Heal through Health Trivia Quiz

Answer: Cancer treatment

After WWII, the health systems of the world concentrated on healing the sick and the infirm. We built big hospitals to demonstrate how good we were at achieving this. Health was seen as a restorative function and the large hospitals, trauma centres and university affiliated health systems were testament to this paradigm. Gradually though, as the destruction of health by WWII faded, the re-emergence of Public Health became more important: Nations around the world recognised that staying healthy was the best way for 'healing'. In other words by staying healthy, a nation would lessen the costly burdens of healing the sick and the loss of productivity through sickness.

Public health is a broad church: it is not just about preventing disease - it is about improving the duration and quality of life through informed choices of nations, communities, organisations and individuals. It includes the determinants of what health is comprised of in a given population, and the threats to compromise that overall health picture. Public health, by nature, is multi-disciplinary: it includes elements of epidemiology, biostatistics, social sciences and health services management. Its scope includes fields include environmental and community health, behavioural health, health education, and occupational safety, disability, mental health, gender, sexual and reproductive health. Public Health, with primary care, secondary care, and tertiary care, are fundamental and integral components of a country's overall health care system.

Epidemiology, a science in its own right and a cornerstone of public health, is defined as the study and analysis of the distribution patterns and determinants of health and disease conditions in defined populations. The same can be said of population health which was defined by Kindig and Stoddart in the American Journal of Public Health in 2003, as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group".

"Healing' and 'health' both stem from the Old English word of 'haelp' meaning "wholeness, a being whole, sound or well" yet the two have vastly different contexts. Healing is about restoring; health is about prevention. The old adage "prevention is better than cure" underpins what health should mean in the 21st century: "Heal" has for too long been seen as the hallmark of a nation's well being. That hallmark is gradually been replaced by "health" as the marker of a nation's well being. Healing through health.

Answer: Diarrhoea

Infant mortality, globally, is one of the major challenges of the public health sector in the 21st century. Death in children under five in the developed world is unusual, for example, in the US, the major causes of child death are car accidents, gun violence and paediatric cancer. Globally, 2.5 billion cases of diarrhoea occur annually, and it is the second leading cause of childhood mortality behind birth and peri-natal issues.

Diarrhoea, with over 95% of cases related to inadequate water, sanitation, and hygiene (WASH), killed 1.5 million children aged 5 years and under in 2001. This is more children than those that died from AIDS, malaria, and measles combined. However, significant measures have been implemented to reduce this. Despite a population rise of 800 million to 6.7 billion (2001-2010), the proportion of the world's population with access to improved drinking water sources increased from 83% to 87% (according to WHO). This covers 800 million people. An additional 570 million benefited from improved sanitation. These improvements were made through WASH initiatives to increase water quality, improved sanitation programs and and promotion of hygienic behaviours such as handwashing. Sadly, access to basic water quality and sanitation remains a major global public health issue.

Answer: Antibiotics

While the taking of antibiotics can have a control function (such as taking them pre-operatively to prevent surgical infections), the major function of antibiotics is to treat infections AFTER they have occurred. Additionally, antibiotics are only really effective against bacterial infections (Antimicrobials directed at viruses have limited efficacy) and increasing antibiotic resistance is a major health concern in itself.

Quarantine as a strategy to control infectious disease can trace its origins back to the 14th century when the city of Dubrovnik issued a declaration of isolation of 40 days (hence the name) on incoming ships. This was to prevent the spread of bubonic plague. The same principle is effective today.

Vaccination as a measure to prevent rapid infectious disease spread is well documented. In the first ten years of the 21st century, an estimated 2.5 million deaths (children under five) were prevented annually due to the use of measles, polio, and diphtheria-tetanus-pertussis vaccines. Increased coverage with the measles vaccine resulted in averting an estimated 12.7 million deaths between 2000-2008. Polio eradication efforts continued with the number of countries where polio is an endemic disease reduced from 20 to four (2000-2010) according to reporting from CDC.

In the first decade of the 21st century the impact of two other vaccines has been very successful. After the introduction of pneumococcal conjugate vaccine, "an estimated 211,000 serious pneumococcal infections and 13,000 deaths were prevented during 2000--2008" as reported by Pilishvili, Lexau, Farley et al in the Journal of Infectious Diseases (2010). Tate, Cortese, and Payne reported in 2011 that "routine rotavirus vaccination, implemented in 2006, now prevents an estimated 40,000-60,000 rotavirus hospitalizations each year". Advances with older vaccines such as hepatitis A, hepatitis B, and varicella all reported cases of record low incidence by the end of 2011.

