Improving Community Health

Richard Riegelman, MD, MPH, PhD Professor and Founding Dean

Milken Institute School of Public Health The George Washington University

Washington, DC

Brenda Kirkwood, MPH, DrPH Clinical Associate Professor

School of Public Health University at Albany, State University of New York

Albany, NY

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Community Health

vAcknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .x Preface: What Is Public Health 101: Improving Community Health All About? . . . . . . . . . . . . . . . . . . . . . . xi About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

SECTION I Principles of Population Health 1

Chapter 1 Public Health: The Population Health Approach . . . . . . . . . . . . . . . . 3

What Do We Mean by “Public Health”? . . . . . . . . . . . . . . 5 How Has the Approach of Public Health

Changed Over Time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 What Is Meant by “Population Health”? . . . . . . . . . . . . .10 What Are the Implications of Each of

the Four Components of Public Health? . . . . . . . . . .10 Should We Focus on Everyone or on

Vulnerable Groups? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 What Do We Mean by Population Health’s

Focus on the Life Cycle? . . . . . . . . . . . . . . . . . . . . . . . . .12 What Are the Approaches Available to

Protect and Promote Health? . . . . . . . . . . . . . . . . . . . .14 What Factors Determine the Occurrence

of Disease, Disability, and Death? . . . . . . . . . . . . . . . .15 What Changes in Populations Over Time

Can Affect Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Chapter 2 Evidence-Based Public Health . . . . 24 How Can We Describe a Health Problem? . . . . . . . . . .25 How Can Understanding the Distribution

of Disease Help Us Generate Ideas or Hypotheses About the Cause Of Disease? . . . . . . . .27

How Do Epidemiologists Investigate Whether There Is Another Explanation for the Difference or Changes in the Distribution of Disease? . . . . . . . . . . . . . . . . . . . . . . . . . . 28

What Is the Implication of a Group Association? . . . .29

Contents Etiology: How Do We Establish Contributory

Cause? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 What Can We Do If We Cannot Demonstrate

All Three Requirements to Definitively Establish Contributory Cause? . . . . . . . . . . . . . . . . . . .32

What Does Contributory Cause Imply? . . . . . . . . . . . . .33 Recommendations: What Works to

Reduce the Health Impact? . . . . . . . . . . . . . . . . . . . . . .36 Implementation: How Do We Get

the Job Done? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Evaluation: How Do We Evaluate Results? . . . . . . . . . .42

SECTION I Cases and Discussion Questions 47

HIV/AIDS Determinants and Control of the Epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

The Aging Society . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Smoking and Adolescents—The

Continuing Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Reye’s Syndrome: A Public Health

Success Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Sudden Infant Death Syndrome (SIDS) . . . . . . . . . . . . .51

SECTION II Tools of Population Health 53

Chapter 3 Public Health Data and Communications . . . . . . . . . . . 55

What Is the Scope of Health Communications? . . . .56 Where Does Public Health Data Come From? . . . . . .56 How Is Public Health Information Compiled

to Measure the Health of a Population? . . . . . . . . . .58 How Can We Evaluate the Display and Quality

of the Presentation of Health Information? . . . . . . .61 What Factors Affect How We Perceive

Public Health Information? . . . . . . . . . . . . . . . . . . . . . . .64 Image credits: ©Jack Berman/Moment/Getty; © Mc Satori/Shutterstock; © KidStock/Blend Images/Getty; © Christian Delbert/Shutterstock; © Jovanmandic/iStock/Getty Images Plus/Getty Improving Community Health

vi Contents

How Can Bioethical Principles Be Applied to Protecting Individuals Who Participate in Research? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

What Can Be Done to Respond to the Threat of Pandemic Diseases? . . . . . . . . . . . . . . . . . . 112

SECTION II Cases and Discussion Questions 117

Don’ s Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 A New Disease Called SADS—A Decision

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 José and Jorge—Identical Twins Without

Identical Lives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 The Obesity Epidemic in the United States—

The Tip of an Iceberg . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Changing Behavior—Cigarette Smoking . . . . . . . . . 121 The New Era of E-Cigarettes . . . . . . . . . . . . . . . . . . . . . . 122 The Elderly Driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

SECTION III Preventing Disease, Morbidity, and Mortality 125

Chapter 6 Noncommunicable Diseases . . . . 129 What Is the Burden of Noncommunicable Disease? . 130 How Can Screening for Disease Address the

Burden of Noncommunicable Diseases? . . . . . . . 131 How Can Identification and Treatment of

