Public Health 101, 2nd Edition

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Contents

Acknowledgments xv
Preface: What Is Public Health 101: Healthy People–Healthy Populations All About? xvii
About the Authors xix

Section I Principles of Population Health 1

Chapter 1 Public Health: The Population Health Approach 3
Learning Objectives 3
What Do We Mean by “Public Health”? 4
How Has the Approach of Public Health Changed Over Time? 5
What Is Meant by “Population Health”? 9
What Are the Implications of Each of the Four Components of Public Health? 9
Should We Focus on Everyone or on Vulnerable Groups? 10
What Are the Approaches Available to Protect and Promote Health? 11
What Factors Determine the Occurrence of Disease, Disability, and Death? 11
What Changes in Populations Over Time Can Affect Health? 14
Key Words 17
Discussion Question 18
References 19

Chapter 2 Evidence-Based Public Health 21

Learning Objectives 21
How Can We Describe a Health Problem? 22
How Can Understanding the Distribution of Disease Help Us Generate
Ideas or Hypotheses about the Cause of Disease? 24
 vi Contents

How Do Epidemiologists Investigate Whether There Is Another

Explanation for the Difference or Changes in the Distribution of Disease? 25
What Is the Implication of a Group Association? 26
Etiology: How Do We Establish Contributory Cause? 27
What Can We Do if We Cannot Demonstrate All Three Requirements
To Definitively Establish Contributory Cause? 28
What Does Contributory Cause Imply? 31
Recommendations: What Works To Reduce the Health Impact? 32
Implementation: How Do We Get the Job Done? 35
Evaluation: How Do We Evaluate Results? 36
Key Words 39
Discussion Questions 42
References 43

Section I Cases and Discussion Questions 44

Hiv/Aids Determinants and Control of the Epidemic 45
Smoking and Adolescents—The Continuing Problem 45
Reye’s Syndrome: A Public Health Success Story 46
Sudden Infant Death Syndrome (SIDS) 47
Oxygen Use in Premature Infants and Blindness 48

Section II Tools of Population Health 51

Chapter 3 Public Health Data and Communications 53
Learning Objectives 53
What Is the Scope of Health Communications? 54
Where Does Public Health Data Come From? 55
How Is Public Health Information Compiled To Measure the
Health of a Population? 55
How Can We Evaluate the Quality of the Presentation of Health Information? 58
What Factors Affect How We Perceive Public Health Information? 60
What Types of Information Needs To Be Combined To Make Health Decisions? 61
What Other Data Needs To Be Included in Decision Making? 63
How Do We Utilize Information To Make Health Decisions? 67
How Can We Use Health Information To Make Healthcare Decisions? 67
Key Words 70
Discussion Questions 71
References 72

Chapter 4 Social and Behavioral Sciences and Public Health 73

Learning Objectives 73
How Is Public Health Related to the Social and Behavioral Sciences? 74
 Contents vii

How Are Social Systems Related to Health? 75

Complex Interactions 75
Influencing Behavior 76
How Do Socioeconomic Status, Culture, and Religion Affect Health? 76
Socioeconomic Status 76
Culture 78
Religion 79
What Are Social Determinants of Health? 79
10 Key Categories of Social Determinants of Health 80
How Do Social Determinants Affect Health? 81
Can Health Behavior Be Changed? 82
Why Are Some Individual Health Behaviors Easier To Change than Others? 83
How Can Individual Behavior Be Changed? 83
How Can Health Behavior Be Explained and Predicted? 84
What Are Some Key Theories and Models Used to Address Health Behavior? 84
Intrapersonal Level 84
Interpersonal Level 85
Population and Community Level 88
How Can Theories Be Applied in Practice? 90
Choosing a Theory/Model 90
Planning Frameworks 90
Key Words 93
Discussion Questions 94
References 95

Chapter 5 Health Law, Policy, and Ethics 97

Learning Objectives 97
What Is the Scope of Health Law, Policy, and Ethics? 98
What Legal Principles Underlie Public Health and Health Care? 99
What Do We Mean by “Health Policy”? 100
How Are Public Health Policy Priorities Established? 101
How Do Philosophies Toward the Role of Government Affect Health Policies? 101
Is There a Right to Health Care? 103
How Does Public Health Attempt To Balance the Rights of
Individuals and the Needs of Society? 104
What Bioethical Principles Are Used to Address Public Health Issues? 104
How Can Bioethical Principles Be Applied to Protecting Individuals
Who Participate in Research? 106
Key Words 108
Discussion Questions 109
References 110
 viii Contents

