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Public Health as a Problem-Solving Activity: Barriers to Effective Action Carrying out the public health mission described in Chapter 2 requires systematic identification of health problems and the development of means to solve those problems. This volume has described the history of the development of this problem-solving capability and its current status in the United States. With that description as a backdrop and drawing on a review of the literature, site visits, statements at the four open meetings, review of other case studies (Miller and Moos, 1981; Institute of Medicine, National Academy of Sciences, 1982b), and the recent evaluation of progress by the U.S. Public Health Service The 1990 Health Objectives for the Nation (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986), the committee has identified some appreciable barriers to effective problem solving in public health. These barriers include: · lack of consensus on the content of the public health mission; · inadequate capacity to carry out the essential public health functions of assessment, policy development, and assurance of services; · disjointed decision-making without necessary data and knowledge; · inequities in the distribution of services and the benefits of public health; · limits on effective leadership, including poor interaction among the technical and political aspects of decisions, rapid turnover of leaders, and inadequate relationships with the medical profession; · organizational fragmentation or submersion; · problems in relationships among the several levels of government; 107
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108 THE FUTURE OF PUBLIC HEALTH · inadequate development of necessary knowledge across the full array of public health needs; · poor public image of public health, inhibiting necessary support; and · special problems that limit unduly the financial resources available to public health. Unless these barriers are overcome, the committee believes that it will be impossible to develop and sustain the capacity to meet current and future challenges to public health while maintaining the progress already achieved. Deaths and disabilities that could be prevented with current knowledge and technologies will occur. The health problems cited in Chapter 1, and many others, will continue to take an unnecessary toll, and the nation will not be prepared to meet future threats to health. Public health faces the simultaneous challenges of responsiveness and continuity. Sustained successes frequently lead to apathy, and the visibility and excitement surrounding new problems promote ad hoc decisions that fragment programs and divert resources from established and successful programs. This chapter concentrates on identification of barriers most needing atten- tion, thereby setting the agenda for the recommendations to follow. Em- phasis on barriers rather than accomplishments may seem to cast public health in an unduly negative light. Public health has a record of accomplish- ment that should be a source of pride. Yet problems that can erode current and future capacities of public health should be identified and faced if public health is to continue its record of accomplishment. THE LACK OF CONSENSUS ON MISSION AND CONTENT OF PUBLIC HEALTH Progress on public health problems in a democratic society requires agree- ment about the mission and content of public health sufficient to serve as the basis for public action. There is no clear agreement among public decision- makers, public health workers, private sector health organizations and per- sonnel, and opinion leaders about the translation of a broad view of mission into specific activities. As described in Chapter 4, the governmental activ- ities that can be described "public health" vary greatly among jurisdictions. This diversity reflects a wide variety of views about the appropriate scope of public health activities among the many publics that must support public health in the political process and through supportive activities in the private sector. Thus, it is difficult to build effective constituencies that extend beyond a particular issue to the support of broad purposes and the necessary continuing infrastructure of public health.
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 109 In our interviews we found many examples of constituencies formed around specific issues (for example, toxic waste disposal, AIDS, Alz- heimer's disease, promotion of healthful life-styles, improvement of infant mortality rates). A democratic society favors organization of action around specific issues, an American tendency identified by De Toqueville in the middle nineteenth century. (De Toqueville, 1899) Although such a specific focus often generates political support for action, it can also contribute to disjointed and fragmented decisions, to lack of concern with longer-term issues, and to lack of support for a more comprehensive vision of the public health mission. Without a coherent and widely shared view of public health, it is difficult to translate specific interests into sustained support for a broader public health capacity. In addition to the diversity of activities among state and local jurisdictions described in Chapter 4, the committee identified several particular issues that divide public health. PUBLIC HEALTH RESPONSIBILITY FOR INDIGEN r CARE Some public health workers are concerned when their agencies serve as providers of last resort for medical care of the indigent, or administer Medicaid or other financing programs. Those concerned see these functions as detracting from essential public health activities such as disease surveil- lance and control through prevention. One county health officer told us that "when you put together preventive and curative, the latter gets the money, because no one has the guts to say I'm going to emphasize prevention. Sickness care takes precedence." Others see the public health role in the care of the indigent as essential at least until other means are devised by society to take care of these needs. In many of our site visits, we were told of overwhelming unmet needs for medical care of the indigent. As noted in Chapter4, almost three-quarters of state and local health agency expenditures are for personal health services. Many public health agencies have a long-standing focus on the provision of maternal and child health services to the indigent, emphasizing those ser- vices that have substantial long-term benefit through disease prevention and health promotion. (Miller and Moos, 1981; Public Health Foundation, 1986) This maternal and child health focus has been especially strong in a number of public health agencies in the South. The tension caused by attempting to provide personal medical care ser- vices without at the same time depriving other public health functions of an appropriate share of scarce funds is aggravated by overall changes in the financing of medical care, which force more of the burden of care of the indigent back on to public agencies. (Desonia and King, 1985) Because the
