What is Public Health?
Historical perspectives
and new challenges
Anna Sidorchuk and Emilie Agardh
I woke up this morning, got out of bed, and went to the bathroom
where I used the toilet, washed my hands, brushed and flossed my
teeth, drank a glass of water, and took my blood pressure
medicine, cholesterol medication, and an aspirin. Then I did my
exercises and took a shower.
On the way to the kitchen, I didn’t even notice the smoke
detector I passed or the old ashtrays in the closet. I took a low fat
yogurt out of the refrigerator and prepared a hot cereal in the
microwave oven for my breakfast.
Then, I walked out of my door into the crisp clean air and got in
my car. I put on my seat belt, saw the light go on for the air bag,
and safely drove to work. I got to my office were I paid little
attention to the new defibrillator at the entrance, the ”non smoking”
signs, or the absence of asbestos. I arrived safely in my well-ventilated
office and got ready to teach.
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Achievements reflecting the
history of Public Health
Clean water, hand washing, indoor plumbing largely eliminate the
transmission of common bacterial disease
Teeth brushing and flossing has a dramatic impact on dental health
Reduction of blood pressure and cholesterol, cigarette cessation
efforts, use of low-dose aspirin, understanding the role of exercise
and availability of defibrillators in prevention of heart disease.
Refrigerator was one of the most important advances in food safety
Awareness and work with the quality of the air we breath both
indoors and outdoors
Highway safety, use of seat belts, air bags
Removal of asbestos from buildings
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What do we mean by Public Health?
Asking parents: “health care for the poor”
Asking grandparents: “Washing your hands”
Asking people from different parts of the world and in different
societies…
”.. Health care is vital to all of us some of the time, but public health is
vital to all of us all of the time...” C. Everett Koop, MD, former US Surgeon General
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Definitions of Health
There is no uniform concept of health
Health is the ability to attain vital goals in life.
Health is an experience of well-being.
Health is an experience of the meaningfulness of life.
Health is not having a disease.
Health is the opposite of disease; a person who has a disease is not healthy.
Health and disease are opposite ends of a scale; a person with more disease
has less health and vice versa.
Health and disease belong to different dimensions; a person with one or
more diseases can at the same time be healthy and vice versa
WHO, 1948: Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.
Has been much criticized. In later WHO definitions health is described more as
a resource, sometimes as an activity.
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Definitions of Public Health
The concerns of society as a whole are always in the forefront of
public health. These concerns keep changing and the methods for
addressing them keep expanding.
Examples of definitions:
Public health is “….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” Charles-Edward E. Winslow, American PH leader, 1920
The substance of public health is the “organized community efforts
aimed at the prevention of disease and promotion of health..” Institute of
Medicine, Washington, 1988
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Health and Public Health – the interplay between living
conditions in a society and the health of the public
Society
Conditions
of Life
Population
Individual
Public Health
Health
Adopted from the “Health in Sweden: The National Public Health Report 2005”, The National Board of
Health and welfare/Centre for Epidemiology (Scand J Public Health Suppl. 2006;67:11-265).
Source: Modified from figure 1:1 in Health in Sweden - The National Public Health Report 2001.
What is Public Health?
Missions
To make health care assessible to all
To ensure that health system acts to benefit people
To empower people to make healthy decisions
To make problems that are invisible visible
To bring opportunities and hope
Skills
To look at the level of population
To understand complex determinants of diseases
Vision
What changes can we make and how can we do that
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Public Health from a historical perspective
1840-1870s: The sanitary movement
1880-1940s: Contagion control
1950s-mid-1970s: Filling holes in the medical care system
Mid 1970s-2000th: Healthy public policy
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1840-1870s: The sanitary movement
Public health awareness began to emerge in Europe in the mid -19th
century
Although very important discoveries for the good of public health and
prevention was made prior to this time, the focus on science at a
population level began to take place now
This era was characterized by infectious diseases, although the germ
theory was not discovered yet. There was a common belief that
miasma spread the diseases.
Scientists searched for causes of disease outside the body
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Ignaz Semmelweis (1818-1865):
The relationship between
fever of childbirth and washing hands
In the mid – 19th century
Fever of childbirth was a major cause
of death. Semmelweis, an Austrian
physician noted that physicians went from
postmortem room to delivery room
without washing their hands. He
instituted a hand washing procedure and
was able to document a dramatic
reduction in the frequency of childbirth
fever.
Unfortunately he was unable to convince
many of his colleges to accept this
intervention without a clear mechanism
of action until the acceptance of the germ
theory.
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Edwin Chadwick (1800-1890):
The relationship between filth and disease
After the influenza and typhoid
epidemics in 1837 and 1838
Edwin Chadwick, a layer in
England, was asked by the
government to carry out an
investigation about sanitation in
London. He came up with the
“Report on the sanitary conditions
of the laboring population”.
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Edwin Chadwick (1800-1890):
The relationship between filth and disease
Chadwick concluded that working-class
neighborhoods and streets were
appallingly and dangerously filthy,
that the poor were getting sicker
more frequently and dying at a
younger age than the better-off,
and that "filth and disease"
were causally related.
