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6 Conclusions and Recommendations Public health in the United States confronts a dilemma. On the one hand, the advances against health problems for which public health was established in this country are largely taken for granted: safe water, substantial protec- tion against formerly epidemic diseases, an infant death rate only one-tenth as high as in 1900. It is difficult to maintain a sense of urgency about these matters, although continuing vigilance is necessary to preserve the gains that have been won. For example, our country's progress in reducing infant mortality has actually slipped: throughout the 1970s, infant mortality de- clined at an average annual rate of 5 to 6 percent, while from 1981 to 1984, the rate of decline slowed to about 3 percent. (Hughes et al., 1986) Infant mortality has actually increased recently in Detroit, Los Angeles, and elsewhere and remains distressingly high in poor communities. Outbreaks of measles, for which effective immunization is available, continue to occur. The rate of syphilis is rising again. (U.S. Department of Commerce, Bureau of the Census, 1986) But warnings about these events by public health officials are sometimes seen as self-serving. On the other hand, despite general complacency that the public health job is done, public concern is mounting over new health problems: toxic sub- stances in air, water, and food; cancer and heart disease; drug abuse and teenage pregnancy; AIDS. Excitement about such new health threats often leads to laws, regulations, agencies, and appropriations that bypass the "old" public health. Action is obviously necessary, but the traditional chan- nels are widely regarded as unsuitable. Thus the dilemma faced by public health is how to take on the new challenges while continuing its work to contain long-existing problems. 138

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CONCLUSIONS AND RECOMMENDATIONS 139 Public health leaders have not succeeded in making clear that both aspects of public health must be tackled vigorously. All too often, political leaders push short-term "solutions" to various health crises without reference to the knowledge base that exists for sound programs. The general public is con- fused. The result is a hodgepodge of fractionated interests and programs, organizational turmoil among new agencies, and well-intended but unbal- anced appropriations without coherent direction by well-qualified profes- sionals. That disarray has stimulated this study and this volume. The first chapter reflects the committee's sense as the study began that public health was in trouble, that few people knew and even fewer cared, and that those who did care were divided over the nature of the problem and what to do about it. In conducting the study, committee members set aside temporarily their individual views-although not their shared con- cern- in order to take a fresh look at public health and to develop a common understanding of it. The aim of the study has been to produce a report that examines the total range of public health activity, not simply an assortment of tax-supported programs. The committee sought to identify a set of functions necessary for the protection and advancement of the public's health, to assess difficulties in carrying out these functions, and to recommend specific strategies for improvement. Judgments about the specific programs that public agencies should undertake or what resources they should command always imply underly- ing assumptions about the agency's proper mission, scope of concern, and functions. In Chapter 2, the committee sought to make its own assump- tions explicit, so that the logic of the ensuing problem analysis, findings, and recommendations would be clear. The committee's own deliberations proceeded along these lines, beginning with clarification of the mission and scope of public health. The committee continued by distinguishing functions and responsibilities that only governmental agencies can under- take from those that should be shared with or left to the private sector. Then, weighing its analysis of the existing dilemma of public health, as outlined in Chapters 3, 4, and 5, the committee asked with respect to each issue: Given our definition of public health and what we believe govern- ment's responsibilities ought to be, how should this challenge be addressed? This final chapter, setting forth the committee's recommendations for the future of public health, traces the same path. The committee is making three basic recommendations dealing with: the mission of public health, the governmental role in fulfilling the mission, and the responsibilities unique to each level of government.

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140 THE FUTURE OF PUBLIC HEALTH The rest of the recommendations are instrumental in implementing the basic recommendations for the future of public health. These instrumental recommendations fall into the following categories: statutory framework; structural and organizational steps; strategies to build the fundamental capacities of public health agencies technical, political, managerial, pro- grammatic, and fiscal; and education for public health. THE PUBLIC HEALTH MISSION, GOVERNMENTAL ROLE, AND LEVELS OF RESPONSIBILITY MISSION The committee defines the mission of public health as fulfilling society's interest in assuring conditions in which people can be healthy. Public health is distinguished from health care by its focus on communitywide concerns- the public interest rather than the health interests of particular individuals or groups. Its aim is to generate organized community effort to address public concerns about health by applying scientific and technical knowledge. These concerns include disease prevention and health promotion, encom- passing physical, mental, and environmental health. Many distinct and diverse professional disciplines are necessary in this effort, such as nursing, medicine, social work, environmental sciences, dentistry, nutrition, and health education. These professions are unified within public health by dedication to its value system, by the public interest in health, and by its core science, epidemiology the study of health Problems in Doculations and the factors that affect them. - r ~~~~~~ ~~~ r -or ~~~~~~~~~ ~~~ The mission of public health is more fundamental and more comprehen- sive than the specific activities of particular agencies. Organized community effort to prevent disease and promote health involves private organizations and individuals, working on their own or in partnership with the public sector. But the governmental public health agency has a unique function: to see to it that vital elements are in place and that the mission is adequately addressed. THE GOVERNMENTAL ROLE IN PUBLIC HEALTH The committee believes that governments at all levels have an irreplace- able role to play in assuring conditions in which people can be healthy. This means that federal, state, and local public health agencies have an obligation to assume certain vital functions directly. In the committee's view, these responsibilities cannot properly be delegated to the private sector. The committee finds that the core functions of public health agencies at all levels of government are assessment, policy development, and assurance.