Multiple Risk Factors Be Used to Address the Burden of Noncommunicable Disease? . . . . 137

How Can Cost-Effective Interventions Help Us Address the Burden of Noncommunicable Diseases? . . . . . . . . . . . . . . . . . . 137

Can Genetic Testing Help Predict Disease and Disease Outcomes and Allow More Personalized Medicine? . . . . . . . . . . . . . . . . . . 139

What Can Be Done to Prevent Long-Term Mortality and Morbidity from Our Treatments? . . . . . . . . . . . . . . . . . . . . . . . . . 141

What Can We Do When Highly Effective Interventions Do Not Exist? . . . . . . . . . . . . . . . . . . . . 142

How Can We Combine Strategies to Address Complex Problems of Noncommunicable Diseases? . . . . . . . . . . . . . . . . . . 143

What Type of Information Needs to Be Combined to Make Health Decisions? . . . . . . . . . . .66

What Other Data Needs to Be Included in Decision-Making? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

How Do We Utilize Information to Make Health Decisions? . . . . . . . . . . . . . . . . . . . . . . .70

How Can We Use Health Information to Make Healthcare Decisions? . . . . . . . . . . . . . . . . . . .72

Chapter 4 Social and Behavioral Sciences and Public Health . . . . . . 76

How Is Public Health Related to the Social and Behavioral Sciences? . . . . . . . . . . . . . . . . . .77

How Are Social Systems Related to Health? . . . . . . . .78 How Do Socioeconomic Status, Culture,

and Religion Affect Health? . . . . . . . . . . . . . . . . . . . . . .79 What Are Social Determinants of Health? . . . . . . . . . .83 10 Key Categories of Social Determinants

of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 How Do Social Determinants Affect Health? . . . . . . .85 Can Health Behavior Be Changed? . . . . . . . . . . . . . . . . .86 Why Are Some Individual Health Behaviors

Easier to Change Than Others? . . . . . . . . . . . . . . . . . . .87 How Can Individual Behavior Be Changed? . . . . . . . .87 How Can Health Behavior Be Explained and

Predicted? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 What Are Some Key Theories and Models

Used to Address Health Behavior? . . . . . . . . . . . . . . .88 How Can Theories Be Applied in Practice? . . . . . . . . . .94

Chapter 5 Health Law, Policy, and Ethics . . . . . . . . . . . . . . . . . . . . 100

What Is the Scope of Health Law, Policy, and Ethics? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

What Legal Principles Underlie Public Health and Health Care? . . . . . . . . . . . . . . . . 102

What Do We Mean by “Health Policy”? . . . . . . . . . . . 104 How Are Public Health Policy Priorities

Established? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 How Do Philosophies Toward the Role of

Government Affect Health Policies? . . . . . . . . . . . . 106 Is There a Right to Health Care? . . . . . . . . . . . . . . . . . . 107 How Does Public Health Attempt to Balance the

Rights of Individuals and the Needs of Society? 108 What Bioethical Principles Are Used to Address

Public Health Issues? . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Contents vii

What Do We Mean by “Intentional and Unintentional Injuries”? . . . . . . . . . . . . . . . . . . . . . . . . 175

What Is Being Done to Keep the Population Safe? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

SECTION III Cases and Discussion Questions 181

High Blood Pressure: A Public Health and Healthcare Success . . . . . . . . . . . . . . . . . . . . . . . . 182

Testing and Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 H. pylori and Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . 184 What to Do About Lyme Disease? . . . . . . . . . . . . . . . . 184 Sharma’s Village . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Type 2 Diabetes—An Epidemic Disease . . . . . . . . . . 186 Legal Drugs That Kill—Death from Prescription

Drug Overdoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

SECTION IV Health Professionals, Healthcare Institutions, and Healthcare Systems 189

Chapter 9 Health Professionals and the Health Workforce . . . . . . . . . . 191

What Do We Mean by a “Health Professional”? . . . . 192 How Do Education and Training Serve to

Define Health Professions? . . . . . . . . . . . . . . . . . . . . . 192 What Are the Educational Options Within

Public Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 What Is the Education and Training

Process for Physicians? . . . . . . . . . . . . . . . . . . . . . . . . . 195 What Is the Education and Training

Process for Nursing? . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 What Roles Can Physicians, Nurses, and

Other Clinical Health Professions Play in Public Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

What Is Meant by “Primary, Secondary, and Tertiary Care”? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

