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INTRODUCTION
TO PUBLIC HEALTH

Maha Nubani Husseini

THREE QUESTIONS
What

is health ?
what is public health ?
who is responsible for the health of
the individual & the population?

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What is Health?
Persons

are healthy when they are doing

their activities with no apparent symptoms
of disease.

Health is a state of being well and free

from disease (oxford students
dictionary, 1991)

WHAT IS HEALTH?
From professional points of view:
Health is defined as a measure of the state of the
physical bodily organs, and the ability of the body
as a whole to function.
It refers to freedom from medically defined
diseases.

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Health is like a mirage

it is unattainable,
but worth pursuing!
Dubos, 1959

Healthy --------------------------------- Sick

An attorney who has been very
successful. He was an associate in a very
well respected firm. He had a large house
etc. He has a loving family, but at the
moment he is unemployed and now has a
much smaller apartment.

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Healthy --------------------------------- Sick

An attorney who is very successful. He is
an associate in a very well respected
firm. He has a large house etc. He has a
loving family. 5 years ago he was
involved in a car accident and is now
confined to a wheelchair.
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The Concept of Health

* The concept of Health depends on culture, values
and lifestyle.
The state of Health is dynamic and can be viewed as
on a continuum:
Health
Optimum
Health

Sickness
Death

* The concept of Health is personal and subjective

and affects everything a person does and how
he feels about himself and his environment.
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HEALTH - A DEFINITION
A

complete state of physical,

mental and social wellbeing and
not merely the absence of
disease.
WHO 1948
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WHO definition of health

Health is the extent to which an
individual or group
is able, on the one hand
to realise aspirations and safety needs;
and, on the other hand, to change or cope
with the environment.
It is to be seen as a resource for everyday life
and not merely the objective of living.
It is a positive concept emphasising
social and personal resources
as well as physical capacities.
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WHO 1986

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WHAT IS PUBLIC HEALTH ?

Public Health is "the Science
and Art of Prolonging Life and
Promoting Health through the
Organised Efforts of Society"

Lewis in Holland et al, 1991

PUBLIC HEALTH IS .
The Science and Art of
1. Preventing disease
2. Prolonging life
C.E.A Winslow, 1920

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PUBLIC HEALTH IS .
The Science and Art of

3. Promoting health and

efficiency
through Organised
Community Effort:
C.E.A Winslow,
1920

PUBLIC HEALTH IS .
a. The sanitation of the environment
b. The control of communicable
infections
c. The education of the individual in
personal hygiene.

C.E.A Winslow, 1920

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PUBLIC HEALTH IS .
d. The organization of medical & nursing
services for the early diagnosis and
preventive treatment of disease, and
e. The development of the social
machinery to ensure everyone a standard
of living adequate for the maintenance of
health

C.E.A Winslow, 1920

PUBLIC HEALTH IS .
SO ORGANISING THESE
BENEFITS AS TO ENABLE
EVERYONE TO REALISE HIS
BIRTHRIGHT OF HEALTH
AND LONGEVITY
C.E.A Winslow, 1920

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THE MISSION OF PUBLIC HEALTH

The mission of public health is:

"Fulfilling society's interest

in assuring conditions in
which people can be
healthy"

PUBLIC HEALTH IS .
"The process of mobilising and
engaging local, state, national
and international resources to
assure the conditions in which
people can be healthy"
Detels & Breslow, 2002

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Dimensions of Health

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PHYSICAL HEALTH
is

concerned with anatomical integrity

and physiological functioning of the body.
It means the ability to perform routine
tasks without any physical restriction.
E.g., Physical fitness is needed to walk
from place to place.

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MENTAL HEALTH
is

the ability to learn and think clearly

and coherently. E.g., a person who is
not mentally fit (retarded) could not
learn something new at a pace in which
an ordinary normal person learns.

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SOCIAL HEALTH
is

the ability to make and maintain

acceptable interaction with other people.
E.g. to celebrate during festivals; to
mourn when a close family member dies;
to create and maintain friendship and
intimacy, etc.

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EMOTIONAL HEALTH is

the ability of expressing emotions in the

appropriate way, for example to fear, to be
happy, and to be angry. The response of
the body should be congruent with that of
the stimuli.
Emotional health is related to mental
health and includes feelings. It also
means maintaining ones own integrity in
the presence of stressful situation such as
tension, depression and anxiety.
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SPIRITUAL HEALTH

being.
Some

people relate health with religion; for

others it has to do with personal values, beliefs,
principles and ways of achieving mental
satisfaction, in which all are related to their
spiritual well being.

