Population Health, Epidemiology, and Public Health: Management Skills for Creating Healthy Communities, Second Edition

By Rosemary M. Caron

COVID-19 triggered broad discussions of population health, epidemiology, and public health, not only in academic communities but also in society at large. Although masks, social distancing, and vaccines helped curb its spread, the novel coronavirus will clearly not be the last infectious disease that tests our preparedness. Healthcare professionals must continue to collaborate and implement new strategies to mitigate future crises.

Population Health, Epidemiology, and Public Health: Management Skills for Creating Healthy Communities presents the principles and tools that administrators and practitioners need to monitor, assess, and manage the health of populations in challenging times. Although public health catastrophes can and will change over time, the key concepts and evidence-based lessons detailed in this book are both timeless and essential.

Author Rosemary M. Caron uses real-world case studies and examples to teach unique and innovative approaches to population health improvement. This significantly updated edition includes five new chapters on the social determinants of health, disease prevention strategies, the value of a systems-thinking methodology, and the application of population health principles during the COVID-19 pandemic.

Other new content in this edition includes:

Current public health initiatives, including Healthy People 2030Discussions on ethical conduct in researchUp-to-date epidemiological case studies on Salmonella, Zika virus, measles, and COVID-19Approaches to population health, such as community health needs assessments and Health in All PoliciesExercises that draw on data sources

Each chapter concludes with discussion prompts and key points to reinforce readers' understanding of the concepts presented.

Healthcare managers who are armed with the foundational principles described in this book will help their organizations take greater strides toward building healthier communities and facing future crises head-on.

• Language: English
• Publisher: Gateway to Healthcare Management
• Release date: Oct 28, 2021
• ISBN: 9781640552890

Book preview

Front Cover: Population Health, Epidemiology, and Public Health, Management Skills for Creating Healthy Communities, Second Edition, Rosemary M. Caron

HAP/AUPHA Editorial Board for Undergraduate Studies

Monica L. Rasmus, DrPH, Chairman

Texas Southern University

Ana A Abad-Jorge, EdD

University of Virginia

Bryan K. Breland, DrPH, JD

University of Alabama at Birmingham

Tina DiFranco

University of Baltimore

Lennox Graham, DM

Howard University

Holly Hampe, DSc

Robert Morris University

Lori Peterson, PhD

Northeastern State University

Jessica L. Ryan, PhD

University of West Florida

Dale L. Sanders, DO, DHA

Alma College

Mark Sciegaj, PhD

Pennsylvania State University

Geoffrey Silvera

Auburn University

James H. Tiessen, PhD

Ryerson University

Population Health, Epidemiology, and Public Health, Management Skills for Creating Healthy Communities, Second Edition, Rosemary M. Caron, Gateway, To Healthcare Management, HAP, AUPHA, Health Administration Press, Chicago, Illinois, Association of University Programs in Health Administration, Washington, DC

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This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The statements and opinions contained in this book are strictly those of the author and do not represent the official positions of the American College of Healthcare Executives or the Foundation of the American College of Healthcare Executives.

Copyright © 2022 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher.

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Library of Congress Cataloging-in-Publication Data

Names: Caron, Rosemary M., author. | Association of University Programs in Health Administration, issuing body.

Title: Population health, epidemiology, and public health : management skills for creating healthy communities / Rosemary M. Caron.

Other titles: Population health | Gateway to healthcare management.

Description: Second edition. | Chicago, Illinois : Health Administration Press ; Washington, DC : Association of University Programs in Health Administration, [2022] | Series: Gateway to healthcare management | Preceded by Population health / Rosemary M. Caron. [2017]. | Includes bibliographical references and index. | Summary: This book presents the principles and tools that administrators and practitioners need to monitor, assess, and manage the health of populations in challenging times—Provided by publisher.

Identifiers: LCCN 2021025710 (print) | LCCN 2021025711 (ebook) | ISBN 9781640552920 (paperback ; alk. paper) | ISBN 9781640552890 (epub) | ISBN 9781640552906 (mobi)

Subjects: MESH: Population Health | Epidemiologic Measurements | Public Health—methods | Health Status Indicators | Social Determinants of Health

Classification: LCC RA418 (print) | LCC RA418 (ebook) | NLM WA 300.1 | DDC 362.1—dc23

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To my family, colleagues, and students (past, present, and future).

To all public health professionals, healthcare providers, and administrators.

BRIEF CONTENTS

Foreword

Preface

Acknowledgments

Chapter 1    Public Health: Prevention, Promotion, Protection

Chapter 2    Social Determinants of Health (Part 1): Where You Live Impacts Your Health

Chapter 3    Social Determinants of Health (Part 2): Keys to Improving Community Health

Chapter 4    Prevention, Challenges, and Population Health

Chapter 5    The Role of Data in Population Health

Chapter 6    Epidemiology: The Basic Science of Public Health

Chapter 7    Descriptive Epidemiology: The Significance of Person, Place, and Time

Chapter 8    Epidemiologic Measures of Disease Burden and Disease Frequency

Chapter 9    Analytic Epidemiology: Steps Toward Establishing Association and Causation Between Exposure and Disease

