Chapter 17. Public Health

Upon completion of the chapter and exercises, the student pharmacist will be able to

1. Define public health.

2. Identify areas in public health where pharmacists can take an active role.

3. Identify partners for pharmacists in order to promote the health of their communities.

4. Describe populations to be targeted by pharmacists.

5. Identify public health content in your curriculum.

Pharmacists have an important role to play in the public's health but often think of their activities in the narrower framework of traditional pharmacy practice. This chapter provides background and tools for reflection on a broader role of pharmacy in public health for you to use as you progress through your education, practice experiences, and professional and community life.

An Internet search for a definition of public health results in a large number of returns. In general, a definition of public health includes such terms as protecting and improving the health of a community, disease prevention, health education, control of communicable diseases, application of sanitary measures, and monitoring of environmental hazards. The Association of Schools of Public Health's (ASPH)1 web site provides a comprehensive definition of public health. Overall, public health professionals are concerned with protecting the health of entire populations. These populations can be as small as a local neighborhood, or as big as an entire country. Public health professionals work to prevent problems from happening or reoccurring through implementing educational programs, developing policies, administering services, and conducting research, in contrast to clinical professionals, such as physicians and nurses, and pharmacists who focus primarily on treating individuals after they become sick or injured. Public health practitioners are concerned with limiting health disparities and a large part of public health practice is the fight for health-care equity, quality, and accessibility. It seems clear to many in the profession, based on the definition of public health, that all pharmacists are now in a position to support, and add to, the role that public health pharmacists have been engaged in for many years.

The study of public health is highly varied and encompasses many academic disciplines and is comprised of the following core areas:

• Environmental Health
• Biostatistics
• Behavioral Science/Health Education
• Epidemiology
• Health Services Administration/Management
• Maternal and Child Health
• Nutrition
• International/Global Health
• Public Health Laboratory Practice
• Public Health Policy
• Public Health Practice

The following sections provide an introduction to each of the areas with respect to what topics are relevant, and the impact of public health professionals in that area.

Environmental Health

"The air we breathe; the water we drink; the complex interactions between human genetics and our surroundings."1

Constructed and natural environments influence our health, and public health professionals ask how we reduce these risk factors? Environmental risk factors are associated with causing diseases such as asthma, cancer, and food poisoning. Chemistry, toxicology, and engineering specialists have combined their expertise to look for answers to questions concerning public health.

Environmental health is broad in scope and so it is often broken down into smaller areas of concern that can be addressed across or within organizations.1

These areas are:

• Air quality
• Food protection
• Radiation protection
• Solid waste management
• Hazardous waste management
• Water quality
• Noise control
• Environmental control of recreational areas
• Housing quality
• Vector control

Biostatistics

"Estimating the number of deaths from gun violence or looking at trends in drunken driving injuries by using math and science is the study of biostatistics."1

Biostatistics is used to identify trends in disease outbreaks, or outcomes that may lead to life-saving measures. Statistical procedures are often used to create graphs and tables that allow for inferences to be made across populations and geographical areas to determine whether a disease has been introduced or become prevalent. Biostatistics is integral to determining trends in disease and prevention measure outcomes. Epidemiologists use biostatistics to report findings, and discuss evidence.1

Behavioral Science/Health Education

"Stopping the spread of sexually transmitted diseases, such as herpes and HIV/AIDS; helping youth recognize the dangers of binge drinking; and promoting seatbelt use."1

Behavioral science/health education focuses on creating programs to persuade people to make healthy choices in their daily lives. These educational endeavors may include development of community-wide education programs that promote lifestyle changes and research of complex health issues. Professionals in this area may review health services and promote more efficient use, and they may develop programs to encourage adoption of patient self-care programs. Areas of mental health, aging and prevention of disease, public health practice, and education are specialty areas found within the field of behavioral sciences.1

Epidemiology

"When food poisoning or an influenza outbreak attacks a community, the disease detectives or epidemiologists are asked to investigate the cause of disease and control its spread."1

