Transcript presentation ( format)
Public Health Principles and Practices: A Platform for College Health
Edward P. Ehlinger, MD, MSPH Director and Chief Health Officer Boynton Health Service University of Minnesota June 4, 2010 [email protected]
Ruth Westheimer
born Karola Ruth Siegel on June 4, 1928 •
"Talking from morning to night about sex has helped my skiing, because I talk about movement, about looking good, about taking risks."
Rosalind Russell
born on June 4, 1911
•
“Flops are a part of life's menu and I've never been a girl to miss out on any of the courses.”
Ruth Westheimer
born Karola Ruth Siegel on June 4, 1928 •
“Don't stint on foreplay -- or afterplay. Be inventive!”
Dik Browne American cartoonist died on June 4, 1989 He wrote and illustrated Hagar the Horrible and illustrated Hi and Lois Examples of strips of his published on June 4 th
Dik Browne American cartoonist died on June 4, 1989 Financial pressures Healthcare reform
The future of College Health is uncertain
• • • Healthcare reform will raise questions that will threaten the existence of college health – “Everyone will have insurance so why have a health service?” – “Everyone will have insurance so what is the need for a health service fee?” Some entrepreneurs may see healthcare reform as an opportunity to gain some college health business.
Some in college health may see healthcare reform as an opportunity to change the model of college health.
Rosalind Russell
born on June 4, 1911
•
"When something happens to you, you either let it defeat you, or you defeat it.“
How will you respond to those questions and challenges?
How will you convince your college/university that what you provide is unique and best meets the needs of students (and others) on your campus and the needs of your institution?
Health is essential to the mission of Post-Secondary Education • “When health is absent, wisdom cannot reveal itself, art cannot become manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.” •
Herophilus of Chalcedon, 335-280 BCE
•
Physician to Alexander the Great
No one provides the constellation of services offered by college health
• • • • On-campus location Interest in serving a unique population with unique needs Expertise in serving college students Provides a constellation of services not provided by any other provider – Services that meet the needs of students and the campus – Services that help meet the needs of the broader community
College Health Services
Service
– Teaching - Research • • • • • • • Medical Care/Primary Care (broadly defined) Dental Care Occupational Health Health Promotion/Wellness Health Education Student Development Environmental Health and Safety •
Public Health
Today is a BIG day in Public Health
June 4, 1912 June 4, 1919
June 4, 1912
• Massachusetts became the first state in the US to set a minimum wage.
Income 12.5
10 7.5
5 2.5
0 0 1 2 3 4 lowest Income Groups highest 5
June 4, 1919
Thursday, June 5, 1919
Suffrage Wins in Senate; Now Goes to States Constitutional Amendment Is Passed, 56 to 25, or Two More Than Two-thirds Women May Vote In 1920 Leaders Start Fight to Get Ratification by Three-fourths of States in Time Debate Precedes Vote Wadsworth Explains His Attitude In Opposition - Resolution Signed with Ceremony
19
th
Amendment
•
The right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of sex. Congress shall have power to enforce this article by appropriate legislation.
19th amendment to the U. S. Constitution Dates of Ratification by States • • • • • • • • • • • Illinois, June 10, 1919 Michigan, June 10, 1919 Wisconsin, June 10, 1919 Kansas, June 16, 1919; New York, June 16, 1919 Ohio, June 16, 1919 Pennsylvania, June 24 Massachusetts, June 25 Texas, June 28, 1919 Iowa, July 2, 1919; Missouri, July 3, 1919 • • • • • • • • • • • Arkansas, July 28, 1919 Montana, August 2, 1919 Nebraska, August 2, 1919 Minnesota, September 8, 1919 New Hampshire, September 10 Utah, October 2, 1919 California, November 1, 1919 Maine, November 5, 1919 North Dakota, December 1, 1919 South Dakota, December 4, 1919 Colorado, December 15, 1919
19th amendment to the U. S. Constitution Dates of Ratification by States • Kentucky, January 6, 1920 • Rhode Island, January 6 • Oregon, January 13, 1920 • Indiana, January 16, 1920 • Wyoming, January 27, 1920 • Nevada, February 7, 1920 • • New Jersey, February 9, 1920 Idaho, February 11, 1920 • • • • • • • • Arizona, February 12, 1920 New Mexico, February 21 Oklahoma, February 28 West Virginia, March 10 Washington, March 22, 1920 Tennessee, August 18, 1920.