Chapter 10  Infectious Disease Epidemiology

Chapter 11  Community Health Assessment: A Public Health Duty

Chapter 12  Population Health: A Culture of Health Improvement Approaches

Chapter 13  Principles of Population Health Management

Chapter 14  Population Health Improvement: A Systems Approach

Chapter 15  Keeping Communities Healthy During the COVID-19 Pandemic

Appendix: Internet and Social Media Resources

Glossary

Index

About the Author

DETAILED CONTENTS

Foreword

Preface

Acknowledgments

Chapter 1    Public Health: Prevention, Promotion, Protection

Learning Objectives

Introduction

Public Health Defined

The History of Public Health

The Public Health Mission, Infrastructure, and Essential Services

The Distinction Between Public Health and Healthcare

Public Health Achievements and Initiatives

Public Health and Politics

Population Health and Public Health

Key Chapter Points

Discussion Questions

References

Chapter 2    Social Determinants of Health (Part 1): Where You Live Impacts Your Health

Learning Objectives

Introduction

Health Determinants

Social Determinants of Health

Equality Versus Equity

Social Justice

Case Study: Childhood Lead Poisoning in a Refugee Resettlement Community

Key Chapter Points

Discussion Questions

References

Chapter 3    Social Determinants of Health (Part 2): Keys to Improving Community Health

Learning Objectives

Introduction

Collective Efficacy, Social Cohesion, and Social Capital: Keys to Improving Community Health

Culture of Health Initiative

Health in All Policies

Social-Ecological Model

Field Model of Health and Well-Being

Social Gradient of Health

Population Health Outcomes

Case Study: COVID-19 in Racial and Ethnic Minority Populations

Key Chapter Points

Discussion Questions

References

Chapter 4    Prevention, Challenges, and Population Health

Learning Objectives

Introduction

Prevention in Public Health

Public Health Challenges and Approaches

Prevention and Population Health

Key Chapter Points

Discussion Questions

References

Chapter 5    The Role of Data in Population Health

Learning Objectives

Introduction

Public Health Data

Healthcare Data

Health Information Privacy and Security

Key Chapter Points

Discussion Questions

References

Chapter 6    Epidemiology: The Basic Science of Public Health

Learning Objectives

Introduction

Epidemiology Defined

Questions and Goals

Quantitative and Qualitative Data

Frequency of Disease

Epidemiologic Tools

Case Study: Ebola Viral Disease Outbreak

Key Chapter Points

Discussion Questions

References

Chapter 7    Descriptive Epidemiology: The Significance of Person, Place, and Time

Learning Objectives

Introduction

The Development of Epidemiology

Case Study: John Snow and the London Cholera Epidemic

Person, Place, and Time

Descriptive Epidemiology Indicators and Methods

Case Study: Pneumocystis Pneumonia—Los Angeles

Epidemiologic and Demographic Transitions

Key Chapter Points

Discussion Questions

References

Chapter 8    Epidemiologic Measures of Disease Burden and Disease Frequency

Learning Objectives

Introduction

Crude Rates

Specific Rates

Adjusted Rates

Key Chapter Points

Discussion Questions

Answers to Chapter Exercises

References

Chapter 9    Analytic Epidemiology: Steps Toward Establishing Association and Causation Between Exposure and Disease

Learning Objectives

Introduction

Ethical Conduct in Research

Case–Control Studies

Cohort Studies

Experimental Studies

Bias and Confounding

Hill’s Criteria

Key Chapter Points

Discussion Questions

Answers to Chapter Exercises

References

Chapter 10  Infectious Disease Epidemiology

Learning Objectives

Introduction

The Epidemiologic Triangle

Infectious Disease Transmission

Tracking Infectious Disease Occurrence

Epidemic Curves

Disease Outbreak Investigation

Case Study: Salmonellosis Outbreak

Public Health Interventions

Emerging Infectious Diseases

Case Study: Zika Virus

Case Study: Measles Outbreak

Case Study: COVID-19

Key Chapter Points

Discussion Questions

References

Chapter 11  Community Health Assessment: A Public Health Duty

Learning Objectives

Introduction

Community Health Assessment

Community Health Improvement Plan

Issues in Data Collection and Analysis for Community Health Assessment

Community Benefit Standard

Improving the Health of a Community Takes a Village

Key Chapter Points

Discussion Questions

References

Chapter 12  Population Health: A Culture of Health Improvement Approaches

Learning Objectives

Introduction

A Population Health Approach

Managerial Epidemiology: Population Health Tool for the Healthcare Setting

Population Health Care Management Model

Key Chapter Points

Discussion Questions

References

Chapter 13  Principles of Population Health Management

Learning Objectives

Introduction

Defining Population Health Management

PHM Drivers

PHM, Population Medicine, Population Health, Public Health: An Issue of Semantics?

PHM Risk Stratification

PHM Measures

CDC PHM Initiatives

PHM Approaches

Data-Driven Approach to PHM

Key Chapter Points

Discussion Questions

References

Chapter 14  Population Health Improvement: A Systems Approach

Learning Objectives

Introduction

Moving Forward with Population Health Management

Addressing PHM Challenges Through Systems Thinking

Tools for Implementing a Systems Approach

Key Chapter Points

Discussion Questions

References

Chapter 15  Keeping Communities Healthy During the COVID-19 Pandemic

Learning Objectives

Introduction

Descriptive Epidemiology of COVID-19

Case Study: COVID-19 Outbreak

COVID-19 and SARS-CoV-2

COVID-19 Symptoms and Transmission

Reproduction Number

Herd Immunity and Interventions

Preparedness and Response

COVID-19 Implications

Effective Tools

COVID-19 Vaccines

Potential Pandemic Outcomes

COVID-19 Variants and Surges

Public Health Lessons

COVID-19 Data Resources

Hospitals and Population Health Approaches During the COVID-19 Pandemic

Key Chapter Points

Discussion Questions

References

Appendix: Internet and Social Media Resources

Glossary

Index

About the Author

FOREWORD

Public health leadership is best approached as a lifelong learning process.