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DETERMINANTS OF HEALTH
Health

or ill health is the result of

a combination of different factors.
There are different perspectives in
expressing the determinants of
health of an individual or a
community.
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THE HEALTH FIELD CONCEPT

According to the Health field

concept. There are four major
determinants of health or ill health.
A. Human biology
B. Environment
C. Lifestyle behaviour
D. Health care organization

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A. HUMAN BIOLOGY
Every Human being is made of genes. In
addition, there are factors, which are
genetically transmitted from parents to
offspring. As a result, there is a chance of
transferring defective trait. The modern
medicine does not have a significant role in these
cases.
a. Genetic Counseling: For instance during
marriage parents could be made aware of their
genetic component in order to overcome some
risks that could arise.
b. Genetic Engineering: may have a role in cases
like Breast cancer.

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B. ENVIRONMENT:

a.
b.
c.

d.

e.

is all that which is external to the individual

human host. Those are factors outside the human
body. Environmental factors that could influence
health include:
Life support, food, water, air etc
Physical factors, climate, Rain fall
Biological factors: microorganisms, toxins,
Biological waste,
Psycho-social and economic e.g. Crowding,
income level, access to health care
Chemical factors: industrial wastes,
agricultural wastes, air pollution, etc

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C. LIFE STYLE (BEHAVIOR):

is

an action that has a specific frequency,

duration, and purpose, whether conscious
or unconscious. It is associated with
practice. It is what we do and how we act.
Recently life style by itself received an
increased amount of attention as a major
determinant of health. Life style of
individuals affects their health directly or
indirectly.
For example: Cigarette smoking, Unsafe
sexual practice, Eating contaminated
food. etc

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D. HEALTH CARE ORGANIZATION

Health care organizations in terms of their resource in
human power, equipments, money and so on determine
the health of people.
It is concerned with
a.
Availability of health service:
b.
Scarcity of Health Services
c.
Acceptability of the service by the community
d.
Accessibility : in terms of physical distance, finance
etc
e.
Quality of care that mainly focuses on the
comprehensiveness, continuity and integration of the
health care.

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FOUR DIFFERENT FACTORS AFFECTING HEALTH

Introduction to Public Health

Physical
determinant

Socio- cultural

Health of the
community

Community
Organizatio
n

Behavioral
Determinant

Fig-1- Factors affecting health of community

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PHYSICAL DETERMINANTS
The

physical factors affecting the

health of a community include:
the geography (e.g. high land
versus low land), the
environment (e.g. manmade or
natural catastrophes) and the
industrial development (e.g.
pollution occupational hazards)

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SOCIO CULTURAL DETERMINANTS

The

socio- cultural factors

affecting the health of a
community include the beliefs,
traditions, and social customs in
the community. It also involves
the economy, politics and
religion in the community.
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COMMUNITY ORGANIZATION Community

organization include the

community size, arrangement and
distribution of resources (relations
of productions)

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BEHAVIORAL DETERMINANTSThe

behavioral determinants
affecting health include
individual behavior and life style
affecting the health of an
individual and the community.
E.g. smoking, alcoholism and
promiscuity
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GLOBALIZATION AND HEALTH

Globalization is the process of increasing political and

social interdependence and global integration that
takes place as capital, traded goods, persons,
concepts, images, ideas and Values diffuse across
the stated boundaries (Hurrel &woods 1995).
Globalization must ensure that people, particularly
the poor, enjoy better health that is the most
important factor in improving the economic
wellbeing of the population in general and in
reducing poverty in particular.
The effects of Globalization on health are diverse;
these can be positive, negative or mixed. Some of the
effects of Globalization are listed here under.

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EFFECTS OF GLOBALIZATION

ON

HEALTH INCLUDES
Externalities of some diseases due to increased
communication decreased human mobility
Accelerated economic growth and technological
advances have enhanced health and life expectancy in
many population
Increasing effects of international and bilateral
agencies (structural adjustment programs and Global
initiatives)
Jeopardizing population health Via erosion of social
and environmental conditions and exacerbating
inequalities

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OTHER HEALTH RISKS OF GLOBALIZATION

INCLUDES
Fragmentation

and weakening of labor

markets due to greater power of mobile
capital
Tobacco induced diseases
Food markets & obesity as well as
chemicals in food
Rapid spread of infectious diseases
Depression in aged and fragmented
population
Adverse effects on the environment

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MODEL OF DISEASE CAUSATION

THEORIES

model is a representation of a
system that specifies its
components and the relationships
among the variables. E.g. includes
graphs, charts, and decision trees

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I NINETEEN-CENTURY
1.

