TURNOCK READING ROOM

Preface to: Public Health: What It Is and How It Works, Third Edition

Turnock BJ---Division of Community Health Sciences, University of Illinois at Chicago School of Public Health

Jones and Bartlett Publishers, Sudbury MA, 2004

The dawn of the 21^st century provide a unique opportunity to reflect on where we have been and what we have accomplished as a nation and as a society. For public health, it is truly an opportunity to examine what we might call, for lack of a better phrase, a Century of Progress. And what a spectacular century it has been!

My grandparents were children at the turn of the last century. At that time, they lived in a young and rapidly developing nation whose 75 million people held not unreasonable hopes of a long and healthy life. However, they also faced an alarmingly large number of health hazards and risks that, when taken together, offered them the prospect of an average life expectancy of only about 47 years. Smallpox, tuberculosis, pneumonia, diphtheria, and a variety of diarrheal diseases were frequent, although unwelcome, visitors. It was not uncommon for families to bury several of their children before reaching adulthood.

By the time my parents were children in the 1920s and 1930s, a variety of economic and social and scientific advances offered more than one additional decade of average life expectancy, despite even the massive social and economic disruption of the Great Depression. Still, tuberculosis, scarlet fever, whooping cough, measles, and other diseases were common. Fewer childhood deaths occurred, but many families still experienced one or more deaths among their children.

By the time those of us in the Baby Boom Generation appeared after World War II, my four siblings and I enjoyed the prospects of living to and even beyond the Golden Years and age 65. When I was a child, polio was one of the few remaining childhood infectious disease threats. Some of my most vivid childhood memories were the mass immunization programs that took place in my home town. Childhood deaths were an uncommon experience and often more likely due to causes other than infectious diseases.

As the twenty-first century unfolds more than 270 million Americans, my children and yours now look for ward to an average life expectancy of about 80 years. Also, today there are no less than 22 different conditions for which immunizations are available--11 of which are recommended for use in all children-- to prevent virtually all of the conditions that threatened their parents, grandparents, and great grandparents over the twentieth century.  Today, children are even being immunized against cancer through the hepatitis B immunization preparations! Overall, childhood deaths have declined more than 95 percent from what they had been a century earlier! Think of that; it means that 19 of the 20 deaths that used to occur to children in this country no longer take place!

To many of us, a century seems like a long time. However, in the grand scheme of things, it is not, and it seems even shorter when we consider how our lifetimes are so interconnected. Just look at the connections linking each of us with our grandparents and our children and even our children's children, each of whom held quite different expectations for their lives and health. These links and connections play critical roles when it comes to understanding the value and the benefits of the work of public health. At the turn of the next century, an estimated 570 million Americans will be enjoying the fruits of public health's labors over the preceding centuries. The vast majority of the people who will benefit from what public health does are yet to be born!

As someone who has spent 15 years in public health practice and another 15 years in teaching and researching the field, I have been concerned about why those who work in the field and those who benefit from its work do not better understand something so important and useful. Throughout my career as a public health physician, I have developed a profound respect for the field, the work, and the workers. However, I must admit that even while serving as director of a large state health department, I lacked a full understanding and appreciation of this unique enterprise.

What has become clear to me is that the story of public health is not simple to tell. There is no one official at the helm, guiding it through the turbulence that is constantly encountered. There is no clear view of its intended destination and of what work needs to be done by whom to get there. We cannot turn to our family physicians, elected officials, or even to distinguished public health officials, such as our Surgeon General, for vision and direction. Surely, these people play important roles, but public health is so broadly involved with the biologic, environmental, social, cultural, behavioral, and ser vice utilization factors associated with health that no one is accountable for addressing everything. Still, we all share in the successes and failures of our collective decisions and actions, making us all accountable to each other for the results of our efforts. My hope is that this book will present a broad view of the public health system and deter current and future public health workers from narrowly defining public health in terms of only what they do. At its core, this book seeks to describe public health simply and clearly in terms of what it is, what it does, how it works, and why it is important to all of us.

