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Public health is about the spectrum of population health and health-related issues, and the collective actions to prevent, promote, maintain, and secure the well-being of peoples. It necessitates a greater appreciation of the determinants of health. It is those underlying factors that contribute to both good and bad public health outcomes. It was unfortunate that public health in the United States was viewed as a separate health care system of health departments that serve the poor, until more recently when the pandemic hit and public health became a household term.
Many Latin American countries chose a different path in response to a more collective health approach, with the rise in the social medicine movements during the 19th century. Western Europe had a great influence on Latin America’s social policies to scrutinize economic inequalities, social class, and other structural factors associated with poor population health outcomes. At the same time, United States was providing education and training to health professionals in the region, and the Rockefeller Foundation and other regional organizations, such as the Pan American Sanitation Bureau, were helping to drive the population health policy agenda. The external influences in the late 1850s and early 1900s may be no different from what we see today, with powerful foundations driving the global to regional public health strategies.
Health to Public Health
Since the founding of the World Health Organization (WHO) in 1948, the uniformly accepted definition of health remains as, “the state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.” Yet, still today, the focus remains on the physical assessments of disease or illness. This traditional biomedical approach subjugates the important contributions of the political, economic, social, cultural, environmental, ecological, and technological factors in society and their impact on population health.
We talk about public health, yet the focus remains on medical solutions. The commitment to invest in the best public health practices and policies is based upon prevention, which remains difficult to motivate decision-makers to support when there are so many competing societal issues of importance. It is unfortunate, however, that public health has sparked limited interest, historically, until a crisis threatens the lives of decision-makers, economically, politically, or emotionally.
The challenge to invest in preventing something that may never happen is the public health battle cry. Striking the right balance to promote public health actions and social policy highlights an exigent path of prevention and protection, especially for at-risk populations. Prevention through such strategies as promoting seat belts, helmets, healthier diets, vaccination policies, mandatory quarantines, or reducing air pollution has led to contentious battles as forms of control versus protection, with no simple solutions. Is it the access to better technology, better education, higher incomes, improved infrastructure, or enforcement and sanctions that provides the best public health protection? It often depends upon where you sit that will influence your point of view. Investments in public health have paid off with great improvements throughout Latin America and the Caribbean, albeit not equally.
Clarity about public health was offered to me very early in my career. I had the opportunity to train and work in Latin America with Professor David Taplin, the head of University of Miami’s Field Epidemiology Survey Team (FEST). He was a noted tropical disease microbiologist who studied infections and infestation of the skin and maintained that while such diseases may not appear to be a prioritized public health concern, they are a major drain on the health care delivery system with populations unnecessarily suffering. This approach provided a big picture view of public health and its inextricable relationship to poverty, environment, living conditions, lack of potable water and hygiene, as well as the structural determinants creating the political will of governments to invest in prevention. I saw it up close in my early field work in Colombia, Panama, Honduras, and Peru. What I also learned through such experiences is that relieving outbreaks of skin infestations and infections can build good relationships with communities since people may immediately feel better, sleep better, and concentrate more without the persistent itching and annoyance. This is where taking the time to understand how people feel matters. A Westernized assumption focuses its attention on what has been referred to as the real needs while we tend to overlook the felt needs. Real needs are based upon what we can measure, then quantify, and as such reveal how many doctors or nurses per population or hospital beds per population are needed. To be responsive we must draw our attention to such felt needs, that is what people feel they need. This requires a better balance of real and felt needs to improve health and well-being of a population.1 Using a community-based participatory strategy has shown the benefit of gathering insights from the recipients of any community-driven health program. An example shared by a colleague shows as she was conducting a study in Colombia to determine the best location for a community health center, she found that people did not feel they needed a health center, and they could take a bus to a nearby location. Rather, they preferred a childcare center as a better investment. Listening to voices of the people in a community is a core component of public health actions. It does not matter if we are talking about mitigating a disease outbreak, or encouraging vaccinations, or promoting public health education to prevent or reduce obesity, high blood pressure, or heart disease.
In the early 1980s I was also fortunate to meet Dr. Carlos “Choclo” Monge, a Peruvian physician with a profound understanding of population health. One of his visits to Miami coincided with our team’s preparation for a “pilot” field survey on the rates of skin infections and infestations in selected indigenous communities along the Ucayali River in Peru with travel to both tropical lowland Amazon and altiplano (high plain) regions.
While Taplin introduced me to the complexity of public health in real-world situations, Monge introduced me to the concept of human ecological niches as a measure of health beyond a biomedical reference. This was the ecological and cultural factors. Monge shared the example of how hemoglobin levels vary among groups living in tropical versus highlands regions. Hemoglobin is a known health indicator that measures the red blood cell count, which carries oxygen to the organs and tissues in the body. Low levels of hemoglobin will indicate anemia, a condition that makes one feel weak and tired. The normal level range was based upon a medical standard, since no one wanted to hire or keep someone employed if they seemed too weak to work. Therefore, in order to meet the determined medical requirement, workers at low altitude would give themselves iron to boost hemoglobin levels while high altitude workers would remove blood just to satisfy pre-determined standards.2 Such measures were insufficient and revealed a much broader understanding of the ecology, environment, and culture concerning the study of population health.
