Notes on Engineering Health, November 2022: On Public Health: Between Populations & Communities

Jonathan Friedlander, PhD
Geoffrey W. Smith

Jonathan Friedlander, PhD & Geoffrey W. Smith

November 29, 2022

We do not count often enough the blessings public health has brought to the world in general and the US in particular. Public health’s greatest successes in the 21st century include things like:

– Cardiovascular diseases in the US: Efforts to prevent uncontrolled hypertension, and elevated cholesterol, reduce smoking and improve treatments, medications, and quality of care reduced by 39% the deaths from cardiovascular disease per a CDC report.
– Malaria In the rest of the world: Malaria is the second leading cause of death from infectious disease in Africa, after HIV/AIDS. The Roll Back Malaria partnership, launched in 1998, is a coordinated response to malaria. Between 2003 and 2010, insecticide-treated bed nets, indoor residual spraying, rapid diagnosis and prompt treatment with artemisinin combination therapy, and intermittent preventive treatment during pregnancy allowed a 21% decrease in estimated global malaria deaths.

So, what exactly is public health? A general definition comes from the American Public Health Association: “Public health promotes and protects the health of people and the communities where they live, learn, work and play.”

A paper published in Science over a century ago entitled “The Untilled Fields of Public Health” gives a more detailed definition:
– The mission of public health is "the fulfillment of society's interest in assuring the conditions in which people can be healthy."
– The substance of public health is "organized community efforts aimed at the prevention of disease and the promotion of health."
– The organizational framework of public health "encompasses both activities undertaken within the formal structure of government and the associated efforts of private and voluntary organizations and individuals."

Public health relies on a set of key tools to be effective. Some are universal and have been used for a long time, such as the establishment of surveillance systems, dissemination of guidelines, implementation of research findings, or development of cost-effective interventions. Others evolved to tackle the constant progression of challenges. For example, the use of the legal system to encourage healthy behavior through taxation or to shape behavior through regulatory action have become increasingly important tools in modern public health practice.

Among the tools recently developed, entire frameworks were established to account for new challenges (e.g, the spread of misinformation and government defiance) and opportunities (e.g., an ever-deepening understanding of the biology of diseases and new ways to promote change among diverse communities in culturally relevant ways). For instance, the difference between the frameworks for public health, population health, and community health can appear like a semantic debate, but these distinctions expand in important ways the toolkit available to public health professionals.

A broadly accepted definition of population health put forth by Evans and Stoddart in 1990 is that it is a component of public health, along with community health. Each of these approaches aim at maintaining and promoting health at the group level in contrast with the individual level. When searching for solutions to a health crisis, practitioners of population health will consider certain attributes of patients to make them a coherent group. For example, patients with the same condition (high blood pressure, diabetes) or exhibiting similar levels of biomarkers (high cholesterol) would constitute a population. In the case of cardiovascular disease , classic markers (high blood pressure, high LDL cholesterol, diabetes, smoking and secondhand smoke exposure, obesity, unhealthy diet, and physical inactivity) can be complemented by specific markers like high-sensitivity cardiac troponin I, adiponectin, adipocyte fatty acid-binding protein, heart-type fatty acid-binding protein, and others to define new at-risk populations.

This approach distinguishes itself from community health, which tends to consider groups evolving in the same regional space and/or sharing other social determinants of health. Instead of just studying the pathophysiology of diseases directly, community health focuses on how factors such as socio-economic factors affect overall health. Understanding how race and ethnicity, location, social status, income, and other factors affect health should help design adaptive strategies to work with communities to adopt lifestyle changes or preventative measures to counteract the spread of diseases (like the use of insecticide bed nets to prevent the spread of malaria, for example).

The groups defined by population health and community health might very well overlap sometimes. Still, the distinction matters as it informs not only how to monitor diseases based on new biomarkers, but it enables communication with people in different ways, through different health professionals, with different messages.

Population and community health are two essential legs on which public health efforts can stand, combining biological understandings and the lived experiences of communities to promote and maintain health for everyone.

Jonathan Friedlander, PhD & Geoffrey W. Smith

First Five
First Five is our curated list of articles, studies, and publications for the month. For our full list of interesting media in health, science, and technology, updated regularly, follow us on Twitter or Instagram.

1/ Bacteria could help regrow the liver
The only solution for many patients suffering from liver damage is a liver transplant. This may change thanks to the bacteria that cause leprosy. It was shown in a new study published in Cell that these bacteria can reprogram liver cells and make the organ regrow.

2/ A mystery solved
An important paper published in Nature (no less) has provided the most definitive answer to an important question: why does it float or sink? Experiments conducted with mouse and human feces prove that gas-producing gut microbes are responsible for making feces float. Nature is indeed full of surprises.

3/ Some sleep, finally
Important progress was made in understanding the causes of insomnia and in devising methods to eradicate sleepless nights. It turns out that pharmacological solutions may not be the panacea and cognitive behavioral therapies yield far better results in most cases.

4/ Football and big data
Billy Beane’s legacy is clearly at play as computer scientists try to decipher the rules of rational football (also known as soccer) tactics. As the FIFA World Cup is in full swing, researchers are ready to help football managers develop new ideas in an impressive Nature paper.

5/ A new model to study how protein functions evolve
How novel gene functions evolve is a fundamental question in biology. A new paper published in Science looks at mucin proteins, a functionally but not evolutionarily defined group of proteins. By analyzing the genomic variation of mucins across a wide range of mammalian genomes, researchers uncovered some mechanisms allowing convergent evolution of gene function. By integrating bioinformatic, phylogenetic, proteomic, and immunohistochemical approaches, they identified instances of evolutionary convergence, where novel mucins originated by gaining densely O-glycosylated exonic repeat domains.

Digitalis Commons
Public-Interest Technologies for Better Health

Digitalis Commons is a non-profit that partners with groups and individuals striving to address complex health problems by building public-interest technology solutions that are frontier-advancing, open-access, and scalable.

The new Advanced Research Projects Agency for Health (ARPA-H) supports transformative research to drive biomedical and health breakthroughs – ranging from molecular to societal – to provide transformative health solutions for all. ARPA-H has just released their website which details the group’s key areas of focus all of which resonate with our work at Digitalis Commons:

Health Science Futures
Expanding what’s technically possible (Accelerating advances across research areas and removing limitations that stymie progress towards solutions. Applying developed tools and platforms to a broad range of diseases.)

Scalable Solutions
Reaching everyone quickly (Addressing challenges that include geography, distribution, manufacturing, data and information, and economies of scale to create programs that result in impactful, timely, and equitable solutions.)

Proactive Health
Keeping people from being patients (Reducing the likelihood that people become patients. Preventative programs will create new capabilities to detect and characterize disease risk and promote treatments and behaviors to anticipate threats to Americans’ health, whether those are viral, bacterial, chemical, physical, or psychological.)

Resilient Systems
Building integrated healthcare systems (Developing capabilities, business models, and integrations to weather crises such as pandemics, social disruption, climate change, and economic instability. Resilient systems need to sustain themselves between crises – from the molecular to the societal – to better achieve outcomes that advance American health and wellbeing.)

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