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25 slides presentation about (pollution in public health)Introduction to
Public
Health
Fifth
Edition
Mary-Jane Schneider, PhD
Clinical Associate Professor
Department of Health Policy, Management, and Behavior
School of Public Health
University at Albany, State University of New York
Rensselaer, New York
with
Henry S. Schneider, PhD
Assistant Professor of Economics
Johnson Graduate School of Management
Cornell University
Ithaca, New York
Drawings by Henry S. Schneider
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Library of Congress Cataloging-in-Publication Data
Names: Schneider, Mary-Jane, 1939- , author. | Schneider, Henry S.
Title: Introduction to public health / Mary-Jane Schneider, with Henry S.
Schneider ; drawings by Henry S. Schneider.
Description: Fifth edition. | Burlington : Jones & Bartlett Learning, MA,
[2017]
Identifiers: LCCN 2016001765 | ISBN 9781284089233
Subjects: | MESH: Public Health | Public Health Practice
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Dedication
To Augustus Anthony Edison Schneider
May he live a long and healthy life
Contents
Preface
Prologue: Public Health in the News
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xv
Part I: What Is Public Health?
1
1
Public Health: Science, Politics, and Prevention
3
What Is Public Health?
Public Health Versus Medical Care
The Sciences of Public Health
Prevention and Intervention
Public Health and Terrorism
Conclusion
References
4
5
7
10
11
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13
Why Is Public Health Controversial?
15
Economic Impact
Individual Liberty
Moral and Religious Opposition
Political Interference with Science
Conclusion
References
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18
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Powers and Responsibilities of Government
25
Federal Versus State Authority
How the Law Works
How Public Health Is Organized and Paid for in the United States
Nongovernmental Role in Public Health
Conclusion
References
26
28
29
36
37
38
2
3
Part II: Analytical Methods of Public Health
39
4
Epidemiology: The Basic Science of Public Health
41
How Epidemiology Works
A Typical Epidemiologic Investigation—Outbreak of Hepatitis
Legionnaires’ Disease
Eosinophilia-Myalgia Syndrome
Epidemiology and the Causes of Chronic Disease
42
43
44
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49
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Contents
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6
7
8
Heart Disease
Lung Cancer
Conclusion
References
49
51
53
54
Epidemiologic Principles and Methods
57
Kinds of Epidemiologic Studies
Conclusion
References
62
67
68
Problems and Limits of Epidemiology
69
Problems with Studying Humans
Sources of Error
Proving Cause and Effect
Epidemiologic Studies of Hormone Replacement
Therapy—Confusing Results
Ethics in Epidemiology
Conflicts of Interest in Drug Trials
Conclusion
References
69
71
73
74
75
78
80
81
Statistics: Making Sense of Uncertainty
83
The Uncertainty of Science
Probability
The Statistics of Screening Tests
Rates and Other Calculated Statistics
Risk Assessment and Risk Perception
Cost–Benefit Analysis and Other Evaluation Methods
Conclusion
References
84
86
88
90
94
98
99
100
The Role of Data in Public Health
103
Vital Statistics
The Census
NCHS Surveys and Other Sources of Health Data
Is So Much Data Really Necessary?
Accuracy and Availability of Data
Confidentiality of Data
Conclusion
References
104
104
107
108
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111
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112
Part III: Biomedical Basis of Public Health
115
9
The “Conquest” of Infectious Diseases
117
Infectious Agents
Means of Transmission
118
120
Contents
Chain of Infection
Rabies
Smallpox, Measles, and Polio
Fear of Vaccines
Conclusion
References
121
125
126
129
131
132
10 The Resurgence of Infectious Diseases
135
The Biomedical Basis of AIDS
Ebola
Other Emerging Viruses
Influenza
New Bacterial Threats
Multidrug-Resistant Tuberculosis (MDR TB)
Prions
Public Health Response to Emerging Infections
Public Health and the Threat of Bioterrorism
Conclusion
References
135
140
144
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150
154
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157
11 The Biomedical Basis of Chronic Diseases
163
Cardiovascular Disease
Cancer
Diabetes
Other Chronic Diseases
Conclusion
References
165
169
171
172
172
173
12 Genetic Diseases and Other Inborn Errors
175
Environmental Teratogens
Genetic Diseases
Genetic and Newborn Screening Programs
Genomic Medicine
Ethical Issues and Genetic Diseases
Conclusion
References
176
177
180
184
185
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188
Part IV: Social and Behavioral Factors in Health
191
13 Do People Choose Their Own Health?
193
Education
Regulation
Does Prohibition Work?
Conclusion
References
197
200
201
203
203
vii
viii
Contents
14 How Psychosocial Factors Affect Health Behavior
Health of Minority Populations
Stress and Social Support
Psychological Models of Health Behavior
Ecological Model of Health Behavior
Health Promotion Programs
Changing the Environment
Conclusion
References
205
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211
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215
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217
15 Public Health Enemy Number One: Tobacco
219
Biomedical Basis of Smoking’s Harmful Effects
Historical Trends in Smoking and Health
Regulatory Restrictions on Smoking—New Focus
on Environmental Tobacco Smoke
Advertising—Emphasis on Youth
Taxes as a Public Health Measure
California’s Tobacco Control Program
The Master Settlement Agreement (MSA)
FDA Regulation
Electronic Cigarettes
Conclusion
References
221
221
16 Public Health Enemy Number Two and Growing:
Poor Diet and Physical Inactivity
Epidemiology of Obesity
Diet and Nutrition
Promoting Healthy Eating
Physical Activity and Health
How Much Exercise Is Enough, and How Much Do People Get?
Promoting Physical Activity
Confronting the Obesity Epidemic
Conclusion
References
17 Injuries Are Not Accidents
Epidemiology of Injuries
Analyzing Injuries
Motor Vehicle Injuries
Pedestrians, Motorcyclists, and Bicyclists
Poisoning
Firearms Injuries
Occupational Injuries
Injury from Domestic Violence
225
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264
267
268
269
271
272
Contents
Nonfatal Traumatic Brain Injuries
Tertiary Prevention
Conclusion
References
18 Maternal and Child Health as a Social Problem
Maternal and Infant Mortality
Infant Mortality—Health Problem or Social Problem?
Preventing Infant Mortality
Family Planning and Prevention of Adolescent Pregnancy
Nutrition of Women and Children
Children’s Health and Safety
Conclusion
References
272
274
275
276
281
282
283
285
290
292
293
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297
19 Mental Health: Public Health Includes
Healthy Minds
301
Major Categories of Mental Disorders
Anxiety
Psychosis
Disturbances of Mood
Disturbances of Cognition
Epidemiology
Causes and Prevention
Children
Eating Disorders
Mental Health in Adulthood
Mental Health in Older Adults
Treatment
Conclusion
References
301
302
302
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302
303
306
307
308
310
310
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311
Part V: Environmental Issues in Public Health
313
20 A Clean Environment: The Basis of Public Health
315
Role of Government in Environmental Health
Identification of Hazards
Pesticides and Industrial Chemicals
Occupational Exposures—Workers as
Guinea Pigs
New Source of Pollution—Factory Farms
Setting Standards—How Safe Is Safe?
Risk–Benefit Analysis
Conclusion
References
316
317
321
324
325
326
327
327
328
ix
x
Contents
21 Clean Air: Is It Safe to Breathe?
333
Criteria Air Pollutants
Strategies for Meeting Standards
Indoor Air Quality
Global Effects of Air Pollution
Conclusion
References
334
336
341
342
344
345
22 Clean Water: A Limited Resource
349
Clean Water Act
Safe Drinking Water
Dilemmas in Compliance
Is the Water Supply Running Out?
Conclusion
References
350
352
364
366
366
367
23 Solid and Hazardous Wastes:
What to Do with the Garbage?
369
Sanitary Landfills
Alternatives to Landfills
Hazardous Wastes
Coal Ash
Conclusion
References
24 Safe Food and Drugs: An Ongoing
Regulatory Battle
Causes of Foodborne Illness
Government Action to Prevent Foodborne Disease
Additives and Contaminants
Drugs and Cosmetics
Food and Drug Labeling and Advertising
Politics of the FDA
Conclusion
References
25 Population: The Ultimate Environmental
Health Issue
Public Health and Population Growth
Global Impact of Population Growth—Depletion of Resources
Global Impact of Population Growth—Climate Change
Dire Predictions and Fragile Hope
Conclusion
References
370
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382
383
388
389
390
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399
401
403
406
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Contents
Part VI: Medical Care and Public Health
415
26 Is the Medical Care System a Public Health Issue?
417
When Medical Care Is a Public Health Responsibility
The Conflict Between Public Health and the
Medical Profession
Licensing and Regulation
Ethical and Legal Issues in Medical Care
Ethical Issues in Medical Resource Allocation
Conclusion
References
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419
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423
426
427
428
27 Why the U.S. Medical System Needs Reform
431
Problems with Access
Why Do Costs Keep Rising?