How Are Clinical Health Professionals Rewarded and Compensated for Their Services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

How Can We Ensure the System Has the Right Number of Healthcare Professionals? . . . . . 204

Chapter 7 Communicable Diseases . . . . . . . . 146 What Is the Burden of Disease Caused by

Communicable Diseases? . . . . . . . . . . . . . . . . . . . . . . 147 How Do We Establish That an Organism

Is a Contributory Cause of a Communicable Disease? . . . . . . . . . . . . . . . . . . . . . . . 148

How Do We Measure the Potential Impact of a Communicable Disease? . . . . . . . . . . . 150

What Public Health Tools Are Available to Address the Burden of Communicable Diseases? . . . . . . . . . 151

How Can Barriers Against Disease Be Used to Address the Burden of Communicable Diseases? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

How Can Immunizations Be Used to Address the Burden of Communicable Disease? . . . . . . . . 153

How Can Screening and Case Finding Be Used to Address the Burden of Communicable Disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

How Can Treatment of Those Diagnosed and Their Contacts Help to Address the Burden of Communicable Disease? . . . . . . . . . . . . 154

What Is the Human Microbiome and Why Is It Important? . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

How Can Public Health Strategies Be Used to Eliminate Specific Communicable Diseases? . . . 155

What Options Are Available for the Control of HIV/AIDS? . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

What Options Are Available for the Control of Influenza? . . . . . . . . . . . . . . . . . . . . . . . . . . 159

What Options Are Available for the Control of Rabies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Chapter 8 Environmental Health and Safety . . . . . . . . . . . . . . . . . . . 163

What Is Meant by “Environment”? . . . . . . . . . . . . . . . . 164 What Is the Burden of Disease

Due to the Physical Environment? . . . . . . . . . . . . . 165 How Do We Interact with Our Physical

Environment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 How Does Risk Assessment Address

the Impacts of the Physical Environment? . . . . . . 168 What Is a Public Health Assessment? . . . . . . . . . . . . . 170 What Is an Ecological Risk Assessment? . . . . . . . . . . 171 What Is an Interaction Analysis

Approach to Environmental Diseases? . . . . . . . . . 172 What Are the Health Impacts of the Built

Environment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

viii Contents

What Conclusions Can We Reach from These Descriptions of the Healthcare Systems in the United States, Canada, and the United Kingdom? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

How Can a Healthcare System Be Scored? . . . . . . . . 232 Using the National Scorecard, How Does the

United States’ Healthcare System Perform Compared to Those of Other Developed Countries? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

How Can the Costs of Health Care Be Controlled in the United States? . . . . . . . . . . . . . . . 233

How Can Population Health Become a Mechanism for Controlling Costs? . . . . . . . . . . . . . 234

SECTION IV Cases and Discussion Questions 237

When Nursing Meets Medicine . . . . . . . . . . . . . . . . . . 238 Jack and Continuity of Care . . . . . . . . . . . . . . . . . . . . . . 238 Donna’s Doctor—To Err Is Human . . . . . . . . . . . . . . . . 239 Health Care in the United States—For

Better or Worse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Excess Costs—How Much Can Be Saved? . . . . . . . . 241 Navigating the Health System . . . . . . . . . . . . . . . . . . . 242 Influenza in Middleburg and Far Beyond . . . . . . . . . 243

SECTION V Public Health Institutions and Systems 245

Chapter 12 Public Health Institutions and Systems . . . . . . . . . . . . . . . . . 247

What Are the Goals and Roles of Governmental Public Health Agencies? . . . . . . . . 248

What Are the 10 Essential Public Health Services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

What Are the Roles of Local and State Public Health Agencies? . . . . . . . . . . . . . . . . . . 251

Is There a Process of Accreditation of Health Departments? . . . . . . . . . . . . . . . . . . . . . . . . . . 253

What Are the Roles of Federal Public Health Agencies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

What Are the Roles of Global Health Organizations and Agencies? . . . . . . . . . . . . . . . . . . 257

How Can Public Health Agencies Work Together? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Chapter 10 Healthcare Institutions . . . . . . . 207 What Institutions Make Up the

Healthcare System? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 What Types of Inpatient Facilities Exist

in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 What Types of Outpatient Facilities Exist

in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 What Do We Mean by the

“Quality of Healthcare Services?” . . . . . . . . . . . . . . . . . . . . .210 How Can Health Care Be Coordinated

Among the Multiple Institutions That Provide Healthcare Services? . . . . . . . . . . . . . . 212

