Table of Contents
Title Page
Copyright Page
Table of Figures
Introduction
HEALTH IN AMERICA
WORKPLACE HEALTH
GOVERNMENT INVOLVEMENT
PUBLIC HEALTH OPPORTUNITIES
ROLE OF PREVENTION
Acknowledgements
THE AUTHORS
THE CONTRIBUTORS
PART 1 - PUBLIC HEALTH PREVENTION FOCUS
CHAPTER 1 - HISTORY AND IMPORTANCE OF PUBLIC HEALTH
A BRIEF HISTORY OF U.S. PUBLIC HEALTH
HEALTHY PEOPLE 2010
RESPONSIBILITIES OF PUBLIC HEALTH
PUBLIC HEALTH ACCOMPLISHMENTS
EMPHASIS ON PREVENTION NOT CONTROL
PUBLIC HEALTH AND OCCUPATIONAL HEALTH
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 2 - EPIDEMIOLOGY OF OCCUPATIONAL SAFETY AND HEALTH
INTRODUCTION TO EPIDEMIOLOGY
SURVEILLANCE SYSTEMS
EPIDEMIOLOGY STUDIES
HEALTH HAZARD EVALUATIONS
PUBLIC HEALTH SYSTEMS IN THE WORKPLACE
CHRONIC DISEASE EPIDEMIOLOGY IN THE WORKPLACE
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
PART 2 - OCCUPATIONAL SAFETY AND HEALTH
CHAPTER 3 - HISTORY AND IMPORTANCE OF OCCUPATIONAL SAFETY AND HEALTH
HEALTH, DISEASE, AND PREVENTION
THE ROLE FOR PUBLIC HEALTH
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 4 - OCCUPATIONAL INJURIES
EPIDEMIOLOGY OF INJURIES
THE CASE FOR AN EPIDEMIOLOGICAL APPROACH
EPIDEMIOLOGY OF ACCIDENTS
EPIDEMIOLOGY OF VIOLENCE
SURVEILLANCE SYSTEMS FOR OCCUPATIONAL INJURIES
SURVEILLANCE RESULTS
INJURY PREVENTION PROGRAMS
FUTURE CHALLENGES
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 5 - COMPLIANCE VERSUS PREVENTION
OSHA STANDARDS DEVELOPMENT
THE INSPECTION PROCESS
COMPLIANCE OR PREVENTION
PREVENTION OF CUMULATIVE PROBLEMS
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
PART 3 - PUBLIC HEALTH ISSUES IN OCCUPATIONAL SAFETY AND HEALTH
CHAPTER 6 - TOXICOLOGY
APPLICATION TO OCCUPATIONAL EPIDEMIOLOGY
SUBDISCIPLINES IN TOXICOLOGY
CLASSIFICATION OF TOXIC AGENTS
ENVIRONMENTAL TOBACCO SMOKE
RISK ASSESSMENT
TOXICOLOGY CASE STUDIES
TOXIN REGULATION AND RESEARCH
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 7 - STRESS
STRESS BASICS
WORKPLACE CHARACTERISTICS AND STRESS
ORGANIZATIONAL RESPONSE TO STRESS
WHEN TO GET HELP
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 8 - THE IMPAIRED EMPLOYEE
DRUG USE FREQUENCY AND DEMOGRAPHICS
EPIDEMIOLOGY OF ADDICTION
SUBSTANCES OFTEN ABUSED
DRUG-FREE WORKPLACES AND EAPS
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 9 - WELLNESS PROGRAMS
CHRONIC DISEASES IN THE WORKPLACE
THE VALUE OF WELLNESS PROGRAMS
ADDRESSING OBESITY AND NUTRITION
ADDRESSING PHYSICAL INACTIVITY
ADDRESSING TOBACCO USE
DEVELOPING COMPREHENSIVE HEALTH PROGRAMS
THE ROLE FOR PUBLIC HEALTH
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 10 - EMERGENCY RESPONSE PLANNING
DEFINITIONS
EMERGENCY MANAGEMENT PLANNING STEPS
TERRORISM AND BIOTERRORISM
WORKPLACE PREPAREDNESS FOR TERRORISM
CDC’S STRATEGIC WORKPLACE PLAN
APPLYING EPIDEMIOLOGY TO PREPAREDNESS
APPLYING AN INFORMATION MODEL TO PREPAREDNESS
INVOLVING OSHA AND NIOSH IN PLANNING
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 11 - ERGONOMICS
TWO APPROACHES: BROAD AND NARROW
ERGONOMISTS’ ROLES AND EXPERIENCE
FEW ABSOLUTE LIMITS
CUMULATIVE TRAUMA DISORDERS
THE INDUSTRIAL ATHLETE
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 12 - COMMUNICABLE DISEASES
EPIDEMIOLOGY OF COMMUNICABLE DISEASES
FOODBORNE AND WATERBORNE DISEASES
TUBERCULOSIS
HEPATITIS
HIV AND AIDS
INFLUENZA
EMERGING INFECTIONS
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 13 - VISION AND HEARING ISSUES
PROTECTING VISION IN THE WORKPLACE
PROTECTING HEARING IN THE WORKPLACE
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 14 - OCCUPATIONAL HEALTH DISPARITIES
DISPARATE POPULATIONS
HOW DO HEALTH DISPARITIES PERSIST?