Approaches to Controlling Medical Costs
Managed Care and Beyond
The Patient Protection and Affordable Care Act
Rationing
Conclusion
References
432
435
436
437
439
440
442
443
28 Health Services Research: Finding What Works
447
Reasons for Practice Variations
The Field of Dreams Effect
Outcomes Research
Quality
Medical Care Report Cards
Inequities in Medical Care
The Relative Importance of Medical Care for
Public Health
Conclusion
References
448
450
451
454
456
458
461
463
464
29 Public Health and the Aging Population
469
The Aging of the Population—Trends
Health Status of the Older Population
General Approaches to Maximizing Health
in Old Age
Preventing Disease and Disability in Old Age
Medical Costs of the Elderly
Proposals for Rationing
Conclusion
References
470
472
473
476
482
485
487
487
xi
xii
Contents
Part VII: The Future of Public Health
491
30 Emergency Preparedness, Post-9/11
493
Types of Disasters and Public Health Responses
New York’s Response to the World Trade Center Attacks
Response to Hurricane Katrina
Principles of Emergency Planning and Preparedness
Bioterrorism Preparedness
Pandemic Flu
Conclusion
References
31 Public Health in the Twenty-First Century:
Achievements and Challenges
494
495
496
500
502
506
507
509
513
Challenges for the 21st Century
Strategic Planning for Public Health
Dashed Hopes for the Integration of Public Health
and Medical Practice
Information Technology
The Challenge of Biotechnology
The Ultimate Challenge to Public Health in the Twenty-First Century
Conclusion
References
515
516
520
521
523
523
524
525
Glossary
Index
529
547
Preface
In the Preface to the First Edition, I wrote about the public’s general ignorance of the field
of public health and my own uncertainty about what public health was when, in 1986, I first
went to work for the newly established School of Public Health, a collaboration between
the University at Albany and the New York State Department of Health. After working
with public health professionals from the Department of Health to design curricula for
the programs at the school, and after teaching an introductory course in public health for
more than ten years in collaboration with many of the same health department faculty,
I feel much more confident about what the term means. After the bioterrorism scare of
2001 and the public health disasters of Hurricane Katrina in 2005 and Hurricane Sandy
in 2012. I believe that the public has a better sense of the field as well.
This book was written as a text for an introductory course that could be included in
the general education curriculum for college undergraduates. As I wrote in the Preface to
the First Edition, I believe that every citizen of the United States should know something
about public health, just as they should know something about democracy, law, and other
functions of government. Public health issues are inherently interesting and important
to almost everyone. They are featured almost every day on the front pages of newspapers
and in the headlines of television news programs, although often they are not labeled as
public health issues. One of my goals is to help people put these news stories into context
when they occur.
The Fifth Edition of this textbook follows the plan of the first four editions, bringing
it up to date and including new developments in infectious disease, injury control, environmental health controversies, the reform of the American healthcare system, and many
other issues. I have illustrated public health principles by presenting stories that have been
in the news; some of these stories have been ongoing sagas that have been supplemented
with each edition. The Second and Third Editions focused on political interference with
science, but as discussed in the Fourth Edition, the Obama administration vowed to restore
honest science as a basis of policy decisions. Issues new to the Fifth Edition include the
arrival of Ebola in the United States, involving the death of an African visitor and the
involuntary quarantine of an uninfected healthcare worker returning from work in an
affected country; the introduction of electronic cigarettes and questions of how they
should be regulated; the importance of eating disorders as a major mental health issue;
and the lawsuit by retired professional athletes against the National Football League for
not disclosing risks of traumatic brain injury. Other issues discussed more extensively
here are population growth and climate change as contributors to wars and migrations
in the Middle East and the implementation of President Obama’s healthcare reform law,
the Patient Protection and Affordable Care Act.
xiv
Preface
I have tried to make this book easily comprehensible to the general reader. One of the
things that makes public health fascinating to me is the fact that it is often controversial,
depending on political decisions as well as scientific evidence. The politics are frustrating
to many practitioners, but it is often the politics that put public health in the headlines.
I hope that by describing both the science and the politics, I will contribute to making
public health as fascinating to the readers as it is to me.
Mary-Jane Schneider
Chapter
Prologue
1
Public Health in the News
What is public health? It is an abstract concept, hard to pin down. Reports about public
health appear in the news every day, but they are not labeled as public health stories, and
most people do not recognize them as such. Here in the prologue are four major public
health stories of the modern era that bring the abstraction to life. The ongoing AIDS epidemic, arguably the greatest challenge that the public health community has faced in the
past 50 years, illustrates the multidisciplinary nature of the field and the complex ethical
and political issues that are often an inherent component of public health. The outbreak
of waterborne disease that sickened more than 400,000 people in Milwaukee, Wisconsin
in 1993 was the consequence of a breakdown in a routine public health measure that
has protected the populations of developed countries for most of the past century. Lest
Americans forget that maintaining the health of the population requires constant vigilance,
the dramatic decline in all measures of health in Russia presents a cautionary lesson of
what can happen to a society that is unable to protect its people in one regard or another.
Finally, the terrorist attacks in the fall of 2001 made it clear that the national security of
the United States depends not only on the U.S. Department of Defense, but also on the
American public health system.
AIDS Epidemic
On July 3, 1981, The New York Times ran a story with the headline: “Rare Cancer Seen in
41 Homosexuals.”1 The cancer was Kaposi’s sarcoma, a form of skin cancer, rare in the
United States but more common in equatorial Africa. The victims were young gay men
living in New York City or San Francisco, and 8 of the 41 had died within 24 months of
being diagnosed. The report noted that several of the victims had been found to have
severe defects in their immune systems, but it was not known whether the immune
defects were the underlying problem or had developed later. Most of the victims had
had multiple and frequent sexual encounters with different partners, the article said,
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Public Health in the News
but there was no evidence that the disease was contagious, since none of the patients
knew each other.
On August 29, there was another story: “2 Fatal Diseases Focus of Inquiry.”2 A rare
kind of pneumonia called pneumocystis had been striking gay men with a 60 percent
fatality rate. According to The New York Times, 53 cases of pneumocystis had been diagnosed. Also, the number of cases of Kaposi’s sarcoma had grown to 47, and 7 patients
had both diseases. No one knew why gay men were affected, but there was speculation
that there might be a link to their sexual lifestyle, drug use, or some other environmental
cause. The article noted without comment that one woman had also been reported to
have pneumocystis pneumonia. A scientific task force had been formed at the Centers
for Disease Control and Prevention (CDC) to investigate what was going on. There was
no further news in The New York Times about what would become known as AIDS until
May 1982.3 In that article, the underlying commonality of the immune defect was recognized, and the condition was called gay-related immune deficiency syndrome (GRID).
While immune deficiencies had been known and studied previously, most were genetic
conditions that afflicted children from birth or were caused by immunosuppressive drugs
used to prevent rejection of transplanted organs. The total suppression of the immune
system by whatever means leads to many infections, one of which eventually kills the
victim. Speculation as to the cause of GRID generally focused on a sexually transmitted
infectious agent, although there was a suspicion that multiple factors might be involved,
perhaps including drugs or an immune response to the introduction of sperm into the
blood through sexual contact.
As the number of reported cases grew, CDC scientists interviewed people with GRID,
questioning them about their sexual behavior and partners. The sexual activities of gay
men became the focus of scientists and the news media alike—reports of promiscuous and
anonymous sex in public baths and use of drugs to enhance sexual pleasure emerged—
which tended to worsen many people’s already negative view of gay men. Linkages were
found that began to confirm that a sexually transmitted infectious agent was responsible.
But the investigations were hampered by lack of funding. President Ronald Reagan had
been inaugurated in January 1981 on a conservative platform. His administration was
not interested in a disease that affected people who behaved in ways so unappealing to
the general population. Nor was there much concern on the part of the general public.
Most people felt no threat to themselves, although people who lived in New York, San
Francisco, Los Angeles, and Miami, where most of the cases had been reported, might
have felt more cause for concern.
Since early in the epidemic, however, there had been occasional reports of the immune
deficiency in women and heterosexual men, many of them intravenous drug users. By
the summer of 1982, cases of the syndrome had also been reported in people with hemophilia who were exposed to blood products used to make a clotting factor and in patients
who had received blood transfusions. A study of female sexual partners of men with the
syndrome suggested that the disease may also be transmitted by heterosexual relations. A
number of babies turned up with a syndrome that resembled GRID, possibly transmitted
from their mothers before or at birth. It was clear that the condition was not limited to
Public Health in the News
gay men, and its name was changed to acquired immune deficiency syndrome (AIDS).
The public began to take notice.
