Chapter 13

Challenges in the New World of Public Health Practice

Learning Objectives

• Describe the complex problems challenging public health organizations
• Discuss the value of evidence-based public health practice
• List examples of global initiatives to improve public health
• Identify some goals for the future of public health practice

The status quo of poor health outcomes and social inequities is reinforced by beliefs that individuals are solely responsible for making unhealthy choices, that life is not fair and health and wealth disparities are just part of life, and that nothing short of a revolution can be done to change these conditions (Rogow, Adelman, Poulain, and Cheng, 2008). Moving beyond these limiting concepts is our common challenge and one that we can meet by reframing the health dialogue into questions about how we put an end to dangerous conditions, create healthy places and spaces, and help communities organize and build partnerships that create and sustain policies protecting the public good in regard to health (Rogow et al., 2008). Reducing community populations' vulnerability to significant threats to health by planning and implementing evidence-based global and local public health strategies will require a redesign of current public health services to ensure a primary focus on population-centered prevention policies, programs, and actions. Evidence-based public health strategies are interventions that have been evaluated and determined to improve health outcomes. The increasing rates of chronic diseases, the effect of climate change on human health and the world ecosystem, and the long-term repercussions of human violence on countries and their populations are just some of the complex threats affecting the health of many communities and nations. Such complex health problems are best addressed by a public health system skilled at providing population-based health services based on the best available knowledge.

Determinants of Health

As the costs of health care in the United States continue to rise with little change in national health status and quality of health, questions have surfaced about what actions, programs, or policies create good health and how much is too much to pay for health care. Awareness is growing that health is about more than access to health care and that those at the bottom of the socioeconomic scale get sicker and die younger than those who are well employed and prospering. Studies of the increasing rates of health disparities point to racism as an added health burden, in part due to the stress of discrimination and the relegation of many people of color to lower socioeconomic status (SES), resulting in exclusion, feelings of hopelessness, and reduced access to health care (Rogow et al., 2008). Under these conditions the stress in people's lives is intensified along with levels of cortisol, a stress hormone. As observed by Stanford biologist Robert Sapolsky, living with a stress response for thirty years, even at a low level, will increase your risk for every chronic disease (California Newsreel, 2008).

Changing individual health behaviors by marketing healthier choices, such as eating more nutritious foods, has been the focus of many prevention programs in the field of public health. Within the local public health agency, government-funded programs emphasize health education as part of a medical visit. For instance, women seeking family planning services are counseled and educated about safe sex, folic acid, healthy diets, and the effects of tobacco use on health. However, an increasing number of public health practitioners are recognizing that choices people make are often shaped by the choices they have. New evidence demonstrates that the places where we live and work clearly affect our health (Wilson et al., 1998). People living in poorer communities often have limited choices, exemplified by the abundance of fast food chains, convenience marts, and liquor stores compared to the limited presence of grocery stores filled with fresh produce, fish, meat, and whole grain foods.

The status of economic, social, and built environments is a result of the decisions that a society has made in the form of government policies, and these decisions shape health. The characteristics of walkable and mixed-use neighborhoods (that is, neighborhoods with parks, businesses, homes, and stores or restaurants with healthy food choices) are related to an improved sense of community and social capital (Dearry, 2004). Unsafe neighborhoods with vacant buildings, limited space for recreation, damaged or nonexistent sidewalks, crime, fumes from motor vehicles, and other similar hazards are less walkable and have fewer possibilities for mixed use. The increased presence of hazards in poorer communities creates health inequities and reduces overall health status. Reducing inequality and implementing policies that protect all people from threats to their health, regardless of their economic status, skin color, or geographical location, are changes that we can make to ensure healthier outcomes and promote the public good (Rogow et al., 2008).

For many developing countries, the situation is much grimmer as people struggle to survive in the midst of civil war, as occurred in Rwanda in 1994 and El Salvador during the 1980s, or armed conflict with another nation—exemplified by the United States' war with Iraq starting in 2003 and the conflict between Pakistan and India from 1990 to 1992. People living in countries involved directly in armed conflict face the complete devastation of their infrastructure, a frequent consequence of war.

