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Summary and Recommendations
WHY STUDY PUBLIC HEALTH
Many of the major improvements in the health of the American people
have been accomplished through public health measures. Control of epi-
demic diseases, safe food and water, and maternal and child health services
are only a few of the public health achievements that have prevented count-
less deaths and improved the quality of American life. But the public has
come to take the success of public health for granted. Health officials have
difficulty communicating a sense of urgency about the need to maintain
current preventive efforts and to sustain the capability to meet future threats
to the public's health.
This study was undertaken to address a growing perception among the
Institute of Medicine membership and others concerned with the health of
the public that this nation has lost sight of its public health goals and has
allowed the system of public health activities to fall into disarray. Public
health is what we, as a society, do collectively to assure the conditions in
which people can be healthy. This requires that continuing and emerging
threats to the health of the public be successfully countered. These threats
include immediate crises, such as the AIDS epidemic; enduring problems,
such as injuries and chronic illness; and impending crises foreshadowed by
such developments as the toxic by-products of a modern economy.
These and many other problems demonstrate the need to protect the
nation's health through effective, organized, and sustained efforts by the
public sector. Unfortunately, the findings of this committee confirm the
concerns that led to the study. The current state of our abilities for effective
1
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2
THE FUTURE OF PUBLIC HEALTH
public health action, as documented in this volume, is cause for national
concern and for the development of a plan of action for needed improve-
ments. In the committee's view, we have slackened our public health vig-
ilance nationally, and the health of the public is unnecessarily threatened as a
result.
An impossible responsibility has been placed on America's public health
agencies: to serve as stewards of the basic health needs of entire populations,
but at the same time avert impending disasters and provide personal health
care to those rejected by the rest of the health system. The wonder is not that
American public health has problems, but that so much has been done so
well, and with so little.
The Committee for the Study of the Future of Public Health is keenly
aware of the public health system's many achievements and of the dedication
and sustained efforts of public health workers across the country. The
committee's purpose, however, is to bring the difficulties of public health to
the attention of the nation in order to mobilize action to strengthen public
health. Successes as great as those of the past are still possible, but not
without public concern and concerted action to restore America's public
health capacity.
This volume envisions the future of public health, analyzes the current
situation and how it developed, and presents a plan of action that will, in the
committee's judgment, provide a solid foundation for a strong public health
capability throughout the nation.
THE APPROACH
During the past 2 years, the committee has studied America's public
health system in detail. It has attempted to see public health in action, as
revealed by data and as perceived by those involved in it, both inside and
outside public health agencies. It has examined demographic and epidem-
iologic statistics, agency budgets, organization charts, program plans, stat-
utes, and regulations. It has visited localities in six states and spoken with
more than 350 people: state and local health officers, public health nurses,
sanitarians, legislators, citizen activists, public administrators, voluntary
agency personnel, private physicians, and many others. In addition, public
meetings were held in Boston, Chicago, New Orleans, and Las Vegas, as well
as a conference in Houston on public health education attended by public
health educators and practitioners. Finally, the committee reviewed the
history of American public health and visited with health officials in Toronto
to glimpse the enterprise as practiced in another country, where universal
entitlement to medical care is part of the context for that practice.
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SUMMARY AND RECOMMENDATIONS
THE STATE OF U.S. PUBLIC HEALTH
Throughout the history of public health, two major factors have deter-
mined how problems were solved: the level of scientific and technical knowl-
edge, and the content of public values and popular opinions. Over time,
public health measures have changed with important advances in under-
standing the causes and control of disease. In addition, practice was affected
by popular beliefs about illness and by public views on appropriate govern-
mental action. As poverty and disease came to be seen as societal as well as
personal problems, and as governmental involvement in societal concerns
increased, collective action against disease was gradually accepted. Health
became a social as well as individual responsibility. At the same time,
advances such as the discovery of bacteria and identification of better ways to
control and prevent communicable disease made possible effective commu-
nity action under the auspices of increasingly professional public health
agencies.