By mid-1983, the public began to panic. A report by a pediatrician in New Jersey
suggested that AIDS had spread within a family by routine household contact. That scared
a lot of people: AIDS was a fatal disease, and people did not want to take any chances of
catching it. Inmates in a New York State prison refused to eat meals in a mess hall used
by a fellow inmate who had died of AIDS. A New York City sanitation worker with no
known risk factors contracted AIDS, perhaps from a syringe protruding from a trash
bag. In San Francisco, with its large gay population, the police officers demanded special
masks and gloves for handling people suspected of being infected with AIDS. Blood
banks reported that blood supplies were critically low because people wrongly feared
that they could contract AIDS through donating blood. In New York City, tenants of a
cooperative apartment building tried to evict a doctor known for treating people with
AIDS. In a few well-publicized incidents, schools refused to allow children with AIDS—
usually hemophiliacs—into the classroom. A special telephone information number on
AIDS, set up by the federal government, was swamped with 8000 to 10,000 calls per
day. Fundamentalist preachers and conservative legislators fulminated that AIDS was
God’s punishment for abominable behavior and that people with AIDS deserved their
fate. Meanwhile, although controversy still restricted federal funding for AIDS research,
biomedical scientists were competing to identify the infectious agent, which most scientists believed would turn out to be a virus. Despite the ill repute of many AIDS patients,
the disease was of great scientific interest, and the growing public concern promised to
reward with acclaim and financial benefits the scientist who isolated the virus. On April
23, 1984, the U.S. Secretary of Health and Human Services convened a press conference
to announce that Dr. Robert Gallo of the National Cancer Institute had discovered the
virus—now known as the human immunodeficiency virus (HIV)—and that a vaccine
would be available within five years.4 While both of those statements proved to be less
than accurate—Gallo’s priority was disputed and eventually disproved, and after more
than 30 years an effective vaccine has still not been developed—the discovery did promise
to allow testing of blood for exposure to the virus. Just a year later, blood banks in the
United States began screening donated blood, greatly reducing the risk to transfusion
recipients and people with hemophilia.
Now, more than three decades after the first reports on AIDS were publicized, most
of the hysteria has faded, while many of the direst predictions have been realized. By
the end of 2012, almost 1.2 million people in the United States had been diagnosed with
AIDS, and 658,504 had died.5 An estimated 1.2 million Americans aged 13 and over are
living with HIV. The proportion of women diagnosed with HIV infection increased
steadily over the first two decades and has stabilized at about 20 percent. A great deal
more is known about the disease. New drugs have “miraculously” restored health to some
dying patients and offer hope that HIV is becoming a chronic, manageable condition
rather than a progressively fatal disease. However, there is still no cure, and long-term
prospects for HIV-infected individuals are uncertain at best. The only prevention is the
avoidance of risky behaviors. The question of how the government should respond to the
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AIDS epidemic raised some of the most difficult ethical and political issues imaginable
in public health. Every new scientific discovery stimulated new dilemmas. Most of
the controversies pitted two opposing principles against each other: the protection of
the privacy and freedom of the individual suspected of being ill, and the protection
of the health of potential victims at risk of being exposed. This conflict is common
to many public health problems. Historically, the protection of the public has taken
precedence over the rights of the individual. Thus, the principle of quarantining patients
with dangerous infectious diseases such as plague, smallpox, or tuberculosis has been
generally accepted and upheld by the courts. However, in the case of AIDS, the issues
were more complicated.
Because people with AIDS belonged to stigmatized groups who may have been
exposed to the virus because of illegal behavior (intravenous drug use or homosexual
acts that were still illegal in many states), they bitterly opposed being publicly identified.
Gay men, who had only recently achieved a degree of liberation from public oppression,
were very well organized politically; they effectively opposed some measures that would
have normally been considered standard public health practice, such as reporting the
names of diagnosed patients to the health department. They had well-founded fears of
being discriminated against for jobs, housing, access to health insurance, and so on. Major
political battles erupted over issues such as whether gay bathhouses should be closed and
whether AIDS should be declared a communicable disease, which would legally require
names of patients to be reported to the local health department. As HIV infection has
become more controllable, much of the controversy has subsided.
AIDS is particularly difficult for government to deal with because the only effective way to prevent its spread is to change people’s behavior. There are precedents for
governmental efforts at promoting behavior change—campaigns to promote smoking
cessation, use of bicycle helmets, and healthy diet and exercise—but their success has
been modest. Generally, the weight of a law adds significantly to the government’s
success in promoting healthy behavior, as in the case of seat-belt laws and laws against
drunk driving. However, behavior that spreads HIV is very difficult to control by law;
intravenous drug use is already illegal everywhere in the United States, and homosexual
acts were also illegal in many states until the U.S. Supreme Court declared these laws
unconstitutional in 2003. From the beginning, public health officials recognized that
AIDS could be prevented only by persuading people to reduce their risk by limiting
their exposure, which requires convincing them to control powerful biological and
social urges.
Beginning with the earliest attempts at AIDS education, conflict arose between the
attempt to communicate effectively with people most likely to be at risk and the likelihood of offending the general public by seeming to condone obscene or illegal acts. Conservatives argued—and still argue—that the only appropriate AIDS education message
is abstinence from sex and drugs. C. Everett Koop, President Reagan’s Surgeon General,
was originally known for his right-to-life views. Later he became an unexpected hero
to public health advocates by taking a strong stand in favor of frank AIDS education.
While stressing the importance of mutually faithful monogamous sexual relationships
Public Health in the News
and avoiding injected drugs, he nevertheless advocated education about the advantages
of condoms and clean needles, and he urged schools to teach children about safe sex. In
response, Senator Jesse Helms, a powerful conservative from North Carolina, denounced
safe sex materials aimed at gay men as “promotion of sodomy” by the government and
sponsored an amendment banning the use of federal funds “to provide AIDS education,
information, or prevention materials and activities that promote or encourage, directly
or indirectly, homosexual activities.”6(p.218) Today, television advertising of condoms, the
most effective barrier to HIV transmission, while not as restricted as it was three decades
ago, is still controversial.7 Despite the abundance of sexually explicit programming and
widespread advertising of Viagra and similar drugs, stations still fear the ire of political
conservatives and moralists.
Drug regimens introduced in the mid-1990s that are capable of controlling the damage the virus wreaks on the immune system stimulated new medical, ethical, and economic
challenges. The drugs have side effects that may prove fatal for some patients and have
long-term adverse effects in others. Complicated regimens for taking many pills per day
have been simplified, but new problems of viral strains resistant to the drugs have arisen.
These strains may be transmitted to others. Moreover, the drugs are expensive, costing an
average of $15,475 for a year’s supply,8 well beyond the budget of most patients, although
government programs pay for the treatment of many patients. The federal government
spent $16.6 billion on HIV-related medical care in the United States in 2014.9
The history of the AIDS epidemic vividly illustrates that public health involves both
science and politics. It took the science of epidemiology, the study of disease in human
populations, to determine the basic nature of the disease and how it is transmitted. The
biomedical sciences, especially virology and immunology, were crucial in identifying
the infectious agent, determining how it causes its dire effects on the human organism,
developing methods to identify virus-infected blood, and devising drugs that can hold
the virus at bay. Biostatisticians help to design the trials that test the effectiveness of new
drugs and, eventually it is hoped, vaccines—believed to be the greatest hope for controlling the virus. In the meantime, behavioral scientists must find ways to convince people
to avoid actions that spread the virus.
The politics of the AIDS epidemic shows the tension between individual freedom
and the health of the community. There is a strong tradition of the use of police powers to
protect the health of the public in all civilized societies. In the United States, there is also
a strong tradition of individual liberty and civil rights. Politics determines the path the
government will take in balancing these traditions. Public health is not based on scientific
facts alone. It depends on politics to choose the values and ethics that determine how science will be applied to preserve people’s health while protecting their fundamental rights.
Cryptosporidium in Milwaukee Water
In early April 1993, an outbreak of “intestinal flu” struck Milwaukee, causing widespread
absenteeism among hospital employees, students, and schoolteachers. The symptoms
included watery diarrhea that lasted for several days. The Milwaukee Department of
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Health, concerned, contacted the Wisconsin State Health Department and an investigation began.10
Stool samples from the most severely ill patients had been sent to clinical laboratories
for testing, and these tests yielded the first clues to the cause of the illness. Two laboratories reported to the city health department that they had identified Cryptosporidium in
samples from seven adults. This organism was not one that most laboratories routinely
tested for, but starting April 7, all 14 clinical laboratories began looking for it in all stool
samples submitted to them—and they began finding it. Ultimately, 739 stool samples tested
between March 1 and May 30 were found positive for Cryptosporidium.
Cryptosporidium is an intestinal parasite that is most commonly spread through contaminated water. In people who are basically healthy, the severe symptoms last a week or
so. In addition to the watery diarrhea, the symptoms include varying degrees of cramps,
nausea, vomiting, and fever. The infection can be fatal in people with a compromised
immune system, such as AIDS patients or people taking immunosuppressive drugs for
organ transplants or cancer treatment.
