiety of knowing that they have cancer. survival appears to be greater simply because it looks like there’s a longer time between detection and death. National Cancer Institute (n.S. FIGURE 6-4. all we have done is expand the pool of diagnosed people by including those with non-life-threatening forms of the disease. This is called the lengthtime bias. though. Here. In fact. An example of length-time bias in screening for prostate cancer is shown in Figure 6-4 (Bhatnagar & Kaplan.
benefits have to be considered in terms of costs. resource demands. and other pressures. As is the case for lead time bias. length time bias makes the statistics look great—more people are surviving after diagnosis!—but it has nothing to do with more people being saved. spending them on one issue affects how other conditions are treated. The apparent differences in survival are more related to the natural history of the disease itself rather than early detection. Another bias that creeps in and distorts the results is that people who get screened may not be representative of the general population. What About the Technical Aspects of Screening? We also have to consider the technical aspects discussed at the beginning of this chapter. This is particularly true for those who are asked to pay for either the screening itself or the consequences. at least in part. by who is screened rather than by what is found. Thus. . This is what health economists call opportunity costs—allocating resources (including money) to one area means that fewer resources are available for other programs. and resources in the health sector are spent. Public health is. Sensitivity and specificity mean what happens to the false positive and false negative cases resulting from this new test. What Is All This Going To Cost and Can We Afford It? In the world of the health care genie where everything is possible. The results of those decisions have an impact on how money. time. 4. this is an abstract question. and the benefits to the broader population have to be considered in context. They are generally more concerned about their health and lead healthier (and often longer) lives. populationbased. Other concerns are raised because screening frequently leads to situations where someone has to make decisions about what to screen for and then what to do with the results. The more we spend to screen for breast cancer. the less we have available to care for premature infants or those with Alzheimer’s disease. in the real world where health care budgets and resources are finite and currently under stress.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 169 ing tumors (in patients with consequentially longer survival) rather that the smaller number of aggressive tumors (associated with shorter survival). the apparent greater longevity among people who are screened is due. 3. Resources and money are not infinite. by definition. However.
170 P DQ : P U BLI C H E A LT H If they are the same as what we are doing right now. breast cancer is among the most common malignancies in women. modeling. it is a wash and the implications remain the same. many people are aware of both the disease and some aspects of screening through reporting in the public media. Because the screening is expensive and requires a degree of technologic and organizational development. Being a common malignancy. If they differ. New technology in medicine is advancing faster than the health sector can pay for and implement them. Much of the mortality is. “I Want the Test”—Screening Decisions More Frequently Involve Those Being Screened. and medical sectors. to ensure that those at greatest need receive the benefits of new advances and the potentially adverse impacts are reduced. with most deaths occurring in less developed regions. Even so. 2009). 5. inequitably distributed around the world. produced by expert consensus groups and delivered by health providers. it’s been shown that. In our genie-free real world. however. it has been more extensively used in the developed world. combined with the move to involve patients in decision-making. in the developed world. In the developed world. and approximately half that number each year die of the disease worldwide (WHO. 1960) and wider use beginning in the late 1970s. Since its development in the 1960s (Egan. This involves greater use of epidemiology. 2009). however. mammography screening is associ- . increasingly involve the public into decisions regarding screening. the subject of statistical discussions and analytical modeling. and evidence-based investigation. It is estimated that there are more than one million cases of the disease diagnosed globally every year (Porter. than we have to look at those outcomes and again balance them against the gains of the new tests. Modern information technology. cancer. those who decide on whether or not new tests are used have to consider the entire health sector. Mammography for breast cancer is a current example. mammography screening has been recommended by many public health. are changing the nature of screening and in some technologically advanced nations. This why a great deal of attention in this aspect of public health now is directed what is called appropriately targeted or specific testing. Historically. screening for diseases could be an arcane science.
This has been considered by some to represent a move toward more personalized cancer screening (Partridge & Winer. This led to a tremendous backlash among cancer advocacy groups. women’s groups. and oncologists. 2009). based on their personal preferences and understanding of the issues. Greater patient involvement in screening decisions (and this is true for most decisions affecting one’s health) is likely to become a more common aspect of health care. The 2009 U. The fact that the report was released during the congressional debates about health insurance most assuredly played a major role in the negative reaction it generated.” These tests cost over $1. However. with relatively low levels of return). as technology offers more options (for some. Over time.S. Preventive Services Task Force guidelines (USPSTF. Congress mandating payment for screening in this age group—yet another example of emotions and politics trumping science. meaning that more younger women have to be screened to find a case. the guidelines also suggest involving lower-risk women in the decision process. they are more likely to have false-positive tests. further complicating the risk/benefit calculations for this age group. Despite this. A recent example involves the host of a very popular TV talk show. have not shown any benefit. 2009) recognized this and recommended dropping the previous guideline that women between 40 and 50 should be screened every 2 years. at least in the developed world for those with greater access to health care services. Moreover. who advocated full-body CT screening for healthy people as “empowering. costs will increase but benefits will not. Because the prevalence of breast cancer is lower in women under 50. The downside of this is that. However.S. expose a healthy person to unnecessary radiation (as we mentioned previously). the positive effects of screening are less than those for women over 50.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 171 ated with a reduction in deaths from breast cancer for women less than 50 years of age. and result in a plethora of “findings” of dubious importance that must now be followed up. thousands of people clamored to get them. guidelines regarding mammography have been modified on the basis of research. ending up with the U. movement in this direction will also increase debate about global equity and disparity in access to . due in part to the fact that the disease is less common in the younger group.000 a shot.
It also provides the ability to predict health risks in future offspring. it really began to affect medical and public health practice about 40 years later. Importantly. but also to their future descendents. Recent advances in molecular biology. Examples of this include genetic predisposition to malignancies such as the BRCA gene (Garber & Offit. While the implications of screening have been the subject of speculative fiction for decades (Brave New World was published in 1932). The Impact of Screening on the Development of Public Health Looking at the history of screening. We now have the ability to screen for conditions and biologic characteristics that are predictive for the potential development of disease. Screening continues to influence the nature and role of public health in modern society. Historically.172 P DQ : P U BLI C H E A LT H and use of preventive health services in a world where great differences in health outcomes are an unpleasant reality of life (and death). it became apparent that this process was changing some of the bases of the practice of medicine. and laboratory technologies have created even more things to look for. rather than simply its earlier presentation. and neurological conditions like Huntington’s chorea. As we gained the ability to detect more and more conditions earlier and earlier. some these developments push the yardsticks beyond the present and extend to future populations. Rose and Barker (1978) noted that screening placed the medical system in a new role. it should be clear that it is a product of both public health science and medical technology. placing the health care system in the position of identifying patients and offering interventions to them before they would have sought care. This has been one of the factors responsible for what has become the modern public health model. This opens a new door (perhaps a door to a Brave New World) allowing for preventive interventions to be applied not only to the individuals themselves today. The continual march of science and technology often exceeds advances in both ethics and medical . patients presented to health care providers with diseases. or ailments. In a classic paper from the late 1970s. genetics. illnesses. Screening for early or occult disease inverted the process. 2005).
That change introduces huge ethical and moral issues into the screening process. 2005). The obverse of that coin . or the cultural demands that boys care for their parents in old age. For example. Recently. making those decisions for offspring or a descendent who doesn’t yet exist raises even more questions and concerns. such as home pregnancy tests and even HIV tests. Cultural and moral behaviors differ across the world. some of those testing technologies have crossed that line between screening and diagnosis. dealing with the potential risk for oneself in the context of screening can be complicated enough. and have or will soon become commercially available for personal use. either because only one child is allowed. as was the case in China (Hesketh & Xing. while girls often require an unaffordable dowry in order to be married. As science and globalization make screening technologies more easily available. prenatal ultrasound.. the uses of screening may end up becoming what they were not intended for. It is important to remember that 90% of the world’s science is done in only 10% of the world. Screening has expanded from detecting what is present into being able to identify what could be present. which was developed to detect fetal abnormalities.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 173 practice. is being used in some developing countries to determine gender of the fetus. and even among groups within the same country. The real and potential availability of screening opportunities for personal use takes the shift in provider-patient roles noted by Rose and Barker in 1978 and makes the situation even more complex. Normal individuals who unknowingly carry genetic traits that could affect their future health or the health of their offspring now have access to screening technologies that can identify these risks (Moyer et al. Balancing these factors against frameworks designed in the context of simple statistical validity and population-based reduction factors will be neither easy nor always possible. Modern benefits of screening now extend beyond the personal one of early disease detection. Several screening tests now approach the levels of reliability of tests used for diagnostic purposes. As we’ve said. The greater desirability of a child of one gender over another may result in termination of a pregnancy. 2008). Providers or payers of health care services may benefit from screening to identify conditions that can be treated more simply and cheaply.
MAKING A DIFFERENCE—MODERN PUBLIC HEALTH INTERVENTIONS For every complex problem. stopping smoking. there’s a simple solution. Adherence is often easy when the intervention takes place over a short period of time (or better still. but they raise the issues of who is making the decisions and the grounds on which those decisions are made. This has huge ramifications for behavioral changes recommended to improve health or prevent adverse outcomes (including dieting. However. as we all know. but it will continue to influence and affect the future evolution of public health. such as requiring changes in behavior. This has been shown to work in some situations. Together these issues mean that screening will be a public health topic of increasing societal interest and discussion. and religious issues associated with screening exceed the scope of this book. The ethical. screening also identifies situations where mitigation or prevention is more complicated. Mencken. one of the anticipated benefits of screening was to identify individuals and groups who would benefit from some intervention. when someone else administers it) and the outcome is readily apparent. Not all of the answers to questions about screening will come from the health care or public health sector. L. and it’s wrong! —Attributed to Oscar Wilde. usually those in which the interventions are readily available and easily administered. Rose and Barker (1978) saw that screening changed the role of the patient and the health care provider. immigration. as we noted. This is part of the reason vaccinations or providing micronutrients such as iodine or folate through basic food supplies are so effective as public health interventions. moral. But. The story on that one. as it identified people who did not know they were ill or at risk. or using cholesterol- .174 P DQ : P U BLI C H E A LT H is that screening may be used exclude those with existing conditions or predispositions from things like employment. and Umberto Eco As noted earlier. H. or access to health insurance. is one of mixed results.
Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 175 lowering drugs for the rest of one’s life). she’d have to tell him. many of these interventions cannot simply be administered by third parties.) Needless to say. for conditions that do not appear to be making them ill and for benefits that may be many years in the future. yet people are told to take medications that are costly and may result in impotence and depression. so that those affected may have seen themselves as “healthy” (bringing to mind the words of the health economist. people are often asked to adhere to regimens. “Given your diastolic blood pressure of 90. Furthermore. though. about 120 patients would have to take this drug for 5 years to prevent one stroke in one of them. making the association between the influences and the outcomes a statistical. the risk factors are often identified before any symptoms appear. Complicating this complex problem even more. Now. or iodine in salt. Perhaps most importantly. as with a vaccine. Most often. some of which have side effects. Furthermore. there are no perceived symptoms of hypertension. Consequently. both the patient and the doctor share that recognition. compliance is poor. The presence of symptoms is a situation that is easily recognized as needing some sort of intervention. Often those outcomes are the result of the long-term effects of several factors. and modifying several factors— seldom an easy tasks for most people. or putting fluoride in drinking water.” (And that number is actually low compared to the statins. Bob Evans: “To many clinicians. observation. some of the preventive activities designed to minimize future adverse outcomes become complex in their own right. if the physician were being up-front with the patient. the adverse outcomes that we’re trying to prevent or control are frequently more complex and less easily seen. They often require long-term personal involvement and commitment. in order to possibly prevent a stroke or heart attack 20 years down the road. where the number needed to treat over 5 years is over 600. Even in cases of adverse outcomes that are primarily caused by a single factor—tobacco use being the prime example—behavioral change is complicated by the short-term benefit seen by the user of the “banned” behavior. . as opposed to a personal. and it is the doctor or a public health agency that deals with the event. health is merely the state of inadequate diagnosis”). For example.
• Finally. public health provides the information. Through all of those elements. As they have become more standardized. this interface between medical knowledge of future outcomes and the corresponding community awareness of what this all means. These can be as mundane such as municipal ordinances mandating bicycle helmets. The public health sector is becoming more and more involved in identifying and dealing with conditions and factors that influence health outcomes of the entire population. . This should take place in an integrated fashion and extend from primary health providers who educate individual patients right up to community information programs using mass media or advertising. Part of this is due to the increasing ability of statisticians and epidemiologists to identify factors that affect outcomes. they often include the following elements: • Educational and promotion programs designed for those determined to be at risk. One example are the HIV/AIDS prevention programs. or as broad as international treaties banning land mines or dealing with climate change. replaced by chronic non-infectious diseases. Other influences on modern public health flow from the fact that the traditional threats to health resulting from poor sanitation or insect vectors are becoming less important in the developed world. • One of the common elements of health promotion is a network of individuals. communities. and organizations with common knowledge and interest in the issue. most health promotion activities involve both public health and those at risk. has given public health a progressively greater social role (Cohen & Swift. health promotion activities should be supplemented by policy and programmatic changes that support their objectives. Involving those who are affected often provides insight into best practices. and feedback about what works and doesn’t work in changing behavior. Increasingly.176 P DQ : P U BLI C H E A LT H In a manner similar to screening. and empirical evidence to support health promotion. 1999). analysis. communications strategies.
and reflects the world and situations in which it developed. economic activity. It must take into account the influences and characteristics of their environment. and cultural factors. genetic. So how did the present era of public health develop? As with the previous phases of public health. and knowledge of its time. behavioral. 2003). Also. and more . social. Like its predecessors. Looking at the history of public health in Chapter 1. —Attributed to Joseph Stalin (although there is some controversy about this) In this chapter. as well as biologic. 2004). There are currently several definitions of population health and the population health approach being proposed. the ‘new spin’ on public health came about as a result of great changes in how other activities evolved.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 177 THE ORIGIN OF POPULATION HEALTH One death is a tragedy. disease prevention. like many of aspects of public health over the years. more complex roles. they are associated with increasing knowledge. commerce. a million is a statistic. it is built on many of the practices developed to deal with transmissible infections and other risks and hazards. the concept becomes broader than the collective total of individual health characteristics. An important part of this evolution has been the steady shift in focus from the disease of individuals towards the health of groups and communities. but at the same time. and environmental biology. the population health approach is a product of the science. This represents the most recent evolutionary phase of public heath models (Awofeso. Each of these phases brought with it new health challenges. better tools. While these latter groups do include individuals. and health promotion activities. many of the phases of public health originated in parallel with changes in science. economic. as we begin to consider the health influences and outcomes of populations in the context of where and how they live. human mobility. we’ve tried to show how many public health activities have evolved into their modern. using examples of screening. In common with the historic phases of public health. what it is can be in the eye of the beholder. analytical capacity. as well as considerable discussion regarding the application of those definitions (Kindig & Stoddart.
In short. maintaining safe food supplies.178 P DQ : P U BLI C H E A LT H effective interventions that have been adapted to manage changing risks. We are currently in the midst of one of these phases. There are many examples. Many of these new tools were both technically complex or expensive (and frequently both). and improving childhood survival. and explosive advances in science and technology. and but a few include antibiotic resistant infections. These activities are on-going. As it has always done when faced with these situations. While traditional practices and activities have continued to rise to current public health challenges. it would be at a cost that would affect other programs (remember ‘opportunity costs’?). which provides a different lens to examine wider aspects of the role and nature of public health. and education. Linking these observations is the modern “holistic” definition of health as being more than the absence of disease. the health of migrant workers. It also became clear that access to these and future services would be possible for only some of the world’s people. and it was clear that the growth would continue. the scope and speed of travel. some observers began to see these events as parts of a larger pattern. The dynamics of what appeared to be individual health outcomes are influenced by changes in economic and social conditions. and even for those who can access them. Each of those changes has measurable impact on health outcomes for some individuals. it is important to remember that medicine was providing seemingly limitless advances in diagnosis and treatment. poverty. and they are developing methods to reduce the impact of these risks. Health and disease indicators are related to changes in factors such as employment. and represent the day-to-day practice of many public health and health care providers. Like earlier eras. commonly called globalization. groups. expanding human migration and mobility. it is marked by rapid change in commerce. they have searched for and defined risks. the international spread of important infections. a nation could wind up spending so . economic and social influences on chronic disease epidemiology. and communities. it was conceivable that through simply treating disease. the public health sector has focused on these specific events and issues. where the same factors have played a role. At this time.
it was believed. including the use of health care services. governments were recognizing that promoting and sustaining good health outcomes was an essential component of health policy. actions. similar conclusions had been reached by less affluent nations which faced choices regarding meeting the health care needs of their citizens while attempting to increase levels of development in other areas. Much of this thinking arose in developed nations with national health care or insurance programs. However. by the last third of the 20th century. These studies provided information regarding where low-cost interventions could have major impacts on service demands.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 179 much of its resources that it might not be able to provide other services. This. It was also realized that attaining those goals would require programs. there would be a major impact in years of potential life lost (YPLLs). Implicit in the principle that health was more than simply the absence of disease is the understanding that maintaining or improving the health of a population should reduce both the need and demand for health care services. Because most accidents occur in younger age groups. the proponents of the population health approach considered the information provided by epidemiology. and recognized that unrestrained growth in the health care sector could eventually affect national fiscal policy and future economic capacity. and helmets for bicycle and motorcycle users. car seats for infants. At the other end of the spectrum. and reducing road trauma has been identified as public health goal of major and easily quantifiable importance. such as motor vehicle accidents and trauma. Making this even more attractive. While some adverse health outcomes were the result of the biological characteristics of the population. Improving and . such as education and infrastructure. Some of the conclusions were relatively simple and came directly out of the health promotion sector. would reduce the costs of care. Preventing and treating disease remain the bedrock principles of medicine and health care. others were induced by environmental factors or behavioral activities. whether they were for treatment or prevention. the interventions are relatively inexpensive—mandating the use of seat belts in cars. and activities that extended beyond the direct provision of health care services. In this process.
decrease the prevalence of adverse health outcomes and both the need for and cost of medical interventions. oil patch workers and trauma. . There are many examples in occupation health. The Population Health Model in Canada. n.180 P DQ : P U BLI C H E A LT H sustaining health through disease prevention and health promotion activities should. Studies had often shown that while economic progress in a country was associated with improved health. over time. where the workers suffered consequences of their jobs (coal miner’s lung. secretaries and repetitive strain injuries) but others reaped enormous financial gains—who gained in the global collapse of the banking system in 2008? While these apparently paradoxical outcomes pose challenges to some of the traditional principles of public health. those gains were not shared equally by everyone. the broader scope of the population health concept included an additional set of conclusions. However. Greater national wealth often came at expense of workers’ health and an increase in injuries. which is outlined in Figure 6-5.d. Public Health Agency of Canada. they are easily included into the population health paradigm. FIGURE 6-5.
can be challenging. However. this would be a moot discussion if resources were infinite. This creates one of the major challenges in trying to implement the population health approach—the need to balance future benefits against current demands. and myriad other social and societal factors had now entered the realm of the health services system and the public health sector. tells us that significant long-term benefits may arise from investments in other sectors. democratic or otherwise. the medical model of public health has resulted in providing much of a nation’s resources to the health care treatment sector. and drugs). These areas are often ones in which statistics and epidemiology play a role in the front lines of decision making. They are. however. such as municipal planning. unfortunately..g. part and parcel of the population health approach.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 181 The population health approach recognizes that societal factors. reallocating resources in most societies. economic development. Economic development. urbanization. It became clear to governments that managing national health care systems could no longer be accomplished through traditional. substance abuse (tobacco. In spite of any disease prevention and health promotion activities. individually-focused health care. could have large health impacts on populations. Continually. and other lifestyle choices (e. however. the growth of cities. and health promotion programs. people will continue to develop diseases. vertical health programs. Accepting the population health paradigm has several important implications for both the health care delivery sector and public health in general. risktaking behaviors like snowboarding or rock climbing). Historically. many of which had been considered to be outside of the scope of traditional. and die. security. pollution control. These factors include things like environmental pollution. as we’ve seen in countries considering changes to health insurance. The population health model. alcohol. illnesses. industrialization. This is truly where the rubber of the population health approach hits the road of health care delivery. As we said earlier. sedentary life styles (decreased physical activity). decisions to allocate resources carry with them many ethical and moral components that are beyond the scope of this book. health departments and ministries have to balance the popula- . climate change. and this is what the health care delivery system is set up for.
balancing investment and return in the context of health requires considering all the players involved. and the environment) in contributing to unwanted health outcomes (there are positive health outcomes from the determinants of health. Added to this are differences in the way various groups seek. In spite of these challenges. the study of health disparities includes understanding the inter-dependent nature of the determinants of health (remember: socioeconomics. and . each new era evolved within the context of resistance to change. use. This interface is also where. those discussions would include the economic. and other sectors. and poor education affect employment. This means considering what may be politically incorrect issues. Discussions and decisions regarding health frequently occur only within the health domain. and environmental components also have large influences on health outcomes.182 P DQ : P U BLI C H E A LT H tion-based benefits of treatments and interventions against the costs of investing in the future. At national and international levels. transport. When explored both in detail and in broad scope. and it’s here that the population health paradigm is still evolving. living accommodation. and diet—all of which result in poorer health. Another major challenge of the population health paradigm is that both the investments and returns are long-term considerations. agriculture. fear. In the history of public health. and inertia. economic. despite the consequences for other sectors. such as the biologic and genetic components of the population that may cause or contribute to poor health outcomes. particularly when the benefits may take decades to be measurable. or how behavior at the personal and societal levels is also significant in some adverse health outcomes. security. if the population health approach has been appropriately introduced and implemented. One of its major foci includes examining population-based disparities in health indicators and outcomes. Social. health would be considered as involving all societal sectors. We can attribute this in part to the inability of most politicians to see beyond the next election. Poverty. genetics and biology. behavior. educational. technology. the health paradigm is the current focus of modern public health. This has proved to be a challenge in systems that attempt to measure short-term outcomes. exclusion. environment. too). To truly apply the principles of modern population health.