MODELS

Contagion theory

2. Supernatural theory
3. Personal behavior theory
4. Miasma theory
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1. CONTAGION

1.
2.
3.
4.
5.

THEORY

Beginning of the 19th century: illness is contagious.

It required:
Keeping sick away from well
Quarantine of ships (forty days la quarantine)
Setting up military cordons around infected towns
Isolation of households, and
Fumigating or washing the bedding and clothing of the
sick.

WHY NOT ACCEPTED: too many instances where people

become ill regardless of their isolation from human contact
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2. SUPERNATURAL THEORY
supernatural forces cause disease.
Disease prevention important to the religious
people: Disease is a punishment for transgression
of Gods laws.
Rich, the healthier rich, can employ it on poor, for
sinful behavior i.e. presumed idleness,
intemperance and uncleanness.
This theory expressed a political philosophy.
People could not advocate the belief that sin causes
disease without, at the same time, implicitly
supporting the idea that government need to
redress poverty.
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3. PERSONAL BEHAVIOR THEORY

Wrong personal behavior.
Responsibility to individuals to control their own
lives.
Source of the disease was not tied up with
the mysterious ways of God, instead people
caused their own disease by living fully
unhealthy.
Improper diet, lack of exercise, poor
hygiene and emotional tension become
the focus of preventive actions.
NOT the poor, but the middle-class life.

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4. MIASMA THEORY
Disease

is caused by the odor of

decaying of organic materials.
Back to the Hippocratic idea that
disease is related to climate.
It contrasted sharply from the other
three theories since it conceptually
separated the source of the disease
from the victim of the disease.
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II TWENTY-CENTURY MODELS

Although economic and ideological considerations

influenced the 19th century disease prevention
policy, sound research determines policy today.
The 20th century theory focuses on:
1. The Germ Theory
2. The Life Style Theory
3. The Environmental Theory
4. The Multi Causal Theory

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1. THE GERM THEORY

Explanations

of disease causations.
Microorganisms cause diseases and it is
possible to control diseases using antibiotics
and vaccines.
There was criticism on this theory by Thomas
Mckeown that stated as the incidence of all
major infectious diseases begun to fall several
decades before the introduction of vaccines
and antibiotics.
Thus rising of living standards was
responsible for the reduction of disease not
the discovery of antibiotics and vaccines.

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2. THE LIFE STYLE THEORY

Unhealthy

lifestyles are causes for

diseases.
It blames stress, lack of exercise, the
use of alcohol and tobacco improper
nutrition for most chronic diseases.
It rejects the notion central to the classic
germ theory, that a single disease has a
single etiology.
It emphasize the interrelatedness of many
variables in disease causality, principally
those under the control of the individual. 47

3. THE ENVIRONMENTAL THEORY

Significant number of chronic disease caused by

toxins
First aspect concentrates on: Disease prevention,
instead of requiring medical treatments or
personal hygiene, demands change in the industrial
production.
Second concentrates focus on concentrates on toxic
substances in the air water and soil (advocates of this
theory places particular emphasis on radioactivity)
Third aspect focus on synthetic additives to foods
organic foods.
Two scientific disputes surround the hypothesis viz
the suitability of extrapolating from animals to
humans and the concept of threshold levels.

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4. THE MULTI CAUSAL THEORY

Also

called Web of disease causation.

It states: Multiple factors for a cause of a
single disease entity.
It suggests that Effective disease
prevention policy as the theories it
replaces.
Its shortcomings are it gives few clues about
how to prevent disease, the actual prevention
policies it implies are inefficient in many
ways and there is a gap between what it
promises and what epidemiologists deliver.

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THE HISTORY OF PUBLIC HEALTH

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The History of Public

Health

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3000-400 BC
3000 BC Dawn of Sumerian, Egyption culturesdrains, flush toilets
1700 The Code of Hammurabi-rules governing
medical practice.
1500 Mosaic Law-personal, food hygiene,
segregating lepers, overriding duty of saving life
as religious imperative.
400 Greece-personal hygiene, nutrition,
sanitation, Hippocrates-clinical and epidemic
observation and environmental health

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500

BC-500 AD

Rome-

public baths, sanitation, municipal

planning, municipal doctors, military and
occupational health.