Epidemiologists determine what causes a disease or spike in injuries across a population. These public health specialists ask question like what the risk is about, who is at risk, and how to prevent accidents and injuries. They study demographic and social trends that influence disease and injury. These public health professionals may evaluate new treatments for injury or prevention of disease outbreak. Epidemiologists first discussed the outbreak of the West Nile virus. The salmonella outbreaks during the years 2008 and 2009 are examples of times when epidemiologists are called to review outbreak of disease. Epidemiologists were responsible for the 1964 Surgeon General's report on smoking tobacco. Their insight and evidence stating the harmful effects of smoking changed history in the United States and elsewhere. Biostatistics is used to support the findings of the epidemiologist.1

Health Services Administration/Management

"Managing the database at a school clinic; developing budgets for a health department; creating polices for health insurance companies; and directing hospital services all depend on health administrators."1

Politics, business, and science are all combined to manage the human and fiscal resources for delivering public health services. The professionals in these roles may specialize in planning, organization, or policy formation in addition to budget and finance.1

Maternal and Child Health

"Providing information and access to birth control; promoting the health of a pregnant woman and an unborn child; and dispensing vaccinations to children are part of maternal and child health."1

These public health professionals deal with all areas of education, advocacy and research for women and children.1

Nutrition

"Promoting healthy eating and regular exercise; researching the effect of diet on the elderly; teaching the dangers of overeating and overdieting are the responsibilities of public health nutritionists."1

Those who specialize in nutritional research and education examine how populations are affected by their eating habits, nutrients, and available food. Much work is needed in terms of the study of obesity and the consequences, as it is a public health problem across the globe. The science of nutrition improves public health from the standpoint of promoting health and prevention of disease.1

International/Global Health

"Addressing health concerns from a global perspective and encompassing all areas of public health (eg, biostatistics, epidemiology, nutrition, maternal and child health, etc.)."1

The specialists in this area of public health are concerned with the differences in cultures and countries worldwide. Globalization links health outcomes more closely to one another than ever before in history. Travel has opened up new public health issues as people and food move across borders. Disease is spread more quickly than in the past due to ability of people to move across continents in aircraft, and on sea. The severe acute respiratory syndrome (SARS) epidemic is an example of how rapidly disease can spread, and the consequences of globalization on prevention of disease.1

Public Health Laboratory Practice

Professionals who work in laboratories such as "bacteriologists, microbiologists, and biochemists test biological and environmental samples in order to diagnose, prevent, treat, and control infectious diseases in communities."1 Safety of food and water is a concern to these individuals. These scientists also screen for the presence of disease within communities, and are asked to respond to emergencies such as bioterrorism.1

Public Health Policy

"Analyzing the impact of seat belt laws on traffic deaths; monitoring legislative activity on a bill that limits malpractice settlements; advocating for funding for a teen antismoking campaign."1

Professionals in public health policy work to improve the public's health through legislative action at the local, state, and federal levels.1

"Public health is an interdisciplinary field and professionals in many disciplines such as nursing, medicine, veterinary medicine, dentistry, and pharmacy routinely deal with public health issues. A degree in public health practice enables clinicians to apply public health principles to improve their practice."1

Student Pharmacy Public Health Practice Exercise

Using the table below to make entries, and the listed areas of public health defined above, write a reflection on how these areas may be applied to pharmacy. An example is given for environmental health.

Public health organizations are an excellent source of information about the profession. Becoming involved in these organizations leads to development of networks and partnerships, and opportunities for improving the health of the community. These organizations are platforms for a pharmacist to advocate for a role in the public health arena for the profession. Membership in one or more of these organizations is an excellent way to stay current with local, state, and national or global activities. Active engagement in the organization provides a means for direct involvement in association activities and leadership.

