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
● Public health focuses on groups of people (population) rather than individuals
● Focused on creating conditions in which people can be healthy
● Fulfilling society’s interest in assuring conditions in which people can be healthy
● To improve the quality of life for all South Carolinians by protecting and promoting the
health of the public and environment
● Concepts of public health
○ Define public health
○ Determinants of public health
○ Why is it controversial

Things to consider…
● How are you going to make a difference?
● The things we do today have future consequences
● Health and our “environment” (not just physical) are inextricably linked (can’t be
separated)
○ Social environment
○ Physical environment
● What does this have to do with public health?

Current events:
● Define the public health issue. Why is this a PH problem?
● What are the factors/determinants involved in this problem?
● What controversial and/or ethical concerns may be involved?

What is public health?

● Surgeon General Koop was one of the first surgeon generals to speak out about tobacco
harm
● Health of the population
● Factors that keep us healthy
● Makes changes to social norm
● “The science and art of preventing disease, prolonging life, and promoting health
through organized efforts…”
● Public health focuses on groups of people (populations) rather than individuals
● Focused on creating conditions in which people can be healthy
● Fulfilling society’s interest in assuring conditions in which people can be healthy
● To improve the quality of life for all South Carolinians by protecting and promoting
the health of the public and the environment (DHEC)
● Successive re-defining of the unacceptable

More than that! (the P’s of Public Health):

 ● Prevention
○ Preventing disease
● Protection
● Promotion
○ Promoting health
● Prolonging
○ Prolonging life and life expectancy
● Product safety
○ Age appropriate on products
● Physical, social, economic environments
● (Big) Picture
○ Public health is the big picture
● Populations

Images of Public Health:

● Hand washing
● Seat belts
● Health department
● Recycling
● Sex ed, condoms
● Etc.

Definitions of Public Health:

● “State of complete physical, mental and social well-being, NOT merely the absence
of disease or infirmity”
○ Use measures of morbidity(illness) or mortality(death)
● Quality of life involving social, emotional, spiritual, and biological fitness on the part of
the individual
○ Varies

Dimensions of Health:
● Physical health- physical condition of body
● Emotional health- ability to feel and express emotions
● Social health- ability to interact and communicate
● Mental health- ability to make decisions
● Spiritual health- meaning in life
● Environmental health- awareness of environment

What makes some people healthy and others unhealthy?

● The range of personal, social, economic, and environment factors that influence health
status are known as determinants of health
● We call these factors that influence your health status determinants of health
● Risk factors
 ○ Set of common causes of death, disability, illness, and injury more likely to be
under the control of individuals at risk
○ Essentially your behavior and what is under your control
● Risk conditions
○ More distal risk tractors: biological and environment and less likely to be under
the control of individuals
● Lifestyle
○ Pattern of behavior; social circumstances and lifestyle habits
○ Overtime what you do

Practicing Defining a Public Problem:

● i.e.) “Woman dead after attack by great white shark off Maine coast, officials say”
○ PH Problem? NO because there is not a lot of people impacted by shark attacks
● i.e) “CMPD investigating the death of Lake Wylie swimmer. 1 person was saved from
water.”
○ PH Problem? YES because there is 10 people every day that die from
unintentional drowning
○ What are determinants? Those more at risk are males, children, and minorities
■ Also lack of swimming ability, lack of barriers, lack of close supervision,
location, failure to wear life jackets, and alcohol use

**Notes on SC universities and college must do more to get students vaccinated:

● Mumps outbreak on college campuses
● Herd immunity- when someone with an immune disease relies on others to be
vaccinated to prevent disease
● College students are more susceptible to disease due to their dorm living
● PH issue? YES because there are a lot of college students that are getting mumps
● Determinants: people with immune diseases, people not vaccinated; behavior to get
vaccinated
● Controversial and/or ethical concern: Controversial getting universities to create a policy
to require vaccination

Controversial or ethical concerns?

