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H S P H I N T R O D U C T I O N T O

Public Health

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“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

PUBLIC HEALTH 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


I N T R O D U C T I O N T O P U B L I C H E A LT H 3

HSPH Introduction to Public Health

CONTENTS

What is public health? 4

Public health is distinct from medicine 5

Major global public health challenges 6

Principal tools of public health research 7

The 8 millennium development goals 8

The 20th century's ten great public health achievements 10

A few milestones in public health history 12

Glossary 20

For more information 30

Connect with HSPH online: 31

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


4 I N T R O D U C T I O N T O P U B L I C H E A LT H

Public Health is the science of protecting and improving the health of communitiesthrough education, promotion of healthy lifestyles, and research for disease andinjury prevention. Public health professionals analyze the effect on health ofgenetics, personal choice and the environment in order to develop programs thatprotect the health of your family and community.

The field of public health is highly varied and encompasses many academicdisciplines. 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

What is public health?


• Public health focuses on populations rather thanindividual patients

• Public health emphasizes disease prevention andsystem-wide response over one-on-one treatment

• Public health stresses the social and environmentalaspects of disease in addition to the physiological

• Public health has a strong human rights and socialjustice orientation


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

Public health is distinct from medicine

Because of their shared concern withhealth, public health and medicine areeasily confused, and few peopleoutside the field realize that health isshaped much more by lifestyle, socialnetworks, the environment, and genesthan by medical care. Some specificdistinctions between public health andmedicine include:

Leading causes of death in the U.S.

Medical view

Heart disease 33%Cancer 24%Injuries 14%Other 29%

Public health view

Tobacco 19%Poor diet/lack of exercise 14%Alcohol 5%Infectious disease 4.5%Firearms 1.5%Other 56%


• 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-drugresistant (MDR) diseases such as MDRtuberculosis

• Confronting emerging threats to healthfrom chronic diseases such as diabetes,heart disease, and obesity that arerelated to lifestyle (e.g., diet, exercise,and tobacco consumption)

• Addressing mental illnesses and socialfactors in health

• Understanding climate change andother environmental health threats

• Studying the impacts of war, violence,and terrorism on health

• Advancing practices, protocols, and strategies to achieve diverse goals such asreducing surgical errors or changing social norms around drunk driving

• Developing health and communications systems to improve health-related policy anddecision-making and increase the speed and effectiveness of responses toemergencies such as disease pandemics, natural disasters, or terrorist attacks


“The enjoyment of the highestattainable standard of health is one ofthe fundamental rights of every

human being without distinction ofrace, religion, political belief,economic or social condition.”

— Constitution of the World Health Organization

Major global public health challenges


POPULATION AND NUMERIC DISCIPLINESEspecially epidemiology, biostatistics, and informatics.

LIFE SCIENCES DISCIPLINESFocusing on infectious and chronic diseases as well as nutritional and environmentallinks to ill health. Largely laboratory based, and emphasizing the biological, chemical,

and genetic basis of health and disease.

SOCIAL AND POLICY DISCIPLINESIncluding health policy and management, global health systems, health economics,

and the social and behavioral determinants of health and disease.


Principal tools of public health research

Social and PolicyDisciplines

Population and NumericDisciplines

Life SciencesDisciplines


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 fromhunger

GOAL 2

ACHIEVE UNIVERSAL PRIMARY EDUCATION

• Target 1: Ensure that all boys and girls complete a full course ofprimary schooling

GOAL 3

PROMOTE GENDER EQUALITY AND EMPOWER WOMEN

• Target 1: Eliminate gender disparity in primary and secondaryeducation 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


The 8 millennium development goals

Adopted by 189 heads of state at the United Nations in the year 2000as targets to be achieved by 2015


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 allthose 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 countrypolicies and programs; reverse the loss of environmental resources

• Target 2: Reduce biodiversity loss, achieving by 2010 a significant reduction inthe rate of loss

• Target 3: Halve the proportion of people without access to safe drinking waterand 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-discriminatorytrading and financial system

• Target 2: Address special needs of the least developed countries, landlockedcountries, and small island developing states

• Target 3: Deal comprehensively with developing countries’ debt

• Target 4: In cooperation with pharmaceutical companies, provide access toaffordable essential drugs in developing countries

• Target 5: In cooperation with the private sector, make available the benefits ofnew technologies, especially information and communications technologies

As of 2010, Goal 5 is the one that most lags. While there has been progress, there arestill 350,000 maternal deaths every year. Most of these deaths are preventable.




1. VaccinationPrograms of population-wide vaccinations resulted in the eradication of smallpox; elimination ofpolio in the Americas; and control of measles, rubella, tetanus, diphtheria, Haemophilus influenzaetype b, and other infectious diseases in the United States and other parts of the world.

2. Motor-vehicle safetyImprovements in motor-vehicle safety have contributed to large reductions in motor-vehicle-relateddeaths. These improvements include engineering efforts to make both vehicles and highways saferand successful efforts to change personal behavior (e.g., increased use of safety belts, child safetyseats, motorcycle helmets, and decreased drinking and driving).

3. Safer workplacesWork-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 anddeaths related to mining, manufacturing, construction, and transportation also have decreased; since1980, safer workplaces have resulted in a reduction of approximately 40% in the rate of fataloccupational injuries.