FUTURE TRENDS IN HEALTH DISPARITIES
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
PART 4 - EVALUATION AND LEADERSHIP ISSUES IN PREVENTION
CHAPTER 15 - ECONOMIC IMPACTS OF PREVENTION
PREMATURE MORTALITY
EMPLOYER HEALTH INSURANCE COSTS
THE PURPOSES OF ECONOMIC EVALUATION
THE BURDEN OF INJURY AND ILLNESS
TYPES OF ECONOMIC ANALYSIS
TARGET AREAS FOR EVALUATION
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
CHAPTER 16 - IMPACTS OF LEADERSHIP AND CULTURE
USING VISION AND MANAGEMENT SKILLS
USING POWER EFFECTIVELY
EXERCISING TRANSFORMATIONAL LEADERSHIP
CHANGING THE PROCESS OF WORK
MOTIVATING EMPLOYEES
BUILDING A CULTURE
EMPOWERING WORKERS
IMPROVING TEAM EFFECTIVENESS
SUMMARY
KEY TERMS
QUESTIONS FOR DISCUSSION
REFERENCES
INDEX
Table of Figures
FIGURE 2.1. The chain of infection.
FIGURE 2.2. Determination of a rate.
FIGURE 2.3. The triad of disease.
FIGURE 2.4. Example of matrix displaying study outcomes.
FIGURE 2.5. Fatal occupational injury rates by industry division, 2002.
FIGURE 3.1. The disease process.
FIGURE 4.1. Distribution of hours worked and occupational injury and illness cases with days away from work in private industry by age of worker, 2001.
FIGURE 4.2. Number of occupational injuries and illnesses with days away from work in private industry for selected occupations, 1992-2001.
FIGURE 4.3. Distribution of nonfatal injury cases with days away from work and nonfatal injury plus illness cases by private industry sector, 2001.
FIGURE 4.4. Median days away from work due to occupational injuries or illnesses in private industry by nature of injury or illness, 2001.
FIGURE 4.5. Distribution of occupational injury and illness cases with days away from work in private industry by body part affected, 2001.
FIGURE 4.6. Distribution of occupational injury and illness cases with days away from work in private industry by source of injury or illness, 2001.
FIGURE 4.7. The Haddon matrix.
FIGURE 4.8. Number and rate of fatal occupational injuries, 1992-2002.
FIGURE 4.9. Number of occupational injury cases by type of case in private industry, 1976-2001.
FIGURE 4.10. Distribution and number of documented cases of occupationaltransmission of HIV among health care workers by occupation, 1981-2001.
FIGURE 4.11. Estimated number of occupational hepatitis B infections
FIGURE 4.12. Distribution of 10,378 reported percutaneous injuries among hospital workers by medical device associated with the injury, 1995-2000.
FIGURE 4.13. Distribution of 6,212 reported percutaneous injuries involving hollow-bore needles in hospital workers by associated medical procedure, 1995-2000.
FIGURE 5.1. Numbers and rates of traumatic occupational fatalities, 1980-2000.
FIGURE 5.2. Number of occupational injury cases by type of case in private industry, 1976-2001.
FIGURE 5.3. Annual rate of fatal occupational injuries by leading cause, 1980-1998.
FIGURE 8.1. Past month illicit drug use among persons aged twelve or older, by age, 2005.
FIGURE 8.2. Current, binge, and heavy alcohol use among persons aged twelve or older, by age, 2005.
FIGURE 8.3. Driving under the influence of alcohol in the past year among persons aged sixteen or older, by age, 2005.
FIGURE 8.4. Dependence on or abuse of specific illicit drugs in the past year among persons aged twelve or older, 2005.
FIGURE 8.5. Reasons for not receiving substance use treatment among persons aged twelve or older who needed and made an effort to get treatment but did not receive treatment and felt they needed treatment, 2004-2005.
FIGURE 11.1. Model of events and behaviors contributing to an accident.
FIGURE 11.2. How a crane operates.
FIGURE 11.3. The human back in a cranelike position.
FIGURE 11.4. Critical dimensions for lifting.
FIGURE 11.5. Angle of asymmetry.
FIGURE 14.1. Distribution of employed U.S. workers in 2000 and nonfatal occupational injury and illness cases with days away from work in private industry in 2001 by race and ethnicity.
FIGURE 14.2. Number and rate of fatal occupational injuries by race in the agriculture, forestry, and fishing industries, 1992-2001.
FIGURE 14.3. Distribution and number of anxiety, stress, and neurotic disorder cases involving days away from work in private industry by race and ethnicity, 2001.
