PLANETARY HEALTH WEEKLY

By Dr. Jay Kravitz

Blog #2 posted November 12, 2020

What is the discipline of public health? This challenging profession, often overlooked or misunderstood, works diligently, typically in the background, to protect everyone – even as more visible attention is drawn during outbreak investigations and/or pandemics. Public health practitioners possess broad educational backgrounds including medicine, nursing, entomology, veterinary, occupational and environmental science disciplines, embracing wide ranging skills, goals and responsibilities.

One cannot readily predict the types of health and environmental/ecological problems or situations that will present themselves on a daily basis that need resolution guided by public health professionals. Their broad scope of responsibilities includes: providing technical assistance for community health care providers; supervising and guiding outbreak investigations; consulting with environmental and epidemiology health officials; offering advice to multiple government agencies, whether local, national or international; and importantly, sharing information with the public.

Additionally, consideration is directed toward developing plans to deal with the potential for bioterrorism, mass fatality incidents and newly emerging diseases, like the current COVID-19 pandemic. Evolving case definitions are integral to this process to guide responsive, effective actions as more information is gained.

But, this is just the tip of the iceberg. While public health practitioners may also be involved in the clinical care – and have concerns about the management – of individual patients, their primary motivation is the practice of population-based health. This strategy embraces recent trends and interests toward managing health care of a population as a whole.¹ This discipline offers an integrative approach for the assurance of public health safeguards and the provision of medical care.

Depending on one’s professional location and jurisdiction, health departments provide varied types of services. Primary care for underserved, vulnerable populations with compromised access to medical attention may be integrated with public health’s typical duties. This is certainly true, for example, regarding the challenges of incorporating surveillance procedures and management of the complexities of tuberculosis. In other public health situations professionals may work directly with community clinicians to solve diagnostic issues and provide feasible services.

The focus is inclusive: to understand, protect and promote healthat the population, community level, while considering health of the single individual.² Therefore, population-based medicine places patients within the context of larger communities, composed of both sick and well individuals. This shared scope of responsibility with an inclusive, expanded health care delivery model is needed to serve diverse social groups, which are ethnically, culturally and economically intertwined.

Dedicated public health professionals, educated about a wide range of issues, generally work quietly behind the scenes to assure that we live in safe and healthy environments. Various agencies protect the water we drink, the air we breathe, and the food we purchase from supermarkets. They also inspect restaurants and public areas, like swimming pools and workplaces. Their interests encompass health education, hygiene, mental health, nutrition, waste management, infectious diseases, immunizations,  maternal and child health, the welfare of newborns, injuries, travel-related illnesses, chronic diseases, sexually transmitted diseases, occupational health, industrial pollutants leading to environmental degradation and sickness, heavy metal exposures (e.g., mercury, lead, arsenic), vector control, zoonotic diseases, cancer, substance abuse, disabilities, community health needs-assessments, and planetary stresses³…to name but a “few”…oh my!

Surveillance for potential disease and health hazard events – inclusive of social determinants of health⁴ – is essential. Mandated clinician reporting⁵ to health departments of laboratory confirmed and clinically-suspect diagnoses is fundamental for well-informed, responsive and collaborative interventions. Reporting regulations assist health departments to identify disease outbreaks of significance and enact contact tracing, as necessary, and other measures. Consequential morbidity patterns may be discerned, which can guide clinical decisions and preventive measures – and help save lives.

Sharing clear, effective risk communication messages with the general public, clinicians, government agencies and community-based organizations is a central responsibility of public health agencies. Strategic prevention and action plans frame protocols, policies and legal statutes as cornerstones of health protection. The public health realm is consistently engaged in local, state, provincial, regional and national dialogue to assure health-related resource availability, while addressing essential public health services, including culturally relevant minority services, disparate societal needs, and enabling equitable health care access.⁶

Public health education directed toward many different professional groups and the public is central to communicating this profession’s objectives, goals, knowledge, perceptions and skills. Over recent years, the inclusion of public safety and first-responder agencies to prepare for natural or man-made events has made an important, positive impact. Many organizations, including medical and laboratory personnel, hospitals, police, fire, emergency medical technicians, 911 access, elected officials and public health specialists, have recognized the need to join together in ways not always previously considered or appreciated. Although these dialogues at times may remain sub-optimal, communication will hopefully continue to improve.

During times of crisis, community-based surveillance in population centers or more remote areas may provide valuable assistance to those professional entities. Conveying timely observations or descriptions of suspected diseases with salient causes and symptoms might signal epidemic potential, smaller outbreaks, or offer caution about an increased mortality risk.⁷ Addressing food-borne illness outbreaks is but one example of this.

Public health practitioners are uniquely suited to bring advocacy arguments into the public space because they have the scientific credentials and a commitment to social justice and equity. Major public health successes, including tobacco control, HIV/AIDS, attention to domestic violence, eradication of certain vaccine-preventable diseases, and reducing drunk driving, are all products of advocacy.⁸

While a lot of work must still be done and challenges abound, we have come a long way in developing and supporting intervention mechanisms to protect the health of populations and respond to adverse events. It is clear that the foundation for assuring communities they are safe from routine and emergent health problems is to explain to everyone the wide-ranging skills and responsibilities assumed by the discipline of public health.

1. Weiss K. A look at population-based medical care. https://pubmed.ncbi.nlm.nih.gov/9735940/#affiliation-1/ 1998;44(8):353-69. doi: 10.1016/s0011-5029(98)90005-0.
2. Stull JD. Personal Communication. Assistant Professor, OHSU-PSU School of Public Health. 2020.
3. Kravitz J. Relative Drought: A global environmental concern. Lancet Planetary Health. July 2017;1(4):e130-131.
4. Ventres W, Kravitz J, Dharamsi S. PEARLS+: Connecting Societal Forces, Social Determinants, and Health Outcomes. Academic Medicine. 2018;93:143.
5. Disease Reporting Guidelines. Oregon Health Authority (2020). https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/COMMUNICABLEDISEASE/REPORTINGCOMMUNICABLEDISEASE/Documents/ReportingPosters/poster-clinicians.pdf/
6. Krisberg K. Equity at center of revised 10 essential public health services. The Nation’s Health. November/December 2020;50(9):1-10.
7. Ratnayake R, Tammaro M, Tiffany A, Kongelf A, Polonsky J, McClelland A. People-centred surveillance: a narrative review of community-based surveillance among crisis-affected populations. Lancet Planet Health. 2020;4:e483–95.
8. Barna M. Advocacy serves as impetus for public health change. The Nation’s Health. October 2020;50(8):4. https://thenationshealth.aphapublications.org/content/50/8/4.2/