PUBH501, Fall 2015: Topics in

Community & Preventive Medicine

Introduction to
Community and Preventive Medicine

Learning Objectives
Describe the relevance of community and preventive
medicine to clinical practice
Describe the contribution of public health and curative
medicine to the decline in mortality in the 20th
century
Give three examples of the interaction of practicing
physicians and public health agencies
Describe the goals of preventive medicine
Define primary, secondary, and tertiary prevention,
and give an example of each
2

PUBH501 Intro to C&PM

Is C+PM Relevant to Me?

In the U.S., 24 specialty boards, 100+ subspecialties
Internal Medicine / General Practice
What counseling for obese patient with borderline
elevated blood sugar level?
Surgery
Which prophylactic antibiotic?
Obstetrics / Gynecology
Why recommend folic acid? To whom?
Pediatrician
What vaccinations are needed before school?
Ophthalmology
Why measure intraocular pressure during an eye exam?
3

PUBH501 Intro to C&PM

Is C+PM Relevant to Me?

What happens in the community affects the health of the
patient
Patients prefer to remain healthy (prevent disease)
rather than to get sick and be treated
Healthcare Effectiveness Data and Information Set
(HEDIS) and other quality of care report cards include
preventive services
Payers are experimenting with bonuses for keeping
patients healthy
So goal is to keep people healthy. What is health?
4

PUBH501 Intro to C&PM

Definition of Heath
A state of complete physical, mental and
social well-being and not merely the
absence of disease or infirmity (WHO,
1947)

PUBH501 Intro to C&PM

Who/What Influences Health?

Innate individual traits, e.g.,
sex, biologic factors
Individual behavior
Social, family, community
networks
Living and working conditions
Broad social, economic,
cultural, health and
environmental conditions, and
policies at the global, national,
state, and local levels
6

PUBH501 Intro to C&PM

Life Expectancy
Life expectancy = average number of years of
life remaining to a person at a particular age,
based on age-specific mortality rates

PUBH501 Intro to C&PM

Life Expectancy at Birth, U.S., 19002000

Life Expectancy (years)

80

77 yrs.

60

47 yrs.
40

20

0
1900

2000

PUBH501 Intro to C&PM

What accounts for gain in life expectancy?

Life Expectancy (years)

80

77 yrs.

60

47 yrs.

40

20

0
1900

2000

Ref: Bunker JP, Frazier HS, Mosteller F. Improving health: measuring effects of medical care.
Milbank Q 1994;72:225-258.
9

PUBH501 Intro to C&PM

What accounts for gain in life expectancy?

Life Expectancy (years)

80

60

77 yrs.
Clinical medicine ~ 5 yrs.
Public health ~ 25 yrs.

40

20

0
1900

2000

Ref: Bunker JP, Frazier HS, Mosteller F. Improving health: measuring effects of medical care.
Milbank Q 1994;72:225-258.
10

PUBH501 Intro to C&PM

Some Factors Contributing to Gains

Clean water and air
Improved sanitation
Safer foods, improved nutrition
Expanded immunizations
Safer environment and workplaces
Improved medical care

11

PUBH501 Intro to C&PM

Community vs. Preventive Medicine

United States perspective
Community medicine attempts to promote health in
populations through the application of organized
community efforts
Preventive medicine seeks to enhance the lives of
individuals by helping them improve their own health
adapted from Jekel et al.

United Kingdom perspective

Community medicine is a branch of medicine concerned
with the total health of the individual with the home
environment and in the community, and with the application
of comprehensive care to the prevention and treatment of
illness in the entire community.
PUBH501 Intro to C&PM

12

Medicine and Public Health Interaction: Examples

Public Health Agency services to clinicians

Laboratory testing
Public health surveillance results
Health alerts, e.g., anthrax, influenza
Selected vaccines, antitoxins, etc.
Prevention materials

Clinicians responsibilities to agencies

Public health surveillance reporting
Completing death certificate
Reporting of suspected child or elder abuse

13

PUBH501 Intro to C&PM

Preventive Medicine
The specialty of medical practice that focuses on
the health of individuals and defined populations in
order to protect, promote, and maintain health and
well-being and prevent disease, disability, and
premature death (American Board of Preventive
Medicine)
In Board certification, three subspecialties
Public health and general preventive medicine
Occupational medicine
Aerospace medicine
14

PUBH501 Intro to C&PM

Core Aspects of Preventive Medicine

Screening (Use of tests, examination, or other
procedures to identify disease, disease
precursors, or susceptibility to disease in
persons without evidence or suspicion of
disease to identify early disease or susceptibility
when it is more easily / more successfully
treated)
Counseling
Immunization (and chemoprophylaxis)
15

PUBH501 Intro to C&PM

Goal of Preventive Medicine

To advance health by
promoting health-enhancing policies, environments, and
behaviors,
preventing disease and injury,
making possible early diagnosis and treatment, and
fostering rehabilitation to minimize disabilities.

