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8/13/2019 No.1 Definition of Health and Wellness
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FMS, UWI, Cave Hill
HEALTH CARE CONCEPTS:
Lecture 1.
Introduction to Public Health &Population Medicine
Alafia Samuels MBBS, MPH, PhDSenior Lecturer, Epidemiology & Public HealthFaculty of Medical Sciences, UWI, Cave Hill
Email: alafia.samuels@cavehill.uwi.edu
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Main References
An Introduction to Public Health andEpidemiology
Susan Carr, Nigel Unwin, Tanja Pless-Mulloli (University of Northumbria, University of Newcastle upon
Tyne, University of Newcastle)
Open University Press, McGraw Hill Education
Basic EpidemiologyR. Bonia, R. Beaglehole, T. Kjellstrom
World Health Organization
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Learning Objectives
To assess a broader definitions of health
To be able to define epidemiology and public health.
To explain the evolution of epidemiology
To compare and contrast clinical medicine andpopulation health
To justify health interventions over time related to thehealth challenges of the era.
To critically appraise the public health successes andremaining challenges globally and in the Caribbean.
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What is health?
Absence of disease
―Health is a state of complete physical,mental and social well-being, and not merely the absence of disease or
infirmity ‖
Narrow medical vs. wider social
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Definitions of public health
‗Public Health is the art and science ofpreventing disease, promoting health
and prolonging life through organisedefforts of society‘. (1987 UK AchesonReport )
‗Collective action for sustainedpopulation wide health improvement‘ .(Beaglehole and Bonitas)
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Clinical medicine, Public health
Clinical medicine – One to one medicine
– Patients who choose
to present – Usually curative –
disease alreadypresent
– History, labs, x-raysetc. to diagnose
Public health – Population medicine,
social / communitymedicine
– Patient is thepopulation
– Prevention and cure
– Epidemiology todiagnose
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What is Public Health?
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Epidemiology - definition
Epidemiology is the study of thedistribution and determinants of
health-related states or events inhuman populations and theapplication of this study to the controlof health problems.
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Clinical epidemiology
Contradiction?
Use of population information for
individual care – Value of tests
– Effectiveness of Treatment
– Prognosis – Evidenced based guidelines
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Roots
epi (upon ) demos (the people ) andlogos (to study )
– still often associated with communicabledisease epidemics
– actually incorporates much wider concepts
– uses quantitative methods to study diseaseand risk factors
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Epidemiology is a
relatively young science Only dating back to John Graunt (1620-1674)
and James Lind (1794).
John Graunt linked population growth andpollution with the health of the public: ―Iconsidered whether a City, as it becomes morepopulous, doth not, for that very cause,become more unhealthfull, …. but chiefly,because I have heard, that 60 years ago fewSea-Coals were burnt in London, which now areuniversally used. For I have heard, thatNewcastle is more unhealthfull than other
places….‖ ( where sea-coal originated )
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Epidemiology - utility1. Determine extent of disease in the
community. – ID and track emerging and ongoing diseases
– ID causes and risk factors for disease.
2. Study natural history and prognosis ofdisease.
3. Evaluate preventive and therapeuticmeasures
4. Provide foundation for public policy – Often long delay between epidemiological evidenceand translation to practice
Improves health of whole populations of
people – saving lives thousands at a time
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History and Achievements in
Public Health and Epidemiology
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What Causes Dis-ease
HIPPOCRATES (400 BC): ―On Airs,Waters, and Places ‖
– disease might be associated with the
physical environment
Galen (129-199 AD)
―Miasma‖ (malodorous, decomposing,
poisonous particles) Theory of Contagion
– (based on ancient practice of isolating ill
people)
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Theory of Contagion
Microscope (1683) and micro-organisms (late 19th Century)
drastically changed the theory ofdisease causation
‘contagion theory‘ dominated public
health thinking from late 19th Centuryto mid 20th Century.
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First Clinical Trial
James Lind was a British navy doctor. hypothesis that scurvy, a debilitating
disease affecting sailors on long sea
journeys was caused by lack of fruit intake. He enrolled 12 sailors with scurvy and split
them into 6 treatment groups of 2 each. The 2 sailors given two oranges and a
lemon per day made an almost completerecovery. From 1795 onwards limes were give to
sailors so present day English sailors are
called ‗limeys‘.