Modern-day health is also seriously affected by the economic interdependence and interconnectedness of today's world, which are transforming the spread of diseases and risk factors for poor health into much larger menaces for global communities. Countless opportunities exist for the rapid spread of communicable diseases, including the potential for outbreaks associated with the accidental or intentional release of infectious agents (World Health Organization [WHO], 2007). Worldwide export and import of consumer goods exposed to contaminants create an easy environment for the immediate disbursement of illness across the planet. The same can be said for humans exposed to microbial contamination or toxic agents who travel from country to country, potentially exposing thousands and more to new viruses, such as severe acute respiratory syndrome (SARS), or reemerging diseases, including multi-drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). Over 120 different diseases, most including multiple cases, occur daily around the world and are tracked by HealthMap (http://healthmap.org/en). A sudden health crisis in China, for example, can easily spread to other parts of the world, as we witnessed with the deadly SARS outbreak in 2003 that sparked an international alert.

In 2009 an influenza pandemic was declared, and by 2010, 214 countries reported confirmed cases of H1N1, resulting in over eighteen thousand deaths. The particular H1N1 strain had never been seen in humans before, and, although it was not the fearsome event expected by many public health practitioners, its occurrence uncovered the lack of readiness for dealing with a potentially more deadly pathogen. In the presence of monumental medical advances over the past century, a new and highly contagious disease still has the potential to destroy populations and wreak havoc on social, economic, political, and legal structures around the world (Harmon, 2010). A new, virulent virus could kill millions, resulting in countries' closing their borders, which would affect global commerce and trade, and potentially abridging basic human rights to prevent the spread of the disease. This situation could last years as each changing season brings new surges of the disease (Harmon).

The World Health Organization (WHO, 2007, p. 5) has issued a call for action, proactive and reactive, “to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international borders.” This effort is known as the Global Public Health Security in the 21st Century. WHO's call for worldwide health security recognizes that a sudden health crisis in one region of the world is now just hours away from threatening another part of the world. Chronic diseases have surfaced as a serious global health threat in the past few decades, attributed primarily to the exportation of the U.S. lifestyle to developing countries and other world economies. Armed conflicts around the world also contribute to the spread of disease, increased rates of violence both during and after wars, and economic disparities across countries. The rest of this chapter presents more detail on the major causes of disease and injury in the world today and calls upon public health practitioners to respond with population-centered public health approaches.

Obesity Epidemic

The obesity epidemic stems from the 1.1 billion overweight adults and 312 million obese people in the world (James, Rigby, Leach, International Obesity Task Force, 2004). The rates of obesity have doubled, possibly tripled, in less than two decades. When we consider children as a population, the rates are rising much more quickly in parts of Europe. The burden of disease from obesity is great—obesity is considered to be among the top five risk factors for poor health (James et al., 2004). In the United States about 68 percent of the population over the age of twenty is either overweight or obese (IOM, 2010a). Annual medical expenditures related to obesity have doubled in the last decade, estimated to be almost $147 billion per year (RTI International, 2009). More than 80 percent of people with type 2 diabetes are either overweight or obese. Being overweight increases the risk of heart disease. People who are overweight or obese are also at higher risk for hypertension or high blood pressure, greatly raising their risk of heart attack, stroke, and kidney failure. Obesity adversely affects metabolic or endocrine disorders, one of the fastest-growing obesity-related health concerns in the United States, creating current and future health problems for almost a quarter of the U.S. population—forty-seven million people. Childhood obesity rates continue to increase in the adolescent young population. Some experts predict that one-third of the children born in 2000 will develop obesity-related diabetes, and half of these cases will occur in Latino or African American communities (The Endocrine Society, 2009). Obese children suffer from lung, liver, heart, and musculoskeletal afflictions and also experience psychological problems.

Chronic, noncommunicable diseases are also increasing at disturbing rates in other countries (Hossain, Kawar, and El Nahas, 2007). Around the world, diabetes and hypertension are the major causes of eighteen million deaths each year from cardiovascular disease. The growing prevalence of overweightness and obesity over the past decade is the major contributor to the increases observed in diabetes and hypertension in developing countries that are already suffering from underweightness, malnutrition, and infectious diseases. Being poor in a very poor developing country where the annual income is less than eight hundred dollars a year per capita increases the likelihood of being underweight or malnourished, whereas being poor in a middle-income developing country, where the annual income is estimated at three thousand dollars per year, is associated with increased risk of obesity. In some developing countries parents are obese while children are underweight (Hossain et al.).

The tripling of obesity rates in developing counties is attributed to the adoption of a Western lifestyle, which results in decreased physical activity and overconsumption of inexpensive, energy-dense foods made available through fast food chains and processed foods suppliers. The biggest threats are to the Middle East, the Pacific Islands, Southeast Asia, and China. From 2 to 7 percent of total health care costs in developing countries are due to obesity (WHO, 2009).

