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Health Informatics

J.A. Magnuson Paul C. Fu, Jr. Editors

Public Health Informatics and Information Systems 2nd Edition

Preface

When the first edition of Public Health Informatics and Information Systems was published in 2002, Public Health Informatics was a relatively young field. That first edition was invaluable in helping to establish the field of study and provide structure for the emerging discipline. A decade later, great progress has been made, but Public Health Informatics is still an emerging field that needs continued focus in order to grow into its full potential.

This edition builds upon the foundation established by the first edition. We have expanded into new areas that have become important due to changing technologies and needs, as well as updating and augmenting many of the original core tenets. The breadth of material included in this work makes it suitable for both undergraduate and graduate coursework in Public Health Informatics, enabling instructors to select chapters that best fit their students’ needs.

Structure and Objective of This Book The template for the chapters in this book contains learning objectives, an abstract or overview, the chapter content, review questions, and references. The book itself is organized into five parts: • Part I. Context for Public Health Informatics provides a background for the textbook. This part begins with an introduction to the subject of Public Health Informatics and a review of the history and significance of information systems and public health. The context of biomedical informatics is discussed and the governmental and legislative context of informatics is reviewed.

• Part II. The Science of Public Health Informatics reviews the technology and science behind the field of informatics. Informatics infrastructure and information architecture are discussed. This part examines data sources and tools, and the critical issue of information standards. The topics of privacy, confidentiality, security, and ethics are explored. Electronic health records are examined, as well as project management and system evaluation.

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Preface

• Part III. Key Public Health Information Systems are studied in this part. The areas of disease prevention and epidemiology, and environmental health, are reviewed.

Specific systems and instances for public health laboratories, risk factor information systems, the National Vital Statistics System, and immunization information systems are discussed.

• Part IV. New Challenges and Emerging Solutions addresses some of the newest challenges facing Public Health Informatics, as well as emerging solutions.

Included are new means of data collection and accessibility, geographic information systems, health information exchange, decision support and expert systems, delivery of preventive medicine, and case-based learning.

• Part V. Case Studies: Information Systems and the Strata of Public Health highlights informatics case studies from the different strata of public health. The case studies begin with local and regional public health, progressing to state examples for both high population and low population states. Then, national perspectives are represented by examples from the USA, Canada, and a collaborative chapter illustrating informatics experiences in Malawi and Rwanda.

Portland, OR, USA Torrance, CA, USA

J.A. Magnuson, PhD Paul Fu, Jr., MD, MPH

Acknowledgements

This book reflects the hard work and dedication of many people.

As editors, we want to acknowledge the contributions of our chapter authors, who generously managed to find the time to share their wealth of knowledge and experience. Their contribution was absolutely critical to this effort, and we are grateful that so many leaders in the field of Public Health Informatics were willing to participate in this project.

We are also grateful to the editors of the previous edition, whose hard work and inspiration pioneered a path for Public Health Informatics. The enthusiasm and encouragement given to us by that edition’s senior editor, Patrick O’Carroll, is especially appreciated.

Finally, we would like to acknowledge the skill and support of our editor at Springer, Grant Weston, and our developmental editor Connie Walsh. Their encouragement, guidance, and skills were invaluable.

J.A. Magnuson, PhD Paul Fu, Jr., MD, MPH

Contents

Part I

Context for Public Health Informatics

1

Introduction to Public Health Informatics . . . . . . . . . . . . . . . . . . . . .

J.A. Magnuson and Patrick W. O’Carroll

2

History and Significance of Information Systems and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

John R. Lumpkin and J.A. Magnuson

19

Context and Value of Biomedical and Health Informatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

William R. Hersh

37

3

4

Governmental and Legislative Context of Informatics . . . . . . . . . . .

Margo Edmunds

3

47

Part II The Science of Public Health Informatics 5

Public Health Informatics Infrastructure . . . . . . . . . . . . . . . . . . . . . .

Brian E. Dixon and Shaun J. Grannis

69

6

Information Architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dina Dickerson and Patricia Yao

89

7

Data Sources and Data Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Edward Mensah and Johanna L. Goderre

107

8

Public Health Information Standards . . . . . . . . . . . . . . . . . . . . . . . . .

J.A. Magnuson, Riki Merrick, and James T. Case

133

9

Privacy, Confidentiality, and Security of Public Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

William A. Yasnoff

155

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Contents

10

Electronic Health Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Stephen P. Julien

11

Ethics, Information Technology, and Public Health: Duties and Challenges in Computational Epidemiology . . . . . . . . . . . . . . . .

Kenneth W. Goodman and Eric M. Meslin

173

191

12

Project Management and Public Health Informatics . . . . . . . . . . . . .

James Aspevig

211

13

Evaluation for Public Health Informatics . . . . . . . . . . . . . . . . . . . . . .

Paul C. Fu, Jr., Herman Tolentino, and Laura H. Franzke

233

Part III

Key Public Health Information Systems

14

Informatics in Disease Prevention and Epidemiology . . . . . . . . . . . .

Richard S. Hopkins and J.A. Magnuson

257

15

Informatics in Toxicology and Environmental Public Health . . . . . .

Edwin M. Kilbourne

277

16

Public Health Laboratories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Riki Merrick, Steven H. Hinrichs, and Michelle Meigs

295

17

The National Vital Statistics System. . . . . . . . . . . . . . . . . . . . . . . . . . .

Charles J. Rothwell, Mary Anne Freedman, and James A. Weed

309

18

Risk Factor Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Alan Tomines

329

19

Setting National Policies and Standards for Immunization Information Systems. . . . . . . . . . . . . . . . . . . . . . . .

Nedra Y. Garrett

Part IV

355

New Challenges and Emerging Solutions

20

New Means of Data Collection and Accessibility . . . . . . . . . . . . . . . .

I. Charie Faught, James Aspevig, and Rita Spear

375

21

Geographic Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Carol L. Hanchette

399

22

Public Health Informatics and Health Information Exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J.A. Magnuson and Paul C. Fu, Jr.

23

Decision Support and Expert Systems in Public Health . . . . . . . . . .

William A. Yasnoff and Perry L. Miller

429 449

Contents

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24

Delivery of Preventive Medicine in Primary Care . . . . . . . . . . . . . . .

Paul C. Fu, Jr., Alan Tomines, and Larry L. Dickey

469

25

Case-Based Learning in Public Health Informatics . . . . . . . . . . . . . .

Herman Tolentino, Sridhar R. Papagari Sangareddy, Catherine Pepper, and J.A. Magnuson

489

Part V

Case Studies: Information Systems and the Strata of Public Health

26

Local and Regional Public Health Informatics . . . . . . . . . . . . . . . . . .

Jeffrey M. Kriseman and Brian J. Labus

27

Public Health Informatics in High Population States: New York and Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Geraldine S. Johnson, Guthrie S. Birkhead, Rachel Block, Shannon Kelley, James Coates, Bob Campbell, and Brian Fowler

28

29

513

531

State Public Health Informatics: Perspective from a Low Population State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

James Aspevig

555

National Public Health Informatics, United States. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Seth Foldy

573

30

Public Health Informatics in Canada. . . . . . . . . . . . . . . . . . . . . . . . . .

Lawrence E. Frisch, Elizabeth M. Borycki, Alyse Capron, Abla Mawudeku, and Ronald St. John

603

31

Perspectives on Global Public Health Informatics . . . . . . . . . . . . . . .

Janise Richards, Gerry Douglas, and Hamish S.F. Fraser

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Part VI 32

Epilogue

Public Health Informatics: The Path Forward . . . . . . . . . . . . . . . . . .

