Introduction to Public Health

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HSPH INTRODUCTION TO

Public Health

Version 1.0

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PU BLIC H EALTH IS…

improving the health of entire populations preventing illness and injury designing health systems shaping evidence-based policies championing health as a basic human right discovering the biological and genetic roots of disease

“Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.”

— C. Everett Koop, former U.S. Surgeon General

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HSPH Introduction to Public Health

CONT ENTS

What is public health?

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Public health is distinct from medicine

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Major global public health challenges

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Principal tools of public health research

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The 8 millennium development goals

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The 20th century's ten great public health achievements

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A few milestones in public health history

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Glossary

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For more information

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Connect with HSPH online:

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This text is intended as a basic primer for individuals who are new to the field of public health and may benefit from a summary overview of terminology, concepts, and historical milestones of general importance in the field and/or of specific relevance to Harvard School of Public Health.

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What is public health?

Public Health is the science of protecting and improving the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention. Public health professionals analyze the effect on health of genetics, personal choice and the environment in order to develop programs that protect the health of your family and community.

The field of public health is highly varied and encompasses many academic disciplines. However, public health is mainly composed of the following core areas:

Environmental Health Biostatistics Behavioral Science/Health Education Epidemiology Health Services Administration/Management Maternal and Child Health Nutrition International/Global Health Public Health Laboratory Practice Public Health Policy Public Health Practice

Excerpted from: http://www.whatispublichealth.org/what/index.html

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Public health is distinct from medicine

• Public health focuses on populations rather than individual patients

Because of their shared concern with health, public health and medicine are easily confused, and few people outside the field realize that health is shaped much more by lifestyle, social networks, the environment, and genes than by medical care. Some specific distinctions between public health and medicine include:

• Public health emphasizes disease prevention and system-wide response over one-on-one treatment • Public health stresses the social and environmental aspects of disease in addition to the physiological • Public health has a strong human rights and social justice orientation

Leading causes of death in the U.S. Medical view Heart disease Cancer Injuries Other

Public health view 33% 24% 14% 29%

Tobacco Poor diet/ lack of exercise Alcohol Infectious disease Firearms Other

19% 14% 5% 4.5% 1.5% 56%

By some estimates, as many as half of the 2.3 million annual deaths in the United States could be prevented or postponed through more effective public health policy and practice.

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Major global public health challenges

• Ending disparities in health between rich and poor and across racial and gender lines • Reducing infant mortality, maternal death rates, and reproductive health problems • Developing solutions and treatments for infectious diseases (e.g., AIDS, tuberculosis, and malaria) • Tackling malnutrition • Preventing the spread of multi-drug resistant (MDR) diseases such as MDR tuberculosis • Confronting emerging threats to health from chronic diseases such as diabetes, heart disease, and obesity that are related to lifestyle (e.g., diet, exercise, and tobacco consumption)

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

• Addressing mental illnesses and social factors in health

— Constitution of the World Health Organization

• Understanding climate change and other environmental health threats • Studying the impacts of war, violence, and terrorism on health • Advancing practices, protocols, and strategies to achieve diverse goals such as reducing surgical errors or changing social norms around drunk driving • Developing health and communications systems to improve health-related policy and decision-making and increase the speed and effectiveness of responses to emergencies such as disease pandemics, natural disasters, or terrorist attacks

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Principal tools of public health research

POPULATION AND NUMERIC DISCIPLINES Especially epidemiology, biostatistics, and informatics.

LIFE SCIENCES DISCIPLINES Focusing on infectious and chronic diseases as well as nutritional and environmental links to ill health. Largely laboratory based, and emphasizing the biological, chemical, and genetic basis of health and disease.

SOCIAL AND POLICY DISCIPLINES Including health policy and management, global health systems, health economics, and the social and behavioral determinants of health and disease.

Social and Policy Disciplines

Population and Numeric Disciplines

Life Sciences Disciplines

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The 8 millennium development goals Adopted by 189 heads of state at the United Nations in the year 2000 as targets to be achieved by 2015

GOAL 1

ERADICATE EXTREME POVERTY AND HUNGER • Target 1: Reduce by half the proportion of people whose income is less than $1 a day • Target 2: Achieve full and productive employment and decent work for all, including women and young people • Target 3: Reduce by half the proportion of people who suffer from hunger GOAL 2

ACHIEVE UNIVERSAL PRIMARY EDUCATION • Target 1: Ensure that all boys and girls complete a full course of primary schooling GOAL 3

PROMOTE GENDER EQUALITY AND EMPOWER WOMEN • Target 1: Eliminate gender disparity in primary and secondary education preferably by 2005, and in all levels of education no later than 2015 GOAL 4

REDUCE CHILD MORTALITY • Target 1: Reduce by two-thirds the mortality rate among children under five GOAL 5

IMPROVE MATERNAL HEALTH • Target 1: Reduce maternal mortality by three-quarters • Target 2: Achieve universal access to reproductive health services

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GOAL 6

COMBAT HIV/AIDS, MALARIA, AND OTHER DISEASES • Target 1: Halt and reverse the spread of HIV/AIDS • Target 2: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it • Target 3: Halt and reverse the incidence of malaria and other major diseases GOAL 7

ENSURE ENVIRONMENTAL SUSTAINABILITY • Target 1: Integrate the principles of sustainable development into country policies and programs; reverse the loss of environmental resources • Target 2: Reduce biodiversity loss, achieving by 2010 a significant reduction in the rate of loss • Target 3: Halve the proportion of people without access to safe drinking water and basic sanitation • Target 4: Improve the lives of at least 100 million slum dwellers by 2020 GOAL 8

DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENT • Target 1: Develop further an open, rule-based, predictable, non-discriminatory trading and financial system • Target 2: Address special needs of the least developed countries, landlocked countries, and small island developing states • Target 3: Deal comprehensively with developing countries’ debt • Target 4: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries • Target 5: In cooperation with the private sector, make available the benefits of new technologies, especially information and communications technologies As of 2010, Goal 5 is the one that most lags. While there has been progress, there are still 350,000 maternal deaths every year. Most of these deaths are preventable.