The increased rates of diabetes will reach pandemic levels by 2030, affecting more than 220 million people (Hossain et al., 2007). The economies of developing countries can easily become overwhelmed by the increase in serious forms of cardiovascular disease and other health complications associated with obesity and diabetes at a time when they are still struggling to contain communicable diseases. In China alone, 92.4 million people are estimated to be diabetic, with another 148.2 million in the prediabetic state, a risk factor for developing type 2 diabetes and cardiovascular disease (Yang et al., 2010). Given its large population, China will most likely experience the greatest burden of diabetes compared to all other countries. An alarming factor for public health experts is the large proportion of Chinese who remain undiagnosed and, hence, untreated. China is expected to lose over $558 billion in income due to the presence of this illness in its population during the ten-year period from 2005 to 2015 (WHO, 2009).

Diabetes has become a major global health problem. Diabetes is preventable, but action is required to produce fundamental social and policy change, making healthy foods more affordable and available and expanding community-wide educational and informational campaigns coupled with increased opportunities for physical activity. WHO recently issued objectives for developing countries to improve the nutritional content of school meals and promote healthy living (Hossain et al., 2007). Some countries are now monitoring policies and programs that target obesity and poor nutrition. However, given the newness of such programs, few data are available on their costs and outcomes. Such initiatives are also expected to generate fierce opposition from food manufacturers and consumer groups that are opposed to any restrictions that affect civil liberties (Hossain et al.).

In the United States, the Centers for Disease Control and Prevention publishes evidence-based practices for increasing rates of physical activity and reducing obesity in the Guide to Community Preventive Services (Community Guide Branch, n.d.). Recommended practices for behavioral interventions to reduce screen time (TV, computers, and so on); multicomponent counseling or coaching to effect and maintain weight loss; and workplace wellness programs to prevent or control obesity and overweightness can be found in the Community Guide. In 2009 the Institute of Medicine reviewed what it believed to be the relevant information for community, environmental, and policy-based obesity prevention programs. The group found a clear evidence gap and developed the LEAD framework (Locate evidence, Evaluate it, Assemble it, and inform Decisions) to support innovative approaches to identify, evaluate, and build the evidence base using a broad, transdisciplinary approach—one that takes a systems perspective (IOM, 2010a).

WHO reports that simple lifestyle measures are known to effectively prevent or delay the onset of type 2 diabetes, such as achieving and maintaining healthy body weight; being physically active, getting at least thirty minutes of regular, moderate-intensity activity on most days; eating a healthy diet of between three and five servings of fruit and vegetables a day and reducing sugar and saturated fat intake; and avoiding tobacco use, which increases the risk of cardiovascular disease (WHO, 2009). However, as stated earlier, the choices people make are based on the choices they have, and policies are needed to ensure that all communities have access to healthy foods, safe areas for recreation, and community-wide efforts to promote and support healthier lifestyles.

Obesity is a complex, population-centered health problem. The IOM's goal in creating the LEAD framework is to provide guidance for gathering and compiling evidence in a transparent manner and in a real-world context. The process is an alternative to randomized experiments and focuses on learning from ongoing policies and practices that can be evaluated for effectiveness and then generalized to address the obesity epidemic on a county, state, national, or global scale (IOM, 2010a). The use of the LEAD framework by public health practitioners with decision-making responsibilities and their key partners, along with researchers working on obesity prevention and other complex public health issues, is an important initiative for understanding and disseminating information about which programs and policies effectively reduce obesity rates. Public health practitioners and decision makers will have the most relevant and accurate knowledge as they work to reverse the rates of obesity by applying the best available evidence and by planning interventions with a keen eye on the importance of measuring their progress and the effect of the planned changes on obesity outcomes. Examples of evidence-based public health interventions developed using the LEAD framework can be reviewed in the CDC's Guide to Community Preventive Services (Community Guide Branch, n.d.).

Climate Change

Climate change is any significant shift in climate, as measured by temperature, precipitation, wind, and storms, lasting decades or longer. According to the Centers for Disease Control and Prevention (CDC, 2011a), the world's climate is becoming warmer, and extremes in weather are more common. Climate change has the potential to create intense heat waves, heavy rain, severe and numerous droughts, air pollution, rising sea levels, and such extreme weather events as flooding, hurricanes, and tornadoes.