FIGURE 14.4. Fatal occupational injury rates among Hispanic and non-Hispanicworkers in the construction industry, 1992-2001.
FIGURE 14.5. Distribution of foreign-born and native-born workers by occupational group, 2000 (percentage).
FIGURE 14.6. Employment and fatality profiles by sex, 2002.
FIGURE 14.7. Distribution of MSD cases and all nonfatal injury and illness cases involving days away from work in private industry by sex, 2001.
FIGURE 14.8. Distribution of anxiety, stress, and neurotic disorder cases involving days away from work in private industry by sex, 1992-2001.
FIGURE 14.9. Distribution of hours worked and occupational injury and illness cases with days away from work in private industry by age of worker, 2001.
FIGURE 14.10. Distribution of the uninsured and total U.S. population by race and ethnicity in 2004.
FIGURE 15.1. A six-step framework for program evaluation.
INTRODUCTION
In the United States the workplace can be hazardous to one’s health through injuries and disease. Although the average worker spends more than forty hours every week in the workplace, many workers are unaware of the potential dangers present in their home away from home.
When young men or women begin their first job, usually at a young age, they are not aware that they have entered a world of potential health problems. This can be a very dangerous period in their lives because they are now exposed both to the possibility of workplace injuries and to the possibility of developing chronic diseases later in life from health behaviors developed or supported in the workplace environment.
According to the Bureau of Labor Statistics (2007), a worker is injured every five seconds and every ten seconds a worker is temporarily or permanently disabled. Individuals usually spend a majority of their lives in the places where they work, and these years in the workplace are the same years when they may be incubating chronic diseases or experiencing serious injuries that often cause disabilities and poor health later in life.
HEALTH IN AMERICA
Length of life has definitely improved in the United States since the early 1900s, and most people can expect to live well into their eighth decade of life. The majority of this increase in life expectancy can be directly attributed to the many public health accomplishments made possible by dedicated workers in the field of public health in this country. The reduction in tobacco use, better nutrition, more physical activity, proper immunizations, and effective health education programs are just a few of the initiatives developed and implemented by public health departments during the past hundred years. Unfortunately, too many Americans still experience premature death, disability, or poor quality of life.
The healthy people concept, which was introduced by the U.S. Surgeon General’s Office a few decades ago, has helped us continue our progress in helping Americans to achieve good health for themselves and their family members. The most recent report, Healthy People 2010 (U.S. Department of Health and Human Services, 2000), has established even more aggressive but achievable goals and objectives to improve the health of all Americans.
It is now time to expand this public health success story to the workplace. There is a captive audience in the workplace who want to be healthier and an employer who wants to keep employees healthy and productive. All that is required is leadership to make the workplace a healthy place to earn a living and experience healthy aging.
WORKPLACE HEALTH
Twenty years ago injury was a leading cause of death in the United States, with 143,000 fatalities in 1983. Today over four hundred deaths a day result from injuries, including injuries happening in the workplace. Injuries are the second leading cause of death in this country before the age of seventy-five. The large numbers of injuries that occur on a daily basis lend themselves very well to a public health model of prevention. According to Finkelstein, Corso, and Miller (2006), an injured worker misses an average of 11.1 days of work and the productivity losses associated with the injury are the value of the goods never produced because of the injury.
Chronic diseases—such as heart disease, cancer, and diabetes—are the leading causes of death and disability in the United States. As the burden of chronic diseases in the United States increases, greater efforts will be made to identify and implement interventions that successfully reduce disease risk, especially in the workplace. These diseases account for seven of every ten deaths and affect the quality of life of ninety million Americans. Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. McGinnis and Foege (1993) point out that daily habits such as smoking, inactivity, eating a poor diet, and using alcohol and their consequences contribute to the development of virtually all morbidity and mortality in industrial nations. Adopting healthy behaviors such as eating nutritious foods, being physically active, and avoiding tobacco use can prevent or control the devastating effects of these diseases.
Employers are becoming more interested in dealing with the economic losses suffered each year as a result of injuries and illness suffered in the workplace. These losses include higher health insurance costs for the employer and loss of employee productivity. Employers are faced with a real need to reduce costs associated with producing a product and the need to have healthy employees who come to work rather than using sick leave to tend to illness and injuries that may have been acquired in the workplace.
GOVERNMENT INVOLVEMENT
The federal government became deeply involved in occupational safety and health after the passage of the Occupational Safety and Health Act in 1970. This act created the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH) to protect American workers from dangers to their health in the workplace.
OSHA is housed in the Department of Labor; it is responsible for creating standards and using those standards to protect the American worker from injury, illness, and death in the workplace. NIOSH is headquartered at the Centers for Disease Control and Prevention, because of its investigative role. It is the research component of the Occupational Safety and Health Act and through the use of the science of epidemiology has helped to discover the causes of injury and disease in the workplace. Through the use of public health expertise, researchers are then able to develop programs to reduce or eliminate workplace injuries and disease.
