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Public Health; Scienee, Politics, and Prevention

l--

Medical Care versus Public Health

One expectation about living in a civilized sociery is that the Iiving conditions will be basically healthy. Unless something unusual happens, like the outbreak of Cryptosporidium in the Milwaukee water supply (discussed in the Prologue), people assume thar they are basically safe: their water is safe to drink; rhe hamburger rhey buy at rhe fast food restauranr is safd to eat; rhe aspirin they take for a headache is what the label says it is; and they are nor likely to be hit by a car-or a bullet-if they use reasonable caution in walking down the street. Even after the attacks of fall 2001, which severely disrupted their serise of securiry mostAmericans regained a
sense

of trust in the safetv of their environment.

Punrtc HrRlrH: SctrNcr, PoLtrtcs' AND PngvrNttoN


t ,-- I- .LI tlf h cen' rcn-i.lrecent develoPmnt' In the mid'i9th In historical terms, this expectation is a reladvely especially

and \rales, death rates were very high' tury, when record-keeping began in England birthday' rwo or rhree never reached their first among children. of e.,reriten"ne*borr,frrf^o.., tn' the ren years old, and only about three of 1tl.-11.y""a Five or six died u.ror. ,i.y were 6 century' largest cause of death in 'the mid-19th age of 25.r Ti.rberculosis was the single all J*.pt rhro,rgh.communities, killing people of Epidemics of cholera, ryphoid, "rrd r-*llpo* workers in mines 1."u. ,hi, ho*.r, Injuries-often fatal*to ages and making,h.*"f,"id,o and equip*.nr, long *orking hours' poor lighting and factories were common due to unsafe

ventilation, and child labor'

than they were people's lives are basically healthier today There are a number of reasons why nutrition; more food; safe disposal of sewage; better 150 ycars ago: cleaner water, air, "rrJ Most of these factors ' behaviors; knowledge concerning-h.J,hy "r,d unhealthy iil :"i1:,rhers. to two different but (."lth. In fact, ih. ,t'* "public health" rifers fall in the domain

relatedconcePts.w.*'saythatthepublichealthhasimprovedsincethelgthcentury,meanthe measures is now rnuch better than it was' But ing rhat the general ,.",u oi people's iealth

"r

i*iii.

tharpeopletakeas"'otit'y*b'i"guboutandmainainthatimprovementarealsoknownas
public health health' peomay be involved in prornoting public Although many sedors of the communiry take the primary locai, srare,{r.national level:to ple most often look ro ro.r.rn^"*"r the sewage disposal' Governmental Gou.rnrient, provide pure water and efficient
responsibility.

regulationsensurethesaferyof,h.foodsupply'Theyalsoensurethequaliryofmedical''.:,:* bepeople's
and other institutions' Laws regulating provided through hospitals, nursing homes, laws requiring immunization of school-aged havior prevenr thern from injuring each other. research and edudiseases' Governments also sponsor children prevent the spread of infecrious of disease' cation programs on causes and prevention

What trs Fublic Health?


survey of registered voters public health is not easy ro. define or to comPrehend. A telephone over half of rhe 1234 respondents rggg by a charitable foundation found that ;;;;;

the mishave chemselves struggled to understand misunderstood the term.2 Leaders in the field why ir is important, and what it should do' charlession of public health, to explain what it is, 'Winslow, a th.oretician and leader of Amerlat' public health during the first half of Edward A. 1920 this way: the 20th century defined public health in

prolonging life, and The science and the art of preventing disease, compro*oring physical health and efficienry through organized

WH,cr

Is PusLrc HrnltH?

muniry efforts for the sanitation of rhe environmenr, rhe conrrol of community infections, the education of rhe 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 mainrenance of health.r(P |
)

Winslow's definition is still considered valid today.

Over the following decades, public healrh had many successes, carrying out many of rhe tasks described in Winslow's definition. It was highly effective in reducing the threar of infectious diseases, thereby increasing the average lifespan of Americans by several decades. By the
1980s, public health was mken for granted, and most people were unaware of im acdvities. But there were signs that

fie

system was not fi.rnctioning well. Government expendirures on health

were alarmingly high, but most of the spending was directed toward medical care. No one was

talking about public health. At the same rirne, 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
as

with

these problems, in part because people were not th inking of them called, The Future

public health problems.

