analysis requires a rethinking of traditional notions and paradigms of population (public) health.

This paper identifies current issues and offers suggestions for integrating concepts to support functional and practical improvement while ensuring population health maintenance and improvement and reasonable access to services in a context of controlled long-term per capita cost. To ensure these desired outcomes, we must expand our vision to encompass both population-based and primary medicine and health care services as a single integrated system; we must work to remove barriers to its formation; we must develop new operating paradigms to ensure its high-quality performance; and we must develop programs to focus its objectives and ameliorate its excesses.

This paper identifies and highlights significant requirements and challenges for leadership within the public health and primary care communities, and for educational and research leadership among academicians serving and supporting those communities. In the final analysis, many of these challenges must also be addressed and changes supported by visionary leaders within our political and health care delivery systems, if such integrated community health systems are to be created and their potential achieved.

In short, we must view both public health and primary care as two interacting and mutually supportive components of an increasingly complex integrated community health system, having the single common goal of improving the health of a community and its diverse populations.

Background: Public Health And Primary Care

We noted with interest the relative paucity of published material directly addressing the intersection and interaction of population-based programs and services (public health) and primary care programs and services. It is significant that many of the seminal documents on the subject are in the form of special reports and studies commissioned by the Institute of Medicine (IOM), a small number of private foundations, and, more recently, the U.S. Public Health Service (USPHS). In short, the subject is rarely dealt with directly but more often is dealt with obliquely, perhaps indicating a need for new concepts to guide our thinking.

Relatively few of the small number of writings identified were written from the perspective of public health. Most were written from the perspective(s) of preventive medicine and family medicine (mostly community-oriented primary care [COPC]). Few were identified in the internal medicine and pediatric literature. In general, the COPC concept has not spread broadly throughout the world of primary care medical practice since being the subject of a 1984 IOM study (1). The COPC practice model appears to be most apparent in staff-model health maintenance organizations (HMOs) and in a relatively small number of academic community-based practices. This report and concept have been important in



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