公共卫生的未来|系列一:公共卫生金字塔
编者按公共卫生在传染病预防控制、慢性病防控治疗、烟草控制方面已经取得了巨大成就,为人民健康事业做出了不可磨灭的贡献是我们有目共睹的。然而,公共卫生的未来会是怎样呢?会遭遇哪些挑战?与相互依存的临床医疗又存在哪些千丝万缕的关系?有哪些发展关键词?如果您也跟我一样充满好奇心,那就让我们跟随作者的脚步,了解痴迷分母的公共卫生特质,控制目标、五层金字塔结构,纵观美国及世界传染病、慢病情况,分析目前的烟草控制措施,一起展望公共卫生的未来。我们分为几部分推出,今天就让我们来看一下系列一,公共卫生金字塔。
公共卫生的未来
系列一:公共卫生金字塔
检索:张冰
翻译:黄辉萍 厦门大学附属第一医院
审校:覃婷 周艳芝
公共卫生领域的目标是在最短时间尽最大可能改善最多人的健康。 自1900年以来,在美国,人均寿命延长了30多年;其中增加的25年获益归因于公共卫生的进步;在20世纪,全球预期寿命增加了一倍,主要归因于扩大免疫覆盖率、清洁饮水、环境卫生和其他儿童生存项目导致的儿童死亡率下降。
公共卫生侧重于分母—所有干预的人有多少比例能实际受益。最大化健康需要来自社会许多部门的贡献,包括广泛的社会、经济、环境、交通和政府在其中发挥关键作用的其他政策;民间社会的参与;公有和私有经济领域的创新;以及医疗和公共卫生行动。虽然有时在医疗与公共卫生领域存在不信任和不尊重,它们不可避免地越来越相互依存:最大限度地提高潜在健康收益是这两个领域具有决定性的一个挑战。
建立公共卫生金字塔
为了影响最大化,公共卫生致力于五个层级(图1)。在第一层——金字塔的基础——是社会经济因素,如收入、教育、住房和种族。虽然这些因素不是疾病,但公共卫生和医疗保健都可能对他们产生一些影响。 例如,通过医疗保险覆盖减少贫困或通过预防青少年怀孕降低贫困的延续。第二层,紧接着高于社会经济因素的是传统的公共卫生干预措施——改变环境,使健康选择成为默认选择(例如,提供干净的饮用水)。第三层是持久的保护性干预,例如只需要卫生保健系统的间歇性行动的免疫接种。第四层是需要长期、日常护理的临床干预,例如血压控制。最后一个层包括咨询和教育,例如敦促人们吃健康食物和锻炼身体。每个层级都很重要,但金字塔底层的干预措施比上层的更能够以较低的单位成本改善更多人的健康。
为了增加临床护理对人群健康的影响,需要更有效地执行第三和第四层级的改善。控制血压,比任何其他临床干预可以挽救更多的生命,但只有大约一半的美国人成功做到;近90%的失控性高血压患者既有健康保险又有常规的护理来源,每年有超过80%的患者与卫生系统有多次联系。
为了最大限度地促进健康,需要在美国和全球加以解决传染病和非传染性疾病带来威胁。感染性和非感染性疾病之间有着重要的联系:大多数宫颈癌和许多肝癌病例可以通过接种疫苗来预防;糖尿病,肥胖,以及烟草和酒精使用增加了患癌和感染的风险。埃博拉病毒病和中东呼吸综合征(MERS)的暴发和耐药性的扩散已经明确证实美国和全球卫生也是密不可分的。虽然如此,分开考虑解决传染性和非感染性疾病的方法也是有用的。
图1 健康影响金字塔
公共卫生侧重于分母—所有干预的人有多少比例能实际受益。金字塔底层的干预措施比上层的更能够以低的单位成本促进更多人的健康,根据Frieden 的许可改编
参考文献:
1.Ten great public health achievements-United States, 1900-1999. MMWRMorb Mortal Wkly Rep 1999;48:241-3.
2.Bunker JP, Frazier HS, Mosteller F.Improving health: measuring effects of medical care. Milbank Q 1994;72:225-58.
