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1
Introduction
BACKGROUND
In the mid-1970s, many in the medical community were confident that the
war against infections diseases was nearly over. Infectious diseases were on the
wane, powerful antibiotics were proven weapons in the armamentarium against
bacterial infections, smallpox was on the verge of eradication, and new vaccines
were being developed to combat a variety of diseases. These improvements to
health were accomplished through advances in public health. The public was
well aware of these advances and the amazing results produced by medical sci-
ence but did not necessarily view them as a function of public health. Neverthe-
less, the public's knowledge led patients to have greater expectations of their
physicians and reinforced the concept of entitlement, that access to health care
services of good quality is a social right of every citizen.
Governments felt the pressure to make modern medicine more widely
available and responded to the appeals of their citizens. Concerns over substance
abuse, chronic diseases, tobacco use, teenage pregnancy, environmental pollut-
ants, and geriatric disorders captured the attention of decision makers. Public
health systems were expected to address these complex, challenging, and diverse
problems facing the public, as well as to continue to perform their traditional
roles in disease surveillance, responding to epidemics and preventing infectious
diseases. Yet, the integration of these new roles was poorly defined, inade-
quately supported, and not fully understood.
Today, the public health system is at a crossroads as to how to define and
sustain its role. The changing face of health care poses new challenges for the
detection, treatment, and prevention of infectious diseases. Historically, local
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INTRODUCTION
25
public health departments, hospitals, and clinics have been the main source for
infectious disease outbreak detection and treatment. The members of managed
care organizations and the rate of privatization of public health laboratories con-
tinue to increase in response to the needs of the communities they serve. Simul-
taneously, many of the specific functions of public health laboratories and insti-
tutions that provide epidemiological services may be being eroded. Along with
that erosion, local public health systems may have a diminished capacity to de-
tect and respond to emerging infectious diseases. Additionally, the public
healthy system's capabilities may also be adversely affected by the growing
number of the uninsured population that focused most of the burden for re-
sources on the public safety net and public laboratories. The challenge for public
health laboratories will be to implement cost-shifting or to obtain new sources of
support.
As expected, conflicts arise in public health and its priority setting as it
moves away from its traditional focus on infectious disease control to address
the evolving fields of chronic diseases and injury prevention. Each of these areas
is consistent with the overall mission of public health. Unfortunately, they are all
vying for the same available resources.
For years, the public health system has been challenged to respond to a va-
riety of new and reemerging disease threats, from Legionnaires' disease, to HIV
infection, to Lyme disease, and, now, to the latest onslaught of reemerging in-
feciions such as those caused by organisms that are resistant to antibiotics. The
enduring problems of chronic illness and injury, the rising specter of environ-
mental pollutants, and the transformation of the nation's health care system pro-
vide strong incentives for public health to develop innovative systems for infec-
tious disease surveillance and response.
Privatization of health care and public health laboratories poses significant
challenges to the traditional way in which disease surveillance has been con-
ducted. Essentially, this has resulted in high-volume, low-cost analyses migrat-
ing to the private sector, while low-volume and high-cost tests remain in the
public sector. Changes in the health care system are posing significant concerns
for the traditional way in which disease surveillance has been conducted. For
example, Medicaid patients, whose health data were once easily available to
public health officials, are now being increasingly served by the private insur-
ance industry (most commonly, managed care), which may not have the same
incentives to share data. A reevaluation and an alternative means to maintain
those important elements that have been effective and that continue to be effec-
tive for infectious disease surveillance are needed. The challenge will lie in how
we in the public health care system can best work with the changing health care
system to create a stronger and more appropriate surveillance system. The op-
portunity will be to promote public health and its special role and importance in
health care.
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26
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
CHANGING LANDSCAPE OF PUBLIC HEALTH
Adapted from a presentation by Margaret Hamburg, M.D.
Assistant Secretary for Planning and Evaluation,
U.S. Department of Health and Human Services
The issue of emerging infectious disease in the changing landscape of pub-
lic health requires a focused examination of the factors that have changed the
nature and extent of human exposure and risk entailed by the agents that cause
infectious diseases (IOM, 1992~. The changing demographics and environmental
conditions both contribute to the emergence or resurgence of infectious diseases.
Likewise, global travel, migration, trade and commerce, and changing socioeco-
nomic conditions affect transmission of infectious diseases. Human behaviors,
such as dietary habits, food preparation practices, poor personal hygiene, unsafe
sexual behavior, and intravenous drug use, also contribute to disease transmis-
sion. The overuse and misuse of certain pesticides has led to the resurgence of a
range of important disease threats in the United States and, perhaps more sig-
nificantly, worldwide.