THE PUBLIC HEALTH MISSION
Knowledge and values today remain decisive elements in the shaping of
public health practice. But they blend less harmoniously than they once did.
On the surface there appears to be widespread agreement on the overall
mission of public health, as reflected in such comments to the committee as
"public health does things that benefit everybody," or "public health pre-
vents illness and educates the population." But when it comes to translating
broad statements into effective action, little consensus can be found. Neither
among the providers nor the beneficiaries of public health programs is there
a shared sense of what the citizenry should expect in the way of services,
and both the mix and the intensity of services vary widely from place to
place.
In one state the committee visited, the state health department was a
major provider of prenatal care for poor women; in other places, women
who could not pay got no care. Some state health departments are active and
well equipped, while others perform fewer functions and get by on relatively
meager resources. Localities vary even more widely: in some places, the
local health departments are larger and more sophisticated technically than
many state health departments. But in too many localities, there is no health
department. Perhaps the area is visited occasionally by a "circuit-riding"
public health nurse and perhaps not.
Lack of agreement about the public health mission is also reflected in the
diversion in some states of traditional public health functions, such as water
and air pollution control, to separate departments of environmental ser-
vices, where the health effects of pollutants often receive less notice.
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THE FUTURE OF PUBLIC HEALTH
In some states, mental health is seen as a public health responsibility, but
in many the two are organizationally distinct, making it difficult to coordi-
nate services to multiproblem clients. Some health departments are part of
larger departments of "social and health services," where public health
scientists find their approaches, which benefit society as a whole, stamped
with a negative welfare label.
Such extreme variety of available services and organizational arrange-
ments suggests that contemporary public health is defined less by what
public health professionals know how to do than by what the political system
in a given area decides is appropriate or feasible.
PROFESSIONAL EXPERTISE AND THE POLITICAL PROCESS
Tension between professional expertise and politics can be observed
throughout the nation's public health system. Public health professionals
rely on expert knowledge derived from such areas as epidemiology and
biostatistics to identify and deal with the health needs of whole populations.
A central tenet of their professional ethic is commitment to use this knowl-
edge to fulfill the public interest in reducing human suffering and enhancing
the quality of life. Thus their aim is to maximize the influence of accurate
data and professional judgment on decision-making to make decisions as
comprehensive and objective as possible.
The dynamics of American politics, however, make it difficult to fulfill this
commitment. Decision-making in public health, as in other areas, is driven
by crises, hot issues, and the concerns of organized interest groups. Deci-
sions are made largely on the basis of competition, bargaining, and influence
rather than comprehensive analysis. The idea that politics can be restricted
to the legislative arena, while the work of public agencies remains neutral
and expert, has been discredited. Professional analysis and judgment must
compete with other perspectives for policy attention and support.
Public health has had great difficulty accommodating itself to these politi-
cal dynamics. Technical knowledge in fact plays a much more restricted role
in public health decision-making than it once did, despite the fact that we
now know more. The impact of politics is clearly evident in the rapid
turnover among public health officials (the average tenure of a state health
officer is now only 2 years); in a marked shift toward political appointees as
opposed to career professionals in the top ranks of health agencies; and in
the gradual disappearance of state boards of health, which have dwindled by
half (from nearly all states to 24) in only 25 years. Too frequently during its
investigations, the committee heard legislators and members of the general
public castigate public health professionals as paper-shufflers, out of touch
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SUMMARY AND RECOMMENDATIONS
s
with reality, and caught up in red tape. There is a sharp tendency to take
what are perceived as "important" programs (for example, Medicaid and
environmental programs) away from health departments. The growing per-
ception of health as big business has led to attempts to take public health
"out of the hands of the doctors" by interposing a nonmedical administrator
between the health officer and elected officials.