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110 THE FUTURE OF PUBLIC HEALTH dollar flow for medical services is large, and because reimbursement through federally matched sources of funding, such as Medicaid, is available, care of the indigent looms large in the state budget-setting process as compared with other public health functions. Identification of public health with care of the indigent in the minds of decision makers and of the general public sometimes clouds the perception of the importance of public health to the entire population. For example, in one state the committee visited, the state health department pays for more than one-third of births each year. This, plus a strong family planning program, has contributed to an impressive reduction in the state's infant mortality rate in recent years. Yet this record does not win the public support that it should: the well-to-do either don't know about the department's services to the poor or see them as unrelated to their own needs. The state's legislature voted more funds for Medicaid, then cut the health department budget. By contrast, in a Canadian city visited during the study, universal entitlement to medical care lifts the burden of indigent care from the public health agency, leaving that agency free to focus its resources on other priorities in public health, such as effects of industrial pollutants on cancer incidence, improving the health outcomes of high-risk infants, smok- ing cessation, monitoring health status, and organizing the community to combat particular health problems. RELATIONSHIP OF PUBLIC HEALTH TO ENVIRONMENTAL HEALTH Many of the early accomplishments in the prevention of infectious disease were accomplished through public health management of water supply and sewage disposal. Even though a certain degree of tension existed from the earliest days of public health between environmental health activities relying heavily on sanitary engineering techniques and surveillance by sanitarians and the work of public health physicians and nurses providing preventive services to individuals, environmental health activities were integral parts of public health services until the 1960s and 1970s. Then major changes oc- curred in environmental health policy, planning, and organization at both state and federal levels of government. (Rabe, 1986) This movement com- bined a concern about such issues as protecting natural resources and energy conservation with the traditional environmental health activities designed to reduce the risk of disease and dysfunction. Many advocates of stronger public actions to prevent contamination of the environment saw existing public health agencies as too slow in responding to the need for new actions. One effect of this increased public attention and the perception of unre- sponsiveness from public health agencies was a splitting off of many environ- mental health concerns from public health activities. The split was symbol- ized at the federal level by the creation of an independent new agency-the Environmental Protection Agency to administer programs concerned with
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 111 air and water, solid waste, pesticides, noise, and ionizing radiation. Most of these programs had once been a part of the Public Health Service. A similar organizational change took place in states. (Hanlon and Pickett, 1984; Rabe, 1986) The implications of these changes are considered later in this chapter, but a notable effect was to separate public health from the broad-based constituency interested in environmental protection. Those environmental protection functions still within the operational purview of public health, such as food protection and enforcement of standards for drinking water quality, were not as well supported and as well publicized as were programs for the control of pesticide use and for the reduction of human exposure to air pollution or ionizing radiation. Responsibility for identification, education, and modification of important environmental factors that increase the risk of illness and premature death was separated from other interrelated public health functions. As a result, many observers believe, the health implica- tions of environmental hazards have not received the depth of analysis or the level of support they deserve. In some cases, uninformed analysis of environ- mental health risks may have exacerbated fears of those risks unnecessarily. RELATIONSHIP OF PUBLIC HEALTH TO MEN ray HEALTH During most of its long history, the public function in mental health primarily was on care of the chronically ill mental patient, as illustrated by the large hospitals for the mentally ill. This activity in personal health services contrasted with the usual public health focus on prevention of disease and protection of the health of the public. Differing perspectives and operating modes were often reflected in organizational separation of mental health from public health at the state level. At the federal level, mental health responsibilities remained within the Public Health Service, although mental health groups have advocated the maintenance of a separate identity for mental health programs both at the state and federal levels in order to assure sufficient attention to these important health problems. The trend in mental health services in the United States since World War II has been away from large custodial institutions and toward community- based services, stimulated by the National Mental Health Act of 1946 and by the federal Community Mental Health Centers legislation in the 1960s. This community approach and the mental hygiene movement, which had its origins in this country, were based on the belief that mental health problems were related to the community context, not only to the individual. (Turner, 1977) Thus, epidemiological concepts began to be applied to the identifica- tion of mental health problems in the population, and an interest in preven- tion of mental illness, promotion of mental health, and the early diagnosis of mental problems began to parallel more closely the traditional concerns of public health. Many health problems, such as those stemming from sub
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112 THE FUTURE OF PUBLIC HEALTH stance abuse, accidents, family violence, and teenage pregnancy, were rec- ognized as having behavioral underpinnings. Despite this expansion of the range of mental health services to include many public health issues, the relationship between public health and mental health remains underdeveloped. Organizational, historical, professional, and interest group barriers to more productive interaction persist even though mental health and public health have moved closer together concep- tually. The need for a community-based strategy for prevention in mental health, drawing on fundamental public health concepts, was recognized by the Joint Commission on Mental Illness and Health in 1961 and the President's Commission on Mental Health in 1978. (Joint Commission on Mental Illness and Health, 1961; President's Commission on Mental Health, 1978) Refer- ring to the progress made by public health in preventing disease and promot- ing health, the President's Commission stated that "The mental health field has yet to use available knowledge in a comparable effort." (President's Commission on Mental Health, 1978) The strategy they recommended would be based on identification of high-risk groups in the population, identification of factors contributing to those risks, and development of cost- effective means of intervention to reduce risks, consistent with this society's community and individual values. This strategy is consistent with the public health vision outlined by this committee in Chapter 2. THE PUBLIC HEALTH ROLE IN ENCOURAGING HEALTHFUL BEHAVIORS THROUGH EDUCATION AND THROUGH MODIFICATIONS IN THE SOCIAL ENVIRONMEN r Many of the modern opportunities for health improvement lie in achieving life-style and behavior changes. The evidence linking health problems to behavior is extensive. Well-known examples include links between lung cancer and smoking; AIDS and sexual behavior; motor vehicle trauma, teenage driving habits, and alcohol consumption; and family violence linked to family and job-related stress. Educational efforts to tell persons about health risks or healthful behavior have been used to effect desired changes. Many of these efforts have been carried out by the private sector, often using the public media or private educational programs (e.g., advertising campaigns by voluntary health orga- nizations). The role of state or local public health agencies has often been relatively minor. In the site visits, we often found that efforts to achieve healthful behavior did not seem to occupy a prominent place on the public health agenda. In addition to intervention to change individual behavior, other strategies seek to control factors in the "social environment." However, health pro
