EXECUTIVE SUMMARY

INTRODUCTION OF PUBLIC HEALTH

NOVIAN FEBIYANTO

PUBLIC HEALTH FACULTY OF MEDICINE PADJAJARAN UNIVERSITY BANDUNG

2011
EXECUTIVE SUMMARY

INTRODUCTION OF PUBLICH HEALTH

PHILOSOPHY AND PURPOSE OF PUBLIC HEALTH The topic of public health explained in this summary is not about the education of public health professionals or the practice of preventive medicine; it is about public health as an organized, social effort, centered in official agencies but intimately involved with voluntary and not-forprofit organizations, intended to protect, promote, and restore the peoples health. Public health necessarily has been closely identified with medicine. The idea of public health is that the conviction of publics health can be improved by altering conditions behavior, the environment, biological interactions, and the organization of services. As a profession, unlike most professions, which have a common body of knowledge and a shared educational experience to bind their members together, the public health profession has an intended outcome as its common ground, as the cohering force that binds its member together in a global effort. As medical knowledge and techniques become outdated with accelerating rapidity, public health also develops its context and content. Those developments have been intimately related in conception and development to a broad and multifaceted philosophic and social revolution that has had as its driving force a growing adherence to the concept of justice. They have been a critical part of a broad spectrum of social reforms that includes public education, public welfare, racial and sexual equity, the rights of labor, the humane care of mentally ill, and penal management, to mention only a few. New factors are introduced into the human environment not only by technical innovations and geologic or climatic changes but also by even evolving human wants, habits, and aspiration. Definition The definition of public health is related with health itself. The constitution of the World Health Organization defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity. This definition then become a basis for determining indicators for health status that will be achieved in public health goal. However, it should be realized that health has value only to the extent that it promotes efficiency and makes possible a satisfactory total living experience. It is the quality of life that is meaningful, not

merely the quantity. Health is better understood as a continuum. A disease or injury is any phenomenon that may lead to an impairment, which is an abnormality of body structure at the organ system level. Then this impairment may cause disability, the disturbances at the level of the whole body. In turn, a disability may lead to a state of dependency. A dependency is a condition that requires external resources to carry out activities of daily living. Health in this continuum may be defined as the absence of a disability. To achieve that condition, public health has a role in it. Public health is defined by Winslow in 1920 as the science and art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community effort for: a) The sanitation of environment. b) The control of communicable disease. c) The education of the individual in personal hygiene. d) The organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and e) The development of the social machinery to insure everyone a standard of living adequate for the maintenance of health This definition was timely and comprehensive. It allowed inclusion of almost everything in the fields of health may be defined as the organization and application of public resources to prevent dependency, which would otherwise result from disease or injury. The Distinctions between Therapeutic Medicine and Preventive Medicine (Public Health) To a major extent, the practice of medicine has been concerned with diagnosis and treatment of damage already done. The treatment accepts the existence of impairment and includes some degree of dependency. Whereas, preventive medicine is concerned with the prevention of disease in the individual which consists of four areas of action: (1) the prevention by biologic means of certain diseases, (2) the prevention of some of the consequences of preventable or treatable diseases, (3) the minimization of some of the consequences of nonpreventable and noncurable diseases, and (4) the motivation of improved health in individuals by changed lifestyles that minimize the potential impact of behavioral and other hazard. It is notable that the emphasis in public health has changed from the
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physical environment, or sanitation to preventive medicine and, more recently, back to the individual and the environment but now in terms of the individuals relationship with the complex social and physical environment. Patient in public health is the entire community or indeed the world, and its armamentarium is more extensive than those of other fields. Meanwhile, therapeutic care systems use only the tools of medicine and surgery, with the occasional input of psychology. Other important distinctions are about the priority and the input-outcome. The priorities of public health are socially determined; the priorities of medical care are unrelated to social goals except by coincidence. Medical care, particularly in the US, seeks to maximize the chance that the best possible outcome will occur, which is often unlimited by any resource constraints, and marginal benefits may be sought at enormous cost. In the opposite, public health seeks to minimize the chance that the worst possible outcome will occur with an estimation of both benefit and cost Scope of Public Health In general, public health is concerned with four broad areas: (1) behavior, (2) the environment, (3) biological interactions, and (4) the organization of health programs and systems. Most of the activities of public health also fall into one of the following nine categories (adapted from a report of the Sun Valley Forum on National Health): (1) preventive health services for all age groups, (2) coordination of public health services, (3) assuming access to care, (4) prevention or control of physical, chemical, and other hazards to health, (5) health status assessment, (6) quality assurance of individual professional institutions and organization, (7) catalyzing the development of needed services, (8) such other functions as community health planning and advocacy, (9) management of public sector programs and service systems. Health and Government The concept that the protection and promotion of the publics health is merely governments duty is objected by social and political philosophy. Some cases of death in previous centuries revealed that the prevailing attitude of people itself that resulted in unnecessary and dangerous pampering of the masses. The condition of people should not be improved lest they lose a sense of responsibility and moral restraint. Chance plays a role, as does individual human behavior. Yet, to apply public health to society is difficult to do without any intervention of government. Many actions, functions, and services would not be carried out if there were not a collective determination to do so.

