National Academies Press: OpenBook

The Future of Public Health (1988)

Chapter: 5. Public Health As A Problem-Solving Activity: Barriers to Effective Action

« Previous: 4. An Assessment of the Current Public Health System: A Shattered Vision
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 107
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 108
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 109
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 110
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 111
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 112
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 113
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 114
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 115
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 116
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 117
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 118
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 119
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 120
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 121
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 122
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 123
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 124
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 125
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 126
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 127
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 128
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 129
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 130
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 131
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 132
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 133
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 134
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 135
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 136
Suggested Citation:"5. Public Health As A Problem-Solving Activity: Barriers to Effective Action." Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/1091.
×
Page 137

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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

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.

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

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

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

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

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

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

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

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

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

118 THE FUTURE OF PUBLIC HEALTH lures, some diversity in the patterns and intensity of public health services is expected and appropriate. However, the committee was concerned about the degree of this diversity. A diverse response to local needs and circum- stances needs to be balanced, in the committee's view, with sufficient atten- tion to equity of access to the benefits of public health programs. The degree of diversity of public health services in the country indicates that states and communities lack agreement on those services to which access should be assured. Although Model Standards can be important tools for establishing a basic level of assurance, they leave wide leeway for states and localities to define their own version of extent of assurance of such public health benefits. (American Public Health Association et al., 1985) The objectives estab- lished by the Public Health Service, with considerable participation of other elements of the society, imply the desirability of universal access to the benefits of public health. (U.S. Department of Health and Human Services, Public Health Service, 1980) As indicated in Chapter 1, and as shown in the considerable progress toward achieving the objectives for 1990, even more equitable distribution of public health benefits is a realistic goal for many problems. (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986) The success in controlling some communicable diseases is so dramatic as to constitute a benefit that is universally available. The benefits of other public health interventions are more inequitably distributed. An effective assess- ment system that provides surveillance at the state and local level is neces- sary to identify inequities, especially for health problems such as injuries or chronic diseases for which the availability of services is more uneven and the role of public health less clearly established. Yet these problems loom large as causes of premature death and disability. Achieving desirable public health objectives such as smoking cessation, limiting the transmission of AIDS, prevention of low birthweight, and control of human exposure to toxic substances raises complex political and value issues in which the protection and improvement of the health of the public conflicts with other social values, such as individual freedoms or economic growth. The conflicts may erode support for effective public health actions, leaving gaps in access to benefits. A special problem in assuring access to the benefits of public health activity is the diversity of funding sources for public health activities. Finan- cial support for public health services varies greatly from state to state even after including federal block grant and project funds provided to the states (see Appendix A). In some states the amount of state and local funding is so minimal that basic services are heavily dependent on a flow of dollars from reimbursement by private and federal sources. Implicit in a concern about achieving assurance under present conditions of wide variation is a willing

PUBLIC HEALTH AS A PROBLEM-SOLVING ACTWI~ 119 ness of higher levels of government-federal and state to reallocate tax revenues to areas of greatest need. LEADERSHIP FOR PUBLIC HEALTH In its inquiries the committee found a number of problems that limit effective leadership for public health. The committee's vision for the future of public health requires leaders whose skills encompass a wide range of necessary characteristics, including technical competence in the substance of public health issues; managerial abilities; communication skills; knowledge of and skills in the public decision process, including its political dimensions; and the ability to marshal! constituencies for effective action. The committee recognizes that this is a demanding and multifaceted characterization of the desirable leadership skills, and, as in most complex organizations, the efforts to identify individuals with potential for leadership and to develop and nurture these capacities will be an ongoing challenge that often falls short of the ideal. However, the committee believes that more attention needs to be given to overcoming the specific problems that inhibit effective leadership. The following are specific problems that we identified. THE INTERACTION OF TECHNICAL EXPERTISE AND POLITICAL ACCOUNTABILITY In exploring the making of public health decisions in particular states and localities, we observed that technical expertise bearing on some public health problems may not be appropriately considered by the political policy- makers, leading to decisions that are technically inadequate. For example, policymakers may not appreciate the problems raised by false positives in a testing program that is screening a low-risk population. The controversy over mandatory testing for AIDS sometimes reflects this lack of understanding. On the other hand, we observed that the technical experts may not under- stand or appreciate the appropriate and fundamental role for the political process in public policy-making, especially as it expresses society's values as criteria for selecting among options that have been defined with appropriate technical competence. CONTINUITY OF LEADERSHIP In many public health jurisdictions, rapid turnover of leadership has been a problem. For example, the median tenure of state health officers in 1987 was about 2 years. (Gilbert et al., 1982) This rapid turnover probably reflects political-technical conflict, inadequate pay, the effects of reorgani- zation, frustrations with the structure of decision-making, and low profes

