Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Health is dependent on a complex interplay among an array of genetic, environmental, and lifestyle factors. As a result, public health is built on expertise and skills from many areas, including biology, environmental and earth science, sociology, psychology, government, medicine, statistics, communication, and many others. Public health is about interventions that prevent disease from occurring. As a result, the benefits tend to be less obvious when compared to life-saving medical procedures designed to treat the problem. Prevention of disease both prolongs life and improves the quality of life. In a sense, public health is the heart disease that never developed, the epidemic that didn’t happen, the outbreak of foodborne illness that never occurred, the child that would have developed asthma, but didn’t. Public health is the disaster that didn’t happen. Timeline Of Epidemiologic Milestones In Public Health Essay Paper

The strategy employed by public health is to:

• Identify and define health problems.
• Identify the determinants, i.e., the factors associated with the problem.
• Develop and test interventions to control or prevent the problem.
• Assess the effectiveness of interventions.

 

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This paper provides a review of the past, present, and future of public health surveillance—the ongoing systematic collection, analysis, interpretation, and dissemination of health data for the planning, implementation, and evaluation of public health action. Public health surveillance dates back to the first recorded epidemic in 3180 B.C. in Egypt. Hippocrates (460 B.C.–370 B.C.) coined the terms endemic and epidemic, John Graunt (1620–1674) introduced systematic data analysis, Samuel Pepys (1633–1703) started epidemic field investigation, William Farr (1807–1883) founded the modern concept of surveillance, John Snow (1813–1858) linked data to intervention, and Alexander Langmuir (1910–1993) gave the first comprehensive definition of surveillance. Current theories, principles, and practice of public health surveillance are summarized. A number of surveillance dichotomies, such as epidemiologic surveillance versus public health surveillance, are described. Some future scenarios are presented, while current activities that can affect the future are summarized: exploring new frontiers; enhancing computer technology; improving epidemic investigations; improving data collection, analysis, dissemination, and use; building on lessons from the past; building capacity; enhancing global surveillance. It is concluded that learning from the past, reflecting on the present, and planning for the future can further enhance public health surveillance.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

he term “surveillance”, derived from the French roots, sur (over) and veiller (to watch) [1], is defined in the dictionary as the “close and continuous observation of one or more persons for the purpose of direction, supervision, or control” [2]. For the purpose of this paper, the following definition is used, “Public health surveillance is the ongoing systematic collection, analysis, interpretation and dissemination of health data for the planning, implementation and evaluation of public health action” (see Section 2.3 below).

Public health surveillance is considered to be an essential public health function [3, 4]. A public health system is said to have five essential functions: population health assessment, health surveillance, health promotion, disease and injury prevention, and health protection [5]. Public health surveillance is considered the best weapon to avert epidemics [6].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

The objective of this paper is to provide a review of the past, present, and future of public health surveillance. The section on the past includes an account of major epidemics in human history, the historical milestones in the development of public health surveillance, and the historical evolvement of the concepts and definitions of public health surveillance. As much as possible, original historical documents have been consulted and quoted in this paper. The section on the present describes the uses and components of public health surveillance as we know it today. The section on the future reviews the literature concerning possible scenarios and proposed directions by various authors for future development of public health surveillance.

2. The Past

2.1. Records of Major Epidemics in Human History

Public health surveillance dates back to the time of Pharaoh Mempses in the First Dynasty, when an epidemic was first recorded in human history [7]. Manetho, the Egyptian priest and historian, stated in his list of pharaohs, “Mempses, for eighteen years. In his reign many portents and a great pestilence occurred” [8, 9]. The “great pestilence” is now known to have occurred in 3180 B.C. (Table 1). Table 1 provides a list of major epidemics recorded in history. It also provides the necessary background and context for the discussion below of the major milestones and historical development of the concepts and definitions of public health surveillance.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

According to Marks and Beatty, the three most devastating epidemics to hit the human race were “The Plague of Justinian” (A.D. 541–591) which lasted 50 years, “The Black Death” (1348–1351) which lasted 4 years, and “Spanish Influenza” (1918) which lasted five months [9] (Table 1). From an analysis of Table 1, it can be seen that three types of information were included in the historical records of epidemics. These are health outcomes, risk factors, and interventions (Table 2). These are also the types of information that should be included in a modern day public health surveillance system. They are the forces guiding the changes in public health. Health outcomes measure the state of public health. Risk factors move the state of public health towards undesirable health outcomes, and interventions if successful move the state of public health towards desirable health outcomes.

Simply recording epidemics is not exactly public health surveillance as we know it today. Major milestones in the historical development of concepts in public health surveillance are given in Table 3. The first record of an epidemic was made in 3180 B.C., starting the practice of collecting and recording data.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

The idea of collecting and analyzing data dates back to Hippocrates (460 B.C.–370 B.C.) [31], an ancient Greek physician who is also known as the father of medicine and the first epidemiologist [40, 41]. He is credited with being the first person to believe that diseases were caused naturally and not because of superstition and gods [42]. Disease was a consequence of local conditions, which had to be favourable for a particular disease to occur. He introduced the concept of categorizing illnesses as acute (short duration) or chronic (long lasting). He also coined the terms endemic (for diseases usually found in some places but not in others; steady state) and epidemic (for diseases that are seen at some times but not others; abrupt change in incidence) [31, 43]. In his book On Airs, Waters, and Places he wrote, “The men are subject to attacks of dysentery, diarrhea, hepialus, chronic fevers in winter, of epinyctis, frequently, and of hemorrhoids about the anus. Pleurisies, peripneumonies, ardent fevers, and whatever diseases are reckoned acute, do not often occur, for such diseases are not apt to prevail where the bowels are loose. Ophthalmies occur of a humid character, but not of a serious nature, and of short duration, unless they attack epidemically from the change of the seasons. And when they pass their fiftieth year, defluxions supervening from the brain, render them paralytic when exposed suddenly to strokes of the sun, or to cold. These diseases are endemic to them, and, moreover, if any epidemic disease connected with the change of the seasons, prevail, they are also liable to it.” [44]. According to the Hippocratic definition, an endemic is a disease determined by the nature of a certain place, and climatic, hydrological, and behavioural determinants are seen as the main forces [45]. This provides the concept of collecting data on place, natural environment and people for determination of illness.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