3.Riley JC. Estimates of regional and global life expectancy, 1800–2001. Popul Dev Rev 2005;31:537-43.
4.Riley JC. Rising life expectancy: a global history. Cambridge, United Kingdom: Cambridge University Press, 2001.
5.Fee E, Brown TM. The unfulfilled promise of public health: déjà vu all over again. Health Aff (Millwood) 2002;21:31-43.
6.Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health 2010;100:590-5.
7.Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the U.S. by improvements in use of clinical preventive services. Am J Prev Med 2010; 38:600-9.
8.Vital signs: awareness and treatment of uncontrolled hypertension among adults — United States, 2003–2010. MMWR Morb Mortal Wkly Rep 2012;61:703-9.
9.CDC National Health Report: leading causes of morbidity and mortality and associated behavioral risk and protective factors — United States, 2005–2013. MMWR Surveill Summ 2014;63:Suppl 4:3-27.
10.Murphy SL, Kochanek KD, Xu J, Heron M. Deaths: final data for 2012. National Vital Statistics Reports. Vol. 63. No. 9. Hyattsville, MD: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2015.
11.Antibiotic resistance threats in the United States, 2013. Atlanta: Centers for Disease Control and Prevention, 2013.
12.Core elements of hospital antibiotic stewardship programs. Atlanta: Centers for Disease Control and Prevention, 2015 (www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html).
13.Vital signs: HIV diagnosis, care, and treatment among persons living with HIV — United States, 2011. MMWR Morb Mortal Wkly Rep 2014;63:1113-7.
14.Vital signs: estimated effects of a coordinated approach for action to reduce antibiotic-resistant infections in health care facilities — United States. MMWR Morb Mortal Wkly Rep 2015;64:826-31.
15.Global update on the health sector response to HIV, 2014. Geneva: World Health Organization, 2014.
16.Global tuberculosis report 2014. Geneva: World Health Organization, 2014.
17.Achieving the malaria MDG target: reversing the incidence of malaria 2000-2015. Geneva: World Health Organization and United Nations Children’s Fund, 2015.
18. Neglected tropical diseases: becoming less neglected. Lancet 2014;383:1269.
19.Progress towards polio eradication worldwide, 2014-2015. Wkly Epidemiol Rec 2015;90:253-9.
20.Progress toward global eradication of dracunculiasis — January 2013–June 2014. MMWR Morb Mortal Wkly Rep 2014; 63:1050-4.
21.Global vaccine action plan 2011-2020.Geneva: World Health Organization, 2013.
22.Global health — global health security agenda. Atlanta: Centers for Disease Control and Prevention; 2015 (www.cdc.gov/globalhealth/security).
23. Frieden TR, Tappero JW, Dowell SF, Hien NT, Guillaume FD, Aceng JR. Safer countries through global health security. Lancet 2014;383:764-6.
24.Frieden TR, Woodley CL, Crawford JT, Lew D, Dooley SM. The molecular epidemiology of tuberculosis in New York City: the importance of nosocomial transmission and laboratory error. Tuber Lung Dis 1996;77:407-13.
25.Frieden TR, Brudney KF, Harries AD. Global tuberculosis: perspectives, prospects, and priorities. JAMA 2014;312:1393-4.
26.Laxminarayan R, Duse A, Wattal C,et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis 2013; 13:1057-98.
27.Banaei N, Anikst V, Schroeder LF. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:2368-9.
28.Maltezou HC, Wicker S. Measles in health-care settings. Am J Infect Control 2013;41:661-3.
29.Xu X, Alexander RL Jr, Simpson SA, et al. A cost-effectiveness analysis of the first federally funded antismoking campaign. Am J Prev Med 2015;48:318-25.
30.Guo F, He D, Zhang W, Walton RG. Trends in prevalence, awareness, management, and control of hypertension among United States adults, 1999 to 2010. J Am Coll Cardiol 2012;60:599-606.
31.Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the US: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief. No. 133. Hyattsville, MD: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2013.
32.Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large-scale hypertensionprogram. JAMA 2013;310:699-705.