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

5. Decline in deaths from coronary heart disease and strokeDecline 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 detectionand better treatment. Since 1972, death rates for coronary heart disease have decreased 51%.

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



6. Safer and healthier foodsSince 1900, safer and healthier foods have resulted from decreases in microbial contamination andincreases in nutritional content. Identifying essential micronutrients and establishing food-fortification programs have almost eliminated major nutritional deficiency diseases such as rickets,goiter, and pellagra in the United States.

7. Healthier mothers and babiesHealthier 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. Since1900, infant mortality has decreased 90%, and maternal mortality has decreased 99%.

8. Family planningAccess 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 betweenthe birth of children; increased opportunities for preconceptional counseling and screening; fewerinfant, child, and maternal deaths; and the use of barrier contraceptives to prevent pregnancy andtransmission of human immunodeficiency virus and other STDs.

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

10. Recognition of tobacco use as a health hazardRecognition of tobacco use as a health hazard in 1964 has resulted in changes in the promotion ofcessation of use, and reduction of exposure to environmental tobacco smoke. Since the initialSurgeon General's report on the health risks of smoking, the prevalence of smoking among adults hasdecreased, 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


2010: the federal Patient Protection andAffordable Care Act passes, enactingcomprehensive reforms of health care insuranceand access in the U.S. while also ignitingsignificant political backlash.

2008: HSPH researchers led by Atul Gawandejoin with the World Health Organization in asafe surgery initiative, introducing new safetychecklists for surgical teams around the world asa simple, inexpensive, and highly effective wayto reduce millions of deaths and injuries frommedical errors during major surgery. Asubsequent study spanning hospitals in four

countries showed that the use of surgicalchecklists helped cut the rate of majorcomplications in surgery by a third andcontributed to a more than 40 percentreduction in inpatient deaths following majoroperations.

2007: a team of HSPH researchers creates adesigner compound that protects mice from anumber of conditions associated withoverweight, providing a stepping-stone toclinical trials in humans.

2007: the Motion Picture Association ofAmerica (MPAA) adds tobacco use to its criteriafor rating films accessible to America’s childrenand youth. The MPAA responds to pressurefrom parents and a presentation by HSPH DeanBarry Bloom and colleagues of scientificevidence linking media depictions of tobaccouse to smoking in young people.

2006: HSPH’s Richard Cash receives the PrinceMahidol Award for “exemplary contributions inthe field of public health.” Cash has beencredited with saving millions of lives worldwideby promoting a simple means by which peoplein resource-poor settings can provide oralrehydration therapy to individuals sufferingfrom cholera and other diarrheal diseases.

2006: HSPH studies help prompt the U.S. Foodand Drug Administration to rule that, as ofJanuary 1, 2006, all food labels must includetrans fats. The labeling law paves the way fornumerous local bans on these heart-harming fatsacross the U.S. and their removal from manyfoods sold in grocery stores.

1 2 I N T R O D U C T I O N T O P U B L I C H E A LT H

HSPH in 2010Highlighting a few accomplishments from the past year alone:

• HSPH researchers opened new frontiers andbrought new insight to the battle againstmalaria; identified a molecular link betweenobesity and disease; shaped landmark healthlegislation in the U.S.; and helped bansmoking in public places throughout Greece.

• HSPH alumni emerged as leaders on the worldstage, taking up posts such as acting Ministerfor Public Health in Afghanistan; setting up afloating hospital in Haiti in the aftermath ofthe earthquake; and assuming leadership rolesin top academic institutions.

• The School launched flagship initiatives inWomen and Health; Policy Translation andLeadership Development; and ComparativeEffectiveness (studying what really works inhealth practice).

A few milestones in public health history


2005: international health regulations are revisedto help countries work together to identify andcontrol risks of disease outbreaks, industrialaccidents, natural disasters, and other healthemergencies 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 toadvance the fight against three of the world’smost devastating diseases.

2001: the Surgeon General issues a “Call toAction to Prevent and Decrease Overweight andObesity,” which “may soon cause as muchpreventable disease and death as cigarettesmoking."

2001: HSPH researchers identify more efficientand cost-effective strategies for screening womento prevent cervical cancer, demonstrating thatdeaths from the disease could be cut by as muchas half in the developing world, where it is theleading cancer killer among women. In the U.S.,HSPH researchers help set screening guidelinesfor girls and young women for the humanpapilloma virus (HPV), the leading risk factorfor cervical cancer.

2001: beginning one week after the terroristattacks of September 11 and continuing forseveral weeks, a series of bioterrorist attacksinvolving anthrax takes place. Letters containinganthrax spores were mailed to several politicalfigures and news organizations, ultimatelyinfecting 22 and killing five people.

2000: one hundred eighty-nine member states ofthe United Nations adopt the MillenniumDeclaration, a precursor to the MillenniumDevelopment Goals.

1999: HSPH researchers help launch the patientsafety movement, incorporating findings fromthe pivotal Harvard Medical Malpractice Studyinto a landmark Institutes of Medicine report,To Err is Human.

1990: the Nutrition Labeling Act is signed intolaw in the United States, requiringmanufacturers to list the fat (saturated andunsaturated), cholesterol, sodium, sugar, fiber,protein, and carbohydrate contents of allpackaged foods sold in the U.S.

