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Introduction to Public Marsha Ivey MSc (Stat) MSc(PH)

Health Public Health and Primary Care

Public Health Definitions and Key Terms

Background/History to Public Health

Essential Public Health Functions

Topics to be
covered The Public Health Approach

Stakeholder Roles in Public Health

Public Health Priorities an Issues in Caribbean

Learning Objectives

• describe the purpose of public health

• define key terms used in public health
• identify prominent events in the history of public health
• identify prominent public health priorities and issues in the Caribbean
region
• state the essential public health functions
• recognise the core public health functions and services
• describe different stakeholders in the field of public health

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• Explanations for disease were based

not on science, but on religion,
superstition, and myth.

• – Zeus crammed all the diseases,

sorrows, vices, and crimes that
Pandora’s Box afflict humanity into a box and gave
it to Epimetheus, the husband of
Pandora. Pandora opened the box,
and all of the ills of the world flew
out and spread throughout the
human world.

What is Health

• “Health is a state of complete physical, mental and social well-being

and not merely the absence of disease or infirmity.”

• From the Preamble to the Constitution of the World Health Organization as

adopted by the International Health Conference, New York, 19-22 June, 1946;
entered into force on 7 April 1948.

• Definition not amended since 1948.

What is Public Health

• “The science and art of preventing disease,

prolonging life, and promoting health through the
organized efforts and informed choices of society,
organizations, public and private communities,
and individuals.”

• —CEA Winslow
Winslow CEA. The untilled field of public health. Mod Med 1920;2:183–91.

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• Public health is the art and science of promoting and

protecting good health, preventing disease, disability,
and premature death, restoring health when it is
impaired, and maximizing the quality of life when
health cannot be restored.
-John M Last

• “The art and science of preventing disease,

prolonging life and promoting health through
the organized efforts of society”
-(Acheson, 1988; WHO)

Public Health Mission & Aim

Mission: Aim: Focus: groups

protect, preserve and provide maximum of people, not
promote the health of benefit for largest just an
the public number of people individual.

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Key Public Health Terms

• Clinical care: prevention, treatment, and management of illness and the
preservation of mental and physical well-being through the services
offered by medical and allied health professions; also known as health
care.

• Health outcome: result of a medical condition that directly affects the

length or quality of a person’s life.

• Intervention: action or ministration that produces an effect or is

intended to alter the course of a pathologic process.

• Determinant: factor that contributes to the generation of a trait.

Stedman TL, ed. Stedman’s medical dictionary. 28th ed. Baltimore, MD: Lippincott, Williams, and Wilkins; 2006.
Farlex, Inc. The free dictionary. Huntingdon Valley, PA: Farlex, Inc.; 2014. Available at: http://www.thefreedictionary.com/.

• Epidemic or outbreak: occurrence in a community or region of cases of

an illness, specific health-related behavior, or other health-related event
clearly in excess of normal expectancy. Both terms are used
Key Terms cont’d

interchangeably; however, epidemic usually refers to a larger geographic

distribution of illness or health-related events.

• Pandemic: denoting a disease affecting or attacking the population of an

extensive region, country, or continent.

• Population health: approach to health that aims to improve the health

of an entire population.

• Prevention: action so as to avoid, forestall, or circumvent a happening,

conclusion, or phenomenon (e.g., disease)
Stedman TL, ed. Stedman’s medical dictionary. 28th ed. Baltimore, MD: Lippincott, Williams, and Wilkins; 2006.
Farlex, Inc. The free dictionary. Huntingdon Valley, PA: Farlex, Inc.; 2014. Available at: http://www.thefreedictionary.com/.

Question
Complete the statement

groups of people
Public health focuses on providing ___________________
with the right to be healthy and live in conditions that
support health.

A. groups of people B. individuals

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Question
Complete the statement

epidemic or outbreak is a disease

A(n) ________________________
occurrence among a population that is in excess of
what is expected for a given time and place.

