The CDC Foundation (CDCF, n.d.) defines public health as “the science of protecting and improving the health of people and their communities.” When you think of public health, you may envision mobile units that screen for breast cancer, hearing screenings in local elementary schools, vaccination initiatives, or county and state health departments that support local doctors in preventative care and the promotion of health through community outreach. These, and many more programs, fall under the umbrella of public health and prevention.

In the 19th century, local public health agencies were created in the United States to address communicable diseases. Since then, public health has also addressed workplace safety, environmental exposures, health education, and access to clinical care (CDCF, n.d.). The history of public health is one of heartbreak and triumph, as agencies have fought to provide clean water and air, immunizations, and access to contraception for individuals and families across the nation.

Public health-funded immunization drives in the 1950s encouraged and provided polio vaccinations through clinics in public school gymnasiums. Prior to the creation of the vaccine by Dr. Jonas Salk, the polio virus killed or paralyzed over 500,000 people annually (WHO, n.d.), sometimes via contaminated food and water.

During the recent COVID-19 pandemic, public health took center stage as government funding provided for public testing, masks, at-home tests, vaccine research, and free meals for children who were no longer in school. The effects of COVID-19 highlighted the interconnectedness of physical and financial health and demonstrated how integral public health is to a functioning society.

In addition to these projects, public health organizations were also integral in addressing disparities between urban and rural health. Rural areas often have populations at higher risk for COVID-19, as they  tend to be older, have lower socioeconomic status, and lack access to quality healthcare (Melvin et al., 2020).

Funding for Public Health Programs

Public health is funded through local, state, and federal sources, as well as revenue streams such as the marijuana tax in Washington State, which pays for Medicaid, substance abuse education, and treatment programs. Private grant money is also an important source of public health funding.

In Washington State, the Department of Health is divided into 35 public health districts and local health departments that serve its 39 counties. Other states may divide public healthcare by city or county. In addition, many public partners, such as universities, collaborate with state and local health departments to provide care and research opportunities. For over a decade, Washington has also partnered with federally recognized tribal organizations for public health service delivery.

On the federal level, public health organizations such as the Centers for Disease Control and Prevention (CDC), the Department of Health and Human Services (DHHS), and the National Institutes of Health (NIH) collaborate with state and local agencies to acquire funds and provide care to communities across the United States.

Many decisions about public health funding are based on politics surrounding specific programs and conditions. For example, in the 1980s, support for HIV/AIDS research was unpopular due to stigmas surrounding the virus and its association with the gay community. As a result, tens of thousands of patients died before effective drug cocktails could be developed.

Public health safer sex initiatives face similar uphill battles for funding in more socially conservative areas, even though school districts that teach abstinence-only sex education have higher rates of teen pregnancy and sexually transmitted infections (STIs) than those that provide contraception education. In the U.S., the congressional budget for abstinence-only education is currently 85 million per year, with prohibitions against teaching about contraception, except for its failure rates, imposed on all states receiving this funding. As a consequence, the rate of formal instruction in birth control methods dropped from 81% for men and 87% for women in 1995 to 55% for men and 65% for women between 2011 and 2013. Meanwhile, the gap between first sexual intercourse and marriage has grown to 11 years for men and 8 years for women (Columbia University, 2017).

Due to these funding limitations, over half the states reject federal money for human sexuality education. Despite these challenges, research shows that comprehensive sexuality education significantly benefits teen pregnancy rates, HIV status, and STI transmission rates, while abstinence-only education shows no benefits in these areas (Chin et. al., 2012).

In another example, the Dickey Amendment, passed in 1996 as part of the congressional omnibus spending bill, prohibited the use of federal funding for “advocating or promoting gun control” (Omnibus Consolidated Appropriations Act, 1997), and the funds were reallocated to research on traumatic brain injuries. In 2018, a report was added to the amendment, clarifying that gun research was not prohibited by the amendment, and the congressional budget now allows the Centers for Disease Control and Prevention (CDC) to study and compile statistics about gun violence in the United States, provided they have the necessary funding.

As we can see, public health can be funded publicly or privately at the local, state, or federal levels. Government funding often comes with restrictions, but popular public health projects can significantly benefit future generations and have a profound impact on communities.

Public Health and Epidemiology

The COVID-19 pandemic catapulted public health into the center of discussions on infectious disease prevention, but many people are still unclear about its role in healthcare.

Public health is a field that promotes and protects the health of individuals and the communities where they live, learn, and play. The American Public Health Association (APHA) is the leading professional organization in the United States, offering valuable information on public health and how to get involved.

Unlike the individual-focused approach commonly seen in medicine, nursing, and pharmacy, public health takes a population-based approach to health interventions. There are many roles in public health, including public health nurses, physicians, social workers, first responders, restaurant inspectors, health educators, scientists, researchers, epidemiologists, community planners, nutritionists, public policy makers, sanitarians, and occupational safety professionals.

Public health offers many government employment opportunities at the national level, including positions at the Centers for Disease Control and Prevention (CDC) and the Commissioned Corps of the U.S. Public Health Service. State and local public health departments also employ public health professionals. Beyond government employment, public health careers include professionals involved in disease identification, policy creation, and interventions that promote health and wellness at the population level.

According to the CDC (2020), the following 10 Essential Public Health Services (EPHS) outline the public health activities that all communities should undertake:

1. Assess and monitor population health status, factors that influence health, and community needs and assets.
2. Investigate, diagnose, and address health problems and hazards affecting the population.
3. Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it.
4. Strengthen, support, and mobilize communities and partnerships to improve health.
5. Create, champion, and implement policies, plans, and laws that impact health.
6. Utilize legal and regulatory actions designed to improve and protect the public’s health.
7. Assure an effective system that enables equitable access to the individual services and care needed to be healthy.
8. Build and support a diverse and skilled public health workforce.
9. Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement.
10. Build and maintain a strong organizational infrastructure for public health.

