What is health protection?
After reading this chapter the reader will be familiar with:
• the definition of health protection,
• the domains of health protection,
• the scope of health protection, and
• its history in the English context.
1.1 Introduction to health protection
As early as the beginning of the twentieth century, a comprehensive definition of public health was formulated by C.-E.A Winslow (1920), following a response to two Yale undergraduate medical students seeking career advice. They wanted to know something about the field of public health, what it included, the nature of the work involved, the necessary qualifications and financial rewards, and what were the more intangible emoluments to be expected by those who may enter this career. It is impossible to summarize the full response without compromising the vision, which meticulously and eloquently articulated the potential, the opportunities, and the future of public health. The full response included the following wide-ranging definition of public health:
Public health is the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organisation of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.
In 1988, a succinct summary of the above definition of public health was put forward by the former Chief Medical Officer of the United Kingdom (Acheson 1988): ‘the science and art of preventing disease, prolonging life and promoting health through organized efforts of society.’
The UK Faculty of Public Health further categorized public health into three domains: health protection, health improvement and health-care public health (Faculty of Public Health 2010).
Although health protection is a distinct domain, in practice it is not, and should not be, delivered in isolation from the other domains of public health; this is illustrated by our working definition of health protection:
The protection of individuals, groups and populations through expert advice and effective collaboration to identify, prevent and mitigate the impacts of infectious disease, and environmental, chemical and radiological threats.
In England, health protection is delivered by Public Health England (PHE). PHE is the expert public health agency with statutory duty to protect health, address inequalities, and promote the health and wellbeing of the nation (Public Health England 2013). In the rest of the UK, Health Protection Scotland (Health Protection Scotland 2005), Public Health Wales (Public Health Wales 2010), and the Public Health Agency for Northern Ireland (Public Health Agency 2011) provide similar health protection functions. There are similar organizations in other countries: e.g. Centers for Disease Control and Prevention (CDC) in the United States, National Institute for Public Health and the Environment (RIVM) in The Netherlands, Robert Koch Institute (RKI) in Germany, Public Health Agency of Canada (PHAC) in Canada, Swedish National Institute of Public Health and Swedish Institute for Communicable Disease Control in Sweden, Institute for Public Health Surveillance (InVS) and National Institute for Prevention and Health Education (INPES) in France. The public health and health protection responsibilities of these agencies are outlined in a recent report that was commissioned by Public Health England (RAND Europe 2014).
Just as the accident and emergency department (A&E) is the front line of health care that deals with acute and sudden health problems, so health protection is the front line of public health, dealing with acute public health emergencies, involving communicable or non-communicable disease. However, unlike A&E, health protection also deals with chronic public health situations (e.g. contaminated land, air, or water), which may have acute or chronic manifestations. Furthermore, health protection concerns itself with gathering evidence and providing intelligence and support to prepare for emergencies as well as anticipating future issues, incidents, emergencies, and other threats to health.
The UK has a defined, local specialist health protection service as part of a national specialist health protection system. The delivery of health protection at both local and national levels is multi-agency, working with other public bodies such as the National Health Service, local authorities, the Food Standards Agency, etc.
1.2 Domains of health protection
Health protection consists of three main domains: communicable disease control; emergency preparedness, resilience and response (EPRR); and environmental public health.
1.2.1 Communicable disease control
Communicable disease control involves prevention, investigation, control, and management of infections through local, regional, and national specialist health protection teams.
EPRR involves preparation, prevention, investigation, control, and management of events that threaten serious damage to human welfare. This includes communicable disease as well as environmental public health situations. The practice of EPRR also includes business continuity planning and recovery to normality.
1.2.3 Environmental public health
Environmental public health does not have an agreed definition. A working definition that was used as part of a review of environmental public health functions by the North West Health Protection Team (Ghebrehewet and Stewart, 2014) is:
The identification, characterisation and provision of a safe and sustainable response, both immediate and prospective, to any kind of threat to health from issues in the natural and man-made environment.
Environmental public health issues are often complex, change with time and involvement and have a unique solution (‘wicked problems’, Head and Alford 2013; Redford et al. 2013). Environmental public health differs from communicable disease control:
◆ The investigation process is not as well developed and tested.
◆ Issues can take months or years to resolve.
◆ Evidence is not so well developed and what is well known (e.g. the effects of particles on respiratory and cardiovascular disease) may be difficult to demonstrate at local level due to the number of people and changes in environmental concentrations required to demonstrate an effect.
◆ There is a frequent lack of specific, diagnostic symptoms, syndromes, and diagnostic tools, particularly in low-level exposures.
◆ The multiplicity of factors and interactions result in the need for a multi-agency response, often led by a non-health agency in most environmental situations.
1.3 The scope of a specialist health protection service
Health protection responsibility can be seen as starting with protecting the individual, through their families and communities, to the wider population. There is a spectrum in health protection from single cases of communicable disease to incidents, clusters, and outbreaks. Planning for outbreaks is part of EPRR through the development of robust plans, but the spectrum continues through planning for major incidents (including chemical spills), into the realm of what may be called environmental public health, which looks into the impact of the environment on health. Examples of the scope of a specialist health protection are considered in the following sections.
1.3.1 Communicable disease
This may range from an individual case of E. coli infection to a large measles outbreak in a community with multiple smaller outbreaks in schools, impacting on the local hospital patients, staff, nearby communities and beyond.
The scope may vary from an incident where three residents living in a house above a restaurant are exposed to carbon monoxide, to a massive chemical incident with a smoke plume containing noxious substances blowing over a large residential community containing nursing homes, health centres, and schools. Furthermore, the scope and range of EPRR services extend beyond planning and preparedness for local, regional, and national situations (e.g., incidents, outbreaks, and epidemics), to preparing and responding to pandemics.