A. pandemic B. intervention
C. epidemic or outbreak D. prevention

Background to Public Health

The Evolving Need for Public Health 1700s-1800s

• Agricultural Revolution and The Age of Industrialization

• People moved from the farms to the cities

• Small pox inoculations - Lady Mary Wortley Montagu (British)

• Involved serious risks; introduced variolation to Britain; using smallpox virus in pus from
blister in mild case and introducing to scratched skin of previously uninfected person; to
promote immunity

• Development of the smallpox vaccine - Edward Jenner (British)

• Worlds first vaccine; circa 1776; protective effect of cowpox

• Introduction of epidemiology – John Snow (British)

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The Evolving Need for Public Health 1700s-1800s

• The Germ Theory of Disease - Louis Pasteur (French)

• Discovered principles for vaccination, microbial fermentation and pasteurization; causation an
prevention of diseases renowned;

• The four postulates of infectious disease – Robert Koch (German)

• Founder of modern bacteriology; identified causative agents of TB, cholera and anthrax; support to
concept of infectious diseases

• The unhealthy conditions of New York City tenements – Lillian Wald (American)
• Considered founder of American community nursing, founder of Henry Street Settlement NYC,
advocate for nurses in public schools

Development of Public Health

Sanitary Movement
• Origins of modern public health started in 1800’s with the sanitary
movement
• Balance between the role of the individual and state protection
• Concept of contagion
• Control of disease and promotion of health through sanitation to
ensure a healthy environment

• The Sanitary Movement - A John Snow Epilogue

https://www.youtube.com/watch?v=cba7di0eL8I

Pandemics

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Pandemics
POLIO HIV SARS

Vaccine introduced 34 million living with 8439 people

in 1955; eradication HIV worldwide; 20% affected, 812 died;
initiative launched in decline in new no new cases since
1988 infections since 2001 2004 but a
continued threat

Disaster Preparedness and

Response

Disaster Preparedness and Response

Biologic Hurricane
Warfare Harvey/Irma/Jose

Plague used as a Emergency services,

weapon of war during public health
the Siege of Kaffa surveillance, and
disease treatment
provided

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Caribbean Disaster Emergency

Management Agency (CEDEMA)

• https://www.cdema.org/

Public Health is many things

A System

A Profession

A Method

Government Service

The Health of the Public

Partners in the Public Health System

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Structure of the
Health Services
Delivery System
in
Trinidad and
Tobago

Source: Ministry of Health Strategic Plan 2012-2016

Map of
Regional
Health
Authorities
sub-divisions
and Health
Facilities,

Trinidad and
Tobago

• Network of 96 health centres; 9 district health facilities (DHF); 9 hospitals

• All RHAs at least one DHF and a referral hospital
• Approximately two-thirds HC located in the western half of the island
which is more densely populated
• Delivery of services decentralised to the RHAs
• MOH manages several vertical services and national programs:
• E.g. Insect Vector Control, National Blood Transfusion Service, and National Oncology
Programmes
• Private sector health care uses a fee for service model, often expensive and
beyond the capacity of most low-income earners.

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Partners in Public Health

• Vehicle for public discourse
Media • Health education and promotion
• Health communication
• Social media as catalyst

Employers/ • Employer-sponsored health insurance programs

Businesses • Wellness initiatives and benefits
• Healthy workplaces and communities

Government/ • City planning

Agencies • Education
• Health in all policies

• Education
Academia • Training
• Research
• Public Service

Regional and International Partners

• CARICOM Secretariat
• Caribbean Public Health Agency
• Caribbean Development Bank,
• Caribbean Tourism Organization (CTO)
• PAHO/WHO and other UN Agencies,
• Food and Agriculture Organisation (FAO)
• World Bank,
• International American Development Bank
• President's Emergency Plan for AIDS Relief (PEPFAR)
• European Union
• Department for International Development (DIFID)
• Public Health Canada
• Centers for Disease Control and Prevention

Policies and Guidelines

• Development of policies are guided by the Government being
signatory to a number of international and sub-regional health
related conventions and agreements
• E,g, The United Nations Sustainable Development Goals (SDG) (formerly Millennium
Development Goals (MDGs));
• Framework Convention on Tobacco Control;
• Convention on the Rights of the Child;
• International Convention on the Protection of the Rights of All Migrant;
• UN Declaration on NCDs (2011);
• Caribbean Cooperation in Health
• Port of Spain Declaration on Chronic NCDs (2007);
• Health Agenda for the Americas 2008-2017;
• Nassau Declaration; and
• Pan Caribbean Partnership against HIV/AIDS (PANCAP).

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Approach to Public Health

Public Health Medical

Model Versus
Model

Approach to Public Health Problems

Problem RESPONSE

Risk Factor Intervention

Surveillance Implementation
Identification Evaluation

Source: CDC

11 Essential Public Health Functions

• EPHF 1. Monitoring, evaluation, and analysis of health status
• EPHF 2. Surveillance, research, and control of the risks and threats to public health
• EPHF 3. Health promotion
• EPHF 4. Social participation in health
• EPHF 5. Development of policies and institutional capacity for public health planning
and management
• EPHF 6. Strengthening of public health regulation and enforcement capacity
• EPHF 7. Evaluation and promotion of equitable access to necessary health services
• EPHF 8. Human resources development and training in public health
• EPHF 9. Quality assurance in personal and population-based health services
• EPHF 10. Research in public health
• EPHF 11. Reduction of the impact of emergencies and disasters on health
Source: PAHO/WHO – EPHF Strategy to Strengthen Performance.

