Public Health Principles and Practices: A Platform for College Health Edward P. Ehlinger, MD, MSPH Director and Chief Health Officer Boynton Health Service.
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Public Health Principles and Practices: A Platform for College Health
Edward P. Ehlinger, MD, MSPHDirector and Chief Health Officer
Boynton Health ServiceUniversity of Minnesota
June 4, 2010
eehlinger@bhs.umn.edu
Ruth Westheimer born Karola Ruth Siegel on June 4, 1928
• "Talking from morning to
night about sex has helped my
skiing, because I talk about
movement, about looking
good, about taking risks."
Rosalind Russell born on June 4, 1911
• “Flops are a part of life's
menu and I've never been
a girl to miss out on any
of the courses.”
Ruth Westheimer born Karola Ruth Siegel on June 4, 1928
• “Don't stint on
foreplay -- or
afterplay. Be
inventive!”
Dik Browne American cartoonist died on June 4, 1989He wrote and illustrated Hagar the Horrible and
illustrated Hi and Lois
Examples of strips of his published on June 4th
Dik Browne American cartoonist died on June 4, 1989
Healthcare reform
Financial pressures
The future of College Health is uncertain• Healthcare reform will raise questions that will
threaten the existence of college health– “Everyone will have insurance so why have a health
service?”– “Everyone will have insurance so what is the need
for a health service fee?”• Some entrepreneurs may see healthcare
reform as an opportunity to gain some college health business.
• Some in college health may see healthcare reform as an opportunity to change the model of college health.
Rosalind Russell born on June 4, 1911
• "When something
happens to you, you
either let it defeat you,
or you defeat it.“
How will you respond to those questions and challenges?
How will you convince your college/university that what you provide is unique and best meets
the needs of students (and others) on your campus and the needs of
your institution?
Health is essential to the mission of Post-Secondary Education
• “When health is absent, wisdom cannot
reveal itself, art cannot become manifest,
strength cannot fight, wealth becomes
useless, and intelligence cannot be
applied.”• Herophilus of Chalcedon, 335-280 BCE
• Physician to Alexander the Great
No one provides the constellation of services offered by college health
• On-campus location• Interest in serving a unique population with
unique needs• Expertise in serving college students• Provides a constellation of services not
provided by any other provider– Services that meet the needs of students and the
campus– Services that help meet the needs of the broader
community
College Health ServicesService – Teaching - Research
• Medical Care/Primary Care (broadly defined)
• Dental Care
• Occupational Health
• Health Promotion/Wellness
• Health Education
• Student Development
• Environmental Health and Safety
• Public Health
Today is a BIG day in Public Health
June 4, 1912June 4, 1919
June 4, 1912• Massachusetts became the first state in the
US to set a minimum wage.
Income
0
2.5
5
7.5
10
12.5
0 1 2 3 4 5
lowest Income Groups highest
Dea
ths
per
1,0
00
June 4, 1919
Thursday, June 5, 1919
Suffrage Wins in Senate; Now Goes to States Constitutional Amendment Is Passed, 56 to 25, or Two More
Than Two-thirds
Women May Vote In 1920
Leaders Start Fight to Get Ratification by Three-fourths of States in Time
Debate Precedes Vote
Wadsworth Explains His Attitude In Opposition - Resolution Signed with Ceremony
19th Amendment
• The right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of sex. Congress shall have power to enforce this article by appropriate legislation.
19th amendment to the U. S. Constitution Dates of Ratification by States
• Illinois, June 10, 1919
• Michigan, June 10, 1919
• Wisconsin, June 10, 1919
• Kansas, June 16, 1919;
• New York, June 16, 1919
• Ohio, June 16, 1919
• Pennsylvania, June 24
• Massachusetts, June 25
• Texas, June 28, 1919
• Iowa, July 2, 1919;
• Missouri, July 3, 1919
• Arkansas, July 28, 1919
• Montana, August 2, 1919
• Nebraska, August 2, 1919
• Minnesota, September 8, 1919
• New Hampshire, September 10
• Utah, October 2, 1919
• California, November 1, 1919
• Maine, November 5, 1919
• North Dakota, December 1, 1919
• South Dakota, December 4, 1919
• Colorado, December 15, 1919
19th amendment to the U. S. Constitution Dates of Ratification by States
• Kentucky, January 6, 1920
• Rhode Island, January 6
• Oregon, January 13, 1920
• Indiana, January 16, 1920
• Wyoming, January 27, 1920
• Nevada, February 7, 1920
• New Jersey, February 9, 1920• Idaho, February 11, 1920
• Arizona, February 12, 1920
• New Mexico, February 21
• Oklahoma, February 28
• West Virginia, March 10
• Washington, March 22, 1920
• Tennessee, August 18, 1920.
