Public Health

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Public health refers to "the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals."[1] It is concerned with threats to health based on population health analysis. The population in question can be as small as a handful of people, or as large as all the inhabitants of several continents (for instance, in the case of a pandemic). The dimensions of health can encompass "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity", as defined by the United Nations' World Health Organization.[2] Public health incorporates the interdisciplinary approaches of epidemiology, biostatistics and health services. Environmental health, community health, behavioral health, health economics, public policy, insurance medicine, mental health and occupational safety and health are other important subfields.

The focus of public health intervention is to improve health and quality of life through prevention and treatment of disease and other physical and mental health conditions. This is done through surveillance of cases and health indicators, and through promotion of healthy behaviors. Examples of common public health measures include promotion of hand washing, breastfeeding, delivery of vaccinations, and distribution of condoms to control the spread of sexually transmitted diseases.

Modern public health practice requires multidisciplinary teams of public health workers and professionals including physicians specializing in public health/community medicine/infectious disease, psychologists, epidemiologists, biostatisticians, medical assistants or Assistant Medical Officers, public health nurses, midwives, medical microbiologists, environmental health officers / public health inspectors, pharmacists, dentists, dietitians and nutritionists, veterinarians, public health engineers, public health lawyers, sociologists, community development workers, communications experts, bioethicists, and others.[3]

There is a great disparity in access to health care and public health initiatives between developed nations and developing nations. In the developing world, public health infrastructures are still forming.

 

Background.

The focus of a public health intervention is to prevent and manage diseases, injuries and other health conditions through surveillance of cases and the promotion of healthy behaviors, communities and environments. Many diseases are preventable through simple, non-medical methods. For example, research has shown that the simple act of hand washing with soap can prevent many contagious diseases.[4] In other cases, treating a disease or controlling a pathogen can be vital to preventing its spread to others, such as during an outbreak of infectious disease, or contamination of food or water supplies. Public health communications programs, vaccination programs, and distribution of condoms are examples of common public health measures. Measures such as these have contributed greatly to the health of populations and increases in life expectancy.

Public health plays an important role in disease prevention efforts in both the developing world and in developed countries, through local health systems and non-governmental organizations. The World Health Organization (WHO) is the international agency that coordinates and acts on global public health issues. Most countries have their own government public health agencies, sometimes known as ministries of health, to respond to domestic health issues. For example, in the United States, the front line of public health initiatives are state and local health departments. The United States Public Health Service (PHS), led by the Surgeon General of the United States, and the Centers for Disease Control and Prevention, headquartered in Atlanta, are involved with several international health activities, in addition to their national duties. In Canada, the Public Health Agency of Canada is the national agency responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. The Public health system in India is managed by the Ministry of Health & Family Welfare of the government of India with state owned health care facilities.

Current practice.

Public health programs.

Most governments recognize the importance of public health programs in reducing the incidence of disease, disability, and the effects of aging and other physical and mental health conditions, although public health generally receives significantly less government funding compared with medicine.[5] Public health programs providing vaccinations have made strides in promoting health, including the eradication of smallpox, a disease that plagued humanity for thousands of years.

 

The World Health Organization (WHO) identifies core functions of public health programs including:[6]

· providing leadership on matters critical to health and engaging in partnerships where joint action is needed;

shaping a research agenda and stimulating the generation, translation and dissemination of valuable knowledge;

· setting norms and standards and promoting and monitoring their implementation;

articulating ethical and evidence-based policy options;

· monitoring the health situation and assessing health trends.

In particular, public health surveillance programs can:[7]

serve as an early warning system for impending public health emergencies;

· document the impact of an intervention, or track progress towards specified goals; and

monitor and clarify the epidemiology of health problems, allow priorities to be set, and inform health policy and strategies.

· diagnose, investigate, and monitor health problems and health hazards of the community

Public health surveillance has led to the identification and prioritization of many public health issues facing the world today, including HIV/AIDS, diabetes, waterborne diseases, zoonotic diseases, and antibiotic resistance leading to the reemergence of infectious diseases such as tuberculosis. Antibiotic resistance, also known as drug resistance, was the theme of World Health Day 2011. Although the prioritization of pressing public health issues is important, Laurie Garrett argues that there are following consequences.[8] When foreign aid is funneled into disease-specific programs, the importance of public health in general is disregarded. This public health problem of stovepiping is thought to create a lack of funds to combat other existing diseases in a given country.

For example, the WHO reports that at least 220 million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is projected that the number of diabetes deaths will double by the year 2030.[9] In a June 2010 editorial in the medical journal The Lancet, the authors opined that "The fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation."[10] The risk of type 2 diabetes is closely linked with the growing problem of obesity. The WHO’s latest[when?] estimates highlighted that globally approximately 1.5 billion adults were overweight in 2008, and nearly 43 million children under the age of five were overweight in 2010.[11] The United States is the leading country with 30.6% of its population being obese. Mexico follows behind with 24.2% and the United Kingdom with 23%. Once considered a problem in high-income countries, it is now on the rise in low-income countries, especially in urban settings. Many public health programs are increasingly dedicating attention and resources to the issue of obesity, with objectives to address the underlying causes including healthy diet and physical exercise.

