Milestones in Public Health: Chapter 11

8/14/2019 Milestones in Public Health: Chapter 11

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)olm Adams, lilrsl'Colld prl!sidt'll/ 4II,e Ulliled Slalrs.

Firs! SIIpcrt' isill,f{ S/Irgcdll)0/111 Maynard~ M . l o d U i o r / 1 1 .

M I ! c , t o u ~ ' CfUpI.:r II US Public J k ~ l t h Inti"J


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,21 4 ; : ' ( ' > r II us Publl, H ~ , l l { h I l l f r " ' t T U c { u r ~ Lookm;: 1I" k

epidemic disease. J3ased on this definition of public health,it could be expected that the first local and state healthde partments would arise during a yellow fever ou tbreakthat terrified the ne w na tion between 1793 and 1806. JIl

Yellou) fever epidemic ill Philadelphia, 1793. Carriages mmbled throlli?ltthe streets 10 pic/': lip tile dyill,\! lind the dead,fact, the first Goard of H ealth was established in Phila-delphia lt 1 1794, followed by 13altimore in [797, BostOn II I1799, Washington , D. c., in 1802, New Orleans in 1804 ,and New York City in 1805... . Once the yellow fever outbreak came under control,public and budgetary support for these newly formed localboards of health also dimlll ished. In terest in public healthremained quiescent until 1830, when N ew York Citycitizens formed a Civilian group known as the "sanitaryreformers" in response to a cholera outbreak. T he r e f o r m ~ ers pressured public officials to take their public healthresponsibilities seriously and improve the city's livingconditions.Fee and Brown further explalll that from 1857 to 1860 thesanitary reformers held "Sanitary Conventions ." Duritlg theCivil War, the group persuaded President Abraham Lincolnto create a Sanitary Commiss ion to investigate conditionsamong the Union Forces and take measures to improvesanitation and health interventions. One of the measurestaken by civilian and military authorities in tesponse to theSanitary Commission's pressure was improved sanitation

,Once the yellowfever ou tbreakcame under c o n ~ trol, public andbudgetary sup por tfor these newlyformed localboards of healthalso diminished.


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,By the 1870s,most major citiesh:ld Illstitutedsome form ofpublic healthorgalllzauoll.

:llllong the troops. Another critical measure - educatingofficers ,1l1d enlisted men - taught the closely confinedtroops about the spread of infectious diseases and the needfor personal and pllblic hygiene. After the war ended,Sanitary Commission measures continued il l Ne w York,Chicago and Massachusetts, creating a record of success(or the first effective boards of health. I3y the 18705,most ll1;ljor ci ties had instituted some (orm of publichealth organiz;ltion.Adv:lllClllg III 11lSto ry to the New Deal years in the 1930sand, ag;liIl. visi ting the Public H ealth Service, as it becameknown in 1912. Congress heeded President Fr:ll1klinR.oosevelt and, in response to the Great Depression, createdth .. wclf:lrc srare. Thl" Public Health Service benefited fromsupport in Congress ;lI1d expanded greatly during the NewDeal years. With the Soci:J.1 Security Act of 1935, Congressestablished soci:ll in5ur:J.tlce :J.nd c:lsh :J.ssist:lnce programsthat Improved the public's he:llth by e]]Suring income

PrIsiril'lll nouscvclt s(\!.lIi/lX lir( Sl(i,,/ Srmrily Art.security for groups at greater risk of poverty :lnd disease.Much bter, in 1965, Congress enacted t he McdiC:J.re :J.ndMedicaid prog rams. expanding soc ial insurance. Medicareand Medicaid broadened significantly the role tbat thefederal government plays in addressing he:J.lth care issuesfor the needy.


