No.1 Definition of Health and Wellness

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: [email protected]



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

http://www.mcgraw-hill.co.uk/cgi-bin/same_author.pl?author=Susan+Carr


http://www.mcgraw-hill.co.uk/cgi-bin/same_author.pl?author=Nigel+Unwin

http://www.mcgraw-hill.co.uk/cgi-bin/same_author.pl?author=Tanja+Pless-Mulloli









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.





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



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)



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



What is Public Health?



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.



Clinical epidemiology

Contradiction?

Use of population information for

individual care – Value of tests

– Effectiveness of Treatment

– Prognosis – Evidenced based guidelines



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



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 )



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



History and Achievements in

Public Health and Epidemiology



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)



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.



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‘.



What is Epidemiology?

Looking to answer the questions:

– Who? - person

– Where? - place

– When? - time

– What? – Why?

– How?



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



http://eemb40.blogspot.com/2009/01/preventives-of-cholera.html









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.



Broad Street Pump

http://milesdowsett.com/index.php/blog/article/data-design-the-genius-of-jon-snow/

















http://www.haitiwater.org/news/0608_newsletter.php





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



What is Epidemiology? TheEpidemiology Hall of Fame



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



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



Descriptive EpidemiologyWho? Where? When?

Person

Place Time



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



Data Characterized by Person

http://www.vdh.virginia.gov/std/AnnualReport2003.pdf



U S A Adj d P l f



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



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



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



An Introduction to Public Health and Epidemiology

Susan Carr , Nigel Unwin , Tanja Pless-Mulloli

D t b D d U S I f ti













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.

http://ocw.jhsph.edu/





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.





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



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



Data Characterized by Place

http://www.vdh.virginia.gov/epi/Data/region03t.pdf




http://www.vahealth.org/civp/preventsuicideva/epiplan%202004.pdf




Source: Olsen, S.J. et al. N Engl J Med. 2003 Dec 18; 349(25):2381-2.

Si i l l i i



Situational Analysis – regionSource: PAHO Basic Indicators 2012 (2010 data)



Analytic EpidemiologyHypotheses and Study Designs



Descriptive vs. Analytic

Epidemiology

Descriptive Epidemiology deals with

the questions: Who, What, When, andWhere

Analytic Epidemiology deals with theremaining questions: Why and How



Analytic Epidemiology

Used to help identify the cause of

disease

Typically involves designing a study to

test hypotheses developed usingdescriptive epidemiology



Borgman, J (1997). The Cincinnati Enquirer. King Features Syndicate.



Epidemiology and Public

Health in the 20th and 21st Centuries



Survival from age 35 for continuing cigarette smokers and



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



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



Disease Patterns in the

Caribbean

Leading Causes of Death in



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







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



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





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



Measles – Koplik Spots,conjunctivitis, rash, coryza

http://www.pimahealth.org/disease/measlespics.asp



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



CongenitalRubella

Syndrome

Courtesy of Centers for Disease Control and Prevention

Eli i i f l d b ll



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

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Irons%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Carrasco%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Morris-Glasgow%20V%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Castillo-Sol%C3%B3rzano%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/pubmed?term=%22de%20Quadros%20CA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/pubmed?term=%22de%20Quadros%20CA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract







http://www.ncbi.nlm.nih.gov/pubmed?term=%22Carrasco%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Irons%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract



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



Measles immunization rate (% of

children ages 12 –23 months)

Source: World Health organization and United Nations Children‘s Fund estimates

Th Ri f N



The Rise of Non-Communicable Diseases

Successes of addressingcommunicable diseases, childhood

mortality Longer life expectancy

Urbanization

Globalization

World Health Organization: Global



g

Causes of Death

CNCD = 60%INJURIES = 10%

COMM / MCH = 30%

Cardiovasculardisease, mainly heartdisease, stroke

Diabetes

Cancer

Chronic respiratory

diseases (asthma)



"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






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

http://esa.un.org/unpp/index.asp?panel=2









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





Global Patterns ofMortality and Fertility



Average Life Expectancy

http://filipspagnoli.files.wordpress.com/2008/05/life_expectancy_region.jpg



http://filipspagnoli.files.wordpress.com/2008/05/life_expectancy_1950_2005.jpg

http://filipspagnoli.files.wordpress.com/2008/05/life_expectancy_1950_2005.jpg









http://filipspagnoli.files.wordpress.com/2008/05/infant_mortality_region.jpg



http://filipspagnoli.files.wordpress.com/2008/05/infant_mortality_france.jpg

http://filipspagnoli.files.wordpress.com/2008/05/infant_mortality_france.jpg



PAHO Epidemiological Bulletin, Vol. 22 No. 2, June 2001

http://www.ops-oms.org/english/sha/be_v22n2-cover.htm

http://www.ops-oms.org/english/sha/be_v22n2-cover.htm



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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No.1 Definition of Health and Wellness