Perhaps because they view their professional knowledge and skills as
effective and therefore obviously valuable, public health professionals ap-
pear to have been slow in developing strategies to demonstrate the worth of
their efforts to legislators and the public. Public health crises, not public
health successes, make headlines. A number of well-informed members of
the public had only vague ideas about what their local health department
did. Without broad support, public health officials appear defensive and
self-serving when they attempt to answer the criticisms of legislators or
mobilize needed resources. Yet many public health professionals who talked
with us seemed to regard politics as a contaminant of an ideally rational
decision-making process rather than as an essential element of democratic
governance. We saw much evidence of isolation and little evidence of constit-
uency building, citizen participation, or continuing (as opposed to crisis-
driven) communications with elected officials or with the community at
large.
PUBLIC HEALTH AND THE MEDICAL PROFESSION
The political difficulties of public health are reflected in an especially vivid
way in its associations with private medicine. Historically, this has been an
uneasy relationship. The discovery of bacteria, which proved such a boon to
public health's disease control efforts, also brought it into competition with
physicians, inasmuch as control measures such as immunizations were car-
ried out not in the environment but on individual patients, who were the
purview of the private doctor. Today, while numerous examples can be
found of medical community support for public health activities (witness the
American Medical Association's stance on AIDS), too often confrontation
and suspicion are evident on both sides. For example, the director of one
state medical association characterized the health department as distrustful
of physicians and cited the director's effort to push a mandatory data-
reporting system through the legislature without consulting the society. The
committee found medical leaders who were unaware of public health activ-
ities in their communities; yet these same leaders are crucial to the imple-
mentation of many public health measures and vital in building political
support.
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THE FUTURE OF PUBLIC HEALTH
THE KNOWLEDGE BASE AND ITS APPLICATION
This summary of the state of U.S. public health began with the observa-
tion that both technical knowledge and public values determine how public
health is practiced. Clearly, the current impact of public values is trouble-
some, as political dilemmas attest. But there are also problems on the
knowledge front.
Effective public health action must be based on accurate knowledge of the
causes and distribution of health problems and of effective interventions.
Despite much progress, there are still significant knowledge gaps for many
public health problems, for example, the health risks of long-term exposure
to certain toxic chemicals or the role of stress in disease.
Because public health is an applied activity, operating under fiscal con-
straints, it is often difficult to mobilize and sustain necessary research. In our
site visits, we found that only one of six states had made a substantial
investment in research. Similarly, technical expertise is unevenly distrib-
uted: public health employees in some larger states have a considerable skill
level, but many others do not. The problem is exacerbated by a shortage of
epidemiologists and other trained experts. In many jurisdictions low salary
structures and unrewarding professional environments may further inhibit
the acquisition of expertise.
In addition, there has been little attention in public health to management
as a technical skill in its own right. Management of a public health agency is a
demanding, high-visibility assignment requiring, in addition to technical and
political acumen, the ability to motivate and lead personnel, to plan and
allocate agency resources, and to sense and deal with changes in the agency's
environment and to relate the agency to the larger community. Progress in
public health in the United States has been greatly advanced throughout its
history by outstanding individuals who fortuitously combined all these quali-
ties. Today, the need for leaders is too great to leave their emergence to
chance. Yet there is little specific focus in public health education on leader-
ship development, and low salaries and a low public image make it difficult to
attract outstanding people into the profession and to retain them until they
are ready for top posts.
THE FUTURE OF PUBLIC HEALTH: RECOMMENDATIONS
In conducting this study, the committee has sought to take a fresh look at
public health its mission, its current state, and the barriers to improve-
ment. The committee has concluded that effective public health activities are
essential to the health and well-being of the American people, now and in
the future. But public health is currently in disarray. Some of the frequently
heard criticisms of public health are deserved, but this society has contrib-
uted to the disarray by lack of clarity and agreement about the mission of
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SUMMARY AND RECOMMENDATIONS
7
public health, the role of government, and the specific means necessary to
accomplish public health objectives. To provide a set of directions for public
health that can attract the support of the total society, the committee has
made three basic recommendations dealing with:
· the mission of public health,
· the governmental role in fulfilling the mission, and
· the responsibilities unique to each level of government.