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216 .\1,k'I"'" ('h.'ptcr II Us Puhllc He,lth Jnt,."tru,tun L{l"k",1': JlJ,k

The consolidation of the modern federal public healthestablishment came in the mid-20th century. In 1930, theRansdell Act established the National Institutes of Health,which have evolved into the current well-funded enginefor biomedical research and t raining throughout the UnitedStates. In 1946, the Centers for Dise ase Control (known asthe CDC) was formed from the Office of Malaria Controlin Wa r Areas and became part of the Public H ealth Service,significantly expanding the federa l governmem's publichealth responsibilities.In 1953, the federal public health and social welfare functions were consolidated into aile cabinet-level de pa rtment,the Department of Health, Edu cation and Welfare. T hisnew department housed virtually all of the federal agencieswith public health responsibilities that had evolved sincethe Civil War, in cluding the M edicare and Medicaid programs. [n 1979, when a new Department of Educationwas formed, the newly named Department of H ealth andHuman ServIces (D H HS) became the home of federalhealth and so ci al services prog rams.Today the nation's public heal th systcm is a complex network of people, sys tems and organizations working at thelocal, state and national levels. The U.S. public healthsystem is distinct from other parts of the health care systemin two key respects: its primary emphasis is preventing disease and disabili ty, and it focuses a ll population rather thanindividual health.Uoth the public and private sectors play important roles inpublic health. The nation is served by more than 3,000county and city health departments, 3,000 local boards ofhealth, 59 state and territorial health departments, andmarc thall 160.000 public and private laboratories. A se riesof fede ral health and envIronmental agencies set nationalstandards and provide funding, training, sc ientific guidanceand technical support.Hospitals, clinics, managed care organizations, civ ic andvolunteer groups, and national associations suppOrt thework of local, state and federal public health agencies. Th eassociations include the National Association of Countyand Ci ty Health Offic ials (NACCHO), the Associationof Sta te and Territorial Health Offic ials (ASTHO), theAssociation of Public H ealth Laboratories (A PH L), the

,The U.S. publicheal th system isdistinct fromother parts of thehealth care systemin two keyrespects: its p r i ~ mary emphasis ispreventing diseaseand disability, andit foc uses on p o p ~ ula tion ratherthan individualhealth.


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,T he gove rn mentalportion of thepublic healthworkforceincludes 448,754professionalsdeployed at thelocal, state andnat io nal levels.

National Association of Local l30ards of Health (NAL I30 1-l),the Council of State :ll1d Tcr ritori:tl Epide miologists (CSTE)and the American Public Health Association (APHA).Although these components :lTe numerous, the publichealth infrastructure is but one piece of a larger publicht'alth system. T he syStem depends on three interrelatedcomponents: the capacity an d COlnpetcncy of the w o r k ~ force, information and data systems, and organization;!]cap:lcity. Deficiencies in one area can have a ripple effectthroughollt the entire public health system.Wo r kforce Capac i ty an d CompetencyWorkforce capacity and competency refers to the expt'rtiseof professionals who work in federal, state and local publichealth agencies to protect the public's health. Thegovcrnmcntal portion of the pubhc health workforceincltldes 448,754 profess ionals deployed at the local, st:J.teand n:J.tionallevels. At the local level, public he:J.llh workersare found in local health :J.genc ies and in pr ivate and nonprofit o rganiz:J.tiolis concerned with the public's hC:J.lth.The most commOil professiollal disciplines withill theU.S. public health workforce are nurses. phys icians.environmental specialists, laboratorians, health educators,disease investigato rs, outreach workers and managers.Public health also includes dentists, soc ial workers, 1ll1tri-tionists, anthropologists, psychologists, econom ists, politicalscientists, engineers, information technology specialists,public heal th infol'maticians, epidemiolog ists, biostatisticiallSand lawye rs. Any professional whose primary fUllctioll is toimprove health can be considered part of the public healthworkforce. However, it is wo rke rs in official public healthagencies wh o are on the front lines in t racking diseasetrends, implementing comlllunitywide he alth pro motionan d disease-prevention programs, and responding toemerg ing threats and outbreaks.T he fedetal government has traditionally supponed a var i-ety of programs to enhance public health workforce capacity. For example, grant programs at the Health Resourcesand Services Administration (HRSA) are devoted to publichcalth professional developmcnt and ttaini ng. Over thelast decade, CDC has also provided va luable ttainingopportun ities for state and loc:J. l public health le:J.ders and


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'. , 218 ' M l l e ' t o l l ~ ' C h " p t ~ r 11 US Public Health lnfra>trtl(tllf


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,Although federalagencies take thelead in collecti ngnational publichealth data, theyrepresent only afraction of themany necessarypartners that co llect, analyze andtranslate thesedata.

person:ll environment and O c c u p : l t o n ~ t 1 risk f:lc tors; onpreventive :l11d tTC:ltlllent services; :llld on program costs.Data from these systcms can assist prevention efforts byfunctioning as early-warning signals for new and emergingconditions. Data systems also t:1c ili tate pl :l11ning, as publichealth agencies use data on disease prevalence to developprevention programs.

