Theodore H. Tulchinsky

Micronutrient Deficiency Conditions: Global Health Issues

Micronutrient deficiency conditions are widespread among 2 billion people in developing and in developed countries. These are silent epidemics of vitamin and mineral deficiencies affecting people of all genders and ages, as well as certain risk groups. They not only cause specific diseases, but they act as exacerbating factors in infectious and chronic diseases, greatly impacting morbidity, mortality, and quality of life. Deficiencies in some groups of people at special risk require supplementation, but the most effective way to meet community health needs safely is by population based approaches involving food fortification. These complementary methods, along with food security, education, and monitoring, are challenges for public health and for clinical medicine. Micronutrient deficiency conditions relate to many chronic diseases, such as osteoporosis osteomalacia, thyroid deficiency colorectal cancer and cardiovascular diseases. Fortification has a nearly century long record of success and safety, proven effective for prevention of specific diseases, including birth defects. They increase the severity of infectious diseases, such as measles, HIV/AIDS and tuberculosis. Understanding the pathophysiology and epidemiology of micronutrient deficiencies, and implementing successful methods of prevention, both play a key part in the New Public Health as discussed in this section, citing the examples of folic acid, vitamin B12, and vitamin D.

What is the "New Public Health"?

The New Public Health is a contemporary application of a broad range of evidencebased scientific, technological, and management systems implementing measures to improve the health of individuals and populations. Its main objectives are the political and practical application of lessons learned from past successes and failures in disease control and the promotion of preventive measures to combat existing, evolving and re-emerging health threats and risks. We address present and anticipated health problems in a complex world with great inequalities with specific targets which would help to achieve higher standards of health and a more just and socially responsible distribution of resources.We present some examples of achievements in public health and clinical medicine, particularly from the past half century, that have resulted in improved disease control and increased health and longevity for populations. Many remaining challenges must be overcome in order to reduce the toll of avoidable morbidity and mortality and to achieve improved and equitable health nationally and internationally. The tools at our disposal today are much more effective than they were even just ten years ago. Promoting wider application of these tools and greater awareness of achievements and failures in public health will improve our capacity to affect greater change in population health in the future.The New Public Health is a moving target, as the science and practice of public health grow in strength. It is relevant to all countries, developing, transitional, or industrialized, all facing different combinations of epidemiologic, demographic, economic and health systems challenges. A greater understanding of these issues is vital to both a European and a wider audience of policy makers, educators, students, health systems managers, and practitioners of public health to address these challenges.

Cancer in Ex-Asbestos Cement Workers in Israel, 1953-1992

A cohort of 3,057 male workers employed in an asbestos-cement plant using 90% chrysotile-10% crocidolite, located in Northern Israel, was followed from 1953-1992 for incidence and mortality from cancer. In the years 1978-1992, the cohort had an elevated risk for all malignant neoplasms combined (n = 153, SIR = 117, ns), lung cancer (n = 28, SIR = 135, ns), mesothelioma (n = 21; SIR > 5000, p < .0001), unspecified pleural cancer (n = 5; SIR = 278, P < .0001), and liver cancer (n = 7, SIR 290, ns). Risks for colo-rectal (n = 19; SIR = 79, ns), bladder (n = 12, SIR 69) and renal cancers (n = 5, SIR 104) were less than expected. Risk for mesothelioma showed a sharp risk gradient with duration of exposure, increasing from 1 per 625 for those employed less than 2 years to 1 per 4.5 workers employed over 30 years. The ratio of mesothelioma to excess lung cancer cases was 2.9 to 1, or 3.6 to 1, if pleural cases of unspecified origin were included; the pleura to peritoneum ratio of verified mesothelioma cases was 20 to 1. This atypically high ratio of mesothelioma to excess lung cancer cases is suggested to be the combined result of high past asbestos exposures in the workers and their low prior risk for lung cancer, and possibly, relatively early smoking cessation in relation to asbestos exposure.

Teaching Ethics in Schools of Public Health in the European Region: Findings from a Screening Survey

Public health ethics is gaining recognition as a vital topic for public health education. The subject was highlighted in a Delphi survey of future priorities of member schools of The Association of Schools of Public Health in the European Region (ASPHER). We conducted a survey of teaching public health ethics in Bachelors and Masters of Public Health programmes targeting all 82 ASPHER member schools in 2010/2011, as an initiative toward improving ethics education in European Schools of Public Health. An eight-items questionnaire collected information on teaching of ethics in public health. A 52 percent response rate (43/82) revealed that nearly all of the responding schools (40 or 95% of the respondents with valid data) included the teaching of ethics in at least one of its programmes. They also expressed the need for support, (e.g., a model curriculum (n=25), case studies (n=24)), which indicates an area for further work to be met by the ASPHER Working Group on Ethics and Values in Public Health. This survey will help guide development of this topic as a teaching priority in public health education in Europe.

