M I L
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S M I L E T O N E
S S T O N E S IN PUBLIC HEALTH
IN PUBLIC HEALTH
ACcOMPLISHmENTS IN PUBLIC HEALTH OVER THE LAST 100 YEARS MILESTONES IN PUBLIC HEALTH Cover photo key
Imhotep, regarded in ancient Egypt as the god of medicine (courtesy National Library of Medicine)
An image from space showing a hole in the Earth’s ozone layer (© NASA–GSFC-SVS)
The bifurcated needle, which simplified the administration of smallpox vaccine (© Creatas)
Dr. Edward Jenner, who pioneered the smallpox vaccine (© Bettman/Corbis)
Margaret Sanger, an early promoter of family planning (© Bettman/Corbis)
The Ebola virus (© Corbis)
MRI of cancerous breast tissue (© Howard Sochurek/Corbis)
Tooth with protective sealant
An image of the human immunodeficiency virus (HIV) (© Michael Freeman/Corbis)
An image from the U.S. Department of Agriculture’s food pyramid (courtesy www.MyPyramid.gov)
Milestones in Public Health is published by Pfizer Global Pharmaceuticals, Pfizer Inc, New York, NY, © 2006 Pfizer Inc. All rights reserved. The contents do not necessarily reflect the views of Pfizer Inc. No part of this publication may be reproduced in any form without prior written permission from the publisher. Correspondence should be addressed to: Milestones in Public Health, c/o Senior Medical Director/Group Leader, Pfizer Inc, 235 East 42nd Street, New York, NY 10017-5755.
ISBN 0-9761815-1-7
Printed in Canada. IN PUBLIC HEALTH
ACcOMPLISHmENTS IN PUBLIC HEALTH OVER THE LAST 100 YEARS i Milestones . Acknowledgments
Acknowledgments
Milestones in Public Health is a journey through the seminal accomplishments in the field of public health during the 20th century, as well as an inquisitive—and hopefully— inspirational look at the next set of challenges faced by our nation’s public health system. It is not intended to be a textbook or research publication. Rather, it is a general-interest book about public health that should appeal to students in any health-related field, as well as public health professionals and others with a keen interest in this field. At the same time, I hope, in a very personal way, that this book will engage those with little knowledge of the field to learn more about it. I know that a book can change a life’s direction, as I myself entered public health after a book awakened my curiosity about the prevention and control of infectious diseases. Readers will note that we have listed all sources by chapter at the end of the book rather than annotating each fact as it appears in the body of the text.This conscious decision on our part should make the book more readable while allowing those who would like to pursue particular topics to find useful references. Milestones in Public Health is the third in a series of books published by Pfizer Inc’s Public Health Group.These books are a part of our ongoing commitment to public awareness and understanding of the field of public health. As with our previous publications – Advancing Healthy Populations: The Pfizer Guide to Careers in Public Health and The Faces of Public Health – this book represents the collective efforts of many individuals who have dedicated countless hours to its development and production. Our sincere thanks go to Dilia Santana and Oscar Perdomo, U.S. Public Health, Pfizer Inc; Ana Rita González, ScD, Sydney Ann Neuhaus, and Nadjha Acosta of Fleishman-Hillard International Communications; David L. Farren; and Matt Warhaftig of Warhaftig Associates. Special thanks must also go to our expert reviewers: Myron Allukian, retired from the Boston Health Commis- sion (Oral Health); Susan Baker, Bloomberg School of Pub- lic Health, Johns Hopkins University (Automotive Safety); ii
Joseph Califano, Executive Director, CASA, Columbia University (Addiction);James Curran, Dean, Rollins School of Public Health, Emory University (Infectious Disease Control);D.A. Henderson, Center for Biosecurity, Universi- ty of Pittsburgh Medical Center and Dean Emeritus, Johns Hopkins University School of Hygiene and Public Health (Vaccines); Richard Jackson, California Department of Health Services (Environmental Health);William Keck, Northeastern Ohio Universities College of Medicine (Public Health Infrastructure);Thomas Pearson, School of Medicine & Dentistry, University of Rochester (Cardiovas- cular Disease); Allen Rosenfield, Dean, Mailman School of Public Health, Columbia University (Maternal and Child Health);John A. Seffrin, Executive Director, American Cancer Society (Cancer); and Ernest Julian, Director of Food Protection, Rhode Island Department of Health (Food Safety).We appreciate as well the contributions of David Satcher, former Surgeon General and Interim President, Morehouse College of Medicine. We are especially grateful to Hugh Tilson, School of Public Health, University of North Carolina at Chapel Hill. Deeply committed to raising the visibility of the public health community, Hugh provided important perspective and insights throughout the development of this book. His energy and enthusiasm for our entire series of books are invaluable and drive us toward continued partnership with this special community.
