Population Health: Principles and Applications for Management

Caron

SECTION 1

PRINCIPLES, SKILLS, AND APPLICATIONS

CHAPTER 1

PUBLIC HEALTH: ORGANIZATION AND FUNCTION

A public health professional is a person educated in public health or a related discipline who is employed to improve health through a population focus.

—Institute of Medicine (2003)

LEARNING OBJECTIVES

After completing this chapter, you should be able to

definepublic healthand identify its mission,

describe the core functions of public health and how they relate to the ten essential services of public health,

list the three types of disease prevention efforts,

describe the organization of the public health system,

compare and contrast the public health and healthcare systems,

describe one public health initiative, and

definepopulation health.

INTRODUCTION

The public health system is essential to ensuring a healthy population. This chapter describes the mission of public health, discusses the essential services this system provides, and highlights the greatest public health achievements accomplished to date. Although public health is vital to our everyday lives, we often do not actually think about how it keeps us healthy. This chapter will demonstrate how public health influences our health on a daily basis. Lastly, the chapter will examine the movement, in the age of healthcare reform, toward the integration of the healthcare and public health systems—which is at the center of the concept of population health.

The general population often thinks of public health as healthcare for the poor. However, providing the poor with access to healthcare is only one aspect of the public health function. The comprehensive approach that the field of public health uses to keep the general population healthy is often misunderstood or underappreciated. This chapter will examine the organization and function of the public health system.

PUBLIC HEALTH DEFINED

The World Health Organization (WHO), in the preamble of its constitution, defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO 1946). The Institute of Medicine (IOM)—now the National Academy of Medicine—defined public health as fulfilling society’s interest in assuring conditions in which people can be healthy (IOM 1988, 7). C. E. A. Winslow (1920, 30), a leader in public health in the early part of the twentieth century, provided a more comprehensive definition that is still cited today:

Public health is the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.

This definition highlights the multidisciplinary nature of the field, which is necessary for preventing disease, prolonging life, and promoting health. The overarching goal of public health is to ensure conditions—that is, living and working conditions—in which people in various geographic settings (e.g., neighborhoods, census tracts, communities, cities and towns, states, regions, counties) can be afforded the opportunity to live a healthy life. Winslow’s definition elaborates on how we are to accomplish this mission via organized community efforts, the organization of medical and nursing services, and the development of the social machinery—functions of a public health system that are still practiced today (Winslow 1920).

THE HISTORY OF PUBLIC HEALTH

Narrowly considered, public health was originally thought to consist of the measures implemented by a community to protect the population from infectious diseases. In fact, a late-1700s outbreak of yellow fever—a viral disease transmitted by infected mosquitoes and most commonly found in South America and Africa (Centers for Disease Control and Prevention 2016)—prompted the development of the first boards of health in major cities, including Philadelphia; Boston; Baltimore; New York City; Washington, DC; and New Orleans. These events were followed by the sanitation movement of the mid-1800s, which led to the improvement of living conditions and the development of a type of public health organization in major cities (Pfizer Global Pharmaceuticals 2006).

The rich history of public health in the United States dates back to the eighteenth century, when President John Adams signed a law providing for the care and relief of sick and injured merchant seamen in US ports (Pfizer 2006). The resulting marine hospitals were later organized into the Marine Hospital Service, which eventually became the US Public Health Service. The position we know today as the surgeon general was created to administer the Marine Hospital Service.

The focus of public health has expanded as our society has become more complex. Public health today is responsible not only for preventing infectious diseases, as was the case centuries ago, but also for ensuring safe living and working environments, preventing lifestyle- and behavior-related diseases, and preparing communities for emergencies, to name a few examples.

For those interested in reading more about the history of public health, George Rosen’s A History of Public Health (Johns Hopkins University Press, 1993) offers a comprehensive overview of significant historical contributions to the field. In addition, the US Department of Health and Human Services maintains a website featuring biographies of past surgeon generals (www.surgeongeneral.gov/about/previous/index.html).

   FOR DISCUSSION: NEW YORK CITY STREET SCENE

Look at this late-1800s Jacob Riis photo of a New York City neighborhood, and identify the obvious and potential public health threats. We do not typically see this type of living environment in the United States today. Why do you think that is?

