Nurseweek/Healthweek|what IS public health?

PUBLIC HEALTH
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DEFINING
PUBLIC HEALTH

At our recent nursing career fair in San Francisco, each of 57 nurses from a variety of backgrounds had a unique response to the question "How would you define public health?"

Here are a few of their responses:

"Public health does not seem to exist in nursing today! When second- and third-year nursing students and nurses are practicing public health nursing in home care and [do] not know the difference between aseptic and septic care and feel you need not know more—this is insane!"
( a holistic health nurse)

"Programs that encourage wellness and help to isolate and treat or prevent community health problems."
(an ICU nurse)

"A community effort. Lives touching lives in order to cope with life."
(a geriatric nurse)

"Health protection, prevention, and health promotion for all."
(a med/surg nurse)

"Health care provided to every person regardless of ability to pay for medical care given."
( a psych nurse)

"The nurse who comes to your door, your workplace, your school."
(a home health nurse)

"Public health is the service of educating the public to take responsibility for meeting their healthcare needs and assisting those who need it to gain access to specific healthcare services needed."
( a family nurse practitioner)

By Anne Federwisch, OTR
Illustrations by Malcolm Garris
March 20, 1998

It’s popular, it keeps us safe, and it has a great track record. But if you ask a thousand people, "What is public health?" you’re likely to get a thousand different answers.

In a Louis Harris and Associates poll of 1,000 people, fewer than 4 percent mentioned the traditional functions of public health: prevention of infectious diseases, immunization, health education, promotion of healthier lifestyles, and medical research. Yet when asked to rate the importance of different public health services, the majority (sometimes as high as 93 percent) said the functions were "very important."

"The very good news from this and other surveys is that the general public strongly supports the goals, objectives, and principles of public health, even though they don’t realize that it is public health that they’re supporting," said Barry S. Levy, MD, MPH, a consultant in public health and an adjunct professor at Tufts University School of Medicine.

Levy said that "How do you define public health?" was the question he got most frequently during his speaking engagements last year as president of the American Public Health Association. "I like to use the Institute of Medicine’s definition of public health: Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy," he said.

Something for everyone

However, the Harris poll found that most people equate public health with health care for the indigent, Levy said. They don’t think of clean water, adequate sanitation services, proper food handling, safe workplaces, violence and injury prevention programs, nutrition labeling of prepared foods, disease surveillance, immunization, or preventive healthcare as being the results of public health policies and interventions. "We all use the public health system day in and day out, if not hour by hour, whether we know it or not. It’s not just poor people or the underserved," Levy said.

A century ago, infectious diseases and safe water supplies were the primary focus of public health, he said. Since then, its efforts have expanded greatly. As the population’s understanding of hygiene has increased, campaigns have moved from instructing people to cover their mouths when they cough and outlawing spitting to advocating safe sex and routine immunizations.

But health involves more than just preventing the spread of infectious disease, so public health efforts are more comprehensive as well. "We’ve expanded our definition of what public health is by what the community is telling us their concerns are," said Karen Jorgensen, MSN, RN, a supervising public health nurse with the Berkeley (California) Health and Human Services Department. "It’s just amazing the different things we can be involved in." For example, she said that her department has developed a partnership with bicycle shops to provide helmets for children.

A quiet profession

She characterized public health as a behind-the-scenes program that often doesn’t get recognition for its achievements. "Public health never was very sexy or glamorous out in the community. We always worked kind of quietly," she said. For example, the bike helmet partnership went along without fanfare until a child wearing one of the helmets survived with just minor injuries after being thrown several feet off his bike by a car.

Despite such success, public health efforts are invisible to most of society. "Because public health has been effective, it’s taken for granted," said Jessie Yoas, MSN, RN, a past president of the Texas Public Health Association. She recently retired as director of the community health nursing section for the Texas Department of Health.

People expect their cities to provide them with clean water, to regulate their restaurants, and to provide sanitation, said Marjorie Kagawa-Singer, PhD, MN, RN, an assistant professor at the UCLA School of Public Health. But they think of such services as government regulatory issues and not public health concerns, she said.

Anonymity hurts funding

That lack of public health identification has hurt its financing. "If it doesn’t catch the media’s imagination, it doesn’t get the focus"—or the funding, Kagawa-Singer said.

Even elected officials do not realize the importance of public health programs. "You talk to a county commissioner and he’ll say, ‘We don’t have any [public health] problems. We don’t need public health,’ " Yoas said. Such thinking, along with the Medicaid population’s move into managed care programs, is contributing to the shrinking of public health funding in Texas, she said.

Formerly, much of the money for public health departments came from fees received for caring for those on Medicaid. Without that support, the public health infrastructure is being eroded, said Yoas, who is a member of a task force created by the House of Representatives to report on what local government’s role should be in strengthening the foundation of public health.

Moving together

Kagawa-Singer said that years ago public health principles and the medical model used to be united. But as technology advanced, the two diverged. With the focus now on prevention and managing care, the two disciplines are again becoming integrated.

"We see great opportunities for us to come together with the medical system," Jorgensen said. "The thing that’s difficult is that we’ve been separated. So people don’t always think of us." She said health professionals should ask their local public health counterparts to provide community outreach and help people receive preventive services. These programs, she said, are part of what public health is all about—even if the public doesn’t realize it.