In Milwaukee, public health officials immediately suspected the municipal water
supply, which comes from Lake Michigan. They inspected records from the two water
treatment plants that supplied the city, and suspicion immediately fell on the southern
plant. The inspectors noted that the water’s turbidity, or cloudiness, which was monitored
once every 8 hours, had increased enormously beginning on March 21, an ominous
sign. On April 7, city officials issued a warning, advising customers of the Milwaukee
Water Works to boil their water before drinking it. On April 9, they temporarily closed
the plant. Looking for evidence that the water was indeed contaminated with Cryptosporidium, they discovered that a southern Milwaukee company had produced and
stored blocks of ice on March 25 and April 9. Testing confirmed that the organism was
present in the ice.
Meanwhile, public health investigators were trying to determine how many people
had been made sick by the contaminated water. Reasoning that only the most severely
affected patients would go to a doctor and have their stools tested, they began a telephone
survey of Milwaukee residents. On April 9, 10, and 12, they called randomly selected phone
numbers and asked the first adult who answered whether anyone in the household had
been sick since March 1. Of 482 respondents, 42 percent reported having had watery diarrhea, which was considered to be the defining symptom of the illness. In a more extensive
telephone survey conducted on 1663 people in the greater Milwaukee area between April
28 and May 2, 30 percent of the respondents reported having had diarrhea. Half of the
respondents whose water came from the southern plant reported the symptoms, while
only 15 percent of those whose homes did not get water from the Milwaukee Water Works
had been ill. These individuals had probably been exposed at work or from visiting the
affected region.10
The investigators, who reported the results of their study in the New England Journal
of Medicine, estimated that at least 403,000 people were made ill by the Cryptosporidium
contamination of the Milwaukee water supply.10 The number of deaths has been estimated
to be 54; 85 percent of them were AIDS patients, whose compromised immune systems
Public Health in the News
made them especially vulnerable.11 In discussing how the contamination had occurred,
the investigators speculated that unusually large amounts of the organism may have come
from cattle farms, slaughterhouses, or human sewage swept into Lake Michigan by heavy
spring rains and snow runoff. Flaws in the water treatment process of the southern plant
led to inadequate removal of the parasites. After the problem was diagnosed, the southern
water treatment plant was thoroughly cleaned, and a continuous turbidity monitor was
installed that automatically sounds an alarm and shuts down the system if the turbidity
rises above a certain level.
Cryptosporidium contamination is probably much more common than is recognized.
It is difficult to control because the organisms are widespread in the environment and
they are resistant to chlorination and other commonly used water disinfection methods.
Cryptosporidium was first recognized as a waterborne pathogen during an outbreak in
Texas in 1984 that sickened more than 2000 people.12 There may be many other pathogens
that could surprise us with waterborne outbreaks; according to a report by the Institute
of Medicine, only 1 percent of the organisms associated with disease that might be found
in water have been identified.13
The United States has one of the safest public water supplies in the world. Nonetheless,
according to the CDC, an estimated 4 million to 33 million cases of gastrointestinal illness
associated with public drinking water systems occur annually.14 Many communities are
still using water treatment technology dating to World War I, while population growth,
modern agricultural technology, toxic industrial wastes, and shifts in weather patterns due
to climate change are challenging the aging infrastructure. Updating the infrastructure
is expensive; but waterborne disease outbreaks are also expensive. An analysis of the cost
of the Milwaukee outbreak in medical and productivity costs done by scientists from
the CDC, the City of Milwaukee Department of Health, the Wisconsin State Division of
Public Health, and Emory University yielded an estimate of $96.2 million.15 These authors
estimated that, based on the approximately 7.7 million cases of waterborne disease annually, waterborne disease outbreaks cost $21.9 billion each year in the United States. They
recommended that the cost of the outbreaks should be considered when costs of maintaining safe water supplies are calculated. Safe drinking water, one of the most fundamental
public health measures, is by no means assured in the United States.
Worst-Case Scenario: Public Health in Russia
The Soviet Union set a high priority on public health soon after the Russian Revolution,
when the population was suffering from the effects of war, including famine, plague, and
a general lack of sanitation. The communist government ran educational campaigns to
teach people to practice basic hygiene and prevent disease. It promised free medical care
to all; it trained physicians and built hospitals and tuberculosis sanitariums. The incidence
of typhus, typhoid fever, and dysentery were dramatically cut. By the 1930s, Western visitors were impressed with the nation’s progress in raising the health of the population to
near European levels. However, the promise was soon eroded by the abuses of the Soviet
system. Progress was choked off by Stalin’s suppression of science, the policy of secrecy
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that concealed bad news, and the Soviet industrial planning process that pushed for continuously increased production at all costs.16
The extent of the public health disaster was not known until the late 1980s when Gorbachev began the policy of glasnost, or openness. Westerners—and Russians ­themselves—
learned that infant mortality rates had been rising since the 1970s but were not published
because they were embarrassing to the government. The extent of environmental degradation throughout the former Soviet Union, together with increasing rates of cancer, respiratory disease, and birth defects, had become obvious. The corruption and incompetence
in the Soviet medical system were also clear: shortages of vaccines, drugs, and medical
supplies; unhygienic practices including the reuse of needles for injections and immunizations; poor training of physicians; and shortages of nurses. Alcoholism was rampant.16
After the Soviet Union disintegrated in 1991, public health in Russia and other former Soviet states grew dramatically worse. In Russia, death rates increased and birth
rates declined so that by the mid-1990s, deaths were almost twice as common as births.
Economic and social conditions have improved considerably since then, and the public
health has improved. Still Russia lags far behind the improvements seen in Europe and the
United States. Life expectancy at birth for Russian men, which was 65.4 years in 1962–1963,
fell to 57.3 in 1994 and has recovered only to 64.4 in 2014.17 Life expectancy for women
is longer, at 76.3 years. (In 2014, the life expectancy for American men was 77.0 and 81.9
for American women.)17
The infant mortality rate fell during the 1990s and 2000s, but still it was 7.1 per 1000
live births in 2014, compared to 6.2 in the United States.17 Abortions were twice as common
as childbirth in the early 1990s; recent government efforts to restrict abortions, together
with the increased availability of birth control, reduced their number; still, the abortion
rate in Russia is double the rate in the United States.18 These factors led to a decline in
the size of the Russian population, which fell by 6 million people after 1992 to about 143
million in 2008, and appears to have stabilized at about that level.19
Although many factors contributed to the alarming statistics of the 1990s, much of
the blame appears to fall on the economic stress and social breakdown that accompanied
the breakup of the former Soviet Union. Middle-aged men were the group most severely
impacted by the changes in the system, and they continue to be disproportionately affected.
They are dying in large numbers from motor vehicle accidents, suicide, homicide, alcohol
poisoning, and cardiovascular disease. In fact, almost 60 percent of deaths in Russia are
caused by cardiovascular disease, and Russians die of cardiovascular disease at ages 10 to
15 years younger than Americans and Western Europeans.19
Unhealthy patterns of alcohol consumption, including binge drinking, and drinking
alcoholic substances not intended for consumption such as perfumes and medicines, contribute to the high death rates, especially among men. These surrogates are cheaper than
vodka and are widely available.20 Other unhealthy behaviors include tobacco smoking—
some 60 percent of Russian men smoke, while the rate is about 22 percent for women.21
Infectious diseases, which had been well controlled during the Soviet era, reappeared
in the 1990s. As recently as 2012, the CDC warned travelers about tickborne encephalitis,
measles, and rabies, but now its website states that “there are no notices currently in effect
Public Health in the News
for Russia,” unless the traveler is going to remote areas.22 Tuberculosis has been a major
problem in Russia, with 105,753 cases reported in 2012, compared with 9945 cases in the
United States.23 The problem in Russia was fed by poverty and social dislocation in the
1990s and overcrowded conditions in prisons, which spreads the disease to communities
when prisoners are released. Improper use of antibiotics has led to drug resistance in
many of these cases.24
Infection with HIV, the virus that causes AIDS, has been spreading out of control,
contributing to the prevalence of tuberculosis. The United Nations estimates that about
1 million Russians carry the HIV virus, almost as many as in the United States, which has
more than double the population.25 Intravenous drug use is responsible for the majority
of infections, although they are expanding in heterosexual populations and are also being
seen more in men who have sex with men.
The Russian medical system is vastly underfunded. Doctors and nurses are poorly
paid and many hospitals are poorly equipped, especially in rural areas. Although health
care is free in principle, many patients must pay under the table for services. 26 According
to World Health Organization figures for 2011, total expenditures on health in Russia
were $1,354 per person annually, which is more than three times what it spent in 2000;
but this still compares poorly with annual expenditures of $3,364 in the United Kingdom. The United States spends $8,467 per person annually, which is generally regarded
as excessive.23 A 2008 World Bank report on recommendations for healthcare reform
in Russia starts with public health strategies that are already widespread in the United
States, strategies that will be discussed later in this book. These are the World Bank’s
recommendations:
1. Control excessive alcohol consumption by targeting supply (e.g., regulation of
production, distribution, prices, access, and advertising) and demand (e.g., information, education, and communication campaigns).