Many public health activities require the legal power of government: the police power that in fact requires, government to curtail the rights of individuals to protect society in certain circumstances. There are three ways in which government can attempt to assure some equity and equality in access to at least a reasonable chance of being healthy: (1) through providing public health programs, (2) through providing access to good medical care, and (3) by altering the social and environmental factors that influence health status. Health and Economics It is no doubt that the social and economic status of individuals and entire groups has a profound impact on health status and vice versa. Most people appreciate the reduction in human suffering that has resulted from the public health movement. It must be realized however that the further removed one is in time and space from the treat of personal suffering, the less consideration is likely to be given to it. Success in public health work tends to mask it value. It is difficult for people to attach value to something prevented. This makes it all the more imperative that health program planning and evaluating procedures incorporate from the beginning a consideration not only of economic cost but also of the anticipated benefits. Public health programs have an opportunity cost; that is, the money used for such purposes cannot be used for other purposes. It is important to demonstrate that money spent wisely for public health services may represent not an increase but an eventual decrease in the net bill for personal and community welfare protection. A sound financial policy for public health services therefore must take into consideration not only the humanitarian and social gains but also the economic advantages that may be attained. As far as countries in general are concerned, the World Health Organization has found the following among the obstacles to adequate quantification: (1) the widespread inadequacy of health and demographic statistic, (2) common exclusive reliance on input rather than output indicators, (3) the lack of an adequate measure of development of national welfare, and (4) the tendency of scientific disciplines to proceed in isolation from political science, economics, and sociology in studies that require a comprehensive approach. Economic Value of Life There were well-known people who tried to value human life and to price its economic worth. Sir William Petty, Adam Smith, Sir William Farr and so
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on. They reported the results in some journals. Overall, they had same in common which was an analogy of the human body similar to a machine. Its proper function depends on various physical and biochemical components. It might be compared to an internal combustion engine with limbs in place of pistons and the endocrine system acting as the carburetor. Superimposed is the supervisory function of the human mind. In like manner, the human body may be regarded as an economic unit brought into existence for measurable, potential, productive purposes. With humans and their societies, there are some variables to be considered in approximating the average value of future earnings and the ultimate economic value of life. Time, place, and economic conditions are critically important. Economic Value of Health Programs As mention before about economic value of life and health, it is important to spend a moment examining some definitions. Cost-effective analysis is an analysis involving a comparison of two or more approaches to achieving the same end result; meanwhile, the cost-benefit analysis is more complex but allows the comparison of quite different programs. In a cost-benefit analysis, the benefits must be reduced to a common unit. The increasing use of cost-benefit analysis has by now provided many examples of the economic justification of public health programs. Mushkin and her colleagues pointed out that the gain in economic resources through the prevention or cure of diseases and postponement of death to an old age takes the form of added number of workers and added work time. A simple count of the number of deaths due to a cause obscures the fact that a death occurring early in life destroys more years of life than does a death occurring late in life. The conference estimating the potential for reducing the loss due to many of causes of death comprises several different phenomena, and the results vary widely among those component parts, but it is reasonable to assume more than 50 percent of these years of life could be saved. Public Health and Natural Selection Public health programs save lives. Many of the lives saved are continued with impairments severe enough to cause disabilities and dependencies, which may result in substantial social costs. Some have criticized public health for interfering with the process of natural selection, which is thought to select for life those with advantages and to pass over those who have such impairments. Those critics therefore created a concern about new concept of public

