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OCR for page 35
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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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.
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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
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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
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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
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Representative terms from entire chapter:
public sector