THE PUBLIC HEALTH MISSION, INFRASTRUCTURE, AND ESSENTIAL SERVICES

The mission of public health can be described as health promotion, disease prevention, and protection of populations so they can live a healthy life. A helpful way to remember the mission of public health is by the three Ps:

Promotion of health in a population

Prevention of disease in a population

Protection of the health of a population

To achieve this mission, public health operates at various levels of government and in different sectors (i.e., private and nonprofit). The core functions of public health, as described by the IOM (1988), are assessment, policy development, and assurance. Because no single health agency can execute all these core functions by itself, we rely on a complex network of community-based agencies and organizations to carry out the mission.

The Centers for Disease Control and Prevention (CDC) defines the public health system as all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction (CDC 2014). The system may comprise local and state governmental public health departments, physician offices, emergency response personnel, community health clinics, charity organizations, schools, recreation facilities, and more.

Exhibit 1.1 shows an illustration, as proposed by the CDC, of the organizations, institutions, and agencies—and their working interrelationships in the community—that make up the public health system.

The CDC outlined the structure of the public health system and further described the activities that public health systems should undertake to prevent disease and promote health in communities. These activities are known as the ten essential public health services (EPHS), and they are displayed in the diagram in exhibit 1.2. The EPHS are aligned with the core functions of public health—assessment, policy development, and assurance—in that each service is categorized according to the core function it fulfills. For instance, the diagram shows that the Monitor Health service corresponds with the Assessment core function.

The CDC’s (2014) detailed descriptions for each essential service are summarized in the sections that follow.

EPHS #1: MONITOR HEALTH STATUS TO IDENTIFY AND SOLVE COMMUNITY HEALTH PROBLEMS

EPHS #1 provides answers to the questions, What’s going on in our state/community? and Do we know how healthy we are? It incorporates the following elements (CDC 2014):

Accurate, periodic assessment of the community’s health status, which includes

– identification of health risks and determinants of health, and the determination of health service needs;

– attention to vital statistics and health status indicators of high-risk groups; and

– identification of community assets that support the local public health system (LPHS) in promoting health and quality of life

Use of appropriate methods and technology, such as geographic information systems (GIS), to interpret and communicate data to diverse audiences

Collaboration among all LPHS components, including private providers and health benefit plans, to establish and use population health registries, such as disease or immunization registries

EPHS #2: DIAGNOSE AND INVESTIGATE HEALTH PROBLEMS AND HEALTH HAZARDS IN THE COMMUNITY

EPHS #2 responds to several questions: Are we ready to respond to health problems or threats? How quickly do we find out about problems? How effective is our response? It involves the following concerns (CDC 2014):

Timely identification and investigation of health threats, including disease outbreaks, patterns of infections, chronic diseases, injuries, environmental hazards, and more

Availability of diagnostic services, including laboratory capacity, to conduct rapid screening and high-volume testing

Response plans to address major health threats

EPHS #3: INFORM, EDUCATE, AND EMPOWER PEOPLE ABOUT HEALTH ISSUES

EPHS #3 responds to the question, How well do we keep all segments of our state/community informed about health issues? It incorporates the following (CDC 2014):

Health information, health education, and health promotion activities designed to reduce health risk and promote improved health

Health communication plans and activities such as media advocacy and social marketing

Accessible health information and educational resources

Health education and health promotion program partnerships with schools, faith-based communities, work sites, personal care providers, and others

EPHS #4: MOBILIZE COMMUNITY PARTNERSHIPS AND ACTION TO IDENTIFY AND SOLVE HEALTH PROBLEMS

EPHS #4 considers the question, How well do we truly engage people in state/community health issues? It involves the following tasks (CDC 2014):

Identifying potential stakeholders who contribute to or benefit from public health and increasing those stakeholders’ awareness of the value of public health

Building coalitions, partnerships, and strategic alliances to draw upon the full range of potential human and material resources to improve community health

Convening and facilitating partnerships and strategic alliances among groups and associations (including those not typically considered to be health-related) in undertaking defined health improvement projects, including preventive, screening, rehabilitation, and support programs.