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The 20th century’s ten great public health achievements Centers for Disease Control and Prevention: The 20th Century's Ten Great Public Health Achievements in the United States

1. Vaccination

Programs of population-wide vaccinations resulted in the eradication of smallpox; elimination of polio in the Americas; and control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae type b, and other infectious diseases in the United States and other parts of the world.

2. Motor-vehicle safety

Improvements in motor-vehicle safety have contributed to large reductions in motor-vehicle-related deaths. These improvements include engineering efforts to make both vehicles and highways safer and successful efforts to change personal behavior (e.g., increased use of safety belts, child safety seats, motorcycle helmets, and decreased drinking and driving).

3. Safer workplaces

Work-related health problems, such as coal workers' pneumoconiosis (black lung), and silicosis -common at the beginning of the century -- have been significantly reduced. Severe injuries and deaths related to mining, manufacturing, construction, and transportation also have decreased; since 1980, safer workplaces have resulted in a reduction of approximately 40% in the rate of fatal occupational injuries.

4. Control of infectious diseases

Control of infectious diseases has resulted from clean water and better sanitation. Infections such as typhoid and cholera, major causes of illness and death early in the 20th century, have been reduced dramatically by improved sanitation. In addition, the discovery of antimicrobial therapy has been critical to successful public health efforts to control infections such as tuberculosis and sexually transmitted diseases (STDs).

5. Decline in deaths from coronary heart disease and stroke

Decline in deaths from coronary heart disease and stroke have resulted from risk-factor modification, such as smoking cessation and blood pressure control coupled with improved access to early detection and better treatment. Since 1972, death rates for coronary heart disease have decreased 51%.

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6. Safer and healthier foods

Since 1900, safer and healthier foods have resulted from decreases in microbial contamination and increases in nutritional content. Identifying essential micronutrients and establishing foodfortification programs have almost eliminated major nutritional deficiency diseases such as rickets, goiter, and pellagra in the United States.

7. Healthier mothers and babies

Healthier mothers and babies are a result of better hygiene and nutrition, availability of antibiotics, greater access to health care, and technological advances in maternal and neonatal medicine. Since 1900, infant mortality has decreased 90%, and maternal mortality has decreased 99%.

8. Family planning

Access to family planning and contraceptive services has altered social and economic roles of women.

Family planning has provided health benefits such as smaller family size and longer intervals between the birth of children; increased opportunities for preconceptional counseling and screening; fewer infant, child, and maternal deaths; and the use of barrier contraceptives to prevent pregnancy and transmission of human immunodeficiency virus and other STDs. 9. Fluoridation of drinking water

Fluoridation of drinking water began in 1945 and in 1999 reaches an estimated 144 million persons in the United States. Fluoridation safely and inexpensively benefits both children and adults by effectively preventing tooth decay, regardless of socioeconomic status or access to care. Fluoridation has played an important role in the reductions in tooth decay (40%-70% in children) and of tooth loss in adults (40%-60%).

10. Recognition of tobacco use as a health hazard

Recognition of tobacco use as a health hazard in 1964 has resulted in changes in the promotion of cessation of use, and reduction of exposure to environmental tobacco smoke. Since the initial Surgeon General's report on the health risks of smoking, the prevalence of smoking among adults has decreased, and millions of smoking-related deaths have been prevented.

Excerpted from: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

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A few milestones in public health history

HSPH in 2010 Highlighting a few accomplishments from the past year alone: • HSPH researchers opened new frontiers and brought new insight to the battle against malaria; identified a molecular link between obesity and disease; shaped landmark health legislation in the U.S.; and helped ban smoking in public places throughout Greece.

• HSPH alumni emerged as leaders on the world stage, taking up posts such as acting Minister for Public Health in Afghanistan; setting up a floating hospital in Haiti in the aftermath of the earthquake; and assuming leadership roles in top academic institutions.

• The School launched flagship initiatives in Women and Health; Policy Translation and Leadership Development; and Comparative Effectiveness (studying what really works in health practice).

countries showed that the use of surgical checklists helped cut the rate of major complications in surgery by a third and contributed to a more than 40 percent reduction in inpatient deaths following major operations.

2007: a team of HSPH researchers creates a designer compound that protects mice from a number of conditions associated with overweight, providing a stepping-stone to clinical trials in humans.

2007: the Motion Picture Association of

America (MPAA) adds tobacco use to its criteria for rating films accessible to America’s children and youth. The MPAA responds to pressure from parents and a presentation by HSPH Dean Barry Bloom and colleagues of scientific evidence linking media depictions of tobacco use to smoking in young people.

2006: HSPH’s Richard Cash receives the Prince

2010: the federal Patient Protection and

Affordable Care Act passes, enacting comprehensive reforms of health care insurance and access in the U.S. while also igniting significant political backlash.

2008: HSPH researchers led by Atul Gawande

join with the World Health Organization in a safe surgery initiative, introducing new safety checklists for surgical teams around the world as a simple, inexpensive, and highly effective way to reduce millions of deaths and injuries from medical errors during major surgery. A subsequent study spanning hospitals in four

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Mahidol Award for “exemplary contributions in the field of public health.” Cash has been credited with saving millions of lives worldwide by promoting a simple means by which people in resource-poor settings can provide oral rehydration therapy to individuals suffering from cholera and other diarrheal diseases.

2006: HSPH studies help prompt the U.S. Food and Drug Administration to rule that, as of January 1, 2006, all food labels must include trans fats. The labeling law paves the way for numerous local bans on these heart-harming fats across the U.S. and their removal from many foods sold in grocery stores.

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HIV virus

2005: international health regulations are revised

to help countries work together to identify and control risks of disease outbreaks, industrial accidents, natural disasters, and other health emergencies that cross borders.

