315Each of the previous eight chapters highlighted two ind.docx

315
Each of the previous eight chapters highlighted two individuals
for their public health con-
tributions in Spotlight on Public Health Figures features, but
there are many other individuals
who have made a significant contribution to public health in the
nation and around the world.
History has shown that change is inevitable, and those changes
have developed into significant
advancements for many realms, including medicine, sociology,
and, of course, public health.
Public health has been part of human civilization since pre-500
BCE. In fact, the ancient Greek
physician Hippocrates was one of the first individuals credited
with focusing on diseases as
part of human health. Over the following centuries, more people
became involved with public
health concerns such as sanitation, traffic safety, and chronic
disease advocacy. Some of their
stories are provided next.
Appendix B
Additional Public Health Figures
© 2019 Bridgepoint Education, Inc. All rights reserved. Not for
resale or redistribution.
316

Additional Public Health FiguresAppendix B
Spotlight on Public Health Figures:
Clara Barton (1821–1912)
Who is Clara Barton?
Clara Barton was born in Massachusetts in 1821.
She originally worked at the U.S. Patent Office and
became an independent nurse during the Civil
War. She is primarily known for collecting and
distributing supplies for the Union Army during
the Civil War. She was nicknamed “the angel of
the battlefield” because of her willingness to walk
onto the field to aid the soldiers.
What was the political climate at
the time?
Barton lived during the Civil War. Before the
Civil War, the nation had already philosophically
divided into the anti-slavery North and pro-
slavery South. There were significant political
battles between the two major political parties:
Whigs and Democrats. The Missouri Compromise,
which consisted of laws that allowed each state to
determine slavery issues, was passed in 1850. It
ended slavery in the northern states, but it wasn’t
until the passage of the 1854 Kansas–Nebraska
Act repealing the Missouri Compromise that
the slavery dispute blew up into a major war. The Kansas–
Nebraska Act also prompted the
founding of the anti-slavery political party now known as
Republicans.
What was her contribution to public health?
She was one of the earliest health educators in the public health

realm, focusing on nursing
and creating positive outcomes for population health. She was
also the founder of the
American Red Cross, one of the most famous quasi-
governmental agencies working to
improve the health of the nation.
What motivated her?
Barton was reportedly a very shy child, but she found her
calling when her brother David
was injured during a farming accident. At age 11, she became
David’s primary caretaker. For
2 years, she stayed home from school to care for her brother,
who did eventually recover. It
was during that time that she realized she felt a calling to care
for the sick and injured.
Sources: Biography.com. (2018a). Clara Barton biography.
Retrieved from https://www.biography.com/people/clara-barton-
9200960
Clara Barton Birthplace Museum. (2017). Clara’s family.
Retrieved from http://www.clarabartonbirthplace.org/claras-
life/claras
-family/
Ourdocuments.gov. (n.d.). Kansas–Nebraska Act (1854).
Retrieved from https://www.ourdocuments.gov/doc.php?f
lash=false&doc=28
University of North Carolina. (n.d.). Civil War era NC.
Retrieved from
https://cwnc.omeka.chass.ncsu.edu/exhibits/show/benjamin
-hedrick/polticalclimate
Photos.com/Photos.com/Thinkstock
Clara Barton founded the American
Red Cross based on her interactions
with the Swiss-inspired Red Cross

network.
https://www.biography.com/people/clara-barton-9200960
http://www.clarabartonbirthplace.org/claras-life/claras-family/
http://www.clarabartonbirthplace.org/claras-life/claras-family/
https://www.ourdocuments.gov/doc.php?flash=false&doc=28
https://cwnc.omeka.chass.ncsu.edu/exhibits/show/benjamin-
hedrick/polticalclimate
https://cwnc.omeka.chass.ncsu.edu/exhibits/show/benjamin-
hedrick/polticalclimate
317
Florence Nightingale (1820–1910)
Who is Florence Nightingale?
Florence Nightingale was born in 1820 to a
very wealthy Italian family. The younger of two
daughters, she was also considered the black sheep
of the family due to the fact that her opinions often
conflicted with those of her parents. Nightingale felt
out of place in the elite circles and social situations
in which she found herself. She was well educated
in mathematics and various languages and received
what at the time was considered a classical
education. However, she found ministering to the
poor people surrounding her family’s estate to be
more rewarding than formal education.

the time?
Italy did not become a state until the country’s
unification in 1861. Before this, the country
struggled for unity and political autonomy. The
Crimean War (1853–1856) was fought between
the French and Russian military over the rights of
Christian minorities in the Holy Land (currently
known as Israel). The French promoted the rights
of Roman Catholics, while Russia fought for the
Eastern Orthodox. Italy joined its European allies,
which led to Nightingale’s involvement.
What was her contribution to public health?
Like her American counterpart, Clara Barton, Nightingale was a
pioneer in the nursing field.
She had a significant impact on 19th- and 20th-century policies
about proper medical care.
She was a solid philanthropist, volunteering her time and skills
to the poor in her community.
She served as a nurse during the Crimean War, in which she saw
deplorable conditions in
military medical facilities. Based on this experience, she
proposed policy reforms for military
hospitals on sanitation in an 1858 publication called “Notes on
Matters Affecting the Health,
Efficiency and Hospital Administration of the British Army.”
What motivated her?
Nightingale, born to very wealthy parents, believed she had a
“divine” calling to help the
poor. Her parents were not pleased with her decision and
actually forbade her from pursuing
the education needed to become a nurse. At the time, taking a
job as a nurse was considered
by the upper class to be menial labor. She ignored the

controversy within her family and
concerns about social status and pursued her career.
Sources: Biography.com. (n.d.-b). Florence Nightingale
biography. Retrieved from https://www.biography.com/people/f
lorence
-nightingale-9423539
Encyclopedia Britannica. (2018a). Crimean War. Retrieved from
https://www.britannica.com/event/Crimean-War
YourGuidetoItaly.com. (2013). Italian culture in the 1800s.
Retrieved from http://www.yourguidetoitaly.com/italian-
culture-in-the
-1800-s.html
GeorgiosArt/iStock/Thinkstock
Florence Nightingale served as
a nurse during the Crimean War
and used her experiences to
propose policy reforms for military
hospitals.
https://www.biography.com/people/florence-nightingale-
9423539
https://www.biography.com/people/florence-nightingale-
9423539
https://www.britannica.com/event/Crimean-War
http://www.yourguidetoitaly.com/italian-culture-in-the-1800-
s.html
http://www.yourguidetoitaly.com/italian-culture-in-the-1800-
s.html
318

Thomas Francis Jr. (1900–1969)
Who is Thomas Francis Jr.?
Thomas Francis Jr. was an American physician
and epidemiologist who grew up in New
Castle, Pennsylvania, and earned his medical
degree from Yale University in 1905. He
initially focused on vaccinations for bacterial
pneumonia but eventually became the first
person to isolate the influenza virus. He also
proved there were various strains of influenza
and participated in the successful development
of influenza vaccinations. One of his students
was the famous Jonas Salk, who ultimately
developed the polio vaccine.
the time?
Francis lived and worked during a time of war.
World War II (1939–1945) escalated the issue
of disease prevention and treatment. Historically, disease had
killed more soldiers than
battle scars had, so controlling influenza was a priority going
into World War II. There was
a fear of another pandemic like the influenza outbreak of 1918,
so the U.S. Army organized
a commission to develop a vaccine against influenza. This
support from the military and
federal government allowed a commission, led by Francis, to
develop and obtain Food and
Drug Administration approval for a vaccine in less than two
years. Frankly, for Francis, there

were no major hurdles to overcome.
What was his contribution to public health?
He was responsible for isolating human influenza and developed
the influenza A and B
vaccines in 1934 and 1940, respectively. Before Francis’s
contributions, the world had
suffered from multiple large-scale influenza outbreaks that had
taken the lives of millions.
What motivated him?
His background in virology and interest in preventing influenza
outbreaks like the ones that
had occurred when he was a teen motivated Francis to take
action. Because the political
climate supported assistance from all entities, and funding and
support was available, it was
just a matter of finding the influenza strain and creating the
vaccines.
Sources: Encyclopedia Britannica. (2018d). Thomas Francis Jr.
Retrieved from https://www.britannica.com/biography/Thomas
-Francis-Jr
The Conversation, US. (2015). How World War II spurred
vaccine innovation. Retrieved from
http://theconversation.com/how
-world-war-ii-spurred-vaccine-innovation-39903
Preston Stroup/Associated Press
Influenza research conducted by
Thomas Francis Jr. contributed to the
development of the influenza A and B
vaccines. Francis was also a teacher
and mentor for Jonas Salk.

https://www.britannica.com/biography/Thomas-Francis-Jr
https://www.britannica.com/biography/Thomas-Francis-Jr
http://theconversation.com/how-world-war-ii-spurred-vaccine-
innovation-39903
http://theconversation.com/how-world-war-ii-spurred-vaccine-
innovation-39903
319
Albert Calmette (1863–1933)
Who is Albert Calmette?
Calmette was born in France. He joined the
School of Naval Physicians at Brest, France, and
worked for the Naval Medical Corps in 1883.
He worked with Dr. Patrick Manson, who was
studying mosquito transmissions that caused
elephantiasis. This work captured his interest
in disease transmission and prevention. When
he returned from his service, he met Louis
Pasteur and began working with him in the
field of immunology.
the time?
Research in bacteria was just beginning,
and people still did not understand disease
transmission from insects to humans or from
human to human. People were motivated to
develop not only vaccines to prevent diseases,

but also safe treatments for such diseases.
However, people were often skeptical when
researchers touted success in one of those
areas.
What was his contribution to
public health?
Calmette, along with his colleague, Camille Guérin, was the
first to create an inoculation
against tuberculosis. Despite several setbacks, the vaccine went
through exhaustive testing
and was finally declared safe and effective in protecting
newborns against the disease. In
1924, the vaccination went global.
What motivated him?
His career allowed him to meet many famous physicians and
scientists, including Louis
Pasteur and Robert Koch. Most of his experiences in the
medical world revolved around
vaccination, an area that began to intrigue Calmette early in his
career.
Source: Hawgood, B. J. (2007). Albert Calmette (1863–1933)
and Camille Guérin (1872–1961): The C and G of BCG vaccine.
Journal of
Medical Biography, 15(3), 139–146.
Keystone-France/Gamma-Keystone/Getty Images
Albert Calmette studied disease
transmission from insects to humans.
Calmette later developed the cure for
tuberculosis along with his colleague,
Camille Guérin.