2004. American Journal of Roentgenology 168: 3–11. 1997. R.Chapter 6 • M I TI G ATI ON AN D P RE VE N TI O N 183 have access to health services for disease prevention.. 2005. Integrated communications systems. R. C. Berrington de González. et al. these things are easier to say than they are to do. Wyer. Injury Prevention 5: 203–207. What’s new about the “new public health”? American Journal of Public Health 94: 705–709. Dans. In reality.. health promotion. S. Mettler.. Archives of Internal Medicine 169: 2071–2077. L.. CMAJ 171: 353–358. 2009. Its applications are supported by many of the elements of globalization.. C.. Barratt. those improvements would include measures to deal with the current disparity as well as identifying all of the precipitating factors. partnerships. Epidemiologic surveillance activities and cooperative analytical networks can provide more sensitive early identification of adverse public health outcomes at thresholds that might not be observable at national level alone. M. & Swift. American Family Physician 71: 1915–1922 Black. 1999.. and political commitment. The population health approach is affecting public health policy and practice at a national and international level. 2004. Long-term interventions to prevent their recurrence would complete the process. The spectrum of prevention: Developing a comprehensive approach to injury prevention.. & Land. Mahesh. more coordinated (and perhaps more effective) response activities are also possible. A. Projected cancer risks from computed tomographic scans performed in the United States in 2007. M. Screening for disease. Bhargavan. If applied with the full intent of the population health approach. C. absolute risk reduction and number needed to treat. S. as integrated solutions often require extensive economic and social mobilization. W. The epidemiologic identification of disparities can... Bhatnagar. or diagnosis. Cohen. P. Relative risk reduction. Treatment options for prostate cancer: Evaluating the evidence. Hatala. Keitz. References Awofeso. T. H. and public health coordination provide both the input and output ends of population health activities. L.. F. Tips for learners of evidence-based medicine: 1. Kim. McGinn. N. global frameworks. .-P. V. M. A.. influence both programs and policies to improve health outcomes. With this earlier recognition. & Kaplan.. K. G. through the lens of the population health paradigm. & Welch. R.. A.. Lewis.
T. National Cancer Institute. & Botkin. M. On mammography—more agreement than disagreement. L. British Medical Journal 2: 1417– 1418. R. J.000 studies.. New England Journal of Medicine 361: 2499–2501. J. H. Pott and the prospects for prevention. J. G. Screening. Expanding newborn screening: Process.d. & Zhang. Retrieved 12/14/2009 from: http://www.. J. M.. 2009.. An integrated model of population health and health promotion. P. Hereditary cancer predisposition syndromes. & Xing.cancer. 1960. Sawaya. Garber. & Offit. (n. P. J. H. Journal of Clinical Oncology 23: 276–292. Moyer. 2005. Experience with mammography in a tumor institution. A. Hesketh. F.H. & Barker. A.S. 2009. van der Maesena. 18.. British Journal of Cancer 32: 263–274. The Hastings Center Report 29: 26–37. Part III: 7th Walter Hubert lecture.d. The Hasting Center Report 38(3): 32–38. R. 2000. Annals of Internal Medicine 151: 716–726.php. Malm.). Cancer screening: The clash of science and intuition. Egan. M. K.. Calonge. 2009. New England Journal of Medicine 353: 1171–1176. Kramer..gov/programs-resources/groups/ ed/programs/ lss/va. G. 1978. . G. 2009.phacaspc. J. F. 9. Continuing the debate on the philosophy of modern public health: Social quality as a point of reference.gc. R.S. S.184 P DQ : P U BLI C H E A LT H Doll. J. (2009). Retrieved 1/ 12/2010 from: http://prevention. History of medical screening: From concepts to action. Journal of Epidemiology and Community Health 54: 134–142. L. Cervical-cancer screening—New guidelines and the balance between benefits and harms. 2003. & Croswell. 2009. W. Teutsch. E.ca/ph-sp/php-psp/php3-eng. Preventive Services Task Force. (n. 1999. D. Rose. New England Journal of Medicine 361: 2503–2505. Annual Review of Medicine 60: 125–137. E. Porter. J. Screening for breast cancer: U. on behalf of the United States Preventive Services Task Force. Radiology 75: 894–900. D. Medical screening and the value of early detection. & Winer. N. Keen. P. Public Health Agency of Canada.1186/1472-6947-9-18. What is population health? American Journal of Public Health 93: 380–383. Published online 4/2/ 2009. E.. 2004. Z... Morabia.. A. doi: 10. Evaluation of 1. The effect of China’s one-child family policy after 25 years. and priorities. G. 51 (Suppl 2): S141–S146. D. Postgraduate Medical Journal 80: 463–469. Early Detection Research Group. What is the point: Will screening mammography save my life? BMC Medical Informatics and Decision Making.. & Nijhuisb. S.).. Preventive Services Task Force recommendation statement. 2005. U. 2008. B. & Stoddart. F. & Keen. Kindig. 1975. Salud Pública de México. Partridge. policy. G. V. Global trends in breast cancer incidence and mortality.
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May you come to the attention of those in authority. the term globalization is becoming entrenched in our language. —The Three Parts of the Chinese curse INTRODUCTION As we discussed earlier. May you find what you are looking for.7 GLOBALIZATION OF PUBLIC HEALTH AND THE INFLUENCE OF POPULATION MOBILITY: A SELECTIVE HISTORY OF HUMAN DISEASE OUTBREAKS May you live in interesting times. or 187 . but often without clear understanding of the scope of the processes that the term does.
is it good or bad. The concept of globalization encompasses a range of social. GLOBALIZATION AND PUBLIC HEALTH OVER THE AGES The ultimate result of shielding men from the effects of folly is to fill the world with fools. English philosopher Pre-1860 This period is relatively easy. political. and post-1968. What is potentially underappreciated in the current fervor over globalization (for example.d. is that globalization and public health threats and risks predate the current interest by at least 2. 1860–1968. or merely a conspiracy of world domination by Big Box Stores) and its impact on the world economy. —Herbert Spencer. and economic changes that have been evolving over many centuries.). n.000 years. One consequence of the rate of change in global interconnectivity is that it has made the world more interdependent than at any other time in human history (Global Policy Forum. We have used a perspective on globalization and public health that allows these two perspectives to be described in three eras: pre-1860s. Human societies across the globe have been establishing progressively closer contacts for eons but recently.188 P DQ : P U BLI C H E A LT H could. or should represent beyond those of international economics. as formal approaches to public health disease prevention and health promotion had not been entrenched in any international tools (such as legislation or regulation) prior to 1832. transportation. and the major step forward in population demographics for the purpose of public health and epidemiology did not occur until a mid-19th century epidemic of cholera in . the pace of this interconnectivity has dramatically increased. The advantage of this temporal approach in this presentation is that it can be proven beyond any serious challenge to be completely arbitrary and virtually entirely random. computers. and law. culture. and other technologies have given the processes of globalization a new impetus. Unprecedented changes in telecommunications.
and legal systems for all of humankind. the arts. That is not to say that there weren’t emerging practices during this period which. there have been only a few ancient descriptions of recognizable disease outbreaks related to interregional population movements. economic development and trade. The description by Thucydides of the illness and . However. or if it was written we haven’t found. could be interpreted as early public health interventions. (In addition. What mostly existed during this time from the perspective of “health of the public” was the emergence of global population distribution through migrations (National Geographic. disfigurement. culture. and [mis]understood it) or to reposition documented history. the impact of major outbreaks of diseases has entered human historic documents and did affect the course of history. by definition. and death in some cases—or near or complete extinction in many other cases—altering the course of the entire global social development by influencing faith-based practices.) and devastating human epidemics of disease and death. But this chapter is not about that. The biblical plagues brought forth by Moses on Egypt not withstanding (only one of which was possibly a contagious disease. in retrospect. n. these events did select for human resistance to certain diseases while dooming others to illness.d. either). While it may be debated when the first humans appeared on Earth some time between October 23.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 189 Europe. but some of the same markers can be used to document the diversity of humans globally and their risks or resistance to certain diseases. maiming. 1650/ 2003) and several million years ago. see Table 7-1).000 years ago as we started to walk out of the African continent. The Athenian plague of 430 BC closely followed the Peloponnesian invasion of Attica linking North Africa (Egypt and Ethiopia) to the north shore of the Mediterranean basin. it is well established by tracing genetic markers that the beginnings of global human migration began about 200. those markers not only allow tracing the migration of humans as they colonized all regions of the globe except Antarctica. was never written in the first place. We’re not going to use modern molecular genetic technologies to re-write human prehistory (which. interpreted. While the genetic migration of humans is not the purpose of this chapter. 4004 BC (Ussher.
spreading disease. The Sixth Plague A disease causing boils and blisters struck next. to ponds. Even people's houses had them inside. causing a terrible stench. The Second Plague (Exodus 8:1–15) Frogs miraculously multiplied in number. no fish means more frog spawn. sheep and goats—but those of the Israelites were unharmed. particularly near stables and barns.blooming algae called Pfisteria could have been the cause. canals. transmitted by tiny midges (see above—the "lice" of the third plague). so. even the Nile River—turned to blood. which means more frogs and an algae-clogged river would drive them on to the land in the millions. the crops went unharvested and the famine increased. or possibly a red. As a result." spread by the animals through the land. The ten plagues visited upon Egypt. stable flies. whcih can bite and mechanically transmit diseases. The Biblical and a Nontheological Explanation The Bible says the Nile turned to blood at the touch of Moses' staff. Pfisteria would have killed all the fish. The Fifth Plague (Exodus 9:1–7) Disease on the livestock— horses. cattle. as is common in public health. It may (Exodus 9:8–12) Festering boils on people and have been the ancient disease "glanders. . so who knows what they really were. choking out the river and killing the fish. The biblical story occurs long before "gnats" were distinguished from other insects such as lice. Fly swarms are not uncommon. It is possible that two diseases decimated Egypt's livestock: African horse sickness and blue tongue. streams. This plague was probably of stable flies. into the stables before the plagues is another mystery that we will ignore).) The Third Plague Without moisture. we will make the facts fit our explanations. The Bible says there came a grievous swarm of flies into the house of Pharaoh. The Fourth Plague (Exodus 8:20–32) Vast swarms of flies through the land. Then all of the fish of the river died. according to the Old Testament Plague Event The First Plague (Exodus 7:14–24) All of the water in Egypt— right from water already in buckets and jars. donkeys. camels. so many that the land was infested with the normally aquatic creatures. removing the only (Exodus 8:16–19) Vast swarms of gnats obstacle to an insect explosion (how the frogs ever got tormented people and animals. (Why the algae did not kill the frogs as well is a weakness in this explanation that we will ignore because it fouls up all the following. the frogs died.190 P DQ : P U BLI C H E A LT H TABLE 7-1.
and in famine conditions. as well as interregionally. the plague. The Biblical and a Nontheological Explanation Hailstorms hit Israel and Jordan from time to time. A sandstorm is the likely culprit. while lyrical.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 191 TABLE 7-1. the custom was to give the eldest child in the family double portions. They devoured everything that survived the hailstorm. according to the Old Testament (continued) Plague Event The Seventh Plague (Exodus 9:13–35) Powerful hailstorms that destroyed the standing crops. 12:1–42) Death of the firstborn. A sandstorm in Cairo in 1997 blacked out the sky for 3 days. They're not rare. The sand would cover any food supplies remaining. and when they do swarm. or some other contagious infection. could not have come at a worse time. a locust plague. it clearly was transmissible. measles. whose crops were their whole livelihood. Microtoxins found in locust droppings contaminating the food were lethal. The loss of life in Athens had significant consequences on social order locally (such as the need to appoint a magistrate or a gynaikonomos—literally. Pharaoh let the Israelites go. but to the weakened Egyptians. The Passover. The Ninth Plague (Exodus 10:21–29) Darkness over the entire land for 3 days—but the Israelites had light in Goshen. The Bible says a 3-day darkness fell next. a hailstorm at this time would have been devastating. has left doubt about the cause of the outbreak. The Tenth Plague (Exodus 11:1–10. The ten plagues visited upon Egypt. like the hailstorm. typhus. The Eighth Plague (Exodus 10:1–20) Locusts in such great numbers that the ground was covered with them. The hailstones were so big that any people or animals caught outside in the storm were injured or killed. Locusts have been known to swarm since ancient times (to which this applies). Whether it was typhoid. To the Egyptians. “controller of women”—to oversee the behavior of women who were temporarily relieved of the cultural constraints of male-dominated Athenian culture). they strip the land of the crops. death of one-third of the population of Athens. with the shifting of military power to Macedonia and subsequently to Rome. The Antonine plague of 166–180 AD in the Roman Empire was described by the physician Galen and was likely due to either .
The total number of plague deaths in the Roman Empire during this outbreak period is estimated at 5 million persons. who. there was an enormous pressure to feed the expanding population of the city. evil behavior. the energy demands to sustain the growing infrastructure of the Empire were enormous. domestic and foreign policies over the last 2 decades or the recent economic growth and energy appetite of China. and lack of true understanding. Meditations. Orent. That is. who succumbed to a febrile disease while leading his armies near Vienna during the late stages of the epidemic. which are also believed to have been the sources of the plague outbreak." The Plague of Justinian (541-542 AD. Marcus Aurelius came up with another quotable quote. he scribed (remember. Large granaries in and near Constantinople supported a bloom in the . Up to one-third of those affected died (case mortality) with 2.2. Marcus Aurelius personally led the Roman troops against the southern push of the Germanic hordes at the Danube River. and possibly Marcus Aurelius Antoninus (died 180 AD). when he wasn’t being a military leader. 2004) is the first recorded interregional epidemic of disease describing what historical scholars agree was an outbreak of Yersinia pestis (plague) disease. Marcus Aurelius wrote his philosophical work. it is generally agreed. 1976.192 P DQ : P U BLI C H E A LT H plague or measles. Grain was being grown and imported for the central Byzantine Empire from as far away as Egypt and possibly Ethiopia. This will be familiar to anyone who followed the Star Wars Trilogy or the U. think rather of the pestilence and the deaths of so many others. the quill and the pen came later) “that even the pestilence around him is less deadly than falsehood. Due to the expansive military conquests of the Byzantine Empire under Justinian I and the rapid urbanization of Constantinople. In 180 AD. as he himself lay dying of the plague. McNeill.” which. The disease was introduced into Rome by military troops returning from the Near East Asia. The fact that historical scholars agree on this is not the only remarkable thing about this outbreak. In passage IX. Of those dead were the Emperors Lucius Verus (died 169 AD). During the Germanic campaign.S.000 deaths per day in Rome. still has a ring of truth about it. died of the Antoine Plague. given the passage of time. "Weep not for me.