Chadwick argued that all the
causes of filth, and therefore
much of the disease, were
preventable.
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1840-1870s: The sanitary movement
This movement put fourth the idea that disease emerges from social
conditions of inequality
Later lead to the improvement of drainage, housing, and water supply
as an essential national economic good.
Fundamental concepts of epidemiology developed during this era
(John Snow and cholera)
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1880-1940s: Contagion control
Scientists searched for the causes of infectious diseases
Without antibiotics much of the public health and prevention work
was focused on identifying cases and isolating diseases to prevent
further contagion
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Louise Pasteur (1822-1895):
Germ theory of disease
In the mid-1800 Louis Pasteur and colleges
discovered that most infectious diseases are
caused by germs, known as the
"germ theory of disease“. Pasteur fought to
convince surgeons that most germs existed
and carried diseases, and dirty instruments
and hands spread germs and therefore disease.
This was a biological revolution, and
the understanding of contributions of bacteria
and other organisms produced novel
diagnostic testing capabilities, for example
identifying tuberculosis cases through skin
testing, bacterial culture and development
of new vaccines against toxins produces by
diphtheria-causing bacteria.
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Alexander Flemming (1881-1955):
Discovery of antibiotics
In 1928 a Scottish bacteriologist,
Alexander Fleming, discovered penicillin
by accident. While conducting research
using dishes of bacteria cultures, he
accidentally left one of the cultures
uncovered for several days. Fleming
found the dish contaminated with a mold and
that something in the mold stopped or slowed
the growth of the bacteria. Fleming named
the part of the mold that attacked bacteria
"penicillin." He was unable to separate the
penicillin from the mold, however.
In 1935, at Oxford University in England,
researchers Howard Florey and Ernst Chain stumbled across an article by Fleming about his work
with penicillin. They obtained a culture (sample) of Fleming's original mold and were able to
separate and purify the penicillin. They all received the Nobel Prize for their discovery.
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1950s-mid-1970s: Filling holes in the medical care system
The discovery of penicillin and the success in medical technology were great
and economical resources good.
The role of public health was now characterized by integrating preventive
efforts into the practice of medicine (care of high risk population). For
example education from nurses and doctors to effect behavioral changes and
combat the risk factors of diseases.
As mortality due do infectious disease declined attention turned to noncommunicable disease and behavioral causes.
Epidemiological methods designed for the study of non-communicable
disease and risk factors began to take place.
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Sir Richard Doll (1912-2005):
The relationship between smoking and lung cancer
In 1951, doctors at the UK's Medical Research Council
published a scientific paper that was truly ground-breaking.
They revealed that smoking can cause lung cancer.
Sir Richard Doll was one man behind the study. Mortality
from lung cancer was increasing every year in the first
decades of the last century and people were getting
concerned. Doll and his colleagues interviewed 700 lung
cancer patients to try to identify a possible link.
They asked them every question they could think of, and
it wasn’t long before it became clear that cigarette smoking
was to blame. However, nobody believed them and the
researchers continued their work. They asked 40,000 doctors
if they smoked and over the course of three years,
they compared smokers with non-smokers among those
who developed lung cancer. In 1954 the UK health minister
called for a news conference saying that it must be regarded as
established that there is a relationship between smoking and cancer of the lung.
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Mid-1970s-2000th: Healthy public policy
The previous era could be characterized by “If you can cure you do
not need to prevent”
However, in the mid-1970s new ideas of public health began to
emerge, moving away from the dominance of the medical model
towards emphasizing health promotion and the building of healthy
public policy.
Some key events;
1974 The Lalonde report
1981 Health For All by the year 2000
1986 Ottawa Charter
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1974: The Lalonde Report
In 1974, a new perspective on the health of Canadians
was published in “The Lalonde Report”. Lalonde identified
environmental factors as crucial for health, and that
action outside the medical health care was needed to
handle illness from for example environmental pollution,
abuse of alcohol, tobacco and harmful eating patterns.
“..For these environmental and behavioral threats to
health, the organized health care system can do little
more than serve as a catchment net for the victims.
Physicians, surgeons, nurses and hospitals together spend
much of their time in treating ills caused by adverse
environmental factors and behavioral risks..”
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1981: Health For All by the year 2000
The World Health Organization took an important lead in the development of
the role of public health through its strategy for Health For All by the year
2000.
The goal was that;
All people in all countries should have at least such a level of health that they are
capable of working productively and of participating actively in the social life of the
community in which they live.
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1986: Ottawa Charter
In 1986, a first conference on Health promotion was arranged in
Ottawa, as a response to growing expectations for a new public
health movement around the world.
At the conference a set of principles was developed, based on WHOs
targets in Health For All;
Building healthy public policy
To identify health as a key issue in determining policy in all areas
Creating supportive environments
Enhancing our living and work environments
Strengthen community action
Communities having the power to influence and control their activities
Develop personal skills
Helping people to develop skills they need to make healthy choices
Re-orienting health services
All people involved in health service must work together in a system that sees
health improvement as a central goal
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Other key events
1988 Adelaide conference
Health is a fundamental human right and sound social investment.