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CONCLUSIONS AND RECOMMENDATIONS Assessment 74' An understanding of the determinants of health and of the nature and extent of community need is a fundamental prerequisite to sound decision- making about health. Accurate information serves the interests both of justice and the efficient use of available resources. Assessment is therefore a core governmental obligation in public health. ~ The committee recommends that every public health agency regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, commu- nity health needs, and epidemiologic and other studies of health problems. The extent to which information will be generated directly or collected from other sources will vary depending on the size of the agency and of the population served. For example, the federal agency will have a nationwide purview, while smaller agencies may lack sufficient mass of expertise neces- sary for sophisticated research; thus interagency and intergovernmental cooperation is crucial. Nevertheless, each public health agency at every level of government bears the responsibility for ensuring that the assessment function is fulfilled. This basic function of public health cannot be delegated. Policy Development Legitimate public decisions reflect a full examination of the public interest and sound analysis of problems and interventions. Attention to the quality of decision-making about health is necessary so that the interests of all affected parties, especially the general public, are considered. This attention is a basic responsibility of government in public health. ~ The committee recommends that every public health agency exercise its responsibility to serve the public interest in the development of comprehen- sive public health policies by promoting use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy. Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process. Specific strategies must be developed by each agency depending on its circumstances. Later recommendations exemplify the kinds of steps that agencies may find appropriate. The intent of this recommendation is to encourage agencies to view policy development as central to their roles and to develop strategic approaches to its achievement that anticipate possible problems. Government should be equipped for this role by the technical knowledge and professional expertise of agency staff. Used judiciously, the knowledge base of public health tempers the excesses of partisan politics and encour- ages just decisions. Technical knowledge will have the best effect, however,

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142 THE FUTURE OF PUBLIC HEALTH when used in the context of a positive appreciation for the democratic political process, by professionals who are politically as well as technically astute. Assurance Government has an inherent responsibility to take positive action to achieve goals that society agrees upon in the interest of individual justice or for the common good. The committee recommends that public health agencies assure their constituents that services necessary to achieve agreed upon goals are pro- vided, either by encouraging action by other entities (private or public sec- tor), by requiring such action through regulation, or by providing services directly. The goals agreed upon should be achievable with the resources and techniques available. The goal for assurance of a particular service or bene- fit, therefore, may represent partial accomplishment of an ultimate goal. However, for a subset of assured services that the society, through govern- ment, has decided are so fundamental to the well-being of the population that access to their benefits should be universally available, assurance should become a guarantee. The committee recommends that each public health agency involve key policymakers and the general public in determining a set of high-priority personal and communitywide health services that governments will guaran- tee to every member of the community. This guarantee should include subsi- dization or direct provision of high-priority personal health services for those unable to afford them. FEDERAL, STATE, AND LOCAL RESPONSIBIEITIES The committee believes that assessment, policy development, and assur- ance are obligatory functions at every level of government. But federal, state, and local governments are far from identical. They vary in power, responsibility, scale of activity, and level of resources. Therefore it is appro- priate that core governmental functions are differently expressed at each level. Also, the idea that there is strength in diversity is a fundamental American belief, reflected in the great variability from place to place in the distribution of functions among levels of government. Nevertheless, there are important public health tasks particularly suitable to each level.

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CONCLUSIONS AND RECOMMENDATIONS 143 States Under the Constitution, states retain all powers not specifically delegated to the federal government. The committee believes that the recent trend toward increasing state government responsibilities is positive in at least one respect: In fulfilling the public health mission, states are close enough to the people to maintain a sense of their needs and preferences, yet large enough to command in most cases the resources necessary to get the important jobs done. During the study, however, the committee observed that many states are not fulfilling this leadership role, and public health activities have lost institutional focus and broad public support. The committee believes that the states are and must be the central force in public health. They bear primary public sector responsibility for health. The committee recommends that the public health duties of states should include the following: assessment of health needs within the state based on statewide data collection; assurance of an adequate statutory base for health activities in the state; establishment of statewide health objectives, delegating power to lo calities as appropriate and holding them accountable; assurance of appropriate organized statewide effort to develop and maintain requisite personal, educational, and environmental health services; provision of access to necessary services; and solution of problems inimical to health; guarantee of a minimum set of essential health services; and support of local service capacity, especially when disparities in local ability to raise revenue and/or administer programs require subsidies, techni cal assistance, or direct action by the state to achieve adequate service levels. The Federal Government Most health issues affect the majority of Americans directly or indirectly. Therefore, the federal government's involvement in national policy develop- ment is necessary. It has the obligation to take the initiative in bringing broad public health policy issues to the attention of the nation, to establish a framework within which interstate and national issues can be debated, and to set national health goals and standards of achievement. The committee recommends the following as federal public health obli- gations: support of knowledge development and dissemination through data gathering, research, and information exchange;