120 THE FUTURE OF PUBLIC HEALTH signal prestige. A rapid turnover of political appointees in federal, state, and local government is an established pattern in the American political system, reflecting the high value Americans place on making their government responsive to the democratic process. However, for an activity like public health, which is based on technical knowledge, rapid turnover of leadership in key positions can erode desirable technical competence. We have ob- served a trend in some jurisdictions to make key public health positions more subject to appointment on primarily political grounds than on the basis of professional expertise and standing, using "responsiveness" to new policy directions as a rationale. In one state the committee visited, political appoin- tees occupy the top three levels of the health department hierarchy. When the governor changes, much of the leadership of the agency is wiped out. In this instance, career employees seem to be regarded as liabilities instead of assets, that is, the governor is widely reputed to see them as holdovers from the previous administration. Another factor in the discontinuity of leadership has been the decline in the role played by the U.S. Public Health Service Commissioned Corps in providing experts on assignment to state and local public health agencies. For decades, the Commissioned Corps provided a personnel system with retirement benefits that allowed assignment of corps officers to state and local positions, constituting a national cadre of trained public health person- nel. Although still used for this purpose, the corps membership has declined and has been less available for state and local assignment. (U.S. Public Health Service, Health Resources and Services Administration, 1987) NATIONAL LEADERSHIP FOR PUBLIC HEALTH The provision of appropriate national leadership for public health is closely related to the problems of governmental structure in our federal system as discussed earlier. The components of necessary national leader- ship include (1) identifying and speaking out on specific health problems, (2) allocating of funds to accomplish national public health objectives, (3) building constituencies to support implementation of appropriate actions, and (4) supporting development of the knowledge and data base by public health. The federal government has been active in all of these components over the years. The role of the Centers for Disease Control in strengthening the public health capacity of the nation is apparent and profound. The establishment of the Office of Disease Prevention and Health Promotion in the Public Health Service provided additional focus on public health issues. Publication of Healthy People (U.S. Department of Health, Education, and Welfare, 1979) in 1979 and the subsequent issuance of The 1990 Objectives for the Nation (U S. Department of Health and Human Services, Public

PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVll-Y 121 Health Service, 1980) and of Model Standards (American Public Health Association et al., 1985) represented a visible national leadership role in the establishment of public health objectives, working with state and local agencies and state and national nongovernmental health groups. The Envi- ronmental Protection Agency has played a major role in reducing environ- mental pollution. The National Institutes of Health led the campaign against hypertension. The National Institute of Mental Health led in the develop- ment of community mental health resources. The leadership role of the Surgeon General and the Public Health Service in reduction of smoking has been essential. Many other examples could be cited. There have been complaints from state and local agencies since the 1960s that the federal government sometimes bypassed them in carrying out some federal health priorities. Examples include health planning, community health centers, regional medical programs, and professional standards re- view organizations. However, the current federal policy stance, going back over several administrations, has been to turn over more public health decision-making to the states. This has been accompanied, however, by a reduction in the flow of federal funds earmarked for public health activities, measured on an equivalent current services basis. For example, when the public health, mental health, and maternal and child health block grants were approved by Congress during the sweeping changes in 1981, decision- making was transferred to the states, but the federal funds included in the block grants were cut by 25 percent. (Omenn, 1982) Some national policy- makers argued for elimination of federal support for these functions. At the same time, federal revenue sharing was being eliminated, thus further reducing available federal funds that could be used for public health pur- poses. While some restoration of federal revenues was made by Congress in 1983, a net reduction from prior levels is still in place. The AIDS epidemic has demonstrated the need for federal leadership in public health. Only the federal government can focus the attention and resources that such a health problem demands. In our site visits, many state and local officials welcomed national leadership on such issues, but at the same time complained about the fragmenting effect of some federal policies and programs and the lack of resources to carry out federal requirements. POOR RELATIONSHIPS WITH THE MEDICAL PROFESSION A particular problem for public health leadership is the lack of supportive relationships with the medical care profession. There are numerous exam- ples of practicing physicians being supportive of public health activities, but confrontation and suspicion too often characterize the relationship from both sides. The director of one state medical association perceived the state

122 THE FUTURE OF PUBLIC HEALTH health department (led by a nonphysician) as failing to seek medical advice and as distrustful of private physicians. He cited the department's effort to get a mandatory data reporting system through the legislature without consulting the association. On the other hand, health department person- nel including the director-told us that it was impossible for the depart- ment to do its job without the support of private physicians. As one official put it, "Without them, we're dead in the water." In contrast, we heard of one local health officer who, confronted with the problem of access to prenatal care, convened a meeting of local obstetricians to ask them each to agree to take one or two patients for whatever they would pay. The doctors all agreed, and the problem was resolved. We found medical care leaders who were simply unaware of the activities carried out by public health; yet those same leaders are often crucial in the achievement of political support for public health activities and in the con- duct of substantive public health activities in which the cooperation of the private medical community is highly desirable (e.g., the reporting of com- municable diseases, the provision of prenatal care, the education of the public on healthful personal habits, and many other examples). Improving these relationships is an important challenge for public health leadership. COMMUNIFY ORGANIZATION FOR PUBLIC HEALTH ACTION In a free and diverse society, effective public health action for many problems requires organizing the interest groups, not just assessing a prob- lem and determining a line of action based on top-down authority. There are many positive examples of public health officials taking leadership in orga- nizing community support for actions toward public health objectives, but this dimension of leadership is not as firmly fixed in public health activities as may be desirable. This capability requires appropriate leadership skills and techniques, as well as an attitude that the community itself is a source of public health actions. These skills include the ability to communicate impor- tant agency values to public health workers and to enlist their commitment to those values, the ability to sense and deal with important changes in the community that are the context for public health programs, the ability to communicate with diverse audiences and to understand their perspectives and needs, and the ability to find common pathways for action. Appropriate training in these leadership skills needs to be a part of the educational preparation of public health leaders.

PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY STRUCTURE AND ORGANIZATION OF PUBLIC HEALTH 123 In the United States, public sector functions must be performed in the midst of a deliberately complex set of organizational and jurisdictional relationships. Policymakers and decision-makers are multiple, and organiza- tional arrangements reflect both constitutionally determined layers of gov- ernment and the multiple interests in a democratic society competing for attention and resources. Coherence and consistency of function are very difficult to attain and sustain under these circumstances. The following are specific problems we have identified. ORGANIZATIONAL SEPARATION OF ENVIRONMENTAL HEALTH PROGRAMS, MENTAL HEALTH PROGRAMS, AND INDIGEN r CARE PROGRAMS In a previous section, we discussed the problems that are created for a perceived coherence of public health activities when environmental health, mental health, and indigent care programs are administered by separate agencies. These separations also raise administrative, structural, and policy questions. In the case of environmental health, the committee was presented during its site visits with tangible indications of barriers to action caused by fragmentation of responsibility. In one county, officials were concerned about several toxic spills on highways, one of which had occurred near the county's open reservoir. They had written more than a year prior to our visit to the state attorney general, who had jurisdiction in such cases, and as yet they had no answer. In another state, a rancher showed us the notebook of correspondence he had amassed over several years of attempts- as yet unsuccessful to dispose legally of two barrels of toxic waste on his property. Concern was also expressed that organizational fragmentation lessens desirable health-related technical input into the policy- and decision-making process especially for environmental health activities and for the Medicaid program when it is administered by a social services agency. For mental health programs, the organizational separation may reflect a continued emphasis within mental health on the provision of services for the mentally ill rather than a "public health" orientation, including epidemiological sur- veillance and prevention. Wherever organizational separation takes place, regardless of the validity of the reasons for that separation, separate program development is encour- aged and desirable program coordination is impeded. Data systems are fragmented, impeding broad assessment and surveillance that make possible comparisons of program impacts on the health of the public and policy formulation based on comparable problem analysis and risk assessment. In the committee's judgment, this separation contributes to the sense of disar .