Became National Law August 26, 1920 November 2, 1920 – Presidential election
–
Warren Harding and Calvin Coolidge elected
1921- The Shepherd-Towner Maternity and Infant Protection Act •
Authorized grants for state programs of maternal and children's services
• • • • • • • Sheppard Towner Act (Maternity and Infancy Care Act) 1921-1929 First public grants-in-aid program in U.S.
Developed MCH units in state Health Depts Birth registration (30 - 46 states) Increased Public Health Nursing Partnership of federal and state government Not continued because of fear of socialism Basis for Title V of Social Security Act
Core Functions of Public Health
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Assessment
•
Policy Development
•
Assurance
– Institute of Medicine, Future of Public Health
John Sundwall, MD, Ph.D.
• • Director of University of Minnesota Health Service 1918-1921 University of Michigan Division of Hygiene and Public Health 1921-1941
“Unfortunately, parents, students, and faculty regard a health service as little more than a clinic or hospital concerned only with illness and injuries, their diagnosis and treatment; and regard the health fee paid directly or indirectly by students as sickness insurance.”
John Sundwall, MD, Ph.D.
•
“Obviously, the best scientific treatment and care of illness and injuries must be one of the major concerns of the Health Service, but, in addition, a health service must be, as the term signifies, a health service. It bears something of the same relation to the university community that a public health department bears to a municipality or county, however in a more progressive and advanced state, in the vanguard of the public health movement.”
C. E. A. Winslow
Dean, Yale School of Pubic Health
•
“a university health service can realize its possibilities of leadership only if it visualizes public health in the broadest terms.”
• 1929
Public Health System
Prevailing View of U. S. Health Care System
Health Care System Medical Care System Health Care System = Public Health Subsystem + Medical Care Subsystem
College Health/Public Health View of Health System HEALTH of the PUBLIC
Core Functions
Assessment Policy Development Assurance
Health Care
Approaches
Health Promotion Health Protection Disease/Injury Prevention Treatment/rehabilitation
Other Influences Medical Care Clinical Preventive Services Community Health Services
Public policies - Education - Economy Scientific advances - Housing Knowledge - Social norms Recreation - Transportation Media/Entertainment - Religion Income inequality - Sense of community Many more
Factors Influencing Health Status
Scope of Public Health
Healthy Public Policy & Public Work Society's Health Response Medical and Public Health Policy
General protection Targeted protection Primary prevention Secondary prevention Tertiary prevention
Safer, Healthier Population
Becoming no longer vulnerable Becoming Vulnerable
Vulnerable Population
Becoming Afflicted
Afflicted without Complications
Developing Complications
Afflicted with Complications
Dying from Complications
Adverse Living Conditions DEMOCRATIC SELF-GOVERNANCE DISEASE AND RISK MANAGEMENT World of Transforming …
• • • • • • • •
Deprivation Dependency Violence Disconnection Environmental decay Stress Insecurity Etc… By Strengthening …
• • • • • • • •
Leaders and institutions Foresight and precaution The meaning of work Mutual accountability Plurality Democracy Freedom Etc… World of Providing …
• • • • • • •
Education Screening Disease management Pharmaceuticals Clinical services Physical and financial access Etc…
Centers for Disease Control and Prevention Bobby Milstein
Guiding principles: Prevailing View/College Health View
Public Health/College Health
Science-based •
Medical Care
Science-based Data are important!
Basic and clinical research are important in medical care.
Surveillance, monitoring, and epidemiology are important in college health/public health.
