road2036

Editors
Charles E. Drum, M.P.A., J.D., Ph.D.
Gloria L. Krahn, Ph.D., M.P.H.
Hank Bersani, Jr., Ph.D.
Disability
and Public Health
“Disability and Public Health opens up a new vista by drawing down a new set of tools and strategies
from the public health domain to examine the social determinants of health for people with
disabilities and to develop systems of health education, health literacy, and organization of services
to improve their health and well-being. This text will most certainly become a cornerstone for
building a public health discipline that will help to develop a more comprehensive approach to
understanding the ecology of health disparities for people with disabilities and strategies to improve
access to affordable, quality health care. This book examines the circumstances of disability from a
personal, cultural, environmental, clinical, and policy perspective, and it ties this together in a public
health paradigm which is both enlightening and exciting.”
Leslie Rubin, M.D., Emory University
“Disability and Public Health is an important and overdue contribution to the core curriculum of
disability studies in public health education. With its broad cross-disability and consumer-centric
focus, nothing quite like this book of readings has been published, to my knowledge, with a public
health perspective. The book covers the right topics, including the history and culture of disability
in society; advocacy and the role of government and public policy toward disability today; the
epidemiology, disparities, and determinants of disability; and disability and health promotion. This
is a thought-provoking and enlightening book for students, faculty, administrators, and service
providers in public health and for the disability-related clinical professions.”
David Braddock, Ph.D., Associate Vice President, University of Colorado System
Executive Director, Coleman Institute for Cognitive Disabilities
The Coleman-Turner Endowed Chair and Professor in Psychiatry
University of Colorado Denver School of Medicine
a
Disability
and
Public
Health
Drum
/
Krahn
/
Bersani

American Public Health Association
American Association on Intellectual and Developmental Disabilities
Washington, D.C. • 2 0 0 9
Editors
Gloria L. Krahn, Ph.D., M.P.H.
Hank Bersani, Jr., Ph.D.
Disability
and Public Health
FRONT matter.indd 1 5/1/09 11:55:23 AM

American Public Health Association
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legal advice, since medical and legal opinions may only be given in response to inquiries regarding specific factual
situations. If medical or legal advice is desired by the reader of this book, a medical doctor or attorney should be
consulted.
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Marilyn Krajicek, Publications Board Liaison
Printed and bound in the United States of America
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ISBN: 978-0-87553-191-5
500 06/2009

Table of Contents
Acknowledgments.
.............................................................................................................................. v
Foreword
.
.......................................................................................................................................vii
Edwin Trevathan, M.D., M.P.H.
1 An Introduction to Disability and Public Health
.
...............................................................1
Charles E. Drum, M.P.A., J.D., Ph.D. and Gloria L. Krahn, Ph.D., M.P.H.
2 A Brief History of Public Health
.
.........................................................................................9
Grant Higginson, M.D., M.P.H. and Bonnie Widerburg, M.P.A.
3 Models and Approaches to Disability
.
.............................................................................. 27
4 A Personal Perspective on Historical Views of Disability.
............................................. 45
Michael J. Ward, Ph.D.
5 Culture and Disabilities
.
..................................................................................................... 65
Germán Núñez G., Ph.D.
6 Governmental Policies and Programs for People with Disabilities
.
............................ 79
Hank Bersani, Jr., Ph.D. and Lisa M. Lyman, Ph.D.
7 Fundamentals of Disability Epidemiology.................................................................... 105
Elizabeth Adams, Ph.D., R.D., Gloria L. Krahn. Ph.D., M.P.H.,
Willi Horner-Johnson, Ph.D., and Richard Leman, M.D.
8 Health of People with Disabilities: Determinants and Disparities
.
........................... 125
Charles E. Drum, M.P.A., J.D., Ph.D, Gloria L. Krahn, Ph.D., M.P.H., Jana J. Peterson, M.P.H.,
Ph.D., Willi Horner-Johnson, Ph.D., and Kathleen Newton, M.P.H.
9 Health Promotion for People with Disabilities
.
............................................................ 145
Jana J. Peterson, M.P.H., Ph.D., Laura Hammond, M.P.H., and Carla Culley, M.P.H.
10 Nobody Left Behind: Disaster Preparedness and Public Health Response for
People with Disabilities
.
................................................................................................... 163
Glen W. White, Ph.D.
11 Public Health as a Change Agent for Disability
.
........................................................... 183
Gloria L. Krahn, Ph.D., M.P.H. and Brian Ritacco, M.P.A.
Index
.
............................................................................................................................................ 205

About the Editors
Charles E. Drum is Associate Professor in the Department of Public Health and Preventive
Medicine at Oregon Health and Science University (OHSU) where he teaches in the M.P.H.
program. He is also the Assistant Director for Public Health, Community Outreach, and Policy
at OHSU’s Child Development and Rehabilitation Center and is the founding director of the
Center on Community Accessibility within the Oregon Institute on Disability & Development.
Dr. Drum received two National Research Service Awards from the National Institutes of Child
Health and Human Development, a Mary Switzer Merit Fellowship with the National Institute
on Disability and Rehabilitation Research, and the 2008 OHSU Distinguished Faculty Award
for Outstanding Collaboration. Dr. Drum has served on the United States Surgeon General’s
Task Force on Health Disparities and Mental Retardation, the Centers for Disease Control and
Prevention’s Healthy People 2010 Chapter 6 Work Group, the Oregon Council on Developmental
Disabilities, and the Governing Council of the American Public Health Association, representing
the Disability Section. Since 1985, Dr. Drum has participated in a range of projects examining
different aspects of disability and health programs, services, and policies, and he is the author
of numerous publications, including articles, book chapters, training curricula, and other
dissemination materials, that focus on children and adults with disabilities.
Gloria L. Krahn received the B.A. (Honours) degree in developmental psychology from
the University of Winnipeg, Ph.D. in clinical psychology from the University of Manitoba as
a Canada Council Fellow, and M.P.H. from the University of California at Berkeley. Dr. Krahn
was Professor of Public Health and Preventive Medicine and of Pediatrics at Oregon Health and
Science University in Portland, Oregon, where she directed the University Center for Excellence
in Developmental Disabilities as well as the Rehabilitation Research and Training Center on
Health and Wellness for People with Long Term Disabilities. She has served on numerous
national committees on disabilities and public health, including chair of the Disability Section
of the American Public Health Association. She has happily blended a career of administration,
teaching, and research, and she has recently assumed the position of director of the Division of
Human Development and Disability at the Centers for Disease Control and Prevention.
Hank Bersani is Professor of Special Education at Western Oregon University and teaches
courses in special education, rehabilitation counseling, and general education. He received a
doctorate from the Division of Special Education and Rehabilitation at Syracuse University, and
has been teaching in masters and doctoral programs since 1976. Dr. Bersani was a recipient of
the Mary Switzer Distinguished Research Fellowship of the Nation Institute on Disability and
Rehabilitation Research. In addition, the Joseph P. Kennedy Jr. Foundation awarded him their
Fellowship for Public Policy in Mental Retardation. He spent his fellowship year in Washington,
D.C., working with the U.S. Senate Finance Committee on Medicaid Reform. The Arc of the U.S.
also awarded him the Franklin Smith Distinguished National Service Award.

