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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