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Introduction to
Public
Health
Fifth
Edition
Mary-Jane Schneider, PhD
Clinical Associate Professor
Department of Health Policy, Management, and Behavior
School of Public Health
University at Albany, State University of New York
Rensselaer, New York
with
Henry S. Schneider, PhD
Assistant Professor of Economics
Johnson Graduate School of Management
Cornell University
Ithaca, New York
Drawings by Henry S. Schneider
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09736-8
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Library of Congress Cataloging-in-Publication Data
Names: Schneider, Mary-Jane, 1939- , author. | Schneider, Henry S.
Title: Introduction to public health / Mary-Jane Schneider, with Henry S.
Schneider ; drawings by Henry S. Schneider.
Description: Fifth edition. | Burlington : Jones & Bartlett Learning, MA,
[2017]
Identifiers: LCCN 2016001765 | ISBN 9781284089233
Subjects: | MESH: Public Health | Public Health Practice
Classification: LCC RA425 | NLM WA 100 | DDC 362.1–dc23 LC record available at http://lccn.loc.gov/2016001765
6048
Printed in the United States of America
20 19 18 17 16 10 9 8 7 6 5 4 3 2 1
Dedication
To Augustus Anthony Edison Schneider
May he live a long and healthy life
Contents
Preface
Prologue: Public Health in the News
xiii
xv
Part I: What Is Public Health?
1
1
3
2
3
Public Health: Science, Politics, and Prevention
What Is Public Health?
Public Health Versus Medical Care
The Sciences of Public Health
Prevention and Intervention
Public Health and Terrorism
Conclusion
References
4
5
7
10
11
13
13
Why Is Public Health Controversial?
15
Economic Impact
Individual Liberty
Moral and Religious Opposition
Political Interference with Science
Conclusion
References
16
18
20
22
23
23
Powers and Responsibilities of Government
Federal Versus State Authority
How the Law Works
How Public Health Is Organized and Paid for in the United States
Nongovernmental Role in Public Health
Conclusion
References
25
26
28
29
36
37
38
Part II: Analytical Methods of Public Health
39
4
Epidemiology: The Basic Science of Public Health
41
How Epidemiology Works
A Typical Epidemiologic Investigation—Outbreak of Hepatitis
Legionnaires’ Disease
Eosinophilia-Myalgia Syndrome
Epidemiology and the Causes of Chronic Disease
42
43
44
47
49
vi
Contents
5
6
7
8
Heart Disease
Lung Cancer
Conclusion
References
49
51
53
54
Epidemiologic Principles and Methods
57
Kinds of Epidemiologic Studies
Conclusion
References
62
67
68
Problems and Limits of Epidemiology
69
Problems with Studying Humans
Sources of Error
Proving Cause and Effect
Epidemiologic Studies of Hormone Replacement
Therapy—Confusing Results
Ethics in Epidemiology
Conflicts of Interest in Drug Trials
Conclusion
References
74
75
78
80
81
Statistics: Making Sense of Uncertainty
83
The Uncertainty of Science
Probability
The Statistics of Screening Tests
Rates and Other Calculated Statistics
Risk Assessment and Risk Perception
Cost–Benefit Analysis and Other Evaluation Methods
Conclusion
References
84
86
88
90
94
98
99
100
The Role of Data in Public Health
Vital Statistics
The Census
NCHS Surveys and Other Sources of Health Data
Is So Much Data Really Necessary?