v
Acknowledgments
The development of this book has gone through a long and arduous process,
and the content of this book has matured in parallel fashion with the nascent field
called Disability and Public Health. In almost a decade of development, many people
provided effort and encouragement to bring desire to reality. It had its beginnings in
1999, when the Association of Teachers of Preventive Medicine, with resources from
the Disability and Health program of the Centers for Disease Control and Prevention
(CDC), funded the Disability and Public Health Project at Oregon Health and Science
University (OHSU) to create a curriculum that introduced disability issues to students
of public health. John F. Hough, Dr.P.H., M.P.H., M.B.A. and, later, Don Lollar, Ed.D.,
served as Project Officers from the CDC guiding the project. Tracy Goff and, later,
Amber Roberts, provided administrative support to the project. Without the infra-
structure support and advice provided by these individuals, the original project would
have been much more difficult, and I appreciate their assistance.
The Disability and Public Health Curriculum Project used a facilitated focus group
process with an interdisciplinary group of faculty and staff from OHSU and the Oregon
Department of Human Services, Public Health Division, to create the curriculum. The
members of the interdisciplinary group (listed alphabetically) included: Hank Bersani,
Jr., Ph.D.; Charles E. Drum, M.P.A., J.D., Ph.D. (facilitator); Michael Garland, D.Sc.
Rel.; Tracy Goff; Pamela Hanes, Ph.D.; Grant Higginson, M.D., M.P.H.; Gloria Krahn,
Ph.D., M.P.H. (co-facilitator); Germán R. Núñez, Ph.D.; Anne Pobutsky, Ph.D.; Michael
J. Ward, Ph.D.; and Dean Westwood, M.S.W. This group met monthly over the course
of two terms, engaging in vigorous debate across different perspectives to identify cur-
riculum topics, primary and contributing authors, and to develop initial papers on the
topics. I am grateful to each member of the group for their diminutive egos, keen in-
sights, ability to engage in thoughtful discussion, and capacity for fun.
In the paper development process, additional authors augmented the original in-
terdisciplinary group. These included: Carla Culley, M.P.H.; Laura Hammond, M.P.H.;
John F. Hough, Dr.P.H., M.P.H., M.B.A.; Willi Horner-Johnson, Ph.D.; David Lamprey;
Brian Ritacco, M.P.A.:H.A.; Mark Sherry, Ph.D.; and Bonnie Widerburg, M.P.A.
Without this influx of effort, many of the original chapters would not have been com-
pleted, and I am deeply thankful to these additional authors for bringing shape to the
substance of previous discussions. In particular, Dr. Hough, a Cal alumnus who must
make Berkeley very proud, was instrumental in creating the framework for a paper in-
troducing the embryonic field of the epidemiology of disability, and he deserves hearty
accolades.
In turn, these papers were summarized and edited into a curriculum outline that
has been used to teach a graduate-level public health course at OHSU. Turning the pa-
pers into a curriculum outline and a teaching tool was a task that required the energy
and verve of a number of people. Gloria Krahn, Brian Ritacco, and Amy Drake provid-
ed valuable editing and copy editing assistance with the curriculum outline. Over sev-

vi
eral years, students who took the public health course reviewed the outline and papers
and offered their critical (sometimes very critical) comments to the authors. Their ob-
servations greatly enriched the chapters and the course. Implementation of the course
at OHSU was also supported by the CDC and the National Institute on Disability and
Rehabilitation Research, U.S. Department of Education. I am also grateful to Thomas
Becker and the faculty of the Department of Public Health and Preventive Medicine at
OHSU for their encouragement and continuous support for developing disability as a
specialty area within public health.
Early on in the Disability and Health Project, it was decided that a logical subse-
quent step would be to convert the curriculum into a full-fledged text book. Gloria
Krahn told me at the time, “This book could make or break your career,” a phrase that
we have humorously reiterated over the years, particularly during times when we ques-
tioned the wisdom of pressing forward with this book. Given the time between the
original declaration and the publication of this book, I am relieved to finally put this
hyperbole to rest.
What really moved our efforts forward was the timely interest of the publishing
division of the American Public Health Association (APHA). Under the guidance of
Marilyn Krajicek, Ed.D., R.N., F.A.A.N., in her role as our liaison to the publishing
board, we updated and augmented the original papers. Dr. Krajicek was very helpful
in identifying additional content for the book and sustaining the editors in this initia-
tive. I thank her for her assistance and support, as well as Terence Mulligan of APHA’s
publishing division.
Given the need to both update content and add new chapters, the original authors
pitched in again to update chapters, and a number of new authors joined this effort
as well. I thank them for their fresh ideas and ability to integrate their content into
this evolving book. New contributors included: Elizabeth Adams, Ph.D., R.D.; Richard
Leman, M.D.; Lisa Lyman, Ph.D.; Kathy Newton, M.P.H.; Jana Peterson, M.P.H., Ph.D.;
and Glen White, Ph.D. Formatting the chapters and finding references was completed
by Susan Wingenfeld, B.Sc., and I want to express my appreciation for this sometimes
challenging accomplishment.
Finally, the co-editors of this current venture need to be recognized with deep grat-
itude. Hank Bersani displayed fortitude and diplomacy in convincing the original au-
thors to revise their material and brought energy and wit to working with the new
authors. Gloria Krahn, in her typical unfussy way, spent an extraordinary amount of
time reading and re-reading and editing and re-editing the chapters, all in marathon
sessions that would shatter mere mortals. I offer my sincere gratefulness to both Hank
and Gloria for their hard work, professionalism, and commitment to the field of dis-
ability and public health.
May 2009