320
Camille Guérin (1872–1961)
Who is Camille Guérin?
Born in France, Guérin studied veterinary
medicine but eventually devoted his career to
finding a cure for tuberculosis. His father died
of the disease in 1882, and his wife succumbed
to it in 1918. In 1905, he discovered that the
bovine tuberculosis bacillus could immunize
animals against tuberculosis without giving
them the disease. After that success, he and
Calmette worked toward a human version of
the inoculation.
the time?
Research in bacteria was just beginning, and
people still did not understand the mechanisms
of disease transmission. The focus was on
developing safe vaccines and treatments.
What was his contribution to
public health?
His contribution, along with that of his
colleague, Calmette, was the successful
development of a vaccine to prevent
tuberculosis. Despite several setbacks, the

vaccine went through exhaustive testing and
finally was shown to be safe and effective in
protecting newborns against the disease.
What motivated him?
His father and wife both died of tuberculosis, so he was highly
motivated to find a cure. He
met Albert Calmette at the Pasteur Institute, where the two
successfully developed a safe and
effective vaccine against tuberculosis.
Source: Hawgood, B. J. (2007). Albert Calmette (1863–1933)
and Camille Guérin (1872–1961): The C and G of BCG vaccine.
Journal of
Medical Biography, 15(3), 139–146.
AFP/Getty Images
Camille Guérin lost family members
to tuberculosis and devoted his
professional career to studying
the disease. Guérin and Albert
Calmette later developed the cure for
tuberculosis.
321
Ignaz Semmelweis (1818–1865)

Who is Ignaz Semmelweis?
Semmelweis was born in Hungary in 1818. The
child of a well-off tradesman, Ignaz attended law
school at the University of Vienna. After a year,
he switched to medicine for reasons that are not
known, and he earned a doctorate in 1844. He
specialized in obstetrics.
the time?
When Semmelweis worked as a physician, little was
known about the benefits of handwashing—even in
the medical community. At the obstetrics hospital
where he worked as an assistant, Semmelweis
claimed there was one cause of puerperal fever, a
bacterial infection of the female reproductive tract
following childbirth or miscarriage. He believed
that if medical workers washed their hands in a
chlorine and lime solution, it would significantly
reduce, if not eliminate, infections. He even called
his colleagues “irresponsible murderers” for not
washing their hands before treating patients.
The members of the Medical Society of Vienna at
the time not only did not believe his theory but
harassed him over it and suggested that he was
losing his mind. He was eventually committed to an
asylum, where he died 14 days later.
He hypothesized that cleanliness could ward off disease. He was
credited for introducing the
idea of handwashing with chlorinated lime solutions to prevent
diseases. While working as
an assistant in the Vienna General Hospital in Austria, he
introduced the concept of washing
hands to reduce childbed fever. His suggested handwashing

practice was never accepted
during his lifetime. It wasn’t until Louis Pasteur developed the
germ theory of disease that
the medical community finally understood the theoretical basis
for Semmelweis’s claims.
What motivated him?
There is no solid record of what motivated Semmelweis’s
actions. He originally attended law
school and then transferred to medical school, and there is no
record of why he decided to
focus on medicine and obstetrics. However, some speculate that
he cared deeply about the
lives of those he treated and actually became fixated on the
issue, which perhaps led to his
admission to an asylum and eventual death. He was right that
handwashing is a solid means
of preventing the spread of diseases.
Sources: Clark, L. (2015, January 15). The doctor who
introduced the virtues of hand washing died of an infection.
Smithsonian.com. Retrieved
from https://www.smithsonianmag.com/smart-news/doctor-who-
introduced-virtues-hand-washing-died-infection-180953901/
Semmelweis Society International. (2009). Dr. Semmelweis’
biography. Retrieved from http://semmelweis.org/about/dr-
semmelweis-biography/
Photos.com/Photos.com/Thinkstock
Ignaz Semmelweis believed that
handwashing with chlorinated
lime solutions would help prevent
the spread of disease during
medical procedures. His colleagues,
however, did not agree with his
cleanliness theory.

https://www.smithsonianmag.com/smart-news/doctor-who-
introduced-virtues-hand-washing-died-infection-180953901/
http://semmelweis.org/about/dr-semmelweis-biography/
289
The U.S. health care system is a complex and ever-evolving
machine. It is the culmination of
various health care policies stemming from numerous special
interests, political expedience,
economic considerations, and theoretical perspectives. Because
the U.S. health care system
fluctuates along with current political climates, any account of
it is subject to change within
the next 3–5 years. While currency can be challenging,
understanding the elements in the cur-
rent health care system is crucial to understanding how public
health affects and is affected
by it. Appendix A focuses on the basics of the health care
workforce, agencies, financing,
insurance, dimensions within the public health system, and the
overall connection between
health care and public health.

A special section is devoted to health care funding in the United
States and includes an out-
line of the Affordable Care Act. How these systems of funding
function and how public health
supports these efforts also is explored. Lastly, Appendix A
details the responsibilities and
accountability of the U.S. public health system, especially those
of the seven specific agencies
that function as part of the health care realm and public health.
A.1 Linking Public Health to the U.S. Health Care System
The link between the U.S. health care system and the public
health realm can be understood
by examining how the system first started.
A Tradition of Giving
The U.S. method of caring for the sick, poor, aged, and
mentally ill historically was grounded in
churches and religious orders and was later expanded on by
charitable organizations such as
the Catholic sisters’ work during war times and epidemics
(Stepsis & Liptak, 1989). The con-
cept that people need to take care of people became rooted in a
system of giving, and it was
through this system that social services assistance such as
Medicare and Medicaid developed.
Indeed, federal and state laws were born from the idea that
health is a partnership between
those who can provide services and those who need them. After
the passage of An Act for the
Relief of Sick and Disabled Seamen in 1798, the nation began to
view health care as a right
and a necessary part of human existence. It became part of the
public realm and thus forged
the link between health care and public health. Table A.1 shows

the progression of the U.S.
health care system.
Appendix A
The Health Care System in the United States
290
Section A.1 Linking Public Health to the U.S. Health Care
System
Table A.1: Transition and growth of the U.S. health care system
Year Event/landmark
1798 Passage of An Act for the Relief of Sick and Disabled
Seamen
1800–1910 Sick insurance offered by the Massachusetts Health
Insurance Company of Boston
1862 Bureau of Chemistry established (forerunner of the Food
and Drug Administration)
1870 Marine hospitals organized into a centrally controlled
Marine Hospital Service
1887 One-room laboratory that eventually would become the
National Institutes of Health
opened

1890 Public Health Service Commissioned Corps legislation
1902 Marine Hospital Service renamed, becomes Public Health
and Marine Hospital Service
1906 Pure Food and Drugs Act passed (eventually became part
of the FDA)
1912 Public Health and Marine Hospital Service shortened to
Public Health Service
1921 Bureau of Indian Affairs Health Division created
(forerunner of the Indian Health Service)
1929 Baylor University began to offer a “sickness” insurance
plan for teachers that would
become the model for Blue Cross plans
The Great Depression began; few people covered by health
insurance
1932 Blue Cross established
1935 President Roosevelt signed into law the landmark Social
Security Act of 1935, a major
turning point in American history; initiated a system of elderly
benefits for workers,
workers’ benefits resulting from industrial accidents,
unemployment insurance, aid for
dependent mothers and children, and benefits for the blind and
the disabled supported
by taxes on individual and employer payrolls
1939 The Federal Security Agency created, merging fields of
health, education, and social
insurance

1942 Rise of unions and economic downturn during World War
II, resulting in the passage of
the National War Labor Board, which set a cap on wages but
allowed labor unions to offer
fringe benefits, such as health insurance, as tax-exempt
deductible income
1944 Public Health Service Act of 1944 made the United States
Public Health Services (PPS) the
primary division of the Department of Health, Education, and
Welfare (HEW)
1946 Communicable Disease Center established (forerunner of
the Centers for Disease Control
and Prevention)
1940–1950 Freezing of wages; employers offered health
insurance not subject to income tax as a
benefit alternative
1950 Forty-year increase in personal health care expenditures
rose from $82 in 1950 to $2,511
in 1990
1953 The Cabinet-level Department of Health, Education, and
Welfare (HEW) created
(continued)
291