—J. W. Holsinger (2018, 29)

Health services transformations differ from transitions in their magnitude, scope, and universality. Although the world has endured countless pandemics over the centuries, the impact from the unprecedented COVID-19 virus distinguishes this seminal event as one that became a primary catalyst for health sector change. The pandemic-related immediate and potential long-term shifts in the way health services are designed, implemented, and ultimately assessed collectively support the urgent need for innovation. How do we envision new delivery models, optimum comprehension of patient/consumer and community health status, and overall coordination and collaboration among health providers and all related professionals? What is the role of the public health leader? This health crisis also highlighted the nation’s weaknesses and gaps in care to the extent that a national consensus emerged on issues such as health equality and equity of care and the importance of social determinants of health for positive population health outcomes.

To move beyond the popular adage of providing the right care at the right time, in the right place, and by the right health professional requires nudging health policy decision makers to energize and elevate a common core of health approaches. Public health leaders need to begin with ensuring a health-in-all-policies perspective that guarantees adhering to public health principles and standards, adopting new technologies to ensure shared epidemiological insights, and integrating population health management insights. To benefit from the recent pandemic challenges, will we use the lesson learned that the context of health is a primary influencer of health status?

Visionaries share a future perspective, leaders master the challenge of implementation, and experts provide guidance to facilitate the adoption of models and the development of competencies. In this second edition, Dr. Caron shares a clear framework for creating healthy communities, the primary goal of public and population health. To prepare future health professionals, the book effectively aligns three primary foundation disciplines—public health, epidemiology, and population health. Together, these three community health–centered domains offer a forward-thinking outline necessary for solving the complex problems challenging all elements of the health sector. How fortunate for the health professions to have this reimagined and timely textbook available now!

Anne M. Hewitt, PhD

Professor and Acting Chair, Department of Interprofessional Health Sciences and Health Administration

Director, Elizabeth A. Seton Institute for Community and Population Health

Seton Hall University

REFERENCE

Holsinger, J. W. 2018. The Nature of Effective Public Health Leadership. In Leadership for Public Health: Theory and Practice, edited by J. W. Holsinger and E. L. Carlton. Chicago: Health Administration Press.

PREFACE

Iwrote this text during the COVID-19 pandemic, a time Charles Dickens would have described as the best of times and the worst of times. It is, as the pandemic is still raging at the time of this writing, the best of times as the utility and significance of public health, epidemiology, and population health in keeping our communities healthy are being discussed in the mainstream media on a daily basis and the lay population is becoming an educated citizenry in these concepts. It is the worst of times because of the fear of a novel virus, mistrust of science, societal disruption, and most regrettably, the widespread morbidity and mortality. If ever there was a time for public health professionals and healthcare administrators to understand and implement public health, epidemiology, and population health tools, it is now. As tragic and trying as the COVID-19 pandemic is, it will not be the last novel infectious disease that tests our systems’ preparedness and resilience. For those who recall the SARS outbreak of 2002, many observers said that was a dress rehearsal. If so, then the COVID-19 pandemic is the main production that I contend we must learn from to advocate for more resources, prepare the public health and healthcare workforces and integrate their respective systems, and implement an interprofessional approach to the work of keeping our communities healthy. As dire as the data may seem some days, we must always be thinking about the public health mission and what we need to promote health, prevent disease, and protect the health of the populations we serve.

The public health and healthcare systems have made progress since the writing of the first edition of this text. Yet, there is more work to be done. I included the following passage from Toward a Healthy Future: Second Report on the Health of Canadians, by the Federal, Provincial, and Territorial Advisory Committee on Population Health (1999, vii) in the first edition of this text as it simplistically calls for the integration of the public health and healthcare systems:

Why is Jason in the hospital?

Because he has a bad infection in his leg.

But why does he have an infection?

Because he has a cut on his leg and it got infected.

But why does he have a cut on his leg?

Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel there that he fell on.

But why was he playing in a junk yard?

Because his neighbourhood is kind of run down. A lot of kids play there and there is no one to supervise them.

But why does he live in that neighbourhood?

Because his parents can’t afford a nicer place to live.

But why can’t his parents afford a nicer place to live?

Because his Dad is unemployed and his Mom is sick.

But why is his Dad unemployed?

Because he doesn’t have much education and he can’t find a job.

But why . . . ?

This vignette is powerful to me as it reminds us that the health of populations is complex and involves multiple determinants—those within our control and those not within our control. The interventions implemented to improve health must involve multiple stakeholders, and resources must be affordable, available, and effective to address the inequities in the community. Further, I am reminded that we need to adopt a collective view in our public health and healthcare systems to look upstream of the community’s health issues to try to intervene at the root cause of the problem—an innovative approach that requires the skills offered by public health and epidemiology to inform a population health management approach that has the ultimate goal of providing quality and affordable care measured by value, not fees. I share this vignette in the courses I teach because it serves, for me, as a reminder of the work remaining to be done and the direction we are heading.