vii
Given the facts below, it should be easy to justify why disability is a major pub-
lic health problem. In the United States alone there are approximately 50 million, or
one in five people, who experience some form of disability. Worldwide, approximate-
ly 10% of the population has a disability—some 650 million people, of which 200 mil-
lion are children. Mounting a coordinated public health response to disability should
be well underway. Yet in a society oriented toward cures for disease rather than health
promotion tailored to our specific circumstances, our response to disability has pri-
marily been a biomedical research investment rather than a public health focus on
one of our nation’s most important opportunities for prevention and health promo-
tion. This minimal investment in a public health response to disability has left mil-
lions of people with disabilities without opportunities for full participation in society,
with the increasing limitations of secondary conditions that reduce both lifespan and
quality of life, and with relatively small investments in primary prevention.
Given the enormous burden on society imposed by disability, what should be our
response? It is natural for professionals working in a field to be passionate and devot-
ed in their approach to a serious problem, and so it is with disability. For those of us
who have worked within what has been referred to as the medical model of disabili-
ty, we have taken great pride in our efforts. Our society’s investment in the medical
model of disability has certainly paid dividends. Advances in bioengineering, neuro-
science, pharmacology, genetics, and computer technology all offer potential for future
improvement in the lives of people with disabilities. Yet for most of the millions of peo-
ple with disabilities, the medical model has been necessary, but not sufficient.
Many of us have strongly embraced the functional model of disability and worked
to coordinate programs for people with disabling conditions, not around the cause of
their disability but focusing on improving their quality of life. Indeed, increasing the
health and participation of people with functional limitations deserves more attention
and offers the advantage of shared resources across condition groups—important for
making our intervention funds go further during times of fiscal hardship. For exam-
ple, people with spinal cord injuries experience functional limitations that are often
quite similar to those of people with spina bifida or who experience transverse myeli-
tis. Shared programs that improve health and participation can benefit people with pa-
ralysis from all of these causes. Measuring the impact of programs that seek to improve
the health and quality of life of people with disabilities in communities can be difficult,
especially when properly viewing disability as a continuous variable of functioning and
successful intervention as having multiple dimensions. Improving our ability to mea-
sure these programs in communities should be a major goal of public health over the
next decade.
Disabling injuries have been prevented, and many people with disabilities have ex-
perienced tangible improvements in their daily lives from work within the social mod-
el of disability. Breaking down the barriers that prevent people with disabilities from
Foreword

fully participating in society cannot be achieved without embracing social models of
disability and disability prevention. The recognition that we can improve the health of
people with disabilities by improving the environment in which they live, work, and
play has been a major contribution that will help people with disabilities in the years
to come.
Has it been easy to convince our society that disability deserves a major, coordi-
nated public health response? No. Our focus on reducing disability to small individ-
ual categories, each with different models of intervention, has fragmented our efforts
and resulted in an inadequate response to one of the major public health problems of
our time. Simply stated, the models of disability intervention are competing with each
other; society and people with disabilities suffer. As the numbers of people with a dis-
ability grow larger in our society, it is critical that we all work together and speak with
one voice, regardless of which approach to disability we work within to improve the
lives of people with disability. From the neuroscientist working to enhance plasticity
of cortical neurons to the urologist who treats bladder dysfunction, and from the pub-
lic health professional working to prevent neural tube defects to the attorney working
to assure full participation and access of people with disabilities, all of us must join to-
gether. This book can help provide all of us a common language and a framework to
mount a public health response to disability. The babies, children, and adults with dis-
ability whom we all serve deserve nothing less.
Edwin Trevathan, M.D., M.P.H.
Director
National Center on Birth Defects and Developmental Disabilities
Centers for Disease Control and Prevention
Atlanta, Georgia
viii

1
Chapter 1
An Introduction to Disability
and Public Health
Charles E. Drum, M.P.A., J.D., Ph.D. and Gloria L. Krahn, Ph.D., M.P.H.
1
Introduction
As we approach the end of the first decade of the twenty-first century, public
health is experiencing an unprecedented paradigmatic shift in how we understand and
respond to disability. This change is nothing short of phenomenal. From having had a
singular focus on preventing disability, public health is beginning to recognize that dis-
ability will always be with us. With that, there is an increasing understanding that pub-
lic health has the responsibility to promote the health and improve the quality of life of
persons who already experience disability. People with disabilities represent a substan-
tial portion of the target population of many public health activities—from diabetes
management to tobacco cessation to emergency preparedness. Failure to acknowledge
and accommodate disability in these target populations will jeopardize the success of
many of these programs. This changing understanding of public health’s responsibility
for people with disabilities has led to the development of this book.
But this change in perspective has been slow in coming. The Healthy People initia-
tives, the nation’s road map for public health, largely ignored disability issues until the
publication of Healthy People 2010 (USDHHS 2001). It was only in the current decade
that the United States Surgeon General (USDHHS 2002, 2005) issued reports recogniz-
ing the historical exclusion of people with disabilities from public health programs and
the unmet long-term health care needs among persons with disabilities.
In general, the disability community has an uneasy relationship with public health.
In the United States, from the post-civil war to the modern era, people with significant
developmental disabilities were institutionalized and many were involuntarily sterilized
(Burgdorf and Burgdorf 1977; Diekema 2003). Despite reversal of policies on institu-
tionalization and sterilization, this history has left a strong sense of suspicion of public
health in the disability community in general. The ongoing primary emphasis of pub-
lic health on prevention leaves some members of the disability community believing
that public health desires to prevent their very existence. Years of public health neglect-
ing disability issues has left lowered expectations regarding promising initiatives such
as the innovative state offices of disability and health funded by the Centers for Disease
Control and Prevention that focus on health promotion for people with disabilities.
DISAB & PH_Chap1.indd 1 5/1/09 12:04:10 PM