System
Forces Shaping the Current System
World wars, the Great Depression, economic issues, social and
health policy, and the gradual
acceptance of the concept of “sickness” and health insurance
further shaped the nature of
the U.S. health care system. These transitional factors
eventually pushed the responsibility of
health care from the individual to the employer, diminishing the
role of individual responsi-
bility and lifestyle choices. See A Closer Look for more details
on the beginnings of employer-
based health insurance.
Year Event/landmark
1965 Medicare and Medicaid passed; federal government
became the largest single purchaser
of health care
1970 National Health Service Corps created
1973 Health Maintenance Organizations (HMO) Act addressed
rising health care costs
1979 Department of Education Organization Act removed the
education duties from the HEW
1980 HEW became the Department of Health and Human
Services
1983 Prospective payment system (PPS) legislation assigned
diagnostic-related groups (DRGs)
for hospital payment, directed to control inflationary hospital

costs
1988 McKinney Act passed to provide health care to the
homeless
1992 Resource-Based Relative Value Scale (RBRVS) created a
relative value affecting
reimbursement for physicians in family practice, internal
medicine, and obstetrics and
lower fees for surgeons and radiologists; resulted in a shortage
of physicians in some
areas of medical practice
1995 Social Security Administration became an independent
agency
1996 Welfare reform passed under the Personal Responsibility
and Work Opportunity
Reconciliation Act
Health Insurance Portability and Accountability Act passed
1997 State Children’s Health Insurance Program (SCHIP)
created
2002 Landmark study by the Institute of Medicine: The Future
of the Public’s Health in the
Twenty-First Century
Office of Public Health Emergency Preparedness created
2003 Medicare Prescription Drug Improvement and
Modernization Act enacted, the most
significant expansion of Medicare with a prescription drug
benefit
2010 Affordable Care Act passed

2016 Affordable Care Act under scrutiny; threats to repeal it
Sources: Klees, Wolfe, & Curtis, 2011; U.S. Department of
Health and Human Services, 2017; U.S. Public Health Service
Commissioned Corps, n.d.-b
Table A.1: Transition and growth of the U.S. health care system
(continued)
292
System
A Closer Look: How Did Insurance Become an Employer
Responsibility?
Payment for health care services started out as a cash-only
affair when a physician’s services
were needed. For those who had little or no money, trades of
food or other commodities
were given in return for health care services. Sickness insurance
was essentially catastrophic
coverage in the event that the breadwinner of a family, usually
the man, could no longer
provide for his family due to sickness or injury. While such
insurance was not mandatory in
the United States, it was exceptionally popular in Europe, where
industries were required
to provide it. Requiring businesses to offer sickness insurance
was considered an intrusion

of government into the practices of businesses, which was
against the democratic system
developed in the United States (Roberts, 2009). The progressive
movement in the early
20th century, a period of widespread activism and political
reform, sought to make health
insurance a national priority, arguing that it would “stabilize the
income of workers, relieving
poverty caused by sickness, and healthier workers would be
more efficient” (Roberts, 2009,
p. 8). However, the demands of World War I halted the push to
create compulsory health
insurance.
During the industrial and technological growth of the 1920s,
newly available diagnostic
tools and treatments were expensive, and they increased the
costs of health care to the
point where most people simply could not afford it. Because of
this, the notion of national
health insurance again became a focal point. Most people in the
medical community did not
want government interference into their work and considered
the possibility radical. In fact,
President Franklin D. Roosevelt had originally planned to
include voluntary health insurance
in his New Deal reforms, but the concept was removed due to
negative reactions from the
medical community.
During the Great Depression, Baylor Hospital in Dallas, Texas,
was facing the dilemma of
choosing between empty beds or patients who could not pay
their bills. To combat this, the
hospital developed a plan where schoolteachers could pay 50
cents per month to the hospital

and receive up to 20 days of care. The first claim under this
“insurance” occurred in 1929,
when one teacher broke her ankle over Christmas break.
Baylor’s health care plan, which utilized the blue cross symbol,
was eventually developed
nationwide into Blue Cross health insurance plans. Hospitals
across the nation began
adopting this type of insurance, and within 10 years, almost 3
million people had Blue Cross
plans.
Over time, employers began to offer such health insurance plans
as incentives for
employment. Considering that the Great Depression caused
significant financial damage to
both individuals and the nation, health plans were a great
opportunity for families to receive
health care without high out-of-pocket expenses at hospital or
doctor visits. This was the
beginning of what is currently the most common scenario:
Health insurance is obtained
through employment.
Sources: Morrisey, M. A. (2013). Chapter 1: History of the
health insurance in the United States. In Health insurance (2nd
ed.). Chicago,
IL: Health Administration Press. Retrieved from
https://www.ache.org/pubs/Morrisey2253_Chapter_1.pdf
Roberts, J. A. (2009). A history of health insurance in the U.S.
and Colorado. University of Denver. Center for Colorado’s
Economic Future.
Retrieved from http://www.du.edu/economic
future/documents/HistoryOfHealthInsurance_CCEF.pdf

https://www.ache.org/pubs/Morrisey2253_Chapter_1.pdf
293
System
As the industrial revolution struck the United States, so did the
need for health care. But for-
malized health care could not keep up with the growing demand
for health care services, so
the American health system implemented quick and temporary
solutions often called “stop-
gap measures.” Unfortunately, these multiple stopgap measures
resulted in a complex, redun-
dant, and fragmented health care system. Broad forces shaping
the evolving system included
• economic incentives fueled by government-enacted programs;
• political expediency;
• compromises on a Cadillac tax (a 40% excise tax on employer
plans that exceed
$10,200 per year for individuals and $27,500 for families) in
exchange for conces-
sions to limit its scope;
• development of diagnostic tools and technology-driven
interventions;
• escalation of increasing efficacy of pharmaceutical
interventions;
• increases in hospital beds and medical manpower linked with
the further enhance-

ment of the need to be able to pay for these services; and
• multiple funding sources from governmental entitlements,
grants, and categorical
programs for similar or the same services.
The appetite of the American consumer for health care services
in conjunction with limited
consumer economic consequences meant that as more people
used health care, the more
expensive it became. Most Americans didn’t realize that the
cost of these consumer-driven
consumption patterns would trigger major economic issues in
the future (National Acade-
mies of Sciences, Engineering, and Medicine, 2017a).
Public Health and Health Care
Working Together
The realization that public health services and the
U.S. health care system are inextricably linked is
an unfolding perspective. By examining the overall
health status in the United States and the perfor-
mance of these two interlocking systems, it is clear
that U.S. spending for health care services is high
and will likely continue to rise (Darzi et al., 2012).
The Public Health Service is responsible for guid-
ing health care in the United States. According to
the Institute of Medicine (IOM), which conducts
an ongoing analysis of public health services and
the U.S. health care system, the first critical step
to a fully functional system is to set a national target for the
health system performance on
two key measures: longevity and per capita health, which is the

amount of money the nation
spends on health care per person (National Committee on Public
Health Strategies, 2012).
Numerous individuals and organizations, including the Robert
Wood Johnson Foundation,
have researched and reviewed both measures for years.
monkeybusinessimages/iStock/Thinkstock
The public health and health care
systems are linked. Spending more
effort on preventing illness and
promoting wellness could help reduce
health care costs.
294
Section A.2 Health Care Systems
Following the passage of the Affordable Care Act, the Robert
Wood Johnson Foundation
charged the Institute of Medicine with examining three public
health issues: measurement,
the law, and funding (National Committee on Public Health
Strategies, 2012). The IOM’s initial
report indicated that there was not enough funding for effective
public health. In addition, the
current funding structure of public health was deemed
dysfunctional and ill equipped. The
IOM strongly suggested that the nation implement population-
based prevention and wellness
initiatives to help reduce costs. That is, rather than sinking

millions of dollars into treatment
and illness, the national focus should be on wellness and
prevention (National Committee on
Public Health Strategies, 2012).
While it may seem obvious that the national health care system
should be linked to pub-
lic health, there are other models that are structured differently.
The next section outlines
the different health care models and describes the elements that
pertain to the existing U.S.
model.
A.2 Health Care Systems
The successful provision of health care services requires strong
collaboration among pro-
viders, services, institutions, and resources in a goal-focused
model. Three basic models
for health care systems have evolved based upon the funding
mechanism of private, public,
blended, and limitation of services. All of the models have
coverage for those with limited
resources, but access to this support has many barriers,
including limitations as to what can
be covered. None of the publicly nationalized health system
models, other than that of the
private–public United States model, offers the scientific,
medical diagnostics, and interven-
tion technology developed by the private sector component of
the U.S. health care system.
Table A.2 compares the three major health system models,
representative countries, funding,
and providers.
Table A.2: Basic health system models

Model Representative countries Funding/providers
Bismarck France, Germany, Austria, Switzerland,
Belgium, Holland, Japan
Premium funded
Mandated insurance
Public/private providers
Beveridge United Kingdom, Italy, Sweden, Spain, New
Zealand, Norway, Finland, Canada, Hong
Kong*, Denmark, Cuba
National health service
Taxation
Limited coverage
Government/public
Tight control of costs
National insurance United States, Taiwan Public
Private providers
*Hong Kong is a special administrative region of the People’s
Republic of China but maintains a large degree of autonomy
after
being under British rule for decades.
295

