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Public Health and the Community As discussed above, a wide range of entities (governmental, private, and nonprofit organizations) have an effect on and a stake in a community's health (Patrick and Wickizer, 1995~. These entities include health care providers, public health agencies, and community organizations explicitly concerned with health. They also include other governmental agencies, community organizations, private industry, and other entities that do not explicitly, or sometimes even consciously, see themselves as having a health-related role; these include, employers, social service and housing agencies, transportation and justice agencies, and faith communities. Many of the relevant entities are based in and focus their attention on the community in question (Box 9~. Others, such as state health departments, federal agencies, managed care organizations, and national corporations that have a broader scope than a single community, often play an essential role in determining local health status (IOM, in press). The discussions of the Committee on Public Health have led to the conclusion that, as communities try to address their health issues in a comprehensive manner, all of the stakeholders will need to sort out their roles and responsibilities and be held accountable for them (IOM, in press). In most communities, there is only limited experience with collaborative or coordinated efforts among these diverse groups. To work together effectively, they will need a common language and an understanding of the multidimensional nature of the determinants of heals. They must also find a way to accommodate diversity in values and goals. Governmental public health agencies have traditionally provided specific services to individuals and to the community at large. Local health departments may need to 31
32 HEALTHY COMMUNITIES BOX 9. Public Health at the Local Level The Committee on Public Health held a workshop on June 27, 1996, at the CDC in Atlanta, Georgia. The first panel session focused on public health functions at the community level. Parcel members included the chief executive officer of DeKalb County, the director of the DeKalb County Health Department, the president of the DeKalb County Local Board of Health, a liaison with the state department of health, and members of community-based organizations. Highlights of the discussion are listed below: Many local health department provide the only source of primary arid preventive care for uninsured populations in their communities. It is not clear that managed care organizations will provide primary and preventive care to uninsured people. There remains a substantial role for public health agencies to assure, and if necessary, to provide those preventive services to uninsured people. Core public health functions are important at the local level and have been incorporated into the legal structure of a number of health departments. Panel members felt that the core functions of public health as defined in The Future of Public Health are important as a basis for organizing, understanding, and evaluating the local public health mission. In light of an increase in the public's general lack of trust in government, panel members felt that it is important for public health agencies to develop more open communication with the public to build their trust. Additionally, it is important for the private sector to work on building institutional trustworthiness because there are many partnerships between the public and private sectors in the area of public health, which will most likely increase over time. Panel members discussed how local public health agencies were dealing with decreased funding for their activities. Many local public health agencies have to deal with diminished funding, but many are responding to these changes in different ways. For example, some local public health departments are collaborating with local managed care plans to provide personal health services to the community. In some local jurisdictions, the process for setting public health priorities is to preserve only those services that are fee-producing. To preserve the non-income producing programs (e.g., smoking prevention), panel members agreed that it is important to establish participatory advisory groups to educate elected officials and community leaders about different public health activities. Panel members concluded that public health at the local level can be responsive to the needs of the public arid effective in providing services to the community. SOURCE: Panel discussion at the June 27, 1996 Public Health Committee meeting. l transform themselves to become leaders in organizing a community's resources to enhance its health (Baker et al., 1994, NACCHO Blueprint, 1994; APHA, n.d.~. The Future of Public Health identifies the authorities of federal, state, and local public health agencies in the United States, and makes recommendations