During the 20th century, life expectancy at birth among U.S. residents increased by 62%, from 47.3 years in 1900 to 76.8 in 2000, and unprecedented improvements in population health status were observed at every stage of life (1). In 1999, MMWR published a series of reports highlighting 10 public health achievements that contributed to those improvements. This report assesses advances in public health during the first 10 years of the 21st century. Public health scientists at CDC were asked to nominate noteworthy public health achievements that occurred in the United States during 2001–2010. From those nominations, 10 achievements, not ranked in any order, have been summarized in this report.Historical reviews of the development of medicine and public health form the basis of our knowledge. Such reviews may provide valuable insights that can contribute to the solution of present and future health problems. Thus, it is useful to regard the evolution of public health from the earliest times as an essential element in modern public health education. Barton (1979) described the development of the health sciences over five major areas: empirical health, basic science, clinical science, public health science, and political science. Ko Ko U (1986) set the tone for integrated health in Public Health Myths, Mysticism and Reality, describing the progress of health development across each of these areas. A study by the Institute of Medicine in the United States (1988) indicated that there had been a growing demand for public health, as a profession, as a governmental activity, or as a commitment to society. The study also indicated that public health was not clearly defined, fully understood, or adequately supported. Public health, as it was expressed, was needed to focus on improving conditions that had a bearing on the health of the people. The goals of public health in broad terms should be to identify problems that affect entire communities or populations, to marshal support to address these problems, and to ensure that the solutions are implemented. Frenk (1993), Curtis and Taket (1996), Detels and Breslow (1997), and many others later defined both the national and international perspectives of the current and future scope and concerns in public health. A series of national, regional, and international conferences, seminars, and workshops have been organized by the World Health Organization (WHO), and recently many other international bodies have been organized on the role of public health in health development in the twenty-first century.Timeline Of Epidemiologic Milestones In Public Health Essay Paper
Detels and Breslow (1997) defined public health in simple terms as the process of mobilizing local, state, national, and international resources to ensure the conditions in which people can be healthy. Historically, public health efforts meant health development to be undertaken by the government as a public sector activity. Public health action was sometimes seen as health interventions addressing more than one individual, such as community hygiene, sanitation, and water supply, health education, maternal and child health care, immunization and nutrition promotion, or disease control activities. The people who carried out such measures were known as public health workers. Commonly, public health covered promotive, preventive, curative, and rehabilitative health measures. Most of the steps previously undertaken by governments included actions to promote and protect the health of the people through segregation, quarantine, prohibition, and other sanitary and hygienic practices that were considered to be public health measures. Disease and environmental control measures or food and drug control carried out by government agencies are considered to be public health activities. Similarly, necessary legislative acts and bylaws proclaimed to control various health problems have been regarded as public health measures. Later, the connotation of the term ‘public’ was widened to encompass the involvement of people together with the government in health development efforts. This concept of a wider public role in health development has become more prevalent today when both non-communicable and infectious diseases present the major public health problems. Without the full involvement of the population, the control of these diseases becomes ineffective.Timeline Of Epidemiologic Milestones In Public Health Essay Paper
Public health problems were historically known as the diseases or conditions that particularly affected large numbers of people leading to either death or disability. They were usually socially interpreted, but not all people saw the same reality. Diseases like malaria, tuberculosis, cholera, and HIV/AIDS, respiratory infections, injuries and trauma, cancer, and problems such as maternal and infant deaths have been identified as major public health issues in the 1990s, likely to continue into this new millennium. In the late 1990s, the concepts of the essential public health functions emerged within the context of health sector reforms undertaken in many developing countries (Bettcher et al. 1998). The functions of public health should be understood as comprehensive as they are linked to each other. The essence of public health is that it deals with the health of the population in its totality.
This chapter traces the historical development of comprehensive public health in the context of over 140 developing countries, of which about one-third are classified as the ‘least developed’. The first part of the chapter deals with the development of public health before the twentieth century, especially how public health in the former colonial countries was developed and the impact on health of globalization of trade during the colonial era. It also documents the efforts of developing countries leading to the establishment of an international health organization. The second part presents the attempts made by the developing countries, as soon as they achieved independence from colonial rule. The chapter highlights how these countries tried to cope with the prevailing high morbidity and mortality conditions, including their major public health achievements and failures in preventing and controlling communicable and non-communicable diseases which are of global importance.Timeline Of Epidemiologic Milestones In Public Health Essay Paper
The third part of the chapter deals with the change in the concept of public health from narrow disease control interventions to multisectoral approaches. This coincides with the period when most countries joined the Health for All movement, which adopted the primary health care approach for reaching the universal goal of health for all by 2000. At the end of the twentieth century, developing countries were moving towards the new era of public health development, but suffering the double burden of diseases—both infectious and chronic problems—while their health systems tried to function with limited investments from both internal and external sources. The new phenomenon of globalization has made more complex challenges to the development of public health in this new millennium. The chapter also covers different phases of public health in different parts of the world. Examples are presented of how communities and countries have mobilized themselves to ensure the health and prosperity of their people. The success of public health measures depends on adhering to the basic principles of equity, social justice, and partnerships.
Early public health
Empirical public health
Since ancient times, human life has been threatened with diseases of all kinds. Historical records from the Egyptian, Roman, Greek, Indian, and Mayan civilizations reveal the dreadful nature of infectious diseases and how they were overcome. The teachings of Lord Buddha, as well as the Bible, the Koran, and Judaic literature, covered various aspects of personal hygiene and other public health practices, including civic duties. Sanitation measures were enforced through royal decrees (Sigerist 1951).
Diseases like syphilis, malaria, leprosy, tuberculosis, smallpox, measles, plague, and cholera were rampant in all parts of the world for many centuries. Most diseases occurred locally, killing thousands in certain years. The concept of ‘disease’ had been postulated within the limited ‘scientific’ knowledge available. Traditional medicine focused on management of illnesses at the individual rather than the public level. The spread of diseases due to contact amongst people or due to hereditary transmission was, however, recognized centuries ago. The treatise on economics and government by Kautilya (around 300 BC), during the early Maurya dynasty in India, showed how a king ensured the health and prosperity of his subjects through various measures and regulations. Heavy punishments were imposed on those guilty of adulteration of food, sexual violence, or of littering the streets. The royal proclamation also prescribed rules establishing brothels and entertainment centres (Rangarajan 1992). Quarantine and prohibition were major measures used historically to protect the transmission of diseases and remain as public health measures used by governments in many countries.
Sir Jeremy Bentham, Thomas Southwood Smith, Edwin Chadwick, Sir John Simon, John Snow, and William Farr stimulated public health conscience and principles in the early eighteenth century. Victorian sanitarians of the pre-Pasteur era mainly conformed to the theory that diseases related to decaying organic matter and its vaporous emanations or ‘miasma’ (Paneth et al. 1998). Max von Pettenkoffer, one of the pioneers of public hygiene, also developed modern public health principles in the same period. He believed that an agent in cholera evacuations became ineffective only after it had spent an extended period in the earth and entered the ground water. He experimented by attempting to drink by himself a glass of water containing rice-water evacuations of a cholera patient, and showed no major effect (Guthrie 1946). However, most historians of health development have related the development of modern public health to the advent of the basic medical sciences in the nineteenth century. The discovery of the microscope, animal cells and bacteria, chemicals and other substances, and other scientific knowledge and skills, including those related to the basic statistical and epidemiological methods, had provided the basis for scientific explanation of the causes of diseases and illnesses as well as their mode of transmission. The Industrial Revolution in the twentieth century encouraged social interest in the prevention and control of diseases. With increasing ability to identify the causal factors for disease, the interest in social, environmental, and political aspects of diseases and their prevention grew tremendously.
Owing to the scarcity of records, the health situation of the world in the early centuries is little known. However, a few records available from Asia, Europe, and the Middle East have made it possible to determine how diseases occurred and spread around the world, and what the early efforts were to control them. With the expansion of commerce, diseases spread from one area to other regions along the trade routes. For example, epidemics of smallpox and measles were reported in China between AD 37 and AD 653. These were due to importation from the northwest regions through migration. One Chinese record showed that around AD 640, bubonic plague was common in Kwangtung but rare in the inner provinces. The global pandemic of plague in the mid-fourteenth century, usually referred to as the ‘Black Death’, took the lives of 25 million people in Europe alone. Plague remained endemic in many countries and also spread both east and west causing millions of deaths (McNeill 1977).
Colonial public health
Trading around the world during the eighteenth and nineteenth centuries for the exploration and exploitation of natural resources led to the discovery of new territories in different parts of the world. Europeans and Americans were engaged in intense rivalry with each other for colonial possessions. In order to expand their control, these colonial powers made massive shifts of people from one continent to another, using both military and economic force. Timeline Of Epidemiologic Milestones In Public Health Essay PaperThousands of Africans and Asians were brought to the Americas during the eighteenth and nineteenth centuries to work on the plantations in the southern part of the present-day United States or at the railway construction sites in the western or northern parts of the country. Later, they were brought to the islands of the West Indies and to South and Central Americas, and made to work in large plantations as well as in mining industries. Similarly, large numbers of people from the Indian subcontinent were shipped to Africa and other parts of Asia and the Pacific Islands. The colonials established their own administrative, legal, and medical care systems with varying degrees of autonomy and authority. The American government established a military medical corps in the nineteenth century to protect the American army, which had been expanding to new territories, as well as to protect the American commercial establishments in Mexico and other Latin American countries. Similarly, the Dutch, Portuguese, British, French, and Spanish colonial rulers first established a series of hospitals and dispensaries amongst the army establishments and later in other commercial places. The Indian Medical Service in British India and the Gold Coast Medical Department in Ghana are good examples of this (Harrison 1994; Mills 1998). Medical teams were brought in from the home countries or hired from other nations.
To protect the health of their own people and the workers, colonial rulers established laws similar to those in their home countries. Specific public health legislation varied with each colonial power, but definite imprints of them still exist. For instance, the Public Health Acts, Local Government Act, Civil Registration Act, Factory Acts, Food Adulteration Act, Vaccination Act, and Contagious Diseases Acts have remained in force for many decades. Some are in place today in many countries in Asia, the Pacific, the Americas, and Africa, where the British, Spanish, French, American, or Dutch colonies existed. European countries adopted Bismarck’s model of national social health insurance scheme, which later spread to other countries, especially in the Americas and Asia. The public health measures enforced under those public laws and regulations made a greater impact in these countries. In most countries, expatriates managed administrative and commercial activities. Some colonial powers introduced their social and cultural identity, mainly through religious groups and their educational systems. Most of the educational systems were designed to meet the administrative and commercial interests of the colonial powers. These systems also created a supply of administrative and clerical staff for assisting in the management, administration, and commercial activities of the colonial rulers (Jaggi 1979b).
European and American religious missionaries also embarked on expeditions around the world along with the colonial powers. Many of them, having allopathic medical backgrounds, established ‘Western’ medical care institutions as well as general educational systems, including nursing and medical schools. These missionaries established medical clinics or dispensaries at first and, later, hospitals in the colonial countries. The introduction of allopathic and homoeopathic medicines by these missionaries resulted in the first exposure and increasing access by people in these countries to so-called ‘Western’ medical care. Clinical and practical training for the management of tropical diseases and the prevention and control of such diseases became major subjects for training medical professionals and public health workers who had to serve in tropical countries (Uragoda 1987; Harrison 1994). The late eighteenth century saw an increasing momentum in public health education with the establishment of undergraduate and postgraduate courses designed specifically for public health, first in the home countries and later in the colonies. Pioneer public health schools were established in the colonial countries in the late nineteenth and early twentieth centuries, in order to function as centres for the development of public health policies, and to train people who had to serve in the tropics. These schools not only provided academic teaching, but also conducted research in tropical diseases. Discoveries of causative organisms and ways of stopping transmission of malaria and sleeping sickness, through clinical and public health intervention research studies initiated by these schools, led to the application and adoption of preventive and curative measures. Through the support of the Rockefeller Foundation, the London School of Tropical Medicine was transformed into the London School of Hygiene and Tropical Medicine in 1920, expanding the scope of research and teaching on tropical medicine, medical statistics, and epidemiology (Wilkinson and Power 1998). Spain also established its National School of Public Health in 1924 and introduced a public health component into its comprehensive rural medical care network.
Similar public health educational and research institutions, such as the Calcutta School of Tropical Medicine and Hygiene and the All-India Institute of Hygiene and Public Health, also in Calcutta, were established in British India in the early 1920s in order to carry out public health training and research in the region. The Haffkine Institute in Mumbai (Bombay), the King Institute of Preventive Medicine in Chennai (Madras), the Central Vaccine Research Institute in Kasauli, the National Institute of Communicable Diseases in Delhi (previously known as the Malaria Institute of India), the Indian Research Fund Association (later redesignated as the Indian Council of Medical Research), and the National Institute of Nutrition in Hyderabad were the exemplary research and teaching institutions established at that time (Jaggi 1979a). Similar educational and research institutions were established in the colonial and other independent countries, such as Thailand, the Philippines, Malaysia, Singapore, Hong Kong, Indonesia, Sri Lanka, Ghana, Nigeria, South Africa, Mexico, Brazil, and so on. These institutions of public health education worked closely with their counterparts in Western nations in order to strengthen the knowledge on disease causation, mainly with the support of the Rockefeller Foundation and colonial governments. These institutions also helped their own countries to improve the capacity of local public health administrators.
However, the actual development of public health and medical care services for the general public remained rudimentary in these former colonial countries and territories. Moving millions of people to totally unfamiliar areas had led to a high incidence of death and disability. These displaced people frequently died due to smallpox, malaria, yellow fever, typhus, typhoid, and cholera, or were disabled due to yaws, leprosy, and syphilis. Infectious diseases posed formidable obstacles in the colonization of new areas. The development of science and technology in the early twentieth century, especially in the area of physics, microbiology, biochemistry, pharmacology, and other diagnostics led to an explosion of its application in public health practices. Radio and telephone also facilitated communication amongst people. Some newspapers and magazines had a global reach. The colonials launched a major international public health initiative in the prevention and control of smallpox through vaccination, first amongst the people working in the colonial administration and later amongst the workers employed. Another notable experience was the massive community health development projects for the prevention and control of communicable diseases, mainly initiated through the support of the Rockefeller Foundation in a few Asian and Latin American countries. The attempt was aimed at developing pilot disease control projects that could be replicated in other parts of the world (Foster and Anderson 1978).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Use of the term “population health” has surged in recent years. Much of this enthusiasm has been driven by the idea that health reform would restructure incentives and unite the priorities of health care and public health. In practice, however, population health is often invoked by various stakeholders using different definitions: in health care, it usually refers to managing the health and cost outcomes of a defined patient population attributed to a health care system. Meanwhile, in public health, population health encompasses the aggregate health status of all people in a given geographic area.

