[MUSIC PLAYING] [MUSIC PLAYING] Welcome to an introductionto public health. My name is Susie McCarthy. As a health educationspecialist at the CDC, I’ve worked in a varietyof areas of public health, including children’shealth, infectious diseases, chronic diseases, and mostrecently public health workforce development. Public health is a dynamicand multi-disciplinary field as you’ll see from thisintroductory course. This slide shows theoutline for the course. We will begin by discussingthe purpose of public health and a few key terms. We will then look at some eventsin history of public health. Next, we’ll go throughthe public health approach and apply it to apublic health problem.We will then coverthe main functions and essential servicesof public health to show the broader context andidentify different groups who have a stake in public health. Lastly, we’ll discuss factorsthat determine health, and I’ll present thehealth impact pyramid as a framework forinfluencing public health at different levels. This introductorycourse should enable you to achieve thelearning objectives on the slide which alignwith the course outline that I just covered. So what is public health? CEA Winslow was a leadingfigure in the development of the modern studyof public health. Read this definitionof public health that he developedalmost a century ago and consider keywords or phrases in the definitionthat speak to you or tell you whatpublic health is.You might notice that as acombination of science and art, public health offers manyopportunities to be creative. Public health is not onlyabout preventing and treating disease, but it’s alsoabout promoting good health. Winslow says this is donethrough organized efforts. So what are some examplesof organized efforts? You might think about hownational surveillance systems are set up, how our wastemanagement infrastructure is built, or how the latestvaccination recommendations are developed and communicated. From Winslow’sdefinition, you might note that public health givespeople and organizations information to helpthem make choices that inform them and helpthem improve their health or the health of others.Public health also occursat different levels. Individual, organizational,and community levels, and even more broadlyat the city-state, national, andinternational levels. So here are two statements aboutthe mission of public health. The Institute ofMedicine says that there is a societal interestin ensuring conditions in which people canbe healthy, and we’ll come back to the concept ofassurance later in the course. The World HealthOrganization, or WHO, says public health is aboutserving the greater good. The maximum benefit for thelargest number of people. From these twostatements, you can see that public healthfocuses on groups of people rather than only on individuals. And at the coreof public health, there is this principleof social justice.That people have theright to be healthy and to live in conditionswhich support their health. So now that we knowwhat public health is, let’s review somecommon key terms. Clinical care is the prevention,treatment, and management of illness, and the preservationof mental and physical well being through health services. This is all also more commonlyreferred to as medical care or health care. A determinant, also knownas a health determinant, is a factor that contributesto the generation of a trait, such as one’s ethnicityor genetic makeup. But more broadly, thecontext of people’s lives determines theirhealth, and we’ll go into more detail abouthealth determinants also later in the course. Epidemic or outbreak, asyou can see on the slide, is the occurrence in acommunity or region of cases of an illness or a specifichealth related behavior in excess of whatyou would normally expect to see in that area.An epidemic and outbreakare used interchangeably. However, epidemic usuallyrefers to a larger geographic distribution of illnessesor health related events. It’s basically an epidemicoccurs when a disease spreads rapidly to many people. You might also hearthe term pandemic, which is kind of anepidemic on steroids. It often has aglobal impact, which means people onmultiple continents are affected by it, oftencrossing borders and going into different countries. A health outcome is the resultof a medical condition that directly affects a person’slife in terms of its quality or length. And think about the healthoutcomes for somebody who’s living with HIV, forexample, or who has diabetes. All right. So now we’ve come toa knowledge check, and I ask you to fill in theblank with the correct answer. Does public healthaim to provide groups of people orindividuals with the right to be healthy andlive in conditions that support their health? The answer is groups of people. Public health focuses onpopulations rather than individuals. The next knowledgecheck is asking, what is a disease occurrenceamong a population that is in excess of what’s expectedfor a given time and place? Is it pandemic, intervention,epidemic or outbreak, or prevention? And the correct answeris epidemic or outbreak.Now we’ll take a look at afew historical highlights of public healththrough the four lenses of sanitation and environmentalhealth, pandemics, disaster response andpreparedness, and prevention through policy. So the first lens willlook through encompasses the control ofdisease and promotion of health through sanitation toensure a healthy environment. Here are three examplesfrom around the globe of how public