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 113 grams to educate youth about the dangers of tobacco and alcohol, for example, are rarely matched by efforts to reduce consumption of these substances by increasing taxes or controlling advertising. Although public health professionals have traditionally recognized influences of the physical environment on health status, they have been less adept at recognizing health-related influences in the business, economic, and social environment and in fashioning and advocating strategies to control these factors. Yet, in spite of the need for further definitive research, considerable evidence now demonstrates that the social environment can be a major cause of illness. (Institute of Medicine, National Academy of Sciences, 1982a; Berkman and Breslow, 1983) Job and family stress; promotion of hazardous products; encouragement of risk-taking behavior and violence through TV programs, movies, and other popular media; and peer pressure for sub- stance abuse, premature sexual behavior (with associated health risks of sexually transmitted disease and teenage pregnancies), and school failure all are potential or actual etiologic factors in health problems, both physical and mental. Public health programs, to be effective, should move beyond pro- grams targeted on the immediate problem, such as teen pregnancy, to health promotion and prevention by dealing with underlying factors in the social environment. To deal with these factors, the scope of public health will need to encom- pass relationships with other social programs in education, social services, housing, and income maintenance. IMPEDIMENTS TO THE ESSENTIAL WORK OF PUBLIC HEALTH In its investigations, the committee found a number of problems impeding the ability of those charged with public health responsibilities to carry out the essential functions of assessment, policy development and leadership, and assurance of access to the benefits of public health. AssEssMENr AND SURVEILLANCE A foundation stone for public health activities is an assessment and sur- veillance capacity that identifies problems, provides data to assist in deci- sions about appropriate actions, and monitors progress. Epidemiology has long been considered the essential science of public health, and a strong assessment and surveillance system based on epidemiologic principles is a fundamental part of a technically competent public health activity. Federal agencies, such as the Centers for Disease Control, the National Center for Health Statistics, and the National Institutes of Health, have
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114 THE FUTURE OF PUBLIC HEALTH provided national leadership, data, and technical assistance, all of which assist states and localities in carrying out their assessment responsibilities. However, many states and localities lack a fully developed capability for this essential function. While the collection of vital statistics has long been a state responsibility, other critical data are available only in the form of national sample surveys that cannot be directly desegregated to state and local areas without significantly compromising their accuracy. Table A.4 in Appendix A tells, for example, that half of the states collect morbidity data and even fewer conduct health interview surveys. On the other hand, the collection of data about communicable disease, health screening for some specific prob- lems, and laboratory analysis are functions conducted by essentially all of the states. The level of support provided for the function of assessment and surveil- lance reflects these difficulties and the competition for limited resources with other more publicly visible public health priorities. For example, in one state the committee visited, vital statistics had not been published at all during the 2 years preceding our visit. In another, a county health officer reported having to wait more than 2 years for aggregated data from the state after sending in local birth and death statistics. Achieving and sustaining a comprehensive and integrated assessment and surveillance capacity is made more difficult by the fragmentation of the assessment function in many states where environmental health and mental health data are gathered by separate agencies. Meanwhile, the lack of direct federal encouragement and assistance to state efforts has limited the avail- ability of good health data at the state and local levels. POLICY DEVELOPMENT Policy development is the means by which problem identification, techni- cal knowledge of possible solutions, and societal values join to set a course of action. The site visits and other information available to the committee raise many issues about the soundness of current policy development in public health. Much good work has been done at the national level in generating health data, in analyzing and applying those data to public health problems, and in the development of planning tools like The 1990 Objectives for the Nation and Model Standards. (U.S. Department of Health and Human Services, Public Health Service, 1980; American Public Health Association et al., 1985) However, in the site visits and other inquiries, we found that policy develop- ment in public health at all levels of government is often ad hoc, responding to the issue of the moment rather than benefiting from a careful assessment of existing knowledge, establishment of priorities based on data, and alloca
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PUBLIC [IEALTH AS A PROBLEM-SOLVING ACTIVITY 115 tion of resources according to an objective assessment of the possibilities for greatest impact. The resulting pattern of policy decisions, which has been described as a "successive limited comparison" or as disjointed and "incremental" (Lind- blom, 1959), is well established in the American public decision process, reflecting, perhaps, our national penchant for immediate problem solving, belief in the desirability of limited government, and widespread distrust of government "social planning." Policy development can follow the interests of charismatic decision-makers (sharp examples were offered in the site visits of the influence of particular legislators or county commissioners on a particular issue) without adequate consideration of options, unintended side effects, long-term results, or effective allocation of resources based on impact on health status. Although The 1990 Objectives for the Nation and Model Standards serve as very good frameworks for objective setting and systematic policy formulation, we saw little evidence of knowledge about or use of these planning tools in our discussions with state and local decision- makers. In fact, as the director of the Medicaid agency in one state observed, policy is too often decided on the basis of single cases. During the time we visited that state, the plight of an uninsured woman in need of a heart-lung transplant was monopolizing public dialogue, while severe stress-related problems among the state's farmers and their families alcoholism, family violence, accidents received little notice even among public health profes- sionals. Another problem is the fragmentation of policy development because of governmental structure. That structure is discussed in greater detail later in this chapter, but it deserves mention here because of its impact on policy formulation. Some of the fragmentation and diffusion of public health policy development is inherent in the U.S. system of government with its separa- tion of powers between executive, legislative, and judicial branches and its federal system of national and state governments with further delegation by the states to local jurisdictions. In addition, health-related responsibilities are frequently divided among several agencies at the federal, state, and local levels (see Appendix A). The result is multiple decision-makers on a given issue, diffusion of responsibility and accountability, delays in decisions, and unresolved conflicts. We should also note, however, that a diversity of decision-makers may create opportunities for initiatives and innovations, for closer tailoring of policies to local circumstances, and for constituency groups to find an action point for a particular issue. In a society that historically has preferred to minimize the role of the public sector, the committee finds that there is often a lack of a clear rationale for the public provision of services in the policy development process. It is not sufficient for the policy process to identify a need and a