The principles and skills that health administrators and public health practitioners need as they monitor, assess, and manage the health of populations in our reformed healthcare system are described in this new textbook edition.

Population Health, Epidemiology, and Public Health: Management Skills for Creating Healthy Communities examines, in great detail, topics that are pertinent to the education and practice of public health and healthcare management in today’s dynamic environment. Representative topics include core functions of public health, public health system organization, social determinants of health, disease prevention challenges, the basic science of public health, community health assessment, population health improvement approaches, the contribution of data to this process, and the role of systems thinking in improving a population’s health.

In addition, the chapters of Population Health, Epidemiology, and Public Health: Management Skills for Creating Healthy Communities use real case studies and examples to educate today’s students about the unique challenges and innovative approaches to evaluating and promoting the health of populations. In particular, the COVID-19 pandemic is highlighted throughout the text as a case study for public health and healthcare practice during challenging times. A third of this second edition includes new chapters focused on an expanded discussion of the social determinants of health, specific prevention challenges (e.g., adverse childhood experiences, e-cigarette or vaping product use–associated lung injury, the opioid epidemic), systems thinking, and application of concepts to the current state of the COVID-19 pandemic. Remaining chapters have been significantly revised and updated with respect to narrative, exhibits, exercises, and discussion prompts. The educational methodologies and case studies included herein impart the knowledge and skills required of today’s healthcare manager and public health professional, presenting a roadmap for a population health improvement approach.

This book is a detailed resource that presents evidence-based approaches useful to instructors and students as they learn how to promote health, prevent disease, and navigate the public health and healthcare challenges of an ever-changing environment. The lessons and topic areas within the text are timeless and offer a framework that can be expanded on by instructors based on their own experiences. Although public health and healthcare crises can and will change over time, the key concepts and lessons provided within this book are essential to our efforts to improve the health of populations.

REFERENCE

Federal, Provincial, and Territorial Advisory Committee on Population Health. 1999. Toward a Healthy Future: Second Report on the Health of Canadians. Ottawa, ON: Minister of Public Works and Government Services Canada.

INSTRUCTOR RESOURCES

This book’s Instructor Resources include a test bank; presentation PowerPoint slides; and an instructor manual with discussion question and case study answers, additional assignments, suggested readings, and web resource lists.

For the most up-to-date information about this book and its Instructor Resources, go to ache.org/HAP and browse for the book’s order code (2445I).

This book’s Instructor Resources are available to instructors who adopt this book for use in their course. For access information, please e-mail [e-mail].

ACKNOWLEDGMENTS

Iwould like to acknowledge my colleagues from the worlds of academia, public health, and healthcare practice for providing the experiences that have contributed to my work, first as a public health practitioner and currently as a professor of health management and policy.

The writing of this book has offered me the opportunity to reflect on my own preparation, both academically and professionally, to work as a public health practitioner and educator. I gratefully acknowledge my mentors at Regis College, the Geisel School of Medicine at Dartmouth, the Boston University School of Public Health, and the Harvard School of Public Health for the rigor their academic programs offered and the training in inquiry and research they so expertly delivered. I also thank my faculty colleagues at the University of New Hampshire for their mentoring and encouragement as I strive to continually perfect my teaching, research, and service responsibilities.

I would also like to acknowledge my colleagues at the Manchester (New Hampshire) Health Department and the New Hampshire Department of Health and Human Services, for these are the organizations where I learned to practice public health.

Education doesn’t always take place in the classroom, and I have enjoyed teaching and learning from students in diverse environments. I have especially enjoyed working with students who are passionate about improving the delivery of public health and healthcare services. I appreciate my students—both those I have had the pleasure to teach and learn from and those I have yet to meet—and I value the chance to share the experience of learning to make our populations healthier.

Further, I am grateful to Janet Davis at Health Administration Press for her excitement and encouragement as I first developed and wrote this book and to Jennette McClain in working with me on the updated second edition. Jennette’s expert listening skills and Lori Meek Schuldt’s expert editing ability—and their joint attention to detail—have resulted in this book being presented in a format of which I could not be more proud. Thank you.

Last but not least, as any author knows, writing a textbook is a labor of love. This book is the product of many hours spent conducting research, developing content, writing, formatting, editing, reflecting, and so on. I am grateful for the opportunity to create a textbook that has the potential to shape the knowledge, attitudes, and behaviors of future healthcare administrators and public health professionals, and I have not taken this task lightly. Because of the time commitment required for this book, I have had to sacrifice time with my family. My family is supportive of all that I do, and I am blessed that they encourage me and are most proud of my achievements. I could not have accomplished this body of work without their love, encouragement, and reassurance. I am forever grateful to them for understanding and appreciating my drive to improve the delivery of healthcare and public health services via teaching undergraduate and graduate students, for these students will work toward preventing disease, promoting health, and protecting the health of populations for a long time to come.

Rosemary M. Caron

CHAPTER 1

PUBLIC HEALTH: PREVENTION, PROMOTION, PROTECTION

A public health professional is a person educated in public health or a related discipline who is employed to improve health through a population focus.