American Public Health Association

The American Public Health Association (APHA) website (www.apha.org)2 describes the organization as follows:

"The American Public Health Association is the oldest, largest, and most diverse organization of public health professionals in the world and has been working to improve public health since 1872. The Association aims to protect all Americans and their communities from preventable, serious health threats and strives to assure community-based health promotion and disease prevention activities and preventive health services are universally accessible in the United States. The American Public Health Association represents a broad array of health professionals and others who care about their own health and the health of their communities."2

The American Public Health Association represents a collective voice for public health. There are two publications of the APHA, a peer-reviewed American Journal of Public Health and a newspaper The Nation's Health. The leadership communicates public health science and practice issues and topics to the members and others who read the journal and newspaper.2

Members of APHA include health officials, educators, environmentalists, policy-makers, and other health providers who work in government offices, clinics, community organizations, and educational institutions. Members have multiple opportunities to be involved at both the national and local levels of the APHA.2

Association of Schools of Public Health

The Association of Schools of Public Health (ASHP) represents the Council on Education for Public Health (CEPH)-accredited schools of public health.3 This organization promotes faculty and administration in schools of public health to advance the education and research of public health.3 The association web site (www.asph.org) is an excellent source of information about public health and public health education.

World Health Organization

The World Health Organization (WHO) is a component of the United Nations (UN) and is the directing and coordinating authority for health for the UN.4 The WHO is responsible for providing leadership on global health matters, shaping the global health research agenda, setting norms and standards for health and disease prevention, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends. The WHO web site (www.who.int/en/)4 is a source of information on global health and an excellent resource for data and statistics on international health topics. More information on programs available from WHO are discussed in Chapter 18.

Centers for Disease Control and Prevention

The mission of Centers for Disease Control and Prevention (CDC) is to collaborate to create the expertise, information, and tools that people and communities need to protect their health—through health promotion, prevention of disease, injury and disability, and preparedness for future health threats.5 It was founded as the Communicable Disease Center on July 1, 1946, in Atlanta Georgia. The CDC is a part of the Department of Health and Human Services (HHS) of the United States government with headquarters in Atlanta, Georgia. The CDC has a global outreach and responsibility for coordinating with other global health promotion and disease prevention agencies.6 The CDC promotes vaccination schedules for children and adults, provides information for travelers, and has educational materials available for use by health-care professionals for the public.

CDC seeks to accomplish its mission by working with partners throughout the nation and the world to

• monitor health,
• detect and investigate health problems,
• conduct research to enhance prevention,
• develop and advocate sound public health policies,
• implement prevention strategies,
• promote healthy behaviors,
• foster safe and healthful environments,
• provide leadership and training.5

A review of the CDC Internet site (www.cdc.gov) provides many opportunities for you to envision, as a student pharmacist and soon to be practitioner, how you can play an important role in protecting the public's health. An example is CDC's Health Protection Goals (www.cdc.gov/osi/goals/goals.html).7 The four overarching Health Protection Goals include as the broader topics:

• Healthy People in Every Stage of Life
• Healthy People in Healthy Places
• People Prepared for Emerging Health Threats
• Healthy People in a Healthy World5

The CDC has broken down these overarching goals into individual statements of achievement. These goals support or match those put forth in the Healthy People documents8 created by HHS. Review of these strategic goals will give you a broad sense of how, as pharmacists, you can become directly involved in the health of your community. By taking one set of goals each month and creating or distributing educational literature to patients, and following up on their understanding and practices, you can impact a community.

Food and Drug Administration

The Food and Drug Administration (FDA) is an agency within HHS and consists of nine centers. Their mission is

"The FDA is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation's food supply, cosmetics, and products that emit radiation. The FDA is also responsible for advancing the public health by helping to speed innovations that make medicines and foods more effective, safer, and more affordable; and helping the public get the accurate, science-based information they need to use medicines and foods to improve their health."9

A history of the FDA can be found on their web site http://www.fda.gov/AboutFDA/WhatWeDo/History/default.htm.10 I encourage you to read the history as it provides an excellent background into the agency responsible for regulating all prescription drugs in the United States. Important to add to your knowledge of public health is the FDA's role in food safety, nonprescription medications, radiation-emitting devices, animal and veterinary products, and so on, and this information is available on the FDA web site.9 The news items posted on the FDA site often relate to public health issues that pharmacists can promote, and provide education in their practices both as students and licensed pharmacists.

