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Public Health Midterm
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the study of the biological basis of human health and disease including genetics, immunology, infectious diseases, chronic diseases and molecular approaches to treatment

individualized care with a focus on disease pathogenesis and biomechanics - the disease begins within the body as opposed to surrounding the body - Western approach to disease/medicine
surgery and emergency care --> high tech instruments
major advancements: drastically lower rates of infant mortality, emergency care, pharmaceuticals - reduced suicide rate/not prevention
distinctive because of reliance on the scientific method - to find some type of objective truth - expanding technologies - therapeutic
less and less focus on prevention before emergency room
Medical anthropology
Medical anthropology is an interdisciplinary field which studies "human health and disease, health care systems, and biocultural adaptation". It views humans from multidimensional and ecological perspectives. It is one of the most highly developed areas of anthropology and applied anthropology, and is a subfield of social and cultural anthropology that examines the ways in which culture and society are organized around or influenced by issues of health, health care and related issues.
one of the core public health functions
three aspects of assurance:
1. Monitor health status
2. Diagnose & investigate
3. Evaluate, efficacy, access & quality

o Enforce laws and regulations that protect health/ensure safety
o Link people to personal health services/assure provision of health care when otherwise unavailable
o Assure a competent phealth workforce
o Evaluate effectiveness/accessibility/quality of pers & pop-based health services
The ongoing and systematic collection, analysis and interpretation of health data essential to the planning, implementation and evaluation of public health practice, closely integrated wit the timely dissemination of these date to those who need to know. The final link in the surveillance chain is the application of these date to prevention and control

• disease notification- if clinician/physician sees new case, must notify state department of health
o salmonella biopsy- aware of outbreaks
o TB, HIV, Malaria, common STDS

organization and management - what to do with info gained at local, state and national levels

prevalence and incidence
total number of cases in a population
• point- prevalence of a condition at a time
• period- total number of cases in a population over a period of time
• usually given as a proportion, usually per 100,000 because figures are meaningless without relation
==> A disease with a high incidence will have a low prevalence if people recover quickly or die within a short period of time
the rate of new cases of a disease in a defined population over a defined period of time
==> For notifiable diseases – found by counting cases reported to health department and diving by the population at risk
==> Incidence measures probability that a healthy person in that pop will develop that disease during that time
true negatives/(true negatives+false positives)
o how likely is it if it gives you a negative result, a person who is without the disease

• first line HIV test has 95% sensitivity and 98% specificity
• which is worse? false positive or fase negative? false positive is worse because it induces anxiety
o breast cancer: too many false positives, women who think they have or will have nocebo effect- negative attitudes can bring about outcome in person

western blot test: specificity = 99.99% (few false positives)
Western Blot Test
doesn't give as many false positives - very high likelihood that if you get a positive result it is actually positive - used as a way to verify first line HIV test - but more $$$$$

• Confirms HIV test results
• Best secondary test, specificity = 99.99% (few false positives)
• But expensive, technically difficult & lower sensitivity (risk of false negatives)
• If you get a positive for a western blot test you are very likely to in fact have it
• Demographic transition comes along with certain effects – increased cost of healthcare yet healthcare costs so much because of demographic transition
o going to get more false negatives than the first line tests
Disease prevention
• Immunization
• Screening
• Environmental modification & development
• Prohibitions, restrictions, regulations, & taxes
o Prohibitions on heroin
o Taxes on corn syrup and tobacco
• Treatments
Health promotion
• Media
• Health communications
• Public education
• Workplace information
• Warning labels & instruction
McKeown Hypothesis
Population growth and increased life expectancy are not due to medical advancements but rather imporvements in the overall standard of living and social infrastructure
medical measures appear to have contributed little to the overall decline in mortality in the US since ~1900

If the major part of the decline in mortality is unrelated to medical care activities, some commitment to social change and a reordering of priorities may ensure.
Structural violence
Paul Farmer's definition:
• “Social structures – economic, political, legal, religious, and cultural – that stop individuals, groups, and societies from reaching their full potential. Disparate access to resources, political power, education, health care, and legal standing are just a few examples.”

