Pthwy to excess mortality – developed vs developing:
Other factors may cause unhealthy lifestyle in developed
Poverty key factor in developing
PH how change/improve  policy, change conditions
Determinants: biological, physical, cultural, economic, political; of health: individual, environ, health care, social
PH = all evidence-based public & private efforts, preserve & promote health, prevent 3D’s, groups
Amount of Federal Spending on clinical services and preventive services:
Spend most $ on CMS = centers for Medicare/caid services; PH spending very small %
Pioneers of PH and how made decisions: (didn’t know anything about bacteriology)
W. Farr – vital stats; registrar, stats on death causes & compared areas, prevent over cure introduced hygiene
E. Chadwick – health officer/commissioner, studied disease & early death in poor, sanitary conditions led to
disease & death, mortality stats, advocated for tax & gov’t intervention, PH Act
L. Shattuck – studied conditions in Boston
J. Snow – London cholera outbreak, diff water sources & diff death rates, remove pump handle
Measures of health burden:
Health = physical, mental, social well-being
Epidemiology = study of causes, distribution, control of disease in pop
Biostatistics = theory & techniques describing, analyzing, interp health data
Shifting the curve – small changes in individ have large effects in pop
Most people avg risk, small % very high and very low, more avg risk die of preventable diseases
Small risk dec for entire pop = greater benefit than large dec among high-risk
Quality (intensity) intervention not as imp as quantity (coverage)
Curve-shift more imp than curve-chop
Morbidity – degree disability; Mortality – degree death (due to disease); course of disease
Incidence rates = #new cases/#ppl at risk; prevalence = #living/#at risk
Case fatality rate relates incidence and mortality
Determination of causality of disease & types studies used to determine, relationship risk factors & diseases:
P.E.R.I.E – problem (what?); etiology (contrib causes?); recommend (what works to reduce?); Implement (how
get job done?); evaluation (how well intervention(s) work in practice?)
Study person -> demographic charac, behaviors/exposures & place -> geographic, connections
Can see risk indicators/markers – factors occur more freq among groups w/disease
Hypothesize and associate – both causes and group associations
Real vs. artificial changes – artificial may appear more “prevalent” (ex. Interest, easier, def changes)
Study types: descriptive (case report/case series: unique/set patient(s), new diseases, new q’s; helpful in clinical
setting, no comp); descriptive (cross-sectional survey: prevalence survey, assess disease & exposure); analytic
(case control: who do/do not have disease, comp exposure, Odds Ratio); analytic (cohort studies: follow-up:
follow through life, what activities put more @ risk? Ex. Framingham heart study); analytic (clinical trials: 2
groups, randomly enroll in 2 dif act, ethics, studying drugs/behaviors - treatment)
Primary (before onset), secondary (after development before symp), tertiary (after initial symp)
Necessary cause = must be exposed to get disease; sufficient = if exposed, sufficient to have disease
Evaluation = reach, effectiveness, adoption, implementation, maintenance
Sources PH data and how used:
Perceive, combine, use info to make decisions: collect-compile-present-perceive-combine-decision
Data collected, published, distributed w/o identifying individ; integrated health data systems/bases
Quant. Sources: single case, stats, sampling, self-report, sentinel monitor, syndromic surveillance ongo
Assessment -> policy develop -> assurance
Monitor trends in disease -> prevention programs; identify subpops at elevated risk, ex. HIV, det new
Risk fact, assess effect of prevention policies & prog
Case report (infec disease), sentinel site report (flu, vaccines), focused surveys disease, surveillance health-rel
behav, passive (by health care prof) vs active (health care prov/facilities) reporting
Measures summary health pop, infant mort, life expec, under 5 mort, health-adj life expec, disabil-adj life year
Causes of improvements infectious disease rates in countries like US: technology, study of disease, etc.…
Relationship of risk fac & unhealthy behav w/socio-economic fac & dif outcomes btwn dif socio-econ groups:
Income & race impact – lack medical care, genetics, behav, stress, environ inf
Lower % deaths from fac like smoking, phys inact, overweight in higher income
Lower status = unhealthy behav, more likely become ill & die
Socioeconomic status – living conditions, education, women opp, occupation, access to goods &
services, family size, exposure to high-risk behav, environmental
Key categories social det: social status, support/alienation, food, housing, education, work, stress,
transportation, place, access to health services
PH law & ethics – federal & state powers & responsibilities, use of ethics & law to determine health interven:
Scope of law, policy, ethics; how determine appropriate role of gov’t; Individual rights vs public safety
Amendment X: powers not delegated to fed reserved to states or people – federalism
Duties of states to take all necessary steps for the promotion and protection health & inhab.