Although federal agenc ies take the lead in collectingnational public health data, they represcnt only a fraction ofthe many necessary partners that collect, analyze and translate these d:ua. Programs II I each area collect inform:nionfrom local communities. Other d:lta-c o llection systemsdepend lIpon the participation of private citizens nationwide. Still other systcms rely on the administrative recordsand Surveys of public and private health care organizations.Despite advances in technology. many loca l health de partments still lack access to basic information-system capabil ities. Access is critied becausc st:ltC and local public he3lthdepartment stam need the Internet 3nd other elt-ctronicillfof11l3 tioll systems to pe rform their job fun ctions effectively. Similarly, it is essential that staff be tra ined ro usethese systems. 111 1999, to address this issue. the CDC partnered with local and state health agencies, as well as national public he:llth organizations, to develop the Health AlertN etwork (HA N ),:l natio nwide , integrated information 3ndcomm uni cation system cap:lble of distributing he:l lth :lIe ns,prevention guidehn es and other information. In 2000, theCDC laullched 3nother program, the Nltioll:J1 Elec tronicDisease Surveillance System, to provide n:ltionaJ st:lndards,specifications,3nd workin g prototypes so that infor1l13tioncollected by loc31 health departments can be used to detect:tlld m3nage outbreaks th at affect more than one 3rea.Orga ni zational CapacityOrg:lnizational ca pacity is the structure and mechanisms 0 11which a functioning public health system relies - its facilities, laborarories and fin:lncing mechanisms. In order toperform activities 3nd provide services that safeguard thehealth of 3 community, public health departments and laboratories must have modern t:1Ci lities, adequ3te financing,sliccessful partnerships with institutions in both the pllblicand private sec[Qr, properly tr:tined persollnel and up- rodate information systems.

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220 M,Ie'tOn


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'. ' . 221

Enhance cOllltllunication within this expanded publichealth system. D

Essentia,1 Public H ealth Functions*1. Monitor health sta tus to identify community health

problems.2. Diagnose and investigate health problem s and

health hazards in the community.3. Inform, cd uca te and empowe r peopl e about hea lth

Issues.4. Mobilize community partnerships to identify and

solve health problems.5. Develop policies and plans that support individual

and commUf1lty health effor ts.6, Enforce laws and regulations that protect health and

cnsure safe ty.7 . Link people to needed personal health se rvices and

assure the provision of health ca re \Vhen it is o therw ise unavailable.

8 . A,sure a compctcilt public health and personalhealthcare \Vorkforce.

9. Evaluate the effectiveness, accessibi lit y. and qualityof personal and population-based health services.

10, Research new insights and innovative solutions tohealth problems.

' I'rom 1"""0"'.


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Case StudyThe Creation of CDCThe Communicable Disease Center (CDC) opened inthe old Office of Mabria Control in War Areas in Atlanta,Georg ia, on Ju ly I, 1946. As a part of the U.S. PublicHea lth Service, the original C DC mission was to workwith state and local health offic ials in the figh t :tgainstmalaria, then sti li prevalent in several Somhern states,as well as typhus and other comlllunicable diseases. ItsfOllndcr,Josepb W. Mountin, MD , a visio nary public

Dr.JM(!plr Mouutiu, thirdfrolll Ip . men;".!! with CDC s/affrr.