2 | D r u m a n d K r a h n A n I n t r o d u c t i o n t o D i s a b i l i t y a n d P u b l i c H e a lt h | 3
Objective of the Book
Public health professionals have had few opportunities to learn about disability in a
public health context. The objective of this book is to provide a thorough introduction
to disability issues to students of public health and related disciplines. This introduc-
tory chapter provides an intellectual road map to the text and describes how disabili-
ty complements a public health context. Public health has been described by a number
of key characteristics including the following: One Field, Many Disciplines; Political
Nature; Resource Allocation; Public Health Economics and Measurement; Broad and
Changing Agenda; Prevention Emphasis; and Values Base in Social Justice (Turnock
2001). These key components are used as an organizing framework to illustrate how
the basic characteristics of public health have linkages to disability and to the different
chapters within this book. It is useful to note, however, that many of the connections
between disability and public health illustrated by the chapters could be nested within
a number of the key characteristics.
The Basic Characteristics of Public Health and
Connections to Disability
One Field, Many Disciplines
The principles, values, and intent of public health provide a sufficiently integrating
framework to define it as a single field of science, advocacy, and application. However,
it encompasses professionals from numerous disciplines. Traditional disciplines have
included the health professions of medicine, dentistry, public health nursing, and social
work, and historically public health has been grounded in sanitation disciplines such
as engineering, chemistry, and biochemistry. In addition, much public health research
has been conducted using the methodologies of epidemiology, health economics, and
social policy analysis. As the public health agenda has increasingly embraced chron-
ic illnesses and lifestyle choices, the social science disciplines of sociology, psycholo-
gy, and psychiatry have played increasingly large roles. At present, up to 50 different
disciplines have been ascribed to the field of public health. This diversity of disciplines
brings a rich array of perspectives and methods for conducting surveillance and re-
search, developing policy, and implementing interventions. At the same time, the mul-
tiple perspectives raise the question of whether public health is really a cohesive field.
This question may be more troubling from an academic perspective than a pragmat-
ic one—public health appears to be alive and constantly in the process of redefining it-
self and its agenda. Higginson and Widerburg, in the chapter entitled “A Brief History
of Public Health,” review the genesis of public health and the definitional and histor-
ical issues that have impacted the growth of the field. The chapter purposefully does
not attempt to review every aspect of the history of public health, but lays the ground-
work for beginning to understand the role of disability in public health’s activities
and agenda.
Connection to Disability
As described in the Drum chapter on “Models and Approaches to Disability,” disability
is an emerging field that includes a number of different conceptualizations of disability.
The chapter describes several approaches to disability, including medical, functional,
social, and integrated models. In brief, the medical model of disability focuses on cur-
ing or ameliorating specific impairments or conditions within individuals. Functional
approaches to disability acknowledge impairments, but focus on disruptions in func-
tional activities, such as mobility or the capacity to work. Social models shift disability
from impairments or limits in functioning to the inability to access different environ-
ments. A number of integrated models combine these approaches.
Given the range of perspectives on disability, the professions that study and work in
disability reflect many disciplines. Much like public health, disability is inherently mul-
tidisciplinary. Traditional disciplines have included the health professions of medicine,
nursing, physical therapy, occupational therapy, and social work. The study of disabil-
ity includes legal and policy scholars, economists, sociologists, community psycholo-
gists, historians, and engineers. A vibrant humanities and arts scholarship in disability
has also emerged. As described by Nuñez in the “Culture and Disabilities” chapter, dis-
ability can also be viewed through a cultural lens. Nuñez explores varies anthropolog-
ical perspectives as applied to disability and the role of cultural competency within a
public health workforce.
Political Nature
Public health is inherently political. Members of society do not agree on the defi-
nition of “health of the public,” on the role of government in protecting the health of
the public, or on acceptable strategies to protect health. Distinctions between health
policies and politics become blurred, and multiple agendas come into play. Even if all
were to agree on an intended outcome (such as preventing bioterrorist attacks and pro-
tecting populations that are potentially threatened), political debates would rage on
about the infringements on individual rights and privacy, the relative roles of differ-
ent government agencies, and the financial costs to be incurred. Political parties are
ever mindful of their historical bases of voter and campaign contribution support.
Lobbyists represent the interests of corporations and other groups with financial inter-
ests at stake. Advocacy groups representing “single-issue” causes develop temporary al-
liances to influence the process, the argument, and the outcome.
Ward, in “A Personal Perspective on Historical Views of Disability” chapter, provides a
deeply personal and political description of the history of disability. He describes both
ancient history and the contemporary development of the self-advocacy movement
among people with disabilities. Ward argues that disability—like public health—is in-
herently political, in large measure because it has oriented itself to civil rights and em-
powerment perspectives and partly because the history of disability is not a happy one.
That is, from Ward’s perspective, the negative treatment of persons with disabilities has
necessarily contributed to an advocacy philosophy.
DISAB & PH_Chap1.indd 2-3 5/1/09 12:04:10 PM

Resource Allocation
Resources for public health, as for all public programs, are finite. The leadership with-
in public health at the local to the federal levels necessarily focuses on prioritizing the
use of those limited resources. What criteria should be used to develop those priori-
ties? Given the political nature of public health, many advocates engage in trying to
convince key stakeholders that their particular issue is deserving of resources. This is
most evident at the federal level when resources are “earmarked” by Congress for spe-
cific public health issues or disorders, such as sexual abstinence education for adoles-
cents, or research funding targeted to particular disorders.
In the United States, public health activities are prioritized through legislative and
administrative processes. Ideally, these processes involve reasoned debate about the
merits of various public health programs with a prioritization of resource allocation
based on importance and effectiveness. In reality, politics and political philosophy in-
fluence the prioritizing of public health activities and the allocation of resources as
much as, if not more than, merit.
Bersani and Lyman, in their chapter “Governmental Policies and Programs for People
with Disabilities,” provide an overview of the numerous federal agencies and govern-
mental policies and programs that affect the lives of people with disabilities. Similar to
public health program and policy development, Bersani and Lyman describe historical
and political prioritization processes that have created a maze of programs and servic-
es. Importantly, they establish a strong case for the need for public health professionals
to be knowledgeable of disability programs and polices because of their potential im-
pact on public health initiatives.
Public Health Economics and Measurement
Public health has incorporated health economics within its fold of disciplines to as-
sess the magnitude of identified public health problems and the effectiveness of efforts
to intervene. Cost–benefit analysis is an attractive method because it provides a stan-
dard measure (i.e., monetary units) that allows decision-makers to make relative com-
parisons across different public health actions. While it may seem imminently sensible
to design public health cost–benefit and cost-effectiveness studies to assist in decision-
making and priority-setting, such studies are very difficult to do well. They are typically
fraught with incomplete measurement of costs or benefits, are often based on assump-
tions that may not hold up to scrutiny, and inherently presume that economics should
be the value base for making decisions.
Measurement is a central component of public health, perhaps even more impor-
tant than the application of economics to health. Public health applies a significant
amount of energy and resources to measuring the health of populations through the
science of epidemiology. Epidemiology uses a number of methods to assess health and
risk factors to health and evaluate health-promoting interventions and activities.
Measurement in disability is also a central and challenging activity. Many of the stan-
dard tools of epidemiology apply to disability. Adams, Krahn, Horner-Johnson, and
Leman, in their chapter on “Fundamentals of Disability Epidemiology,” describe a num-
ber of conventional epidemiologic methods and apply them to the study of disability
in populations. They describe the challenges in case definition and incidence measure-
ment in disability and the role of values and politics in disability epidemiology.
Broad and Changing Agenda
As described by the Institute of Medicine in its seminal report The Future of Public
Health: “Public health is what we, as a society, do collectively to assure the conditions
in which people can be healthy” (Institute of Medicine 1988). This outlines a broad
agenda for public health—an agenda that changes and is determined by the social and
political context of the times. For example, the history of public health documents
ongoing tensions between maintaining a narrower focus on biomedical contribu-
tors to health versus expanding to include consideration of the social circumstanc-
es that influence health status. The tale of the contaminated water pump in London
and Chadwick’s success in pinpointing and eliminating it as the source of contagion
is standard lore in public health. Just as important, but perhaps less well known, was
Chadwick’s contemporary William Farr, a physician and statistician whose charge was
to analyze cause-of-death data in England and Wales. Farr began to emphasize so-
cial factors such as diet and working conditions as determinants of health and illness
(Hamlin 1995). Chadwick, wanting to focus on the biomedical causes of morbidity and
mortality, would not concede that economic policies and poverty played a role in the
disease process (Krieger and Birn 1998).
These divergent views in how broadly to define the agenda of public health contin-
ues today and is evident in the arguments regarding whether or not to include disabil-
ities within its scope. Some proponents have argued for a narrower scope that would
only extend to primary prevention of disability through activities such as injury and
disease prevention and birth defects detection. An alternative and growing view, in-
cluding that of the authors, contends that public health should fully incorporate dis-
abilities within its bailiwick, with a focus on the numerous contributors to disabilities
and activities that address health promotion and advocacy of full rights and participa-
tion within a broader society.
These divergent views in how broadly to define the agenda of public health contin-
ues today. Drum, Krahn, Peterson, Horner-Johnson, and Newton, in their chapter
“Health of People with Disabilities: Determinants and Disparities,” hold that public
health should fully incorporate disabilities within its activities, with a focus on the
broad range of contributors to the health of people with disabilities. The purpose of
their chapter is to describe a broader approach to health and describe how addressing