Divergent definitions of population health reflect a broader reality that, despite the potentially complementary approaches of public health and health care, health reform has not resulted in as much productive collaboration as had been hoped. There are many reasons for this, including still-conflicting financial incentives, the slow pace of institutional culture change, and an inconsistent measurement and outcome framework. These challenges are obstacles to uniting such a broad and diverse set of stakeholders.

We propose two objectives to better shape the path toward population health: (1) connecting the patients who would most benefit from health care and supportive services—such as those with undiagnosed chronic conditions—to appropriate clinical and community resources; and (2) developing strategies to address diseases with high quality-of-life (morbidity) burdens, not just those with high mortality burdens. A truly integrated population health platform, meanwhile, would move further beyond these milestones to more fundamentally address determinants such as education, poverty, and exposure to trauma.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

 

 

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During the past 150 years, two factors have shaped the modern public health system: first, the growth of scientific knowledge about sources and means of controlling disease; second, the growth of public acceptance of disease control as both a possibility and a public responsibility. In earlier centuries, when little was known about the causes of disease, society tended to regard illness with a degree of resignation, and few public actions were taken. As understanding of sources of contagion and means of controlling disease became more refined, more effective interventions against health threats were developed. Public organizations and agencies were formed to employ newly discovered interventions against health threats. As scientific knowledge grew, public authorities expanded to take on new tasks, including sanitation, immunization, regulation, health education, and personal health care. (Chave, 1984; Fee, 1987)

The link between science, the development of interventions, and organization of public authorities to employ interventions was increased public understanding of and social commitment to enhancing health. The growth of a public system for protecting health depended both on scientific discovery and social action. Understanding of disease made public measures to alleviate pain and suffering possible, and social values about the worthiness of this goal made public measures feasible. The history of the public health system is a history of bringing knowledge and values together in the public arena to shape an approach to health problems.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

With advanced perinatal care and technology, survival among infants born very preterm (<32 weeks gestation) has improved dramatically over the last several decades. However, adverse medical and neurodevelopmental outcomes for those born very preterm remains high, particularly at the lowest gestational ages. Public health plays a critical role in providing data to assess population-based risks associated with very preterm birth, addressing disparities, and identifying opportunities for prevention, including improving the health of reproductive-age women, before, during, and after pregnancy.

