EDITOR S

ELENA ANDRESEN ERIN DEFRIES BOULDIN

Concepts and Practices

Public Health Foundations

Public HealtH Foundations

Public HealtH Foundationsconcepts and

Practices

elena andReseneRin deFRies bouldin

Copyright © 2010 by John Wiley & Sons, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Public health foundations : concepts and practices / [edited by] Elena Andresen, Erin DeFries Bouldin. p. cm. Includes bibliographical references and index. ISBN 978-0-470-44587-7 (pbk.); ISBN 9780470890165 (ebk.); ISBN 9780470890172 (ebk.); ISBN 9780470890189 (ebk.) 1. Public health–United States. I. Andresen, Elena. II. Bouldin, Erin DeFries. RA445.P834 2010 362.10973–dc22 2010036301

Printed in the United States of America

first edition

PB Printing 10 9 8 7 6 5 4 3 2 1

To my husband.EMA

To my husband, mom, and dad.EDB

Figures and Tables ix

Preface xv

The Editors and Contributors xix

Introduction xxiii

Part 1: History, Development, and Organization

Chapter 1: History and Development of Public Health 3

Chapter 2: Modern Public Health Systems 25

Part 2: Analytic Tools and Methods

Chapter 3: Data for Public Health 51

Chapter 4: Epidemiology: Introduction and Basic Concepts 73

Chapter 5: Study Design 95

Chapter 6: Biostatistics 139

Chapter 7: Pharmacoepidemiology 161

Chapter 8: Infectious Disease Epidemiology 177

Chapter 9: Environmental Public Health 197

Chapter 10: Risk and Exposure Assessment 231

C O N T E N T S

viii CONTENTS

Part 3: Behavior and Health

Chapter 11: Social and Behavioral Sciences in Public Health 267

Chapter 12: Qualitative Data and Research Methods in Public Health 299

Chapter 13: Tuberculosis 321

Part 4: Health Services and Social Determinants

Chapter 14: Health Policy and the U.S. Health Care System 349

Chapter 15: Health Services Research 367

Chapter 16: Health Disparities 387

Part 5: Forecasting Public Health

Chapter 17: Future of Public Health 417

Glossary 449

Index 507

Figures

Figure 1.1 Timeline of Major Developments in Public Health History 5Figure 1.2 Core Public Health Disciplines 16Figure 2.1 Public Health Core Functions and Ten Essential Services 29Figure 2.2 Levels of Influence 31Figure 2.3 Multiple Determinants of Health 33Figure 3.1 Prevalence of Disability Among Women Age 16 to 64 by

County in Florida, Census 2000 55Figure 3.2 Example of a Death Certificate, Orville Wright 57Figure 3.3 A United States Standard Death Certificate 59Figure 3.4 Lung Cancer Epidemic in the United States 1975–2006 60Figure 3.5 Percentage of Infants Born Preterm or Low Birth Weight,

United States 1990–2004 61Figure 3.6 Prevalence of Adults Classified as Heavy Drinkers in the

United States, by State 63Figure 3.7 Youth Risk Behavior Survey, 1991–2007 64Figure 4.1 Prevalence of Obesity (BMI ≥30) in the United States in

1990, 2000, and 2008 78Figure 4.2 Prevalence of Obesity (BMI ≥30) in the United States by

Race and Ethnicity, 2006–2008 79Figure 4.3 Infant Mortality Rate (Death in the First Year of Life) per

1,000 Live Births for the United States, 1995–2005, by Race and Ethnicity 81

Figure 4.4 Infant Mortality Rate (Death in the First Year of Life) per 1,000 Live Births for the United States, 2000–2006 81

Figure 4.5 Crude and Age-Adjusted Death Rates: United States, 1960–2005 83

Figure 4.6 John Snow’s Cholera Mortality Map from an 1848 Outbreak in London 92

F i g u r e s a n d T a b l e s

x LIST OF FIGURES AND TABLES

Figure 5.1 Major Types of Study Designs Within Epidemiology 96Figure 5.2 Prevalence of Spina Bifida and Anencephaly at Birth in the