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During the first years of CDC, medical epidemio logistswere scarce. It was nor umil 1949 that Dr. Al exanderLangmuir, no w known as rhe f:1 ther of infectious diseaseepidemiology, arrived to head the epid emiology branch. Helaunched the first-(:ver disease sur veillance program andco nfirmed hi s sllspicions tbat malaria co ntrol. the largestpart of rhe C D C budget, had lon g since become unn ecessa ry. Subsequently, disease sur vei ll:l.1l ce becal1lt" the co rn erstone of C D C "s mission of se rvice and. in time, ch:mgedthe practice of public health . Langmuir was C D C's chiefepidemiologist from 1949 to 1970 . He spellt the rest ofhi s life teachin g at Harvard Medi ca l School and at John sH opkins, where he had earned his degree in public ht"alth .In 1993. he died of kidney cancer at the age of83.Wo rld events also had an impact on C D C 's miss ion. III1950, the start of the Korean War gave illlpetus to creat ingthe Epidemic Int elligence Service (E1S ). With the threa t ofbiological warf:1re looming , Langmuir wanted to train epi dem iologists to detec t new emergin g agents and at thesam e time gua rd against cO lllmon threa ts to public health.In 1955, CDC broadened its focus to include poliomyelitis(po lio) and established the Polio Surveillance Unit.Two major health crises in the mid- 1950s ccmentedCDC's crcdibility and long-term survival. In 1955, afterpolio :lppea red in ch ildren wh o had rece ived the Salk

Arr El5 ojjiCl'r usiu,(! rir(' muscle eva/ualiou leSlj.rr polio.vacci ne, only recently approved, CD C stopped thenational inoculation prog r:llll. The cases were traced tocontam inated vaccine from a laboratory in California;


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once the problem was corrected, the inoculation programresum ed. at least for first - and second -g raders. Two yearslate r, surveillance traced the co urse of a massive influenzaepidemic. From data gathered in 1957 and sub sequl:!lt years,national guidelines for influen za vaccine were developed.In the 1950s and 19605, C DC grew by acquisition. Thevc nereal disease program came to Atlanta in 1957 andwith it, the first Public Health Advisors. The tuberculosisand immunization programs we re moved under C D C's"umbrella" in 1960; and in 1961 , CDC took over publication of the Morbidit), alld Mortalit), Weekly Rep(lrl (MM WR).The MMWR , whi ch lists important data on deaths andcertain diseases from every state every week, is still pub lished evcry wcek and is considered an essential publichealth too!' The Foreign Qu:nantine Service, one of theoldest and mO st prenigious units of PHS. became part ofCDC in 1967. followed by the long-established nutritionprogram and the National Insriwte for Oc cupational Safetyand Hea lth.On e of C D C's grea tes t accomplishments, the worldw ideeradi cation of smallpox, was launched in 1966. TheSmallpox Eradication Program aimed to eradicate smallpoxand co ntrol measles in 20 African countries and supportthe worldwide efforts of the World Health Organization'ssmallpox crusade. The disease had killed millions of peopleover the centuries. 13y the late J970s, just over a decadelater, CDC efforts helped eradicate smallpox from theworld. CDC also achieved notable success at hOlTle tracking new emerging infections such as Legionnaire's disease,toxic-shoc k syndrome and hantavirus. More import:lntly,[he MM WR published the first report of a new :lnd f;mldi sease, acquired irlll11utlodefic iency syndrome (AIDS), inthe June 5, 1981, issue. DUfmg the 1990s and early 20005,CDC broadened its focLls to address chronic diseaseprevention and obesity.As C D C's activities expan ded in scope far beyondcommunicable diseases to include chronic disease controland health promotion, its name had to be changed toreflect a broader mission. In 1970, the name became theC enter for Dise ase Control. In 1981, after extellSive reorganizatio n, "C enter" became "C e nt ers." In 1992, th e words"a nd Prevention" were added, but by law, CDC retainedits well- kno wn three - letter abbrev iation. a

Dr. Slali FOSle r EISofficer, ai/millis/aiIlSslIIallpo.\" vlIccinr /0,/ N igeriall II'PI/Jallill '1967.