Some programs and policies associated with public health promotion and prevention can be controversial. One such example is programs focusing on the prevention of HIV transmission through safe sex campaigns and needle-exchange programmes. Another is the control of tobacco smoking. Changing smoking behavior requires long-term strategies, unlike the fight against communicable diseases, which usually takes a shorter period for effects to be observed. Many nations have implemented major initiatives to cut smoking, such as increased taxation and bans on smoking in some or all public places. Proponents[who?] argue by presenting evidence that smoking is one of the major killers, and that therefore governments have a duty to reduce the death rate, both through limiting passive (second-hand) smoking and by providing fewer opportunities for people to smoke. Opponents[who?] say that this undermines individual freedom and personal responsibility, and worry that the state may be emboldened to remove more and more choice in the name of better population health overall.

Simultaneously, while communicable diseases have historically ranged uppermost as a global health priority, non-communicable diseases and the underlying behavior-related risk factors have been at the bottom. This is changing however, as illustrated by the United Nations hosting its first General Assembly Special Summit on the issue of non-communicable diseases in September 2011.[12]

Many health problems are due to maladaptive personal behaviors. From an evolutionary psychology perspective, over consumption of novel substances that are harmful is due to the activation of an evolved reward system for substances such as drugs, tobacco, alcohol, refined salt, fat, and carbohydrates. New technologies such as modern transportation also cause reduced physical activity. Research has found that behavior is more effectively changed by taking evolutionary motivations into consideration instead of only presenting information about health effects. Thus, the increased use of soap and hand-washing to prevent diarrhea is much more effectively promoted if its lack of use is associated with the emotion of disgust. Disgust is an evolved system for avoiding contact with substances that spread infectious diseases. Examples might include films that show how fecal matter contaminates food. The marketing industry has long known the importance of associating products with high status and attractiveness to others. Conversely, it has been argued that emphasizing the harmful and undesirable effects of tobacco smoking on other persons and imposing smoking bans in public places have been particularly effective in reducing tobacco smoking.[13]

Applications in health care.

As well as seeking to improve population health through the implementation of specific population-level interventions, public health contributes to medical care by identifying and assessing population needs for health care services, including:[14][15][16][17]

Assessing current services and evaluating whether they are meeting the objectives of the health care system

Ascertaining requirements as expressed by health professionals, the public and other stakeholders

· Identifying the most appropriate interventions

· Considering the effect on resources for proposed interventions and assessing their cost-effectiveness

· Supporting decision making in health care and planning health services including any necessary changes.

Informing, educating, and empowering people about health issues

Implementing effective improvement strategies.

To improve public health, one important strategy is to promote modern medicine and scientific neutrality to drive the public health policy and campaign, which is recommended by Armanda Solorzana, through a case study of the Rockefeller Foundation's hookworm campaign in Mexico in the 1920s. Soloranza argues that public health policy can't concern only politics or economics. Political concerns can lead government officials to hide the real numbers of people affected by disease in their regions, such as upcoming elections. Therefore, scientific neutrality in making public health policy is critical; it can ensure treatment needs are met regardless of political and economic conditions.[18]

The history of public health care clearly shows the global effort to improve health care for all.[citation needed] However, in modern-day medicine, real, measurable change has not been clearly seen, and critics argue that this lack of improvement is due to ineffective methods that are being implemented. As argued by Paul E. Farmer, structural interventions could possibly have a large impact, and yet there are numerous problems as to why this strategy has yet to be incorporated into the health system. One of the main reasons that he suggests could be the fact that physicians are not properly trained to carry out structural interventions, meaning that the ground level health care professionals cannot implement these improvements. While structural interventions can not be the only area for improvement, the lack of coordination between socioeconomic factors and health care for the poor could be counterproductive, and end up causing greater inequity between the health care services received by the rich and by the poor. Unless health care is no longer treated as a commodity, global public health can ultimately not be achieved.[citation needed] This being the case, without changing the way in which health care is delivered to those who have less access to it, the universal goal of public health care cannot be achieved.[19]

Public Health 2.0.

Public Health 2.0 is a movement within public health that aims to make the field more accessible to the general public and more user-driven. The term is used in three senses. In the first sense, "Public Health 2.0" is similar to "Health 2.0" and describes the ways in which traditional public health practitioners and institutions are reaching out (or could reach out) to the public through social media and health blogs.[20][21]

In the second sense, "Public Health 2.0" describes public health research that uses data gathered from social networking sites, search engine queries, cell phones, or other technologies.[22] In the third sense, "Public Health 2.0" is used to describe public health activities that are completely user-driven.[23] An example is the collection and sharing of information about environmental radiation levels after the March 2011 tsunami in Japan.[24] In all cases, Public Health 2.0 draws on ideas from Web 2.0, such as crowdsourcing, information sharing, and user-centred design.[25] While many individual healthcare providers have started making their own personal contributions to "Public Health 2.0" through personal blogs, social profiles, and websites, other larger organizations, such as the American Heart Association (AHA) and United Medical Education (UME), have a larger team of employees centered around online driven health education, research, and training. These private organizations recognize the need for free and easy to access health materials often building libraries of educational articles.