United States from 1995 to 2005 and Phases of Folic Acid Fortification of the Grain Supply 101

Figure 5.3 Generic Cross-Sectional Study Design Showing the Various Points in Exposure or Disease Process at Which Individuals May Be Surveyed 104

Figure 5.4 Generic Scheme of Cohort Study Design in Which All Participants Are Free of the Outcome at the Beginning of the Study 105

Figure 5.5 Generic Scheme of a Case–Control Study Design in Which Participants with and Without the Outcome Are Identified (Cases and Controls, Respectively) 114

Figure 6.1 Histograms of Baseline CD4 Count in the Non-Zidovudine Group (Top) and in the Zidovudine Group (Bottom) 149

Figure 7.1 The FDA Drug Development Process 164Figure 7.2 Causal or Not Causal Relationships in Confounding 172Figure 8.1 Koch’s Postulates 179Figure 8.2 Diagram of the Chain of Infection 180Figure 8.3 Epidemic Curves Illustrating a Point Source Outbreak, a

Common Source Outbreak, and a Propagated Outbreak 181Figure 8.4 Cases of Polio Before and After Introduction of the

Inactivated and Live Oral Polio Vaccines 184Figure 8.5 Smallpox Pustules on a Child 185Figure 8.6 Artist’s depiction of Edward Jenner inoculating James Phipps

with cowpox virus isolated from Sarah Nelmes’s hand. Edward Jenner (1749–1823) Performing the First Vaccination Against Smallpox in 1796, by Gaston Melingue (1840–1914) 188

Figure 8.7 Photograph of Ali Maow Maalin, the Last Person to Have Naturally Acquired Smallpox 189

Figure 8.8 Photograph of a Child Receiving Oral Polio Vaccination 190

Figure 8.9 Dracunculiasis Life Cycle 192Figure 9.1 Relationship Between Host, Environment, and Interaction in

Infectious Disease 201Figure 9.2 Map Showing the Location and Source of Various Emerging

or Reemerging Infectious Zoonotic Diseases Worldwide 204Figure 9.3 Estimated Rate of Emergency Department Visits with Asthma

as the First Diagnosis by Age and Year 210

xiLIST OF FIGURES AND TABLES

Figure 9.4 Estimated Rate of Hospital Discharges with Asthma as the First Diagnosis by Age and Year 211

Figure 9.5 Universal Symbol of Radiation Warning 220Figure 9.6 The Comparative Strength of Three Forms of Ionizing

Radiation: Alpha Particles, Beta Particles, and Gamma Rays 221

Figure 10.1 Components of Risk Assessment, Considered in Their Physical and Social Context 235

Figure 10.2 A Simplified Schematic of the Mechanisms of Urinary Excretion and Oxidative Metabolism of Toxicants 237

Figure 10.3 The Typical S-Shaped Curve Produced by Animal Studies for Non-Cancer Effects 241

Figure 10.4 Typical Results of an Animal Study for Cancer Effects 244Figure 10.5 Exposure Is Defined as the Product of Concentration and

Time at Any Given Instant 247Figure 11.1 The Health Belief Model 275Figure 11.2 The Theory of Planned Behavior 277Figure 11.3 The Stages of Change Model 278Figure 11.4 Social Networks Are a Web of Social Relationships 282Figure 13.1 Chest X-Ray Showing Tuberculosis Infection 327Figure 13.2 Estimated Incidence of Tuberculosis by Country, 2007 333Figure 14.1 The Growth in Health Expenditures in the United

States 353Figure 14.2 Managed Care Versus Conventional Insurance in Employer-

Sponsored Health Plans, United States 1988–2008 356Figure 15.1 Model of Access to Personal Health Care Services 369Figure 15.2 Total Rates of Reimbursement for Noncapitated Medicare

per Enrollee 377Figure 16.1 Age-Adjusted U.S. Mortality Rates Due to Breast Cancer

Among Women by Race/Ethnicity, 1975–2005 394Figure 16.2 Age-Adjusted Prevalence Trends for High Blood Pressure in

