that we may have to seek or develop new organizational methods and public-private political structures to balance the competing requirements of community and shareholder accountability. It is entirely possible that the growing complexity of our communities, combined with the increasing recognition of the need to develop new ways to bridge the public-private chasm will lead us in the directions of exploring Schauffler's Community Based Health Promotion and Disease Prevention (CBHPDP) partnership concept, referenced earlier (6).

In any event, Schauffler recognizes the complexity of organizing the complete spectrum of community-accountable population-based and personal services required to create an environment within which health can be assured. Thus, a community, in the context of CBHPDP, is defined by its people, institutions organization, and locality.

Many of our communities are experiencing growing economic, cultural, and ethnic diversity; significant inequities in health status have accompanied this diversity. As a result, it is imperative that we recognize the important role communities must play if we are to improve and maintain the health status of our population. Two choices are available: (1) we can continue down the current path and support models that fragment care and focus only on the individual as the unit of prevention interventions, thereby risking an increase in the health status gaps that exist between the most advantaged and disadvantaged subgroups of our population; or (2) we can build a model for the twenty-first century that recognizes the diversity of our communities by developing a multidisciplinary, intersectoral approach that encourages and supports the significant role communities can and must play in promoting health and preventing disease (6, p. 9).

The difficulty of achieving this result and of reconciling the tensions described above between the community-accountable and non-community-accountable components of our integrated health system must not be underestimated. Ultimately, this is a problem that must be solved through our political system—local, regional, state, and national.

As we survey the path suggested in this paper, we ask, will it be risky to move in the direction(s) suggested? Ultimately, we also ask, will it be even more risky to make no movement at all?


1. IOM. Community Oriented Primary Care: A Practical Assessment, Vol. 1. The Committee Report. Washington, D.C.: National Academy Press, 1984.

2. IOM. Defining Primary Care: An Interim Report. Washington, D.C.: National Academy Press, 1994.

3. IOM. The Future of Public Health. Washington, D.C.: National Academy Press, 1988.

4. Partnership for Prevention. Prevention Is Basic to Health Reform: A Position Paper from an Expert Panel. Washington, D.C.: Partnership for Prevention, March 1993.

5. Lashof, J. Public Health and Prevention. Presented at Public Health Agencies and Managed Care: Partnerships for Health Conference, Atlanta, Ga., 1994.

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