health, which concerns for the quality of life as well as its quantity, for living wills, for the right to die. Then after this era, we need to simply measure who are the fit? Would a good old-fashioned epidemic select just those with severe impairment, or would everyone be at risk? Observation indicates that definition varies with time and places. In most instances uncontrolled disease strikes blindly, producing a variety of illness in all component society. The reasons have varied: religious, political, ethnic, economic, social, and cultural whatever reason was most expedient at the moment. Although some people and even groups suffer from physical or other handicaps, it is false reasoning to suppose that they are necessarily unfit.

HISTORICAL PERSPECTIVES

Historical review provides insight into the significance of current events. Many circumstances and events of the past help to explain some presentday problems and trends that otherwise might be puzzling. There are some eras of the development of public health. Primitive Societies Little is known about the prehistoric origins of either personal or community hygiene, but rules against the fouling of family or tribal envitonments are almost universal, for example, many have taboos against the use of the upstream side of the campsite for excretory putposes. However, this practice is sometimes based on superstition rather than sanitary concepts. Nowadays, something from superstition called folk medicine is still widely practiced throughout the world.

Classical Cultures The most prominent cultures involved in this era are Egyptian, Athenian, and Roman. The Egyptians had a considerable sense of personal cleanliness, possesed numerous pharmaceutic preparations, and constructed earth privies for sewage and public drainage pipes. Whereas Athenians concern was given to personal cleanliness, exercise, and dietetics in addition to environmental sanitation. However, in contrast with the present-day public health though, the weak, ill, and crippled were ignored and sometimes destroyed. The Roman civilization provided numerous public sanitary services. Provision was made for the cleaning and repair of streets and for the removal of garbage and rubbish. The construction of public bath and safe public water supply was also made. The Middle Ages Western ideology believes that the material is good and the spiritual is better but they are not opposed to each other since the material world is necessary for the achievement of the spiritual world. One of its reminiscent characteristics was a reaction against anything reminiscent of the Roman Empire, included a significant change in attitude toward sanitation and personal hygiene. People seldom bathed and diet in general were apparently poor. However as time passed, some significant medical and hygienic developments occured. Generally they were reactions to the disastrous effects of uncontrolled nature or ill-conceived habits and customs, Terrifying pandemic of disease occured, such as cholera and leprosy, that were the most intense experiences in the history of humanity. But the reaction of society to the sufferers of the terrifyng disease was inhuman. In many places lepers were declared civilly dead and were banished from human communities. This had a twofold: it was an effective isolation measure, and it usually brought about a relatively rapid death from hunger and exposure. The black death era, years of spreading a deathly disease caused by Yersinia pestis in fleas and infected marmosets, rhodents, and human, almost eradicated human race. Millions of people died of this disease. It came from Mongols who lived nomaden by conquering the areas they entered. Because of this plague, some ports like Venice banned entry of infected or suspected ships and travelers. It was ruled that travelers from plague areas must stop at designated places outside the port and remain free of diseas for 2 months before being allowed to enter. It marked the