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What is Epidemiology?
Looking to answer the questions:
– Who? - person
– Where? - place
– When? - time
– What? – Why?
– How?
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Average age of death
(Chadwick 1842)Locality Professional,
Gentry
Tradesman Labourers,
Servants
Wiltshire (rural) 50 48 33
Derby (urban industrial) 49 38 21
Kensington (wealthy urban) 44 29 26
Leeds (urban industrial) 44 27 19
Liverpool (urban industrial
sea port)
35 22 15
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http://eemb40.blogspot.com/2009/01/preventives-of-cholera.html
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Snow and Cholera
John Snow –
– London cholera epidemics 1848-54.
–Generated hypothesis based on personand place
– Formulated natural epidemiological
experiment to test the hypothesis thatcholera was transmitted by contaminated
water.
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Broad Street Pump
http://milesdowsett.com/index.php/blog/article/data-design-the-genius-of-jon-snow/
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http://www.haitiwater.org/news/0608_newsletter.php
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Water Company Populatio
n in
1851
Census
Deaths
from
Cholera
in 14
weeks
(end Oct
1854)
Deaths in
10,000
living
Southwark and Vauxhall
(includes Broad St. pump)
263,516 4,093 153
Lambeth 173,748 461 26
Rest of London 2,362,236 10,367 43
h i id i l ? h
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What is Epidemiology? TheEpidemiology Hall of Fame
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1. Descriptive
Who? - person
Where? - place
When? - time
2. Analytical
What? - Deaths
Why? – Hypothesis: sewage contaminatedwater from Broad St pump
How? – Unknown: microbes (cholerabacillus) as agents of infectious diseases hadnot yet been identified.
3. Intervention and Evaluation
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Causes of Infectious DiseaseMortality
Likelihood of getting infected – Hygiene and overcrowding
–environment that bring host and agent
Likelihood of getting ill, once infected – Nutritional status and personal hygiene
(knowledge and means)
Likelihood of dying – Access to health care
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Descriptive EpidemiologyWho? Where? When?
Person
Place Time
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Person Data
May be characterized by age, race, sex,education, occupation, or other personal
variables
Age and Sex are almost always used inlooking at data
– Age data are usually grouped
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Data Characterized by Person
http://www.vdh.virginia.gov/std/AnnualReport2003.pdf
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U S A Adj d P l f
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0 5 10 15 20 25
U.S. Age-Adjusted Prevalence ofDiabetes* by Race/Ethnicity
Percent
www.hypertensiononline.org
*In people 20+ years old
CDC. National Diabetes Fact Sheet. 2002.
Sources: 1997-1999 National Health Interview Survey and 1988-1994 NationalHealth and Nutrition Examination Survey (NHANES) estimates projected to year
2000. 1998 outpatient database of the Indian Health Service
19%
15%
14%
7%
T i id d T b 1994
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Gender& Place
0.00 0.50 1.00 1.50 2.00 2.50
Canada 1996
U. S. A. 1997
Argentina 1996
Chile 1997
Costa Rica 1994
Cuba 1997
Ecuador 1996
Colombia 1996
Paraguay 1992
Rep. Dominicana 1997
Brasil 1997
El Salvador 1998
Panamá 1997
Venezuela 1996
Puerto Rico 1997
Barbados 1994
México 1998
Jamaica 1990
Trinidad y Tobago 1994
Years of Life Lost
Men Women
Years of lifeexpectancy lostdue to
mortality fromdiabetesmellitus frombirth to 85years incountries of the Americas, circa1995-1997
Source: PAHO. Health in the Americas,
2002 edition
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Time Data
Usually shown as a graph
– Number / rate of cases on vertical (y) axis
– Time periods on horizontal (x) axis
Used to show trends, day of week / time
of day, seasonality, epidemic period – May look at time of illness onset, whenexposure to risk factors occurred
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An Introduction to Public Health and Epidemiology
Susan Carr , Nigel Unwin , Tanja Pless-Mulloli
D t b D d U S I f ti
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Data by Decades: U.S. InfectiousDiseases Mortality 1906 - 1996
"Crude Death Rate for Inf ectious Diseases: US, 1906-1996" from Epidemiology of Infectious Diseases. Available at:http://ocw.jhsph.edu. Copyright © Johns Hopkins Bloomberg School of Public Health. Creative Commons BY-NC-SA. Adapted
by CTLT from Armstrong, G. L., Conn, L. A., Pinner, R. W. (1999). Trends in infectious disease mortality in the United Statesduring the 20th century. Journal of the American Medical Association, 281, 61?66.