2003: Severe Acute Respiratory Syndrome

(SARS) breaks out, concentrated in East Asia, and is brought under control.

2002: the Global Fund to Fight AIDS,

Tuberculosis and Malaria is established to advance the fight against three of the world’s most devastating diseases.

2001: the Surgeon General issues a “Call to

Action to Prevent and Decrease Overweight and Obesity,” which “may soon cause as much preventable disease and death as cigarette smoking."

2001: HSPH researchers identify more efficient and cost-effective strategies for screening women to prevent cervical cancer, demonstrating that deaths from the disease could be cut by as much as half in the developing world, where it is the leading cancer killer among women. In the U.S., HSPH researchers help set screening guidelines for girls and young women for the human papilloma virus (HPV), the leading risk factor for cervical cancer.

2001: beginning one week after the terrorist

attacks of September 11 and continuing for several weeks, a series of bioterrorist attacks involving anthrax takes place. Letters containing anthrax spores were mailed to several political figures and news organizations, ultimately infecting 22 and killing five people.

2000: one hundred eighty-nine member states of the United Nations adopt the Millennium Declaration, a precursor to the Millennium Development Goals.

1999: HSPH researchers help launch the patient

safety movement, incorporating findings from the pivotal Harvard Medical Malpractice Study into a landmark Institutes of Medicine report, To Err is Human.

1990: the Nutrition Labeling Act is signed into

law in the United States, requiring manufacturers to list the fat (saturated and unsaturated), cholesterol, sodium, sugar, fiber, protein, and carbohydrate contents of all packaged foods sold in the U.S. 1988: beginning in this year, an HSPH-led mass media campaign enlists Hollywood’s film and TV industries to help spread a new catch phrase—the “Designated Driver.” This campaign contributes to establishing a new social norm: drivers don’t drink. With increasing public awareness and new, much more severe laws on the books, previously flat drunk-driving fatality rates fall by 25 percent within three years. continued

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A few HSPH achievements in the fight against AIDS

Public health milestones

• Discovered that HIV/AIDS can be transmitted through blood and blood products.

• Provided key research that led to the screening test used to protect the world’s blood supply from HIV/AIDS. • Presented the first evidence that HIV/AIDS could be transmitted through heterosexual intercourse.

• Conducted the first HIV vaccine trial in southern Africa.

• Discovered a second human immuno-deficiency virus, HIV-2, the cause of most infections in West Africa. Also discovered that HIV-2 seems to offer some protection against HIV-1.

• Established a model program in Senegal in the mid-1980s, led by world-renowned AIDS researcher Max Essex, which is now one of the longest running AIDS programs in Africa.

• Formed a partnership with the government of Botswana—which had one of the highest rates of HIV infection in the world—to conduct collaborative, population-centered research and improve the country’s technical, medical, and structural capacity to address the epidemic.

• Provided professional training and guidance to partner clinical sites in Botswana, Senegal, and Nigeria, which has led to the enrollment of 47,000 HIV-infected people, more than half of whom are now on anti-retroviral therapy.

• Developed drug treatment regimens in Botswana that can dramatically reduce the rate of motherto-child HIV transmission. By revising the standard AIDS drug regimen, health care workers can also save HIV-infected mothers who might otherwise die after developing drug resistance.

• Proved that certain AIDS drug combinations given to pregnant women block 99 percent of HIV transmission to breastfed babies.

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c.1982-2010: the global AIDS epidemic surfaces

in the 1980s and rages for decades. Since the beginning, HSPH has been at the forefront of efforts to stem the pandemic, focusing on HIV/AIDS laboratory research, clinical trials, education, and leadership.

1980-2010: deaths in the U.S. from heart

disease decline thanks to evidence-based medical therapies and a reduction in risk factors such as high blood pressure, cholesterol levels, and tobacco smoking.

1980-2008: maternal deaths worldwide are

estimated to have dropped from 526,300 to 342,900—substantial improvement, but still short of the UN Millennium Development Goal 5.

1981: the first diagnosis of the disease later known as AIDS is described in the June 5, 1981 issue of MMWR (the CDC’s Morbidity and Mortality Weekly Report). The New York Times’ first article on the nascent AIDS epidemic appears in 1982, written by Robin Herman who is now Assistant Dean for Research Communications at HSPH. 1981: HSPH’s Dimitrios Trichopoulos

publishes a groundbreaking study demonstrating that passive smoke is associated with increased lung cancer risk in nonsmokers.

1980: the World Health Organization (WHO) declares the successful eradication of smallpox after a global campaign initiated in 1967.

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1977: the last known outbreak of smallpox takes

1960s: vaccines are developed for rabies and

place in Somalia.

measles, mumps, and rubella.

1975: HSPH produces the first strong evidence that a lethal suppression of the immune system can be caused by an infectious agent—a discovery that will play a central role in the scientific understanding of AIDS.

1960: the contraceptive pill and IUDs become available to the general public.

1970: landmark worker and workplace safety law, the Occupational Health and Safety Act, is passed by the U.S. Congress.

1966: the Highway Safety Act and the National

Traffic and Motor Vehicle Safety Act is passed, authorizing the federal government to set and regulate standards for motor vehicles and highways.

1964: U.S. Surgeon General Luther T. Terry releases the landmark Surgeon General’s Report on Smoking and Health, acknowledging the link between smoking and lung cancer and other major diseases.

1954: Jonas Salk develops a vaccine using

inactivated poliovirus. The vaccine is responsible for a reduction in polio cases from 20,000 in 1952 to just 2,525 in 1960.

1952: the Great Smog of London—a thick cloud made up mainly of coal smoke that lasts for five days and causes an estimated 12,000 deaths—descends on the British capital. The Great Smog eventually leads to new environmental research, improved government regulation, and increased public awareness of the relationship between air quality and health.

