Public Health and Clinical Medicine
Natural Partners
Paul Jarris, MD, MBA
Executive Director
Association of State and Territorial Health Officials
ASTHO – From Micronesia to Alaska and Across the U.S. to the Virgin Islands
ASTHO – From Micronesia to Alaska and Across the U.S. to the Virgin islands
10 Essential Public Health Services

Monitor health status to identify community 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.
10 Essential Public Health Services, Cont’d

Enforce laws and regulations that protect health and ensure safety.

Link people to needed personal health services and assure the
provision of health care when otherwise unavailable.

Assure a competent public health 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.
Determinants of Health

Debisette, et. al., 2005
Determinants of Health
(by percent contribution)
100%
90%
80%
5
10
15
70%
Environmental Exposures
60%
30
50%
Medical Care
Social Circumstances
Genetic Predispositions
40%
Behavioral Patterns
30%
20%
40
10%
0%
McGinnis
Determinants of Health
et. al., 2002
US Spending on Health
National Health Spending (2005)
Government Public Health
Activities
100%
90%
$56.60
$126.80
$143.00
80%
Investment (Research and
Equipment)
70%
60%
50%
Government
Administration and Net
Cost of Private Health
Insurance
40%
$1,661.40
30%
20%
Personal Health
(Hospital/Clinical
Services, Nursing Home,
Home Health Care,
Medical Products)
10%
0%
$1,987.80
Per Capita Total

Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group;
U.S. Department of Commerce, Bureau of Economic Analysis, and U.S. Bureau of the Census.
Clinical Interactions

Year one and two: 13 visits
All ages: 3.1 visits

Typical patient with a Chronic illness




4 visits/year X 30 minutes = 120 minutes
365 X 24 X 60 = 525,600 minutes per year
120/525,600 = 0.02% of time
The Real Threats to Our Health
Prevention

Primary prevention/Universal


Secondary prevention/Selective


Reduction or control of causative factors for a health
problem and includes reducing risk and environmental
exposures
Early detection and treatment
Tertiary prevention/Indicated

Appropriate supportive and rehabilitative services to
minimize morbidity and maximize quality of life

CDC, 1992
Prevention in Public Health



Policy
Development and
Implementation
Population-based
Services
Direct Services
Example: Smoking Interventions*

Clean Indoor Air Legislation

Tobacco Price Increases

Mass Media Campaigns

Telephone Quitlines

Provider reminders with
Provider education
*Recommended with Strong Evidence by the Guide to Community Preventive Services
Smoke-Free Laws
Restaurants & Bars
Restaurants
* Arizona law effective 5/1/07; New Mexico law effective 6/15/07
* The Montana and Utah laws extend to bars in 2009.
March 2007
Effects of a 10% Increase in Tobacco Price

Nearly 7% decline in youth prevalence

A 2% decline in adult prevalence

A 4% decline in overall consumption
Mass media campaigns when combined with other
interventions


Median decrease in tobacco use initiation in
youth exposed to mass media campaigns was
eight percentage points.
Studies evaluating the impact of mass media
campaigns on statewide tobacco consumption
found a median decrease of 15 packs per capita
per year.
Patient telephone quitlines


Median improvement in quit rates among smokers who
used telephone support when compared with smokers
who did not was 41 percent.
When combined with other interventions such as medical
therapies, telephone quitlines were found effective in
helping smokers quit in both community and clinical
settings.
Provider reminders with provider education


