Preventable diseases; the scope of public health

The purpose of a department of public health is to put into effect for the benefit of all the people of a community the practical lessons of preventive medicine. The scope of public health work is chiefly determined by our knowledge of the causes of the preventable diseases. We do not know how to prevent all diseases. We do, however, know effective ways to prevent or to reduce the occurrence of at least a dozen varieties of disease. Every health department ought to provide for a program and services which will prevent so far as possible the preventable diseases and the preventable hazards to health. To concentrate on prevention is to avoid diversion by specious arguments into the fields of medical care of the sick.     

MEDICAL CARE AND PUBLIC HEALTH SERVICES

Medical care applies to the individual, and public health to the community. One is the concentrated application of diagnosis and treatment for the life, the comfort of a patient, and includes guidance in health as for motherhood, infancy, childhood and old age.Public health services, provided by the community through its local government and the local department of health, are concerned with the prevention of diseases of all kinds. Some are controlled by sanitary authority, but the majority of preventable diseases are dealt with by public health education.It is not the function of the health department to treat the sick. The family physicians, the hospitals and dispensaries provide for medical care. Medical care of the sick and public health protection are two parallel activities to make use of medical science, one for treatment, the other for prevention of disease.     

HPV technologies advancing public health: discussion of recent evidence

Effective primary and secondary cancer prevention programmes are key to improve public health. Cervical cancer is preventable if high quality screening programmes, diagnosis and treatment are offered to female populations at high coverage. Nevertheless, it continues to be a public health problem, and screening programmes need improvements. Human papillomavirus (HPV) has been firmely established as the necessary cause of virtually all cervical cancer cases. To date we count two clinically validated and approved HPV technologies, available to prevent cervical cancer, and other diseases caused by these carcinogenic viruses: Prophylactic vaccines for primary prevention, and HPV DNA tests for secondary prevention, to detect life threatening infections by carcinogenic HPV types, allowing timely diagnosis and clinical management of precancerous lesions. The new technologies will help improve the health of the public if made widely accessible. Similar to vaccination programmes, systematic and well organized cervical screening programmes, with high quality validated HPV tests, can save more lives than ever and improve women's health, in an effective manner.     

Addressing Parental Vaccine Concerns: Engagement,Balance, and Timing

The recent United States measles epidemic has sparked another contentious national discussion about childhood vaccination. A growing number of parents are expressing concerns about the safety of vaccines, often fueled by misinformation from the internet, books, and other nonmedical sources. Many of these concerned parents are choosing to refuse or delay childhood vaccines, placing their children and surrounding communities at risk for serious diseases that are nearly 100% preventable with vaccination. Between 10% and 15% of parents are asking physicians to space out the timing of vaccines, which often poses an ethical dilemma for physicians. This trend reflects a tension between personal liberty and public health, as parents fight to control the decisions that affect the health of their children and public health officials strive to maintain high immunization rates to prevent outbreaks of vaccine-preventable diseases. Interventions to address this emerging public health issue are needed. We describe a framework by which web-based interventions can be used to help parents make evidence-based decisions about childhood vaccinations.

About the Author

Jason Glanz, PhD, is an epidemiologist and senior research investigator at Kaiser Permanente Colorado, Institute for Health Research. He is also an assistant professor in the Department of Epidemiology, Colorado School of Public Health. Dr. Glanz’s research focuses on vaccine safety and vaccine hesitancy. Dr. Glanz is currently a principal investigator with the Vaccine Safety Datalink, a national Centers for Disease Control and Prevention (CDC)-funded project that examines the safety of vaccines. Dr. Glanz also leads research efforts to develop risk communication strategies to help reduce parental vaccination concerns.     

The Relationship between Same-Day Access and Continuity in Primary Care and Emergency Department Visits

We examined how emergency department (ED) visits for potentially preventable, mental health, and other diagnoses were related to same-day access and provider continuity in primary care using administrative data from 71,296 patients in 22 VHA clinics over a three-year period. ED visits were categorized as non-emergent; primary care treatable; preventable; not preventable; or mental health-related. We conducted multi-level regression models adjusted for patient and clinic factors. More same-day access significantly predicted fewer non-emergent and primary care treatable ED visits while continuity was not significantly related to any type of ED visit. Neither measure was related to ED visits for mental health problems.     

Sweet or not: Using information and cognitive dissonance to nudge children toward healthier food choices

In the interest of public health, it is important to nudge children toward healthier food choices (e.g., beverages with less added sugar). We conducted a field experiment in a peri-urban region in Vietnam to evaluate the effects of information and cognitive dissonance on the food choices of children. Our sample consisted of more than 1200 primary school children, randomly assigned into three groups: control, health information, and health information plus hypocrisy inducement. The third group was intended to raise cognitive dissonance by illustrating the gap between what people know they should do (socially desired behaviors) and what they actually do (transgressions). The results indicate that health information increased the likelihood of selecting milk with less sugar by around 30 %, as compared to the control group. Hypocrisy inducement did not make any additional contribution to healthier food choices. The treatment effects declined when there was a delay between the treatment and the behavioral choice. We discuss the practical implications of our findings for short-term intervention field studies.     