000 to 10. and the outbreak may have killed up to 40% of the citizens of the city. A very similar thing happened to the Roman Empire. which was an accounting of his new possessions. This is a potential lesson that is relevant in today’s drive to economic globalization based on centralist national interests. the plague-filled. Guillaume le Conquérant or Guillaume le Bâtard. as well as maintaining or expanding the rest of the Empire (Homer-Dixon. allowing these cultures to develop and mature in Europe. and chattels. hungry fleas sought out other hosts to feed on. The plague ultimately spread around the Mediterranean basin. and completed around 1086. 2006).d. As the rats died off.000 people died each day during the peak of the plague epidemic. vassals. A second plague epidemic that occurred in 588 AD extended as far northwest around the Mediterranean to affect the area of modern day France. when the Black Death of the 14th century arrived with the merchant and military return movements through Africa and Asia. killing an estimated 25 million people. The rest.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 193 rat population. Unfortunately. henceforth forever entrenching death and economics in legislation. The second consequence was that the Byzantine Empire could no longer withstand the resistance of the Vandals in the Carthage area and Ostrogoth Kingdom in Italy. is history. but that’s another story) invaded England from France in 1066 AD. n.). this latter benefit of knowing social demographics and the ability to maintain leadership and political control did not really click until William the Conqueror (or as he is known on the other side of the English Channel. In the city. from 5.000 years later. Another major epidemic of plague would not occur in Europe until nearly 1. as they say. This concept of counting what was in the Kingdoms of Europe . A third consequence was that being able to count the living and the dead was important if a ruler wanted to be able to manage all their acquired lands. William the Conqueror commissioned The Domesday Book (The Domesday Book Online. The first is that Justinian I enacted laws to address the burden of inheritance claims following the death of so many urban citizens. when its ability to protect the length of the “food chain” to feed its central demands outstripped the military resources that could be dedicated to its security. which was infested with plague-carrying fleas. There were several consequences of the Plague of Justinian outbreak in Constantinople.
agricultural and textile industries began to mechanize. It is important to note. That epidemic was followed for another half century by smaller outbreaks in Europe (Knox. shows a remarkable consistency between epidemics occurring a thousand years apart. Unfortunately. too. despite the fact that the denominator of population at risk was unknown.d. this modest beginning would take another 500– 700 years to evolve to where we are today. epidemiology did not exist yet. Venereal syphilis . was an outbreak of Yersinia pestis infection but of much greater geographic magnitude than the one experienced during the rule of Justinian I. Although the Black Death was the most significant epidemic of contagious disease of the pre-1860’s period and was clearly introduced by international population mobility. Being able to count things also came into use during the Black Death epidemic of 1328–1351. resulting in the Peasant Revolt in England of 1381 (a first in labor-management negotiations to provide better pay and improved working conditions on the farms. the Black Death may have killed up to one-third of the population. In Europe. and the ruling monarchies. As before.194 P DQ : P U BLI C H E A LT H came in handy when planning taxation of the nobles who in turn taxed the serfs to support various kingly projects (mostly cathedrals and castles) or wars. so there were no epidemiologists around to make this observation. Plague was recorded in China in 1328 where 35 million people are estimated to have died over 50 years. True enough. aristocracies.500 deaths per day in the urban centers of Europe during the Black Death. there were estimates of 7. which. or about 200 million people. This outbreak probably originated in the Gobi Desert and spread both east and west along the exploration and mercantile routes of the time. there were several other disease importations of nearly equal significance also associated with the movement of people. population die-offs of this magnitude had consequences: labor markets shifted. Again. that was 35 million from an estimated starting population of 125 million (a denominator!). This.) and Asia. n. leading to child labor and the sweat shops of the Industrial Age). from an epidemiologist’s perspective. but things moved slower back then. and theocracies began to be challenged by the emerging middle classes (democracies).
rolled genital ulcers of primary syphilis and the highly contagious rash of secondary syphilis. In any case. following the voyages of Christopher Columbus to the New World in 1492. as it was alternatively proposed at the time. painless. cutaneous disfiguring lesions.” the Russians called it the “Polish disease.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 195 appeared in Europe. That is in addition to the unsightly. Either that or. Yale University. perhaps coincidentally. Les Filles des Joyes (the ladies of joy). To reflect its international flavor. like many newly introduced diseases in an immunologically naïve population. which caused miscarriages.” the English called it the “French disease. syphilis could have been linked to the cosmic alignment of several planets in 1488 (Stratman-Thomas. and madness.” It is estimated that by the mid-15th century.” and the Arabs called it the “Christians’ disease. FIGURE 7-1. 1930). Many of these clinical manifestations figure very prominently in the artwork and history of medieval times in Europe. the French have called it the “Italian” or “Neapolitan disease. up to 15% of adults in Europe were afflicted with this new disease.” the Italians called it the “Spanish disease. Harvey Cushing/John Hay Whitney Medical Library.” the Poles called it the “German disease. We may never know what the true origins of syphilis were. it was more virulent than syphilis is today. .
Zink et al. and lawyers had not gotten into medical malpractice claims. 2003) and probably other mammalian species (Rothschild et al. Once again. the rest. is history. public health and global management for the purpose of control and eradication of the scourge of smallpox would not begin until the end of the next period under discussion (1860’s– 1968) and would not be achieved until the late 20th century. there are stories of smallpox-susceptible children being recruited for the long sea voyage to the New World to act as serial reservoirs through vaccinia inoculation to bring fresh. but the cost of the intervention was very low. and cholera. 2008. The commodities market for dried scabs and pustules from smallpox patients was within the economic reach of most practitioners at the time. evolving migration of humans in the pre-19th century period would probably be inaccurate. the outbreaks of disease were frequent and devastating. Smallpox reached Europe between the 5th and 7th century AD and was present in major European cities until the 18th century. variolation was clearly a success with a cost. Later on. colonists and aboriginals... The first known historical record of what was probably a smallpox epidemic was in 1350 BC. moving with human beings (Hershkovitz et al. and side effects from variolation all dropped precipitously following the “vaccination” practices of Jenner. tuberculosis (TB). It would be a challenge to not mention TB in the context of public health and the origins of the human race and global migrations. as they say. Smallpox cases. While the origins of smallpox are obscure. As previously presented. there are three other infectious agents that deserve special mention: smallpox.196 P DQ : P U BLI C H E A LT H While there were undoubtedly many other outbreaks of transmissible infectious diseases between the 14th century and prior to 1832. The fact is that TB may have been a co-migrant from the early beginnings. Two percent to 3% mortality from a preventative intervention would seem too high to be acceptable today. it is believed to have emerged in Africa and migrated to India and China thousands of years ago.. to bring smallpox under control in the Americas. weeping scab material for vaccination of the susceptible adults and children. smallpox mortality. during the Egyptian-Hittite war. Its high . However. Despite this knowledge and the availability of vaccinia virus. 2001) in its global distribution for more than 10.000 years. linking large epidemic TB outbreaks to the slow.
Although the Germ Theory of disease is often attributed to 19th century Europeans.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 197 infectivity in cloistered communal groups (like families) but relatively slow clinical progress and low case fatality in symptomatically diseased individuals (compared to all the other things that would kill you pre-1860’s) also suggest that it has been with humans for a long time and is a well-adapted pathogen with low virulence but high enough patency to maintain itself through person-to-person transmission. We could discuss the contributions of the astrolabe. but that would be diverging from the issue at hand. genetic-biological. consumption. about the time that Jenner was scraping the pus from the teats of cattle onto the arms of children (1796). Global population mobility had been especially affected by the invention of the wheel. the 1798 origins of the U. environmental. if we talk about everything in the first part of this chapter there will be nothing to do later in later parts. the use of sails and masts that allowed boats to move from human-oar power to wind power and allowed freedom from the limitations of riverine or coastal transportation to crossing seas and oceans. the white plague. As we mentioned in Chapter 3. schachepheth. an appreciation of the “transmissibility” of disease probably occurred at least as early as the 14th century in Asia during the outbreaks of plague. domestication of the horse. These were very important. and others). The maritime sailor and link to the . All of this is not to say that TB. Besides. As presented in Chapter 1. that probably reflects the Eurocentric views of the people writing history books for European and North American audiences.S. Equally. was not a significant cause of disease prior to the 1860’s. cartography. not only in the movement of people but also of diseases. a legislative act addressing public health was being passed in the U. It just became a bigger cause of disease and outbreaks related to some very interesting sociological.S. and human behavioral factors. Public Health Service was to provide for the care and relief of sick and injured merchant seamen. there were many convergent events —particularly technological advances—that promoted changes in the approach to public health toward the end of this period. and human curiosity and greed as important determinants of human global movement and pestilence. under its many manifestations and names (phthisis. Also.
Third Pandemic 1852–1860 Fourth Pandemic 1863–1875 Fifth Pandemic 1881–1896 Sixth Pandemic 1899–1923 .000 dying in 1849. cholera spread east to Indonesia.000 in each of Hungary and Belgium. then sequentially. The 1883–1887 epidemic claimed 250. and Africa. Cholera spread with the Austro-Prussian war in 1866 and is estimated to have killed 165.000 in Persia. and 113. causing the Cholera Riots in the streets of major urban centers.738. The disease reaches Russia. London's epidemic in 1852–1854 killed 10. In 1859. Second Pandemic 1829–1851. the disease spreads from Germany to the UK.000 lives in Europe and. More than 800. In 1852. an outbreak in Bengal once again led to the transmission of the disease to Iraq. Arabia. .198 P DQ : P U BLI C H E A LT H TABLE 7-2. About 30.000 to 12.000 pilgrims to Mecca developed cholera. the outbreak reached North America. Asia. 90.000 of the 90. In 1849. This was the last cholera pandemic of this magnitude in Europe. with more than 1 million deaths. the epidemic has reached Quebec and New York.000 deaths.000 cholera deaths during the first quarter of the 20th century. China. By 1866.000 in Egypt. London.000 in the Netherlands. The fourth pandemic began in 1863 and spread throughout Europe. and North Africa. but commercial travel along land and sea trading routes introduced cholera throughout India. 20.000 in Austria.000 people. claiming 14. 30. and more than 58.500 people (5.137 lives.000 in America.000 in Italy. the cholera epidemic killed 200.000 in Japan. Russia was affected early in this cholera pandemic. with more than 20. The Pandemics of Cholera First Pandemic 1816–1826. to China and Japan in 1854. in spreading. More than 15 million cholera deaths in India are estimated to have occurred between 1817 and 1860. the Philippines in 1858. The outbreak in Soho. France. Between 1831 and 1832. Cholera is endemic in the Indian subcontinent (Ganges River delta). 60. with 6. and Russia. John Snow and the parish priest Henry Whitehead. if not more. Europe also experienced outbreaks during this time.000 died in India due to cholera during this period.890 in Russia. Another outbreak in London was linked to the East London Water Company and was brought under control quickly. In North America. 3. It was the worst outbreak in London’s history. causing up to 50. In 1832. In the Philippines in 1902–1904. killing tens of thousands. The major Russian cities reported more than 500. 120. and Korea in 1859. Twenty-seven cholera epidemics were recorded during pilgrimmages to Mecca from the 19th century to 1930. 267. and by 1834. Iran.000 Americans dying of cholera between 1832 and 1860.5% of Chicago’s population) died of cholera in 1854. killed at least 50.000 pilgrims dying of cholera during the 1907–08 Hajj. ended after removal of the Broad Street pump handle following the studies and recommendations of Dr. The 1849 cholera outbreak in Ireland is estimated to have killed as many people as died during the Irish Famine. and Indonesia.000 in Spain. more than twice as many as the 1832 outbreak. with up to 150. a second cholera wave occurred in Paris and London. Cholera also followed along with the settlers heading to the California gold rush. the people of the Pacific west coast of North America are affected.
It reached Italy from North Africa in 1973. but became pandemic following the outbreaks in India in the late 18th century that reached other parts of Asia and then Europe in 1816 (see Table 7-2). that have been responsible for millions of deaths worldwide. with multiple conferences over the next 9 years. They met initially for 6 months in 1851. specifically mentioned were “women of low moral turpitude. totally drained. the South Pacific. prompted the First International Sanitary Conference which was held in Paris. Greece. These . international movement of people and disease to the U. This multi-national conference on health and trade included representation from the Papal States. and everything else that was also important but not mentioned. was soon followed by U. a similar but not identical El Tor strain of cholera was found in Peru. There have been seven pandemics of cholera. there were more than 1 million cholera cases in South America.S. and Turkey. the two Sicilies. Russia.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 199 TABLE 7-2. by its descriptive name. Great Britain. defined by the criteria above. can leave one feeling totally drained. Cholera is caused by the bacterium Vibrio cholerae. France. It spread to 1961–1994 Bangladesh (1963). The disease presents without fever and with a rapid onset of profuse watery diarrhea that. India (1964). and the USSR (1966). and.5 years of this outbreak. or what was labelled the Asiatic Cholera in Europe. with restrictions on the admission of the foreign-born to the country. Spain. Tuscany. represented a shift in the strain of Vibrio cholerae 01 (classical) to El Tor. with at least 10.000 deaths. Sardinia. Literally.” But having said all this. Austria. in a manner of a few hours. Cholera likely existed in the Ganges River delta for a very long time. Portugal. there were small outbreaks in Japan.S. immigration legislation. From 1991 to 1993. the really pivotal thing that happened next related to population mobility and globalization of disease was cholera or. generated nearly 200 regulations intended to protect interregional trade while controlling disease importations. Over the 3.S. In the late 1970s. The Pandemics of Cholera (continued) Seventh Pandemic This pandemic. This outbreak was brought directly to Los Angeles by contaminated food served on an airplane flight (336 passengers) from Lima. with 75 cases and one death occurring in the U. The Second Pandemic of Cholera. and again in the USSR. which started in Indonesia. the flux.
S. the Third Pandemic of Cholera (1852–1860) is one of the most significant events in the history of public health. including tobacco-related ailments. Stewart went on to make significant contributions to noninfectious and chronic disease management and control of many diseases of public health significance. 2003). and yellow fever—had either been controlled . Stewart. As it turned out on the subject of infectious diseases. this one begins with a flash-forward. From the mid-19th to the mid-20th century. Think of that the next time you are walking along the Embankment (the sewer) in London.. a). the development and application of new aspects in public health sanitation (CDC.d. The four horsemen of the public health apocalypse—plague.. then Surgeon General of the U. Public Health Service. cholera. London invested in a major sewer drainage system to carry the effluent from the city core to the far east of the city and dump it into the Thames River. In 1969. in this case to 1969. One of the results of John Snow’s work with the Soho parish priest Henry Whitehead was the proposed link of Germany to the first (index) case in Soho. 2004). Dr. to declare that it was “time to close the book on infectious diseases. or sipping your tea in Greenwich (East London).” Whether Dr. This was the origin of modern epidemiology and the global movement of disease. smallpox. As discussed in Chapter 1. infrastructure engineering developments (Thompson et al. Dr. vaccines (WHO. these advances prompted William H. As Surgeon General. 2008). The concepts of disease being transmitted by water and the use of epidemiology to understand disease outbreaks still took decades to be accepted. Stewart actually said this or not is hotly contested in some circles (which means there is a good chance that he did say it). 1860–1968 As with many good stories. Nonetheless. n. and antimicrobial drugs significantly contributed to huge advances in the control of infectious disease morbidity and mortality.200 P DQ : P U BLI C H E A LT H Maritime Sanitation Regulations have evolved over time to become the International Health Regulations (WHO. Stewart was absolutely right…and he was terribly wrong.
1997). no antimicrobials effective against viruses or secondary bacterial complications of influenza. agricultural. the number of Spanish flu deaths in that pandemic is all over the map).5% compared to the expected 0. and the use of antituberculosis antimicrobials gained control over this former deadly disease…in some populations (WHO. and polio—all vaccine-preventable diseases (WHO. virulence was higher. b). which was a period of significant international population mobility of both displaced civilians and military forces. Meanwhile. tetanus. Tuberculosis sanitoria that circled the globe as a remnant of the British Empire were closing as better housing. with a case mortality of up to 2. these were diphtheria. and animal health.. such as better housing. nutritional. there was severe global physiological. There were other characteristics that made 1918–1920 a different influenza season: it had its onset near the end of the Great War (1914–1918). rubella. eventually killing 15 to 50 million people globally (note that even in this book. Notably. other diseases of public health significance were also coming under control. .1%. there were no existing international disease surveillance and reporting systems. through the 19th and 20th centuries in western nations (meaning the rich ones). public health screening. there were no intensive care health services for respiratory support. only one new. water sanitation systems. mumps. Stewart’s alleged statement. and no coordinated international disease control response capacity. n. or knowledge of disease processes applied to human.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 201 through active public health programs or through the consequences of general improvements in social circumstances.d. measles. 2009a). At the time of Dr. major global pandemic had occurred in the 20th century—the Spanish Flu of 1918–1920. The role of Bacillus Calmette-Guérin (BCG) vaccination in TB disease control remains an epidemiologic quagmire and is often debated (we won’t go there here—“debates” is the second door down the hall). and psychological stress. The Spanish Flu spread around the world in many directions following trade and transportation routes. and young adults aged 20–35 years old suffered a 20-fold increase in influenzarelated death compared to previous influenza seasons (Billings. Several epidemiological characteristics differentiated this influenza from previous influenza events: its attack rate has been reported as higher (estimated 30%) than the expected 10%–20%.
Traditional communicable disease surveillance. Weinstein’s reports. perhaps he can be excused for his belief. delays in vaccine and program delivery. yellow fever. Two of those people infected three and five others respectively. The last major imported disease event reported in the U. Health Commissioner of New York City (Weinstein. made this a pressing national public health issue at the time and an enduring historical example of public health responsiveness. out of an urban population of 7. urban center. As these diseases dwindled in significance to become local events only and usually confined to distant lands. Israel Weinstein. The point here is that the perception of public health risk in a major U. A total of 12 cases of smallpox occurred in this outbreak. and smallpox were driven back into local confined areas of the developing world (where they were felt to be of little consequence to the economically advanced nations). 1947). and response programs in most western nations fell somewhat by the wayside. international public health attention was turned to nontransmissible diseases. there was another consequence of disease control that went unappreciated in population and public health.8 million New Yorkers.S. but this may not represent complete reporting. a hub for national and international travel. screening. Complications related to the vaccine were alluded to in Dr. The report by Dr. plague.5 million persons based on estimates of vaccine availability.S. 2004).3 million. Vaccine coverage was reported at the time to have been 6. and public concern were all media reported issues at the time (déjà vu all over again). had been a smallpox outbreak in February 1947 that followed the pathway of a 47-year-old merchant travelling by bus from Mexico City to New York City (Sepkowitz. A mass smallpox vaccination program was promoted and implemented targeting all of the 7.202 P DQ : P U BLI C H E A LT H As cholera. with at least three deaths directly related to the vaccine. The index case infected three other people. but may have been closer to 2. Vaccine supply shortages. If Dr. and the procurement of products for control. the processes for containment. and the uncertainty surrounding the population risk characteristics.8 million. chronicles the events. Two of the nine cases in New York City died of smallpox disease. there were two smallpox disease deaths and three . Or to put it another way. Stewart failed in recognizing that infectious diseases were not defeated.
In 1952. live oral polio vaccine (OPV) resulted in rapid containment. 2005). if the population has been vaccinated against polio. The beginnings of the control of polio began in 1921 when.000 cases of polio in the U. subsequently. contracted a fever and rapidly progressed to bilateral lower limb paralysis. development. rehabilitation. community medicine. polio changed from being a relatively rare clinical entity to become a major concern clinically as well as for public health officials. approval. There had clearly been a shift to a managed public health response to the threat of a significant outbreak of “the scourge” of smallpox. and release of the first polio vaccine in April 1955 (Langmuir.S. Franklin D.. at the age of 39. Even in regions where environmental sanitation with human fecal contamination of drinking water supplies remains an issue. . the future President of the United States. large outbreaks caused significant morbidity and mortality. with global representation in disease occurrences. Roosevelt. control. the disease does not occur or occurs only rarely. Another example of contagious disease control that supported Stewart’s statement that it was “time to close the book on infectious diseases” was the 20th century response to paralytic poliomyelitis (polio). In those who recovered. 2006). and a recurrence of the peripheral limb symptoms decades after the primary event. In the late 19th century. public campaigns in support of medical care of polio victims and research (Presidential Birthday Balls.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 203 public health intervention (vaccine) deaths. and elimination of wild polio disease in all public health jurisdictions where the vaccination programs were implemented (Trevelyan et al. What Stewart and his contemporaries in public health. there were often sequelae. leading to the National Foundation for Infantile Paralysis. including permanent paralysis or limb weakness. and infectious diseases could not have anticipated was that these successes in disease elimination (smallpox. death. His personal commitment to medical philanthropy. killed polio vaccine (IPV) or the attenuated. frequently. Vaccination with either the injectable. later renamed the March of Dimes) were directly related to the funding. the Centers for Disease Control estimated that there were 21. resulting in respiratory and limb paralysis and. and. This devastating viral illness caused fever and inflammation of the nervous system.
and re-emerging diseases were lurking in the primordial ooze to fill those vacuums in nature created through disease control. few such pathogens can match smallpox for its historical morbidity and mortality. What certainly was not missed in celebrating the control and eradication of smallpox was that unless the success is truly global in nature. yellow fever. filariasis. Malaria. Or as Douglas Adams put it. are also remarkable for their apparent disinclination to do so. This expansion includes large numbers of the elderly and physiologically frail— that is. From a human pathogen perspective. who are almost unique in having the ability to learn from the experience of others. and which are amenable to control and potential eradication.. with the availability. and affordability of cheap international air travel beginning in the 1950s. the global marketplace of disease-susceptible populations to feast upon was rapidly expanding. that the eradication of a significant human pathogen from all parts of the world may remain as the greatest achievement and future challenge in public health—polio and measles are two potential future candidates for eradication through vaccination. "Human beings. Lastly. Personal vulnerability to disease has been further increased by health systems that have created new risk . new. this has repeatedly become a reality (MacPherson & Gushulak. plague) were going to be severely challenged by other events. emerging. cholera) or near complete control (diphtheria. Mobile populations bridge these prevalence gaps. local gaps in disease control create new prevalence differentials between disparate regions where the disease is still active and areas that no longer have it. 1988). It is so big." 1969–Now Global smallpox eradication was an ambitious undertaking and is a public health success story of unimaginable magnitude (Fenner et al. in fact. tetanus. Dracunculiasis (or Guinea worm due to Dracunculus medinensis) in Africa is well on its way to control and potential eradication through targeted treatment of at-risk populations. and hepatitis A are among the significant pathogens for which humans are the sole host or an essential host in the lifecycle. people with comorbid diseases that affect immune competency. however.204 P DQ : P U BLI C H E A LT H polio. 2001). accessibility.