The science of public health relies heavily on epidemiology, which the Dictionary of Epidemiology defines as the study of the distribution and determinants of health-related states among specific populations and the application of that knowledge to control health problems. “Distribution” refers to the frequency or pattern of disease, while “determinants” are the causes or risk factors of diseases and other health-related events. Some examples of public health investigations are provided below.

Epidemiologists are sometimes called “disease detectives” because they investigate the causes of diseases, identify people who are most at risk, and determine how to stop the spread of or eradicate diseases. They often work hand-in-hand with other disease detectives trained in public health principles, including veterinarians, nurses, physicians, scientists, and nutritionists.

In public health, disease detectives investigate the causes and spread of both communicable and noncommunicable diseases, as well as non-disease hazards that can impact health, such as noise pollution, sun exposure, smoke inhalation, or even legal, socioeconomic (such as poverty and access to healthcare), and structural factors.

Public Health and Disease Prevention

Prevention can be categorized into primary, secondary, and tertiary interventions. Primary interventions involve avoiding disease and maintaining good health. Secondary prevention occurs when a provider diagnoses and treats a disease as early as possible to prevent more serious complications or sequelae. Tertiary prevention involves managing chronic illnesses in a way that enhances quality of life and improves longevity.

Primary interventions require the evaluation of individual risk factors, such as smoking, high-risk jobs, risky behaviors, and other diet and lifestyle factors. After evaluating these risk factors, decisions can be made about preventive programs that address the specific diseases or conditions that people with these risk factors are more likely to develop. For example, smoking cessation programs may be instituted to prevent lung cancer and other adverse effects of tobacco use. These programs can be promoted in primary care clinics and high schools in communities where adolescent tobacco use is prevalent. Additional examples include community vaccination drives for polio, flu, and COVID-19 vaccines. The next time you are watching television or using social media, pay close attention to any public service announcements you see. Many are directed toward primary disease prevention.

Secondary intervention, which prevents diseases from becoming more serious, can be seen in the many cancer screening programs at free clinics and in provider offices nationwide. Mobile clinics, such as those providing mammograms,  provide secondary preventive services to underserved rural and low-income urban areas. Another example is contact tracing, which has become more common since COVID-19 but has long been used for sexually transmitted and other infectious diseases. This process allows public health providers to notify individuals who have been exposed to a disease so they can get tested and treated.

Finally, tertiary interventions focus on improving the quality of life and longevity of people with chronic illnesses. For example, blood sugar management and diabetic foot care programs for people with type 1 and type 2 diabetes can have positive effects on their condition and its progression. Individuals who participate in diabetic foot care programs at senior centers or long-term care facility, for example, are less likely to develop unnoticed ulcers that could otherwise lead to gangrenous wounds requiring amputation.

Primary, secondary, and tertiary prevention programs are all part of public health. Programs may be funded at the city, county, state, regional, or federal levels, either through existing programs or through grant funding for new projects (CDC, 2013).

Skill Stitch: Advocating for Your Patient

Healthcare is a polarizing topic in the United States, and so are protests. However, protests are one of the many ways in which healthcare providers can advocate for their patients on a large scale.

In your workplace, you can advocate for patients by making sure they are being heard and that any safety risks are understood by decision-makers such as managers, providers, patient ombudsmen, and social workers. Practicing before speaking to a supervising physician or other authority figures can boost your confidence and make you a more powerful advocate for patient safety. Another key strategy is to offer potential solutions when raising concerns. This can make it easier for these concerns to be successfully addressed.

Outside of your workplace, you can also advocate for patients in the community. As a healthcare professional, your reputation can lend weight to your opinion on health-related matters such as public health efforts, climate change, voting access, and drug policy.

If large protests are not your style, you can participate in voter registration efforts, phone banking for local nonprofits that support or oppose current legislation, or letter-writing or texting campaigns to engage elected officials.

For more involved efforts, consider volunteering or working for nonprofits whose healthcare goals align with your own. You could also collaborate with your coworkers to conduct research and collect data that supports patient-centered improvements in your workplace or community.

In this section, you will practice writing out what you want to say to an office manager to advocate for a patient who has difficulty with her healthcare. After reading the scenario, write down the concerns you have and how you would like to see them addressed. Include a suggestion for how to prevent this situation from happening in the future.

Cleo is an 86-year-old transgender female patient being seen in your clinic for primary care. She has been a patient for decades and is always polite and friendly to the staff. Lately, you have noticed with some concern that she appears worried when she comes in to see the new provider assigned to her care. Although she does not complain, she seems less enthusiastic about seeing this new provider than she did about her previous one, who has retired. She has been struggling to comply with her provider’s directions and often seems on the verge of tears when leaving the clinic. She frequently pays her outstanding balance with small bills and change, promising to bring more money at the next visit.

What are some possible concerns about Cleo’s medical care and daily life? What allies (persons who support the rights of another group or individual) might you find in your office to help support her? What barriers might you face when advocating for Cleo? How do you feel about advocating for a patient whose needs may extend beyond medical care? How could you address this situation and prevent similar ones in the future?

Attributions

1. Figure 3.3: CloseTheCamps_30Days_Day18_IMG_2861-1 by Peg Hunter is released under CC BY-NC 2.0