• Became National Law August 26, 1920
• November 2, 1920 – Presidential election
– Warren Harding and Calvin Coolidge elected
1921- The Shepherd-Towner Maternity and Infant Protection Act
• Authorized grants for state
programs of maternal and
children's services
Sheppard Towner Act (Maternity and Infancy Care Act)
1921-1929
• First public grants-in-aid program in U.S.• Developed MCH units in state Health Depts• Birth registration (30 - 46 states)• Increased Public Health Nursing• Partnership of federal and state government• Not continued because of fear of socialism • Basis for Title V of Social Security Act
Core Functions of Public Health
• Assessment
• Policy Development
• Assurance– Institute of Medicine, Future of Public Health
John Sundwall, MD, Ph.D. • Director of University of Minnesota Health Service
1918-1921 University of Michigan Division of Hygiene and Public Health 1921-1941
• “Unfortunately, parents, students, and faculty regard a health service as little more than a clinic or hospital concerned only with illness and injuries, their diagnosis and treatment; and regard the health fee paid directly or indirectly by students as sickness insurance.”
John Sundwall, MD, Ph.D.• “Obviously, the best scientific treatment
and care of illness and injuries must be one of the major concerns of the Health Service, but, in addition, a health service must be, as the term signifies, a health service. It bears something of the same relation to the university community that a public health department bears to a municipality or county, however in a more progressive and advanced state, in the vanguard of the public health movement.”
C. E. A. WinslowDean, Yale School of Pubic Health
• “a university health service can
realize its possibilities of
leadership only if it visualizes
public health in the broadest
terms.”
• 1929
Prevailing View of U. S. Health Care System
Health Care System
PublicHealthSystem
MedicalCare
System
Health Care System = Public Health Subsystem + Medical Care Subsystem
College Health/Public Health View of Health System
HEALTH of the PUBLIC
Health CareOther
Influences
Public policies - Education - Economy Scientific advances - Housing
Knowledge - Social normsRecreation - Transportation
Media/Entertainment - Religion Income inequality - Sense of community
Many more
Core FunctionsAssessment
Policy DevelopmentAssurance
ApproachesHealth PromotionHealth Protection
Disease/Injury PreventionTreatment/rehabilitation
Medical Care
Clinical Preventive
Services
Community Health Services
Factors Influencing Health Status
Safer,Healthier
Population BecomingVulnerable
Becoming nolonger vulnerable
VulnerablePopulation Becoming
Afflicted
Afflictedwithout
Complications DevelopingComplications
Afflicted withComplications
Targetedprotection
Primaryprevention
Secondaryprevention
Dying fromComplications
Tertiaryprevention
Society's HealthResponse
Generalprotection
Adverse LivingConditions
World of Providing…
• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…
Medical and Public Health Policy
DISEASE AND RISK MANAGEMENT
World of Transforming…
• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…
By Strengthening…
• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…
Healthy Public Policy & Public Work
DEMOCRATIC SELF-GOVERNANCE
Centers for Disease Control and Prevention Bobby Milstein
Scope of Public Health
Guiding principles: Prevailing View/College Health View
Medical Care
• Science-based
Public Health/College HealthPublic Health/College Health
Science-basedScience-based Data are important!
Basic and clinical research are important in medical care.
Surveillance, monitoring, and epidemiology are important in college
health/public health.
