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Healthy Communities: New Partnerships
for the Future of Public Health
Michael A. Stoto, Cynthia Abel, and Anne DievIer, Editors
A Report of the First Year of the
Committee on Public Health
INSTITUTE OF MEDICINE
TOM
NATIONAL ACADEMY PRESS
Washington, D.C. 1996
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INSTITUTE OF MEDICINE 2101 Constitution Avenue, NW, Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of the
National Academy of Sciences, the National Academy of Engineering, and the Institute of
Medicine. The members of the committee responsible for this report were chosen for their
special competencies and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to
procedures approved by a Report Review Committee consisting of members of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences
to enlist distinguished members of the appropriate professions in the examination of policy
matters pertaining to the health of the public. In this, the Institute acts under both the
Academy's 1863 congressional charter responsibility to be an adviser to the federal
government and its own initiative in identifying issues of medical care, research, and
education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
Support for this project was provided by W. K. Kellogg Foundation, The Robert Wood
Johnson Foundation, and by Grant Number H75/CCH311468-02 from the Centers for
Disease Control and Prevention. The contents of this report reflect the views of the
Committee on Public Health and are not necessarily those of the sponsors.
International Standard Book Number 0-309-05625-X
Additional copies of this report are available for sale from the National Academy
Press, Box 285, 2101 Constitution Avenue, N.W., Washington, DC 20055. Call (800) 624-
6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line
bookstore at http://www.nap.edu.
Copyright 1996 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all
cultures and religions since the beginning of recorded history. The image adopted as a
logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now
held by the Staatlichemuseen in Berlin.
-
~. -
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COMMITTEE ON PUBLIC HEALTH
STUART BONDURANT (Cochair), Interim Dean and Professor of Medicine,
University of North Carolina School of Medicine, Chapel Hill
HUGH H. TILSON (Cochair), Professor of Epidemiology and Health Policy,
University of North Carolina School of Public Health, Chapel Hill
MARGARET A. HAMBURG, Health Commissioner, New York City
Department of Health
JOHN LUMPKIN, Director, Illinois Department of Public Health, Springfield
ROBERT B. WALLACE, Professor of Preventive and Internal Medicine and
Director, Cancer Center, University of Iowa
Institute of Medicine Staff
MICHAEL A. STOTO, Director, Division of Health Promotion and Disease
Prevention
CYNTHIA ABEL, Program Officer
DONNA THOMPSON, Division Assistant
ANNE DIEVLER, Consultant
MONA BRINEGAR, Financial Associate (through July 1995)
SHARON GALLOWAY, Financial Associate (after September 1995)
Liaison Panel to the Committee on Public Health
EDWARD L. BAKER, Director, Public Health Practice Program Office,
Centers for Disease Control and Prevention, Atlanta, Ga.
STEVE BOEDIGHEIMER, Deputy Director, Division of Public Health,
Delaware Health and Social Services, Dover
JO IVEY BOUFFORD, Principal Deputy Assistant Secretary for Health,
U.S.Public Health Service, Department of Health and Human Services,
Washington, D.C.
E. RICHARD BROWN, Professor of Public Health, School of Public Health
and Director, Center for Health Policy Research, University of California,
Los Angeles
THOMAS A. BRUCE, Program Director, W.K. Kellogg Foundation, Battle
Creek, Mich.
CASWELL A. EVANS, JR., Assistant Director of Health Services, Director,
Public Health Programs and Services, County of Los Angeles, Department
of Health Services
*Institute of Medicine member.
. . .
zz!
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KRISTINE M. GEBBIE, Assistant Professor of Nursing, Columbia University
School of Nursing
KAREN IGNAGNI, President and CEO, American Association of Health Plans,
Washington, D.C.
NANCY KAUFMAN,Vice President, The Robert Wood Johnson Foundation,
Princeton, New Jersey
ROZ LASKER, Director, Division of Public Health, New York Academy of
Medicine, New York City
CHARLES MAHAN, Dean College of Public Health, University of South
Florida College of Public Health
KATHY NEWMAN, Director, Barron County Health Department, Barron, Wis.
ROBERT PESTRONK, Health Officer, Genesee County Health Department,
Flint, Mich.
WILLIAM L. ROPER, Senior Vice President, Prudential Health Care,
Roseland, New Jersey
DAVID SATCHER, Director, Center for Disease Control and Prevention,
Atlanta, Ga.
