CONTENTS

1 Public health practice: Selected issues ........................................................................................................... 3 1.1 1.2 1.3 2 Coronary heart disease .......................................................................................................................... 3 Abortion and fertility ............................................................................................................................. 3 Violence ................................................................................................................................................. 3

Public health in practice: Selected countries ................................................................................................. 4 2.1 2.1.1 2.1.2 2.1.3 2.1.4 2.1.5 2.2 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.2.6 2.2.7 2.2.8 2.2.9 2.2.10 2.2.11 2.3 2.3.1 2.3.2 2.3.3 2.3.4 2.4 2.4.1 2.4.2 2.4.3 2.4.4 2.4.5 France .................................................................................................................................................... 4 Major health problems facing the country ....................................................................................... 4 Organisation, provision, utilisation and impact of health services ................................................... 4 The strengthening of health administration structures and human resources ................................ 4 Major challenges for the health services .......................................................................................... 4 Economic impact and feasibility ........................................................................................................ 4 Germany ................................................................................................................................................ 5 Major health problems facing the country ....................................................................................... 5 Age, gender and social class effects .................................................................................................. 5 Nutrition ............................................................................................................................................ 5 Environmental hazards...................................................................................................................... 5 Provision, utilisation and impact of health services .......................................................................... 5 Organisation of health services ......................................................................................................... 5 Public and private health insurance .................................................................................................. 5 Preventive health care ...................................................................................................................... 5 Rehabilitation services ...................................................................................................................... 6 Public health services .................................................................................................................... 6 Major challenges ........................................................................................................................... 6

United Kingdom ..................................................................................................................................... 6 Public Health ..................................................................................................................................... 6 Teaching and Research ...................................................................................................................... 7 Functions of public health ................................................................................................................. 7 Major problems for the future .......................................................................................................... 7 United States ......................................................................................................................................... 7 Population and health ....................................................................................................................... 7 Infectious diseases ............................................................................................................................ 7 Chronic conditions............................................................................................................................. 7 Mental health .................................................................................................................................... 8 Access to primary health services and poverty ................................................................................. 8

2.4.6 2.4.7 2.4.8 2.4.9 2.4.10 3

Prevention - Controlling environmental and nutritional risk factors ................................................ 8 Measures for change ......................................................................................................................... 8 Infrastructure of training and research in public health ................................................................... 8 The environment ............................................................................................................................... 8 Availability of personal health services ......................................................................................... 9

Conclusions................................................................................................................................................... 10

PUBLIC HEALTH PRACTICE: SELECTED ISSUES

The fact that public health is multidisciplinary, affected by many sectors, and tackled in various ways based on its overlapping domains is demonstrated in the following examples. These discuss important considerations in dealing with three specific public health issues. 1.1 CORONARY HEART DISEASE

Risk factors for coronary heart disease include high blood pressure, obesity, smoking, and a lack of exercise. At a local level, GPs and community pharmacies may run blood pressure screening programmes so that individuals are aware of their blood pressure and subsequent disease risk; individuals with increased risk should then receive follow-up care to treat their blood pressure. Local authorities should also offer smoking cessation services; whilst at the national level, government should implement policies, such as smoking bans and ensure that smoking prevention education occurs in schools. Also, individual behaviours such as diet and exercise are very much constrained by structural issues, such as environment and access to healthy food. Regional and local planning commissions must ensure that sports facilities are available to all and that cost is not a barrier to sport. Moreover, at the national level, the government can set targets for supermarkets to reduce the amount of salt in their prepared foods and explore the option of subsidising the cost of healthy foods, such as fruit and vegetables. 1.2 ABORTION AND FERTILITY

Abortion and fertility are significant public health issues, particularly in areas which have high abortion rates. The government should ensure appropriate sexual education in schools, and easy access to contraception, such that cost is not a barrier for those unable to afford contraceptive measures. Sexual health clinics should be easily accessible, staff should be supportive, and it should not be difficult or stigmatizing for a woman to utilize these clinics. 1.3 VIOLENCE

Violence includes road accidents, family violence and industrial accidents, all of which may or may not be related to alcohol, drugs and education. Towards achieving the public health goal of reducing road accidents, appropriate alcohol and drugs policies at the national level should be adopted to prevent drink driving, and should be followed up with appropriate education, both in schools and more widely. Preventing family violence is also within the realm of education. For instance, children living in a violent household may not realise that what is happening to them in not right. Additionally, teachers and other educators should be trained to notice signs of abuse and to have a system in place where they can report these to the local authorities and know that these will be addressed. Finally, industrial accidents should be prevented through both a system of worker education and training, which is the responsibility of their employer, and through industrial regulation that is ensured through worksite safety inspections carried out by government authorities.