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M I I ~ s ' o n c , Ch"p,n 11 U.::.. l'"hh( I kohh l l 1 f " b ' ' ' K ' ' ' V I ! ( n c l ! ~

VignetteSurgeon General's Report of 1964More than 40 years ago on January 11, 1964, Luther L. Terry, M D,Surgeon Gem: ral of the U.S. Public Health Service, released thereport of the Surgeon General's Advisory Commi ttee on Smokingand Health. This landmark document, now referred to as the first5urgeol/ GCI/I'ra/'s Rcport Oil 51110kill}; alit! I-lea/rll, had a tremendousimpact on pllblic attitudes and policy for three important reasons.First , an official U.S. agency recognized for the first time that cigarettesmokin g caused cancer and other seriOllS diseases. Secon d , it prompted a series of public health actions reflecting changes in societalatt itudes toward the health hazards of tobacco usc. Third, the SurgeonGeneral's report was the first to rece ive widespread media and publicattention. Although evidence that smoking caused harm had acculllu lated since the 19305, official sources did no t recognize the ill effectsat rhe time. Epidemiologists used statistics and large-scale, long-termcase control surveys [Q link the increase in hm g cancer mortality tosmokin g. Pathologists and laboratory sc ientists confir med the statistical relationship of smoking to lung cancer as well as to other seriousdiseases, such as bronc hitis, emphysema and coronary heart di se ase. In1957, then- Surgeon General Leroy E.13urney declared as the officialposition of the U.S. Public Health Service dut smoki ng causedlu ng cancer.The impulse for an official report 011 smoking and health did notcome until 1961, however, pushed by an alliance of pro min ent privatehealth organizations. Th e American Cancer Society, the AmericanHeart Association , rhe National Tuberculosis ASSOC iation, and theAmer ican Public Health Association called for a national comm issionon smoking In a letter addressed to President John F. Kennedy. Th eletter sought a commission dedicated to "seekin g a solution to thishealth problem that would interfere least with the freedom of indllstry or rhe happiness of individual s."Th e Kennedy administration responded the following year. In 1962,recently appointed Surgeon Ge neral Luther L. Terry announced thathe would convene a co mmittee of experts to conduct a co mprehensive review of the scientific lite rature on the smoking question. Terryinvited representatives of the fOllT voluntary medical organizationswho had first proposed the commission, as well as the Food andDrug Administration , th e Federal Trade Commission, the AmericanMedical As sociation , and the Tobacco Institute (the lobbying armof the tobacco industry) to nominate ten commission members.

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226 M ! I ~ j l O l l ~ I ' C l " ' I " ~ r 11 U.S, Publoc k ~ l t h J " r " ! l r " c u , , ~ ' Vlguenc

From November 1962 through January 1964, the committeereviewed more th:m 7,000 scientific articles with the help of morethan 150 consul tants. T he advisory committee concluded that cigarerre smoking caused both lung canc er and chronic bronchitis. Thecommittee recognized for the first time, officially, that "cigarettesmoking is a health hazard of sufficient importance in the UnitedStates to warrant approp r iate remedial action."Th e 1964 Surgeon General's repon became the first of a seriesof steps to reduce the impact of tobacco lise on the health of theAm erican people. The circumstances surrollnding the release ofthe first report 111 !964 were peculiar. Surgeon General Terry Issuedthe commiss ion 's report on a Saturday, a strategy meant to minimizethe effect on the stock market and maximize coverage in the Sundaypapers. "This sttategy succeeded,"Terry remcmbered two decadeslater, "because the report hit the coumry like a bombshell. It wasfront-page news and a lead s[Qry on eve ry radio :l.Ild televisionstation in the United States and many abroad."Among the steps that followed the report were banning tobaccoadvertising on broadcast media, placing mandatory health warningsall cigarette packages and developing effective treatments for tobaccodependence. The Office of the Surgeon General has issued 27 subsequent reports on tobacco lise, cove rin g such topics as environmental(i.e., secondhand) tobacco smoke. These reports helped lead the wayto smo ke-f ree public places, restaurants and bars .The widespread media and public attention led to significant ch angesin public attitudes toward smoking. A Gallup survey conducted in1958 found that only 44 percent of Americans believed smokingcaused cancer; that figure grew to 78 percent by 1968. l3 etween 1965and 2002, adult smoking rates have been cut from 42.4 percent to22.5 percent, nearly in half, and per-capita consumption of tobaccoproduccs has fallen from 4,345 cigarettes in 1963 to 1,979 ciga rett esin 2002, marc than half.Th e 1964 Surgeon General's report was significant because it markedthe first of a series of authoritative sc ientific statements by theSurgeon General that helped shape the debate on the responsibility ofgovernment , physicians and individual citizens for the nation's health.Ind eed, Surgeon General's reports since 1964 have addressed a br03drange of he3lth issues. Th ese include secondhand smoke, maternal andchild health, nutrition and physical exercise, mental health, and issuesth:\( he outside medicine. stich as suicide and gun violence, that arestudied for how they affect public health. 0