3,700 at risk African American & Latino in 37 urban STD clinics - randomized to 1-hour video or 7 weekly 90 minute sessions, both focused on risk reduction through education, skills, and self esteem - controls had 34% condom use and no change

cases had 43% condom use and slight reduction in STD rates - No major improvement suggests that something more than education is needed
epilepsy in china: stigmatized to have a seizure in public so people don't leave their homes - barrier for help seeking
Cuba: mandatory quarantine for everyone HIV positive – makes people much less likely to get an HIV test
Leprosy: ostracized from community – most stigmatized condition in the history of medicine – Leper bells go off when they can leave houses. In biblical terms leprosy = unclean
Smallpox long term effect = social stigma
Health informatics
discipline at the intersection of information science, computer science, and health care.

• Vital statistics, coroner reports, hospital records, census
• Official reports
• WHO’s Weekly Epidemiological Report
Vital statistics
Systematically collected statistics on births, deaths, marriages, divorces and other life events. More broadly, the statistics of life, health, disease and death - the stats that measure progress or lack of it against disease
Police power
The police powers form a portion of that immense mass of legislation which embraces everything within the territory of the state. Inspections on laws, quarantine laws, health laws of every description are component parts of this mass. – Chief Justice John Mashall G v. O
Miasma theory
theory that smell is disease

held that diseases such as cholera, chlamydia or the Black Death were caused by a miasma - a noxious form of "bad air". The theory explained the origin of these epidemic diseases was an emanation from rotting organic matter.

The miasma theory was accepted from ancient times in Europe, India and China. The theory was eventually displaced in the 19th century by the discovery of germs and the germ theory of disease.
Germ theory
• Shift away from abstract focus on places and populations – new focus on vectors & at-risk groups
• Importance of statistics and scientific research
• Structural violence is a kind of neo-miasma theory
o Embrace germ theory but also an emphasis on environmental conditions – poverty – biochemical ideology on its own = narrow-minded and misses some broad environmental component

There’s transmission through spores – germ theory – actual living organisms such a challenge to earlier idea that you can see everything that’s there
Sanitary idea
Edwin Chadwick - 1800's

o The great preventives, drainage, street and house cleansing by means of supplies of water and improved sewage, especially the introduction of cheaper and more efficient modes of removing all noxious reguse from the towns, are operations for which aid must be sought from the science of the engineer, not from the physician” – Edward Chadwick, Report (1840s)
Informed consent
medical ethics - before participating in a trial or anything else people must be informed of relevant risks, pros and cons, patient autonomy
Tuskegee Syphilis Study

most infamous biomedical research study in US history
post civil war economy of the South was still agrarian basically and poor share croppers who lived off the land sold labor for share of take of tobacco/corn/cotton
feudal system: sharecroppers indebted to rich, white landowners
segregated Jim Crow south
white physicians recruiting African American male sharecroppers into study - 399 men recruited
purpose of study = natural course of how untreated syphilis plays out
spinal taps show impact of bacteria within neuro system
men in study told that they were being given opportunity for "special free treatment" NO INFORMED CONSENT dangerous, invasive and painful procedures
deception: told they were being treated for "bad blood"
regular checkups and funerary fund

rationales: "standard of care"/no existing care free check ups and considered subjects not actual sick people

aftermath: 74 of 399 subjects alive in 1972 & wives/children infected - NYT expose