Despite the success of OSHA and NIOSH over the last few decades, there are still those who dislike any form of business regulation. The conservative governance of the last several years in this country has cut OSHA and NIOSH budgets, experimented with reorganizations and taken away some of these agencies’ power, and even tried to abolish these agencies.
There could be a leadership role for OSHA and NIOSH in bringing together partnerships between the businesses they regulate and public health agencies. Such collaborations will be necessary if we are to improve the overall health status of the American worker. In order to make a difference in workers’ health we have to go beyond the talent and resources found in any one agency. Because there is a very large difference between what is known about injury and illness prevention in the workplace and what is actually being done to prevent these important health problems, we can accomplish a great deal through collaboration among multiple stakeholders.
PUBLIC HEALTH OPPORTUNITIES
Public health efforts in this country are carried out by numerous agencies with a mandate to improve the health of the population. These agencies have produced remarkable success stories on very limited budgets. In addition they are receiving more new challenges to deal with, including bioterrorism preparedness, emerging infections, the AIDS pandemic, and now avian and swine influenza.
Moreover, in recent years public health agencies have shifted their focus from communicable diseases to the behaviorally caused chronic diseases. These diseases have a very long incubation period and cannot be cured, only treated or prevented from ever starting. Even though chronic diseases and injury prevention programs have high costs at the start, they do very well when cost-benefit analysis is applied to the outcomes associated with them.
The public health success with identifying the causes of chronic diseases needs to be expanded into an effort of preventing the occurrence of these diseases or at the very least postponing their complications until later in life. This knowledge should be of great value to corporate America in reducing chronic and noncommunicable disease costs. Public health has a tremendous opportunity to help businesses reduce the costs of health insurance and keep their employees healthy and productive. The return to the public health field could be the availability of resources from businesses and a captive audience of employees who are practicing prevention techniques and whose results can be documented.
ROLE OF PREVENTION
The Institute of Medicine report titled The Future of the Public’s Health in the 21st Century (2003) recommends that the corporate community and public health agencies work together to strengthen health promotion and disease prevention programs for employees and their communities. The results of the Framingham study (discussed in Chapter One) have given us guidance for reducing the incidence and damage caused by chronic diseases such as cancer, diabetes, heart disease, and arthritis among all members of society. The answers produced in the Framingham study need to be given to employers to help them develop programs to prevent chronic disease occurrences in the workplace.
This book was written to discuss the many health problems facing the American worker as he or she ages in the workplace. The authors’ premise is that a number of these health problems can be prevented if public health skills are applied in the workplace. The opportunity to eliminate or reduce injuries and many illnesses in the workplace is within reach of employers, employees, and public health officials. Now is the time to learn about this wonderful opportunity that has presented itself and to do the right things to make the workplace safe and healthy.
This book begins with a discussion of the history of public health in the United States, paying particular attention to the many successes of public health programs in the last century. This leads to a discussion concerning the need for public health expertise to understand and reduce occupational illness and injury occurrences. The reader is also introduced to the many uses of epidemiology in developing injury and illness surveillance systems that can help all concerned to better define occupational health problems.
A discussion of occupational safety and health history and the importance in protecting workers from morbidity and mortality follows, and a discussion of OSHA and NIOSH helps the reader understand the various problems faced by workers as they earn a living. Special attention is given to the types of injuries and illnesses that occur in the workplace and the role of legislation in reducing these occurrences.
The text then moves to a discussion of specific public health problems and their potential solutions, paying particular attention to public health prevention strategies for the workplace. The topics in this section of the book include workplace stress, drug and alcohol abuse, worker exposure to toxins, workplace wellness programs, and emergency planning and bioterrorism in the workplace. This book also looks at ergonomics, communicable diseases, vision and hearing problems, and health disparities as they affect the employer and employee. Additional topics include the economics of public health prevention activities in the workplace, the need for program evaluation, and a discussion of leadership and partnerships in keeping the American worker safe, healthy, and productive.
ACKNOWLEDGMENTS
We would like to begin by acknowledging the dedicated people who work in public health and who, despite limited resources, have accomplished so much in making the United States a better place to lead a healthy life. This is really a book about their success stories and their attempt to bring the healthy people concept to the places where people work to earn a living. Once you are bitten by the bug of serving others by making the world a safer place to live, you can never stop being a public health person.
During the process of writing this book we met many dedicated people who demanded professionalism in everything they tried to accomplish. One such person was John P. Sestito, surveillance program coordinator in the Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health. He was there to help Bernard Healey with the chapter on injuries in the workplace. He shared his work and went out of his way to make this chapter the best that it could be.
Four more individuals to whom we are truly indebted helped us with the writing of particular chapters. They are Bridget McKenney Costello, Alison Healey, Kristin Joseph, and Jason R. Smith. Their biographies appear in the next section.