A srudy conducted by the Institute of Medicine and published in 1988

of

Public Heahh refocused attention on the importance of public health and did a great deal to re-

vitalize rhe field. One of rhe firsr tasks the srudy committee set for imelf was to re-examine the definition of public health, reasoning that for it to be effective, public health had to be broadly defined.a The committee's report gives a four-part definition describing public health's mission,
substance, organizational framework, and core functions.

d!fines the mission of public health as "the fulfillment of sociery's interesr in assuring the conditions in which people can be healthy.i'atr<o)The substance of public health is "organized communiry efforts aimed at the prevendon of disease and the promoThe Future of Public Heahh

The organizarional framework of public health encompasses "both activiries undertaken within the formal structure of government and the associared eFforts of privare and voluntary organizations and individuals.""tpqu) The three core functions of public
health.'4(P'41)

rion of

heahh are these:

l.
3.

Assessment

2. Policy development
ASSUranCe4(p.43)

PusLIc

Hrnlrs: ScrrNcr, Potttrcs,

AND pRtvrNrtoN

These core funcdons were iater translated by another committee into a more concrere ser of activities called The rbn Essential ?ublic Health seruicu, shown in Thble I - I .

Table

1-1

The Ten Essential Public Health Services

Public Health versus Medical Care


One way to better understand public health and irs functions is ro compare and conrrast ir with medical pracdce. \)7hile medicine is concerned with individual patienrs, public health regards the community as its patient, trying ro improve rhe health of rhe population. Medicine focuses on healing patients who are ill. Public health focuses on preventing illness.

In carrying out its core firnctions, public heahh-like a doctor with his/her patientthe health of a population, diagnoses its problems, seeks the causes of rhose problems, and devises strategies to cure them. Assessment consrirures the diagnostic function, in which a public health agency collects, assembles, analyzes, and makes available informarion on the health of the population. Policy development, like a docror's development of a rrearmenr plan
assesses

for a sick patient, involves the use of sciendfic knowledge to develop a strategic approach to improving the community's health. Assurance is equivalent to the docror's actual rrearmenr of the patient. Public health has the responsibiliry of assuring rhar rhe services needed for rhe pro-

Pusrrc Hslrrg vERsus

Me ore

nl Clns

tection of public health in the communiry are available and accessible ro everyone. These include environmental, educational, and basic medical services. If public health agencies do not provide these services themselves, they must encourage others to do so or require such actions

tlrough reguladon.
more abstract rhan medicine, and its achievements are therefore more difficult to recggnize. The docror who cures a sick person has achieved a real, recognizable benefit, and the patient is grateful. Public health cannor point to the people who have been spared illness by its efforts. fu \(/inslow wrote in 1923,"\f wehad but the gift of second sight to transmute abstract figures into flesh and blood, so rhar as we walk along rhe $ret we could say 'That man would be dead of ryphoid fever,' 'That woman would have succumbed to tuberculosis,' 'That rosy infant would be in irs coffin,'-then only should we have a 6.int conception of rhe meaning of the silent vicrories of public hsal1h."3rr'05) This "silence" accoun$ in large part for the relative lack of amention paid ro public health by

Public hedrh's focus on prwention'makes

it

politicians and the general public in comparison with medical care. It is esrimared rhat only abour 3 percent of rhe nation's total health spending is spent on public heahh.s During the healthcare reform debate oF 1993 and 1994, and again in 2008 during rhe presidential campaign, virtually all of the,discussion focused on paying for medical care, while very lirde attention was paid to funding for public health. Although federal resources devoted ro some public health activities increased,dramaticdly after.september 11,2001, as discussed in the Prologue and Chapter 29, budget deficits are again p,rnirrg downward pressure on public
health allocations. Effective public health prograrru clearly save money on medical costs in addirion to saving lives. Moieover, public health csntributes a great deal more to the health of a popul4tion than medicine does. According to one analysis, the life xpectancy of Americans has increased from

45 rc 75

of the 20rh century.7 Only five of those thirry addidonal years can be acributed to the work of the medical crre system. The majority of the gain has come from improvements in public health, broadly defined as includ.ing berrer nutrition, housing, sanitatiSn, and occupational safery. One responsibilityof public health, therefore, as noted in
years over the course

fhe Institute of Medicine report, is to educate the public and polidcians about "the crucial role that a strong public health capaciry must play in mainminfqg and improving the health of rhe

public

. . . By its very

nature, public health requires supporr by members

of rhe public-

its benefi ciarl.r."a(r'32) Public health, like medical practice, is based on science. However, even when public hedrh 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. \fhen a doctor diagnoses a patient's illness and recommends a treatment, ir is up to the patient ro accept or reject the doctor's recommendation.'When.rhe