2. Control tobacco consumption (e.g., development of policies for smoke-free worksites and public places; taxation; legislation for banning tobacco advertising and
promotion, as well as sale to minors).
3. Promote changes in diet and physical activity (e.g., public health policy incentives to promote dietary guidelines for healthier eating; school programs on the
importance of health, nutrition, and physical activity).
4. Improve road safety by promoting the use of seat belts and helmets, enforcing laws
to prevent accidents due to drunk driving, and retrofitting current road infrastructure with low-cost safety design features (e.g., medians, separation for pedestrians
and cyclists) and systematic maintenance to remediate road hazards.27
The report then goes on to discuss methods for improving the medical care system.
In addition to all of these issues, environmental pollution contributes to the public
health crisis. The Soviet emphasis on industrialization and competitiveness in waging the
Cold War led to a neglect of environmental protection and civilian public works. A 2007
report, The World’s Worst Polluted Places by the Blacksmith Institute, an international nonprofit organization focused on the health effects of industrial pollution in the developing
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world, found that 10 of the 30 worst places, the “Dirty Thirty,” were in the former Soviet
Union. At the top of the list was Dzerzhinsk, a city of 300,000 that is still a center of Russian
chemical manufacturing and was listed in the 2007 Guinness Book of World Records as the
most chemically polluted city in the world.28 Over recent years, efforts have been made to
clean up the environment in Dzerzhinsk, and the Blacksmith Institute has dropped the
city to fourth on its list of top ten toxic threats.
In cities across the nation, Soviet factories of 1930s vintage still spew black smoke and
toxic chemicals into the air, causing asthma, chronic bronchitis, cardiovascular disease, and
lung cancer. An analysis by the Environmental Defense Fund, published in 2008, concluded
that 10 percent of all deaths in Russian cities could be attributed to air pollution. In the
remainder of Russia the data are not as reliable, but the authors estimated that, overall,
air pollution caused about the same number of deaths as suicide and homicide combined
and double the number from transportation accidents.29
According to a 1999 report by the U.S. National Intelligence Council, water pollution is the most serious environmental concern in Russia. Raw sewage and industrial
wastes pour into rivers used for drinking water and almost three-quarters of the nation’s
surface water is polluted. Less than half of Russia’s population has access to safe drinking
water.30 Rivers used for irrigation have run dry, leaving contaminated dust to blow in the
wind. Soil and water are heavily contaminated by the excessive use of pesticides, many
of them banned in the United States because of their toxicity. The dismal state of Russia’s
waterways was confirmed in 2010 by the environmental group Greenpeace, which sent a
month-long research expedition to determine pollution levels in Russian rivers, finding
that waterways are still heavily contaminated with industrial wastes.31
The accident at the Chernobyl nuclear power station in 1986 poured quantities of
radioactive material into the atmosphere that contaminated water and soil over 50,000
square miles of the Ukraine, Belarus, and western Russia. A 19-mile zone around the plant
remains uninhabited and uninhabitable. Other less publicized nuclear accidents, as well
as atomic tests and deliberate dumping of nuclear materials, have exposed thousands of
citizens to dangerous levels of radiation. Genetic damage, caused by exposure to radiation
and toxic chemicals, is one hypothesis put forward to explain the dramatic increases in
birth defects and other health problems that are taking their toll on the Russian people.16,28
There does not seem to be much hope for improvement in the environment in the
foreseeable future. The Russian government tends to focus its efforts more on economic
development than environmental concerns. Even when local authorities wish to take
measures to protect the health of their communities, they tend to be overridden by federal
bureaucracies driven by economic concerns.32 The public health disaster in Russia serves
to remind Americans how lucky they are and how wise they have been—through local,
state, and federal governments—to take measures to protect the environment and their
health. Americans take most public health protections for granted—safe water, clean air,
freedom from exposure to dangerous radiation, sterile medical instruments, the availability
of effective antibiotics to treat infections, and access to immunizations against formerly
common diseases. Most Americans expect to live a long and healthy life. However, the
Public Health in the News
benefits of effective public health measures require continued vigilance. The Russian experience illustrates what can happen if these protections are not maintained.
Public Health and Terrorism
On September 11, 2001, the United States was struck by foreign terrorists, and Americans
entered a new phase of civic life. Four passenger airliners were simultaneously hijacked;
three were crashed into buildings filled with people going about their work, and one
crashed in an empty field in Pennsylvania, apparently headed for another target but retaken
by passengers.
The immediate public reaction to these disasters was the activation of emergency
response plans in the regions where the crashes occurred. Police, firefighters, and ambulances rushed to the scenes; hospital emergency rooms were alerted; extra doctors and
nurses were called in. In the New York City area, healthcare facilities in the whole region
readied themselves to receive the expected large numbers of people wounded at the World
Trade Center. Unfortunately, much of this preparation was not utilized because there were
so few injured people who survived.
Although the disaster of September 11 was unprecedented in its magnitude, it
was similar in kind to other emergencies and disasters for which communities plan:
plane and train crashes, factory explosions, earthquakes, hurricanes, and so on. In New
York, public health agencies were concerned not only with coordinating emergency
medical care, but also with ensuring the safety of cleanup workers and area residents.
Problems with polluted water, contaminated air, spoiled food, infestation of vermin,
and so on, had to be dealt with in lower Manhattan just as they must be dealt with
after any natural disaster. The longer-term response to September 11 has focused on
law enforcement and national defense, with the goal of preventing future hostile acts
by terrorists. The federal government has tightened security at airports and borders;
it has attacked or warned foreign countries thought to harbor terrorists; and national
intelligence agencies have increased their surveillance of persons and groups suspected
of being a threat to the United States, to the extent that there are concerns that civil
liberties are being eroded.
In contrast to the dramatic events of September 11, the second terrorist attack
occurring in autumn 2001 became apparent only gradually. On October 2, Robert Stevens,
an editor for a supermarket tabloid, was admitted to a Florida hospital emergency room
suffering from a high fever and disorientation. An infectious disease specialist made a
diagnosis of anthrax, in part because of heightened suspicions of bioterrorism provoked
by the September 11 attacks. The doctor notified the county health department, which
notified the state and the CDC. After further tests, the health agencies announced
on October 4 that a case of inhalational anthrax had been confirmed. An intensive
investigation into the source of exposure began at once. Mr. Stevens died on October 5.33,34
On that same day, another case was diagnosed in a worker at the same tabloid office
as Robert Stevens. Tests done throughout the building detected a few anthrax spores on
Mr. Stevens’ computer keyboard and more in the mailroom. The building was closed,
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and all employees were offered antibiotics to protect them against the development of
disease.
On October 9, the New York City Department of Health announced that a newsroom
worker at NBC in New York City had developed cutaneous anthrax. She had handled a
suspicious letter containing a powder, later identified as anthrax spores.35 Shortly after, a
7-month-old infant, who had visited his mother’s workplace at ABC-TV 2 weeks earlier,
was diagnosed with cutaneous anthrax. The child had developed a severe, intractable
skin lesion that progressed to severe anemia and kidney failure, but anthrax had not been
suspected as a cause of these symptoms. After two weeks in the hospital, the infant was
correctly diagnosed with anthrax, given antibiotics, and he gradually recovered, as did the
NBC worker.36 By this time, it was clear that the outbreak was intentionally caused and
that a bioterror attack was under way.
On October 15, a staff member working in Senator Tom Daschle’s office in
­Washington, DC opened a letter and noticed a small burst of powder from it. Alert to
the threat of anthrax, the aide notified the police and the Federal Bureau of Investigation (FBI), and the area was vacated. The letter tested positive for anthrax. Staff and
visitors who were potentially exposed were offered antibiotics, as were workers in the
Capitol’s mail rooms.37
The bad news continued. At about the same time that workers in the media and in
Congress were being exposed, the disease was breaking out in postal workers in New
Jersey, Maryland, and Virginia, although it took days to weeks to recognize what was happening. While it was known by mid-October that anthrax spores were being sent through
the mail, they were not believed to escape from sealed envelopes. As it turned out, postal
workers were among the most affected by the outbreak. The Brentwood Mail Processing
and Distribution Center in the District of Columbia was closed on October 21 after four
postal workers were hospitalized with inhalational anthrax; two of these workers died.38
All told, a total of 22 cases of anthrax were diagnosed over a 2-month period, of which
11 were the inhalational form. Five of the latter group died, one of whom was a 94-yearold woman in Connecticut whose source of exposure was never verified. It was surmised
that a piece of mail received at her home had been cross-contaminated by another piece
of mail at a postal facility.39 The CDC estimated that 32,000 potentially exposed people
received prophylactic antibiotic therapy, which may have prevented many more cases.40
Contaminated buildings, including five U.S. Postal Service facilities, had to be closed and
laboriously decontaminated; some of these building could not be reopened for more
than a year.41,42
Investigation of postal service records determined that letters to the media were
mailed in Trenton, New Jersey in mid-September. The letter to Senator Daschle and
one to Senator Patrick Lahey, which was not opened until it was irradiated to kill
the bacteria, were mailed in Trenton on October 9. A number of hoax letters, similar
to the anthrax letters, some containing innocuous white powder, were also mailed
to media and government offices from St. Petersburg, Florida. Since they were sent
before the news broke about the anthrax letters, they were presumably sent by the
same person. The perpetrator of the anthrax mailings was finally identified in 2008
Public Health in the News
as a scientist working on drugs and vaccines against anthrax at the U.S. Army Medical Research Institute of Infectious Diseases. As the FBI began to close in on him
as a suspect, Bruce Ivins committed suicide. Many of his colleagues doubt that he
was responsible, and the case will never be proven in court. The U.S. Department
of Justice released its evidence against him and requested the National Academy of
Sciences to conduct a review of the evidence.43 The Academy’s report concluded
that the evidence was consistent with Dr. Ivins’s lab being the source of the anthrax
spores but did not prove it.44
Meanwhile, a congressional inquiry into the FBI’s work, conducted by the Government Accountability Office (GAO), found that the scientific evidence linking the
mailed anthrax spores with samples from Dr. Ivins’s lab was “not as conclusive” as the
FBI had claimed. The GAO report noted several gaps in the FBI investigation. The
New Jersey congressman who requested the GAO investigation has called for the case
to be reopened.45
The anthrax attacks terrorized the population far beyond the actual damage done.
