Foundations of Public Health PH-200 Fall 2009

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Outline. 9:30 AM ? 9:45 AM : Questions and Review9:45 AM ? 11:00 AM : Where we are: Core contents of public health education.11:00 AM ? 11:15 AM : Recess11:15 AM ? 12:15 PM : How we got here: Evolution of public health understanding and the debate over causation The Global Burden of Diseases

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Foundations of Public Health PH-200 Fall 2009

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1. Foundations of Public Health PH-200 Fall 2009 Week 2

2. Outline 9:30 AM – 9:45 AM : Questions and Review 9:45 AM – 11:00 AM : Where we are: Core contents of public health education. 11:00 AM – 11:15 AM : Recess 11:15 AM – 12:15 PM : How we got here: Evolution of public health understanding and the debate over causation The Global Burden of Diseases Case studies on disease eradication; Injury AJPH articles 12:15 PM – 12:30 PM : Review

3. Pop-quiz Describe the core functions of public health. How do these translate into essential public health services in communities? Describe the five core subjects of public health? Do these demarcations make sense to you? Explain. What are the seven cross-cutting, interdisciplinary themes included in public health education? Are these too many or too few? How should these themes be embedded in the curriculum?

4. Where are we? Or what is the role of “Academic” Public Health? Public health is the art and science of protecting and improving the health of a community through an organized and systematic effort that includes education, assurance of the provision of health services and protection of the public from exposures that will cause harm.

5. Cost-Effective Disease Prevention Public health is often summarized by the phrase “disease prevention” but it is broader, as it includes “improvement to quality of life” even in disease-free states as defined by clear diagnosis. The path from health to disease is a continuum. The challenge is to move the fulcrum of expenditure and results so that the balance is tilted more toward health maintenance and improvement than toward disease and treatment.

6. Those are the ideals. How does it work in practice? The State of Health Care…. Dr Manuel Carballo of the World Health Organization said in 1987: “the health systems of most developed regions have become highly bureaucratized, over structured, regimented and unable to respond to their population’s needs; they are basically medical, curative care systems, creating dependency, unable to stimulate social autonomy or empowerment and are, in nearly all cases, becoming financially deficient ... health plans are developed in an ivory tower by elites who often do not understand the people they are working with, and in many cases do not even know them ... we must try to move towards [a health system] in which we all participate in defining needs and expectations, imposing guidance on the health care system at a political level.”

7. Public Health Care and Reform in the United States The U.S. Gross Domestic Product as of September 2009 is ~ $14.3 Trillion. ( We spend ~16% on health care ($2.25 Trillion / year). This is much more than any other nation spends on health care, and as a percentage of GDP, we spend twice as much as other developed countries. The trend is growing in the U.S., and we are expected to be spending 20% of our GDP on health care within the next decade or two. Yet, we are not leading in terms of the metrics of quality-adjusted life expectancy, and composite measures of morbidity and mortality (Disability-Adjusted Life Years, or DALYs).

8. Distribution of “Public” Health Resources Of the $2.25 Trillion that we spend on we spend on health care, almost 90% is dedicated to diagnosis and treatment after we get sick. Only 2% is spent on prevention and health promotion, 3% on community health, and 3% on public health. Thus, in combination, approximately 8% of our health budget is dedicated to “public health” or prevention (The balance is spent on continuing care of patients).

9. The path forward: Training public health professionals in the core competencies and cross-cutting themes in public health education

10. Core competencies Cross-cutting themes

11. Biostatistics Biostatistics Biostatistics is the development and application of statistical reasoning and methods in addressing, analyzing and solving problems in public health; health care; and biomedical, clinical and population-based research. UC Irvine Department of Statistics Dr. Hal Stern (Chair)

12. (Bio) Upon graduation a student with an MPH should be able to….. 1. Describe the roles biostatistics serves in the discipline of public health. 2. Describe basic concepts of probability, random variation and commonly used statistical probability distributions. 3. Describe preferred methodological alternatives to commonly used statistical methods when assumptions are not met. 4. Distinguish among the different measurement scales and the implications for selection of statistical methods to be used based on these distinctions. 5. Apply descriptive techniques commonly used to summarize public health data. 6. Apply common statistical methods for inference. 7. Apply descriptive and inferential methodologies according to the type of study design for answering a particular research question. 8. Apply basic informatics techniques with vital statistics and public health records in the description of public health characteristics and in public health research and evaluation. 9. Interpret results of statistical analyses found in public health studies. 10. Develop written and oral presentations based on statistical analyses for both public health professionals and educated lay audiences.