During the entire research and writing of this book we were surrounded by intelligent, caring individuals who cared only about making our ideas better. We are very fortunate individuals to have the opportunity to write a book for a national publisher but equally fortunate to have been able to work with such talent.
THE AUTHORS
Bernard J. Healey is professor of health care administration and director of the graduate program in health care administration at King’s College in Wilkes-Barre, Pennsylvania. He began his career in 1971, as an epidemiologist for the Pennsylvania Department of Health, retiring from that position in 1995. He has been teaching undergraduate and graduate courses in business, public health, and health care administration at several colleges for more than thirty years. During his tenure with government, he completed advanced degrees in business administration and public administration. In 1990, he earned a PhD degree at the University of Pennsylvania.
Kenneth T. Walker is a certified safety professional operating his own safety consulting company in Tunkhannock, Pennsylvania. He is retired from the position of industrial hygiene and safety and emergency response manager for Procter & Gamble Paper Products Company in Mehoopany, Pennsylvania. He has received advanced training in ergonomics, electrical safety for general industry, and construction safety and has completed numerous courses at National Safety Council Congress and Exposition sessions and American Society of Safety Engineers Professional Development Conferences. He is also a retired U.S. Army captain. He holds an MS degree from the University of Scranton.
THE CONTRIBUTORS
Bridget McKenney Costello is assistant professor of sociology at King’s College, where she teaches courses in social problems, gender, and culture. She earned her PhD degree in sociology from the University of Pennsylvania, concentrating in social inequality and cultural consumption. Her scholarly works have investigated trends in school redistricting since Brown v. Board of Education, the changing occupational health profile of women, trends and correlates of pseudoscientific belief, the gendered reception of mainstream and alternative scientific information, and the educational trajectories of disadvantaged students, including the aspirations and outcomes for low-income mothers. Currently, she is launching a study of cultural influences on individual health practices.
Alison Healey has managed the New York City bureau of an international financial magazine for Thomson Financial, has written and edited copy for a biweekly magazine and daily electronic news updates, and has also written and edited news stories and feature articles for this publication and its supplements, as well as comprehensive sector-specific management reports. She covered North American project finance activity, including but not limited to energy and infrastructure sectors. She is currently employed by Northeast Counseling conducting crisis assessments of children and adolescents in Northeast Counseling offices and emergency rooms. She determines the lethality of crisis patients and consults with on-call psychiatrists. She also conducts psychosocial assessments and links new patients to outpatient medication and therapy services. In addition, she teaches abnormal psychology, general psychology, and stress and coping at Marywood University, in Dunmore, Pennsylvania. She earned her MA degree in clinical/counseling psychology from Fairleigh Dickinson University and her MA degree in journalism from Temple University.
Kristin Joseph is a registered and licensed dietitian with more than ten years of experience in the field of nutrition. She has counseled individuals and groups on improving their eating and lifestyle habits and has conducted more than three hundred print, TV, and radio interviews on topics such as weight management, child and adolescent nutrition, school nutrition, and nutrition for disease prevention. She has also worked as a newspaper correspondent covering health and nutrition topics. She earned her BS degree at Indiana University of Pennsylvania and completed a postgraduate internship at Texas Woman’s University in Houston, where she also earned an MS degree in nutrition. Experienced in the areas of clinical practice, community nutrition, and nutrition education, she acts as a resource to health professionals, consumer leaders, the media, and employee wellness programs.
Jason R. Smith is an optometrist in private practice at Forty Fort Eye Associates in Forty Fort, Pennsylvania, and the founder of Home Eye Care, which provides eye care to homebound and nursing home patients. He is currently the staff optometrist at fifteen nursing homes in Luzerne County. He is a 1993 graduate of the New England College of Optometry in Boston, and in 1999 he received an MS degree in health care administration from King’s College in Wilkes-Barre, Pennsylvania. He is the first and only optometrist to receive this degree from King’s College.
PART 1
PUBLIC HEALTH PREVENTION FOCUS
CHAPTER 1
HISTORY AND IMPORTANCE OF PUBLIC HEALTH
After reading this chapter, you should be able to
• Understand the use of the skills of public health in the prevention of workplace illness and injuries.
• Understand what public health departments do and how they accomplish their goals.
• Discuss the advantages of partnerships between workplaces and public health departments.
• Explain the evolution of public health responsibilities in the United States.
It is difficult for most people to understand what public health does because they very rarely if ever have to deal with a public health department. Public health agencies become visible only when a health problem receives extensive media coverage. Yet the work that has been completed by public health over the last century is one of the main reasons for the long life expectancy of most Americans.
One way to understand public health is to compare a physician and a public health professional. The physician is most concerned with the health of his or her individual patient whereas the public health professional is concerned with the health of the community. More broadly, the medical care system in our country focuses attention and resources on the individual and the cure of disease whereas the public health system is concerned with the population and the prevention of disease.