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144 THE FUTURE OF PUBLIC HEALTH establishment of nationwide health objectives and priorities, and stim- ulation of debate on interstate and national public health issues; provision of technical assistance to help states and localities determine their own objectives and to carry out action on national and regional objec- tives; provision of funds to states to strengthen state capacity for services, especially to achieve an adequate minimum capacity, and to achieve national objectives; and assurance of actions and services that are in the public interest of the entire nation such as control of AIDS and similar communicable diseases, interstate environmental actions, and food and drug inspection. Localities Localities are clearly creatures of the state in legal terms, yet politically they are a significant force in the development of policy and the allocation of resources. Because of the great diversity in size, powers, and capacities of the many thousands of local governments in the United States, generaliza- tions about their proper functions must be made with caution. Yet everyone actually lives and works in a "locality," and the local level represents the final delivery point for all public health efforts. The committee understands that there are many thinly populated areas in this country where it may be unrealistic to envision a full-fledged local health department. Nevertheless, the committee fully supports the concept of "a governmental presence [in public health] at the local level" as developed in the Model Standards. According to this concept, "every community must be served by a governmental entity charged with . . . responsibility . . . for providing and assuring public health and safety services." (American Public Health Association et al., 1985) In the case of many county and municipal governments this requirement is indeed fulfilled, usually with state financial assistance and sometimes through direct state operation of the local health department (Chapter 4; Appendix A). But where local government is clearly unequipped on its own to meet the operational responsibility for a public health presence, the state must in cooperation with local officials- take action to establish it. It is difficult to generalize about what constitutes an adequate operational definition of "a governmental presence at the local level." Clearly, each tiny hamlet in a county whose total population is only a few hundred people cannot maintain an independent free-standing, full-service, local public health unit. Acknowledging this fact, the committee nonetheless finds that: ~ No citizen from any community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health

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CONCLUSIONS AND RECOMMENDATIONS 145 protection, which is possible only through a local component of the public health delivery system. Definitive statements about the embodiment of the governmental pres- ence at the local level are difficult for they range from the full-service metropolitan health department, including a municipal hospital and envi- ronmental protection capacity with full delegation of responsibility from the state, to the half-day-a-week traveling public health nurse and visiting envi- ronmental health worker from the state health department, or even to a telephone or radio communications network. Although definitive statements about the nature of the governmental presence may be difficult, it is possible to say with some certainty what it is not. When local people cannot find help or even advice to deal with sus- pected toxic waste; when low-income women have literally nowhere to go for prenatal care; when persons designated as local health officers by the state are ignorant of their official status or are even deceased; when the crum- bling, neglected "county health department" behind the courthouse has neither information nor the ability to help citizens gain access to needed primary medical care all circumstances the committee encountered during its study-one can say positively that government's responsibility for the health of the people is not being met. The committee recommends the following functions for local public health units: -assessment, monitoring, and surveillance of local health problems and needs and of resources for dealing with them; policy development and leadership that foster local involvement and a sense of ownership, that emphasize local needs, and that advocate equitable distribution of public resources and complementary private activities com- mensurate with community needs; and assurance that high-quality services, including personal health ser- vices, needed for the protection of public health in the community are avail- able and accessible to all persons; that the community receives proper consid- eration in the allocation of federal and state as well as local resources for public health, and that the community is informed about how to obtain public health, including personal health, services, or how to comply with public health requirements. FULFILLING THE GOVERNMENT ROLE: RECOMMENDATIONS In order to carry out the public health mission by fulfilling the governmen- tal roles and responsibilities outlined above, a number of enabling steps must

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146 THE FUTURE OF PUBLIC HEALTH be taken. They fall into three categories. First, certain improvements are needed in the statutory base of public health. Second, the committee recom- mends several structural and organizational modifications that hold promise for strengthening the framework within which key functions must be carried out. Third, a number of strategies are detailed to improve public health agency capacities for action: technical, political, managerial, programmatic, and fiscal. Finally, the committee addresses needs in education for public health. STATUTORY BASE State public health laws are in many cases seriously outdated. Statements of public health agency authority, responsibility, and organizational struc- ture are inadequate to deal with contemporary problems. Procedural safe- guards protecting individual rights are frequently weak or absent. The committee recommends that states review their public health stat- utes and make revisions necessary to accomplish the following two objectives: clearly delineate the basic authority and responsibility entrusted to public health agencies, boards, and officials at the state and local levels and the relationships between them; and support a set of modern disease control measures that address contem- porary health problems such as AIDS, cancer, and heart disease, and incor- porate due process safeguards (notice, hearings, administrative review, right to counsel, standards of evidence). STRUCTURAL/ORGANIZATIONAL STEPS The committee believes that several organizational measures can be taken to improve the fundamental ability of public health agencies to translate their duties into specific, effective action. The committee notes that "reor- ganizing" is frequently the first resort of a beleaguered bureaucracy when in many cases the problem is not truly structural. Reorganizing will not create a policy commitment where none exists; but the right reorganization may enable a commitment to be implemented more effectively. Organizational modifications should form part of a total approach. Some of the committee's organizational recommendations are specific to a particular level of government; others relate to the nature of appropriate linkages with public health-related concerns such as environmental health, mental health, indigent care, and social services. All are intended as steps to enable governments to perform the vital functions of assessment, policy development, and assurance. They have the additional aim of identifying organizational focal points for public health activity.