Barbara A. DeBuono, MD, MPH November 2005 iii Milestones . Contents
Contents
Prologue 1 With remarks by David Satcher, MD, PhD Morehouse School of Medicine, 16th U.S. Surgeon General
1.Vaccines and the Eradication of Smallpox 5 Expert Reviewer: D.A. Henderson, MD, MPH Center for Biosecurity, University of Pittsburgh; and Dean Emeritus, Bloomberg School of Public Health, Johns Hopkins University Looking Back 5 Case Study: Eradication of Smallpox 9 Vignette: Hib Vaccine 15 Looking Ahead: Advances in Vaccine Research 16
2. Automotive Safety 21 Expert Reviewer: Susan Baker, MPH Bloomberg School of Public Health, Johns Hopkins University Looking Back 21 Case Study: Development of Seat Belts 28 Vignette: Air Bags 31 Looking Ahead: Advances in Automobile Manufacturing 33
3. Environmental Health 37 Expert Reviewer: Richard Jackson, MD, MPH Division of Environmental Health Sciences University of California, School of Public Health Looking Back 37 Case Study: Lead Poisoning 41 Vignette: Asbestos 49 Looking Ahead: Asthma 51
4. Infectious Disease Control 59 Expert Reviewer: James Curran, MD, MPH Rollins School of Public Health, Emory University Looking Back 59 Case Study: HIV/AIDS 65 Vignette: Development of Penicillin 73 Looking Ahead: Antibiotic Resistance 76 iv
5. Cancer 83 Expert Reviewer: John Seffrin, PhD American Cancer Society Looking Back 83 Case Study:Screening Tools for Cancer Detection 90 Vignette: Skin Cancer and Sunblock/SPF Products 100 Looking Ahead:Genomic Research and Medicine 101
6. Cardiovascular Disease 107 Expert Reviewer:Thomas A. Pearson, MD, MPH, PhD University of Rochester School of Medicine Looking Back 108 Case Study: Risk Assessment 111 Vignette: Statins 114 Looking Ahead: Obesity in Young Populations 116
7. Safer and Healthier Foods 123 Expert Reviewer: Ernest Julian, PhD Rhode Island Department of Health Looking Back 123 Case Study: Jack in the Box E. coli Outbreak 132 Vignette: Nutrition Labeling on Food Packaging 138 Looking Ahead: How to Ensure a Safe Food Supply 142
8. Advances in Maternal and Child Health 147 Expert Reviewer: Allen Rosenfield, MD Mailman School of Public Health, Columbia University Looking Back 147 Case Study: Folic Acid 158 Vignette: Amniocentesis 161 Looking Ahead: Genetic Screening 163
9. Oral Health 167 Expert Reviewer: Myron Allukian, DDS, MPH Former Director of Oral Health, Boston Public Health Commission Looking Back 167 Case Study: Fluoridation 176 Vignette: Dental Sealants 182 Looking Ahead: Oral Diseases, Still a Neglected Epidemic 183 v Milestones . Contents
Contents
10. Addiction 191 Expert Reviewer: Joseph A. Califano, Jr. National Center on Addiction and Substance Abuse, Columbia University Looking Back 191 Case Study: Tobacco 199 Vignette: Mothers Against Drunk Driving (MADD) 204 Looking Ahead: Fighting Addiction in Young Women 207
11. U.S. Public Health Infrastructure 213 Expert Reviewer: C.William Keck, MD, MPH Northeastern Ohio Universities College of Medicine Looking Back 213 Case Study: The Creation of CDC 222 Vignette: Surgeon General’s Report of 1964 225 Looking Ahead: Public Health – A 21st Century Perspective 227
Epilogue 233 Barbara A. DeBuono, MD, MPH Pfizer Inc.