The global introduction of a novel infectious agent such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2020 has tested the limits of public health measures to control the spread of the virus. Interestingly the strategies employed to control the outbreak were traditional methods based on isolation, physical separation and vaccination. Because the latter had to be developed from scratch and approved, individual countries needed to employ quarantine, isolation and physical separation (distancing and mask wearing) to buy time until vaccines could be developed and approved. Various nations had variable results from this approach. It should be noted that the control methods implemented were done so to reduce the number of patients requiring hospitalisation for treatment - a classic case of treatment options needed in the 'restorative' component of our health care systems. We have to believe that our health care systems in total can cope with any massive threat to life. Sadly, in various parts of the world during the pandemic, some countries could not cope with the massive number of hospitalisations required and patients died before they could receive treatment.

Answer: Plain packaging for cigarettes

In the late 20th century, death due to cigarette smoking was the leading cause of preventable death. Since that time there has been a global decrease in deaths attributable to smoking due mainly to implemented public health measures in the health promotion area.

Plain packaging for cigarettes was first mentioned in New Zealand in 1989 but it was Australia, with the enactment of the Tobacco Plain Packaging Act in 2011, that became the first country in the world to require tobacco products to be sold in plain packaging (drab brown packaging, graphic photo effects of smoking and only a small space for a generic brand name). Australia faced sustained legal challenges from tobacco companies but the Australian government won every case. By 2020, twenty other countries had implemented their own plain paper packaging laws including the UK, Canada and New Zealand.

The Australian government initiated a review of packaging change impact and reported that smoking rates fell an additional 0.55 percentage points between December 2012 and September 2015 - attributed to the packaging changes only (and not the other anti-tobacco policies in place during this time period). "This equates to more than 108,000 people quitting, not relapsing or not starting to smoke during that period," reported WHO in 2017. Australia also has several other aggressive anti-smoking health promotion strategies including blanket bans on tobacco advertising and promotion, campaigns and programs to reduce smoking and, importantly, to dissuade potential smokers, especially young people from starting to smoke, support for smokers to quit, including subsidising nicotine replacement therapy subsidies and policies to reduce the affordability of tobacco products. In 2000 the excise duty on a cigarette was 21 cents. By 2017 that had risen to 78 cents/cigarette. On a pack of fifty that's $39/pack.
In 2017 Australia (16%) had a lower proportion of smokers than the US (25%), UK (21%), Canada (17%) but not New Zealand (14%). Some countries, like Nigeria, Ghana and Ethiopia had 2021 rates under than 5%. (World Population Review 2021 figures).

Australia's death rate from smoking related causes dropped from 150/100 00 in 1990 to 50.8/1000 000 in 2017. New Zealand had a similar drop. These were among the biggest drops in the developed world. (Ourworldindata.org figures).

Answer: Education level of the baby's mother

Social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and become older. They also include, according to WHO criteria, "the wider set of forces and systems shaping the conditions of daily life". These include economic policies/systems, public development and infrastructure programs, as well as social norms, policies and political systems.

Health inequities arise when there are unfavourable and avoidable differences in health status seen within and between countries especially when comparing the developing world outcomes with the developed world outcomes. Health and illness follow a social gradient: the lower the socioeconomic factors, the worse the health and health outcome. WHO lists the SDH as:

- "Income and social protection
- Education
- Unemployment and job insecurity
- Working life conditions
- Food insecurity
- Housing, basic amenities and the environment
- Early childhood development
- Social inclusion and non-discrimination
- Structural conflict
- Access to affordable health services of decent quality."

Countries with a high level of Human Development will have a life expectancy 19 years higher than those in a less developed country.

A key measurement of United Nations Millennium Development Goal 4, is child mortality which is defined as deaths in children aged less than five years. This factor serves as a major indicator of a nation's health and development. In the second decade of the 21st century, an estimated 8.1 million children died each year before reaching five, which represented a decrease of approximately 2 million over the first decade. A high percentage of all childhood deaths occur in developing countries, with "49% occurring in sub-Saharan Africa and 33% in southern Asia" according to WHO.

Meanwhile, in the developed world, where infant mortality is very low, efforts were made in specific programs such as those to reduce neural tube defects (eg spina bifida) in new-born babies. In Canada and Australia and other countries, these neural tube defects were not rectified post birth but by public health measures such as fortification of bread and cereals with folate vitamins (where low maternal folate levels are associated with increased incidence of NTD in babies). The programs reduced NTD by one third as described in the published literature.