healthhas been implemented to contain infectious diseasethrough environmental measures.So around 500 BCE, it’srecorded that the ancient Greeks and Romans actively practicedsanitation measures. Fast forward approximatelytwo millennia and we see the workbegun long ago in Greece continuing in the UnitedKingdom through the passage of the PublicHealth Act of 1848, which established acentral board of health and placed responsibilitiesfor sanitation in the hands of burroughs. In 1970 in the UnitedStates, the administration of President Nixon establishedthe Environmental Protection Agency, which stilltoday protects our health by safeguardingair, water, and land. So next we’ll explorepandemics, and you’ll recall that these are similarto epidemics except that they affect even larger populations,often across countries and continents. So influenza, or the flu, hascaused pandemics many times during both the distantpast and in recent history.Almost a centuryago, the Spanish flu infected 500 millionpeople across the world, including in remote PacificIslands and the Arctic. And it’s estimated that itkilled between 20 and 50 million people. More recently, theinfluenza pandemic in 2009 infected peoplein 214 countries, causing almost 19,000confirmed deaths. And while 19,000confirmed deaths is still many deaths too many,it’s nowhere near the type of fatality rate thatwe saw 100 years or so ago when the Spanishflu ran rampant. So we have made tremendousstrides in public health in terms ofcontrolling influenza, but preparing forand controlling the effects of influenza willlikely remain top priorities for public health. Historically, polio was acommon and highly feared disease that causedsevere illness, including paralysis and even death. Thousands of people lined upto receive the polio vaccine after it was introduced in 1955. An initiative toeradicate polio was launched in 1988because of outbreaks in more than 125 countries.And because of thoseefforts, at this time, polio exists in onlya few countries. Lastly, with our lastexample, during the 1980s, human immunodeficiencyvirus, or HIV, emerged and spreadrapidly across the globe. Public health hasresponded to this pandemic by developing new waysto diagnose and treat those who are infected. New infections of HIV are down20% over the past 10 years, and that’s a signthat the public health interventions are successful. So the third area we’llexplore is public health’s role in preparedness anddisaster response, both for natural disastersand human made threats.The use the biological warfareto infect people and animals goes back centuries. One of the earliestaccounts is the use of plague as a weapon of warduring the Siege of Caffa in the 14th century AD. And Caffa is now an areawhere modern day Ukraine is. So back then,attacking Tartar forces likely catapulteddead bodies filled with the infection of plagueinto the city of their enemy. This contributed to thespread of the Black Death in that area. During diseaseoutbreaks that could be related tobioterrorism today, the public health communityis prepared to distribute lifesaving pharmaceuticals inantidotes, medical supplies, and equipment to locationsacross the country and even the world. In the wake of the terroristattacks in the United States on September 11, 2001,which I’m sure all of you remember, publichealth workers were on the ground at the WorldTrade Center and at the Pentagon to conduct surveillance toidentify outbreaks of disease and health conditions that mighthave resulted from the attacks.Public health workersmonitored occupational health of first respondersand city residents as well asenvironmental conditions to detect health threats inthe aftermath of the attacks. Public health also responseto natural disasters. After HurricaneKatrina hit in 2005, public health workers joineddisaster relief agencies to provide emergencyservices and dispatched teams to conduct surveillancefor illness and injury among residents in theirhomes and those who had been relocated to shelters. So the last lenswe’ll look through as we view public healthhistory is health policy as a means of prevention. We implement a range of policiesacross areas of public health to support effortson a societal level. So as far back as 1500 BCE,Leviticus, the third book of the Hebrew Bible, is believedto be the first written health code in the world. The book addresses personaland community responsibilities and includes guidanceabout bodily cleanliness, sexual health behaviors, andprotection against contagious diseases, includingthe isolation of people with leprosy.You might recall hearingabout leper colonies back then in history. So in recent decades, we’vehad tremendous movement in tobacco legislation. Laws banning smoking inthe workplace, restaurants, and other publicplaces have been passed to encouragesmokers to quit while also protectingnonsmokers from the effects of secondhand smoke. Also, increasesin cigarette taxes have been shown to bea deterrent for buying cigarettes. And you’ve probably heardthe term obesity in the news. Approximately 60 millionAmericans– nearly one third of all adults– and about onein five children are obese. And doctors usuallydefine obesity as a condition in which aperson’s weight is 20% or more above normal weight oras a body mass index measurement of 30 or more. Policies and lawsrelated to food labeling, minutes of physicaleducation and resource for children inschools, and even access to healthy foods and safeplaces to be physically active in communities. These