1988: beginning in this year, an HSPH-led massmedia campaign enlists Hollywood’s film andTV industries to help spread a new catchphrase—the “Designated Driver.” Thiscampaign contributes to establishing a newsocial norm: drivers don’t drink. Withincreasing public awareness and new, muchmore severe laws on the books, previously flatdrunk-driving fatality rates fall by 25 percentwithin three years.


HIV virus

continued



A few HSPH achievements in the fight against AIDS

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

• Provided key research that led to the screeningtest used to protect the world’s blood supplyfrom HIV/AIDS.

• Presented the first evidence that HIV/AIDS couldbe transmitted through heterosexual intercourse.

• Conducted the first HIV vaccine trial in southernAfrica.

• Discovered a second human immuno-deficiencyvirus, HIV-2, the cause of most infections in WestAfrica. Also discovered that HIV-2 seems to offersome protection against HIV-1.

• Established a model program in Senegal in themid-1980s, led by world-renowned AIDSresearcher Max Essex, which is now one of thelongest running AIDS programs in Africa.

• Formed a partnership with the government ofBotswana—which had one of the highest ratesof HIV infection in the world—to conductcollaborative, population-centered research andimprove the country’s technical, medical, andstructural capacity to address the epidemic.

• Provided professional training and guidance topartner clinical sites in Botswana, Senegal, andNigeria, which has led to the enrollment of47,000 HIV-infected people, more than half ofwhom are now on anti-retroviral therapy.

• Developed drug treatment regimens in Botswanathat can dramatically reduce the rate of mother-to-child HIV transmission. By revising thestandard AIDS drug regimen, health care workerscan also save HIV-infected mothers who mightotherwise die after developing drug resistance.

• Proved that certain AIDS drug combinationsgiven to pregnant women block 99 percent ofHIV transmission to breastfed babies.

c.1982-2010: the global AIDS epidemic surfacesin the 1980s and rages for decades. Since thebeginning, HSPH has been at the forefront ofefforts to stem the pandemic, focusing onHIV/AIDS laboratory research, clinical trials,education, and leadership.

1980-2010: deaths in the U.S. from heartdisease decline thanks to evidence-basedmedical therapies and a reduction in risk factorssuch as high blood pressure, cholesterol levels,and tobacco smoking.

1980-2008: maternal deaths worldwide areestimated to have dropped from 526,300 to342,900—substantial improvement, but stillshort of the UN Millennium Development Goal 5.

1981: the first diagnosis of the disease laterknown as AIDS is described in the June 5, 1981issue of MMWR (the CDC’s Morbidity andMortality Weekly Report). The New York Times’first article on the nascent AIDS epidemicappears in 1982, written by Robin Herman whois now Assistant Dean for ResearchCommunications at HSPH.

1981: HSPH’s Dimitrios Trichopoulospublishes a groundbreaking studydemonstrating that passive smoke is associatedwith increased lung cancer risk in nonsmokers.

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

Public health milestones


1977: the last known outbreak of smallpox takesplace in Somalia.

1975: HSPH produces the first strong evidencethat a lethal suppression of the immune systemcan be caused by an infectious agent—adiscovery that will play a central role in thescientific understanding of AIDS.

1970: landmark worker and workplace safetylaw, the Occupational Health and Safety Act, ispassed by the U.S. Congress.

1966: the Highway Safety Act and the NationalTraffic and Motor Vehicle Safety Act is passed,authorizing the federal government to set andregulate standards for motor vehicles andhighways.

1964: U.S. Surgeon General Luther T. Terryreleases the landmark Surgeon General’s Reporton Smoking and Health, acknowledging thelink between smoking and lung cancer andother major diseases.

1960s: vaccines are developed for rabies andmeasles, mumps, and rubella.

1960: the contraceptive pill and IUDs becomeavailable to the general public.

1954: Jonas Salk develops a vaccine usinginactivated poliovirus. The vaccine is responsiblefor a reduction in polio cases from 20,000 in1952 to just 2,525 in 1960.

1952: the Great Smog of London—a thickcloud made up mainly of coal smoke that lastsfor five days and causes an estimated 12,000deaths—descends on the British capital. TheGreat Smog eventually leads to newenvironmental research, improved governmentregulation, and increased public awareness ofthe relationship between air quality and health.

1948: the World Health Organization isestablished by the UN to succeed the League ofNations’ Health Organization.

1947: HSPH succeeds for the first time ingrowing the poliovirus in non-nervous systemtissue—a monumental breakthrough that willlead to the development of a protective vaccineand a Nobel Prize for faculty member ThomasWeller.

1946: Communicable Disease Center, nowknown as the Centers for Disease Control andPrevention (CDC), is established in Atlanta,Georgia.

1945: the city of Grand Rapids, Michiganbecomes the first municipality in the U.S. toadd fluoride to its water system.


Polio vaccinations, 1955continued



Spotlight on health-oriented government agencies, programs and multilateral organizations

• CDC/CDCp (Centers for Disease Control and Prevention): the premier U.S. agency forhealth promotion, prevention, and preparedness.

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

• HHS (U.S. Department of Health and Human Services): The U.S. government’s mainagency 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 SurgeonGeneral, and more.