CIRO SUMAYA, Administrator, Health Resources and Services
Administration, Rockville, Md.
MARTIN WASSERMAN, Secretary, Health and Mental Hygiene Department,
State of Maryland, Baltimore
IV
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Preface
In 1988, after extensive review of data, interviews, forums, and analyses, the
Institute of Medicine (IOM) released a landmark report, The Future of Public
Health. While this report raised questions about many aspects of public health as
it was practiced at the time, it also found much to commend. Its primary impact
was setting forth a "vision" for public health, including the mission and substance
of governmental public health agencies, an organizational framework, and specific
recommendations. The Future of Public Health also served as a catalyst for
change in the public health system, and the response to the report was wide
ranging, varied, and extensive. During the years since The Future of Public
Health was released, there has been a significant strengthening of practice by
governmental public health agencies in many respects.
Almost a decade abler the committee that wrote The Future of Public Health
was created, the IOM established the Committee on Public Health to review He
progress that has been made since the release of The Future of Public Health and
to address selected areas that have experienced substantial changes. To assist the
committee in its efforts, the IOM also identified a liaison panel of people from
government, academia, industry, and citizen and other private-sector groups to
help identify emerging issues and to facilitate an informed dialogue on current
issues in public health. This group was called the Public Health Roundtable.
The discussions initiated by the Committee on Public Health were richly
substantive and allowed its members to address, fundamental issues in public
health that were not being dealt with in other settings. Over a nine-month period,
the committee held three meetings focused on (1) progress toward achieving the
recommendations presented in The Future of Public Health, (2) the relationship
v
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vi
HEALTHY COMMUNITIES
between public health agencies and managed care organizations, and (3) the
emerging role of the public health agency in the community. These discussions
revealed that although they are making gains on some fronts and losing ground on
others, public health agencies are alive and well. The discussions also revealed an
astonishing array of activities being carried out in response to The Future of Public
Health.
The substance of this report is drawn from the committee's discussions and
other related IOM projects, but the conclusions presented in this report are those of
the Committee on Public Health. The material in the text boxes is drawn from
presentations at committee meetings and from members of the liaison panel.
These boxes are intended to give the reader a sense of the committee's discussions
but do not necessarily represent a consensus of the committee.
During its first year, the Committee on Public Health was able to address only
some of the many issues in public health today. In the course of its deliberations,
the committee encountered evidence that many of the problems identified in The
Future of Public Health were still with us. In light of these limitations, the
committee's first-year report does not aim to replace The Future of Public Health,
but rather to supplement and update it in two critical areas: the relationship
between public health agencies and the public's health and managed care, and the
role of the public health agency in the community. The committee recognizes that
not all local public health agencies are currently dealing with the issues covered in
the report, but we believe that the report should be useful to all agencies as they
think about how to approach these issues in the future.
As cochairs of the Committee on Public Health, we gratefully acknowledge
the contributions of the committee, the Public Health Roundtable, and the many
people (listed in the appendixes) with whom we met during the course of our
work. We would like to thank Anne Dievler, who worked with IOM staff
members in drafting several sections of the report and Michael Edington, who
provided excellent editorial skills. We would like to give special thanks to the
staff for this project, Michael Stoto, Cynthia Abel, and Donna Thompson, for their
tireless efforts to organize and synthesize the committee's activities.
Stuart Bondurant, Cochair
Hugh Tilson, Cochair
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Contents
EXECUTIVE SUMMARY
INTRODUCTION
Factors Affecting Public Health, 9
Summary and Organization of This Report, 11
PUBLIC HEALTH AND MANAGED CARE
Strengths and Weaknesses of Managed Care for Public Health, 15
Defining Roles and Responsibilities, 19
Conclusions, 26
PUBLIC HEALTH AND THE COMMUNITY
Policy Development in Public Health, 33
Collaboration with the Community, 34
Difficult Problems and Difficulty Solving Problems, 35
Conclusions, 40
REVISITING THE FUTURE OF PUBLIC HEALTH
Better Definitions of Public Health, 43
Public Health Capacity, 46
Practice Guidelines for Prevention, 46
Training of Public Health Professionals, 48
Developing Stronger Leaders and Practitioners, 48
Conclusions, 49
. .
V11
7
13
31
43
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~ . .
V111
REFERENCES
APPENDIX A
APPENDIX B
APPENDIX C
HEALTHY COMMUNITIES
51
57
67
75