International public health efforts actually intensified in the early eighteenth century when European nations applied protective legislative measures to prevent importation of epidemic diseases by trading ships. It became obligatory for all incoming ships, prior to unloading passengers and cargo, to follow strict quarantine measures. Later, business interests in these countries clashed with concern by governments for the health of their own population. The First International Sanitary Conference, organized by 12 European nations in Paris in 1851, tried to work out solutions for the ‘Defense of Europe’. This was the first attempt to reach a consensus on drafting international quarantine regulations (Howard-Jones 1974a).Timeline Of Epidemiologic Milestones In Public Health Essay Paper
For the next 50 years, a series of similar international sanitary conferences were held but failed to produce an international sanitary code. The reasons for delaying international consensus were partly due to the non-availability of a sound scientific basis for the prevention and control of epidemics, and partly to the vested political and commercial interests of each colonial power. The Eleventh International Sanitary Conference, held in Paris in 1903, was a major milestone in international health as it was the first international sanitary convention for the prevention and control of three epidemics: plague, cholera, and yellow fever. Based on this convention, the French Government hosted the first international health office, called L’ Office International d’ Hygiene Publique (OIHP) in 1907 in Paris. At its inception, the main objective of OIHP was to protect Europe against three notifiable diseases (Howard-Jones 1974b). Ultimately, in 1911, the tasks of OIHP were expanded as the first truly international health agency, to monitor and report the outbreaks of the three notifiable diseases, and to provide general public health information on measures taken to combat these diseases through a monthly bulletin (McNeill 1977).
Around the time of the establishment of the League of Nations, major epidemics, including the great influenza pandemic of 1918, were rampant in various parts of the world and some infectious diseases, such as cholera and plague, were threatening to become pandemics. The League had to cope with many other postwar rehabilitation problems and the Paris-based OIHP was unable to deal with such pandemics even with its originally assigned tasks. Based on the proposal of the Brazilian delegation, the League of Nations agreed, in 1920, to the establishment of an international health organization. Finally, after intensive negotiations between the League, the colonial rulers, and other countries, the League of Nations Health Organization was formed in 1923 (Howard-Jones 1977). The League of Nations Health Organization was originally assigned to handle international health matters relating to both technical assistance and clearing-house functions. The epidemiological information service of the League of Nations Health Organization was strengthened through regional bureaux in Washington, Alexandria, Singapore, and Sydney, in addition to the service provided by OIHP. A series of basic clinical and field research studies on medicine and public health were also undertaken. These were done by organizing various committees or commissions of leading public health experts in a wide range of subjects, such as malaria, tuberculosis, leprosy, maternal and child health, health systems, and medical education. In addition to its research promotion function, the League of Nations Health Organization provided technical advice as well as technical assistance to countries and promoted international medical education, including postgraduate education in public health. It also organized international health conferences, conventions, and study tours (WHO 1967).Timeline Of Epidemiologic Milestones In Public Health Essay Paper
As early as the 1930s, health administrators had expressed their concerns on the health status of mass populations, especially of those living in rural areas. The international health conferences organized by the League of Nations Health Organization in the early 1930s provided a forum for sharing experiences on public health development in the countries under colonial rule, especially those in Asia and Africa. The Intergovernmental Conference of Far-Eastern Countries on Rural Hygiene, held in 1937 at Bandoeng (Bandung), The Netherlands East Indies (Indonesia), was a cornerstone in public health and rural health development in Asia (League of Nations Health Organization 1937). The Conference, while noting the rampant conditions of communicable diseases and nutritional deficiency disorders in rural areas, studied the public health interventions of the participating countries. It also defined the central role of health in development, and emphasized the need for integrating health care and intersectoral action, which is now the current view. The countries recognized the heavy socio-economic costs of diseases. They also recognized that the adoption of possible approaches, such as bringing maternal and child health care, hospitals, and health centres nearer to the people could prevent death and disability. However, the onset of the devastating Second World War delayed effective follow-up of the Bandung Conference principles. Many developing countries became battlefields. These countries experienced destruction, destitution, and disease, as well as human misery and suffering, with a very heavy death toll. In addition, there were a series of epidemics of smallpox, cholera, typhus, and malaria. Large displacements of people and the existence of very little or no public health infrastructure or public utility distribution systems resulted in more epidemics. The situation was further accentuated by famines, which took many lives.Timeline Of Epidemiologic Milestones In Public Health Essay Paper
Implementation of the International Health Institution
The spirit of international solidarity, peace, security, and tranquillity, immediately after the Second World War, led to the creation of intergovernmental organizations like the United Nations and its specialized agencies. The original draft of the United Nations Charter did not include health. The Brazilian and Chinese delegations, however, submitted a joint declaration to the United Nations to include health in its Charter. They also called for an international conference whose purpose was to foster consensus to establish an international health organization, and to bring this organization under the aegis of the United Nations Economic and Social Council. With the unanimous approval at the first United Nations General Assembly, a landmark international health conference was held in New York in June and July 1946. At this conference, a total of 61 nations, many of which were still under colonial rule, approved the Constitution of the WHO on 22 July 1946. This initiated the establishment of the WHO as a specialized agency of the United Nations. After ratification by the member governments, the WHO Constitution came into force on 7 April 1948, and the WHO officially came into being. Attainment by all people of the highest possible level of health was its constitutional mandate. The WHO’s main functional roles are directing and co-ordinating international health work and providing advice and advocacy on international health development. The WHO is also given authority to adopt international regulations, to set international standards for biological and pharmaceutical agents, as well as other diagnostic procedures and products, and to adopt international conventions and agreements (WHO 1992). Since then, the membership of the WHO has grown to over 190 countries and territories. The WHO has worked with great harmony for over 50 years, through its six regional organizations and its headquarters, as a single international health organization.
Science-oriented public health
Development of basic health services
Former colonial countries saw the end of the Second World War as the beginning of the end of colonial rule. They all hoped for national development and believed that the period would bring peace and relief from suffering and shortages, through liberation from colonialism. There were strong nationalist movements and political agitations in all countries, preventing the reimposition of colonial rule. Within a few years, many countries achieved independence. They all started reconstruction work for immediate economic growth and social development, to catch up with the technological advances in the colonial powers.
A few countries in Asia, the Pacific, and Africa entered the post-Second World War period in a relatively calm and favourable economic position for reconstruction and rehabilitation. A few others, however, were challenged by their own internal ethnic conflicts. Many developed countries demonstrated special consideration for the welfare and economic development of their former colonies. During the first few decades after independence, developed countries had assisted newly independent developing countries, especially those devastated by the war, through multilateral and bilateral aid programmes in order to support reconstruction and rehabilitation. The United Nations General Assembly launched a programme of international economic co-operation in 1961. This programme, known as ‘the United Nations Development Decade’, was aimed at promoting self-sustaining growth and social advancement. While the countries aimed for sustainable development, the tensions and turmoil of another war, the Cold War, gripped the world. The separation of the Communist blocs (East Europe) from the capitalist states (Western Europe and the United States) created an environment marked by political and social tensions as well as confrontations and conflicts.
These early days of the reconstruction period were termed as the age of contradiction and opportunity. It was a time of increasing affluence in the developed countries, in stark contrast to the relentless march of poverty amongst the less fortunate majority in the rest of the world. The period was also termed as the age of opportunity that saw remarkable scientific and technological advancements which opened up limitless vistas and unlimited possibilities for solving the age-old problems of poverty and disease (Gunaratne 1977). The various inventions and innovations during and following the Second World War provided tremendous impetus for the application of science and technology. These included the jet aircraft, microwave instruments, radar, and other telecommunication facilities, including satellites. The discovery and mass production of quinine, dichlorodiphenyltrichloroethane (DDT), penicillin, and sulphonamides, the development of newer and effective vaccines and other drugs to prevent and control communicable diseases, the introduction of birth-control pills and injectables, the introduction and use of computers, and the improvement in imaging technologies (X-ray and CT scanning) facilitated advanced applications in public health practices. Advances in microbiology and immunology contributed greatly to the development of vaccines and diagnostic technologies. An outstanding achievement in the field of food and nutrition was the virtual disappearance of large-scale famines from many developing countries. Timely intervention of Green Revolution initiatives in the 1960s, in order to produce high-yielding varieties of grains with higher standards of farming techniques and good seeds, enhanced agricultural output, promoted self-sufficiency, and increased exports.Timeline Of Epidemiologic Milestones In Public Health Essay Paper
After gaining independence, many countries adopted ambitious plans for socio-economic development, including health. Health-care facilities, however, were almost non-existent in the post-Second World War period. There were a few professionals for health care and most were expatriates. Many countries thus initiated reviews of their national health situations and formulated long-term development plans. In India, the Bhore Committee was established in 1945 to review the health situation and to recommend improvements in the Indian health system. In Myanmar, the Sorrenta Villa Plan in 1947 and the Pyidawtha Plan in 1950 were drawn up for achieving rapid socio-economic growth, including the expansion of health and education immediately after the war. Similar socio-economic plans were initiated by other developing countries.
Regional co-operation for socio-economic and cultural development was also sought in order to increase intercountry collaboration. For example, the Colombo Plan for Cooperative Economic and Social Development in Asia and the Pacific was conceived at the Commonwealth Conference, held in Sri Lanka, in January 1950. The Colombo Plan proved to be a valuable source of technical and financial assistance to the participating countries, in the area of economic and social development and national capacity building, including health. During the same period, different bodies for regional social and economic co-operation were established in quick succession, such as the Council for Mutual Economic Assistance, the Commonwealth Association, and the Common Markets for Central America and Caribbean. Similarly, in the 1980s, the Association of Southeast Asian Nations, the South Asian Association for Regional Co-operation, and other regional political, social, and economic co-operation organizations were established. These regional political and economic groupings were organized with the aim of having common markets and co-operation in socio-economic and cultural areas amongst neighbouring developing countries, sometimes in alliance with developed nations. In order to support economic development activities, regional development banks were also established. The developed countries got together and formed the Organization for Economic Co-operation and Development in 1961. Many developed countries also established their own development agencies, such as the Australian Agency for International Development, the Danish International Development Agency, the German Agency for Technical Co-operation, the Japan International Co-operation Agency, the Norwegian Agency for International Development, the Overseas Development Administration of the United Kingdom (later renamed as the Department for International Development), and the United States Agency for International Development.
Immediately after the Second World War—with advice and support from the WHO, the United Nations International Children’s Emergency Fund (UNICEF), other United Nations agencies, and multilateral and other bilateral donors—developing countries started building up health systems infrastructures based on a network of hospitals and health centres. Minimally trained basic health workers ran these centres, especially in the rural areas. Expansion of basic health services was made through national public health projects on maternal and child health, school health, environmental sanitation, nutrition, and so on. During the early 1950s most countries adopted the Beveridge model of national health and social welfare policy and they initiated ‘free’ health services for all. Health-care facilities such as hospitals, health centres, or dispensaries, managed by medical doctors, were very few and were mainly concentrated in towns and cities. These facilities essentially were an expansion of the institutions already established during the colonial period.Timeline Of Epidemiologic Milestones In Public Health Essay Paper
Training of different categories of health auxiliaries, such as health assistants, medical assistants, health visitors, nurses, midwives, vaccinators, sanitary workers, community educators, laboratory technicians, pharmacists, and compounders, was initiated by the establishment of paramedical training institutes. These workers were deployed to serve at the various health institutions, especially those established in the rural areas. A number of rural health development and demonstration centres were also established in many countries. The Kalutara rural health project in Sri Lanka, the pilot project of the Aung San demonstration rural health unit in Myanmar, and the Singur rural health project in India were a few of them. The development of human resources for health, especially by creating medical, nursing, and other paramedical schools, was more intense between the 1950s and 1970s. Most countries did not have adequate personnel with appropriate professional training. Myanmar, Malaysia, and Sri Lanka even had to arrange for medical doctors from abroad to serve in their hospitals and educational institutions. Training institutions and related field training centres were established later to meet the local demand.
Exactly 20 years after the Bandung Conference in 1937, another international rural health conference was organized in New Delhi, India, in October 1957, this time under the auspices of the WHO. This conference reviewed and analysed a wide range of subjects: the concepts and functioning of rural health services, the training and use of multipurpose village workers, the enhancement of prevention and control of epidemic and endemic diseases, the utilization of local resources and promoting intersectoral action, and the participation of local people, including formation of village health committees. The conference recognized that the rural health centres were the basic health units where comprehensive health care could be provided to the rural population, and that they should be strengthened (WHO 1957).
Maternal and child health services in developing countries were very rudimentary during the early 1950s and the 1960s. Only a few countries had an administrative authority for maternal and child health matters at the central government level. Maternal and child health services were mainly provided through health clinics and centres employed with briefly trained midwives or auxiliary nurse–midwives. Maternal and infant mortality remained at higher levels in some countries, compared with others that had experienced high women’s status in society and better access to health care and other essential services. With advice and support from the WHO and UNICEF, developing countries started establishing separate maternal and child welfare departments in the early 1950s and the 1960s. With financial and technical inputs by the United Nations and other partners, the numbers of maternal and child health centres expanded rapidly. However, experience within a few decades showed that the vertical approach of opening maternal and child health centres and deploying maternal and child health workers alone did not serve the purpose of improving accessibility. Countries recognized the importance of providing comprehensive basic health care while focusing on the problems of mothers and children. Excessive pregnancies, inappropriate timing and spacing of pregnancies, poor health and nutritional status of the mother, inadequate care during pregnancy and childbirth, and poor educational levels of mothers were identified as the main factors responsible for most maternal and infant mortality, as well as serious morbidity amongst women and children. The United Nations International Women’s Decade (1976–1985) helped to increase awareness of these problems. The tragedy was that maternal health had received far less attention than child health (Rosenfield and Maine 1985).
Figure 1 shows the decline in trends in infant mortality rates in developing and developed countries in the last 20 years. The persisting relatively high levels of infant and maternal mortality and morbidity, and rapid population growth during the last three decades in developing countries, have added a heavy burden to improving the social and economic status of these countries. More food, more schools and health centres, and more funds from the government were needed to cope with the burden.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