Accuracy and Availability of Data
Confidentiality of Data
Conclusion
References
69
71
73
103
104
104
107
108
109
111
111
112
Part III: Biomedical Basis of Public Health
115
9
The “Conquest” of Infectious Diseases
117
Infectious Agents
Means of Transmission
118
120
Contents
Chain of Infection
Rabies
Smallpox, Measles, and Polio
Fear of Vaccines
Conclusion
References
121
125
126
129
131
132
10 The Resurgence of Infectious Diseases
135
The Biomedical Basis of AIDS
Ebola
Other Emerging Viruses
Influenza
New Bacterial Threats
Multidrug-Resistant Tuberculosis (MDR TB)
Prions
Public Health Response to Emerging Infections
Public Health and the Threat of Bioterrorism
Conclusion
References
135
140
144
146
148
150
154
155
156
157
157
11 The Biomedical Basis of Chronic Diseases
163
Cardiovascular Disease
Cancer
Diabetes
Other Chronic Diseases
Conclusion
References
12 Genetic Diseases and Other Inborn Errors
Environmental Teratogens
Genetic Diseases
Genetic and Newborn Screening Programs
Genomic Medicine
Ethical Issues and Genetic Diseases
Conclusion
References
165
169
171
172
172
173
175
176
177
180
184
185
187
188
Part IV: Social and Behavioral Factors in Health
191
13 Do People Choose Their Own Health?
193
Education
Regulation
Does Prohibition Work?
Conclusion
References
197
200
201
203
203
vii
viii
Contents
14 How Psychosocial Factors Affect Health Behavior
Health of Minority Populations
Stress and Social Support
Psychological Models of Health Behavior
Ecological Model of Health Behavior
Health Promotion Programs
Changing the Environment
Conclusion
References
205
207
208
209
211
213
215
216
217
15 Public Health Enemy Number One: Tobacco
219
Biomedical Basis of Smoking’s Harmful Effects
Historical Trends in Smoking and Health
Regulatory Restrictions on Smoking—New Focus
on Environmental Tobacco Smoke
Advertising—Emphasis on Youth
Taxes as a Public Health Measure
California’s Tobacco Control Program
The Master Settlement Agreement (MSA)
FDA Regulation
Electronic Cigarettes
Conclusion
References
221
221
16 Public Health Enemy Number Two and Growing:
Poor Diet and Physical Inactivity
Epidemiology of Obesity
Diet and Nutrition
Promoting Healthy Eating
Physical Activity and Health
How Much Exercise Is Enough, and How Much Do People Get?
Promoting Physical Activity
Confronting the Obesity Epidemic
Conclusion
References
17 Injuries Are Not Accidents
Epidemiology of Injuries
Analyzing Injuries
Motor Vehicle Injuries
Pedestrians, Motorcyclists, and Bicyclists
Poisoning
Firearms Injuries
Occupational Injuries
Injury from Domestic Violence
225
226
227
228
230
232
233
233
234
237
238
242
243
247
249
250
252
254
254
259
260
263
264
267
268
269
271
272
Contents
Nonfatal Traumatic Brain Injuries
Tertiary Prevention
Conclusion
References
18 Maternal and Child Health as a Social Problem
Maternal and Infant Mortality
Infant Mortality—Health Problem or Social Problem?
Preventing Infant Mortality
Family Planning and Prevention of Adolescent Pregnancy
Nutrition of Women and Children
Children’s Health and Safety
Conclusion
References
19 Mental Health: Public Health Includes
Healthy Minds
Major Categories of Mental Disorders
Anxiety
Psychosis
Disturbances of Mood
Disturbances of Cognition
Epidemiology
Causes and Prevention
Children
Eating Disorders
Mental Health in Adulthood
Mental Health in Older Adults
Treatment
Conclusion
References
272
274
275
276
281
282
283
285
290
292
293
296
297
301
301
302
302
302
302
302
303
306
307
308
310
310
311
311
Part V: Environmental Issues in Public Health
313
20 A Clean Environment: The Basis of Public Health
315
Role of Government in Environmental Health
Identification of Hazards
Pesticides and Industrial Chemicals
Occupational Exposures—Workers as
Guinea Pigs
New Source of Pollution—Factory Farms
Setting Standards—How Safe Is Safe?
Risk–Benefit Analysis
Conclusion
References
316
317
321
324
325
326
327
327
328
ix
x
Contents
21 Clean Air: Is It Safe to Breathe?
333
Criteria Air Pollutants
Strategies for Meeting Standards
Indoor Air Quality
Global Effects of Air Pollution
Conclusion
References
334
336
341
342
344
345
22 Clean Water: A Limited Resource
349
Clean Water Act
Safe Drinking Water
Dilemmas in Compliance
Is the Water Supply Running Out?