Studies that evaluated
healthcare systems
interventions to encourage
provider efforts to advise
patients on tobacco use
cessation showed that:
 Median absolute
percentage increase in the
number of patients who
received provider advice on
cessation was 20 points
 the median absolute
percentage increase in the
number of patients who quit
was 4.7 points.
Provider reminders alone were
only found to be recommended
with sufficient evidence
Poor Diet and Physical Activity
Obesity Is Linked To A Significant Increase In Chronic Conditions
% increase in chronic conditions
70
60
50
40
30
20
10
0
g
g
g
ty
50
ity
n
n
n
r
i
i
i
s
e
k
k
k
v
30
o
n
o
be
i
o
r
m
m
O
P
ng
D
S
i
S
st
vy
Ag
a
a
P
He
Sturm R. Health Affairs. 2002; 21 (2): 245-253
Public Health. 2001; 115:229-295
Baseline –
comparable
normal weight
individuals with
no history of
smoking or
heavy drinking
Increased Risk of Obesity-Related Diseases with Higher
BMI
BMI of 25
or less
BMI between
25 and 30
BMI between
30 and 35
BMI of 35 or
more
Arthritis
1.00
1.56
1.87
2.39
Heart Disease
1.00
1.39
1.86
1.67
Diabetes (Type
2)
1.00
2.42
3.35
6.16
Gallstones
1.00
1.97
3.30
5.48
Hypertension
1.00
1.92
2.82
3.77
Stroke
1.00
1.53
1.59
1.75
Disease
Centers for Disease Control. Third National Health and Nutrition Examination Survey. Analysis by The Lewin Group, 1999.
Reducing diabetes deaths: options
Deaths Per Thousand Adults
2.50
No Change
2.25
Better Care
2.00
Obesity
Prevention
1.75
1.50
1.25
1980
1990
2000
2010
Time (Year)
Systems Dynamic Change Model
2020
2030
2040
2050
Reducing diabetes deaths:
The Vermont Blueprint Approach!
Deaths from comp per thousand Adults
2.50
No Change
No major changes –
status quo
2.25
2.00
1.75
Care and
reductionand
in Better Care
Obesity
Prevention
caloric intake
1.50
1.25
1980
1990
2000
2010
2020
Time (Year)
2030
2040
2050
America’s Obesity Epidemic
The percentage of overweight
children has more than
doubled in the past 20 years.

65% of U.S. adults are
overweight.
30% are obese.
Overweight adolescents
have a 70% chance of
becoming overweight or
obese adults.
Connecting Health & the Environment

Modern American communities are
designed for cars, not walking, recreation, or
physical activity.
Kids Don’t Walk Anymore!

Only 13% of kids walk to school today
 Up to 90% who lived a mile away walked to
school in the ‘70s
Fear of crime and safety
concerns are top
reasons parents don’t
allow kids to walk to
school – each year
5,000 pedestrians die
The Built Environment Influences Health
ASTHO’s Policy Statement

State and local governments, private developers, and
community groups can promote physical activity by
increasing access to:


Sidewalks, playgrounds, parks, bike
paths, and safe streets & neighborhoods.
Community groups and local governments can work
together to increase capital improvement projects that
promote physical activity.
Public Health Focus




School-based interventions
Worksite interventions
Healthcare system interventions
Community-wide interventions
New York’s Healthy Heart Program
Comprehensive Approaches to Promote Activity



Developed toolkit to promote
walking and biking trails.
Conducted over 15 Walkable
Community workshops in the
state With NY DOT and law
enforcement.
Convenes local decision
makers, health and planning
professionals, to learn how
to make communities more
pedestrian friendly and safer
Goals
Create walking and bicycle
trails
Increase physical activity
options in after-school
programs
Open schools for physical
activity use by residents
before and after school hours




Arkansas Addresses Childhood
Obesity
Three years of
statewide assessments
of student BMIs reveals
that the progression of
the childhood obesity
epidemic has been
halted in Arkansas.
Linking Public Health and Clinical Medicine
Vermont Blueprint for Health
Source: Vermont Department of Health, Agency of Human Services, 2007
Self Management
99.98%
Healthier Living Workshop

Stanford University Stanford Patient Education Research Center
Kate Lorig
http://patienteducation.stanford.edu/programs/cdsmp.html
•11 Hospital Service Areas
•80 Certified Professional and Lay leaders
•Over 300 Vermonters
Self Management Participants
Linking Public Health and Clinical Medicine
Vermont Blueprint for Health
Source: Vermont Department of Health, Agency of Human Services, 2007