Climate and health are inextricably linked. The presence of some diseases and conditions that threaten our health are attributed to the climate in which we live. Heat causes hyperthermia, cold causes hypothermia, and droughts cause famine. Hurricanes, tornadoes, floods, and forest fires cause injuries, deaths, disruption, and relocation. Climate and weather affect the distribution and risk of vector-borne diseases, such as malaria or dengue fever (Frumkin et al., 2008). The effect on human health from global warming will be great; injuries and fatalities are expected to increase due to severe weather events, extremes of temperature and rainfall, the spread of vector-borne infectious diseases, respiratory problems related to pollution and poor air quality, and famine. Increased temperatures can result in a range of health effects, from mild heat rashes to deadly heat strokes. Heat increases ground-level ozone concentrations that cause lung injury and exacerbate such respiratory diseases as asthma and chronic obstructive pulmonary disease (COPD). Longer bouts of higher temperatures lead to drought and ecosystem changes, such as shifting migratory patterns of disease vectors that can be very deleterious to health. Agricultural products are significantly affected by drought conditions, creating food insecurity and increasing hunger. Seas are expected to rise as a result of the warming atmosphere, and this will affect coastal communities, particularly in developing countries where resources are inadequate for protection from changes in sea levels. Climate change will also affect biodiversity and the goods and services from the ecosystem on which humans rely (Haines, Kovats, Campbell-Lendrum, Corvalan, 2006).

Global warming has become possibly the most complex issue facing the world today. Scientific evidence continues to mount concerning the increasing dangers from the buildup of greenhouse gasses. The world's climate has been warming primarily due to the buildup of greenhouse gasses in the atmosphere, which is attributed in great part to the burning of fossil fuels and deforestation. Evidence of warming is found in increased global average temperatures and ocean temperatures, extensive melting of snow and ice, and rising average global sea levels. Climate warming is expected to continue and accelerate—end-of-the-century projections for the overall increase in temperature approach 1.4°C to 5.8°C (2.5°F to 10.4°F) (Haines et al., 2006). Although the lower estimate of warming could be tolerated, increased temperatures of 10°F or more would result in disastrous long-term effects on ecosystems and economies.

Global warming has been linked to increased incidences of extreme weather, including more floods and more frequent and intense storms. Increases in natural disasters are expected to produce widespread psychological distress and increases in social disruption, physical problems, and psychological disorders, particularly among those who are most vulnerable, such as young children, older adults, impoverished communities, and those suffering from chronic conditions (Jenkins and Phillips, 2009). Mental health problems are expected to grow as more and more communities experience devastating storms and floods. Table 13.1, produced by the CDC, highlights the effects of climate on health.

Table 13.1 Weather Events and Health Effects

Source: CDC, 2009c.

Reducing global warming and reversing, or at least mitigating, its effects calls for a worldwide effort that addresses technological, economic, political, and social issues—a systems approach. The challenges of reaching a global treaty on global warming have proven to be overwhelming during the early part of the twenty-first century. The best we can achieve for the foreseeable future is a reduction in emissions and increased aid for developing countries to help them adapt to the effects of global warming and climate change. The concern for developing countries is centered on their lack of resources to defend against the effects of climate change, including rising sea levels, increased incidence and intensity of tropical storms, and the expansion of tropical diseases. In 2009 the world's leaders agreed upon a dangerous climate threshold, 1.3°F above the current average global temperature of 57°F, or no more than a 3.6°F–increase in temperature from the time of the Industrial Revolution (Baker, 2009). The eight industrial powers also agreed to a 50-percent reduction in global emissions by 2050 that would require the richest countries to lower their emissions by 80 percent. China and India, the two fastest developing nations in the world, did not join the other eight industrial powers in agreeing to lower emissions.

Public health professionals, including their community partners and stakeholders, have recognized the need to respond to climate change for practical as well as ethical reasons (Frumkin et al., 2008). Quality public health services are characterized as being population-centered, proactive, equitable, risk reducing, and effective (U.S. Department of Health and Human Services, 2008). Preventing the effects of climate change requires public health practitioners to work with others to slow, stabilize, or reverse climate change. We must also anticipate and prepare for the harmful effects of climate change by reducing risks and the health burden on populations, paying particular attention to those most vulnerable. Identifying such groups in advance—being proactive—will provide crucial information for planning and preparedness and prevent avoidable loss of lives.