What Types of Coordination of Care Are Needed and What Purposes Do They Serve? . . . 213

What Types of Healthcare Delivery Systems Are Being Developed and How Can They Help Ensure Coordination of Health Care? . . . . . . 214

How Can Electronic Medical Records Be Used To Facilitate Coordination of Care and Improve Quality? . . . . . . . . . . . . . . . . . . 214

How Is Technology Being Used to Improve the Quality of Care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

What Mechanisms Are Being Used to Monitor and Ensure the Quality of Health Care in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Chapter 11 Health Insurance and Healthcare Systems . . . . . . . . . . 222

How Much Money Does the United States Spend On Health Care? . . . . . . . . . . . . . . . . . . . . . . . . 223

What Types of Government-Supported Health Insurance Are Available? . . . . . . . . . . . . . . . . . . . . . . . 223

What Types of Employment-Based Health Insurance Are Available? . . . . . . . . . . . . . . . . . . . . . . . 226

What Mechanism Is Available to Obtain Insurance for Those Not Otherwise Eligible for Health Insurance? . . . . . . . . . . . . . . . . . . 226

What Are the Extent and Consequences of Being Uninsured and Underinsured in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Are There Other Programs Available for Those Who are Disabled or Injured on the Job? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

How Does the United States’ Health System Compare with Other Developed Countries? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

How Can We Describe the Healthcare Systems in Canada and the United Kingdom? . . . . . . . . . . . 229

Contents ix

What Is Meant by One Health? . . . . . . . . . . . . . . . . . . . 295 What Is the One Health Initiative? . . . . . . . . . . . . . . . . 297 What Is the One Health Educational

Framework? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 Microbiological Influences on

Health and Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 Ecosystem Health/Physical Environment . . . . . . . . . 298 How Can Global Movements of

Populations Affect Health? . . . . . . . . . . . . . . . . . . . . . 301 How Can Agricultural Practices and

Changes in Food Distribution Influence the Occurrence of Infectious Diseases in Humans? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302

How Can Ecological Changes in Land and Resource Use Affect the Development of Infectious Diseases? . . . . . . . . . . . . . . . . . . . . . . . . . . . 302

How Can Climate Change Affect Human Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

Human–Animal Interactions . . . . . . . . . . . . . . . . . . . . . 303 What Is the Human–Animal Bond and

What Are Its Health Benefits? . . . . . . . . . . . . . . . . . . 303 What Are the Major Risks from Cats and

Dogs and How Can They Be Minimized? . . . . . . . 305 What Is Meant by Exotic Pets and What Risks

Do They Pose for Infectious Disease? . . . . . . . . . . . 305

SECTION V Cases and Discussion Questions 309

Public Health Departments—Getting the Lead Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

Community-Oriented Primary Care (COPC) . . . . . . 310 Hurricane Karl and the Public Health Success

in Old Orleans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 Lung Cancer: Old Disease, New Approaches . . . . . 312 Restorital—How Do We Establish Safety? . . . . . . . . 313 West Nile Virus: What Should We Do? . . . . . . . . . . . . 314 Antibiotic Resistance: It’s With Us for the

Long Run . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

What Other Government Agencies Are Involved in Health Issues? . . . . . . . . . . . . . . . . . . 258

What Roles Do Nongovernmental Organizations Play in Public Health? . . . . . . . . . . . 259

How Can Public Health Agencies Partner with Health Care to Improve the Response to Health Problems? . . . . . . . . . . . . . . . . . 260

How Can Public Health Take the Lead in Mobilizing Community Partnerships to Identify and Solve Health Problems? . . . . . . . . . . . 260

Chapter 13 Food and Drugs As Public Health Issues . . . . . . . . . . . . . . . . 265

What Are Important Milestones in the History of Food and Drugs As Public Health Issues in the United States? . . . . . . . . . . . . . . . . . . . . 266

Food and Food Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Drugs and Drug Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

Chapter 14 Systems Thinking: From Single Solutions to One Health . . . . . . . 282

What Makes Systems Thinking Different? . . . . . . . . . 283 What Is a System? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 What Are the Initial Steps in Systems Analysis? . . . 284 What Additional Steps Are Needed

to Complete a Systems Analysis? . . . . . . . . . . . . . . . 286 How Can We Use a Systems Analysis to

Better Understand a Problem Such As Coronary Artery Disease? . . . . . . . . . . . . . . . . . . . . . . 286

How Can We Use Systems Diagrams to Display the Workings of a System? . . . . . . . . . . . . . 287