J.A. Magnuson

647

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

653

Contributors

James Aspevig, MS, MPH Health Care Informatics, Montana Tech of the University of Montana, Butte, MT, USA Guthrie S. Birkhead, MD, MPH New York State Department of Health, Public Health Informatics and Project Management Office, Albany, NY, USA Rachel Block New York State Department of Health, Office of Health Information Technology Transformation, Albany, NY, USA Elizabeth M. Borycki, RN, PhD School of Health Information Science, University of Victoria, Victoria, BC, Canada Robert J. Campbell, PhD Ohio Department of Health Alyse Capron, Masters of Nursing Clinical Strategy Unit, HealthLink BC, Victoria, BC, Canada James T. Case, MS, DVM, PhD California Animal Health and Food Safety Laboratory, University of Calafornia, Davis, Davis, CA, USA James Coates, MS, DVM, PhD Informatics Division, Explorys, Inc., Cleveland, OH, USA Dina Dickerson, MPH Maternal and Child Health Assessment, Evaluation and Informatics, Oregon Health Authority Center for Prevention and Health Promotion, Portland, OR, USA Larry L. Dickey, MD, MPH California Department of Health Care Services, Health Information Technology, Sacramento, CA, USA Brian E. Dixon, MPA, PhD Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, IN, USA Center of Excellence on Implementing Evidence-Based Practice, Health Services Research and Development Service, Department of Veterans Affairs, Veterans Health Administration, Indianapolis, IN, USA

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Contributors

Gerry Douglas, PhD Department of Biomedical Informatics, Center for Health Informatics for the Underserved, University of Pittsburgh, Pittsburgh, PA, USA Margo Edmunds, PhD Evidence Generation and Translation, Academy Health, Washington, DC, USA I. Charie Faught, PhD, MHA Health Care Informatics, Montana Tech of the University of Montana, Butte, MT, USA Seth Foldy, MD, MPH, FAAFP Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Brian Fowler, MPH Division of Prevention and Health Promotion, Ohio Department of Health, Public Health Informatics and Vaccine-Preventable Disease Epidemiology, Columbus, OH, USA Laura H. Franzke, PhD, MPH Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA Hamish S. F. Fraser, MBChB, MRCP, MSc, FACMI Division of Global Health Equity, Department of Medicine, Brigham and Womens Hospital, Boston, MA, USA Mary Anne Freedman, MA Poinciana Consulting, LLC, Venice, FL, USA Lawrence E. Frisch, MD, MPH School of Population and Public Health, University of British Columbia; Vancouver Coastal Health Research Institute, Vancouver, BC, Canada Paul C. Fu, Jr., MD, MPH David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA Nedra Y. Garrett, MS Division of Informatics Practice, Policy and Coordination, Centers for Disease Control and Prevention, Atlanta, GA, USA Johanna L. Goderre, MPH Health Policy and Administration Division, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA Kenneth W. Goodman, PhD University of Miami Bioethics Program, Miami, FL, USA Shaun J. Grannis, MD, MS Department of Family Medicine, Indiana University School of Medicine, Indianapolis, IN, USA Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, IN, USA Carol L. Hanchette, PhD Department of Geography, University of Louisville, Louisville, KY, USA

Contributors

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William R. Hersh, MD Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA Steven H. Hinrichs, MD Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA Richard S. Hopkins, MD, MSPH Department of Epidemiology, University of Florida College of Public Health and Health Professions and College of Medicine, Gainesville, FL, USA Geraldine S. Johnson, MS New York State Department of Health, Public Health Informatics and Project Management Office, Albany, NY, USA Stephen P. Julien Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA Shannon Kelley, MPH New York State Department of Health, Office of Health Information Technology Transformation, Albany, NY, USA Jeffrey M. Kriseman, PhD, MS Department of Informatics, Southern Nevada Health District, Las Vegas, NV, USA Edwin M. Kilbourne, MD Health Solutions Group, Science Applications International Corporation (SAIC), Atlanta, GA, USA Brian J. Labus, MPH Health Solutions Group, Southern Nevada Health District, Las Vegas, NV, USA John R. Lumpkin, MD, MPH Robert Wood Johnson Foundation, Princeton, NJ, USA Abla Mawudeku, MPH Health Security and Infrastructure Branch, Public Health Agency of Canada, Ottawa, ON, Canada J. A. Magnuson, PhD Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA Michelle Meigs Informatics Program, Association of Public Health LaboratoriesSilver Spring, MD, USA Edward Mensah, PhD Health Policy and Administration Division, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA Riki Merrick, MPH Consultant, Public Health Informatics, Carmichael, CA, USA Eric M. Meslin, PhD Indiana University Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, USA Perry L. Miller, MD, PhD VA Connecticut Healthcare System, West Haven, CT, USA Center for Medical Informatics, Yale University, School of Medicine, New Haven, CT, USA

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Contributors

Patrick W. O’Carroll, MD, MPH, FACPM, FACMI Office of the Assistant Secretary for Health, US Department of Health and Human Services, Seattle, WA, USA Sridhar R. Papagari Sangareddy, MS (EECS), MS (MIS) Public Health Informatics Fellowship Program, Centers for Disease Control and Prevention, Atlanta, GA, USA Catherine Pepper, MLIS, MPH Medical Sciences Library, Texas A&M University, Round Rock, TX, USA Janise Richards, PhD, MPH, MS Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA Charles J. Rothwell, MS, MBA National Center for Health Statistics, CDC, HHS, Hyattsville, MD, USA Rita Spear, MS Health Care Informatics, Montana Tech of the University of Montana, Butte, MT, USA Ronald St. John, MD, MPH St. John Public Health Consulting International, Manotick, ON, Canada Herman Tolentino, MD Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA Alan Tomines, MD Department of Pediatrics, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA, USA James A. Weed, PhD, National Center for Health Statistics, CDC, HHS (Retired), Hyattsville, MD, USA Patricia Yao, MSc (Medical Informatics) Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA William A. Yasnoff, MD, PhD NHII Advisors, Arlington, VA, USA

Part I

Context for Public Health Informatics

Chapter 1

Introduction to Public Health Informatics J.A. Magnuson and Patrick W. O’Carroll

Abstract The transformation of public health by informatics is still in the nascent stages. Thus far, informatics in public health generally has been relegated to “pushing the broom” at the end of the parade: public health has tended to bring in informaticists to help resolve systemic issues such as non-interoperability, rather than realizing the full potential benefits that would accrue from their involvement at the outset.

To facilitate the understanding of Public Health Informatics, this chapter includes a brief review of public health, discussing the purpose, history, structural organization, and challenges of public health. Once the context of public health has been reviewed, the principles of Public Health Informatics are described, including some history and background, and the challenges encountered, as well as the drivers for change.

Although the discipline of public health informatics has much in common with other informatics specialty areas, it differs from them in several ways. These include (a) a focus on applications of information science and technology that promote the health of populations, rather than of individuals, (b) a focus on disease prevention, rather than treatment, (c) a focus on preventive intervention at all vulnerable points in the causal chains leading to disease, injury, or disability, and (d) operation within a governmental, rather than a private, context.

Drivers of change forcing public health professionals to be conversant with the development, use, and strategic importance of computerized health information J.A. Magnuson, PhD (*) Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, 5th Floor Biomedical Information Communication Center (BICC), 3181 S.W. Sam Jackson Park Rd., Portland, OR 97239, USA e-mail: jamagnuson@gmail.com P.W. O’Carroll, MD, MPH, FACPM, FACMI Office of the Assistant Secretary for Health, US Department of Health and Human Services, 2201 Sixth Avenue, Seattle, WA 98105, USA e-mail: patrick.ocarroll@hhs.gov J.A. Magnuson, P.C. Fu, Jr. (eds.), Public Health Informatics and Information Systems, Health Informatics, DOI 10.1007/978-1-4471-4237-9_1, © Springer-Verlag London 2014

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systems include health reform, advances in information technology, the advent of Big Data, and continuation of disruptive innovation.

