KEY CONCEPTS:
Upon completion of this topic, it is expected that the reader will understand these following concepts:
• Improvement of a community’s health status—the broad mission of public health
• The international issues relating to public health
• EMS as a "safety net" in public health
• EMS roles in healthcare access and disaster management
Case study:
The local Paramedic agency had been called upon to assist in a mass flu inoculation program. Several of the inexperienced Paramedics said that while flu inoculation was important, they didn’t see the relevance to EMS. Weren’t nurses supposed to be doing this?
A senior Paramedic overheard them and suggested that after the program had concluded, they might want to research the relationship of flu immunization programs, public health, disaster management, and EMS. He offered to assist them in their research.
OVERVIEW
Public health extends farther than just the measurement of a community’s absence of disease and infirmity. Rather, its broad mission is carried out through prevention and active response to improve the public health of communities. Many organizations exist, both internationally and in the United States, that contribute to the overall goal of public health. These organizations are beginning to recognize the value of EMS and the need to strengthen it as a "safety net" for public health. The growing role of EMS as an integrated part of today’s public health system is discussed throughout the t.
What Is Public Health?
Health is defined by the World Health Organization (WHO), the most prominent and influential international public health agency, as "a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity."1 This state of well-being applies to not only individuals, but extends also to large groups, communities, and nations. Public health, therefore, is defined as the practice and discipline of improving the health of communities, and is focused primarily on prevention of illness and injury.As a secondary mission, public health agencies respond to disease outbreaks and disasters. In these instances, public health will work closely with Paramedics to prevent such occurrences from reaching catastrophic proportions. Thus, it is important for Paramedics to have an understanding of the organization of public health services in order to fully appreciate their mission and cooperate with their efforts for injury and illness prevention as well as disaster response.
Public Health in History
The concept of community-based disease prevention reaches far back into antiquity. The practice of quarantine (isolating diseased individuals from the larger community) can be traced back to biblical times when lepers were forced to live outside city limits and maintain their distance from non-lepers.
The ancient Romans understood the importance of sanitation in preventing the spread of disease throughout the empire and developed separate sewers and water delivery systems. Many of these aqueducts can still be seen throughout Europe, reminding us of the Romans’ accomplishments in public health and disease prevention (Figure 7-1).
Figure 7-1 Roman aqueduct in Pont du Gard, France. Aqueducts like this one, built circa 19 B.C., would have carried water to supply an entire city.
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Koch’s Postulates |
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1. The organism must be found in all animals suffering from a disease, but not in healthy animals. |
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2. The organism must be isolated from a diseased animal and grown in pure culture. 3. The cultured organism should cause disease when introduced into a healthy animal. |
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4. The organism must be reisolated from the experimentally infected animal. |
Figure 7-2 Koch’s postulates.
The practice of quarantine was even more prominent during the period of the bubonic plague (i.e,, Black Death), in fourteenth century Europe. During those times dead bodies were removed from the towns and cities in an attempt to eradicate the spread of the plague, another example of a public health practice.
Despite these early attempts at prevention, communicable diseases continued to spread largely unchecked. This was primarily due to a misunderstanding of the origins of disease. In the late nineteenth century, the germ theory of disease emerged, largely due to the work of the German physician Robert Koch (1843-1910).2 Koch developed four "postulates" to establish that an organism is the cause of a particular disease (Figure 7-2). This landmark theory permitted public officials the opportunity to incorporate the ancient principles of quarantine while allowing physicians and scientists to identify, isolate, and inoculate the population. This combination of public health medicine and clinical medicine started to have an impact on mortality and morbidity from infectious disease.
Traditional Public Health Missions
The traditional focus of public health has been on women and children’s health, substance abuse prevention, and workplace safety, including environmental safety. Accomplishing these public health missions requires the efforts of both healthcare providers such as physicians and nurses, as well as individuals and organizations from many disciplines. Table 7-1 lists some of the individuals involved in public health.
Challenges to the public’s health (e.g., the H1N1 outbreak and the looming threat of cross-species infection) have placed a growing emphasis on public health medicine, spotlighting its ability to quickly identify infectious disease and prevent further progression of that disease through immunization.
Public Health Organization
Within public health there are several different subdivisions. These include epidemiology, environmental health, social and behavioral health, occupational health, and disaster planning and response. While there is considerable overlap between these individual subdivisions, their responsibilities and contributions to the overall well-being of communities and populations are each unique.
Table 7-1 Multidisciplinary Public Health Team
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• Biologists |
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• Sociologists |
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• Social anthropologists |
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• Engineers |
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• Politicians |
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• Health educators |
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• Industrial hygienist |
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• Health reporter |
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• Sanitarians (Environmental health specialist) |
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• Physicians |
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• Nurses |
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• Paramedics |
Epidemiology/Biostatistics
Public health’s mission has been to monitor, identify, and prevent outbreaks of disease. That mission is accomplished through epidemiology. Epidemiology is defined as "the branch of medical science that deals with the incidence, distribution, and control of disease in a population."3 Epidemiologists are engaged in the surveillance of disease outbreaks and how particular diseases are spread within and between various populations. Based on these observations and the information gained from their research, recommendations can be made regarding public health intervention. The ongoing investigations in HIV are one example in which epidemiologists have been able to track which population groups are at greatest risk of contracting HIV and have assisted in developing prevention programs for these groups. Biostatistics is the application of statistical analysis to biological data, and is the mathematical component of epidemiology.