The rest of the recommendations are instrumental in implementing the
basic recommendations for the future of public health. These instrumental
recommendations fall into the following categories: statutory framework;
structural and organizational steps; strategies to build the fundamental
capacities of public health agencies technical, political, managerial, pro-
grammatic, and fiscal; and education for public health.
THE PUBLIC HEALTH MISSION, GOVERNMENTAL ROLE,
AND LEVELS OF RESPONSIBILITY
MISSION
· The committee defines the mission of public health as fulfilling society's
interest in assuring conditions in which people can be healthy. Its aim is to
generate organized community effort to address the public interest in health
by applying scientific and technical knowledge to prevent disease and pro-
mote health. The mission of public health is addressed by private organiza-
tions and individuals as well as by public agencies. But the governmental
public health agency has a unique function: to see to it that vital elements are
in place and that the mission is adequately addressed.
THE GOVERNMENTAL ROLE IN PUBLIC HEALTH
· The committee finds that the core functions of public health agencies at
all levels of government are assessment, policy development, and assurance.
Assessment
· The committee recommends that every public health agency regularly
and systematically collect, assemble, analyze, and make available information
on the health of the community, including statistics on health status, commu-
nity health needs, and epidemiologic and other studies of health problems.
Not every agency is large enough to conduct these activities directly; inter-
governmental and interagency cooperation is essential. Nevertheless each
agency bears the responsibility for seeing that the assessment function is
fulfilled. This basic function of public health cannot be delegated.
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THE FUTURE OF PUBLIC HEALTH
Policy Development
· The committee recommends that every public health agency exercise its
responsibility to serve the public interest in the development of comprehen-
sive public health policies by promoting use of the scientific knowledge base in
decision-making about public health and by leading in developing public
health policy. Agencies must take a strategic approach, developed on the basis
of a positive appreciation for the democratic political process.
Assurance
· The committee recommends that public health agencies assure their
constituents that services necessary to achieve agreed upon goals are pro-
vided, either by encouraging actions by other entities (private or public
sector), by requiring such action through regulation, or by providing services
directly.
· The committee recommends that each public health agency involve key
policymakers and the general public in determining a set of high-priority
personal and communitywide health services that governments will guaran-
tee to every member of the community. This guarantee should include subsi-
dization or direct provision of high-priority personal health services for those
unable to afford them.
LEVELS OF RESPONSIBILITY
In addition to these functions, which are common to federal, state, and
local governments, each level of government has unique responsibilities.
States
· The committee believes that states are and must be the central force in
public health. They bear primary public sector responsibility for health.
~ The committee recommends that the public health duties of states should
include the following:
lion;
state;
-assessment of health needs in the state based on statewide data collec
assurance of an adequate statutory base for health activities in the
-establishment of statewide health objectives, delegating power to lo-
calities as appropriate and holding them accountable;
assurance of appropriate organized statewide effort to develop and
maintain essential personal, educational, and environmental health services;
provision of access to necessary services; and solution of problems inimical to
health;
-guarantee of a minimum set of essential health services; and
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SUMMARY AND RECOMMENDATIONS
9
support of local service capacity, especially when disparities in local
ability to raise revenue and/or administer programs require subsidies, techni-
cal assistance, or direct action by the state to achieve adequate service levels.
Federal
· The committee recommends the following as federal public health obli-
gations:
support of knowledge development and dissemination through data
gathering, research, and information exchange;
-establishment of nationwide health objectives and priorities, and stim-
ulation of debate on interstate and national public health issues;
-provision of technical assistance to help states and localities determine
their own objectives and to carry out action on national and regional objec
tives;
provision of funds to states to strengthen state capacity for services,
especially to achieve an adequate minimum capacity, and to achieve national
objectives; and
assurance of actions and services that are in the public interest of the
entire nation such as control of AIDS and similar communicable diseases,
interstate environmental actions, and food and drug inspection.