EPHS #5: DEVELOP POLICIES AND PLANS THAT SUPPORT INDIVIDUAL AND COMMUNITY HEALTH EFFORTS

EPHS #5 addresses the questions, What policies in both the government and private sector promote health in our state/community? and How well are we setting health policies? It includes the following elements (CDC 2014):

Effective local public health governance

Development of policy, codes, regulations, and legislation to protect the health of the public and to guide the practice of public health

Systematic planning at the LPHS and state levels for health improvement in all jurisdictions

Alignment of LPHS resources and strategies with community health improvement plans

EPHS #6: ENFORCE LAWS AND REGULATIONS THAT PROTECT HEALTH AND ENSURE SAFETY

EPHS #6 considers the question, When we enforce health regulations, are we technically competent, fair, and effective? It incorporates the following (CDC 2014):

Assurance of due process and recognition of individuals’ civil rights in all procedures, enforcement of laws and regulations, and public health emergency actions taken under the board of health or other governing body’s authority

Review, evaluation, and revision of laws and regulations designed to protect health and safety, reflect current scientific knowledge, and utilize best practice for achieving compliance

Education of persons and entities obligated to obey and agencies obligated to enforce laws and regulations, with the aim of encouraging compliance

Enforcement activities in a wide variety of areas of public health concern under authority granted by local, state, and federal rule or law, including such areas as abatement of nuisances, animal control, childhood immunizations, food safety, housing code, protection of drinking water, school environment, solid waste disposal, tobacco control, and enforcement activities during emergency situations

EPHS #7: LINK PEOPLE TO NEEDED PERSONAL HEALTH SERVICES AND ASSURE THE PROVISION OF HEALTHCARE WHEN OTHERWISE UNAVAILABLE

EPHS #7 addresses the question, Are people in my state/community receiving the health services they need? It involves the following concerns (CDC 2014):

Assuring the identification of populations with barriers to personal health services

Assuring identification of personal health service needs of populations with limited access to a coordinated system of clinical care

Assuring the linkage of people to appropriate personal health services through coordination of provider services and development of interventions that address barriers to care (e.g., culturally and linguistically appropriate staff and materials, transportation services)

EPHS #8: ASSURE A COMPETENT PUBLIC AND PERSONAL HEALTHCARE WORKFORCE

EPHS #8 answers the questions, Do we have a competent public health staff? and How can we be sure that our staff stays current? It involves the following elements (CDC 2014):

Education, training, and assessment of personnel (including volunteers and other lay community health workers) to meet community needs for public and personal health services

Use of efficient licensure processes for professionals

Adoption of continuous quality improvement and life-long learning programs that include determinants of health

Active partnerships and strategic alliances with professional training programs to assure community-relevant learning experiences for all students

Continuing education in management and leadership development programs for those charged with administrative/executive roles

EPHS #9: EVALUATE EFFECTIVENESS, ACCESSIBILITY, AND QUALITY OF PERSONAL AND POPULATION-BASED HEALTH SERVICES

EPHS #9 considers several important questions: Are we meeting the needs of the population we serve? Are we doing things right? Are we doing the right things? It incorporates the following (CDC 2014):

Assurance of ongoing evaluation and critical review of health program effectiveness, based on analysis of health status and service utilization data

Assurance of the provision of information necessary for allocating resources and reshaping programs

EPHS #10: RESEARCH FOR NEW INSIGHTS AND INNOVATIVE SOLUTIONS TO HEALTH PROBLEMS

EPHS #10 addresses the question, Are we discovering and using new ways to get the job done? It incorporates the following public health research activities (CDC 2014):

Initiating research

Participating in research done by others

Reporting results

Implementing policy based on the results

THE WHEEL OF PUBLIC HEALTH SERVICES

Students should take the time to review and understand the significance of the wheel of EPHS, shown in exhibit 1.2. The wheel provides the blueprint by which public health acts in every community (with possible variations based on infrastructure and available resources). Notice that Research is at the center of the circle, meaning that, in order to implement these ten essential services and core functions of public health, the work must be grounded in research. In other words, public health research findings inform how the system carries out its services and functions. Furthermore, when thinking about the functions and services illustrated in exhibits 1.1 and 1.2, notice the different areas of knowledge, skills, and disciplines required to ensure a healthy population.