Section II Cases and Discussion Questions 111

Don’s Diabetes 112
A New Disease Called SADS—A Decision Analysis 113
José and Jorge—Identical Twins without Identical Lives 113
The Obesity Epidemic in the United States—The Tip of an Iceberg 114
Changing Behavior—Cigarette Smoking 115
The Elderly Driver 116

Section III Preventing Disease, Disability, and Death 117

Chapter 6 Noncommunicable Diseases 119
Learning Objectives 119
What Is the Burden of Noncommunicable Disease? 120
How Can Screening for Disease
Address the Burden of Noncommunicable Diseases? 120
How Can Identification and Treatment of Multiple Risk
Factors Be Used To Address the Burden of Noncommunicable Disease? 124
How Can Cost-Effective Interventions Help Us Address the Burden of
Noncommunicable Diseases? 127
How Can Genetic Counseling and Intervention Be Used To Address
the Burden of Chronic Diseases? 129
What Can We Do When Highly Effective Interventions Do Not Exist? 130
How Can We Combine Strategies To Address Complex Problems of
Noncommunicable Diseases? 131
Key Words 132
Discussion Questions 133
References 134

Chapter 7 Communicable Diseases 135

Learning Objectives 135
What Is the Burden of Disease Caused by Communicable Diseases? 136
How Do We Establish that an Organism Is a Contributory Cause of
a Communicable Disease? 138
What Factors Affect the Ease with which a Communicable Disease
is Transmitted? 138
Route of Transmission 138
Asymptomatic Transmission 138
Reproduction Ratio 139
What Public Health Tools Are Available To Address the Burden of
Communicable Diseases? 139
How Can Barriers Against Disease Be Used To Address the Burden
of Communicable Diseases? 139
 Contents ix

How Can Immunizations Be Used To Address the Burden of

Communicable Disease? 140
How Can Screening and Case Finding Be Used To Address the Burden of
Communicable Disease? 140
How Can Treatment of Those Diagnosed and Their Contacts Help To
Address the Burden of Communicable Disease? 141
How Can Public Health Efforts Maximize Effectiveness of Treatment
and Prevent Resistance? 141
How Can Public Health Strategies Be Used To Eliminate Specific
Communicable Diseases? 141
What Options Are Available for the Control of HIV/AIDS? 143
What Options Are Available for the Control of Influenza? 146
What Options Are Available for the Control of Rabies? 147
Key Words 148
Discussion Questions 149
References 150

Chapter 8 Environmental Health and Safety 151

Learning Objectives 151
What Is Meant by “Environment”? 152
What Is the Burden of Disease Due to the Physical Environment? 153
How Do We Interact with Our Physical Environment? 155
How Does Risk Assessment Address the Impacts of
the Physical Environment? 156
What Is a Public Health Assessment? 158
What Is an Ecological Risk Assessment? 158
What Is an Interaction Analysis Approach to Environmental Diseases? 160
What Do We Mean by “Intentional and Unintentional Injuries”? 162
What Is Being Done To Keep the Population Safe? 162
Key Words 165
Discussion Questions 166
References 167

Section III Cases and Discussion Questions 168

High Blood Pressure: A Public Health and Healthcare Success 169
Testing and Screening 169
H. pylori and Peptic Ulcers 170
What to do about Lyme Disease? 171
Sharma’s Village 172
Legal Drugs that Kill—Death from Prescription Drug Overdoses 172
 x Contents

Section IV Health Professionals, Healthcare

Institutions, and Healthcare Systems 175
Chapter 9 Health Professionals and the Health Workforce 177
Learning Objectives 177
What Do We Mean by a “Health Professional”? 178
How Do Education and Training Serve To Define Health Professions? 179
What Are the Educational Options within Public Health? 179
What Is the Education and Training Process for Physicians? 181
What Is the Education and Training Process for Nursing? 184
What Roles Do Physicians, Nurses, and Other Clinical Health
Professions Play in Public Health? 185
What Is Meant by “Primary, Secondary, and Tertiary Care”? 185
How Are Clinical Health Profesionals Rewarded and
Compensated for Their Services? 186
How Can We Ensure the System has the Right Number of
Healthcare Professionals? 188
Key Words 189
Discussion Questions 190
References 191