Conclusion
References
350
352
364
366
366
367
23 Solid and Hazardous Wastes:
What to Do with the Garbage?
369
Sanitary Landfills
Alternatives to Landfills
Hazardous Wastes
Coal Ash
Conclusion
References
24 Safe Food and Drugs: An Ongoing
Regulatory Battle
Causes of Foodborne Illness
Government Action to Prevent Foodborne Disease
Additives and Contaminants
Drugs and Cosmetics
Food and Drug Labeling and Advertising
Politics of the FDA
Conclusion
References
25 Population: The Ultimate Environmental
Health Issue
Public Health and Population Growth
Global Impact of Population Growth—Depletion of Resources
Global Impact of Population Growth—Climate Change
Dire Predictions and Fragile Hope
Conclusion
References
370
372
373
377
377
378
381
382
383
388
389
390
392
394
395
399
401
403
406
409
411
412
Contents
Part VI: Medical Care and Public Health
415
26 Is the Medical Care System a Public Health Issue?
417
When Medical Care Is a Public Health Responsibility
The Conflict Between Public Health and the
Medical Profession
Licensing and Regulation
Ethical and Legal Issues in Medical Care
Ethical Issues in Medical Resource Allocation
Conclusion
References
27 Why the U.S. Medical System Needs Reform
Problems with Access
Why Do Costs Keep Rising?
Approaches to Controlling Medical Costs
Managed Care and Beyond
The Patient Protection and Affordable Care Act
Rationing
Conclusion
References
28 Health Services Research: Finding What Works
Reasons for Practice Variations
The Field of Dreams Effect
Outcomes Research
Quality
Medical Care Report Cards
Inequities in Medical Care
The Relative Importance of Medical Care for
Public Health
Conclusion
References
29 Public Health and the Aging Population
The Aging of the Population—Trends
Health Status of the Older Population
General Approaches to Maximizing Health
in Old Age
Preventing Disease and Disability in Old Age
Medical Costs of the Elderly
Proposals for Rationing
Conclusion
References
418
419
422
423
426
427
428
431
432
435
436
437
439
440
442
443
447
448
450
451
454
456
458
461
463
464
469
470
472
473
476
482
485
487
487
xi
xii
Contents
Part VII: The Future of Public Health
491
30 Emergency Preparedness, Post-9/11
493
Types of Disasters and Public Health Responses
New York’s Response to the World Trade Center Attacks
Response to Hurricane Katrina
Principles of Emergency Planning and Preparedness
Bioterrorism Preparedness
Pandemic Flu
Conclusion
References
31 Public Health in the Twenty-First Century:
Achievements and Challenges
494
495
496
500
502
506
507
509
513
Challenges for the 21st Century
Strategic Planning for Public Health
Dashed Hopes for the Integration of Public Health
and Medical Practice
Information Technology
The Challenge of Biotechnology
The Ultimate Challenge to Public Health in the Twenty-First Century
Conclusion
References
515
516
520
521
523
523
524
525
Glossary
Index
529
547
Preface
In the Preface to the First Edition, I wrote about the public’s general ignorance of the field
of public health and my own uncertainty about what public health was when, in 1986, I first
went to work for the newly established School of Public Health, a collaboration between
the University at Albany and the New York State Department of Health. After working
with public health professionals from the Department of Health to design curricula for
the programs at the school, and after teaching an introductory course in public health for
more than ten years in collaboration with many of the same health department faculty,
I feel much more confident about what the term means. After the bioterrorism scare of
2001 and the public health disasters of Hurricane Katrina in 2005 and Hurricane Sandy
in 2012. I believe that the public has a better sense of the field as well.