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

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

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

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



1942: HSPH establishes the Department ofNutrition, the first such department in amedical or public health school in the world.

1932-1972: the U.S. Public Health Service,working with the Tuskegee Institute, begins astudy involving 600 black men—399 withsyphilis, 201 without the disease. The study,generally known as the Tuskegee Study, allowedthe disease to progress untreated in its subjects.It was conducted without the informed consentof its participants. Although penicillin isaccepted as the primary treatment for syphilis asearly as 1945, the study continues until 1972,when news articles condemning the study beginto surface. A subsequent court settlementawards $10 million and lifetime medicalbenefits to living participants, and in 1997President Bill Clinton issues a formal apologyfor the conduct of the study.

1930: Assistant Professor Harold Coe Stuart ofHSPH launches the landmark LongitudinalGrowth and Development Study, the first majorstudy of the growth and development of thehealthy child.

1928: Alexander Fleming discovers penicillinwhen he notices by chance that a commonmold, Penicillium notatum, has inhibited thegrowth of colonies of the microbeStaphylococcus aureus on an old culture plate.Use of penicillin as a medicine began in the1940s with the successful isolation of the mold’sactive ingredient and its introduction in apowdery form.

1927: Philip Drinker, HSPH Professor ofIndustrial Hygiene, invents the Drinkerrespirator, which will become known as the“iron lung.” The iron lung enabled polio victimsafflicted by respiratory paralysis to breathe.

1925: HSPH faculty investigate mercurypoisoning in the felt hat industry and take astance against newly introduced leaded gasoline.

1920s: vaccines are developed for diphtheria,pertussis (whooping cough), and tuberculosis.

1913: a joint venture is undertaken betweenHarvard University and the MassachusettsInstitute of Technology (MIT) to form the firstprofessional training program for public healthin America. The program, known as theHarvard-MIT School for Health Officers, is thedirect predecessor of HSPH. Nine years later theschool will split off from MIT, helped by asizeable grant from the Rockefeller Foundation.From the start, faculty members are expected tocommit themselves to research as well asteaching.


Alexander Fleming

continued


1912:Margaret Sanger undertakes an effort todistribute contraceptives and disseminateinformation about family planning, setting inmotion a process that will ultimately establishlegal precedents protecting the right ofphysicians to prescribe contraceptives andprovide advice on birth control to their patients.

1906: in his novel The Jungle, Upton Sinclairdescribes unsanitary conditions in the Chicagomeatpacking industry. Public outrage leads tothe passage of the Pure Food and Drug Act,paving the way for the U.S. Food and DrugAdministration (FDA) to be established.

early 1900s: new data leads to the discovery thatfood contains “vital amines” and that the lack ofthese “vitamins” could contribute to illness.These scientific discoveries and the public healthinitiatives they give rise to, such as foodfortification programs, lead to substantialreductions in nutritional deficiency diseasesduring the first half of the century.

20th century: against the backdrop of two worldwars, the Great Depression, the Cold War, apopulation explosion, and the dawn of thenuclear age, global citizens in the 20th centuryenjoy greater gains in life expectancy than in allother periods of human history combined.According to the CDC, life expectancy at birthin the U.S. increased by approximately 26years—from 49 in 1900 to 77 in 1990. Advances in scientific knowledge have broughtabout improved medical care and sanitation,better nutrition, vaccinations, and other criticaladvances that have helped reduce infantmortality rates and increase life expectancyaround the globe. However, life expectancy stillvaries dramatically among populations, withnearly two thirds of people in high-incomecountries living beyond the age of 70 and fewerthan 25 percent reaching the age of 70 in low-income countries, according to WHO figures.

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

1885-1919: advances in bacteriology, the adventof pasteurization, and improved hygienicconditions contribute to a reduction in infantdeath rates among New York City’s tenementdwellers from nearly 25 percent in 1885 to eightpercent in 1919.

1860s: Louis Pasteur ushers in the modern era ofpublic health with the germ theory of disease.He developed the technique we callpasteurization to rid foods such as milk, cheese,and orange juice of disease-causing germs.



Influenza ward, c. 1913


1840s-1850s: John Snow provides evidence thatcholera spreads through polluted drinking water.Snow maps the outbreak of the disease, andidentifies the famous Broad Street Pump as thesource of the outbreak. He arrests the spread ofthe disease by removing the pump’s handle. Theorganism that causes cholera would not becomewidely known for another 30 years.

1842-3: Edwin Chadwick publishes reports onsanitation in Great Britain, recommending thecreation of a central public healthadministration to provide drains, sewers, streetcleaning, and other environmental regulations.

1840s: the epidemic of puerperal fever caused byunsanitary baby deliveries ends when handwashing with an antiseptic lotion, advocated byOliver Wendell Holmes, becomes commonpractice. Twenty years later, surgeon JosephLister would introduce antisepsis procedures inlabor wards and operating rooms.

1666: the Great Fire of London destroys 80percent of the city. Some historians believe thatone positive effect was that the plague, whichhad ravaged London since 1665, diminishedgreatly due to the mass death of rats and theplague-carrying fleas they brought.

1520: the Aztec population is ravaged bysmallpox introduced by Spanish invaders.