Guiding Principles
Medical Care
• Science-based
• Focus on individual
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
NIAAA - College Drinking Prevention 4 Tiers of Effectiveness
• Tier 1: Evidence of Effectiveness Among College Students
• Tier 2: Evidence of Success With General Populations That Could Be Applied to College Environments
• Tier 3: Evidence of Logical and Theoretical Promise, But Require More Comprehensive Evaluation
• Tier 4: Evidence of Ineffectiveness
College Drinking PreventionNIAAA 4 Tiers of Effectiveness
• Tier 1: Evidence of Effectiveness Among College Students– Strategy: Combining cognitive-behavioral skills
with norms clarification and motivational enhancement interventions.
– Strategy: Offering brief motivational enhancement interventions.
– Strategy: Challenging alcohol expectancies.
• We should implement these strategies as part of our clinical role.
College Drinking PreventionNIAAA 4 Tiers of Effectiveness
• Tier 2: Evidence of Success With General Populations That Could Be Applied to College Environments– Strategy: Implementation, increased publicity, and
enforcement of laws to reduce alcohol-impaired driving.
– Strategy: Restrictions on alcohol retail outlet density – Strategy: Increased prices and excise taxes on
alcoholic beverages. – Strategy: The formation of a campus and community
coalition involving all major stakeholders may be critical to implement these strategies effectively.
College Drinking PreventionNIAAA 4 Tiers of Effectiveness
• Tier 3: Evidence of Logical and Theoretical Promise, But Require More Comprehensive Evaluation– Strategy: Increasing publicity about and
enforcement of underage drinking laws on campus and eliminating "mixed messages."
– Strategy: Conducting marketing campaigns to correct student misperceptions about alcohol use.
– Strategy: Regulation of happy hours and sales.• We should implement Tier 2 and Tier 3 strategies as
part of our public health role.
Guiding Principles
Medical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
The Ecosystem of an IndividualThe Ecosystem of an Individual
AttitudesAttitudes ValuesValues
CultureCultureNormsNorms
LawsLaws ...isms...isms
SOCIETYSOCIETY
courts
multinationalcorporations
crime
immigrants
violence
government
T.V.
moviesCOMMUNITYCOMMUNITY
FAMILYFAMILYschools
friends
work
police
peers
child care
health care providers
relativessibs
grandparentsparents
IndividualIndividual
Health PromotionHealthy People 2000
• Personal choices have powerful influence over one’s
health. While health behaviors are personal, choices
are made in a broader social context that is difficult
to separate from the psychology of the individual. So
while the choice may be individual, the locus of
intervention needs to be wide enough to incorporate
the environment that will either support or
undermine personal choice.
Guiding Principles
Medical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
• Focus on specific
illnesses or diseases
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
Broad definition of healthBroad definition of health
College Health View of Health System
HEALTH of the PUBLIC
Health CareOther
Influences
Public policies - Education - Economy Scientific advances - Housing
Knowledge - Social normsRecreation - Transportation
Media/Entertainment - Religion Income inequality - Sense of community
Many more
Core FunctionsAssessment
Policy DevelopmentAssurance
ApproachesHealth PromotionHealth Protection
Disease/Injury PreventionTreatment/rehabilitation
Medical Care
Clinical Preventive
Services
Community Health Services
Did women’s suffrage affect health?