are all examples ofprevention through policy that can impact obesityin a positive way.So to summarize thissection of the course, we work in public healthto prevent epidemics and the spread ofdisease and injuries, protect againstenvironmental hazards, promote and encouragehealthy behaviors, and respond todisasters and outbreaks. All right. It’s time for anotherknowledge check. Which of the following eventsin public health history have been pandemics? And just a hint. There’s more than one answer. Also remember, pandemics arenot the same as epidemics. So the correctanswers are B and C.Both influenza andpolio are examples of pandemic in thehistory of public health. So now let’s talk about publichealth in the broader context. As we’ve seen, publichealth problems are diverse. They include infectiousdiseases, chronic diseases, emergencies, injuries,environmental health problems, as well as a multitudeof other health threats. Regardless of thetopic though, we take the same approach toa public health problem by following four general steps. First we ask, whatis the problem? In public health, weidentify the problem by using surveillancesystems to survey and monitor health events and behaviorsamong a population. And then after we’ve identifiedthe problem, the next question is, what is thecause of the problem? For example, arethere risk factors that certain populationsmay have that make them more susceptible to disease? Maybe it’s somethingin the environment or it’s certain behaviorsthat people are practicing.Once we’ve identified the riskfactors related to the problem we ask, well, what interventionworks to address the problem? We look at what’sworked in the past. Maybe in addressingthe same problem with differentpopulations we look to see if something mightwork with our population, and we look to see if a proposedintervention would make sense with our affected population. In the last step we ask, how canwe implement the intervention? Given the resourceswe have and what we know about theaffected population, will this intervention work? And this is a verysimplified approach.Each of these stepscan be spliced into more specific activities,but these are really just the generalquestions that must be answered to identify aresponse to a public health problem. Surveillance, risk factoridentification, intervention evaluation, and implementation. Now to implement thepublic health approach, practitioners use andapply scientific methods that come from aseries of core courses. These sciences includepublic health surveillance, which we use to monitor apublic health situation, and epidemiologyenables us to determine where diseases originate,how or why they move through populations,how they spread, and how we can prevent them. Public health laboratorieshave a very important role in supporting publichealth by performing tests to confirm disease diagnoses. And laboratories alsosupport public health by conducting researchand training that’s valuable to the field. As far as informaticsgoes, as we continue to move from the useof paper documents more to electronichealth records, public healthinformatics continues to increase in importance. Informatics dealswith the methods for collecting, compiling, andpresenting health information, and it enables us to useelectronic data effectively when addressing apublic health problem.And lastly, preventioneffectiveness. This is closely linkedto public health policy. Prevention effectivenessstudies provide important economicinformation to decision makers to help them compareinterventions and then choose one to implement. So together, thesefive core sciences can help us protect andpromote the public’s health by giving public healthpractitioners the answers that they need. Public health isbetter able to respond to a given situation orproblem by using contributions from each of these sciences. So let’s take a look atthe public health approach and how can it can be appliedto a historical example of an infectious disease.During the 1800s in London,cholera, an often fatal intestinal disease,was rampant, causing deaths of thousandsof people within hours sometimes of first symptoms. So at that time, and this wasbefore bacteria and viruses were recognized as the causefor many illnesses and diseases, popular opinionheld that cholera was caused by bad air comingfrom rotting organic matter. This was known as themiasma or miasma theory. John Snow, a Britishphysician during that time, he had a differentopinion of cholera.He believed that theillness was spreading by way of a contaminatedwater supply because sewage wasbeing routinely dumped into the Thames River and incesspools near town wells. Because of his work tracing theroute of the cholera outbreak, Dr. Snow’s often considered thefather of modern epidemiology, and his research changed theway we look at disease today. So let’s apply the public healthapproach to Dr. Snow’s research of cholera outbreak. So this is a slide of aneighborhood in London, and you’ll recall thatfirst we need to identify the public health problem.Snow conducted publichealth surveillance looking at where those peoplewith cholera lived in London, and he saw that largeclusters of cases were occurring inspecific areas. So you’ll note thered circle, and you’ll see more black dotsare in that circle and those representcholera cases. So the concentration ofcholera cases, you’ll note, are surroundingthe area of Broad. Street and the blackdots represent the deaths from cholera. Notice the higher density ofdeaths