14th century: starting around 1347, the plague(Black Death) spreads across the Europeancontinent, wiping out entire villages andbringing cities such as Paris to a standstill.Quarantine—isolating travelers who came fromplaces known to be infected—was established aspublic health policy in many jurisdictions.


Louis Pasteur

Images of the plague, England, 14th century


10/90 gap: coined by theGlobal Forum for HealthResearch, the term refers to thesmall percentage(approximately 10 percent) oftotal research funding devotedto health problems thataccount for 90 percent of theglobal disease burden. Thepercentages have changed sincethe term was introduced, butthe 10/90 gap remainssymbolic of an ongoingdiscrepancy.

Adjusted life years, disabilityand quality: quality-adjustedlife-years (QALYs) anddisability-adjusted life-years(DALYs) are measuresdeveloped to assess the burdenof disease. These measures,which combine years of lifelost due to premature death with equivalent years of“healthy” life lost due to poorhealth, offer a more nuancedview of disease burden thanmortality alone.

AIDS (Acquired ImmuneDeficiency Syndrome): anincurable disease of theimmune system caused byinfection from the humanimmunodeficiency virus(HIV). First reported in aCenters for Disease Control(CDC) publication in 1981,AIDS so far has killed an

estimated 25 million peopleglobally. According toUNAIDS, about 33 millionpeople in the world are livingwith HIV; two-thirds live insub-Saharan countries.

ART (antiretroviral therapy): acombination of drugs thatsuppresses the HIV virus. ARTdoesn’t cure AIDS, but thetherapy can significantlyprolong the life of someoneliving with HIV/AIDS bykeeping HIV under control.

Capacity building: coordinatedinvestment in upgradingpeople’s skills and educationand strengthening systems,institutions, and practices sothat countries or communitiescan achieve developmentobjectives. Capacity is builteffectively when countries canmanage their own affairs withless reliance on donor aid.

Case-control study: anepidemiological study designthat compares subjects with acertain condition (cases) tosubjects without the condition(controls).

Causality: determiningcausality—what causes lead toparticular outcomes—isamong the fundamental tasksof epidemiology. A “necessary

cause” is one that is alwayspresent when a given outcomeoccurs, but may not be thesole cause of that outcome ormay lead to that outcome onlywhen combined with othercauses. A “sufficient cause”indicates a cause that alwaysand inevitably leads to a givenoutcome.

Chronic diseases: medicalconditions that are long-lasting, such as diabetes,cardiovascular disease, andsome cancers. Chronic diseasesare the leading causes of deathin developed countries such asthe U.S. and are increasinglyprevalent in emergingeconomies such as India,China, and Africa. Undersome circumstances, such aswhen HIV/AIDS is beingtreated with ART, infectiousdiseases can be chronic.A large body of HSPHresearch has shown that overhalf of cancer deaths and alarge majority of diabetes andcoronary heart disease cases inthe U.S. could be preventedwith lifestyle changes,including exercise, weightcontrol, dietary improvements(healthy fats andcarbohydrates, moderatealcohol, plenty of fruits andvegetables), and smokingcessation.


Glossary

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


Clinical trials: investigate thesafety and benefits of healthcare treatments, screeningefforts, prevention methods,and other facets of medicalpractice. They can takedifferent forms. According tothe NIH, “interventionalstudies are those in which theresearch subjects are assignedby the investigator to atreatment or otherintervention, and theiroutcomes are measured.Observational studies are thosein which individuals areobserved and their outcomesare measured by theinvestigators.” The double-blinded randomized controltrial is the gold standard ofclinical trials and can form thebasis for establishing a causalrelationship between theintervention and outcome.

Cohort study: a type of studythat follows a group ofindividuals (a cohort) overtime, compares differencesamong members of the cohort,and identifies associationsbetween certain characteristics,behaviors, and/or other factorsand particular healthoutcomes. The Nurses’ HealthStudy and the FraminghamHeart Study are examples ofcohort studies.

Comparativeeffectiveness/costeffectiveness research:research that aims to identifythe best values for limitedhealth care dollars.

Confidence interval: indicatesthe margin of error when apopulation sample is used toestimate a value for the entirepopulation. Wider intervalsindicate a lower degree ofcertainty in the populationestimated.

Demographic dividend: aconcept developed by HSPHeconomist David Bloom andcolleagues in part to explainthe pattern of rapid economic

growth seen in the “Asiantiger” economies—HongKong, Taiwan, Singapore, andSouth Korea—after WorldWar II. The demographic dividend results from ademographic shift thattypically takes place indeveloping countries asadvances in health care andpublic health bring about atransition from high birth ratecoupled with high childmortality to lower birth ratecombined with lower childmortality. At an early stage inthis transition, when mortalityrates have fallen but birth rateshave not yet come down inproportion, a “baby boom”takes place. When educational


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

continued


opportunities and otherpositive social forces are inplay, the baby boomgeneration ignites rapideconomic growth as it entersthe workforce and expandslabor supply while falling birthrates simultaneously reducethe number of childdependents. For perhaps 50years, a bulge in thepopulation of educated,working-age adults driveseconomic growth andprosperity, and the countryreaps the demographicdividend.