U of MN Student Health Advisory Committee
• Smoke-free campus• Bicycle trails• Farmers Market• Menu labeling• Year-round fees• Extended hours of operation• Insurance RFP• Late night transportation• FDA blood donation policy
Guiding PrinciplesMedical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
• Focus on specific
illnesses or diseases
• Specialization
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
Broad definition of healthBroad definition of health
Interdisciplinary/Interdisciplinary/
multidisciplinarymultidisciplinary
Scope of Clinical Specialists, Clinical Generalists, and Public Health
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Centers for Disease Control and Prevention, Bobby Milstein
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Guiding Principles
Medical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
• Focus on specific
illnesses or diseases
• Specialization
• Competitive
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
Broad definition of healthBroad definition of health
Interdisciplinary/Interdisciplinary/
multidisciplinarymultidisciplinary
Collaboration/ Collaboration/
Cooperation/IntegrationCooperation/Integration
Public Health
• What we, as a society, do collectively to assure the conditions in which people can be healthy. – Institute of Medicine
College Health View of Health System
HEALTH of the PUBLIC
Health CareOther
Influences
Public policies - Education - Economy Scientific advances - Housing
Knowledge - Social normsRecreation - Transportation
Media/Entertainment - Religion Income inequality - Sense of community
Many more
Core FunctionsAssessment
Policy DevelopmentAssurance
ApproachesHealth PromotionHealth Protection
Disease/Injury PreventionTreatment/rehabilitation
Medical Care
Clinical Preventive
Services
Community Health Services
Guiding Principles
Medical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
• Focus on specific
illnesses or diseases
• Specialization
• Competitive
• Treatment
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
Broad definition of healthBroad definition of health
Interdisciplinary/Interdisciplinary/
multidisciplinarymultidisciplinary
Collaboration/ CooperationCollaboration/ Cooperation
Prevention/Promotion/Prevention/Promotion/
ProtectionProtection
Leading Causes of Death• Heart disease 725,790• Cancer 537,390• Stroke 159,877• Lung diseases 110,637• Injuries 92,191• Pn/influenza 88,383• Diabetes 62,332• Suicide 29,725• Kidney disease25,570• Cirrhosis 24,765
Real Leading Causes of Death• Tobacco 400,000• Diet/inactivity 300,000• Alcohol 100,000• Microbial agents 90,000• Toxic agents 60,000• Firearms 35,000• Sexual behavior 30,000• Motor vehicles 25,000• Illicit drug use 20,000
Factors Influencing Health Status
Guiding Principles
Medical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
• Focus on specific
illnesses or diseases
• Specialization
• Competitive
• Treatment
• Short term responsibility
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
Broad definition of healthBroad definition of health
Interdisciplinary/Interdisciplinary/
multidisciplinarymultidisciplinary
Collaboration/ CooperationCollaboration/ Cooperation
Prevention/Promotion/Prevention/Promotion/
ProtectionProtection
Long-term responsibilityLong-term responsibility
Adoption of Health-risk Behaviors
Social, Emotional, & Cognitive Impairment
EarlyDeath
Adverse Childhood Experiences
Death
Disease, Disabilityand Social Problems
ConceptionAdverse Childhood Experiences: childhood abuse and neglect growing up with domestic violence, substance abuse or mental illness in the home, parental discord, crime
ACE Score and Alcoholism, Suicide Attempts, or Sexual
Assault
0
5
10
15
20
25
30
35
Per
cen
t W
ith
Hea
lth
Pro
ble
m
(%)
0 1 2 3 4 or more
Number of adverse factors:
Considers selfan alcoholic
Ever attemptedsuicide
Sexually assaultedas an adult (women)
College Students Should Be A Long-term Public Health Priority Group
• Numbers are large and increasing
– Can be targeted
– Last time we have relatively easy access to them
• Establishing lifestyle and behaviors
• Role models for younger individuals
• Set norms of behavior
• Leaders of the future
Robert Fulgumborn June 4, 1937
• “Don't worry that
children never listen to
you; worry that they
are always watching
you.”
Guiding PrinciplesMedical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
• Focus on specific
illnesses or diseases
• Specialization
• Competitive
• Treatment
• Short term responsibility
• Reimbursement driven
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
Broad definition of healthBroad definition of health
Interdisciplinary/Interdisciplinary/
multidisciplinarymultidisciplinary
Collaboration/ CooperationCollaboration/ Cooperation
Prevention/Promotion/Prevention/Promotion/
ProtectionProtection
Long-term responsibilityLong-term responsibility
Social responsibilitySocial responsibility
How our healthcare money is spent
5%
95%
Medical CarePublic Health
Guiding PrinciplesMedical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
• Focus on specific
illnesses or diseases
• Specialization
• Competitive
• Treatment
• Short term responsibility
• Reimbursement driven
• Market justice
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
Broad definition of healthBroad definition of health
Interdisciplinary/Interdisciplinary/
multidisciplinarymultidisciplinary
Collaboration/ CooperationCollaboration/ Cooperation
Prevention/Promotion/Prevention/Promotion/
ProtectionProtection
Long-term responsibilityLong-term responsibility
Social responsibilitySocial responsibility
Social justiceSocial justice
Market Justice and US Health Care• In the United States, health care competes for consumers with
other items in the marketplace. Individual resources and choices determine the distribution of health care, with little sense of collective obligation or a role for government. Known as market justice, this approach derives from principles of individualism, self-interest, personal effort, and voluntary behavior.