Shi and Singh (2008) point out that many people believe that public health is nothing more than a massive welfare system. The agency responsible for the good health of Americans is not a welfare program but a separate agency of government that is supplemented by many nonprofit public health agencies. Every organization should have an interest in the important programs that protect and promote the health of all citizens. It is unfortunate that most people do not come to really understand public health until there is an emergency and that they forget about public health after the emergency ends.
Schneider (2006) believes that public health is concerned with the prevention of disease and the promotion of health. This definition places public health in the area of primary care. McKenzie, Pinger, and Kotecki (2005) argue that public health involves governmental actions to promote, protect, and preserve the health of a population. However, public health activities are also performed by nongovernmental agencies. The perception of public health agencies as responders to health emergencies prevents even health policy experts from understanding the contribution that could be made by public health departments in solving the current health care problems in this country. These departments do many things that prevent disease but that are never publicized and therefore are not known by the average person.
The public health system is always working at making good health available for all individuals. It is usually seen as a silent component of health services, one that demands few resources and still produces immense value for all of our citizens in terms of better health for all. This system employs some of the most dedicated health professionals to be found in any part of this country’s health care system. These individuals have special skills that could be extremely useful in helping employers keep their workforces healthy and free from disease and injury.
A BRIEF HISTORY OF U.S. PUBLIC HEALTH
As just described, the valuable contribution made by public health professionals year after year is largely taken for granted. People think of public health and public health departments only when an emergency threatens their health and they need guidance and answers from public health officials and the various governmental agencies that they represent. Problems like E. coli in our food supply, anthrax in the mail, contaminated water, or drug-resistant tuberculosis bring public health to the forefront until the crisis subsides, and then public health departments seem to disappear until we need their help again.
Many definitions of public health point to a science dedicated to the improvement of the health of everyone. In 1926, Winston defined public health as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.” McKenzie et al. (2005) define public health as the health status of the population, including governmental action to promote, protect, and preserve people’s health. Novick, Morrow, and Mays (2008) define public health as “organized efforts to improve the health of communities.” Vetter and Matthews (1999) argue that public health is “the process of promoting health, preventing disease, prolonging life and improving the quality of life through the organized efforts of society.” And Turnock (2009) points out that public health represents a collective effort to deal with unacceptable realities that usually result in poor life outcomes that could have been prevented.
These various definitions of public health also offer a vision of population-based medicine rather than medical care centered around a specific individual. They emphasize prevention of health problems rather than a cure for health problems. If fully employed, the principles of public health could provide an answer to many of the problems that plague our current medical care delivery system. There also seems to be a major role for public health involvement in workplace health and safety issues.
Awofeso (2004) identifies six major approaches to public health that have been taken over the centuries:
• Public health as health protection (antiquity to 1830s)
• Public health as sanitary movement (miasma control) (1840s to 1870s)
• Public health as contagion control (1880s to 1930s)
• Public health as preventive medicine (1940s to 1960s)
• Public health as primary health care (1970s to 1980s)
• The “new public health”—health promotion (1990s to present)
These approaches offer a number of insights into the history of public health in the United States. There has been an emphasis on control of disease, regulation of some parts of the health care system, and more recently a stronger role in the development and implementation of prevention programs. The word control is frequently heard when describing the historical development of public health: control of disease, control of the free movement of people (quarantine), and control of certain high-risk behaviors.
Public health departments in the late 1800s and early 1900s became very successful at controlling the spread of diseases but were not so good at preventing these diseases from occurring in the first place. This changed with the development of vaccines that virtually eliminated childhood illnesses. In addition, the discovery of penicillin allowed public health departments to cure many sexually transmitted diseases in special clinics that concentrated on the control of venereal diseases. Public health professionals were trained to interview those infected with venereal diseases, find their sexual contacts, and bring them to treatment. This strategy resulted in a reduction in these diseases until public health resources were reduced through budget cuts.
It has taken a long time for the emphasis to begin to shift from the word control to a new word, prevention. Public health departments are now assuming greater roles in prevention that entail keeping people healthy and free from disease. Unfortunately, up to this time, limited budgets never allowed these departments to truly prevent anything except through the use of vaccines.
Nevertheless, from these earlier approaches came a number of very effective public health programs that saved lives, reduced morbidity, and added several years to the average life span of most Americans. In antiquity, in the very early years of the development of public health, people believed that disease was somehow caused by supernatural forces and therefore that epidemics were a punishment by god or other spiritual forces. When epidemics of plague, leprosy, cholera, and the like occurred, it was thought very little could be done about these outbreaks, some of which had mortality rates greater than 30 percent of the population.
Miasma control, an approach beginning in the 1830s, was usually the result of industrialism and urbanization that allowed public health conditions to worsen. The United States and other countries moved from farming to manufacturing, and people moved from farms to cities. People working and living closer together provided an environment for disease to develop and spread rapidly from person to person. According to McKenzie et al. (2005), the major theory of disease at this time was that vapors or miasmas were the cause of many diseases and that these diseases, resulting from a filthy environment, could be eliminated only by cleaning and other environmental precautions. A famous report by Edwin Chadwick, titled Report on an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain, documented the influence of filthy conditions on the occurrence of disease.