1948: the World Health Organization is

established by the UN to succeed the League of Nations’ Health Organization.

1947: HSPH succeeds for the first time in

growing the poliovirus in non-nervous system tissue—a monumental breakthrough that will lead to the development of a protective vaccine and a Nobel Prize for faculty member Thomas Weller.

1946: Communicable Disease Center, now

known as the Centers for Disease Control and Prevention (CDC), is established in Atlanta, Georgia.

1945: the city of Grand Rapids, Michigan

becomes the first municipality in the U.S. to add fluoride to its water system.

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Public health milestones

Spotlight on health-oriented government agencies, programs and multilateral organizations • CDC/CDCp (Centers for Disease Control and Prevention): the premier U.S. agency for health promotion, prevention, and preparedness.

• DFID (Department for International Development): UK government department responsible for promoting development and the reduction of poverty.

• HHS (U.S. Department of Health and Human Services): The U.S. government’s main agency for providing health and human services, especially to needy populations in the U.S. HHS divisions include CDC, Medicare and Medicaid, FDA, NIH, the office of the Surgeon General, and more.

• NIH (National Institutes of Health): U.S. government agency that invests over $31 billion annually in medical research to benefit the American public. The NIH funds research at more than 3,000 universities, medical schools, and other research institutions, mostly in the U.S.. The NIH also has a staff of almost 6,000 scientists who conduct research in its own laboratories, most of which are in Bethesda, Maryland.

• PAHO (Pan American Health Organization): founded in 1902, PAHO is the world's longest-lived international public health agency.

• UNICEF (United Nations Children’s Fund): partners with corporations, agencies, and other groups to address issues such as poverty, violence, disease, discrimination, immunization, girls’ education, and AIDS prevention, while working to protect children from abuse and exploitation.

• USAID (United States Agency for International Development): supports “long-term and equitable economic growth and advances U.S. foreign policy objectives by supporting: economic growth; agriculture and trade; global health; and democracy, conflict prevention and humanitarian assistance.”

• WHO (World Health Organization): established in 1948, WHO is the arm of the U.N. responsible for global health matters.

• World Bank: fights global poverty by providing financial and technical assistance to developing countries.

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Alexander Fleming

1942: HSPH establishes the Department of

Nutrition, the first such department in a medical or public health school in the world.

1932-1972: the U.S. Public Health Service,

working with the Tuskegee Institute, begins a study involving 600 black men—399 with syphilis, 201 without the disease. The study, generally known as the Tuskegee Study, allowed the disease to progress untreated in its subjects.

It was conducted without the informed consent of its participants. Although penicillin is accepted as the primary treatment for syphilis as early as 1945, the study continues until 1972, when news articles condemning the study begin to surface. A subsequent court settlement awards $10 million and lifetime medical benefits to living participants, and in 1997 President Bill Clinton issues a formal apology for the conduct of the study.

1930: Assistant Professor Harold Coe Stuart of

HSPH launches the landmark Longitudinal Growth and Development Study, the first major study of the growth and development of the healthy child.

1928: Alexander Fleming discovers penicillin

when he notices by chance that a common mold, Penicillium notatum, has inhibited the growth of colonies of the microbe Staphylococcus aureus on an old culture plate.

Use of penicillin as a medicine began in the 1940s with the successful isolation of the mold’s active ingredient and its introduction in a powdery form.

1927: Philip Drinker, HSPH Professor of

Industrial Hygiene, invents the Drinker respirator, which will become known as the “iron lung.” The iron lung enabled polio victims afflicted by respiratory paralysis to breathe.

1925: HSPH faculty investigate mercury

poisoning in the felt hat industry and take a stance against newly introduced leaded gasoline.

1920s: vaccines are developed for diphtheria,

pertussis (whooping cough), and tuberculosis.

1913: a joint venture is undertaken between

Harvard University and the Massachusetts Institute of Technology (MIT) to form the first professional training program for public health in America. The program, known as the Harvard-MIT School for Health Officers, is the direct predecessor of HSPH. Nine years later the school will split off from MIT, helped by a sizeable grant from the Rockefeller Foundation.

From the start, faculty members are expected to commit themselves to research as well as teaching.

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Public health milestones

1912: Margaret Sanger undertakes an effort to

20th century: against the backdrop of two world

distribute contraceptives and disseminate information about family planning, setting in motion a process that will ultimately establish legal precedents protecting the right of physicians to prescribe contraceptives and provide advice on birth control to their patients.

wars, the Great Depression, the Cold War, a population explosion, and the dawn of the nuclear age, global citizens in the 20th century enjoy greater gains in life expectancy than in all other periods of human history combined.

According to the CDC, life expectancy at birth in the U.S. increased by approximately 26 years—from 49 in 1900 to 77 in 1990.

Advances in scientific knowledge have brought about improved medical care and sanitation, better nutrition, vaccinations, and other critical advances that have helped reduce infant mortality rates and increase life expectancy around the globe. However, life expectancy still varies dramatically among populations, with nearly two thirds of people in high-income countries living beyond the age of 70 and fewer than 25 percent reaching the age of 70 in lowincome countries, according to WHO figures.

1906: in his novel The Jungle, Upton Sinclair

describes unsanitary conditions in the Chicago meatpacking industry. Public outrage leads to the passage of the Pure Food and Drug Act, paving the way for the U.S. Food and Drug Administration (FDA) to be established. early 1900s: new data leads to the discovery that

food contains “vital amines” and that the lack of these “vitamins” could contribute to illness.

These scientific discoveries and the public health initiatives they give rise to, such as food fortification programs, lead to substantial reductions in nutritional deficiency diseases during the first half of the century.

1896-7: a vaccine for the plague is developed.

1885-1919: advances in bacteriology, the advent of pasteurization, and improved hygienic conditions contribute to a reduction in infant death rates among New York City’s tenement dwellers from nearly 25 percent in 1885 to eight percent in 1919.