PUBLIC HEALTH AND THE COMMUNITY 33 about governmental structures to carry out the responsibility of public health. Among other conclusions, The Future of Public Health supports the American Public Health Association's Model Standards Committee's concept that "every community must be served by a governmental entity charged with . . . responsibility . . . for providing and assuring public health and safety services." The committee's discussions, however, have shown that many communities in the United States currently lack the ability to provide essential public health services. Some communities have nothing comparable to a local department of health, and the variability in capacity and commitment in those that do is quite large. These facts have led CDC Director David Satcher to comment that China has attempted to ensure that every village has access to a village doctor (formerly know as barefoot doctors) whose major role is to provide health education, screening, and other public health interventions at the community level. It is important, Dr. Satcher feels, that every community in the United States has access to a basic public health unit that provides information and interventions needed to optimize its health (D. Satcher, personal communications, 1996~. POLICY DEVELOPMENT IN PUBLIC HEALTH The Future of Public Health defined policy development as "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." This definition suggests that partnerships between public health agencies and community-based organizations are essential if policy development is to be successful. The Future of Public Health, however, notes that fragmentation is pervasive and persistent in public health. Fragmentation is "the division of responsibility for health care among multiple, separate individuals and agencies, each with a categorical purpose, and the whole lacking a coherent policy, an integrated direction, and coordinated relationships" (Roemer et al., 1975~. Many services of public health agencies are funded by the federal government through a myriad of"categorical programs" aimed at specific underserved populations and specific health problems (DHHS, n.d.-a). For example, prenatal and infant care, immunizations, family planning services, and the prevention of STDs and AIDS are funded through separate streams, some going directly to the local level and others passing through the state or another fiscal intermediary. Some have proposed general block grants, with few restrictions on how these federal funds would be used as a solution to this fragmentation, but others are concerned that unpopular but essential public health programs would not get priority at the state or local level (Brown, 1996~. Another alternative are the Performance Partnership Grants proposed by the Department of Health and
34 HEALTHY COMMUNITIES Human Services (DHHS, n.d.-b), which would have the local flexibility of block grants and performance measures to ensure accountability. Although the committee was not able to give this issue careful attention, these options deserve further consideration. One of the key considerations in public health is the extent to which public health policymakers accept the essential political nature of public health and develop ways to work with elected officials (Slivers, 1991~. Elected officials face many different and sometimes contradictory expectations and demands from the public (Stark, 1995), and therefore, public health agencies must compete for limited attention. For improving the public's health to become a higher priority, its importance must be made clear to elected officials. Recent research at the county level indicates that when local health officials demonstrate various forms of leadership on public health problems, it is possible to achieve improvements in the health care system (Mirando et al., 1994) and develop support for the public health department through the active advocacy of other community organizations. COLLABORATION WITH THE COMMUNITY The Future of Public Health acknowledged that public health policy is formulated and implemented by a wide range of participants, including public health professionals, other health professionals, public officials, and the community (see Box 9~. Traditionally, public health was seen as the province of the public health department; but increasingly, government agencies are contracting with private community-based providers to carry out service programs (Baker et al., 1994~. In substance abuse, HIV/AIDS, childhood disabilities, and many other areas, there are a growing number of sophisticated organizations that are directly providing personal preventive and care services In recent years, community advisory boards, planning groups, and coalitions have become common in public health. Currently, community participation through an advisory group or coalition is mandated by a wide range of public health programs addressing tobacco control (the COMMIT and ASSIST projects), substance abuse (Office of Substance Abuse program's community partnership grants), HIV/AIDS (Ryan White Care Act), maternal and child health (Healthy Mothers/Healthy Babies, Healthy Start, Immunization, WIC, and Injury Prevention), and women's health (Breast and Cervical Cancer Screening) (Sofaer, 1992~. Community-based organizations of this sort act as "advisors" and "partners" to governmental public health agencies. This latter role involves a long-term mutual commitment, a genuine desire of each partner to understand the other, benefits to each partner that outweigh the costs of the partnership, and meaningful collaboration in defining agendas and action strategies. Through this