Keywords Big Data • Disruptive innovation • Electronic Health Record • Gene patenting • Healthy People • Informatician • Informaticist • Informatik • Informatique • Infrastructure • Meaningful use • Mobile technology • Open access • Personal health record • Personalized medicine • Prevalence • Preventability • Severity • Software as a Service • SaaS • Telehealth • Value • Variety • Velocity • Volume

Learning Objectives 1. Define the concept of public health informatics and explain the aspects that it has in common with medical informatics.

2. Understand the four principles that define, guide, and provide the context for the types of activities and challenges that comprise public health informatics and differentiate it from medical informatics.

3. Describe the history, organization, purpose, and challenges of public health in the US. 4. Explain how the four main drivers of change are affecting the future of public health informatics.

5. Discuss the major developments that have increased the importance and immediate relevance of informatics to public health.

Introducing Public Health Informatics Karl Steinbuch (1917–2005) is often credited with creating the term informatik [1], for automatic information processing, a term which came to denote computer science in German. In 1962, Philippe Dreyfus [2] devised the French term informatique, and in 1966 Alexander Mikhailov et al. [3] promoted the Russian term informatika for the theory of scientific information. In the US, a public health informaticist or informatician (both are correct) is a professional in the “systematic application of information and computer science and technology to public health practice, research, and learning” [4], illustrating the relation but clear distinction between computer science and informatics in this usage.

The scope of public health informatics includes the conceptualization, design, development, deployment, refinement, maintenance, and evaluation of communication, surveillance, information, and learning systems relevant to public health.

Public health informatics requires the application of knowledge from numerous disciplines, particularly information science, computer science, management, organizational theory, psychology, communications, political science, and law.

Its practice must also incorporate knowledge from the other fields that contribute to public health, including epidemiology, microbiology, toxicology, and statistics.

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Although public health informatics draws from multiple scientific and practical domains, computer science and informatics science are its primary underlying disciplines. Computer science, the theory and application of automatic data processing machines, includes hardware and software design, algorithm development, computational complexity, networking and telecommunications, pattern recognition, and artificial intelligence. Informatics science encompasses the analysis of the structure, properties, and organization of information, information storage and retrieval, information system and database architecture and design, library science, project management, and organizational issues such as change management and business process reengineering.

An important distinction between medical and public health informatics is illuminated by the difference between medicine and public health. Public health is concerned with the health of populations, whereas clinical medicine involves the health of the individual. The World Health Organization perspective of health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [5] can be extrapolated to population health as well.

Public health includes not only the often-spotlighted communicable disease programs, but also chronic disease control, health and wellness promotion, environmental health, mental health, and other program areas.

Public health informatics differs from other informatics specialties in that it involves: 1. A focus on applications of information science and technology that promote the health of populations, rather than of individuals; 2. A focus on disease prevention, rather than treatment; 3. A focus on preventive intervention at all vulnerable points in the causal chains leading to disease, injury, or disability; and 4. Operation typically within a governmental, rather than a private, context.

Principles of Public Health In order to understand public health informatics, it is necessary to have a good introduction to public health. As referenced earlier in this chapter, public health is concerned with the health of populations. The key characteristics of public health as contrasted with medicine are presented in Table 1.1.

History of Public Health Data forms the foundation of public health, and has very early roots in that area.

Some of the earliest known examples of public health data involve the pneumonic plague surveillance conducted by the Venetian Republic in the fourteenth century, and the recording of vital events in the sixteenth century in the London Bills of

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Table 1.1 Some critical differences between public health and medicine Attribute Source Primary focus Primary strategy Timing of action Intervention context Operational context

Medicine Clinicians, health practitioners Persons with disease, injuries, other health problems Treatment of persons with disease, injury, or disability; secondary emphasis on prevention Usually taken after illness/injury occurs Clinical and surgical encounters and treatment Private practices, clinics, hospitals

Public health Agencies and organizations Populations (in communities, states, the nation) Prevention of disease, injury, and disability Both before illness/injury (e.g., prevention) and after (e.g., surveillance) Any vulnerable points in the causal chain.

Modes include education, policy, research, monitoring, assurance Governmental context, requiring responsiveness to legislative, regulatory, policy directives, and political context

Mortality [6]. As time passed, these rich sources of data came to be increasingly analyzed and studied for public health reasons. In the US, Massachusetts developed a postcard-based reporting system in 1874, which marks the beginning of US infectious disease reporting [7].

The Communicable Disease Center, precursor of the Centers for Disease Control and Prevention (CDC), was established in 1946 [8]. The new center was an extension of the wartime agency MCWA (Malaria Control in War Areas), developed to combat malaria through mosquito control. From those DDT-drenched roots grew today’s CDC, with its emphases on working with states and other partners to monitor and prevent outbreaks; maintain national health statistics; and, as included in its very name (Disease Control and Prevention), to prevent and control infectious and chronic diseases, injuries, and environmental health hazards.

Public Health Strata in the United States Public health in the US is a composite of agencies/responsibilities. Although some regions differ in their public health composition or have entirely different structures such as tribal health agencies, in general, public health agencies in the US are arranged into three strata – federal, state, and local.

• Federal level – There are numerous so-called “operating divisions” within the US Department of Health and Human Services (HHS) that comprise the federal public health family: CDC, US Food and Drug Administration (FDA), National Institutes of Health (NIH), Indian Health Service (IHS), Substance Abuse and Mental Health Services Administration (SAMHSA), and Health Resources and Services Administration (HRSA) foremost among them. However, as regards the day-to-day practice of public health, the CDC [9] may be considered HHS’s

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Introduction to Public Health Informatics

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primary federal public health agency. It has many important responsibilities, including but not limited to: – Development and dissemination of prevention guidelines and policies.

– Distribution of federal funds to states (and, to a lesser degree, directly to local health departments) for specific public health programs (e.g., immunization, HIV-AIDS, preparedness). Many state initiatives and program areas rely almost exclusively on federal funding.

– Collaboration, representation, and leadership in the public health arena – Assistance to other public health organizations, at their request. In 2011, for example, CDC sent Epi-Aid assistance (Epi-Aids are requests to the CDC for epidemiological assistance) to US states (Wisconsin, Arkansas, Louisiana, and Georgia), and Ethiopia [10].

• State and Territory level – State health departments coordinate public health at the state level. Responsibilities include: – Assisting local health departments (LHDs) with investigations such as outbreak investigations – Coordinating statewide initiatives and programs, such as statewide electronic laboratory reporting, vital statistics, immunization registries, etc.

– Setting state policy and legislation, such as state notifiable conditions. The Council of State and Territorial Epidemiologists (CSTE) maintains a State Reportable Conditions Assessment (SRCA) that represents an annual assessment of reporting requirements by state and territory [11].

– Distributing funds (often federal funds) to LHDs. • Local level – The local level includes county health departments, metropolitan area health organizations, tribal public health, and regional collaboration organizations.

– LHDs often have the primary responsibility for investigating cases and outbreaks.

– Not all states have LHDs; some may perform all investigations at a state level.

– Many large metropolitan areas have health organizations that function at the level of an LHD. For example, the New York City Department of Health and Mental Hygiene gathers data and provides information on residents of New York City [12].

– The National Indian Health Board (NIHB) works with a variety of partners, including the Indian Health Service (IHS) and CDC, on public health projects such as the recent Traditional Foods Project and the Methamphetamine and Suicide Prevention Initiative (MSPI) [13].

– Regional public health initiatives may adhere to the ten HHS-designated regions of the US [14] or may constitute a response to local needs, such as Alaska’s public health centers [15].

