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A Vision of Public Health in America: An Attainable Ideal The discussion in Chapter 1 implicitly asked, "Why be concerned about public health?" and gave two broad answers. The first answer focused on present threats to the health of the public. Urgent new problems like AIDS and toxic wastes have been added to the public health agenda. At the same time, a changing U.S. health system has brought more sharply into focus the unsolved dilemma of how to care for some 30 million uninsured and underinsured Americans, and has called into question old understandings about the respective roles of the private and public sectors. These new concerns have heightened competition for scarce financial resources and public attention and support. Americans assume that government is equipped to fulfill its obligation to protect the public from such threats. But the nation's public health capacity has become seriously weakened, and public support-always fragile because of limited aware- ness- is increasingly being eroded by controversy. The second answer pointed to past achievements as the basis for believing that public health still retains fundamental problem-solving capacity. Histor- ically, public health has made a difference in the quality of life for all Americans. Governmental actions to assure the health of the people such as water quality control, immunizations, and food inspection-have pre- vented much illness and many deaths. These traditional and ongoing accom- plishments have demonstrated the value of public health efforts, and exem- plify the kind of success that is possible as a result of organized effort on the basis of technical knowledge. If they demonstrate the best of which public health has been capable, they also underscore the urgency of rescuing this vital public capacity from its current decline. 35

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36 THE FUTURE OF PUBLIC HEALTH Chapters 3 and 4 give a more detailed picture of the current status of U.S. public health. They spell out its history, organization, current activities, and problems. But first, the observation that something is wrong with public health implies some sense of what would be right: a vision against which to assess current realities and guide decisions about what changes should be made. "Vision" as used here is not meant to suggest a form of impractical utopianism that results in a set of impossible dreams. Instead, the aim is to fashion in the mind's eye-as the prerequisite to doing so in reality an attainable ideal. This chapter sets forth the committee's vision of public health. It presents the value framework in which it has reflected about the present dilemma of public health and formed its recommendations. The vision appears early in the report to encourage readers to weigh this ideal while they reflect on public health as described in the report and as they view it in their own communities. The committee hopes readers will ask themselves not only whether or not they share the values or agree with the conclusions in this report, but also how closely the current reality of public health approximates their own ideal model and what they can do to move practice in directions they consider sound. The committee's vision of public health includes the following conceptual elements: A definition of "public health" that the committee believes is consistent with key American values. This definition sets forth the committee's view of what the term "public health" should mean and what values are implied by that understanding. The definition has three parts: 1. The mission of public health: a statement of ultimate goals or purposes. This section addresses the question: What are the common goals of public health? 2. The substance of public health: a statement about subject matter. This section addresses the question: What areas of concern does public health deal with? 3. The organizational framework of public health: a statement that distin- guishes the concerns included in the term "public health" from the ways in which society organizes to deal with them. This section addresses the question: How is "public health" different from "what public health agencies do?" The governmental functions of public health. Federal, state, and local agencies as institutions of government have unique authority, obligations, and duties. This section discusses public health as a government respon- sibility. It considers: 1. the duties that are essential to government's responsibility for public health; 2. the expression of these duties at the federal, state, and local levels; and

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A VISION OF PUBLIC HEALTH IN AMERICA 3. the relationship between government and the private sector. 37 The basic services of public health. This section discusses the activities, tasks, programs, and benefits that are required to address the mission of public health. In contrast to functions that are specific to the role of the public agency, responsibility for the provision of basic services is shared by public and private sectors. Figure 2.1 is a diagram of how the conceptual elements of the public health vision relate to one another. A DEFINITION OF PUBLIC HEALTH "When I think of public health, I think of early intervention, prevention." "Public health is immunization, school health, control of contagious disease." "It's anything that affects the health of the community on a mass basis." "Public health is the area of health outside the capability of the individual private practitioner." "The core of public health is the capacity to identify problems, and having found them, measure them and attempt to intervene."* The quotations above, gathered during the course of this study, illustrate that the effort to define public health is complex. When asked, people tend to mix observations about what actual health departments do with assertions about what society as a whole ought to do. Some emphasize a community focus, in contrast to individual patient care. Others concentrate on ideas of government response to market failure. Still others list the contents of practice, such as control of environmental hazards or care of the poor, or refer to professional skills, such as epidemiology or sanitary engineering. As we will see in Chapters 3 and 4, this variety of definitions is exceeded" and perhaps also explained by the complexity of the system in which, somewhere, "public health" is found. The United States is notable among the countries of the world for complicated policy relationships among na- tional, state, and local levels of government and for its interweaving of private and public sector activity. Health affairs share in this complexity. Given this intricate arrangement, the committee hopes that a clear defini- tion will help those who work in, are served by, or study the system to sort out its elements, understand it, and work to make it perform more effectively. From the beginning of its work, the committee believed that it was impor- tant not to limit understanding of "public health" to what health depart * These and following quotations are taken from interviews conducted during the course of the study. See Chapter 4 for a description of study activities.

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38 THE FUTURE OF PUBLIC HEALTH | DEFINITION OF l PUBLIC HEALTH ~r MISSION: GOALS ORGANIZATIONAL FRAMEWORK: OPERATIONS PUBLIC AGENCY FUNCTIONS 1 , ~1 FEDERAL/STATE/ LOCAL ROLES PUBLIC/PRIVATE ROLES | BASIC | SERVICES | FIGURE 2.1 Conceptual elements of public health. CONCERNS: SUBJECT MATTER, DISCIPLINES meets do. Instead, it aimed to place government activities within a broader framework that can guide a wide range of institutional participants. The intent is not to deemphasize the role of the public agency. On the contrary, it is to point out the indispensability of its prerogatives and functions by calling attention to the context in which they are exercised. This distinction between "public health" and "what health departments do" is reinforced by dividing the definition into three parts. By separating the organizational expression of public health from understandings of its mission and subject matter, the committee intends to emphasize that the goals and concerns of public health can and should be addressed not only by health departments, but also by private organizations and practitioners, other public agencies, and the com- munity at large. The governing role of the official public health agency in assuring that the overall system works is, however, indispensable. THE MISSION OF PUBLIC HEALTH In eighteenth- and early nineteenth-century America, public health mea- sures were taken in response to particular epidemic crises. Thus the earliest definition of public health's mission was practical rather than formal: control of epidemic disease. The first explicit statement came with the justly famous Shattuck Report of 1850, which declared "the conditions of perfect health, either public or personal" to be the goal of public health. (Rosenkrantz, 1972)

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A VISION OF PUBLIC HEALTH IN AMERICA 39 One of the earliest deliberate efforts to define public health's mission is still one of the most frequently cited. According to C. E. A. Winslow (as quoted in Hanlon and Pickett, 1984~: Public health is the science and the art of (1) preventing disease, (2) prolonging life, and (3) organized community efforts for (a) the sanitation of the environment, (b) the control of communicable infections, (c) the education of the individual in per- sonal hygiene, (d) the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and (e) the development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity. More recently, Ellencweig and Yoshpe have conceived the goal of public health to be protection of the community against the hazards engendered by group life. (Ellencweig and Yoshpe, 1984) Beauchamp sees the mission of public health as social justice and the protection of all human life. (Beau- champ, 1976) The common themes that run through these interpretations are reflected in the words "public" and "health." What unites people around public health is the focus on society as a whole, the community, and the aim of optimal health status. Clearly, public health is "public" because it involves "organized commu- nity effort." It is not simply the outcome of isolated individual efforts. Its mission is to ensure that organized approaches are mobilized when they are needed. For example, both smallpox vaccination of countless individuals and treatment of unvaccinated patients would not have rid us of smallpox with- out strategies aimed specifically at the communitywide (in this case, the worldwide) level, such as epidemiologic studies, consistent reporting of cases, and organized distribution of vaccine. In a similar way, neither treat- ment of lung disease nor exhorting individuals to avoid smoking could have achieved the reduction of smoking In public places made possible by orga- nized community effort to adopt laws and regulations restricting smoking. Seat belt legislation is still another instance in which a communitywide approach has augmented individual effort. Public health is also public in terms of its long-range goal, which is optimal health for the entire community. This goal encompasses both the sum of the health status of individual community members and communitywide bene- fits such as clean air and water. The "health" aspect of the public health mission is perhaps best understood by reference to the well-known World Health Organization (WHO) definition. WHO has defined health as "a state of complete well-being, physical, social, and mental, and not merely the absence of disease or infirmity." (World Health Organization, as quoted by Hanlon and Pickett, 1984) Our shared sense of what "complete well-being"

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40 THE FUTURE OF PUBLIC HEALTH might be, though none of us has ever experienced it, serves as a focus for commitment to extend community efforts beyond the narrow concerns of special interests and the boundaries of any one professional discipline. The committee's own definition takes into consideration all of the dimen- sions outlined above. The committee defines the mission of public health as: the fulfillment of society's interest in assuring the conditions in which people can be healthy. THE SUBSTANCE OF PUBLIC HEALTH Within this mission fall a number of characteristic themes, which over the course of a long historical tradition have coalesced around th.e goal of the people's health. Early public health focused on sanitary measures and the control of communicable disease. With the discovery of bacteria and immu- nologic advances, disease prevention was added to the subject matter of public health. (Hanlon and Pickett, 1984) In recent decades, health promo- tion has become an increasingly important theme, as the interrelationship among the physical, mental, and social dimensions of well-being has been clarified. Over time, the substance of public health has expanded. A 1985 editorial in the Journal of Public Health Policy pointed out that a commit- ment to multidimensional well-being implies the need to address factors that fall outside the normal understanding of "health," including decent hous- ing, public education, adequate income, freedom from war, and so on. (Terns, 1986) While encouraging a holistic approach, this tendency to widen the boundaries of public health has the effect of forcing practitioners to make difficult choices about where to focus their energies and raises the possibility that public health could be so broadly defined so as to lose distinctive meaning. Even restricting public health's subject matter to disease prevention and control, health promotion, and environmental measures necessitates the involvement of a broad spectrum of professional disciplines. In fact, it is frequently pointed out that public health is a coalition of professions united by their shared mission (described in the section above); their focus on disease prevention and health promotion; their prospective approach in contrast to the reactive focus of therapeutic medicine (Draper et al., as quoted in Hanlon and Pickett, 1984~; and their common science, epidemiology: Each "profession] brings to the public health task the distinctive skills of a primary professional discipline; but, in addition, each shares a distinctive and unique body of knowledge . . . The mother science of public health is epidemiology, i.e., the systematic, objective study of the natural history of disease within populations and the factors that determine its spread. (as quoted by Terris, 1985)

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A VISION OF PUBLIC HEALTH IN AMERICA 41 Epidemiology is the "glue" that holds public health's many professions together. It is by means of the application of scientific and technical knowl- edge, above all else, that public health practitioners strive to improve the lot of humankind, to understand the causes of disease, to identify populations at risk, and to develop new approaches to prevention. (Robbing, 1985) Thus the committee defines the substance of public health as: organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of epidemiology. THE ORGANIZATIONAL FRAMEWORK OF PUBLIC HEALTH Specific attention to the organizational framework for public health activ- ities is important because many Americans support the goals of public health but are highly critical of a particular health department. During the course of the study, when committee members and staff told people that its subject was "the future of public health," the most common first question they received was, "Do you mean what health departments do, or are you talking about public health in general?" For many people the normal range of health department activities, whatever the level of govern- ment under study, does not adequately define "public health." Clearly, the committee sees public health as more than what health departments do and perceives important roles for the private sector and for public-private part- nerships in the future of public health, as subsequent discussion will amplify. But the tone of some site visit conversations (see Chapters 3 and 4) suggests another consideration. Numerous comments implied not only that the con- tent of public health's future might vary depending on whether the reference point is health departments or a broader set of entities, but its likely qual- it~the prognosi& might also be different. In other words, as site visits have illustrated, while the mission and substance of public health appear to have wide support around the country, the health department frequently does not. There appears to be a gap between popular support for public health concerns and public confidence in the value and effectiveness of current health department activities. People tend to be positive about public health values, but negative about the present public health agency. No doubt some of this censure is due to the shadow that has been cast over public opinion about all public sector activity during the last decade. The last two presidents of the United States have been elected on "less-government" platforms embellished with overtly antigovernment rhetoric. Scorn for the capabilities and dedication of the public servant has become commonplace. It is little wonder that in such a climate skepticism should be voiced about the effectiveness of health departments. Although some of the criticism aimed at health departments may be deserved, the committee believes that the future of public health depends on

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42 THE FUTURE OF PUBLIC HEALTH redefining and restoring the role of health agencies at all levels of govern- ment to a position of respect. Clearly, re-valuing the public sector respon- sibility for health will require strategies to respond to sound criticisms and improve the effectiveness of health departments. But it also requires a change in the American dialogue about the necessity and worth of public sector activity of governance. In summary, the committee defines the organiza~nalframework of public health to encompass both activities undertaken within the formal structure of government and the associated efforts of private and voluntary organizations and individuals. THE ROLE OF GOVERNMENT IN PUBLIC HEALTH "The state is a facilitator . . . a convener . . . maybe a funder." "I believe government ought to be involved in all areas where people can't do for themselves, health included." "Who is responsible for planning health care delivery? Who will provide leader- ship?" "Public health can lead the way . . . can get the ear of the decision-makers. Politics is going to be a part of this; there's no way around it." "The overall responsibility of government is to assure the public that the environ- ment is safe. Rules and regulations must be designed to serve that goal." "A big job of government is to collect information, to figure out what causes the problem." In general, Americans are skeptical about the role of government. Con- cern for individual rights shapes the public philosophy and attitudes of policymakers and ordinary citizens alike. (Heclo, 1986) From this perspec- tive, society is made up of individual persons with "inalienable rights." The purpose of government is to protect those rights and ensure the basic conditions necessary for their exercise-civil order, a free market, and equal individual opportunity. Government, in other words, ensures that the basic means to the good life are available, but it refrains from specifying what the content of that life should be or how individuals should behave, except to prevent them from infringing on the rights of others. This mainstream perspective is tempered somewhat by another long- standing tradition in American political philosophy, rooted in concern for the community as a whole. This view emphasizes the social ties that bind people together, including the values they share. It sees government as a facilitator of the social bond and the policy process as a means of defining

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A VISION OF PUBLIC HEALTH IN AMERICA State Health Agency State Health Council Assessment 1 Policy Development FIGURE 2.2 Relationship between government functions. 43 Assurance Guaranteed Assured Services Services positive goals and taking concerted action. These two themes are reflected in the history of American governance. In general, the philosophy of limited government implied by a concern for individual rights has prevailed. But the theme of positive values and community effort has persisted, and deliberate government steps to combat acknowledged social ills have become increas- ingly acceptable to most Americans, remaining so even during the renewed stress on individualism in recent years. Given the caution with which government action is approached in the United States, it is appropriate that the role envisioned for government in the mission of public health should be somewhat limited. Nevertheless, within this limited scope fall a number of key functions that fulfill values implied by each of the two philosophical traditions. If the range of govern- ment action is narrow, the substance is no less crucial to the well-being of the American people. THE FUNCTIONS OF GOVERNMENT IN PUBLIC HEALTH The committee sees the government role in public health as made up of three functions: assessment, policy development, and assurance (see Figures 2.2 and 2.3~. These functions correspond to the major phases of public problem-solving: identification of problems, mobilization of necessary effort and resources, and assurance that vital conditions are in place and that crucial services are received. Assessment ~ Policy Development ~ Assurance Evaluation FIGURE 2.3 The government role in health.

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44 THE FUTURE OF PUBLIC HEALTH Assessment Under this heading are all the activities involved in the concept of commu- nity diagnosis, such as surveillance, identifying needs, analyzing the causes of problems, collecting and interpreting data, case-finding, monitoring and forecasting trends, research, and evaluation of outcomes. Assessment is inherently a public function because policy formulation, in order to be legitimate, is expected to take in all relevant available informa- tion and to be based on objective factors to the extent possible. Private sector entities are expected to have self-interests. Therefore the information they generate, while frequently quite useful to the policy process, is not judged by its fairness. In contrast, although public agencies in practice do not always weigh all sides of a question, in principle they are obligated to do so. Moreover, public decisions take place in the context of limited resources. Society cannot do everything it would like to do or with the intensity it might prefer. Thus trade-offs among competing uses of resources are necessary. The wisdom, justice, and perceived legitimacy of public decisions are cru- cially affected by the quality of the information on which they are based. A function of government is to provide a central mechanism by means of which competing proposals can be assessed equitably. In addition, the government has an important responsibility to develop a broader base of knowledge in order to ensure that policy is not driven by purely short-range issues constrained by current knowledge. Public sector assessment activities should include supporting and conducting research into fundamental determinants of health behavioral, environmental, biolog- ical, and socioeconomic as well as monitoring health status and trends. The assessment function facilitates good decisions in both the private and public sectors. Since assessment seldom has its own constituency, however, it is often starved for resources. A fully developed assessment function is an absolutely essential part of the ideal public health system, and it is one that the committee believes to be in large measure attainable. Policy Development Policy formulation takes place as the result of interactions among a wide range of public and private organizations and individuals. It is the process by which society makes decisions about problems, chooses goals and the proper means to reach them, handles conflicting views about what should be done, and allocates resources. Government provides overall guidance in this pro- cess. In contrast to private entities, it alone has the power to give binding answers. Therefore, although it joins with the private sector to arrive at decisions, government has a special obligation to ensure that the public interest is served by whatever measures are adopted. As with other govern- mental entities, the public health agency bears this responsibility.

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A VISION OF PUBLIC HEALTH IN AMERICA 45 Examples of the governmental policy development role include planning and priority-setting; policy leadership and advocacy; convening, negotiat- ing, and brokering; mobilizing resources; training constituency building and provision of public information; and encouragement of private and public sector action through incentives and persuasion. The public health agency's special role in policy development means it must pay attention to the quality of the process itself, in addition to that of particular decisions. It must raise crucial questions that no one else raises; initiate communication with all affected parties, including the public-at- large; consider long-range issues in addition to crises; plan ahead as well as react; speak on behalf of persons and groups who have difficulty being heard in the process; build bridges between fragmented concerns; and strive for fairness and balance. The public health agency should be equipped for this role by its technical knowledge and professional expertise. Used judiciously, the knowledge base of public health tempers the excesses of partisan politics and makes for more just decisions. Technical knowledge will have the best effect, however, 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 A core public sector function is to make sure that necessary services are provided to reach agreed upon goals, either by encouraging private sector action, by requiring it, or by providing services directly. The assurance function in public health involves seeing to the implementa- tion of legislative mandates as well as maintaining statutory responsibilities. It includes developing adequate responses to crises and supporting crucial services that have worked well for so long that they are now taken for granted. It includes regulation of services and products provided in both the private and public sectors, as well as maintaining accountability to the people by setting objectives and reporting on progress. Assurance implies the maintenance of a level of service needed to attain an intended impact or outcome that is achievable given the resources and techniques available. Carrying out the assurance function requires the exercise of authority. This is not a responsibility that can be delegated to the private sector. Members of society expect government to make certain that they enjoy at least adequate safety and security. The public health agency must be able to exercise authority consistent with fulfilling citizens' expectations and must account to them for its actions with equal energy. As a part of the assurance function, in the interest of justice public health agencies should guarantee certain health services. Such a guarantee ex- presses a measurable public commitment to each member of society. In

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46 THE FUTURE OF PUBLIC HEALTH operational terms, this implies guaranteeing both that the services are available (present somewhere in the community) and, in the case of services to individuals, that the costs will be borne by the government for those unable to afford them. When these services are not and cannot be present in the larger community, it is the public health agency's responsibility to provide them directly. Such a guarantee reflects a community consensus that access to certain health services is necessary to maintain our notion of a decent society. A guarantee acts as a barrier to service cuts in hard times, which tend to fall on the must vulnerable. Such a step also serves as a stimulus to improvement, as has happened in the case of public education, where community efforts have moved from ensuring universal coverage to enriching the quality of the service. The committee notes the examples set by the State of Michigan, which has guaranteed by law prenatal care to every woman in the state, and by San Diego County, California, which has a county-funded system making avail- able acute care to all medically indigent adults. In recent years a competitive market approach to the provision of health services has been advanced as the potential solution to ills that plague the U.S. health system, cost inflation in particular. While recognizing the exis- tence of competition in service delivery, the committee believes that the responsibilities outlined above must be exercised by government in order to ensure basic capacity throughout the system. The government role in public health provides the necessary context for private sector activity. Government is responsible for striving to achieve a balance between the two great concerns in the American public philosophy: individual liberty and free enterprise on the one hand, just and equitable action for the good of the community on the other. Many times during the study, the committee heard public health defined as "what the market can't or won't do." Such comments usually refer to particular services and activities for which the market offers inadequate incentives, such as primary health care for those who can't pay or public services such as air pollution control. The committee acknowledges the existence of this residual view of public health, but observes that to define public health as what the market can't or won't do implies a passive or indifferent public sector and suggests that what the market can't do is not worth the concerned attention of society. On the contrary, recognition of the shortcomings or indifference of the market with respect to certain crucial needs should act as the rationale and catalyst for government action. Such action can take various forms: encouraging the development of private sector financial incentives where none now exist, so that, for example, the care of the uninsured could be made attractive to private providers; building helping relationships between public and private personnel, as when public health

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A VISION OF PUBLIC HEALTH IN AMERICA 47 nurses complement the work of private practice physicians serving indigent patients; or imposing sanctions for failure to abide by regulatory require- ments. Where incentives cannot be mobilized, the public health agency must and should provide necessary services directly. At any level of government, the public sector responsibility for the health of the people must have a focal point in one agency charged with taking the lead in assuring that necessary obligations are fulfilled. Although it may sometimes be appropriate for public health-related responsibilities to be allocated among more than one public agency in addition to the health department the committee believes that fulfilling the assurance function adequately requires that there be one place of ultimate responsibility and accountability. Figure 2.4 presents a schematic diagram that illustrates the relative roles of the government and the private sectors in assuring and guaranteeing public health services. STATE, LOCAL, AND FEDERAL ROLES IN PUBLIC HEALTH The framers of the Constitution of the United States understood that the "federal" system of government they created was not an end in itself but a means to distribute power among the national government and those of the states. (Grodzins, 1985) They provided for state delegation of specific powers to the national government. All other powers were reserved to the states, and to this day states and the central government that which we now call "federal"- share functions and power. States in turn are the architects of local governments, of which today there are a bewildering array, including counties, municipalities, townships, school districts, and special districts. The overall three-level system of fed- eral, state, and local governments includes over 80,000 governmental units. As one observer notes: The enormous complexity of this system . . . suggests that it is impossible to have enough data to operate within it in a consistently rational fashion.... [E]fforts to orchestrate dramatic change . . . are bound to fall short of expecta- tions.... (O'Toole, 1985) Relationships among the many parties in the system are not hierarchical, but a matter of give and take. "Different governments need each other, and bargaining . . . is the norm." (O'Toole, 1985) Nor are patterns of interac- tion static; rather they are constantly changing. In addition, the distribution of functions and responsibilities among levels of government varies greatly from place to place, and many functions are shared, often in complex ways. Nevertheless, some broad generalizations can be made.

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48 THE FUTURE OF PUBLIC HEALTH 100 LL LLJ an an 8 so IL o LLJ CD a: z 111 o _ 6N A B C Guaranteed l \\\\ \\\' D E F Assured SERVICE Provided by Health Agency ~3 Provided by Other Government Agencies ~ Provided by Private Sector FIGURE 2.4 Government role in assured and guaranteed services. Each column shows how need for a specific health service may be met. The percentage of need met for each service by the three sources will vary by service and by location. In all cases 100 percent of need for Guaranteed Services should be met. While meeting 100 percent of the need for Assured Services should remain the ultimate public health objective, only part of this need will be met at the present time because of resource constraints or other limitations. State Governments Under the Constitution, the states are the repositories of powers not specifically delegated to the federal government. They have the primary responsibility for the well-being including the health of their citizens, and have exercised their powers over the years in a multitude of ways. They are the constitutional source of local government authority and can delegate broad powers over health matters to county and municipal governments. The marked expansion of federal activism beginning in the Franklin D. Roosevelt presidency and the huge increase in intergovernmental fiscal

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A VISION OF PUBLIC HEALTH IN AMERICA 49 transfer programs during the 1960s and 1970s added greatly to state respon- sibilities without removing existing ones. At the same time, because conven- tional policy wisdom was critical of state administrative capability and skeptical of some states' willingness to fulfill national priorities, many fed- eral funding programs bypassed state governments entirely. Today, despite increased state activity and despite considerable efforts in the states to reform governance processes, according to the Advisory Commission on Intergovernmental Relations, "it does seem that improvements in state governmental performance have not been matched by a commensurate increase in their role as independent polities and policymakers." (Advisory Commission on Intergovernmental Relations, 1985) Yet their constitutional role and accumulated responsibilities guarantee that states will continue to be the "pivotal actors in our federal system." (Advisory Commission on Intergovernmental Relations, 1985) The recent decline in federal activism and growing tolerance for state- and local-level diversity provide an opening for states to demonstrate their effectiveness. This context sets the stage for asserting the central position of the states in public health. The key ingredients of this role include: O Statewide assessment, policy development, and assurance. It is the state's responsibility to see that functions and services necessary to address the mission of public health are in place throughout the state. This can be done by encouraging, providing assistance to, and/or requiring local govern- ments or private providers to perform certain of these functions. The state may also elect to provide certain services directly. Designating a lead agency for public health in the state (the place of ultimate responsibility) to fulfill the functions of assessment, policy develop- ment, and assurance. In most cases this will be the state health department, which has the obligation and should have the authorit~to ensure that important public health policy goals are being met, even when their imple- mentation has been assigned to another entity. State primacy in public health presents an opportunity for the entire nation to benefit by learning from evaluations of innovations and variations in public health programs at the state level. Federal Government Two developments since the founding period laid the groundwork for the enormous expansion of federal government health activity in modern times. First, the Supreme Court decision in McCulloch v. Maryland set out the doctrine of implied powers, which expanded the potential powers of the national government beyond those specifically delegated in the Constitution to those reasonably implied by the delegated powers. (~McCulloch v. Mary- [and, 1819) Second, the passage in 1913 of the Sixteenth Amendment,

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so THE FUTURE OF PUBLIC HEALTH authorizing a national income tax, substantially expanded the federal reve- nue-raising capability. The commerce clause, interpreted under the doctrine of implied powers, and the power to tax for the general welfare under the Constitution have been the primary bases for much of national government health activity. Under the commerce clause, the Congress has the power to regulate com- merce affecting more than one state, including health aspects of commerce. Federal grants-in-aid to states and localities in support of the general welfare have enabled the federal government to influence state- and local-health activity in line with national priorities. In addition, the federal government provides technical advice and assistance to states. A long era of expansion in the federal role began in the 1930s and continued through the Great Society period of the 1960s. During the follow- ing decade the tide turned, and a nationwide redirection of emphasis emerged. This trend has decreased the federal presence in health, among other policy areas, and resulted in increasing reliance on state- and local- level activity and funding. Despite the relative Reemphasis on national government action, the fed- eral role remains crucial. A primary activity is overall health policy develop- ment for the nation, including a variety of efforts to focus nationwide attention on major public health problems and encourage action on the part of other levels of government and of private groups. Such efforts may appropriately include provision of funds, but the potential for federal health policy leadership extends far beyond what can or should be expressed in dollars. Federal leadership in public health issues is particularly critical if national scientific and professional expertise is to play its proper role in the policy process, offsetting the influence of special interests that tend to be especially decisive in smaller-scale public affairs. Public health's knowledge base is the core of what it has to offer to protect the health of the American people, and this knowledge depends on national government advocacy in order to func- tion most effectively. The federal government also plays an irreplaceable role in the develop- ment of national health data and in the conduct of research. Local Governments The vast numbers, overlapping jurisdictions, and varying authority of local governments make generalization difficult. Service responsibilities and fiscal capabilities are heterogeneous, and often the unit obligated to provide a service is not responsible for its financial support. From the public health perspective, perhaps the central problem is that our three-level model of government, placing basic responsibility for the people's health at the state

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A VISION OF PUBLIC HEALTH IN AMERICA 51 level, does not fit well with the reality that health services must be delivered locally. In constitutional law, local governments are clearly creatures of the states. Still, tradition and politics have combined to give the locals a strong voice in intergovernmental affairs, and in most states public health authority is substantially decentralized. In addition, in recent years many local govern- ments have dealt directly with the federal government in connection with federal grants-in-aid and revenue sharing. Given this context, the strengths of local governments for the provision of public health are (1) to serve as a governmental presence at the local level, ensuring each citizen's access to the security, protection, and au- thority of government; (2) to provide a mechanism for implementation and integration of a complex array of needed services; (3) to perform these functions on the basis of both professional and community-specific knowl- edge and in line with community values to the extent that they are consistent with the maintenance of individual rights; and (4) to convey information on local needs, priorities, and program effects to the state and national levels. THE PUBLIC AND PRIVATE SEC rORS IN PUBLIC HEALTH In the history of public health the line between public and private respon- sibilities has never been hard and fast. It has shifted and blurred in response to changes in public health knowledge and in political agendas. In many respects, the varying points at which the boundary was drawn during the evolution of public health became de facto definitions that continue today to shape the way in which it is perceived. Early public health activities, focused on combating and preventing epi- demics, were mainly matters of sanitary engineering and environmental hygiene, because illness was believed to be associated with "dirt." Private physicians were among a wide range of active participants in the early citizen hygiene associations that joined with governments in these efforts. (Duffy, 1979) During this period, public health was aimed at preventing illness by improving living conditions, and care of individual patients was left to private physicians. With the discovery of bacteria and the development of immunization techniques, however, disease prevention could no longer be so easily defined solely as a communitywide affair. The line between preven- tion and treatment began to fade, and the domains of public health and private medicine could no longer be easily separated. This development created a certain amount of tension between the two that has never fully been resolved. (Rosenkrantz, 1974; Duffy, 1979; Starr, 1982) Given its continuing need for medical expertise, public health has struggled ever since

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52 THE FUTURE OF PUBLIC HEALTH to assert a positive role for itself and to maintain an accord with the medical ~ . profession. In modern times the focus of tension has shifted again, ironically in the direction of bringing the medical care of individual patients more strongly within the purview of public health than ever before. Increasingly, health departments have become "providers of last resort" for uninsured patients and those Medicaid patients rejected by or simply beyond the reach of private providers and institutions. Once immersed exclusively in population- wide and community-based efforts, health departments have rapidly be- come de facto family doctors for millions of Americans. While aware that there are complex reasons behind these developments, the committee does not believe that the ideal public health system is defined in the way in which Robert Frost once defined "home" as that place where, "when you have to go there, they have to take you in." Clearly, the line between community-based and individual strategies in disease prevention and health promotion cannot be simply drawn. It is evident, however, that the failure to define a positive role for the public sector in public health is producing what one observer of U.S. attempts to deal with AIDS has called a "crisis of authority." (Fox, 1986) As the place where the health buck stops, the official health agency at a given level of government must be the locus of decision-making to assure that necessary functions and services are in place. The public sector is also the most appropriate provider of health services that are poorly handled in the market. But the direct provision by health departments of personal health care to patients who are unwanted by the private sector absorbs so much of the limited resources available to public health money, human resources, energy, time, and attention that the price is higher than it appears. Mainte- nance functions those communitywide public services that are truly ill- suited to the private sector become stunted because they cannot compete, and key functions such as assessment and policy development wither because they are not seen as life-and-death matters. In the ideal U.S. health system, given our traditions and values, most personal medical care, regardless of payment status, would be provided by the private sector. In the same ideal, public health would emphasize spe- cialized personal health services uniquely needed for fulfilling the assurance function of the public health mission. The committee notes that care of the poor and the uninsured has indeed become an issue in the private sector, in the form of concern over "uncompensated care." The slow starvation of classic public health activities offers an additional compelling reason for finding what one public health official interviewed in the study called a "medical home" for poor Americans, one that makes sense in terms of patient needs and professional capabilities, not simply a place that has to take them in.

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A VISION OF PUBLIC HEALTH IN AMERICA THE BASIC SERVICES OF PUBLIC HEALTH 53 The potential list of basic public health services is diverse. Although the practice of public health can be traced back to the ancient Greek interest in the relationship between environmental factors and disease (Ellencweig and Yoshpe, 1984), over the centuries a wide range of notions has come to be more or less accepted under the public health umbrella. To environmental health, preventive medicine, epidemiology, and disease control have been added such disparate concerns as primary medical care, advocacy, school health, crisis response, family planning, care of the poor, dental care, licensure and certification, mental health, and home health care, to name only some of the topics raised in the committee's conversations with practi- tioners, clients, and others. A basic service is one that fulfills society's interest in assuring conditions in which people can be healthy, to refer back to the defined mission of public health. It should be emphasized again that assuring the presence of these services is a governmental function, but their provision is a responsibility shared by both public and private sectors. There are several possible ways to consider the issue of basics; combined, they may provide workable guidance for policy-making. One aspect of the issue is the substantive areas that make up the commit- ment. Health activities can be grouped under three broad headings: per- sonal health services, or medical care; environmental measures; and educa- tion. Certainly the governmental commitment, the public health mission, requires attention to all three of these substantive areas. Another aspect of the question "What are the basics?" has to do with shared objectives. Model Standards: A Guide for Community Preventive Health Services is a set of standards for organizing local health services. It was developed by the American Public Health Association, the national organizations for state health officers, county health officials, local health officers, and the U.S. Public Health Service. It has demonstrated that commitment to "a governmental presence at the local level" can be carried beyond vague generalities and translated into specifics about what consti- tutes an acceptable effort. This document lists 34 categories of public services that should be available at the local level. (American Public Health Associa- tion et al., 1985; see also Appendix C) The 1990 Objectives for the Naizon of the U.S. Public Health Service also encourage conscious and systematic assessment of need, setting of targets, monitoring of progress, and evaluation of outcome to promote health and prevent disease. It is important to set goals and report to the public on progress toward them even when their accomplishment cannot be assured. (U.S. Department of Health and Human Services, 1980; see also Appendix C) The document targets 18 health problems with objectives for preventing

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54 THE FUTURE OF PUBLIC HEALTH them. Subsequent documents by the Public Health Service have measured the nation's and states' progress toward meeting these goals. Finally, there is the issue of whether the idea of basic services suggests a minimum set, full provision of which should be guaranteed by government to all members of society. The next two chapters will paint the picture of a public health system that is incredibly diverse. The fact that there is consid- erable inconsistency among states and in local areas as to existing services in government health agencies raises the question of whether certain services should be available everywhere as a matter of justice. Clearly, although there is widespread agreement about the value of many so-called basic services, in practice the trade-offs made necessary by limited resources means that some basics are sacrificed to still higher pnorities, some of them perhaps outside the health area entirely. Are there some public health services that should never be sacrificed, no matter what? Does a governmen- tal obligation to assure conditions in which people can be healthy extend to requiring certain of these conditions? The committee believes that the answer to these questions is "Yes." In Michigan, prenatal care is guaranteed to every resident, with support pro- v~ded for those unable to pay. The Michigan example does not imply that every state should guarantee prenatal care; it does imply that every state should ask itself explicitly what services are so crucial that access to their benefits ought to be guaranteed, and make good its obligation by providing the required resources when other providers can't or won't. To sum up, the answer to the question "What are the basics?" of govern- ment's responsibility for the people's health encompasses the following elements: assuring a substantive core of activities, assuring adequacy of means and methods, establishing objectives, and providing guarantees. In the ideal health system, the substance of basic services will entail adequate personal health care for all members of the community, the education of individuals about healthy life-styles and the education of the community-at- large, the control of communicable disease, and the control of environmen- tal hazards-biological, chemical, social, and physical. Explicit priorities will be set in each community and at each level of government so that clear objectives guide organized community efforts. And governments will hold themselves accountable to the people by undertaking to guarantee certain services to all as a matter of justice. REFERENCES Advisory Commission on Intergovernmental Relations. 1985. The Question of State Govern- ment Capability. Advisory Commission on Intergovernmental Relations, Washington, D.C. American Public Health Association, Association of State and Territorial Health Officials, National Association of County Health Officials, U.S. Conference of Local Health Offi

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A VISION OF PUBLIC HEALTH IN AMERICA 55 cials, Department of Health and Human Services, Public Health Service. 1985. Model Standards: A Guide for Community Preventive Health Services. American Public Health Association, Washington, D.C. Beauchamp, Dan. 1976. "Public Health as Social Justice." Inquiry 13:3-14. Duffy, John. 1979. "The American Medical Profession and Public Health: From Support to Ambivalence." Bulletin of the History of Medicine 53(Spring):1:1-22. Ellencweig, Avi Yacar, and Ruthellen B. Yoshpe. 1984. "Definition of Public Health." Public Health Review 12:65-78. Fox, Daniel M. 1986. "AIDS and the American Health Policy: The History and Prospects of a Crisis of Authority." The Milbank Quarterly 64(Spring Supplement):1:7-33. Grodzins, Morton. 1985. "The Federal System." Pp. 43-50 in American Intergovernmental Relations, Lawrence J. O'Toole, Jr., ed. Congressional Quarterly Press, Washington, D.C. Hanlon, G., and J. Pickett. 1984. Public Health Administration and Practice. Times Mirror/ Mosby. Heclo, Hugh. 1986. "Reaganism and the Search for a Public Philosophy." In Perspectives on the Reagan Years, John L. Palmer, ed. Urban Institute Press, Washington, D.C. McCulloch v. Maryland 17 U.S.~4 Wheaton)316 (1819~. O'Toole, Jr., Lawrence J. 1985. "American Intergovernmental Relations: Concluding Thoughts," Lawrence J. O'Toole, Jr., ed. American Intergovernmental Relations. Congres- sional Quarterly Press, Washington, D.C. Robbins, Anthony. 1985. "Public Health in the Next Decade." Journal of Public Health Policy 6~4~:440-46. Rosenkrantz, Barbara Gutmann. 1972. Public Health and the State: Changing Views in Massa- chusetts,l842-1936.HarvardUniversityPress,Cambridge. Rosenkrantz, Barbara Gutmann. 1974. "Cart Before Horse: Theory, Practice and Professional Image in American Public Health, 1870-1920." Journal of the History of Medicine (Janu- ary):55-73. Starr, Paul. 1982. The Social Transformation of American Medicine. Basic Books, New York. Terris, Miller. 1985. "The Public Health Profession." Journal of Public Health Policy 6:1 :7-14. Terris, Milton. 1986. "Preventing the Final Epidemic: The Role of the American Public Health Association and the International Epidemiological Association." Journal of Public Health Policy 7~18:7-11~. U.S. Department of Health and Human Services, Public Health Service. 1980. Promoting Health Preventing Disease: Objectives for the Nation. U.S. Department of Health and Human Services, Washington, D.C.