16

PUBH501 Intro to C&PM

Levels of Prevention
Primary prevention prevention of disease
or injury, e.g., by eliminating causes of
disease or by increasing resistance to
disease
Secondary prevention early detection and
prompt treatment of disease before it
becomes symptomatic
Tertiary prevention limitation of the impact
(e.g., disability) from disease
17

PUBH501 Intro to C&PM

Levels of Prevention

Stage of Disease

Level of
Prevention

Predisease

Primary

Health promotion
Specific protection

Latent disease

Secondary

Screening and treatment

Symptomatic disease Tertiary

Appropriate Response

Treatment, disability limitation,

rehabilitation

Jekel et al.
PUBH501 Intro to C&PM

18

Primary Prevention
Primary prevention prevention of disease or
injury
Two approaches
Health promotion efforts to prevent disease and enhance health in
general
Specific protection efforts aimed at specific diseases, deficiencies,
injuries, toxic exposures

By community or clinical intervention or both

19

PUBH501 Intro to C&PM

Health Promotion
Social marketing
Counseling
Environmental modification
Other structural changes

20

PUBH501 Intro to C&PM

Social Marketing
= application of commercial marketing
principles to the analysis, planning, execution,
and evaluation of programs designed to
influence the voluntary behavior of target
audiences in order to improve personal and
societal welfare (Andreason, 1995)
Examples
MADD
Know Your Numbers
A.B.C.

21

PUBH501 Intro to C&PM

Specific Protection
Prevention of

specific diseases (mostly infectious)

specific deficiencies
injuries
toxic exposures
iatrogenic diseases and injuries

22

PUBH501 Intro to C&PM

Chain of Infection /
Prevention Opportunities
Route of
Transmission

Reservoir

Susceptible Host
(via portal of entry)

Agent

23

PUBH501 Intro to C&PM

Protection Against
Specific Infectious Diseases

Eliminate agent
Control / eliminate reservoir
Control transmission
Prevent exposure
Improve host resistance

24

PUBH501 Intro to C&PM

Non-infectious Concerns
Injuries (both unintentional and intentional)

Motor vehicle crashes

Occupational and non-occupational injuries
Poisonings, drownings, etc.
Suicide and other intentional injuries

Health Conditions and Diseases

Obesity (adult and child)

Cancer
Cardiovascular disease
Occupational illness
et al.

25

PUBH501 Intro to C&PM

Protection Against
Specific Deficiency States

Food fortification

Iodine in salt
Vitamin D in milk
Fluoride in water
Folic acid in cereal grain products

iodine-deficiency goiter
rickets
dental caries
neural tube defects

Supplementation
Iron

Adequate nutrition
e.g., in refugee camps

26

PUBH501 Intro to C&PM

Protection Against
Iatrogenic Diseases and Injuries

Iatrogenic = iatros (physician) + gennao (to

produce)
Nosocomial (hospital-acquired) infections
100,000 per year in U.S.
#1 problem = handwashing by HCW!

Medication errors
computer entry instead of handwritten orders

Surgical and medical errors

training, system changes, surveillance (including reporting)

27

PUBH501 Intro to C&PM

Secondary Prevention
Secondary prevention early detection and
prompt treatment of disease before it
becomes symptomatic
Screening programs used to detect diseases in early preclinical
stages
Case finding, e.g., periodic health exam

28

PUBH501 Intro to C&PM

Tertiary Prevention
Tertiary prevention limitation of the impact
(e.g., disability) from disease

Treatment
Disability limitation, esp. risk factor modification
Monitoring for long-term sequelae
Rehabilitation

29

PUBH501 Intro to C&PM

What are the modifiable risk factors

for heart disease?

High blood pressure

High cholesterol
Smoking
Obesity
Diabetes
Physical inactivity

30

PUBH501 Intro to C&PM

What are the interventions used to reduce the risk

of heart disease or its complications?
I
Law restricting sale of cigarettes to minors
Screening for hypertension, high cholesterol, II
diabetes
Daily aspirin after having an acute myocardial III
infarction (heart attack)
Echocardiogram or Exercise Treadmill Test for
II
person with diabetes and 3 other risk factors
Availability of playgrounds, recess, sports
I
31

PUBH501 Intro to C&PM

What are the interventions used to reduce the risk

of diabetes or its complications?
II
Screening using fasting plasma glucose
)
Measurement of glycosolated hemoglobin (HbA1cIII
every 34 months in diabetic patients
Counseling obese non-diabetic patient to lose I
weight
Annual eye exam in diabetic patients to look for
III
diabetic retinopathy

32

PUBH501 Intro to C&PM

Summary
Goal of preventive medicine to promote health,
minimize disease, injury, sequelae
Primary = avoid, secondary = screen / identify
asymptomatics, tertiary = minimize impact
Many strategies and approaches
think both individual and community
Consider health promotion, specific protection, legislation / regulation,
environmental modification, etc.

33

PUBH501 Intro to C&PM

Preventive vs. Curative Medicine

An Analogy

If people are falling over the edge of a cliff and

sustaining injuries, the problem can be dealt
with by stationing ambulances a the bottom, or
erecting a fence at the top.
- Denis Burkitt

34

PUBH501 Intro to C&PM