Localities
Because of great diversity in size, powers, and capacities of local govern-
ments, generalizations must be made with caution. Nevertheless, no citizen
from any community, no matter how small or remote, should be without
identifiable and realistic access to the benefits of public health protection,
which is possible only through a local component of the public health delivery
system.
· The committee recommends the following functions for local public
health units:
- assessment, monitoring, and surveillance of local health problems and
needs and of resources for dealing with them;
policy development and leadership that foster local involvement and a
sense of ownership, that emphasize local needs, and that advocate equitable
distribution of public resources and complementary private activities com-
mensurate with community needs; and
assurance that high-quality services, including personal health ser-
vices, needed for the protection of public health in the community are avail-
able and accessible to all persons; that the community receives proper consid-
eration in the allocation of federal and state as well as local resources for
public health; and that the community is informed about how to obtain public
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THE FUTURE OF PUBLIC HEALTH
health, including personal health, services, or how to comply with public
health requirements.
FULFILLING THE GOVERNMENT ROLE: IMPLEMENTING
RECOMMENDATIONS
A number of specific steps should be taken to enable public health
agencies to fulfill the functions outlined above. These include modification
of public health statutes, changes in the organizational structure, special
linkages, strategies for building agency capacity, and improvements in edu-
cation for public health.
STATUTES
· The committee recommends that states review their public health
statutes and make revisions necessary to accomplish the following two
objectives:
-clearly delineate the basic authority and responsibility entrusted to
public health agencies, boards, and officials at the state and local levels and
the relationships between them; and
-support a set of modern disease control measures that address contem-
porary health problems such as AIDS, cancer, and heart disease, and incor-
porate due process safeguards (notice, hearings, administrative review, right
to counsel, standards of evidence).
ORGANIZATIONAL STRUCTURE
States
As the primary locus for action in the public health arena, states must
establish a clear organizational focal point for public health responsibility.
· The committee recommends that each state have a department of health
that groups all primarily health-related functions under professional direc-
tion-separate from income maintenance. Responsibilities of this department
should include disease prevention and health promotion, Medicaid and other
indigent health care activities, mental health and substance abuse, environ-
mental responsibilities that clearly require health expertise, and health plan-
ning and regulation of health facilities and professions.
~ The committee recommends that each state have a state health council
that reports regularly on the health of the state's residents, makes health
policy recommendations to the governor and legislature, promulgates public
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SUMMARY AND RECOMMENDATIONS
11
health regulations, reviews the work of the state health department, and
recommends candidates for director of the department.
· The committee recommends that the director of the department of
health be a cabinet (or equivalent-level) officer. Ideally, the director should
have doctoral-level education as a physician or in another health profession, as
well as education in public health itself and extensive public sector administra-
tive experience. Provisions for tenure in office, such as a specific term of
appointment, should promote needed continuity of professional leadership.
· The committee recommends that each state establish standards for local
public health functions, specifying what minimum services must be offered,
by what unit of government, and how services are to be financed. States
(unless providing local services directly) should hold localities accountable for
these services and for addressing statewide health objectives, using the
Model Standards: A Guide for Community Preventive Health Services as a
guide.
Localities
Local circumstances will determine the appropriate balance between state
and local responsibilities. But in general the committee prefers delegation of
responsibilities to the local level.
· The committee finds that the larger the population served by a single
multipurpose government, as well as the stronger the history of local control,
the more realistic the delegation of responsibility becomes: for example, to a
large metropolitan city, county, or service district. Two attributes of such a
locally responsible system are strongly recommended:
To promote clear accountability, public health responsibility should be
delegated to only one unit of government in a locality. For example, in the case
of large cities, public health responsibility should be lodged either in the
municipal or the county government, but not both.
