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Foundations of Public Health (FPH):

Epidemiology, Ethics,
& the Health Care System

Course Director
G. Jayakumar
Foundations of Public Health
Objectives of FPH Module

This module has 3 components: Epidemiology, Ethics and

Health Care System.

The objectives of this module are for students to develop basic

knowledge and understanding of:

•Ethical principles that apply to medicine;

•Epidemiologic methods and their application to medicine; and

•Health system related challenges physicians encounter in their


Note: Foundations of Medical Research is within the same module

At PUGSOM this Module is be taught by:

Dr. G. Jayakumar, Dr. Nazmul, Dr Wendy, Dr Chan, Dr Jamie,

Dr Chan Soon Choy,

This module will be conducted from 17th- 25rd April 2018


Exam (MCQ) 60
Group Work, Presentations or assignments 30
Participation in group discussion 10

Examination for FPHEE is on 25 April at 10.00am

Role of FPH in GTS Curriculum

Introductory anchor for Horizontal Strands in:

Ethics & Professionalism
Health Care Systems
Cultural Competence & Disparities
Patient Safety

Issues raised in FPH could be explored in Scholarly

Overview of Public Health

Objectives of lecture

At the end of the lecture the students will be able:

• Define health and public health

•Describe public health system
•State the public health disciplines
•State the Health Related Millennium Development Goals
•Describe levels of prevention
•Describe the importance of comprehensive health care
•Discuss the differences between medical care and public
Definitions of Health and Public Health

Health is a state of complete physical, mental and social well-being and

not merely the absence of disease or infirmity (World Health

Public health is "the science and art of preventing disease, prolonging life
and promoting health and efficiency through organized community efforts
for the sanitation of the environment, the control of community infections,
the education of the individual in principles of personal hygiene, the
organisation of medical and nursing services for the early diagnosis and
preventive treatment of disease, and the development of the social
machinery which will ensure to every individual in the community a
standard of living adequate for the maintenance of health. (C.E.A.
Winslow - 1923).
Ten Great Public Health Achievements in US 1900-99

• Vaccination
• Motor-vehicle safety
• Safer workplaces
• Control on infectious diseases
• Decline in deaths from CHD and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard
CDC MMWR 1999: 48(12)241-243
Results from public health achievements

In the United States in 2006:

• 900,000 fewer cases of measles than in 1941

• 200,000 fewer cases of diphtheria than in 1921
• 250,000 fewer cases of whooping cough than in 1934
• 21,000 fewer cases of polio than in 1951
• 50 million fewer smokers than expected based on trends
through 1965
• 2 million alive that otherwise would be dead from heart
disease and stroke
•100,000 alive as a result of automobile seat belt use
• 1.5 million hepatitis B and C infections and 50,000 HIV
infections prevented because of protection of blood supply
• Average blood lead levels in children a third of what they
were a quarter century ago
Turnock BJ. Essentials of Public Health 2nd Ed. 2012
Major eras in Public Health in the US

Prior to 1950 Battling epidemics

(1793 Yellow fever epidemic in Philadelphia)

1850-1949 Establishing state and local infrastructure

(Local and State Boards of Health)
(Marine Health Service to Public Health

1950-1999 Filling gaps in medical care delivery

After 1999 Preparing for and responding to

community health threats
Public Health System
• Capacity (Inputs)
• Resources necessary to carry out public health functions
Human resources
Information resources
Physical resources
Fiscal resources

• Process (Practices and outputs)

• Process needed to ensure public health functions
implemented effectively – identify health problems and
carry out intervention programs

•Outcomes (Results)
• Indicators of health status, risk reduction and quality of
CDC Public Health Program Office 1990

• Basis in social justice philosophy

• Inherently political in nature

• Dynamic ever expanding agenda

• Link with government

• Grounding in the sciences

• Use of prevention as a prime strategy

• Uncommon culture and bond

Turnock BJ. Essentials of Public Health 2nd Ed. 2012

Public Health Disciplines



Biomedical sciences

Environmental health sciences

Social and behavioral sciences

Health policy and management

The Ten Essential Public Health Services
US Institute of Medicine: The Future of the Public’s Health in the 21 st
Century (2003) –
Mission of public health : Fulfillment of society’s interest in assuring the
conditions in which people are healthy

1.Monitor health status to identify community health problems

2.Diagnose and investigate health problems and health hazards in the

Policy Development
3.Inform, educate and empower people about health issues
4.Mobilize community partnerships to identify and solve health problems
5.Develop policies and plans that support individual and community health
6.Enforce laws and regulations that protect health and ensure safety
7.Link people to needed personal health services and assure the provision
of health care when otherwise unavailable
8.Assure a competent public health and personal health care workforce
9.Evaluate effectiveness, accessibility, and quality of personal and
population-based health services

Serving all functions

10. Research for new insights and innovative solutions to
health problems
Natural history of disease

Agent – Host – Environment (Equilibrium/Disequilibrium)

•Pre-pathogenesis or pre-clinical stage

•Pathogenesis or clinical stage

•Post-pathogenesis stage
Prevention Framework

• Public Health prevention framework:

 Primary

 Secondary

 Tertiary

©2002 Microsoft Corporation.

Levels of Prevention

Disease prevention is the deferral or elimination of specific

illnesses and conditions by one or more interventions of
proven efficacy.

Three levels of prevention

•Primary prevention - prevention of disease before biological

•Secondary prevention - prevention of clinical illness through

the early and asymptomatic detection

•Tertiary prevention - prevention of disease progression and

complications after clinical disease is manifest
What is Prevention?

 Actions that minimize or eliminate

conditions known to contribute to a
specific condition, problem, illness, or

 Establishing conditions that enhance

opportunities to achieve healthy outcomes

 Occurs prior to the problem appearing or

becoming serious/severe
Steps in prevention
• Health promotion e.g. health talks, distribution of pamphlets
and posters, health campaigns

• Specific protection e.g. immunization, helmet, car seat belt,

safety gloves, ear plugs, iodized salt, tobacco legislation

• Early diagnosis and treatment e.g. active case detection,

passive case detection, screening specific high risk groups,
case specific care plan, ensuring patient compliance

• Disability limitation e.g. availability of facilities and equipment

– ICU, high dependency ward, availability of high potency
drugs, family support

• Rehabilitation e.g. physiotherapy, occupational therapy,

Primary Preventions vs Secondary Prevention
Pre-pathogenesis Pathogenesis Post-
(preclinical) (clinical) pathogenesis
(post clinical)
early late
Primary Secondary Tertiary
prevention prevention prevention
Step 1 Step 2 Step 3 Step 4 Step 5
Health Specific Early Disability Rehabilitation
promotion protection diagnosis limitation
and early
Comprehensive Health Care

• Treat patient as a whole: physically, socially,

mentally and spiritually and not merely the
• Taking into consideration the three levels of
• Use all health infrastructure at all stages as the
referral system
• Treat patient as individual, a family or
community member with unique values and
• Continuous treatment under supervision
Medical Care vs Public Health

Medical Care Public Health

Individual as patient Community as patient
Treating patients Preventing disease
Diagnosis of patient based Diagnosis of community’s
on history and investigations health based on data on
health of population
Treatment plan for patient Policy and plan developed
Treatment given to patient Assure medical and health
care services are available to
the community
Doctor’s cure recognizable Benefits from public health
and patient grateful not easily recognized
Attention paid by politicians Lack of attention by
and public politicians and public