 

Developing countries.

There is a great disparity in access to health care and public health initiatives between developed nations and developing nations. In the developing world, public health infrastructures are still forming. There may not be enough trained health workers or monetary resources to provide even a basic level of medical care and disease prevention.[26] As a result, a large majority of disease and mortality in the developing world results from and contributes to extreme poverty. For example, many African governments spend less than US$10 per person per year on health care, while, in the United States, the federal government spent approximately US$4,500 per capita in 2000. However, expenditures on health care should not be confused with spending on public health. Public health measures may not generally be considered "health care" in the strictest sense. For example, mandating the use of seat belts in cars can save countless lives and contribute to the health of a population, but typically money spent enforcing this rule would not count as money spent on health care.

Large parts of the developing world remained plagued by largely preventable or treatable infectious diseases and poor maternal and child health, exacerbated by malnutrition and poverty. The WHO reports that a lack of exclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year.[27] Intermittent preventive therapy aimed at treating and preventing malaria episodes among pregnant women and young children is one public health measure in endemic countries.

Each day brings new front-page headlines about public health: emerging infectious diseases such as SARS, rapidly making its way from China (see Public health in China) to Canada, the United States and other geographically distant countries; reducing inequities in health care access through publicly funded health insurance programs; the HIV/AIDS pandemic and its spread from certain high-risk groups to the general population in many countries, such as in South Africa; the increase of childhood obesity and the concomitant increase in type II diabetes among children; the social, economic and health effects of adolescent pregnancy; and the public health challenges related to natural disasters such as the 2004 Indian Ocean tsunami, 2005's Hurricane Katrina in the United States and the 2010 Haiti earthquake.

Since the 1980s, the growing field of population health has broadened the focus of public health from individual behaviors and risk factors to population-level issues such as inequality, poverty, and education. Modern public health is often concerned with addressing determinants of health across a population. There is a recognition that our health is affected by many factors including where we live, genetics, our income, our educational status and our social relationships; these are known as "social determinants of health." A social gradient in health runs through society. The poorest generally suffer the worst health, but even the middle classes will generally have worse health outcomes than those of a higher social stratum.[28] The new public health advocates for population-based policies that improve health in an equitable manner.

Sustainable Development Goals.

Text Box: Further information: Sustainable Development Goals

To address current and future challenges in addressing health issues in the world, the United Nations have developed the Sustainable Development Goals 2015 building off of the Millennium Development Goals of 2000 to be completed by 2030.[29] These goals in their entirety encompass the entire spectrum of development across nations, however Goals 1-6 directly address health disparities, primarily in developing countries.[30] These six goals address key issues in global public health: Poverty, Hunger and food security, Health, Education, Gender equality and women's empowerment, and water and sanitation.[30] Public health officials can use these goals to set their own agenda and plan for smaller scale initiatives for their organizations. These goals hope to lessen the burden of disease and inequality faced by developing countries and lead to a healthier future.

The links between the various sustainable development goals and public health are numerous and well established:

Living below the poverty line is attributed to poorer health outcomes and can be even worse for persons living in developing countries where extreme poverty is more common.[31] A child born into poverty is twice as likely to die before the age of five compared to a child from a wealthier family.[32]

The detrimental effects of hunger and malnutrition that can arise from systemic challenges with food security are enormous. The World Health Organization estimates that 12.9 percent of the population in developing countries is undernourished.[33]

Health challenges in the developing world are enormous, with "only half of the women in developing nations receiving the recommended amount of healthcare they need.[32]

Educational equity has yet to be reached in the world. Public health efforts are impeded by this, as a lack of education can lead to poorer health outcomes. This is shown by children of mothers who have no education having a lower survival rate compared to children born to mothers with primary or greater levels of education.[32] Cultural differences in the role of women vary by country, many gender inequalities are found in developing nations. Combating these inequalities has shown to also lead to better public health outcome.

In studies done by the World Bank on populations in developing countries, it was found that when women had more control over household resources, the children benefit through better access to food, healthcare, and education.[34]

Basic sanitation resources and access to clean sources of water are a basic human right. However, 1.8 billion people globally use a source of drinking water that is fecally contaminated, and 2.4 billion people lack access to basic sanitation facilities like toilets or pit latrines.[35] A lack of these resources is what causes approximately 1000 children a day to die from diarrhoel diseases that could have been prevented from better water and sanitation infrastructure.[35]

Education and training.

Education and training of public health professionals is available throughout the world in Schools of Public Health, Medical Schools, Veterinary Schools, Schools of Nursing, and Schools of Public Affairs. The training typically requires a university degree with a focus on core disciplines of biostatistics, epidemiology, health services administration, health policy, health education, behavioral science and environmental health.[36][37] In the global context, the field of public health education has evolved enormously in recent decades, supported by institutions such as the World Health Organization and the World Bank, among others. Operational structures are formulated by strategic principles, with educational and career pathways guided by competency frameworks, all requiring modulation according to local, national and global realities. It is critically important for the health of populations that nations assess their public health human resource needs and develop their ability to deliver this capacity, and not depend on other countries to supply it.[38]