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1 The Disarray of Public Health: A Threat to the Health of the Public This study was undertaken to address a growing perception among the Institute of Medicine membership and others concerned with the health of the public that this nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray. Public health is what we, as a society, do collectively to assure the conditions for people to be healthy. This requires that continuing and emerging threats to the health of the public be successfully countered. These threats include immediate crises, such as the AIDS epidemic; enduring problems, such as injuries and chronic illness; and growing challenges, such as the aging of our population and the toxic by-products of a modern economy, transmitted through air, water, soil, or food. These and many other problems raise in common the need to protect the nation's health through effective, organized, and sustained efforts led by the public sector. Unfortunately, the explorations of this committee, as docu- mented in this report, confirm that our current capabilities for effective public health actions are inadequate. In the committee's view, we have let down our public health guard as a nation, and the health of the public is unnecessarily threatened as a result. As a society we seem to assume that we are fully capable of maintaining past progress (often dramatic improvements in the public's health and longevity), of addressing current problems, and of being prepared to re- spond to new crises or emergent health problems. Instead, this committee has found a public health system that is incapable of meeting these respon- sibilities, of applying fully current scientific knowledge and organizational skills, and of generating new knowledge, methods, and programs. 19

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20 THE FUTURE OF PUBLIC HEALTH The rest of this report sets out a conception of the vision that should guide the future of public health, analyzes the current situation and how it devel- oped, and presents a plan of action that will, in the committee's judgment, provide a solid foundation for a strong public health capability throughout the nation. The strengthening of that capability requires understanding and support by many actors in this society, not just those in public health agencies. Therefore, the committee intends this report for a broad audience that includes elected public officials at all levels of government, voluntary health organizations, health care providers, educators of all of the health professions, and private citizens with interests in maintaining and improving health in their communities. To help these broad audiences understand why we believe this topic is important to them and their communities, we begin by citing examples of specific threats that can be averted or lessened only through collective actions aimed at the community, in contrast with personal medical services initiated by patients or individual practitioners. These examples will serve to illustrate ultimate targets of public health activity. Improved organization, professional competence, and decisions about public interventions are val- ued not as ends in themselves, but as means to combat real dangers to the public's health. IMMEDIATE CRISES The following are examples of problems that constitute immediate crises and can only be solved by collective action. Both examples are major current concerns for most public health agencies throughout the nation. AIDS (ACQUIRED IMMUNE DEFICIENCY SYNDROME) The infectious disease of AIDS, caused by the human immunodeficiency virus (HIV), became an epidemic in little more than 5 years after its discov- ery. The virus now infects more than a million people in the United States and millions more in other countries. The cases of AIDS reported thus far are only the beginning of the expected toll because of the long period between infection and overt disease. A sizable proportion of those now infected will progress to severe disease and death. (Figure 1.1; Committee on a National Strategy for AIDS, Institute of Medicine, and National Acad- emy of Sciences, 1986) As noted by the Institute of Medicine and National Academy of Sciences in their 1986 report, the unchecked spread of HIV could convert the current epidemic into a catastrophe. To slow the spread until a vaccine or definitive treatment is developed, the report recommended that the United States

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THE DISARRAY OF PUBLIC HEALTH 270,000 (a) 35,000 1 986 (b) (c) 1 8,000 E~ ~"''' ~ 1 986 9,000 1991 (estimated) 1 79,000 1991 (estimated) 54,000 i, ;2;;~. .'0- O','. , 'it: -. 'O 1991 (estimated) 21 FIGURE 1.1 (a) Cumulative cases of AIDS in the United States at the end of the year. (b) Cumulative deaths in the United States at the end of the year. (c) Deaths in the United States during the year. SOURCE: Committee on a National Strategy for AIDS, Insti- tute of Medicine, and National Academy of Sciences, 1986, Appendnx G. p. 328. undertake a massive media, educational, and public health campaign. This campaign would include effective education to inform the public of the danger and to describe changes in behavior that can minimize the risk of infection, voluntary testing to identify persons infected with the virus, and counseling of infected persons in order to contain the spread. (Committee on a National Strategy for AIDS, Institute of Medicine, and National Academy of Sciences, 1986) More than any other event of recent years, the AIDS epidemic has reminded us of the necessity of effective public health actions to protect individuals and society. ACCESS TO HEALTH CARE FOR THE INDIGENT About 43 million Americans, or 18 percent of the population, do not have a physician, clinic, or hospital as a regular source of health care. Some 38.8 million Americans, or 16 percent of the population, have difficulty obtaining

