Expanding the Definition of Public Health

In its 1988 “Future of Public Health” report, the U.S. Institute of Medicine (IOM) described public health in terms of its mission, substance, and organizational framework – which in turn address such important and interrelated topics as prevention, a community approach, health as a public good, and the contributions made by various partners. The same report defined the mission of public health, at that time, as “fulfilling society’s interest in assuring conditions in which people can be healthy.”   A much earlier definition was provided by Charles-Edward Amory Winslow in a 1923 paper on “The Evolution and Significance of the Modern Public Health Campaign,” in which he described public health as “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities, and individuals.”

The core functions of public health agencies, as defined in the 1988 IOM report mentioned above, are assessment, policy development, and assurance. In 1994, the Core Public Health Functions Steering Committee – a panel composed of representatives from U.S. Public Health Service agencies and other major public health organizations – of the U.S. Centers for Disease Control and Prevention (CDC) went into much greater detail by defining “Public Health Essential Services” as, among other things:

  • Monitoring health status;
  • Diagnosing and investigating health problems and health hazards;
  • Informing, educating, and empowering people about health issues;
  • Mobilizing community partnerships toentify and solve health problems;
  • Developing policies and plans that support individual and community health;
  • Enforcing laws and regulations that protect health and ensure safety;
  • Linking people to needed personal health services and ensuring the provision of health care when otherwise unavailable;
  • Ensuring the availability of a competent public health and personal health care workforce;
  • Evaluating the effectiveness, accessibility, and quality of personal and population-based health services; and
  • Conducting research leading to new insights and innovative solutions to health problems.

Traditional Tasks, Plus Two for Modern Times No matter which definition of public health, core function, or essential service is the principal focus, most U.S. public health agencies – whether they are municipal, county, regional, or even state – organize themselves around functional operational divisions, or units.  These divisions traditionally include, but are not limited to, such specialized fields as maternal and child health, surveillance/epidemiology, administration, environmental health, and behavioral health.

Curiously, what is still lacking in most if not quite all of the preceding (and other) definitions, core functions, and essential services are two words that have become increasingly relevant in recent years: “emergency”; and “preparedness.” However, since the terrorist attacks of 11 September 2001 considerable funding has been provided to local, state, and federal public health agencies and organizations to orient them toward the more comprehensive state of public health preparedness needed to cope with the changed and more dangerous realities of today’s world.   One of the more expansive definitions of Public Health Preparedness comes from the Harvard School of Public Health’s Center for Public Health Preparedness website, which states specifically that the “key elements” of public health preparedness now include “regularly exercised plans, timely access to information, clear knowledge of individual and agency roles and responsibilities, reliable communications systems, and connectivity between and among responding agencies.”

Another updated definition of public health emergency preparedness – provided by the RAND Corporation in a 2007 report titled Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism – goes into greater detail with the assertion that “The capability of … public health and health care systems, communities, and individuals to prevent, protect against, quickly respond to, and recover from health emergencies … threatens to overwhelm routine capabilities.” The threat is greater, the report also says, during emergencies “whose scale, timing, or unpredictability” is uncertain. “Preparedness involves a coordinated and continuous process of planning and implementation,” the report continues, “that relies on measuring performance and taking corrective action.”

A Tip-of-the-Spear Summary There are numerous responsibilities, including the following, currently assigned to the Public Health Preparedness units of today’s post-9/11 Health Departments:

  • Establishing an Incident Command System (ICS) structure for the Health Department; most of the emergency management continuum – which consists primarily of mitigation, preparedness, response, and recovery operations – is best handled by the entire department within the Incident Command System.
  • Assuring National Incident Management System (NIMS) compliance within the Health Department;  Homeland Security Presidential Directive 5 mandates that local and state government agencies adopt the National Incident Management System as the preferred model for their own emergency-response policies, procedures, and protocol-development and practice;
  • Overseeing the mass dispensing of medications. Traditionally, this responsibility was related primarily to a prophylaxis medication distribution to the public following a bioterrorism incident, and was carried out in cooperation with the CDC’s Strategic National Stockpile (SNS) – or a state’s predesignated RSS (Receipt, Store, and Stage) site. However, as recent H1N1 (“Swine Flu”) events have proved, this “dispensing” task can also include vaccinations.
  • Developing, analyzing, testing, exercising, and revising various emergency and contingency plans – including and involving, for example, but not limited to, pandemic preparedness, SNS distribution, and both medical surge and Continuity of Operations requirements.

To summarize: Whether preparing and planning for, or responding to, public health emergencies, it is imperative that, in today’s world, health departments of all sizes – and whether local, county, regional, or state – realize that protecting the health of those living in their communities requires a public health workforce that is fully prepared to respond to a broad range of public health threats.  It is also in the best interest of these departments, therefore, which stand at the tip of the spear in protecting the general public, to establish fully funded divisions of Public Health Preparedness.

Raphael Barishansky

Raphael M. Barishansky, DrPH, is a public health and emergency medical services (EMS) leader with more than 30 years of experience in a variety of systems and agencies in positions of increasing responsibility. Currently, he is a consultant providing his unique perspective and multi-faceted public health and EMS expertise to various organizations. His most recent position prior to this was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. Mr. Barishansky recently completed a Doctorate in Public Health (DrPH) at the Fairbanks School of Public Health at Indiana University. He holds a Bachelor of Arts degree from Touro College, a Master of Public Health degree from New York Medical College, and a Master of Science in Homeland Security Studies from Long Island University. His publications have appeared in various trade and academic journals, and he is a frequent presenter at various state, national, and international conferences.

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