The Community Tool Box (2016), an online resource developed by the University of Kansas (KU) Work Group for Community Health and Development and its partners, offers examples of how the EPHS are practiced in daily public health work. For example, Informing the public about an epidemiological outbreak investigation in the community is presented as an example of EPHS #2 (Diagnose and investigate health problems and health hazards in the community), and Maintenance of a sanitary restaurant environment for public well-being is an example of EPHS #6 (Enforce laws and regulations that protect health and ensure safety). The Community Tool Box represents part of the KU Work Group’s role as a designated World Health Organization Collaborating Centre for Community Health and Development.

   FOR DISCUSSION: PUBLIC HEALTH PRACTICE IN THE COMMUNITY

The field of public health is multidisciplinary in nature and requires collaboration among community organizations and agencies that, on first glance, may appear to have nothing in common. Consider this example: An urban community is experiencing elevated rates of teenage pregnancy. The community also lacks places where adolescents can engage in recreational activities after school, and the parks that do exist are home to gang violence. How do you think teenage pregnancy and violence are related in this example? What community organizations should be involved to help address this public health problem? (Explain your rationale.) Describe two approaches that these identified community organizations should implement to prevent gang violence and teen pregnancy.

THE DISTINCTION BETWEEN PUBLIC HEALTH AND HEALTHCARE

Because the health of a population differs from the health of an individual, public health and healthcare professionals approach their work differently. For example, the public health practitioner’s work focuses on the prevention of disease and promotion of health in the population as a whole. In contrast, the healthcare provider addresses health at the individual level by diagnosing and treating one person’s medical condition. The treatment utilized in public health includes interventions that could be educational or policy-based in nature, for example. Meanwhile, healthcare focuses on classic diagnosis and treatment.

Healthcare matters to all of us some of the time; public health matters to all of us all of the time.

—C. Everett Koop, former US Surgeon General (What Is Public Health? 2014)

Healthcare provides the diagnosis and treatment, whereas public health addresses the assurance of access to those services. Thus, public health and healthcare should be viewed as complementary health systems that collaborate to help develop the healthiest population possible. Goldsteen, Goldsteen, and Graham (2011, 5) state, accurately, that public health shares with the clinical professions a fundamental caring for humanity through concern for health. In public health practice, health is achieved via disease and injury prevention, and this prevention can be categorized into three types (Fos and Fine 2000):

Primary prevention is concerned with eliminating risk factors for a disease. An example of primary prevention might involve providing health education and immunizations.

Secondary prevention focuses on early detection and treatment of disease (subclinical and clinical). An example of secondary prevention might include a screening such as a colonoscopy or a mammogram.

Tertiary prevention attempts to eliminate or moderate disability associated with advanced disease. Examples of tertiary prevention might include physical therapy or diabetic foot checks.

Healthcare focuses mainly on secondary and tertiary prevention, when a disease has already occurred and a person is attempting to detect it early so treatment may be initiated (secondary prevention) or working to minimize further disability (tertiary prevention). Public health works in these areas of secondary and tertiary prevention through such efforts as providing access to medical visits, ensuring health literacy among the population, and promoting cultural competence among healthcare providers. The administration of immunizations is an example of an area in which healthcare and public health overlap in prevention, because immunizations are intended to prevent the development of disease (primary prevention). Another example of primary prevention is health education, which can inform people about disease risk factors and prevention methods. These examples highlight the potential for integration of the public health and healthcare systems that are often viewed as distinct.

PUBLIC HEALTH ACHIEVEMENTS AND INITIATIVES

An ongoing debate between the public health and healthcare systems has involved which field is more responsible for the increased life expectancy that Americans experience today. Many are surprised to learn that public health, rather than medical advancements, is the greater contributor. The CDC (2013) states that public health is credited with adding 25 years to the life expectancy of people in the United States in the twentieth century. In 2010, the average life expectancy in the United States was 76.2 years for males and 81.0 years for females (Murphy, Xu, and Kochanek 2013)—a significant increase from the 1900 life expectancy of 47.9 years for males and 50.7 years for females (Arias 2012).

The CDC (2013) has identified what it considers the ten greatest achievements in public health in the twentieth century, and those achievements are listed in exhibit 1.3. These advances have been largely responsible for increasing the lifespan of populations; over 25 of the 30 years [of increase in life expectancy] can be accredited to public health initiatives, while medical advances account for less than 4 years (What Is Public Health? 2014).