1860s: Louis Pasteur ushers in the modern era of

public health with the germ theory of disease.

He developed the technique we call pasteurization to rid foods such as milk, cheese, and orange juice of disease-causing germs.

Influenza ward, c. 1913

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Louis Pasteur

1666: the Great Fire of London destroys 80

percent of the city. Some historians believe that one positive effect was that the plague, which had ravaged London since 1665, diminished greatly due to the mass death of rats and the plague-carrying fleas they brought.

1520: the Aztec population is ravaged by

smallpox introduced by Spanish invaders.

14th century: starting around 1347, the plague 1840s-1850s: John Snow provides evidence that

cholera spreads through polluted drinking water.

Snow maps the outbreak of the disease, and identifies the famous Broad Street Pump as the source of the outbreak. He arrests the spread of the disease by removing the pump’s handle. The organism that causes cholera would not become widely known for another 30 years.

(Black Death) spreads across the European continent, wiping out entire villages and bringing cities such as Paris to a standstill.

Quarantine—isolating travelers who came from places known to be infected—was established as public health policy in many jurisdictions.

1842-3: Edwin Chadwick publishes reports on

sanitation in Great Britain, recommending the creation of a central public health administration to provide drains, sewers, street cleaning, and other environmental regulations.

1840s: the epidemic of puerperal fever caused by

unsanitary baby deliveries ends when hand washing with an antiseptic lotion, advocated by Oliver Wendell Holmes, becomes common practice. Twenty years later, surgeon Joseph Lister would introduce antisepsis procedures in labor wards and operating rooms.

Images of the plague, England, 14th century

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Glossary This section is provided as a reference covering a limited selection of commonly used terms and concepts in the field.

10/90 gap: coined by the

Global Forum for Health Research, the term refers to the small percentage (approximately 10 percent) of total research funding devoted to health problems that account for 90 percent of the global disease burden. The percentages have changed since the term was introduced, but the 10/90 gap remains symbolic of an ongoing discrepancy.

Adjusted life years, disability and quality: quality-adjusted

incurable disease of the immune system caused by infection from the human immunodeficiency virus (HIV). First reported in a Centers for Disease Control (CDC) publication in 1981, AIDS so far has killed an

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ART (antiretroviral therapy): a

combination of drugs that suppresses the HIV virus. ART doesn’t cure AIDS, but the therapy can significantly prolong the life of someone living with HIV/AIDS by keeping HIV under control.

Capacity building: coordinated

life-years (QALYs) and disability-adjusted life-years (DALYs) are measures developed to assess the burden of disease. These measures, which combine years of life lost due to premature death with equivalent years of “healthy” life lost due to poor health, offer a more nuanced view of disease burden than mortality alone.

AIDS (Acquired Immune Deficiency Syndrome): an

estimated 25 million people globally. According to UNAIDS, about 33 million people in the world are living with HIV; two-thirds live in sub-Saharan countries.

investment in upgrading people’s skills and education and strengthening systems, institutions, and practices so that countries or communities can achieve development objectives. Capacity is built effectively when countries can manage their own affairs with less reliance on donor aid.

Case-control study: an

epidemiological study design that compares subjects with a certain condition (cases) to subjects without the condition (controls).

Causality: determining causality—what causes lead to particular outcomes—is among the fundamental tasks of epidemiology. A “necessary

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cause” is one that is always present when a given outcome occurs, but may not be the sole cause of that outcome or may lead to that outcome only when combined with other causes. A “sufficient cause” indicates a cause that always and inevitably leads to a given outcome.

Chronic diseases: medical

conditions that are longlasting, such as diabetes, cardiovascular disease, and some cancers. Chronic diseases are the leading causes of death in developed countries such as the U.S. and are increasingly prevalent in emerging economies such as India, China, and Africa. Under some circumstances, such as when HIV/AIDS is being treated with ART, infectious diseases can be chronic.

A large body of HSPH research has shown that over half of cancer deaths and a large majority of diabetes and coronary heart disease cases in the U.S. could be prevented with lifestyle changes, including exercise, weight control, dietary improvements (healthy fats and carbohydrates, moderate alcohol, plenty of fruits and vegetables), and smoking cessation.

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Clinical trials: investigate the

safety and benefits of health care treatments, screening efforts, prevention methods, and other facets of medical practice. They can take different forms. According to the NIH, “interventional studies are those in which the research subjects are assigned by the investigator to a treatment or other intervention, and their outcomes are measured.

Observational studies are those in which individuals are observed and their outcomes are measured by the investigators.” The doubleblinded randomized control trial is the gold standard of clinical trials and can form the basis for establishing a causal relationship between the intervention and outcome.

Cohort study: a type of study

that follows a group of individuals (a cohort) over time, compares differences among members of the cohort, and identifies associations between certain characteristics, behaviors, and/or other factors and particular health outcomes. The Nurses’ Health Study and the Framingham Heart Study are examples of cohort studies.

Top journals in the field of public health • AJPH – American Journal of Public Health • BMJ – British Medical Journal • Health Affairs • JAMA – Journal of the American Medical Association • The Lancet • MMWR – Morbidity and Mortality Weekly Report, a publication of the CDC • NEJM – New England Journal of Medicine • PHR – Public Health Reports • PNAS – Proceedings of the National Academy of Sciences

Comparative effectiveness/cost effectiveness research:

research that aims to identify the best values for limited health care dollars.

Confidence interval: indicates

the margin of error when a population sample is used to estimate a value for the entire population. Wider intervals indicate a lower degree of certainty in the population estimated.