historycally a quarantine procedure based on incubation period of the disease. These are also historic landmark in public health administration and epidemiology. Renaissance and Reason The great pandemics of the Midde Ages must have caused considerable social and political frustations that could lead only to attitudes of fatalism and general disregard for the welfare of individuals. This period marked the transition of peoples thought from perceiving that disease was a superstitious thing and therefore people did not have to do anything to improve their living condition to enlightening to inquire into the causation if disease. The Eighteen and Nineteenth Centuries This era was marked by the development of nationalism, imperialism, and industrialization, with both their benefits and their tragic. Humans were seen as an expendable resource, and lives were sacrificed on a scale probably unprecedented since the building of the pyramids. Children mostly suffered in this time. In England a legally condoned practice of apprentice slvery developed whereby pauper children were indentured to owners of mines and factories. More than one half of the children and the working classes died before their fifth birhtday. During this period also, the condition of the streets of most European cities became deplorable, caused in part by nightmen and scavengers emptying their carts in the streets instead of the available baskets. The accumulated filth of the eighteen century house was in many cases simply thrown from the doors or windows. As a consequence, smallpox, cholera, typhoid, tuberculosis, and many other diseases reached exceedingly high endemic levels. Some people then concerned to construct the political and social platform on which it was possible to promote and develop sanitary reforms and other measures for the protection of the public health. Public health went unrecognized in a legal sense in England until 1837 when the first sanitation legislation was enacted and a few vaccination stations were set up in London. The knowledege about Biology also developed in this era. John Snow deducted that a microscopic living organism caused a disease, Lister described antisepsis, Louis Pasteur discovered how microorganisms reproduced, Rudolf Virchow developed the science of pathology, and Robert Koch enunciated a set of postulates. Changes in social policy, a subject of political science, made it possible to translate the new biological knowledge into effective public health
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programs, as superstition and intuition founded an inadequate understanding of science gave way to knowledge. Legislation was passed concerning factory management; child welfare; care of the aged, the mantally ill, and the infirm; education; and many other aspects of human life. As early as 1830, Chadwick had recommended the employment of local sanitary officers, including medical personnel, for adequate coverage of the nation. Colonial America Nevertheless, the early intimate ties-social, economic, and otherwisebetween the North American continent and Great Britain made events in the latter of particular significance to the former. Thus when the time came for American communities to pass sanitary ordinaces, they did so in the tradition of the English common law. The colonies of America started to recognized the importance of public health considering many of the early settlements had been completely obliterated by epidemic diseases. Ironically, it was probably because of disease that colonial powers were able to establish footholds on the American continents. Some innovations on public health fields were a Massachusetts act that colony should order that each birth and death be recorded, because the registration of vital events is essential to efficient public health awareness and practice. Massachusetts Bay Colony then passed a regulation to prevent pollution of Boston Harbor which concerned with gross insanitation and attempts to prevent the entrance of exotic diseases. Also the law of isolation and quarantine of patients and ships had been legalized. The multifaceted Dr. Benjamin Rush wrote that political institutions, economic organization, and disease were so interrelated that any general social change produced accompanying changes in health. It became an idea to establish the local board of health which were made up of prominent citixens who were to advise the elected officials of the community about public health matters. The Nineteenth Century in America The United States expanded greatly in size and population between 1800 and 1850 but public health activities remained essentially stationary, althought threat to public health and welfare and the resulting incindence of disease were high.The inadequacies of the times were reflected in the low quality of medical care. Professional teaching facilities were few and inadequate. Early approaces to formulating public health policy were thus devoid any social concern about organizing or paying for the personal