In addition to governmental structure, public health is arranged into program areas based on activity and purpose. The Public Health Accreditation Board (PHAB) offers public health department accreditation options to tribal, state, local, and

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J.A. Magnuson and P.W. O’Carroll

territorial public health departments in the US. The core public health programs and activities covered under PHAB [16] include: • • • • • • • • • • • • •

Access to clinical services Chronic disease prevention and control Communicable disease Community health Environmental public health Governance Health education Health promotion Injury prevention Management/administration of public health programs and activities Maternal and child health Public health emergency preparedness Public health laboratory services

The CDC is arranged into centers, institutes, and offices that reflect focus on different public health concerns [17]. These include such examples as the Office of Infectious Diseases, National Institute for Occupational Safety and Health (NIOSH), National Center for Environmental Health/Agency for Toxic Substances and Disease Registry, and Office of Surveillance, Epidemiology, and Laboratory Services.

The Purpose of Public Health The Institute of Medicine’s 1988 report on public specifies that the “core functions of public health agencies at all levels of government are assessment, policy development, and assurance” [18]. The CDC National Public Health Performance Standards Program (NPHPSP) determined ten Essential Public Health Services [19] essential to all communities, listed as: 1. Monitor health status to identify and solve community health problems.

2. Diagnose and investigate health problems and health hazards in the community.

3. Inform, educate, and empower people about health issues.

4. Mobilize community partnerships and action to identify and solve health problems.

5. Develop policies and plans that support individual and community health efforts.

6. Enforce laws and regulations that protect health and ensure safety.

7. Link people to needed personal health services and assure the provision of healthcare when otherwise unavailable.

8. Assure competent public and personal healthcare workforce.

9. Evaluate effectiveness, accessibility, and quality of personal and populationbased health services.

10. Research for new insights and innovative solutions to health problems.

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These ten essential services of public health harmonize well with the IOM’s three core functions (assessment, policy development, and assurance), and all are improved by the application of informatics. Assessment includes collection and analysis of health data, as well as the critical step of distribution of information gained to the community: informatics can advance the accuracy and security of health data collection, and increase the value of knowledge distribution. In addition, informatics-enhanced data improves the efficacy of both policy development and assurance, including enactment of regulations or provision of services.

Public Health has achieved tremendous accomplishments in the twentieth century. From the Morbidity and Mortality Weekly Report (MMWR) list of ten highlysignificant public health achievements in the US, it is easy to see that the principles of PHI must have been involved [20]. The unordered list below includes some selected highlights of those achievements: • Vaccination – worldwide eradication of smallpox, and elimination of poliomyelitis in the US • Motor-vehicle safety – such as seat belt implementation, reduction in drunk driving • Safer workplaces – reduction in occupational injuries and unsafe working conditions • Control of infectious diseases – improved sanitation, improved therapies • Decrease in coronary heart disease/stroke deaths – smoking cessation programs, improved treatment and detection • Safer and healthier foods – food fortification, reduction in contamination • Healthier mothers and babies – improvements in nutrition and healthcare access • Family planning – contraception, STD prevention, and treatment • Fluoridation of drinking water – reduced tooth decay • Recognition of tobacco as health hazard – antismoking campaigns Public health has significantly increased life expectancy. Since 1900, the average life expectancy in the US has increased 30 years, and a startling 25 of those years are attributed to public health initiatives. In the twentieth century alone, smallpox killed around 300 million people [21]. In 1977, a dedicated public health initiative brought about worldwide eradication of this disease [22]. And in the 1970s, a huge majority (88 %) of US children had elevated levels of blood lead, but by 1994, public health had reduced that percentage to only 4.4 % [23].

Public Health’s Unique Challenges and the Promise of Public Health Informatics Public health usually operates in a resource-scarce environment, dependent upon inconstant but always inadequate public funding. Additionally, the public health workforce is impacted by detrimental factors including: between 1980 and 2000, the number of public health workers per 100,000 Americans declined from 220 to

10 Fig. 1.1 Diagram illustrating the intersection of qualifying conditions for a public health response

J.A. Magnuson and P.W. O’Carroll

Preventability

Prevalence

Severity

158; around half of the public health workforce is nearing retirement age; and four out of five public health employees lack formal public health training [24]. Given these and other challenges, public health must be cautious about committing resources to a program. In order for a condition to realistically be of interest to public health, it usually needs to match some degree of each of the following criteria: severity – the condition/disease must be severe enough in its effects to warrant some type of intervention/monitoring; preventability – the condition must be preventable or at least able to be mitigated by health interventions, behavioral modifications, etc.; and prevalence – the condition must be prevalent enough in the population to warrant some type of intervention/monitoring (Fig. 1.1). In this environment of scarcity, public health is beginning to realize the benefits that can accrue from application of informatics.

Principles of Public Health Informatics History and Background Public health informatics is related to medical informatics in several respects [25].

Both disciplines seek to use information science and technology to improve human health, and there are subject matter areas of common concern (e.g., standards for vocabulary and information exchange). Moreover, lessons learned in medical informatics often apply to public health informatics. Further, there are informatics applications for which there is no real distinction between public health and medical informatics. Examples of such applications include systems for accessing public health data from electronic medical record systems or for providing patient-specific prevention guidance at the clinical encounter.

Nevertheless, we believe that public health informatics is a distinct specialty area within the broader discipline of informatics, a specialty area defined by a specific set of principles and challenges.

Our view is that the various informatics specialty areas – for instance, nursing informatics and medical informatics – are distinguished from one another by

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the principles underlying their respective application domains (i.e., nursing and medicine), as well as by the differing nature and challenges of their informatics applications. In the case of public health informatics, there are four such principles, flowing directly from the scope and nature of public health, that distinguish it from other informatics specialty areas. These four principles define, guide, and provide the context for the types of activities and challenges that comprise this field: 1. The focus of public health informatics is on applications of information science and technology that promote the health of populations as opposed to the health of specific individuals.

2. Another focus of public health informatics is on applications of informatics science and technology that prevent disease and injury by altering the conditions or the environment that put populations of individuals at risk. Although notable exceptions exist, traditional healthcare largely treats individuals who already have a disease or high-risk condition, whereas public health practice seeks to avoid the conditions that led to the disease in the first place. This difference in focus has direct implications for the ways in which informatics technology might be deployed.

3. Public health informatics applications explore the potential for prevention at all vulnerable points in the causal chains leading to disease, injury, or disability; applications are not restricted to particular social, behavioral, or environmental contexts. In public health, the nature of a given preventive intervention is not predetermined by professional discipline, but rather by the effectiveness, expediency, cost, and social acceptability of intervening at various potentially vulnerable points in a causal chain. Public health interventions have included, for example, legislatively mandated housing and building codes, solid waste disposal and wastewater treatment systems, smoke alarms, fluoridation of municipal water supplies, redesign of automobiles, development of inspection systems to ensure food safety, and removal of lead from gasoline. Contrast this approach with the approach of the modern healthcare system, which generally accomplishes its mission through direct patient care services such as clinical and surgical encounters. Although some of these healthcare system encounters can properly be considered public health measures (e.g., vaccination), public health action is not limited to the clinical encounter.

4. As a discipline, public health informatics reflects the governmental context in which public health is practiced. Much of public health operates through government agencies that require direct responsiveness to legislative, regulatory, and policy directives; careful balancing of competing priorities; and open disclosure of all activities. In addition, some public health actions involve authority to take specific (sometimes coercive) measures to protect the community in an emergency. Examples include medication or food recalls, closing down a restaurant or a contaminated pool or lake, and making changes to immunization policy.

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Challenges of Public Health Informatics In addition to these principles, the nature of public health also defines a special set of informatics challenges. For example, in order for public health practitioners to assess a population’s health and risk status, they must obtain data from multiple disparate sources, such as hospitals, social service agencies, police departments, departments of labor and industry, population surveys, on-site inspections, etc. Data from these various sources about particular individuals must be accurately combined. Then, individual-level data must be compiled into usable, aggregate form at the population level. This information must be presented in clear and compelling ways to legislators and other policymakers, scientists, advocacy groups, and the general public. At the same time, the public health practitioner must insure that the confidentiality of the health information about specific individuals is not compromised.