1970s developments of IRBs/informed consent doctrine
Nazi Medicine
Hitler first to prohibit smoking in public places
o Alcohol/tobacco – fascism – commitment to population health
o Racial hygiene – mainstream German physicians developed various extreme – now unheard of – experimentation
==> Exposing people to radical changes in diet
==> Pressure changes
==> Experiments on twins – isolate hereditary features
==> Looking for signs of criminality/indolence
==> All part of process of extermination of Jews, homosexuals, etc.
==> Overarching theme = hygiene practices – looking at disability, thinking about race – whitening/’cleaning’ the population
Bacteriological Revolution
• James Lind’s (1716-1794) famous study of the “Black death of the sea” (aka scurvy) is a disease that causes deterioration of gums/mouth – happening a lot in British navy on ship – military medicine – a lot of p-health measures going on here since having healthy soldiers is of utmost importance – maybe due to diet?
• Lind gave one group of soldiers no dose of fruit/citrus and one some and others none to see if food/acid causes scurvy
o Found out that scurvy was caused by vitamin C deficiency

• Peak of disease discovery from 1880-1898:
o Typhoid, leprosy, malaria
o Tuberculosis (Koch)
o Cholera (Koch), strep
o Diphtheria, tetanus
o Pneumonia
o Plague, botulism
o Dysentery

Empirical Basis for the Bacteriological Revolution- besides microscope
• fermentation and rotting known for thousands of years
o beer, cheese, wine, yogurt
o natural processes
• why do liquids and solid foods spoil?
o never had a clear answer
• is the appearance of mold on bread or cheese "spontaneous generation"? - aristotle
the occurrence in a community/geographic area of a disease at a rate that clearly exceeds the normally expected rate
ex. cholera
Regularly found among particular people or in a certain area.
A pandemic is an epidemic of infectious disease that has spread through human populations across a large region; for instance multiple continents, or even worldwide. A widespread endemic disease that is stable in terms of how many people are getting sick from it is not a pandemic.
Isolation is used to separate ill persons who have a communicable disease from those who are healthy.
Quarantine is used to separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill.
• A very rudimentary/early form of inoculation
• Take a piece of skin ex. scab/pustule of infected individual and keeping it and then letting someone not infected ingest it through the nose – mucus membrane → whatever in the scab would be transmitted
• Take a moderately sick person and expose healthy person → will not get severe/virulent strain of illness
• 900s AD China
• Early 1700s Europe
• Much lower mortality rates in major cities
• 1775-1830: life expectancy in Europe rose from 25 to 40 – pre industrial rev
• People can get inoculated primarily against smallpox
• Introduction of a substance or microorganism into the human body to generate the growth of various kinds of biochemical agents that aid immunity & prevention
• From the Middle English “inoculaten,” to graft or relocate a section of material
Reduction of incidence to zero as a result of deliberate efforts
disease pathogen goes extinct
control to the point of very low or no growth in a particular area
Descriptie epidemiology
• observing the characteristics of people who have certain diseases
o who what where when how
o gender, ethinicity, biological variables, history of condition, occupation, where do you live, travels, etc
o first step in epidemiology, esp. infectious diseases because it is communicable
triangle of host (person in whom pathogen resides), agent (pathogen itself or intermediate host), and environment (where contagent occurs)
• chronic disease is different than this- latency period
Dose-response relationship
describes the change in effect on an organism caused by differing levels of exposure (or doses) to a stressor (usually a chemical) after a certain exposure time.[1] This may apply to individuals (e.g.: a small amount has no significant effect, a large amount is fatal), or to populations (e.g.: how many people or organisms are affected at different levels of exposure).