They also disrupted the public health and emergency response systems out of proportion to the actual threat. Any encounter with white powder evoked panic, causing people
to send samples to public health laboratories for testing. At New York State’s Wadsworth
Center in Albany, scientists worked around the clock throughout the fall, testing more
than 900 samples. Some of the unlikely specimens sent for testing were a pair of jeans, a
box of grape tomatoes, a box of Tic Tac® breath freshener, and several packets of cash from
automatic teller machines. The largest amount of cash submitted at one time was $8000,
carefully guarded and picked up by police immediately after the anthrax tests proved to
be negative (L. Sturman, personal communication).
The events that occurred in the autumn of 2001 disturbed Americans’ sense of
security within their borders. The terrorists’ hijacking of four airplanes prompted
major efforts to strengthen homeland security through more rigorous screening of
airline passengers and of international travelers at the borders, precautions that are
now routine and are expected to be maintained. The anthrax attacks called attention
to the fact that the public health system is America’s best protection from bioterrorism.
Increased funding for disease surveillance, public health laboratories, and emergency
response systems has strengthened the ability of the public health system to respond
to bioterrorist attacks as well as to natural disasters and epidemics. These precautions
are just as important as other homeland security measures for Americans to be safe in
their homeland.
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February 20, 2002.
37. U.S. Centers for Disease Control and Prevention,“Update: Investigation of BioterrorismRelated Anthrax and Interim Guidelines for Exposure Management and Antimicrobial
Therapy, October 2001,” Morbidity and Mortality Weekly Report 50 (2001): 909–919.
38. U.S. Centers for Disease Control and Prevention, “Evaluation of Bacillus anthracis Contamination Inside the Brentwood Mail Processing and Distribution Center—District of
Columbia, October 2001,” Morbidity and Mortality Weekly Report 50 (2001): 1129–1133.
xxix
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Public Health in the News
39. U.S. Centers for Disease Control and Prevention, “Update: Investigation of Bioterrorism-
Related Anthrax—Connecticut, 2001,” Morbidity and Mortality Weekly Report 50 (2001):
1077–1079.
40. U.S. Centers for Disease Control and Prevention,“Update: Investigation of BioterrorismRelated Anthrax and Adverse Events from Antimicrobial Prophylaxis, 2001,” Morbidity
and Mortality Weekly Report 50 (2001): 973–976.
41. U.S. Centers for Disease Control and Prevention, “Follow-Up of Deaths Among U.S.
Postal Service Workers Potentially Exposed to Bacillus anthracis—District of Columbia,
2001–2002,” Morbidity and Mortality Weekly Report 52 (2003): 937–938.
42. I. Peterson, “Postal Center Hit by Anthrax Is Now Clean, Officials Say,” The New York
Times, February 10, 2004.
43. S. Shane, “Portrait Emerges of Anthrax Suspect’s Troubled Life,” The New York Times,
January 3, 2009.
44. National Research Council, “Review of the Scientific Approaches Used During the FBI’s
Investigation of the 2001 Anthrax Letters” (Washington, DC: National Academies Press),
2011. http://www.nap.edu/catalog/13098/review-of-the-scientific-approaches-used
-during-the-fbis-investigation-of-the-20010anthrax-letters, accessed December 10, 2015.
45. W. J. Broad, “Inquiry In Anthrax Had Gaps, Report Says, ” The New York Times, December
20, 2014.
Part I
What Is Public Health?
Chapter
Chapter11
Public Health: Science, Politics,
and Prevention
key terms
Assessment
Health
Public health
Assurance
Health outcomes
Risk factor
Biomedical sciences
Health promotion
Statistics
Community
Infectious disease
Substance abuse
Disability
Interventions
Virus
Effectiveness
Life expectancy
Epidemiology
Policy development
One expectation about living in a civilized society is that the living conditions will be
basically healthy. Unless something unusual happens, like the outbreak of Cryptosporidium in the Milwaukee water supply, people assume that they are basically safe: Their
water is safe to drink; the hamburger they buy at the fast food restaurant is safe to eat;
the aspirin they take for a headache is what the label says it is; and they are not likely to
be hit by a car—or a bullet—if they use reasonable caution in walking down the street.
Even after the attacks in the fall of 2001, which severely disrupted their sense of security,
most Americans regained a sense of trust in the safety of their environment.
In historical terms, this expectation is a relatively recent development. In the mid19th century, when record-keeping began in England and Wales, death rates were very
high, especially among children. Of every ten newborn infants, two or three never reached
their first birthday. Five or six died before they were six years old, and only about three
of the ten lived beyond the age of 25.1 Tuberculosis was the single largest cause of death
in the mid-19th century. Epidemics of cholera, typhoid, and smallpox swept through
communities, killing people of all ages and making them afraid to leave their homes.
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Injuries—often fatal—to workers in mines and factories were common due to unsafe
equipment, long working hours, poor lighting and ventilation, and child labor.
There are a number of reasons why people’s lives are basically healthier today than they
were 150 years ago: cleaner water, air, and food; safe disposal of sewage; better nutrition;
more knowledge concerning healthy and unhealthy behaviors; and many others. Most
of these factors fall in the domain of public health. In fact, the term “public health” refers to
two different but related concepts. We can say that the public health has improved since
the 19th century, meaning that the general state of people’s health is now much better than
it was. But the measures that people take as a society to bring about and maintain that
improvement are also known as public health.
Although many sectors of the community may be involved in promoting public health,
people most often look to government—at the local, state, or national level—to take the
primary responsibility. Governments provide pure water and efficient sewage disposal.
­Governmental regulations ensure the safety of the food supply. They also ensure the q
­ uality
of medical services provided through hospitals, nursing homes, and other institutions. Laws
regulating people’s behavior prevent them from injuring each other. Laws requiring immunization of school-aged children prevent the spread of infectious diseases. Governments also
sponsor research and education programs on causes and prevention of disease.
What Is Public Health?
Public health is not easy to define or to comprehend. A telephone survey of registered
voters conducted in 1999 by a charitable foundation found that over half of the 1234
respondents misunderstood the term.2 Leaders in the field have themselves struggled to
understand the mission of public health, to explain what it is, why it is important, and what
it should do. Charles-Edward A. Winslow, a theoretician and leader of American public
health during the first half of the 20th century, defined public health in 1920 this way:
The science and the 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 services 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.3(p.1)
Winslow’s definition is still considered valid today.
Over the following decades, public health had many successes, carrying out many of
the tasks described in Winslow’s definition. It was highly effective in reducing the threat
of infectious diseases, thereby increasing the average lifespan of Americans by several
decades. By the 1980s, public health was taken for granted, and most people were unaware
of its activities. But there were signs that the system was not functioning well. ­Government
expenditures on health were alarmingly high, but most of the spending was directed
Public Health Versus Medical Care
toward medical care. No one was talking about public health. At the same time, new health
problems were appearing: The AIDS epidemic broke out, concern about environmental
pollution was growing, the aging population was demanding increased health services, and
social problems such as teenage pregnancy, violence, and substance abuse were becoming
more common. There was a sense that public health was not prepared to deal with these
problems, in part because people were not thinking of them as public health problems.
A study conducted by the Institute of Medicine and published in 1988 called The Future
of Public Health refocused attention on the importance of public health and did a great
deal to revitalize the field. One of the first tasks the study committee set for itself was to
re-examine the definition of public health, reasoning that for it to be effective, public health
had to be broadly defined.4 The committee’s report gives a four-part definition describing
public health’s mission, substance, organizational framework, and core functions.