References 238 Milestones . Prologue 1
Prologue
Public health is the art and science of protecting and improving the health of a community through an organ- ized and systematic effort that includes education, assurance of the provision of health services and protection of the public from exposures that will cause harm. In other words, public health is what we as a society do collectively to assure the conditions in which people can be healthy. In order to effectively address challenges to people’s health, public health practice requires an organized and sustained population-based approach. Milestones in Public Health portrays public health as the vital, critical field it is today in the United States. Each chapter in the book celebrates an acknowledged milestone of public health, exploring first its historical developments, followed by an in-depth case study of the milestone and a vignette that illustrates another facet of the milestone, and concluding with a look ahead.The “Looking Ahead” sec- tion predicts advances yet to come in each of the broad areas of public health where milestones occurred, and acknowledges the paramount issue of preparedness now facing the public health community.The “Looking Ahead” sections may also explore issues of particular concern to the public health community – such as asthma or obesity in young people – that have yet to be fully resolved or eradicated. What are these milestones? In keeping with the list of ten acknowledged milestones in public health that have been identified by the Centers for Disease Control and Preven- tion, they are advances in addiction, automotive safety, can- cer, cardiovascular disease, environmental and occupational health, food safety, infectious disease control, maternal and child health, oral health, and vaccines.To bring it all together, the concluding chapter explores how the devel- opment of the public health infrastructure in the United States has contributed greatly to advances in public health, serving as a model for the world. The milestones identified in this book signify the most significant achievements in public health from the last 2 Milestones . Prologue
century.As you read the chapters, the long, rich history of public health should come to life.Through the historical developments, case studies and vignettes, your insights into the many successes of public health and the challenges that were overcome should deepen.Too often we fail to appre- ciate the way public health, so basic to the overall health of Americans, improves our daily lives. Public health works best when its successes are hidden, forestalling crises before the public grows alarmed.This book seeks to shed light on the underappreciated achievements of public health and to lay claim, in the open, to its vital work. It is time to celebrate public health. Milestones in Public Health also seeks to reinforce a core trait of public health, namely that success redefines the challenge.Whether with cancer, infectious diseases, oral health, vaccines, or a host of other areas, advances yet to come owe their possibility to the hard, focused work of public health professionals today and in preceding decades. For example, in the chapter on vaccines, we learn that global eradication of smallpox finally succeeded in 1977 only after an intense, years-long effort led by the World Health Organization in sub-Saharan Africa and South Asia. Currently, public health professionals are overseeing an intense worldwide effort to eradicate polio. Once they succeed, other debilitating diseases will become targets, and the hard work of global eradication will continue.With each succeeding battle, refinements in the particular skills and techniques of public health will allow millions more of the world’s people to benefit from advances that have benefited the people of the United States. Another example of how success redefines the challenge comes from the chapter on oral health. Each community in the United States that has fluoridated its water supply demonstrates a reduction in the rate of dental caries in its young population.Yet, despite compelling evidence, the process of fluoridating the nation’s water supply is far from complete. Even as public health experts gather and share statistics that demonstrate the good of a particular mile- stone, the challenge never dissipates. Each case study and vignette in this book examines in depth the complexities of public health, highlighting how 3
each milestone contributed so remarkably to the health of the American public. Furthermore, the lessons learned from these contributions promise to benefit the world’s population. For example, in the chapter on infectious disease control, the public health response to the AIDS pandemic, which was first identified in 1981, demonstrates truly astounding progress against a disease that was at first always fatal and is now often a treatable, chronic condition. Despite this progress, however, the public health communi- ty still confronts the threat of a continuing AIDS pandem- ic, especially in sub-Saharan Africa, and the cold truths of no vaccine, no cure, and no inexpensive treatment thera- pies. As with the global eradication of smallpox, progress in fighting an epidemic – whether it is AIDS, dental caries, or polio, in one country or in one county – redefines the challenge. Always, new aspects of epidemics and new popu- lations around the world await the vital work of the public health community. David Satcher, MD, PhD, former U.S. Surgeon General and current Interim President of the Morehouse School of Medicine in Atlanta, observes,“It is certainly true that public health always faces new