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Three Core Functions of Public Health

Systematically collect, analyze,
Assessment and make available information
on healthy communities
Promote the use of a scientific
Policy knowledge base in policy and
Development decision making
Ensure provision of services to
Assurance
those in need

Institute of Medicine. The future of public health. Washington, DC: National Academies Press; 1988.

Ten Essential Public Health Services 1. Monitor Health

2. Diagnose and Investigate
3. Inform, Educate, Empower
4. Mobilize Community
Partnership
5. Develop Policies
6. Enforce Laws
7. Link to/Provide Care
8. Assure a Competent Workforce
9. Evaluate
10. Research

Knowledge Check
Match each stakeholder to its role in public health.
A. Academia B. Employers and businesses
C. Government D. Media

D. Media 1. Vehicle for public discourse

C. Government
2. Health in all policies

A. Academia 3. Education and training

B. Employers and businesses 4. Wellness initiatives and benefits

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Knowledge Check

Which of the following is NOT a core function of public

health?

A. Assurance

B. Assessment

C. Authority

D. Policy development

Knowledge Check

The essential health function of monitoring health and

diagnosing and investigating disease relate to which
core public health function?
A. Assurance

B. Assessment

C. Policy Development

The 10 Essential Public Health Services

1. Monitorhealth status to identify and solve community health
problems
2. Diagnose and investigate health problems and health hazards
in the community
3. Inform, educate, and empower people about health issues
4. Mobilize
community partnerships to identify and solve health
problems
5. Develop
policies and plans that support individual and
community health efforts

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The 10 Essential Public Health Services

6. Enforce laws and regulations that protect health and ensure
safety
7. Link people to needed personal health services and assure
the provision of health care when otherwise unavailable
8. Assure a competent public and personal health care
workforce
9. Evaluate effectiveness, accessibility, and quality of personal
and population-based health services
10. Research for new insights and innovative solutions to
health problems

Public health in the 21st century

https://www.youtube.com/watch?v=8maFVItzDTY

Administrators
Biostatisticians
•Behavioral science/health education.
Dieticians
•Biostatistics. Environmental health
•Environmental health. specialists
•Epidemiology. Epidemiologists
•Health services administration. Health care providers
Health communication
specialists
Health educators
Health law experts
Labratorians
Occupational health
specialists
Public health nurses
Researchers
Sanitarians
Social scientists
Toxicologists
Others

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Ten Great Public Health Achievements Worldwide,

2001--2010
1. Reductions in Child Mortality
2. Vaccine-Preventable Diseases
3. Access to Safe Water and Sanitation
4. Malaria Prevention and Control
5. Prevention and Control of HIV/AIDS
6. Tuberculosis Control
7. Control of Neglected Tropical Diseases
8. Tobacco Control
9. Increased Awareness and Response for Improving Global Road Safety
10. Improved Preparedness and Response to Global Health Threats
Source: MMWR 2011 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6024a4.htm

Caribbean Public Health Achievements

• First in the Americas to
eliminate poliomyelitis
• 1982: last case of
poliomyelitis in the
Caribbean Community
• Eradication strategies
sustained - effective and
timely AFP surveillance;
maintaining vaccination
coverage >95%

First to eliminate indigenous

measles and rubella

• last reported case of indigenous measles

– 1991; last imported case (tourist)- 1998;
• measles had been considered eliminated
from the Americas since 2002
• A country is considered disease-free if
there have been no new cases for three
years
• 2014 Disney outbreak – increased
vigilance
• Caribbean region remains at high risk due
to international travel related to tourism

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Cricket World Cup in 2007

• Successful management of health aspects – mass gatherings:

• Threat of disease and threat of terrorism
• Enhancing the health sector; building inter-country collaboration into the emergency
response system
• Developed a mass gathering surveillance system - to detect disease outbreaks or possible
acts of biological terrorism.
• Data reviewed daily, for prompt PH interventions and response.
• Surveillance system supplemented by “Roving Public Health Technical Teams,”
• comprised of public health nurses and senior environmental health officers who had expertise in food
safety and port health.
• Rigorous training programs for public health personnel
• Early warning system, foodborne diseases and the management of solid wastes
• Rigorous training of food vendors in each of the host countries
• Mass casualty management training – for disaster preparedness and management entities in
all the countries
• Medical stations were erected at each stadium and other strategic sites, such as airports and
hotels.
• CAREC, PAHO, the Public Health Agency of Canada, and the European Union collaborated on
providing financial and technical support activities