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Data Characterized by Time (days)
"London "Killer" Smog of 1952" from Environmental Health. Available at: http://ocw.jhsph.edu. Copyright© Johns Hopkins Bloomberg School of Public Health. Creative Commons BY-NC-SA. Adapted fromTurco, R. P.
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Person (gender) and Time:
Caribbean trends in Diabetes Mortality
20
30
40
50
60
70
80
R a t e / 1 0 0 , 0
0 0
1985 1990 1995 2000
Male
Female
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Place Data
May include information on home,workplace, school
Can be shown in a table; usually betterpresented pictorially in a map
Two main types of maps used: – Use different shadings/colors to indicate thecount / rate of cases in an area
– Spot maps show location of individual cases
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Data Characterized by Place
http://www.vdh.virginia.gov/epi/Data/region03t.pdf
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Data Characterized by Place
http://www.vahealth.org/civp/preventsuicideva/epiplan%202004.pdf
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Data Characterized by Place
Source: Olsen, S.J. et al. N Engl J Med. 2003 Dec 18; 349(25):2381-2.
Si i l l i i
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Situational Analysis – regionSource: PAHO Basic Indicators 2012 (2010 data)
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Analytic EpidemiologyHypotheses and Study Designs
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Descriptive vs. Analytic
Epidemiology
Descriptive Epidemiology deals with
the questions: Who, What, When, andWhere
Analytic Epidemiology deals with theremaining questions: Why and How
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Analytic Epidemiology
Used to help identify the cause of
disease
Typically involves designing a study to
test hypotheses developed usingdescriptive epidemiology
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Borgman, J (1997). The Cincinnati Enquirer. King Features Syndicate.
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Epidemiology and Public
Health in the 20th and 21st Centuries
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Survival from age 35 for continuing cigarette smokers and
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Copyright ©2004 BMJ Publishing Group Ltd.
Doll, R. et al. BMJ 2004;328:1519
Survival from age 35 for continuing cigarette smokers andlifelong non-smokers among UK male doctors born 1900-
1930, with percentages alive at each decade of age
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New knowledge from Doll studies About half of all persistent cigarette smokers are killed by
their habit —a quarter while still in middle age (35-69 years)
Among British men born 1900-1909, cigarette smokingapproximately doubled the age specific mortality rates in
both middle and old age
Longevity has been improving rapidly for non-smokers, butnot for men who continued smoking cigarettes
On average, cigarette smokers die about 10 years youngerthan non-smokers
Stopping at age 60, 50, 40, or 30 gains, respectively, about3, 6, 9, or 10 years of life expectancy
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Disease Patterns in the
Caribbean
Leading Causes of Death in
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Leading Causes of Death inCARICOM Countries by Sex, 2004
1. Heart Disease
2. Cancers
3. Injuries and violence
4. Stroke
5. Diabetes
6. HIV/AIDS
7. Hypertension
8. Influenza/pneumonia
1. Heart Disease
2. Cancers
3. Diabetes
4. Stroke
5. Hypertension
6. HIV/AIDS
7. Influenza/pneumonia
8. Injuries and violence
MALESFEMALES
Source: CAREC, based on country mortality reports
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Caribbean Successes
Expanded Programme on Immunisation(EPI) in the elimination of indigenouspoliomyelitis, measles and rubella in the
Caribbean The Caribbean has one of the highest rates
of increase in the older populations ( >50years) increasing in part due to thesuccesses of earlier water, sanitation,nutrition, maternal and child healthprograms [i].
[i] George A. O. Alleyne, Chancellor, University of the West Indies: TheChallenges of Managing Cardiovascular Disease and Its Related Co-morbidities among the Elderly in the Caribbean October 8, 2007, ChristChurch, Barbados
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Polio (infantile paralysis)
http://leftbrainrightbrain.co.uk/2008/09/better-dead-than-autistic-2/
http://faculty.ksu.edu.sa/saadeddin/Pictures%20Library/Forms/AllItems.aspx
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Measles (Merck Manual)
cough, coryza, conjunctivitis,
fever, maculopapular rash
enanthem (Koplik's spots) on the
buccal or labial mucosa, Diagnosis is usually clinical.
