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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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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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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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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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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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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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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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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.
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Representative terms from entire chapter:
health agencies