This book was written as a text for an introductory course that could be included in
the general education curriculum for college undergraduates. As I wrote in the Preface to
the First Edition, I believe that every citizen of the United States should know something
about public health, just as they should know something about democracy, law, and other
functions of government. Public health issues are inherently interesting and important
to almost everyone. They are featured almost every day on the front pages of newspapers
and in the headlines of television news programs, although often they are not labeled as
public health issues. One of my goals is to help people put these news stories into context
when they occur.
The Fifth Edition of this textbook follows the plan of the first four editions, bringing
it up to date and including new developments in infectious disease, injury control, environmental health controversies, the reform of the American healthcare system, and many
other issues. I have illustrated public health principles by presenting stories that have been
in the news; some of these stories have been ongoing sagas that have been supplemented
with each edition. The Second and Third Editions focused on political interference with
science, but as discussed in the Fourth Edition, the Obama administration vowed to restore
honest science as a basis of policy decisions. Issues new to the Fifth Edition include the
arrival of Ebola in the United States, involving the death of an African visitor and the
involuntary quarantine of an uninfected healthcare worker returning from work in an
affected country; the introduction of electronic cigarettes and questions of how they
should be regulated; the importance of eating disorders as a major mental health issue;
and the lawsuit by retired professional athletes against the National Football League for
not disclosing risks of traumatic brain injury. Other issues discussed more extensively
here are population growth and climate change as contributors to wars and migrations
in the Middle East and the implementation of President Obama’s healthcare reform law,
the Patient Protection and Affordable Care Act.
xiv
Preface
I have tried to make this book easily comprehensible to the general reader. One of the
things that makes public health fascinating to me is the fact that it is often controversial,
depending on political decisions as well as scientific evidence. The politics are frustrating
to many practitioners, but it is often the politics that put public health in the headlines.
I hope that by describing both the science and the politics, I will contribute to making
public health as fascinating to the readers as it is to me.
Mary-Jane Schneider
Chapter
Prologue
1
Public Health in the News
What is public health? It is an abstract concept, hard to pin down. Reports about public
health appear in the news every day, but they are not labeled as public health stories, and
most people do not recognize them as such. Here in the prologue are four major public
health stories of the modern era that bring the abstraction to life. The ongoing AIDS epidemic, arguably the greatest challenge that the public health community has faced in the
past 50 years, illustrates the multidisciplinary nature of the field and the complex ethical
and political issues that are often an inherent component of public health. The outbreak
of waterborne disease that sickened more than 400,000 people in Milwaukee, Wisconsin
in 1993 was the consequence of a breakdown in a routine public health measure that
has protected the populations of developed countries for most of the past century. Lest
Americans forget that maintaining the health of the population requires constant vigilance,
the dramatic decline in all measures of health in Russia presents a cautionary lesson of
what can happen to a society that is unable to protect its people in one regard or another.
Finally, the terrorist attacks in the fall of 2001 made it clear that the national security of
the United States depends not only on the U.S. Department of Defense, but also on the
American public health system.
AIDS Epidemic
On July 3, 1981, The New York Times ran a story with the headline: “Rare Cancer Seen in
41 Homosexuals.”1 The cancer was Kaposi’s sarcoma, a form of skin cancer, rare in the
United States but more common in equatorial Africa. The victims were young gay men
living in New York City or San Francisco, and 8 of the 41 had died within 24 months of
being diagnosed. The report noted that several of the victims had been found to have
severe defects in their immune systems, but it was not known whether the immune
defects were the underlying problem or had developed later. Most of the victims had
had multiple and frequent sexual encounters with different partners, the article said,
xvi
Public Health in the News
but there was no evidence that the disease was contagious, since none of the patients
knew each other.
On August 29, there was another story: “2 Fatal Diseases Focus of Inquiry.”2 A rare
kind of pneumonia called pneumocystis had been striking gay men with a 60 percent
fatality rate. According to The New York Times, 53 cases of pneumocystis had been diagnosed. Also, the number of cases of Kaposi’s sarcoma had grown to 47, and 7 patients
had both diseases. No one knew why gay men were affected, but there was speculation
that there might be a link to their sexual lifestyle, drug use, or …
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