—Institute of Medicine (2003)

LEARNING OBJECTIVES

After completing this chapter, you should be able to

Arrow points    define public health and explain its mission,

Arrow points    describe the core functions of public health and how they relate to the ten essential services of public health,

Arrow points    explain the three types of disease prevention efforts,

Arrow points    describe the organizational infrastructure of the public health system,

Arrow points    compare and contrast the public health and healthcare systems,

Arrow points    describe one public health initiative,

Arrow points    explain the greatest achievements in public health from the twentieth century, and

Arrow points    define population health.

INTRODUCTION

The public health system is essential to ensuring a healthy population. This chapter describes the mission of public health, discusses the essential services this system provides, and highlights the greatest public health achievements accomplished to date. This chapter will also demonstrate how public health influences our health on a daily basis. Finally, the chapter will examine the movement, in the age of healthcare reform, toward the integration of the healthcare and public health systems—which is at the center of the concept of population health.

The general population often thinks of public health as healthcare for the poor. However, providing the poor with access to healthcare is only one aspect of the public health function. The comprehensive approach that the field of public health uses to keep the general population healthy is often misunderstood or underappreciated. This chapter will examine the organization and functions of the public health system necessary to ensure the health of populations through efforts that prevent disease, promote health, and protect the health of the population.

Although public health is vital to our everyday lives, we often do not think about how it keeps us healthy until there is a significant event or tragedy, such as a pandemic, which Porta (2014, 209) defines as an epidemic occurring worldwide, or over a very wide area, usually affecting large numbers of people. A prime example is the COVID-19 pandemic, which our collective world population is attempting to manage via prevention and mitigation efforts during the writing of this text. Given this public health crisis, which is occurring on a global scale, I could not agree more with an editorial board member from the New York Times who stated, Time to give new life to an old idea: A strong public health system is the best guarantor of good health (Interlandi 2020). I hope you will agree as you examine the public health successes acknowledged and the challenges that public health works to prevent, on a daily basis, via its mission, functions, operational framework, collaborations, and multidisciplinary approaches.

PUBLIC HEALTH DEFINED

The World Health Organization (WHO), in the preamble of its constitution, defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO [1946] 2006, 1). The Institute of Medicine (IOM)—now the National Academy of Medicine—defined public health as fulfilling society’s interest in assuring conditions in which people can be healthy (IOM 1988, 7). C. E. A. Winslow, a leader in public health in the early part of the twentieth century and the first chair of the Department of Public Health at the Yale University School of Medicine, provided a more comprehensive definition that is still cited today (Winslow 1920, 30):

Public health is the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.

This definition highlights the multidisciplinary nature of the field, which is necessary for preventing disease, prolonging life, and promoting health. The overarching goal of public health is to ensure conditions—that is, living and working conditions—in which people in various geographic settings (e.g., neighborhoods, census tracts, communities, cities and towns, states, regions, counties) can be afforded the opportunity to live a healthy life. Winslow’s definition elaborates on how we are to accomplish this mission via organized community efforts, the organization of medical and nursing service, and the development of the social machinery—functions of a public health system that are still practiced today (Winslow 1920, 30). Exhibit 1.1 illustrates a public health word cloud—that is, words related to the meaning and function of public health.

EXHIBIT 1.1 Public Health Word Cloud

An illustration shows a word cloud with the words health, hygiene, medicine, life insurance, policy, diagnosis, public health, pills, virus, professional, doctor, health care, biology, vaccination, illness, and infections.

Apl Functional Symbol Circle White Rightwards Arrow FOR DISCUSSION: WHY PUBLIC HEALTH MATTERS

WhyPublicHealthMatters.org is a website developed by the de Beaumont Foundation (2020), an organization that advances policies and establishes partnerships to create healthy communities and a proficient public health workforce. Explore this website and discuss why public health matters to you.

THE HISTORY OF PUBLIC HEALTH

Narrowly considered, public health was originally thought to consist of the measures implemented by a community to protect the population from infectious diseases. In fact, a late-1700s outbreak of yellow fever—a viral disease transmitted by infected mosquitoes and most commonly found in South America and Africa, as documented by the Centers for Disease Control and Prevention (CDC 2019)—prompted the development of the first boards of health in major cities, including Philadelphia; Boston; Baltimore; New York City; Washington, DC; and New Orleans, to help prevent and mitigate the spread of disease. These events were followed by the sanitation movement of the mid-1800s, which led to the improvement of living conditions and the development of a type of public health organization in major cities (Pfizer Global Pharmaceuticals 2006). Exhibit 1.2 illustrates an 1872 smallpox vaccination campaign in New York City.

EXHIBIT 1.2 Smallpox Vaccination Campaign in New York City, 1872

A sketch shows people gathered around a person giving a smallpox vaccination another man

The rich history of public health in the United States dates back to the eighteenth century, when President John Adams signed a law providing for the care and relief of sick and injured merchant seamen in US ports (Pfizer 2006). The resulting marine hospitals were later organized into the Marine Hospital Service, which eventually became the US Public Health Service. The position we know today as the surgeon general was created to administer the Marine Hospital Service. The US Department of Health and Human Services maintains a website featuring biographies of past surgeon generals (www.surgeongeneral.gov/about/previous/index.html).