● Controversy typically arise from difference in money, values, or individual liberty
● Money
● Values
○ Religion, belief, how you were raised
● Individual liberty
○ Doing something you want to do

PH Problem or determinant?
● Heart disease- determinant
● Vaping- PH problem
● Tanning- PH problem
 ● Premature delivery- determinant b/c leads to diseases in infants
● Obesity- both
○ Determinant b/c obesity can lead to morbidity or mortality
○ PH Problem b/c growing problem in U.S.
● Homicide- PH problem
● Physical inactivity- determinant
● Human trafficking- determinant b/c can lead to illness or death due to HIV, PTSD, injury
● Skin cancer- PH problem
● Food insecurity- determinant
● Flu shots- determinants

**Notes on How to preserve, protect health of all South Carolinians:

● DHEC analyze SC public health
● Have professionals that assist in chronic disease, aging, safe drinking water, disaster
response, tobacco control, etc.
● DHEC works to prevent disease outbreaks and respond to public health threats

HISTORY OF PH
Group Survival:
● In early civilizations (cavemen), wanted babies and mothers to live

Early Civilizations Requirements for Survival:

● Care
● Shelter
● Food
● Water
● Air

Public Health Codes:

● Different rules that help keep people safe and healthy
● Tribal rules
● Hieroglyphs
● Chinese empire
● Bible
● Koran
● Roman Senate

Ancient Greeks:
● Personal hygiene (brushing teeth, washing hands)
● Physical fitness
○ Olympics
● Naturalistic concept
○ Disease caused by imbalance
● Also believed in thoughts and mental wellness
 ● Hippocrates
○ Father of Western medicine
○ Causal relationships
■ Believed illness had rational and physical explanation
○ Coined the term “epidemic”

Roman Empire (23 BC - 476 AD):

● Adopted Greek health values
● Great engineers
○ Sewage systems
○ Aqueducts
● Administrations
○ Public baths
○ Water supply
○ Markets
● Replaced pipes with lead pipes then suffered from lead poisoning

Middle ages:
● Shift away from Greek and Roman values
○ Physical body less important than spiritual self
○ Decline of hygiene and sanitation
● Beginning of PH tools
○ Quarantine of ships
○ Isolation of diseased individuals
● Prayer and meditation were treatments
● Gave us idea of isolation

The Plague “Black Death”

● 25-50% of population in Western Europe died
● Types: bubonic and pneumonic

Renaissance:
● Disease, spread by traders and explorers
● Killed 90% of indigenous people in New World

Age of Reason and Enlightenment:

● Birth of modern medicine - William Harvey
○ 1628- theories of circulation
○ First to suggest that humans and other mammals reproduce via the fertilization of
an egg by sperm
○ Used dissection to create theories
● Edward Jenner
○ 1796 - cowpox experiment
○ Coined the term “vaccine”
Industrialization Urbanization (1800s):
● Life expectancy started to drop during revolution
● Poverty
● Slums
● Disease
● In 1840, 57% of working-class children in Manchester died before their fifth birthday; a
laborer in Rutland had a life-expectancy of 38; a factory worker in Liverpool had an
average age death of 15

**Notes for TED talk: How the “ghost map” helped end a killer disease:
● London was a smelly city in the 1800s due to the waste people kept in their basement
called cesspools
● Public Health system was convinced it was the smell that was killing people
● Cholera came to London in 1832 and killed thousands of people every four or five years
● Nuisances Act- made people pour waste out of cesspools into river
● John Snow argued that cholera was a water borne disease
● 10% of city died in 7 days after large cholera outbreak b/c of baby Lewis
● Henry Whitehead tracked down people who had and had not drank from the pump, and
Snow created a map of those people
● Snow used this map to try to prove his point
● In 1866, authorities believed Snow’s idea and asked people to boil their water
● Why is John Snow known as the father of Epidemiology?
○ Argued that cholera disease was in the water not the air
○ Helped prevent future outbreaks of cholera
○ 1st one to disease track
● Who are the people in the TED talk?
○ The people of London in 1800s
○ John Snow
○ Rev. Henry Whitehead was the social aspect or gatekeeper that knew everyone
and spoke to them about whether they were drinking from the water
○ Steven Johnson (presenter)

