Understanding Public Health: Challenges, History, and Functions

1. Topics • What is Public Health? • Public Health Functions • Government Authority for Public Health • Challenges and Opportunities “Public health affects the lives of Americans profoundly, but more often than not it is invisible to them.” Text, p. 58

2. The Public Health Problem • Can we postulate that efforts to achieve public health are not as effective as they could be? • Or that the level of public health is not as high as it could be? • If so, we want to look for all of the factors raised in the chapter that impede achieving the best possible level of public health • Also identify those efforts that are helpful • Why were they implemented? • Why are they helpful? • Who pays and who benefits?

3. History of Public Health • What are the implications of Table 4.1 for the efficient maintenance of public health in the United States? • Just as we did with health care financing, outline the history of public health in the U.S. and how this history resulted in the structure of public health activities we have today.

4. What is Public Health? • Three Assumptions (p. 91) • Healthy population is in the public interest • Health is strongly determined by community and societal-level forces • Working at a collective or community level, these forces can be marshaled to improve a population’s health

5. What is Public Health (cont.) StudentPresentation#1, #3 • Public Interest in Public Health • The text gives limited justifications for how public health is in the public interest • Expand all of the mechanisms through which individual and collective welfare is improved when your neighbors are healthy… • …or when efforts to improve public health are undertaken • Is Health a “right” as defined by the WHO? (p. 92)

6. Individual behaviors (50%) • Genetic makeup (20%) • Medical practice (10%) • Environment (20%) • Source: HAS 3111 Slides What is Public Health (cont.) • Determinants of Health • “Yet health care services account for an estimated 95% of federal health expenditures, even though effective public health interventions would do much more to improve health” (p. 93) • “It then follows that the nation’s heavy investment in the personal health care system is a limited future strategy for promoting health” (pp. 93-4, quoting Institute of Medicine, 2003) • Once again, why is it that we see this situation?

7. What is Public Health (cont.) • Determinants of Health (cont.) • Consider the section “Challenges for Public Health Policy” on p. 94. What argument is this section making…? • Importance • Prevalence • Modifiability • Effectiveness of Changes • … and how come the authors concluded with this statement, “Yet with notable exceptions, the public health field has been slow to adopt evidence-based practice or the analysis of effectiveness and cost-effectiveness.” (p. 94) See next slide

8. What is Public Health (cont.) • Intervention Considerations for a health risk from p. 94 • Importance: How big an impact does the risk have? • Prevalence: How common is the risk? • Modifiability: How easy is it to change the risk? • Effectiveness: How easy is it to change the outcomes of the risk (impacts on quality of life)? • Let’s add • Acceptability: The willingness of individuals or groups to accept specific interventions

9. What is Public Health (cont.) • Three Categories of Intervention • Primary Prevention: Avoid the onset of a condition • Secondary Prevention: Identifying and treating people with risk factors or preclinical disease • Tertiary Prevention: Treating an established disease to restore functioning, minimize negative impact, or prevent complications • Prevention Targets • Universal • Targeted

10. What is Public Health (cont.) • We have developed a framework for evaluating public health activities • Risk intervention considerations • Importance • Prevalence • Modifiability • Effectiveness of Changes • Acceptability • Categories of intervention • Primary • Secondary • Tertiary • Intervention target • Universal • Targeted

11. Public Health Functions • Distinctive* Approach to Problem Solving • Assessment • Policy Development • Assurance (monitoring) * This approach isn’t distinctive at all. Many disciplines with a formalized decision making process have these steps in disciplines as diverse as military decision making and the systems development lifecycle taught in informationsystems courses

12. Public Health Functions (cont.) • Assessment • Which element(s) of our framework does assessment affect? • What tools are available for performing assessment? • Revisit Chapter 2 • How have these tools changed over time? • What weaknesses remain?

13. Public Health Functions (cont.) • Policy Development • What is “policy development”? • Name a public health policy not mentioned in the text • Identify policy originator • Whether formal or informal • Give examples of agencies or types of individuals that engage in policy development

14. Public Health Functions (cont.) • Assurance • Assurance is the ability to ensure that policies are implemented and followed • Communication • Monitoring and detection • Enforcement& correction • West’s Comment: Any organization’s (including government’s) effectiveness is in large part tied to its ability to enforce its will across the decision space over which it claims authority. The quality of the decisions are also important.

15. Public Health Functions (cont.) • Assurance (cont.) • What are the bases for most forms of assurance in government activities (including health care)?

16. Public Health Functions (cont.) • Problem Solving Example (pp. 101-2) • Note the 6-step process listed here (in contrast to the 3-step process on p. 99) • Also note the interweaving of the three steps within the six-step process • And the multiple agencies involved • Consider the 6th step, “Revisit and Refine” as being cyclically related back to the first step, “Define the problem” • If the evaluation reveals continuing issues these become the kickoff of a new solution round

17. Public Health Functions (cont.) • Overlap in Functionality • Note the multiple mentions of layers of responsibility for many issues • Each participant has distinct motivations, decisions, costs, and expected payoffs • Identify when these conflict and align • What impediments are there to cooperation?

18. StudentPresentation#2 Governmental Authority for Health • In 1974 the United States implemented a national 55 MPH maximum speed limit to conserve fuel in the wake of the 1973 oil crisis • Where is the constitutional authority for this law? • How was it actually implemented and enforced? • What are the implications for health care policy

19. Governmental Authority for Health (cont.) • Federal Agencies • No fewer than 13 major agencies under DHHS • Also VA, USDA, EPA, NHTSA, OSHA, HUD • State Agencies • No uniform organization among the states • Division of responsibility between state & local • State laws “fragmented and badly out of date” (p. 109) • What states actually provide • Professional licensing

20. Challenges and Opportunities • New Name for National Association of County and City Health Officials • Improving competencies • Performance standards • Performance evaluation • What are the costs and payoffs!!? • Standardizing services • Accrediting services

21. Challenges and Opportunities (cont.) • What do the lessons of Hurricane Katrina have for public health services in the U.S? • What other threats are looming? • Are public health organizations prepared for these? • What about individuals?

22. Challenges and Opportunities (cont.) • Consider a repeat on the scale of the 1918 influenza pandemic • 40-50 million deaths in 18 months worldwide • 550,000 deaths in the U.S. (out of 92 million) • What would be the impact on and what preparations should these agencies conduct? • A private hospital ‒ Law enforcement • Medical office ‒ School board • Grocery chain ‒ County health department

23. Challenges and Opportunities (cont.) • Bioterrorism and mass casualty terrorist threat • Some funding resources • Efforts to modernize public health statutes • Resistance to public health efforts on the grounds of individual liberty or political or religious beliefs • Develop a chain of causality that might lead to someone believing that adding fluoride to the municipal water supply was a Communist plot

24. Challenges and Opportunities (cont.) • Public Relations • Is it justifiable for public health officials to lobby for increased funding? • What weaknesses do public health organizations have with respect to funding? • What impediments are there to building trust with the public?

25. Governmental Authority for Health (cont.) • State & Federal Relations • Dominated by funding • Categorical funding removes flexibility • Tradeoffs • Local knowledge and resources • National resources • Economies of scale and scope at the national level • Federal government authorized to act in multi-state situations