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22 THE FUTURE OF PUBLIC HEALTH health care when they need it. Half these people have difficulty because they are unable to pay for care. (The Robert Wood Johnson Foundation, 1987) Those who cannot afford health care the medically indigent include poor and near poor, employed and unemployed, uninsured and underin- sured. They include children, adults, and the elderly. A survey in 1986 conducted by The Robert Wood Johnson Foundation estimated that some 22 million Americans did not have health insurance, public or private. (The Robert Wood Johnson Foundation, 1987) About half of these people are employed but not insured; the other half are unemployed. (The Robert Wood Johnson Foundation, 1985) Of those citizens with incomes below the federal poverty line, fewer than half receive Medicaid. Those who do receive Medicaid may be covered only for selected services. In many states, Medi- caid covers basic hospital and ambulatory services, but not other basic needs such as dental services. (Desonia and King, 1985) The proportion of persons below the poverty line who do not receive Medicaid increased from 47 percent in 1975 to about 54 percent in 1985. (The Robert Wood Johnson Foundation, 1985) The proportion of persons with no regular source of health care has increased substantially, by 65 percent, in the past 5 years. And the proportion of citizens who had health problems but refrained from making an ambulatory visit in the course of a year increased by 70 percent in the past 5 years. (The Robert Wood Johnson Foundation, 1987) The 1986 survey documented the difficulties that poor Americans encoun- ter in obtaining health care. Despite their generally worse health status, the indigent are less likely to have a regular source of health care, are less likely to be insured, and are less likely to receive health care services than more affluent persons. The better-off population made 37 percent more ambula- tory visits to health care facilities than did poor persons of similar health status. Yet it has been well documented that the indigent tend to have more illnesses and disabilities than more affluent citizens. It has also been docu- mented that the gap between rich and poor is widening. Access to health care services in this country has become a crisis both for the population that has difficulty obtaining care and for providers of care, the latter often publicly owned or financed, and the growing reluctance of private health care institutions to provide free care is placing an increasing financial burden on public institutions. The evidence shows that many Americans are going without needed health care. Since 1984, more than half the states have passed legislation concerned with the health care needs of the medically indigent. More than 20 states have appointed commissions to study means of providing care. (Desonia and King, 1985) This issue prom- ises to be a critical problem throughout the 1980s. When the uninsured and poor do seek health care, the burden of provid- ing this care falls disproportionately on a small number of institutions, often

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THE DISARRAY OF PUBLIC HEALTH 23 the public providers of health care. Ten percent of the hospitals in the country provide more than 40 percent of all inpatient and ambulatory health care services to the uninsured. (The Robert Wood Johnson Foundation, 1985) Studies in several cities indicate that an overwhelming proportion of the medically indigent are admitted or transferred to public hospitals and university hospitals when seeking care. These hospitals, in turn, are in increasing financial jeopardy. (Annas, 1986) The burden of ambulatory care for the uninsured and poor is also carried by community clinics and public health departments. For a subset of these people, the problems are com- pounded by homelessness (IOM study, to be published). ENDURING PUBLIC HEALTH PROBLEMS Although such immediate crises as AIDS and care of the indigent tend to attract attention of the public and of policymakers, other public health problems with equally great significance for the health of the public and the well-being of our society require continuing attention. Progress against an enduring problem may lead to complacency, and the very permanency of the problem may undermine continued vigilance and actions. The four examples given here have all been targets of concerted action through public efforts, and some progress has been achieved. Yet maintenance of that progress and continued advances require sustained effort. INJURIES William Foege, former director of the federal Centers for Disease Control, has stated that injury is the principal public health problem in America today, affecting primarily the young, and will touch one of every three Americans each year. Each year, more than 140,000 Americans die from injuries and another 70 million sustain nonfatal injuries. Injury is the leading cause of death for children and young adults. Motor vehicle accidents are the leading cause of severe injury and death, causing about 3.2 million injuries in 1982 and about one-third of the fatal deaths each year. (Figure 1.2; Committee on Trauma Research, Commission on Life Sciences, National Research Council, and Institute of Medicine, 1985) We have not done enough to reduce this toll. Public action can reduce nJurles by: -education that persuades people to protect themselves from injury; legal requirements for desirable protective actions, such as auto seat belt use or the use of smoke detectors; and