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116 THE FUTURE OF PUBLIC HEALTH technical means to address the need. The policy determination also should include consideration of the appropriate public and private roles in which the public purpose is made clear, regardless of whether public or private means are chosen for conduct of the activity. The scope of public health often includes objectives that can be and are accomplished through stimulation of private actions rather than through direct public provision of services. In our interviews, several persons observed that public agencies often seem more comfortable with direct conduct of activities than with more indirect modes of action, such as stimulation of private activity to accomplish the public objective. The relationship between the public and private sectors for the accom- plishment of public health objectives becomes particularly apparent when regulation is the mode of public health activity chosen through the policy development process. Here again, a clear identification of the public pur- pose in the policy development process is necessary, along with the technical underpinning that can be provided by a solid assessment function. (Commit- tee on the Institutional Means for Assessment of Risks to Public Health, Commission on Life Sciences, National Research Council, 1983) Sound analysis of health risk in the development of regulatory policies (e.g., water and air pollution controls, food safety, licensing of health providers) can lead to more rationality and credibility in the final regulatory decisions. It also can better concentrate public effort on activities that will lead to the greatest reduction of health problems for the effort and funds invested. The recom- mendations of the recent Institute of Medicine report on the regulation of nursing homes is an example of the link between a public assessment function and desired private actors. (Institute of Medicine, National Acad- emy of Sciences, 1986) The importance of health risk analysis has also been recognized in the recent Federal Appeals Court decision holding that, in assessing the impact of proposed regulations, the Environmental Protection Agency must consider potential health risks rather than potential costs as the overriding factor. (`National Resources Defense Council v. Environmental Protection Agency, 1987) One by-product of a systematic policy development process is the identi- fication of gaps or uncertainties in the knowledge base that should guide . . c .eclslons. Some problems with the policy development process can be accentuated through the domination of the process by very narrow special interests. For example: the board of health in one state consists entirely of representatives of the state medical society. Other special interests may dominate through the activities of key legislators, county commissioners, or appointments to public health leadership positions on the basis of narrow political interests. The final determinations in public health should always be political in the sense of being responsive to broad public values, but the committee is
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 117 concerned that particular decisions especially those with important techni- cal content may not have passed through a technically competent policy development process. Another limitation on the development process is a constraint on the ability to respond to new challenges. This constraint may result from limited funding for public health activities or from the structure of budgetary deci- sions (e.g., 2-year budget cycles, limits on shifts among budget line items, Propositions 13 and 4 in California, Gramm-Rudman-Hollings at the fed- eral level). Such structural boundaries on the decision process can hamper response to new challenges (e.g., AIDS, toxic waste disposal) by forcing substitution of the new activity for old functions. Added to the typical inertia of any organization and budget, these negative pressures put a special strain on the policy development process. In theory a good policy development process should be just as important for deciding on program reductions as it is for determining desirable program expansions. In practice, a ratchet effect is often observed in which it is much easier to consider program expansions on top of existing activities than it is to consider realignment of programs according to program priorities. ASSURANCE OF ACCESS ~ THE BENEFITS OF PUBLIC HEALTH Assurance of the availability of the benefits of public health to all citizens reflects a primary reason for the existence of public health activities. The committee identified many problems that impede the achievement of that assurance. As described in Chapter 4 and Appendix A, the committee observed very wide variation of the content and intensity of public health activities across the country. Because benefit from well-conceived public health activities is clearly established, this variation means that there is considerable inequity in access to these benefits from jurisdiction to jurisdiction, as well as by social and income status. Decentralization of decisions and funds from the federal level accentuates this inequity, as does decentralization within states to local jurisdictions. For example, in one county visited, all the obstetri- cians-gynecologists in the county had unilaterally declared that they would no longer provide prenatal care to Medicaid or other poor patients. This was partly a protest against low reimbursement rates and partly an effort to pressure the state to do something about skyrocketing malpractice costs. Whatever the reason, the effect on poor women was devastating: they had literally nowhere to go for prenatal care since the health department did not provide such services. Women were presenting in labor at the local emer- gency room, having not seen a physician during their entire pregnancy. Concern about equity implies that wide access to specified benefits is desirable. Within a nation of diverse needs, resources, and political struc