. As Stewart was making the “close the book” statement. this is expressed as threats of disease. The linkages to the focal emergence of HIV and the global distribution of the infection and disease through human mobility are complex. new data and modelling of the genetic evolution of the viruses have pushed the potential origin of HIV to as far back as 1884 to 1924 (Worobey et al. and real disease risks. What is known is that HIV is related to and evolved from the simian immunodeficiency virus (SIV) that existed in chimpanzees and other simians in west-central Africa. Sociopolitical issues and cultural sensitivity complicate the story as researchers using advances in scientific technology are trying to recreate the history of human HIV in retrospect. What has come to be known as human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) was firmly established as a global pandemic before anyone even noticed. This new disease affected men. Bailes et al. and deficiencies in health protection and disease prevention policies. As expected. processes. 1982). individually and as a global population. 1999. women.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 205 environments. This new syndrome with an unknown cause was leaving its victims open to rare. All of these factors have left the world susceptible to new outbreaks of virulent. This is a major blow to the conspiracy theorists that HIV was a man-made bioweapon or that it was accidentally introduced into Africa through either the smallpox eradication or polio vaccination programs. 2003). and programs. transmissible diseases. and chronic wasting leading to death.. 1981. The Democratic Republic of the Congo (previously known as Zaire) and Cameroon appear to be the simian epicenters for this group of viruses (Gao et al.. gaps in knowledge and training. atypical malignancies.. perceptions of disease risks. opportunistic infections. . Using molecular genetics to trace back this viral linkage has suggested that viral transfer to humans occurred in the late 1940s or early 1950s (Zhu et al. and children. From a public health perspective. 1998). What was first noted in the richest country in the world was followed by reports of disease from every other corner of the globe. a new pandemic disease had been emerging with slow global spread before being recognized through its consequences—severe immunodeficiency (CDC. 2008).
colonial presence was that it frequently led to conflicts of geopolitical separation and independence that increased the opportunities for a blood-borne virus to spread locally and internationally. subsequently. At a low frequency of transmission. trauma. intravenous drug use.. Hunters in west-central Africa are likely to have come in contact with simian viruses during the killing and butchering of animals for food (“bush meats”) and exposure to infected simian blood through their own cuts and scratches.206 P DQ : P U BLI C H E A LT H Detecting the first human case of HIV also poses challenges as the illness is unlikely to have been recognized and specimens are unlikely to have been preserved.. What is known is that HIVpositive tests have been found in a plasma sample taken in 1959 from an adult male living in what is now the Democratic Republic of the Congo (Zhu et al. Blood and body fluid exchanges undoubtedly occurred through unsterilized medical equipment. would have brought greater numbers of people together in closer and potentially less discriminating circumstances. Louis in 1969 (Kolata. originating largely from Europe and. tattooing. Colonialization in Africa. and in tissue samples from a Norwegian sailor who died around 1976 (Frøland et al. 1998). and commercial or exploited sexual service providers. all of which probably hold a piece of a very complicated picture. or intimate sexual contacts (is there another kind?). Colonialization of Africa also was associated with the movement of foreign-born settlers. missionaries. with the advent of large urban centers. they could have brought and introduced these viruses into others in their villages through tribal scarification or tattooing practices.. 2008). and others. One of the consequences of the foreign. With that process came the arrival of government diplomatic and foreign service personnel. blood transfusions. as well as mercantile providers of supplies. Many theories have been proposed to explain how HIV moved from a very focal and local human disease to a global pandemic. 1988). and a lymph node sample taken in 1960 from an adult female also from the Democratic Republic of the Congo (Worobey et al. HIV has also been found in tissue samples from an American teenager who died in St. separation of traditional family village units. including military forces from within Africa and from Europe to Africa. . and other more intimate means (see above. from Asia. Some of these circumstances would have included male-dominated labor camps. 1987). humanitarian workers.
intravenous drug abuse. the global impact of HIV/AIDS continues. and people. “setting aside for 40 days” was just not going to do it for control and containment of this disease.7 million [2. 2008). asymptomatic.. There remains a global disparity in access and availability to and affordability of health promotion and disease prevention interventions for HIV/AIDS.. Then. 2008) or high-prevalence to low-prevalence regional migrations (MacPherson et al. and criminality. 2006. such as the use of unscreened blood products and unsterilized medical equipment. Unfortunately. Pandey et al. 2006). but it also contin- . 33 million [30 million–36 million] people were living with HIV.3 million] people died of HIVrelated causes” (UNAIDS. environmental and infrastructure failures.2 million] people became infected with the virus.S. it quickly spread to other cities on the continent and around the globe by any means associated with the movement of people: by road (Stratford et al. and violent. Zencovich et al. exploited populations. and 2 million [1. with its long. Twenty-seven years after the first sentinel cases of severe immune deficiency with death were reported in the U. importations of infections through population mobility still occurs through low-prevalence to high-prevalence return travel (Benotsch et al.8 million–2. especially. Even though HIV/AIDS is now endemic in all regions around the world.. and the socioeconomic realities of poverty. 2006. 2000. exploitative. “In 2007 alone. unlike plague and cholera with their short incubation periods leading to fulminant clinical presentations. 1992). 2. to mention just a few). HIV/AIDS. services. 2008) and by air (Flahault & Valleron..2 million–3. As infected people entered into the cities in westcentral Africa. handcuffed public health in a way no previously recognized disease had.. The global redistribution of HIV/AIDS through the hubs of transportation was linked with human risk determinants—behaviors such as unprotected sexual contacts. with ever-increasing efficiencies came mass transportation of goods. HIV/AIDS was not recognized in its beginnings and.. HIV/AIDS is a now local disease with international public health implications.. chronic but transmissible phase. with the poorest of the poor and the most vulnerable of global society bearing the greatest brunt of both infection and disease.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 207 and yes there are other kinds: anonymous. Strathdee et al.
with half of that risk occurring in the first 2 to 5 years following infection—unless you also have HIV.. The intent of screening for TB in HIV-infected individuals and how the information is used is probably important in clinical and public health. The bottom-line message: the convergence of both TB and HIV in high-prevalence countries that are also source countries for migration (outwards. and Taiwan—most western nations have succeeded in reducing native-born TB rates to below WHO target levels. in Canada.000 new cases of TB disease occur per year. the risk of developing active TB disease increases to 5%–10% per year (Boerma et al. 2006). With the exception of those countries with significant numbers of at-risk indigenous peoples (formerly known as aboriginal people)—for example. TB has been traveling with humans for a very long period of time. DeRiemer et al. as in tourism for short-term visits) creates the potential for bridging of zones of differential fre- . One-third of the world’s population is infected with TB and an estimated 8. but the greatest TB disease trend in these nations has been the growing case burden in the foreign born (Gilbert et al. or inwards. The lifetime risk of conversion from asymptomatic TB infection to active disease is 5%–10%. 2006).000. as in immigration for permanent change in residency. Khan et al. with 1.. 2008). So.... The first of these was the relative success in economically advanced countries in gaining control over endemic TB. despite declining rates of TB in most western nations. are often over-represented in TB disease statistics. the U. 2007). 1998. In persons with both HIV and TB infection. Australia.208 P DQ : P U BLI C H E A LT H ues to be an internationally introduced disease of public health significance. 2009. due to a combination of factors related to the determinants of health. the proportion of total cases of TB disease due to the foreign born is increasingly related to migration between countries with a high TB disease rate to countries with a lower rate (MacPherson & Gushulak. Indigenous peoples.000 TB-related deaths annually.000.S. The second public health event that occurred relevant to current discussions on TB was HIV/AIDS.. Enough said. even though screening compliance may not be very common (Harris et al. but two significant public health events occurred in this period that have made this a disease of global reimportation. even in wealthy countries. As mentioned previously.
below) from the year before. Known circulating influenza strains do genetic shifts and drifts as they circle the globe moving from east to west and from the northern hemisphere to the south and back again. or emergence.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 209 quency of the conditions and their importation. affecting people. the influenza viruses are either a variation of the previous year’s (see shift and drift. it may have been inevitable by definition (Gross. with about 0. and those with comorbid medical conditions. from a public health perspective. there are three other conditions worthy of mentioning in the context of globalization of public health threats and risks through international population mobility: influenza (again). and vaccine production a crapshoot for influenza supply and vaccine procurement. into lower-prevalence areas. Rarely. severe acute respiratory syndrome (SARS). that’s just the way it is. 2009) (see Table 7-3). or postinfluenza complications like bacterial pneumonia. Every year. . These latter scenarios create great concern in public health officials as the very definition of a “pandemic” includes a new pathogen. or somewhat or completely different (see mutation. like swine. the very young. influenza is special because of viral chameleon-ike factors—the virus is unpredictable as to what it will look like from year to year. with interregional importation and establishment of local transmission. quite honestly. What is special about influenza is that it happens every year with a predilection for the winter months in both the northern and southern hemispheres and continuous transmission the closer to the equator one gets. It could be that. such as the elderly. This makes diagnostic tracking a challenge for those responsible for epidemiologic projections. During this period. below). Influenza is special because…well.1% dying due to influenza pneumonitis. singly or together. recombination. usually the avian ooze but it may pass through other animal species. Most of those who die are the very vulnerable. and everything else. myocarditis. but occasionally an apparently healthy person will also die because of influenza. a recombination. influenza strains may do a genetic mutation. before getting to humans. It affects 10%–20% of people every year. or have an entirely new strain come out of the zoonotic primordial ooze. So although another influenza pandemic was inevitable. encephalitis.
the risk of human infection or disease is considered to be low. 2005. 2009b . or at most rare instances of spread to a close contact. infection may be present in animals. Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized. suggesting that the virus is not well adapted to humans.210 P DQ : P U BLI C H E A LT H TABLE 7-3. An influenza circulating among animals has been virus subtype that has caused human reported to cause infection in humans. Pandemic alert period Phase 3: Human infection(s) with a new subtype. suggesting that the virus is becoming increasingly better adapted to humans. Differences between 2005 and 2009 WHO criteria for an influenza pandemic 2005 WHO criteria for pandemic flua 2009 WHO criteria for pandemic flub Interpandemic period Phase 1: No new influenza virus subtypes Phase 1: No animal influenza virus have been detected in humans. Post Pandemic Period: Levels of influenza activity have returned to the levels seen for seasonal influenza in most countries with adequate surveillance. Phase 3: An animal or human–animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people. but no human-to-human spread. Pandemic period Phase 6: Pandemic: increased and sustained transmission in general population. If present in animals. a circulating animal influenza virus subtype poses a substantial risk of human disease. Phase 6: In addition to the criteria defined in Phase 5. Phase 2: No new influenza virus subtypes have been detected in humans. Possible New Wave: Level of pandemic influenza activity in most countries with adequate surveillance rising again. but has not resulted in human-tohuman transmission sufficient to sustain community-level outbreaks. the same virus has caused sustained community level outbreaks in at least one other country in another WHO region. However. Post Peak Period: Levels of pandemic influenza in most countries with adequate surveillance have dropped below peak levels. aAdapted from WHO. Phase 4: Human-to-human transmission (H2H) of an animal or human-animal influenza reassortant virus able to sustain communitylevel outbreaks has been verified. Phase 2: An animal influenza virus circulating in domesticated or wild animals is known to have caused infection in humans and is therefore considered a specific potential pandemic threat. Phase 5: Larger cluster(s) but human-tohuman spread still localized. Phase 5: The same identified virus has caused sustained community level outbreaks in two or more countries in one WHO region. but may not yet be fully transmissible (substantial pandemic risk). bAdapted from WHO.
which was probably one of the initial problems in detection. and creating an agreed upon case definition. 262 have died. A mortality rate of that magnitude would be really bad for the entire human race. SARS was a global event with clear linkages to inter- . Millions of healthy birds have been killed with an uncalculated impact on personal and local economies. H5 has been considered the greatest risk for conversion to a mass human pathogen.. Of the reported 444 confirmed human H5 avian influenza cases. as have occurrences of avian influenza in both domestic and wild flocks. only H1. This gave a significant boost to international and national influenza and pandemic influenza planning and intensive influenza surveillance (WHO. So the entire public health world—or so it seemed—was watching intently for a pandemic influenza. The cumulative number of confirmed cases of human H5 disease between 2003 and 2009 is shown in Table 7-4. and H3 of the 16 known H markers were thought capable of attaching to human respiratory cells. declaration as a public health event. analysis. H2.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 211 Bird flu burst onto the public scene in 1997. when a H5N1 strain of avian virus was found in humans (Mounts et al. Then in 2003. “Yet. Fortunately for us as a species. it actually started in the fall of 2002. H7.. Of course. particularly if it could cause severe disease including death. Wild migratory birds have carried on their merry way. avian influenza has been confined to a few hundred persons worldwide. n. c). but was not declared a public health event until March of 2003. in the words of some experts. and H9 viruses. While there have been several avian-human influenza outbreak scares since 1997 due to H5. one of the public health responses to avian influenza has included culling of both affected and unaffected flocks. and potentially cause a global pandemic. Of the hemagluttinin (H) markers on influenza viruses. be transmitted from person to person. SARS happened. Or. but it just hasn’t happened.” Unfortunately for chickens and poultry farmers. there were six deaths—a 33% case-mortality rate. 1999). this only affected the mobility component of those captive birds. Of the initial 18 cases of H5N1 in Asia. The finding of an H5 influenza virus in humans was very concerning. The causative agent (a zoonotic coronavirus) was not identified until well into the event itself. Well.d. It was not influenza. for a case mortality of 59%.
dates refer to onset of illness. numbers refer only to laboratory-confirmed cases. 0 0 0 0 8 5 0 0 0 0 0 0 8 5 0 7 25 0 27 115 2 2 0 1 1 17 4 56 262 Bangladesh 0 0 0 0 212 P DQ : P U BLI C H E A LT H Cambodia 0 0 0 0 China 1 1 0 0 Djibouti 0 0 0 0 Egypt 0 0 0 0 Indonesia 0 0 0 0 Iraq 0 0 0 0 Lao People's Democratic Republic 0 0 0 0 Myanmar 0 0 0 0 Nigeria 0 0 0 0 Pakistan 0 0 0 0 Thailand 0 0 17 12 Turkey 0 0 0 0 Viet Nam 3 3 29 20 Total 4 4 46 32 aAdapted from WHO. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO.b. . as of 27 November 2009a. 2009c.c 2005 2006 2007 2008 2009 Total 2003 2004 Country 0 0 4 8 0 0 20 0 0 0 0 0 5 0 61 98 bAll cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths 0 0 4 5 0 0 13 0 0 0 0 0 2 0 19 43 115 0 0 79 12 4 0 8 88 3 3 0 0 0 3 1 0 0 5 59 cTotal Azerbaijan 0 2 13 1 18 55 3 0 0 0 0 1 1 0 1 0 0 0 0 0 0 6 44 0 2 2 0 2 0 0 0 0 0 0 0 0 0 0 5 33 45 42 37 24 20 10 25 9 8 4 38 0 0 0 0 0 0 0 0 4 49 0 0 0 0 0 0 8 5 3 4 4 7 4 0 4 0 0 0 0 0 0 0 0 4 12 2 1 1 1 0 0 0 0 0 0 1 0 0 0 1 8 38 1 89 141 3 2 1 1 3 25 12 111 444 number of cases includes number of deaths.TABLE 7-4.
WHO—using criteria that were developed in contingency planning exercises for a global epidemic of H5N1 avian influenza— raised the level of pandemic alert from cautious watching (level 4) to full. Never mind that it was the wrong time of year—flu season being October to March in the northern hemisphere—or potentially a fluke of technology that found something that no one was really looking for. Vaccines had to be manufactured. None of these things mattered. Then. an assessment of the global response to this event will be undertaken in the postevent period. and then moving to Taiwan (China).” “SARS. or even case-mortality (9. “all hands to action stations” response (level 6) (WHO. the interested reader is pointed to “9/11. Vietnam. Singapore. and. and communication were among the other consequences. Programs for the pandemic public health emergency response and interventions had to be designed and implemented. at least in its ability to sell books like this one. antiviral drugs stockpiled. 2009d). It is clearly too early to measure the full global impact of influenza A (2009) H1N1.” “Katrina. Canada. with international importation and local spread. As is often done for large-scale events with a public health component. to a lesser degree.) A simple Google search of . Within a matter of weeks. It was a new pathogen. society did not cease to be.C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 213 regional human mobility.” “tsunami. This was The Pandemic that everyone was expecting and waiting for. coordination. causing human illness. and the world has carried on. other countries (see Table 7-5). Calls for better preparedness. and body bags made and distributed.8%) over the eight months of its international course. it was estimated that SARS would cost the global economy in the range of $30 billion dollars. The magnitude of impact of SARS cannot be measured only in total cases (8096) or deaths (774). but the very fact that you are reading this chapter suggests that we didn’t all die. swine flu—influenza A (2009) H1N1—was detected in Mexico in the spring of 2009. or that it actually had never before been found in swine. with the index cases beginning in southern China and Hong Kong. masks purchased. ventilators procured. but its other consequences must also be considered. Early on during the SARS event. (For other post-event reports.” and probably the many recent earthquakes around the world. This was big.