Health care is an economic function providing health care
services. The model for the U.S.
health care system is market driven. It is a complex system with
multiple funding resources
and navigation issues. The major stakeholders in the U.S. health
care system model include
consumers (insured and uninsured), providers, employers,
government agencies, insurance
companies, managed care organizations, manufacturers of
pharmaceuticals, medical suppli-
ers, and professional organizations—essentially the consumers
and suppliers of direct and
indirect patient/client services.
National Insurance Model
The U.S. health care system primarily aligns with the national
insurance model. Taiwan’s
health care system is also based on the national insurance
model. However, the U.S. system
is quite different, as it is a blend of the fragmented public–
private partnership model. In fact,
the current health care system in the United States is made up of
small elements from vari-
ous national health care systems fused into a larger system. This
blending of private–public
resources results in a health care system with a unique structure
and funding mechanisms.
Further complicating this organizational structure is the
movement of individuals into and
out of both the private model and the public model. The public
model is considered categori-
cal health care for the poor, elderly, disabled, and mentally ill.
But individuals can fall between
the two systems and fail to receive services.
The number of Americans under 65 years of age covered by

employer-sponsored health
insurance declined slightly from 58.6% in 2010 to 58.3% in
2011; this is attributable to the
impact of unemployment during the most recent recession
(Gould, 2012). Individuals with-
out employer-sponsored insurance can purchase insurance from
a private insurance com-
pany, pay out of pocket, or access public funds. These public
funds are usually distributed
categorically by age and other criteria. This type of additional
insurance purchase is known
as a “safety net” system. All Americans can access the public
sector for health services as long
as they meet the service’s qualifying guidelines. The public
component provides health care
services for the vulnerable populations of the elderly, the
disabled, the poor, and children
through programs such as Medicare, Medicaid, Title V Maternal
and Child Health Services,
the Children’s Health Insurance Program (CHIP), State Health
Insurance Programs (SHIPs),
school health programs, supplemental food programs for
children and the elderly, public
health immunization and health services, federally qualified
health care providers, and Indian
Health Services (U.S. Department of Health and Human
Services, 2017).
The U.S. health care system attempts to link services between
providers such as hospitals
to skilled long-term care facilities, residential services,
rehabilitation, in-home services, and
mental health facilities. Within the larger hospitals and
facilities, there may be specialized
services targeting specific patient care needs such as mental
health care, intensive care, pedi-

atrics, obstetrics, burn units, cancer, and cardiovascular
services. Hospital-owned or con-
tracted services within a facility may include imaging,
laboratory, specialized surgical centers,
radiation therapy, emergency services, in-home, hospice,
ambulatory care, and outpatient
services. These types of services can be provided by private
practitioners, medical groups,
not-for-profit or for-profit organizations, physician-owned or
public health services, the mili-
tary, or Indian Health Services. In addition, hospitals may have
specific designations, such as
critical access, tertiary, primary, or academic health care center,
with varying reimbursement
296
patterns. Coordination of health care services can be offered by
physicians but happens pri-
marily through social assistive services, like a public health
agency or family services office
for complex and case-managed patients.
Health services for the patient or client are in part organized by
the personal physician who
directs client health needs by weeding through a multitude of
potential institutional and
provider services. In some instances, coordination happens
through case management ser-

vices and social assistance organizations, driven initially by
insurance companies and public
entities. Social Services, in collaboration with physicians,
provide a gatekeeping function for
publicly funded programs and insurance companies. Case
management is a system of man-
aging integrated health and human services for a defined group
of patients or clients. The
patients or clients may be high risk for hospitalization or
special care needs, or they may be
clients with various publicly funded community-home waivers
for Medicaid and long-term
care, mental health, and rehabilitation services. Case
management services are organized to
support the patient or client with wraparound services,
community-based interventions that
provide a multitude of needs for children and their families that
typically involve some level
of mental health needs, and to enhance independence. Some
insurance plans/providers have
case management services and health maintenance organizations
to manage access and costs.
State public health agencies have oversight responsibility for
safe practices of health care
service using a system of licensure/credentialing requirements,
inspections, and specific
monitoring for health care and human service providers and
institutions. While licensed
practitioners have state and professional organizations
overseeing the practice guidelines
and standards, the state department of public health or one of its
branches is generally the
licensing body.
Health Care Workforce

The United States Labor Occupational Handbook identifies 41
categories of health care work-
ers (U.S. Bureau of Labor Statistics, 2018b). The health care
workforce is diverse, drawn from
fields such as the life sciences, social science, and information
technology (financial, eco-
nomic, and educational areas). Professional schools provide the
skills and knowledge needed
to fulfill these roles. According to the Bureau of Labor
Statistics (2018a), there will be 2.4
million new health care jobs by 2026, a projected expansion rate
of 18%.
• Physicians provide diagnostic and treatment interventions as
well as a first point
of contact into the health care system for patients. From
selected national stud-
ies concerning physician resources, Young, Chaudhry, Rhyne,
and Dugan (2010)
reported that there were 850,085 physicians in 2010 with an
active license to prac-
tice medicine in the United States. By studying the complexity
of physician supply
and demand and referencing multiple government and
professional organizations’
research studies, Dill and Salsberg (2008) projected that by the
year 2025, there
may be a physician shortage as high as 130,000 physicians.
• Registered nurses (RNs) make up the bulk of the health care
occupation workforce.
RNs provide and coordinate patient care, educate patients and
the public, and pro-
vide case management and emotional support to patients and
their family members.
Practicing requires an associate, bachelor’s, and/or master’s

degree in nursing.
297
• In response to the projected health care services demands,
there has been an
accelerated expansion of advanced nurse practitioners.
Advanced nurse practitio-
ners (ANPs) have advanced academic nursing degrees with
specialty areas and/or
general practice areas. They are licensed to practice at an
advanced level and cre-
dentialed to diagnose and provide treatment options for acute,
episodic, or chronic
illnesses, independently or as part of a health care team (O-NET
Online, 2018).
• Licensed practical nurses (LPNs) or licensed vocational nurses
(LVNs) provide nurs-
ing care in nursing homes, physician offices, hospitals, and
private homes under the
supervision of a registered nurse or physician. LPNs/LVNs must
complete a state-
approved academic program and be licensed to practice.
• Physical therapists are in above-average demand, extending
into 2020. Physical
therapists assist people with illnesses and/or injuries limiting
mobility. A physical

therapist may also supervise a physical therapy technician or
assistant. Academic
preparation is advancing from the master’s degree to doctorial
preparation. Physical
therapists are licensed.
• Occupational therapists treat patients with injuries, illnesses,
and/or disabilities
facilitating the resumption of activities of daily living.
Occupational therapists
supervise occupational technicians and occupational assistants;
entry into the field
requires a master’s degree licensure.
• Medical and clinical laboratory technologists and technicians
vary in occupational
preparation based upon future practice area. Academic
preparation also varies
and may include certification and associate’s, bachelor’s, and/or
graduate degrees.
Licensure and/or certification consistent with legislated practice
standards is
required in each state.
• Health care managerial/administration occupations are another
health care job
area projected to expand. As Americans are experiencing an
increased incidence of
chronic conditions combined with lon-
ger lives, the demand for health care will
require additional workers to provide
health care services and access into the
system for recipients of categorical pro-
grams such as Medicaid and other sources
of welfare funding. Integration of these
health and social services will be increas-

ingly managed by a case manager sys-
tem. Case management is “a collaborative
process of assessment, planning, facilita-
tion, care coordination, evaluation, and
advocacy for options and services to meet
an individual’s and family’s comprehensive
health needs through communication and
available resources to promote quality,
cost-effective outcomes” (Case Manage-
ment Society of America, 2017, para. 1).
Demand will also expand for those in the health education and
health promotion fields, par-
ticularly in light of the Affordable Care Act now covering
prevention services. Many individu-
als are unaware of how to become healthier; hence, the need for
health educators alongside
health promoters is expected to grow.
XiXinXing/iStock/Thinkstock
Demand in the health care workforce
goes beyond doctors and nurses. As
longevity increases in the United
States, health care administrators
become more and more integral to
the system.
298

Other health care personnel positions expected to experience
increases include the following
ancillary personnel (U.S. Bureau of Labor Statistics, 2018a):
• emergency medical technicians
• paramedics
• medical sonographers
• medical records personnel
• medical transcriptionists
• health information technologists
• nursing assistants and medical assistants
Health Institutions and Agencies
There are many institutional health care organizations. They
include inpatient care facilities
such as hospitals, long-term care facilities such as nursing
homes and assisted living, and out-
patient clinics. Classification is based upon function and type,
such as government (federal,
state, community, city, military), specialty service focused,
community organizations, and fis-
cal profiles. In this section, health care institutions are profiled
and categorized as inpatient,
outpatient, or community providers.
• Inpatient health care facilities employ the largest number of
health care providers.
The CDC discovered that in 2014 (the most recent data
available), hospitals were
about 63% full with an average length of stay being 5.5 days
(CDC, 2016d). Any facil-
ity allowing for overnight stays is considered an inpatient
facility; however, most
hospitals allow for a stay of no more than 25 nights
(Medicare.gov, 2017).

• Long-term care focuses on patient stays of longer than 25
days. Long-term care
hospitals (LTCHs) are certified as acute-care facilities for those
who need critical or
intensive care. In addition, this category includes nursing
homes, assisted living, and
any other health care facility that becomes a home for
individuals (Medicare.gov,
2017). In some cases, certified group home environments that
provide special care
for disabled persons are also considered long-term care
facilities.
• Outpatient care and community providers include doctor’s
offices, clinics, and other
one-time visit facilities. There are no beds for any overnight
stays. Community pro-
viders and clinics handle most patient needs in the United
States.
Financing and Reimbursement
Insurance and/or public programs finance health care services
that provide the client or
patient coverage. The consumer can also privately purchase
supplemental insurance to
cover copays, deductibles, and other out-of-pocket expenses not
covered by insurance. Major
sources of financing and reimbursement for health care services
are provided primarily by
the government, out of pocket, and by private insurance. Table
A.3 outlines of a few of these
major funding sources.