EXHIBIT 1.3

The Ten Greatest Public Health Achievements in the Twentieth Century

Immunizations

Motor vehicle safety

Workplace safety

Control of infectious diseases

Declines in deaths from heart disease and stroke

Safer and healthier foods

Healthier mothers and babies

Family planning

Fluoridation of drinking water

Tobacco as a health hazard

Source: CDC (2013).

Notice that the twentieth-century public health achievements listed in exhibit 1.3 largely represent issues that we, as members of the public, have come to expect as standard today. Our increased life expectancy and enhanced quality of life are the result of continued improvements in such areas as nutrition, housing, and environmental hygiene. We should continue to allocate resources to promote healthy workplaces and a reduced maternal and infant mortality rate; however, more focused efforts could be directed toward, for example, reducing premature and low-weight births among African American women and providing safer work environments for hazardous occupations. At the same time, we must stay vigilant to researching and preparing for new threats to the public health system in the twenty-first century, such as antimicrobial resistance, food safety, violence, global pandemics, and obesity, to name a few.

The following sections highlight noteworthy public health initiatives at the national, state, county, and local levels.

NATIONAL PUBLIC HEALTH INITIATIVE: HEALTHY PEOPLE

Healthy People (2016a), an initiative within the US Department of Health and Human Services, provides a model framework to guide health promotion and disease prevention efforts. It uses ten-year plans to develop benchmarks and monitor progress for achieving a healthy population. The mission and goals of Healthy People 2020, the fourth edition of the ten-year plan, are outlined in exhibit 1.4.

EXHIBIT 1.4

Healthy People 2020: Mission and Goals

Mission

Healthy People 2020 strives to:

Identify nationwide health improvement priorities.

Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress.

Provide measurable objectives and goals that are applicable at the national, state, and local levels.

Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge.

Identify critical research, evaluation, and data collection needs.

Overarching Goals

Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

Achieve health equity, eliminate disparities, and improve the health of all groups.

Create social and physical environments that promote good health for all.

Promote quality of life, healthy development, and healthy behaviors across all life stages.

Four foundation health measures will serve as an indicator of progress towards achieving these goals:

General health status

Health-related quality of life and well-being

Determinants of health

Disparities

Source: Reprinted from Healthy People (2016a).

Healthy People 2020 has 42 topic areas with more than 1,200 objectives. A smaller set of objectives, called Leading Health Indicators (LHIs), has been chosen to communicate high-priority health issues and actions that can be taken to address them (Healthy People 2016b). These LHI topic areas are listed in exhibit 1.5.

EXHIBIT 1.5

Healthy People 2020: Leading Health Indicator Topic Areas

Access to health services

Clinical preventive services

Environmental quality

Injury and violence

Maternal, infant, and child health

Mental health

Nutrition, physical activity, and obesity

Oral health

Reproductive and sexual health

Social determinants

Substance abuse

Tobacco

Source: Healthy People (2016b).

Goldsteen, Goldsteen, and Graham (2011, 191) write: Healthy People has been a highly influential initiative for assessing the health of the nation and, by implication, the performance of the public health system. The Healthy People initiative acknowledges that even though the agenda is national, the improvements will come through local actions, which will then affect the state, regional, and national outcomes reports.

Healthy People is the core initiative for prevention efforts across the US Department of Health and Human Services. Exhibit 1.6 lists several other prevention programs currently being administered at a national level.

EXHIBIT 1.6

Examples of National Prevention Programs

Let’s Move! Campaign

National Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis

National Action Plan to Improve Health Literacy

National Action Plan to Prevent Healthcare-Associated Infection

National Action Plan to Reduce Racial and Ethnic Health Disparities

National HIV/AIDS Strategy

President’s Food Safety Working Group

Tobacco Control Strategic Action Plan

US National Vaccine Plan

Source: CDC (2015).

   FOR DISCUSSION: HEALTHY PEOPLE 2020

The framework offered by the Healthy People 2020 initiative provides an action plan by which states and local communities can select which Leading Health Indicators to address based on the communities’ health status, economic resources, and personnel. States can compare their progress relative to prior years or to similar states, and they can observe the nation’s progress toward the vision of a society in which all people live long, healthy lives (Healthy People 2016a). Review the EPHS, discussed earlier in the chapter, in light of the Healthy People 2020 initiative. Which services do you think apply to the successful implementation of Healthy People 2020? Explain your rationale.

