Public health as defined by Charles-Edward A. Winslow 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.”1The World Health Organization (WHO) defines the whole of public health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”2 Public health’s charge is to protect the health of the population, which can range in size from a small group of people to several continents. Overall, public health strives to prevent illness and injury by protecting individuals from things they cannot directly control (eg, drinking contaminated water, inhaling tuberculosis bacteria) and promoting healthy behaviors for things they can directly control (eg, eating healthily, exercising regularly, not smoking).
Public health utilizes the elements of epidemiology, surveillance, and prevention. Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control health problems.3Epidemiological investigations are conducted to determine the distribution and determinants of disease and to attempt to categorize disease by person, place, and time.
Surveillance is the ongoing process of collecting, analyzing, and interpreting health data, and disseminating the conclusions to relevant entities. There are several types of surveillance utilized in routine public health practice including passive, active, sentinel, and syndromic. Passive surveillance is frequently utilized at the local and state levels in the form of case reporting. Depending on the locale, there may be well over 50 communicable diseases that must be reported to public health officials when diagnosed or suspected by physicians, laboratories, hospitals, and others. This differs from active surveillance in which public health agencies attempt to proactively identify individuals meeting specific criteria. Finding sexual partners of an individual with HIV or another confirmed sexually transmitted disease would be an example.4
Primary prevention, one of the most common public health strategies, includes actions to stop disease from occurring. Examples of primary prevention are childhood immunizations, hand washing, and seat belt use. Secondary prevention involves screening asymptomatic individuals to detect disease in the early stage and thereby preventing clinical manifestations. Examples of secondary prevention include blood pressure screening to detect hypertension, mammography to detect breast cancer, colonoscopy to detect colon cancer, and urine screening in adolescent girls to detect occult sexually transmitted diseases like chlamydia. Tertiary prevention is treatment of clinically manifested disease to halt the progression and complications of the disease.
Display a general understanding of the history, principles, and core disciplines of public health.
Discuss the differences between governmental public health departments and the public health system.
Understand primary, secondary, and tertiary prevention and how they relate to public health and EMS.
Understand many of the commonalities, synergies, and partnerships, as well as some of the differences between EMS and public health.
Understand the benefits from partnerships between EMS and public health.
Public health concepts are evident from ancient times and developed out of necessity as primitive civilizations began to establish cities. Municipal water supplies and sewage systems have been documented by archeologists from ancient cities in Africa, Asia, Europe, and South America. Ancient sanitary engineering peaked in Rome where aqueducts supplied the city with water as effectively as modern water systems do today.
The practice of isolation (separating those with a communicable disease from those without) was practiced in early medieval times. Special rules created separate housing to exclude lepers from communities.
The Renaissance marked the beginning of a period of cultural growth and was also the beginning of a series of epidemics that devastated Europe and the Near East. This included the Black Death (bubonic plague), which killed 25% of the European population in 4 years. These events led to three important contributions to public health: the organization of boards of health, the promulgation of a theory of contagion, and the introduction of vital statistics (contagious disease and mortality data). 5,6
Concepts emerged during the Enlightenment (1750 through mid-19th century) that encouraged government programs designed to protect the population against disease and to promote health. Theories of Utilitarianism (greatest good for the greatest number) led to legislation regarding prison reform, birth control, establishment of a ministry of health, and sanitary measures. Implementation of these ideas was championed by Edwin Chadwick in his publication General Report on the Sanitary Condition of the Labouring Population of Great Britain (1842). This report illustrated many population-based inequities and resulted in movement toward sewage systems, potable water supplies, refuse disposal, ventilation of housing and work locations, and supervision of public works by qualified individuals.
In 1854, a cholera outbreak in London resulted in a defining moment in epidemiology founded by physician John Snow. Snow was skeptical of the then current miasma theory, which postulated that diseases like cholera or plague were caused by breathing “bad air.” Snow’s study of the pattern of cholera in London led to the removal of the Broad Street pump based on his conclusion that ingestion of water contaminated with fecal matter resulted in illness. In the 1870s and 1880s tremendous advances were made by French scientist Louis Pasteur and German physician Robert Koch. Together these two scientists are known as the fathers of the germ theory and bacteriology. Pasteur is best known for his recognition that fermentation is caused by growth of microorganisms and spoiling of beverages like beer, wine, and milk. The process of heating liquids to kill harmful bacteria was later termed pasteurization. Pasteur also developed vaccinations for rabies and anthrax. Koch furthered the support of the germ theory with his development of the Koch postulates that outline the characteristics an organism must have to cause disease. He is also famous for isolating several organisms including Bacillus anthracis, tuberculosis bacillus, and Vibrio cholerae. 5,6
The improvements in sanitary conditions and development of bacteriology in the early 20th century reduced mortality from enteric diseases and shifted the focus of public health interventions to other problems. Development of maternal and child health programs to reduce infant mortality, government regulation of the food processing industry, industrial hygiene and occupational health programs to address occupational injury and disease, and focus on mental health and nutrition were among the highlights of this period.
A developmental process known as epidemiological transition occurs as a country undergoes modernization from Third World to First World. Population rates sharply increase and then level off due to declining fertility rates. Infectious disease rates decrease because of immunization and communicable disease control, and public health initiatives shift to chronic diseases like heart disease and cancer.6 In the second half of the 20th century, the role of public health expanded to address aging populations in industrialized nations, recognition of the importance of behavioral risk factors (eg, diet, tobacco use, obesity, high-risk sexual practices), increasing social inequalities in health, and violence.5 Box 9-1 10 Essential Functions of Public Health
Monitor health status to identify and solve community health problems.