Answer: Sub-Saharan Africa

Of the estimated 37.7 million people living with HIV at the end of 2020, 25.4 million, or two thirds, of those infected are in the southern half of Africa.

A diagnosis of AIDS (acquired immunodeficiency syndrome) caused by HIV was a death sentence when the disease was discovered in the US in 1980. It was transmitted sexually and there was no cure. It created a massive public health response to educate people on how it was transmitted and a concurrent massive research push to find treatment options. The health promotion programs were successful in Europe, North America and Australasia but they were not as effective in other parts of the world, particularly in Africa where some governments provided misinformation about prevention and treatment. AIDS was in epidemic proportions in the 1990s and early 2000s in Africa.

The HIV virus was isolated in 1983 and the first diagnostic kits were approved in 1985. The first therapeutic option, AZT, was approved in 1987. AZT works by blocking enzymes that the virus needs to replicate itself. However, the virus could mutate and adapt when given a single drug. Other new antivirals in the same class (nucleoside reverse transcriptase inhibitors (NRTIs) were quickly approved but, by 1990, HIV was the number one cause of death in Americans aged 25 to 44. It wasn't until 1995 and 1996 when new classes of drug called protease inhibiters (eg saquinavir) and non-nucleoside reverse transcriptase inhibitor (NNRTI) (eg nirviropine) were approved and available. Both these classes of drugs stop the virus from copying itself, but at different stages during the infection cycle. When used in combination these drugs stopped the progression of asymptomatic infection to systemic infection but this required life-long treatment. However it did stop the transmission of the virus to other people and this was seen as the best preventative measure of all, exceeding contemporary health education programs. Access to antivirals has been problematic in low income countries but access continued to improve in the second decade of the 21st century. HIV will never be eradicated but incidence is decreasing, even in Africa, which means the combination of public health programs and access to therapeutics drugs to stop transmission are working.

Answer: False

The incorporation of new safety features into the 21st century automobile have become either standard fitting or are available as an option. These safety features have been a factor in why the road toll in automobiles has dropped significantly. Consider the inclusion of airbags, anti-locking braking systems, crumple zones, shatter-resistant glass, blind spot monitoring, lane-keeping assist & cruise control and pre-crash warning alerts & autonomous emergency braking.

However, the main reason the road toll has decreased in nearly every developed country, is increased programs to change driver behaviours: especially targeted are non-wearing of seatbelts(first legislated by Australia in 1972), drink (and drug) driving, excessive speed, driver fatigue and, more recently, use of mobile phones whilst driving.

Whilst the push for safer driving is public health policy, its compliance is defined in prescribed legislation and enforced (usually) by a nation's police force who use deterrents such as fines, usually heavy, and driver demerit points which result in loss of license when points accumulate. Change of attitude to drink-driving has arguably been the biggest change in driver behaviours. In the last part of the 20th century through to the second decade of the 21st century we have seen a change in attitude from "Don't get caught" to finding alternatives to drinking and driving. There is a direct correlation in reduction of drink driving fatalities and allowable blood alcohol content. The most prevalent allowable limit is 0.05% though some countries like England and the US have higher limits of 0.08%. Additionally, most countries have lower limits for provisional drivers and commercial vehicle operators. Countries which have random roadside breath testing programs like Australia and New Zealand have proven to lower road tolls further.

In most developed countries, road toll deaths are the leading cause of death in 18-45 year olds. Such premature deaths are a tragedy prompting some counties to adopt aspirational goals of eliminating road deaths entirely.

Answer: USA

Gun violence is a significant public health concern as many countries have tried hard to reduce the impact of such sudden, preventable, premature death. The UK, Australia and New Zealand have all enacted much tighter gun availability and ownership legislation after mass shootings in each country. After a massacre in Hungerford, UK in 1988, the UK banned semi-automatic weapons and after Dunblane, when 16 five and six year old children were killed, most handguns were banned in 1997 and then all handguns when a new government came to power. In 1996 a gunman killed 36 people in Port Arthur in Tasmania. The Australian prime minister acted swiftly enacting legislation banning semi-automatic guns and restricting handguns. Australia now has a permanent amnesty on semi-automatic weapons. New Zealand introduced similar legislation after a 2019 mosque shooting in Christchurch which claimed 51 lives.

Japan has an almost zero-tolerance for guns, making the process of buying one so onerous that few people even try. The respective 2020 gun deaths per 100,000 people are Japan 0.06, UK 0.25, Australia 1.04 and New Zealand 1.07, all in the bottom 10% of countries worldwide.