Together with the four principles that distinguish public health informatics from other informatics specialty areas, then, these and other special challenges define public health informatics as a distinct specialty area.

Change Is a Constant: The Future of Public Health Informatics There are many drivers mediating the rapid advances and changes in Public Health Informatics. The escalating power and speed of these factors make it increasingly critical that public health professionals be conversant with the development, use, and strategic importance of computerized health information systems and resources.

Some of these drivers are discussed briefly in this chapter; many will be covered in detail in the following chapters.

Driver for Change: Health Reform Both clinical care and public health are undergoing massive changes. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was enacted as part of the American Recovery and Reinvestment Act (ARRA) to foster the adoption and meaningful use of health information technology. In 2010, the Patient Protection and Affordable Care Act (PPACA, or commonly, ACA) was signed; it seeks to change the very nature of clinical practice, in part by changing financial incentives that promote health and wellness versus pay-for-procedure reimbursement. In this new context, healthcare entities can potentially increase reimbursement by keeping their patients healthier – potentiating a new focus on prevention and new partnerships with public health agencies.

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Public health is (still) eagerly anticipating the bonanza of information it expects to accrue from the HITECH Act [26]. Electronic Health Records (EHRs) have traditionally elicited an almost Pavlovian response from public health workers as they anticipate a cornucopia of surveillance and research data, but in truth, public health is only just starting to realize the full extent of the confidentiality and data access problems involved.

The HITECH Act incentivizes adoption of EHR technology by offering Medicare and Medicaid payment to healthcare providers and hospitals that use certified EHR systems to achieve meaningful use, a set of standards specified by the Centers for Medicare & Medicaid Services (CMS) [27]. And the incentives are at an unprecedented level – a total of US$27 billion over 10 years, on a per clinician basis of up to US$44,000 (Medicare) and US$63,750 (Medicaid) per clinician. Now at the beginning of 2013, US Healthcare IT News reports that “Medicare and Medicaid electronic health record payments are estimated to have blasted through [US]$10.3 billion to a total of 180,200 physicians and hospitals through December [2012] since the program’s inception” [28].

Meaningful Use is planned to develop in three stages, as described on the HealthIT.gov site referenced above: • Stage 1, 2011–2012: Data capture and sharing. This stage concentrates on capturing data electronically and in standardized format and reporting clinical quality measures and public health information.

• Stage 2, 2014: Advance clinical processes. This stage emphasizes increased health information exchange (HIE) and e-prescribing, and incorporation of laboratory results.

• Stage 3, 2016: Improved outcomes. This stage is planned to lead to better outcomes through elevated quality, safety, and efficiency, and to improved population health.

EHRs are expected or hoped to produce three general benefits for patients, and to a lesser degree, to public health. First, more complete and accurate information should lead to better patient care. Second, providers will have better access to information. Third, patients will be empowered by increased access to their medical information, including the ability to download and share (if desired) their medical records.

Realizing the benefits of EHRs is not an easy task. Many of the factors needed for effectiveness of an EHR system, such as acceptance by partners (including the public), interoperability, implementation of coding systems and standard formats, and utilization of a unique health identifier (UHI), are also barriers to implementation.

Driver for Change: Advances in Information Technology The information technology revolution continues unabated. Today’s computer systems are both faster and less expensive than ever before, and prices are continuing

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to decrease rapidly. In fact, computer hardware is no longer the major cost it once was in information system development projects.

More important, the Internet has emerged as both a universal communications medium and the source of a universal graphical user interface – the World Wide Web, accessed with Internet browser software. In fact, the growth in use of the Internet has been little short of phenomenal in recent years.

The broad deployment of the Web has provided a powerful paradigm for standardized implementation of the communication capabilities that are central to all information systems. A Web browser interface allows broad access without the necessity for development or deployment of specific software or communications protocols for potential users. Updating information systems is greatly simplified, since new versions of Web-based applications are immediately available to users without distribution of new end-user-installed software. Most system development has utilized this paradigm, with the resultant creation of many new and powerful tools to streamline and simplify the process. Consequently, information system development is now faster and easier than ever before, with collaborative development, interactive Web experiences, and explosive growth of social media continuing to unlock new opportunities. In this environment, the benefits of public health information systems are more obvious and more easily achievable, and thus much more compelling.

However, along with advances in capabilities come parallel advances in system hacking, identity theft, and other malicious intent. The goals of privacy, confidentiality, and security have never before been so challenging or so critical. While public health is accustomed to handling sensitive data, handling those data in electronic form introduces new and continually evolving spheres of ethical and security concerns.

Driver for Change: Big Data Advances in medicine and public health, such as the explosion of genomic data and the implementation of EHR systems, are rapidly bringing attention to the topic of Big Data in health fields. As noted by IBM recently, “Every day, we create 2.5 quintillion bytes of data – so much that 90 % of the data in the world today has been created in the last 2 years alone” [29].

Health data is rapidly exceeding conventional database capacities. The overwhelming volume of data and its rapid accumulation are further complicated by the inherent variability of the data; health data can be structured, such as data from monitoring equipment and laboratory results, or unstructured, such as medical transcription and imaging. The traditional Three V’s of Big Data – volume, velocity, and variety – can and should be supplemented by a fourth V, value [30]. This applies to any kind of data, and especially to public health data – the resources invested in accumulating and analyzing data must be offset by the value to the population. The ultimate goals for all health data sources and

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tools, both public and private, should be to improve cost, increase efficiency, and improve health.

Driver: Disruptive Innovation Disruptive innovation, which creates new markets/fields and displaces existing technologies, has become the norm for technological advances. For example, today’s (2013) smart phones have more computing power than was used for the NASA moon landing in 1969 [31].

Public Health Informatics, undergirded as it is by information technology, will experience the same disruptive changes. Ten years into the future, today’s public health informatics students will be working at jobs that are not even visualized yet.

Therefore, it is absolutely critical that public health today embrace rather than resist (futilely) the turbulence of disruptive innovation.

Many of the disruptive innovations taking place in healthcare also will affect public health. A few examples of these innovations include: • Mobile technology: increasingly utilized by private health clinicians for purposes such as data access and entry during hospital rounds, mobile technology can similarly be used by public health professionals in clinics or for surveillance and tracking purposes, such as mapping wells or disease outbreaks using GPS. • Telehealth: both public and private health consultation and diagnostic services can be provided to remote districts using telecommunication technologies or telehealth.

• Personalized medicine: private health can provide treatment that is customized or tailored to an individual being, based on detailed knowledge gained from specialized testing such as genetic screening. Genetic data are just beginning to be used by public health, usually for purposes such as HIV genotype research and tracking, but these usages are destined to expand greatly as genetic screening technologies simultaneously expand in value and decrease in price.

• Personal health record (PHR): a PHR is maintained by the patient, as opposed to an electronic health record (EHR) that is maintained by an institution. Public health should work to develop ways to add value to PHRs, in order to increase engagement with the public and foster prevention of adverse health conditions.

• Open Access (OA): OA publishing offers the potential to enable greater access to research articles, which would benefit both private and public health researchers.

• Gene patenting: fully as controversial as the patenting of genetically modified organisms, gene patenting is (currently) allowed in the US. Although gene patents do not apply to naturally-occurring genes, the repercussions and legal issues are guaranteed to affect medical research and testing, making them important to both private and public health.

• Software as a Service (SaaS): software delivery over a network, rather than through individually purchased installations, has the potential to greatly reduce IT support costs for both private and public health.

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Conclusion Informatics has become something of a buzzword, which has the potential damage of diluting the power of the field. When a popular term is co-opted, there is a danger of devaluation. Currently, examples of this incorrect usage include IT professionals and web designers often self-identifying as informaticists. While many of the skills held by these professions can and indeed should be part of an informaticist’s toolbox, the possession of those skills does not automatically bestow the title of informaticist.