Adults 20 Years of Age or Older in the United States by Race/Ethnicity, Sex, and Survey (NHANES: 1988 to 1994, 1999 to 2004, and 2005 to 2006) 396

Figure 16.3 Prevalence of Obesity (Body Mass Index ≥30 kg/m2) Among U.S. Adolescents by Ethnicity, Using National Longitudinal Survey of Adolescent Health, 1994–1996 Data 398

Figure 16.4 Relationship Between Access to Care and Use of Preventive Care and Chronic Disease Management Services 402

xii LIST OF FIGURES AND TABLES

Tables

Table 1.1 Number of Deaths and Crude Mortality Rate for Leading Causes of Death in the United States in 1900 12

Table 1.2 Number of Deaths and Crude Mortality Rate for Leading Causes of Death in the United States in 2000 12

Table 2.1 The Three Levels of Prevention 36Table 3.1 Examples of Information Available from Standard U.S.

Birth Certificates 61Table 4.1 Number of Deaths and Crude and Age-Adjusted Mortality

Rates in the United States in 1980 and 2005 82Table 4.2 Alcohol Consumption and Lung Cancer Diagnosis Among

1,000 Men Age 65 and Older 88Table 4.3 Alcohol Consumption and Cigarette Smoking Status

Among 1,000 Men Age 65 and Older 88Table 5.1 Generic 2 × 2 Table for Analyzing Epidemiological Study

Data 110Table 5.2a, b. Two-by-Two Tables with Data and Relative Risk (RR)

Calculations for a Hypothetical Cohort Study Investigating Whether Wearing a Seatbelt During a Crash (Exposure) Is Associated with Traumatic Brain Injury (TBI; Outcome) 111

Table 5.3 Number of Malignant Extrathyroid Tumors Among Individuals Irradiated for Enlarged Thymus During Infancy and Their Nonirradiated Siblings, Rochester Radiation Cohorts 112

Table 5.4 Number of Malignant Extrathyroid Tumors and Person-Years at Risk for Individuals Irradiated for Enlarged Thymus During Infancy and Their NonIrradiated Siblings, Rochester Radiation Cohorts 113

Table 5.5 Exposure Data for Male Controls in a Case–Control Study of Artificial Sweetener Use and Urinary Tract Cancer, Detroit, Michigan, 1978 116

Table 5.6 Generic Example of a 2 × 2 Table and Formula for Odds Ratio (OR) 118

Table 5.7 Hypothetical Case–Control Study of Maternal Illicit Drug Use and Birth Defects, Showing the Effect of Differential Misclassification Caused by Recall Bias on the Odds Ratio (OR) Estimate 119

xiiiLIST OF FIGURES AND TABLES

Table 5.8 Necessary Sample Sizes for a Given Effect Size Measuring the Relationship Between Hypothetical Contaminant X and Spina Bifida Using Various Study Designs 120

Table 5.9 Criteria for Assessing Causal Inference in Observational Epidemiological Studies 127

Table 5.10 Risk of Benign Thyroid Adenomas (Tumors) After X-Ray Irradiation for Enlarged Thymus Gland at Birth 131

Table 6.1 Descriptive Statistics for the TOHP Follow-Up Study 147Table 6.2 Analytic 2 × 2 Table for TOHP Follow-Up Study 147Table 6.3 Sensitivity Analysis in Terms of Descriptive Statistics for

the TOHP Follow-Up Study 148Table 7.1 Case–Control Study Results Comparing the Risk for

Myocardial Infarction or Sudden Cardiac Death in Patients Exposed to Rofecoxib or Ibuprofen to Remote Use of Pain Medications 167

Table 9.1 Examples of Environmental Exposure and Adverse Health Effects 212

Table 9.2 Examples of MCLs for Selected Contaminants on the National Primary Drinking Water Regulations (NPDWR) List 217

Table 11.1 Social-Ecological Levels and Their Targets of Change, Focus of Change, and Strategies 272