299
The U.S. health care system is financed through a complex
private–public system. Health care
consumes a large part of the gross domestic product (GDP) and
is growing faster than the
national income—which is a source of significant concern. The
GDP is a measurement of the
economic health of a nation. It consists of the monetary value of
all goods and services pro-
duced within a nation (Investopedia, 2018). Both the private and
the public sectors are reel-
ing under the increased costs of funding employee health
benefits and retirement health ben-
efits. States concerned with the increasing costs of Medicaid
and other federal programs are
changing guidelines to limit coverage. The private sector has
sought to control bottom-line
costs by limiting dependent coverage and by implementing
larger copays and deductibles.
Thus, both the public and private sectors are passing along the
growing costs of health care
to the beneficiaries.
The Debate Over Health Care Financing
Several major viewpoints drive the health care financing debate,
such as the role of per-
sonal responsibility for health, social justice, utilitarian
concepts, and economic and political
theories.
• Philosophical: From a social justice perspective, the question

is basic: Is health care
a right or a privilege? Is it the responsibility of citizens to pay
for the health services
of others, even though they can afford to purchase health
insurance, and even for
individuals maintaining unhealthy lifestyle choices?
• Economic: Does health care enhance a utilitarian function
such as “healthy” status,
in which an individual is able to work and purchase economic
goods? Or is it an
economic incentive? This viewpoint can be observed in the
historical economies in
which merchant seamen were provided with health services to
ensure the transport
of trade goods.
• Political: More recently, the view has turned political, where
funding can be a means
of gaining favor with selected population groups or causes.
Table A.3: Major funding sources for health care services
Capitation A system whereby the funder reimburses the provider
based upon a set cost for a population. Capitation is used
in some grant-funded programs, in experimental projects
such as Medicaid, in health care management organizations,
and in grant funding with a designated population/sample.
Capitation minimizes risk to the funder.
Managed care A program/service providing coordination,
utilization, and
cost containment for a group of designated clients or patients
Health care management organization An organization that
manages a system of integrated health

care for a designated group of clients or patients
Health care insurance An agreement or contract protecting the
patient or client from
a health care cost
300
These are typical questions and dilemmas that arise in
discussions of the entitlement pro-
grams and the Affordable Care Act of 2010. The philosophical
conflict about who should have
insurance, who should pay for it, how much individuals should
pay, and how much should
be paid for by others is part of the conundrum of conflicting
economic, political, and philo-
sophical perspectives. The debate remains active today, and
some believe it has moved the
nation away from viewing health care as a charitable and
humanitarian service for the sick
and disabled toward one of varying personal agendas: gaining
notoriety, improving a political
position, or pushing for social justice.
Two Approaches to Financing Health Care
Regardless of the ongoing debate, the financing of health care is
still an issue and can be
divided into two major approaches: a market-based approach
and a government-driven

approach.
In the market-based approach, private entities fund health care,
and the government may
cover designated vulnerable populations. In the market-based
model, consumer demands
fuel the second driver of increased health care costs, which is
the health care industry itself.
Innovative technologies, treatments, and pharmaceuticals
supporting interventions that
were not possible in previous times (such as heart transplants or
knee replacement surgery)
also feed this cycle.
Private enterprises have implemented various cost management
strategies, including man-
aged care, provider networks, and health care management
services. These actions tend to
decrease how often people use higher-cost services such as
emergency department visits
and hospitalization. Private financing insurance funding
generally includes some deductibles,
copays, and waiting periods to reduce costs to the insurance
agency and to discourage unnec-
essary use. Some individuals elect to pay out of pocket for
health care services, and that puts
them at risk for exorbitant health care expenses.
In the government-driven approach, or the public system
approach, the government finances
health care expenses through funds allocated by taxes.
Examples of this are Medicaid,
Medicare, military health care (Veterans Administration), and
specific funding for targeted
populations.

The private market-based model is quite flexible in providing
health care services, especially
innovations in the medical field. For example, individuals in the
market-based model tend to
have earlier and easier access to the newest diagnostic testing or
surgical techniques. This
often translates into earlier diagnoses and treatments for
illnesses (Thorp, Howard, & Glac-
tionnova, 2007). With the government model, it is difficult to
control abuse or unnecessary
use of the benefits, and there are fewer incentives for change
and access to early diagnostic
tests and emerging treatment innovations (Thorp et al., 2007).
301
As the overall costs of health care spending have provoked a
national debate, one question
remains: How much will be spent on health care? Despite the
cost, the Centers for Medicare
and Medicaid Services (2012) noted that the major coverage
expansions from the Affordable
Care Act would result in 22 million fewer uninsured people,
from the 46 million who were
uninsured before the passage of the act. While more people did
gain insurance from the ACA,
it was also predicted that the 10 years that followed would see
the fastest increases of most
health-related expenditures, which include prescription drugs,

out-of-pocket expenses, clini-
cal services, and physician services. Hospital usage was also
projected to increase over the
next decade, but at a much slower rate than other services.
Dimensions of the U.S. Public Health System
The National Academies of Sciences, Engineering, and
Medicine (NASEM) (2017a) reported
that if the United States is to achieve a higher level of quality
of prevention and treatment ser-
vices, then the fundamental concepts that have molded the
system will need to be assessed,
evaluated, and developed into reliable affordable health care
services. Citing administrative
waste, inadequate funding for public health, and failure to
utilize public health in reforming
U.S. health care, NASEM (2017b) sent a strong message to the
secretary of the Department of
Health and Human Services recognizing the enormity of the
lack of emphasis on prevention
and declaring that the system needed to be fundamentally
assessed and reevaluated.
While health care costs will continue to expand, so will the role
of the public health system
within the realm of health services. The current public health
model was shaped through
the integrated patterns of population growth, global economics,
wars, depressions, and sci-
entific technology-fueled revolutionary growth in medical
science, disease prevention, and
intervention.
Continued growth in scientific knowledge about health and
disease and the importance
of health resulted in the merging of the U.S. Department of

Health, Education, and Welfare
(DEW) and the U.S. Public Health Service (PHS) into the
Department of Health and Human
Services (U.S. Department of Health and Human Services,
2017).
The United States Department of Health and Human Services is
a large organization that
provides monitoring, coordination, and health policy formation.
(Refer to Chapter 1 for the
organizational structure.) Within each region, state, county, and
city, public health services
directly implement the core public health functions: assessment,
policy development, and
assurance. Figure A.1 displays the location of the 10 U.S.
regional health offices.
302
Each state department of public health coordinates
communication, funding, and policy
among the state’s county and city public health organizations.
The state and local public
health departments touch many community agencies. They
monitor food vendors, agricul-
ture, waste disposal, recreational sites, lead exposure,
immunizations, childcare and residen-
tial facilities such as nursing homes, and licensing of nursing
home administrators. Coordina-

tion of policy and program activities is found at both the local
and state levels.
State health departments’ activities are administrated by a
public health official along with
a medical officer. The same structure is applied to smaller
populations at the local, county,
or city public health organizations, generally termed boards of
health. Duties of the state
and local boards of health include implementing public health
programs, monitoring and
assessing health status, and coordinating fiduciary concerns,
including funding allocations.
The state and local boards funnel federal funds into state and
local health programs. These
programs include Title V Maternal and Child Health Services
and administrative needs for
implementing the Department of Agriculture’s Women, Infants,
and Children (WIC) program.
Also, size and characteristics of a population determine the
extent of public health activities.
Figure A.1: The 10 regional health offices
Each regional office is responsible for assessment, policy
development, and assurance for the states
within its region.
Source: Adapted from “Regional Offices,” by U.S. Department
of Health and Human Services, 2014
(https://www.hhs.gov/about/agencies
/iea/regional-offices/index.html).
PR
Boston

VI
Regions
8
10
7
6
4
3
1
NYC
DC
Chicago
Kansas
City
Atlanta
Dallas
Denver
Seattle

HI
AK
San
Francisco
2
5
9
https://www.hhs.gov/about/agencies/iea/regional-
offices/index.html
https://www.hhs.gov/about/agencies/iea/regional-
offices/index.html
303
Section A.3 Funding the U.S. Health System
For example, some public health agencies may provide in-home
health care services for aging
adults and the disabled, while others may pass the funds through
to a contracted agency.
Finally, state and local boards of health are responsible for the
implementation and evalua-
tion of the Healthy People 2020 goals and action plans.
The Connection to Community Health
With the Healthy People goals driving public health efforts
nationwide, it is important to rec-

ognize the connection to the community. Community health is
part of the public health sys-
tem when it comes to assessing, evaluating, and implementing
activities that improve the
health of a target population. It could be considered the smaller
segment of public health in
a specific community. As one example, public health would
emphasize population well-being
within the state of Nebraska, while community health efforts
would focus on the population
of Omaha—one community within the state. To break that down
further, the city of Omaha
could be segmented by municipalities, each one having its own
community health focus.
Regardless of the size of the community, community health
services monitor the health status/
characteristics of the people residing within specified
geographical areas. Community health
professionals perform their functions best—to assess, evaluate,
and implement actions to
improve the health of a specific population—in an environment
fostering collaboration. They
work with local agencies, professional organizations, and
nongovernment organizations to
implement and monitor the Healthy People 2020 goals and
action plans (CDC, n.d.-c). The
Healthy People initiative just began its third decade of
providing goals and objectives focused
on improving the nation’s health. It is a collaborative effort
among the United States Depart-
ment of Health and Human Services, the Centers for Disease
Control and Prevention, and the
National Center for Health Statistics (CDC, n.d.-c). Within the
publication, the leading health
indicators are stipulated under 42 focus areas and 1,200

objectives. Public health agencies, in
collaboration with federal, state, and local organizations,
develop strategies for realizing the
Healthy People 2020 objectives and goals.
The provision of health care services requires strong
collaboration among providers, ser-
vices, institutions, and resources in an informal framework. The
U.S. health care system is
unlike any other in the world. The Department of Health and
Human Services is the large
agency in which the Public Health Service is embedded. Public
health, in cooperation with
the private health care system, has the responsibility of
overseeing the health of the nation;
however, accountability is grounded in the Public Health
Service.
A.3 Funding the U.S. Health System
The U.S. health care system is composed of a vast group of
legislative funding streams and
programs, the most recent being the Affordable Care Act (ACA)
of 2010. To understand how
the ACA is funded, it is important to first understand what it
accomplishes.
304
The Affordable Care Act