Infrastructure and Public Health
Great improvements in public health infrastructure have been made in Latin America and the Caribbean, although 34 million are still using unimproved drinking water sources and 18 million have no access to sanitation services with one in ten living in rural areas across ten countries using open defecation.3 Access to critical public health infrastructure and related health disparities has its roots in social and economic development, but political exigencies should not be excluded from the broader analysis. As stated in the introduction to this book, history has shown us how public health has significantly improved across industrialized nations such as England, Wales, and the United States in the early 1900s. This depended upon the political will to invest in better housing, potable water, sanitation, nutrition, and family planning. Controlling pests and vermin and promoting cleanliness with access to safe water and disposal of human waste and refuse have become the fundamental building blocks of public health.
With population shifts and fast urbanization, the United States learned important lessons in the early 1900s about the significance of public health along with the growth of cities, industrialization, and poverty. Pestilence and filth plagued the expanding cities until it became evident that health improvements rested upon the provision of improved infrastructure, better nutrition, improved working conditions, and the political will to encourage these investments. Nevertheless, post-WWII, the U.S. foreign assistance focused on a mixed bag of strategies to Latin America and the Caribbean versus the need for building and strengthening public health infrastructure. During the 1960s the emphasis was placed on vaccines and antibiotics as the investment in potable water, disposal of human waste and refuse, and appropriate protective housing was never fully realized equally throughout the region. A public health approach toward lifestyle changes shifted in the 1980s from infectious diseases to chronic disease prevention; yet, the burden of communicable diseases continued to disproportionately impact the poor.
Latin America and the Caribbean has made great progress in improving the access to safe water with variations within and across countries based upon urban and rural differences, as well as racial and ethnic populations. According to the Inter-American Development Bank’s World Water Week Report 2019, 490 million people (69% of the population in the region) still lack appropriate sanitation and 80% of the industrial and residential wastewater is untreated, thereby increasing the risk to freshwater. Let’s consider populations without access to safe water, sanitation, housing, and the relationship to public health. The example of a child with diarrhea shows how we think about the problem will influence how we respond. Applying a biomedical approach suggests we treat diarrhea with antibiotics if it is a bacterial infection or fluids to prevent dehydration. A behavioral approach seeks to educate mothers about how to reduce the risks at home and the necessity of handwashing, overall hygiene, and providing fluids. A broader sustainable consideration is to provide the necessary infrastructure as an investment in human development. The political and economic investments in public health address the structural barriers and highlight the inequities, imbalanced resource allocation, and power relations that continue to perpetuate poor health outcomes. This is where the state takes responsibility for the health and welfare of its people.
Poor infrastructure is also associated with childhood infestations from helminths (parasitic worms), which are endemic in many resource poor areas. Research by 2019 Nobel Prize for Economics, Esther Duflo and Abhijit Banerjee (MIT’s Abdul Latif Jameel Poverty Action Lab (JAPAL) and Michael Kramer (Harvard) shows greater educational outcomes and better school attendance with fewer absences due to illnesses through simple deworming treatments. Their evidence-based research documents better educational performance from deworming compared to giving children books. Using rigorous scientific methods, such as what is used in clinical drug trials, researchers were able to place science squarely into the nexus of public health and development, with focus on alleviating poverty. However, the question arises, could deworming children serve as band aid approach to much deeper problems? Would it not be better to provide the improved infrastructure and reduce the threat of re-infestations? The simple answer is yes.
The lack of a sound public health infrastructure provides a happy home to microbes and disease vectors, which may place the most vulnerable at risk for illness, disease, and injury. Another example is the case study of Mexico’s Piso Firme (Solid Foundation) initiated in 2000 to lessen parasitic infections and improve child health. The government’s commitment to install cement floors in homes where previous dirt floors existed resulted in 20% less parasitic infestations, almost 30% fewer cases of diarrhea, and 20% less cases of anemia along with the improved cognition of children. The unexpected outcomes also revealed that mother’s depression decreased by 12.5% and perceived stress by 10.4%.4 This evidence supports investments in housing, coupled with a targeted engineering approach to replace dirt floors with cement will reduce parasitic infestations with a range of other health-promoting benefits for a family.
Terms
Epidemiology is the science of public health. It is centered on the provision of evidence-based research to study population health. The most noted historical example is the classic field epidemiological work by John Snow in 1854 that identified the source of a cholera outbreak from the Thames River in London. Recognized as the father of epidemiology, Snow reasoned that if he removed the handle from the Broad Street pump the spread of cholera would cease since this contaminated water was the point o...