For those interested in reading more about the history of public health, George Rosen’s A History of Public Health (Johns Hopkins University Press 1993) offers a comprehensive overview of significant contributions to the field including sanitation, housing, occupational health, environmental health, public health administration, urban growth, epidemics, miasma versus contagion, provision of medical care, human welfare, and so on from the Middle Ages to the modern bacteriological era. According to J. M. Last, editor of A Dictionary of Public Health, miasma is a theory that had considerable currency during the 18th and 19th centuries as a way to explain the origin and propagation of some epidemic diseases, particularly cholera. The theory was that the cause was miasma, an ill-defined emanation from rotting organic matter. The theory derived empirical support from the observed distribution of malaria and yellow fever in marshy regions, until it was discovered that these are mosquito-borne diseases (Last 2007, 237). By contrast, contagion is transmission of infection by direct contact. In common usage and in public health, ‘contagious’ implies a condition that is highly infectious and usually severe, although one of the most contagious diseases, the common cold, is seldom severe (Last 2007, 75).

The focus of public health has expanded over time as human society has become more complex. Public health today is responsible not only for preventing infectious diseases, as was the case centuries ago, but also for ensuring safe living and working environments, preventing lifestyle- and behavior-related diseases, and preparing communities for natural and anthropogenic emergencies, to name a few examples.

THE PUBLIC HEALTH MISSION, INFRASTRUCTURE, AND ESSENTIAL SERVICES

The mission of public health can be described as disease prevention, health promotion, and protection of populations so they can live a healthy life. A helpful way to remember the mission of public health is by the three Ps:

Diamond shape bullet    Prevention of disease in a population

Diamond shape bullet    Promotion of health in a population

Diamond shape bullet    Protection of the health of a population

Taken together, the public health mission saves money, improves our quality of life, helps children thrive and reduces human suffering, according to the American Public Health Association (APHA 2021b).

To achieve this mission, public health operates at multiple levels of government (i.e., local, state, regional, county, national, federal, international) and in multiple sectors (i.e., private, nonprofit, voluntary). The core functions of public health, as described by the IOM (1988), are assessment, policy development, and assurance. Because no single health agency can execute all these core functions by itself, we rely on a complex network of community-based agencies and organizations to carry out the public health mission.

Exhibit 1.3 shows an illustration, as proposed by the CDC, of the organizations, institutions, and agencies—and their working interrelationships in the community—that make up the public health system. This illustration is not intended to be an all-inclusive representation of the entities involved in work that is related to assuring a healthy population, but it is a fair portrayal. This visual is further supported by the IOM, which describes the organizational infrastructure of public health as including the efforts of government (i.e., all levels), private and voluntary associations, and individuals (IOM 1988).

EXHIBIT 1.3 The Public Health System

A network diagram shows the public health agency and other organizations which contribute to the public health system

Note: EMS = emergency medical services; CHCs = community health centers.

Source: CDC (2014a).

The CDC outlined the structure of the public health system and further described the activities that public health systems should undertake to prevent disease, promote health, and protect the community’s health. These activities are known as the ten essential public health services (EPHS), and they are displayed in the diagram in exhibit 1.4. The EPHS are aligned with the core functions of public health—assessment, policy development, and assurance—in that each service is categorized according to the core function it fulfills. For instance, the diagram shows that the Monitor Health essential service corresponds with the Assessment core function. The EPHS were initially developed in 1994 and provide a framework for conducting the public health mission.

EXHIBIT 1.4 The Ten Essential Public Health Services

A circular diagram shows the ten essential public health services ensuring assurance, assessment, and policy development.

Source: CDC (2014b).

The CDC’s detailed descriptions for each essential service are summarized in the sections that follow.

EPHS #1: MONITOR HEALTH STATUS TO IDENTIFY AND SOLVE COMMUNITY HEALTH PROBLEMS

EPHS #1 provides answers to the questions, What’s going on in our state/community? and Do we know how healthy we are? It incorporates the following elements (CDC 2014b):

Diamond shape bullet    Accurate, periodic assessment of the community’s health status

Diamond shape bullet    Use of appropriate methods and technology, such as geographic information systems (GIS), to interpret and communicate data

Diamond shape bullet    Collaboration among all public health partners to establish and use disease or immunization registries

EPHS #2: DIAGNOSE AND INVESTIGATE HEALTH PROBLEMS AND HEALTH HAZARDS IN THE COMMUNITY

EPHS #2 responds to several questions: Are we ready to respond to health problems or threats? How quickly do we find out about problems? How effective is our response? It involves the following concerns (CDC 2014b):

Diamond shape bullet    Timely identification and investigation of health risks (e.g., disease outbreaks, chronic diseases, injuries, environmental hazards)

Diamond shape bullet    Availability of laboratory capacity to conduct rapid, diagnostic screening and testing

Diamond shape bullet    Response plans to address major health threats

EPHS #3: INFORM, EDUCATE, AND EMPOWER PEOPLE ABOUT HEALTH ISSUES

EPHS #3 responds to the question, How well do we keep all segments of our state/community informed about health issues? It incorporates the following (CDC 2014b):

Diamond shape bullet    Accessible health information and education to fulfill the public health mission

Diamond shape bullet    Health communication plans (e.g., media advocacy and social marketing)

Diamond shape bullet    Health education and health promotion activities conducted in conjunction with community partners

EPHS #4: MOBILIZE COMMUNITY PARTNERSHIPS AND ACTION TO IDENTIFY AND SOLVE HEALTH PROBLEMS

EPHS #4 considers the question, How well do we truly engage people in state/community health issues? It involves the following tasks (CDC 2014b):