Chapter 10 Healthcare Institutions 193

Learning Objectives 193
What Institutions Make up the Healthcare System? 194
What Types of Inpatient Facilities Exist in the United States? 194
What Types of Outpatient Facilities Exist in the United States? 196
What Do We Mean by the “Quality of Healthcare Services?” 196
How Can Health Care Be Coordinated Among the Multiple
Institutions that Provide Healthcare Services? 198
What Types of Coordination of Care Are Needed and What
Purposes Do They Serve? 198
What Types of Healthcare Delivery Systems Are Being Developed
and How Can They Help Ensure Coordination of Health Care? 198
How Can Electronic Medical Records Be Used To Facilitate
Coordination of Care and Improve Quality? 200
How Is Technology Being Used To Improve the Quality of Care? 202
What Mechanisms Are Being Used To Monitor and Ensure the Quality
of Health Care in the United States? 203
Can Disclosing Medical Errors Contribute to Quality of Care
and Serve as an Alternative to Malpractice? 203
Key Words 205
Discussion Questions 206
References 207
 Contents xi

Chapter 11 Health Insurance and Healthcare Systems 209

Learning Objectives 209
How Much Money Does the United States Spend on Health Care? 210
What Types of Government-Supported Health Insurance Are Available? 211
Medicare 211
Medicaid 212
What Types of Employment-Based Health Insurance Are Available? 213
What Are the Key Health Insurance Changes Incorporated into
the ACA Legislation? 215
What Might the United States Health Insurance System Look Like
When the ACA Phase-In Is Completed? 216
How Can We Describe Heathcare Systems in General
and the United States Healthcare System in Particular? 217
How Can We Describe the Healthcare Systems in Canada
and the United Kingdom? 217
What Conclusions Can We Reach from These Descriptions of the Healthcare
Systems in the United States, Canada, and the United Kingdom? 217
How Can a Healthcare System Be Scored? 219
Using the National Scorecard, How Does the United States’ Healthcare
System Perform Compared to Those of Other Developed Countries? 219
How Can the Costs of Health Care Be Controlled in the United States? 220
Key Words 223
Discussion Questions 224
References 225

Section IV Cases and Discussion Questions 226

When Nursing Meets Medicine 227
Jack and Continuity of Care 227
Donna’s Doctor—To Err Is Human 228
Health Care in the United States—For Better or Worse? 229
Excess Costs—How Much Can Be Saved? 230

Section V Public Health Institutions and Systems 231

Chapter 12 Public Health Institutions and Systems 233
Learning Objectives 233
What Are the Goals and Roles of Governmental Public Health Agencies? 234
What Are the 10 Essential Public Health Services? 235
What Are the Roles of Local and State Public Health Agencies? 237
What Are the Roles of Federal Public Health Agencies? 239
What Are the Roles of Global Health Organizations and Agencies? 242
How Can Public Health Agencies Work Together? 243
What Other Government Agencies Are Involved in Health Issues? 243
 xii Contents

What Roles Do Nongovernmental Organizations Play in Public Health? 244

How Can Public Health Agencies Partner with Health Care To
Improve the Response to Health Problems? 244
How Can Public Health Take the Lead in Mobilizing Community
Partnerships To Identify and Solve Health Problems? 245
Key Words 247
Discussion Questions 248
References 249

Chapter 13 Food and Drugs as Public Health Issues 251

Learning Objectives 251
What Are Important Milestones in the History of Food
and Drugs as Public Health Issues in the United States? 252
Food and Food Safety 253
What Ways Can Food Affect Health and Disease? 253
How Important Is Foodborne Communicable Disease
as a Cause of Morbidity and Mortality? 255
What Are the Steps in Foodborne Outbreak Investigation? 255
What Is Being Done To Prevent Foodborne Diseases? 256
In the United States, What Other Programs Aim to
Prevent Food-Related Disease and Disability? 257
Drugs and Drug Safety 258
Why Is Drug Safety Considered an Important
21st Century Public Health Issue? 258
What Do We Mean By “Preclinical Research” on Drugs? 259
What Is Phase 1? 259
What Are Phase 2 and Phase 3? 260
What Are the Implications of FDA Approval of a Drug? 260
How Are Adverse Effects of a Drug Monitored in Phase 4,
after FDA Approval? 262
What Else Can Be Done? 262
Do All FDA-Regulated Products Receive the Same Effectiveness
and Safety Assessment as Prescription and Nonprescription Drugs? 264
What Other Products Does the FDA Regulate? 264
Key Words 264
Discussion Questions 265
References 266