• The contrasting approach, social justice, allocates goods and services according to the individual's needs. It stems from principles of shared responsibility and concern for the communal well-being, with government as the vehicle for ensuring equity.
• Peter P. Budetti, MD, JD, JAMA. 2008;299(1):92-94.
• Market Justice: You get what you want and what you can pay for.
• Social Justice: Everyone gets basic needs met and no one benefits at the expense of someone else.
Public HealthGeoffrey Vickers - 1957
• The constant redefinition of the unacceptable.
“The philosophy of science is to discover truth.
The philosophy of medicine is to use truth to treat individuals.
The philosophy of public health is social justice.”
William Foege, M.D.
Guiding PrinciplesMedical Care
• Science-based
• Focus on individual
• Health an individual
responsibility
• Focus on specific
illnesses or diseases
• Specialization
• Competitive
• Treatment
• Short term responsibility
• Reimbursement driven
• Market justice
Public Health/College HealthPublic Health/College Health
Science-basedScience-based
Population-basedPopulation-based
Health an individual and Health an individual and
societal responsibilitysocietal responsibility
Broad definition of healthBroad definition of health
Interdisciplinary/Interdisciplinary/
multidisciplinarymultidisciplinary
Collaboration/ CooperationCollaboration/ Cooperation
Prevention/Promotion/Prevention/Promotion/
ProtectionProtection
Long-term responsibilityLong-term responsibility
Social responsibilitySocial responsibility
Social justiceSocial justice
C.E. A. WinslowDean, Yale School of Pubic Health
• “a university health service
can realize its possibilities of
leadership only if it visualizes
public health in the broadest
terms.” • 1929
Public Health on College Campuses
The Role of College Health in Shaping the Future of Health Care
Evolving View of Health and Health Care
• From disease to risk factors
Leading Causes of Death• Heart disease 725,790• Cancer 537,390• Stroke 159,877• Lung diseases 110,637• Injuries 92,191• Pn/influenza 88,383• Diabetes 62,332• Suicide 29,725• Kidney disease25,570• Cirrhosis 24,765
Real Leading Causes of Death• Tobacco 400,000• Diet/inactivity 300,000• Alcohol 100,000• Microbial agents 90,000• Toxic agents 60,000• Firearms 35,000• Sexual behavior 30,000• Motor vehicles 25,000• Illicit drug use 20,000
Evolving View of Health and Health Care
• From disease to risk factors
– Particularly important for young adults
• From treatment to prevention
Factors Influencing Health Status
Need for treatment and preventionIn tobacco control
Evolving View of Health and Health Care
• From disease to risk factors
• From treatment to prevention
– From a population perspective, the younger the
population, the more important the prevention
efforts.
• From short-term to long-term perspective
AdultPreconception
Prenatal
Intrapartum
Infant
Child
Adolescent
Non-child bearingParenting
HealthCare Influences
Environmental and Social Influences:
Parents/extended familyCulture/MediaRoles of men/women/childrenNorms/PoliciesEconomyCommunityEducationMultiple other influences
Health Care Influences:
Health PromotionDisease PreventionHealth ProtectionMedical Care ( 10, 20 , 30)Surveillance and data Environmental and Social Influences
Cycle of Development
Evolving View of Health and Health Care
• From disease to risk factors
• From treatment to prevention
• From short-term to long-term perspective
– Modifying risk-factors and seeing effects of
prevention require long-term perspective
• From individual to population
Evolving View of Health and Health Care
• From disease to risk factors
• From treatment to prevention
• From short-term to long-term perspective
• From individual to population
– College health is one of few fields responsible for
both individual and population-based outcomes
• From population to context
The Ecosystem of a PopulationThe Ecosystem of a PopulationCollege Health Focuses on ContextCollege Health Focuses on Context
AttitudesAttitudes ValuesValues
CultureCultureNormsNorms
LawsLaws ...isms...isms
SOCIETYSOCIETY
courts
multinationalcorporations
crime
immigration
violence
government
T.V.
moviesCOMMUNITYCOMMUNITY
FAMILIESFAMILIESschools
friends
work
police
peers
health care providers
relativessibs
parents
STUDENTSSTUDENTS
Evolving View of Health and Health Care
• From disease to risk factors
• From treatment to prevention
• From short-term to long-term perspective
• From individual to population
• From population to context
• From individual population problems to syndemic
context
Context is the Community
• Whereas the usual public health
approach begins by defining the
disease and the population in
question, a syndemic orientation first
defines the community in question.