Diamond shape bullet    Identifying potential stakeholders who value public health

Diamond shape bullet    Developing diverse, formal, and informal coalitions, partnerships, and strategic alliances to utilize human and material capital to improve the health of the community

EPHS #5: DEVELOP POLICIES AND PLANS THAT SUPPORT INDIVIDUAL AND COMMUNITY HEALTH EFFORTS

EPHS #5 addresses the questions, What policies in both the government and private sector promote health in our state/community? and How well are we setting health policies? It includes the following elements (CDC 2014b):

Diamond shape bullet    Effective public health governance

Diamond shape bullet    Development of policy, codes, regulations, and legislation to protect the public’s health

Diamond shape bullet    Systematic planning at the local and state levels for health improvement

EPHS #6: ENFORCE LAWS AND REGULATIONS THAT PROTECT HEALTH AND ENSURE SAFETY

EPHS #6 considers the question, When we enforce health regulations, are we technically competent, fair, and effective? It incorporates the following (CDC 2014b):

Diamond shape bullet    Review, evaluation, and revision of laws and regulations designed to protect health and safety

Diamond shape bullet    Education of persons and entities or businesses obligated to obey and agencies obligated to enforce laws and regulations

Diamond shape bullet    Enforcement activities to protect the public’s health, including abatement of nuisances, animal control, food safety, housing code, protection of drinking water, tobacco control, and enforcement activities during emergency situations

EPHS #7: LINK PEOPLE TO NEEDED PERSONAL HEALTH SERVICES AND ASSURE THE PROVISION OF HEALTHCARE WHEN OTHERWISE UNAVAILABLE

EPHS #7 addresses the question, Are people in my state or community receiving the health services they need? It involves the following concerns (CDC 2014b):

Diamond shape bullet    Identifying barriers to care

Diamond shape bullet    Ensuring the connection of people to appropriate health services through coordination of provider services and development of interventions that address such barriers to care as inadequate culturally and linguistically proficient services and lack of transportation services

EPHS #8: ASSURE A COMPETENT PUBLIC AND PERSONAL HEALTHCARE WORKFORCE

EPHS #8 answers the questions, Do we have a competent public health staff? and How can we be sure that our staff stays current? It involves the following elements (CDC 2014b):

Diamond shape bullet    Education, training, and assessment of personnel to fulfill the public health mission

Diamond shape bullet    Development of continuing education opportunities

Diamond shape bullet    Development of community-relevant learning experiences for all students

EPHS #9: EVALUATE EFFECTIVENESS, ACCESSIBILITY, AND QUALITY OF PERSONAL AND POPULATION-BASED HEALTH SERVICES

EPHS #9 considers several important questions: Are we meeting the needs of the population we serve? Are we doing things right? and Are we doing the right things? It incorporates the following (CDC 2014b):

Diamond shape bullet    Implementation of ongoing evaluation approaches to assess program effectiveness

Diamond shape bullet    Continuous quality improvement and performance management processes

EPHS #10: RESEARCH FOR NEW INSIGHTS AND INNOVATIVE SOLUTIONS TO HEALTH PROBLEMS

EPHS #10 addresses the question, Are we discovering and using new ways to get the job done? It incorporates the following public health research activities (CDC 2014b):

Diamond shape bullet    Initiating research and reporting results

Diamond shape bullet    Establishing linkages among academia, research, public health practice entities, and the community

Diamond shape bullet    Implementing policy based on the research results

THE WHEEL OF PUBLIC HEALTH SERVICES

Take the time to review and understand the significance of the wheel of EPHS, shown in exhibit 1.4. The wheel provides the blueprint by which public health acts in every community (with possible variations based on infrastructure and available resources). Notice that Research is at the center of the circle, meaning that, in order to implement these ten essential services and core functions of public health, the work must be grounded in research. In other words, public health research findings inform how the system carries out its services and functions. This research contributes toward establishing evidence-based public health practice, defined by Last (2007, 116), as application of best available evidence in setting public health policies and priorities. . . . Evidence-based public health is an approach that makes informed, explicit use of validated studies to arrive at judicious decisions on public health policies and best practices. Furthermore, when thinking about the functions and services illustrated in exhibits 1.3 and 1.4, notice the diverse areas of knowledge, skills, and disciplines required to ensure a healthy population.

The Community Tool Box (2021), an online resource developed by the University of Kansas Work Group for Community Health and Development and its partners, offers examples of how the EPHS are practiced in daily public health work. For example, Informing the public about an epidemiological outbreak investigation in the community is presented as an example of EPHS #2 (Diagnose and investigate health problems and health hazards in the community), and Maintenance of a sanitary restaurant environment for public well-being is an example of EPHS #6 (Enforce laws and regulations that protect health and ensure safety). The Community Tool Box represents part of the work group’s role as a designated World Health Organization Collaborating Centre for Community Health and Development.

Apl Functional Symbol Circle White Rightwards Arrow FOR DISCUSSION: PUBLIC HEALTH PRACTICE IN THE COMMUNITY

The field of public health is multidisciplinary in nature and requires collaboration among community organizations and agencies that, on first glance, may appear to have nothing in common. Consider this example: An urban community is experiencing elevated rates of teenage pregnancy. The community also lacks places where adolescents can engage in recreational activities after school, and the parks that do exist are home to gang violence. How are teenage pregnancy and violence related in this example? What community organizations should be involved to help address this public health problem? (Explain your rationale.) Describe two approaches that these identified community organizations should implement to prevent gang violence and teen pregnancy.