33.Luepker RV, Steffen LM, Jacobs DR Jr, Zhou X, Blackburn H.Trends in blood pressure and hypertension detection, treatment, and control 1980 to 2009: the Minnesota Heart Survey. Circulation 2012;126:1852-7.
34.Shah NR. Identifying hypertension in electronic health records: a comparison of various approaches. Presented at the AHRQ Comparative Effectiveness Research Methods Symposium, Rockville, MD, June 1-2, 2009.
35.Rakotz MK, Ewigman BG, Sarav M, et al. A technology-based quality innovation to identify undiagnosed hypertension amongactive primary care patients. Ann Fam Med 2014;12:352-8.
36.Wall HK, Hannan JA, Wright JS. Patients with undiagnosed hypertension: hiding in plain sight. JAMA 2014;312: 1973-4.
37.Coxson PG, Cook NR, Joffres M, et al. Mortality benefits from US populationwide reduction in sodium consumption: projections from 3 modeling approaches. Hypertension 2013;61:564-70.
38.Bibbins-Domingo K, Chertow GM, Coxson PG,et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590-9.
39.Adler AJ, Taylor F, Martin N, Gottlieb S, Taylor RS, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database Syst Rev 2014; 12:CD009217.
40.He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2014;28:345-52.
41.He FJ, Pombo-Rodrigues S, Macgregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open 2014;4(4):e004549.
42.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806-14.
43.Frieden TR, Dietz W, Collins J. Reducing childhood obesitythrough policy change: acting now to prevent obesity. Health Aff (Millwood) 2010;29:357-63.
44.WHO report on the global tobacco epidemic, 2015: raising taxes on tobacco. Geneva: World Health Organization, 2015.
45.Levy DT, Ellis JA, Mays D, Huang AT. Smoking-related deaths averted due to three years of policy progress. Bull World Health Organ 2013;91:509-18.
46.Angell SY, De Cock KM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015;385:825-7.
47.Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure: results for 24 hour urinary sodium and potassium excretion. BMJ 1988;297:319-28.
48.Frieden TR. Government’s role in protecting health and safety. N Engl J Med 2013;368:1857-9.
49.Ten great public health achievements- United States, 2001–2010. MMWR Morb Mortal Wkly Rep 2011;60:619-23.
50.Bayer R, Galea S. Public health in the precision-medicine era. N Engl J Med 2015; 373:499-501.
公共卫生的未来
系列一:公共卫生金字塔
检索:张冰
翻译:黄辉萍 厦门大学附属第一医院
审校:覃婷 周艳芝
公共卫生领域的目标是在最短时间尽最大可能改善最多人的健康。 自1900年以来,在美国,人均寿命延长了30多年;其中增加的25年获益归因于公共卫生的进步;在20世纪,全球预期寿命增加了一倍,主要归因于扩大免疫覆盖率、清洁饮水、环境卫生和其他儿童生存项目导致的儿童死亡率下降。
公共卫生侧重于分母—所有干预的人有多少比例能实际受益。最大化健康需要来自社会许多部门的贡献,包括广泛的社会、经济、环境、交通和政府在其中发挥关键作用的其他政策;民间社会的参与;公有和私有经济领域的创新;以及医疗和公共卫生行动。虽然有时在医疗与公共卫生领域存在不信任和不尊重,它们不可避免地越来越相互依存:最大限度地提高潜在健康收益是这两个领域具有决定性的一个挑战。
建立公共卫生金字塔
为了影响最大化,公共卫生致力于五个层级(图1)。在第一层——金字塔的基础——是社会经济因素,如收入、教育、住房和种族。虽然这些因素不是疾病,但公共卫生和医疗保健都可能对他们产生一些影响。 例如,通过医疗保险覆盖减少贫困或通过预防青少年怀孕降低贫困的延续。第二层,紧接着高于社会经济因素的是传统的公共卫生干预措施——改变环境,使健康选择成为默认选择(例如,提供干净的饮用水)。第三层是持久的保护性干预,例如只需要卫生保健系统的间歇性行动的免疫接种。第四层是需要长期、日常护理的临床干预,例如血压控制。最后一个层包括咨询和教育,例如敦促人们吃健康食物和锻炼身体。每个层级都很重要,但金字塔底层的干预措施比上层的更能够以较低的单位成本改善更多人的健康。