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CONCLUSIONS AND RECOMMENDATIONS 147 States States are the primary force in public health. It is appropriate for states to delegate service responsibilities to localities when local governments are or can be equipped to carry them out. But states have the ultimate respon- sibility for the health of their residents. To fulfill this obligation states must take action to establish a clear, organizational focal point for public health responsibility, one that is accountable to the people through the political process, yet one in which expert professional judgment about issues requir- ing such input is not confounded or obscured by excessively partisan politics or narrow ideology. The committee recommends that each state have a department of health that groups all primarily health-related functions under professional direc- tion- separate from income maintenance. Responsibilities of this department should include disease prevention and health promotion, Medicaid and other indigent health care activities, mental health and substance abuse, environ- mental responsibilities that clearly require health expertise, and health plan- ning and regulation of health facilities and professions. The committee believes that diffusion of primarily health-related func- tions among different agencies and the organizational linkage of health with a particular set of related activities-income maintenance for low-income populations-has gone too far in many states. The effect of organizational trends toward fractionation or submersion of health concerns during the past 25 years has been the creation of impediments to the use of the assessment function in the development of health-related policies and programs that focus on the most significant threats to the health of the public. While a variety of organizational steps might improve this situation, the committee is persuaded that a forthright organization that puts primarily health-related functions over competent health-oriented leadership is the most direct approach. The committee observes that in some states it may not be politically feasible to transfer authority for a particular public health-related function to the department of health from another state agency. But the fact that authority is shared with other agencies does not relieve the department of health from its obligation to assure that public health functions are per- formed. To accomplish this critical objective, in cases of shared authority, the assessment, policy development, and assurance functions can be sup- ported by mechanisms such as an interagency council chaired by the director of the department of health to review health problems and encourage and coordinate multiagency efforts. The committee recommends that each state have a state health council that reports regularly on the health of the state's residents, makes health

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148 THE FUTURE OF PUBLIC HEALTH policy recommendations to the governor and legislature, promulgates public health regulations, reviews the work of the state health department, and recommends candidates for director of the department. The committee notes that whereas 25 years ago nearly all states had boards of health, many of which had responsibilities similar to those it envisions for state health councils, today half the states have dissolved their boards. (Gossret and Miller, 1973; Gilbert et al., 1982) There has been little research on the factors underlying this development. Whatever sound rea- sons there may be, the committee believes that the disbanding of state boards has meant the loss of an important resource for public health policy. The state health councils should not be means for control of health matters by health professionals, as has occasionally been true of state boards of health in the past. Rather, a council should be a positive framework within which community values and professional knowledge can be blended to reach wise policy judgments that will assure the conditions in which people can be healthy. The committee believes that lay citizens should be in the majority of the membership. To give weight to the body, both lay citizens and health profession members should have considerable stature in the state and be widely perceived as wise leaders. The committee recommends that the director of the department of health be a cabinet (or equivalent-level) officer. Ideally, the director should have doctoral-level education as a physician or in another health profession, as well as education in public health itself and extensive public sector adminis- trative experience. Provisions for tenure in office, such as a specific term of appointment, should promote needed continuity of professional leadership. It is often argued that all officials at the agency head level should serve at the pleasure of the governor to assure accountability to the governor's program. We believe that the desirable objective of accountability needs to be balanced with appropriate concern for continuity of competent profes- sional leadership for a set of functions in which the governor, the legislature, and the society as a whole will expect knowledge and experience when the health of the public is on the line. The committee therefore has recom- mended appointment of a specific term as a means of meeting both the objectives of accountability and appropriate continuity. For example, the health department director might be appointed for 4 years, with the possi- bility of renewal. To assure orderly transition between governors, the term might begin 1 year after the governor takes office. Other variations of this approach might be developed to accomplish this purpose, but the committee believes that its specific recommendation should focus attention on an im- portant issue.