Public mental health: the time is ripe for translation of evidence into practice

Public mental health deals with mental health promotion, prevention of mental disorders and suicide, reducing mental health inequalities, and governance and organization of mental health service provision. The full impact of mental health is largely unrecognized within the public health sphere, despite the increasing burden of disease attributable to mental and behavioral disorders. Modern public mental health policies aim at improving psychosocial health by addressing determinants of mental health in all public policy areas. Stigmatization of mental disorders is a widespread phenomenon that constitutes a barrier for help-seeking and for the development of health care services, and is thus a core issue in public mental health actions. Lately, there has been heightened interest in the promotion of positive mental health and wellbeing. Effective programmes have been developed for promoting mental health in everyday settings such as families, schools and workplaces. New evidence indicates that many mental disorders and suicides are preventable by public mental health interventions. Available evidence favours the population approach over high-risk approaches. Public mental health emphasizes the role of primary care in the provision of mental health services to the population. The convincing evidence base for population-based mental health interventions asks for actions for putting evidence into practice.     

Promoting state health department evidence-based cancer and chronic disease prevention: a multi-phase dissemination study with a cluster randomized trial component

Background

Cancer and other chronic diseases reduce quality and length of life and productivity, and represent a significant financial burden to society. Evidence-based public health approaches to prevent cancer and other chronic diseases have been identified in recent decades and have the potential for high impact. Yet, barriers to implement prevention approaches persist as a result of multiple factors including lack of organizational support, limited resources, competing emerging priorities and crises, and limited skill among the public health workforce. The purpose of this study is to learn how best to promote the adoption of evidence based public health practice related to chronic disease prevention.

Methods/design

This paper describes the methods for a multi-phase dissemination study with a cluster randomized trial component that will evaluate the dissemination of public health knowledge about evidence-based prevention of cancer and other chronic diseases. Phase one involves development of measures of practitioner views on and organizational supports for evidence-based public health and data collection using a national online survey involving state health department chronic disease practitioners. In phase two, a cluster randomized trial design will be conducted to test receptivity and usefulness of dissemination strategies directed toward state health department chronic disease practitioners to enhance capacity and organizational support for evidence-based chronic disease prevention. Twelve state health department chronic disease units will be randomly selected and assigned to intervention or control. State health department staff and the university-based study team will jointly identify, refine, and select dissemination strategies within intervention units. Intervention (dissemination) strategies may include multi-day in-person training workshops, electronic information exchange modalities, and remote technical assistance. Evaluation methods include pre-post surveys, structured qualitative phone interviews, and abstraction of state-level chronic disease prevention program plans and progress reports.

Trial registration

clinicaltrials.gov:NCT01978054.

     

Development of a new platform for neglected tropical disease surveillance

An expanded global focus on the control and elimination of neglected tropical diseases (NTDs) has called attention to the need to develop and validate surveillance strategies that are cost effective and can be integrated across diseases. Here, we describe a multiplex tool for the sensitive detection of antibody responses to NTDs as well as vaccine preventable diseases, malaria, and waterborne and zoonotic infections. The assay platform is robust, can be performed with either serum or dried blood spots and can be adapted to local epidemiological conditions and public health priorities. Multiplex assays open the door to conducting routine serosurveillance for NTDs through demographic health surveillance or malaria indicator surveys.     

Climate change and local public health in the United States: preparedness, programs and perceptions of local public health department directors

While climate change is inherently a global problem, its public health impacts will be experienced most acutely at the local and regional level, with some jurisdictions likely to be more burdened than others. The public health infrastructure in the U.S. is organized largely as an interlocking set of public agencies at the federal, state and local level, with lead responsibility for each city or county often residing at the local level. To understand how directors of local public health departments view and are responding to climate change as a public health issue, we conducted a telephone survey with 133 randomly selected local health department directors, representing a 61% response rate. A majority of respondents perceived climate change to be a problem in their jurisdiction, a problem they viewed as likely to become more common or severe over the next 20 years. Only a small minority of respondents, however, had yet made climate change adaptation or prevention a top priority for their health department. This discrepancy between problem recognition and programmatic responses may be due, in part, to several factors: most respondents felt personnel in their health department--and other key stakeholders in their community--had a lack of knowledge about climate change; relatively few respondents felt their own health department, their state health department, or the Centers for Disease Control and Prevention had the necessary expertise to help them create an effective mitigation or adaptation plan for their jurisdiction; and most respondents felt that their health department needed additional funding, staff and staff training to respond effectively to climate change. These data make clear that climate change adaptation and prevention are not currently major activities at most health departments, and that most, if not all, local health departments will require assistance in making this transition. We conclude by making the case that, through their words and actions, local health departments and their staff can and should play a role in alerting members of their community about the prospect of public health impacts from climate change in their jurisdiction.     

