• Policy at all levels often develops as a result of immediate and pressing needs rather than from analysis of carefully collected data.

  • Unequal access to public health services means that certain populations, such as the poor, receive inadequate medical care.

  • Public Health leadership, particularly at the state and local levels, suffers from inadequate technical knowledge and rapid turnover, among other things.

It is the perception of this committee that there has been little positive change in the state of U.S. public health since the release of the 1988 IOM report. As partial evidence for this statement, the recent rapid increase in measles incidence (which is now beginning to subside) and the current upswing in cases of tuberculosis (TB) (including multidrug-resistant disease) can be offered. These emerging disease problems are largely the result of complacency—a misguided perception that the advanced U.S. health care system with its array of medical technologies is able to disarm almost any infectious disease.

In the case of measles, successful vaccination programs had diminished disease incidence to such a degree that the public, health care professionals, and public health organizations reduced their levels of vigilance and effort. The result was a resurgence in the disease that only last year reached a peak. Partly as a response, Congress appropriated an additional $40 million in 1992 (a 19 percent increase over 1991) to support the CDC immunization program. The money was targeted at children under the age of two living in communities in need, such as inner cities (National Foundation for Infectious Diseases, 1991).

As discussed earlier, the declines in incidence of TB since the early 1950s led to a belief held by many public health officials, beginning in the early 1980s, that the disease no longer posed a significant health problem. Research efforts waned, and in 1986, the CDC's surveillance program for tracking TB drug resistance trends was terminated. Increases in homelessness, poverty, substance abuse, HIV infection, and active TB among immigrants have now contributed to a resurgence in TB cases (Fox, 1992), which has been further complicated by outbreaks of multidrug-resistant TB (MDRTB) and poor availability or unavailability of some antituberculosis drugs. As recently as 1989, the Department of Health and Human Services developed a national plan to eliminate TB as a health problem in the United States, and at that time, the prospects appeared excellent for success. The plan was not implemented, however, because of both insufficient resources and a lack of conviction regarding the plan's effectiveness.

An aggressive response to the current TB/MDRTB crisis is now being pursued. A national coalition of more than 40 patient and provider organizations has been formed to address TB elimination issues (U.S. Department



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