Importance of linked economic, social and health policies
1991 Sundsvall conference
Focus on environments and their spiritual, cultural, social, economic,
political and ideological dimensions
1997 Jakarta conference
Reviews and evaluate impact of health promotion
1998 World Health Assembly resolution on health promotion
Continuous trust on HFA in the 21st century. Sets out global priorities of
and targets of the first two decades for helping people world wide to
reach and maintain the highest attainable level of health throughout
their lives.
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Notable Public Health achievements
in the 20th century
Adopted from The "Ten Great Public Health Achievements -- United States, 1900-1999“,
the U.S. Centers for Disease Control and Prevention (CDC)
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Vaccination Vaccination has resulted in the eradication of smallpox; elimination of
Motor-vehicle safety Improvements in motor-vehicle safety have resulted from
Safer workplaces Work-related health problems, such as coal workers‘
poliomyelitis in the Americas; and control of measles, rubella, tetanus, diphtheria,
Haemophilus influenzae type b, and other infectious diseases in the United States and
other parts of the world.
engineering efforts to make both vehicles and highways safer and from successful
efforts to change personal behavior (e.g., increased use of safety belts, child safety
seats, and motorcycle helmets and decreased drinking and driving). These efforts have
contributed to large reductions in motor-vehicle-related deaths.
pneumoconiosis (black lung), and silicosis -- common at the beginning of the century -have come under better control. Severe injuries and deaths related to mining,
manufacturing, construction, and transportation also have decreased; since 1980, safer
workplaces have resulted in a reduction of approximately 40% in the rate of fatal
occupational injuries.
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Control of infectious diseases Control of infectious diseases has resulted from clean
water and improved sanitation. Infections such as typhoid and cholera transmitted by
contaminated water, a major cause of illness and death early in the 20th century, have
been reduced dramatically by improved sanitation. In addition, the discovery of
antimicrobial therapy has been critical to successful public health efforts to control
infections such as tuberculosis and sexually transmitted diseases (STDs).
Decline in deaths from coronary heart diseases and stroke Decline in deaths
from coronary heart disease and stroke have resulted from risk-factor modification,
such as smoking cessation and blood pressure control coupled with improved access to
early detection and better treatment. Since 1972, death rates for coronary heart
disease have decreased 51%.
Safer and healthier foods Since 1900, safer and healthier foods have resulted from
Healthier mothers and babies Healthier mothers and babies have resulted from
decreases in microbial contamination and increases in nutritional content. Identifying
essential micronutrients and establishing food-fortification programs have almost
eliminated major nutritional deficiency diseases such as rickets, goiter, and pellagra in
the United States.
better hygiene and nutrition, availability of antibiotics, greater access to health care,
and technologic advances in maternal and neonatal medicine. Since 1900, infant
mortality has decreased 90%, and maternal mortality has decreased 99%.
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Family planning Access to family planning and contraceptive services has altered
Fluoridation of drinking water Fluoridation of drinking water began in 1945 and in
Recognition of tobacco use as a health hazard Recognition of tobacco use as a
social and economic roles of women. Family planning has provided health benefits such
as smaller family size and longer interval between the birth of children; increased
opportunities for preconceptional counseling and screening; fewer infant, child, and
maternal deaths; and the use of barrier contraceptives to prevent pregnancy and
transmission of human immunodeficiency virus and other STDs.
1999 reaches an estimated 144 million persons in the United States. Fluoridation safely
and inexpensively benefits both children and adults by effectively preventing tooth
decay, regardless of socioeconomic status or access to care. Fluoridation has played an
important role in the reductions in tooth decay (40%- 70% in children) and of tooth loss
in adults (40%-60%).
health hazard and subsequent public health anti- smoking campaigns have resulted in
changes in social norms to prevent initiation of tobacco use, promote cessation of use,
and reduce exposure to environmental tobacco smoke. Since the 1964 Surgeon
General's report on the health risks of smoking, the prevalence of smoking among
adults has decreased, and millions of smoking-related deaths have been prevented.
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What is a public health problem?
Needs to affect more than 1% of the population
Should be associated with serious consequences for;
Health
Economy
The social life
Contribute to inequalities in health
Should be possible to prevent
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Major Public Health problems in Sweden
Cardiovascular diseases
Diabetes
Overweight and obesity
Cancer
Mental ill-health
Musculoskeletal disorders
Injuries
Allergic disorders
Infectious diseases
Dental health
Adopted from the “Health in Sweden: The National Public Health Report 2005”, The
National Board of Health and welfare/Centre for Epidemiology (Scand J Public Health
Suppl. 2006;67:11-265)
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Future challenges (?)
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Future challenges
Globalization increases the potential for the spread of existing and
emerging diseases and raises concerns about the products we use
Climate change and ongoing environmental deterioration continue to
produce new territory for ex malaria
Clean water
Overuse of technologies, such as antibiotics have encouraged the
emergence of resistant bacteria
Emerging and re-emerging infectious diseases
Bioterrorism
The epidemic of obesity
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