In the context of the challenges discussed in this chapter, familiarity with at least the basic principles and practices of informatics is becoming essential. This may not be a welcome development for many public health practitioners, who already must be conversant with such wide-ranging fields as epidemiology and statistics, risk communication, community organization, legislative development, behavioral modification, emergency response, and of course program management. Nevertheless, facility in at least the use of key information technologies for public health (e.g., the Web, social media tools, web conferencing, secure communications, and epidemiologic databases) is already a requirement for state-of-the-art public health practice.

And more advanced informatics expertise is undeniably critical for the development of future information systems such as immunization registries, improved disease and epidemic surveillance, and so forth. Like it or not, informatics has already joined the long list of disciplines with which public health practitioners must be conversant.

Public health informatics has often found itself in the position of “pushing the broom” at the end of the parade, being brought in to solve problems such as noninteroperability or poor data quality. But as informatics continues to grow as a field, public health will begin to realize the full potential benefits of public health informatics when it becomes routine to involve informaticists at the outset or ground level of project planning and system improvement.

Review Questions 1. What are the main differences between public health informatics and other informatics fields?

2. Discuss the history of public health in the US. What do you think has been the most important factor in developing today’s public health infrastructure?

3. Of the top achievements of public health in the US, which do you think is most closely dependent upon informatics, and why?

4. Compare and contrast the functions performed by public health professionals and practitioners of traditional healthcare. How do they differ in their approach to (1) the individual, and (2) the community? To what parties are these two categories of professionals accountable for their actions, and how?

5. Discuss the drivers of change in public health informatics. Which do you think will have the greatest impact, and why?

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11. Council of State and Territorial Epidemiologists [Internet]. Surveillance/informatics: SRCA query results. Available from: http://www.cste.org/group/SRCAQueryRes. Cited 13 Feb 2013.

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16. Public Health Accreditation Board, Accepted Program Areas for PHAB Documentation [Internet]. 2012. Available from: http://www.phaboard.org/wp-content/uploads/AcceptedProgram-Areas-for-PHAB-Documentation-December-2012.pdf. Cited 15 Feb 2013.

17. Centers for Disease Control and Prevention. CDC organization [Internet]. 2012. Available from: http://www.cdc.gov/about/organization/cio.htm. Cited 15 Feb 2013.

18. Institute of Medicine, Committee for the Study of the Future of Public Health, Division of Health Care Services. The future of public health. Washington, DC: The National Academies Press; 1988.

19. Centers for Disease Control and Prevention [Internet]. National Public Health Performance Standards Program (NPHPSP). 2010. Available from: http://www.cdc.gov/od/ocphp/nphpsp/ EssentialPHServices.htm. Cited 14 Feb 2013.

20. Centers for Disease Control and Prevention. Ten great public health achievements – United States, 1900–1999. Morb Mortal Wkly Rep. 1999;48(12):241–3. Available from: http://www. cdc.gov/mmwr/preview/mmwrhtml/00056796.htm. Cited 14 Feb 2013.

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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least the Newala of to-day does; there was once another Newala in a lovely valley at the foot of the plateau. I visited it and found scarcely a trace of houses, only a Christian cemetery, with the graves of several missionaries and their converts, remaining as a monument of its former glories. But the surroundings are wonderfully beautiful. A thick grove of splendid mango-trees closes in the weather-worn crosses and headstones; behind them, combining the useful and the agreeable, is a whole plantation of lemon-trees covered with ripe fruit; not the small African kind, but a much larger and also juicier imported variety, which drops into the hands of the passing traveller, without calling for any exertion on his part. Old Newala is now under the jurisdiction of the native pastor, Daudi, at Chingulungulu, who, as I am on very friendly terms with him, allows me, as a matter of course, the use of this lemon-grove during my stay at Newala.

FEET MUTILATED BY THE RAVAGES OF THE “JIGGER” (Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley, some 1,600 feet lower down. The way is not only long and fatiguing, but the water, when we get it, is thoroughly bad. We are suffering not only from this, but from the fact that the arrangements at Newala are nothing short of luxurious. We have a separate kitchen—a hut built against the boma palisade on the right of the baraza, the interior of which is not visible from our usual position. Our two cooks were not long in finding this out, and they consequently do—or rather neglect to do—what they please. In any case they do not seem to be very particular about the boiling of our drinking-water—at least I can attribute to no other cause certain attacks of a dysenteric nature, from which both Knudsen and I have suffered for some time. If a man like Omari has to be left unwatched for a moment, he is capable of anything. Besides this complaint, we are inconvenienced by the state of our nails, which have become as hard as glass, and crack on the slightest provocation, and I have the additional infliction of pimples all over me. As if all this were not enough, we have also, for the last week been waging war against the jigger, who has found his Eldorado in the hot sand of the Makonde plateau. Our men are seen all day long—whenever their chronic colds and the dysentery likewise raging among them permit—occupied in removing this scourge of Africa from their feet and trying to prevent the disastrous consequences of its presence. It is quite common to see natives of this place with one or two toes missing; many have lost all their toes,

or even the whole front part of the foot, so that a well-formed leg ends in a shapeless stump. These ravages are caused by the female of Sarcopsylla penetrans, which bores its way under the skin and there develops an egg-sac the size of a pea. In all books on the subject, it is stated that one’s attention is called to the presence of this parasite by an intolerable itching. This agrees very well with my experience, so far as the softer parts of the sole, the spaces between and under the toes, and the side of the foot are concerned, but if the creature penetrates through the harder parts of the heel or ball of the foot, it may escape even the most careful search till it has reached maturity.

Then there is no time to be lost, if the horrible ulceration, of which we see cases by the dozen every day, is to be prevented. It is much easier, by the way, to discover the insect on the white skin of a European than on that of a native, on which the dark speck scarcely shows. The four or five jiggers which, in spite of the fact that I constantly wore high laced boots, chose my feet to settle in, were taken out for me by the all-accomplished Knudsen, after which I thought it advisable to wash out the cavities with corrosive sublimate. The natives have a different sort of disinfectant—they fill the hole with scraped roots. In a tiny Makua village on the slope of the plateau south of Newala, we saw an old woman who had filled all the spaces under her toe-nails with powdered roots by way of prophylactic treatment. What will be the result, if any, who can say?

The rest of the many trifling ills which trouble our existence are really more comic than serious. In the absence of anything else to smoke, Knudsen and I at last opened a box of cigars procured from the Indian store-keeper at Lindi, and tried them, with the most distressing results. Whether they contain opium or some other narcotic, neither of us can say, but after the tenth puff we were both “off,” three-quarters stupefied and unspeakably wretched. Slowly we recovered—and what happened next? Half-an-hour later we were once more smoking these poisonous concoctions—so insatiable is the craving for tobacco in the tropics.

Even my present attacks of fever scarcely deserve to be taken seriously. I have had no less than three here at Newala, all of which have run their course in an incredibly short time. In the early afternoon, I am busy with my old natives, asking questions and making notes. The strong midday coffee has stimulated my spirits to

an extraordinary degree, the brain is active and vigorous, and work progresses rapidly, while a pleasant warmth pervades the whole body. Suddenly this gives place to a violent chill, forcing me to put on my overcoat, though it is only half-past three and the afternoon sun is at its hottest. Now the brain no longer works with such acuteness and logical precision; more especially does it fail me in trying to establish the syntax of the difficult Makua language on which I have ventured, as if I had not enough to do without it. Under the circumstances it seems advisable to take my temperature, and I do so, to save trouble, without leaving my seat, and while going on with my work. On examination, I find it to be 101·48°. My tutors are abruptly dismissed and my bed set up in the baraza; a few minutes later I am in it and treating myself internally with hot water and lemon-juice.

