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Public health is about those things that make us sick, keep us healthy, and what we do together about it.

Health is often perceived as individual health and wellness. Public health focuses on the health of communities and society as a whole. This focus shifts from the individual to the population. It is about examining the impact on individuals and groups at risk as well as the population as a whole. United States Federal Executive Departments Uniformed ervices !" including # $rmed ervices %$rmy, &avy, $ir 'orce, (arine )orps, )oast *uard+ and , &oncombatant ervices%&-$$, PH . /-/ 0 U $rmy 0 U &avy 0 U $ir 'orce 0 U (arine )orps /H 0 U )oast *uard !U )*. HH 0 U Public Health ervice )ommissioned )orps !PH . /-) 0 &ational -ceanic and $tmospheric $dministration )ommissioned )orps !&-$$. Charles-Edward Amory Winslow !1 'ebruary 23"" 4 3 5anuary 26#". was an $merican bacteriologist and public health expert who was a seminal figure in public health. In 26,7 he wrote8 Public health is 9the science and art of preventing disease, prolonging life and promoting health through the organi:ed efforts and informed choices of society, organi:ations, public and private, communities and individuals.; In 2633, the nstitute o! "edicine created a steering committee to describe the !uture o! public health. They described public health as The substance of public health is the organized community efforts aimed at the prevention of disease and the promotion of health. #ie$elman points out that Public health continues to evolve. 0 <uality of life is more important today. 0 Protecting health that already exists 0 Promoting health when it is at risk 0 How we describe and define communities has had an impact 0 How we communicate with each other and the population continues to change 0 =vidence>based public health is re?uired to @ustify costs associated with interventions, describing health threats, and raising awareness. 0 Alurring of public health and clinical care options re?uire new strategies

Note: IOM not!for!profit" nongovernmental advisory body established in #$%& to advise on biomedical science, medicine, and health, and its mission to serve as adviser to the nation to improve health PAH considers environmental% social and economic determinants of health, even those not considered part of what we traditionally consider public health and clinical health. It also would encompass the range of interventions to address health issues including the structure and function of healthcare delivery systems, and how public policies affect health. There are , distinct characteristics of public health8 2. It deals with preventive rather than curative aspects of health ,. It deals with population>level, rather than individual>level health issues Public health is typically divided into core disciplines including8 0 =pidemiology 0 Aiostatistics 0 =nvironmental health 0 Health management and policy 0 ocial and behavioral sciences Bhile this is a good start to describing public health, in 2661, when the country was exploring issues related to health care reform, the public health sector felt that a better de!inition and description o! public health was needed. $ &Core Functions o! Public 'ealth Steerin$ Committee( was convened to address this need. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> 0 0 0 0 0 0 0 0 0 0 0 2"17s 5ames Cind, a Aritish &aval commander demonstrated that lemons and other citrus fruit could prevent and treat scurvy. curvy due to lack of vitamin ). Ditamins were unknown in his day Performed one of the first clinical experiments on record =dward 5enner is credited as the pioneer o! smallpox vaccine, Father o! mmunolo$y )n *+ "ay *,-., 5enner tested his 'ypothesis/ n!ection with cowpox $ives immunity to smallpox Inoculated 0ames Phipps, !3 year old son of his gardener., with material from the cowpox blisters of the hand of Sarah 1elmes% a mil2maid who had caught cowpox from a cow !Alossom. This produced a fever and some uneasiness but no great illness. Phipps was the *,th case described in 0enner3s !irst paper on vaccination4 ubse?uently challenged him with variolous material

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n *-,-% the World 'ealth )r$ani5ation declared smallpox an eradicated disease4 samples still remain in laboratories in )enters for /isease )ontrol and Prevention !)/). in Atlanta% 6eor$ia in the United tates, and tate Eesearch )enter of Dirology and Aiotechnology D=)T-E in 7oltsovo% 1ovosibirs2 )blast% #ussia.