13. Environmental Health Sciences Environmental Health Sciences Environmental health sciences represent the study of environmental factors including biological, physical and chemical factors that affect the health of a community. UC Irvine Center for Occupational and Environmental Health Dr. Dean Baker, Director

14. (EHS) Upon graduation a student with an MPH should be able to….. 1. Describe the direct and indirect human, ecological and safety effects of major environmental and occupational agents. 2. Describe genetic, physiologic and psychosocial factors that affect susceptibility to adverse health outcomes following exposure to environmental hazards. 3. Describe federal and state regulatory programs, guidelines and authorities that control environmental health issues. 4. Specify current environmental risk assessment methods. 5. Specify approaches for assessing, preventing and controlling environmental hazards that pose risks to human health and safety. 6. Explain the general mechanisms of toxicity in eliciting a toxic response to various environmental exposures. 7. Discuss various risk management and risk communication approaches in relation to issues of environmental justice and equity. 8. Develop a testable model of environmental insult.

15. Epidemiology Epidemiology Epidemiology is the study of patterns of disease and injury in human populations and the application of this study to the control of health problems. UC Irvine Department of Epidemiology Dr. Hoda Anton-Culver, Chair

16. (EPI) Upon graduation a student with an MPH should be able to….. 1. Identify key sources of data for epidemiologic purposes. 2. Identify the principles and limitations of public health screening programs. 3. Describe a public health problem in terms of magnitude, person, time and place. 4. Explain the importance of epidemiology for informing scientific, ethical, economic and political discussion of health issues. 5. Comprehend basic ethical and legal principles pertaining to the collection, maintenance, use and dissemination of epidemiologic data. 6. Apply the basic terminology and definitions of epidemiology. 7. Calculate basic epidemiology measures. 8. Communicate epidemiologic information to lay and professional audiences. 9. Draw appropriate inferences from epidemiologic data. 10. Evaluate the strengths and limitations of epidemiologic reports.

17. Health Policy and Management Health Policy and Management Health policy and management is a multidisciplinary field of inquiry and practice concerned with the delivery, quality and costs of health care for individuals and populations. This definition assumes both a managerial and a policy concern with the structure, process and outcomes of health services including the costs, financing, organization, outcomes and accessibility of care. UC Irvine Center for Health Policy and Research Dr. Shelly Greenfield, Director

18. (HPM) Upon graduation a student with an MPH should be able to…. 1.Identify the main components and issues of the organization, financing and delivery of health services and public health systems in the US. 2. Describe the legal and ethical bases for public health and health services. 3. Explain methods of ensuring community health safety and preparedness. 4. Discuss the policy process for improving the health status of populations. 5. Apply the principles of program planning, development, budgeting, management and evaluation in organizational and community initiatives. 6. Apply principles of strategic planning and marketing to public health. 7. Apply quality and performance improvement concepts to address organizational performance issues. 8. Apply "systems thinking" for resolving organizational problems. 9. Communicate health policy and management issues using appropriate channels and technologies. 10. Demonstrate leadership skills for building partnerships.

19. Social and Behavioral Sciences Social and Behavioral Sciences The behavioral and social sciences in public health address the behavioral, social and cultural factors related to individual and population health and health disparities over the life course. Research and practice in this area contributes to the development, administration and evaluation of programs and policies in public health and health services to promote and sustain healthy environments and healthy lives for individuals and populations. UC Irvine Department of Population Health and Disease Prevention Dr. Oladele Ogunseitan, Chair

20. (SBS) Upon graduation a student with an MPH should be able to….. 1. Identify basic theories, concepts and models from a range of social and behavioral disciplines that are used in public health research and practice. 2. Identify the causes of social and behavioral factors that affect health of individuals and populations. 3. Identify individual, organizational and community concerns, assets, resources and deficits for social and behavioral science interventions. 4. Identify critical stakeholders for the planning, implementation and evaluation of public health programs, policies and interventions. 5. Describe steps and procedures for the planning, implementation and evaluation of public health programs, policies and interventions. 6. Describe the role of social and community factors in both the onset and solution of public health problems. 7. Describe the merits of social and behavioral science interventions and policies. 8. Apply evidence-based approaches in the development and evaluation of social and behavioral science interventions. 9. Apply ethical principles to public health program planning, implementation and evaluation. 10. Specify multiple targets and levels of intervention for social and behavioral science programs and/or policies.