Macao Special Administrative Region China.5 (25–54) 50 30 (26–84) 32 (17–63) 67 41 (29–73) 56 0 37 1 0 0 0 0 0 2 0 0 2 0 0 11 14 0 0 0 0 0 40 0 0 14 0 1 (100) 21 (6) 7 (100) 9 (100) 3 (100) 2 (100) 4 (100) 1 (100) 5 (100) 8 (89) 1 (100) 7 (50) 1 (100) 40 (0–100) 299 17 Not Applicable 386 (22) 0 (0) 68 (20) 2 (29)e 1 (11) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 4 (29) 0 (0) 15 (1–45) 49 (1–98) Not available 0 43 349 0 17 7 6 (100) 5 (2) Not Applicable 0 (0) 109 (43) 1002 (19) 26 Feb 03 23 Feb 03 16 Nov 02 15 Feb 03 5 May 03 25 Feb 03 21 Mar 03 9 Mar 03 25 Apr 03 6 Apr 03 12 Mar 03 9 Apr 03 14 Mar 03 31 Mar 03 20 Apr 03 25 Feb 03 27 Feb 03 Female Male Total Median age (range) Case Number fatality of ratio deathsb (%) 1 Apr 03 12 Jun 03 3 Jun 03 Number of imported cases (%) Number Date Date of HCW onset first onset last affected probable probable (%) case case 4 151 2674 2 100 2607 Australia Canada China China.TABLE 7-5. Taiwan France Germany India Indonesia Italy Kuwait Malaysia Mongolia New Zealand Philippines Republic of Ireland 977 778 31 May 03 5 May 03 15 Jun 03 3 May 03 6 May 03 6 May 03 17 Apr 03 20 Apr 03 9 Apr 03 22 Apr 03 6 May 03 20 Apr 03 5 May 03 27 Feb 03 0 218P 1 4 0 0 1 1 1 8 1 8 0 1 128 6 5 3 2 3 0 4 1 0 6 1 . Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003 a Cumulative number of cases 214 P DQ : P U BLI C H E A LT H Areas 6 251 5327c 1755 1 346d 7 9 3 2 4 1 5 9 1 14 1 28 42 (0–93) 49 (26 – 61) 44 (4–73) 25 (25–30) 56 (47–65) 30. Hong Kong Special Administrative Region China.
e Includes Health Care Workers who acquired illness in other areas. China. of which 101 died. 2003. 325 cases have been discarded in Taiwan. Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003 a (continued) Cumulative number of cases Areas 3 1 1 238 1 1 5 1 9 4 27 63 40 (20–80) 52 25 35 (1–90) 62 33 43 (33–55) 35 42 (2–79) 59 (28–74) 36 (0–83) 43 (20–76) Female Male Total Median age (range) 25 Apr 03 19 Mar 03 5 May 03 25 Feb 03 3 Apr 03 26 Mar 03 28 Mar 03 9 Mar 03 11 Mar 03 1 Mar 03 24 Feb 03 23 Feb 03 Case Number fatality of ratio deathsb (%) Number of imported cases (%) Number Date Date of HCW onset first onset last affected probable probable (%) case case 10 May 03 19 Mar 03 5 May 03 5 May 03 3 Apr 03 26 Mar 03 23 Apr 03 9 Mar 03 27 May 03 1 Apr 03 13 Jul 03f 14 Apr 03 Republic of Korea Romania Russian Federation Singapore South Africa Spain Sweden Switzerland Thailand United Kingdom United States Viet Nam 0 0 0 161 0 0 3 0 5 2 13 39 Total 3 1 1 77 1 1 2 1 4 2 14 24 8096 0 0 0 33 1 0 0 0 2 0 0 5 774 0 0 0 14 100 0 0 0 22 0 0 8 9. f Due to differences in case definitions.6 3 (100) 1 (100) Not Available 8 (3) 1 (100) 1 (100) 5 (100) 1 (100) 9 (100) 4 (100) 27 (100) 1 (2) 142 0 (0) 0 (0) 0 (0) 97 (41) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11)e 0 (0) 0 (0) 36 (57) 1706 C h a pter 7 • G LO B A L I Z ATI O N A N D T H E I N F LU E N C E O F P O P U L A R M O B I L I T Y 215 a Adapted from WHO. . the United States has reported probable cases of SARS with onsets of illness after 5 July 2003. Laboratory information was insufficient or incomplete for 135 discarded cases. cCase classification by sex is unknown for 46 cases. dSince 11 July 2003.TABLE 7-5. bIncludes only cases whose death is attributed to SARS.
substandard. adulterated. antimicrobial resistance (MacPherson et al. toys (Weidenhamer. these are definitely interesting times for public health. 2007). and the ugly. including the spread of arthropod vectors (Benedict et al. So.200. 2006) . or something else. Humans. economic. political. USFDA. 2007). whether the change is environmental. The “everything else” of globalization of public health threats and risks through international population mobility includes not just the human component as a vector. one goal of international public health is to not disable all other sectors of the global integrated economy (or trade or security or culture or the environment and all others) due to public health and emerging events. and counterfeit drugs (Primo-Carpenter & McGinnis.d. that is not working out so well for us." —Charles Robert Darwin Population mobility is both a force and a consequence of change. As was said.. As it was in the mid-19th century. security.. toxic dog food (Brown et al. technological. and goods have all been heavily implicated in the importation of diseases of public health significance. Surveillance in public health is certainly at its highest intensity now than at any other time in human history.. the bad. The challenge with all of this surveillance seems to be the ability—or inability—to sort the background “noise” from the “signal” of an event of public health significance..216 P DQ : P U BLI C H E A LT H “pandemic influenza 2009” 6 months after the WHO elevation of swine flu to pandemic status yields “about 14. this was big. It is the one that is the most adaptable to change. health-related. n.00” hits. 2009) and many others. . So far. 2009). SUMMARY "It is not the strongest of the species that survives. It is an integral and essential component of globalization. conveyances. public health. nor the most intelligent that survives. and risk management—the good.
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and new or more accurate interpretations of events. —P. but rather we must seek to solve the problems which are directly the outcome of the growth of a complex. applications of new technologies. and the biologic and social consequences of great inequity.8 THE FUTURE So it has become with the public health problems of today. urbanized society. because the methods of their control are known and generally accepted. disparities in health outcomes. etc. The past exerts its effects through the experiences acquired over time in dealing with epidemic infections. H. No longer is our chief concern with the eruptive communicable diseases of childhood as smallpox. One consists of the parts that reflect the past. the 223 . To deal with them.. measles. the other of new elements arising from newly identified issues. Bryce (1920) INTRODUCTION Public health has always been constituted from two major components. in which the individual meets and has constantly to deal with some new experience forced upon him through modern inventions.
failures. environmental. these determinants and their interactions produce a yin-yang relationship. and adverse events Growth in scientific and medical capacity and abilities Improved information systems for data gathering. and use those capacities and abilities Lack of capacity and intellectual limits in interpreting the significance of more information. not only within public health but also with all other social sectors. trade. be a consequence of our interactions with our environment (everything old was once new). and risk perception. equitably distribute. and behavior are interactive factors that take a complex situation and quickly make it even more complicated. The issues for the future of public health will be. and others) Inability to pay for. and can the future of public health be something different than what its past might dictate?” New and future public health problems will. risk. like their predecessors. security. Together. . 2002). such as surveillance and monitoring (greater sensitivity) New antimicrobials and vaccines Positive effects of greater human mobility Consequences of movement between on social cohesiveness and integration disparate determinants of health on threat. TABLE 8-1. biology. and managing vaccine effectiveness. economic. The human components of genetics. antibiotics and sanitation—as well as more recently developed health promotion and economic advancement approaches (Institute of Medicine. such as ability to distinguish threat and risk and cogently analyze these for appropriate management response (less specificity) Development and spread and of antimicrobial resistance.224 P DQ : P U BLI C H E A LT H public health sector has a complex toolbox containing traditional actions and policies honed and developed over time—programs based on interventions such as vaccines. Public Health Demons The Bright Side Increased benefits of globalization and socioeconomic integration The Dark Side Consequences resulting from the greater proximity of continued global disparities (health. “Can the past inform without unduly influencing the future of public health.
provide a reasonable forecast of what the future of public health holds. In many ways. Both the nature of these. the demons of public health remain the same as they have for millennia (see Table 8-1). and a lifting of both hands. The French say this with eloquence. for every advance. we suggest.” accompanied by a pout of the lips. market analyst. Some consequences are . by its very nature. How we manage these will have great impact on how public health develops during the rest of the century. a slight shrug of the shoulders. and virtually every researcher. does not account for the fact that threat. Less eloquently. CHANGING MANAGEMENT OF THREATS. “S**t happens!” describes the existential observation that life is full of unexpected and sometimes unpleasant surprises. and parent in the world. is not predictable. —Attributed to Albert Einstein. Life message: everything has consequences. and the responses they generate. Teasing those principles away from the temporal situations themselves can. as they all are with the acuity of 20/20 vision). the history of public health is a combination of scientific and social responses to a series of recurrent events posing either a threat or real risk to life and health. As we have seen throughout this book.C h a p ter 8 • T H E F U T U R E 225 We hope that we will continue to generate new discoveries that will make life easier or safer for most people. RISKS. engineer. As the first decade of the 21st century is now in the books. reflect the technology and circumstances of the time. and public health’s fostering of our expectations. Benjamin Franklin. However. “C’est la vie. One of these principles is that predicting significant threats is an imperfect science and unanticipated events will still occur (even if they are predictable in hindsight. Behind the evolution of the threat/risk-response dialectic have been some basic (some would say “entrenched”) principles that are really not all that complicated. Rita Mae Brown. AND THE PERCEPTION OF RISK IN PUBLIC HEALTH Insanity: doing the same thing over and over again and expecting different results. our expectations of public health. clinical psychologist. there is often a corresponding potential downside.
for example. and even musical instruments). When new events are associated with any morbidity and mortality (numerators without denominators. Some of these associations are predictable. animal by-products (including food. the environment. new things can also be challenging. it was not true for the bikini. with adverse health outcomes. work. clothing. In simple epidemiologic terms. So we can usually expect new or rarely experienced health events to be perceived as posing greater risks at the beginning of the event than later on. The emergence of new public health situations often is related to human activities—either as a cause or an effect of the activity. can be anticipated to continue as more and more people travel. security. in. we often lose sight of the broader life context that none of us is getting out of this alive. they’re not call swine flu and bird flu for nothing. such as previously isolated or remote regions of the world. and pizza). nature. and other sectors tend to be associated with greater social anxiety—and.” a phrase with oxymoronic potential). in some cases. So. Contact with diverse species from foreign places. as well. Everything else falls into the category of “C’est la vie. the mullet hairstyle. again).226 P DQ : P U BLI C H E A LT H unacceptable and manageable (note the two concepts working together). and on the animals—after all. fear—than may be warranted based on the facts available at the time or as they emerge. cell phones. regardless of the source of the threat. (Although this is true for loathsome and vile diseases. The occurrence of new animal-associated or zoonotic infections in humans. man-made accidents. events of this nature often receive more public health and public media attention than they will receive once they are better understood. As we have seen throughout history. Just as change is difficult for most of us to accept. and malfeasant humans will periodically produce new risky events with significant consequences. As a consequence. novel situations in health. and live in greater contact with animals. expanding human activities will expose more vulnerable hosts to a greater number of novel . can only increase the frequency of animal-to-human disease transmission. no matter how good surveillance and our analytic capacity are (or the movement to “public health intelligence.” This is true in public health and in the threat of public health events. and the pests and organisms that live with. and what interpretation and actions are placed on that analysis.
Institute of Medicine (Lederberg et al.C h a p ter 8 • T H E F U T U R E 227 pathogens over longer periods of time and greater physical distances.S.. As we are writing this book. —Attributed to the people of the State of Maine. 1992). and many aspects of disease emergence predicted in that work continue around us today. what worked. the genetic plasticity of many microbial organisms allows for their rapid evolutionary change. the existing public health interventions and practices will be modified in response to how they performed. “What was this all fuss about?” The truth of how well this event was managed globally will lie somewhere between these two positions. 1964 You can’t get there from here. they will be met with the best science and technology of the day. How effective those will be in dealing with the event becomes one of the outcomes to be analyzed. with few daring to ask. including. further increasing the development of pathogens with clinically aggressive (from the human perspective) or successful survival (from the microbial perspective) characteristics. is that new input triggers a preponderance of traditional responses. In a traditional feedback loop. what could we have done better? It’s not difficult to predict that there will be a great deal of self-congratulatory backslapping and an equal amount of deprecatory commentary. those outcomes and analyses influence public health awareness and responses. —Marshall McLuhan. In an ideal world. . INTERCONNECTIVITY AND GLOBALIZATION OF PUBLIC HEALTH The medium is the message. U.A. the postevent analysis and reporting of how the world and public health sectors managed this event will influence public health policy and practices for the future. ideally. These processes associated with emerging microbial threats were eloquently explored in the early 1990s by the U. At the same time. the world is beginning to look at the influenza (2009) H1N1 pandemic event in that light: What was done.S. What is more frequently seen. When emerging or reemerging diseases occur. though. “Should it have been a public health management issue at all?” Again.
followed the same time and physical pathway as the transportation of goods and people. a year before the first Sanitary Conference in Paris.time” awareness of events taking place in distant locations. the functional . For example. as a process. trans-Atlantic telegraphic communication was provided by undersea telegraph cable. As we have seen in earlier chapters. They monitor infectious agents at their point of origin. Acute events taking place on other continents were often over by the time the news of it traversed landmasses and oceans. public health workers. and public health have combined to produce one of the major modern advances for the future of public health policy and practice. involving epidemiologists. this physical exchange of information took considerable time and. Technology now allows public health authorities to take action in advance of the arrival of the event itself. Wolf (2009) describes a Global Viral Forecasting Initiative. When news travelled by letter (rather than letter-bombs or the anthrax bioweapon letters that have occurred in more recent times). Rapid international communication provides the wherewithal to both alert surveillance and trigger response systems. This is part of the reason that public health practices that were initiated at the municipal or local level took weeks or months to spread internationally. and biologists. Nonetheless. By 1866. and alerting health agencies of impending outbreaks. people learned about threats and risks only through the physical movement of documents. This is one illustration of how the relationships between information technology. In historical context. this was a step up from the town crier or balladeer bringing forth the 6 o’clock news. It is no coincidence that the International Sanitary Conferences began to standardize international activities to control the spread of infections at the same time as the telegraph was providing rapid communication over great distances. More rapid international communication led to improved international coordination and collaboration when events of public health significance were happening. The first undersea telegraph cable was laid between England and France in 1850. communication. keeping track as they migrate from animals to humans. making possible “real.228 P DQ : P U BLI C H E A LT H Another principle in public health is that the extent and nature of public responses are directly influenced by the nature of the communication systems present at the time.
More recent networks include TropNetEurop (European Network. However.. GeoSentinel (ISTM.. integrated networks of data gathering and information generation. real risks. b) level.d. the future will in all likelihood be marked by the greater use of widely dispersed. At the same time. Differentiating these three types of events is a new and pressing challenge. n. n. n. and perceived—points to the need to integrate public health in an international . and a variety of diseases and conditions on both regional (Kimball et al.d. n..C h a p ter 8 • T H E F U T U R E 229 shrinking of the planet through faster transportation and communication creates situations where events that historically would have had little or no regional or international impact can now be globally important. —Mark Twain. modern technology can bring the awareness of potential threats.d.) which monitors imported tropical infections in Europe.d. some of these networks already exist. but for real bona fide stupidity there ain’t nothing can beat teamwork. ProMed (International Society for Infectious Diseases. INTEGRATION OF HEALTH AND PUBLIC HEALTH CAPACITIES— COORDINATION AND COLLABORATION One man alone can be pretty dumb sometimes. but more on that later. combined with public health surveillance and response. a). Modern internationally coordinated disease surveillance activities extend back to the 1950s with WHO’s Global Influenza Surveillance Network (WHO. result in local events which (also more rapidly) have international implications. as mentioned above. Rapid communication and transportation (rapid. these relationships form one of the pillars of modern public health that will continue into the future. American humorist The globalization of risk—potential. Together. only after we’ve passed through airport preboarding screening). n. that is.) for infectious diseases in general.d. this pillar still needs some work. As we’ve seen. real. and perceived risks to many locations and organizations. At the level of surveillance and awareness. 2008) and global (WHO.) which tracks the health of returned international travellers.
Another example of this is the global activities for HIV/AIDS through a special program created by WHO in 1987 and which now includes the Joint United Nations Programme on HIV/AIDS (UNAIDS. created in 1999. a fairly traditional. established by WHO in 1974. We must understand that local health events can have an influence far beyond their immediate environment.d).d. Since the success of that international public health control program. with the member organizations participating as equals around the table. Other examples are global approaches to deal with vaccinepreventable diseases through the Expanded Programme on Immunization. with most of the decision-making authority emanating from the top and then carried out on the ground by the member countries. multinational activities. Continuing with that model. the implications for public health policies and practice become clearer. as seen in Figure 8-2. . a consortium of agencies. the obvious conclusion is that international and global health policy strategies and programs will be required to deal with what are international and global situations. Figure 8-1 shows the way that international efforts had been set up. In contrast. The Smallpox Eradication Program demonstrated the importance—and necessity—of international coordination and collaboration (Henderson. an increasing number of health and disease issues have been addressed through coordinated. n. organizations.230 P DQ : P U BLI C H E A LT H context. and has been one of the major drivers of public health since the end of World War II and the creation of the World Health Organization. institutions. n. Activities to improve vaccination now include the Global Alliance for Vaccines and Immunization (GAVI). 1987). Once that reality is recognized. and foundations (GAVI. Over the years. collaborations now are much more truly collaborative. hierarchical structure. it means that local or national policies and programs will have a limited impact in dealing with what are really international health challenges. the international and global aspects of public health have assumed ever-greater prominence in the curricula and research focus of schools of public health. with the goal to vaccinate all children in the world. if those local or national officials don’t engage with the international health community. the structure of these collaborations has changed dramatically.). Since then. This has been recognized for some time now. In practical terms.
the structure of the WHO. 2010. 2010. FIGURE 8-2. The traditional approach to public health. . The modern approach to public health. Modified from Szlezák et al.C h a p ter 8 • T H E F U T U R E 231 Adapted from Szlezák et al.. FIGURE 8-1..
a few cases of unusual or unexpected findings might not. The principles behind widely dispersed. may be epidemiologically linked.232 P DQ : P U BLI C H E A LT H Global and international approaches in public health are not limited to transmissible infectious diseases. These events. Large surveillance networks increase the collective reporting of what otherwise would be seen as individual or unrelated “data points. The problem is that meeting those challenges will often be beyond the ability of single nations. When these separate events are systematically put together. integrated networks for coordination. collaboration. systematic food production and distribution. Public health will be increasingly shaped by globalization and what comes with it— more travel and migration. surveillance. and will require greater coordination and collaboration. humans have an amazing propensity to “see” patterns where none exist. analyzed. as evidenced by the face of Jesus or Mary being spotted on all sorts of toasted foods and stains on walls. The Global Alliance for Chronic Diseases (GACD) was formed in June 2009. These examples show the modern evolution of public health and will most likely be models for the future. Similar to these other examples. But by the same token.) An example of this. and greater use of information technology. or agencies.). organizations. Kodacolor and Polaroid didn’t exist two millennia ago. and information are those we discussed in earlier chapters.d. as far as we know. The collective gasp you just heard when reading that last sentence was the sucking intake of breath from every government and corporate lawyer worldwide. (We always wondered how people recognized the faces. illustrating one of the hazards of . which might be widespread. be recognized as being significant. reported. The more you know. This begins to broach the issue of a “borderless” approach to deal with policies and programs on a global level. more integrated commercial and trades systems. the individual dots might combine to reveal a pattern earlier than if we have to wait for a significant number of cases to show up through other means. and interpreted. and those who fear a “new world order” led by people in black helicopters. on their own.” In the early phases of an outbreak or epidemic. the clearer the picture becomes (we hope). GACD is intended to coordinate and support collaboration of research activities to address prevention and treatment of chronic diseases at the global level (GACD. n.
resulted in quickly identifying the agent and its animal host (Chapman & Khabbaz. integrated surveillance and reporting systems provided near–realtime observations and analysis as the disease in a local rural community progressed to affect health and public health systems globally. At the same time. lupus. is that the boundary drawn around the “cluster” is often arbitrary and far too small to detect real patterns. 1994). Subsequently.C h a p ter 8 • T H E F U T U R E 233 identifying “clusters. in addition to the mind’s tendency to try to make random patterns meaningful. Indian Health Service. in 1997. Wide area coverage and very high sensitivity to unusual or unexpected events can provide early indications and advance warning of newly developing situations. in large part because the providers were related through a system provided by the U.S. and technical ability can help assess the risk of the event and propose appropriate responses—including doing nothing.100 cluster investigation requests in the U. and concluded that few required further investigation. This array of insight. Cases of serious and sometimes fatal disease of unknown etiology and puzzling pathology showed up in rural areas of four states. knowledge.S. usually cancers. and other rare disorders. A more recent example of international coordination and collaboration is provided by the influenza (2009) H1N1 pandemic. the disease cluster was recognized early. experiences.” is the concern of citizens in a community about purported clusters of diseases. A small-scale example of this is seen in an outbreak of hantavirus pulmonary syndrome in the U. but also involving autism. Although patients came from a relatively large area and were treated by a number of different physicians. in 1993. The difficulty. Early identification of an outbreak of a novel influenza A virus strain through novel technology alerted the world to the emergence of a potentially significant pathogen. coupled with the integrated use of specialized diagnostics and investigative services at national level. The size and scope of integrated information networks is one of the main anticipated benefits (further supporting the concept that size does matter in some areas). leukemia. linked networks of public health providers with diverse backgrounds. Trumbo (2000) documented almost 1. .S. This early recognition. and skill sets offer a multidisciplinary response capacity.