Table 11.2 Ten Strategies Used to Change Behavior 278Table 11.3 The Stages of Change: Definitions and Strategies 279Table 11.4 Stages of Communications Campaign Development,

Implementation, and Evaluation 292Table 14.1 Key Elements of Medicare and Medicaid 354Table 14.2 Competing Interests in the Health Policy Process 359Table 15.1 Selected Access Measures from Healthy People 2010 372Table 15.2 Institute of Medicine (IOM) Priority Research Areas 379Table 15.3 Health Information Technology (HIT) Applications 381Table 17.1 Millennium Project: Where Is Humanity Winning and

Losing? 421

Public health is all around us. It is in the air we breathe, the water we drink, the homes we live in, and the behaviors in which we engage. It includes our health care systems and the agencies and services that protect

our health and environment. Public health is a vital yet often overlooked com-ponent of modern life; most of us do not think about it as part of our daily lives. It may only receive public attention when a crisis occurs or when the public health system falters or fails. It may become an important personal focus when we need a specialized service, when we don’t have access to a private clinic, or when we face a neighborhood environmental concern. Public health encom-passes a broad range of activities and functions, but among its most important are promoting and preserving the health of populations through prevention. Prevention has several meanings or levels, as we discuss in the ensuing chapters, giving public health a breadth of purview uncommon to many disciplines. To address this breadth, the field of public health includes professionals from many backgrounds, including not only medicine and health professions but also sociol-ogy, microbiology, engineering, planning and development, marketing, and others. Public health even includes nonprofessionals; the entire public is part of the field because public health’s activities and its funding are largely determined by the will and the needs of the people. This focus on populations and on the public is reflected in the cover photo for this textbook.

Audience

In recent years, multiple public health- and education-related organizations have highlighted the need to create an educated citizen as part of general undergradu-ate training. In 2003, the Institute of Medicine called for the educated citizen to have a basic grounding in public health and for all undergraduate students to have access to a public health education[1]. The Association of American Colleges and Universities (AAC&U) began The Educated Citizen and Public Health

P r e f a c e

xvi Preface

initiative to help integrate public health into the liberal arts education programs offered at colleges and universities across the United States[2]. Partly as a result of this movement, undergraduate public health courses are becoming more common throughout the United States and elsewhere. This book is designed to meet the needs of undergraduate instructors teaching introductory public health courses, including upper-division undergraduate courses.

This book is designed to be flexible and accommodate a variety of intro-ductory public health courses. For a course targeting freshman or sophomore students, an instructor may choose to cover only the basics of each discipline, leaving aside the more in-depth chapters on study design, qualitative methods, and risk assessment, for example. Likewise, instructors could choose to cover the material in a different sequence than that presented here, using section headings as guides for similar content areas. The book is laid out in such a way that it follows the ten essential public health services[3], but other configu-rations would work equally well.

Content

In this book, we outline the history of public health, tracing the field from its roots in sanitation to its early endeavors to assure a basic level of education and services to all people. We then explore its more modern effort at quantifying health and intervening to improve the health of disadvantaged groups. Today, public health often is divided into five core disciplines: epidemiology, biostatistics, environmental health, social and behavioral sciences, and health policy and management. We have a chapter devoted to each of these broad subspecialties and also delve deeper into how public health is structured. We discuss quantitative and qualitative study designs, including a special look at pharmacoepidemiology, infectious diseases and tuberculosis, and risk management and communication. We end with a pro-jection of where public health is likely to go in the rest of the twenty-first century as we face new challenges and continue to address ancient issues.

Features

⦁ Learning Objectives Each chapter begins with a set of learning objectives to help students organize the material.

⦁ Introduction Following the learning objectives, each chapter provides an overview of the content to prepare students for the information to come and to link it to previous chapters.

xviiPreface

⦁ Public Health Connections Throughout the text, more detailed explana-tions and case studies content of interest appear in text boxes. These fea-tures not only link to the chapter’s content but also connect students to the practicality of the field of public health.

⦁ Summary A summary closes each chapter, providing a recap for students and emphasizing key content and themes.