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. " . , ~ . . - . " ~ " ~ - ~ ' - r , - ." . , - , . .,. . M , I ~ , w l l c , ('h31'l


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CDC and public health authorities became aware of thethreat of domestic bioterrorism after several small acts offocused bacteriologic criminal assault in the United States.These acts included the intentional comamin:nioll of sa ladbars with Sfdmo"ellil organisms in 1984 in Oregon and ofmuffins and pastr ies with Shigella organisms in Texas in 1996.As a result, the United States government decided to revisitand update a national plan for bioterrorism preparedness andresponse. In 1999, as part of this strategy, C DC collaboratedwith the Association of Public Health Laboratories and theFederal 13ureau of Investigation to es tablish the LaboratoryResponse Network.This network d e l o local, state andfederal publ ic he:tlth laboratory capacity to respond tobioterrorisl11 events.

AII/hm.\' was spread Ihrm/.r:/1 IIII' pos/1I1 sys/rlll i/l Ihe fall (1 200 I.Only in the f:111 of 200 I were CDC's bioterrorism plansput imo action, in response to an anthrax attack in the U.S.At a time of heightened tension due to the events of Sep-tember II , lette rs co ntaining anthrax powder spread thi sinfectious disease deliberately through the postal sys tem;22 people were infected and five people died.

Li fes ty le an d Be hav ior C hangeWhile this century's medica l advances and publi c healthefforts have dramatically reduced the threat of in fectiollSdisease in the U.S., poor hC:llth due to lifestyle behaviorsremains a threat co public health. Poor lifestyle behaviorsarc linked to chronic dise ases, the heaviest burden on the


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'. . ' 29CDC /)ire(/urJulie L. Grrbadillg

. . . .,. .health care sys telll today. These behaviors involve tobaccotlse. alcohol and drllg abuse, lack ofheahh y diet :ll1d exercise,and risky sexual practices. [n p:micular, poor Ilutrition and asedentary lifestyle arc considered by some experts to be "the21st century plague" as they lead to obesity and diabetes,now considered national epidemics. They also contribute toa host of other serious medical problems, such as heart disease and cancer - the two leading causes of death in the U.S.Public health professionals know that promoting healthybehaviors is one of the best ways to prevent disease anddisability. Consequently, many public health activities aredesigned to help individuals and communities acbieve andmaintain a healthy lifestyle at ally age. For example, CDClaunched a campaign called VERB (to connote action) in2002 to fight childhood obesity, encouraging young peopleages nine to 13 to be physically active every day. The calllpaign combines paid advertising, marketing strategies andpartnership efforts to reach the distinc t audiences of tweensand a d u l ~ l i n f 1 1 1 t : : n c e r s . As CDC Director Dr. Julie L.Gerberding said. "The VERU camp:lign Ius sllrp:lssedexpectations and is responsible for improving physic;!1activity levels alllong youth." In February 2004, C DCreleased the results or a tdephone smvcy that indicate thatphysical activity aillong the nation's youth is increasing asa result of the VEIU3 campaign.C hronic-Di sease Prevention and Con t ro lChronic diseases. such as heart disease, strok e, diabetes andcancer, cause 70 percent of a[[ deaths in the Uni ted Stateseach year. A la rgt:: number or these deaths are preventable.People with chronic conditions are the largest, most cos tlyand f..1stest-growing grou p in health care, and their numbt::rsare expected to swell in the 21 St century.From specific laboratory measures to morc complex studi esof behaviors and risk ractors, CDC's efforts arc design cd tounderstand the causes and consequences of chronic disc:lsesand to place the powerful cools of prevention within reachof more people every day. Moreover, CDC works to ensurethat :ldvances in basic scientific and be h:lVioral research areput into practice to benefil all Americans. As p:lrt or its mission, C DC works with states to develop comp rehensive, sustainable prcvcmion programs that target the leading causes of