more than 15 years in retrospect. A month earlier. and from there to the rest of the world. Just because more people now know about them does not make them more important. In the midst of widespread concern (see again “panic. border closures. what these networks also can do—in addition to increasing the chance of pattern recognition for low-intensity events—is turn up the sensitivity and increase the reporting of false-positive events. many people left the city of Surat (read “fled”) clogging the transportation systems as far away as Bombay (Mumbai). A subsequent outbreak of a respiratory disease in Surat was initially reported as potential pneumonic plague. Getting back to the basics of epidemiology.234 P DQ : P U BLI C H E A LT H One of the challenges resulting from all of this newly available.” above). Electronic media reporting at both national and international level brought the attention of the world to this event. and refusal to accept goods from India (Campbell & Hughes. Extensive concern (read “panic”) affected large numbers of people in Surat and the surrounding area. India in September of 1994. travel restrictions. But even now. There are many things that routinely happen below threshold reporting levels that have no implications beyond their immediate environment. it is difficult to be a voice of calm. These initial reports were associated with considerable concern about the international risks for spread of the disease. it is still important to point out that pigs do . National responses varied and included screening and the individual surveillance of travellers. unprocessed case information was rapidly disseminated to the rest of India. Unconfirmed reports of other cases of respiratory disease began to be reported from other areas of India. An example of this type of surveillance “hypersensitivity reaction” took place in Surat. Those issues were heightened at the process level of concern (see “panic. real-time. Simply turning up the reporting sensitivity without corresponding changes to process the information and determine its importance (remember specificity) can overload response systems or lead to unnecessary control activities. a small outbreak of bubonic plague had occurred in an adjacent province that is endemic for the disease. Raw. 1995). information is that a lot of it may not mean very much of anything.” above) as plague was one of the diseases specifically listed in the version of the International Health Regulations current at the time.
to manage uncertainty and rumors. even with cogent and analytic conversion to information. Later analyses and evaluation showed that the number of actual number of cases of plague was few (if any). widespread personal electronic information.. The subsequent development of social networking websites. The outbreak and some of the over-the-top response was one of the factors that led to the revision of the International Health Regulations and the move towards greater international coordination for public health response measures. Since then. But this is a challenge in moving from syndromic surveillance directly to the presumption of an agent (in this case Yersinia pestis) causing a specific disease (plague) of international public health regulatory significance. Balancing these factors in the new age of public health is not only an ongoing future activity but also an essential component of risk management. However. it also allows the rapid spread of unverified or confirmed “information” from many sources. globally disseminated reporting by electronic media was an integral component of the outbreak. and communications capacity ensure that public health events of real or potential importance are both reported and managed in the public eye. needs to be balanced by a method of determining its relevance. . These need to be done quickly and require more resources (Lindberg & Humphreys. instruction and guidelines (Valaitis et al. unconfirmed data. 2008). advanced electronic communication technologies do have their positive sides. and that several of the response measures were unnecessary and more costly than the impact of disease itself (Dennis. which then become overlaid by multiple “media experts” expressing their opinions. This brings with it the increased need to provide timely and accurate information.C h a p ter 8 • T H E F U T U R E 235 not fly and plague outbreaks have always been predominantly bubonic and do not present as only respiratory disease. Twitter and Facebook to the contrary notwithstanding. public health practitioners have needed to ensure that control and mitigation programs and practices include strategic and crisis communication components. 2005). and to authoritatively correct errors. such as facilitating the rapid and widespread dissemination of advice. 1994). The episode was one of the first in which real-time. The India-plague event does continue to remind us that unprocessed.
. I travel for travel’s sake. and not a characteristic of the virus itself. The great affair is to move. At the same time. Travels with a Donkey (1878) As we’ve said earlier. a pathogen will challenge any and all new vaccine preparation contingencies. One of the principles of population health is that an individual’s risk for an adverse outcome cannot be considered in isolation from the population-based risk for that outcome in the population to which the individual belongs (Rose. when it takes a vaccine more than six months to be produced and clear the regulatory processes for human safety and licensing. some of the important aspects of modern public health that can be expected to further expand in the future are those associated with increasing migration and mobility. The effects of a person’s place of origin will become increasingly important as population-specific differences in outcomes are better appreciated. Don’t even start thinking about other pharmaceuticals that can take years to decades to move from concept through development and regulatory affairs. processes. The implications of cohort . before reaching the market. Rapid globalization of a new pathogen (regardless of its virulence) can exceed existing policies. Future public health preparedness and mitigation strategies for emerging and reemerging diseases will have to include modelling and contingency components reflecting human mobility. migration will increasingly influence aspects of the population health paradigm. As a stark example. The speed with which a novel influenza virus became globally distributed in 2009 was a direct consequence of human mobility. and response capacities that are based on past experiences. 1992). bringing with it the risks that certain infectious diseases will continue to be transported across borders. —Robert Louis Stevenson. 1987). but to go. One example is the difference in outcomes for cardiovascular disease related to ethnic or cultural origin (Derry et al. In a globalized world. many groups extend across national or regional boundaries.236 P DQ : P U BLI C H E A LT H POPULATION MOBILITY AND INTERNATIONAL DIVERSITY AND DISPARITY For my part. I travel not to go anywhere.
V. with some of the lowest levels of disease-related morbidity and mortality. One of the other migration-related aspects of public health that will be an important element in the future will be the exodus of health care professionals from underdeveloped countries. There undoubtedly are personal and societal benefits associated with international population mobility for both temporary and permanent relocation.. Wealthier nations. many of whom may actually have moved from regions of the world with the greatest need. But note that studying something and doing something about it are two different things. —Jim Johnson. Understanding the public health implications of these patterns of migration will be a more active area of future study.P. For example. Their distribution is uneven and often is inversely related to health services needs. MOVING FROM STAKEHOLDERS TO STEWARDSHIP: INTEGRATION OF HEALTH. Looking forward to address the immediate and longer-term significance of movement between disparate health and public health environments needs both study and action. Strategies to deal with this are already the subject of international attention. have the highest proportion of service providers. Some of the conclusions of these studies may be surprising. and action—as population diversity introduces disparities that affect health. Liberty Mutual .C h a p ter 8 • T H E F U T U R E 237 origin and diversity are likely to become integral components of all aspects of public health—education. Comparing the long-term health benefits of the economic returns from the diaspora with the direct impacts of the providers remaining at home after training is necessary to determine the full effects on health outcomes. PUBLIC HEALTH WITH OTHER NONHEALTH SECTORS It is a challenge to get all the stakeholders to the table and reach agreement. study. developing nations that are the source of large numbers of expatriate health care providers receive large economic benefits through the remittances returned by their health care diaspora.
the derivation of the term is from poker. Chilean diplomat A conference is a gathering of important people who singly can do nothing but together can decide that nothing can be done. American humorist All of the above principles in public health are clearly complementary and interdependent: identifying threat and managing risk. But this is neither new or startling or—in the bureauspeak of today—innovative. We need business leadership which goes beyond shareholder value to understand the needs and fears of other stakeholders and their communities. globalization of public health in an interconnected world. and response networks. if not everything. such as promoting better “birth to death” outcomes. which means that they have something to protect.238 P DQ : P U BLI C H E A LT H What we need is political leadership which can give guidance to the development of global governance. and mortality—have greatly expanded. it’s not that kind of stake). They are holding a stake. morbidity. “So what?” The “what” is this. —Fred Allen. and are often coming with the perspective that they have at least something. as we’ve said before. the future will increasingly involve integrated surveillance. sanitation. and improving the “healthy living” of those who are currently disadvantaged. Such is the way with bureaucratic gobbledegook. The field now includes other considerations within health. and the role of population mobility as a bridging factor for risk. The problem with stakeholders is exactly that. which will identify and define problems that often exceed the capacities of traditional public health sectors. these players are usually referred to as stakeholders (vampires can relax.) The reality is that the future public health will continue to involve a growing number of health and nonhealth perspectives. —Juan Somavia. Meeting those challenges requires other players. It raises the question. preventing future adverse health events for both for those alive now and those yet to come. (Ironically. integrating health and public health capacities. The old frontiers of public health—disease numbers. monitoring. In the vernacular of health bureaucracy. Many of those goals cannot be met simply through control or treatment of disease within the traditional . It is clear that. the stakeholder is the person holding the stake and who has no investment in the outcome. to lose.
As we have seen in our review of the past history (versus the future history) of public health. Coordination. similar albeit smaller-scale events like the resistance to the polio control program in Nigeria have happened before. transportation. agricultural. communications. 2009). unsubstantiated concerns about the safety of polio vaccines resulted in the suspension of some polio eradication activities in parts of Nigeria (CDC. In 2003. 2005). and geopolitical roots (Da Costa. security. and humanitarian communities. faith-based organizations. educational. The practices and policies of public health for the future will increasingly involve (take a big breath) the business. The rationale behind the rumors about the vaccine had cultural. faith-based. including the political. standardization. and. for example. However. but complex situations can be predicted to have complex responses with different sectors and people coming together and creating their own unique demands. dealing with them will require the participation and action of across a broader cross-cut of society. religious. justice. cultural. linguistic. as well as political. economic. “problems”) experienced in the global attempts to eradicate polio. trade. economic. 2007). both real and perceived. military elements. Yellow fever control and the Panama Canal also had their issues. and agreement on uniform goals . Dealing with the polio control program issue in Nigeria required the efforts of many. An example of intersectorial response coordination is provided by some the challenges (that is. The one thing that’s absolutely guaranteed is that there will be others who both want and need to be included but neither they nor we know it yet. in some cases (such as complex emergencies). travel and population mobility ensured that the negative consequences. civil liberties. and health sectors. cultural. The rumors revolved around suggestions that the vaccine contained components that would reduce fertility as part of a “Western” plot to reduce population growth in the Muslim world (VOA. regulatory. environmental.C h a p ter 8 • T H E F U T U R E 239 purview of the public health or health care sector. social. and behavioral factors within and beyond health. This situation reflects many of the complex aspects of modern public health. Because many of the adverse health outcomes in the modern world are the result of the complex relationships of environmental. affected the global polio control efforts.
Disparities that historically were considered simply in terms of . This is where the future of public health will increasingly depend on the technical components of statistics and epidemiology to inform and influence social policy analysis. and coordination planning (as always.240 P DQ : P U BLI C H E A LT H and outcomes can be difficult. eventually in the context of the global viewpoint it will increasingly include comparisons across countries and regions. The health performance and outcome measurements discussed in Chapter 5 will be the a priori basis for critical decision-making by the partnerships of health and non-health sectors. Much of the early history of public health was written in terms of infections and transmissible disease epidemics. environmental. It is also in that arena where the involvement other sectors will be increasingly important as the socioeconomic. At stakeholder consultations it is almost a foregone conclusion that it will be impossible to meet all the demands of everyone. In anticipation of the challenges in setting priorities with a diverse group of stakeholders. congresses. The actuaries and analysts are increasingly demonstrating that the largest positive impacts of health promotion and disease prevention interventions on the “LYs” (DALYs. so many of these meetings are held to set priorities. and complex undertakings (just ask all those who were part of the Climate Consultations in Copenhagen in December of 2009). One of the major issues for public health in the future in all likelihood will be the health outcomes related to regional disparities. expect lots of international meetings. these meetings are called “consensus conferences. Everyone loses. but the demands of dealing with noninfectious events and the determinants of health will assume greater and greater importance. costly. everyone has given up something to reach a consensus. By definition. Dealing with infectious diseases will continue to be an important part of the future of public health. The obvious pitfall in this approach is that a consensus is the lowest common point of agreement. As the focus of health follows the population health paradigm. and behavioral determinants of health play such an important role in noncommunicable diseases. in exotic places that rack up those air miles). genetic-biological.” and “consensus reports” are issued following the meetings. QALYs. So for the future. YPLLs) come from the noninfectious disease side of the health scene.
” the strategy attempts to ensure that public health activities designed and developed within the context of municipal.C h a p ter 8 • T H E F U T U R E 241 local or at best national responsibility will be viewed more and more through a broader lens at the international level. 2007). and hence has the greatest potential for resistance to change. It has no fairness. Only one of the eight goals is classical infectious disease and public health (Goal 6: combat HIV/AIDS. As more partners from different sectors come together to deal with issues in public health. and collaboration associated with these discussions can be expected to be long and complicated. This process of looking at the global implications of human activity and applying it to public health is already in process. In 2007 the Director General of the WHO said: In terms of fair access to care. different.” first described in 1971.d. But if we look at the present situation in a different way. We see growing signs of solidarity in health (Chan. The consultation. United Nations Development Program. and other diseases). they will bring new. however. or regional . coordination. Goal 5: maternal health). If we focus on these glaring gaps in health outcomes. we have to conclude that the landscape of public health is out of balance. The United Nations identified several goals and targets as part of the Millennium Development Goal (MDG) process (see Table 8-2. prevails: the availability of good medical care tends to vary inversely with the need for it in the population served. Stewardship based on true partnerships (Goal 8) for the MDG is possibly the area with the greatest potential to bring a new future to public health. and two others directly mention health (Goal 4: child health. Meeting those goals and their targets will be more difficult than planned. but all of them are health related (WHO. we see that the concerns of the international community are converging. recognizing the existence of problems and even agreeing on their solutions through setting priorities and agreeing on goals and outcomes does not mean that they will be reached. malaria. n. national. Frequently described as “thinking globally. As we have learned. the “inverse care law.). and valuable perspectives to the table. 2005). acting locally. This will inevitably lead to discussions about health inequalities and the disparate use health resources between nations.
Develop a global partnership for development 1: Address the special needs of least developed countries. by 2010. the proportion of people who suffer from hunger 1: Ensure that. by 2015. rule-based. Improve maternal health 6. by 2015. landlocked countries and small island developing states 2: Develop further an open. the proportion of the population without sustainable access to safe drinking water and basic sanitation 4: By 2020. Promote gender 1: Eliminate gender disparity in primary and secondary equality and empower education. nondiscriminatory trading and financial system 3: Deal comprehensively with developing countries’ debt 4: In cooperation with pharmaceutical companies. a significant reduction in the rate of loss 3: Halve. and in all levels of education women no later than 2015 4. by 2010. to have achieved a significant improvement in the lives of at least 100 million slum dwellers 8. between 1990 and 2015. will be able to complete a full course of primary schooling 2. the proportion of people whose income is less than $1 a day 2: Achieve full and productive employment and decent work for all. Combat HIV/AIDS. the underfive mortality rate 5. malaria and other diseases 1: Reduce by three quarters the maternal mortality ratio 2: Achieve universal access to reproductive health 1: Have halted by 2015 and begun to reverse the spread of HIV/AIDS 2: Achieve. provide access to affordable essential drugs in developing countries 5: In cooperation with the private sector. Ensure environmental 1: Integrate the principles of sustainable development into sustainability country policies and programmes and reverse the loss of environmental resources 2: Reduce biodiversity loss. children everywhere. especially information and communications . make available benefits of new technologies.242 P DQ : P U BLI C H E A LT H TABLE 8-2. United Nations’ Millennium Development Goals and Targets Goal 1. universal access to treatment for HIV/ AIDS for all those who need it 3: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases 7. between 1990 and 2015. preferably by 2005. boys and girls alike. between 1990 and 2015. Achieve universal primary education 3. achieving. including women and young people 3: Halve. Eradicate extreme poverty and hunger Targets 1: Halve. Reduce child mortality 1: Reduce by two thirds. predictable.
hospital design and use (World Health Design.d. and policies to allow for the international comparability of data. it can be anticipated that emerging global events will be more frequently considered through the lens of public health implications and consequences. its public health implications (for example. 2009). As awareness of climate change has gained significant international importance over the past 20 years. the secondary implications of vector distribution. which exemplifies this is climate change (United Nations. the spread of “tropical” diseases such as malaria and dengue to Europe and North America) are being more often considered (Haines et al. Others include applying universal standards for infection control. information.C h a p ter 8 • T H E F U T U R E 243 public health organizations consider and reflect international and global factors. and outcomes. and drug resistance surveillance. addressing the public health components will be increasingly multidisciplinary in both scope and content (Remoundou & Koundouri. n. The widespread use of standardized software for epidemiologic and statistical analysis (such as EPI Info [CDC. and we can expect them to increase. Related to the broader issue of climate change. As public health assumes these global attributes. 2009). Thinking globally and acting locally will be a major pillar of future public health activities. From air pollution resulting from .. poverty. 2009]) is a practical example. and coordinating medical education in an international context (Macfarlane et al. There are several examples of this approach already in use in public health. and nutritional scarcities that may result from climate change and extreme weather events will be important areas of interest across the public health spectrum for the foreseeable future (Luber & Prudent. Because the effects of climate change involve many aspects of human activity. Together. and the health consequences of possible population displacement. An area of current interest.. 2009). issues related to the future of generating energy are increasingly likely to have public health implications. 2006). these and other actions that reflect international influences will continue to give public health programs and polices a progressively more international dimension. The potential effects on direct disease epidemiology. 2008). Some include using internationally standardized procedures. practices.). antibiotic use. even if the events don’t arise in the field of health.
Public health policy and programs will support those working in the field to continue to deal with the traditional challenges of infectious disease control and prevention. Better integration with other sectors can be anticipated for all future public health activities. public health in the future will become an integral aspect of sectors not widely appreciated as being a part of the health domain. promote health. public health will be part of those considerations.244 P DQ : P U BLI C H E A LT H coal fired power plants and more people driving cars in the developing world. British explorer and writer SUMMARY The future of public health will be. Disease prevention and health promotion aspects of several global undertakings can be expected to assume greater prominence in the near future. Issues of social and economic equity and inequality. from their previous use to limit immigration and “purify” the race. As a consequence. and behavioral standards in their immediate environment and internationally. due to cultural sensitivities stemming. The understanding of the role of genetics and biology in health and public health is more difficult to predict. Public health programs will be increasingly multidisciplinary. to potential adverse effects from wind farms (Pedersen et al. and internationally integrated and multi-partnered planning and program delivery. Those issues will also assume greater prominence in schools of public health and public health training. Perhaps differently than we have seen in the past.. environmental. collaboration . 2009). at least in part. like the world itself. the health implications of nuclear power. and prevent disease through greater integration of socioeconomic. public health will try to maintain health. more globalized and diverse. Along with the benefits of globalization and diversity will be greater disparities that have a negative impact on health and public health internationally. not only should be but also must be more frequent elements of public health. shared intelligence on threats and risk management. Further. When doctors differ who decides amid the milliard-headed throng? –Sir Richard Francis Burton.