PUBLIC HEALTH IN PRACTICE: SELECTED COUNTRIES

In the present chapter examples of public health structure, functions, etc. in selected countries are provided. These include France, Germany, the United Kingdom and the United States. 2.1 FRANCE

France has a total population of around 57 to 58 million. French citizens benefit from a wide coverage in terms of health services and enjoy, in theory, quasi universal access. Thus cost-containment issues and various question marks about health system efficiency are prominent as in most other countries. 2.1.1 MAJOR HEALTH PROBLEMS FACING THE COUNTRY

Since 1960, national health surveys have provided a description of the morbidity of the French population. Average life expectancy at birth is similar to that of most other western developed countries, almost 80 years. Cardiovascular diseases are the leading cause of death but at a lower rate than in other European countries. Mental illnesses are a major problem. Following the same pattern as in most industrialised countries, 3 factors are important contributors to chronic disease: partial control of previously rapidly lethal diseases, increase of life span for chronic diseases and the ageing process of the population with more co morbidities in the late years of life. 2.1.2 ORGANISATION, PROVISION, UTILISATION AND IMPACT OF HEALTH SERVICES

The Ministry of Health is the leading public authority on health affairs. Medical research is under supervision of the Research Ministry. Health issues and health care services organisation are systematically discussed with the Finance Ministry. The Health Ministry, with the Finance Ministry, play a key role in the control of social security. In France, despite the existence of a national health insurance system, 2 sectors coexist for the organisation of health care delivery. The public sector concerns mostly hospital care, where two thirds of acute care beds are directly managed by the public administration. The private sector is based on liberal practice and serves a larger part of ambulatory care. All health institutions are subject to the control of the state, aimed at improving safety, improving the quality of health care services and adapting them to the changes of technology and needs. Professional organisations have only a secondary say in these matters. 2.1.3 THE STRENGTHENING OF HEALTH ADMINISTRATION STRUCTURES AND HUMAN RESOURCES

The undertaking of global programmes on perinatal care, anaesthetic safety, emergency care and networks for the care of target groups such as Aids and alcoholism are examples of recent developments. 2.1.4 MAJOR CHALLENGES FOR THE HEALTH SERVICES

The main objectives proposed for the coming years by the High Committee of Public Health are derived from 4 major goals: reduce avoidable deaths, reduce avoidable handicaps, improve the quality of life for patients and disabled persons and reduce inequities in health. Specific objectives, which focus on key health problems, representing the main identified priorities in terms of severity, have been developed. 2.1.5 ECONOMIC IMPACT AND FEASIBILITY

The main targets include the reduction of traffic accidents, domestic accidents, work accidents and cancer prevention. Special attention is being paid to reduce HIV infection. Some health determinants are also considered as key objectives because of their known detrimental impact on health e.g. tobacco and alcohol. The last issue is a great concern, as is environmental health and pollution control. In Paris hospitals, childrens consultations for respiratory disease are linked to air pollution in one case out of three. Waste elimination, water control and toxic agent exposure still need to be reduced.