21. Cross-cutting Themes Communication and Informatics The ability to collect, manage and organize data to produce information and meaning that is exchanged by use of signs and symbols; to gather, process, and present information to different audiences in-person, through information technologies, or through media channels; and to strategically design the information and knowledge exchange process to achieve specific objectives.

22. (C&I) Upon graduation a student with an MPH should be able to….. 1.Describe how the public health information infrastructure is used to collect, process, maintain, and disseminate data. 2. Describe how societal, organizational, and individual factors influence and are influenced by public health communications. 3. Discuss the influences of social, organizational and individual factors on the use of information technology by end users. 4. Apply theory and strategy-based communication principles across different settings and audiences. 5. Apply legal and ethical principles to the use of information technology and resources in public health settings. 6. Collaborate with communication and informatics specialists in the process of design, implementation, and evaluation of public health programs. 7. Demonstrate effective written and oral skills for communicating with different audiences in the context of professional public health activities. 8. Use information technology to access, evaluate, and interpret public health data. 9. Use informatics methods and resources as strategic tools to promote public health. 10. Use informatics and communication methods to advocate for community public health programs and policies.

23. Diversity and Culture Diversity and Culture The ability to interact with both diverse individuals and communities to produce or impact an intended public health outcome.

24. (D&C) Upon graduation a student with an MPH should be able to….. 1.Describe the roles of, history, power, privilege and structural inequality in producing health disparities. 2. Explain how professional ethics and practices relate to equity and accountability in diverse community settings. 3. Explain why cultural competence alone cannot address health disparity. 4. Discuss the importance and characteristics of a sustainable diverse public health workforce. 5. Use the basic concepts and skills involved in culturally appropriate community engagement and empowerment with diverse communities. 6. Apply the principles of community-based participatory research to improve health in diverse populations. 7. Differentiate among availability, acceptability, and accessibility of health care across diverse populations. 8. Differentiate between linguistic competence, cultural competency, and health literacy in public health practice. 9. Cite examples of situations where consideration of culture-specific needs resulted in a more effective modification or adaptation of a health intervention. 10. Develop public health programs and strategies responsive to the diverse cultural values and traditions of the communities being served.

25. Leadership Leadership The ability to create and communicate a shared vision for a changing future; champion solutions to organizational and community challenges; and energize commitment to goals.

26. (L) Upon graduation a student with an MPH should be able to….. 1. Describe the attributes of leadership in public health. 2. Describe alternative strategies for collaboration and partnership among organizations, focused on public health goals. 3. Articulate an achievable mission, set of core values, and vision. 4. Engage in dialogue and learning from others to advance public health goals. 5. Demonstrate team building, negotiation, and conflict management skills. 6. Demonstrate transparency, integrity, and honesty in all actions. 7. Use collaborative methods for achieving organizational and community health goals. 8. Apply social justice and human rights principles when addressing community needs. 9. Develop strategies to motivate others for collaborative problem solving, decision-making, and evaluation.

27. Public Health Biology Public Health Biology Public health biology is the biological and molecular context of public health.

28. (PHB) Upon graduation a student with an MPH should be able to….. 1. Specify the role of the immune system in population health. 2. Describe how behavior alters human biology. 3. Identify the ethical, social and legal issues implied by public health biology. 4. Explain the biological and molecular basis of public health. 5. Explain the role of biology in the ecological model of population-based health. 6. Explain how genetics and genomics affect disease processes and public health policy and practice. 7. Articulate how biological, chemical and physical agents affect human health. 8. Apply biological principles to development and implementation of disease prevention, control, or management programs. 9. Apply evidence-based biological and molecular concepts to inform public health laws, policies, and regulations. 10. Integrate general biological and molecular concepts into public health.

29. Professionalism Professionalism The ability to demonstrate ethical choices, values and professional practices implicit in public health decisions; consider the effect of choices on community stewardship, equity, social justice and accountability; and to commit to personal and institutional development.