- Where sparse population or scarce resources prevail, delegation to
regional single-purpose units, such as multicounty health districts, may be
appropriate. In order to be effective, health districts must be linked
by formal ties to, and receive resources from, general-purpose govern-
ments.
· The committee recommends that mechanisms be instituted to promote
local accountability and assure the maintenance of adequate and equitable
levels of service and qualified personnel.
· The committee finds that the need for a clear focal point at the local level
is as great as at the state level, and for the same reasons. Where the scale of
government activity permits, localities should establish public health councils
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THE FUTURE OF PUBLIC HEALTH
to report to elected officials on local health needs and on the performance of
the local health agency.
Federal
· The committee recommends that the federal government identify more
clearly, in formal structure and actual practice, the specific officials and
agencies with primary responsibility for carrying out the federal public health
functions recommended earlier.
· The committee recommends the establishment of a task force to consider
what structure or programmatic changes would be desirable to enhance the
federal government's ability to fulfill the public health leadership respon-
sibilities recommended in this report.
SPECIAL LINKAGES
The committee finds that environmental health and mental health activ-
ities are frequently isolated from state and local public health agencies,
resulting in disjointed policy development, fragmented service delivery, lack
of accountability, and a generally weakened public health effort.
Environmental Health
The removal of environmental health authority from public health agen-
cies has led to fragmented responsibility, lack of coordination, and inade-
quate attention to the health dimensions of environmental problems.
O The committee recommends that state and local health agencies
strengthen their capacities for identification, understanding, and control of
environmental problems as health hazards. The agencies cannot simply be
advocates for the health aspects of environmental issues, but must have direct
operational involvement.
Mental Health
The separation of public health and mental health leads to fragmentation
at the service delivery point, to the detriment of clients.
· The committee recommends that those engaged in knowledge develop-
ment and policy planning in public health and in mental health, respectively,
devote a specific effort to strengthening linkages with the other field, partic-
ularly in order to identify strategies to integrate these functions at the service
delivery level.
O The committee recommends that a study of the public health/mental
health interface be done in order to document how the lack of linkages with
public health hampers the mental health mission.
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SUMMARY AND RECOMMENDATIONS
13
Social Services
In states where public health is part of a "super" department of social
services, the income maintenance function tends to detract from commu-
nitywide services and give public health a negative welfare image.
· The committee recommends that public health be separated organiza-
tionally from income maintenance, but that public health agencies maintain
close working relationships with social service agencies in order to act as
effective advocates for, and to cooperate with, social service agency provision
of social services that have an impact on health.
Care of the Indigent
Many public health agencies have become last-resort providers of per-
sonal medical care, draining vital resources away from populationwide
services.
· The committee endorses the conclusion of the President's Commission
for the Study of Ethical Problems in Medical Care and Biomedical and
Behavioral Research that the ultimate responsibility for assuring equitable
access to health care for all, through a combination of public and private
sector action, rests with the federal government.
· The committee finds that, until adequate federal action is forthcoming,
public health agencies must continue to serve, with quality and respect and to
the best of their ability, the priority personal health care needs of uninsured,
underinsured, and Medicaid clients.
STRATEGIES FOR CAPACITY BUILDING
To equip public health agencies to fulfill adequately their assessment,
policy development, and assurance functions, it is necessary to go beyond
reorganization to build agency competence. The types of competence
needed are technical, political, managenal, programmatic, and fiscal. The
committee recommends the following steps.
Technical
· A uniform national data set should be established that will permit valid
comparison of local and state health data with those of the nation and of other
states and localities and that will facilitate progress toward national health
objectives and implementation of Model Standards: A Guide for Community
Preventive Health Services.
· There should be an institutional home in each state and at the federal
level for development and dissemination of knowledge, including research and
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THE FUTURE OF PUBLIC HEALTH
the provision of technical assistance to lower levels of government and to
academic institutions and voluntary organizations.