Great Sanitary Awakening:

● 1800s- 1900s
● Growth in scientific knowledge
● Humanitarian ideals
● Connection between poverty and disease
○ Poverty is the single best predictor of poor health
● Water supply and sewage removal
● Monitor community health status

England Sanitary Reform:

● Focused on Chadwick’s report
 ● 1842 Chadwick Report “Survey into the Sanitary Condition of the Laboring Classes in
Great Britain”
○ Landmark research
○ Graphic descriptions of filth and disease spread in urban areas
○ Reforms in sanitation, health care, treatment of poor, children, working classes
● Charles Dickens’ novels brought public attention to the desperate position of the poor
and the squalid conditions in which they were living

U.S. Sanitary Reform:

● 1850 “Report of the Sanitary Commision of Mass.”
● 1869 MA State Board of Health
● Health records, vital public health statistics as tools to fight disease
● System of sanitary inspection
● Vaccination programs
● Public health info for citizens
○ Programs in nursing and medical school

Growth in Scientific Knowledge:

● Louis Pasteur
○ 1862 germs (not bad air) relationship with disease
○ 1888 first public health lab
● Robert Koch
○ 1883 identified the vibrio that causes cholera, 20 years after Snow’s discovery
○ Discoverd tuberculosis bacterium

Sanitation Revolution:
● Life expectancy increases due to
○ Clean water
○ Food inspection
○ Soaps, disinfectants, and pharmaceuticals
○ Personal hygiene
○ Public works departments; garbage collection, landfills, and street cleaning
○ Public health departments and regulation

Public Health Eras:

● Best thing during those times were doing the best we could
● Build infrastructure throughout
● Before 1850- battling epidemics and infectious disease
● 1850-1949- building state and local public health infrastructure
● 1950-1985- filling gaps in Medical Care delivery, controlling infectious disease, SC report
on smoking
● 1985-2000- health promotion, disease prevention, multiple risk factor interventions, HIV/
AIDS
 ● 2000- now- preparing for and responding to community health threats, population health,
global collab, health care

Current event ex.: Hurricane Ida

● Determinant (health issues in () )
○ Flooding and poor water quality (can be determinant of cholera)
○ Loss of power and shelter (can lead to COVID-19 with no working ventilators)
○ Flooding (can be determinant of drowning)
● Controversial issues
○ Living in hurricane prone areas
○ Limited resources

Population Health:
● Consists of...
○ Health care systems
○ Traditional public health
○ Social policy
● Addressed through “evidence based” strategies to prevent disease, disability, death, and
to protect class
● Goes beyond just...
○ Physical health
○ Geographic boundaries

Why is PH important?
● Mortality and morbidity prevented
● Longer life expectancy
● Quality of life
● 20th century achievements

Recommendations for Measuring Population Health:

● Life expectancy from birth or age-adjusted mortality rate
● Condition-specific changes in life expectancy or condition-specific or age-specific
mortality rates
○ Focus on infant mortality rates in PUBH 302
● Self-reported level of health, functional status, and experiential status

Disparities:
● Differences in trends of morbidity and mortality based on gender, race, ec.
○ Goal of public health is to limit disparities

Infant Mortality
● Death of an infant from time of live birth to the age of 1 year
● Overall infant mortality = neonatal deaths + postneonatal deaths
Quality of Life:
● Quality of life is a broad multidimensional concept that usually includes subjective
evaluations of both positive and negative aspects of life
○ Impacted by injury, illness, and death
○ Perceived (by you)
● HRQofL (health-related) is an individual’s or group’s perceived physical and mental
health over time

Health-related QofL Measures:

● Questions that examine quality of life
● Physical health?
● Mental health?
● i.e.) living in poverty, but be one of the happiest people

10 Great Achievements in PH:

● Vaccination
● Motor-vehicle safety
● Safer workplaces
● Control of infectious diseases
● Decline in deaths from heart disease and strokes
● Safer and healthier foods
● Family planning
● Fluoridation of drinking water
● Recognition of tobacco use as a health hazard

PUBLIC HEALTH IS ABOUT PREVENTION

3 Levels of Prevention:
● Primary Prevention
○ Things we do ourselves to stay healthy
○ Action taken to avert occurrence of disease
○ i.e.) eating healthy
● Secondary Prevention
○ Checking or early detecting for diseases
○ Action taken to identify diseases at their earliest stages and to apply appropriate
treatments to limit their consequences and severity
○ i.e.) going to get BP checked
● Tertiary Prevention
○ Treatment; doing something about the disease
○ Specific interventions to assist deceased or disabled persons in limiting the
effects of their diseases or disabilities and prevent reoccurrence of disease
○ i.e.) physical therapists rehabilitation

Han’s Rosling 200 Countries Video:

● In 1810, most countries populations were sick and poor
 ● Life expectancy was below 40 years old
● Industrial revolution , World War, Great Depression caused changes to occur between
countries
○ Revolution made England rich, Great Depression made some suffer greater
financially
● In 1948, biggest difference between countries
● Now, countries transition towards healthy and wealthy, especially with new ideas and
technology

Han’s Rosling winning war against child mortality:

● U.N. created Millennium Development goals:
○ End poverty
○ Education
○ Gender
○ Child health
○ Maternal health
○ Control infections
○ Environment
○ Global links
● Aims to reduce child mortality by 4% every year
● Measure statistics in lower income countries, like Kenya, with interviews instead of death
certificates
● Investments in economics effect public health
● Decreasing family size reduces child mortality in countries
● Female education plays an important role in child mortality rates
●

Current event: Chinese Communist Party banned video games during the week.:
● Determinant: banning video games
● Behavior: playing video games
● PH issue? Homicide, obesity, etc.
● Ethical/Controversial issues? Individual liberty issue, detrimental to video game
companies
‘
LAW, GOVERNMENT, AND PUBLIC HEALTH
Unique Features of Public Health:
● Inherently political
○ Political b/c it addresses people’s behavior
● Link with government
● Evolving expectations>> expanding agenda
● Grounding in science
● Focus on prevention
● Social justice perspective
○ View that everyone deserves equal rights and opportunities
 ● Create law and policies because we want to prevent morbidity and mortality

Components of Health Law, Policy, and Ethics:

● Health care
○ Professionals in health care
○ Must take tests or boards
● Public health
○ Mandatory report on diseases that affect the population
● Bioethics
○ How we protect human subjects

Government and Public Health:

● “All politics is local” but is all public health local as well?
● Federalism and public health
○ Health hard to find in U.S. Constitution
○ Relative roles of national, state, and local governments in health matters shift
over time
○ Social values shift over time as well
● Anything health related usually falls under commerce laws, unless it's across state lines

Types of U.S. Law:

● Different sources of law
○ Constitutionally based
○ Legislatively based
○ Administrative
○ Judicially based
● Purpose of Public Health Laws
○ Protect and promote health
○ Ensure rights of individual
Governmental Public Health:
● Levels
○ National- federal health agencies
○ Tribal- Indian Health service
○ State- state health agencies
○ Local- local public health agencies
● State/local health agencies
○ Where the “rubber meets the road”
○ Health roles and duties often scattered among dozens of agencies
○ Many different configurations for health agency

Current events: 9/11

● PH issues from 9/11- mental health issues, mass casualties and deaths
● Determinants- tensions between countries, lack of airport security
** Bolton’s article: Laws work because people respect them
●
●

Controversy from PH issues (3rd guiding question):

● Money
● Religions or values
● Individual rights
○ Freedom

Purpose of PH laws:
● To promote health and well-being, while respecting individual rights
○ Finding a delicate balance

How has PH extended Life Expectancy?