Diarrheal diseases: severediarrhea leads to dehydrationand can be life threatening,especially to young childrenand those with weakenedimmune systems. Sources ofinfection include bacteria,viruses and parasites, which areusually ingested withcontaminated food or drinkingwater. These diseasesaccounted for 50 percent ofinfant deaths in New YorkCity as of 1882. Today, theyremain the fifth leading causeof death globally and thesecond leading cause of deathamong children under 5.Diarrheal diseases kill 1.5

million children every year, 80percent of them under the ageof 2. See also, Oral rehydrationtherapy.

Environment: used in publichealth to encompass all of theextrinsic factors affectinghealth including not justenvironmental pollution butalso diet, exercise, smoking,drugs, and social exposuressuch as racism or violence.

Epidemiology: the study of thedistribution and determinantsof disease in a population.Epidemiologists identify riskfactors for diseases andstrategies to prevent them bystudying data from largepopulations.

Epidemic: when a diseasespreads widely and oftenrapidly from person to person,affecting large groups. Anepidemic becomes a pandemicwhen it has spread over asignificant geographical area,usually crossing into multiplecountries as in the case of aglobal flu pandemic.

Evidence-basedpolicy/evidence-baseddecision-making: applies thesame basic principle used todetermine treatments inmedical practice—thatobjectively verifiableinformation achieved throughrigorous scientific testing isrequired to determine effectivecourses of action—in therealm of public policygenerally and health policy inparticular.

Food pyramid: food pyramidshave been used for decades todiagram governmentrecommendations for foodintake. The current U.S.government version is knownas “My Pyramid.” HSPHfaculty (Walter Willett andothers) have developed analternative called the HealthyEating Pyramid. Thefoundation of the HealthyEating Pyramid is dailyexercise and weight control.Other layers emphasize eatingwhole grains and vegetables,while red meat, refined grains,sugary drinks, and salt are leastencouraged.


Glossary


Framingham Heart Study:begun in 1948, theFramingham Heart Study is aresearch project directed by theNational Heart, Lung andBlood Institute (NHLBI) oncommon factors thatcontribute to cardiovasculardisease (CVD). The studyfollows the development ofCVD over a long period oftime in a large group ofparticipants. The originalcohort consisted of 5,209 menand women between the agesof 30 and 62 from the town ofFramingham, Massachusetts.Since then, the Study hasadded several additionalcohorts and yielded valuable

findings on the effects of bloodpressure, blood triglycerideand cholesterol levels,psychological factors andmore.

Gene expression: refers to theprocess by which genetic traitsare “turned on” or “turnedoff” in an organism. Geneexpression can be affected byenvironmental and behavioralas well as inherited factors. Forexample, a geneticpredisposition to cancer mightnot become manifest unlesstriggered by exposure totobacco smoke.

Global Burden of DiseaseStudy (GBD 1990 Study andGBD 2010 Study): the WorldBank commissioned the firstGlobal Burden of DiseaseStudy (GBD 1990 Study) in1991 to undertake acomparative assessment ofglobal and regional burdensfor more than 100 diseases andinjuries and ten designated riskfactors. The new GlobalBurden of Diseases, Injuries,and Risk Factors Study (theGBD 2010 Study) began in2007 and is led by aconsortium that includesWHO, Harvard, and severalother universities around theworld. Government and non-


HEALTHY EATING PYRAMIDDepartment of Nutrition, Harvard School of Public Health

continued


governmental agencies havemade extensive use of GBDStudy results to set research,funding, policy, and otherpriorities.

Global Fund to Fight AIDS,Tuberculosis and Malaria: aninternational public/privatefinancing institution that hascommitted $19.3 billion in144 countries since 2002 tosupport large-scale prevention,treatment, and care programsagainst these three diseases.

GHI (Global Health Initiative):launched in 2009 by the U.S.government with $63 billionin funding, this effort aims toimprove health outcomes inpartner countries using abusiness model approach tostrengthen health systems. TheGHI focuses in particular onimproving the health ofwomen, newborns, andchildren through programsaimed at infectious disease,nutrition, maternal and childhealth, and safe water.

Health disparities: gaps inhealth and quality of healthacross racial, ethnic, andsocioeconomic groups, bothwithin a country and betweencountries. See also, 10/90 gap.

Healthy People 2010: a healthpromotion program featuring467 health objectives forAmericans led by the U.S.Department of Health andHuman Services. The HealthyPeople initiative began in 1979under the leadership ofSurgeon General JuliusRichmond and has released aseries of reports at roughly ten-year intervals since itsinception.

HPV (human papillomavirus):the principal risk factor forcervical cancer, which is theleading cancer killer of womenin the developing world.

Incidence vs. prevalence: inepidemiology, incidence is ameasure of the number of newcases for a given disease in apopulation, while prevalence isa measure of the total numberof cases present in thatpopulation. For chronicdiseases, prevalence mayremain high even whenincidence falls.

Infant mortality: the widelyused WHO definition ofinfant mortality rate is thenumber of deaths during thefirst 28 completed days of lifeper 1,000 live births in a givenyear or period.