"patient" is a communiry or a whole

PusLrc HgRLrs: Scrrltcr, PoLtrtcs, AND PngvsNrtoN


counrry, it is usually a government-federal, srate, or local-:-that must make the decision to accept or reject the recommendations of public health experrs. Sometimes the.process srarts within the community when, like a patient going to a docror with a complaint, the people recognize a problem and demand that the government rake action. This has occurred in many communities when victims of drunk drivers form organizarions such as Morhers Againsr Drunk Driving (MADD) to lobby for stricter laws, or when neighbors of pollution-generaring factories demand that the governmenr force rhe industry to clean up the environmenr.

Politics enters the public health process

as

part of the policy developmenr function and espe-

cially as part of the assurance function. Since the community will have to pay for the "treatments," usually drrough taxes, they must decide how much "healrh" they are willing to fund.
They also must decide whether they are willing to accept the possible limirations on their freedom that may be required in order to improve rhe communiry's health. Among the assurance firnctions of public health is the provision of basic medical services: how this should be done is
a mamer of great political controversy, as is apparent whenever there is a national debate over -reform healthcare reform, which explains why true has not yer raken place, as discussed in

Chapter 26. Public health professionals are often impadent with politics, as the Instirure of Medicine repon notes, seeming to "regard politics as a contaminanr of an ideally rational decision-making process rather than as an essential element of democraric governan6s."4(n
5)

The Sciences of Public Health


The sciendfic knowledge on which public health is based spans a broad range o[ professional disciplines. The Insdtute of Medicine report notes rhat "public,healrh is a coalirion of professions united by their shared mission" as well as by "their focus on disease prevenrion and healrh promotion; their prospective approach in contrast to the reacrive focus of rherapeuric medicine, and their common science, epidemiology.'4{p 40) The disciplines of public health can be divided somewhar arbirrarily into six areas. Epidemiology and stadsrics are rhe basis for rhe assessmenr functions of public health, including the collection and analysis of information. Both assessment and policy developmenr need an understanding of the causes of heakh problems in the communiry, an understanding,that depends on biomedical sciences, social and behavioral sciences, and environinental sciences.

fu part of rhe

assurance funcrion, public health seeks to un-

derstand the medical care system in an area of srudy generally referred ro as health poliry and management or healch administration, which also includes the administration and fi.rncrioning

of the public healrh sysrem.

Tup ScrENcEs op Puslrc Hrnlrg


of public health. As its name of epidemics. lt focuses on human populadons, usually startingwirh an outbreak of disease in a communiry. Epidemiologisrs look for common exposures or other shared characteristics in the people who are sick, seeking the causative facror.
has been called the basic science

Epidemiohgy (Chapters

4-6)

suggesrs' epidemiology is the study

Epidemiology often provides the firsr indications'of the nature of a new disease. \X/hen AIDS was first recognized in the early 1980s, the cause was unknown. Do.io.s reporred cases of rhis unusual disease to the U.S. Centers for Disease Control and Prevention, and epidemiologists

of rhe patienrs. Epidemiologic ,esear.h indicated that it was an infectious disease spread through blood and body fluids and suggested a virus as the cause. This prompteci the biomedical sciendsts ro srep in and look for the virus. Epidemiology is important not only for deciphering the causes of exoric new diseases, but for preventing the spread of old, well-undersrood diseases. Epidemiologisrs are mainsrays of local health departments. In whar is commonly known as "shoe-learher epidemiology," rhey track down, for example, the source of a food-poisoning outbreak and force a resrauranr to clean up

began looking for common characteristics

im kitchen. Or they rrace everyone who has been in contact wirh a college student diagnosed with meningitis in order to administer high doses of anribiotic ro prevenr firrther spread of that
dangerous disease. Epidemiologic sudies have also been importanr in identifying the causes chronic diseases such as heart disease and cancer.

of

Because public health deals with the health of populations, it depends very heavily on statitrlrs (Chapters 7 and 8). Governments collect data on births and dearhs, causes of dearh, out-

of communicable diseases, cases of cancer, occupational injuries, and many other health-related issues. These numbers are diagnosric tools, informing experrs how healthy or sick a sociery is, and where irs weaknesses are. For example, the fact thar rhe United Stares ranks
breala-