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GERMANY

Germany has a population of around 82 million. The birth rate has been declining and, like most countries, the population structure is showing an increase in the proportion of the elderly. 2.2.1 MAJOR HEALTH PROBLEMS FACING THE COUNTRY

Infectious diseases notifiable diseases are in the majority. Immunisation rates could be improved. HIV infections are a very important problem, as is virus hepatitis. Chronic illnesses are becoming an increasing problem with rates of disablement rising in all age groups, particularly amongst the elderly. Mental health is a major problem. 2.2.2 AGE, GENDER AND SOCIAL CLASS EFFECTS

Health and illness correlate in numerous ways with age and gender. Illness and health are linked to social position. Some 6.5 million of Germanys 80+ million inhabitants are from abroad. These show a higher infant mortality and higher mortality rate in all age groups, particularly amongst the young. 2.2.3 NUTRITION

Several diseases are considered to be precipitated by nutrition that may be caused by a deficiency as well as an excess of supply of nutritional elements. The proportion of obese people is increasing, particularly with age. Amongst women aged over 65, 30% can be considered heavily overweight. 2.2.4 ENVIRONMENTAL HAZARDS

In the last 10 to 15 years, there has been an increase in emphasis on environmental and epidemiological hazards and several Chairs for Environmental Health have been created at a variety of universities. There are still, however, few population studies and the research lacks sophistication. Individual studies have been done on chemical solvents, carcinogenic compounds and the effects of climate change and traffic emissions. 2.2.5 PROVISION, UTILISATION AND IMPACT OF HEALTH SERVICES

With the implementation of a statutory social insurance system throughout Germany, there is a comprehensive social safety net including statutory health insurance, statutory accident insurance, statutory pension insurance and statutory unemployment insurance. 2.2.6 ORGANISATION OF HEALTH SERVICES

There are 3 components of the German health system: 1) ambulatory medical care through private practice 2) inpatient medical care in hospitals 3) public health services 2.2.7 PUBLIC AND PRIVATE HEALTH INSURANCE

The German social insurance system is based on legislation formulated towards the end of the nineteenth century. The most significant elements, that are still valid, are the statutory insurance for employees under a certain level of income (those above a certain level can opt out), the right of the insured to benefits, mandatory employer contributions and self-governing insurance companies. The relationship between the health care providers, the insured and the insurance organisations is summarised in a social code which consists of ten volumes. Its declared goal is the realisation of social justice and social security. 2.2.8 PREVENTIVE HEALTH CARE

The preventive health care system is subdivided into different areas. Health education in kindergartens and schools is subject to the jurisdiction of the education departments in the individual states. Different organisations on the federal, state and city level are engaged in health education through the public media.

They are usually joined at the national level. On the state level, activities on prevention and health promotion are carried out by the central state associations. The health insurance legislation obliges physicians and health insurers to support health promotion and illness prevention. 2.2.9 REHABILITATION SERVICES

The German system of rehabilitation is based on medical, professional and educational rehabilitation. It relies on the support of several institutions: Statutory Pension and Health Insurance, the National Ministry for Labour and the Welfare Offices. 2.2.10 PUBLIC HEALTH SERVICES Among the tasks of government with respect to the health care system are the following: 1) National and state specific health administration 2) Health administration of the statutory health and pension insurance companies 3) Public health offices of the states, communes and cities. 2.2.11 MAJOR CHALLENGES The major challenges that Germany faces are common to most developed countries. Namely, changes in disease pattern, changes in demand by populations, increasing differentials in the development of illness in different social groups, increasing cost of institutional services, problems with personal data and how population health can be improved. 2.3 UNITED KINGDOM

Infectious diseases play a rather lesser role in being a health problem as in most other western countries. There is a National Health Service which is funded largely from taxation. The basic principle of health care delivery is that all health services are provided for free although co-payments need to be made for drugs, dental services and for ophthalmic services, depending upon the age of the individual patient and their income. There is no bar on private practice and about 12 to 14% of the population is insured privately. Private practice is largely used for elective surgical care. Every member of the population is registered with a general practitioner to whom they have to go if they have a complaint or wish to seek medical care. The general practitioner may provide the care, or will refer the individual to a hospital and specialist services. 2.3.1 PUBLIC HEALTH

Public health development in the UK goes back several hundred years and dates back to concern of Local Authorities with the diseases of poverty (e.g.dysentery, erysipelas) in the 19th Century. The first Medical Officer of Health was appointed in Liverpool around 1850, followed soon after by the appointment of a Medical Officer of Health for London, followed by a Chief Medical Officer to the Local Authority Board, the forerunner of the Ministry of Health. Since the middle of the 19th Century, each local authority has had a public health department headed by a Medical Officer of Health. In 1974 there was a restructuring of the NHS whereby public health, which was a function of Local Authority, became a function of the NHS. Since 1974 there has been a series of reorganisations in the structure of public health within the NHS but functions and responsibilities have remained essentially the same. Each Primary Care Trust has a Director of Public Health and a staff of several specialists in public health. Some of these will be medically qualified. The Health Protection Agency, staffed by microbiologists and epidemiologists, is responsible for the control of infectious disease and toxic hazards.