The Future of Public Health defines the mission of public health as “the fulfillment
of society’s interest in assuring the conditions in which people can be healthy.”4(p.40) The
substance of public health is “organized community efforts aimed at the prevention of
disease and the promotion of health.”4(p.41) The organizational framework of public health
encompasses “both activities undertaken within the formal structure of government and
the associated efforts of private and voluntary organizations and individuals.”4(p.42) The
three core functions of public health are these:
1. Assessment
2. Policy development
3. Assurance4(p.43)
These core functions were later translated by another committee into a more concrete set
of activities called The Ten Essential Public Health Services, shown in (Table 1-1).
Public Health Versus Medical Care
One way to better understand public health and its functions is to compare and contrast it with medical practice. While medicine is concerned with individual patients,
public health regards the community as its patient, trying to improve the health of the
population. Medicine focuses on healing patients who are ill. Public health focuses on
preventing illness.
In carrying out its core functions, public health—like a doctor with his/her patient—
assesses the health of a population, diagnoses its problems, seeks the causes of those
problems, and devises strategies to cure them. Assessment constitutes the diagnostic function, in which a public health agency collects, assembles, analyzes, and makes available
information on the health of the population. Policy development, like a doctor’s development
of a treatment plan for a sick patient, involves the use of scientific knowledge to develop
a strategic approach to improving the community’s health. Assurance is equivalent to the
doctor’s actual treatment of the patient. Public health has the responsibility of assuring
that the services needed for the protection of public health in the community are available
and accessible to everyone. These include environmental, educational, and basic medical
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Table 1-1 The Ten Essential Public Health Services
Assessment
1. Monitor health status to identify community health problems
2. Diagnose and investigate health problems and health hazards in the community
Policy Development
3. Inform, educate, and empower people about health issues
4. Mobilize community partnerships to identify and solve health problems
5. Develop policies and plans that support individual and community health efforts
Assurance
6. Enforce laws and regulations that protect health and ensure safety
7. Link people to needed personal health services and assure the provision of health care
when otherwise unavailable
8. Assure a competent public health and personal healthcare workforce
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health
services
Serving All Functions
10. Research for new insights and innovative solutions to health problems
Reproduced from The Future of the Public’s Health in the 21st Century (Washington, DC: National Academy Press,
2002): 99. With permission of the National Academy of Sciences, Courtesy of the National Academies Press.
services. If public health agencies do not provide these services themselves, they must
encourage others to do so or require such actions through regulation.
Public health’s focus on prevention makes it more abstract than medicine, and its
achievements are therefore more difficult to recognize. The doctor who cures a sick person
has achieved a real, recognizable benefit, and the patient is grateful. Public health cannot
point to the people who have been spared illness by its efforts. As Winslow wrote in 1923,
“If we had but the gift of second sight to transmute abstract figures into flesh and blood,
so that as we walk along the street we could say ‘That man would be dead of typhoid
fever,’ ‘That woman would have succumbed to tuberculosis,’ ‘That rosy infant would be
in its coffin,’—then only should we have a faint conception of the meaning of the silent
victories of public health.”3(p.65)
This “silence” accounts in large part for the relative lack of attention paid to public
health by politicians and the general public in comparison with medical care. It is estimated that only about 3 percent of the nation’s total health spending is spent on public
health.5 During the healthcare reform debate of 1993 and 1994, and again in 2008 during
the presidential campaign, virtually all of the discussion focused on paying for medical
care, while very little attention was paid to funding for public health. However, President
Obama’s health reform law, passed in 2010, did include provisions and funding for prevention, wellness, and public health.6
Effective public health programs clearly save money on medical costs in addition
to saving lives. Moreover, public health contributes a great deal more to the health of a
The Sciences of Public Health
population than medicine does. According to one analysis, the life expectancy of Americans
has increased from 45 to 75 years over the course of the 20th century.7 Only 5 of those
30 additional years can be attributed to the work of the medical care system. The majority
of the gain has come from improvements in public health, broadly defined as including
better nutrition, housing, sanitation, and occupational safety. One responsibility of public
health, therefore, as noted in the Institute of Medicine report, is to educate the public
and politicians about “the crucial role that a strong public health capacity must play in
maintaining and improving the health of the public . . . By its very nature, public health
requires support by members of the public—its beneficiaries.”4(p.32)
Public health, like medical practice, is based on science. However, even when public
health scientists are certain they know all about the causes of a problem and what should
be done about it, a political decision is generally necessary before action can be taken to
solve it. When a doctor diagnoses a patient’s illness and recommends a treatment, it is up
to the patient to accept or reject the doctor’s recommendation. When the “patient” is a
community or a whole country, it is usually a government—federal, state, or local—that
must make the decision to accept or reject the recommendations of public health experts.
Sometimes the process starts within the community when, like a patient going to a d
­ octor
with a complaint, the people recognize a problem and demand that the government take
action. This has occurred in many communities when victims of drunk drivers form
organizations such as Mothers Against Drunk Driving (MADD) to lobby for stricter laws,
or when neighbors of pollution-generating factories demand that the government force
the industry to clean up the environment.
Politics enters the public health process as part of the policy development function
and especially as part of the assurance function. Since the community will have to pay
for the “treatments,” usually through taxes, they must decide how much “health” they are
willing to fund. They also must decide whether they are willing to accept the possible
limitations on their freedom that may be required in order to improve the community’s
health. Among the assurance functions of public health is the provision of basic medical
services: How this should be done has been a matter of great political controversy. Public
health professionals are often impatient with politics, as the Institute of Medicine report
notes, seeming to “regard politics as a contaminant of an ideally rational decision-making
process rather than as an essential element of democratic governance.”4(p.5)
The Sciences of Public Health
The scientific knowledge on which public health is based spans a broad range of professional disciplines. The Institute of Medicine report notes that “public health is a coalition
of professions united by their shared mission” as well as by “their focus on disease prevention and health promotion; their prospective approach in contrast to the reactive focus of
therapeutic medicine, and their common science, epidemiology.”4(p.40) The disciplines of
public health can be divided somewhat arbitrarily into six areas. Epidemiology and statistics
are the basis for the assessment functions of public health, including the collection and
analysis of information. Both assessment and policy development need an understanding
of the causes of health problems in the community, an understanding that depends on
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Chapter 1
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biomedical sciences, social and behavioral sciences, and environmental sciences. As part
of the assurance function, public health seeks to understand the medical care system in an
area of study generally referred to as health policy and management or health administration, which also includes the administration and functioning of the public health system.
Epidemiology has been called the basic science of public health. As its name suggests,
epidemiology is the study of epidemics. It focuses on human populations, usually starting
with an outbreak of disease in a community. Epidemiologists look for common exposures
or other shared characteristics in the people who are sick, seeking the causative factor.
Epidemiology often provides the first indications of the nature of a new disease. When
AIDS was first recognized in the early 1980s, the cause was unknown. Doctors reported cases
of this unusual disease to the U.S. Centers for Disease Control and Prevention, and epidemiologists began looking for common characteristics of the patients. Epidemiologic research
indicated that it was an infectious disease spread through blood and body fluids and suggested
a virus as the cause. This prompted the biomedical scientists to step in and look for the virus.
Epidemiology is important not only for deciphering the causes of exotic new diseases,
but for preventing the spread of old, well-understood diseases. Epidemiologists are mainstays of local health departments. In what is commonly known as “shoe-leather epidemiology,” they track down, for example, the source of a food-poisoning outbreak and force a
restaurant to clean up its kitchen. Or they trace everyone who has been in contact with a
college student diagnosed with meningitis in order to administer high doses of antibiotic
to prevent further spread of that dangerous disease. Epidemiologic studies have also been
important in identifying the causes of chronic diseases such as heart disease and cancer.
Because public health deals with the health of populations, it depends very heavily
on statistics. Governments collect data on births and deaths, causes of death, outbreaks of
communicable diseases, cases of cancer, occupational injuries, and many other healthrelated issues. These numbers are diagnostic tools, informing experts how healthy or sick a
society is, and where its weaknesses are. For example, the fact that the United States ranks
27th in infant mortality among the nations of the world, 26th in life expectancy of men,
and 28th of women is one indication that the public health in this country is not as good
as that in many others.8(Tables 14,15)
To understand what the numbers mean, it is necessary to understand certain statistical concepts and calculations. The science of statistics is used to calculate risks from
exposure to environmental chemicals, for example. Statistical analysis is an integral part
of any epidemiologic study seeking the cause of a disease or a clinical study testing the
effectiveness of a new drug.
Both public health and medicine depend on the biomedical sciences. A major proportion
of human disease is caused by microorganisms. Prevention and control of these diseases
in a population require an understanding of how these infectious agents are spread and
how they affect the human body. Control of infectious diseases was a major focus of public
health in the 19th and early 20th centuries. Biomedical research was very successful in
gaining an understanding of the major killers of that period, providing the information
and techniques from which successful public health measures could bring these diseases
under control.