How Can We Apply Systems Thinking to Population Health Issues? . . . . . . . . . . . . . . . . . . . . . . 292

How Can Systems Thinking Help Us Incorporate Interactions Between Factors to Better Understand the Etiology of Disease? . . . . . . . . . . . 292

How Can Systems Thinking Help Take into Account the Interactions Between Diseases? . . . 293

How Can Systems Thinking Help Identify Bottlenecks and Leverage Points That Can Be Used to Improve Population Health? . . . . . . . . . . . 294

How Can Systems Thinking Help Us Develop Strategies for Multiple Simultaneous Interventions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

How Can Systems Thinking Help Us Look at Processes As a Whole To Plan Short-Term and Long-Term Intervention Strategies? . . . . . . . . . . . . 295

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Acknowledgments Public Health 101: Improving Community Health, 3rd Edition is the culmination of two decades of effort aimed at introducing public health to undergraduates. The effort originated with the teaching of an introduc- tory course in public health in 1998 at the then newly created George Washington University School of Pub- lic Health and Health Services. The new course, orga- nized by associate dean Nancy Alfred Persily, inspired efforts to teach and to learn from a new generation. The approach was designed as part of a liberal arts education, stimulating the movement that came to be called the Educated Citizen and Public Health.

Efforts to think through the content of an intro- ductory course in public health have involved a large number of people throughout the United States. Pub- lic health, arts and sciences, and clinical educators all participated in the 2006 Consensus Conference on Public Health Education, which put forward the framework for Public Health 101 upon which this book is based. Among those who led and continue to lead this effort is Susan Albertine, whose insights into the relationship between public health and liberal education have formed the basis for much of the Edu- cated Citizen and Public Health movement.

I have taught Public Health 101 since 2002, which has provided me with an opportunity to teach and to learn from well over 500 undergraduate students at The George Washington University. Their feedback and input has been central to writing and rewriting this book. I would also like to thank Alan Green- berg and Heather Young, the chair and vice chair of the Department of Epidemiology and Biostatistics at The George Washington University Milken Insti- tute School of Public Health, for their support of my

efforts to expand the audience for undergraduate pub- lic health.

I am pleased that Brenda Kirkwood has joined me as a co-author. I first had the opportunity to work with Brenda while she was a DrPH student at The George Washington University. Dr. Kirkwood has made extraordinary contributions to Public Health 101. Her insights and careful reviews and dedication to getting the details right have been key to the quality of this edi- tion. Brenda is truly exceptional and a pleasure to work with, as will be confirmed by all who work with her.

Mike Brown, Director of Product Management of the Public Health and Health Administration line of products for Jones & Bartlett Learning, has made special contributions to this book and the Essential Public Health series as a whole. His vision has helped craft the series, and his publishing expertise made it happen. The production, marketing, and editorial staff of Jones & Bartlett Learning deserve special recogni- tion. Their commitment to this book and the entire Essential Public Health series has gone well beyond the expectations of their jobs.

Last, but by no means least, is my wife, Linda Riegelman, who encouraged this book and the Essen- tial Public Health series from the beginning. She saw the need to reach out to students and make real the roles that public health plays in their everyday lives.

Confronting the challenge of putting together Public Health 101 has been one of the great joys of my professional life. I hope it will bring both joy and challenge to you as you enter into the important and engaging world of public health.

Richard Riegelman, MD, MPH, PhD

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Preface: What Is Public Health 101: Improving Community Health All About? Public health is more than a profession; it is a way of thinking. Public Health 101: Improving Community Health introduces you to the profession and also the way of thinking that we will call population health. Population health is an important way of looking at the world, whether you are going into public health as a profession, a clinically oriented health profession, business, law, international affairs, or a range of other professions.

Population health is also a key way of thinking, which prepares you for the challenges of citizenship in a democracy. Many of the issues that come before us as a society stem from or benefit from a popula- tion health perspective. Whether we are dealing with AIDS, the impact of aging, climate change, or the costs of health care, the population perspective can help us frame the issues and analyze the options to inter- vene. Population health requires an evidence-based approach to collecting and using the facts to develop and implement approaches to improve community health.

In addition, the population perspective leads us to look broadly at the way issues intertwine and interact with each other. We call this systems thinking. In pop- ulation health, systems thinking is taking center stage as we increasingly struggle with complex problems that require us to look beyond the traditional bound- aries of health and disease and the traditional lines between the roles of the health professions.