124 THE FUTURE OF PUBLIC HEALTH ray in public health that inhibits coherent governmental effort to improve and protect the health of the public. Such separation also divides constituen- cies that might otherwise help develop a broader vision of the public health . . mlsslon. CREATION OF HEALTH AND HUMAN SERVICES SUPERAGENCIES As described in Appendix A, almost half of the states have created umbrella health and human services "super" agencies. This combination of health and welfare accentuates the image in the minds of some policymakers that public health is predominately a welfare program. As a result, the relevance of public health to the broader society may be diminished. The emphasis of such health and welfare agencies on the coordination of services to particular individual clients, although a worthy objective, may give less attention to the broad population-based functions of public health that benefit the entire public. Another problem with these umbrella health and human services agencies that was described to us is the appointment to managerial positions in these agencies of administrative generalists, with little or no health background or expertise. Desirable inputs from technically competent persons may there- fore be subordinated in the policy and administrative process. Generalist managers may also be less attuned to a broad vision of public health, such as that set forth by this committee in Chapter 2. It should be noted that at the federal level the Public Health Service has been part of such a "super" health and human services agency since before World War II (until 1977 also including education). From the perspective of advancing a public health mission, the committee notes that both in the fragmentation model described above and the super- agency model, the role of public health leadership founded on a technically competent assessment function is lessened. Case studies have been made of these organizational changes (Lynn, 1980), but we note that there is no solid evidence of the impact of alternative organizational patterns on health status. Nevertheless, on the assumption that organizational structure can enhance or inhibit some aspects of program effectiveness, the committee believes the structural issues deserve attention. We also believe that whatever the organizational structure, coordination with other human services programs will be necessary. For example, many issues of policy and program coordination will continue to exist at the interface between social programs and public health programs, especially for multiproblem families or vulnerable individuals, such as the disabled or the frail elderly. Likewise, such programs as housing, land-use planning, crimi- nal justice, and education have important health implications. Public health