Syndemic Contextual View of Health• A syndemic is two or more
afflictions, interacting synergistically, contributing to excess burden of disease in a population.– Synergistic epidemics– Syndrome of epidemics
• Syndemics occur when health-related problems cluster by person, place, or time
Bobby Milstein
Syndemics
• The word syndemic was coined by anthropologist Merrill Singer and first published in 1992 to convey what he saw as inextricable and mutually reinforcing connections between health problems such as substance abuse, violence, and AIDS among urban women in the US.
• Singer, 1994; 1996; Singer M and Snipes C, 1992; Singer M and Romero-Daza N, 1997
SAVA Syndemic
** Adapted from Singer M, 1996
SAVA Syndemic• "Commonly, violence, substance abuse, and AIDS have
been described as concurrent epidemics among inner-city populations. However, the term epidemic fails to adequately describe the true nature of the contemporary inner city health crisis, which is characterized by a set of closely interrelated, endemic and epidemic conditions, all of which are strongly influenced by a broader array of political-economic and social factors, including high rates of unemployment, poverty, homelessness and residential overcrowding, substandard nutrition, infrastructural deterioration and loss of quality housing stock, forced geographic mobility, family breakup and disruption of social support networks, youth gang formation, and health care inequality
• (Wallace R, 1988; 1990; Wallace D, 1990).
DAT Syndemic
Tobacco
DATSyndemi
c
Alcohol
Depression
Syndemic Contextual View of Health
Problems are important but the ties between them are often even more important. Pay attention to confounding factors – that’s where the issues are most intense.
To Understand Syndemics…
•"You think that if you understand
one, you understand two-because
one and one are two. But you must
also understand 'and'."
Sufi saying
Contextual/Syndemic View of Health among College Students
Alcohol
Tobacco
Depression
ObesityStress
Violence
Health System Dynamics
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Centers for Disease Control and Prevention, Bobby Milstein
Safer,Healthier
Population BecomingVulnerable
Becoming nolonger vulnerable
VulnerablePopulation Becoming
Afflicted
Afflictedwithout
Complications DevelopingComplications
Afflicted withComplications
Targetedprotection
Primaryprevention
Secondaryprevention
Dying fromComplications
Tertiaryprevention
Society's HealthResponse
Generalprotection
Adverse LivingConditions
World of Providing…
• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…
Medical and Public Health Policy
DISEASE AND RISK MANAGEMENT
World of Transforming…
• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…
By Strengthening…
• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…
Healthy Public Policy & Public Work
DEMOCRATIC SELF-GOVERNANCE
Centers for Disease Control and Prevention Bobby Milstein
Syndemic Context
An involved population
Change is coming!
• “Willed change” the Sufi say, “is not real. Only unwilled change is real.” Only unwilled change catapults us into what we did not plan to do. Only unwilled change really matters to the molding of the soul, to the stretching of the self beyond the self, in other words. And matter it does. Deeply. Willed change is what I seek and shape. Unwilled change is what seeks and reshapes me.”
– From “The Story of Ruth” by Joan Chittester
Robert Fulgumborn June 4, 1937
• Author of “All I Really Need to Know, I Learned in Kindergarten.”
• “The world does not need tourists who ride by in a bus clucking their tongues. The world as it is needs those who will love it enough to change it, with what they have, where they are.”
C. E. A. Winslowat the 1929 dedication of University Health Service
University of Minnesota
“…a university health service …can realize its possibilities of leadership only if it visualizes public health in the broadest terms. Public health is concerned with the prevention of disease and the promotion of health in the widest sense…”
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