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 127 ior, as an essential component of a successful public health strategy to limit the spread of this dread disease. (Committee on a National Strategy for AIDS, Institute of Medicine, National Academy of Sciences, 1986) Also relevant is evaluative research drawing on the social sciences in determining the effectiveness of public health interventions, both retrospectively and prospectively. Because public health is an applied activity-usually carried out under firm fiscal constraints it is often very difficult to nurture and sustain the necessary research activities in support of the public health effort. In our six site visits, we found only one state that made a substantial investment in research. It may be logical to aggregate much of the research effort to the federal level as has traditionally been done; however, this may leave unde- veloped the function of applied research as a link between a generation of new basic knowledge and its application in the field. Private foundations have played a valuable role in the demonstration and education of new public health approaches. Just as developments in clinical practice have been enhanced by the conduct of clinical research, so it is essential that public health be enriched by appropriate basic and applied research in the full range of sciences relevant to public health. THE NEED FOR WELL TRAINED PUBLIC HEALTH PERSONNEL Many sections of this report have mentioned the need for well-trained public health professionals who can bring to bear on public health problems the appropriate technical expertise, management and political skills, and a firm grounding in the commitment to the public good and social justice that gives public health its coherence as a professional calling. The committee has identified a number of problems in meeting this need. Most public health workers, including some public health leaders, have not had formal educa- tional preparation focused primarily on public health. (Institute of Medi- cine, Conference, March 1987) Those with adequate technical preparation may lack the training in management, political skills, and community diag- nosis and organization that is appropriate for leadership roles in a complex, multifaceted social service activity. Public health leadership also requires an appreciation of the processes and values of government in the United States. The continuing evolution of public health constantly raises new challenges to public health personnel, requiring updating of knowledge and skills. Many educational paths can lead to careers in public health, but the most direct is to obtain a degree from a school of public health. Schools of public health were established in major private universities early in the century. They now number 25 7 in private universities and 18 in public. During the early decades of their existence, they concentrated on training people with degrees in the health and related professions (physicians, nurses, engineers,
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128 THE FUTURE OF PUBLIC HEALTH dentists, and others) to become public health professionals. In recent years, however, as the mandate of public health has broadened and as public health problems and their solutions have become more complex, the schools have responded to this evolution by recruiting individuals from the behavioral sciences, from mathematics, from the biological sciences, and from other relevant fields and disciplines, as well as health professionals. (Institute of Medicine, Conference, March 1987) Modern schools of public health serve important dual roles: that of a public health research institute and that of a public health educational facility. These roles reflect the great successes of public health in developing new knowledge and applying that knowledge in a social and political context to the benefit of the population. The complexity of modern issues in public health requires that the field continue to develop new technologies delivered in new ways. These technologies require both fundamental and applied research before they can be implemented as public health programs in an agency setting. Schools of public health have traditionally operated to serve this basic and applied research function, linking knowledge generation with practical problem solving. Meeting the challenges to public health described in this report will require a strengthening of this linkage. The schools can build on their previous efforts to work cooperatively with agencies in eval- uating public health programs and in assisting in their initial implementa- tion. Many schools of public health are located in research universities and therefore have specific responsibilities to the academic objectives of their institutions as well as to their fields of professional practice. This situation is by no means limited to public health, but characterizes graduate professional education in medicine, dentistry, engineering, law, and other fields. Each of these areas must accept the dual responsibility to develop knowledge and techniques of use to the profession and to produce well-trained professional practitioners. Many observers feel that some schools of public health have in recent years become somewhat isolated from the field of public health practice. The result of this changing emphasis may be that some schools no longer place a sufficiently high value on the training of professionals for work in health agencies. The variation in public health practice noted earlier in this report and the limitations on employment opportunities in health agencies for well- trained professionals, restricting opportunities for graduates, have inhibited desirable responses by the educational institutions to the needs of practice. This situation is exacerbated by the fact that most public health workers have not had appropriate formal professional public health training. However, we lack sufficient knowledge about the public health workforce and its needs and opportunities.
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 129 Recognizing the importance of these and other issues relating to the education and training of public health personnel, the committee sponsored an invitational conference in Houston in March 1987 in cooperation with the University of Texas School of Public Health. The conference brought to- gether public health educators, practitioners, and other concerned individ- uals to consider the future of education and training for public health. It helped identify issues, clarify consensus and areas of disagreement, and provide a broader input into the committee's deliberations. The proceedings of that conference will be published separately from this report. DISTRIBUTION OF TECHNICAL EXPERTISE Technical expertise in public health is not evenly distributed among juris- dictions. Some of the larger states have considerable internal expertise. Others lack such expertise. The consultation role of the Centers for Disease Control and the larger state public health agencies help fill this need, but important gaps remain. For example, in one of the states we visited, an assignee from the Centers for Disease Control was carrying out an important epidemiological study. When his short-term assignment was completed, however, the expertise necessary for essential assessment activities was no longer present on the staff. Public hearing participants reported that cut- backs in federal staffs, especially at the regional office level, have reduced the federal consultative capacity. This problem is further exacerbated by the lack of trained experts in such fields as epidemiology. Previous studies have shown persistent deficits in their availability. (Institute of Medicine, Confer- ence, March 1987) In some jurisdictions, low salaries and unrewarding professional environments would inhibit the attraction of such expertise even if a sufficient aggregate supply existed. BUILDING CONSTITUENCIES FOR PUBLIC HEALTH Our inquiries indicate that public health seems to suffer from a poor image or lack of attention even when its success in the solving of specific problems is highly publicized and commended. We were told by state and local elected officials that the general population often cannot identify the benefits they have received through public health activities. Public health, in this regard, suffers from its successes. Such achievements as a safe water supply, the disappearance of many childhood infectious diseases, reduction of the inci- dence of stroke, fewer childhood poisonings, reductions in lead poisoning, and control of food-borne infections are taken for granted until a problem occurs. Also, the identification of public health programs with means-tested welfare programs adds to the perception that public health concerns are not an integral part of the entire community.