· Research should be conducted at the federal, state, and local levels into
population-based health problems, including biological, environmental, and
behavioral issues. In addition to conducting research directly, the federal
government should support research by states, localities, universities, and the
private sector.
Political
· Public health agency leaders should develop relationships with and edu-
cate legislators and other public officials on community health needs, on
public health issues, and on the rationale for strategies advocated and pursued
by the health department. These relationships should be cultivated on an
ongoing basis rather than being neglected until a crisis develops.
· Agencies should strengthen the competence of agency personnel in com-
munity relations and citizen participation techniques and develop procedures
to build citizen participation into program implementation.
· Agencies should develop and cultivate relationships with physicians and
other private sector representatives. Physicians and other health profession-
als are important instruments of public health by virtue of such activities as
counseling patients on health promotion and providing immunizations. They
are important determinants of public attitudes and of the image of public
health. Public health leaders should take the initiative to seek working rela-
tionships and support among local, state, and national medical and other
professional societies and academic medical centers.
· Agencies should seek stronger relationships and common cause with
other professional and citizen groups pursuing interests with health implica-
tions, including voluntary health organizations, groups concerned with im-
proving social services or the environment, and groups concerned with eco-
nomic development.
· Agencies should undertake education of the public on community health
needs and public health policy issues.
· Agencies should review the quality of "street-level" contacts between
department employees and clients, and where necessary conduct in-service
training to ensure that members of the public are treated with cordiality and
respect.
Managerial
· Greater emphasis in public health curricula should be placed on mana-
gerial and leadership skills, such as the ability to communicate important
agency values to employees and enlist their commitment; to sense and deal
with important changes in the environment; to plan, mobilize, and use
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SUMMARY AND RECOMMENDATIONS
15
resources effectively; and to relate the operation of the agency to its larger
community role.
· Demonstrated management competence as well as technical/professional
skills should be a requirement for upper-level management posts.
· Salaries and benefits should be improved for health department man-
agers, especially health officers, and systems should be instituted so that they
can carry retirement benefits with them when they move among different
levels and jurisdictions of government.
Programmatic
· The committee recommends that public health professionals place more
emphasis on factors that influence health-related behavior and develop com-
prehensive strategies that take these factors into account.
Fiscal
· The committee recommends the following policies with respect to ~nter-
governmental strategies for strengthening the fiscal base of public health:
Federal support of state-level health programs should help balance
disparities in revenue-generat~ng capacities and encourage state attention to
national health objectives. Particular vehicles for such support should include
"core" funding with appropriate accountability mechanisms, as well as
funds targeted for specific uses.
State support of local-level health services should balance local reve-
nue-generating disparity, establish local capacity to provide minimum levels
of service, and encourage local attention to state health objectives; support
should include "core" funding. State funds could be furnished with strings
attached and sanctions available for noncompliance, and/or general support
could be provided with appropriate accountability requirements built in.
States have the obligation in either case to monitor local use of state
funds.
EDUCATION FOR PUBLIC HEALTH
Many educational paths can lead to careers in public health. However, the
most direct educational path to a career in public health is to obtain a degree
from a school of public health. Many of the 25 schools of public health are
located in research universities and thus have a dual responsibility to develop
knowledge and to produce well-trained professional practitioners. These
dual roles are not always easy to balance.
Many observers feel that some schools have become somewhat isolated
from public health practice and therefore no longer place a sufficiently high
value on the training of professionals to work in health agencies. The dearth
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THE FUTURE OF PUBLIC HEALTH
of professional agency leadership noted by the committee during the study
may lend support to this view. The observed variations in agency practice,
inadequate salaries, and frequently negative image of public health practice
may partly account for any less-than-desirable responses by the educational
institutions to the needs of practice.