⦁ Key Terms An indexed list of key terms is available in each chapter to bring students’ attention to important concepts introduced and also to assist them in locating these topics within the text.

⦁ Review Questions Each chapter’s review questions encourage students to apply new concepts to practical applications or to recall specific details of a model or concept.

⦁ References Resources used to construct each chapter are cited at the end of each chapter and provide a valuable link to both students and instructors looking for more information on a topic.

⦁ Glossary Brief definitions of all key terms used in the text are included as an appendix to facilitate students’ learning.

An overall goal of the textbook is to encourage the development of practical interpretation and problem-solving skills. In everyday life we must make deci-sions about what behaviors to engage in, what substances we are willing to ingest or inhale, and how to apply statistics and data about the relationship between various exposures and health outcomes. This book provides a framework through which to consider these decisions as well as a basic toolkit for synthesiz-ing information and delivering it to others.

References

1. Institute of Medicine. Who Will Keep the Public Healthy? Washington, D.C.: National Academies Press; 2003.

2. Association of American Colleges and Universities (AAC&U). The Educated Citizen and Public Health initiative Web page. Available at: www.aacu.org/public_health/index.cfm. Accessed March 10, 2010.

3. Public Health in America. Mission statement. Available at: www.health.gov/ phfunctions/public.htm. Accessed March 10, 2010.

Elena M. Andresen, PhD, is a professor in the Department of Epidemiology and Biostatistics at the University of Florida’s College of Public Heath and Health Professions. Dr. Andresen received her PhD in epidemiology from the University of Washington, Seattle. She also trained in health services research and was a pre-doctoral Health Services Research and Development fellow at the Seattle VA Medical Center. Dr. Andresen has taught Introduction to Public Health and Public Health Concepts together with Erin DeFries Bouldin, MPH, to under-graduates at the University of Florida since 2006. In addition, she has many years of graduate teaching experience, including epidemiology methods courses and disability epidemiology courses, both in the United States and abroad. Her train-ing and research interests include chronic disease epidemiology among older adults, disability epidemiology, and outcomes research in rehabilitation and disability.

Erin DeFries Bouldin, MPH, is a lecturer in the Department of Epidemiology and Biostatistics at the University of Florida’s College of Public Heath and Health Professions. She received her MPH in epidemiology from the University of Florida, Gainesville. Ms. Bouldin has taught Introduction to Public Health and Public Health Concepts together with Elena Andresen, PhD, to undergraduates at the University of Florida since 2006. Ms. Bouldin’s training and research interests include nutrition and maternal and child health, and her current work focuses on the health impacts of caregiving and improving the health and quality of life of Floridians with disabilities through the Florida Office on Disability and Health.

David Ashkin, MD, is the medical director and co-principal investigator of the Southeastern National Tuberculosis Center (SNTC), medical executive direc-tor at the A.G. Holley TB Hospital in Lantana, Florida, and Florida State TB health officer for the Florida Department of Health.

T h e e d i T o r s a n d C o n T r i b u T o r s

xx THE EDITORS AND CONTRIBUTORS

Alan Becker, PhD, MPH, is an assistant professor of environmental and occu-pational health at Florida A&M University, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health.

Lori Bilello, MBA, MHS, is a doctoral student in the Department of Health Services Research, Management and Policy at the University of Florida’s College of Public Health and Health Professions.

Babette A. Brumback, PhD, is an associate professor in the Department of Epidemiology and Biostatistics at the University of Florida’s College of Public Health and Health Professions.

Lisa R. Chacko, MPH, is a medical student in the School of Medicine at the University of Pennsylvania.

Sara A. Chacko, MPH, is a doctoral candidate in the Department of Epidemiology at the University of California Los Angeles.

Lisa Conti, DVM, MPH, DACVPM, CEHP, is the director of the Division of Environmental Health at the Florida Department of Health.

Barbara A. Curbow, PhD, is professor and chair of the Department of Behavioral Science and Community Health at the University of Florida’s College of Public Health and Health Professions.