2.3.2

TEACHING AND RESEARCH

Since the mid-1930s there has been a development of academic Public Health Departments in all English medical schools which received a particular impetus after the end of World War II. Since 1968, all medical schools have had Departments of Public Health under a variety of different names, such as Epidemiology, Public Health, Public Health Sciences and Community Medicine. These departments are responsible for the teaching of public health to all future doctors who have to pass a final examination in the subject in order to be able to practice Medicine. Public health is also taught in a variety of other academic institutions to non-medical individuals such as nurses, sanitary engineers and so on. There is a National School, The London School of Hygiene and Tropical Medicine, which is one of the institutions responsible for postgraduate training in public health. However, it is important to appreciate that postgraduate training in public health occurs in other university institutions as well, in fact, most universities and medical schools are involved. 2.3.3 FUNCTIONS OF PUBLIC HEALTH

1) The surveillance of the health of the population centrally and locally. 2) To encourage and develop policies both central and local to promote and maintain health. 3) To ensure that the means are available to evaluate existing health services and to undertake these evaluations. 2.3.4 MAJOR PROBLEMS FOR THE FUTURE

Major problems are similar to those of other countries, namely the ageing of the population, change in the incidence of disease and the relationships between clinical medicine and public health medicine. General practitioners are responsible for much health promotion work, usually together with public health departments. A major function in the future is likely to be the development of appropriate programmes for long term continuing care of individuals developing chronic disease such as diabetes, dementia and so on. 2.4 2.4.1 UNITED STATES POPULATION AND HEALTH

The population in the United States is more than 260 million. It is one of the most diverse populations on earth and has become increasingly heterogeneous in the twentieth century. Blacks comprise more than 15% of the population. The largest percentage increase however, is among Asian and Pacific islanders. Immigration patterns have dramatically affected ethnic composition. The number of immigrants to the United States from Mexico and Central America has doubled from around 1.65 million to over 3 million now. European immigrants have decreased very considerably. 2.4.2 INFECTIOUS DISEASES

Advances in public health have vastly reduced the occurrence of infectious disease epidemics and pandemics. The nations current experience, however, with HIV, as well as other infectious diseases such as Hantavirus and Lyme disease is a sobering reminder that serious microbial threats to health remain. Vaccines are one of the most cost effective means for prevention of infectious diseases. Although there are more than 20 diseases that can be prevented through the use of vaccines, many diseases have no vaccine available. This means that vaccine development is an important consideration for the control of microbial threats to health. 2.4.3 CHRONIC CONDITIONS

The 10 leading causes of death in the United States are: diseases of the heart, malignant neoplasm, cerebrovascular disease, unintentional injuries, chronic obstructive pulmonary disease, pneumonia and influenza, diabetes, chronic liver disease, atherosclerosis and suicide.

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MENTAL HEALTH

Deinstitutionalisation has been the single most important issue of those in the mental health sphere for the past 3 decades. The most commonly cited statistic used to describe the course of deinstitutionalisation is the yearly count of residential patients in the state and county mental hospitals. In 1955 there were almost 600,000 patients. In the next 3 decades the total has decreased by more than 80%. The major threat to mental health is homelessness. Of all the age related syndromes, perhaps the most age associated one is dementia. Before the mid-1970s, dementia was considered a natural, indeed a normal consequence of aging. Alzheimers disease was primarily considered a cause of pre senile dementia whereas the so called senile dementia was largely ignored by both the public and medical practitioners. It is now known that Alzheimers disease affects adults of all ages but only rarely those under the age of 60. The prevalence increases dramatically for each age group over 65. Because of the high percentage of aging, the past decade has seen an increasing awareness that dementia is a problem of immense importance to public health. 2.4.5 ACCESS TO PRIMARY HEALTH SERVICES AND POVERTY