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Vaccine-Preventable Diseases

The past decade has seen substantial declines in cases, hospitalizations, deaths, and health-care costs associated with vaccine-preventable diseases. New vaccines (i.e., rotavirus, quadrivalent meningococcal conjugate, herpes zoster, pneumococcal conjugate, and human papillomavirus vaccines, as well as tetanus, diphtheria, and acellular pertussis vaccine for adults and adolescents) were introduced, bringing to 17 the number of diseases targeted by U.S. immunization policy. A recent economic analysis indicated that vaccination of each U.S. birth cohort with the current childhood immunization schedule prevents approximately 42,000 deaths and 20 million cases of disease, with net savings of nearly $14 billion in direct costs and $69 billion in total societal costs (2).

The impact of two vaccines has been particularly striking. Following the introduction of pneumococcal conjugate vaccine, an estimated 211,000 serious pneumococcal infections and 13,000 deaths were prevented during 2000–2008 (3). Routine rotavirus vaccination, implemented in 2006, now prevents an estimated 40,000–60,000 rotavirus hospitalizations each year (4). Advances also were made in the use of older vaccines, with reported cases of hepatitis A, hepatitis B, and varicella at record lows by the end of the decade. Age-specific mortality (i.e., deaths per million population) from varicella for persons age <20 years, declined by 97% from 0.65 in the prevaccine period (1990–1994) to 0.02 during 2005–2007 (5). Average age-adjusted mortality (deaths per million population) from hepatitis A also declined significantly, from 0.38 in the prevaccine period (1990–1995) to 0.26 during 2000–2004 (6).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Prevention and Control of Infectious Diseases

Improvements in state and local public health infrastructure along with innovative and targeted prevention efforts yielded significant progress in controlling infectious diseases. Examples include a 30% reduction from 2001 to 2010 in reported U.S. tuberculosis cases and a 58% decline from 2001 to 2009 in central line–associated blood stream infections (7,8). Major advances in laboratory techniques and technology and investments in disease surveillance have improved the capacity to identify contaminated foods rapidly and accurately and prevent further spread (9–12). Multiple efforts to extend HIV testing, including recommendations for expanded screening of persons aged 13–64 years, increased the number of persons diagnosed with HIV/AIDS and reduced the proportion with late diagnoses, enabling earlier access to life-saving treatment and care and giving infectious persons the information necessary to protect their partners (13). In 2002, information from CDC predictive models and reports of suspected West Nile virus transmission through blood transfusion spurred a national investigation, leading to the rapid development and implementation of new blood donor screening (14). To date, such screening has interdicted 3,000 potentially infected U.S. donations, removing them from the blood supply. Finally, in 2004, after more than 60 years of effort, canine rabies was eliminated in the United States, providing a model for controlling emerging zoonoses (15,16).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Tobacco Control

Since publication of the first Surgeon General’s Report on tobacco in 1964, implementation of evidence-based policies and interventions by federal, state, and local public health authorities has reduced tobacco use significantly (17). By 2009, 20.6% of adults and 19.5% of youths were current smokers, compared with 23.5% of adults and 34.8% of youths 10 years earlier. However, progress in reducing smoking rates among youths and adults appears to have stalled in recent years. After a substantial decline from 1997 (36.4%) to 2003 (21.9%), smoking rates among high school students remained relatively unchanged from 2003 (21.9%) to 2009 (19.5%) (18). Similarly, adult smoking prevalence declined steadily from 1965 (42.4%) through the 1980s, but the rate of decline began to slow in the 1990s, and the prevalence remained relatively unchanged from 2004 (20.9%) to 2009 (20.6%) (19). Despite the progress that has been made, smoking still results in an economic burden, including medical costs and lost productivity, of approximately $193 billion per year (20).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Although no state had a comprehensive smoke-free law (i.e., prohibit smoking in worksites, restaurants, and bars) in 2000, that number increased to 25 states and the District of Columbia (DC) by 2010, with 16 states enacting comprehensive smoke-free laws following the release of the 2006 Surgeon General’s Report (21). After 99 individual state cigarette excise tax increases, at an average increase of 55.5 cents per pack, the average state excise tax increased from 41.96 cents per pack in 2000 to $1.44 per pack in 2010 (22). In 2009, the largest federal cigarette excise tax increase went into effect, bringing the combined federal and average state excise tax for cigarettes to $2.21 per pack, an increase from $0.76 in 2000. In 2009, the Food and Drug Administration (FDA) gained the authority to regulate tobacco products (23). By 2010, FDA had banned flavored cigarettes, established restrictions on youth access, and proposed larger, more effective graphic warning labels that are expected to lead to a significant increase in quit attempts (24).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Maternal and Infant Health

The past decade has seen significant reductions in the number of infants born with neural tube defects (NTDs) and expansion of screening of newborns for metabolic and other heritable disorders. Mandatory folic acid fortification of cereal grain products labeled as enriched in the United States beginning in 1998 contributed to a 36% reduction in NTDs from 1996 to 2006 and prevented an estimated 10,000 NTD-affected pregnancies in the past decade, resulting in a savings of $4.7 billion in direct costs (25–27).