Three hours later, the thermometer marks nearly 104°, and I make them carry me back into the tent, bed and all, as I am now perspiring heavily, and exposure to the cold wind just beginning to blow might mean a fatal chill. I lie still for a little while, and then find, to my great relief, that the temperature is not rising, but rather falling. This is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment, that it has fallen below 98·6°, and I feel perfectly well. I read for an hour or two, and could very well enjoy a smoke, if I had the wherewithal—Indian cigars being out of the question.

Having no medical training, I am at a loss to account for this state of things. It is impossible that these transitory attacks of high fever should be malarial; it seems more probable that they are due to a kind of sunstroke. On consulting my note-book, I become more and more inclined to think this is the case, for these attacks regularly follow extreme fatigue and long exposure to strong sunshine. They at least have the advantage of being only short interruptions to my work, as on the following morning I am always quite fresh and fit.

My treasure of a cook is suffering from an enormous hydrocele which makes it difficult for him to get up, and Moritz is obliged to keep in the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy from somewhere in the bush, knows still less of cooking than Omari; consequently Nils Knudsen himself has been promoted to the vacant post. Finding that we had come to the end of our supplies, he began by sending to Chingulungulu for the four sucking-pigs which we had

bought from Matola and temporarily left in his charge; and when they came up, neatly packed in a large crate, he callously slaughtered the biggest of them. The first joint we were thoughtless enough to entrust for roasting to Knudsen’s mshenzi cook, and it was consequently uneatable; but we made the rest of the animal into a jelly which we ate with great relish after weeks of underfeeding, consuming incredible helpings of it at both midday and evening meals. The only drawback is a certain want of variety in the tinned vegetables. Dr. Jäger, to whom the Geographical Commission entrusted the provisioning of the expeditions—mine as well as his own—because he had more time on his hands than the rest of us, seems to have laid in a huge stock of Teltow turnips,[46] an article of food which is all very well for occasional use, but which quickly palls when set before one every day; and we seem to have no other tins left. There is no help for it—we must put up with the turnips; but I am certain that, once I am home again, I shall not touch them for ten years to come.

Amid all these minor evils, which, after all, go to make up the genuine flavour of Africa, there is at least one cheering touch: Knudsen has, with the dexterity of a skilled mechanic, repaired my 9 × 12 cm. camera, at least so far that I can use it with a little care.

How, in the absence of finger-nails, he was able to accomplish such a ticklish piece of work, having no tool but a clumsy screw-driver for taking to pieces and putting together again the complicated mechanism of the instantaneous shutter, is still a mystery to me; but he did it successfully. The loss of his finger-nails shows him in a light contrasting curiously enough with the intelligence evinced by the above operation; though, after all, it is scarcely surprising after his ten years’ residence in the bush. One day, at Lindi, he had occasion to wash a dog, which must have been in need of very thorough cleansing, for the bottle handed to our friend for the purpose had an extremely strong smell. Having performed his task in the most conscientious manner, he perceived with some surprise that the dog did not appear much the better for it, and was further surprised by finding his own nails ulcerating away in the course of the next few days. “How was I to know that carbolic acid has to be diluted?” he mutters indignantly, from time to time, with a troubled gaze at his mutilated finger-tips.

Since we came to Newala we have been making excursions in all directions through the surrounding country, in accordance with old habit, and also because the akida Sefu did not get together the tribal elders from whom I wanted information so speedily as he had promised. There is, however, no harm done, as, even if seen only from the outside, the country and people are interesting enough.

The Makonde plateau is like a large rectangular table rounded off at the corners. Measured from the Indian Ocean to Newala, it is about seventy-five miles long, and between the Rovuma and the Lukuledi it averages fifty miles in breadth, so that its superficial area is about two-thirds of that of the kingdom of Saxony. The surface, however, is not level, but uniformly inclined from its south-western edge to the ocean. From the upper edge, on which Newala lies, the eye ranges for many miles east and north-east, without encountering any obstacle, over the Makonde bush. It is a green sea, from which here and there thick clouds of smoke rise, to show that it, too, is inhabited by men who carry on their tillage like so many other primitive peoples, by cutting down and burning the bush, and manuring with the ashes. Even in the radiant light of a tropical day such a fire is a grand sight.

Much less effective is the impression produced just now by the great western plain as seen from the edge of the plateau. As often as time permits, I stroll along this edge, sometimes in one direction, sometimes in another, in the hope of finding the air clear enough to let me enjoy the view; but I have always been disappointed.

Wherever one looks, clouds of smoke rise from the burning bush, and the air is full of smoke and vapour. It is a pity, for under more favourable circumstances the panorama of the whole country up to the distant Majeje hills must be truly magnificent. It is of little use taking photographs now, and an outline sketch gives a very poor idea of the scenery. In one of these excursions I went out of my way to make a personal attempt on the Makonde bush. The present edge of the plateau is the result of a far-reaching process of destruction through erosion and denudation. The Makonde strata are everywhere cut into by ravines, which, though short, are hundreds of yards in depth. In consequence of the loose stratification of these beds, not only are the walls of these ravines nearly vertical, but their upper end is closed by an equally steep escarpment, so that the

western edge of the Makonde plateau is hemmed in by a series of deep, basin-like valleys. In order to get from one side of such a ravine to the other, I cut my way through the bush with a dozen of my men.

It was a very open part, with more grass than scrub, but even so the short stretch of less than two hundred yards was very hard work; at the end of it the men’s calicoes were in rags and they themselves bleeding from hundreds of scratches, while even our strong khaki suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR MAHUTA

I see increasing reason to believe that the view formed some time back as to the origin of the Makonde bush is the correct one. I have no doubt that it is not a natural product, but the result of human occupation. Those parts of the high country where man—as a very slight amount of practice enables the eye to perceive at once—has not yet penetrated with axe and hoe, are still occupied by a splendid timber forest quite able to sustain a comparison with our mixed forests in Germany. But wherever man has once built his hut or tilled his field, this horrible bush springs up. Every phase of this process

may be seen in the course of a couple of hours’ walk along the main road. From the bush to right or left, one hears the sound of the axe— not from one spot only, but from several directions at once. A few steps further on, we can see what is taking place. The brush has been cut down and piled up in heaps to the height of a yard or more, between which the trunks of the large trees stand up like the last pillars of a magnificent ruined building. These, too, present a melancholy spectacle: the destructive Makonde have ringed them— cut a broad strip of bark all round to ensure their dying off—and also piled up pyramids of brush round them. Father and son, mother and son-in-law, are chopping away perseveringly in the background—too busy, almost, to look round at the white stranger, who usually excites so much interest. If you pass by the same place a week later, the piles of brushwood have disappeared and a thick layer of ashes has taken the place of the green forest. The large trees stretch their smouldering trunks and branches in dumb accusation to heaven—if they have not already fallen and been more or less reduced to ashes, perhaps only showing as a white stripe on the dark ground.

This work of destruction is carried out by the Makonde alike on the virgin forest and on the bush which has sprung up on sites already cultivated and deserted. In the second case they are saved the trouble of burning the large trees, these being entirely absent in the secondary bush.

After burning this piece of forest ground and loosening it with the hoe, the native sows his corn and plants his vegetables. All over the country, he goes in for bed-culture, which requires, and, in fact, receives, the most careful attention. Weeds are nowhere tolerated in the south of German East Africa. The crops may fail on the plains, where droughts are frequent, but never on the plateau with its abundant rains and heavy dews. Its fortunate inhabitants even have the satisfaction of seeing the proud Wayao and Wamakua working for them as labourers, driven by hunger to serve where they were accustomed to rule.

But the light, sandy soil is soon exhausted, and would yield no harvest the second year if cultivated twice running. This fact has been familiar to the native for ages; consequently he provides in time, and, while his crop is growing, prepares the next plot with axe and firebrand. Next year he plants this with his various crops and

lets the first piece lie fallow. For a short time it remains waste and desolate; then nature steps in to repair the destruction wrought by man; a thousand new growths spring out of the exhausted soil, and even the old stumps put forth fresh shoots. Next year the new growth is up to one’s knees, and in a few years more it is that terrible, impenetrable bush, which maintains its position till the black occupier of the land has made the round of all the available sites and come back to his starting point.