Lemuel Shattuck’s 1850 Report of the Sanitary Commission of Massachusetts was one starting point for the development of public health in the United States. This report called for the development of public health departments that would have the responsibility for handling the public health concerns of the population of a locality or state. This report was a response to the need to have the authority to deal with infectious diseases and environmental problems, and it focused on state and local responsibility to deal with these issues.
The next era of public health involved the germ theory of disease, first proposed by Louis Pasteur in 1862. Discoveries in this era revealed the identity of such bacterial diseases as typhoid fever, leprosy, tuberculosis, cholera, diphtheria, and tetanus. This era also saw the founding of the American Public Health Association, the start of local public health departments, and the pasteurization of milk. It was now known that many diseases were caused by microbes and that the spread of disease could be controlled through public health activities. As the public health departments were established, they were given the goal of protecting the health of the community. In order to accomplish this goal these departments were granted powers to enforce public health laws and regulations. These powers included quarantine, isolation, immunization, and investigative powers.
Public health was now ready to move to the next stage of development, which involved the effort to prevent communicable diseases and to focus that prevention on high-risk groups. The discovery of penicillin gave physicians a weapon that could be used to cure many communicable diseases. The development of vaccines allowed the virtual elimination of many childhood diseases. Public health departments became very good at organizing and implementing mass immunization campaigns, which were credited with preventing enormous morbidity and mortality from communicable diseases.
The science of epidemiology was also developing. In 1849, John Snow, a London physician, had used epidemiological techniques to discover the cause of the spread of cholera in a particular city district. Having previously studied the transmission of cholera through contaminated water, Snow surveyed households of cholera victims and traced their water supply to the Broad Street well, one of three wells being used in that area. Once the suspect well was closed at his urging, the outbreak ended.
A study conducted by Doll and Hill in the 1950s implicated the use of tobacco in causing a form of cancer rarer at that time than now, lung cancer. This study paved the way for additional chronic disease studies that linked secondhand smoke to the same deadly form of cancer. Tobacco became identified as the leading cause of death for 430,000 Americans every year. Secondhand smoke was identified as a cause of over 80,000 additional deaths from lung cancer. After Doll and Hill’s study, it seemed a natural follow-up to start using epidemiology to evaluate high-risk health behaviors as a potential cause of other chronic diseases. Epidemiology was now ready to deal with diseases involving very long incubation periods that had no visible starting point.
Epidemiology has been called the basic science of public health by people who work in the field of public health, and in fact most of the major accomplishments of public health are a direct result of exhaustive studies conducted by epidemiologists. Epidemiology focuses on human populations and has been used in the determination of the causes of many chronic diseases. This science relies heavily on the use of descriptive and analytical statistics to determine the major risk factors of disease (Schneider, 2006).
One of the most important studies ever conducted involved an epidemiological evaluation of chronic noninfectious diseases in Framingham, Massachusetts. This cohort study, begun in 1947, evaluated the relation of heart disease to factors that included high blood pressure, serum cholesterol, and cigarette smoking. Oppenheimer (2005) argues that this successful epidemiological study, which coined the term risk factor, was also able to uncover the causes of many other chronic diseases.
The Framingham Heart Study was instrumental in proving the value of involving a community in a collaborative effort designed to improve the health of that community. This was an important first step in the expansion of population-based medicine, which allowed a differentiation between the medical care system and public health departments. It also demonstrated that even when goals are different, there is real value in collaboration with others.
The next phase of public health development involved an interest in providing health care that was geared toward the community. This focus on primary care involved greater consideration of socioeconomic concepts and an evaluation of all of the determinants of good health. Public health started to move closer to the community through federal and state grants that encouraged the formation of local health departments with city or county health responsibilities. Public health at this time involved an increased focus on the prevention of diseases that were long term or chronic in their etiology. The country was gaining in its war against communicable diseases, and public health departments began to move resources to the control of the epidemic of noncommunicable chronic diseases. This effort began with a concentration on heart disease, stroke, and cancer. In recent years public health has also moved toward dealing with physical inactivity, diet, tobacco use, and obesity.
Public health entered the current health promotion era in 1979. Public health officials became convinced that population-based medicine would have a much better chance than individually focused medical care of solving the major problems found in the U.S. medical care delivery system. It also seemed obvious to some public health leaders that if we could keep individuals free of chronic diseases, we could reduce the costs of health care delivery and at the same time reduce the numbers of individuals who require access to health services. At this time prevention should have become the main focus of public health efforts, leaving the medical care delivery system to focus on cure. However, many public health professionals continued to support programs that focused on control of disease rather than on preventing disease. This failure to put the primary emphasis on prevention was a result of budget reductions and a bureaucratic structure that was unable to move beyond disease counseling and testing. A good example of this failure is found in the public health response to HIV in the early years of that disease. Public health agencies seemed to believe that counseling and testing of individuals could somehow prevent the HIV epidemic from growing. They were wrong.