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CONCLUSIONS AND RECOMMENDATIONS 149 The committee recommends that each state establish standards for local public health functions, specifying what minimum services must be offered, by what unit of government, and how services are to be financed. States (unless providing local services directly) should hold localities accountable for these services and for addressing statewide health objectives, using the Model Standards: A Guide for Community Preventive Health Services as a guide. Localities Local government variations will determine the exact balance appropriate between direct state operation of local services delivery, partial local govern- ment participation, or delegated full operational responsibility for local health units. Regarding state delegation of responsibility to local governments, in general, the committee finds that the larger the population served by a single multipurpose government, as well as the stronger the history of local control, the more realistic the delegation of responsibility becomes: for example, to a large metropolitan city, county, or service district. Two attributes of such a locally responsible system are strongly recommended: To promote clear accountability, public health responsibility should be delegated to only one unit of government in a locality. For example, in the case of large cities, public health responsibility should be lodged either in the municipal or the county government, but not both. Where sparse population or scarce resources prevail, delegation to regional single-purpose units, such as multicounty health districts, may be appropriate. In order to be effective, health districts must be linked by formal ties to, and receive resources from, general-purpose governments. Delegation has the great advantage of fostering true independent local advocacy, ownership, and funding capabilities; greater sensitivity to chang- ing local delivery patterns; and greater responsiveness to community priori- ties. In general, delegation of responsibility to the local level is the commit- tee's preferred option. The committee recommends that mechanisms be instituted to promote local accountability and assure the maintenance of adequate and equitable levels of service and qualified personnel. Such mechanisms include: performance contracting with the state; negotiated local standards (for example, based upon the Model Stan- dards: A Guide for Community Preventive Health Services; and local public health councils. The committee finds that the need for a clear focal point at the local level is as great as at the state level, and for the same reasons. When the scale of

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150 THE FUTURE OF PUBLIC HEALTH government activity permits, localities should establish public health councils to report to elected officials on local health needs and on the performance of the local health agency. Federal The committee is primarily concerned in directing public attention to states and localities where much of the vital decision-making and work of public health goes on. For this reason, research in connection with this study was conducted largely with states and localities as the focus, and public health practice at the federal level was not reviewed in depth. The commit- tee, however, does note the concerns expressed consistently by state and local public health leadership about the lack of a clearly identified national focal point for the exercise of public health leadership and for the support of the state and local public health systems. The impact at the state and local level of the absence of a clear national public health focal point is reflected in the state of affairs discussed in Chapter 5. ~ The committee recommends that the federal government identify more clearly, in formal structure and actual practice, the specific officials and agencies with primary responsibility for carrying out the federal public health functions recommended. The committee recommends the establishment of a task force to consider what structure or programmatic changes would be desirable to enhance the federal government's ability to fulfill the public health leadership respon- sibilities recommended in this report. SPECIAL LINKAGES The committee finds that environmental health and mental health activ- ities are frequently isolated from state and local public health agencies, resulting in disjointed policy development, fragmented service delivery, lack of accountability, and a generally weakened public health effort. Environmental Health Many environmental health concerns and the authority to deal with them have been removed from the purview of public health agencies. This has led to diffused patterns of responsibility, lack of coordination, and inadequate analysis of the health effects of environmental problems. As a result, soci- ety's ability to deal appropriately with these vital issues has been con- strained. ~ The committee recommends that state and local health agencies strengthen their capacities for identification, understanding, and control of environmental problems as health hazards. The agencies cannot simply be

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CONCLUSIONS AND RECOMMENDATIONS 151 advocates for the health aspects of environmental issues, but must have direct operational involvement. The agencies should have expertise, particularly at the state level, in environmental health science planning and operations, as well as environmental health risk assessment and management. They should maintain ongoing working relationships with organizations that have access to relevant environmental data, encourage regional cooperation in control- ling environmental hazards within the state, and work to establish similar cooperation across state lines. In addition to environmental services tradi- tional to the public health mission, such as outdoor air and drinking water quality, food protection, and control of occupational hazards, public health agencies should concern themselves with toxic exposures, pesticide manage- ment, indoor air pollution, the health and safety features of health facilities, and groundwater contamination. Mental Health The relationship between public health and mental health has been com- plex and sometimes counterproductive. Although each field has developed useful scientific knowledge and expertise, the separation of the two fields has often produced fragmentation at the service delivery point to the detriment of clients. The existing interface between core public health disease preven- tion and health promotion and similar efforts in mental health is inadequate to fulfill either the public health mission or the mission of mental health. The committee recommends that those engaged in knowledge develop- ment and policy planning in public health and in mental health, respectively, devote specific effort to strengthening linkages with the other field, partic- ularly in order to identify strategies to integrate these functions at the service delivery level. The committee recommends that a study of the public health/mental health interface be done in order to document how the lack of linkages with public health hampers the mental health mission. In contrast to environmental health and mental health, where the problem is isolation from and lack of coordination with public health, the committee believes that social services and indigent medical care are often inap- propriately linked organizationally with core public health services, so that public health functions are impaired. Social Services In many states arid some localities, public health functions are subsumed organizationally under a "super" department of human services (see Ap- pendix A). It is important to develop and sustain productive interactions between activities aimed primarily at improving health and social services directed at general improvements in the quality of life. Examples of areas