Paracelsus to parascience: the environmental cancer distraction

Entering a new millennium seems a good time to challenge some old ideas, which in our view are implausible, have little supportive evidence, and might best be left behind. In this essay, we summarize a decade of work, raising four issues that involve toxicology, nutrition, public health, and government regulatory policy. (a) Paracelsus or parascience: the dose (trace) makes the poison. Half of all chemicals, whether natural or synthetic, are positive in high-dose rodent cancer tests. These results are unlikely to be relevant at the low doses of human exposure. (b) Even Rachel Carson was made of chemicals: natural vs. synthetic chemicals. Human exposure to naturally occurring rodent carcinogens is ubiquitous, and dwarfs the general public's exposure to synthetic rodent carcinogens. (c) Errors of omission: micronutrient inadequacy is genotoxic. The major causes of cancer (other than smoking) do not involve exogenous carcinogenic chemicals: dietary imbalances, hormonal factors, infection and inflammation, and genetic factors. Insufficiency of many micronutrients, which appears to mimic radiation, is a preventable source of DNA damage. (d) Damage by distraction: regulating low hypothetical risks. Putting huge amounts of money into minuscule hypothetical risks damages public health by diverting resources and distracting the public from major risks.     

二级及以上公立医疗机构公共卫生相关科室设置分析

目的 摸底二级以上医疗机构公共卫生工作的组织方式,并对其设置公共卫生职能科室的必要性进行讨论。方法 检索北大法律信息数据库查找相关政府文件,梳理医疗机构设置公共卫生相关科室的要求。对发文要求设立公共卫生科室的省份和对比省份的163家医疗机构进行问卷调查。结果 原卫生部要求500张床位以上的医疗机构设立预防保健科,2003年以后部分省份发文要求二级以上医疗机构设立疾病预防控制或公共卫生科。72.5%的发文地区医疗机构和39.8%的未发文地区医疗机构设立了公共卫生相关科室,二级以上公立医疗机构设置公共卫生科室对公共卫生职责的承担有促进作用。结论 二级以上医疗机构应当设置公共卫生职能科室,以促进公共卫生职责的落实。     

Impact of disease characteristics and knowledge on public risk perception of zoonoses

Zoonoses represent a global public health threat. Understanding lay perceptions of risk associated with these diseases can better inform proportionate policy interventions that mitigate their current and future impacts. While individual zoonoses (e.g. bovine spongiform encephalopathy) have received scientific and public attention, we know little about how multiple zoonotic diseases vary relative to each other in lay risk perceptions. To this end, we examined public perceptions of 11 zoonoses across 12 qualitative attributes of risk among the UK public (n = 727, volunteer sample), using an online survey. We found that attribute ratings were predominantly explained via two basic dimensions of risk related to public knowledge and dread. We also show that, despite participants reporting low familiarity with most of the diseases presented, zoonoses were perceived as essentially avoidable. These findings imply that infection is viewed as dependent upon actions under personal control which has significant implications for policy development.     

Public health and public medical care

This paper deals briefly with the historical development of the major movements and organizations dedicated to the preservation of the health and security of the American people. Statements of various national organizations on the need for integration of these various services for the protection of the indigent are presented, and the experience of one county department in San Mateo which operates a completely integrated department of public health and welfare is reviewed, giving the pros and cons of the operation of a number of disciplines through a single administration. The major advantage of an integrated department of this kind is that all the services having to do with human needs-the needs arising from emotional distress, economic reverses or illness-are combined under the direction of a physician. It is probable that failure of the health discipline to provide such services was a factor in the presentation of the Wagner Act in 1938 and the Wagner-Murray-Dingell Bill in 1943. Continued close cooperation between the various disciplines devoted to the protection of the health and welfare of American citizens can help in solving some of the current problems.     

Genetic Counseling—A Health Department Service to Physicians

Questions about inheritance in all kinds of diseases and defects are commonly asked of nearly all physicians. In attempting to answer these questions, however, the physician is often hampered by lack of formal instruction in clinical genetics.Since the health department, if it is to carry out its epidemiologic function, must be as concerned over the increasing identification of genetic agents in disease as it is and has been over environmental disease agents, it should come to represent a source of assistance not now generally available to the physician. In short, as it carries out those activities by which its store of general genetic information is increased, and until other sources of genetic consultation become reasonably available, the health department can be of real service to physicians as a resource to which they may turn for help when dealing with families wanting genetic information.Such a service has been provided experimentally for the last two years by the Contra Costa County Health Department.This program calls for the taking of family pedigrees by public health nurses on families with questions of a genetic nature who are health department clients and on families who are referred by their private physicians for this service. An interpretation of each pedigree is made by the department''s physician in charge of the program and submitted to the family''s physician for his use in counseling the family. Evidence to date suggests the process can be a highly useful service to the practitioner and his patient.     