STATE PUBLIC HEALTH INITIATIVE: HEALTHIER WISCONSIN PARTNERSHIP PROGRAM

The Healthier Wisconsin Partnership Program (HWPP) is part of a Medical College of Wisconsin endowment titled Advancing a Healthier Wisconsin. The endowment—which was established as a result of the state’s health insurance plan, Blue Cross & Blue Shield United of Wisconsin, converting to a for-profit stock insurance corporation—aims to address public health issues affecting the population of the state. HWPP provides funding to academic and community-based partners who plan to jointly address public health issues in three core areas: infrastructure to transform health improvements, affected populations, and health focus areas (Kerschner and Maurana 2012). A list of proposals funded through the program shows a variety of project types, reflecting the diversity of public health issues faced by the state of Wisconsin (Advancing a Healthier Wisconsin Endowment 2016).

COUNTY PUBLIC HEALTH INITIATIVE: COUNTY HEALTH RANKINGS & ROADMAPS PROGRAM

Another useful tool to promote health in the community is the County Health Rankings & Roadmaps program, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute (County Health Rankings & Roadmaps Program 2016).

The County Health Rankings report health information for every county in every US state. The rankings examine factors that influence health, such as income, high school graduation rate, unemployment rate, access to healthy food, teen births, and obesity. The County Health Roadmaps complement the County Health Rankings. Once a community has assessed its rankings (with information available at www.countyhealthrankings.org), the community and its public health partners can decide which health issues pose the most significant challenge and which health issues are feasible to address given the community’s available resources and economic and political climate. The community and public health stakeholders work together to assess needs and resources, communicate, act on what is important (which may require policy development), and evaluate the actions taken.

LOCAL PUBLIC HEALTH INITIATIVE: NEIGHBORHOOD HEALTH IMPROVEMENT

Often, serious health problems and unstable social conditions are concentrated in a relatively small number of distressed areas of urban communities. One such community is Manchester, the largest city in New Hampshire. With a 2010 census population of 109,565, Manchester represents more than 8 percent of the state’s total population.

The Manchester Health Department (MHD) closely examined the health status of the community’s residents and identified eight neighborhoods that have been shown to share significantly higher rates of overall neighborhood deprivation and poor health outcomes such as higher rates of coronary heart disease mortality, violent crime, expectant mothers with late or no prenatal care, adolescent pregnancies, lead poisonings, childhood obesity, pedestrian accidents and fatalities, uncontrolled asthma, and substandard housing as compared with other neighborhoods (MHD 2014).

To address these conditions, the MHD, along with other public health system partners, proposed a "collective impact approach. Research has contrasted collective impact strategies with traditional isolated impact strategies (Kania and Kramer 2011, 2013), finding that successful collective impact initiatives typically have five conditions that together produce true alignment and lead to powerful results: a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations" (MHD 2014, 56). The community of Manchester and its public health partners are working collaboratively to reduce the impact of persistent public health issues.

Another example of a collective impact approach is Shape Up Somerville, an antiobesity campaign in Somerville, Massachusetts. The citywide program aims to reduce obesity by engaging schools, city government, civic organizations, community groups, businesses, and other people who live in, work in, and visit the city (Collective Impact Forum 2013). The effort has had a significant impact through programming, policy work, and physical infrastructure improvements.

   FOR DISCUSSION: A DAY IN THE LIFE

Consider the typical day described below and discuss the role that public health plays to keep you healthy and safe.

7:00 am

Your alarm clock rings, and you roll out of bed. You turn the faucet to brush your teeth, and fluoride-enriched water flows out. Despite being reluctant to commute to work this morning, you have slept well.

7:30 am

Before you leave the house, you have a balanced, nutritious breakfast. The milk, orange juice, and coffee you prepare have all been inspected and approved as ready for human consumption. The same goes for your bread, bagels, cereal, bananas, or any other breakfast food you choose.

8:00 am

You hop in the car for your daily commute to work and buckle your seatbelt. As you are driving, you can be assured that public health experts have conducted research that has led to improved traffic safety laws.

9:00 am

Your workday has begun. The air filters provide the office with clean air. Public health experts who researched the effects of proper posture on chronic musculoskeletal injuries developed your office chair with