The Makonde are, body and soul, so to speak, one with this bush.

According to my Yao informants, indeed, their name means nothing else but “bush people.” Their own tradition says that they have been settled up here for a very long time, but to my surprise they laid great stress on an original immigration. Their old homes were in the south-east, near Mikindani and the mouth of the Rovuma, whence their peaceful forefathers were driven by the continual raids of the Sakalavas from Madagascar and the warlike Shirazis[47] of the coast, to take refuge on the almost inaccessible plateau. I have studied African ethnology for twenty years, but the fact that changes of population in this apparently quiet and peaceable corner of the earth could have been occasioned by outside enterprises taking place on the high seas, was completely new to me. It is, no doubt, however, correct.

The charming tribal legend of the Makonde—besides informing us of other interesting matters—explains why they have to live in the thickest of the bush and a long way from the edge of the plateau, instead of making their permanent homes beside the purling brooks and springs of the low country.

“The place where the tribe originated is Mahuta, on the southern side of the plateau towards the Rovuma, where of old time there was nothing but thick bush. Out of this bush came a man who never washed himself or shaved his head, and who ate and drank but little.

He went out and made a human figure from the wood of a tree growing in the open country, which he took home to his abode in the bush and there set it upright. In the night this image came to life and was a woman. The man and woman went down together to the Rovuma to wash themselves. Here the woman gave birth to a stillborn child. They left that place and passed over the high land into the valley of the Mbemkuru, where the woman had another child, which

was also born dead. Then they returned to the high bush country of Mahuta, where the third child was born, which lived and grew up. In course of time, the couple had many more children, and called themselves Wamatanda. These were the ancestral stock of the Makonde, also called Wamakonde,[48] i.e., aborigines. Their forefather, the man from the bush, gave his children the command to bury their dead upright, in memory of the mother of their race who was cut out of wood and awoke to life when standing upright. He also warned them against settling in the valleys and near large streams, for sickness and death dwelt there. They were to make it a rule to have their huts at least an hour’s walk from the nearest wateringplace; then their children would thrive and escape illness.”

The explanation of the name Makonde given by my informants is somewhat different from that contained in the above legend, which I extract from a little book (small, but packed with information), by Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my results agree exactly with the statements of the legend. Washing?

Hapana—there is no such thing. Why should they do so? As it is, the supply of water scarcely suffices for cooking and drinking; other people do not wash, so why should the Makonde distinguish himself by such needless eccentricity? As for shaving the head, the short, woolly crop scarcely needs it,[49] so the second ancestral precept is likewise easy enough to follow. Beyond this, however, there is nothing ridiculous in the ancestor’s advice. I have obtained from various local artists a fairly large number of figures carved in wood, ranging from fifteen to twenty-three inches in height, and representing women belonging to the great group of the Mavia, Makonde, and Matambwe tribes. The carving is remarkably well done and renders the female type with great accuracy, especially the keloid ornamentation, to be described later on. As to the object and meaning of their works the sculptors either could or (more probably) would tell me nothing, and I was forced to content myself with the scanty information vouchsafed by one man, who said that the figures were merely intended to represent the nembo—the artificial deformations of pelele, ear-discs, and keloids. The legend recorded

by Pater Adams places these figures in a new light. They must surely be more than mere dolls; and we may even venture to assume that they are—though the majority of present-day Makonde are probably unaware of the fact—representations of the tribal ancestress.

The references in the legend to the descent from Mahuta to the Rovuma, and to a journey across the highlands into the Mbekuru valley, undoubtedly indicate the previous history of the tribe, the travels of the ancestral pair typifying the migrations of their descendants. The descent to the neighbouring Rovuma valley, with its extraordinary fertility and great abundance of game, is intelligible at a glance—but the crossing of the Lukuledi depression, the ascent to the Rondo Plateau and the descent to the Mbemkuru, also lie within the bounds of probability, for all these districts have exactly the same character as the extreme south. Now, however, comes a point of especial interest for our bacteriological age. The primitive Makonde did not enjoy their lives in the marshy river-valleys.

Disease raged among them, and many died. It was only after they had returned to their original home near Mahuta, that the health conditions of these people improved. We are very apt to think of the African as a stupid person whose ignorance of nature is only equalled by his fear of it, and who looks on all mishaps as caused by evil spirits and malignant natural powers. It is much more correct to assume in this case that the people very early learnt to distinguish districts infested with malaria from those where it is absent.

This knowledge is crystallized in the ancestral warning against settling in the valleys and near the great waters, the dwelling-places of disease and death. At the same time, for security against the hostile Mavia south of the Rovuma, it was enacted that every settlement must be not less than a certain distance from the southern edge of the plateau. Such in fact is their mode of life at the present day. It is not such a bad one, and certainly they are both safer and more comfortable than the Makua, the recent intruders from the south, who have made USUAL METHOD OF good their footing on the western edge of the CLOSING HUT-DOOR plateau, extending over a fairly wide belt of country. Neither Makua nor Makonde show in their dwellings anything of the size and comeliness of the Yao houses in the plain, especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a Makonde hamlet not far from Newala, on the road to Mahuta, is the

most important settlement of the tribe I have yet seen, and has fairly spacious huts. But how slovenly is their construction compared with the palatial residences of the elephant-hunters living in the plain.

The roofs are still more untidy than in the general run of huts during the dry season, the walls show here and there the scanty beginnings or the lamentable remains of the mud plastering, and the interior is a veritable dog-kennel; dirt, dust and disorder everywhere. A few huts only show any attempt at division into rooms, and this consists merely of very roughly-made bamboo partitions. In one point alone have I noticed any indication of progress—in the method of fastening the door. Houses all over the south are secured in a simple but ingenious manner. The door consists of a set of stout pieces of wood or bamboo, tied with bark-string to two cross-pieces, and moving in two grooves round one of the door-posts, so as to open inwards. If the owner wishes to leave home, he takes two logs as thick as a man’s upper arm and about a yard long. One of these is placed obliquely against the middle of the door from the inside, so as to form an angle of from 60° to 75° with the ground. He then places the second piece horizontally across the first, pressing it downward with all his might.

It is kept in place by two strong posts planted in the ground a few inches inside the door. This fastening is absolutely safe, but of course cannot be applied to both doors at once, otherwise how could the owner leave or enter his house? I have not yet succeeded in finding out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe Chauro, however, have a much more complicated, solid and original one. Here, too, the door is as already described, except that there is only one post on the inside, standing by itself about six inches from one side of the doorway. Opposite this post is a hole in the wall just large enough to admit a man’s arm. The door is closed inside by a large wooden bolt passing through a hole in this post and pressing with its free end against the door. The other end has three holes into which fit three pegs running in vertical grooves inside the post. The door is opened with a wooden key about a foot long, somewhat curved and sloped off at the butt; the other end has three pegs corresponding to the holes, in the bolt, so that, when it is thrust through the hole in the wall and inserted into the rectangular opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second showed me on the spot the action of this greatest invention of the Makonde Highlands. To both with an admiring exclamation of “Vizuri sana!” (“Very fine!”). I expressed the wish to take back these marvels with me to Ulaya, to show the Wazungu what clever fellows the Makonde are. Scarcely five minutes after my return to camp at Newala, the two men came up sweating under the weight of two heavy logs which they laid down at my feet, handing over at the same time the keys of the fallen fortress. Arguing, logically enough, that if the key was wanted, the lock would be wanted with it, they had taken their axes and chopped down the posts—as it never occurred to them to dig them out of the ground and so bring them intact. Thus I have