1.3.3 Environmental public health
The scope of environmental public health ranges from an enquiry about an alleged impact of power lines on the health of the residents of a few houses to a complex, ongoing issue involving contaminated land from which the pollutants are leaking into the air and water, with health effects which may be physical, psychological, or perceived but require investigation, reassurance, and long-term follow-up.
The provision of health protection services, in whichever domain and whether large or small in scope, are supported and underpinned by:
◆ good surveillance,
◆ strong multi-agency partnerships,
◆ clear and robust epidemiology,
◆ supportive science (microbiology, toxicology, environmental sciences, clinical sciences, and radiation science),
◆ timely audit,
◆ focused research,
◆ clear communication strategy, and
◆ learning and development.
Learning and development is important at all levels, from the individual through the team, agency, multi-agency to national and even international levels, while the sciences are supported locally by regional and national experts.
Health protection effectiveness is judged by a lack of incidents, clusters/outbreaks, new and emerging diseases, events, situations/disasters. Although it could be argued that some of the significant incidents that have occurred in recent years could have been predicted and/or prevented, in practice not all are preventable or predictable. For example:
◆ the catastrophic fire in Buncefield, UK, 2005 (Buncefield Major Incident Investigation Board Report 2008),
◆ pandemic influenza, 2009 (Hine 2010),
◆ a leak of highly toxic gas (methyl isocyanate) from a pesticide plant in 1984, Bhopal, India (Broughton 2005),
◆ uncontrolled radioactive iodine and caesium releases in 1986, following an explosion and fires at the Chernobyl nuclear plant in Ukraine (IAEA 2006; Cardis and Hatch 2011), and
◆ devastating outbreaks of Ebola (Shears and O’Dempsey 2015).
Nevertheless, the discipline of health protection includes planning and preparing for similar situations, assessing their immediate and long-term impacts, reflecting and learning from previous situations, and mounting a robust response in order to mitigate their impact and protect the health of the population.
1.4 Brief history of health protection in England
The development of the domains and scope of health protection can be illustrated by its history in England.
In 1984, an outbreak of Salmonella in Stanley Royd Hospital, a large psychogeriatric hospital in Wakefield, Yorkshire, claimed the lives of 19 patients (Department of Health and Social Security 1986). Six months later, an outbreak of Legionnaires’ disease at Stafford District General Hospital caused 28 deaths (O’Mahonya et al. 1990). Few health authorities in England had written plans for dealing with outbreaks of food poisoning or communicable disease. Public enquiries followed, resulting in 1988 in the Chief Medical Officer, Donald Acheson, establishing the post of Consultant in Communicable Disease Control (CCDC), a local public health doctor with responsibility for investigating outbreaks of communicable diseases in the community (Kapila and Buttery 1986; Keeble 2006).
These CsCDC worked independently in health authorities, with a small team of nurses and administrative staff, until the establishment of the Health Protection Agency (HPA) in 2003 in England through the Chief Medical Officer, Liam Donaldson’s report Getting Ahead of the Curve (Department of Health 2002). The existing functions of the Public Health Laboratory Service and three other national bodies (the National Radiological Protection Board, the Centre for Applied Microbiology and Research, and the National Focus for Chemical Incidents) were integrated to protect the health of the public against infectious diseases as well as chemical and radiological hazards. The report further announced that, at local level, health protection services would be delivered by the new agency, working with the NHS and local authorities. Similar organizations were created in the devolved administrations in the UK.
With the establishment of the CCDC post, planning for outbreaks of communicable disease became standardized across the health service and the public health community. In 2004, local arrangements for civil protection (Civil Contingencies Act 2004) widened the response from outbreak planning to EPRR: planning for an emergency, ensuring essential services continue, and answering the crisis (HM Government, CCA 2004 Regulations (2005); HM Government, CCA 2004 and its associated Regulations (2006) and Non-Statutory).
The HPA and its similar organizations in devolved administrations created opportunities for CsCDC and other health protection staff to work together across larger boundaries providing the same support to local and health authorities as before, but in a strengthened, systematic, and resilient manner. Similar to general practitioners, who work in teams, know their local community, and coordinate specialist care, CsCDC also work in teams, and know the local epidemiology of infectious diseases and environmental health threats in their community, while integrating public health and specialist health protection knowledge, skills, and competencies. Health protection teams are often faced by the growing nature of health protection challenges. Nevertheless, local health protection teams have developed a reputation in their communities for reliability, sound advice, strong leadership, and commendable partnership working.
In April 2013, as a result of the Health and Social Care Act 2012, the HPA was combined with other public health services into Public Health England. PHE is an Executive Agency of the Department of Health, tasked with protecting and improving the nation’s health and wellbeing, and reducing health inequalities. This is the first time in England that responsibilities for public health in all its many forms have been brought together within a national organization, creating an opportunity for the delivery of integrated public health at local, regional and national levels.
We have used a comprehensive definition of health protection, that outlines the scope and domains of the subject, while offering a practical approach that describes the subject in a recognizable manner.
Within health protection there are three domains that are interrelated, especially at the local level. They function in parallel, allowing professionals, partner agencies, and stakeholders one port of entry to a consistent and integrated local service with access to expert advice and support.
The scope of health protection is wide, covering communicable disease control, environmental public health and EPRR. These domains are integrated horizontally and vertically, both in planning and delivery, from local to national levels. In all three domains, it is vital to practice and integrate the art (e.g. relationship with partners, influencing behaviour, using resources wisely) and science (e.g. surveillance, epidemiology, modelling, environmental and social sciences) of public health to achieve the best possible protection of the health of the public.
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