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152 THE FUTURE OF PUBLIC HEALTH that benefit from these interactions are maternal and child health and substance abuse. In many such departments, however, the emphasis on the welfare payment role, on certifying client eligibility to receive income main- tenance, and on making the payment creates a negative image and detracts from organized community effort to maintain crucial public health functions as well as from the delivery of substantive social services. Desirable integra- tion of service delivery at the client level does not mean that organization and policy must be unified. The committee recommends that public health be separated organiza- tionally from income maintenance, but that public health agencies maintain close working relationships with social service agencies in order to act as effective advocates for, and to cooperate with, social service agency provision of social services that have an impact on health. Care of the Medtically Indigent Many state and local health agencies have become providers of last resort for uninsured persons and Medicaid clients unable to secure services in the private sector. This development is consistent with the committee's belief that government is obliged to assure all members of society access to services and to guarantee a basic set. But the responsibility for providing medical care to individual~precisely because it is so compelling-has drained vital resources and attention away from disease prevention and health promotion efforts that benefit the entire community. These latter efforts encounter great difficulty in competing for policy attention with personal health ser- vices. The U.S. failure to find a societywide answer to the question of financial access to needed care has seriously strained the public health system. The committee endorses the conclusion of the President's Commission for the Study of Ethical Problems in Medical Care and Biomedical and Behavioral Research, that: Society has an ethical obligation to ensure equitable access to health care for all.... The societal obligation is balanced by individual obligations ... to pay a fair share of the cost of their own health care and take reasonable steps to provide for such care when they can do so without excessive burdens. Nevertheless, the origins of health needs are too complex, and their manifestation too acute and severe, to permit care to be regularly denied on the grounds that individuals are solely responsible for their own health.... When equity occurs through the operation of private forces, there is no need for government involvement, but the ultimate responsibility for ensuring that society's obligation is met, through a combination of public and private sector arrangements, rests with the Federal government. (President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1983)

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CONCLUSIONS AND RECOMMENDATIONS 153 The committee finds that, until adequate federal action is forthcoming, public health agencies must continue to serve, with quality and respect and to the best of their ability, the priority personal health care needs of uninsured, underinsured, and Medicaid clients. Nevertheless, Americans should not assume, as they now appear to, that the public health system is adequately equipped to handle these needs, and they should be aware that this respon- sibility will remain a continuing threat to the maintenance of crucial disease prevention and health promotion efforts. The committee also wishes to note that even when the problem of financ- ing personal medical care for all Americans is solved, the public health system will and should retain important responsibilities for furnishing spe- cialized personal health services. Public health personnel are specialists in health problem identification, disease and disability prevention, and health promotion, a multidisciplinary expertise that addresses social and health needs not met simply by financing medical services. The exemplar of this role is the public health nurse engaged in outreach and case finding, direct service delivery, and management of the needs of multiproblem clients. Social workers functioning as case managers can also serve aspects of this role. STRATEGIES FOR CAPACITY BUILDING In the effort to equip public health agencies to fulfill adequately their assessment, policy development, and assurance functions, it is necessary to go beyond reorganization to consider how to build agency competence, especially the human resources and skills that will be required for effective action. There are five types of competence needed to improve the ability of public agencies to meet their responsibilities for the people's health: techni- cal, political, managerial, programmatic, and fiscal. Each requires particu- lar strategies and approaches for improvement. Technical Public health agencies must be able to acquire and mobilize scientific and other substantive knowledge, data, and technical skills to solve health prob- lems. Currently, technical capacity is unevenly distributed: some states and localities have considerable expertise, others appear deficient. Some regu- larly publish data, others do not. Some gather data but lack the ability to analyze it adequately. The committee recommends the following steps to strengthen public health agency technical capacity: A uniform national data set should be established that will permit valid comparison of local and state health data with those of the nation and of other

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154 THE FUTURE OF PUBLIC HEALTH states and localities and that will facilitate progress toward national health objectives and implementation of Model Standards: A Guide for Community Preventive Health Services. An institutional home in each state and at the federal level for develop- ment and dissemination of knowledge, including research and the provision of technical assistance to lower levels of government and to academic institutions and voluntary organizations. Research at the federal, state, and local levels into population-based health problems, including biological, environmental, and behavioral is- sues. In addition to conducting research directly, the federal government should support research by states, localities, universities, and the private sector. Political Public health agencies should be able to mobilize the support of important constituencies, including the general public, to compete successfully for scarce resources, to handle conflict over policy priorities and choices, to establish linkages with other organizations, and to develop a positive public image. The committee's research suggests that public health agencies are having difficulty striking a balance between political responsiveness and professional values. Some endeavor to insulate themselves from politics; others are buffeted by political firestorms. Too frequently, public health professionals view politics as a contaminant rather than as a central attribute of democratic governance. The committee recommends the following steps to improve political capacity: Public health agency leaders should develop relationships with and educate legislators and other public officials on community health needs, on public health issues, and on the rationale for strategies advocated and pursued by the health department. These relationships should be cultivated on an ongoing basis rather than being neglected until a crisis develops. Agencies should strengthen the competence of agency personnel in com- munity relations and citizen participation techniques and develop procedures to build citizen participation into program implementation. Agencies should develop and cultivate relationships with physicians and other private sector representatives. Physicians and other health profes- sionals are important instruments of public health by virtue of such activities as counseling patients on health promotion and providing immunizations. They are important determinants of public attitudes and of the image of public health. Public health leaders should take the initiative to seek working