Diagnose and investigate health problems and health hazards in the community.
Inform, educate, and empower people about health issues.
Mobilize community partnerships and action to identify and solve health problems.
Develop policies and plans that support individual and community health efforts.
Enforce laws and regulations that protect health and ensure safety.
Link people to needed personal health services and ensure the provision of health care when otherwise unavailable.
Ensure competent public and personal health care workforce.
Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
Research for new insights and innovative solutions to health problems.
From http://www.cdc.gov/nphpsp/essentialServices.html.
As we move into the 21st century, public health faces challenges such as naturally emerging infections like severe acute respiratory syndrome (SARS) and the H1N1 pandemic; bioterrorism by the intentional release of anthrax and diseases previously eradicated such as smallpox; health inequities and lack of access to affordable health care; childhood obesity; and long-term effects of natural disasters including the Indian Ocean tsunami (2004), Hurricane Katrina (2005), and the Haiti earthquake (2010).
The 1988 Institute of Medicine (IOM) report The Future of Public Health describes three core functions of public health that are necessary to maintain and improve the health of the community. These include assessment, policy development, and assurance. Assessment involves the ongoing collection of community health data, and the analysis of these findings to identify trends in illness, injury, and death. Priorities determined from assessment are used to develop local, state, and federal health policies, which must consider community, political, and social infrastructures for successful implementation. Assurance is making sure that all members of the population have access to appropriate and cost-effective health services including those for prevention and health promotion along with evaluation of the effectiveness of these efforts.7
The 1994 Vision of Public Health in America “Healthy People in Healthy Communities” outlined the goals of public health to prevent epidemics and the spread of disease, protect against environmental hazards, promote and encourage healthy behaviors and injury prevention, respond to disasters and assist communities in recovery, and ensure the quality and accessibility of health services.8 The 10 essential functions of public health (Box 9-1) are those public health services necessary to achieve these goals. Together, they provide a working definition of public health and a guiding framework for the responsibilities of public health systems. These essential services operationalize the core functions of public health. The relationship between the core functions and the essential services are illustrated in Figure 9-1.
Although somewhat subjective, health scientists at the CDC nominated the most noteworthy public health achievements in the United States from 2001 to 2010. These include vaccine-preventable diseases, prevention and control of infectious diseases, tobacco control, maternal and infant health, motor vehicle safety, cardiovascular disease prevention, occupational safety, cancer prevention, childhood lead poisoning prevention, and public health preparedness and response. These advances in public health led to significant contributions in the decrease in the age-adjusted death rate from the leading causes of death in the United States.9
Effective delivery of services by public health organizations at the federal, state, tribal, and local levels requires a capable and qualified workforce, up-to-date data and information systems, and public health agencies capable of assessing and responding to public health needs.10 A strong public health infrastructure depends on effective coordination among all of these organizations.
WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends. WHO fulfills these objectives through its core functions that include providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the 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; providing technical support, catalyzing change, and building sustainable institutional capacity; and monitoring the health situation and assessing health trends.11
Most US governmental health agencies fall under the Department of Health and Human Services (HHS). HHS is the principal department responsible for protecting the health of all Americans along with providing essential human services especially for those who are least able to help themselves. HHS comprises the Office of the Secretary (18 staff divisions) and 11 operating divisions including the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Health Resources Services Administration (HRSA), and the National Institutes of Health (NIH).
The CDC is considered the national authority on public health. It promotes health and quality of life by preventing and controlling disease, injury, and disability. The CDC is composed of the Office of the Director, the National Institute for Occupational Safety and Health, the Center for Global Health, and five offices including Public Health Preparedness and Response; State and Local Support; Surveillance, Epidemiology and Laboratory Services; Non-communicable Diseases, Injury, and Environmental Health; and Infectious Diseases.12
The FDA is responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, cosmetics, products that emit radiation, and our nation’s food supply. Ideally, this is accomplished while simultaneously helping speed innovations that make medicines and foods more effective, safer, and more affordable. In addition, the FDA ensures that the public receives accurate, science-based information on medicines and food to improve their health.13
The HRSA is the primary federal agency responsible for improving access to health care services especially for people who are uninsured, isolated, or medically vulnerable. The Indian Health Services (IHS) provides a comprehensive public health and health care delivery system for approximately 1.9 million American Indians and Alaska Natives who belong to 564 federally recognized tribes in 35 states.14
In addition to the agencies that fall under the HHS umbrella, there are several other agencies responsible for protecting specific aspects of the public’s health. The Environmental Protection Agency (EPA) is tasked with protecting human health and the environment by writing and enforcing regulations based on laws passed by Congress. Since 1970, the EPA has been working for a cleaner, healthier environment for the American people. The Occupational Safety and Health Administration (OSHA) ensures the health and safety of America’s workers by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual improvement in workplace health and safety. The mission of the National Highway Traffic Safety Administration or NHTSA is to save lives, prevent injuries, and reduce economic costs due to road traffic crashes through education, research, safety standards, and enforcement activity. It includes the office of EMS, which leads federal EMS efforts.
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