In addition, most public health workers have no formal training in public
health, and their need for basic grounding may not be appropriately met by
the degree programs appropriate to prepare people for middle- and upper-
level positions. To these ends the committee recommends:
· Schools of public health should establish firm practice links with state
and/or local public health agencies so that significantly more faculty members
may undertake professional responsibilities in these agencies, conduct re-
search there, and train students in such practice situations. Recruitment of
faculty and admission of students should give appropriate weight to prior
public health experience as well as to academic qualifications.
· Schools of public health should fulfill their potential role as significant
resources to government at all levels in the development of public health
policy.
· Schools of public health should provide students an opportunity to learn
the entire scope of public health practice, including environmental, educa-
tional, and personal health approaches to the solution of public health prob-
lems; the basic epidemiological and biostatistical techniques for analysis of
those problems; and the political and management skills needed for leader-
ship in public health.
· Research in schools of public health should range from basic research in
fields related to public health, through applied research and development, to
program evaluation and implementation research. The unique research mis-
sion of the schools of public health is to select research opportunities on the
basis of their likely relevance to the solution of real public health problems
and to test such applications in real life settings.
· Schools of public health should take maximum advantage of training
resources in their universities, for example, faculty and courses in schools of
business administration, and departments of physical, biological, and social
sciences. The hazards of developing independent faculty resources isolated
from the main disciplinary departments on the campus are real, and links
between faculty in schools of public health and their parent disciplines
should be sought and maintained.
· Because large numbers of persons being educated in other parts of the
university will assume responsibilities in life that impact significantly on the
public's health, e.g., involvement in production of hazardous goods or the
enactment and enforcement of public health laws, schools of public health
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SUMMARY AND RECOMMENDATIONS
17
should extend their expertise to advise and assist with the health content of the
educational programs of other schools and departments of the university.
· In view of the large numbers of personnel now engaged in public health
without adequate preparation for their positions, the schools of public health
should undertake an expanded program of short courses to help upgrade the
competence of these personnel. In addition, short course offerings should
provide opportunities for previously trained public health professionals, espe-
cially health officers, to keep up with advances in knowledge and practice.
· Because the schools of public health are not, and probably should not
try to be, able to train the vast numbers of personnel needed for public health
work, the schools of public health should encourage and assist other institu-
tions to prepare appropriate, qualified public health personnel for positions in
the field. When educational institutions other than schools of public health
undertake to train personnel for work in the field, careful attention to the
scope and capacity of the educational program is essential. This may be
achieved in part by links with nearby schools of public health.
· Schools of public health should strengthen their response to the needs for
qualified personnel for important, but often neglected, aspects of public
health such as the health of minority groups and international health.
· Schools of public health should help develop, or offer directly in their
own universities, effective courses that expose undergraduates to concepts,
history, current context, and techniques of public health to assist in the
recruitment of able future leaders into the field. The committee did not
conclude whether undergraduate degrees in public health are useful.
· Education programs for public health professionals should be informed
by comprehensive and current data on public health personnel and their
employment opportunities and needs.
CONCLUDING REMARKS
This report conveys an urgent message to the American people. Public
health is a vital function that is in trouble. Immediate public concern and
support are called for in order to fulfill society's interest in assuring the
conditions in which people can be healthy. History teaches us that an
organized community effort to prevent disease and promote health is both
valuable and effective. Yet public health in the United States has been taken
for granted, many public health issues have become inappropriately politi-
cized, and public health responsibilities have become so fragmented that
deliberate action is often difficult if not impossible.
Restoring an effective public health system neither can nor should be
achieved by public health professionals alone. Americans must be concerned
that there are adequate public health services in their communities, and
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18
THE FUTURE OF PUBLIC HEALTH
must let their elected representatives know of their concern. The specific
actions appropriate to strengthen public health will vary from area to area
and must blend professional knowledge with community values. The com-
mittee intends not to prescribe one best way of rescuing public health, but to
admonish the readers to get involved in their own communities in order to
address present dangers, now and for the sake of future generations.
Representative terms from entire chapter:
health professionals