Chapter 14 From Single Solutions to Systems Thinking—The Future

of Population Health 267
Learning Objectives 267
What Makes Systems Thinking Different? 268
What Is a System? 269
 Contents xiii

How Can Systems Analysis Be Used To Understand

the Health Research Process? 269
What Are the Initial Steps in Systems Analysis? 270
What Additional Steps Are Needed To Complete a Systems Analysis? 271
How Can We Use a Systems Analysis To Better Understand a Problem
such as Coronary Artery Disease? 272
How Can We Use Systems Diagrams To Display the Workings of a System? 273
How Can We Apply Systems Thinking to Population Health Issues? 278
How Can Systems Thinking Help Us Incorporate Interactions
Between Factors To Better Understand the Etiology of Disease? 278
How Can Systems Thinking Help Take into Account
the Interactions Between Diseases? 279
How Can Systems Thinking Help Us Understand the Impact of
a Disease over the Life Span? 279
How Can Systems Thinking Help Identify Bottlenecks and Leverage Points
that Can Be Used To Improve Population Health? 280
How Can Systems Thinking Help Us Develop Strategies
For Multiple Simultaneous Interventions? 280
How Can Systems Thinking Help Us Look at Processes as a Whole To
Plan Short-Term and Long-Term Intervention Strategies? 281
How Can Systems Thinking Help Us Predict the Future Frequency
of Diseases? 282
What Can Systems Thinking Contribute to Public Health,
and What Are Its Limitations? 283
Key Words 283
Discussion Questions 284
References 285

Section V Cases and Discussion Questions 286

Public Health Departments—Getting the Lead Out 287
Community-Oriented Primary Care (COPC) 287
Hurricane Karl and the Public Health Success in Old Orleans 288
Lung Cancer: Old Disease, New Approaches 289
Restorital—How Do We Establish Safety? 290
The Future of HIV/AIDS 291

Glossary 293

Index 305
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Acknowledgments

Public Health 101: Healthy People–Healthy Populations, Second Edition, is the culmination of 15 years of effort aimed
at introducing public health to undergraduates. The effort originated with the teaching of an introductory course in
public health in 1998 at the then newly created The George Washington University School of Public Health and Health
Services. The new course, organized by associate dean Nancy Alfred Persily, inspired efforts to teach and to learn from
a new generation. The approach was designed as part of a liberal arts education, stimulating the movement that came
to be called the Educated Citizen and Public Health.
Efforts to think through the content of an introductory course in public health have involved a large number of
people throughout the United States. Public health, arts and sciences, and clinical educators all participated in the 2006
Consensus Conference on Public Health Education, which put forward the framework for Public Health 101 upon
which this book is based. Among those who led and continue to lead this effort is Susan Albertine, whose insights into
the relationship between public health and liberal education have formed the basis for much of the Educated Citizen
and Public Health movement.
I have taught Public Health 101 since 2002, which has provided me with an opportunity to teach and to learn from
over 400 undergraduate students at The George Washington University. Their feedback and input has been central
to writing and rewriting this book. Madison Hardee and Katie Harter deserve special recognition for their extensive
feedback on many chapters of the first edition. Yifen Liu provided important feedback for the second edition. I would
also like to thank Alan Greenberg and Dante Verme, the chair and vice chair of the Department of Epidemiology and
Biostatistics at The George Washington University School of Public Health and Health Services, for their support of
my efforts to expand the audience for undergraduate public health.
A key change in the second edition is the addition of a second author. I am pleased to welcome and acknowledge
the contributions of Brenda Kirkwood, MPH, DrPH. I first had the opportunity to work with Brenda while she was a
DrPH student at The George Washington University. Dr. Kirkwood has made extraordinary contributions to the sec-
ond edition. She has taken the primary responsibilities for writing and rewriting several chapters. Her careful reviews
and dedication to getting the details right have been key to the quality of this edition. Brenda is truly exceptional and
a pleasure to work with, as will be confirmed by all who work with her.
The draft of the second edition went through extensive review and feedback. I am grateful to all those who read
chapters and provided constructive input. Mike Brown, Publisher of the Public Health and Health Administration
line of products for Jones & Bartlett Learning, has made special contributions to this book and the series as a whole.
His vision has helped craft the series, and his publishing expertise made it happen. The production, marketing, and
editorial staff of Jones & Bartlett Learning deserve special recognition. Their commitment to this book and the entire
Essential Public Health series has gone well beyond the expectations of their jobs.
 xvi Acknowledgments