The Centers for Disease Control and Prevention (2009c) has identified the following priority health actions for climate change for public health organizations:

The World Health Organization's work plan on climate change is aimed at supporting health systems in all countries, particularly in low- and middle-income nations and small island states; building capacity for assessing and monitoring risks to and impacts on populations due to global warming and climate change; developing strategies and actions to protect human health, with a focus on the most vulnerable; and sharing knowledge and good practices (WHO, 2010). Some of the strategies WHO is promoting to reduce the impact of warming are (1) advocating to raise awareness about the threats to human health; (2) partnering with agencies to ensure representation of health on the climate change agenda; (3) building the scientific evidence on the links between climate change and health, pursuing a global research agenda; and (4) strengthening the health system to work with countries on assessing their vulnerability to the effects of climate change and building capacity to reduce health consequences (WHO, 2010).

War and Armed Conflicts

Wars and their aftermath produce arguably as much mortality and morbidity as many major diseases combined. More than 191 million people died as a result of war, over half of whom were civilians, during the twentieth century (Levy and Sidel, 2008). Many civilian casualties occurred when innocent people were caught in the cross fire between combatants. Wars are devastating to individuals, families, communities, and, at times, entire states or nations by the killing, maiming, and displacement of people. Millions have died as a result of starvation and disease brought about by the destruction of infrastructure and agricultural systems, and by being forced, along with entire communities, to flee their homes (Taipale, 2002). A large proportion of soldiers and civilians are disabled because of injuries suffered during war. Survivors of war suffer long-term health consequences, including physical, psychological, and emotional problems from their exposure to the brutalities of war that include torture, rape, the violent death of loved ones, and the destruction of entire communities. People who spend much of their lives in armed conflict or exposed to war will think of violence as the solution for many problems, and in this environment criminal acts and domestic violence rates will rise in communities. Women are particularly vulnerable during wars in which rape is used as a weapon to humiliate and assault female family members of enemies (Levy and Sidel). Children are also vulnerable, suffering or dying from malnutrition, disease, or violence during a war, and experiencing extreme psychological trauma in its aftermath.

The loss of human lives is the most significant cost of war. War also has economic consequences that affect both industrialized and developing nations because major resources are devoted to war and the preparation for war. Almost all wars since 1948 have been fought in developing countries (Taipale, 2002). The resources spent on arms pose a great burden to developing countries, draining already scarce resources that could be used for development. Regions at war experience the destruction of their infrastructure, including health systems, and their resources are redirected toward efforts that damage, rather than promote, the health of populations. Medical care facilities, energy generating plants, food supply, water systems, sanitation facilities, transportation, and communication are routinely destroyed as a result of war (Levy and Sidel, 2008). Developing countries are most severely affected by the economic costs of militarism, which create delay or reversal of economic development and produce huge gaps in essential nutrition, housing, education, and health services for populations (Taipale). Many industrialized countries have spent enormous financial and human resources on armed conflicts they could not afford, leaving their children with huge debts to repay (Taipale). The diversion decreases the amount of money available for health and human services. In the United States, individuals from minority communities form a disproportionate number of those on active military duty, exposing a greater percent of minority groups to the very real risks of early mortality and disabling injuries. War veterans suffering from mental and physical health problems due to their tour of duty during wartime often find inadequate support to address the many areas of life affecting their well-being, including economic, social, physical, community, and policy factors.

War and its effects are preventable. Public health practitioners can work to prevent war and its repercussions by conducting surveillance and reporting on the short- and long-term effects of war on the health of soldiers and civilians. Public health professionals can use this information to raise awareness and educate communities on the human and economic costs of war, including the ability or inability of the health care system to care for the casualties of war. Supporting policies to prevent war and its health consequences are also areas for public health professionals to develop in partnership with others concerned about the impact of war on community health.

Summary

The obesity epidemic, climate change, and war are major, complex public health problems facing twenty-first-century public health practitioners around the world. Public health policies and actions directed at preventing or mitigating the effects of these important health problems for populations would prevent human and economic costs. Devising strategies for addressing these problems requires skilled public health professionals capable of planning and implementing interventions across multiple levels of the system based on the best available evidence and knowledge. The skills of surveillance and communication are also needed to monitor improvements; evaluate the effect of interventions in addressing multiple, complex health problems; and build advocacy for policy changes that prevent disease or injury and reduce the impact on people and communities adversely affected by these complex problems.

Key Terms

Discussion Questions