Amy B. Dailey, PhD, MPH, is an assistant professor in the Department of Epidemiology and Biostatistics at the University of Florida’s College of Public Health and Health Professions.

Kendra Goff, PhD, is a toxicologist in the Division of Environmental Health at the Florida Department of Health.

Allyson G. Hall, PhD, MBA/MHS, is an associate professor in the Department of Health Services Research, Management and Policy at the University of Florida’s College of Public Health and Health Professions.

Stephanie L. Hanson, PhD, ABPP (Rp), is the executive associate dean of the College of Public Health and Health Professions at the University of Florida.

xxiTHE EDITORS AND CONTRIBUTORS

Vito Ilacqua, PhD, is a research assistant professor in the Department of Environmental and Global Health at the University of Florida’s College of Public Health and Health Professions.

JoAnne Julien, MD, is the deputy TB health officer for the Florida Department of Health, medical consultant for the Southeastern National Tuberculosis Center, and an adjunct assistant professor in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Florida.

Greg Kearney, DrPH, MPH, RS, is an epidemiologist in the National Center for Environmental Health at the Centers for Disease Control and Prevention.

Michael Lauzardo, MD, MSc, is the director of the Southeastern National Tuberculosis Center, deputy TB health officer for the Florida Department of Health, and chief of the Division of Mycobacteriology at the University of Florida.

Ellen D. S. López, MPH, PhD, is an assistant professor in the Department of Psychology and the Center for Alaska Native Health Research at the University of Alaska Fairbanks.

Cindy Prins, PhD, MPH, CIC, is an infection control practitioner at Shands Hospital at the University of Florida.

Sharleen Simpson, PhD, ARNP, is an associate professor in the Department of Women’s, Children’s, and Family Nursing at the University of Florida’s College of Nursing.

Sandra Whitehead, MPA, is an environmental health planner in the Division of Environmental Health at the Florida Department of Health.

Almut G. Winterstein, PhD, is an associate professor and director FDA/CDER Graduate Training Program in the Department of Pharmaceutical Outcomes and Policy at the University of Florida’s College of Pharmacy.

Mary Ellen Young, PhD, CRC/R, is a clinical associate professor in the Department of Behavioral Science and Community Health at the University of Florida’s College of Public Health and Health Professions.

Public health became a college discipline at the University of Florida in 2003 under the direction of the dean of the College of Public Health and Health Professions, Dr. Robert (Bob) Frank. The college was established

in 1958 as the College of Health Related Services and included occupational therapy, physical therapy, and medical technology. Today, the mission of the College of Public Health and Health Professions is to preserve, promote, and improve the health and well-being of populations, communities, and individuals. It is a unique environment in which faculty and students work across a variety of levels of prevention and research, from preventing hearing loss to improving function after a spinal cord injury and from basic science research to population level interventions. The college has a number of graduate programs, including a master of public health degree, and a large bachelor of health science degree program. To raise awareness about the new discipline in the college, Dean Frank suggested that an undergraduate level public health course be implemented and offered to both the bachelor of health science students and other undergraduates across campus. We were excited by this proposal and agreed to teach Introduction to Public Health (PHC2100) to a group of thirty students in the fall of 2006.

In the summer of 2008, Andy Pasternack, senior editor at Jossey-Bass, con-tacted us. He had seen our course syllabus for Introduction to Public Health and wondered if we were interested in writing a textbook for the course. By that time, we had reworked the class to be an upper-level undergraduate course called Public Health Concepts (PHC4101). We had not, however, found a textbook that suited the course and were excited at the idea of crafting our own. We could not have imagined the journey on which we were embarking, but we are grateful to Andy for his vision and his request. We hope this textbook will serve the needs of many other undergraduate public health instructors who, like us, have found it challenging to identify a single textbook that covers the basics of public health, including methodology and topics of current interest. Our Public Health Concepts course is now required for all bachelor of health science students in our college, and the yearly enrollment in the class is nearly three hundred

I n t r o d u c t I o n

xxiv introduction

students. This book is the result of the assistance of many of our colleagues, some of whom have visited our course over the years and contributed their expertise to make the class, and now this book, a success. This book’s production would not have been possible without the support, direction, and keen editorial skills of Seth Schwartz, Sandra Kiselica, Gary Kliewer, and Jane Loftus. We are also grateful to Robert E. Aronson, University of North Carolina at Greensboro; Yaw A. Nsiah, Eastern Connecticut State University; and Ashley C. Wells, University of Georgia, who served as reviewers for many of the chapters in this book.