Influenza (flu): a viralinfection, flu is estimated tokill between 250,000 and500,000 people every year.Outbreaks of flu tend to beseasonal and can becomepandemic, spreading rapidlyand affecting many people.For example, the 1918 Spanishflu, now thought to be a strainof avian flu, killedapproximately 50 millionpeople. The recent H1N1 fluwas declared a pandemic butwas not as severe as feared.Worldwide response to H1N1illustrated both strengths andweaknesses in the ability ofvarious health systems toeffectively prepare for, respondto, and contain futurepandemics or possible terroristattacks involving biologicalagents.


Glossary


Knowledge translation: guidespolicy and practice based onevidence. Knowledgetranslation is part of whatHSPH Dean Julio Frenkdescribes as the “circle ofknowledge,” which includes“the production of knowledgethrough research, the re-production of knowledgethrough education, and thetranslation of knowledge intoevidence.”

Leading health indicators:individual behaviors, physicaland social environmentalfactors, and important healthsystem issues that affect thehealth of individuals andcommunities.The leading health indicatorsas defined by the U.S.government are:

• Physical activity• Overweight and obesity• Tobacco use

• Substance abuse• Responsible sexual behavior• Mental health• Injury and violence• Environmental quality• Immunization• Access to health care

Underlying each of theseindicators is the significantinfluence of income andeducation.

Life expectancy: a keyindicator of overall quality oflife, which can be measured atvarious points in the lifespan. The CIA World Factbookranks life expectancy at birthfor every country in the world.Below are a few samplestatistics for life expectancyfrom the Factbook (2010estimates):

• 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-bornedisease that is a growing publichealth problem in the U.S.Lyme disease is transmitted bythe bite of infected ticks.Symptoms are initially flu-likebut the disease, if leftuntreated, can impact the

joints, heart and nervoussystem. In the late 1970sHSPH scientists identified arecently discovered tick speciesas the vector of Lyme disease,which was then a newlyemerging infection.

Longitudinal study: a researchdesign in which the samepeople are observed over time(sometimes over decades) forrisk factors and healthoutcomes. Researchers do notcontrol factors (for example,no one is randomly assigned toeat a high- or low-fat diet), sothey cannot prove that theeffect was caused by thatfactor. However, longitudinalstudies reveal associations offactors with certain outcomes.See Nurses’ Health Study.

Malaria: once on the brink ofelimination, malaria has comeback with a vengeance. About3.3 billion people—half of theworld’s population—are at riskof malaria today. An estimated247 million people areinfected every year. The diseasecauses debilitating cycles ofpain, fever, coma, and evendeath. Malaria is one of themajor public health challengesundermining development inthe poorest countries in theworld and is the secondleading cause of death from


Circle of knowledge

continued


infectious diseases in Africa,after HIV/AIDS. Most of thenearly one million livesclaimed by malaria every yearare impoverished children insub-Saharan Africa.

Maternal mortality: the widelyused WHO definition ofmaternal mortality rate is thenumber of deaths of womenwhile pregnant or within 42days of termination ofpregnancy, from any causerelated to or aggravated by thepregnancy or its management,per 100,000 live births.

Metabolic syndrome: aconstellation of interrelatedconditions that includeoverweight, high blood sugars,high blood fats, and highblood pressure. It is linked toincreased risk of diabetes andheart and blood vessel disease.

MDGs: MillenniumDevelopment Goals. In 2000,189 heads of state met at theUN and endorsed theMillennium Declaration, acommitment to work togetherto build a safer, moreprosperous, and equitableworld. The Declaration wastranslated into a roadmapsetting out eight goals with theobjective of reaching them by2015. According to WHO, some countries have made

impressive gains in achievinghealth-related targets, whileothers, particularly thoseaffected by high levels ofHIV/AIDS, economichardship, or conflict, arefalling behind.

MDR (multi-drug resistant):diseases such as multi-drugresistant tuberculosis (MDR-TB) and extensivelydrug-resistant tuberculosis(XDR-TB) cannot beeffectively treated with first-line drugs (FLDs) andstandard treatment regimensbecause the disease-causingorganism has developedresistance to the FLDs. MDRdiseases require the use, oftenover prolonged periods oftime, of less optimal and/ormore expensive second-linedrugs (SLDs). The U.S.National Academy of Sciencesfirst reported on the dangersof antibiotic-resistant diseasesin 1992.

Microfinance: provision ofsmall loans, savings, andfinancial assistance to poorpeople who would otherwisenot have access to theseresources. Clients of IFC(International FinanceCorporation), the World BankGroup’s lead investor inmicrofinance, disbursed $16billion in 2008.


Glossary

continued

Morbidity: the presence of adiseased or unhealthy condition.Mortality refers to the terminalresult of morbidity or other causes.

Mother-to-child transmission: aprime route by which HIV can betransmitted.

Nurses’ Health Studies: TheNurses' Health Study, establishedin 1976 by HSPH’s Dr. FrankSpeizer and the Nurses' HealthStudy II, established in 1989 byHSPH’s Dr. Walter Willett, areamong the largest prospectiveinvestigations into the risk factorsfor major chronic diseases inwomen. The studies includeclinicians, epidemiologists, andstatisticians at HSPH, theChanning Laboratory, HarvardMedical School, and a number ofmajor hospitals. The studies havefollowed approximately 238,000female nurses for as long as 30years, surveying them every twoyears. The studies have resulted inmore than 265 published scientificpapers and revealed associationsbetween health factors such asfood, exercise, and medications,with illnesses.