The importance of his work does not stop there. His vaccine also laid the groundwork for modern>day discoveries in immunology Igna: Philipp emmelweis !5uly 2, 2323 4 $ugust 2F, 23G#.+ 0 physician who worked in Dienna *eneral HospitalHs 'irst -bstetrical )linic 0 -bserved and postulated !231". that the incidence of puerperal fever !childbed fever. could be drastically cut by the use of hand disin!ection !by means of hand washing with chlorinated lime solution. in obstetrical clinics. 0 Puerperal !ever !or childbed !ever. was common in mid>26th>century hospitals and often fatal, with maternal mortality at 27I4F#I. 0 /octorsH wards had three times the mortality o! midwives3 wards. 0 /espite various publications of results where hand>washing reduced mortality to below 2I, emmelweisHs practice earned widespread acceptance only years after his death, when 8ouis Pasteur con!irmed the $erm theory4 0 Died *9.: at a$e +,4 In mid>26th century in =ngland, the recording of vital statistics !birth and death records. began. Edwin Chadwic2%diseasesJpathological condition should be basis for death record William Farr%risk factors and social should be basis for death record The work of Couis Pasteur contributed to the *erm Theory of disease. The $erm theory o! disease laid the $roundwor2 !or modern public health. Identification of diseases that did not have a 9cure.; Borked to prevent those from getting the disease in the first place. Interestingly, sometimes the cause of a disease was not due to germs as noted with pellagra, which was discovered to be caused by a deficiency of vitamin A>G !niacin.. Advances in disease causation led to methods to prevent disease be!ore they occurred. The key was still preventing disease. Isolation and ?uarantine were still used. anatoriums for Tb were established. 0 Sanitation and 'y$iene 0 The 26th century shift in population !rom country to city that accompanied industriali5ation and immi$ration

led to overcrowding in poor housing served by inade;uate or nonexistent public water supplies and waste-disposal systems. 0 These conditions resulted in repeated outbrea2s o! cholera% dysentery% <=% typhoid !ever% in!luen5a% yellow !ever% and malaria4 Ay 2677, however, the incidence of many of these diseases had begun to decline because of public health improvements, implementation of which continued into the ,7th century. Cocal, state, and federal efforts to improve sanitation and hygiene reinforced the concept of collective >public health> action !e.g., to prevent infection by providing clean drinking water.. n *-??, the three leading causes of death were pneumonia% tuberculosis @<=A% and diarrhea and enteritis, which !together with diphtheria. caused one third of all deaths. -f these deaths, +?B were amon$ children a$ed less than : years4 n *--,% heart disease and cancers accounted !or :+4,B o! all deaths, with 1.#I attributable to pneumonia, influen:a, and human immunodeficiency virus !HID. infection. =xpresses an Epidemiolo$ic <ransition8 /iscussed in depth in chapter G.

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In 261#, 'leming was awarded the 1obel Pri5e in Physiolo$y and "edicine% alon$ with Ernst Chain and 'oward Florey% who helped develop penicillin into a widely available medical product. <en 6reat Public 'ealth Achievements CUnited States% *-??-*--0 Daccination 4eradication of smallpox, poliomyelitis in the $mericas, control of measles, rubella, tetanus, diptheria, etc. in U and parts of world 0 (otor>vehicle safety 0 afer workplaces 0 )ontrol of infectious diseases 0 /ecline in deaths from coronary heart disease and stroke 0 afer and healthier foods These are three key principles that underlie public health and health care law 2. The U. . )onstitution is a fundamental document that governs the issues of public health and healthcare law. )onstitution does not mention health Ceft to the primarily to the states who might delegate to local @urisdictions Police Power%allows states to pass legislation to take actions to protect the common goodKprotect its citi:ens Eegulate healthcare professionals and facilities Health and safety standards in retail and occupational settings )ontrol ha:ards !car restraints, vaccinations, sale of tobacco. ,. Interstate )ommerce )lause of the U. . )onstitution is the ma@or source of federal authority in public health and health care.

ource of federal authority Tax, spend and regulate interstate commerce -ffer federal funding incentives to states for them to enact certain types of legislation Alood alcohol levels 5ustify national standards that overrule and limit state rules and regulations ranging from ?uality controls on drugs Permissible exposures to toxic substances F. U . )onstitution grants individual rights !explicit and inferred. 'reedom of speech, religion, assembly, bear arms Eight to procreation privacy, bodily integrity, travel Eight to utili:e contraception, have an abortion, limit the state and federal authority to use ?uarantine and other travel restrictions Constitutional law%Includes U. . )onstitution and all #7 tate constitutions. Eemember responsibilities for health lie with the states unless the federal constitution grants authority to the federal government. They do not usually mandate roles of government in area of health. The commerce clause sand due process clauses of the constitution have the basis for extensions of federal authority in areas of health. tate constitutions are easier to amend. 8e$islative statutesCwritten by legislative bodies at fed, state and local level. 'ederal statutes typically overrule state and local legislation. Be often see that state and local legislation may be more restrictive than federal statutes. tatutes often address directly health issues. (ay be written in general language. Administrative re$ulationsD produced by executive agencies at federal, state, and local governments in order to implement legislative statutes. Think of them as operationali:ing the statuteKBho is eligible for services, how are the services to be provided, what levels of reimbursement are receivedL... =xamples8 re?uirements for immuni:ation to enroll in public education, regulation of food establishments, medical devises 0udicial% case% common lawD law made by courts when applying constitutional, statutory, or administrative law to specific cases. (ay fill in holes when statutory law does not provide guidance. =xamples8 defining 9nuisances; excess noise, disposal of garbage. 5udge 5udyK5udge BapnerK5udges apply previous rulings or precedence to new cases, and they may consider existing traditions and customs of society when applying law to cases. 'rom 26GF through 26GG, studies were carried out at the Billowbrook tate chool, a &ew Mork tate institution for 9mentally defective persons.; These studies were designed to gain an understanding of the natural history of infectious hepatitis and subse?uently to test the effects of gamma globulin in preventing or ameliorating the disease. The sub@ects, all children, were deliberately infected with the hepatitis virus+ early sub@ects were fed extracts of stools from infected individuals and later sub@ects received in@ections of more purified virus preparations.