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130 THE FUTURE OF PUBLIC HEALTH Some of the public may have additional negative views of public health based on perceived interference with private freedoms and a moralistic tone of public health pronouncements. For example, smokers may resent efforts of public health authorities to limit smoking in public places. Other impor- tant interest groups, such as the tobacco industry, may oppose public health actions and question the competence of public health agencies because those actions may interfere with the economic interests of the group. Although the broader medical community can and does identify with such public health issues as smoking, injury control, infectious disease control, and dietary change related to cardiovascular disease and cancer, many physicians look down on public health, as an organized activity, believing it to be second rate or meddlesome. The one-on-one orientation of most medical training, the limited exposure to such population-based concepts as epidemiology, and the lack of experience during the training process with interdisciplinary collaboration contribute to this lack of a natural alliance between the physicians and public health. Finally, public health has both an enforcement (negative) and a facilitative (positive) aspect. This sends mixed signals about the image of public health to various population and interest groups. We identify image as a problem not because we are concerned about the sensitivities of public health workers, but because we believe that these problems interfere with the capacity of public health agencies to mobilize the support of important constituencies, including the general public, for the public health mission. The image problem may also limit recruitment of talented persons into the field of public health practice. In a free society, public activities ultimately rest on public understanding and support, not on the technical judgment of experts. Expertise is made effective only when it is combined with sufficient public support, a connection acted upon effectively by the early leaders of public health. MANAGERIAL CAPACITY We have identified many aspects of the needed managerial capacity in the previous discussions, specifically under the label of leadership. Here, we reemphasize the complexity of the managerial tasks faced by the public health manager. We cannot think of a managerial responsibility that involves a wider range of skills, including not only the usual management and leadership skills for running a complex and interdisciplinary organization, but also the communication and constituency building skills of a public executive, and finally, but not least, access to up-to-date technical informa- tion, sometimes in emergency circumstances. The high visibility and intense public interest that arises when a public health emergency occurs adds to the stress of these positions. Finally, the nature of public health decisions often
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 131 places the manager at the center of a conflict among competing societal values and political forces. The early progress of public health in this country was advanced by the fortuitous presence of individuals who combined these many managerial characteristics. The present challenge is how to assure the ready availability of managers with these capabilities. This is unlikely to occur without special attention and a plan for the development and support of a cadre of talented persons with appropriate educational preparation and experience. Leader- ship development would be aided by adequate salary levels, particularly in the case of state and local health officers (the current low salaries for many of these positions are documented in Chapter 4 and Appendix A). Moderniz- ing benefit programs so that personnel could accept "promotions" involving a change of political jurisdiction without losing accumulated pension funds would also help with the career development of a management cadre. THE LACK OF FISCAL SUPPORT The wide array of challenges facing public health and the strongly in- grained American belief in limited government make it unlikely that ade- quate financial support for public health activities will ever be available. In the competition with other important public functions, it is probably naive to think that the "right" distribution of available public funds exists. However, we would note these special problems for public health as compared with other public functions: · an explicit reduction of federal support for public health activities; · the special financial problems faced by particular states as a result of declines in their economies; · the appearance of new challenges to public health such as AIDS or the hazardous by-products of modern economies; · the advance of our techniques both biological and epidemiological to identify risks to human health; · the changing demographics of American society (e.g., an aging popula- tion); · an interconnected world that shares health risks with increasing rapid- ity; · the need to maintain and replace expensive public infrastructures for health, such as water and sewage systems; · the rise in the costs of modern health care, which both add to the burden on public provision of health services and compete with funds for other public health functions; · the need to provide sufficient core support for a public health delivery system; and
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32 THE FUTURE OF PUBLIC HEALTH · the complex requirements and limited rewards for public health man- agers. This list could be expanded, but these problems illustrate the challenge of achieving adequate fiscal support for public health activities. HOW THE PUBLIC HEALTH SYSTEM WORKS-AIDS AS AN EXAMPLE What are the problems public agencies are having in fulfilling their unique functions of assessment, policy development, and assurance? Is the statu- tory base adequate to cope with a new and compelling issue? The intent of this section is to illustrate some of the problems by focusing on one, acquired immune deficiency syndrome (AIDS), and tracing through the system, largely by means of quotations obtained in our site visits. STATUTORY BASE According to Gostin (Gostin, 1986), the statutory base of public health is poorly suited to dealing with AIDS. The powers provided in statute are too restrictive, including outdated concepts of full isolation and quarantine that are inappropriate given the mode of transmission of AIDS. Also there are no clear criteria to guide officials in exercising their powers. Due process procedures are sketchy or absent. This leaves too much room for unfettered administrative discretion about how to apply the law. A modern public health law should remove the rigid distinctions between venereal and com- municable disease and should enact strong, uniform confidentiality pro- cedures. Otherwise, public health is left with a stick too big to wield. Site visit comments bear out this view. For example: "This state has strange confidentiality laws that make it difficult to target appropriate information to appropriate recipients." "In the legislature there is inordinate emphasis on the physician's lack of information. They're not confronting the position the doctor faces in inform- ing people and their contacts about the disease for instance, the wife of an AIDS patient. They tried to make knowing donation of infected blood a crime, but it didn't go anywhere." "Our law has made AIDS a reportable disease. We have little in the way of confidentiality. The new law makes knowing transmission of AIDS second- degree murder."