Elena AndresenErin DeFries Bouldin

P A R T

I

H I sTo Ry, D e v e lo P m e n T,

A n D o RgA n I zAT I o n

C H A P T e R 1

H I s T o R y A n D D e v e l o P m e n T o f P u b l I C H e A lT H

E r i n D . B o u l d i n , M P H

Public health is all around us. It is the air we breathe, the water we drink, the places we work. Public health is a broad discipline, encompassing profes-sionals from various backgrounds: anthropology, sociology, economics, health behavior, biology, and statistics, to name a few. Perhaps because of its amor-phous and expansive nature, public health is not well understood by the American public[1]. Although its functions touch our everyday lives, public health is not always identified as the source of the benefits it provides. In the absence of large-scale national or global health threats, the public may become complacent about the need for sustaining public health activities, even though it is a field that is always working to improve lives and health.

In this chapter, we will describe public health, beginning with a definition of health. We will discuss public health’s mission and its core functions, which will provide a foundation for the rest of this book. We will trace public health’s development over the centuries, identifying some of the major historicalfigures

Learning Objectives

⦁ Define health and public health.⦁ Describe major historical milestones in the development of public health and identify

major figures such as John Graunt, John Snow, and Lemuel Shattuck.⦁ Compare and contrast endemic, epidemic, and pandemic diseases.⦁ Identify and describe the three hallmarks of public health: philosophy of social justice,

focus on prevention, and focus on populations.⦁ List and distinguish the five core public health disciplines.⦁ Understand ethics and be aware of situations in public health in which ethical con-

cerns arise.

4 Public HealtH Foundations: concePts and Practices

who advanced the field. We will also cover three hallmarks of public health: a philosophy of social justice, a focus on populations, and a focus on prevention. Finally, we will introduce you to some ethical considerations in public health.

What Is Public Health?

So what is public health? Let us first consider what we mean by health. The World Health Organization (WHO)[2] defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” This holistic view of health, incorporating body, mind, and com-munity, is one consistent with the concept of public health, and it will be used as the definition of health in this text. Public health has been defined in differ-ent ways. In 1920, Charles Edward Amory Winslow said it is “the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort … to ensure everyone a standard of living adequate for the maintenance of health … .”[3, p. 10] In 1958, Geoffrey Vickers said public health consists of “successive re-defining of the unacceptable”[3, p. 10]. Both of these definitions highlight the role played by members of the commu-nity in improving health and in defining what is socially and publicly acceptable. Thus public health seeks to improve or maintain the health of a population, but does so according to the values and norms of its people.

The mission of public health is to “[fulfill] society’s interest in assuring conditions in which people can be healthy”[4]. This mission comprises two areas that are vital to an understanding of public health. The first is fulfilling society’s interest. As mentioned, public health is very much concerned with the needs and demands of the public. Much of the financing for public health activities comes from the federal government, and activities funded with public dollars are subject to input from the citizenry. This responsiveness to the will of the public also means public health is a fluid discipline. Although it has core functions and hallmarks, the purview and activities of public health change over time. The second part of this mission statement, assuring conditions in which people can be healthy, highlights the supportive role public health plays in the health of the populace. Public health does not necessarily provide medical care to individuals but rather assures conditions that support health. For example, smoking bans in restaurants and food-labeling requirements are public health efforts to prevent harmful exposures and to provide information to the public in order to promote healthful choices. This aspect of public health is one of the cornerstones of the field, namely that public health embraces a social-ecological model of health. This model essentially holds that health is not a result of individual factors alone but