medical care. American public health in the midnineteenth century is most notable for the extraordinary Report of the Sanitary Commision of Massachusetts by Lemuel Shattuck. It included a detailed consideration of the present and future public health of the nation as a whole. Among the many recommendations made by Shattuck were those for the establishment of state and local boards of health; a system of sanitary police or inpectors; the collection and analysis of vital statistics; sanitation programs for towns and buildings, studies of health of school children, tuberculosis, alcohol, mental diseases, problems of immmigration, and so on. Development of Official Health Agencies in the United States Except for the international affairs, most activities of the new nations government were carried out at the local level: first in the cities, then at the state level, and finally in counties and rural areas. Local health departments Because there was some controversy in mid nineteenth that some health staffs should work full time, the full-time local heath departments emerged as distincts from boards of health. Its basic principle that no single disease or sanitary or public health problem could be succesfully attacked without concurrent efforts aimed at all phases of public health. The initial activities of these early health departements were determined by current epidemiologic theories, which placed particular emphasis on the elimination of what were thought to be environmental hazards. State health departments Some outbreaks in several states needed organized data to prevent such event being repeated. The state officials asked the local boards of health to inquire about their powers and duties and to collect for publication teh number and prevailing causes of deaths in the most populous cities and towns in the state. It then precedented the establishment of state health departements, in which at the first are a combination of Departement of Health and Departement of Lunacy and Charity. National health agencies Some events and institutions that gave the first establishments of national health agencies were as follows: 1. The Marine Hospital Service, was first founded to meet the demand of national sailors who did not belong to any other states for health services. Because the port was the primary entrance of diseases,
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the American Congress passed the Marine Hospital Service Act to accomodate the sick and disabled seamen. 2. The Port Quarantine Act, concerned to the epidemic diseases that were easily to enter the state via ports. At that time, entrance into the country was limited to its ports, which represented the nation;s first line of defense against epidemic diseases. 3. The National Quarantine Conventions, discussed many subjects of common interest, including prevention of epidemic diseases, port quarantine, the role and stagnant and putrid bilge water, putrescible matters, filthy bedding, baggage and clothing of immigrant passengers, and air that has been confined. It marked the founding of The American Public Health Asociation. 4. The National Board of Health, was born by early concern of quarantine convention and APHA, but it did not last long because the Congress lost interest to it, and the United States ha snever had a cabinet level health department or an official comparable to the minister of health. 5. The Public Health Service, was a descendant of the Marine Hospital Service because its responsibility was becoming broadened. Congress renamed it the Public Health and Marine Hospital Service and gave it a definite form of organization under the direction of the Surgeon General. 6. The Social Security Act, passed in 1935, was written for the purpose of assisting states, counties, health districts, and other political subdivisions of the states in establishing and maintaining adequate public health service. The grant that was submitted to Surgeon General was ruled by this Act, and it was allocated on the basis: (1) population, (2) public health problems, (3) economic need, and (4) training of public health personnel. As the Act was applied and the fund allocated correctly, the Public Health Service developed to be 8 divisions under an assitant surgeon general. At the end of World War II, Congress passed the Hospital Services and Construction Act which gave the Public Health Service administrative responsibilty for a nationwide program of hospital and health center contruction. 7. Research: the National Institutes of Health, initially was a laboratory devoted to bacteriologic studiesof returning seamen, then it grew slowly to become the National Hygienic Laboratory. It provoked other research institutes to establish, and in 1948 all those institution was pluralized to become the National Institutes of

Health. 8. Legislation, was made by Congress who has shown increasing concern about the prompt application of acquired knowledge for the well-being of the people, and not only for the research activities. It therefore gave birth to some well-known institutions, such as CDC, EPA, and FDA. National Center for Disease Control, not only the worlds great epidemiologic centers but also an outstanding training center, is also part of this institute. An EPA (Environmental Protection Agency) is another famous institution that deals with pollution. Food and Drug Administration also become a part of the Public Health Service. The cummulative effect of the foregoing developments has been a remarkable growth in the size and usefulness of the health component of the Department of Health and Human Service. But most the action takes place in the states and their communities, where the federal structure may make little sense in an operational setting. 9. The Childrens Bureau, established because an effective argument that the federal government had already set centers of research and information in other fields relating to national esources, but it might not forget the most important resource, the mothers and children of the nation. After a long way to be set, the Act that established the Childrens Bureau placed it in the Department of Commerce and Labor. From the Social Security Act, the Childrens Bureau was given responsibility for the administration of programs dealing with maternal and child health, crippled children, and child welfare services. After the amandment of Social Security Act in 1965, the objective of the Childrens Bureau was focused on reducing maternal, infant, and child morbidity by assisting communities to organize and use their services and resources to maximum efficiency. 10.The Food and Drug Administration, was an effort of the federal government to bring about control and supervision of the quality of foods. The legislation to it resulted in establishment of a program to supervise and control the circumstances of manufacture, labelling, and sale of food, then it was broadened to include not only food, meat, and dairy products but also pharmaceuticals, cosmetics, toys, and numerous household products and appliances. All the responsibilities are therefore under the FDA supervision as the basic components of the Public Health Service.
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