Haines. A. (n. Plague in India: A new warning from an old nemesis.net/index_2. (n.C h a p ter 8 • T H E F U T U R E 245 and true partnerships will become correspondingly more complex as well. References Bryce. 2007. M. Setback for Nigeria's polio fighters. Public Health 120: 585–596. S. Derry. W. A. Annals of Internal Medicine 122: 151–153. white and Asian population groups in the RSA. E.html. Lessons for public health everywhere.) TropNetEurop. Chan. anyway—will undoubtedly be a dynamic and vital component of the health sector. C.d.. Plague in India. 1920.8599. Taylor. GACD. T.d.org/. Retrieved 12/28/2009 from: http://www. R. 2006.). Campbell. (n. While predicting the future is never easy. Ischaemic heart disease. Chapman. G. Progress toward interruption of wild poliovirus transmission – worldwide.. (n. MMWR 54: 408–412.com/time/health/article/ 0. 2007. Da Costa. Bourne. Retrieved 12/ 29/2009 from: http://www. Dennis. M. 2005.gov/ epiinfo/. Kovats.cdc. D.time. 1978–1982. & Hughes.. 1993. G. Canadian Medical Association Journal 10: 1–10. D.html. CDC.d. Demands will continue to outstrip capacity at the global level and this gap between need and capacity will subject programs and policies to more rigorous and empiric evaluation. Public health in the 21st century: Optimism in the midst of unprecedented challenges.who. Sayed. B. The Global Alliance for Vaccines and Immunization. Retrieved 12/27/2009 from: http://www. Part VI.int/ dg/speeches/2007/030407_whd2007/en/index. Rip. The Global Alliance for Chronic Diseases. South African Medical Journal 72: 698–700. Variations in mortality of the coloured. January 2004 – March 2005. Infectious Agents and Disease 3: 234–244. The scope of a Federal Department of Health. What Is Epi Info? Retrieved 12/30/2009 from: http:// www. R. April 3. GAVI. C. 1994. one can say with some certainty that public health—or parts of it. Campbell-Lendrum.)...tropnet. Time. Oct.. 1978. et al. H.gavialliance. Retrieved 12/29/2009 from: http://www. & Khabbaz. R.1675423. vulnerability and public health. & Corvalan. BMJ 309: 893–894. P.ga-cd. Etiology and epidemiology of the Four Corners hantavirus outbreak. L.. E.d.. J.org/. P. D. Climate change and human health: Impacts.).. L.. . 25. European Network on Imported Infectious Disease Surveillance.00. F.. S. Retrieved 12/29/2009 from: http:// www. 1994.html. Disler. P. CDC. R. M.
E. M. Luber. DC: Institute of Medicine.).246 P DQ : P U BLI C H E A LT H Henderson. The global health system: Actors. International Society for Infectious Diseases. A. & Humphreys. Rutherford. 1992. Michaud. & Oaks. Wibulpolprasert. Oxford: Oxford University Press. & Clark. Pedersen. M. C. J. Shope. Agabian. Washington.org/ geosentinel/main. Washington. The future of the public’s health in the 21st century. 2008. DC: National Academy Press.. H.nap. Moon. K.. Rising expectations: Access to biomedical information..php?record_id=10548&page=1. (eds.. B. doi:10.. Lederberg.. Retrieved 12/12/2009 from: http://www.. Bloom. G. 2009. E. Stewart.istm.. Keusch. A. S. and collaborate internationally: Global health sciences at the University of California. The strategy of preventive medicine. B. Remoundou.).promedmail. E.. N. San Francisco. C.. L. 7 (1): e1000183. 2002.. W. H. T. Think globally. & Bouma. W. et al. ISTM. PLoS Medicine. Arima. and expectations in transition. S. Principles and lessons from the smallpox eradication programme.. T. 2000.html. Lindberg. Academic Medicine 83: 173–179. act locally. Public requests for cancer cluster investigations: A survey of state health departments. 2008. Rose. & Koundouri.edu/openbook. D. Retrieved 12/26/2009 from: http:// www. F.1371/ journal. Bakker. D. Kimball.. Retrieved 12/30/2009 from: http://www. 2009. Climate change and human health.. K. Moore.d. Methods of Information in Medicine 47 Suppl. B. norms. (n. GeoSentinel. T. CDC. G. 2008.d. Bulletin of the World Health Organization 65: 535–546. G. Novotny.. Emerging infections: Microbial threats to health in the United States. M. S. G. American Journal of Public Health 90: 1300–1302. Journal of the Acoustical Society of America 126: 634–643. Ungchusak. & Debas.). 1: 165–72. French. D. 2010.. P.pmed.. S. A. 2009. Szlezák. C.. Regional infectious disease surveillance networks and their potential to facilitate the implementation of the international health regulations. C. Jr. (n. R.org/pls/otn/f?p=2400:1000. N. C.1000183 Trumbo. Response to noise from modern wind farms in The Netherlands. van den Berg.. C. . 1992. Medical Clinics of North America 92: 1459– 1471. M. T. International Journal of Environmental Research and Public Health 6: 2160–2178... 1987.. Macfarlane. Environmental effects on public health: An economic perspective. J. R. ProMed Mail.. A. N. & Prudent. W. Transactions of the American Clinical and Climatological Association 120: 113– 117. R.. Institute of Medicine. Y. Jamison.
2009.php. (n. United Nations.d. R. Retrieved 1/5/2010 from: http://www. Preventing the next pandemic.worldhealthdesign. Akhtar-Danesh. 2005. World Health Design.com. b).) Dialogue: Think globally act locally..d. (n. (n. BMC Medical Informatics and Decision Making 5: 17.d. N. (n. Feb. A Severe Acute Respiratory Syndrome extranet: Supporting local communication and information dissemination. & Thomas.who.html.html. Global Alert and Response Network. a). Nigeria still fighting false rumors about polio vaccine. Wolf. Global influenza surveillance.int/csr/outbreaknetwork/en/. Retrieved 12/28/2009 from: http://www1. N.unaids.. .org/mdg/. H.int/2860. WHO. 2009.org/en/. Retrieved 12/28/2009 from: http://www.pdf. Retrieved12/ 28/2009 from: http://www.com/Think-Globally-ActLocally. Health and the millennium development goals.d.d.com/ english/news/a-13-2009-02-17-voa48-68672337. Retrieved 12/29/2009 from: http://www. The Joint United Nations Programme on HIV/AIDS. WHO.int/ mdg/ publications/MDG_Report_revised. (n. Millennium Development Goals (MDG). M.who. Valaitis.). VOA. 17. M.int/csr/disease/influenza/influenzanetwork/en/ index. K.d.undp.. Kealey.) United Nations framework convention on climate change.C h a p ter 8 • T H E F U T U R E 247 UNAIDS. 2005. Retrieved 11/23/2009 from: http://www. Retrieved 12/28/2009 from: http://www. Scientific American 300(4): 76– 81. WHO. Brunetti. United Nations Development Program. G.aspx. Geneva: World Health Organization. VOANews. (n.).. C.voanews.who... Retrieved 1/6/2010 from: http://unfccc.
54. 13f Bird flu. 137. 216 Asiatic cholera. See Attributable risk percent Arboviruses. 161 Bacterial pneumonia. 17 ether. 12. 109. 108 American Journal of Public Health. 94. 216 Antisepsis. 4 Alar. 55. 119–121 Autism. 118 Acquired immune deficiency syndrome. 42. 69. Joseph. 57. 152 deaths. 143 Aymé. 84 Behavioral risk factors. See HIV/AIDS Active surveillance. 107. Marcel. 16 Annelids.INDEX* A A Journal of the Plague Year. 181 Alice’s Adventures in Wonderland. 89 development of vaccine for. 104. 115. 20 Antibiotics. 148 Alcohol abuse. 10 Absolute risk reduction. 145–146 Anesthesia chloroform. 190 Age-specific mortality rate. 125 Alzheimer’s disease. 101 B Bacillus Calmette-Guérin (BCG) vaccination. 42 Bacterial meningitis. 57 ARR. 21 Antoine Plague 192 AR%. 109– 110 Age-standardized mortality rate. 19 Annales d’hygiène publique et de médécine légale. 238 Allen. Fred. 55 Anopheles gambiae mosquito. See Absolute risk reduction Arthritis. 87 Black Death (1328–1351). 15 Behavioral Risk Factor Surveillance System (BRFSS). 27 Anthrax. Woody. 91 Benzopyrene. See HIV/AIDS Akee. 17 obstetric 17 Animalcules. 150 Bills of Mortality. 42. See also Plague Blind Lemon Jefferson. 109t mortality. 115 Anchoring. 209 Bazalgette. 201 Bacteria. 28 American Statistical Association. 51. 211 Birth defects. 106. 27 Antimicrobial resistance. 163 Berra. 54 Aedes albopictus. 88 Aedes aegypti. 119 Attributable risk. 7 African horse sickness. 84–85 laboratory data as source of. 199 Attributable fraction. Yogi. 16 “Anconal-nates confusion” (ANC). 108t. 42 *Entries with f following a page number indicate a figure. 112 AIDS. entries with t following a page number indicate a table. 57. 249 . 105 Arthropods. 105. 211 Availability bias. 27 Allen. 233 Avian flu.
43 incubation period and. 115 CIHI. 243–244 Climate Consultations (Copenhagen. 78–80 confidentiality and. 44–45 notifiable. 165. 89 Chlamydia. 199 Third Pandemic of (1852–1860). 205 Campylolbacter jejuni infection. 172 BRFSS. See Behavioral Risk Factor Surveillance System Bryce. prostate. 21–22 Climate change. 2009). 196. 190 Botulism. Winston. 165 Candidemia. 165 uterine. 124t Centers for Disease Control and Prevention. 202 Broad Street pump and. Sir Richard Francis. 199–200 signs and symptoms of. 5 Canadian Census Mortality Follow-Up Study. 42 Brain cancer and cell phone use. 18 Cholera Riots. See Centers for Disease Control and Prevention Cell phones and brain cancer. 109 Cardiovascular disease. 86 Canadian Institute for Health Information. Albert. 75 Camus. 43 Computed tomography (CT) scanning. 199. 198t seven pandemics of. 240 Coal miner’s lung. 180 Cohort design study. P. 49. 165 lung. 87 Cleanliness religious tenets and. 198 Cholesterol screening. 124t Brave New World. 146 . 165 prevention and screening. H. 56 Chernobyl nuclear accident. 181 public health implications. 17 Cholera. 167 Confidence intervals. 81. 43 CA-MRSA. 81 breast. 152 Childbed fever. 199 discovery of nature and transmission of.250 P DQ : P U BLI C H E A LT H Blood donation screening programs. 170 brain. 42. 10 Cameroon. 54 Burton. 165 colon. 111t–112 risk factors. 87 Bovine spongiform encephalopathy (Mad Cow disease). 165 Case fatality rate. 188. 203 Chadwick. 244 C Cadavers (of plague victims). 7 and role in disease prevention. 47 Chloroform anesthesia. 19f causative organism. 236 mortality. 56 Blue tongue. 200. 54. 6. 2. 166. 124t cervical. 18 water-borne theory of transmission. Edwin. 14. 107–108 Case reports.. 57– 58. 115 ethnic and cultural influences on. 78. 17–18 pandemics. 79 vs. contagious disease. 15. 122–123 Colonoscopy. 223 BSE (bovine spongiform encephalopathy). 165 Communicable disease(s) definition. 79–80 Case-control study. 16 Chagas’ disease. 87 Cancer. 4 CDC. 84 Cardiac disease. 90 Case surveillance. 21 Childbirth mortality. 66. 17. 123–125 Cassava. 77f Churchill.
47. 167 CVD. 176 Disease prevention activity. 5 C-reactive protein (CRP). 43 Contamination early societies’ concept of. 181 Drugs adulterated. 21 Domesday Book.. 60 definition. 206 den Hartog. coli outbreaks. 144–145 Congenital disorders screening. Rick. Charles Robert. 165 Diet religious tenets involving. 127–128. 115 Democratic Republic of the Congo. 101 Dengue fever. 129 Cost/QUALY. 55 Ebola cases in Uganda in 2000. 27 Disease-based public health services. 216 Cowpox. 91 Coronavirus (SARS-causing). 216 substandard. 201 Disability. 88 Eastern equine encephalitis. 141f CRP. 46 virus. 60–65 international population mobility and.• I N DE X 251 Confirmation bias. 211 Coronavirus. See Cardiovascular disease D Dafoe. 62 Deuteronomy (in The Bible). 59 global population diversity and. See also Epidemics burdens 128f early detection of. 44– 55. 140f Dracunculiasis. 42. 193 Dose-response assessment. 106 E E. 176 of public health importance. Daniel. 42 Drug abuse. 6 weight loss. 79 Counterfeit drugs. 107 screening for. 167–169 outbreaks related to population migration. The. 139 Dose-response curve extrapolation. 7 Cook. 52t registries. 10 DALYs. See Disability adjusted life years Darwin. 30 Disinfection. 28 standardized elements of. 204 Dracunculus medinensis. 240 Constantinople. 200 prevention. 161 Consensus conferences. 49. 50 Diabetes. 205. 71t hemorrhagic fever. 216 Darwin. 240 Disease(s). 87. 89 Disability adjusted life years (DALYs). 129 Council of State and Territorial Epidemiologists.S. S. 175 Determinants of health characteristics of. 166 screening asymptomatic individuals. 8 ritual cleansing following. 65–66 socioeconomic factors and. 54 Cost/DALY. 62 globalization and. 119–121 Crime statistics in U. 216 Duration. 216 counterfeit. See C-reactive protein CT scanning. 59 factors. 90 Depression. 54 . 192 Consumption. 165 Conjugated vaccines. 174 Diphtheria. (1960– 2007). 204 Drippy willy. 197 Contagious disease. Sir Francis 17 Deltamethrin.
130–131 Essential optimum balance. See Public health emergencies Emerging Infections Program. 28 markers of. 24 social engineering and. 71 early attempts at controlling. Sir Francis. 24 immigration restriction and. 36 Epidemic diseases effect of urbanization on. 28–29 Environmental pollution. Umberto. 25–27 EF. 24 Nazi atrocities. 175 Excess fraction. 18 vs. 4 FoodNet. 46 Epidemic Commission (of League of Nations). 44 Food taboos. 230 F Factors in development of public health. 138 Eugenics forced sterilization and. 54. 174 Fomites. 28 marriage laws and. 3–4 False-positive results 93 Fecal occult blood test. Redd. 14 written history of public health and. 42. 58 Fungus/fungi. 209 Endemic events. 139 Environmental issues and public health. 34– 35 plague. 10 Evans. 138 Epiglottitis. 17. 45–46 Environmental hazards. 137 Ellis Island (New York). 165 Filariasis. 23 Gaucher’s disease. 50 Genetics disorders of. 174 Economic development and public health. 71 Foxx. See Global Alliance for Vaccines and Immunization 230 Genesis (in The Bible). public health. 151 Ether anesthesia. 136 Framework Convention on Climate Change. 42 G GACD (Global Alliance for Chronic Diseases). 204 First International Sanitary Conference. 10–11 urbanization in. 24 Fort Dix (NJ) swine flu epidemic. 175 Flux. See Influenza Fluoridation (of drinking water). 161 Equity (health). See Etiologic fraction Einstein. 42 Galton. 55 Emergencies. 27 detection of. 189 . 199 Fischoff. 84 Forced sterilization. 24. 152 Flies infections borne by.252 P DQ : P U BLI C H E A LT H Eco. Bob. 17 Etiologic fractions. 89–90 Epidemiology birth of modern. 24 increased knowledge of genetics and. 43 Flu. 22–24 Eugenics Review. 50 Expanded Programme on Immunization. 55. 10 reporting systems for. 17 Europe impact on developments in public health. 191 Galloping consumption. Albert. 87 GAVI. 199 Folate. 11 Epidemic(s) in at-risk populations. 232 Galen. Baruch. 181 Epidemic definition. 119 Exodus (in The Bible). 84 Encephalitis.
59–66 holistic. John. 173. 205 prevention programs. 91. Gerhard. 244 GeoSentinel. 56. 80. 188–200 Gobi Desert. 148 Guinea worm. 229 Global population demographics demographics. 93 Heuristics anchoring. 232 Global Alliance for Vaccines and Immunization.47 ebola. 80 pulmonary syndrome. See Healthy Life Expectancy Hansen. 54. 194 Gonorrhea. 204 type B. 81 H H1N1 influenza. 14 development of. 236– 237 pre-1860. See Haemophilus influenzae type B (HiB) Hindsight bias. 178 inequalities. 146–147 scope neglect. 145–146 availability bias. 78 Hantavirus infection outbreak. 26 Graunt. 190 Global Alliance for Chronic Diseases. 8. 230 Global burden of disease. 43. See also Leprosy. 205–208 joint United Nations activities on. Donald. 162 vaccines. 56. 58–60 rate of growth. 13 Great Depression. See also Public health clerical institutions and health care. 6 HALE. 6 promotion. 145 Hemorrhagic fevers. 144 in risk assessment. 227–229 1860–1968. 204 Gunshot wounds. 8 determinants of. 130 Heart disease. 46 Henderson. 54. 187–188 three eras of. 228 Globalization concept beyond economics. 208–209 . See under Influenza H5NI influenza. 17–22 origin of. 144–145 hindsight bias. 143 overconfidence bias. 43. 104. 143 confirmation bias. 43.• I N DE X 253 Genetics (continued) screening and. 45. 88. 22 Glanders. 204–216 population mobility and. 147 HiB. 176 tuberculosis and. 47 Gotthard Tunnel workers. 144 History of public health. 62 Global Influenza Surveillance Network. See under Influenza Haemophilus influenzae type B (HiB). 197 and role of cleanliness in preventing disease. 233 Health. 64t Global Burden of Disease Project. 29 Hepatitis virus infection type A. 49 Helicobacter pylori bacterium. 106 type C. 200–204 1969–present. 21–22 Gerrold. 229 Germ theory of disease. 32–33 Healthy Life Expectancy. 36 Guillain-Barré syndrome. 161 hospitalizations and lab-reported cases in New Zealand. 188 Globalization and public health. 230 origin of human infection with. 20 Hansen’s disease. 1–5 HIV/AIDS. 56. David. 59t Global Viral Forecasting Initiative. 161 Halal dietary laws.
43 Infectious disease(s). 36 International Health Regulations. 71. 210t pneumonitis. 29 Intervention(s). 43 noninfectious consequences of. 51–57 travel-related changes in transmission of. 25 anemia and. 209 H1N1 (2009) pandemic. 34–35 public health implications of. 44 Infection(s). 56 Impotence.254 P DQ : P U BLI C H E A LT H Hookworm infection. 43 notifiable. 42 diseases from. 175 Incidence. 209 pandemic. 25 and Gotthard Tunnel workers. 75–76 arthropod-borne. 43 Influenza. 233 H5N1 (2009). 209 encephalitis related to. 57 shift and drift. See Screening programs tradition of naming. 209–216 avian flu (H5N1). 49. 43 vs. 209 Spanish Flu (1918–1920). 57. 228 International travel and epidemic diseases. 47. 71. 209 myocarditis related to. 105–106 Incubation period. 44–45 definition. 44–45 screening programs for. 43 mite-borne. 137 Hypertension. 44 tick-borne. 234. 43 Hypercholesterolemia. 66. 56–57 vaccine-preventable. 209 seasonal. 8 Hospitals. 209 emergence of new strains of. 43 nosocomial. 49. 213–216. 75–76 subclinical. See also Infectious disease(s) antimicrobial-resistant. 71. 43 Human immunodeficiency virus. 57. 211 bacterial pneumonia related to. 210t International Health Organization (of League of Nations). See Vaccinepreventable diseases 85 Infestation definition. 36 International Sanitary Conferences. 138. 209 mutation of virus. infection. 55. 43 to infection. See also under specific disease names definition. 49 prepatent period and. 227. 71 vaccine complications. 46. 209 bird flu. infestation. See also Screening adherence. 179t. See HIV/AIDS Human papillomavirus (HPV) infection. 43 lice-borne. 174 . 29. 25 Hospices. 209 recombination of virus. See also Communicable diseases. 85. 211 complications of. 216 definition. 201 swine flu. 71 genetic mutation of virus. 209 Fort Dix (NJ) swine flu epidemic. 55. 81. 235 International Health Regulations. 43 WHO criteria for pandemic. 57. 35 International Red Cross. 51–54 transmissibility of. 8 Host immune response signs and symptoms of inflammation. 43 vs. 48 International Office of Public Hygiene. 77f I Immigrant health screening. 42. 175 screening for.