The Sciences of Public Health
Biomedical research is still important to the understanding and control of new
­diseases such as AIDS, which has become the major epidemic of the late 20th and early
21st centuries worldwide. It has also contributed increasingly to an understanding of
noninfectious diseases such as cancer and heart disease, which have become increasingly
important as many infectious diseases have been controlled. Recent progress in understanding human genetics is providing new insights into people’s inherent susceptibility
to various diseases, raising new hopes of cures as well as concerns about discrimination.
Environmental health science, a classic component of public health, is concerned
with preventing the spread of disease through water, air, and food. While it is not strictly
a separate science, because it shares concerns about the spread of infectious organisms
with biomedical sciences and depends on epidemiology to track environmental causes
of disease outbreaks, it is usually considered a separate area of public health. Much of
the great improvement in public health in the United States during the 20th century was
due to improved environmental health, especially the fact that most Americans have safe
drinking water. In its concern with safe water and waste disposal, environmental health
depends on engineering to design, build, and maintain these systems.
Despite the fact that the importance of safe air, water, and food has been recognized
for so many decades, there are many new challenges to environmental health. Not only
do old systems fail, as occurred in Milwaukee, but new problems arise, brought about by
modern lifestyles. Thousands of new chemicals enter the environment every year, and
little is known about their effects on human health. Chemicals known to be toxic have
accumulated in the environment, and methods must be devised to dispose of them safely.
Other environmental threats to health include ultraviolet rays in sunlight, an increasing
problem as the ozone layer of the earth’s atmosphere is depleted, and exposure to other
kinds of radiation. Recently it has become apparent that human activities are causing
changes in the climate of the earth, changes that are permanently altering our environment and are already having important effects on human health.
Increasingly, public health is concerned with social and behavioral sciences. As biomedical and environmental sciences have conquered many of the diseases that killed
people of previous generations, people in modern societies are dying of diseases caused
by their behavior and the social environment. Heart disease is related to nutrition and
to exercise patterns; many forms of cancer are caused by smoking; abuse of drugs and
alcohol is a notorious killer. Violence is a significant cause of death in our society and
attracts ongoing concern.
Some subgroups of the population have poorer health overall than others, for reasons
that, while not completely understood, relate to social and behavioral factors. People with
low incomes are less healthy than those with a higher socioeconomic status. Black Americans have lower life expectancy overall than white Americans, even when their incomes
are similar. Other ethnic minority groups, including Hispanics, Asians, and ­American
Indians are at increased risk for a variety of health problems.
Social and behavioral sciences involve more unanswered questions than biomedical
and environmental sciences do. Very little is known about why racial and ethnic groups
differ in their health-related behavior, why many people of all races behave in unhealthy
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Chapter 1
Public Health: Science, Politics, and Prevention
ways, and how to prevent self-destructive behaviors. In the social and behavioral sciences,
of all areas, research and application of its findings are most likely to make a difference
in the future.
Until the beginning of the 20th century, public health and medicine overlapped substantially in their spheres of interest and activity. Both fields were concerned primarily
with understanding the causes and prevention of infectious disease because medicine was
relatively powerless to cure them. With the discovery of antibiotics, however, medicine
gained the power to work miracles of healing, leading to a period of rapidly growing
influence. Meanwhile, because of its less glamorous task of preventing disease, public
health faded into obscurity.
Over the past few decades, it has become apparent that our society’s emphasis on curing disease rather than preventing it has gone out of control. Medical care has become so
expensive that an increasing proportion of the population cannot afford it, and spending
for medical care has eaten up resources that could more profitably be used for education, housing, and the environment. Concern about runaway costs, lack of access, and
questionable quality of care has led to an increasing interest in studying the medical care
system, its effectiveness, efficiency, and equity, leading to a science called health services
research. Traditional categorization of public health fields puts this study into the area of
health policy and management or health administration.
Prevention and Intervention
Public health’s approach to health problems in a community has been described as a
five-step process:
1. Define the health problem.
2. Identify the risk factors associated with the problem.
3. Develop and test community-level interventions to control or prevent the cause
of the problem.
4. Implement interventions to improve the health of the population.
5. Monitor those interventions to assess their effectiveness.6
Thus, a main task of prevention is to develop interventions designed to prevent
specific problems that have been identified either through an assessment process initiated by a public health agency or through community concern raised by an unusual
course of events. For example, statistical data may show that a community has a high
rate of cancer in comparison with other similar communities. Or a series of fatal
crashes caused by drunk driving may mobilize a community to demand action to
prevent further tragedies.
Public health has developed systematic ways of thinking about such problems that
facilitate the process of designing interventions that prevent undesirable health outcomes.
One approach is to think of prevention on three levels: primary prevention, secondary
prevention, and tertiary prevention. Primary prevention prevents an illness or injury from
occurring at all, by preventing exposure to risk factors. Secondary prevention seeks to
minimize the severity of the illness or the damage due to an injury-causing event once the
Public Health and Terrorism
event has occurred. Tertiary prevention seeks to minimize disability by providing medical
care and rehabilitation services.
Thus interventions for primary prevention of cancer include efforts to discourage teenagers from smoking and efforts to encourage smokers to quit. In secondary
prevention, screening programs are established to detect cancer early when it is still
treatable. Tertiary prevention involves the medical treatment and rehabilitation of
cancer patients.
This way of thinking was very effective in developing traffic safety programs that, over
the past five decades, have significantly reduced the rates of injury from motor vehicle
crashes. Primary prevention focused on preventing crashes from occurring, for example,
by building divided highways and installing traffic lights. Secondary prevention included
the design of safer automobiles with stronger bumpers, padded dashboards, seat belts, and
airbags. It also included laws requiring drivers and passengers to wear the seat belts. And
tertiary prevention required the development of emergency medical services including
ambulances, 911 calling networks, and trauma centers.
Another approach to designing interventions is to think of an illness or injury as the
result of a chain of causation involving an agent, a host, and the environment. This approach
is traditional when thinking of infectious diseases: the agent may be a disease-causing
bacterium or virus; the host is a susceptible human being; and the environment includes
the means of transmission by which the agent reaches the host, which may be contaminated air, water, or food, or it may be another human being who is infected. Prevention
is accomplished by interrupting the chain of causation at any step. Rendering a potential
host unsusceptible through immunization, for example, can interrupt the chain. Or the
bacterium infecting a host can be killed through the use of antibiotics. Or the environment
can be sanitized through the purification of water and food.
The chain of causation model can also be used for other kinds of illnesses or injuries.
For example, suicide is the second leading cause of death in the age group 15 to 24.8(Table 21)
In applying the model to prevention of youth suicide, the host is the susceptible young
person; the agent is most often a gun or an overdose of pills; the environment includes
the young person’s whole social environment, including family, school, and the media.
A public health intervention could focus on how to make young people less susceptible to
self-destructive thinking; it could try to change the messages presented by television and
schoolmates that may lead a young person to think he or she is unattractive or otherwise
inferior. However, the public health perspective tends to be that the most effective target of
intervention for youth suicide prevention is the agent, especially guns. Many adolescents
are susceptible to depressed moods and think of killing themselves, but the best predictor
of whether they will succeed is whether they have access to a gun.
Public Health and Terrorism
The events in the fall of 2001 disturbed the sense of complacency many people felt about
the health and safety of their living conditions. Evidence that there were groups or individuals who not only wanted to cause harm to Americans at home but who had the resources
and the will to succeed in that goal forced us to think about how to prevent similar events
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Chapter 1
Public Health: Science, Politics, and Prevention
in the future. While prevention of violent acts such as hijacking airplanes is primarily a
responsibility of law enforcement, public health has an important role to play in controlling the damage caused by such events. In other words, primary prevention of terrorist
acts may be out of the domain of public health, but secondary and tertiary prevention are
very much a part of public health’s mission. Success at these services depend on having
well-designed plans in place before a disaster occurs.
The crashing of two planes into the World Trade Center triggered the activation of
emergency response plans developed for New York City and New York State, plans designed
as secondary prevention—minimizing the damage—and tertiary prevention—providing
medical care to those injured in the disaster. Most critically important for saving lives was
the ability for occupants of the buildings to get out as fast as possible. The fact that all but
2092 of the 17,400 people who were in the towers when the planes hit made it out is evidence
that some aspects of the plans were effective.9 However, studies done later found many flaws
in the emergency planning. Plans for providing medical care to survivors were not seriously
tested, because the capacity—including the arrival of numerous volunteers—exceeded the
number of injured survivors. The greatest problem was a lack of coordination.
The public health response to the terrorism of September 11, 2001 was essentially the
same as the response needed for other emergencies and disasters: factory explosions, plane
and train crashes, earthquakes, hurricanes (such as Katrina in 2005), and so on. Public
health was concerned not only with coordinating emergency medical care, but also with
ensuring the safety of cleanup workers and area residents. Problems with polluted water,
contaminated air, spoiled food, …
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