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。


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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


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