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Irvan Afriandi Dept.

of Public Health Faculty of Medicine, Padjadjaran University

the science and the art of: 1) preventing disease, 2) prolonging life, and 3) promoting physical health and efficiency through organized community efforts for: - the sanitation of the environment, - the control of community infections, - the education of the individual in principles of personal hygiene, - the organization of medical and nursing service for - the early diagnosis and preventive treatment of disease, and - the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health so organizing these benefits as to enable every citizen to realize his birthright of health and longevity (Winslow, 1920)

efforts organized by society to protect, promote and restore the

peoples health. It is the combination of science, skills and beliefs that is directed to the maintenance and improvement of the health of all people through collective or social actions (Last, 1988)

what we, as a society, do collectively to assure the conditions for

people to be healthy (IOM, 1988)

the organization and application of public resources to prevent,

dependency, which would otherwise result from disease or injury (Pickett & Hanlon, 1990)








a state of relative equilibrium of body form and

function which results from its successful dynamic adjustment to forces tending to disturb it. It is not passive interplay between body substance and forces impinging upon it but an active response of body forces working toward readjustment (Perkins, 1938) and a cheerful acceptance of the responsibilities that life puts upon the individual (Sigerist, 1941)

something positive, a joyful attitude toward life,

a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO, 1948)
a state characterized by anatomic integrity, ability to perform personally valued family, work, and community roles; ability to deal with physical, biologic, and social stress; a feeling of well-being; and freedom from the risk of disease and untimely death (Stokes et al., 1982)

a state of equilibrium between humans and

the physical, biologic, and social environment, compatible with full functional activity (Last, 1987)

keadaan sejahtera dari badan, jiwa dan sosial

yang memungkinkan setiap orang hidup produktif secara sosial dan ekonomis (UU No. 23 Tahun 1992) keadaan sehat, baik secara fisik, mental, spritual maupun sosial yang memungkinkan setiap orang untuk hidup produktif secara sosial dan ekonomis (UU No. 36 Tahun 2009)

the interdisciplinary science & art of disease, disability and injury prevention and control, and health promotion in the human population

A. Early History Diversion of human waste to protect public health (Ancient Rome) Variolation (subcutaneous inoculation of attenuated pustule material in patients) following smallpox epidemic around 1000 BC (China) Removing dead bodies to prevent bacterial infection during the Black Death in Europe (14th century) Quarantine to mitigate infectious diseases (Medieval Europe) Vaccination to treat smallpox by Edward Jenner (1820s) Development of the miasma theory of disease after cholera pandemic in Europe (1829-1851)

B. Modern History Observation of microorganisms as the cause of most infectious diseases (Anton van Leewenhoek, 1680) Identification of polluted well water as the source of cholera epidemic in London in 1854 (John Snow), which indicated transition: miasma theory germ theory Germ theory: disease, single pathogen, defines a one-toone relationship between a microorganism & the occurrence of disease (Robert Koch, mid- to late 1880s)

B. Modern History (contd) Artificial vaccine production & the theory that specific transmissible pathogens are responsible for disease (Louis Pasteur, mid-1800s) Increase in average life span in late 20th & early 21st century

Assessment Policy development Assurance

the regular, systematic collection, assembly, analysis and dissemination of information on the health of the community

the exercise of responsibility to serve the public interest in the development of comprehensive public health policies by promoting the use of scientific knowledge base in decision making

the guarantee to constituents that services necessary to achieve agreed upon goals are provided by encouraging actions of others, requiring action through regulation or providing service direction

Assess the health needs of the community Investigate the occurrence of health effects and health hazards in the

community Analyze the determinants of identified health needs

Policy development:
Advocate for public health, build constituencies and identify resources in the

community Set priorities among health needs Develop plans and places to address priority health needs


Manage resources and develop organizational structure Implement programs Evaluate programs and provide quality assurance Inform and educate the public

Monitor health status to identify community health problems Diagnose and investigate health problems and health hazards in the community 3. Inform, educate, and empower people about health issues 4. Mobilize community partnerships to identify and solve health problems 5. Develop policies and plans that support individual and community health efforts 6. Enforce laws and regulations that protect health and ensure safety 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable 8. Assure a competent public health and personal health care workforce 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services 10. Research for new insights and innovative solutions to health problems
1. 2.