Improvements in technology and endorsement of a uniform newborn-screening panel of diseases have led to earlier life-saving treatment and intervention for at least 3,400 additional newborns each year with selected genetic and endocrine disorders (28,29). In 2003, all but four states were screening for only six of these disorders. By April 2011, all states reported screening for at least 26 disorders on an expanded and standardized uniform panel (29). Newborn screening for hearing loss increased from 46.5% in 1999 to 96.9% in 2008 (30). The percentage of infants not passing their hearing screening who were then diagnosed by an audiologist before age 3 months as either normal or having permanent hearing loss increased from 51.8% in 1999 to 68.1 in 2008 (30).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Motor vehicle crashes are among the top 10 causes of death for U.S. residents of all ages and the leading cause of death for persons aged 5–34 years (30). In terms of years of potential life lost before age 65, motor vehicle crashes ranked third in 2007, behind only cancer and heart disease, and account for an estimated $99 billion in medical and lost work costs annually (31,32). Crash-related deaths and injuries largely are preventable. From 2000 to 2009, while the number of vehicle miles traveled on the nation’s roads increased by 8.5%, the death rate related to motor vehicle travel declined from 14.9 per 100,000 population to 11.0, and the injury rate declined from 1,130 to 722; among children, the number of pedestrian deaths declined by 49%, from 475 to 244, and the number of bicyclist deaths declined by 58%, from 178 to 74 (33,34).

These successes largely resulted from safer vehicles, safer roadways, and safer road use. Behavior was improved by protective policies, including effective seat belt and child safety seat legislation; 49 states and the DC have enacted seat belt laws for adults, and all 50 states and DC have enacted legislation that protects children riding in vehicles (35). Graduated drivers licensing policies for teen drivers have helped reduce the number of teen crash deaths (36).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Cardiovascular Disease Prevention

Heart disease and stroke have been the first and third leading causes of death in the United States since 1921 and 1938, respectively (37,38). Preliminary data from 2009 indicate that stroke is now the fourth leading cause of death in the United States (39). During the past decade, the age-adjusted coronary heart disease and stroke death rates declined from 195 to 126 per 100,000 population and from 61.6 to 42.2 per 100,000 population, respectively, continuing a trend that started in the 1900s for stroke and in the 1960s for coronary heart disease (40). Factors contributing to these reductions include declines in the prevalence of cardiovascular risk factors such as uncontrolled hypertension, elevated cholesterol, and smoking, and improvements in treatments, medications, and quality of care (41–44)

Occupational Safety

Significant progress was made in improving working conditions and reducing the risk for workplace-associated injuries. For example, patient lifting has been a substantial cause of low back injuries among the 1.8 million U.S. health-care workers in nursing care and residential facilities. In the late 1990s, an evaluation of a best practices patient-handling program that included the use of mechanical patient-lifting equipment demonstrated reductions of 66% in the rates of workers’ compensation injury claims and lost workdays and documented that the investment in lifting equipment can be recovered in less than 3 years (45). Following widespread dissemination and adoption of these best practices by the nursing home industry, Bureau of Labor Statistics data showed a 35% decline in low back injuries in residential and nursing care employees between 2003 and 2009.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

The annual cost of farm-associated injuries among youth has been estimated at $1 billion annually (46). A comprehensive childhood agricultural injury prevention initiative was established to address this problem. Among its interventions was the development by the National Children’s Center for Rural Agricultural Health and Safety of guidelines for parents to match chores with their child’s development and physical capabilities. Follow-up data have demonstrated a 56% decline in youth farm injury rates from 1998 to 2009 (National Institute for Occupational Safety and Health, unpublished data, 2011).

In the mid-1990s, crab fishing in the Bering Sea was associated with a rate of 770 deaths per 100,000 full-time fishers (47). Most fatalities occurred when vessels overturned because of heavy loads. In 1999, the U.S. Coast Guard implemented Dockside Stability and Safety Checks to correct stability hazards. Since then, one vessel has been lost and the fatality rate among crab fishermen has declined to 260 deaths per 100,000 full-time fishers (47).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Cancer Prevention

Evidence-based screening recommendations have been established to reduce mortality from colorectal cancer and female breast and cervical cancer (48). Several interventions inspired by these recommendations have improved cancer screening rates. Through the collaborative efforts of federal, state, and local health agencies, professional clinician societies, not-for-profit organizations, and patient advocates, standards were developed that have significantly improved cancer screening test quality and use (49,50). The National Breast and Cervical Cancer Early Detection Program has reduced disparities by providing breast and cervical cancer screening services for uninsured women (49). The program’s success has resulted from similar collaborative relationships. From 1998 to 2007, colorectal cancer death rates decreased from 25.6 per 100,000 population to 20.0 (2.8% per year) for men and from 18.0 per 100,000 to 14.2 (2.7% per year) for women (51). During this same period, smaller declines were noted for breast and cervical cancer death rates (2.2% per year and 2.4%, respectively) (52).

Childhood Lead Poisoning Prevention

In 2000, childhood lead poisoning remained a major environmental public health problem in the United States, affecting children from all geographic areas and social and economic levels. Black children and those living in poverty and in old, poorly maintained housing were disproportionately affected. In 1990, five states had comprehensive lead poisoning prevention laws; by 2010, 23 states had such laws. Enforcement of these statutes as well as federal laws that reduce hazards in the housing with the greatest risks has significantly reduced the prevalence of lead poisoning. Findings of the National Health and Nutrition Examination Surveys from 1976–1980 to 2003–2008 reveal a steep decline, from 88.2% to 0.9%, in the percentage of children aged 1–5 years with blood lead levels ≥10 µg/dL. The risks for elevated blood lead levels based on socioeconomic status and race also were reduced significantly. The economic benefit of lowering lead levels among children by preventing lead exposure is estimated at $213 billion per year (53).Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Public Health Preparedness and Response

After the international and domestic terrorist actions of 2001 highlighted gaps in the nation’s public health preparedness, tremendous improvements have been made. In the first half of the decade, efforts were focused primarily on expanding the capacity of the public health system to respond (e.g., purchasing supplies and equipment). In the second half of the decade, the focus shifted to improving the laboratory, epidemiology, surveillance, and response capabilities of the public health system. For example, from 2006 to 2010, the percentage of Laboratory Response Network labs that passed proficiency testing for bioterrorism threat agents increased from 87% to 95%. The percentage of state public health laboratories correctly subtyping Escherichia coli O157:H7 and submitting the results into a national reporting system increased from 46% to 69%, and the percentage of state public health agencies prepared to use Strategic National Stockpile material increased from 70% to 98% (54). During the 2009 H1N1 influenza pandemic, these improvements in the ability to develop and implement a coordinated public health response in an emergency facilitated the rapid detection and characterization of the outbreak, deployment of laboratory tests, distribution of personal protective equipment from the Strategic National Stockpile, development of a candidate vaccine virus, and widespread administration of the resulting vaccine. These public health interventions prevented an estimated 5–10 million cases, 30,000 hospitalizations, and 1,500 deaths (CDC, unpublished data, 2011).