The USA by comparison, has a gun death rate of 12.2/100,000 making it one of the worst ten countries in the world for deaths caused by guns. This equates to an average 35 people per day who will die from gun shots in the US. Mass shootings are not uncommon in the US, but the right to bear arms is protected by the Second Amendment to the Constitution meaning legislation to control gun ownership is unlikely to be passed into law.

Answer: Cervical cancer

Screening tests for these three cancers have been known for many years. The Pap test for cervical cancer was developed in the 1920s, the mammogram for breast cancer can be traced back to Berlin in 1913 and the faecal occult blood test was developed for colon cancer in the 1970s and later a more sensitive test, the faecal histochemical test, was introduced. However, it took somewhat longer for these collective tests to be incorporated into mass screening programs.

Pap smears became available in the 1940s with professional societies mandating their efficacy in the 1960s. Traditionally, these have been initiated in the general practitioner domain with the smears (on slides) sent to specialised laboratories for analysis and early detection of cervical cancer.

Breast screening programs started to emerge, as mass public health prevention programs, in the 1960s and by the 1980s they were well established in many countries. Most developed countries have government funded surveillance programs with reminders sent out, and registers kept to provide incidence reports.

Colon cancer (including colo-rectal cancer) is the third most diagnosed cancer in the world but screening programs are not as prevalent as those for breast cancer. Most programs were initiated in the early 2000s. In 2015 there were 24 countries in Europe with such programs, three in the Americas (Canada, Chile, USA) and five in Asia/Oceania (Japan, Thailand, South Korea, Taiwan and Australia). Incidence reduction has been variable across the various participating counties but reductions between 4% and 31% have been reported since screening programs began. .

In 1991 Ian Frazer and Jian Zhou succeeded in making virus-like particles that trigger an immune response against Human Papilloma Virus, the agent that causes cervical cancer. The vaccine was developed for distribution and, in 2007 each Australian 12-13 year old girl was offered the vaccine with a catch-up program for 14-26 year olds offered in 2007-2009. The vaccine uptake has been reported by the Australian government at 83%. By 2021, similar vaccine programs had been offered in 107 WHO member nations but with concern about lack of available programs in low and middle income countries. Cervical cancer incidence had dropped markedly by 2020 in those countries that had vaccination programs. For example, US CDC data reports a reduction of 13% annually between 1999 and 2017. Cancer Research UK reports that between 1990 and 2018, "cervical cancer incidence rates have decreased by a quarter (25%) in females in the UK". However, globally, in 2020, only about 15% of women are fully protected. In 2015, WHO stated the world-wide aim of a 90% reduction in cervical cancer incidence by 2030.

Answer: 2009 Swine Flu

The 9/11 attacks demonstrated to the watching world that nations were not prepared for public health disasters. These tragic events served as a wake up call to mobilise public health preparedness for such a crisis. The decade long plan implemented in the US had two phases. The first five years was spent purchasing and stockpiling of supplies and equipment. In the second part of the plan (2006-2010), the need focused on improving the laboratory, epidemiology and surveillance, and capacity of the public health systems. Other countries followed the US lead and prepared similar programs.

During the 2009 H1N1 Swine Flu pandemic, public health improvements in the capacity to produce a coordinated response in an emergency facilitated the scope and detection of the outbreak. Implementation of pre-validated laboratory tests, increased and available personal protective equipment distribution from the US Strategic National Stockpile, development of a suitable vaccine and widespread administration of the successful vaccine. CDC reported that these health interventions prevented an estimated "five to ten million cases, 30,000 hospitalizations, and 1,500 deaths".

However, the COVID pandemic which commenced in 2020 showed that, despite our best planning efforts, we were not prepared for a global pandemic and the lack of a single global response was very visible as individual countries were forced to implement strategies and responses in a rapidly changing landscape. The results were extremely variable. The best health outcomes associated with the pandemic were those created with the national economy playing only a minor role in the overall management of the epidemic. Lockdowns became common and effective in slowing incidence rates. Clearly more and extensive public health planning is needed to avert any subsequent global pandemic.

Conclusion: While this quiz has demonstrated considerable improvements in the public health achievements of the early 21st century, it has also mentioned the health inequalities that exist between the developed and the developing worlds, and the requirement to work even more diligently to increase community, population and public health outcomes. We use the word 'heal' as a word meaning the restoration of the whole or at least in this case, a health outcome improvement. We need to replace 'heal' with 'health' where health is the required outcome. We are a long way off this aspirational target despite our best efforts on the topic. As a public health practitioner this author looks forward to a day when we can consider "Health" and "Heal" as synonyms.