28th in infant mortaliry among the nations of the world and23rd in life expectancy of men and 25th of women is one indicarion that the public health in rhis counrry is not as good as rhar in
many others.s

To understand what the numbers mean, it is necessary to understand certain sraristical concepm and calculadons. The science ofstatistics is used to calculare risks from exposure to environmental chemicals, for example. Statistical analysis is an integral parr of any epidemiologic
study seeking the cause ofa disease or a clinical study testing rhe effecriveness ofa new drug. Both public health and medicine depend on the biomedical sciences (Chaprers 9-12). A major proPortion of human disease is caused by microorganisms. Prevenrion and control of these diseases in a population require an understanding of how these infecrious agenrs are spread and

how they affect the human body. Control of infectious diseases was a majer focus of public lgth and early 20th centuries. Biomedical research was very successful in gaining an understanding of the major killers of that period, providing rhe information and techniques from which successful public health measures could bring these diseases under control.
healch in the

Purltc Hralrs: ScrrNcs, PoLrrrc.s,

AND PRrvgNrton

Biomedical research is still important ro the undersranding and control of new diseases such
as

AIDS, which has become the major epidemic of the late 20th cenrury worldwide. It has also contribured increasingly to an understanding ofnoninfectious diseases such as cancer and hearr disease, which have become increasingly importanr as many infectious diseases have been controlled. Recent progress in understanding human genetics is providing new insights inro people's inherent susceptibiliry to various diseases, raising new hopes of cures as well as
concerns about discrimination. Enuironmental heahh science (Chaprcrs 19-24),

concerned with preventing the spread of disease

a classic component of public health, is through water, air, and food. \Vhile it is not

strictly a separate science, because it shares concerns about the spread cif 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 Srates 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 mariy decades, there are many new challenges to environmental health. Not only do old systems

fail, as occurred in Milwaukee (see the Prologue), but new problems arise, brought about by modern lifestyles. Thousands of new chemicals enter the environment every year, and little is known abbut their effecs on human healrh. Chemicals known ro be roxic have accumulared in
the environment, and merhods rnust be devised to dispose of thern safely. Orher environmental threats to health include ultraviolet rays in sunlight, an increasing problem as rhe ozone layer the earth'i atmosphere is depleted,

o[

other kind, of ."di"tion, Recently it has be"rrd.*porurJto come apparent that human activities arq causing changes in thi climare of the earrh, changes that arb permanently altering our environmenr and are already having important effects on human health.
Increasingly, public health is concerned wkh social and behauioral sciences (Chaprers 13-18). As biomedical and environmental sciences have conquered rnany.of the diseases that killed people of previous generations. people in modern ro.i.ties are dying of diseases caused by their be-

havior and the social environment. Heart disease is related to nutrition and to exercise parrerns; many forms of cancer are caused by smoking; abuse of drugs and alcohol is a nororious killer. Violence is a significant cause of death in our sociery and attracts ongoing concern. Some subgroups of the population have poorer hea.lth overall rh"n oihers, for reasons rhar, while not complercly understood, relate to social and behavioral factors. People with low in-,
comes are less healthy than those

with a higher socioeconomic sratus. Black Americdns

have

PnrveNrloN AND It*ttsRvsNttotl


lower life expecmncy 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

variery of health problems.

Social and behavioral sciences involve more unanswered questions than biomedicd and en-

vironmental sciences do..Very linle is known about why racial and ethnic groups differ in their heahh-related behavior, why many people of all races behave in unhealthy ways, and how to
prevent self-destrucdve behaviors. In the social and behavioral sciences, ofall areas, research and

applicadon of irs findings are most likely to make a difference in the future.

Undl the beginning of the 20th century public health and medicine overlapped substantially in their spheres of incerest and activiry. Both fields were concerned primarily with understanding the causes and prevention of infectious disease because medicine was reladvely powerless to cure them. lVith 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 prevendng disease, public health faded into obscurity.
Over the past few decades, it has become apparent that our sociery's emphasis on curing disrather rhan 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 moie profitably be used for educadon, housing, and the enviease

ronment. Concdrn about runaway costs, lack of access, and questionable qudity of care has led
ro an increasing interest in srudying the medical care qzstem, its effecciveness, efficiency, and eq-

uiry leading to a science called health services research. taditional categorization of public
hedth fields puts this study into the area of (Chapters 25-28).
heahh policy and management

or heahh adminis*ation

Preventicn and Interventi0n


Public health's approach ro hedrh problems in a communiry has been described as a five-step
Process:

1. Define the health problem. 2. Identifr the risk factors associated with the problem. 3. Develop and test communiry-lwel interveqtions 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

PusLrc HslrrH: SclrNcr, PoLrrrcs, RNn PnrvENTroN


Thus, a main task of prevention is to develop interventions designed ro prevenr specific
problems that have been idenrified either through an assessmenr process inidated by a public health agenry or through communiry concern raised by an unusual course of events. For example, stadsdcd data may show that a communiry has a high rate of cancer in comparison with
ocher similar communities. Or a series of fatal crashes caused by drunk driving may mobilize a

communiry to demand action ro prevent firrther tragedies. Public health has developed systematic ways of thinking about such problems that facilitate
the process of,designing interventions rhat 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 prwenting exposure to risk factors. Secondary prevention seeks to minimize the severiry of the illness

or the damage due to an injury-causing event once rhe event has occurred. Tertiary prevention seeks to minimize disabiliry by providing medical care and rehabilitation services. Thus interventions for primary prevention of cancer iriclude efiForts 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 safery programs that, over rhe
past four decades, have gignificandy reduced rhe rates of injury from motor vehicle crashes (as

in Chapter l7). Primary prevention focused on preventing crashes from occurring, for example, by building divided highways and installing traffic lights. Secondary prevencion included the design of safer automobiles with stronger bumpers, padded dashboards, seat belts,
discussed

and airbags.
lances,

It

also included laws requiring drivers and passengers ro wear the seat belrs. And

tertiary prevention required the development of emergenry medical services including *by9l I calling nehvorls, and trauma centers. Another approach to designing intervenrions is to think of an ilJness or injury as rhe result of a chain of causarion involving an agent, a host, and the environmenr. This approach is traditional when thinking of inlectious diseases: the agenr may be a disease-causing bactcrium or
virus; the host is a susceptible human being; and the environmenr includes the means of transmission by which the agent reaches the host, which may be conraminated air, warer, or food, or

it may

be another human being who is infected (See Chapter 9). Prevention is accomplished by

interrupting the chain of causation at any step. The chain can be inrerrupred by rendering a porcntial host uns'lsceptible through immunization, for example. Or the bacrerium infecring a host can be killed through the use of antibiotics. Or the environmenr can be sanirized through the purification of warcr and food.
The chain of causation model can also be used for other kinds of illnesses or injuries. For example, suicide is the founh lead.ing cause of death in the age group 15 rc 24.s In applying the

PusLIc

Hrllrs

,qNp TpRRoRrsrvr

W-

model to prevention of youth suicide, the host is the susceptible young person; the agenr is rnost often a gun oran overdose of pills; che environment includes the young person's wholesocial environment' including family, school, and the media. A public health intervention could focus on how to make young people less susceptible ro self-desrructive rhinking; ir could rry to change the messages presented by television and schoolmates that may lead a young person ro think he or she is unattractive or otherwise inferior. Howeve! the public health perspective tends to be, as discussed in Chapter 17, that the most efrective target of interyenrion for youth
suicide prevention is the agenr, especially guns. Many adolescenrs are susceprible to depressed moods and think of killing themselves, but the best predictor of wherher they will succeed is

whether they have access ro a gun.

Public Heaitli and Terroristn


The events of fall 2001 disnrbed.the sense of complacency many people felt about the health and safery of their living conditions. Evidence that there were groups or individuals who not oniy 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 prevenr similar

events

in the furure.

1ff4rile

prevention of violent acts such as hijacking airplanes is primarily a responsibiliry of law enforcement' public health has an important role to play in conrroiling rhe damage caused by such eeents. In other words; primary prevention of rerrorist acrs may be out of the domain of public health, but secondary and tertiary prevention are very much a pan of public health's mission.
Success

at these services depend on having well-designed plans in piace before a disaster occurs. The crashing of rwo planes into the \VorlC Tiade Cenrer rriggered the activation of

emergency response plans developed for New York Ciry and New York State, plans designed as secondary prevention-minimizing the damage-and terriary prevenrion-providing medical
care to those injured in the disaster. Most critically important for saving lives was the abiliry for occupants of the buildings to get out as Ast as possible. The fact rhat all but 2092 of the 17,400

in the towers when the planes hit made it our is evidence that some of the plans were efFective.e However, studies done later found many flaws in the emergency- planning, as discussed in Chapter 29. Plans for providing medical care ro survivors were not seriously tested, because the capaciry-including the arrival of numerous y6lun16s15people who were
asPects
l I

exceeded the number of injured survivors- The greatest problem was a lack oFcoordinarion.