● The foundation for public health lies within the 3 core functions by IOM:
○ Assessment- trying to figure out what is going on
○ Policy development- we should do something about it
○ Assurance- is what we are doing worthy and are the people (performing the
function) doing what we need them to do
● Public health is guided by the Ten Essential Public Health Services

Public Health Core Functions and 10 Essential Services:

● Assessment
○ Monitor health
○ Diagnose and investigate (i.e. looking into any public health problem or concern)
● Policy development
○ Inform, educate, and empower (the public)
○ Mobilize community partnerships (i.e. churches and schools giving away healthy
food options)
○ Develop policies
● Assurance
○ Enforce laws (Bolton’s idea: laws can be enforced because people respect them)
○ Link to and provide care
○ Assure competent workforce
○ Evaluate

Framework for Improving the Performance of PH:

● Starts with strong infrastructure
● To be able to change or improve current conditions

Federal Public Health Responsibilities:

● Ensure all levels of government have the capabilities to provide essential public health
services
 ● Act when health threats may span more than one state or entire nation
● Act where the solutions may be beyond the jurisdiction of individual states
● Act to assist the states when they lack the expertise or resources to effectively respond
in a public health emergency
● Facilitate the formulation of public health goals
○ Goals established based off of national data

Other roles of Federal Public Health:

● Providing leadership, through regulatory powers in setting health
● Contributing operational and financial resources
● Financing research and higher education
● Supporting the development of scientific and technological tools

State/local health departments:

● Local/decentralized- led by local governments
● Mixed- some local health departments led by state gov. and some led by local gov.
● State/centralized- led by units of state government
○ SC is state/centralized (DHEC)
● Shared- all local health departments are governed by both state and local

What is “social justice”?

● Overall fairness of a society
● Government is responsible to ensure basic quality of life for all citizens

Health Equity and Social Justice:

● Goal: everyone has the opportunity to attain their highest level of health
● Create conditions that give everyone the opportunity to reach their best health
● This requires valuing all individuals and populations

How do we achieve health equity?

● Social determinants of health are where you live, who you are surrounded by, what you
learn, distribution of money, power and resources
● Equality is NOT equity

EPIDEMIOLOGY:
Epidemiology definition:
● The study of distribution and determinants of disease
● Has been called “population medicine”
○ Diagnosing and preventing diseases
○ Diagnosis in population is finding out what is causing morbidity and mortality in
the population
● John Snow is father of epidemiology

Epi as a “cornerstone” for PH:

 ● “Evidence-based”
● Utilize data for prevention efforts
● Try to explain why some things happen to some people and not others
● Shift from traditional epi (John Snow- diagnosing) to wider uses (strategies for
measuring chronic diseases)
● Target multiple causal factors

Framingham Heart Study:

● Longitudinal study (observing people all from one area but have different lives) in 1948
until present
● Framingham, Massachusetts (near Boston)
● Wanted to gather data to see how people live and what their outcomes were
○ What people eat
○ If people exercise
○ Stress levels
○ Blood pressure, HR, cholesterol
○ Behavioral and biological measures (determinants)
● Have observed 3 generations of people
● Conclusion: led to the identification of the major CVD risk factors

Recommendations for Measuring Population Health:

● Morbidity and mortality are presented as rates
● Life expectancy from birth or age-adjusted mortality rates
● Condition-specific mortality rates
● Age-specific mortality rates

Current way we measure “health”:

● Objective
○ Death (mortality)
○ Illness (morbidity)
○ injury/disability
○ Disability-adjusted life years (DALY)
● Subjective
○ Quality of life
○ Healthy days of life
○ Psycho-social measures