• NCD edpidemic; problem worst in

Americas – principally cardiovascular
disease including heart disease, stroke,
hypertension, diabetes, cancer and
asthma
• First region in the world heads of
government (CARICOM) met, discuss
and make policy decisions to prevent
and control chronic NCDs (2007)
• Declaration of Port-of-Spain - “Uniting to
Stop The Epidemic of Chronic Non-
Communicable Diseases”; 15 target items
• Initiated the UN General Assembly
High-Level Meeting on NCDs in 2011

Caribbean Health Priority Areas

Previously eight (8) priority health area under Caribbean Cooperation in Health (CCH) III
1. Chronic non-communicable diseases
2. Human resources development
3. Health systems Strengthening
4. Mental health
5. Environmental health
6. Family and child health
7. Communicable diseases and
8. Food and nutrition.
REVISED to four (4) strategic priority areas under CCH IV
• each with a key expected outcome.
• principal mode of implementation will be the production of Regional Public Goods
(RPGs)
• focus is strengthening primary health care and promoting health in all policies to
address the social determinants of health.
Source: http://carpha.org/downloads/CCH-IV-Version7.pdf (pg 17)

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Some Caribbean PH Issues/Challenges

• Epidemiologic transition and chronic non-communicable diseases

(NCDs):

• CARICOM states have decreased infant mortality, declining birth rates,

increased life expectancy; thus increased burden of disease resulting
from chronic and NCDs such as hypertension, diabetes, cancer, and
obesity

Population structure, by age and sex, Trinidad and

Tobago, 1990 and 2015
90+
90+
85-89
85-89
80-84
80-84
75-79
75-79
70-74
70-74
65-69
65-69
60-64
60-64
55-59
55-59
50-54 50-54
45-49 45-49
40-44 40-44
35-39 35-39
30-34 30-34
25-29 25-29
20-24 20-24
15-19 15-19
10-14 10-14
5-9 5-9
0-4 0-4

14 12 10 8 6 4 2 0 0 2 4 6 8 10 12 14 0 2 4 6 8 10
10 8 6 4 2 0
Percentage Percentage
Men Women Men Women

Source: Pan American Health Organization, based on the United Nations Department of Economic and
Social Affairs, Population Division. Revision 2015, New York, 2015

Some Caribbean PH Issues/Challenges cont’d

• Training and distribution of human resources in health: Few countries in

the region meet international indicators, such as number of doctors/nurses
per 10,000 inhabitants, or hospital beds available per 1,000 inhabitants.

• Financing health systems: Changes in patterns of disease and increased

longevity increase the cost of health care.

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Heads of Gov - 10th Anniversary POS Declaration on

NCDs
Progress made was variable; need to
address issues such as the
• banning smoking in public places;
• trade related measures;
• banning advertisement of
potentially harmful foods which
specifically target children;
• elevating taxes on foods high in
sugar, salt and trans-fats

Purpose of Public Health

• Prevent epidemics and spread of disease
• Prevent injuries

• Promote and encourage healthy behaviors

• Protect against environmental hazards

• Respond to disasters and assist communities in recovery

• Assure the quality and accessibility of services

Discussion

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Summary
• Public Health Definitions and Key Terms
• Background to Public Health
• Public Health issues in Caribbean
• The Public Health Approach
• Core Functions and Essential Services of Public Health
• Stakeholder Roles in Public Health
• Determining and Influencing the Public’s Health

Resources
Reference Texts
• Last John M. Public Health and Human Ecology. McGraw-Hill Professional, 1998 2nd Edition.
• R. Bonita, R. Beaglehole, T. Kjellström. Basic Epidemiology. 2nd edition. Geneva: World Health Organization; 2006. (pdf available
online)

Additional Resource
• Beaglehole R and Bonita R. Public Health at the Crossroads: Achievements and Prospects, Cambridge University Press, 2004.
• Pomerleau J and McKee M. Issues in Public Health, London, October 2016.

Readings
• PAHO (2012). A century of public health in the Americas. Health in the Americas.
• Caribbean Cooperation in Health Phase III (CCH III)
• Theodore K and Edwards-Wescott P (2011). An assessment of Primary Care in the Caribban Pre and Post Alma Ata Declaration and
A way Forward. IJHSS Vol1 No 8.
• MMWR (pg814)- 10 great PH Achievements globally https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6024a4.htm

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