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CONCLUSIONS AND RECOMMENDATIONS 155 relationships and support among local, state, and national medical and other professional societies and academic medical centers. Agencies should seek stronger relationships and common cause with other professional and citizen groups pursuing interests with health implica- tions, including voluntary health organizations, groups concerned with im- proving social services or the environment, and groups concerned with eco- nomic development. Agencies should undertake education of the public on community health needs and public health policy issues. Agencies should review the quality of "street-level" contacts between department employees and clients, and where necessary conduct in-service training to ensure that members of the public are treated with cordiality and respect. Managerial Public health agencies must have the capacity for organizational planning; development and implementation of programs; deployment of available resources for maximum efficiency and efficacy; leadership, motivation, and development of individual employees; and organizational evaluation and change in response to changes in the agency environment and its social . . milieu. Although many public health managers display these capabilities, the emphasis in the field on technical competence and professionalism some- times leads to a neglect of management as a skill in its own right. Manage- ment is often assumed to be purely a matter of common sense or innate ability rather than a body of knowledge that can be acquired through training and experience. The committee recommends the following measures to strengthen mana- gerial capacity: Greater emphasis in public health curricula should be placed on mana- gerial and leadership skills, such as the ability to communicate important agency values to employees and enlist their commitment; to sense and deal with important changes in the environment; to plan, mobilize, and use resources effectively; and to relate the operation of the agency to its larger community role. Demonstrated management competence as well as technical/profes- sional skills as a requirement for upper-level management posts. Salaries and benefits should be improved for health department man- agers, especially health officers, and systems should be instituted so that they can carry retirement benefits with them when they move among different levels and jurisdictions of government.

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156 THE FUTURE OF PUBLIC HEALTH Programmatic Public health agencies must have the capacity to deal with the "social environment" in fashioning and implementing public health strategies to address behavior-related health problems. The committee recommends that public health professionals place more emphasis on factors that influence health-related behavior and develop com- prehensive strategies that take these factors into account. Broadening public health emphasis from focus on the individual to consideration of the external factors that influence individual behavior can often result in more cost- effective strategies and, in some cases, stronger legal and political support. Public health leadership should consider all of the social, political, economic, psychological, cultural, and physical factors that shape health-related con- duct. Fiscal Public health agencies must have the capacity to generate enough re- sources to fulfill statutory responsibilities and established objectives and to use available resources efficiently and effectively. Currently, however, public health functions are handicapped by reductions in federal support; economic problems in particular states and localities; the appearance of new, expen- sive problems like AIDS and toxic waste; and the diversion of resources from communitywide maintenance functions to individual patient care. The committee recommends the following policies with respect to inter- governmental strategies for strengthening the fiscal base of public health: -Federal support of state-level health programs should help balance disparities in revenue-generating capacities and encourage state attention to national health objectives. Particular vehicles for such support should include "core" funding with appropriate accountability mechanisms, as well as funds targeted for specific uses. -State support of local-level health services should balance local reve- nue-generating disparity, establish local capacity to provide minimum levels of service, and encourage local attention to state health objectives; support should include "core" funding. State funds could be furnished with strings attached and sanctions available for noncompliance, and/or general support could be provided with appropriate accountability requirements built in. States have the obligation in either case to monitor local use of state funds.