为了增加临床护理对人群健康的影响,需要更有效地执行第三和第四层级的改善。控制血压,比任何其他临床干预可以挽救更多的生命,但只有大约一半的美国人成功做到;近90%的失控性高血压患者既有健康保险又有常规的护理来源,每年有超过80%的患者与卫生系统有多次联系。
为了最大限度地促进健康,需要在美国和全球加以解决传染病和非传染性疾病带来威胁。感染性和非感染性疾病之间有着重要的联系:大多数宫颈癌和许多肝癌病例可以通过接种疫苗来预防;糖尿病,肥胖,以及烟草和酒精使用增加了患癌和感染的风险。埃博拉病毒病和中东呼吸综合征(MERS)的暴发和耐药性的扩散已经明确证实美国和全球卫生也是密不可分的。虽然如此,分开考虑解决传染性和非感染性疾病的方法也是有用的。
图1 健康影响金字塔
公共卫生侧重于分母—所有干预的人有多少比例能实际受益。金字塔底层的干预措施比上层的更能够以低的单位成本促进更多人的健康,根据Frieden 的许可改编
参考文献:
1.Ten great public health achievements-United States, 1900-1999. MMWRMorb Mortal Wkly Rep 1999;48:241-3.
2.Bunker JP, Frazier HS, Mosteller F.Improving health: measuring effects of medical care. Milbank Q 1994;72:225-58.
3.Riley JC. Estimates of regional and global life expectancy, 1800–2001. Popul Dev Rev 2005;31:537-43.
4.Riley JC. Rising life expectancy: a global history. Cambridge, United Kingdom: Cambridge University Press, 2001.
5.Fee E, Brown TM. The unfulfilled promise of public health: déjà vu all over again. Health Aff (Millwood) 2002;21:31-43.
6.Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health 2010;100:590-5.
7.Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the U.S. by improvements in use of clinical preventive services. Am J Prev Med 2010; 38:600-9.
8.Vital signs: awareness and treatment of uncontrolled hypertension among adults — United States, 2003–2010. MMWR Morb Mortal Wkly Rep 2012;61:703-9.
9.CDC National Health Report: leading causes of morbidity and mortality and associated behavioral risk and protective factors — United States, 2005–2013. MMWR Surveill Summ 2014;63:Suppl 4:3-27.
10.Murphy SL, Kochanek KD, Xu J, Heron M. Deaths: final data for 2012. National Vital Statistics Reports. Vol. 63. No. 9. Hyattsville, MD: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2015.
11.Antibiotic resistance threats in the United States, 2013. Atlanta: Centers for Disease Control and Prevention, 2013.
12.Core elements of hospital antibiotic stewardship programs. Atlanta: Centers for Disease Control and Prevention, 2015 (www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html).
13.Vital signs: HIV diagnosis, care, and treatment among persons living with HIV — United States, 2011. MMWR Morb Mortal Wkly Rep 2014;63:1113-7.
14.Vital signs: estimated effects of a coordinated approach for action to reduce antibiotic-resistant infections in health care facilities — United States. MMWR Morb Mortal Wkly Rep 2015;64:826-31.
15.Global update on the health sector response to HIV, 2014. Geneva: World Health Organization, 2014.
16.Global tuberculosis report 2014. Geneva: World Health Organization, 2014.
17.Achieving the malaria MDG target: reversing the incidence of malaria 2000-2015. Geneva: World Health Organization and United Nations Children’s Fund, 2015.
18. Neglected tropical diseases: becoming less neglected. Lancet 2014;383:1269.
19.Progress towards polio eradication worldwide, 2014-2015. Wkly Epidemiol Rec 2015;90:253-9.
20.Progress toward global eradication of dracunculiasis — January 2013–June 2014. MMWR Morb Mortal Wkly Rep 2014; 63:1050-4.