Attempting to address cost, quality, and access concerns in the
U.S. health care system, and
taking inspiration from the successes of health care plans of
other countries, the United States
passed the Affordable Care Act of 2010. Also known as the
Patient Protection and Afford-
able Care Act, it combined the concepts of cost,
quality, and access to health care for the Ameri-
can people. This landmark legislation focused on
providing health coverage for every citizen in the
United States. It is not national health care—which
provides free health care—but it is a step toward
a national health care plan. This particular act
brought in two very different perspectives that
were not originally part of health insurance pro-
grams in the past: Prevention services were now
fully covered, and every individual was mandated
to purchase some type of health insurance.
Under the Affordable Care Act, new guidelines
for access to care, financial resources, and access
to health care insurance were enhanced. Limits
on cost sharing for covered benefits and new rules for private
health insurance, health care
exchanges, a decrease in reimbursement for health care
providers, rationing, and review
panels were some of the primary factors initiating the prominent
Congressional discussions.
These discussions included additional issues such as the extent
to which the legislation would
reduce the cost for low-income consumers, addressing the
shortage of critical health provid-
ers and reducing reimbursement of providers and the total cost
of the legislation (Kaiser
Family Foundation, 2012). A major argument in favor of the
health care act was the access to

preventive care with no additional costs.
The Affordable Care Act was passed with limited vetting by the
legislators. The fiscal and eco-
nomic case for the pending legislative agenda was based on the
assumption that the continu-
ing fiscal shortfall in the U.S. economy was due to excessive
health care cost inflation—and
that comprehensive health care reform would fix the fiscal
issue. This continues to be a major
subject of debate.
Prior to the ACA’s passage, critics suggested that the law would
eventually betray the nation’s
commitment to care for its vulnerable populations, meaning
these individuals would not be
able to receive the same standards of care as other consumers
(Aaron, 2009).
The Affordable Care Act is a complex piece of legislation. The
passage of this act has differing
pros and cons, depending on the evaluator. The law has three
main goals:
1. Make affordable health insurance available to more people
2. Expand the Medicaid program to cover all adults with income
levels below 138% of
the federal poverty level
3. Support innovative medical care delivery methods designed
to lower all health care
costs (Healthcare.gov, n.d.-a)
Prevention services, such as annual

physicals, are now fully covered
services under the Affordable Care Act
of 2010.
305
One of the benefits of the ACA for the public health realm was
the addition of the Prevention
and Public Health Fund, which was created by section 4002 of
the ACA. It is the nation’s first
mandatory funding stream dedicated to improving the nation’s
public health. See Spotlight
on Public Health Figures to learn about a prior attempt to pass a
national health plan, during
Franklin D. Roosevelt’s presidency.
Franklin D. Roosevelt (1882–1945)
Who is Franklin D. Roosevelt?
Franklin Delano Roosevelt was born in 1882
in New York. He was the only child born into
a wealthy family, so his upbringing was very
different from that of most of the nation during
that time. He attended Harvard University and
later went to law school at Columbia University,
passing the bar exam in 1907. He married his
fifth cousin, Eleanor Roosevelt, and entered the
political arena shortly afterward. He was the

32nd president of the United States, serving the
country during one of the most difficult periods
in American history. His passion for reform
and improvements won over the hearts of the
nation. He was diagnosed with polio, for which
there was no cure or vaccine. He died in 1945 of
a cerebral hemorrhage, just before World War
II ended.
What was the political climate at the time?
Roosevelt’s tenure in office occurred during what many
historians consider one of the
most difficult periods in American history. Roosevelt served as
president during the Great
Depression, built a new nation through his New Deal program,
and saw the nation through
World War II. His leadership, including his reforms and public
programs, helped shape the
nation into a stronger world power.
While the New Deal was a significant contribution to the
nation’s overall well-being,
Roosevelt’s main contribution to public health was the
development of a national health care
plan. Roosevelt proposed within the Social Security Bill of
1935 his first draft of a national
health insurance plan. Due to significant opposition, especially
from the American Medical
Association, the health insurance plan was left out of the bill.
The second and last attempt
at national health care in the United States occurred only 4
years later. The Wagner Bill
included the National Health Act of 1939. Sen. Robert Wagner
introduced the bill, which
granted states the right to establish compulsory health

insurance. Roosevelt was in full
Circa Images/Glasshouse Images/SuperStock
President Franklin D. Roosevelt
developed a national health care plan
as part of the Social Security Bill of
1935, but strong opposition from the
medical community forced him to
remove it from the bill.
(continued)
306
Other System Funders
Other significant players in the health care arena include a
blend of private pay and employer-
based insurance companies, Medicare, Medicaid, specific
entitlements (such as Title V, WIC,
SHIP, and CHIP), state/county and local government
expenditures, and grants. An entitlement
refers to rights to services for certain populations or groups. In
the case of Medicare, people
age 65 and older are entitled to receive those funds. This differs
from a benefit, which is
not automatically awarded to someone because of membership
in a population. For example,
even if a person is age 65, the individual is not entitled to
additional health care benefits

through a private insurer. Purchasing additional health care is a
benefit provided through the
purchase agreement or through an employer if the individual is
still working. There are also
programs funded directly through public health and other
government agencies.
Medicare
A federal health insurance program for people age 65 and older,
Medicare has been in exis-
tence since 1965. It also provides health insurance for some
younger people with disabilities
and those with permanent kidney failure. It contains four parts:
A, B, C, and D.
Franklin D. Roosevelt (1882–1945) (continued)
support of such legislation, which would have been funded by
federal grants given to
the states for the establishment of health insurance programs.
Strong opposition from
the American Medical Association again forced the bill to die in
committee. Although
Roosevelt’s efforts seemed to die with him, President Barack
Obama’s administration passed
the Affordable Care Act in 2010—an act that gave the nation
exactly what Roosevelt had
envisioned in 1935.
What motivated him?
Roosevelt was a peacemaker who believed that nations should
be able to cohabitate without
fighting. He devoted a significant amount of his time to
planning the United Nations, a
coalition that he thought would help build international

relationships and create a safer and
peaceful world. That belief in a more peaceful world, along
with his own failing health due to
polio, motivated him to seek better health outcomes for the
people of the United States.
Sources: Biography.com. (2018b). Franklin D. Roosevelt
biography. Retrieved from
https://www.biography.com/people/franklin-d
-roosevelt-9463381
Freidel, F., & Sidey, H. (2006). Franklin D. Roosevelt.
Retrieved from https://www.whitehouse.gov/about-the-white-
house/presidents
/franklin-d-roosevelt/
Physicians for a National Health Program. (2016). A brief
history: Universal health care efforts in the US. Retrieved from
http://www
.pnhp.org/facts/a-brief-history-universal-health-care-efforts-in-
the-us
Rorabaugh, A. (n.d.). Wagner bills: Wagner National Health Act
of 1939. The American Government’s Responsibility in Health
Care:
The Chronic Debate. Retrieved from
http://76478895.weebly.com/wagner-bills.html
https://www.biography.com/people/franklin-d-roosevelt-
9463381
https://www.biography.com/people/franklin-d-roosevelt-
9463381
https://www.whitehouse.gov/about-the-white-
house/presidents/franklin-d-roosevelt/
https://www.whitehouse.gov/about-the-white-
house/presidents/franklin-d-roosevelt/

http://www.pnhp.org/facts/a-brief-history-universal-health-care-
efforts-in-the-us
http://www.pnhp.org/facts/a-brief-history-universal-health-care-
efforts-in-the-us
http://76478895.weebly.com/wagner-bills.html
307
• Medicare Part A covers hospitalizations, nursing home care,
hospice, and some
home health care services.
• Medicare Part B is the medical insurance section, which
covers prevention services,
screenings, doctor visits, and medical supplies such as insulin
for diabetes.
• Medicare Part C is an advantage plan, which consists of
Medicare parts A and B
together under one policy. This plan is mainly offered through
private companies
under Medicare contracts and may include health maintenance
organizations
(HMOs), preferred provider organizations (PPOs), private fee-
for-service plans,
special needs plans, and savings account plans. In addition,
most Part C plans cover
prescriptions.
• Medicare Part D is more commonly referred to as the
Prescription Drug Plan. It cov-
ers medications that might be prescribed by physicians,
hospitals, or other health

care providers (Centers for Medicare and Medicaid Services,
n.d.).
Medicaid
Medicaid is a state-run operation that provides health care
coverage for low-income people
of any age. Eligibility varies from state to state, but most offer
coverage for a base income
rate near the poverty level. Beginning in 2014, all people under
age 65 with incomes up to
$15,000 per year became eligible for Medicaid. Those age 65
and over qualify for Medicare
(Healthcare.gov, n.d.-b).
Title V
Title V is a portion of the Maternal and Child Health (MCH)
Services Block Grant, which pro-
vides services for mothers and their children. Title V was
created in 1935 as part of the Social
Security Act and provides programs for mothers, infants, and
children, including those with
congenital disabilities. Today, Title V is the only federal
program that focuses solely on the
health of mothers and children. It makes a special effort to help
communities deliver various
services such as care coordination, transportation, home visits,
and nutrition counseling. It
provides prenatal services for more than 2 million women and
primary prevention services
to more than 17 million children, 1 million of whom have
special needs. Title V receives nearly
85% of the MCH funding, which is allocated to the states. From
there, the states distribute the
funds to the various local and county programs (Health
Resource and Services Administra-
tion, n.d.).