Lack of access to a reliable source of primary care when being affected by poverty is also associated with an increased risk of death from a variety of causes. People who are poor have higher mortality rates for heart disease, diabetes mellitus, high blood pressure, lung cancer, neural tube defects, injuries and low birth rates, as well as low survival rates from breast cancer and heart attacks. 2.4.6 PREVENTION - CONTROLLING ENVIRONMENTAL AND NUTRITIONAL RISK FACTORS

From the increasing realisation that environmental health factors influence the occurrence of disease, a variety of control measures have been introduced. Such as for example, the Clean Air Act, recycling has become an increasingly attractive option for handling waste, multiplication of an abundant food supply with critical trace nutrients and better methods for determining and improving the nutrient content of foods. As the diseases of nutritional deficiency have diminished, they have been replaced by diseases related to dietary excess and imbalance. 4 of the 10 leading causes of death are associated with over eating as well as the consumption of alcohol. 2.4.7 MEASURES FOR CHANGE

In recent years, dissatisfaction with the health care system has become widespread and there are many attempts to improve health insurance coverage and decrease health care costs. (In March 2010 a Bill was, at last passed, increasing health insurance coverage to 95% of the population). 2.4.8 INFRASTRUCTURE OF TRAINING AND RESEARCH IN PUBLIC HEALTH

Changes in the nature of the nations health over the last fifty or so years and the increasing difficulty of redirecting programmes in governmental departments, the trend in the United States to downplay the role of public agencies in dealing with major social problems which confront health providers, educators and the public in need of quality health care. This precipitated a crisis in public health, documented in the report by the Institute of Medicine in 1994. Traditionally, health departments provided protection against epidemic communicable disease and the health hazards of pregnancy and childhood. As these conditions came under increasing control, with the exception of Aids, a whole new set of problems, mainly the non-communicable diseases replaced them; health departments now redirect their efforts to deal with them. 2.4.9 THE ENVIRONMENT

Preventing the spread of microbial infections through water and food has been a central feature of public health from its beginning. That task continues as is evident by the recent outbreaks of water and meat borne disease. But environmental control measures need to be extended to provide protection against a host of toxic chemicals and physical agents that pervade work places, homes and the atmosphere. While basic sanitary

engineering and inspections for water and food services survive from the past, more extensive efforts to evaluate and intervene are needed to curtail the hazards of modern industrial life. 2.4.10 AVAILABILITY OF PERSONAL HEALTH SERVICES When public health agencies implemented widespread immunisation programmes to benefit the US population, public health departments provided direct services to the economically disadvantaged, as well as oversight of health services to prevent the spread of communicable disease. More recently however, the public health role has been limited to caring for those who cannot afford private sector care. Separate public agencies apart from health departments have often been established to organise and deliver these services for the poor.

CONCLUSIONS

Public health is concerned with health at the population-level, not at the individual level; it is concerned with health services insomuch as the health care service must be properly organised and equipped, but it is not concerned with individual patients. Achieving good health for a community or a nation is accomplished through the organised efforts of society at multiple levels and by multiple actors, from governmental ministries to grass-roots community organisations. The knowledge of changes in health issues facing developed countries over the past two centuries facilitates an understanding of how public health has evolved to tackle these issues and where the field stands today. Throughout its history, public health has addressed the direct and broader material, social and ecological conditions affecting health, such as sanitation and standards of living. Also, in many ways, the concept of controlling infectious disease has been the basis for many of public health structures. Currently, public health is still evolving and adapting in an attempt to control chronic diseases. The short description of public health structures and functions in a number of countries shows the importance of an organisation with responsibility for the delivery of public health services. Public health is concerned with more than the control of communicable diseases in the 21st century. To be effective in the improvement of health status in a country public health attitudes and actions are required at all areas of government at all levels e.g. education, environment, transport, industry, agriculture including health. For this adequately trained individuals are required. Research to investigate both possible new and current hazards must be supported. Information services are also essential.