The =ac2 to Sleep campai$n be$an in *--+ as a way to educate parents, caregivers, and health care providers about ways to reduce the ris2 !or Sudden n!ant Death Syndrome @S DSA4 The campaign was named for its recommendation to place healthy babies on their backs to sleep. Placing babies on their backs to sleep reduces the risk for I/ , also known as Ncrib death.N This campaign has been successful in promoting infant back sleeping and other risk>reduction strategies to parents, family members, child care providers, health professionals, and all other caregivers of infants. Eeduced deaths by up to #7I since program was initiated. /ownstream factors 'ocus directly on individuals and individual behaviors (ainstream factors 'ocus on relationship of individuals with a larger group or population Peer pressure Taxation of cigarettes Upstream factors 'ocus on social structure and policies

'ive teps individuals go through in changing behavior8 Useful in suggesting ways to help individuals change behavior Sta$es o! chan$e In the transtheoretical model as of 266", change is a Nprocess involving progress through a series of six stagesN Precontemplation > Npeople are not intending to take action in the foreseeable future, usually measured as the next G months9 Precontemplators tend to drop out of programs early Contemplation > Npeople are intending to change in the next G months9 $ personal problem exists $ttempts to understand in order to regain some control over their lives Perceive a link between overeating and hypertension%seek dietaryJexercise information Perceive a link between excessive drinking and marital problems% (ay take months or years Preparation > Npeople are intending to take action in the immediate future, usually measured as the next monthN Action > Npeople have made specific overt modifications in their life styles within the past G months9 (ay try a healthier diet (ay try to increase exercise (ay take steps to limit alcohol consumption *o to a support group elf esteem seems to rise because they demonstrate self>efficacy through action "aintenance > Npeople are working to prevent relapse,N a stage which is estimated to last Nfrom G months to about # years9 )ontinuance of change rather than an absence of change

<ermination > Nindividuals have :ero temptation and 277I self>efficacy... they are sure they will not return to their old unhealthy habit as a way of copingN In addition, the researchers conceptuali:ed NrelapseN !recycling. which is not a stage in itself but rather the Nreturn from action or maintenance to an earlier stage; The Health Aelief (odel is a values expectancy model8 people will engage in a healthy behavior if 2. they value the outcome related to the behavior and ,. they think the behavior is li2ely to result in the outcome4 The 'ealth =elie! "odel is a health behavior chan$e and psycholo$ical model developed by rwin "4 #osenstoc2 in *-.. for studying and promoting the uptake of health services. The model was furthered by Aecker and colleagues in the 26"7s and 2637s. ubse?uent amendments to the model were made as late as 2633, to accommodate evolving evidence generated within the health community about the role that knowledge and perceptions play in personal responsibility. -riginally, the model was designed to predict behavioral response to the treatment received by acutely or chronically ill patients, but in more recent years the model has been used to predict more general health behaviors. Perceived susceptibility !an individualHs assessment of their risk of getting the condition. Perceived severity !an individualHs assessment of the seriousness of the condition, and its potential conse?uences. Perceived barriers !an individualHs assessment of the influences that facilitate or discourage adoption of the promoted behavior. Perceived bene!its !an individualHs assessment of the positive conse?uences of adopting the behavior.. elf efficacy > $ personOs belief in his or her ability to take action. ocial (arketing4 the use of marketing theory, skills and practice to achieve social change. Product%I/ the behavior or innovation being marketed Price%Identifying the benefits, barriers, final costs Place%Identify the target audiences and how to reach them Promotion4 -rgani:ing a campaign or program to reach the target audience!s. Early adopters4 those who seek to experiment with innovative ideas Early "aEority AdoptersCopinion leaders whose social status fre?uently influences others to adopt the behavior !5ohn *ummer and daughter )ordelia eating hamburgers in 2667 in *reat Aritain. It was 9safe; to eat. 8ate adopters or laggards%those who need support and encouragement to make adoption possible. Promote ease of use and widespread acceptance

Problem/ What is the health ProblemL 0 Bhat is the burden of disease and has it changed over timeL