500-1000 AD
Europe

destrucyion of Roman society and

the rise of Christianity\
Sickness as punishment for sin.
Mortification of the flesh, prayer, fasting
and faith as therapy.
Poor nutrition and hygiene, pandemics.
Antiscience-care of the sick as religious
duty.

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700-1200
Islam-preservation

of ancient health
knowledge, schools of medicine,
medical advances (Ibn Sinna)
Rise of cities, trade and commerce.
Crusades-contact with Arabic
medicine.

AGE OF ENLIGHTENMENT (1700S)

Period of revolution, industrialization, and the growth of
cities
Miasma Bad Air
Dr. James Lind discovered that scurvy could be controlled
by lime juice
Jenner discovered a vaccine against smallpox

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Smallpox,

THE 1800S

cholera, typhoid, TB, and other

diseases reached exceedingly high endemic levels
Dr. John Snow was the first to say that diseases were
caused by microorganisms
Louis Pasteur furthered the study of disease etiology
(germs/bacteria) and introduced the 1st scientific
approach to immunization and pasteurization
Lister developed the antiseptic method of treating
wounds by using carbolic acid & he introduced the
principle of asepsis to surgery

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modern sanitation was

one of the greatest public
health accomplishments of
the late
19th and early 20th
centuries.

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FALL IN STD DEATH RATES FOR INFECTIOUS

DISEASES US 1900-1973 ( PNEUMONIA)
1.8

1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0

Sulphonamide

1900

1920

1940

1960

1973

FALL IN STD DEATH RATES FOR INFECTIOUS

DISEASES US 1900-1973 (DIPHTERIA)
0.5
0.45
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0

Toxoid

1900

1920

1940

1960

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FALL IN STD DEATH RATES FOR INFECTIOUS

DISEASES US 1900-1973 (POLIOMYELITIS)
0.03
0.025
0.02

Vaccine
Vaccine

0.015
0.01
0.005
0
1900

1920

1940

1960

1973

FALL IN STD DEATH RATES FOR INFECTIOUS

DISEASES US 1900-1973 (TUBERCULOSIS)
2.5
2
1.5

Isoniazid

1
0.5
0

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FALL IN STD DEATH RATES FOR INFECTIOUS

DISEASES US 1900-1973 (MEASLES)
0.14
0.12
0.1

Vaccine

0.08
0.06
0.04
0.02
0
1900

1920

1940

1960

1973

MEASLES INCIDENCE
450
400
350
300
250
200
150
100
50
0

Measles case rate per

100,000 population

12 20 28 36 44 52 60 70 78

Year

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0.50
Environmental
changes improvements in
standard of living
especially diet

TB
(respiratory
and nonrespiratory

0.38

0.25
Specific measures of
sanitary reformers public and personal
hygiene

Cholera,
Typhus Typhoid

Change in character
of disease

Scarlet Fever

0.29

MORTALITY
DECLINE
(19th century
England)

0.12

0.25

HISTORICALLY FROM
INDUSTRIALIZED COUNTRIES
Improved health and reduced (child) mortality
and fertility: mainly before application of
effective modern health technology.
Socio-economic improvements (income , general
education): Health improves only when scientific
knowledge on disease causation adopted by the
public.

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WHERE ARE WE NOW?

TEN GREAT ACHIEVEMENTS IN PUBLIC

HEALTH, 1900-1999
1.
2.

3.
4.
5.
6.
7.
8.
9.
10.

Vaccination.
Motor-vehicle safety.
Safer workplaces.
Control of infectious diseases.
Decline in deaths from coronary heart disease and
stroke.
Safer and healthier foods.
CDC, Morbidity and Mortality
Weekly Report, December 24, 1999
Healthier mothers and babies.
/ 48(50); 1141.
Available at:
Family planning.
http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm4850bx.htm
Fluoridation of drinking water.
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Recognition of tobacco use as a health hazard.

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Deaths

HEALTH DISPARITIES

Access and Outcomes

Infant

Mortality
Cancer Screening and Management
Cardiovascular Disease
Diabetes
HIV Infection/ AIDS
Immunizations
70

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MULTIPLE DETERMINANTS
OF HEALTH
Policies and Interventions

Behavior
Physical
Environment

Individual

Social
Environment

Biology

Access to Quality Health Care

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Source: U.S. Department of Health and Human Services, Health People 2010

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