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death and disability in ou r soc iety and the ir risk factors. [naddition, numerous efforts to manage chronic disease, alongwith social marketing campaigns, changes in food (such asremoval of trans f..1tS) and a new food pyramid have gainedan increasing role ill ch roni c-disease prevention. Newapproaches to prevention afe cruc ial to fight chronic diseasesin th is century.Infectio us Diseases an d Em e rg in g ThreatsDespite incredible gains in combating infectious diseases,they remain a public hea lth concern in the 21sr century.Infectious diseases are the third leading cause of death inthe United States and still predominate worldwide, withacute lower respiratory tract infections, 1-1 IV / AIDS, diarrhealchseases, tuberculosis and malaria as the major threats.Although the combination of improved hygiene an d sanitation, v:lccinations and antibiotics has helped turn the tide:lgainst infectious dise:lses in this country, new diseases :lndthe resurgence of old ones make infectious diseases a con-stant concern. Emerging lIlfections are those that h:lYCnot been previously recognized. .. Th e AIDS p:lndemicis an eX:lmple of:l truly new and emerging infectiollS d iseasewhose public health impact had not been previously exper ienced . On the other hand, infections that have beenexperienced previously reappear in a more virulent form01" in a new epidemiological setting. The influenza type Apandemics of 1918,1957 and 1968 are exam p les of thi s.Global air travel, now widely available and affordable,introduces infected travelers to the U.S. with diseases thatol1ce might have stayed overseas. For example, severe acuterespiratory syndrome (SAR S) was first reponed in AS!:l inFebruary 2003. Over th e next few months, du e to global airtravel, the illness spread to more than two dozen countries inNonh America, South America, Europe :lnd Asia. Accordingto the World Health Organization (WHO), a total of 8,098people worldwide became SIck with SARS during the 2003outbreak. Of these, 774 died. In the United States, only eightpeople had laboratOry evidence of SARS infection and all ofthem had been traveling in other coumries where SAlt.S hadbeen identified. Fortunately, C DC worked closely with theW H O and other partners in a global effort to address the

,The AIDS pandemic is all exam-ple of a truly newand emerginginfectious diseasewhose publichealth impact hadno t been previously experienced.

... " < '" ... ,). . .


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,CDC continues itswork of increasingthe capacity oflaboratories andsur vei !l,mce sys-tems here andabroad to detectand monitorchanges in diseasepatterns and toserve as :tn C3rly-warning system.

Paramedics d u r i ' I . ~ Ihe SA RS oil/break ill 7(mmlo.SARS outbreak of2003, preventing SARS frolll spread in gmore widely in the United States.

CDC continues its work of increasing the c:lpaci ry oflaboratories and surveillance sys tems hert' and abroad todetect :Hld mOnitor ch:ll1ges in disease patterns and to serveas an early-warning system . For example, stlrveill:1l1ce centersin both the U.S. and Asia monitor the ever-present th reatof inf1t1cnza pandemics. CDC also continues to wo rk withpublic and private panners to ch:lll ge the way antibiotics areprescribed and used in hospitals and other settings. CDChelps form working teams that link epidellliolob'Y, partnerships, edu cat ion of health care providers and patie nts, andvector control to counter the spread of specific infectiousdisea$l' threats. These threats range from sexuall y rransJllirreddiseases, like syphilis and chlamydia, to bloodborne threats,like hepatitis C. The teams help control existing infectiousdisease t h r e a t . ~ and prepare the nation for new o nes.Meeting the challenges of in fectious d iseases in the 21 stcentury means tha t the scientific and technological advancesthat forllJ the foundation of a public health respollSc mustevolVl' quickly an d continu:tlly. As former C DC director Dr.Jeffrey Kaplan observed in th e 2002 [O M R.eport, "We areo nly as prepared as the least prepared among us." []

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232 M,le.!o"" Ch.'plef 11 US Puhhc H".dth lufn'!ructu ...

Photo " ,ediUI ' ~ s e 213:John Adams. c o u r t < ~ y l ,bn,y dCong ....~ s , I'rum ~ n d I ' h o t ~ r a p h s I1,VI

Milestones in Public Health: Chapter 11

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