Guiding Principles
Public Health/College Health
Science-based Population-based • •
Medical Care
Science-based Focus on individual
NIAAA - College Drinking Prevention 4 Tiers of Effectiveness
• • • •
Tier 1: Evidence of Effectiveness Among College Students Tier 2: Evidence of Success With General Populations That Could Be Applied to College Environments Tier 3: Evidence of Logical and Theoretical Promise, But Require More Comprehensive Evaluation Tier 4: Evidence of Ineffectiveness
College Drinking Prevention NIAAA 4 Tiers of Effectiveness
• • Tier 1: Evidence of Effectiveness Among College Students – Strategy: Combining cognitive-behavioral skills with norms clarification and motivational enhancement interventions. – Strategy: Offering brief motivational enhancement interventions. – Strategy: Challenging alcohol expectancies.
We should implement these strategies as part of our clinical role.
•
College Drinking Prevention NIAAA 4 Tiers of Effectiveness
Tier 2: Evidence of Success With General Populations That Could Be Applied to College Environments
– Strategy: Implementation, increased publicity, and enforcement of laws to reduce alcohol-impaired driving.
– Strategy: Restrictions on alcohol retail outlet density – Strategy: Increased prices and excise taxes on alcoholic beverages. – Strategy: The formation of a campus and community coalition involving all major stakeholders may be critical to implement these strategies effectively.
• •
College Drinking Prevention NIAAA 4 Tiers of Effectiveness
Tier 3: Evidence of Logical and Theoretical Promise, But Require More Comprehensive Evaluation
– Strategy: Increasing publicity about and enforcement of underage drinking laws on campus and eliminating "mixed messages." – Strategy: Conducting marketing campaigns to correct student misperceptions about alcohol use.
– Strategy: Regulation of happy hours and sales.
We should implement Tier 2 and Tier 3 strategies as part of our public health role.
Guiding Principles
Public Health/College Health
Science-based Population-based Health an individual and societal responsibility • • •
Medical Care
Science-based Focus on individual Health an individual responsibility
The Ecosystem of an Individual
Laws Norms
multinational corporations government
Culture
friends health care providers violence child care parents grandparents work crime courts peers
Individual
sibs relatives schools
FAMILY
police T.V.
...isms
COMMUNITY
movies immigrants
Attitudes SOCIETY Values
Health Promotion
Healthy People 2000 • Personal choices have powerful influence over one’s health. While health behaviors are personal, choices are made in a broader social context that is difficult to separate from the psychology of the individual. So while the choice may be individual, the locus of intervention needs to be wide enough to incorporate the environment that will either support or undermine personal choice.
Guiding Principles
Public Health/College Health
Science-based Population-based Health an individual and societal responsibility Broad definition of health • • • •
Medical Care
Science-based Focus on individual Health an individual responsibility Focus on specific illnesses or diseases
College Health View of Health System HEALTH of the PUBLIC
Core Functions
Assessment Policy Development Assurance
Health Care
Approaches
Health Promotion Health Protection Disease/Injury Prevention Treatment/rehabilitation
Other Influences Medical Care Clinical Preventive Services Community Health Services
Public policies - Education - Economy Scientific advances - Housing Knowledge - Social norms Recreation - Transportation Media/Entertainment - Religion Income inequality - Sense of community Many more
Did women’s suffrage affect health?
U of MN Student Health Advisory Committee
• • • • • • • • • Smoke-free campus Bicycle trails Farmers Market Menu labeling Year-round fees Extended hours of operation Insurance RFP Late night transportation FDA blood donation policy
Guiding Principles
Public Health/College Health
Science-based Population-based Health an individual and societal responsibility Broad definition of health Interdisciplinary/multidisciplinary • • • • •
Medical Care
Science-based Focus on individual Health an individual responsibility Focus on specific illnesses or diseases Specialization
Scope of Clinical Specialists, Clinical Generalists, and Public Health
Centers for Disease Control and Prevention, Bobby Milstein
Guiding Principles
Public Health/College Health
Science-based Population-based Health an individual and societal responsibility Broad definition of health Interdisciplinary/multidisciplinary Collaboration/ Cooperation/Integration • • • • • •
Medical Care
Science-based Focus on individual Health an individual responsibility Focus on specific illnesses or diseases Specialization Competitive
Public Health
•
What we, as a society, do collectively to assure the conditions in which people can be healthy.