the relationship between the dose of some agent or the extent of some exposure and a physiological response. A dose-response effect means that the effect increases with the dose
General fertility rate
• Decline in overall reproductive output in a society
• When there are high fertility rates says less economic development, lesser higher education and less urban areas
Infant mortality rate
• U.S. infant deaths 2003 28,025
• total live births 2003 4,089,950
• 6.85 per 1,000 (this is not low in comparison, 3 times higher than world leader in IMR)
• (29.2 in 1950s)
• why is the infant mortality rate important?
o key statistic to compare health condition of a state/nation
o level of prenatal care has changed. healthcare before birth
o bulk of death within 1st weeks
o post delivery care, well baby care, for mother too
o nutrition
o skilled physicians: not necessarily true that you need a physician and they may actually create different problems, midwives are an alternative
o prenatal risk factors for low birth weight: smoking
Proportional Mortality Rate
Proportion of observed deaths from a specified condition in a defined population divided by the proportion of deaths expected from this condition in a standard population
Relative Risk
the ratio of probability of two events
o If p is the probability of the first event and q is the probability of the second, then the RR = p/q
o “Smoker’s risk of developing coronary heart disease is 2 to 4 times that of nonsmokers”
o if the risk of a disease is 20% for a nonsmoker, a smoker’s risk would be 40% - 80%
RR titanic example
• In Titanic example, divide # men died/# total men and same for women
• Then take those two numbers (.83 and .33) divide and found RR – 2.5
• SO, the probability of death for men is 2.5x more likely than women
Ecological fallacy
a situation that can occur when a researcher or analyst makes an inference about an individual based on aggregate data for a group

one thing is said to cause something when it doesn't

simpsons paradox: depending on how you divide up a sample you can get different results
Confounding variables
suggest an association where one does not exists -factors associated with exposure independently affect risk of developing the disease
a pathological process, most often physical. The quality which identifies disease is some deviation from a biological norm. There is an objectivity about disease which doctors are able to see, touch, measure, smell
a feeling, an experience of unhealth which is entirely personal, interior to the person of the patient

Often it accompanies disease, but the disease may be undeclared, as in the early stages of cancer or tuberculosis or diabetes. Sometimes illness exists where no disease can be found
the external and public mode of unhealth

Sickness is a social role, a status, a negotiated position in the world, a bargain struck between the person henceforward called ‘sick’, and a society which is prepared to recognise and sustain him
Substantive freedom
Amartya Sen
o Argues against idea of freedom construed as lack of constraint
o Too much constraint on people so you get rid of constraints such as government so that people can do something
o Freedom is a much more complex concept – someone cannot possibly make a business unless they have access to healthcare – food, water, education → productivity in economy
Whitehall I
Whitehall district of London
1967 - 18,000 men in this cohort study
high stratification environment with full & equal healthcare
People working at all different levels of the socioeconomic statures of the Whitehall district - clericcal, magerial and exec positions
Higher mortality in lower grade employment ranks
controlling for risk factors accounted for only 40% of the differential 9 RR still 2.1 for IHD
very controlled, confined, study
stress in workplace -> heart disease? blood pressure/cholesterol?
Whitehall II
1985: 10,000 men and women
focus on work, stress & health
causal modeling of pathophysiology (abnormal human biology) and sub/clinical disease markers associated qwith relative status
regular tests on people to show how you move from sub/clinical -> more correlated with heart disease
pathophysiology = something going on with physical biology of people - where they sit in workplace hierarchy
constant threat of being let go -> disempowerment
biosocial model of stress linked to balance of reward and effort
impacts of Whitehall
myths dispelled - access does not assure health equality
stress is related to a lack of control and imbalance of work/control
people see themselves as closed off/not exposed due to culture not biology - skin is porous in many way

Poor Law/New Poor Laws
"new poor laws" in england: Under Queen Elizabeth’s jurisdiction in the 1620s were a very liberal progressive idea – providing social welfare to anyone poor/disabled in any way - first welfare system

o said that monarch now takes interest in poor people, poor people have right to petition monarchies for social assistance
o people who are landless, released from feudal estates, famine, etc could receive social assistance
o redistribute taxes
o infectious disease rates improved
Koch's postulates
microorganisms are found in abundance in diseased organisms
they can be isolated from the organism, grown in a pure culture and reintroduced into healthy organisms to induce sickness
disease-causing microorganisms are sometimes also found in abundance in asymptomatic individuals
notion that you can manipulate disease is new
cholera vibrio wager - koch recruited projects as a p-health official/bacteriologist - sand water filtration technology - water run through sand using gravity then remove water from sand - sand filters water - he thought enviro wasn't causing disease but instant waterborne bacteria
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