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24 FIGURE1.2 Percentagesofyearsofpoten- tial life lost to injury, cancer, heart disease, and other diseases before age 65. Modified from Centers for Disease Control. SOURCE: Committee on Trauma Research, Commis- sion on Life Sciences, National Research Council, and Institute of Medicine, Injury in America: A Continuing Public Health Prob- lem, 1985, p. 20. THE FUTURE OF PUBLIC HEALTH / All Other Diseases 24.8% by\ Heart / \ Disease / \ 16.4% / \` Injury 40,8% _ / Cancers \` ~18.0% 6' -protection through product and environmental design, e.g., highway safety standards, automatic seat belts or air bags, sprinkler systems, child- proof caps on medicines, and so on. (Committee on Trauma Research, Commission on Life Sciences, National Research Council, and Institute of Medicine, 1985) TEEN PREGNANCY About half a million babies are born each year to teenage mothers in the United States. Births to teenagers represented about 13 percent of all births in the nation in 1984. Rates of teen pregnancy and delivery in the United States are significantly higher than those of comparable countries. For example, 15-year-old girls in the United States are 5 times more likely to get pregnant than girls in any other developed country for which data are available. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987) The number of births to teenage mothers in this country has serious public health implications. Pregnant teenagers have higher rates of miscarriages, complications, stillbirths, and infant and maternal deaths than pregnant adults. Low-income teenagers are more likely than adults to have premature births, increasing the likelihood of poor pregnancy outcomes. (Committee to Study the Prevention of Low Birthweight, Institute of Medicine, 1985) Surviving children of teenage mothers are more likely to suffer injuries and more likely to be hospitalized by age 5 than children of adult mothers. Adolescent pregnancies and births cause significant health problems both for teenage mothers and for their children. In addition, teenage pregnancy is

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THE DISARRAY OF PUBLIC HEALTH 25 linked to school dropout, contributing to low future incomes, which are in turn associated with poorer health in future years. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Edu- cation, National Research Council, 1987) Many of the health problems associated with early pregnancy and child- bearing can be significantly reduced with proper prenatal care and nutrition. Yet adolescents are the least likely mothers to receive prenatal care. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Develop- ment, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987) Only about half of all teen mothers begin prenatal care in their first trimester of pregnancy, and about 12 percent never receive any prenatal care. (Hughes et al., 1986) Also, teenagers are far more likely to have poor eating habits. Moreover, most teenage parents have difficulty in financing health care for themselves and for their children. In many locations, teenage girls rely on public health agencies for health services. Family planning services offered by many public health agencies as well as by private providers can prevent unwanted preg- nancies but are underutilized. When pregnancies do occur, efforts in health education and maternal and child health services are needed to improve pregnancy outcomes. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Coun- cil, 1987) CONTROL OF HIGH BLOOD PRESSURE Public health measures, once associated mainly with control of infectious disease, can also be effective against chronic diseases. Epidemiological and statistical studies have established factors associated with high risk from heart disease and stroke. One of these risk factors is high blood pressure, which affects about 60 million Americans. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1983) In 1972, the Public Health Service mounted a national campaign to identify the population afflicted with high blood pressure and to lower the blood pressure levels. (Roccella, 1985) The success of that campaign, which involved private agencies as well as national, state, and local public health agencies, is illustrated by the increased control of high blood pressure (see Figure 1.3~. The progress in reducing high blood pressure has undoubtedly contributed to the considerable reduction in the incidence of stroke between 1972 and 1982 (see Figure 1.4~.

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26 FIGURE 1.3 (a) Prevalence of high blood pressure for per- sons 25-74 years of age in the United States. (b) Proportion of persons with high blood pressure whose disease is controlled (aware and adequately treated). SOURCE: Lenfant and Roc- cella, 1984, p. 460. (a) (b) THE FUTURE OF PUBLIC HEALTH 22.0% 18.2% .~ ~ -A ~ i, 1971-72 1976-1 980 34.1% 1 6.5% 1971-72 1976-1 980 Continued public health efforts will be required to maintain this progress because the incidence of uncontrolled hypertension is still very substantial. Up to two-thirds of those with hypertension in 1976-1980 were not in control programs. (Lenfant and Roccella, 1984) In 1986, high blood pressure con- trol rates varied among communities from 25 to 60 percent. (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986) SMOKING AND SUBSTANCE ABUSE Thirty percent of American adults are addicted to cigarettes. Cigarette smokers have a 70 percent higher death rate from all causes than non- smokers. Smoking is the single greatest cause of premature death in this country. It is estimated that smoking contributes to as many as 225,000 deaths from coronary heart disease, 100,000 deaths from cancers, and 20,000 deaths from chronic obstructive lung disease each year. Additionally,

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THE DISARRAY OF PUBLIC HEALTH Percent decline from 1968 rate rat :~_ 4.1 -10 -20 -30 40 -50 27 9.4~ ~ ~ - _ Noncardiovascular disease 13.5 Percent decline from 1972 rate 12.0 Broke 34 3 28.7 Start of the | National High Blood Pressure Education Program 1 1 1 1 1 1 1 1 49.6 I I ' 1 1 1 ~I 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 FIGURE 1.4 Death from stroke. SOURCE: Roccella, 1985, p. 655. 44.8 10 million Americans suffer from debilitating chronic diseases caused by smoking. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1983) Also, smoking is the major identifiable cause of residential fire deaths and injuries in the country and is associated with higher injury and chemical illness risk in many occupations. About 30 percent of all adults and about 20 percent of high schoolers in the United States regularly smoke cigarettes, but those proportions have decreased from 33 percent of adults and 27 percent of high school teenagers in 1979. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1986) Annual per capita alcohol consumption in the United States has remained steady, at slightly under 3 gallons per person age 14 and over since 1978. But alcoholism may be on the rise. For example, 1982 data indicate that as many as 41 percent of teenagers engage in occasional binge drinking, an increase from 37 percent in 1975. (Office of Disease Prevention and Health Promo- tion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1986) During the late 1970s and early 1980s, drug use remained relatively stable and even declined for some substances. About 16 million Americans regu

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28 THE FUTURE OF PUBLIC HEALTH larly smoke marijuana, 1 to 2 million regularly use cocaine, 1 million misuse barbiturates, and thousands are addicted to heroin. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1983) Between 1977 and 1982, use of marijuana in young adults declined from about 19 percent to about 16 percent, and from 9 percent to 6 percent in teenagers. But use of other drugs by adults, particularly cocaine, more than doubled, from under 1 percent to over 2 percent. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1983) Alcohol and drug abuse are major factors in much illness, disability, and death in the United States. Some problems are immediate, and some evolve over a period of time. Ten percent of all deaths in the United States are related to alcohol use. Cirrhosis of the liver, which is largely attributable to alcohol use, caused 10.7 deaths per 100,000 population in 1984. Alcohol abuse is also frequently related to motor vehicle injuries and deaths. In 1984, the death rate from alcohol-related motor vehicle accidents was 9.5 per 100,000, and from other alcohol-related accidents, 4.3 per 100,000. Drug abuse has also been related to premature death, severe physical disability, psychological disability, homicides, suicides, and injuries. In 1984, it was estimated that there were more than 3,500 drug-related deaths in 26 major metropolitan areas of the United States. Drug use causes some 100,000 to 350,000 hospital admissions per year. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1986) Intravenous drug use also is a major risk factor for contracting AIDS virus infection from contaminated needles and syringes. The three habits of smoking, alcohol abuse, and drug abuse have consistently been related to poor pregnancy outcomes. Despite some declining trends in substance abuse, the health effects of current and previous use will be felt for years to come. There is some indication that public health measures directed toward controlling substance abuse, including health education of the public and of health professionals, have contributed to the reductions in substance abuse mentioned above. In general, in the early 1980s more adults and teenagers reported awareness of the dangers of smoking, alcohol abuse, and drug abuse than had in the late 1970s. But an ongoing effort will be required to reduce the long-term burden on the public health caused by substance abuse.

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THE DISARRAY OF PUBLIC HEALTH GROWING CHALLENGES AND IMPENDING CRISES 29 Some health problems are likely to be increased by factors that are already identifiable. These "time bombs" of public health include the following two examples. Toxic SUBSTANCES The problem of hazardous waste generated by industry becomes bigger with each new discovery of environmental contamination from improper disposal of toxic materials. Contamination exists in ground water, air, soil, and food and has serious implications for public health. (Walker, 1985) Most toxic substances are present in more than one medium and may be readily transferred from air to soil to food and water. For example, when residues from waste water treatment plants are incinerated, a portion of the pollutants is converted to air pollutants, which in turn contaminate water and soil. Pollution of groundwater and other drinking water supplies is a serious threat to public health. For example, for nearly 17 years, until voluntary closure in 1972, the Stringfellow acid pit near Riverside, California, accepted about 35 million gallons of industrial waste. Thirteen years after the site stopped receiving toxic waste and 5 years after the pits were capped, a major groundwater basin was still being contaminated. Various containment ef- forts were made to prevent these wastes from migrating. These old technolo- gies failed at this site as they have at other waste holding pits. (Embers, 1985) Pesticides contaminate many common American foods (tomatoes, beef, potatoes, oranges, lettuce) and may be responsible for some cancers, accord- ing to Regulating Pesticides in Foods: The Delaney Paradox, a National Academy of Sciences report released in 1987. That study focused on 28 of the 53 pesticides classified as carcinogenic or potentially carcinogenic. More than 80 percent of those analyzed exceeded the Environmental Protec- tion Agency threshold of acceptable cancer risk for an environmental toxicant no more than one additional case of cancer for every 1 million persons exposed. (Board on Agriculture, National Academy of Sciences, 1987) Although recent attention has been focused mainly on cancer, the range of adverse human health effects of exposure to chemicals and other toxic substances is broad. Exposure to high levels of some substances for even short periods may produce acute, though often temporary, effects such as rash, burns, or poisoning. Prolonged exposure to low doses can cause lung

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30 THE FUTURE OF PUBLIC HEALTH disease and neurobehavioral disorders. There is growing evidence that environmental toxicants can cause reproductive problems, including miscar- riages and birth defects. An increased incidence of abortion and stillbirth among women exposed to high lead concentrations has long been recog- nized. Studies of mercury and aluminum indicate that these metals, too, may affect pregnancy outcome. The National Institute of Occupational Safety and Health reports that more than 4 million workers are directly exposed to those metals that can cause chronic kidney disease. (Walker, 1985; National Academy of Engineering, 1986) Controlling toxic substances in the environment will continue to present new challenges for the legal and the public health systems of the nation. With growing evidence of the human health effects of some toxic substances, the number of lawsuits and other efforts to obtain compensation by injured parties will rise. Implementation of federal toxic substances control laws, such as the Toxic Substance Control Act (TSCA) and the Federal Insec- ticide, Fungicide and Rodenticide Act, has raised numerous questions con- cerning testing of thousands of chemicals in commercial use, including who should test them, when they should be tested, and for what effects they should be tested. These and similar issues have slowed the rate at which the laws can be implemented. (Embers, 1985; Walker, 1985) ALZHEIMER'S DISEASE OR DEMENTIA OF THE ALZHEIMER TYPE As many as 2 million Americans are suffering from Alzheimer's disease, resulting in severe, disabling intellectual impairment. The exact causes of Alzheimer's are unknown, but it is clearly associated with age. (Katzman, 1986) Although a small percentage of those under age 60 are believed to have Alzheimer's, more than 20 percent of the population over age 80 is believed to have the disease. The prevalence of cases of Alzheimer's in- creases 10- to 20-fold between age 60 and age 80 years. (Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services, 1984) The number of Alzheimer's disease cases is expected to increase dramati- cally over the next several decades as the population ages. The elderly are the most rapidly growing group within our population, and, within that group, the proportion of elderly age 85 and over is increasing the most rapidly. In 1980, the elderly population in the United States (age 65 and over) numbered some 26 million, or about 11 percent of the population. By the year 2025, as the baby boom of the mid-twentieth century reaches old age, the elderly population is expected to reach a peak of 58.5 million people, or a full 20 percent of the population. (Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services, 1984)

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THE DISARRAY OF PUBLIC HEALTH 31 The association between Alzheimer's dementia and the aging of the population will increase greatly the demand for long-term care. Currently, over half of the million and a half residents of nursing homes are estimated to have Alzheimer's disease. (Katzman, 1986) Many others are cared for in sheltered housing or day care facilities. When care is provided by family members or friends, the care givers themselves may suffer economic depri- vation or declines in physical or mental health status. Although considerable research is being done on the causes of Alzheimer's, it is likely that treatment of the disease will continue to require some form of long-term health care. (Katzman, 1986) Alzheimer's represents a particular challenge to public health leadership to assure access to and quality of appropriate services. REVITALIZATION OF PUBLIC HEALTH CAPACITIES To counter these and other threats to the health of the public will require a vital and effective public health system capable of the full range of responses necessary to make further progress against disease, disability, and prema- ture death. Controlling communicable disease, encouraging healthy life- styles, reducing hazards in the environment, and targeting and assuring necessary personal health and long-term care services all of the classic tools of public health- are necessary to maintain the benefits of past success and to respond to current and future challenges. The successes of past public health efforts are many. The virtual elimina- tion of many infectious diseases, such as typhoid fever and paralytic polio; great reductions in many of the common childhood communicable diseases (Committee on Public-Private Sector Relations in Vaccine Innovation, Insti- tute of Medicine, 1985~; and initial progress in the control of common chronic diseases, such as heart disease, stroke, and some forms of cancer (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986), are ample evidence of the effectiveness of public health measures that join scientific knowledge and effective social action. However, the success of past efforts can lead to complacency about the need for a vigorous public health enterprise at the national, state, and local levels. To achieve public health objectives, public health will need to serve as leader and catalyst of private efforts as well as performing those health functions that only government can perform. The committee believes firmly that the substantial improvements in health status that are the result of public health activities require vigorous, scientifically competent, politically astute, comprehensive, and sustained public health capacity. It is, therefore, with great concern and some alarm that the committee has observed the current state of public health. We have observed many symp

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32 THE FUTURE OF PUBLIC HEALTH toms of systemic problems, solutions to which will require a comprehensive strategy and a strong commitment on the part of the entire society. We have observed disorganization, weak and unstable leadership, a lessening of professional and expert competence in leadership positions, hostility to public health concepts and approaches, outdated statutes, inadequate finan- cial support for public health activities and public health education, gaps in the data gathering and analysis that are essential to the public health func- tions of assessment and surveillance, and lack of effective links between the public and private sectors for the accomplishment of public health objec- tives. In our view, these problems reflect a lack of appreciation among the general public and policymakers for the crucial role that a strong public health capacity must play in maintaining and improving the health of the public. Attention is focused on specific health problems such as AIDS, exposure to specific toxic agents, or substance abuse. But these specific foci of interest lead to episodic actions, not to the sustained effort that is needed. The necessary public health capacity to cope with the immediate, enduring, and impending threats to health cannot, in the committee's view, be turned on and off as particular health problems arise and receive attention. This necessary capacity must be nurtured and supported by the society that reaps the benefits; it requires competent people, effective leadership, a scien- tifically sound knowledge base, the tools to monitor health problems and measure progress, a productive organizational structure, adequate financial resources, and a legal foundation that supports effective action, all moti- vated by a vision of the public's health that is understood and supported by that public. By its very nature, public health requires support by mem- bers of the public its beneficiaries. While individual action to improve health is necessary, it is not enough, and, as the above examples illustrate, health status will fall short of the achievable if public health is not strong. To provide a comprehensive and well-founded strategy to overcome the current disarray, the rest of this volume will examine and reaffirm the concepts of public health, develop a desirable framework for public health action, assess the current status of public health as an organized activity in the United States, and finally, recommend specific actions and directions that will provide a vigorous and effective public health enterprise sufficient to the challenges that lie ahead.

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THE DISARRAY OF PUBLIC HEALTH 33 REFERENCES Annas, George J. 1986. "Your Money or Your Life: 'Dumping' Uninsured Patients from Hospital Emergency Wards." American Journal of Public Health 76~1~:74-77. Board on Agriculture, National Academy of Sciences. 1987. Regulating Pesticides in Foods: The Delaney Paradox. National Academy Press, Washington, D.C. Committee on a National Strategy for AIDS, Institute of Medicine, and National Academy of Sciences. 1986. Confronting AIDS: Directions for Public Health, Health Care, and Re- search. National Academy Press, Washington, D.C. Committee on Public-Private Sector Relations in Vaccine Innovation, Institute of Medicine, 1985. Vaccine Supply and Innovation, National Academy Press, Washington, D.C. Committee on Trauma Research, Commission on Life Sciences, National Research Council, and Institute of Medicine. 1985. Injury in America: A Continuing Public Health Problem. National Academy Press, Washington, D.C. Committee to Study the Prevention of Low Birthweight, Institute of Medicine. 1985. Preventing Low Birthweight. 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. Embers, L. R. 1985. "Clean-up Mishaps Show Need to Alter Superfund Law." Chemical and Engineering News 63~21~:11-21, May 27. Hughes, Dana, Kay Johnson, Janet Simons, and Sara Rosenbaum. 1986. Maternal and Child Health Data Book: The Health of American's Children. Children's Defense Fund, Wash- ington, D.C. Katzman, Robert. 1986. "Alzheimer's Disease." New England Journal of Medicine 314(15):964-973. Lenfant, Claude, and Edward Roccella. 1984. "Trends in Hypertension Control in the United States." Chest 86:459-462, September. National Academy of Engineering. 1986 Hazards: Technology and Fairness. National Acad- emy Press, Washington, D.C. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services. 1983. Public Health Service Implementation Plans for Obtaining Objectives for the Nation. Public Health Reports, supplement to the September-October 1983 Issue. Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986. The 1990 Objectives for the Nation: A Midcourse Review. U.S. Department of Health and Human Services, Washington, D.C. Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences Edu- cation, National Research Council. 1987. Risking the Future: Adolescent Sexuality, Preg- nancy, and Childbearing, Cheryl D. Hayes, ed. National Academy Press, Washington, D.C. The Robert Wood Johnson Foundation. 1985. Announcing the Health Care for the Uninsured Program. Brochure. The Robert Wood Johnson Foundation. The Robert Wood Johnson Foundation. 1987. Access to Health Care in the United States: Results of a 1986 Survey. Special Report Number 2. The Robert Wood Johnson Foundation. Roccella, Edward J. 1985. "Meeting the 1990 Hypertension Objectives for the Nation: A Progress Report." Public Health Reports 100~6~:652-56, November-December.

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34 THE FUTURE OF PUBLIC HEALTH Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services. 1984. Alzheimer's Disease. U.S. Government Printing Office, Washington, D.C. Walker, B. 1985. "The Present Role of the Local Health Department in Environmental Toxicology." Journal of Environmental Health 48~3~:133-137, November-December.