around Broad Street. Snow was assisted backthen by a local clergyman by the name of ReverendHenry Whitehead. He was very, very familiarwith the neighborhood and people who lived there. So together– kind ofworking separately but then their efforts combinedtogether later on– they were able to track down andinterview surviving cholera victims and their familiesand geographically map the outbreak. And their effortshighlight the benefit of linking scientificinquiry with engagement of communitystakeholders to build the shared ownership of health. So next, Dr. Snowexamined the data and tried to identifyrisk factors. So that is he tried todetermine the cause of deaths by using the pattern ofwhere cases were occurring.So this slide illustratesthe location of the water pumps in the neighborhood. These are the black boxes. So on the basis ofhis previous work, Snow believed that water wasa potential source of cholera. So the map reveals thatthe larger number of cases occurred in areasnear water pumps, and this observation promptedDr. Snow to further research the distribution ofwater pumps in London. And he identified wherepeople who had cholera were drawing their water. His findings showed thatclusters of cholera cases were more commonly locatedaround certain pumps, particularly the pump onBroad Street, smack dab in the center of that graph. So through thisresearch, Dr. Snow concluded that drawing waterfrom the Broad Street pump was a primary risk factor forbecoming ill with cholera. So after identifyingthe likely risk factors, the next step in thepublic health approach is to evaluatepotential interventions.With the water supply from theBroad Street pump identified as the risk factor,Snow then worked to identify interventionsto address the problem. He did a lot ofcontinuous research, and from thatresearch he understood that the interventions requiredto control the cholera outbreak were basically twodifferent interventions. One was to stop exposureto the contaminated water supply in the neighborhood,and then on a larger scale, to stop exposure to the entiresupply of contaminated water in the area. So using the final step ofthe public health approach, Snow implementedthe intervention by getting the handle removedfrom the Broad Street pump. And that prevented peoplefrom drawing their water from that pumpbecause, again, he believed that thesupply of water was the source ofthe contamination. That was a prettysimple but brilliant way of effectivelystopping their exposure to the contaminatedwater supply. And then, after a very longbattle with the politicians and the watercompanies in the area, Dr. Snow finally convincedthe British government that water contaminated withsewage, and not smell or bad air coming fromthe waste itself, that it was the water thatwas the source of cholera and as well as other diseases.So this resulted in theimplementation of policies and laws for water sanitation,and that was an intervention on a much larger scale thanjust eliminating the threat from any one single water pump. But both interventionshad their importance. All right. It’s time for anotherknowledge check. So this knowledgecheck just asks you to fill in the blankswith the correct answers. Each public healthcore science helps us to blank and blankthe public’s health by providing public healthpractitioners with the answers they need. So I’ll give you a hint. The answers both start with P’s. Public health core scienceshelp us protect and promote the public’s health. But if you had anything remotelyclose to protect and promote we’ll count that as correct. So with this knowledge check–this is a matching one. And just match each componentof the public health approach with thequestions that they answer. So again, when we askwhat is the problem, we’re basically talkingabout surveillance.When we ask whatis the cause, we’re looking at riskfactor determination. And then we want to know,well, what’s going to work? What’s going to help to solvethis public health problem? That’s when we’re lookingat intervention evaluations. Possible interventionsthat we might be able to implement withour particular population. And then lastly, by process ofelimination, how do you do it? And that’s where youbasically decide what are you going to implement. So this section of the courseintroduces the core functions and essential servicesof public health. In 1988, theInstitute of Medicine defined three core functionsof public health agencies that must be carried outat all levels of government for the overall public healthsystem to work effectively. The three core functions areassessment, policy development, and assurance. So assessment is knowingwhat needs to be done, and it’s based on thecollection and analysis of data.You have to have data beforeyou can do anything else. Policy developmentis much broader than legislation for one. It can be guidelines, standardoperating procedures, laws, rules, regulations– allof that is encompassed by policy development. And policy development isbased on the information that comes from theassessment function, and it provides theuse of such information in policy and decision making. Assurance is making sure thatpolicies and programs get implemented by providingpublic health services to those who need them.So if you’ll briefly reflecton the mission statement that we discussed earlier ofthe Institute of Medicine, that public health is assuringconditions in which people can be healthy, this iswhat this core function is talking about. In this graphic, thethree