Police power = right of state to protect the health & safety of its citizens
Criminal law vs administrative, where court hearing not nec. B4 PH action, takes time, PH officer knowl.
State powers through state laws, federal only through funding and interstate commerce, State officers
PH law – environ reg, disease/injury report, vital stats, disease control, immunizations, quarantine
Quarantine – hearing not necessary first, right to contest confinement
Market vs. social justice – economics vs. social resource, rights; individ respons vs. collective responsibility
No right to health care; Health policies can be made by private groups, commercial trade assoc, gov’t org
Individ rights vs society needs: self-imposed risk = knowingly & willingly takes; imposed = out of control
Healthy People establish priorities, health indicators, give direction of federal/state PH laws
Ethics = transp, inclus, reason, responsive, accountability; Conflict – prolong life vs. prevent suff, indiv. freedom
vs. pub good, priv. vs transp, respec for cultural dif vs. prev disease, timely action vs estab effective
Belmont Report: informed consent, weigh risks & benefits to subj, protect minorities
Advan/disadvan of using policy vs. programs to affect health behaviors & types advocacy to influence policy:
PH policies for criminal laws, OSHA standards, can increase health by affecting phys/social environ,
Change operations impacting health – immunizations, drinking age; seatbelt laws, diet guideline
Advan: low or no $, large # w/ ease, long-last, transparent, inclusive
Disadvan: 1 size good for all?, enforcement probs, resisters, unintended conseq, time, politics needed
Advocate w/ lobbyists, interest group, action committee, voter
Insider: existing relations, collegial, decision makers; outsider: confrontational, emotional, “non-traditional” –
mass meetings, mailings, demonstrations, media advocacy- advertising, reporters, social media
Typhoid Mary: 1906, fever diarrhea deliria, bac in intestine, feces, G. Soper, healthy carrier, NY, Dr. S J. Baker inspector,
quarant island, sup court w/health off H. Biggs, E. Letterman – new officer, ethics of quarant vs. release to public
Screening prog charac & diseases screen for to address non-comm & comm:
Non-comm = non-infec; comm = infec
Non-comm screening  detection @ early stage, reduce disability &/or death
Criteria for screening: imp PH prob, accepted treatment, facilities available, latent/early symp stage, suitable
test/examination, natural history understood, agreed definition, other conditions detected, treatment
influence prognosis fav, cost balanced to disorder, continuous process
4 criteria for screen prog: disease produces substantial death/disabil, early detec possible & improves
outcome, feasible testing strategy, acceptable in harms, costs, patient acceptance
Comm screening  controls spread, case finding: confidential interviews, control spread b4 & after treatment
Environmental Health Challenges: Def = study of environ agents introduced by humans causing adverse health effects
Water quality and quantity – amt available fresh waters; sanitation
Natural & man-made disasters – earthquakes, Haiti, Katrina, Molds, Floods, Typhoons –responses
GMO’s/food supplies – enhancement of crops, changing genetics through breeding dif
Food & feed additives – improve color, tast, appearance, preserve, ease processing, substitutes
Nano particles – exposure cause inflammation of lungs, impair resp syst
Newly emerging diseases/TB/AIDS
Air quality – pollution, transportation, diesel engines, mold
Aqua-culture & accumulation chemical contaminants
Solid waste gasification
Climate change