– Institute of Medicine
College Health View of Health System HEALTH of the PUBLIC
Core Functions
Assessment Policy Development Assurance
Health Care
Approaches
Health Promotion Health Protection Disease/Injury Prevention Treatment/rehabilitation
Other Influences Medical Care Clinical Preventive Services Community Health Services
Public policies - Education - Economy Scientific advances - Housing Knowledge - Social norms Recreation - Transportation Media/Entertainment - Religion Income inequality - Sense of community Many more
Guiding Principles
Public Health/College Health
Science-based Population-based Health an individual and societal responsibility Broad definition of health Interdisciplinary/multidisciplinary Collaboration/ Cooperation Prevention/Promotion/Protection • • • • • • •
Medical Care
Science-based Focus on individual Health an individual responsibility Focus on specific illnesses or diseases Specialization Competitive Treatment
• • • • • • • • • Real Leading Causes of Death Tobacco 400,000 Diet/inactivity 300,000 Alcohol 100,000 Microbial agents 90,000 Toxic agents 60,000 Firearms Sexual behavior 35,000 30,000 Motor vehicles 25,000 Illicit drug use 20,000 • • • • • • • • • • Leading Causes of Death Heart disease 725,790 Cancer 537,390 Stroke 159,877 Lung diseases 110,637 Injuries 92,191 Pn/influenza 88,383 Diabetes 62,332 Suicide 29,725 Kidney disease 25,570 Cirrhosis 24,765
Factors Influencing Health Status
Guiding Principles
Public Health/College Health
Science-based Population-based Health an individual and societal responsibility Broad definition of health Interdisciplinary/multidisciplinary Collaboration/ Cooperation Prevention/Promotion/Protection Long-term responsibility • • • • • • • •
Medical Care
Science-based Focus on individual Health an individual responsibility Focus on specific illnesses or diseases Specialization Competitive Treatment Short term responsibility
Death Early Death Disease, Disability and Social Problems Adoption of Health-risk Behaviors Social, Emotional, & Cognitive Impairment Adverse Childhood Experiences Conception
Adverse Childhood Experiences: childhood abuse and neglect growing up with domestic violence, substance abuse or mental illness in the home, parental discord, crime
15 10 5 0 35 ACE Score and Alcoholism, Suicide Attempts, or Sexual Assault 30 25 Number of adverse factors: 0 1 2 3 4 or more 20 Considers self an alcoholic Ever attempted suicide Sexually assaulted as an adult (women)
College Students Should Be A Long-term Public Health Priority Group • Numbers are large and increasing – Can be targeted – Last time we have relatively easy access to them • Establishing lifestyle and behaviors • Role models for younger individuals • Set norms of behavior • Leaders of the future
Robert Fulgum born June 4, 1937
•
“Don't worry that children never listen to you; worry that they are always watching you.”
Guiding Principles
Public Health/College Health
Science-based Population-based Health an individual and societal responsibility Broad definition of health Interdisciplinary/multidisciplinary Collaboration/ Cooperation Prevention/Promotion/Protection Long-term responsibility Social responsibility • • • • • • • • •
Medical Care
Science-based Focus on individual Health an individual responsibility Focus on specific illnesses or diseases Specialization Competitive Treatment Short term responsibility Reimbursement driven
How our healthcare money is spent
5% Medical Care Public Health 95%
Guiding Principles
Medical Care Public Health/College Health
• Science-based Science-based • Focus on individual Population-based • Health an individual Health an individual and societal responsibility responsibility • Focus on specific illnesses Broad definition of health or diseases Interdisciplinary/multidisciplinary • Specialization Collaboration/ Cooperation • Competitive Prevention/Promotion/Protection • Treatment Long-term responsibility • Short term responsibility Social responsibility • Reimbursement driven Social justice • Market justice
Market Justice and US Health Care
• • In the United States, health care competes for consumers with other items in the marketplace. Individual resources and choices determine the distribution of health care, with little sense of collective obligation or a role for government. Known as market justice, this approach derives from principles of individualism, self interest, personal effort, and voluntary behavior. The contrasting approach, social justice, allocates goods and services according to the individual's needs. It stems from principles of shared responsibility and concern for the communal well-being, with government as the vehicle for ensuring equity. • Peter P. Budetti, MD, JD, JAMA. 2008;299(1):92-94.