PUBLIC HEALTH AS A PROBLEM-SOLVING ACTIVITY 125 will always have to reach across organizational boundaries for health-related inputs on policies and programs, just as other agencies will have to seek appropriate inputs from health agencies on their policies and programs. We question whether the "super" agency health and welfare model has been a useful solution to those coordination needs. LACK OF A CLEAR DELINEATION OF RESPONSIBILITIES BETWEEN LEVELS OF GOVERNMENT The federal structure established in our Constitution deliberately intro- duces a degree of ambiguity and tension concerning the roles of the various levels of government. This ambiguity can clearly be seen in public health where we observe a "patchwork quilt" of relationships. Questions about the appropriate division of responsibilities will probably persist as long as we have a federal structure of government. However, the committee is concerned that the lack of a clearer delineation of those roles impedes desirable cooperation and optimal use of the unique capacities peculiar to each level. Some patterns of relationship, such as the relationship of the Centers for Disease Control with states and localities in the control of communicable disease, seem to be relatively clear and productive. For other functions the relationships are less well established and are often sources of considerable tension. In the 1960s, the federal government deliberately bypassed official health agencies at the state and local levels in establishing certain federal health programs, such as neighborhood health centers and regional medical programs, to assure that federal objectives were met. Some environmental health problems raise complex questions of interstate or even international relationships in which a purely state or local focus of authority is insufficient for the problem. For example, in one of our site visits a county commissioner pointed out that pollution of beaches in his jurisdiction was caused by sewage effluent from a foreign country that borders on his district. The relationship between the state and localities is extremely varied and is a product of particular provisions of state constitutions, political history, and inherent tensions between large urban areas and rural areas within a state. In most states, the statutes describing the authority of and relationships be- tween state and local health agencies lack clarity and consistency. Often these statutes consist of successive overlays on prior law, rather than compre- hensive codifications. Previous grants of authority to village, town, city, county, and state health officers and boards may have been made at different times using inconsistent language, resulting in a confusing patchwork of law which often mirrors an equally ambiguous set of relationships in practice. These ambiguities are often reflected in poor communication and in under- standings between state and local officials.

126 THE FUTURE OF PUBLIC HEALTH This complex of problems deserves explicit attention if the future of public health is to be assisted by appropriate cooperation rather than impeded by dispute and confrontation. DEFICITS IN THE CAPACITY TO CONDUCT PROGRAMS In carrying out its functions, public health must possess the fundamental capacity for effective actions. These capacities include the technical knowl- edge base and its application, well-trained and competent personnel, the generation and maintenance of adequate constituencies and political sup- port, managerial competence sufficient for these complex public sector tasks, and adequate fiscal support for the agreed-upon public health mission. The committee has identified problems with each of these capacities. KNOWLEDGE AND ITS APPLICATION Effective public health actions must be based on accurate knowledge of health problem causation, distribution, and the effectiveness of interven- tions. Actions often must be taken on the basis of incomplete knowledge, but these knowledge gaps can impede effectiveness of programs and ultimately public support for actions. For many public health problems the knowledge base, including knowledge about the effectiveness of specific interventions, is inadequate. Arguments in the policy formulation and regulatory decision processes often question knowledge that does exist, e.g., human health risks of toxic chemicals or effects of smoking on nonsmokers. Filling these knowl- edge gaps requires substantial resources, yet the need for additional knowl- edge is often perceived by decision-makers only when the decision needs to be made. Public health may then be accused of lacking competent expertise relevant to the immediate needs of decision makers. Another problem with filling these knowledge gaps is the extraordinary breadth of substantive areas that are relevant to public health actions. Some knowledge arenas such as epidemiology are obvious, but public health is also a primary beneficiary of advances in biomedical knowledge that lead to definitive interventions, such as the development of new screening tests and vaccines. The research response to the AIDS problem illustrates this rele- vance. The same can be said for toxicological research that improves the ability of public health to perform informed risk assessments. The incredible ferment in research that is adding to our basic understanding of biological processes is, therefore, highly relevant to public health, as is reflected by the conduct of such research in a number of schools of public health. Other knowledge bases are not quite so obvious but, nevertheless, impor- tant. For example, the recent report Confronting AIDS noted the impor- tance of behavioral research, including fuller knowledge about sexual behav

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,

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.

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.

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

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

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."

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

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,

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.

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.

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.

Next: 6. Conclusions and Recommendations »
The Future of Public Health Get This Book
×
Buy Paperback | $49.95 Buy Ebook | $39.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

"The Nation has lost sight of its public health goals and has allowed the system of public health to fall into 'disarray'," from The Future of Public Health. This startling book contains proposals for ensuring that public health service programs are efficient and effective enough to deal not only with the topics of today, but also with those of tomorrow. In addition, the authors make recommendations for core functions in public health assessment, policy development, and service assurances, and identify the level of government—federal, state, and local—at which these functions would best be handled.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!