The public health response to the terrorism of September 1 I , 2001 was essentially rhe same as the response needed for other emergencies and disasters: factory explosions, plane and train

in 2005), and so on. Public healrh was concerned not only with coordinating emergency medica-l care, but also with ensuring rhe safery of
crashes, earthquakes, hurricanes (such as Katrina

Punrtc Hralru: SclrNcE, Porrrtcs, lNp PRrvsNTroN


cleanup workers and area residents. Problems with pollured waret conraminated. air, spoiled food, infesration of vermin, and so on, had to be dealt wirh in downtown Manhatran just as they must be dealt wirh after a natural disaster. The importance of public health became even more obvious in the aftermath of the anrhrax mailings. These bioterrorism attacks did not announce themselves in the dramatic Fashion of
the airplane hijackings. The first signs that a terrorist event had occurred were nor recognized as such. No alarm bells rang when a few patients showed up in hospital emergency rooms with

hard'to-diagnose illnesses. Anthrax announced itself

in the

same way rhat

AIDS appeared,
who

as an outbreak
then investigared.

of

something new that was reporred

to public health authorities,

The damage done by the anthrax mailings was relatively minor. Ffowever, the potential disaster that would result if a more infectious microorganism were used in a bioterror attack forced many sectors of sociery to pay anenrion to public health. In speculadng abour what would happen if a terrorist clandestinely released smallpox virus into a crowd, public health authorities realized that only epidemiologic methods for controlling natural epidemics could even begin to deal with the crisis. Suddenly the media and politicians began talking about public health. Ironically, the threat of bioterrorism did more to teach the public about public health than any educational program. As Robert F. Meenan, dean of the Boston Universiry School of Public Health, is quoted as saying, the anrhrax attacks provided "a marketing campaign we could never have bought."'o It is nor clear, however, rhat the lessons learned about public health during those difficult times will stay with.us when the public's attention shifts to the more politically demanding concerns about paying for medical care.

Conclusion
This chaprer has shqwn &at public health is a broad term thar-is difficult to define. It includes a goal-maximum. health for all-as well as the means of amempting ro achieve that goal.
Public health is concerned with the prevention of disease and disabiliry. It is aimed at benefiting the entire population in contrast wirh medicine, which focuses on rhe individual.

The functions of public health in a community can be compared with the funcrions of
physician in caring for
a

patient. Public health diagnoses and treats the community's ills by way of assessment, policy developmint, and assurance. Ir relies on rhe tools of science and politics. The public health sciences of epidemiology and statistics are applied in assessing a population's health. Policy is developed based on biomedical sciences,.social and behavioral sciences, environmental health sciences, and the study of the medical care sysrem. Public healrh depends on politics for decision making. Decisions on public health interventions to be taken by the com-

muniry insofar

as

they require governmenr acrion, are reached through politics.

cor.rcrusroN

Public health focuses on prevention ofdisease and disabiliry. Prevenrive measures can be applied at three levels: primary prevention aims to prevenr a disease or injury from occurring at all; secondary Prevention aims to minimize the damage caused by the illness or injury-caujng
event when it occurs; and tertiary prevention viding medical care and rehabilitarion.
seela.

ro minimize any ensuing disability by pro-

Public health prevention programs frrnction through interventions designed to inrerrupt the chain of causation that leads ro an illness or an injury. Interventions can be direcred to*"rd

eliminating or suppressing the agent that causes an illness or injury strengrhening the resisrance of the host to the agent, or changing the environment in such a way rhat the host is less likely to encounter the agenr.
Public health is an abstract concepr that is nor well understood and is ofren neglected. The dramatic events of fall 2001 forced the government and the media ro p"y ro the im"r...,rioi portance of public health, both in mitigating the effects of obvious disasrers, and in recognizing and controlling the more insidious effects of bioterrorism, although understanding will endure

it

is not clear whether that

Re fe

ren ce s
T. McKeown, The Role of Medicine: Dream, Mirage or
1979).
Nemesis?

l.

(Oxford: Basil Blackwell,

2. U.S. Centers

unired
3. C.-E.

Scates, 1999,"

r (1984). 4. U.S' Institute of Medicine, Commirtee for the Srudy of the Future of Public Heafth,
5.

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