• • Market Justice: You get what you want and what you can pay for.
Social Justice: Everyone gets basic needs met and no one benefits at the expense of someone else.
Public Health Geoffrey Vickers - 1957
•
The constant redefinition of the unacceptable
.
“The philosophy of science is to discover truth.
The philosophy of medicine is to use truth to treat individuals.
The philosophy of public health is social justice.”
William Foege, M.D.
Guiding Principles
Medical Care Public Health/College Health
• Science-based Science-based • Focus on individual Population-based • Health an individual Health an individual and societal responsibility responsibility • Focus on specific illnesses Broad definition of health or diseases Interdisciplinary/multidisciplinary • Specialization Collaboration/ Cooperation • Competitive Prevention/Promotion/Protection • Treatment Long-term responsibility • Short term responsibility Social responsibility • Reimbursement driven Social justice • Market justice
C.E. A. Winslow
Dean, Yale School of Pubic Health
•
“a university health service can realize its possibilities of leadership only if it visualizes public health in the broadest terms.”
• 1929
Public Health on College Campuses
The Role of College Health in Shaping the Future of Health Care
Evolving View of Health and Health Care • From disease to risk factors
• • • • • • • • • Real Leading Causes of Death Tobacco 400,000 Diet/inactivity 300,000 Alcohol 100,000 Microbial agents 90,000 Toxic agents 60,000 Firearms Sexual behavior 35,000 30,000 Motor vehicles 25,000 Illicit drug use 20,000 • • • • • • • • • • Leading Causes of Death Heart disease 725,790 Cancer 537,390 Stroke 159,877 Lung diseases 110,637 Injuries 92,191 Pn/influenza 88,383 Diabetes 62,332 Suicide 29,725 Kidney disease 25,570 Cirrhosis 24,765
Evolving View of Health and Health Care • From disease to risk factors – Particularly important for young adults • From treatment to prevention
Factors Influencing Health Status
Need for treatment and prevention In tobacco control
Evolving View of Health and Health Care • From disease to risk factors • From treatment to prevention – From a population perspective, the younger the population, the more important the prevention efforts.
• From short-term to long-term perspective
Cycle of Development Environmental and Social Influences
: Non-child bearing Parenting
Parents/extended family Culture/Media Roles of men/women/children Norms/Policies Economy Community Education Multiple other influences
Adolescent Adult Preconception Health Care Influences
Health Care Influences
: Child Prenatal Intrapartum
Health Promotion Disease Prevention Health Protection Medical Care ( 1 0 , 2 0 , 3 0 ) Surveillance and data
Infant Environmental and Social Influences
Evolving View of Health and Health Care • From disease to risk factors • From treatment to prevention • From short-term to long-term perspective – Modifying risk-factors and seeing effects of prevention require long-term perspective • From individual to population
Evolving View of Health and Health Care • From disease to risk factors • From treatment to prevention • From short-term to long-term perspective • From individual to population – College health is one of few fields responsible for both individual and population-based outcomes • From population to context
The Ecosystem of a Population
College Health Focuses on Context Laws Norms
multinational corporations government
Culture
friends health care providers violence courts peers parents work
STUDENTS
sibs relatives schools
FAMILIES
police crime T.V.