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CONCLUSIONS AND RECOMMENDATIONS EDUCATION FOR PUBLIC HEALTH 157 As a large, complex, socially important service enterprise, public health depends for its effectiveness on well-qualified professionals (Chapter 5~. Many educational paths can lead to careers in public health. However, the most direct route, especially for positions of public health leadership, is to obtain a degree from a school of public health. Training for public health professional work in the field, especially for technical and administrative leadership, now requires greater emphasis in schools of public health. That training involves substantial development in one or more specific aspects of public health, for example, epidemiology, biostatistics, management of personal health services, environmental sci- ence, or health education. It also entails an understanding of how a particu- lar discipline relates to the whole of public health, and an appreciation of the relationship of public health to social endeavor as a whole. Public health professionalism further requires commitment to the public good, the value system that gives public health its coherence. Also, public health profes- sionals require an ability to analyze public health problems from the per- spective of their particular discipline as these problems emerge over a professional career and an appreciation for and skill in the political process. The task now is to assist the schools in developing a greater emphasis on public health practice and to equip them to train personnel with the breadth of knowledge that matches the scope of public health. The task also includes ensuring that public health educational efforts include short courses to upgrade that substantial majority of public health professionals who have not received appropriate formal training, as well as ensuring that public health personnel are abreast of new knowledge and techniques. To that end the committee recommends that: Schools of public health should establish firm practice links with state and/or local public health agencies so that significantly more faculty members may undertake professional responsibilities in these agencies, conduct re- search there, and train students in such practice situations. Recruitment of faculty and admission of students should give appropriate weight to prior public health experience as well as to academic qualifications. Schools of public health should fulfill their potential role as significant resources to government at all levels in the development of public health policy. Schools of public health should provide students an opportunity to learn the entire scope of public health practice, including environmental, educa- tional, and personal health approaches to the solution of public health prob- lems; the basic epidemiological and biostatistical techniques for analysis of

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158 THE FUTURE OF PUBLIC HEALTH those problems; and the political and management skills needed for leader- ship in public health. Research in schools of public health should range from basic research in fields related to public health, through applied research and development, to program evaluation and implementation research. The unique research mis- sion of the schools of public health is to select research opportunities on the basis of their likely relevance to the solution of real public health problems and to test such applications in real-life settings. Schools of public health should take maximum advantage of training resources in their universities, for example, faculty and courses in schools of business administration, and departments of physical, biological, and social sciences. The hazards of developing independent faculty resources isolated from the main disciplinary departments on the campus are real, and links between faculty in schools of public health and their parent disciplines should be sought and maintained. Because large numbers of persons being educated in other parts of the university will assume responsibilities in life that impact significantly on the public's health, e.g., involvement in production of hazardous goods or the enactment and enforcement of public health laws, schools of public health should extend their expertise to advise and assist with the health content of the educational programs of other schools and departments of the university. In view of the large numbers of personnel now engaged in public health without adequate preparation for their positions, the schools of public health should undertake an expanded program of short courses to help upgrade the competence of these personnel. In addition, short course offerings should provide opportunities for previously trained public health professionals, espe- cially health officers, to keep up with advances in knowledge and practice. Because the schools of public health are not, and probably should not try to be, able to train the vast numbers of personnel needed for public health work, the schools of public health should encourage and assist other institu- tions to prepare appropriate, qualified public health personnel for positions in the field. When educational institutions other than schools of public health undertake to train personnel for work in the field, careful attention to the scope and capacity of the educational program is essential. This may be achieved in part by links with nearby schools of public health. Schools of public health should strengthen their response to the needs for qualified personnel for important, but often neglected, aspects of public health such as the health of minority groups and international health. Schools of public health should help develop, or offer directly in their own universities, effective courses that expose undergraduates to concepts, history, current context, and techniques of public health to assist in the recruitment of able future leaders into the field. The committee did not conclude whether undergraduate degrees in public health are useful.

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CONCLUSIONS AND RECOMMENDATIONS 159 Education programs for public health professionals should be informed by comprehensive and current data on public health personnel and their employment opportunities and needs. CONCLUDING REMARKS This report conveys an urgent message to the American people. Public health is a vital function that requires broad public concern and support in order to fulfill society's interest in assuring the conditions in which people can be healthy. History teaches us that organized community effort to prevent disease and promote health is both valuable and effective. Yet public health in the United States has been taken for granted, many public health issues have become inappropriately politicized, and public health respon- sibilities have become so fragmented that deliberate action is often difficult if not impossible. Restonng an effective public health system cannot be achieved by public health professionals alone. Americans must concern themselves with whether there are adequate public health services in their communities and must let their elected representatives know of their concern. The specific actions appropriate to strengthen public health will vary from area to area and must blend professional knowledge with community values. The com- mittee intends not to prescribe one best way of rescuing public health, but to urge that readers get involved in their own communities in order to address present dangers, now and for the sake of future generations. REFERENCES American Public Health Association, Association of State and Territorial Health Officials, National Association of County Health Officials, U.S. Conference of Local Health Offi- cials, U.S. 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. Gilbert, B., Mary K. Moos, and C. A. Miller. 1982. "State Level Decision-Making for Public Health: The Status of Boards of Health." Journal of Public Health Policy, March. Gossret, D., and C. A. Miller. 1973. "State Boards of Health: Their Numbers and Commit- ments." American Journal of Public Health June 63~6~:486-493. Hughes, Dana, Kay Johnson, Janet Simmons, and Sara Rosenbaum. 1986. Maternal and Child Health Data Book: The Health of America's Children. Children's Defense Fund, Washing- ton, D.C. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1983. Securing Access to Care. Government Printing Office, Wash- ington, D.C. U.S. Department of Commerce, Bureau of the Census. 1986. Statistical Abstract of the United States, 106th ed. Government Printing Office, Washington, D.C.