Environmental Health
Environmental health is considered the physical, chemical, biological, and psychosocial well-being of a person as it is related to the natural environment. It considers whether the environment is healthy for that person. Perhaps the most common subject in the field of environmental health is pollution. While pollution control has been practiced for centuries, it is only in the past 50 years that significant public health agendas have been aimed at reducing environmental pollution. Among these agendas have been programs to reduce noise, air, and light pollution, as evidenced in motor vehicle production standards. Sanitation, specifically human and consumer waste, is a branch of environmental health directed at preventing waste from polluting the soil and water. Finally, industrial and other toxic waste disposal is an important concern of environmental public health. Strict standards,such as the federal clean air act, have been established in an effort to contain such harmful waste and prevent it from contaminating soil, water, and air resources.
Social and Behavioral Health
While social and behavioral health issues may initially seem out of place in the public health sector, addressing these issues is very important to a population’s overall well-being. An example of a problem that affects social health is overpopulation. Overcrowding is a significant public health problem in some urban parts of the United States as well as many countries throughout the world, notably China and India. Having a high concentration of people in a small area increases the risk of disease and raises public health concerns over sanitation and safety.
Recently this issue has been addressed in the prison systems, a microcosm of overcrowding, where there are barriers to healthcare access. The European section of the WHO has undertaken a project to improve the conditions in European prisons. Although significant progress has been made, there is still much to be done.4
Other social and behavioral health issues to address include adolescent sexual activity, sexually transmitted diseases, substance abuse, and mental health.
Occupational Health
In the past, workplace injury was commonplace. As a result, productivity suffered and the taxpayer’s burden to support persons injured and out of work via worker’s compensation was staggering. The field of occupational health is responsible for helping to maintain safety within workplaces, to decrease worker injury, and as a result to reduce health-related expenses.
In 1995, the International Labor Organization (ILO) and the WHO established goals for occupational health (Figure 7-3). Common workplace hazards identified included biological or chemical exposure, high noise levels, physical hazards such as falls and dangerous machinery, long hours, and sexual harassment. According to the ILO, the primary purpose of promoting occupational health is to decrease worker injury and to improve worker morale (i.e., a worker should not have to expect to risk life or limb by going to work). The ILO and the WHO, along with many professional organizations, are trying to develop a "culture of safety" where foreseeable risks are eliminated and injuries prevented.
Disaster Planning/Response
Within the past 10 years the world has witnessed numerous disasters, both natural and manmade. Natural disasters such as hurricanes, floods, tornados, and tsunamis have garnered international attention, as have the emergency services responses to these disasters. Since these disasters cannot be prevented, the quick and coordinated response to such events is crucial to prevent death and disability. Through preplanning for predictable public disasters, public health planners can mitigate the resultant harm from these disasters.
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1. The promotion and maintenance of the highest degree of physical, mental, and social well-being of workers in all occupations. |
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2. The prevention amongst workers of departures from health caused by their working conditions. |
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3. The protection of workers in their employment from risks resulting from factors adverse to health. |
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4. The placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities. |
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5. The adaptation of work to man and of each man to his job. |
Figure 7-3 Goals of occupational health as developed by the Joint Committee of WHO/ILO in 1950 (revised 1995).
Pandemics, outbreaks of diseases that spread throughout a country or a region, are a constant threat to public health.5-9 These outbreaks of infectious disease may reach disaster proportions if not prevented or controlled in an appropriate fashion. Recent scares have included SARS and H1N1 flu. In addition to these natural disasters, large-scale accidents and mass casualties pose a threat not only for injury, but also for exposure to chemical and other environmental toxins. Witness the increase in asthma among responders to the World Trade Center attack of September 11, 2001.
Public health officials and researchers are involved in planning escape routes, resource mobilization, and response policies for such disasters, and continue to work with EMS providers in order to be prepared for these events if and when they occur.
Public Health Management
Several organizations exist to conduct public health research and implement public health law and policy. From international organizations such as the WHO to local health departments, these organizations work together to meet the goal of public well-being. Since each nation’s public health structure is unique, it is not possible to describe the "typical" structure worldwide. Therefore, the remainder of the discussion, aside from an introduction to the international bodies, is based on the configuration in the United States.
International
The World Health Organization (WHO) is the most prominent and influential international public health agency. Founded in April 1948 as a specialized health agency under the United Nations, the WHO lists as its primary constitutional objective the "attainment by all peoples of the highest possible level of health."1 Based in Geneva, Switzerland, the WHO is governed by 193 member nations and is managed by the
World Health Assembly, its international decision-making body. The WHO focuses efforts on monitoring disease outbreaks such as SARS, influenza, and HIV/AIDS, as well as assisting individual governments with the development and administration of vaccines. Largely through the efforts of the WHO, smallpox was declared eradicated in 1979, and polio is on the horizon to follow suit in the next several years. In addition to infectious disease research, the WHO is actively involved in dozens of other areas of medical and public health interest. These include chronic diseases such as hypertension and diabetes, as well as more indolent disorders such as blindness and birth defects. Further information about WHO can be obtained from their website: http://www.who.int
The World Federation of Public Health Associations (WFPHA) is an international nongovernmental organization established in 1967 to bring together multiple international public health workers for professional exchange, collaboration, and action. There are currently 70 member organizations, including the American Public Health Association, who meet annually to discuss partnerships and collaborative efforts in public health research and policy, share information and publications, and assist each other in the implementation of these policies in their respective countries. The WFPHA has an official liaison to the WHO, and they work in close cooperation. Current WFPHA projects include an international hand-washing campaign, global tobacco control and smoking cessation programs, HIV/AIDS research, and persistent organic pollutants eradication.