Although there is no dearth of fine books in this field, there is most certainly a shortage of understanding, appreciation, and support for public health and its various manifestations. Many of the current texts on public health attempt to be comprehensive in covering the field without the benefit of a conceptual framework understandable to insiders and outsiders alike. The dynamism and complexity of the field suggest that public health texts are likely to become even larger and more comprehensive as the field advances. In contrast, this book aims to present the essentials of public health, with an emphasis on comprehensibility, rather than comprehensiveness. It presents fundamental concepts but links those concepts to practice in the real world.

These are essential topics for public health students early in their academic careers, and they are increasingly important for students in the social and political sciences and other health professions, as well. However, this book is intended as much for public health practitioners as it is for students. It represents the belief that public health cannot be adequately taught through a text, that it needs to be learned through exploration and practice of its concepts and methods. In that light, this book should be viewed as a framework for learning and understanding public health, rather than the definitive catalog of its principles and practices. Its real value will be its ability to encourage thinking "outside the book."

The first four chapters cover topics of interest to general audiences. Basic concepts underlying public health are presented in Chapter 1; included are definitions, historical highlights, and unique features of public health. This and subsequent chapters focus largely on public health in the United States, although information on public health globally and comparisons among nations appear in Chapters 2 and 3. Health and illness and the various factors that influence health and quality of life are discussed in Chapter 2. This chapter also presents data and information on health status and risk factors in the United States and introduces a method for analyzing health problems to identify their precursors. The third chapter addresses the overall health system and its intervention strategies, with a special emphasis on trends and developments that are important to public health. Interfaces between public health and a rapidly changing health system are highlighted. Chapter 4 examines the organization of public health responsibilities in the United States by reviewing its legal basis and the current structure of public health agencies at the federal, state, and local levels. Together, these four chapters serve as a primer on what public health is and how it relates to health interests in modern America .

The final five chapters flesh out the skeleton of public health introduced in the first half of the book. They examine how public health does what it does, addressing issues of the inner workings of public health that are critical for the more serious students of the field. Chapter 5 reviews the core functions of public health and both how and how well these are currently being addressed. This chapter identifies key processes or practices that operationalize public health's core functions and tools that have been developed to improve public health practice. Chapter 6 builds on the governmental structure of American public health (from Chapter 4) and examines other inputs of the public health system, including human, informational, and fiscal resources. Outputs of the public health system, in the form of programs and services, are the subject of Chapter 7. Evidence-based public health practice is examined in terms of its population-based community prevention services and clinical preventive services, and an approach to program planning and evaluation for public health interventions is presented. Chapter 8 examines the emergency preparedness and response roles of public health, including the opportunities afforded by increased public health expectations and a substantial influx of federal funding. The final chapter looks to the future of public health as embarks upon a new century, building on the lessons learned from the preceding century. Emerging problems, opportunities afforded by the expansion of collaborations and partnerships, and obstacles impeding public health responses are also examined in the concluding chapter.

Each chapter includes a variety of figures, tables, and exhibits to illustrate the concepts and provide useful resources for public health practitioners. A glossary of public health terminology is provided for the benefit of those unfamiliar with some of the commonly used terms, as well as to convey the intended meaning for terms that may have several different connotations in practice. At the end of each chapter are discussion questions and exercises, many of which involve Internet-based resources, that complement the topics presented and provide a framework for thought and discussion. These allow the text to be used more flexibly in public health courses at various levels, using different formats for learners at different levels of their training and careers.

Together, the chapters present a systems approach to public health, grounded in a conceptual model that characterizes public health by its mission, functions, capacity, processes, and outcomes. This model is the unifying construct for this text. It provides a framework for examining and questioning the wisdom of our current investment strategy that directs 100 times more resources toward medical services than it spends for population-based prevention strategies--even though treatment strategies contributed only 5 of the 30 years of increased life expectancy at birth that have been achieved in the United States since 1900.

Whatever wisdom might be found in this book has filtered through to me as a result of my mentors, colleagues, co-workers, and friends. For those about to toil in this vineyard of challenge and opportunity, this is meant to be a primer on public health in the United States . It is a book that seeks to reduce the vast scope, endless complexities, and ever-expanding agenda to a format simple enough to be understood by first-year students and state health commissioners alike.