Healthy People refers to a set of health objectives created over the last 30 years based on a 1979 Surgeon General's report for the United States population to achieve into the 21st century. Healthy People 2010 builds on initiatives pursued over the past two decades. Healthy People 2010 was developed through a broad consultation process, built on the best scientific knowledge, and designed to measure programs over time.8 The document and ideals can be used by many different people, leaders of States, communities, and professional organizations to help create programs to improve health for a defined population.

Every 10 years, HHS leaders leverage scientific insights and lessons learned from the past decade, along with new knowledge to update the document. "Healthy People 2020 will reflect assessments of major risks to health and wellness, changing public health priorities, and emerging issues related to our nation's health preparedness and prevention."11

The American College of Clinical Pharmacy (ACCP) produced and published a White Paper "Healthy People 2010: Challenges, Opportunities, and a Call to Action for America's Pharmacists" in 2004.12 A committee of pharmacist professionals classified each of the 28 Healthy People 2010 primary focus areas into one of four categories according to the perceived role of pharmacists in meeting the specified objectives (Table 17.1). An analysis was conducted for each of 14 focus areas that the committee had placed into a category of 1 or 2 (ie, those for which a pharmacy role is already well established or for which pharmacists are capable and reasonably well positioned to assume a leadership role). A comprehensive literature review was completed to identify pharmacists' contributions toward each of the 28 focus areas.

The ACCP White Paper discussion underscores the fact that the Healthy People 2010 document does not address many areas where pharmacists have potential to play an important role. The authors reported that little or no role exists for pharmacists in these areas, and opportunities for expansion are limited (Category 4). These focus areas included:

• Environmental health
• Food safety
• Injury and violence prevention
• Occupational safety and health
• Oral health
• Public health infrastructure
• Vision and hearing
• Based on information and practices of pharmacists in some areas in 2008, some of the topics placed in Category 4, like environmental health, injury and violence prevention and recognition, oral health, and public health infrastructure, may need to be reexamined.

The committee placed opportunities for pharmacists' in Category 3 if pharmacists are involved, but primarily in a supportive role. Future leadership roles are possible, but only if additional efforts are made and if existing barriers to the success of programs (eg, inadequate training, insufficient manpower) are addressed. Included in this category are:

• Disability and secondary conditions
• Educational and community based programs
• Maternal, infant, and child health
• Nutrition and overweight
• Physical activity and fitness
• Sexually transmitted diseases
• Substance abuse

Categories 3 and 4 are areas where pharmacists can impact the public's health. These topics and areas of practice are now being included in college of pharmacy curricula and student pharmacists are becoming engaged in improving practice in these areas. Engagement by pharmacists in the development of Healthy People 2020 is important as pharmacists should be a part of the nation's plans for a healthier population. Involvement of pharmacists and student pharmacists in Healthy People 2020 at the formative stage and after the goals are finalized is a meaningful role for your advocacy activities.12

As you seek to be more involved in public health activities, it is appropriate to examine the educational background that will be helpful to you. The background offered by the Master of Public Health (MPH) degree provides coursework and practicum's that will help develop skills in the public health arena. The content areas can be offered in stand-alone courses or in an integrated fashion. Key content includes many of the previously mentioned public health specialties.

Epidemiology

Core functions of the discipline can be categorized into five areas:

1. Exploring the existence or occurrence of an exposure or a disease within a group or population.

2. Conducting disease surveillance and recognizing potential disease epidemics.

3. Describing if differences exist in the occurrence of exposure and/or disease in subgroups of the same population or different populations.

4. Identifying and then quantifying the effect of the causation of disease.

5. Testing interventions that may aid in disease identification or mitigation in a population.

An understanding of epidemiology is useful to pharmacists involved with any aspect of disease prevention or treatment. Knowledge and ability to interpret biostatistics allows a pharmacist to make learned judgment as to the quality of data for studies involving prevention and treatment of disease.