core functions are on the outsideof the circle. You’ll see assessmenton the top right leads to policy developmentunderneath and then assurance on the other side. The 10 essentialpublic health services are grieved underneaththese three core functions. These services arenot a prescription for what public healthagencies should do, but rather they’rereally intended to capture the fieldof public health and communicatewhat it provides. The strength of apublic health system rests on its capacityto effectively deliver the 10 essential servicesof public health.So using the issue oftobacco use prevention, let’s explore how the essentialservices can be implemented. Under the functionof assessment, what are examples of number one,monitoring health for tobacco use prevention? So one example is to monitorhealth among segments of the population. For example, youth. Another example could bemonitoring global tobacco use prevention by country. For number two, public healthinvestigates risk factors associated with tobacco use,such as the risk of developing a certain kind of cancer. Assessing the problemprovides more data to inform policydevelopment, and that’s the second core function,you’ll recall, of public health.And that’s, again, onthe outside of the circle at the bottom right side. The third essentialservice, which is under policy development, isto inform, educate, and empower people about health concerns. So think of differentways that you hear about the dangerof using tobacco. Do you hear it fromyour physician? So you see publicservice announcements maybe in magazines? So all of those are examples. People must beinformed and educated before they becomeempowered to make changes, such as quitting tobacco useor never starting at all. On a larger scale,empowerment leads to community mobilization,which is number four. This might include thework of advocacy groups to rally support aroundbanning smoking in restaurants.And that leads to numberfive, where policymakers then develop policies to do thatwork, to accomplish that work. So what other policiesregarding tobacco use prevention can you think of? Often, people might say,well, raising tobacco taxes or not selling tobacco productsto people under a certain age. Having a minimum agerequirement and enforcing that in retail establishments. And those are all greatexamples of policies. After policies areenacted, they must be enforced to have an impact. If they’re not enforced,they don’t do any good. So enforcement is number sixof the essential services of public health. And using our example, thismight be fining someone for smoking on an airplanebecause smoking is not permitted on airplanesper federal legislation. Number seven is to linkpeople to needed public health services. So an example is to refersmokers to tobacco quit lines or for counseling so thatthey can stop smoking.For number eight,we need to ensure that a competent publichealth workforce is in place to help people quit smoking. And for all of theinterventions we develop, it is critical to evaluatethem for their effectiveness, both during and at their end. And this is number nine. So we ask, did theanti-smoking campaign do what it was supposed to do? Did the tobaccocessation program achieve its intended objectives? How successful was thepolicy that we implemented to raise taxes on tobacco? Did it deter peoplefrom buying cigarettes and thus, helppeople stop smoking? So evaluation is criticalthroughout the entire process. The essential services ofenforcing laws, linking to care, assuring a competentworkforce, and evaluation, they fall under that corefunction of assurance on the left side of the circle. And you’ll recallthat assurance is ensuring provision of servicesto those who need them. Now you’ll note in the middleof this graph there’s research.So research is inthe middle of all of these core functionsand essential services because it’s continuallyinforming everything. So think about as new tobaccoproducts are developed and there are new thingscoming out all of the time, CDC’s laboratoriesare continuously conducting researchon these new products to help us discover theirpotential negative health effects and help us to lookat new products that are being marketed or sold and how wemight combat those and battle the tobacco industry.One important point aboutthese essential services is that while they’reshown in a very nice graph and that they occurin a sequential order, they actually don’t alwaysoccur that way in reality. You might have itwhere you are you doing a couple of theessential services and then you mightskip around or you might skip a coupleof essential services and move to a different one. Sometimes things justaren’t neatly packaged. Sometimes you might do a fewservices and then actually loop back and do them over again. And again, with newresearch continually informing everything,that again prevents a nice chronological,sequential flow. But if you were to look atthis in a sequential order, it does make sensethat you’d start with monitoringhealth and then moving all the way through to insuringcompetent workforce to actually carry out whatever theinterventions are that you’ve decided to implementto achieve better health of the population. So the core functions ofassessment, policy development, and assurance, theymust be carried out at all levels of the governmentfor the public health system to function effectively.And this slide shows thecore functions at the top and the three different levelsof government at the left. So I’ll