REVISED WHEEL OF 2020

The EPHS were revised in 2020 by two organizations, the Public Health National Center for Innovations and the de Beaumont Foundation. Exhibit 1.5 illustrates the revised wheel of public health services. The ten EPHS for the revised wheel are the following (CDC 2021):

EXHIBIT 1.5 Revised Wheel of Essential Public Health Services, 2020

A diagram shows the new revised essential public health services in a wheel format.

Source: CDC (2021).

Assess and monitor population health status, factors that influence health, and community needs and assets.

Investigate, diagnose, and address health problems and hazards affecting the population.

Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it.

Strengthen, support, and mobilize communities and partnerships to improve health.

Create, champion, and implement policies, plans, and laws that impact health.

Utilize legal and regulatory actions designed to improve and protect the public’s health.

Assure an effective system that enables equitable access to the individual services and care needed to be healthy.

Build and support a diverse and skilled public health workforce.

Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement.

Build and maintain a strong organizational infrastructure for public health.

THE DISTINCTION BETWEEN PUBLIC HEALTH AND HEALTHCARE

Because the health of a population differs from the health of an individual, public health and healthcare professionals approach their work differently. For example, the public health practitioner’s work focuses on the prevention of disease and promotion of health in the population as a whole. In contrast, the healthcare provider addresses health at the individual level by diagnosing and treating one person’s medical condition. The treatment utilized in public health includes interventions that could be educational or policy-based in nature, for example. Meanwhile, healthcare focuses on classic diagnosis and medical treatment.

Healthcare provides the diagnosis and treatment of disease and injury, whereas public health addresses the ensurance of access to those necessary services. Thus, public health and healthcare should be viewed as complementary health systems that collaborate to help develop the healthiest population possible. Goldsteen, Goldsteen, and Graham (2011, 5) state, accurately, that public health shares with the clinical professions a fundamental caring for humanity through concern for health. In public health practice, health is achieved via disease and injury prevention, and this prevention can be categorized into three types (Fos and Fine 2000):

Primary prevention is concerned with eliminating risk factors for a disease. An example of primary prevention might involve providing health education and immunizations.

Secondary prevention focuses on early detection and treatment of disease (subclinical and clinical). An example of secondary prevention might include a screening such as a colonoscopy or a mammogram.

Tertiary prevention attempts to eliminate or moderate disability associated with advanced disease. Examples of tertiary prevention might include physical therapy or diabetic foot checks.

Healthcare focuses mainly on secondary and tertiary prevention, when a disease has already occurred and a person is attempting to detect it early so treatment may be initiated (secondary prevention) or working to minimize further disability (tertiary prevention). Public health works in these areas of secondary and tertiary prevention through such efforts as providing access to medical visits, ensuring health literacy among the population, and promoting cultural competence among healthcare providers. The administration of immunizations is an example of an area in which healthcare and public health overlap in prevention, because immunizations are intended to prevent the development of disease (primary prevention). Another example of primary prevention is health education, which can inform people about disease risk factors and prevention methods so disease or injury can be avoided. These examples highlight the potential for integration of the public health and healthcare systems that are often viewed as distinct.

PUBLIC HEALTH ACHIEVEMENTS AND INITIATIVES

An ongoing debate between the public health and healthcare systems has involved which field is more responsible for the increased life expectancy that Americans experience today. Many people are surprised to learn that public health, rather than medical advancements, is the greater contributor. The CDC (1999) reported that public health is credited with adding 25 years to the life expectancy of people in the United States in the twentieth century. In 2017, the average life expectancy in the United States was 76.1 years for males and 81.1 years for females (Arias and Xu 2019)—a significant increase from the 1900 life expectancy of 47.9 years for males and 50.7 years for females (Arias 2012).

COVID-19 has been a significant cause of mortality during the pandemic and has resulted in a decrease in life expectancy. The National Center for Health Statistics (2021) reported that life expectancy declined from 78.8 in 2019 to 77.8 by June 2020. This result is the most significant decline in life expectancy since 1943, the middle of World War II. These data also confirm that minority populations, including African Americans, Latinos, and Native Americans, have been disproportionately affected by the pandemic. Life expectancy is not expected to rebound quickly because of pandemic-related long-term health effects and social and economic impacts on vulnerable populations (Andrasfay and Goldman 2021).

The CDC (1999) has identified what it considers the ten greatest achievements in public health in the twentieth century, and those achievements are listed in exhibit 1.6. These advances have been largely responsible for increasing the life span of populations (CDC 1999).

EXHIBIT 1.6 The Ten Greatest Public Health Achievements in the Twentieth Century

A textbox shows the ten greatest achievements of the twentieth century in the public health sector.

Source: CDC (1999).

Notice that the twentieth-century public health achievements listed in exhibit 1.6 largely represent issues that we, as members of the public, have come to expect as standard today. Our increased life expectancy and enhanced quality of life are the result of continued improvements in such areas as nutrition, housing, and environmental hygiene. We should continue to allocate resources to promote healthy workplaces and a reduced maternal and infant mortality rate to maintain the successes already achieved. However, in addition, efforts could be directed toward persistent public health issues