Demographic dividend: a

concept developed by HSPH economist David Bloom and colleagues in part to explain the pattern of rapid economic

growth seen in the “Asian tiger” economies—Hong Kong, Taiwan, Singapore, and South Korea—after World War II. The demographic dividend results from a demographic shift that typically takes place in developing countries as advances in health care and public health bring about a transition from high birth rate coupled with high child mortality to lower birth rate combined with lower child mortality. At an early stage in this transition, when mortality rates have fallen but birth rates have not yet come down in proportion, a “baby boom” takes place. When educational

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Glossary

opportunities and other positive social forces are in play, the baby boom generation ignites rapid economic growth as it enters the workforce and expands labor supply while falling birth rates simultaneously reduce the number of child dependents. For perhaps 50 years, a bulge in the population of educated, working-age adults drives economic growth and prosperity, and the country reaps the demographic dividend.

Diarrheal diseases: severe

diarrhea leads to dehydration and can be life threatening, especially to young children and those with weakened immune systems. Sources of infection include bacteria, viruses and parasites, which are usually ingested with contaminated food or drinking water. These diseases accounted for 50 percent of infant deaths in New York City as of 1882. Today, they remain the fifth leading cause of death globally and the second leading cause of death among children under 5.

Diarrheal diseases kill 1.5

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million children every year, 80 percent of them under the age of 2. See also, Oral rehydration therapy.

Environment: used in public health to encompass all of the extrinsic factors affecting health including not just environmental pollution but also diet, exercise, smoking, drugs, and social exposures such as racism or violence.

Evidence-based policy/evidence-based decision-making: applies the

same basic principle used to determine treatments in medical practice—that objectively verifiable information achieved through rigorous scientific testing is required to determine effective courses of action—in the realm of public policy generally and health policy in particular.

Epidemiology: the study of the

distribution and determinants of disease in a population.

Epidemiologists identify risk factors for diseases and strategies to prevent them by studying data from large populations.

Epidemic: when a disease spreads widely and often rapidly from person to person, affecting large groups. An epidemic becomes a pandemic when it has spread over a significant geographical area, usually crossing into multiple countries as in the case of a global flu pandemic.

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Food pyramid: food pyramids have been used for decades to diagram government recommendations for food intake. The current U.S. government version is known as “My Pyramid.” HSPH faculty (Walter Willett and others) have developed an alternative called the Healthy Eating Pyramid. The foundation of the Healthy Eating Pyramid is daily exercise and weight control.

Other layers emphasize eating whole grains and vegetables, while red meat, refined grains, sugary drinks, and salt are least encouraged.

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HEALTHY EATING PYRAMID Department of Nutrition, Harvard School of Public Health

Framingham Heart Study:

begun in 1948, the Framingham Heart Study is a research project directed by the National Heart, Lung and Blood Institute (NHLBI) on common factors that contribute to cardiovascular disease (CVD). The study follows the development of CVD over a long period of time in a large group of participants. The original cohort consisted of 5,209 men and women between the ages of 30 and 62 from the town of Framingham, Massachusetts.

Since then, the Study has added several additional cohorts and yielded valuable

findings on the effects of blood pressure, blood triglyceride and cholesterol levels, psychological factors and more.

Gene expression: refers to the process by which genetic traits are “turned on” or “turned off” in an organism. Gene expression can be affected by environmental and behavioral as well as inherited factors. For example, a genetic predisposition to cancer might not become manifest unless triggered by exposure to tobacco smoke.

Global Burden of Disease Study (GBD 1990 Study and GBD 2010 Study): the World

Bank commissioned the first Global Burden of Disease Study (GBD 1990 Study) in 1991 to undertake a comparative assessment of global and regional burdens for more than 100 diseases and injuries and ten designated risk factors. The new Global Burden of Diseases, Injuries, and Risk Factors Study (the GBD 2010 Study) began in 2007 and is led by a consortium that includes WHO, Harvard, and several other universities around the world. Government and non-

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Glossary

governmental agencies have made extensive use of GBD Study results to set research, funding, policy, and other priorities.

Global Fund to Fight AIDS, Tuberculosis and Malaria: an

Infant mortality: the widely

health and quality of health across racial, ethnic, and socioeconomic groups, both within a country and between countries. See also, 10/90 gap.

used WHO definition of infant mortality rate is the number of deaths during the first 28 completed days of life per 1,000 live births in a given year or period.

Healthy People 2010: a health

international public/private financing institution that has committed $19.3 billion in 144 countries since 2002 to support large-scale prevention, treatment, and care programs against these three diseases.

GHI (Global Health Initiative):

launched in 2009 by the U.S. government with $63 billion in funding, this effort aims to improve health outcomes in partner countries using a business model approach to strengthen health systems. The GHI focuses in particular on improving the health of women, newborns, and children through programs aimed at infectious disease, nutrition, maternal and child health, and safe water.

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Health disparities: gaps in

promotion program featuring 467 health objectives for Americans led by the U.S. Department of Health and Human Services. The Healthy People initiative began in 1979 under the leadership of Surgeon General Julius Richmond and has released a series of reports at roughly tenyear intervals since its inception.

HPV (human papillomavirus):

the principal risk factor for cervical cancer, which is the leading cancer killer of women in the developing world.

Incidence vs. prevalence: in

epidemiology, incidence is a measure of the number of new cases for a given disease in a population, while prevalence is a measure of the total number of cases present in that population. For chronic diseases, prevalence may remain high even when incidence falls.

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Influenza (flu): a viral

infection, flu is estimated to kill between 250,000 and 500,000 people every year.

Outbreaks of flu tend to be seasonal and can become pandemic, spreading rapidly and affecting many people.

For example, the 1918 Spanish flu, now thought to be a strain of avian flu, killed approximately 50 million people. The recent H1N1 flu was declared a pandemic but was not as severe as feared.

Worldwide response to H1N1 illustrated both strengths and weaknesses in the ability of various health systems to effectively prepare for, respond to, and contain future pandemics or possible terrorist attacks involving biological agents.

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Knowledge translation: guides

policy and practice based on evidence. Knowledge translation is part of what HSPH Dean Julio Frenk describes as the “circle of knowledge,” which includes “the production of knowledge through research, the reproduction of knowledge through education, and the translation of knowledge into evidence.”