chal- lenges. However, embedded within these challenges are also new oppor- tunities. It is clear that the focus of Healthy People 2010 on the quality of life and on the targeting of disparities in health among different racial, ethnic and socioeconomic groups, repre- sents both new challenges and new opportunities for public health. Public health is challenged to improve com- munication and to become more visible while developing new partnerships with and in the communities.Through these partnerships, the opportunity to better impact the all-important social determinants of health is real and tremendous.” The fact that public health is often invisible to the society it serves does not mean that its successes need to be hid- den. Milestones in Public Health seeks to highlight how pub- lic health is at the core of our nation’s progress and devel- opment and, at the same time, at the center of every family 4
and community. Milestones in Public Health celebrates inno- vative solutions to public health challenges and the people and institutions that have implemented them.We hope this book will inspire new generations to become public health professionals and to hold in their hands the privilege and responsibility of building new milestones in public health. Milestones . Chapter 1. Vaccines . Looking Back 5
Chapter 1 Vaccines and the Eradication of Smallpox Looking Back “Ring around the rosy / A pocket full of posies / Ashes, ashes / We all fall down!” Who isn’t familiar with this childhood song? Many people might be surprised that this verse from the 1600s refers to an outbreak of the plague that devastated much of western Europe. Humans are still vulnerable to infectious diseases that through history have run rampant and killed vast numbers of people.The plague and smallpox did just that through much of the Dark and Middle Ages. New viruses such as HIV and SARS threaten humans in this century. The development of vaccines, therefore, is one of man's
Dr. Edward Jenner greatest achievements.Vaccines protect people from fatal inoculating a child diseases, increase life expectancy and spare countless with vaccinia virus millions from pain and suffering. taken from a cow. The word vaccine comes from “vaca,” Latin for cow. In 1796 in Gloucestershire, England, Dr. Edward Jenner 6 Milestones . Chapter 1.Vaccines . Looking Back
discovered the first vaccine for smallpox. Jenner used mate- rial from a skin pustule which contained live vaccinia virus,a virus believed to be spread by cows to milkmaids, causing cowpox. Milkmaids who contracted cowpox, a mild disease in humans, seemed to be immune to smallpox, a virulent disease in humans. Jenner inoculated 24 children with the vaccinia virus and, like the milkmaids, they became immune to smallpox. Despite its success, the smallpox vaccine never became widespread enough to fully control the disease until late in the 20th century. It was especially problematic in the tropics, where suspensions could not be kept cool enough to be effective. In 1895, Louis Pasteur developed the second vaccine, this one for rabies, a groundbreaking achievement. As the first example of a pathogen being altered for a therapeutic purpose, Pasteur’s success opened the door to the field of immunobiology.That same year, Emil von Behring of Marburg University in Germany introduced the diphtheria vaccine.Three other vaccines – for typhoid, cholera and plague – were also developed late in the 19th century, but their use was not widespread at the beginning of the 20th century.Too many impoverished countries had no public Louis Pasteur health infrastructure, and the costs of vaccine distribution were prohibitive. Although smallpox was still widely prevalent in the United States at the beginning of the 20th century, it was by no means the only infectious disease to affect the American population. In 1920, for example, 469,924 cases of measles resulted in 7,575 deaths.That same year, nearly 148,000 diphtheria cases resulted in more than 13,000 deaths and 107,473 pertussis cases resulted in more than 5,000 deaths. The development of the polio vaccine in 1955 had a radical impact on the use of vaccines in the United States. Parents were eager to protect their children from the “iron lung” disease, and Congress appropriated funds to inoculate school children with the polio vaccine.The U.S. government then began a major push to promote the use of vaccines. Today, most Americans don’t think twice about vaccination. Children routinely undergo a series of vaccinations from birth through early childhood.These include vaccinations against diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella, chicken pox and Haemophilus influenzae 1955 polio vaccination. 7
type b (Hib). Some of these vaccines – measles, mumps and rubella (MMR), for example – have been combined and can be administered in one dose.
Child with the red blotchy pattern of measles.
Child being inoculated today.
What exactly is a vaccine, and how is it made?
A vaccine is formally defined as “a preparation of killed, weakened, or fully infectious microbes that is given to produce or increase immunity to a particular disease.” It can be given as an injection or in a form that can be swallowed (such as the polio vaccine).Vaccine researchers are inventing other means of safely and effectively delivering vaccines, such as nasal sprays. Child with mumps before vaccine was Vaccines fall into three broad categories: introduced in 1967. Live (Attenuated) Vaccine.This type of vaccine uses a live, although weakened, version of the virus; it usually provides lifelong immunity to the recipient. Measles, mumps and rubella vaccines are examples of the live vaccine type.