Why Measure?
● Track diseases, conditions
● Monitor health and quality of life
● Identify opportunities for prevention and protection
● Create “surveillance systems
● Distributions of resources
The Epidemiologists Technique: P.E.R.I.:
● Problem
○ Who, what, where
● Etiology
○ Why (causes)
● Recommendations
● Implementation

Measuring Health and Disease:

● Medical model used to describe illness
● Rate = a measure of some event, disease, or condition in relation to a unit of population
● Death rates- mortality or fatality rates often expressed as # of deaths per 100,000
● Adjusted rates- statistically adjusted for certain characteristic
○ Used to make populations more comparable
● Crude rates- rate for an entire population without an adjustment
● Specific rates- rate for a particular subgroup
○ Can tell where a disease typically lies
● Incidence rate- number of new cases of a disease in a population
○ Know how active a disease is in a population
● Prevalence rate- proportion of a population that has a disease
● Attack rate- a special incidence rate for a single disease outbreak

Epidemiologic Terms:
● Endemic- the constant presence of disease or infectious agent within a geographic area
● Epidemic- the occurrence of a disease in excess of normal expectancy
● Pandemic- an outbreak of a disease over a wide geographical area, such as a continent

Current Event: Biden announced that companies would have to mandate COVID-19 vaccine
● Behavior: getting vaccinated
● Determinant: having a policy in place
● PH Issue: morbidity or mortality rates due to COVID-19
● Controversial/ethical concerns: taking away employee freedom to decide on vaccine;
company may receive incentive for following mandate

The causes Etiology of the PH Problem:

● Contributory causes tell how determinants cause an outcome
○ Established by looking at evidence over time
● i.e.) cholera disease and John Snow- longitudinal study
○ Finding the actual cause of cholera was not in the air but in the water
● Usually several causes will lead to one problem
● The determinant has to occur before we can see the outcome ( cause precedes effect)

Factors influencing health outcomes:

● Determinants can lead to other determinants that will lead to health outcomes
 ● Determinants = influences of health
● Behavior is powerful in changing health outcomes
○ Behavior has to change for outcome to change
○ “Bull’s eye” model- socioeconomic model
■ Has micro influences (small parts that influence outcomes) and macro
influences (conditions that create conditions for micro i.e. environment)
■ Micro has modifiable and nonmodifiable
● Behavior is modifiable
■ Macro influences micro
● i.e.) Vaping
○ Micro: modifiable behavior
○ Macro (closest >> broadest): family member smoking create social norm, smoke
break concept, create law to ban vaping, raise price of vapes
○ Vaping companies were targeting younger generation

Health Influences:
● 4 main types
○ Heredity
○ Social/physical environment
○ Access to health care services
○ Behavior (54%)
■ Plays an enormous role in health determinants

Causes of preventable premature death (death before 80):

● Tobacco and lack of physical/dietary activity are main causes
● Tobacco was leading cause in 1990, but in 2010 diet/activity patterns was leading
causes (tobacco 2nd)
● People smoking less due to knowledge, more to go food, more sedentary jobs influence
leading causes

Multicausation Disease Model:

● Another model that explains the influences on health outcomes
● Similar to socioeconomic model

Epi & Evidence based PH:

● Consider these four things to determine the
● Strength
○ Measured with relative risk
○ Weak or strong association
● Dose response
○ The more you do something, the more likely you will have a health outcome
● Consistency
○ Repetition of actions leading to same outcomes
● Plausibility
Relative Risk:
● Measures how likely a health outcome will occur when determinant exists vs. when it
does not exist
● i.e.) smoker is 10 x more likely to develop lung cancer than nonsmoker

Dose Response:
● Calculation that shows how occasional response can lead to more of a health outcome
● Moderation principle
● i.e.) the more you smoke, the greater your chances of lung cancers

Recommendations for Reducing/Eliminating the PH problem:

● Coming up with recommendations and seeing how effective they are

What steps do we take to Implement?

● Actually doing the work
● Hardest part because it involves people
● Are we reaching the right people?