30. (P) Upon graduation a student with an MPH should be able to….. 1. Discuss sentinel events in the history and development of the public health profession and their relevance for practice in the field. 2. Apply basic principles of ethical analysis (e.g. the Public Health Code of Ethics, human rights framework, other moral theories) to issues of public health practice and policy. 3. Apply evidence-based principles and the scientific knowledge base to critical evaluation and decision-making in public health. 4. Apply the core functions of assessment, policy development, and assurance in the analysis of public health problems and their solutions. 5. Promote high standards of personal and organizational integrity, compassion, honesty and respect for all people. 6. Analyze determinants of health and disease using an ecological framework. 7. Analyze the potential impacts of legal and regulatory environments on the conduct of ethical public health research and practice. 8. Distinguish between population and individual ethical considerations in relation to the benefits, costs, and burdens of public health programs. 9. Embrace a definition of public health that captures the unique characteristics of the field (e.g., population-focused, community-oriented, prevention-motivated and rooted in social justice) and how these contribute to professional practice. 10. Appreciate the importance of working collaboratively with diverse communities and constituencies (e.g. researchers, practitioners, agencies and organizations). 11. Value commitment to lifelong learning and professional service.

31. Program Planning Program Planning The ability to plan for the design, development, implementation, and evaluation of strategies to improve individual and community health.

32. (PP) Upon graduation a student with an MPH should be able to….. 1. Describe how social, behavioral, environmental, and biological factors contribute to specific individual and community health outcomes. 2. Describe the tasks necessary to assure that program implementation occurs as intended. 3. Explain how the findings of a program evaluation can be used. 4. Explain the contribution of logic models in program development, implementation, and evaluation. 5. Differentiate among goals, measurable objectives, related activities, and expected outcomes for a public health program. 6. Differentiate the purposes of formative, process, and outcome evaluation. 7. Differentiate between qualitative and quantitative evaluation methods in relation to their strengths, limitations, and appropriate uses, and emphases on reliability and validity. 8. Prepare a program budget with justification. 9. In collaboration with others, prioritize individual, organizational, and community concerns and resources for public health programs. 10. Assess evaluation reports in relation to their quality, utility, and impact on public health.

33. Systems Thinking Systems Thinking The ability to recognize system level properties that result from dynamic interactions among human and social systems and how they affect the relationships among individuals, groups, organizations, communities, and environments.

34. (ST) Upon graduation a student with an MPH should be able to….. 1. Identify characteristics of a system. 2. Identify unintended consequences produced by changes made to a public health system. 3. Provide examples of feedback loops and “stocks and flows” within a public health system. 4. Explain how systems (e.g. individuals, social networks, organizations, and communities) may be viewed as systems within systems in the analysis of public health problems. 5. Explain how systems models can be tested and validated. 6. Explain how the contexts of gender, race, poverty, history, migration, and culture are important in the design of interventions within public health systems. 7. Illustrate how changes in public health systems (including input, processes, and output) can be measured. 8. Analyze inter-relationships among systems that influence the quality of life of people in their communities. 9. Analyze the effects of political, social and economic policies on public health systems at the local, state, national and international levels. 10. Analyze the impact of global trends and interdependencies on public health related problems and systems.

35. Evolution of Public Health Understanding, or, “how did ‘we’ get here?

36. Miasma versus Germ Theory: The origin of scientific public health John Snow and the Cholera epidemic in London (1849 – 1854). “Snow was a skeptic of the then-dominant miasma theory that stated held that diseases such as cholera or the Black Death were caused by pollution or a noxious form of "bad air". The germ theory was not widely accepted at this time, so he was unaware of the mechanism by which the disease was transmitted, but evidence led him to believe that it was not due to breathing foul air. He first publicized his theory in an essay On the Mode of Communication of Cholera in 1849. In 1855 a second edition was published, with a much more elaborate investigation of the effect of the water-supply in the Soho, London epidemic of 1854.”

37. Austin Bradford Hill (1897-1991): Contributions to the core foundations of public health

38. Hill’s Guidelines Precedence Correlation Dose-response Consistency Plausibility Alternatives Empiricism Specificity Coherence

39. Precedence The cause must precede the disease… Snow’s work on drinking water contamination and cholera in London

40. Correlation Occupational exposures E.g. Asbestos mining and mesothelioma

41. Dose-response “The dose makes the poison” Ionizing radiation? “Hormesis (from Greek hormćin, meaning “to excite”) is the term for generally-favorable biological responses to low exposures to toxins and other stressors. A pollutant or toxin showing hormesis thus has the opposite effect in small doses than in large doses.”

42. Consistency Observable health effects of risk factors should cut across populations and generations. E.g. “mad hatter disease” from mercury exposure.