Environmental Health

Understanding environmental health has grown in importance with the recent focus on emergency preparedness and response. Nationwide, many pharmacists are engaged in preparing and responding to a natural or terrorist-induced disaster. The principles of exposure, risk assessment, and toxicology are important to active engagement by pharmacists on the emergency preparedness team.

Behavioral Health

A pharmacist's involvement in mental health is a major asset to public health. From the traditional role played in medication and adherence management to providing information on mental illness to patients and caregivers, pharmacists through their community involvement are equipped to play a significant role in community awareness of mental illness and the treatment involved. Advanced courses in psychology and sociology broaden the background beyond the traditional pharmacology and therapeutics experiences.

Cultural Competence

Health-care professionals will practice in diverse communities and interact with patients and caregivers, whose life experiences may differ greatly from the provider. An understanding of the differences among cultures, religious groups, and individuals is critical to the delivery of appropriate and understood patient care. The National Center for Cultural Competence (NCCC)13 web site descriptions of the critical factors in the provision of culturally competent health-care services include understanding of the:

• beliefs, values, traditions, and practices of a culture;
• culturally defined, health-related needs of individuals, families, and communities;
• culturally-based belief systems of the etiology of illness and disease and those related to health and healing; and
• attitudes toward seeking help from health-care providers.13

The NCCC has put together a document that describes the "Compelling Need for Cultural and Linguistic Competence" (www11.georgetown.edu/research/gucchd/nccc/foundations/need.html).14 The six reasons given for including cultural competence in organizational policy are:

1. To respond to current and projected demographic changes in the United States.

2. To eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds.

3. To improve the quality of services and health outcomes.

4. To meet legislative, regulatory, and accreditation mandates.

5. To gain a competitive edge in the marketplace.

6. To decrease the likelihood of liability/malpractice claims.14

Disease Prevention and Health Promotion

This is an area where a large impact by pharmacists is likely. According to the CDC:

"Chronic diseases—such as heart disease, cancer, and diabetes—are the leading causes of death and disability in the United States. Chronic diseases account for 70% of all deaths in the U.S., which is 1.7 million each year. These diseases also cause major limitations in daily living for almost 1 out of 10 Americans or about 25 million people. Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. Adopting healthy behaviors such as eating nutritious foods, being physically active, and avoiding tobacco use can prevent or control the devastating effects of these diseases."15

The CDC web site (www.cdc.gov/NCCdphp/overview.htm) provides data on the costs of chronic disease. In 2005, 133 million people, almost half of all Americans lived with at least one chronic condition. The medical care costs of people with chronic diseases account for more than 75% of the nation's $2 trillion medical care costs. Table 17.2 lists statistics known in 2009. Table 17.3 lists the cost effectiveness of prevention.15

The data in Tables 17.2 and 17.3 provide compelling reasons that pharmacists should be focused on public health. Pharmacists can address the health of our population and the rising costs for health care.

Student Pharmacist Practice Exercise

As an exercise, list behaviors that have the potential to either increase or decrease health outcomes. List the steps you would take to reinforce healthy behaviors or alter nonhealthy activities. Describe how these interventions can be carried out in community pharmacies, in institutional practice, in clinics, or with community-based groups.

The public health is everyone's business because it affects the workplace, health-care costs across the globe, and many chronic diseases that are preventable. As a student and future pharmacist the responsibility lies with you to become informed, involved, advocate for the role of the pharmacist as a public health professional and practitioner, and to be a public health professional. As a student pharmacist getting involved in providing education to improve health literacy, addressing public health issues such as osteoporosis, obesity, asthma, and diabetes, will enable you to learn about the treatment and prevention of diseases, practice your clinical skills, and become adept at advocacy. There are a variety of areas of public health, such as epidemiology, environmental health, safety, laboratory, maternal and child, and disaster preparedness, where you can specialize as a pharmacist.