Recently, certain health care practices have also contributed to the problem
of emerging infections. Among these practices are the increased use and inten-
sity of certain health care services, including invasive medical procedures and
immunosuppressive therapies, and the overuse and misuse of antibiotics, leading
to a broad range of concerns about the development of antimicrobial resistance.
Concomitant with these changing practices is the transformation of the health
care delivery system and the emergence and deepening penetration of managed
care.
Delivery of Clinical Services
The delivery of most clinical services has shifted largely from the inpatient
to the outpatient setting, and physicians are increasingly providing empiric
treatment rather than relying on laboratory tests for confirmatory diagnosis be-
fore initiating treatment. Reliance on empiric treatment, however, decreases the
completeness and accuracy of disease reporting and, when coupled with the
availability of fewer routine laboratory tests, results in the loss of traditional
means of disease reporting and approaches to disease management. These
changes have compromised our ability to accurately monitor and respond to
emerging disease threats.
Another area of change in the health care arena is the evolving role of
many public health departments in the delivery of clinical services. Providing
health care services to underserved and indigent populations is viewed by many
as an important role of public health departments, as part of the health care
"safety net". Alternatively, some public health departments have focused their
efforts on providing a more limited set of clinical services that are important for
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INTRODUCTION
27
overall disease control objectives, for example, providing directly observed
therapy for patients with tuberculosis or antibiotic treatment for sexually
transmitted diseases.
Each of the paths described above is important to the changing identity of
public health and the future stability of public health systems. In particular,
many public health departments are dependent on clinical activities and the
revenues from those activities. Revenues from clinical care services often cross-
subsidize some of the other important public health functions, such as surveil-
lance. Thus, discontinuing clinical services delivery in health departments can
destabilize the financial infrastructure on which many public health systems
depend for financial viability. Yet, continuing to provide clinical services in
light of the changing and increasingly competitive health care environment and
growth of managed care, can also be a destabilizing force for many public health
departments.
To be effective, health departments must look outside the context of clinical
care delivery to a range of often unique services and functions that they can pro-
vide to promote health and prevent disease. For example, communication about
the importance of the public health infrastructure in addressing the potential
threat of bioterrorism requires vigorous effort. Increased funding to build the
fundamental capacity for infectious disease surveillance is an important first step
in the detection of and response to a potential bioterrorist threat.
The public health system is often fragmented and dependent on categorical
funding streams at the federal, state, and local levels. One-time investments in
public health activities, such as infectious disease surveillance, do not provide
the consistent and sustained leadership and support needed to strengthen the
public health system.
Laboratory-Based Reporting
The problems of a fragmented system of public health are echoed when one
examines the plight of public health laboratories. For example, the structural
mechanism of financing differs in each state laboratory. Each state laboratory
resides within a unique health care and public health system, and each operates
its own unique information system.
Public health laboratories are struggling to find their position and role in the
changing health care environment. Some of the important shifts in the landscape
are related to competitive market forces that promote the growth of independent
laboratories and the consolidation of hospital laboratories. Many managed care
organizations are contracting with laboratories that offer the lowest prices.
These laboratories often differ across states. Consequently, conflicts arise when
guidelines for disease reporting vary across jurisdictions. Cost-saving programs
have also decreased the volume of samples and the numbers of tests that are
performed because of the greater use of empiric treatment of diseases. Health
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28
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
care systems no longer send their specimens to the traditional laboratory that
they may have previously used. With the breakup of local laboratory networks
and with the performance of fewer routine laboratory tests by public health labo-
ratories, there is a concomitant breakdown in some of the traditional systems of
communications and collegial relationships that foster information exchange and
.
disease reporting.
Improving Communication of Health Information
Communicating the value and importance of the public health system is a
perennial challenge in part because when the public health system functions
well, it is invisible to the public and to public policy makers. The public health
community must recognize that both policy makers and the public understand
and respond to disease-specific issues. Theoretical issues in public health are not
well understood by the lay public, but presenting clear, concise inflation
about specific disease threats can help to communicate concepts of risk which
are better understood by policy makers and the public. Communication of public
health issues requires a strategy that reframes a number of important issues in
terms that people understand. This is an important transition for public health,
and the public health community must be positioned to maximize the opportu-
nity to promo~te~public health and its special role and importance in health care.
Representative terms from entire chapter:
health laboratories