43. Plausibility Lead (Pb) poisoning Saturnism, Plumbism or Painter's colic Variation in disease endpoints is explained by the understanding of the biochemical and genetic basis of effects associated with Pb exposure. Anemia – Pb binding to delta-aminolevulinate dehydratase, crucial for heme synthesis. Neurological effects due to accumulation of precursor and crossing of blood-brain barrier. Gout – accumulation of uric acid in joints – inflammation. Crime ??

44. Alternatives Alternative explanations for disease causation should be considered alongside plausible environmental associations. Low level pesticide exposures and chronic disease conditions. Gina Solomon, Oladele Ogunseitan and Jan Kirsch. 2000. Pesticides and Human Health. Physicians for Social Responsibility & Californians for Pesticide Reform.

45. Empiricism The course of an environmental disease should be alterable with intervention and removal of exposure. Chelation therapy for toxic metal exposure. Disinfection and antibiotic therapy for water-borne diseases. Koch’s postulates

46. Empiricism continued: Modified Koch’s postulates 1. Exposure to environmental agent must be demonstrable in all organisms suffering from the disease,, but not in healthy organisms. 2. The identity, environmental concentrations, and transformation pathways of the agent must be known as much as possible. 3. The agent should cause disease when introduced into health organisms. 4. Biomarkers showing modification of the physiological target must be observable in experimentally exposed organisms.

47. Specificity An environmental disease should be associated with one environmental agent. Strengthens the argument for causality. Extremely rare situation. Neurodegenerative diseases associated with prion protein remains mysterious. Are toxic metals involved? Nanoparticles and respiration health.

48. Coherence The cause-and-effect interpretation of our data should not seriously conflict with the generally known facts of the natural history and biology of the disease.

49. Where are we headed? Population growth and public health

50. Outline The real causes of death and disability: “The Global Burden of Diseases.” Essential Resource: World Health Organization’s GBD project (

51. The World Health Organization

52. Established 7 April 1948 (Annual World Health Day – April 7th)

53. WHO Six Regional Offices

54. The role of WHO in public health WHO fulfils its objectives through its core functions: providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; providing technical support, catalyzing change, and building sustainable institutional capacity; and monitoring the health situation and assessing health trends.

55. Future Projections of Public Health Needs: The 2008 World Population Data Sheet © 2008 POPULATION REFERENCE BUREAU

56. Global Demographic Divide Widens © 2008 POPULATION REFERENCE BUREAU

57. Scaled World Population by Region

58. Number of working physicians

59. The United States Has Been Growing Faster Than Expected.

60. Continued Population Growth Sets the United States Apart From Other Developed Countries Around the World.

61. Focus on Geriatrics and Chronic Diseases: By 2050, One in Every Five Americans Will Be Age 65 or Older.

62. Focus on Socio-cultural Diversity and Health: The U.S. Will Continue to Become More Racially and Ethnically Diverse.

63. Ten Percent of U.S. Counties Have Already Reached Majority-Minority Status.

64. Minorities Make Up at Least 50 Percent of the Youth Population in One in Seven Counties Nationwide.

65. How do we prioritize health research and translational projects? The Global Burden of Disease Project

66. The disease-adjusted life year is a composite indicator of the time lived with a disability (YLD) and the time lost due to premature mortality (YLL) (Murray & Lopez, 1996). DALYi [0,0] = YLLi + YLDi Where: YLLi = Years of Life Lost due to disease i (# deaths x standard life expectancy at age of death) YLDi = Years of Life lived with Disability due to disease i # incident cases x disability weight x average duration of disease case until remission or death.

67. Estimating Years of Life Lost (YLL)

68. Years Lived with Disability (YLDs)

69. Global Disease-Adjusted Life Years (DALYs)

70. Future projections of disease burden ln M = C + b1lnY + b2lnHC + b3T Where: M = projected mortality level C = constant term Y = GDP per capita HC = Human capital (including population growth) T = Time

71. Estimating “Attributable Risk” Attributable Risk is assessed, using published data on relative risks for each cause of death and disability related to the exposure, levels of exposure (prevalence), and burden of disease due to each cause of death and disability in the population: AB = ? AFj Bj = ?Pj (RRj – 1) ÷ ?Pj (RRj – 1) + 1 Where AB = Attributable Burden for a risk factor AFj = Fraction of Burden from cause j Bj = population level burden of cause j P = Prevalence of exposure RRj = Relative Risk of disease or injury for cause j in exposed versus unexposed group. n = Maximum exposure level

72. Environmental burden of disease: Country profiles

73. Burden of Disease Attribution to Environmental Factors in the U.S.

74. Angola

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