health disparities and the social determinants of health as they relate to disability is an
integral role for public health.
Prevention Emphasis
Traditionally, public health has emphasized the prevention of injury and disease. In
fact, the primary prevention of health problems has become a hallmark of public
health. In a public health context, prevention programs typically include a description
in epidemiological terms of the issue or problem, an assessment of risk factors, and a
program design that includes a determination of the intervention population, which
preventive strategy to be used, and the setting for the intervention. Public health ef-
forts are particularly important for problems that require societal or environmental
interventions. For example, while road hazards increase the likelihood of motor vehi-
cle accidents and associated injuries or deaths, it is harder to predict which specific in-
dividuals will experience a motor vehicle accident as a result of a road hazard. On the
other hand, requiring the use of seat belts by all drivers is an effective injury preven-
tion strategy for accidents.
Within public health, there has been considerable effort centered on the primary pre-
vention of disability through activities such as injury and disease prevention and birth
defects detection. Peterson, Hammond, and Culley, in “Health Promotion for People
with Disabilities,” discuss how public health can address the ongoing health needs
of persons with disabilities through health promotion efforts. The chapter describes
health promotion for people with disabilities, including the application of health be-
havior theory in disability-focused health promotion research and models of health
promotion that incorporate a disability context. Peterson, Hammond, and Culley make
a strong case that health promotion for people with disabilities is a prevention strategy,
and that health promotion includes both increasing primary health and reducing sec-
ondary conditions. The foundation of this perspective is the view that people with dis-
abilities can also be healthy.
White, in his chapter “Nobody Left Behind: Disaster Preparedness and Public
Health Response for People with Disabilities,” discusses the application of a broader
prevention framework as it relates to disaster preparedness and emergency response
for people with disabilities. The chapter describes current government, university, and
other organization efforts to address disaster preparation and emergency response for
people with disabilities, as well as how disaster preparedness connects with the ten es-
sential services of public health.
Values Base in Social Justice
One of the most distinguishing features of public health is its foundation in a philos-
ophy of social justice (Easley, Marks, and Morgan 2001; Krieger and Birn 1998). The
concept of social justice emerged in the mid-1800s as the articulation of principles that
espouse equity among members in their opportunity to access benefits accrued to a
society. Examples of these benefits include health, happiness, safety, income, and so-
cial status. The enjoyment of these benefits is generated in large part because of actions
that are taken at a societal level. Justice dictates that these benefits be distributed fair-
ly; injustice occurs when some members are denied equitable access or opportunity to
these benefits (Turnock 2001). To experience health as a human right requires a soci-
etal commitment to equity among groups as a fundamental principle. Susser (1993)
describes four constituents of an equitably distributed health right: 1) equal access to
appropriate services; 2) equity in health states; 3) evaluative mechanisms to monitor
the distribution of both states of health and specific needs for health; and 4) equita-
ble sociopolitical arrangements that give a voice to all groups in sustaining equity in
health. This basis in a social justice principle has made public health an advocate for
unserved and underserved populations on many health-related issues.
The Krahn and Ritacco chapter, “Public Health as a Change Agent for Disability,” is
a call to incorporate disability awareness into national, state, and local public health
agendas and to use public health approaches to reduce the health and social disparities
experienced by people with disabilities. The authors argue that public health has the
mandate and the capacity to improve the health status of people with disabilities, but
that it must act in partnership with disability advocates, local, state, and national orga-
nizations, and researchers. They ask public health professionals to provide the leader-
ship in making communities a healthier place for all its citizens, including people with
disabilities.
Conclusion
The preservation and enhancement of the population’s health demands sophisticat-
ed, professional skills and the integration of many disciplines into a broad strategy that
understands the way people live, the environment, and systems of health care. By its
nature, public health is an ever-evolving field. Yet, the academic discipline of public
health has been slow to incorporate disabilities into its practice, research, and curric-
ular offerings. When disability has been included in public health, the focus has tradi-
tionally been on the primary prevention of disabilities.
A central tenet of this book is that the current fragmentation of knowledge re-
garding disability can be rectified by providing conceptually coherent, integrated, and
in-depth knowledge of the universality of disability to students in public and relat-
ed health training programs and, thus, meet the goal of the Council on Education for
Public Health to provide a “general understanding of the areas of knowledge basic to
public health.” The overriding mission of every public health training program is to
advance the public’s health through learning and discovery. The overarching purpose
of this text, then, is to provide an introduction to disability perspectives to the public
health leaders of the future. By promoting an understanding of disability, it provides a
basis for enhancing the success of all of public health.