Until recently, public health was considered a dis- cipline taught only at the graduate level. Today, under- graduate public health is booming at 4-year colleges and is beginning to take hold at community colleges as well. Its roots in general and liberal education go back to the 1980s, when David Fraser, the president of Swarthmore and an epidemiologist who led the

investigation of Legionnaires’ disease, wrote a now classic article called “Epidemiology as a Liberal Art.”1

In 2003, the National Academy of Medicine, for- merly called the Institute of Medicine, recommended that “all undergraduates should have access to educa- tion in public health.”2 That recommendation encour- aged the development of the Educated Citizen and Public Health initiative, a collaboration of undergrad- uate educators and public health educators to define and stimulate public health curricula for all under- graduates. Public Health 101 was written to implement the recommendations that came out of this initiative and continues to form the basis for undergraduate education in public health.

The third edition of Public Health 101 has a new subtitle, Improving Community Health. Improving Community Health is designed to highlight the impor- tance of community-wide collaboration to promote and protect health as well as to prevent disease and disability. The third edition more fully addresses the work of a wide range of health professionals whose roles are an indispensable part of improving commu- nity health.

This third edition of Public Health 101 has been thoroughly updated and expanded. Each chap- ter includes new material designed to expand your understanding of public health. From e-cigarettes to the opioid epidemic, from aging as a public health issue to the One Health movement, Public Health 101 aims to make public health relevant to today’s students and today’s world. Each of the five sections includes new case studies challenging you to apply what you have learned.

Public Health 101: Improving Community Health will not try to overload your mind with facts. It is about providing you with frameworks for thinking, Improving Community Health

xii Preface: What Is Public Health 101: Improving Community Health All About?

and applying these frameworks to real situations and thought-provoking scenarios. Each chapter begins and ends with vignettes designed to show you the types of situations you will confront in public health. After each section, there are case studies that relate to one or more chapters in the section. They provide realistic, engaging exercises and open-ended questions to help you think through the application of the key concepts presented in each section.

Hopefully, you will come away from reading Pub- lic Health 101 with an appreciation of how the health of the public is influenced by and can be improved by

efforts directed at the population level, as well as at the individual level. Let us begin in Chapter 1 by explor- ing the ways that public health affects everyone’s daily life.

▸ References 1. Fraser DW. Epidemiology as a liberal art. N Engl J Med. 1987;

316:309–314. 2. Gebbie K, Rosenstock L, Hernandez LM. Who Will Keep the

Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: National Academy Press; 2003. Improving Community Health

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Brenda Kirkwood, MPH, DrPH, works in academic administration and is clinical associate professor at the School of Public Health, University at Albany, State University of New York. Dr. Kirkwood has expe- rience in higher education spanning public and pri- vate institutions on the associate, baccalaureate, and graduate levels, including development and teaching of undergraduate and graduate public health courses, development and management of public health aca- demic programs, student advisement and mentorship, and contributing to public health education research. Prior to her career in higher education, Dr. Kirkwood held positions within the New York State Department of Health. She received a BS from Ithaca College, MPH from the University at Albany, State University of New York, and DrPH from The George Washington University.

Dr. Kirkwood has been actively involved in national efforts to expand public health education and strengthen the public health workforce. Her numer- ous publications and presentations have focused on the roles of, and opportunities for, public health edu- cation in 2-year and 4-year colleges and universities as well as at the graduate level.

About the Authors Richard Riegelman, MD, MPH, PhD, is professor of epidemiology–biostatistics, medicine, and health pol- icy, and founding dean of The George Washington Uni- versity Milken Institute School of Public Health. His education includes an MD from the University of Wis- consin, plus an MPH and PhD in epidemiology from The Johns Hopkins University. Dr. Riegelman prac- ticed primary care internal medicine for over 20 years.

Dr. Riegelman has over 75 publications, including 6 books for students and practitioners of medicine and public health. He is editor of the Jones & Bartlett Learn- ing Essential Public Health series. The series provides books and ancillary materials for the full spectrum of curricula for undergraduate public health education.

Dr. Riegelman has spearheaded efforts to fulfill the National Academy of Medicine’s recommendation that “all undergraduates should have access to educa- tion in public health.” He continues to work with pub- lic health and undergraduate education associations to integrate public health into the mainstream of under- graduate education at 2-year as well as 4-year colleges and universities. Richard Riegelman teaches under- graduate and graduate public health courses, which include Public Health 101 and Epidemiology 101. Improving Community Health