just go througheach level of government and give you the example ofassessment, policy development, and assurance. So at the federal level,an example of assessment would be conductingnational public health surveillance about tobacco. And then a policy, aswe’ve already discussed, is that they’ve banned smokingon commercial airline flights. And then assurance is thatthe federal government, such as CDC, providesfederal grants for anti-smokingresearch and tobacco use preventioncessation and control.At the state level, statesalso monitor tobacco use. States have autonomy forincreasing tobacco taxes. If you look acrossall states, there are a whole bunch of differenttypes of tobacco taxes. They’re not all the same amount. That’s completely up to thestates to regulate that. And then lastly, assurance. An example of thatmay be a estate that has a proposition, suchas Proposition 99– I believe that was in California–funding for campaigns to prevent smoking.At a local level,local communities also report on tobacco use. So that is a way thatthey conduct assessment to gather data and diagnose. Then that moves, again,to policy development. So you have county lawsthat prohibit smoking in bars and restaurants. Maybe in your countythose are good things. And then assurance,at the last level, an example of thatat the local level are resources that countyor a local health department might develop to helppeople quit smoking. And they might putthose resources in different languagesthat are representative of the populations of peoplewho live in those communities. So again, very differentlevels, but each level has to have a role for all ofthese functions and services to work togetherand be successful. All right. So this brings us toa knowledge check. Which of the following is not acore function of public health? And hopefully youall got this right.The correct answer is authority. So assurance assessmentand policy development are all functionsof public health. So here’s a secondknowledge check. The essential healthservices of monitoring health and diagnosing andinvestigating disease relate to which corepublic health function? Is it assurance, assessment,or policy development? And remember, it’s learningmore about the health problem, and so you do thatthrough assessment. And you have to do thatbefore you can do anything else in a meaningful way. So the next sectionof this course is about the rolesof different groups who have a stakein public health. The field of public healthrequires stakeholders with skills and interventionprograms, policies, research, education, et cetera. Partners include governments,community groups, clinical care providers, employers andbusinesses, the media, academia.I could go on andon but those are the main groups, at leastthat this slide shows, in addition to theinfrastructure provided by the government at alllevels as we just covered. So what other sectorsand fields can you think of that have astake in public health? When I talk this overwith other groups, some of the answersthat they provide are transportation, housing,schools, city planning, law enforcement, faithbased institutions. I mean, all of thoseare great examples of just other partners whohave a stake in public health.And some of those are considerednontraditional partners, but our hope is that theywill become more traditional and people won’t think aboutonly providing with health care providers, for example. Or that basically, werealize that there’s a health and allpolicies approach, which I’ll get to in a moment. Nongovernmental organizations,often referred to as NGOs, play a key rolein public health, especially at thecommunity level. NGOs serve manydifferent purposes, from advocacy or educationto emergency relief and economic development. [INAUDIBLE] types of NGOsinclude professional membership organizations, groups thatfocus on a specific health problem, citizengroups, advocacy groups, and foundations thatsupport health projects and work at the policy level.So the column atthe right just shows an example of each one ofthese types of organizations. Along with publichealth, health care plays a vital role inprotecting and promoting the health of people. So while the roles of publichealth and health care are complementary,there are differences that are shown on this slide. Public health, as we’vetalked about before, focuses on populationswhile health care focuses on theindividual patient, which is reflected indifferent guiding ethics for both those areas. Public health focuseson prevention. And while health care isconcerned with prevention to some extent,its main focus is more on diagnosing andtreating the problem. Each type of laboratoryworks jointly, yet public healthinteracts with the field on behalf of groups of people.And clinical laboratories workwith health care providers on behalf ofindividual patients. And the last rowof the table shows that while clinical sciencesare of peripheral importance to public health, they areessential to the training of health care providerson the clinical side. So here are some of theother primary partners in public health. We’re seeing the rolethese days of social media as a vehicle forpublic discourse on all matter of issues,including public health concerns. Whereas historically, it wasmore public health agencies and other partners thathave educated the public and promoted healthy behaviorsthrough news and entertainment media. But now, there is moreof a self promotion as well as social mediacontinues to take off. Employers