Treatment is supportive. Vaccination
is highly effective. Worldwide, measles infects about 30
to 40 million annually, causing about800,000 deaths, primarily in children
l lik S
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Measles – Koplik Spots,conjunctivitis, rash, coryza
http://www.pimahealth.org/disease/measlespics.asp
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CRS (Merck Manual)
First trimester infection in themother
– multiple anomalies, or death in utero. – intrauterine growth restriction,
meningoencephalitis, cataracts,retinopathy, hearing loss, cardiacdefects (patent ductus arteriosus andpulmonary artery stenosis),hepatosplenomegaly
Congenital
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CongenitalRubella
Syndrome
Courtesy of Centers for Disease Control and Prevention
Eli i i f l d b ll
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Elimination of measles and rubella
in the Caribbean
1988, CARICOM Ministers of Health resolved toeliminate measles.
1998, selected Caribbean countries focused on rubella
control. Integrated surveillance for both measles and rubella 1995 and 2000, 98%-99% surveillance sites reported
weekly. Suspected cases investigated within 48 h improved
from 89% in 1996 to 95% in 2000.
Irons B, Carrasco P, Morris-Glasgow V, Castillo-Solórzano C, de Quadros CA. Integratingmeasles and rubella surveillance: the experience in the Caribbean (CAREC) J InfectDis. 2003 May 15;187 Suppl 1:S153-7
C ibb S
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Caribbean Strategy
Caribbean vaccination strategy(1) mass vaccination of males and females < 40
yrs with MMR(2) introduction of rubella vaccine into the regular
schedule of infant/young child immunization The strategy in the Caribbean was effective
both in planning and in reality and was cost-effective.
Measles and rubella are no longerindigenous diseases in the English-speakingCaribbean.
http://www.scielosp.org/pdf/rpsp/v14n5/18866.pdf
Measles immunization rate (% of
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Measles immunization rate (% of
children ages 12 –23 months)
Source: World Health organization and United Nations Children‘s Fund estimates
Th Ri f N
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The Rise of Non-Communicable Diseases
Successes of addressingcommunicable diseases, childhood
mortality Longer life expectancy
Urbanization
Globalization
World Health Organization: Global
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g
Causes of Death
CNCD = 60%INJURIES = 10%
COMM / MCH = 30%
Cardiovasculardisease, mainly heartdisease, stroke
Diabetes
Cancer
Chronic respiratory
diseases (asthma)
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"Deaths from Heart Disease as a Percent of Deaths from All Causes" from Fundamentals ofEpidemiology I . Available at: http://ocw.jhsph.edu. Copyright © Johns Hopkins Bloomberg
School of Public Health. Creative Commons BY-NC-SA.
Increases in the elderly
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Increases in the elderlypopulation ≥75 yrs old (in
millions) in the Americas
Source: World Population Prospects: The 2004 Revision.http://esa.un.org/unpp/index.asp?panel=2. 03/15/06
6,1 8,7 12,3
16,4 21,5
29,0
36,7
47,1
69,8
97,7
117,9
0
20
40
60
80
100
120
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
M i l l i o n s
L di i f ti kill ld id
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Leading infectious killers worldwide
"Leading Infectious Killers, Worldwide, All Ages" from Epidemiology of Infectious Diseases. Available at:http://ocw.jhsph.edu. Copyright © Johns Hopkins Bloomberg School of Public Health. Creative
Commons BY-NC-SA. Adapted from WHO, 1999
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Global Patterns ofMortality and Fertility
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Average Life Expectancy
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PAHO Epidemiological Bulletin, Vol. 22 No. 2, June 2001
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Maternal Mortality
There is a bigger gulf in experiencebetween the Global North and theGlobal South in maternal death rates
than there is on any other humandevelopment measure.
The average lifetime risk of maternaldeath – 1 in 8,000 in the rich world
– 1 in 850 in developing countries
– 1 in 450 in least developed countries.
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