...isms
COMMUNITY
movies immigration
Attitudes SOCIETY Values
Evolving View of Health and Health Care • From disease to risk factors • From treatment to prevention • From short-term to long-term perspective • From individual to population • From population to context • From individual population problems to syndemic context
Context is the Community
•
Whereas the usual public health approach begins by defining the
disease and the population in
question, a syndemic orientation first defines the community in question.
Syndemic Contextual View of Health Bobby Milstein • • A syndemic is two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.
– Synergistic epidemics – Syndrome of epidemics Syndemics occur when health-related problems cluster by person, place, or time
Syndemics
• The word syndemic was coined by anthropologist Merrill Singer and first published in 1992 to convey what he saw as inextricable and mutually reinforcing connections between health problems such as substance abuse, violence, and AIDS among urban women in the US.
• Singer, 1994; 1996; Singer M and Snipes C, 1992; Singer M and Romero-Daza N, 1997
SAVA Syndemic
*
* Adapted from Singer M, 1996
•
SAVA Syndemic
"Commonly, violence, substance abuse, and AIDS have been described as concurrent epidemics among inner city populations. However, the term epidemic fails to adequately describe the true nature of the contemporary inner city health crisis, which is characterized by a set of closely interrelated, endemic and epidemic conditions, all of which are strongly influenced by a broader array of political-economic and social factors, including high rates of unemployment, poverty, homelessness and residential overcrowding, substandard nutrition, infrastructural deterioration and loss of quality housing stock, forced geographic mobility, family breakup and disruption of social support networks, youth gang formation, and health care inequality
•
(Wallace R, 1988; 1990; Wallace D, 1990).
Alcohol
DAT Syndemic
Depression Tobacco
Syndemic Contextual View of Health Problems are important but the ties between them are often even more important. Pay attention to confounding factors – that’s where the issues are most intense.
To Understand Syndemics…
•
"You think that if you understand one, you understand two-because one and one are two. But you must also understand 'and'."
Sufi saying
Contextual/Syndemic View of Health among College Students
Tobacco Violence Depression Alcohol Stress Obesity
Health System Dynamics
Centers for Disease Control and Prevention, Bobby Milstein
Syndemic Context
Healthy Public Policy & Public Work Society's Health Response Medical and Public Health Policy
General protection Targeted protection Primary prevention Secondary prevention Tertiary prevention
Safer, Healthier Population
Becoming no longer vulnerable Becoming Vulnerable
Vulnerable Population
Becoming Afflicted
Afflicted without Complications
Developing Complications
Afflicted with Complications
Dying from Complications
Adverse Living Conditions DEMOCRATIC SELF-GOVERNANCE World of Transforming …
• • • • • • • •
Deprivation Dependency Violence Disconnection Environmental decay Stress Insecurity Etc… DISEASE AND RISK MANAGEMENT By Strengthening …
• • • • • • • •
Leaders and institutions Foresight and precaution The meaning of work Mutual accountability Plurality Democracy Freedom Etc…
An involved population
World of Providing …
• • • • • • •
Education Screening Disease management Pharmaceuticals Clinical services Physical and financial access Etc…
Centers for Disease Control and Prevention Bobby Milstein
Change is coming!
•
“Willed change” the Sufi say, “is not real. Only unwilled change is real.” Only unwilled change catapults us into what we did not plan to do. Only unwilled change really matters to the molding of the soul, to the stretching of the self beyond the self, in other words. And matter it does. Deeply. Willed change is what I seek and shape. Unwilled change is what seeks and reshapes me.”
– From “The Story of Ruth” by Joan Chittester
Robert Fulgum born June 4, 1937
• Author of “ All I Really Need to Know, I Learned in Kindergarten.
” •
“The world does not need tourists who ride by in a bus clucking their tongues. The world as it is needs those who will love it enough to change it, with what they have, where they are.”
C. E. A. Winslow
at the 1929 dedication of University Health Service University of Minnesota “…a university health service …can
realize its possibilities of leadership only if it visualizes public health in the broadest terms. Public health is concerned with the prevention of disease and the promotion of health in the widest sense…”