andbusinesses, obviously. They contribute tothe public’s health by providing health insurance.Workplaces also havewellness initiatives, such as gym subsidies orworkout facilities on site, and these can promote thehealth of their employees. Government agencies,such as the CDC– they work in partnership withstate, local, and tribal health departments. However, importantcontributions are made by other governmentalagencies at all levels. City planning departments caninclude sidewalks and bike paths to promote and supportsafe places for people to be physically active. Education departments can ensurehealthy food options in schools and in vending machines. Similarly, many othergovernment agencies work as partnersin public health by including healthconsiderations in their policy development, and this is knownas a health and all policies approach. There’s just thisconcept that regardless of what you do asyou’re planning, think about how canimpact public health. And so that’s what Ireferred to earlier. It says health and all policies. And really, that opens up theopportunity for public health to partner with avariety– there’s really an endless number of differenttypes of organizations.And lastly, but notleastly, academia educates and trains thepublic health workforce and conducts researchthat informs public health and provides a greatservice to the field. So we have anothermatching exercise for this knowledge check. You need to matcheach stakeholder to its role in public health. So for a vehicle forpublic health discourse, the correct answer is media. Newspapers, opinion editorials,social media, all media. Health in allpolicies, as I said, is something that thegovernment definitely can have an activerole in doing, as well as other organizations. But for the purposes ofthis knowledge check, the correct answeris C, government. Education and trainingare things that academia contribute to public health. And the stakeholder thatprovides wellness initiatives and employee benefits isemployers and businesses. So the last sectionof this course covers determinantsof health and explains how they affect public health.As we discussedearlier, certain factors determine a person’sstate of health. Scientists typically recognizethe same general categories of health determinantsfor any population, and these are genes andbiology, health behaviors, social or societalcharacteristics, and health services or medical care. So I would like you to thinkof some examples of each of these broad categories. What are some examplesof genes and biology? You might think of a person’ssex or age or immunity levels. For health behaviors itcould be whether or not a person is a smoker. What are that person’seating habits? Whether or not a persontakes medications that are prescribedfor a chronic condition that person has. Social or societalcharacteristics. They can includeone’s ability to work, the quality of schools,where a person lives. What’s the quality ofair, water, and sanitation in that person’simmediate neighborhood? And then, examplesof medical care are insurance coverage andeven one’s proximity to getting quality health care. This chart is an estimate ofhow these four major categories of health determinants influencehealth at the population level. The chart shows thathealth care is not the major factordetermining our health, yet it represents a substantialportion of the United States budget.Most of what determinesour health you’ll see at the population levelare the social and societal characteristics, whereasgenes in and biology, they have the leastamount of influence. And then healthbehaviors, again, a pretty substantial amount. But it’s really the socialand societal characteristics and the ecology, includingthe person’s environment, that has the greatest impact. To address the healthdeterminants on this slide that we just discussed, wehave to have a plan of attack. A means to effect change. The health impact pyramiddescribes such a plan.It shows the impact ofdifferent types of public health interventions. So as we move down the pyramid,the public health impact grows greater, and aswe move up the pyramid, the amount of individual effortto achieve impact increases. So let’s start at the top. When we start atthe top and go down, we can providecounseling and education. We can provide ongoingdirect clinical care. Next, we can provideclinical interventions that require a morelimited contact but confer long term protection. That’s kind of whatpreventive medicine does. We can change the contextto make individuals default decisions be easy decisions butones that are the healthiest. And at the bottomof the pyramid, that addresses the socioeconomicdeterminants of health. Interventions focusing on thelower level of the pyramid tend to be more effectivebecause they reach broader segmentsof society and they require less individual effort. This isn’t to say that what’sat the top of the pyramid is not important because it is,but implementing interventions at all levels ofthe pyramid, that’s what’s going to achievethe maximum possible sustained public health benefit.And a point toemphasize here too is that there are trade offs. We have to sometimes giveup resources in one area in order to have alarger impact in another. But let’s take alook at some examples of each level of intervention. So the pyramidillustrates the impact of different types ofpublic health interventions. And again, working our wayfrom the top to the bottom. Counseling and educationin clinical settings, public