8 | D r u m a n d K r a h n
References
Burgdorf, R. and M. Burgdorf. The wicked witch is almost dead: Buck v. Bell and the sterilization
of handicapped persons. Temple Law Q 50 (1977):995–1034.
Diekema, D. Involuntary sterilization of persons with mental retardation: An ethical analysis.
Ment Retard Dev Disabil Res Rev 9 (2003):21–26.
Easley, C.E., S.P. Marks, and R.E. Morgan, Jr. The challenge and place of international human
rights in public health. Am J Public Health 91 (2001):1922–1926.
Hamlin, C. Could you starve to death in England in 1839? The Chadwick-Farr controversy and
the loss of the “social” in public health. Am J Public Health 85 (1995):856–866.
Institute of Medicine. The Future of Public Health. Washington, D.C.: Institute of Medicine (1988).
Krieger, N. and A.E. Birn. A vision of social justice as the foundation of public health:
commemorating 150 years of the spirit of 1848. Am J Public Health 88 (1998):1603–1606.
Susser, M. Health as a human right: An epidemiologist’s perspective on the public health. Am J
Public Health 83 (1993):418–426.
Turnock, B.J. Public Health: What it is and How it Works, 2nd ed. Gaithersburg, MD: Aspen
Publishers (2001).
U.S. Department of Health and Human Services (USDHHS). Healthy People 2010. Washington,
D.C.: U.S. Department of Health and Human Services, Office of the Surgeon General (2001).
U.S. Department of Health and Human Services (USDHHS). Closing the Gap: A National Blueprint
to Improve the Health of Persons with Mental Retardation. Washington, D.C.: Office of the
Surgeon General, U.S. Department of Health and Human Services (2002).
U.S. Department of Health and Human Services (USDHHS). The Surgeon General’s Call to Action to
Improve the Health and Wellness of Persons with Disabilities. Washington, D.C.: U.S. Department
of Health and Human Services, Office of the Surgeon General (2005).

9
Chapter 2
A Brief History of Public Health
Grant Higginson, M.D., M.P.H. and Bonnie Widerburg, M.P.A.
9
What in the Health is Public Health?
This text introduces disability issues to students of public health. Disability—
from a traditional public health perspective—is still in its very early stages of recogni-
tion as a separate area of focus. Public health, on the other hand, has a robust history
that has touched on or is related to disability in a number of ways and, appropriately so,
is separate in a number of ways. In this context, it is useful to examine the roots of pub-
lic health and understand the definitional and historical issues that have impacted the
growth of the field. The chapter does not attempt to review every aspect of the history of
public health. Rather, it provides an overview of public health both to increase our un-
derstanding of its history and the role of public health in the future vis a vis disability.
The Institute of Medicine (IOM), in its seminal report, The Future of Public Health
(IOM 1988), defined the mission of public health as “the fulfillment of society’s interest
in assuring the conditions in which people can be healthy.” What does this definition
mean for public health professionals or the public they serve? In a national telephone
survey conducted by the Harris group in 1996, 35% of respondents could not define
public health while 28% thought it was primary health care services for the poor. Less
than 4% of the respondents correctly associated public health with disease prevention,
immunization, health education, and promotion of healthy lifestyles (CDC 1998).
As the Harris survey revealed, one of the problems in public health is that its mis-
sion, function, and activities are not self-evident or clearly communicated to the pub-
lic or to policy-makers. The terms that are used to define public health are important
to convey the concept that public health is a broad endeavor aimed at optimizing the
health status of entire communities. On the other hand, broad definitions may lack
clarity in defining public health activities and what they accomplish and thus may not
provide meaning for many individuals. Unfortunately, this vagueness and obscurity of
understanding has had clearly negative ramifications for public health. For example,
according to Sommer and Ahkter (2000), public health can take credit for 80% of in-
creased longevity and health in the United States. Yet, U.S. investments in public health
in 1970 were 1.14% of total health spending and only 1.32% of total health spending in
2000 (Frist 2000).

10 | H i g g i n s o n a n d Wi d e r b u r g A B r i e f H i s t o r y o f P u b l i c H e a lt h | 11
In The Future of Public Health, the IOM (1988) provided a clear explanation of the
basic framework from which all public health activities flow.
…the government role in public health [is] made up of three core func-
tions: assessment, policy development, and assurance. These functions
correspond to the major phases on public problem-solving: identification
of problems, mobilization of necessary effort and resources, and assur-
ance that vital conditions are in place that crucial services are received.
To make this definition explicit and specific, a group of organizations, including the
American Public Health Association, the Association of State and Territorial Health
Officials, the National Association of County and City Health Officials, and the Centers
for Disease Control and Prevention, developed a nationally recognized description of
public health activities. They articulated the ten essential elements that must be in place
to create and sustain a healthy community.
These ten essential services reflect the IOM characterization that the substance of
public health consists of organized community efforts aimed at preventing disease and
promoting health, links across many disciplines, and that it rests upon the scientific
core of epidemiology (Institute of Medicine 1988). They incorporate within the frame-
work of public health and encompass both activities undertaken within the formal
structure of government and the associated efforts of private organizations and indi-
viduals (Institute of Medicine 1988). Further discussions of the ten essential services
and the principles that serve as their foundation are included in Chapter 11 of this vol-
ume. Although significant contemporary effort has been made to keep public health
current, the origins of public health continue to reflect the pillars of disease prevention/
health promotion, multidisciplinary efforts, and epidemiology.
The Origins of Modern Public Health
The origins of public health span millennia. For instance, in the fourth century B.C.,
Hippocrates, as quoted in Lloyd (1978), provided timeless advice on the environmen-
tal effects on health:
Whoever would study medicine aright must learn of the following sub-
jects. First he must consider the effect of each the seasons of the year
and the differences between them. Secondly he must study the warm
and the cold winds, both those which are common to every country
and those peculiar to a particular locality. Lastly, the effect of water on
the health must not be forgotten.
Throughout history, humankind has been plagued with epidemics. Until recent-
ly, infectious diseases have had the greatest impact on human populations. During the
Dark Ages and beyond, many people associated these diseases with a lack of morals or
a failure of spiritual commitment, and disease interventions consisted of repentance
and divine intervention. In the late 1600s, many European cities created public bod-
ies to report and record deaths from the plague and to enforce quarantine measures.
While infectious disease causation was not well understood and was still often consid-
ered to be representative of a moral failing, the eighteenth century witnessed a change
in thinking. Disease started to be seen as a potentially controllable event and the iso-
lation of ill patients and the quarantine of those who were exposed became common
measures in Europe and the United States. By the late 1700s, most major U.S. seaports
had established councils responsible for developing and enforcing isolation and quar-
antine regulations.
Urbanization resulting from the Industrial Revolution in the 1800s created un-
healthy environmental conditions previously unseen in human history. London expe-
rienced unprecedented levels of smallpox, cholera, typhoid, and tuberculosis. Edwin
Chadwick’s General Report on the Sanitary Conditions of the Laboring Population of
Great Britain (Chadwick 1965) was “a damning and fully documented indictment of
the appalling conditions in which masses of working people were compelled to live,
and die” (Chave 1998). Chadwick’s controversial report led to Great Britain’s Public
Health Act of 1848, which laid the foundations for the public infrastructure critical for
combating communicable disease. Similarly appalling conditions were found in the
United States at the same time. Inspired by Chadwick in England, a number of local
sanitary surveys were conducted in the United States. The most famous, Report of the
Massachusetts Sanitary Commission (Shattuck 1948), documented the differences in
mortality rates associated with different locations across the state.
In addition to the prevailing view that disease was related to an immoral lifestyle,
Shattuck attributed the high rates of disease in urbanized areas to the foulness of the air
created by decay of waste in areas of dense population. Illness began to be seen as being
determined by social and environmental conditions, in addition to moral and spiritu-
al ones. The Shattuck report showed that “even those persons who attempted to main-
Table 1. Ten Essential Services of Public Health
1. Monitorhealthstatustoidentifycommunityhealthproblems
2. Diagnoseandinvestigatehealthproblemsandhealthhazardsinthecommunity
3. Inform,educate,andempowerpeopleabouthealthissues
4. Mobilizecommunitypartnershipstoidentifyandsolvehealthproblems
5. Developpoliciesandplansthatsupportindividualandcommunityhealthefforts
6. Enforcelawsandregulationsthatprotecthealthandensuresafety
7. Linkpeopletoneededpersonalhealthservicesandassuretheprovisionofhealthcarewhenotherwiseunavailable
8. Assureacompetentpublichealthandpersonalhealthcareworkforce
9. Evaluateeffectiveness,accessibility,andqualityofpersonalandpopulation-basedhealthservices
10. Researchfornewinsightsandinnovativesolutionstohealthproblems
Source:
C
ore Public Health Functions
C
ommittee (1994). www.health.gov/phfunctions/public.htm