Access to Care (10%)

Genetics (20%)
Environment (20%)

Health Behaviors (50%)




Environment Source: adapted from Gordis (1996)



Horizontal a. Common vehicle - Single exposure - Multiple exposure - Continuous exposure b. Contact (person-to-person) c. Vector Vertical

Discernible effect

CELL RESPONSE Lysis of cell

HOST RESPONSE Death of organism

Inclusion body formation or cell transformation or cell dysfunction

Viral multiplication without visible change or incomplete viral maturation Exposure without attachment &/or cell entry

Clinical disease

Classical & severe disease

Moderate severity mild illness

Below visual change

Infection without clinical illness (asymptomatic infection)

Subclinical disease

Exposure without infection

1. 2.


characterized by symptoms & signs

NON-CLINICAL (IN-APPARENT) Pre-clinical Sub-clinical

not yet clinically apparent, but in a stage that is destined to progress to clinical disease not clinically apparent & not destined to become clinically apparent, often diagnosed by serologic or culture of the organism

Persistent (chronic)

fails to shake off the infection & it persists for years, at times for life


no active multiplication of the agent, as when viral nucleic acid is incorporated into the nucleus of a cell as a provirus

Tubercle bacillus

Measles virus

Rabies virus









Severe (non fatal)


Before man is involved Interrelation of the various: - AGENT - HOST - ENVIRONMENT factors (known & unknown) which bring AGENT & HOST together, or produce a disease-provoking STIMULUS

The course of the disease in man

Chronic state Defect Disability Illness Signs & symptoms Tissue & physiologic changes STIMULUS & AGENT becomes established & increases by multiplication or increment Immunity & resistance



in the Interaction of human HOST & STIMULUS HOST

Early pathogenesis

HOST reaction
Advanced disease Convalescence

Discernable early lesions






Age Sex Race Religion Customs Occupation Genetic profile Marital status Family background Previous disease Immune status

Biologic (e.g. bacteria) Chemical (e.g. poison) Physical (e.g. trauma) Nutritional (e.g. deficiency)

Temperature Humidity Altitude Crowding Housing Neighborhood Water Milk Food Radiation Air pollution Noise

Health Promotion

Health education Good standard of nutrition adjusted to developmental phases of life Attention to personality development Provision of adequate housing, recreation & agreeable working conditions Marriage counseling & sex education Genetics Periodic selective examination

Specific Protection Use of specific immunization Attention to personal hygiene Use of environmental sanitation Protection against occupational

hazards Protection from accidents Use of specific nutrients Protection from carcinogens Avoidance of allergens

Early Diagnosis & Prompt Treatment

Case-finding measures, individual & mass Screening surveys Selective examinations

Objectives: - to cure & prevent disease processes - to prevent the spread of communicable disease - to prevent complications & sequelae - to shorten period of disability

Disability limitation Rehabilitation

Adequate treatment to

arrest the disease process & to prevent further complications & sequelae Provision of facilities to limit disability & to prevent death

Provision of hospital &

community facilities for retraining & education for maximum use of remaining capacities Education of the public & industry to utilize the rehabilitated As full employment as possible Selective placement Work therapy in hospitals Use of sheltered colony



Portal of exit

Portal Transmission of entry Establishment of disease in new host

Pasteurization Chlorination Antibiotics Antivirals Disinfectants


Portal of exit


Portal of entry

Establishment of disease in new host

Immunizations Health education Nutrition promotion Sexual abstinence

Gowns Masks Condoms Hair nets insect repellents

Masks Condoms Safety glasses Insect repellents Isolation Hand washing Vector control Sanitary engineering Sneeze glass Sexual abstinence Safe sex

Isolation Surveillance Quarantine Drug treatment

Distal socioeconomic causes

Proximal causes

Physiological & pathophysiological causes



D1 D2 D3..n

P1 P2 P3..n

Pa1 Pa2 Pa3..n

O1 O2..n

S1 S2 S3..n



* Treatment of infectious disease can lead to prevention of further cases if it interrupts transmission
Distal socioeconomic: income, education & occupation Proximal factors: inactivity, diet, tobacco use & alcohol intake Physiological & pathophysiological causes: blood pressure, cholesterol levels, glucose metabolism Outcomes: stroke or CHD Sequelae include death & disability, e.g. angina or hemiplegia