21st Century Public Health: Learn From the Past and Build the Future

Group yoga for public health

During the past two decades, the public health community’s attention has been drawn increasingly to the social determinants of health (SDH). A search on Google results in millions of hits, which indicates that people are talking about this term. So, what does Social Determinants of Health (SDH) mean? And why do we need to know about it and how to act on it?

Before we answer these questions, let’s digress for a moment and talk about the origin and character of the current medical care model that we are trained for to provide care for our patients. Ever since human being existed, he has been facing diseases and death. He has been searching for the causes of poor health and how to prevent them, cure them and delay the death; in public health, terminology reducing morbidity and mortality.

The prehistoric population believed the causes of diseases are supernatural, that some kind of demon gets into the body or as a result of a spell cast upon the victim, make the person sick and even die. They used different methods to treat the sick. For example, they used magic, rituals, or even some surgical procedures such as drilling a hole in the skull to release the demon, as shown by archeological discoveries.

However, centuries later ancient Greek philosophers / physicians said the causes of the illness are not supernatural, it is the natural causes. Hippocrates, in one of his most interesting books (“Air, Waters, and Places”) noted the effect of food, occupation, and climate in causing disease. Hippocrates stated that “our natures are the physicians of our diseases.”

Romans, who have been known as the founders of public health, believed public sanitation and hygiene are the keys to improving the life and health of populations. In recent centuries, particularly since the Industrial Revolution, the social structure of the human population has become more and more complex, the population has been growing and demands for material goods keep rising up. The man-made conflicts and wars, as well as natural disasters, have been spreading diseases, disturbing human habitats, leading to mass migration, poverty, ill health, death, and disabilities. Nevertheless, the human quest for living longer and better life has led to remarkable discoveries and breakthroughs.

For example, advances in science and technology, in particular germ theory, immunization, the invention of X-ray, breakthroughs in molecular biology, genetics, genomics, precise diagnostics tools, advanced surgical procedures, sophisticated drugs in the last 2 centuries, have made it possible for us to benefit from an advanced and complex medical care particularly in the rich developed countries. The origin of this model is mainly based on the premise that our biological endowment is the key to our health and longevity and any disruption of this biology can lead to abnormality. Hence, the attempt has been to interrupt and correct this biological disruption. This model has made a large improvement in human health. But there is a problem with this model. It ignores or overlooks what is the root cause of this disruption of biological norms.

According to the latest genomic discoveries, we all have more or less similar biology and genes for the most part. One would wonder why then infant mortality is higher in certain populations, or why the life expectancy is lower in certain groups? Isn’t it possible that some factors such as what we eat, the air we breathe, the environment we live in, and many more put some of us at higher risks for morbidity and mortality? To ignore these risk factors and focus solely on biological factors surely will lead to a health care system that addresses only the manifestations of diseases, not their root causes.

The consequence of this model is an endless attempt to rescue those who have become the victim of this biological disruption. This system incurs high costs and results in health inequalities. Health care becomes a “commodity” that only some can afford to have.

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The alternative model which takes advantage of the medical indicators of health and its scientific foundation is the one that takes into consideration the social indicators or determinants of health, and it focuses on the “causes of causes.” This model will be able to better address the health inequalities and the ever-increasing cost of health care. It seeks to influence social policies to promote the health of populations while focusing on the root causes of ill-health and taking advantage of medical advances.

The World Health Organization’s Commission on the Social Determinants of Health (SDH)) has defined SDH as “the conditions in which people are born, grow, live, work and age” and “the fundamental drivers of these conditions.” There is an abundance of scientific evidence which points to the socio-economic factors such as education, income, as determinants of health.

These two major determinants of health impact health-related behaviors and lifestyles such as affordability and accessibility to food, housing, recreational areas, safe walkable neighborhoods, child care, clean air and water, employment, and medical care.

For example, Sir Michael Marmot in his Commissioned report for WHO showed the impact of income and education on mortality in the UK. In his report, he states “People with a higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked: the more favored people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviors – it should become the main focus. Surely this is a goal worth striving for.”

A quick look at the recent history of public health shows us how population-focused strategies that addressed social determinates of health resulted in better health and a lower mortality rate. For example, public health pioneers such as Edwin Chadwick, a London lawyer and secretary of the Poor Law Commission in 1838, one of the most recognized names in the sanitary reform movement, made a remarkable impact on public health. His study documented the disparities in life expectancy among different social groups. He identified the causes of this disparity in “filth” as both the cause of the diseases and vehicle for transmission.

To remedy the situation, Chadwick proposed what came to be known as the “sanitary idea”. In the United States The “Report of the Massachusetts Sanitary Commission” published in 1850, which was inspired by Edwin Chadwick’s work, recommended multiple public health measures such as new censuses and surveys of health conditions as well as sanitary regulations among others.

John Snow’s epidemiological studies and public health recommendations in London England in the 18th century led to the control of Cholera. Over centuries population strategies have been very effective in promoting health. Fast forward, today we are witnessing how public health experts and scientists, as well as health care professionals, are fighting the devasting COVID-19 pandemic. The daily report of this pandemic by the media shows how this pandemic impacted certain communities and how certain public health measures such as wearing masks, social distancing, hand washing, mass vaccination to reach herd immunity can save lives and livelihoods.

As the population increases, climate changes, resources get lower and lower, ecological systems get disturbed we face more challenges. The current health care landscape and challenges show us the need for fundamental reform on health care by focusing on public health. Well-planned educational programs and a well-educated workforce are the key to the success of this new health care system in the 21 century and beyond. A well-trained public health workforce who has the knowledge and skills to monitor population health conditions, educate, advocate for a better life, and bring innovation and leadership into public health is one of the key components to improve quality of life.

Herman Ostrow School of Dentistry, with almost half a century tract record in community oral health, has pioneered not only in expanding its services to underserved populations in Southern California but also train the oral health care workforce who understand the underlying causes of poor oral health. The Master and Certificate in Community Oral Health provides an excellent opportunity to prepare a competent workforce. They learn the principles of public health, develop leadership skills in developing, implementing, and assessing public health programs, promote health by educating communities and stakeholders, and advocate for better health in the communities they serve.

Earn an Online Postgraduate Degree in Community Oral Health

Like what you’re learning? Consider enrolling in the Herman Ostrow School of Dentistry of USC’s online, competency-based certificate or master’s program in Community Oral Health.

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