tain clean and decent homes were foiled in their efforts to resist diseases if the behavior
of others invited the visitation of epidemics” (Rosenkrantz 1972). This shift in thinking
was clearly reflected in the report’s recommendations which included 1) regular sur-
veys of local health conditions, 2) supervision of water supplies and waste disposal, 3)
special studies on specific diseases, and 4) the establishment of a state board of health
and local boards of health to enforce sanitary regulations. Shattuck’s recommendations
reflect a number of issues at the core of public health: 1) using data to analyze health
problems, 2) considering environmental factors as health determinants, and 3) identi-
fying government as having responsibility for ensuring adequate sanitary conditions in
order to promote the public good.
After the U.S. Civil War, governmental agencies began to be established to deal with
these issues. The techniques of isolation and quarantine that had been used previously
were simply inadequate to address the overcrowded and filthy conditions where masses
of people now lived and worked. In 1866, the New York City Department of Health be-
came the first public health agency in the country. In 1869, Massachusetts established
the first state Board of Health. By the end of the nineteenth century, 40 states and sev-
eral counties or cities had established health departments. Sanitary improvements of
the nineteenth century marked a great advancement in public health. Winslow (1920)
wrote, “Sanitation, the maintenance of cleanly and healthful environmental conditions,
does indeed represent the first stage of public health.”
The Emergence of Epidemiology
Perhaps the greatest turning point of modern public health was the birth of epidemi-
ology. Epidemiology is defined as “the study of the distribution and determinants of
health-related states and events in populations, and the application of this study to the
control of health problems” (Last 1983). Epidemiology depends on “careful clinical ob-
servation, precise counts of well-defined cases, and demonstration of relationships be-
tween cases and the characteristics of the populations in which they are most likely to
occur” (Last 1986).
Many public health professionals believe John Snow and William Farr to be the
fathers of epidemiology. During the summer of 1854, as a cholera epidemic raged
in London, John Snow visited the homes where people had died from cholera and
painstakingly collected the facts about their sources of drinking water. He was able to
show that the mortality rates for cholera were much higher for people who drank wa-
ter drawn from unknowingly contaminated water sources downstream of London, in
comparison to those who drank from upstream sources where the water was free of fe-
cal pollution. In essence, John Snow (1855) demonstrated the mode of transmission of
an infectious disease 30 years prior to the discovery by Nobel laureate Robert Koch of
the bacterium Vibrio cholerae responsible for cholera. Snow also formulated and im-
plemented a public health intervention when he removed the handle on the Broad
Street pump of the Southward and Vauxhall Water Company, the source of the con-
taminated water. These events mark Snow’s genius in population-based problem-solv-
ing and pragmatic applied strategy development, characteristics that continue to mark
best practices in public health.
A contemporary and co-patriot of John Snow, William Farr defined and clarified
many basic concepts of vital statistics and epidemiology. He developed the concepts of
“person-years” and “retrospective” versus “prospective” studies. He defined standard-
ized mortality rates, dose–response relationships, herd immunity, and the relationship
between incidence and prevalence. Farr’s work developed more than a century ago led
to the publication of Vital Statistics, A Memorial Volume of Selections from the Writings
of William Farr (Farr and Humphreys 1885) that is considered by many to be the finest
textbook on epidemiology ever written.
Epidemiological investigation has evolved greatly since the mid-1800s. However,
this evolution has been more in practice than in theory and changes in practice have
been relatively recent. The concepts of “case-control” studies, “prospective” studies,
and “cohort” studies were contained in nineteenth century scientific reports, but these
methods were not used with any kind of scientific rigor until well into the 1900s. Case-
control studies were not seen in the health care literature until the 1930s, although
these studies now form the basis for most disease investigations and clinical trials.
Prospective, cohort studies were not used until after World War II, but are now a pri-
mary means of identifying risks associated with behaviors and/or the environment.
The development of sophisticated statistical methods and the proliferation of com-
puters have also changed the face of epidemiology. There is tremendous potential and
power in the ability to analyze large data sets rapidly and apply the findings to identifying
clinical and population-based interventions. While this exciting present relies on high-
technology hardware and software, the usefulness of epidemiology in the future will de-
pend on the extent to which health professionals embrace a population perspective.
Enter the Era of Microbiology
Throughout most of recorded history, people lived in constant dread that some fulmi-
nating, infectious disease would kill one or more of their family members. Dramatic
reductions of infectious disease rates have been accomplished in the twentieth centu-
ry based on insights gained through microbiology. At the turn of the twentieth cen-
tury, influenza and pneumonia were the leading causes of death, at 202 deaths per
100,000 people. Current levels of the influenza and pneumonia deaths are now 30 per
100,000. Similarly, tuberculosis has dropped from 195 per 100,000 to 3 per 100,000.
Gastroenteritides, (e.g., cholera, typhoid), the third leading cause of death, dropped
from 143 deaths per 100,000 people to 1.1 per 100,000.
The waning years of the nineteenth century saw rapid advances in scientific knowl-
edge about the causes and treatment of numerous infectious diseases. In 1877, Louis
Pasteur proved that anthrax is caused by bacteria, and by 1884 he had developed an
immunization against the disease. Similar discoveries of the bacteriologic agents of tu-
berculosis, diphtheria, typhoid, and yellow fever followed over the next several years.
In 1891, W.T. Sedgwick, a biologist in Massachusetts, identified the presence of fecal