healthsettings– they are regarded by some as the essenceof public health action. I went to school and I actuallymajored in health education and promotion when Igot my master’s degree in public health. But being at CDC, I’velearned a lot about how all of those otherareas, including the area at the bottom, reallymake a substantial impact in interventions. But that’s, again, not–counseling and education– they’re not as effectiveas we would like.But that being said,there are times when counselingand education are the only forms ofintervention that are available or appropriate. And when they’re appliedconsistently and repeatedly, they can have a positive impact. So moving to clinicalinterventions, ongoing medical care for ahealth condition is an example. For example, in the caseof cardiovascular disease, these interventions canhave a considerable effect. But we’re also limitedby a lack of access to certain patients whoneed that type of care and a lack of adherenceto medical instructions and taking prescriptions asprescribed in the real world. So again, that medicalcare has its limitations. So in the verymiddle of the pyramid looking at the interventionlevel of preventive medicine, let’s talk aboutvaccinations as an example. Vaccinations prevent 2.5million deaths among children around the world every year. So in this case, a single doseor instance of an intervention can have a lifelong effect. So this is an example of a longlasting preventive medicine intervention.The next leveldown on the pyramid is where we makedecisions the default by changing the contextin which behaviors occur. And it makes it more difficultto avoid the intervention. So for example, changing lawsto require seat belt use. Making it easier forpeople to wear their seat belts because if you don’tput your seat belt on, you get this really annoyingbeeping noise until you put it on, so you want to put it onand just make the noise go way.But it’s much easier than itused to be to wear your seat belt. Banning smokingin certain public places is another example. Both of these examplesand accomplishments in public health havehad a tremendous impact and saved many,many, many lives. In another basic example,some of the buildings at CDC– the newer buildingsfor example– when you first walk in, the stairsare what you see before you see the elevator.And the stairs havewindows and maybe have some plants or some music. So that makes it much moreenjoyable and very easy for people to decide totake the stairs instead of going all the way around thecorner to find the elevator. So that’s a real basic exampleof making the healthy decisions the default. At the base of the pyramid arethe public health interventions that affectsocioeconomic factors.If we can improvethe quality of life by helping peopleout of poverty, providing basic sanitation,improving access to education, helping them get jobs, providinghealthy food, medical care, we can greatly improvea population’s health. So it’s time foranother knowledge check, and I’d like you to just listfour determinants of health. Now remember, it can be genesand biology, health behaviors, social societal characteristics,and health services or medical care. In our last knowledgecheck of the course, just fill in the blanksusing the two choices. For number one, as we movedown the health impact pyramid, the public healthimpact grows greater.Remember, the baseof the pyramid is the socioeconomic factors. As we move up thepyramid, the health impact becomes greater in terms ofthe amount of individual effort that’s required. Again, all levels of thepyramid are important, but it’s just a niceframework for thinking about how interventionscan be implemented at different levels. Within each of the topicswe’ve covered in this course, underlying all of ouractions and decisions is the application of thepublic health core sciences. I encourage you to build on thisintroduction to public health by learning more aboutthese core sciences and how they contribute tothe field of public health. Let’s review the learningobjectives for this session. The course providedcontent to help you describe the purposeof public health, define some key termsused in public health. You’ll recall we talked aboutepidemics, health determinants.The course helped youidentify prominent events in the history of public health. That’s where we looked ata few historical highlights of public healththrough sanitation and environmentalhealth, pandemics, disaster preparedness andresponse, and prevention through policy. The course helped you recognizethe core public health functions– those threefunctions– and 10 essential services. You should be ableto describe the role of different stakeholders inthe field of public health, as well as to list some ofthe determinants of health.And lastly, youshould recognize how individualdeterminants of health affect population health. Thank you for your attentiontoday for the introduction to public health. To receive continuingeducation units, CEU credits, fortoday’s webinar, please complete the webinarevaluation on CDC TRAIN by logging in and lookingunder My Learning. If you or one of yourcolleagues were not able to attend today’swebinar, an archived version of this webinar will beavailable on CDC TRAIN in approximatelytwo to three weeks. For further informationon CDC webinars, please visitwww.cdc.gov/labtraining. Again, thank youfor participating in today’s webinar. Have a positive andhealthy afternoon. [MUSIC PLAYING].
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