Role of Endocrinologists In Eliminating Health Care Disparities

ObjectiveTo review some of the persistent disparities in health and health care in the United States related to race, ethnicity, and socioeconomic status, with a focus on diabetes mellitus and obesity, and to discuss the role of endocrinologists in preventing these disparities.MethodsSome of the efforts made by the US government, such as public health strategies, to address health disparities are outlined, and statistics about diabetes and obesity are presented.ResultsThe elimination of health disparities, recognized as a national challenge for decades, is a national priority as defined in the national goals for Healthy People 2010. Health disparities refer to the differences in the quality of health and health care access and outcomes across racial, ethnic, and socioeconomic groups. Such disparities may be related to the patient (education, socioeconomic status, environment, language), the health care system (location, structural barriers, financial resources), or the provider, including a lack of diversity in the health care workforce. Endocrinologists are responsible for the care of many patients with chronic diseases, including obesity and diabetes mellitus. Both of these chronic diseases are diagnosed with increased frequency in minority populations and are preventable, difficult to manage, and associated with many complications and high health care costs.ConclusionThe role of endocrinologists is to provide equitable, affordable, accessible, high-quality, timely, cost-effective, and culturally sensitive health care. They must be involved in population health decisions and development of optimal health care policy so that endocrine disorders can ultimately be prevented. In addition, they must educate themselves, their patients, and the community regarding maintenance of healthy lifestyles to prevent complications. (Endocr Pract. 2009;15:612-623)     

STIGMATIZATION AND PUBLIC HEALTH ETHICS

Encouraged by the success of smoking denormalization strategies as a tobacco‐control measure, public health institutions are adopting a similar approach to other health behaviors. For example, a recent controversial ad campaign in New York explicitly aimed to denormalize HIV/AIDS amongst gay men. Authors such as Scott Burris have argued that efforts like this are tantamount to stigmatization and that such stigmatization is unethical because it is dehumanizing. Others have offered a limited endorsement of denormalization/stigmatization campaigns as being justified on consequentialist grounds; namely, that the potential public health benefits outweigh any stigmatizing side effects. In this paper, I examine and reject the blanket condemnation of stigmatization efforts in public health. I argue that the moral status of such efforts are best evaluated within a contractualist, as opposed to a consequentialist, framework. Contractualism in public health ethics asks whether a particular stigmatizing policy could be justified to reasonable individuals who do not know whether they will be affected by that policy. Using this approach, I argue that it is sometimes permissible for public health institutions to engage in health‐related stigmatization.     

Controlling Antimicrobial Resistance through Targeted,Vaccine-Induced Replacement of Strains

Vaccination has proven effective in controlling many infectious diseases. However, differential effectiveness with regard to pathogen genotype is a frequent reason for failures in vaccine development. Often, insufficient immune response is induced to prevent infection by the diversity of existing serotypes present in pathogenic populations of bacteria. These vaccines that target a too narrow spectrum of serotypes do not offer sufficient prevention of infections, and can also lead to undesirable strain replacements. Here, we examine a novel idea to specifically exploit the narrow spectrum coverage of some vaccines to combat specific, emerging multi- and pan-resistant strains of pathogens. Application of a narrow-spectrum vaccine could serve to prevent infections by some strains that are hard to treat, rather than offer the vaccinated individual protection against infections by the pathogenic species as such. We suggest that vaccines targeted to resistant serotypes have the potential to become important public health tools, and would represent a new approach toward reducing the burden of particular multi-resistant strains occurring in hospitals. Vaccines targeting drug-resistant serotypes would also be the first clinical intervention with the potential to drive the evolution of pathogenic populations toward drug-sensitivity. We illustrate the feasibility of this approach by modeling a hypothetical vaccine that targets a subset of methicillin-resistant Staphylococcus aureus (MRSA) genotypes, in combination with drug treatment targeted at drug-sensitive genotypes. We find that a combined intervention strategy can limit nosocomial outbreaks, even when vaccine efficacy is imperfect. The broader utility of vaccine-based resistance control strategies should be further explored taking into account population structure, and the resistance and transmission patterns of the pathogen considered.     

Bright ideas to market your department

Nobody can do everything discussed in this article. Choose several ideas and try them. Increase your profile by letting more people in the hospital know who you are, what you do, when you do it, and how you do it. Get noticed and develop a reputation as the "go to" department. It will be worth the effort and increase your stature within the hospital. It may also help you get more staff and assume additional duties. Most of all, it will increase the respect of your department, and promote a more smoothly operating asset management system.