bacteria in water as the cause of typhoid fever, and developed the first sewage treat-
ment techniques. “With the relish of a good storyteller, Sedgwick would unravel the
plot in which the villain was a bacterial organism; the victim, the unwitting public;
the hero, sanitary hygiene brought to life through the application of scientific method”
(Rosenkrantz 1972). The work of these early public health practitioners effectively re-
duced the threat of many infectious diseases, a truly remarkable achievement.
The effective control of infectious diseases required a multifaceted approach.
Improvements in waste disposal, antibiotic therapy, immunizations, decreases in wa-
ter contamination, and improved housing conditions all played a role. The eradication
of infectious diseases as the leading causes of death is often attributed to medical sci-
ence. However, others strongly argue that the critical factors have been the efforts of
epidemiologists, public health officials, and sanitation engineers. This argument is sup-
ported by trend analysis of mortality rates. These data show that the majority of the
progress in reducing infectious diseases took place in the early decades of the twentieth
century, prior to the discovery of effective antibiotic or vaccination treatment (Foege,
Millar, and Lane 1971). Regardless of the relative contribution, public health and med-
ical science are both essential for promoting optimal health.
The Example of Smallpox and Public Health
Historically, the most devastating communicable disease has been smallpox (Last 1986).
The disease antedates written history and the first cases probably occurred 4,000 to 5,000
years ago when population densities grew large enough to support person-to-person
transmission. By the early Middle Ages, smallpox was rampant in Europe with a case–
fatality rate of 20–40% and substantial disabilities resulting from nonfatal cases. It was
also devastating in previously unexposed populations, with more than 3.5 million in-
digenous people dying when smallpox was introduced into Mexico. It has been argued
that this disease may have been more responsible than the conquistadors for the col-
lapse of the Aztec civilization (Dubos 1959).
Microbiology was already at play in the first primitive attempts at inoculation for
smallpox, which used pustular material taken from convalescing patients. In 1796,
Edward Jenner developed an inoculation using a virus from cowpox, a virus that is re-
lated to smallpox. By the end of the nineteenth century, the production of mass vac-
cine was perfected and smallpox was eliminated from Europe and the United States by
the mid-twentieth century. In 1967, the World Health Organization announced a two-
pronged approach to eradicate smallpox worldwide: the vaccination of at least 80% of
the population and containment of outbreaks. The last known case of naturally oc-
curring smallpox on this planet was diagnosed in October 1977. The eradication of
smallpox is unquestionably one of the greatest scientific and social mobilization ac-
complishments of human history. In only a decade and at a cost of about $300 million
dollars, a devastating disease was wiped off the face of the earth. This effort resulted in
billions of dollars in savings in health care costs and enormous savings in lives and hu-
man suffering. The basis of this success was the microbiology discovery of the vaccine,
but the successful eradication of the disease was dependent on a public health strategy,
including tracking the distribution of the disease, and population-based intervention.
Contemporary Public Health: Linking Microbiology,
Epidemiology, and Intervention
While tremendous advances have been made in combating communicable diseases,
the recent identification of Legionnaire’s Disease, Hanta virus, HIV/Acquired Immune
Deficiency Syndrome (HIV/AIDS), Ebola virus, and West Nile virus has shown that
emerging infections and public health interventions will continue to play a role in hu-
man history for at least the foreseeable future.
The Example of HIV/AIDS and Public Health
In 1981, the CDC’s Morbidity and Mortality Weekly Report contained a brief arti-
cle about five cases of Pneumocystis carinii pneumonia affecting young gay men in
Los Angeles, in which two of the men had died (CDC 1981). Since that first notifica-
tion of the onset of AIDS into our society, as of December 2005, 550,394 people have
died of AIDS in the United States and 984,155 cases of infection have been reported
to the CDC. Halting the spread of HIV/AIDS has been a daunting challenge. Within
18 months of the diagnosis of the first AIDS-related diseases, all major routes of HIV
transmission were identified, and prevention recommendations were issued in 1983.
However, the research into HIV transmission showed the disease can only be spread
by the exchange of bodily fluids, particularly sexual intercourse—which had major im-
plications for how the disease was viewed and handled. Its sexual transmission made
it difficult to be discussed openly and, because AIDS first struck in the gay population,
policymakers and the general public dismissed it as a “gay disease.” It was difficult to get
national leaders to attend to the terrible potential of the disease, much less fund pre-
vention and educational awareness and research programs. To some degree, the myth
that AIDS is a gay disease still persists, and today, as in the 1980s, AIDS is often seen as
a social stigma associated with blame, fear, and shame.
When dealing with other sexually transmitted diseases, public health relies upon
contact tracing—working with the infected individual to identify sexual partners, test-
ing and counseling them, and providing antibiotics to cure the disease. HIV, however,
cannot be cured with antibiotics and intervention requires behavioral changes to con-
tain and prevent further spread. Today, HIV is a global epidemic that has caused hun-
dreds of thousands of deaths around the world and affected millions more. Political
and social issues still surround public health’s ability to combat this disease. New treat-
ments and drugs have greatly extended the life expectancy for infected persons, but
this can only be accomplished through early detection and treatment. In countries with
advanced health care systems, many at-risk persons resist getting tested for HIV for
fear of discrimination. Across the globe, the costs of HIV drugs are prohibitively ex-
pensive and governmental and health organization budgets are rapidly outstripped by
the many people identified in need of them. In many cultures, it is still difficult to dis-
seminate messages about safe sex, because sexual intercourse is not openly discussed.
Microbiology, epidemiology, and public health interventions can only succeed when
they operate in a political and social environment that allows them to go forward.
Halting the spread of HIV and AIDS has been and will continue to be a daunting chal-

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