• Substance abuse • Responsible sexual behavior • Mental health • Injury and violence • Environmental quality • Immunization • Access to health care Underlying each of these indicators is the significant influence of income and education.

Life expectancy: a key

indicator of overall quality of life, which can be measured at various points in the lifespan.

The CIA World Factbook ranks life expectancy at birth for every country in the world.

Below are a few sample statistics for life expectancy from the Factbook (2010 estimates): Circle of knowledge

Leading health indicators:

individual behaviors, physical and social environmental factors, and important health system issues that affect the health of individuals and communities.

The leading health indicators as defined by the U.S. government are: • Physical activity • Overweight and obesity • Tobacco use

• Highest life expectancy, Macau = 84.36 years • Lowest life expectancy, Angola = 38.20 years • U.S. life expectancy = 78.11 years (49th out of 224 measured in the world) Lyme disease: a tick-borne

disease that is a growing public health problem in the U.S. Lyme disease is transmitted by the bite of infected ticks.

Symptoms are initially flu-like but the disease, if left untreated, can impact the

joints, heart and nervous system. In the late 1970s HSPH scientists identified a recently discovered tick species as the vector of Lyme disease, which was then a newly emerging infection.

Longitudinal study: a research

design in which the same people are observed over time (sometimes over decades) for risk factors and health outcomes. Researchers do not control factors (for example, no one is randomly assigned to eat a high- or low-fat diet), so they cannot prove that the effect was caused by that factor. However, longitudinal studies reveal associations of factors with certain outcomes.

See Nurses’ Health Study.

Malaria: once on the brink of

elimination, malaria has come back with a vengeance. About 3.3 billion people—half of the world’s population—are at risk of malaria today. An estimated 247 million people are infected every year. The disease causes debilitating cycles of pain, fever, coma, and even death. Malaria is one of the major public health challenges undermining development in the poorest countries in the world and is the second leading cause of death from

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Glossary

infectious diseases in Africa, after HIV/AIDS. Most of the nearly one million lives claimed by malaria every year are impoverished children in sub-Saharan Africa.

impressive gains in achieving health-related targets, while others, particularly those affected by high levels of HIV/AIDS, economic hardship, or conflict, are falling behind.

Maternal mortality: the widely used WHO definition of maternal mortality rate is the number of deaths of women while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, per 100,000 live births.

Morbidity: the presence of a

diseased or unhealthy condition.

Mortality refers to the terminal result of morbidity or other causes.

Mother-to-child transmission: a prime route by which HIV can be transmitted.

MDR (multi-drug resistant):

Metabolic syndrome: a

constellation of interrelated conditions that include overweight, high blood sugars, high blood fats, and high blood pressure. It is linked to increased risk of diabetes and heart and blood vessel disease.

MDGs: Millennium Development Goals. In 2000, 189 heads of state met at the UN and endorsed the Millennium Declaration, a commitment to work together to build a safer, more prosperous, and equitable world. The Declaration was translated into a roadmap setting out eight goals with the objective of reaching them by 2015. According to WHO, some countries have made

diseases such as multi-drug resistant tuberculosis (MDRTB) and extensively drug-resistant tuberculosis (XDR-TB) cannot be effectively treated with firstline drugs (FLDs) and standard treatment regimens because the disease-causing organism has developed resistance to the FLDs. MDR diseases require the use, often over prolonged periods of time, of less optimal and/or more expensive second-line drugs (SLDs). The U.S. National Academy of Sciences first reported on the dangers of antibiotic-resistant diseases in 1992.

Microfinance: provision of

small loans, savings, and financial assistance to poor people who would otherwise not have access to these resources. Clients of IFC (International Finance Corporation), the World Bank Group’s lead investor in microfinance, disbursed $16 billion in 2008.

Nurses’ Health Studies: The

Nurses' Health Study, established in 1976 by HSPH’s Dr. Frank Speizer and the Nurses' Health Study II, established in 1989 by HSPH’s Dr. Walter Willett, are among the largest prospective investigations into the risk factors for major chronic diseases in women. The studies include clinicians, epidemiologists, and statisticians at HSPH, the Channing Laboratory, Harvard Medical School, and a number of major hospitals. The studies have followed approximately 238,000 female nurses for as long as 30 years, surveying them every two years. The studies have resulted in more than 265 published scientific papers and revealed associations between health factors such as food, exercise, and medications, with illnesses.

NGOs (non-governmental organizations): also known as

PVOs (private voluntary organizations). By some estimates, NGOs contribute as much as 20 percent of all external health aid to developing countries. continued

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Spotlight on non-governmental organizations focused on public health and related issues • Doctors Without Borders, aka Médecine Sans Frontières (MSF): provides medical care to people in crisis, serving affected communities on the ground during and in the immediate aftermath of war, natural disaster, epidemic, and famine. MSF operates in nearly 60 countries around the world and was awarded the Nobel Peace Prize in 1999.

• Human Rights Watch: a leading global watchdog group investigating and calling attention to human rights violations.

• Malaria No More: works to eliminate malaria, applying a business-style operations approach to delivering solutions such as bed nets, medicines, and insecticides to populations in need.

• OXFAM: founded in 1995, Oxfam International is a confederation of 14 member organizations focused on issues of poverty and injustice. The name “Oxfam” comes from the Oxford Committee for Famine Relief, founded in Britain in 1942.

• Partners In Health (PIH): takes a partnership and solidarity-based approach to strengthening health care services in underserved communities and providing a preferential option for the poor in health. Then-Harvard medical student Paul Farmer and others founded PIH in 1987. Farmer and the work of PIH—first in Haiti and later in several other countries—were the subject of Tracy Kidder’s widely read book, Mountains Beyond Mountains.

• Project HOPE: founded in 1958, Project HOPE (Health Opportunities for People Everywhere) is well known for the SS HOPE, which was the world’s first peacetime hospital ship. Project HOPE now provides medical training, health education, and humanitarian assistance in more than 35 countries.