21.Global vaccine action plan 2011-2020.Geneva: World Health Organization, 2013.
22.Global health — global health security agenda. Atlanta: Centers for Disease Control and Prevention; 2015 (www.cdc.gov/globalhealth/security).
23. Frieden TR, Tappero JW, Dowell SF, Hien NT, Guillaume FD, Aceng JR. Safer countries through global health security. Lancet 2014;383:764-6.
24.Frieden TR, Woodley CL, Crawford JT, Lew D, Dooley SM. The molecular epidemiology of tuberculosis in New York City: the importance of nosocomial transmission and laboratory error. Tuber Lung Dis 1996;77:407-13.
25.Frieden TR, Brudney KF, Harries AD. Global tuberculosis: perspectives, prospects, and priorities. JAMA 2014;312:1393-4.
26.Laxminarayan R, Duse A, Wattal C,et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis 2013; 13:1057-98.
27.Banaei N, Anikst V, Schroeder LF. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:2368-9.
28.Maltezou HC, Wicker S. Measles in health-care settings. Am J Infect Control 2013;41:661-3.
29.Xu X, Alexander RL Jr, Simpson SA, et al. A cost-effectiveness analysis of the first federally funded antismoking campaign. Am J Prev Med 2015;48:318-25.
30.Guo F, He D, Zhang W, Walton RG. Trends in prevalence, awareness, management, and control of hypertension among United States adults, 1999 to 2010. J Am Coll Cardiol 2012;60:599-606.
31.Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the US: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief. No. 133. Hyattsville, MD: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2013.
32.Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large-scale hypertensionprogram. JAMA 2013;310:699-705.
33.Luepker RV, Steffen LM, Jacobs DR Jr, Zhou X, Blackburn H.Trends in blood pressure and hypertension detection, treatment, and control 1980 to 2009: the Minnesota Heart Survey. Circulation 2012;126:1852-7.
34.Shah NR. Identifying hypertension in electronic health records: a comparison of various approaches. Presented at the AHRQ Comparative Effectiveness Research Methods Symposium, Rockville, MD, June 1-2, 2009.
35.Rakotz MK, Ewigman BG, Sarav M, et al. A technology-based quality innovation to identify undiagnosed hypertension amongactive primary care patients. Ann Fam Med 2014;12:352-8.
36.Wall HK, Hannan JA, Wright JS. Patients with undiagnosed hypertension: hiding in plain sight. JAMA 2014;312: 1973-4.
37.Coxson PG, Cook NR, Joffres M, et al. Mortality benefits from US populationwide reduction in sodium consumption: projections from 3 modeling approaches. Hypertension 2013;61:564-70.
38.Bibbins-Domingo K, Chertow GM, Coxson PG,et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590-9.
39.Adler AJ, Taylor F, Martin N, Gottlieb S, Taylor RS, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database Syst Rev 2014; 12:CD009217.
40.He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2014;28:345-52.
41.He FJ, Pombo-Rodrigues S, Macgregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open 2014;4(4):e004549.
42.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806-14.
43.Frieden TR, Dietz W, Collins J. Reducing childhood obesitythrough policy change: acting now to prevent obesity. Health Aff (Millwood) 2010;29:357-63.
44.WHO report on the global tobacco epidemic, 2015: raising taxes on tobacco. Geneva: World Health Organization, 2015.
45.Levy DT, Ellis JA, Mays D, Huang AT. Smoking-related deaths averted due to three years of policy progress. Bull World Health Organ 2013;91:509-18.
46.Angell SY, De Cock KM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015;385:825-7.
47.Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure: results for 24 hour urinary sodium and potassium excretion. BMJ 1988;297:319-28.
48.Frieden TR. Government’s role in protecting health and safety. N Engl J Med 2013;368:1857-9.
49.Ten great public health achievements- United States, 2001–2010. MMWR Morb Mortal Wkly Rep 2011;60:619-23.
50.Bayer R, Galea S. Public health in the precision-medicine era. N Engl J Med 2015; 373:499-501.