HEALTHY PEOPLE 2010
Many people in the United States have long had an interest in the prevention of health problems. This interest is evident when we look at the strong support for the elimination of childhood diseases through the funding of vaccine development and distribution by public health departments. At the same time, there was also a long-term reluctance to move past the care of children and young adults with well-developed prevention programs.
Then, in 1979, the healthy people concept came into being, documented in a report titled The Surgeon General’s Report on Health Promotion and Disease Prevention. This report was responsible for the start of a national discussion on the relationship of personal health behaviors to the development of many serious diseases and injuries, and the Healthy People program represents a change from the physician and hospital emphasis on the individual to the public health focus on the population. Healthy People program objectives were then outlined in a 1990 report. The latest report, Healthy People 2010 (U.S. Department of Health and Human Services, 2000), establishes twenty-eight broad focus areas for the Healthy People program (see Table 1.1). These focus areas contain 467 target objectives for communities to use in the effort to improve the health status of their residents.
TABLE 1.1. Healthy People 2010 focus areas
Source: U.S. Department of Health and Human Services, 2000.
In giving concrete goals and objectives to communities, the Healthy People initiative helps these communities to increase collaboration and to build community agreement with and support of constant improvement toward a healthier community. The objectives are tracked and reported as moving in the right direction, moving in the wrong direction, showing no change, or being untrackable. This ongoing evaluation process allows public health agencies to measure results and attempt to change community-supported programs that are not working. It is not a perfect process, but for those interested in the health of the community it represents a step in the right direction.
One of the focus areas for improvement in Healthy People 2010, as shown in Table 1.1, is occupational safety and health. This section has very specific, measurable objectives that employers can apply to their place of employment and motivate employees to achieve (Table 1.2 shows the areas that these objectives address).
TABLE 1.2. Healthy People 2010: short titles of occupational safety and health objectives
Source: U.S. Department of Health and Human Services, 2000.
One issue that has long inhibited the accomplishment of workplace health and safety objectives has been uniting the players in the process and offering appropriate incentives to make collaboration happen. The interest is now present for the development of strong partnerships between employers and public health agencies for the improvement of the health of workers, which benefits everyone.
RESPONSIBILITIES OF PUBLIC HEALTH
The general consensus of those who work in public health is that the
core responsibilities of public health include
• Assessing and monitoring of the health of the community in order to identify health problems and health priorities
• Developing public policies to solve identified local, state, and national health problems and health priorities
• Ensuring that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluating the effectiveness of that care.
These responsibilities all entail prevention of disease and protection of the health of the population. They are carried out by a cadre of dedicated public health professionals working for federal, state, and local public health departments. Public health professionals’ duties are usually defined in terms of minimum program requirements, and involve communicable disease control, laboratory services, health education, environmental health, epidemiology, maternal and child health services, public health nursing, and chronic disease control. (As we have noted, the word control does not support the development of public health efforts in prevention and indicates that there is still much to do in shifting the public health focus.)
PUBLIC HEALTH ACCOMPLISHMENTS
Public health departments have been key players in many of the great achievements of medical care over the last century. They had very little support in terms of staffing and financial resources, and they also had to be innovative within a very restrictive bureaucratic structure. Their success is a direct result of dedicated employees, a strong culture, and a desire to improve the health of the community. In addition, one of our public health departments’ greatest strengths has always been the ability to partner with others in the reduction of diseases in the community. Exhibit 1.1 lists their major accomplishments.
These accomplishments that resulted from public health programs are very impressive, and they were made possible by the formation of partnerships involving community leaders, including leaders from the business community. It must also be revealed, however, that public health has had its share of failed programs. One of the most notable occurred in 1976 when the government’s response to the reporting of one case of swine flu at Fort Dix, New Jersey, was perceived as a complete failure. A mass immunization program was instituted to protect the public from a potential epidemic, but the outbreak never materialized and the vaccinations resulted in several cases of Guillain-Barré syndrome that caused paralysis. Failures like this went a long way toward making people fear large public health interventions.
EXHIBIT 1.1. Ten great public health achievements—United States, 1900-1999
Source: Adapted from Ten Great Public Health Achievements—United States, 1900-1999, 1999.
The third accomplishment listed has to do with the improvement of workplace safety, which can go a long way toward the improvement of community health. Turnock (2009) points out that workplaces are safer today but more needs to be done to protect workers from disease and injuries. Public health departments are capable of using epidemiology and sophisticated surveillance systems to reduce injuries and develop disease screening and intervention programs. This can be accomplished only if businesses and public health work together in the reduction of illness and injuries in the workplace.
EMPHASIS ON PREVENTION NOT CONTROL