8–9 coins issued by. 237 Jungle. Robert. 175 Irwin. 195f . 8 Leprosy. 80. 161–162 modern. 168f Leprosaria. 114t lifespan increases. 47. 204 Meat Inspection Act of 1906. 21 Low. Mary (Typhoid Mary). 47. 192. 174. 57 eradication of. 167f Leeches. 48. Joseph. 192 Maritime Sanitation Regulations 48 Maritime Sanitation Regulations. The. 5 Length-time bias. 167 example. Edward. 90. 30 Meditations. 162 Knebel. 9 J J. Fletcher. Jim. Wallace. 115–119 public health intervention case. 55. See Millennium Development Goal Measles. 115t Malignancies. 80 M Mad cow disease (bovine spongiform encephalopathy). 197 Johnson. 44 mosquitoes and. 113–115. 50 Marriage laws. 69 Lazarettos. 167. 201 changes in transmission patterns of. 81. 21 Koch’s postulates. FROG effect. 43 Life expectancy. 233 Lice-borne infections. 106. Blind Lemon. See also Notifiable diseases Mange. 42. 174–176 Iodine. P. 9f depiction of. 54 Major depression. 22 Legislative processes in public health.and middle-income countries (LMIs). 22 Médecins Sans Frontières. 200 Mark (New Testament book). 203 Marcus Aurelius Antoninus. 20t Kosher dietary laws. 91 Lead-time bias. 24 Maternal-child care interventions. 54 L Laboratory data. 108 Jefferson. 227 MDG. 10–17 Leishmania tropica. 5. 22 pharmaceuticals industry regulation. 6 Kuru. 28 Lister. 28 McLuhan. 20. 66. 111 Lucius Verus 192 Lupus. Walt. 5 Leishmaniasis. 32 March of Dimes. 55 Legislation and public health food industry regulation. 193 Leukemia. Marshall. 8 Lead poisoning. 170–171 Mandated reporters/reporting. 42 Jenner. 192 K Kelly. 22 Justinian I. 8. 168–169 example. 51. 165. 78 transmission of 20 Les Filles des Joyes (The Ladies of Joy). 27 public health intervention case.• I N DE X 255 Intervention(s) (continued) measuring benefits of. Mickey. 196. 204 as a communicable disease. See Cancer Mallon. 56 Mammography. 233 Lyme disease. Alexander. 54 Mantle. 70 Isolation (of the sick). 3. 105 Malaria. 88 Langmuir. 91 Koch.
28 O Obesity. 47. 84 NIOSH. 50. See also Tuberculosis Myocarditis. 17 Obstetric anesthesia 17 .256 P DQ : P U BLI C H E A LT H Mencken. 27 psychiatric evaluations for inductees. 4 Morbidity as years lost to disability. 174 Meningococcal disease. 55. 18. 189 global estimates of migrant populations. 189–192 traced through genetics. 105 NHAMCS. 42 Micronutrients. 55 Montagu(e). 85–86 measures of. 81 Number needed to treat (NNT).S. 78 Mycobacterium tuberculosis infection. 84 National Hospital Ambulatory Medical Care Survey (NHAMCS). 87 National Foundation for Infantile Paralysis. 89 NNT. 72f Obstetric analgesia. 42. 23. 107–115 rate. 79–84 definition.. 127 definition. 78 Nutrition and public health. 87 National Ambulatory Medical Care Survey (NAMCS).. 201 Mycobacterium leprae. 209 N NAMCS. 64t Morton. 63t related to disease outbreaks. 28 Mesothelioma. 82t mandated reporters of. in 2007. 83f WHO requirements. 47 infectious diseases. (in The Bible). 175 Numbers. 86–87 disease-specific registers of. 49 in the U. 118.. 81 reporting form example. 86 National Vital Statistics System. 165 Millennium Development Goal. 75–76 Notifiable diseases/conditions. 19 Migration. H. 75 Miasmas. 137 Molluscs. Mary Wortley. 45 data. 118. 189 Military forces health requirements in. 107 ten leading causes of death by income groups. 105 Mumps. 10 protecting health of.S. 49 in U. 43 Mode of Communication of Cholera (1849). 86 Natural disasters and public health response. 175 Nosocomial infections. 44 infections borne by. 51 Microbes. 89 National Mortality Feedback Survey. 45 Mental disorders and public health. 174 Microscope (invention of). L. Roy J. 136 Methicillin-resistant Staphylococcus aureus (MRSA). 241 Mite-borne infections. 87 NHANES. 203 National Health and Nutrition Examination Survey (NHANES). 18 Modifiable risk factors. See methicillin-resistant Staphylococcus aureus Multiple sclerosis. 87 Mortality data. 43 MRSA. 30 Natural history (of diseases). 1 Mosquitoes as malaria vectors. 87 National Institute of Occupational Safety and Health (NIOSH).
203 eradication of. 192– 194 memorial to victims of. See Relative risk reduction relative risk. Louis. 239 . 108–109 Pneumocystis carinii pneumonia. 11 quarantines and. 48. 209. See Relative risk screening and. 71–73 of diseases of public health significance. 115–125 incidence. 6. 194 Constantinople and. 216 PAR%. 189 Black Death (1328–1351) 192– 194 in China. 106 future. 2. 35 Pandemic events. 46 Opportunity costs. 81. The.. 21 Peasant Revolt (1381). 146–147 P Panama Canal. 193 of Justinian (541–542 AD). 189. See HIV/AIDS influenza. 46 Plasmodium sp. 17 Ottawa Charter. 73 estimating magnitude of. 102 disability adjusted life years. 200.• I N DE X 257 Odds ratio (OR). 213. 51 PMR. 51 Penicillin. See Population attributable risk Paralytic poliomyelitis. 80–84 Pasteur. 202. 5 Osler. 192 of Egypt (biblical). 234 Antonine (166–180 AD). 122 Onchocerciasis infection. 75 Penicillinase. 122 Oriental ulcer. 47–49 reporting requirements for. 78 hite. 198t HIV/AIDS. 89. parasites. 80 Pneumonia. 35 Pan-American Sanitary Bureau. 46–47 determining geographic distribution of. 55. 46 avian flu (H5N1). 20. See Polio/ poliomyelitis Parasites. 35 Pan-American Health Organization (PAHO). William. 176 identifying factors affecting. 152. 75 Pesticide poisoning. 125– 127 Overconfidence bias. 71 cholera. 6 Pfisteria. 191– 192 Athenian (430 BC). 66. 2. Canada). 161–162 mortality. 105–106 measuring benefits of interventions. 104 relative risk reduction. 3. 169 OR. 102–103 dichotomous. 81 Pestilence. 32 Outbreaks definition. 42 Parent-Duchâtelet. 204. 190t–191 epidemic of 588 AD. Alexandre. See Population attributable risk percent PAR. 47. 109 Pneumonitis. 19. 55 Plague. 194 Pediculosis. 51 Pediculus humanus spp. 5 Plague(s). 69. 49 Outcomes “Anconal-Nates Confusion” example. 80 Pneumocystis jiroveci pneumonia. 190 Pharmaceuticals (regulation of). 176 impact measures. See Mortality prevalence. See Screening duration. 209 Polio/poliomyelitis. 15 Passive surveillance. 75. See Screening years of potential life lost. 127–128 disease prevention. 197 Plasmodium falciparum malaria. 197 Pier 21 (Nova Scotia. 199–200. 22 Phthisis.
258 P DQ : P U BLI C H E A LT H Polio/poliomyelitis (continued) new cases by year. 229–235 integration of health. current demands of. public health. 93 Prevalence. 21 Pure Food and Drug Act of 1906. 78 origin of concept of. 25–27 sociology of. 48 Public health intelligence. 189 mobility. 181–182 leaders in. 240 Quarantine. 5–9 traditional approach to. 231 training in. 59t targets for public health. 236–237 technology impact on. 104 Prevention global equity and disparity and. 26 Public Health Act of 1848 (Great Britain). 177–183 and population-based disparities in health indicators and outcomes. 30 Population attributable risk. 164 . 182 disease associated with. 161 future benefits vs. See Surveillance Puerperal fever. 23. 74. 54 ProMed. 244 interconnectivity and globalization of. 42 Prostate-specific antigen (PSA) test. 231f overview of future of. 167 Psychiatric evaluations. 167 PPV. 225–245 global coordination and collaboration in. 26–27 modern approach to. See Disease prevention Principles of public health. 42 Prions/prion diseases. 239 vaccines. 3 conjugated vaccines and. 180f implications of paradigm. 165 Public health communications impact on. 161 Poor Laws. 22 Q QALYs. 3 Public health surveillance. 226 Public health principles borderless approach to globalization in. 236–237 rates of growth of. 93–94 Pott. 75f in Nigeria. risks. and nonhealth sectors. 10 Pox. 50. 14 Population(s) of countries and regions. 163 Poverty. 244–245 social development and. 224t. See Public health principles Prions. 31 of international concern. 236–237 population mobility. 15 Public health demons. 121– 122 Population health model in Canada. 225–227 future. 171 Prevention. 182–183 Positive predictive value (in surveillance systems). 225 Public health emergencies 30–32 issues in. Percival. 227–229 international diversity and disparity. 108– 109 PSA (prostate-specific antigen) test. 59t migration of. and perception of risk. 9 R Rabies disease. 203 Polysaccharide vaccines. 6 social support systems and. 45 Radiologic screening. 229 Proportional mortality rate. 232 changing management of threats. 181 origin of.
138–140 surveillance of. 209 Recorded history and public health. 7 Re-engineering. 55 Schizophrenia. 54 Risk assessment. 164 . 166 factors required for effective. 3 Scope insensitivity. 173 evaluating new tests. 164 ethical and moral issues in. 225–227 relative. See also Surveillance tolerance. 165 Rickettsia prowazeki. 138 RRR. modificable risk factor. 94–95 Respiratory syncytial virus infections. and decomposition. Robert J. 142–147 communicating. 175 definition. 136–137 Risk factor(s). 33 Schachepheth. 26 Rockefeller. See Waste and sanitation SARS. 90 Salmonella typhi. 136 dose-response assessment of.. 26 RR. 90. Franklin D. 201 Rubeola. 88 Reiter’s syndrome. See Severe acute respiratory syndrome Sawyer. Wilbur A. 139–140 heuristics and perception of. 46 Rh incompatibility. 26 Schools of public health.. 165–166 controversies concerning. Wickliffe. decay. 165 cost of. 115–117. 151 Sanitation. 151–153 types of. 88. 197 Schistosomiasis. 7 diet and. 69. 90 Rumsfeld. 139 estimation of. 26 Rockefeller Sanitary Commission for the Eradication of Hookworm Disease 25. 138 Relative risk reduction (RRR). 71. 117 Rubella. 136 vs. 140.. 6 Representativeness (in surveillance systems). 162–172.• I N DE X 259 Randomized controlled trial(s) (RCT). 165– 172 early standardized. 136 determinant. 136 Risk marker definition.. 122–123 Recombination influenza virus. 42 Screening. 50 S Salmonella poisoning. 117 Religion cleanliness and. 47. 26–27 Scientific advances. 122–123 RCT. 169 development of. 105 School for Health Officers. 142. 147 Scope neglect. 203 Rose. 6 tenets regarding death. Donald. 42 Scrapie. 46 Rockefeller Foundation International Health Board. 164–165 early detection and. 136 perception of. 138 markers of. 137–140 biases in perception of. 78. 142–147 identification of hazards. 174 absolute risk and. 147 Scourge. 25 Roosevelt. 43 Relative odds. 148–151 definition. John D. 167–169 early detection dilemma. 137 Risk-averse choices. 56 Samuelson. 181 River blindness. 43. 122 Relative risk (RR). 138 steps in assessing. 142 Risk-taking behaviors. 140–147 public health perception of. 115–117.
21 Sensitivity. 156 Statistical analysis as a major development in public health. 33 Standardized mortality rate. 198. 243 elements in a system. Herbert. 74f Surveillance attributes of systems.. Lemuel. 211– 213 probable cases.. Robert Louis. 75 methicillin-resistant. 200 Stiles. 16 Shaw. 209t Shattuck. 201 Spanish flu era poster. 230 Smoking. 6 early societies and. 70 evaluation of control measures and. 171 fundamental concept of. 54. 169–170 Semmelweis. 188 St. 4 global strategy to eradicate. 165–166 technical aspects of. 76 changes in infectious agents and. 75–76 definition. Surgeon General William H. 89–90 vs. 14–15 Social engineering. Louis encephalitis. 69. 48. 49. 110–113 Staphylococcus aureus infection. 175 Snow. 196. 229 Global Influenza Surveillance Network 229 . 4–5. 236 Stewart. See Eugenics and social engineering Society for Healthcare Epidemiology of America. 152 Subclinical infections. 25 Stroke. 69–70 drug resistance. 170–172 purported benefits of. 200. 165 full-body CT screening for healthy people. 196 New York City outbreak (1947). 202–203 origins of. George Bernard. 84 Socioeconomic status as a risk marker. 163 genetic. 4 origins of disease control practices. Charles W. 78. 54 Slovic. 88–89 Severe acute respiratory syndrome (SARS). 12–14 Statistical surveillance. Chauncey. 202. 174. 152 Smallpox. Ignaz. 172–174 patient/public involvement in decision-making regarding. 76f Starr. 173 impact on development of public health. 2f Spencer. 70 epidemic reporting. 5 Sociology of public health. 74–75 future efforts in. Josiah. 55 Stakeholders. 238 Spanish Flu (1918–1920). 80 Stevenson. 2002–2003. John. 137 Sociology of public health codes of behavior in early societies affecting. 180–181. 17–18. 200 Social assistance programs (in Great Britain). 181 Suicide. 70 Ship fever. 75 prevalence rates. 91–95 changes in health practices and. 209. 90.260 P DQ : P U BLI C H E A LT H Screening (continued) false-positive test results. 204 control. 164f radiologic. 44 Substance abuse. 165 relative risk and. 94 Sentinel health reporting. Paul. 85 Stamp. 45. Sir Josiah. 5–9 Somavia. Juan. 66. epidemiology. 54. 86 Standardization of public health approaches. 29 initial spread of. 12 origin of. 238 Stamp. 229 GeoSentinel. 196 Smallpox Eradication Program.
Infectious disease(s) definition. 43 evolution of. 189 Tick-borne infections. See also Influenza Syphilis. 70–77 Surveillance systems. 3 Tetanus. 93–94 representativeness. 95 Swine flu. 201. 48. 34–35 public health implications of. 56 TST. 233 U. 194 Systemic lupus erythematosus. 88. 42 Tuberculin skin test (TST). 55 Technology impact on public health. 213–216. 80 Transmissible disease(s). Martha W. 232 sensitivity of. 227 U. 159. 73 simplicity in. 233 T Taft. Institute of Medicine. 77–85 morbidity data. 53f Travel and epidemic diseases. 78. 42 Tuberculosis. 175. 91 sources of data. 95 Tissue donation screening programs. See Surveillance systems TropNetEurop. 54 U U. 145 Twain. 181 Toffler. 165. 174. 86 mortality data. 90f uses of.. 106. 77 ProMed. 56 Tobacco use. 229 under-reporting of exposure. 229 Typhoid Mary (Mary Mallon). 94–95 sensitivity of. 47. 196. 69–70 hypothesis generation based on. 93 simplicity in. 92 sustainability in. See Notifiable diseases planning public health strategies and. 91 systems of. Amos. 56. 208–209 outbreaks prior to 1860. 88–89 showing natural history of a disease. Alvin. 47. 80. 95 timeliness. 165. 85–86 notifiable diseases. See Notifiable diseases methods of. 47 Tversky. 229 Trypanosomiasis.S. 229 public health globalization and. 42 Tularemia. 74 individual case reports. Indian Health Service. 47.S. 56. David. Public Health Service origin of 197 . Mark. 92–93 flexibility in. 161 Toxic shock syndrome. 43. 201 Thelen. 196– 197 tuberculin skin test for. 29 TropNetEurop. 90 laboratory data. 104. 37 Three Mile Island nuclear accident. 93 sentinel systems.• I N DE X 261 Surveillance (continued) government responsibility for. 208 HIV/AIDS and. 85–90 spectrum of outcomes. 50 acceptability of. 143. 234– 235 mandatory reporting. 142. 88 low-intensity events and. 56 Typhus. 43 Timeliness in surveillance systems. 92 positive predictive value and.S. See also under Communicable disease(s). 152 Thucydides. 57 Tapeworm infections.
16 Wolf. 239 . 4 X Xenopsyllya cheopis. 2. 15 microbiology advances and. 200 Wilde. 1 World Health Organization (WHO). 42 Vital Statistics Act of 1842 (Massachusetts). 126f. 81. 181 and epidemic diseases. 54 traditional and nontraditional concepts of. William. 89 V Vaccination/vaccines. 196 Vaccine-preventable diseases. 17 Weber’s law. 66.. 200. Peter. 48 Viruses. 54. 4–5. 199 Villermé. 90 Variola major. 80 White plague. 4 Y Years lost to disability (YLD). 231t World War I public health poster.262 P DQ : P U BLI C H E A LT H Ultrasonography. 230 formation of. 69. 197 Whitehead. 127 Years of potential life lost (YPLL). 15 Viral hepatitis. 26 Welch-Rose Report. 147 Weinstein. 19 Varicella. 26 Urbanization. 25 the Great Stink. 193 Winslow.-E. 242t United States public health development in. 47–49 structure of. 27 West Nile virus encephalitis. 45 as an outcome measure in public health. 5 van Leeuwenhoek. 202 Welch. 7 eradication of hookworm infection and. 3f Work-related disability. 91 HiB vaccination in New Zealand. 15 international conferences regarding. 78. Charles Jr. Anton. 240 Yellow fever. 5 expanding science of. 174. 4. 16 Voltaire. 54 01 strain. 52t transmission of disease by. 54 definition. 179. Oscar. 54– 56 Vibrio cholerae. 7–8 cholera reduction and. 11 Ustinov. 34 in London. Louis-René. 202 control efforts in Panama Canal. 16 United States Pharmacopeia. 175 early resistance to. 198. 229 and outbreaks of diseases of public health significance. C. 196 Vectors animal. Israel. 22 University of London School of Tropical Medicine. 15 in Deuteronomy. 174 William the Conqueror.. 173 United Nations’ Millennium Development Goals and Targets. 85 Vaccinia. 5. 28 Virulence. 36 Global Influenza Surveillance Network. 135 W Waste and sanitation. 161 smallpox. Henry. 127 Years of life lost (YLL). 125–127. 199 El Tor strain. 27 failures of. 54 Variolation.
205 Zoonotic diseases. 51. See Years of potential life lost. 127 Yogi Berra. 27 Yersinia pestis infection. 194. See also Plague YLD (Years lost to disability). Z Zaire. 47 . 127 YLL (Years of life lost). 235.• I N DE X 263 Yellow fever (continued) mosquitoes and. 192. 69 YPLL.
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