WIC
WIC (Women, Infants, and Children) is a supplemental food and
nutrition program that serves
low-income pregnant, postpartum, and breastfeeding women, as
well as infants and children
up through age 5. The program is offered in all 50 states, along
with 34 Indian tribal organi-
zations; Samoa; Washington, DC; Guam; the Northern Mariana
Islands; Puerto Rico; and the
Virgin Islands. Operating under the auspices of the United
States Department of Agriculture,
the program provides foods and nutritional counseling to those
who are eligible (U.S. Depart-
ment of Agriculture, n.d.).
308
Section A.4 Responsibility and Accountability of the U.S.
Public Health System
SHIP
The State Health Insurance Assistance Program (SHIP) is a
national counseling and assis-
tance program that provides educational services to those with
Medicare. Every state has a
SHIP, which offers assistance via telephone or in person.
Elements included in this counseling
are the provision of educational materials and offers of referrals
for services (Administration
for Community Living, 2017).

CHIP
All 50 states operate a Children’s Health Insurance Program
(CHIP), which is a public offer-
ing of free or low-cost health insurance for those under age 18
(Healthcare.gov, n.d.-c). This
coverage pays for pediatrician visits, medications,
hospitalizations, and other needed health
care. The program is similar to Medicaid but is jointly funded
by both federal and state gov-
ernments. In 2009, Congress passed the Children’s Health
Insurance Program Reauthoriza-
tion Act (CHIPRA), which provided additional funds for CHIP,
some of which were to be used
for a new program to reach eligible children who were not
enrolled.
A.4 Responsibility and Accountability of the U.S. Public
Health System
The United States Public Health Service is a large department
of the United States Department
of Health and Human Services. It has far-reaching
responsibilities. This vast array of respon-
sibilities and accountabilities is communicated downward
through the state and county or
city levels of public health. These functional entities include
approximately 3,000 county and
city health departments and local boards of health; 59 state,
territorial, and island nation
health departments; more than 160,000 public and private
laboratories, hospitals, and other
private-sector health care providers; and volunteer
organizations such as the American Red
Cross and American Diabetes Association (Lister, 2005).

These social services offer vulnerable populations
of low-income individuals, mothers and children,
the mentally ill, patients with addiction problems,
and patients lacking access to health care a wrap-
around public health safety net. However, there
are some populations that fall through the system,
such as the working poor. Public health officials at
the local, state, and federal levels continue to work
to address these system holes. Regardless, public
health entities at all levels collaborate to ensure
the quality of the health care services throughout
the nation. Furthermore, public health’s three core
functions (policy development, assessment, and
assurance) can truly be found within all commu-
nity and governmental entities in order to provide
much-needed services to all, but especially these
vulnerable populations.
John Rowley/Photodisc/Thinkstock
Public health entities can help ensure
that health services are accessible for
vulnerable populations, such as low-
income persons, women, children, and
the disabled.
309
Seven Key Agencies and Their Responsibilities

Seven primary agencies deliver public health services. Given
this broad array of responsibil-
ity, the United States Department of Public Health’s overall
charge was set forth in a landmark
study by the Institute of Medicine (1988), which named the core
functions of the national
public health service: assessment, policy development, and
service assurance. These three
core functions have been used to organize and adapt the
department to meet the challenges
of emerging threats and environmental hazards, allocation of
resources, and service provi-
sion to meet the population’s needs. Table A.4 outlines the
responsibilities and accountabili-
ties of these seven agencies. More details on each agency can be
found in Chapter 1.
Table A.4: U.S. public health system organizational chart
Agency Primary services Extended services
National Institutes
of Health (NIH)
Medical research Includes 27 separate health institutes
and centers
Food and Drug
Administration
(FDA)
Ensures safety of food and
cosmetics and safety and efficacy of
pharmaceuticals, biological products,
and medical devices

Products represent 24 cents out of
every U.S. consumer dollar spent
Centers for Disease
Control and
Prevention (CDC)
Health surveillance; monitors and
prevents disease outbreaks; implements
disease prevention strategies and
maintains national health statistics;
immunization services, workplace
safety and environmental disease
prevention; includes the Agency for
Toxic Substances and Disease Registry
Maintains personnel in more than 25
foreign countries, guarding against
international disease transmission;
prevents exposure to hazardous
substances from waste sites on the
EPA’s national priorities list
Indian Health
Service (IHS)
Works to provide health services 46 hospitals, 324 health
centers, 309
health stations, and 34 urban Indian
health programs
Health Resources
and Services
Administration
(HRSA)

Provides access to essential health care
services for low-income people, the
uninsured, or those who live in rural
areas or urban areas where health care
is scarce; maintains the National Health
Service Corps
Provided medical care to nearly 17
million patients and more than 4,000
sites nationwide in fiscal year 2009;
helps to build the health care workforce,
administers programs to improve the
health of mothers and children (Title V,
WIC Program), serves people living with
HIV/AIDS through the Ryan White CARE
Act, and oversees the nation’s organ
transplantation system
Substance Abuse
and Mental
Health Services
Administration
(SAMHSA)
Ensures quality and availability of
education, prevention, and treatment
for addiction services and mental health
services
Monitors prevalence and incidence of
substance abuse and provides funding
through block grants to states to
support substance abuse and mental
health services
Agency for Health

Care Research and
Quality (AHRQ)
Supports research on health care
systems and quality, cost, access, and
effectiveness of medical treatments
Provides evidence-based information on
health care outcomes and quality of care
Source: From “HHS Agencies and Offices,” by U.S. Department
of Health and Human Services, 2015
(https://www.hhs.gov/about
/agencies/hhs-agencies-and-offices/index.html).
https://www.hhs.gov/about/agencies/hhs-agencies-and-
offices/index.html
https://www.hhs.gov/about/agencies/hhs-agencies-and-
offices/index.html
310
Ethics and Legal Implications of the U.S. Public Health System
Ethics in government operations, including lawmaking, are
overseen by the Office of Gov-
ernment Ethics (OGE), which was established by the Ethics in
Government Act of 1978. It
provides direction, oversight, and accountability of executive
branch policies (U.S. Office of

Government Ethics, n.d.).
According to the Office of Government Ethics (n.d.), the OGE
is responsible for six key elements:
1. Maintaining enforceable standards of ethical conduct
2. Overseeing a financial disclosure system
3. Ensuring that executive branch ethics programs are in
compliance with laws and
regulations
4. Providing education and training to the more than 5,700
ethics officials, as well as
executive branch employees
5. Conducting outreach to the general public
6. Sharing good practices with, and providing technical
assistance to, state, local, and
foreign governments and international organizations
The OGE has no jurisdiction within state or local governments,
nor does it conduct investiga-
tions of individuals. It is meant solely for the executive branch
of government.
Ethics are applied and enforced through the laws that have had
an impact on the nation’s
health. Table A.5 is a brief synopsis of health care laws that
have undergone significant ethical
considerations prior to approval.
Table A.5: Laws with strong ties to ethical concerns
Law/act Explanation
General public policies These are principles that state laws

should not be made to injure the
public or go against the public good.
Sherman Trust Act of 1890 Conspiracy to restrain trade among
certain states is illegal, including such
health issues as market competition, price fixing, and preferred
provider
agreements. In other words, it limits the creation of monopolies.
Civil Rights Act of 1964 All individuals, regardless of race,
color, or national origin, living in the
United States will have equal rights, including admission to a
medical
facility for treatment.
Privacy Act of 1974 All individual privacies are protected from
the misuse of federal records,
which includes those under Medicare, Medicaid, and other
government
health care services.
Emergency Medical Treatment
and Active Labor Act of 1986
Any individual seeking medical treatment in the event of an
emergency
will receive it regardless of the ability to pay or means of
payment.
Ethics in Patient Referrals Act
of 1989
Doctors are prohibited from requiring the use of specific
laboratories for
testing based upon a prior financial arrangement.

Patient Self-Determination Act
of 1990
Patients should be informed of their rights before receiving
care. This law
extends to end-of-life decisions as well as routine examinations.
Health Insurance Portability and
Accountability Act of 1996
The privacy of all medical health records in all forms
(electronic, paper,
verbal) should be maintained.
Sarbanes–Oxley Act of 2002 Top executives from public
corporations must account for the corporation’s
financial statements. It was passed as a result of the Enron
scandal.
311
Section A.5 Issues and Trends in the U.S. Health Care System
A.5 Issues and Trends in the U.S. Health Care System
The U.S. health care system is in a state of escalating costs and
access issues. The same inge-
nuity, creative forces, and political dynamics that set the
foundation for the emergence of the
modern health care system after World War II also produced
today’s struggling health care
system. Changes in population dynamics and personal

responsibility will continue to present
a challenge.
Social Changes and Personal Responsibility
Social changes affect how the people of a nation view health.
The World Health Organization
has defined health as “a state of complete physical, mental, and
social well-being and not
merely the absence of disease or infirmity” (Grad, 2002, p.
984). With Americans participat-
ing in fewer physical activities, the nation has become
overweight and obese—issues that
have been linked to chronic diseases such as heart disease,
diabetes, and stroke. As a whole,
the people of this nation do not believe that their poor habits
(sedentary lifestyle and over-
eating) are unhealthy. This has become a new culture that will
likely strain the health care
system if the trend isn’t reversed. Unless each individual takes
responsibility for his or her
own health, chronic diseases will become the norm, draining the
resources of the existing
health care system.
Organizational Issues
Considering that some health researchers believe that the health
care system is fragmented,
duplicated, and lacking in the coordination of services, it likely
will not be able to handle the
potential increase in health needs (Bipartisan Policy Center,
2012). Others complain that the
system is rife with administrative cost, waste, and fraud, which
could become another con-
cern in the future (Bipartisan Policy Center, 2012). To combat
this, public health professionals
are focusing their attention on prevention to reverse the trend of