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY ASSESSMENT 133 Exercise of the assessment function is closely linked to the enabling structure put in place by statute. Public health officials feel keenly the need to monitor the disease and mount effective programs to limit its spread. Pursuing these functions raises many political sensitivities. In addition, the speed with which the problem developed has public health struggling to keep up with changing dimensions and new technologies. This makes long-range or even rather short-range planning a luxury agencies can't afford. Some health agencies are accused of overemphasizing surveillance at the expense of preventive efforts such as education. "The state has taken a commanding lead. They are secretive about sharing stats. I don't want names, but they'll only give out information on a coun- tywide basis. The hospitals are also tight lipped. The vital statistics give us the deaths." "We're skeptical about the individuals themselves revealing the informa- tion. We need to track sero-positive individuals and maintain confiden- tiality." "The gay rights groups are concerned about list collecting; they are resisting public health moves to get people in for counseling. On the other hand, there are scientific concerns about anonymous testing. These are new issues for disease control." "The Department of Health Services has been so busy getting the new initiative implemented we can't really plan adequately. No one has yet been able to take a broader system view of the AIDS problem. No one is thinking about how to fit the pieces together." "The research program at the university was good, but the main need now is for technology transfer. The results are not getting into the hands of community physicians fast enough." "The department is trying to use the STD (sexually transmitted disease) model, emphasizing surveillance and epidemiology. I would argue that prevention should take precedence." Po~cY DEvE~oPMENr AIDS is extraordinarily controversial, and the political heat has been intense. Pressure to do something fast, but not to infringe on the rights of high-risk groups, has health agencies struggling to balance basic knowledge development with the obligation to respond to immediate situations. Among the many groups and individuals, public and private, engaged in fighting AIDS, health agencies have not taken a clear initiative in supplying leader- ship, and the public is unclear about what level of government it should look to for guidance or what it can appropriately and realistically expect any
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134 THE FUTURE OF PUBLIC HEALTH particular health agency to do. Lack of public understanding about the real nature of the risk makes matters worse; on the other hand, as one person said: "If they knew they had practically no chance of getting it, then they really wouldn't give a damn." "It was publicity that finally raised the consciousness of the eighth floor thealth department leaders]." "The legislature has been the leader. It convened the hearing and put funding in place. Such leadership should have come from the Department of Health Services, but it hasn't. The department has held no hearings. The state health director knows less than I do about what's happening in the state." (Legislative staff) "The president and the governor should have taken the lead, but they seem not to want to discuss it. At the federal level, only CDC and NCI have been effective." (Activist) "AIDS dictates the entire public health program in the state to an inap- propriate degree. I spend one-third of my time on it. Don't ask me what we're doing about diabetes or high blood pressure. I simply don't know." "There's not enough attention being paid. What gets done depends on the public mood. Much better education of the general public is needed so they will accept future expenditures." "In the end, the lack of responsible public health organization for the nation will prove our greatest handicap. Governments, too, can suffer a wasting disease; the gradual erosion of the coordinated leadership of the Public Health Service has created a void. Surveillance of the nation's health is no longer the clear responsibility of any agency of government, nor is the surveillance of proposals for meeting crises. Isolated islands of excellence [CDC, NIH] do not alone constitute a national strategy to defend and promote the national health." (Keller and Kingsley, The Milbank Quarterly, 1986) ASSURANCE Public health officials at the state and local level are very much aware of their responsibility to make sure that AIDS is combated effectively. But they are hamstrung by the speed with which the problem has developed and the political heat it has generated, as well as by the difficulty of marshalling enough resources to do what they feel is needed. At present, they lack the technology either to cure AIDS or to control its spread through the definitive and simple means of a vaccine. The fiscal implications of caring for AIDS patients are poorly understood because estimates of the potential number of cases are in dispute. In some places where there are large numbers of AIDS patients, the private sector especially voluntary groups such as gay rights organizations-have taken the lead in providing treatment and counseling,
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PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 135 with the health department struggling to keep track of what is being done. The nature of the problem makes the regulatory apparatus difficult to mobilize. THE STATE OF PUBLIC HEALTH This discussion of how the public health system is coping with the AIDS epidemic illustrates many of the problems encountered by these agencies when confronted by such a major new challenge. Other examples would have revealed different sets of problems, such as how to sustain a continuing effort to maintain high rates of childhood immunizations where prior success breeds complacency, liability concerns raise the price and threaten the availability of vaccines, and limited resources are diverted to new chal- lenges. Both types of examples, the new crisis and the continuing effort, support a central theme of this report the essentiality and proved effective- ness of public health measures for improving and protecting the health of the public and the imposing array of problems that undermine the public health capacity to respond. AIDS illustrates both a strain on the public health system and remarkable accomplishments by the public health community in a short time. Response to a highly publicized crisis like AIDS cannot serve as the model for a sustained and effective public health effort addressed to the many health problems that, in the aggregate, dwarf the health impact of AIDS. For example, the great increase in lung cancer took place more slowly and therefore lacked the dramatic impact of AIDS on the public conscious- ness, but it is a larger problem in terms of death and disability, and sustained public health effort cart affect the magnitude of the disease burden. The same is true for such major sources of health deficits as injuries, substance abuse, and environmental pollutants. That public health accomplishes so much is a tribute to the effectiveness of its techniques and the dedication of its workforce. Yet the problems and disarray that we have documented through our inquiries are a source of strong concern to the committee. The next chapter contains our recommen- dations to help overcome these problems, strengthen the public health capability, correct the disarray, and refocus public health on its important . . mlsslon. REFERENCES American Public Health Association, Association of State and Territorial Health Officials, National Association of County Health Officers, U.S. Conference of Local Health Offi- cials, Department of Health and Human Services, Public Health Service. 1985. Model Standards: A Guide for Community Preventive Health Services. American Public Health Association, Washington, D.C.