Folic Acid and Vitamin B12 Fortification of Flour: A Global Basic Food Security Requirement

Folic acid is an essential water soluble B vitamin which has been used for decades in the prevention of folate deficiency anemia of pregnancy. In 1991, folic acid taken prior to the start of pregnancy was shown unequivocally to prevent spina bifida and anencephaly—two of the most serious and common birth (neural tube) defects. Soon governments recommended that women of reproductive age consume folic acid daily to prevent these birth defects. Because compliance was low and since more than half of pregnancies are unplanned, the United States Food and Drug Administration mandated in 1998 that all enriched flour be fortified with folic acid at a concentration estimated to give the average woman an intake of 100 micrograms of folic acid a day. Canada and Chile followed with similar requirements for folic acid fortification of wheat flour. Now there is mandatory fortification in more than 50 countries globally.Where fortification has been implemented and studied, it has led to dramatic increases in serum folate concentrations, reduction in neural tube defects, folate deficiency anemia, as well as the reduction in homocysteine concentrations and stroke mortality with no known risk. Australia implemented mandatory folic acid fortification in 2009. To date, no country in Europe has implemented mandatory folic acid fortification of flour, although it has been recommended by the UK Food Safety Authority. This review discusses the vital importance of mandatory flour fortification with folic acid and vitamin B12, for public health food security and as a challenge to the New Public Health in Europe and globally.

National Health Systems

Abstract Health care systems ideally include universal access to comprehensive prepaid medical care along with health promotion and disease prevention. National health insurance and national health services of various models have evolved in the developed world and increasingly in developing countries as well. Some models, such as the Bismarckian social security model and the Bereidge National Health Service model, or National Health insurance such as in pioneered in Canada, are used by a number of countries. The common features are based on principles of national responsibility and solidarity for health, social solidarity for providing funding and searching for effective ways of providing care. Various universal systems of health coverage exist in all industrialized countries, except in the United States which has a mix of public and private insurance but with high percentages of uninsured and poorly insured. Health reform is a continuing process as all countries aspire to assure health care for all. Aging populations, increasing costs, advancing and increasing technology all require nations to modify and adapt organization and financing systems of health care, health protection and promotion.

Editorial: Why a Theme Issue on Public Health Ethics?

This issue of Public Health Reviews is dedicated to exploring the origins of the modern dialogue on public health ethics, which are based on historic religious and humanistic origins and long held medical and public health values. The concept of solidarity is fundamental to public health ethics as health is not only an individual phenomenon, it is also a societal issue, and those working in health must have ethical guidelines within the law and civil protections of the courts and public opinion. However, in the 20th century, medical doctors provided leadership and participation in euthanasia and genocide, which peaked with the Holocaust during World War II. From these horrif c events emerged the Nuremberg Doctors Trials (1946), the Universal Declaration of Human Rights (1948), the United Nations Convention on the Prevention and Punishment of the Crime of Genocide (1948), the World Medical Association Declaration of Helsinki — Ethical Principles for Medical Research Involving Human Subjects (1964 and subsequently revised many times) to protect against such abuses. But the horrors continue to occur well into the 21st century with incitement and acts of genocide. Biomedical ethics of individual patient care and protection of human rights in research are vital outcomes of these international codes. Public health is responsible for population health, are its ethical base is not synonymous with individual bioethics. The ideas of societal solidarity, social inequalities, culture and physical environment all play a role in the epidemiology of health and disease. Such determinants are interdependent and influence, shape and control the health status of individuals and communities. In this issue of PHR we explore both gross violations of human rights in public health experimentation and in genocide of the last century. We also address current dilemmas of community rights versus individual rights in current public health. Ethical issues in public health apply both when evidence-based interventions are implemented as well as when there is neglect or failure to implement current best practices. The study and conversation of public health ethics are essential components of education of health professionals and the practice of public health.

Environmental and Occupational Health

Abstract Environmental and occupational health is affected by chemical, physical, radiological, and biological agents in the air, water, and soil. Health risks include injury, and exposure to toxic radiation, carcinogenic and teratogenic agents, leading to cancer, lung and heart diseases. Environmental factors may result in instant death or long-term illness from unsafe environmental or working conditions. The environment affects populations from small workplace settings to large-scale communities, as well as having global effects. International and governmental responsibility, through policies, laws, regulations, standards, policies, and planning, is vital for tackling global aspects of pollution, including climate change, cataclysmic natural events, drought, air and water pollution, and the potentially catastrophic effects of weather changes. Preparation for disasters is a core public health function in managing the after-effects of tsunamis, hurricanes, floods, and drought. These are potent political and public health issues with huge economic and societal effects.

Prioritizing maternal and child health in independent South Sudan.

With its independence secured on 9th July 2011, the Republic of South Sudan faces a daunting task to improve public health and primary care in one of the poorest countries in the world. Very high maternal and child mortality rates must be a major concern for the new national government and for the many international agencies working in the country. Poor maternal health outcomes are primarily due to poor prenatal, delivery and post natal care services in health facilities, coupled with low literacy, widespread poverty, and poor nutrition among the general population. Child mortality is the result of widespread malnutrition, pneumonia, malaria, vaccine preventable diseases and diarrheal diseases. National responses to HIV and AIDS with international assistance have been encouraging with relatively low rates of infection. This paper explores barriers and identifies opportunities available to work toward achieving the targets for Millennium Development Goals (MDGs) 5 and 4 to reduce maternal mortality from its current rate of 2,054 deaths per 100,000 live births, and child mortality (currently 135 deaths per 1,000 live births) respectively in the new nation. National and international organizations have a social responsibility to mobilize efforts to focus on maternal, child health and nutrition issues targeting the worst affected regions for improving access to primary care and obstetrical services. Initiatives are needed to build up community access to primary care with a well supervised community health workers program, as well as training mid level management capacity with higher levels of funding from national and international sources to promote public health than current in the new republic.

It is not just the broad street pump.

I congratulate Gillam and Maudsley on a wide-ranging review of the topic, and I appreciate being asked to provide a commentary as someone from outside the UK with a different experience and point of view on public health and training in public health for medical students. Let us start with the idea that medical students and tomorrows doctors are vital to the medical community and the health system, but they are also part of the educated population of a country. Today, everyone can see on television and on the Internet quite sophisticated programs on public health issues, globally and locally, such as on the BBC, and much of it of superb quality. This means that the public has access to information and attitudes about public health that the medical graduate needs to know about. Public health is now more than ever part of the general culture. It now seems important to recognize that public health is not only a medical field, it is broadly multi-professional and it is implemented through multi-dimensional sets of programs and activities staffed by professionals from backgrounds as varied as nursing, veterinary, laboratories, sociology, anthropology, economics, law and many other fields. Public health is part of the activities of governmental agencies but also many non-governmental organizations, advocacy groups and even the private sector, such as food, vaccine and pharmaceutical manufacturers. Clearly, medical students should have basic courses in public health as should all health professions. Indeed, there is good justification to have public health courses as part of undergraduate studies not only in the health sciences fields, but also in liberal arts studies such as sociology, anthropology, economics and especially as a requirement for many graduate studies programs in such fields. The great achievements of public health in the twentieth century were outlined by the US Centers for Disease Control showing that health and life expectancy in the USA improved dramatically, as it did in all industrialized countries. Since 1900, average lifespan lengthened by .30 years; 25 years of this gain were attributable to advances in public health. This includes: control of infectious diseases through water safety and sanitation, improved medical care and immunization; motor vehicle safety; safer workplaces; reduced mortality from coronary heart disease, strokes; safer and healthier foods; healthier mothers and babies; family planning; fluoridation of drinking water; and recognition of tobacco as a health hazard. The list included many topics in which the medical practitioner plays a key role and others where regulatory and legislative functions are the key to health promotion, such as in anti-tobacco legislation and in food fortification. The UK tradition in epidemiology is rich and goes back a long time before the Broad St pump, let us say to James Lind and his classic controlled trial of treatment of scurvy in 1747. More recently, the UK Science Council studies in 1991 established than folic acid taken by women before pregnancy reduces the incidence of neural tube defects. Yet, while mandatory fortification of flour has been implemented in more than 50 countries including Canada, the USA and many countries in Latin America, the Middle East since 1998, the Food Standards Agency recommendation in 2007 proposed mandatory fortification of British flour has not yet been adopted in the UK.