rising chronic diseases so
that the health care system won’t have to suffer.
Quality and Access Questions
While some believe the health care system lacks
quality, others ask, in response, why people from
other nations come to the United States for health
care services. The issue cited is that other nations’
health care systems provide mediocre care because
of their lower costs. However, that may not mean the
care is poor. The definition of “quality” is dependent
in some part on the perceptions of the consumer.
While it has its flaws, the U.S. health care system is
still an innovative one, providing services for a large
multicultural population. While some argue that the
number of uninsured remains a major issue in the
United States, there is a safety net within the public
Cost, quality, and access issues
contribute to the U.S. health care
system’s constant changes. Developing
collaboration between the public and
private domains could help improve
care efficiency and access.
312
Section A.5 Issues and Trends in the U.S. Health Care System
health system to provide for various groups, including women

and children, the elderly, low-
income citizens, and the disabled. The U.S. public health
system, through encompassing ser-
vice outreach programs, targets at-risk populations in an
approach that is not significantly
different from that of socialized medical systems. With a
private–public partnership such
as the one that now exists, the United States’ model does not
differ significantly in opera-
tional aspects from other national models. The differentiating
factor is the emphasis on the
employer-sponsored health care function.
The U.S. health care system is in constant flux, partly
predicated on the cost, quality, and
access issues and the implementation of the Affordable Care
Act. From a health care system
perspective (private and public), major challenges appear to
reside in supply and demand in
caring for vulnerable populations, such as the uninsured, the
poor, the chronically diseased,
the aging, and the mentally ill. The problem involves high
demand with limited supply (i.e.,
availability) of health care workers. Perhaps, the answer could
lie in developing a collabora-
tion of health care services between both public and private
domains to provide seamless and
easy access to health care services.
Controlling Costs
In its report What Is Driving U.S. Health Care Spending?, the
Bipartisan Policy Center (2012)
reported four factors driving the growth in health care costs:
1. Prices
2. Population

3. Use
4. Intensity
The key areas that will drive spending further are the following:
• fee-for-service reimbursement
• fragmentation in care delivery
• administrative burden on providers, payers, and patients
• populations aging, rising rates of chronic disease and
comorbidities, as well as life-
style factors and personal health choices
• advances in medical technology
• tax treatment of health insurance
• insurance benefit design
• lack of transparency about cost and quality, compounded by
limited data, to inform
consumer choice
• cultural biases that influence care utilization
• changing trends in health care market consolidation and
competition for providers
and insurers
• high unit prices of medical services
• the health care legal and regulatory environment, including
current medical mal-
practice and fraud and abuse laws
• structure and supply of the health professional workforce,
including scope of prac-
tice restrictions, trends in clinical specialization, and patient
access to providers
(Bipartisan Policy Center, 2012, pp. 6–7)

313
Summary & Resources
A review of the current health care spending levels suggests
that spending would reach nearly
$5 trillion, or 20% of the gross domestic product (GDP) by 2021
(Ginsburg et al., 2012). It is
critical for policymakers to take heed of what is happening and
focus on mitigating this situ-
ation before it becomes far too expensive to live in the United
States.
Frankly, there is no single entity driving up costs. In addition to
the aforementioned list, tech-
nology will also contribute to health care cost increases,
including the following factors:
1. Mobile health smartphones, tablets, computers, and phone
applications
2. Comparative effectiveness research
3. Personal medical records
4. Telemedicine
5. Enhanced medical technology providers
Besides these ever-increasing costs, many politicians are
currently seeking to repeal the ACA.
A repeal of such a large piece of legislation is a difficult task;
however, if the political climate
is ripe for such actions, it is possible. That would undo much of
the success the nation has

experienced in expanding access to health care through lower-
cost insurance and eliminate
the public health fund.
Summary & Resources
Chapter Summary
A health care system did not exist for many years in the United
States, but it eventually became
a nation of health insurance holders—most of whom received
such insurance through their
place of employment. The current public health system was
shaped through the integrated
patterns of population growth, global economics, wars,
depressions, and scientific technology-
fueled revolutionary growth in medicine, disease prevention,
and interventions. There are
different models of health care throughout the world, including
Bismarck (premium funded
and mandated), Beveridge (universal health coverage), and
national insurance (public and
privately funded).
There are several key funding areas for the nation’s people—
especially those who do not have
employer-sponsored health insurance plans. This includes the
expansions made through the
ACA as well as Medicaid and Medicare. Title V, WIC, SHIP,
and CHIP also provide a vast array
of health services to vulnerable populations such as children
and senior citizens.
The overarching body that handles public health aspects is the
U.S. Department of Health and
Human Services. While the structure of public health was
outlined in depth in Chapter 1, this

appendix focused on seven key organizations that interact with
the health care system for
both access to care and prevention services. Within the system
is an important set of ethical
and legal responsibilities, all of which are managed and
coordinated under the Office of Gov-
ernment Ethics.
314
Summary & Resources
The largest national concern currently on the table is the
potential repeal of the Affordable
Care Act. While the ACA is not a perfect piece of legislation, it
certainly has brought some
relief to people who did not have access to health care prior to
its passage. Repealing may
undo such successes. The political climate often guides
decisions on legislation, which means
that as the political parties come and go from leadership, so will
threats to and benefits for
the public health system.
Additional Resources
Henry Kaiser Family Foundation
http://www.kff.org/medicare/medicare-timeline2.cfm
http://www.kff.org/medicaid/
Visit the first site to watch the Medicare video for additional

information about the history
and goals of Medicare. Visit the second site to learn more about
Medicaid.
The Affordable Care Act
https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-
111publ148.pdf
The Affordable Care Act is an official public law. The certified
full-text version of the law can
be found here.
United States Department of Labor, Bureau of Labor Statistics
http://www.bls.gov/ooh/health care/
Visit this site for additional information about the different
occupations in the field of health
care.
http://www.kff.org/medicare/medicare-timeline2.cfm
http://www.kff.org/medicaid/
https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-
111publ148.pdf
http://www.bls.gov/ooh/health care/
6 Epidemiology
Microgen/iStock/Thinkstock
Learning Outcomes

After reading this chapter, you should be able to
• Explain epidemiology and its use in public health.
• Outline methods for disease surveillance.
• Compare descriptive and analytic epidemiology.
• Apply the 13 epidemiological steps to investigations.
182
Section 6.1 What Is Epidemiology?
Understanding how, when, and why disease occurs is crucial for
successful public health ini-
tiatives. This chapter will demonstrate how studying the
incidence, distribution, and control
of disease contributes to the field of community health.
Epidemiology is important because
many circumstances that produce adverse health effects among
community residents occur
at the population level; thus, it is vital to take a population
perspective when examining indi-
vidual health outcomes in the community. For example, people
in communities surrounded
by high traffic volume are likely to suffer from respiratory
issues because of the exhaust par-
ticles in the air. A city susceptible to frequent cloud cover and
very few sunny days, such as

Seattle, Washington, might struggle more with mental
health/depression. The study of how,
when, and why disease occurs focuses on the health of
populations, and, in this respect, it dif-
fers from clinical medicine’s involvement with individual
patients.
In fact, epidemiology provides a method-
ological foundation for the entire public
health field by embracing a spectrum of
tools for studying health and illness. These
methodologies include natural experiments,
descriptive and analytic study designs (e.g.,
cross-sectional, case-control, cohort, and
experimental), and mapping technologies.
Epidemiologic research findings help develop
hypotheses that can be applied to the health
of the community and the study of potential
causal relationships.
Epidemiologic research is likened to detective
work because the causes of many diseases—
especially when they first appear—are
unknown. Some examples are hantavirus in national parks,
periodic episodes of foodborne
illnesses, West Nile virus, and the resurgence of whooping
cough (pertussis). This chapter
presents epidemiologic procedures and methodologies that aid
in unraveling the causes of
mysterious disease outbreaks and health conditions that can
afflict community members.
6.1 What Is Epidemiology?
Epidemiology is the study of the occurrence and distribution of
illnesses, injuries, and dis-

eases in specific populations. It also includes the study of the
factors that influence illnesses,
diseases, and injuries in an effort to help reduce or eliminate the
problem.
Epidemiology is a discipline that describes, quantifies, and
finds possible causes, or deter-
minants, for health phenomena in populations. Determinants are
also known as etiological,
or causal, factors. Recall that a determinant of health is a factor
that affects health either
negatively or positively. For example, economic status is
considered a determinant. Those
with more money seem to have better health outcomes than
those with less money, making
income also a determinant of health. Other examples of
determinants or etiological factors
are behavioral, such as smoking (negative) or physical activity
(positive). Smoking is a factor
in the development of arteriosclerosis, which is a poor health
outcome. Physical activity can
ward off obesity and obesity-related diseases, which is a good
health outcome.
PBFloyd/iStock/Thinkstock
Epidemiologists study the how, when,
and why of a disease outbreak by using
different methods of investigation, including
experiments and mapping.
183

315Each of the previous eight chapters highlighted two ind.docx

315Each of the previous eight chapters highlighted two ind.docx

Recommended

Recommended

More Related Content

More from rhetttrevannion

More from rhetttrevannion (20)

Recently uploaded

Recently uploaded (20)

315Each of the previous eight chapters highlighted two ind.docx