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Major foundations donating to public health research and programs Foundations • Bill and Melinda Gates Foundation • Ford Foundation • Robert Wood Johnson Foundation • Atlantic Philanthropies • Rockefeller Foundation

2009 Assets $34 billion $10.4 billion $8.1 billion $3 billion $3.2 billion

2009 Grants $2.6 billion $490 million $355 million $375 million $143 million

All figures are approximate.

the likelihood of developing a certain condition.

Oral rehydration therapy (ORT): a simple treatment

(swallowing a salt, sugar, and boiled water solution) for dehydration from diarrheacausing diseases, including cholera and rotavirus infection. It saves millions of children each year from death due to diarrhea. HSPH’s Richard Cash played a key role in proving ORT is effective and practical when he and his colleagues conducted the first clinical trials of the therapy.

Pandemic: See Epidemic.

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PEPFAR (U.S. President's Emergency Plan for AIDS Relief): history-making effort

to establish and build on AIDS/HIV prevention and treatment programs in the world’s hardest-hit regions.

Launched in 2003, the plan was reauthorized in 2008 with funding up to $48 billion over five years to combat global HIV/AIDS, tuberculosis, and malaria.

Relative risk: indicates the

degree to which, all other factors being equal, the presence of a particular genetic marker or risk factor increases

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Robin Hood Index: a measure

of income equality that attempts to determine the amount of wealth that would have to be redistributed from rich to poor in order to achieve parity. Higher Robin Hood Index scores signal greater disparities in wealth.

Seguro Popular (Popular Health Insurance): started in

2004, a program of comprehensive national health insurance that has expanded access to health care for tens of millions of previously uninsured Mexicans. The effort was spearheaded by

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then-Minister of Health Julio Frenk, MD, PhD, now the dean of HSPH. Six Cities Study: one of the most influential, innovative, and longest-running experiments concerning the health effects of air pollution in America. Begun in 1974, the study linked fine particle emissions from fossil fuels to increased death rates, particularly deaths related to cardiovascular disease. The study led to a revision of existing air quality standards by the EPA. HSPH’s Douglas Dockery and his colleagues published their findings in the New England Journal of Medicine in 1993.

Social determinants of health:

socioeconomic conditions that influence individuals’ health and risk of early death. These factors can include economic deprivation, discrimination, and lack of access to health services, as well as violation or neglect of human rights.

Taking action to address social determinants of health has been identified by WHO as essential to advancing health equality.

SNS (Strategic National Stockpile): a large supply of

medicines and medical supplies held by the CDC against the possibility of local shortages during future public health emergencies (e.g., epidemic, natural disaster, and terrorist attack).

TB (tuberculosis): an infectious

disease that attacks the lungs.

TB can be asymptomatic and latent but also can progress to an active form. People with the active form can spread the illness through coughing, sneezing, and speaking, and if left untreated, the active form can be fatal. TB is notorious for its ability to develop resistance to drug treatments, and the illness is the cause of death for as many as half of people living with AIDS. See also, MDR (multi-drug resistant).

Major corporate donors to public health research and programs • Abbott Labs • Bristol Myers Squibb • Exxon Mobil • Johnson & Johnson • Merck • Pfizer

Vector: in medicine and

epidemiology, the carrier or transmitter of disease from one organism to another. For example, mosquitoes are vectors of malaria. In genetics, the vector is the transmitter of genetic material from one cell to another.

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For more information

Online Resources: • Harvard School of Public Health: www.hsph.harvard.edu • Nutrition Source, resources for healthy eating maintained by the HSPH Department of Nutrition: www.hsph.harvard.edu/nutritionsource • World Health News, a news digest from the HSPH Center for Health Communications: www.worldhealthnews.harvard.edu • American Public Health Association: www.apha.org • Centers for Disease Control and Prevention: www.cdc.gov • U.S. Environmental Protection Agency: www.epa.gov • World Health Organization: www.who.int Further Reading • Milestones in Public Health: Accomplishments in Public Health Over the Last 100 Years, Pfizer (2006) • WHO’s Commission on Social Determinants of Health FINAL REPORT (2008) • Institute of Medicine’s Future of Public Health in the 21st Century (2002) • Public Health: What It Is and How It Works, Bernard J. Turnock (2004)

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Connect with HSPH online:

HOME PAGE:

http://www.hsph.harvard.edu NEWS PAGE:

http://www.hsph.harvard.edu/news HARVARD PUBLIC HEALTH REVIEW (MAGAZINE):

http://www.hsph.harvard.edu/review TWITTER:

http://twitter.com/HarvardHSPH FACEBOOK:

http://www.facebook.com/harvardpublichealth YOUTUBE:

http://www.youtube.com/user/HarvardPublicHealth

CONTACT: Sarah Wood Director of Volunteer Leadership Office for External Relations Harvard School of Public Health 401 Park Drive, Third Floor East Boston, MA 02215 Phone: 617-384-8992 Fax: 617-384-8989 Email: swood@hsph.harvard.edu

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Impact of public health The dramatic achievements of Public Health in the 20th century have improved our quality of life: an increase in life expectancy, worldwide reduction in infant and child mortality, and the elimination or reduction of many communicable diseases.

Advances in public health have been largely responsible for increasing the lifespan of populations. Since 1900, the average life expectancy for Americans has increased by about 30 years. Over twenty-five of the 30 years can be accredited to public health initiatives, while medical advances account for less than 4 years.

Today, Public Health leaders continue to strengthen their roles as advocates for improved population-based health in an international, global community.

Source: http://www.whatispublichealth.org/impact/index.html, referencing Turnock, BJ, Public Health: What it is and How it Works, 3rd Edition. Sudbury, MA: Jones and Bartlett Publishers, 2004.

Š Harvard School of Public Health, 2010