Existing systems also have been adapted to respond to public health threats. During the 2009 H1N1 influenza pandemic, the Vaccines for Children program was adapted to enable provider ordering and distribution of the pandemic vaccine. Similarly, President’s Emergency Plan for AIDS Relief clinics were used to rapidly deliver treatment following the 2010 cholera outbreak in Haiti.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

From 1999 to 2009, the age-adjusted death rate in the United States declined from 881.9 per 100,000 population to 741.0, a record low and a continuation of a steady downward trend that began during the last century. Advances in public health contributed significantly to this decline; seven of the 10 achievements described in this report targeted one or more of the 15 leading causes of death. Related Healthy People 2010 data are available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5_addinfo.htm. The examples in this report also illustrate the effective application of core public health tools. Some, such as the establishment of surveillance systems, dissemination of guidelines, implementation of research findings, or development of effective public health programs, are classic tools by which public health has addressed the burden of disease for decades.

The first public health action that can be attributed to surveillance occurred during the 1348 bubonic plague epidemic which started the “Black Death”. The Venetian Republic appointed 3 guardians of public health to detect and exclude ships which had infected people aboard [26, 27]. Quarantine as a means to control the spread of infectious diseases was used again in 1377 in Marseilles to detain travellers from plague-infected areas for 40 days [12].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

The concept of systematic ongoing collection of mortality data was first used in 1532 when the town council of London, England started to keep a count of the number of persons dying from the plague [28]. These Bills of Mortality were collected on and off for over 100 years [46]. However, these data were not used for surveillance purpose until the 1600s, when the clerks of London reported the number of burials and causes of death to the Hall of the Parish Clerk’s Company and released in a weekly Bill of Mortality [33].

Comprehensive analysis and interpretation was introduced by John Graunt (1620–1674), a haberdasher and serious amateur scientist in London, who analyzed the weekly bills and published in 1662 his book Natural and Political Observations Made upon the Bills of Mortality [29]. For this work he was subsequently elected a fellow of the Royal Society, whose members initially were uncomfortable with the idea of a haberdasher being elected [47]. Graunt was the first to quantify the patterns of disease and to understand that numerical data on a population could be used to study the cause of disease [31]. He was the first to estimate the population of London and to count the number of deaths from specific causes.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

The practice of epidemic field investigation began with the personal diary Samuel Pepys (1633–1703) kept from 1660 until 1669. His diary is an important primary source of data and first-hand account for London, with personal revelation and eyewitness reports of many great events [48]. During the “Great Plague of London” in 1665, Pepys’ diary made almost daily reference to the epidemic, “15th [June]… The towne grows very sickly, and people to be afeard (afraid) of it: there dying this last week of the plague 112, from 43 the week before… 20th [July]…Walked to Redriffe, where I hear the sickness is, and indeed is scattered almost every where, there dying 1089 of the plague this week… 31st [August]… In the City died this week 7496, and of them 6102 of the plague… 30th [November]… Great joy we have this week in the weekly Bill, it being come to 544 in all, and but 333 of the plague” [49]. Not using the modern terminology, he actually introduced the concept of proportionate mortality, or the proportion of total deaths resulting from the index disease [50]. According to the numbers kept in Pepys’ diary, the proportionate mortality for plague was 81% (6102/7496) on August 31, 1665, which decreased to 61% (333/544) on November 30, 1665 when the epidemic started to subside (Table 4). These numbers recorded by Pepys from the beginning of June to the end of November indicate the effectiveness of the natural intervention, that is, the coming of the November frosts and the winter [7]. The plague ended with the “Great Fire of London” in 1666 that destroyed and cleansed the overcrowded neighbourhoods [9].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Legislation for surveillance was first introduced in 1741 in the Americas, when the colony in Rhode Island passed an act requiring tavern keepers to report contagious disease among their patrons. In 1743, the colony passed a law requiring the reporting of smallpox, yellow fever, and cholera [30]. This started the concept of compulsory reporting of infectious diseases.

Surveillance was felt to need to link to policy development. In 1776, Johann Peter Frank in Germany advocated a comprehensive form of public health surveillance which dealt with school health, injury prevention, maternal and child health, and public water and sewage treatment [30]. Frank formulated comprehensive health policy which had considerable impact both within Germany and in countries such as Hungary, Italy, Denmark, and Russia that had close cultural contact with Germany [51].

In addition, leaders of the French revolution (1788–1799) declared that the health of the people was the responsibility of the state [27]. This started the concept of a welfare state.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Surveillance efforts were used to develop legislation and social change. Sir Edwin Chadwick, secretary of the Poor Law Commission in England, using surveillance data, demonstrated the link between poverty and disease [31]. He published the report of 1834 recommending the reform of the old Poor Law. The new Poor Law system was in existence until the emergence of the modern welfare state after the Second World War (1939–1945) [52]. The New Poor Law is considered to be one of the most “far-reaching pieces of legislation of the entire Nineteenth Century” [53]. At about the same time, Louis-René Villermé (1782–1863) studied the mortality rate variations across the 12 arrondissements (districts) of Paris 1817–1826, by district, population density, and income and showed the association between poverty and mortality [54].

William Farr (1807–1883) is recognized as the founder of the modern concept of surveillance [32]. In 1836, the General Register Office was established in England and Wales to provide more accurate and complete mortality data [25]. Medical certification of death and universal death registration was introduced in 1837 [55]. Farr was the first Compiler of Abstract (medical statistician) at the General Register Office. He began the practice of collecting and analyzing vital statistics to describe the impact of diseases in various populations [32]. From 1838 to 1879 (for 41 years), he concentrated his efforts on collecting vital statistics, on assembling and evaluating those data, and on reporting his results to both the responsible authorities and to the general public [56] and created a modern surveillance system [55].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Surveillance was proposed to link to statewide public health infrastructure. In the United States, Lemuel Shattuck published in 1850 his “Report of the Massachusetts Sanitary Commission”, based on the survey of sanitary conditions in Massachusetts [31]. This report was a landmark publication that related death, infant and maternal mortality, and communicable diseases to living conditions [56]. In this report, Shattuck proposed the creation of a permanent statewide public health infrastructure and recommended establishing health offices at the state and local levels in order to gather statistical information on public health conditions [57]. He recommended a decennial census, standardization of nomenclature for diseases and causes of death, and the collection of health data by age, sex, occupation, socioeconomic level, and locality [31]. Although the legislature did not adopt his comprehensive plan, his specific proposals became routine public health activities over the course of the twentieth century.

John Snow (1813–1858), an anaesthesiologist, is famous for his investigations into the causes of the 19th century cholera epidemics and is also known as the father of modern epidemiology [33, 58]. In 1849, Snow mapped cholera cases in London and identified the source of the outbreak as the public water pump on Broad Street (now Broadwick Street). Using a dot map, he illustrated the cluster of cholera cases around the pump. Snow wrote: “On proceeding to the spot, I found that nearly all the deaths had taken place within a short distance of the [Broad Street] pump. There were only ten deaths in houses situated decidedly nearer to another street-pump. In five of these cases the families of the deceased persons informed me that they always sent to the pump in Broad Street, as they preferred the water to that of the pumps which were nearer. In three other cases, the deceased were children who went to school near the pump in Broad Street… With regard to the deaths occurring in the locality belonging to the pump, there were 61 instances in which I was informed that the deceased persons used to drink the pump water from Broad Street, either constantly or occasionally… The result of the inquiry, then, is, that there has been no particular outbreak or prevalence of cholera in this part of London except among the persons who were in the habit of drinking the water of the above-mentioned pump well. I had an interview with the Board of Guardians of St James’s parish, on the evening of Thursday, 7th September, and represented the above circumstances to them. In consequence of what I said, the handle of the pump was removed on the following day” [59]. On September 8, 1854, Snow removed the pump handle and the epidemic waned [13, 60]. Snow’s work is a good illustration of collection, analysis, interpretation, and dissemination of data leading to public health intervention.Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Systematic reporting of various diseases started in the United States in 1874 in Massachusetts [61]. The Massachusetts State Board of Health inaugurated a plan for weekly voluntary reporting of prevalent diseases by physicians [34]. A sample postcard was designed to “reduce to the minimum the expenditure of time and trouble incident to the service asked of busy medical men” [35]. In Europe mandatory reporting of infectious diseases started in Italy in 1888, and in the United Kingdom in 1890. Finally, the 20th century brought the expansion and diversification of public health surveillance systems. Table 3 gives some of the more important events related to the development of surveillance in the last century.