NGOs (non-governmentalorganizations): also known asPVOs (private voluntaryorganizations). By some estimates,NGOs contribute as much as 20percent of all external health aidto developing countries.



Spotlight on non-governmental organizations focused on public health and related issues

• Doctors Without Borders, aka Médecine Sans Frontières (MSF): provides medical careto people in crisis, serving affected communities on the ground during and in theimmediate aftermath of war, natural disaster, epidemic, and famine. MSF operates innearly 60 countries around the world and was awarded the Nobel Peace Prize in 1999.

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

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

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

• Partners In Health (PIH): takes a partnership and solidarity-based approach tostrengthening health care services in underserved communities and providing apreferential option for the poor in health. Then-Harvard medical student Paul Farmerand others founded PIH in 1987. Farmer and the work of PIH—first in Haiti and laterin 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 PeopleEverywhere) is well known for the SS HOPE, which was the world’s first peacetimehospital ship. Project HOPE now provides medical training, health education, andhumanitarian assistance in more than 35 countries.


Oral rehydration therapy(ORT): a simple treatment(swallowing a salt, sugar, andboiled water solution) fordehydration from diarrhea-causing diseases, includingcholera and rotavirusinfection. It saves millions of children each year from deathdue to diarrhea. HSPH’sRichard Cash played a key rolein proving ORT is effectiveand practical when he and hiscolleagues conducted the firstclinical trials of the therapy.

Pandemic: See Epidemic.

PEPFAR (U.S. President'sEmergency Plan for AIDSRelief): history-making effortto establish and build onAIDS/HIV prevention andtreatment programs in theworld’s hardest-hit regions.Launched in 2003, the planwas reauthorized in 2008 withfunding up to $48 billion over five years to combat globalHIV/AIDS, tuberculosis, andmalaria.

Relative risk: indicates thedegree to which, all otherfactors being equal, thepresence of a particular geneticmarker or risk factor increases

the likelihood of developing acertain condition.

Robin Hood Index: a measureof income equality thatattempts to determine theamount of wealth that wouldhave to be redistributed fromrich to poor in order toachieve parity. Higher RobinHood Index scores signalgreater disparities in wealth.

Seguro Popular (PopularHealth Insurance): started in2004, a program ofcomprehensive national healthinsurance that has expandedaccess to health care for tens ofmillions of previouslyuninsured Mexicans. Theeffort was spearheaded by


Glossary

Major foundations donating to public health research and programs

Foundations 2009 Assets 2009 Grants• Bill and Melinda Gates Foundation $34 billion $2.6 billion• Ford Foundation $10.4 billion $490 million• Robert Wood Johnson Foundation $8.1 billion $355 million• Atlantic Philanthropies $3 billion $375 million• Rockefeller Foundation $3.2 billion $143 million

All figures are approximate.


then-Minister of Health JulioFrenk, MD, PhD, now thedean of HSPH. Six Cities Study: one of themost influential, innovative,and longest-runningexperiments concerning thehealth effects of air pollutionin America. Begun in 1974,the study linked fine particleemissions from fossil fuels toincreased death rates,particularly deaths related tocardiovascular disease. Thestudy led to a revision ofexisting air quality standardsby the EPA. HSPH’s DouglasDockery and his colleaguespublished their findings in theNew England Journal ofMedicine in 1993.

Social determinants of health:socioeconomic conditions thatinfluence individuals’ healthand risk of early death. Thesefactors can include economicdeprivation, discrimination,and lack of access to healthservices, as well as violation orneglect of human rights.Taking action to address socialdeterminants of health hasbeen identified by WHO asessential to advancing healthequality.

SNS (Strategic NationalStockpile): a large supply ofmedicines and medicalsupplies held by the CDCagainst the possibility of localshortages during future publichealth emergencies (e.g.,epidemic, natural disaster, andterrorist attack).

TB (tuberculosis): an infectiousdisease that attacks the lungs.TB can be asymptomatic andlatent but also can progress toan active form. People with theactive form can spread theillness through coughing,sneezing, and speaking, and ifleft untreated, the active formcan be fatal. TB is notoriousfor its ability to developresistance to drug treatments,and the illness is the cause ofdeath for as many as half ofpeople living with AIDS. Seealso, MDR (multi-drugresistant).

Vector: in medicine andepidemiology, the carrier ortransmitter of disease from oneorganism to another. Forexample, mosquitoes arevectors of malaria. In genetics,the vector is the transmitter ofgenetic material from one cellto another.


Major corporate donors to publichealth research and programs

• Abbott Labs • Bristol Myers Squibb • Exxon Mobil • Johnson & Johnson • Merck • Pfizer



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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CONTACT:Sarah WoodDirector of Volunteer LeadershipOffice for External RelationsHarvard School of Public Health401 Park Drive, Third Floor EastBoston, MA 02215Phone: 617-384-8992 Fax: 617-384-8989 Email: [email protected]

Connect with HSPH online:


The dramatic achievements of Public Health in the 20th century have improved ourquality of life: an increase in life expectancy, worldwide reduction in infant andchild mortality, and the elimination or reduction of many communicable diseases.

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

Today, Public Health leaders continue to strengthen their roles as advocates forimproved 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.

Impact of public health

© Harvard School of Public Health, 2010


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