Last, but by no means least, is my wife, Linda Riegelman, who encouraged this book and the Essential Public Health series
from the beginning. She saw the need to reach out to students and make real the roles that public health plays in their everyday
lives. Linda went the extra mile by reading and rereading both the first and the second edition. She deserves the credit for what
works, but the blame for what fails is all mine.
Confronting the challenge of putting together Public Health 101 has been one of the great joys of my professional life. I hope
it will bring both joy and challenge to you as you enter into the important and engaging world of public health.

Richard Riegelman, MD, MPH, PhD

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Preface: What Is Public Health 101: Healthy

People–Healthy Populations All About?

Public health is more than a profession; it is a way of thinking. Public Health 101: Healthy People–Healthy Populations
introduces you to the profession and also the way of thinking that we will call population health. Population health is
an important way of looking at the world, whether you are going into public health as a profession, a clinically oriented
health profession, business, law, international affairs, or a range of other professions.
Population health is also a key way of thinking, which prepares you for the challenges of citizenship in a democ-
racy. Many of the issues that come before us as a society stem from or benefit from a population health perspective.
Whether we are dealing with AIDS, the impact of aging, climate change, or the costs of health care, the population
perspective can help us frame the issues and analyze the options to intervene.
In addition, the population perspective leads us to look broadly at the way issues intertwine and interact with
each other. We call this systems thinking. In population health, systems thinking is taking center stage as we increas-
ingly struggle with complex problems that require us to look beyond the traditional boundaries of health and disease.
Until recently, public health was considered a discipline taught only at the graduate level. Today, undergraduate
public health is booming at four-year colleges and is beginning to take hold at community colleges as well. Its roots
in general and liberal education go back to the 1980s, when David Fraser, the president of Swarthmore and an epi-
demiologist who led the investigation of Legionnaires’ disease, wrote a now classic article called “Epidemiology as a
Liberal Art.”1
In 2003, the Institute of Medicine of the National Academies of Sciences recommended that “all undergraduates
should have access to education in public health.”2 That recommendation encouraged the development of the Edu-
cated Citizen and Public Health initiative, a collaboration of undergraduate educators and public health educators to
define and stimulate public health curricula for all undergraduates. Public Health 101 was written to implement the
recommendations that came out of this initiative and continue to form the basis for undergraduate education in public
health.
This second edition of Public Health 101 has been thoroughly updated and expanded. Each chapter includes new
material designed to expand your understanding of public health. Two new chapters have been added, one on food and
drugs as public health issues and the other on systems thinking as the future of population health. These chapters are
designed to keep Public Health 101 at the cutting edge of new developments and ways of thinking. In addition, each
of the five sections includes new case studies challenging you to apply what you have learned.
Public Health 101: Healthy People–Healthy Populations will not try to overload your mind with facts. It is about
providing you with frameworks for thinking, and applying these frameworks to real situations and thought-provoking
scenarios. Each chapter begins and ends with vignettes designed to show you the types of situations you will confront
in public health. After each section, there are cases studies that relate to one or more chapters in the section. They
 xviii Preface: What Is Public Health 101: Healthy People–Healthy Populations All About?

provide realistic, engaging exercises and open-ended questions to help you think through the application of the key concepts
presented in each section.
Public Health 101 is designed as a gateway to the world of public health. It provides an introduction to the Essential Public
Health series, a comprehensive series designed primarily for undergraduate public health education. You should take advantage
of the Essential Public Health series’ website at www.essentialpublichealth.com. It provides information on all the books in the
series.
Hopefully, you will come away from reading Public Health 101 with an appreciation of how the health of the public is
influenced by and can be improved by efforts directed at the population level, as well as at the individual level. Let us begin in
Chapter 1 by exploring the ways that public health affects everyone’s daily life.

References
1. Fraser DW. Epidemiology as a liberal art. N Engl J Med. 1987;316:309–314.
2. Gebbie K, Rosenstock L, Hernandez LM. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington DC:
National Academy Press; 2003.