The United States has been taking a lead in the development of concepts and models for public health surveillance. A detailed account of the development of the public health surveillance system in the United States for 1850–1950 is given elsewhere [30, 36, 62]. It is of interest to know the brief history of the US agency known as “CDC” that is responsible for public health surveillance in the United States. The CDC was founded in 1942 as the Office of National Defense Malaria Control Activities [63, 64]. Atlanta was chosen as the location because malaria was endemic in the Southern US. In 1946, the agency changed its name to Communicable Disease Center, and hence the acronym “CDC” [63]. In 1947, CDC took over the Public Health Service Plague Laboratory in San Francisco, thus acquiring an Epidemiology Division. In 1955, CDC established the Polio Surveillance Program, in order to prove that an epidemic could be traced to a single vaccine manufacturer [33]. In 1961, CDC took over publication of Morbidity and Mortality Weekly (MMWR). The Communicable Disease Center was renamed the Center for Disease Control in 1970, then the Centers for Disease Control effective 1980 [63, 64]. An act of the United States Congress appended the words “and Prevention” to the name effective 1992. However, Congress also specified that the agency continue to use the acronym “CDC” because of its recognition within the public health community and among the public [65].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Globally, the public health surveillance program is coordinated by the World Health Organization (WHO). In 1965, the Director General of the World Health Organization established the epidemiological surveillance unit in WHO’s Division of Communicable Diseases [33, 38]. The first communicable disease surveillance report was published in 1966. In 1968, the 21st World Health Assembly established surveillance as an essential function of public health practice [39] (Table 3).

In 1662, John Graunt first suggested in his book Natural and Political Observations Made upon the Bills of Mortality the need for ongoing systematic collection of data and proposed the basic principles for data analysis and interpretation, although he did not conceptualize the link of surveillance information to public health practice [29] (Table 5).

In those days, mortality data collection was simple but routine. Every night, towards twelve o’clock, a cart goes about with a lantern and a bellman (or sexton), and as he rings the bell, he cries out, “Bring out your dead!” As described by Graunt, “When any one dies, then, either by tolling, or ringing of a Bell, or by bespeaking of a Grave of the Sexton, the same is known to the Searchers, corresponding with the said Sexton. The Searchers hereupon repair to the place where the dead Corps lies, and by view of the same, and by other enquiries, they examine by what Disease or Casualty the Corps died. Hereupon they make their Report to the Parish Clerk, and he, every Tuesday night, carries in an Accompt of all the Burials and Christnings happening that Week, to the Clerk of the Hall. On Wednesday the general Accompt is made up and printed, and on Thursday published and dispersed to the several Families who will pay four Shillings per Annum for them” [81].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

Graunt’s method of data analysis was to reduce voluminous data to a few perspicuous tables (Table 5). Using this method, he was the first to recognize that there were more male than female deaths in London. He tried to interpret the findings and was able to explain the observation by noticing that there were more males than females by counting the number of births, and he suggested that this phenomenon in London should be searched for elsewhere. In Graunt’s words, “There have been Buried from the year 1628, to the year 1662, exclusivè, 209436 Males, and but 190474 Females: but it will be objected, that in London it may indeed be so, though otherwise elsewhere; because London is the great Stage and Shop of business, wherein the Masculine Sex bears the greatest part. But we Answer, That there have been also Christned within the same time, 139782 Males, and but 130866 Females, … What the Causes hereof are, we shall not trouble our selves to conjecture, as in other Cases, onely we shall desire, that Travellers would enquire whether it be the same in other Countries” [82].

Graunt’s concepts described in 1662 (Table 5) can be translated to a first definition of public health surveillance as follows: surveillance is the successful analysis of population-based ongoing data (such as death records) to reduce volumes of data to a few easy-to-understand tables, then interpret them, and prepare a few brief and precise paragraphs, so as to gain profit from the data analysis, in order to understand the increase and decrease of diseases [7].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

A contemporary of Graunt, Sir William Petty, in his 1687 essay on “Mankind and political arithmetic”, termed the science of Graunt “Political Arithmetic” [46, 66, 83]. This term is a good description for today’s public health surveillance, which requires arithmetic skills for analysis of data and a keen political sense for interpretation of results.

Before 1963, the term surveillance was used initially in public health to describe the close monitoring of persons who, because of an exposure, were at risk for developing highly contagious and virulent infectious diseases [84]. These persons were monitored so that, if they exhibited symptoms of disease, they could be quarantined to prevent spreading the disease to others.

In his classic 1963 paper, Alexander Langmuir (1910–1993), chief epidemiologist of US CDC, defined surveillance for a disease to mean “the continued watchfulness over the distribution and trends of incidence through the systematic collection, consolidation, and evaluation of morbidity and mortality reports and other relevant data” [67]. He illustrated this application with four communicable diseases: malaria, poliomyelitis, influenza, and hepatitis [67]. He explained that the data and their interpretations must be disseminated to all who have contributed and to all others who need to know [33]. But his definition did not include direct responsibility for disease control activities [27].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

In 1968, the 21st World Health Assembly adopted the concept of population surveillance which was defined as “the systematic collection and use of epidemiologic information for the planning, implementation, and assessment of disease control” [69]. The Assembly expanded Langmuir’s definition to include the assumption that surveillance information is collected in order to take appropriate action to improve health outcomes [33]. In other words, surveillance is “information for action” [70]. The Assembly also affirmed the three main features of surveillance: (a) the systematic collection of pertinent data, (b) the orderly consolidation and evaluation of these data, and (c) the prompt dissemination of results to those who need to know, particularly those in position to take action [69].

The 1986 CDC definition of surveillance reflects Langmuir’s view [67] that the concept of surveillance did not encompass direct responsibility for control activities and avoids the use of the term surveillance for control activities, although it states that the final link in the surveillance chain is the application of these data to prevention and control [71].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

The 1988 definition by Stephen Thacker and Ruth Berkelman is very similar to the 1986 CDC definition. While the 1986 CDC definition uses the term “epidemiologic surveillance,” the 1988 Thacker and Berkelman definition introduces the new term “public health surveillance.” Epidemiologic surveillance focuses on using surveillance information for epidemiologic research, while public health surveillance focuses more on public health practice [85, 86]. Thacker and Berkelman compared the distinctions between public health surveillance and epidemiologic research and decided that the term epidemiologic surveillance is misleading, and surveillance does not equal research [30].

In his 1998 paper on “Perspectives on epidemiologic surveillance in the 21st century”, Bernard Choi presents arguments why it is important for epidemiologic surveillance to come back full circle in the 21st century and become once again the focus of health research: “Epidemiologic surveillance dates back to the time of John Graunt … In the subsequent 300 years, however, the focus of health research shifted to sample-based studies: cross-sectional, cohort and case-control studies, and clinical trials. In recent decades, awareness of the limitations of sample-based epidemiologic studies has grown. … [H]ealth research can be conducted in the next century using well-maintained and well-validated surveillance databases” [74]. Epidemiologic research studies that are sample-based are subject to errors caused by the “False Positive Research Cycle”: false positive associations (positive associations that are not true) will continue to be confirmed by a multitude of subsequent studies that are designed to test a hot topic due to an initial false positive report that is incorrect (hot topic bias), and subsequent amplification of the errors through cycles caused by the tendency of authors to write up and submit positive findings but not the true negative findings (positive results bias) and of editors to accept and publish positive findings (editor’s bias) [74, 87, 88]. One way to resolve these errors is population-based epidemiologic surveillance. Choi’s 1998 [74] definition of surveillance stresses on the concept of “population-based” (Table 5). Resources required for population-based epidemiologic surveillance systems can be formidable, but progress in technology and informatics may soon make implementation much easier to achieve [89].Timeline Of Epidemiologic Milestones In Public Health Essay Paper

More recent definitions of surveillance, including the 2001 US Centers for Disease Control and Prevention (CDC) [75] and 2006 Public Health Agency of Canada (PHAC) [77] definitions, emphasize on “public health action.” The World Health Organization has three webpages that provide definitions of surveillance. The definitions are very similar, except that the phrase “action can be taken” on one webpage is interpreted as “the planning, implementation, and evaluation of public health practice” on the other two webpages (Table 5).

Table 6 shows a comparison of the evolvement of definitions of public health surveillance over time, from 1662 to 2012. It can be seen that while the components “ongoing,” “systematic,” “collection,” “analysis,” “interpretation,” and “dissemination” have been consistent in the definitions, there are changes in the other components. For example, “epidemiologic surveillance” shifts to “public health surveillance”; “mortality data” to “health data,” and “disease control” to “public health action” (Table 6). Timeline Of Epidemiologic Milestones In Public Health Essay Paper