$re there differences in the distribution of diseaseL )an we use the differences to generate hypotheses about their etiologyL 0 $re the differences or changes used to suggest group associations artifactual or realL Etiolo$y/ What isFare the contributory cause@sAG 0 Has the association been established at the individual levelL 0 /oes the cause precede the effectL 0 Has altering the cause been shown to alter the effectL !if not use ancillaryJHill )riteria to determine association. #ecommendations/ What wor2s to reduce the health impactsG 0 Bhat is the ?uality of the evidence for the interventionL 0 Bhat is the impact of the intervention in terms of benefits and harmsL 0 Bhat grade should be given indicating the strength of the recommendationL mplementation/ 'ow can we $et the Eob doneG 0 Bhen should the implementation occurL 0 $t who should the implementation be directedL 0 How should the intervention!s. be implementedL 0 This is an on$oin$ process that describe the framework for defining, analy:ing and addressing public health issues 0 Be will break this process down to its elements. 0 0 0 0 Aurden of /isease8 Impact it is having on the community+ the occurrence of disability and death in the population. (orbidity8 ickness (ortality8 /eath =tiology8 )ause

Using at-ris2 populations for calculations are often more precise and should be used where possible. =xample8 prostate cancer can not occur among women so only men are at risk for developing prostate cancer+ cervical cancer would only include women. ncidence8 measures the chances of individuals to develop a disease during a particular time period Prevalence8 measures the proportion of individuals who have the disease at a point of time !or during a time period.. ncidence rate P of ne' cases of a disease over a period of time P of people in the at>risk population Prevalence #ate P living with a particular disease P in the at>risk population 0 0 Usually describes a point in time )an use a period of time !period prevalence.

*ood for describing the total burden or impact o! the health problem in the population at a $iven time

prevalence Q incidence x duration of disease $rtifactual changes in rates 0 )hanges in the interest in identifying the disease 0 )hanges in the ability to identify the disease 0 )hanges in the definition of the disease *roup Cevel $ssociations and all differences identified at the group level need to be assessed. 0 /etermined using Ecolo$ic studies or Population comparisonsH !correlation statistics. 0 $ssociations at a group level may not hold true at the individual level 0 (ay lead to hypothesis $eneration and further study to determine the existence of associations at the individual level Study Desi$ns 0 Cross-Sectional Studies assesess a snapshot in time of risk factor and case status 0 Case Control studies begin with knowledge of disease status and seeks associations with a risk factor 0 Cohort studies begin with assessing those withJwithout the risk factor and follow them forward in time to see if they develop the disease. 0 #andomi5ed Clinical <rials start with individuals who are assigned to the exposure !cause. to see if they develop the effect. (ay lead to ethical concernsK )an be used to determine e!!icacy !did the intervention workL. Hills criteria for determining casual association 2. Stren$th ,. Consistency F. pecificity 1. Temporal relationship !Temporality. #. Aiological gradient !Dose-response relationship. G. Plausibility !=iolo$ical plausibility. ". )oherence 3. =xperiment 6. $nalogy !)onsideration of alternate explanations. Stren$th8 how closely related the risk factor is to the disease+ Eelative Eisk and -dds Eatios are measures of strength of relationship. !-ptional8 if time permits, cover the ,x, table+ calculate a relative risk and odds ratio. Consistency8 seen across studies, preponderance of evidence across time, geographic areas, groups =iolo$ic 6radient/ /ose>response relationship8 amount of exposure affects development of the outcome

=iolo$ical Plausibility/ can accept based on acceptedJknown biologic mechanisms Criteria */ Iuality o! evidence *ood8 fulfills re?uirements for ?uality 'air Poor8 fatal flaws in evidenceKinsufficient evidence !under powered studies. Criteria J "a$nitude o! the impact 4 How much of the disability andJor death due to the disease be potentially removed by the interventionL !&et Aenefit Q benefits of interventions minus potential harms. 0 ubstantial 0 (oderate 0 mall 0 ReroJ&egative )ombined overall core @A$ency !or 'ealthcare #esearch and IualityA $%(ust A% hould )%(ay /%/onOt I%Indeterminant, insufficient, donOt know Implementation When/ timin$ o! the intervention Primary econdary tertiary Who/ individuals tar$eted !or the intervention Dulnerable groups =ntire population 'ow/ process o! implementin$ interventions Information !=ducation.%individual encounters, mass media, group interactions (otivation !incentives.%it implies a tangible reward for changing behavior, -bligation !re?uirements. Primary/ 0 before the onset of disease 0 prevent smoking Secondary/ 0 after the development of a disease or risk factor, but before symptoms appear 0 screening programs to detect disease+ smoking cessation programs <ertiary/ 0 after occurrence of symptoms, but before irreversible disability 0 diagnose and treat disease, prevent permanent disability or death !maintenance of disability.