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136 THE FUTURE OF PUBLIC HEALTH Berkman, Lisa F., and Lester Breslow. 1983. Health and Ways of Living: The Alameda County Study. Oxford University Press: New York. Committee on the Institutional Means for Assessment of Risks to Public Health, Commission on Life Sciences, National Research Council. 1983. Risk Assessment in the Federal Govern- ment: Managing the Process. National Academy Press, Washington, D.C. Committee on a National Strategy for AIDS, Institute of Medicine, National Academy of Sciences. 1986. Confronting AIDS: Directions for Public Health, Health Care, and Re- search. National Academy Press, Washington, D.C. Desonia, Randolph A., and Kathleen M. King. 1985. State Programs of Assistance for the Medically Indigent. Intergovernmental Health Policy Project, Washington, D.C. De Toqueville, Alexis. 1899. Democracy in America. Colonial Press, New York. Gilbert, Benjamin, Mary K. Moos, and C. Arden Miller. 1982. "State Level Decision-Making for Public Health: The Status of Boards of Health." Journal of Public Health Policy (March):51-61. Gostin, Larry J. 1986. "The Future of Communicable Disease Control: Toward a New Concept in Public Health Law." The Milbank Quarterly 64(Supplement 1~:79-96. Hanlon, J., and G. Pickett. 1984. Public Health Administration and Practice. Times Mirror/ Mosby. Institute of Medicine, National Academy of Sciences. 1982a. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences. National Academy Press, Washington, D.C. Institute of Medicine, National Academy of Sciences. 1982b. Health Services Integration: Lessons for the 1980s, vol. 2: Case Studies. National Academy Press, Washington, D.C. Institute of Medicine, National Academy of Sciences. 1986. Improving the Quality of Care in Nursing Homes. National Academy Press, Washington, D.C. Joint Commission on Mental Illness and Health. 1961. Action for Mental Health. Basic Books New York. Keller, Lewis H., and Lawrence A. Kingsley.1986. "The Epidemic of AIDS: A Failure of Public Health Policy." The Milbank Quarterly 64(Supplement 1~:56-78. Lindblom, Charles E. 1959. "The Science of Muddling Through." Public Administration Review l9(Spring):79-88. Lynn, Lawrence E. 1980. The State and Human Services. MIT Press, Boston, Mass. Miller, C. Arden, and Mary K. Moos. 1981. Local Health Departments: Fifteen Case Studies. Public Health Association, Washington, D.C. National Resources Defense Council v. Environmental Protection Agency. 824 F. 2d 1211 (D.C. Cir., 1987~. Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986. The 1990 Health Objectives for the Nation: A Midcourse Review. U.S. Department of Health and Human Services, Washington, D.C. Omenn, G. S. 1982. "What's Behind Those Block Grants in Health?" New England Journal of Medicine 306~17~: 1057-60. President's Commission on Mental Health. 1978. Report of the President's Commission on Mental Health, vol. 1. Government Printing Office, Washington, D.C. Public Health Foundation. 1986. Public Health Agencies, 1984. Public Health Foundation, Washington, D.C. Rabe, Barry G. 1986. Fragmentation and Integration in State Environmental Management. The Conservation Foundation, Washington, D.C. Turner, John B., ed. 1977. Encyclopedia of Social Work, 17th ed. National Association of Social Workers, Washington, D.C. U.S. Department of Health, Education, and Welfare. 1979. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. U.S. Department of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary for Health, and Surgeon General, Washington, D.C.
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737 U.S. Depar1meD1 of Health and Human Serv~es, ~bUc HeaRb Serv~e 1980. ~g ~~/~ng ~: ^e 7P90 Or ~e ^~ Ha. Department of HeaRb and Human Services, ~sbiDg10D, D.C. O.S. IBM ~1b Sedge, ~1b Sources and Sedges AdmiDi~radon. 1987. Unpubl~bed data supphed 10 Inshtute of Medicine Commi11ee far 1be Study of 1be Mature of Ably Healib.
Representative terms from entire chapter: