History/Milestones in Public Health and Community Health Specialty

• Health Epidemiology
• Biostatistics / Quantitative Methods
• Primary Health Care
• Reproductive Health
• Health Education
• Occupational Health
• Environmental Health
• Public Health Nutrition
• Social Medicine (Medical Sociology) Public Health Management & Policy International Health (Global Health) Health Economics
• Disaster Management and Emergency Preparedness

Community health has a broader perspective and encompass other health practitioners at community level, these include;

• Community Health officers,
• Community Nursing Officers,
• Community Health Extension workers
• Environmental Health Officers
• Voluntary village health workers

Community Medicine however is practiced by physicians only

Public health and Community health often used interchangeably but has some differences

Public health is broad and include community health.

Involves health care services which are not necessarily provided at the level of the community (geographical Boundary) and includes activities of other professionals like environmental engineers as well as many other professions whose activities directly affect health of people

Public Health— Science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals

Aims to improve quality of life through prevention and treatment of disease

Analyzing the health of a population and the threats

Public can be a handful of people, entire village and as big as continents

Public Health is Interdisciplinary

• Epidemiologists
• Biostatisticians
• Public Health Nurses and midwives
• Medical microbiologists
• Community Health Workers
• Environmental Health Officers
• Nutritionists
• Veterinarians
• Economists
• Sociologists
• Geneticists, etc

For Physicians

Postgraduate training in Public Health through diploma and Master’s degree

Postgraduate training in residency programme— Fellowship

Postgraduate training in the sub-specialties and related specialties

Virtually all other specialties in medicine are developing the public health component of their specialty and several physicians in other specialties now acquire training in public health

Increasing popularity globally more so in developed countries

Increasing relevance in health and medicine

Academics

Public Health Service

International Agencies

Government

Non-Governmental Organizations

Individual public health establishment

• Consultancies
• Health service for individuals and groups

Very wide and dynamic

Can be passed easily and can be failed easily

Requires reading and observation of health activities around you and around the world

Those who fail are the very bad students and those who take the posting for granted

At the beginning of the 20th century, infectious diseases such as smallpox, measles, diphtheria, and pertussis were widely prevalent.

Since there were few effective measures available, death tolls were high.

Jenner used cowpox to vaccinate against smallpox, 1796.

Vaccination used by British troops in 1800 and made compulsory in the UK by the Vaccination Act of 1853, spreading the practice to Europe and the Americas.

Smallpox eradicated globally in 1980.

Vaccination

Jonas Salk develops first inactivated polio vaccine and performs largest field trial in history in 1954.

Sabin’s live, attenuated polio vaccine follows in 1961.

Americas declared free of polio in 1990.

Vaccination now widely available against measles, mumps, rubella, polio, diphtheria, tetanus, pertussis, H. influenzae, meningococcal meningitis, Pneumococcus spp., HPV, influenza and herpes zoster, hepatitis A, hepatitis B and yellow fever.

Since 1925, there has been a 90% decrease in the annual death rate due to motor vehicle travel.

Number of motor vehicles, drivers, and miles traveled in motor vehicles increased dramatically since 1925.

1930s-1950s: Several US physicians install lap belts in their personal vehicles, begin lobbying auto manufacturers.

Colorado State Medical Society (1953) published policy calling for universal seat belt installation.

Some of the biggest interventions include:

Regulations developed and enforced regarding safety belts

Alcohol-impaired drivers, young drivers, pedestrians

Child safety and booster seats

Improved car design

Improved policing and public attitudes reducing drunk driving

Improved roads and lighting, and others

Occupational health one of the oldest sectors of public health: Scurvy among sailors (James Lind, 1753, treats scurvy with citrus fruits)

Scrotal cancer among English chimney sweeps

“Black lung” in coal miners

Mercury poisoning in hat makers (thus the phrase “mad as a hatter” - e.g., Lewis Carroll’s Mad Hatter)

Mesothelioma in asbestos workers

Hepatitis B in health care workers

Factory and Workshops Act (1833) in UK led to general improvement in working conditions.

Thomas Legge became first medical doctor appointed Chief Factory Inspector in UK (1898)

CDC's National Institute for Occupational Safety and Health (NIOSH) National Traumatic Occupational Fatalities (NTOF) surveillance system indicate that from 1980 1995:

• Annual work-related deaths decreased by 28%
• 43% decrease in occupational injuries during the same time.

Dr. John Snow traced cholera deaths to the Broad Street pump and to two water companies in 1854.

Infection control multifactorial:

• Germ theory (Pasteur, 1854 and Koch, 1883); Pasteur is popularly known as the "father of microbiology"
• Antisepsis (Lister, 1867);
• Chlorination;
• Vector control;
• Antibiotics (Fleming, 1928);
• Vaccination.

Development of “risk factor” concept: “biologic, lifestyle, and social conditions were associated with increased risk for disease” (Turnock, 2009)

Multiple parallel interventions for control of CVD:

• Cigarette smoking reduction (42% of adults in 1965 to 25% of adults in 1995).
• More aggressive hypertension treatment.
• Changes in diet including decrease in saturated fat, cholesterol and trans-fats.
• Improved medical response and in-hospital care (e.g., cardiac catheterization, stenting, thrombolytics and coronary artery bypass).

Contaminated food and water resulted in many foodborne infections in early in the 20th century.

Advances, such as refrigeration, pasteurization, pest control, animal control, and food safety regulations that promoted better hygiene and sanitation practices all contributed to decrease in foodborne infections

1887: Federal nutrition laboratory established, forerunner of NIH 1927: US Food and Drug Administration established

1939: Federal food stamp program launched

1972: USDA established WIC program.

US nutritional status followed by periodic NHANES surveys (1971-4, 1976- 80, 1988-91, 2005-6).

Food safety depends on overlapping responsibilities of farmers and ranchers, private companies, transportation, local and federal government.

1958 - US Food, Drug, and Cosmetics Act required food manufacturers to comply with federal law regarding additives:

Banned cyclamates, cobalt salts, polyvinyl chloride, some food coloring, some pesticides and herbicides.

Improvements in maternal and child health

Childbirth use to come with great risk to many mothers and infants. Over the span of the century, the infant mortality rate declined greater than 90% and the maternal mortality rate declined almost 99%

19th century France: gouttes de lait (“milk stations”- preventive health for women and children); incentive payments to women whose infants survived one year.

Koplik, 1889 and Strauss, 1893 - promoted safe milk supply to children in NYC slums.

Lillian Wald (bottom) coins “public health nurse,” leading to VNAs, public perinatal health services and school health services.

1990s - Immunizations provided as part of WIC, expanding coverage to vulnerable populations.

Improvements in obstetrical safety, perinatal care and technology have resulted in age of viability decreasing to ~ 22 weeks gestation. However, no intervention yet proven to prevent preterm labor and delivery.

Better family planning interventions resulted in longer birth intervals and smaller family sizes, both of which have been associated with improved maternal and child health outcomes.

1952-4: Margaret Sanger supports hormonal contraceptive research of Pincus and Rock.

1956: Clinical trials of first combined hormonal contraceptive, Enovid.

Modern contraception: barrier/physical methods (e.g., condoms, IUD), chemical (e.g., pills, implants, spermicides) and traditional (e.g., rhythm method, withdrawal), surgical (vasectomy, tubal ligation).

Teenage pregnancy continues to be a widespread and serious public health problem, commoner in lower socioeconomic populations and associated with poorer health outcomes.

Progress made:

• Rates of teen pregnancy declined, and
• Teen abstinence increased from 1990-2004.

Dentist Frederick McKay spends thirty years investigating “Colorado brown teeth” - mottled but cavity-free dentition seen in high-fluoride areas.

1930s-1940s: NIH publishes research showing that fluoridation significantly reduces decay and cavities; advocates for universal fluoridation.

“Fluoridation of community water supplies reduces the number of caries and extractions in both children and adults by some 60%. This is one of the most effective public health interventions available.”

Recognition of Tobacco Use as a Health Hazard

Smoking has been associated with a number of morbidities including cardiovascular disease, cancer, chronic obstructive pulmonary disease, and low birth weight.

At the beginning of the century, extensive dental caries was common, with tooth extraction being the main treatment option available.

Cigarette smoking became endemic with WWII - and lung cancer rates increase almost 10x compared to 1930s rates.

Recognition of Tobacco Use as a Health Hazard

1950s-1960s: first research supporting link between smoking and lung cancer; first Surgeon General’s report.

Late 20th century - reduction seen in adult smoking rates but plateauing at 25%.

Taxation and price increases seem most successful at decreasing population smoking rates.

Little change seen in use of smokeless tobacco.