P UBLIC HEAL TH AND THE COMMUNITY 35 kind of genuine partnership trust can be established, and this ultimately gets translated into a more powerful system to address community health problems and to advocate for policy support. Beginning in 1992, the W. K. Kellogg Foundation funded seven community- based public health (CBPH) projects (in California, Georgia, Maryland, Massachusetts, Michigan, North Carolina, and Washington) to link public health agencies and their communities with academic leaders in public health. The primary purpose of this four-year initiative was to implement the recommendations of The Future of Public Health to reform professional education by linking it more effectively with practitioners. Kellogg achieved this by connecting both the academic and practice partners with communities that have serious public health problems. Not only were the educational objectives realized, but the initiative enhanced the capacity of all partners to improve the public's health. For the partners, it provided access to new opportunities such as leadership, education, and employment; skills in mobilizing resources; and, of primary importance, an enhanced delivery of services. More specifically, it proved a highly effective way of realizing the potential of public health's core functions. One of the key lessons learned was that genuine partnership with and by members of the community significantly enhances public health education, research, and service including that which occurs in the practice agencies. The Flint, Michigan project is profiled in Box 10. When grass-roots communities recognize that public health agencies are their assurance that the health system operates to protect and improve their collective health, they will advocate for the fiscal and regulatory tools to enable the agencies to carry out that role. Rather than being seen as a component of government that taxes them and does things to them, public health agencies can be recognized as the visible expression of the community's desire to collectively address its common health problems. Thus the strategy of forming deep, long-lasting community partnerships is part of the same strategy that can ultimately provide public health agencies with the tools to assure Hat the managed care system operates to the benefit of the health of the public as awhole. DIFFICULT PROBLEMS AND DIFFICULTY SOLVING PROBLEMS In a democratic and pluralistic society, such as in the United States, public policy-making in practice is not a rational or neutral process. Instead, it is a dynamic and political process that involves a constant struggle of ideas and interests (Stone, 1988~. Sometimes this process is disjointed and incremental;
36 HEALTHY COMMUNITIES BOX 10. Community-Based Public Health: GeneseeCounty,Michigan The Flint and Vicinity Action Community and Economic Development Corporation (FACED) is a member of a partnership in Genesee County, Michigan, comprising community members, community-based neighborhood organizations, the University of Michigan, arid the Genesee County Health Department. Along with organizational counterparts in the City of Detroit, this Michigan consortium is one of seven state partnerships funded by the W.K. Kellogg Foundation to improve the public's health through the practice of community-based public health (CBPH). FACED was begun by a group of ministers who were confronted regularly in their congregations with a broad range of economic, social arid health dilemmas. CBPH facilitated the formation of a nonprofit organization through which their ministry could be expressed. CBPH subsequently contributed to the organization's financial, business, administrative, and technical capacities. Among current activities, FACED now transports community residents for health care appointments, coordinates the work of seven "church health teams," orients local residents to services offered through community agencies, trains and develops other organizations, and delivers tobacco use prevention programming. Over the four years of the CBPH partnership, wide gaps in culture, race, trust, orientation, and history have been bridged among team members whose experience working jointly now forms the foundation for work with an expanded network of community residents and organizations. Experiences helping to pass local tobacco control regulations, successful advocacy in the area of lead poisoning prevention and abatement, and work along with other partners to begin fact-finding in association with a potential case of environmental discrimination were also described. The active arid supportive presence of the CBPH partnership enabled organizations to: both preserve and lose their traditional identity dependent upon the special challenges of the task; recognize and value the "voice" of community residents; and be adaptive in the design and funding of programming and research. SOURCE: Based on a presentation by Yvonne Lewis, program coordinator of the Flint and Vicinity Action Community Economic Development, Inc., at the June 27, 1996, meeting of the Public Health Committee. other times it is more erratic and random (Lindblom, 1959; Kingdon, 1995). Public health, like other areas of public policy such as education or criminal justice, faces internal and external struggles in the development and implementation of policy. These challenges include conflicting and competing values and goals, struggles with defining and resolving problems, and obstacles to the implementation of programs. Additionally, in recent years, a growing public mistrust of government, government institutions, and politics has created other challenges to society (Box 1 1~.
PUBLIC HEALTH AND THE COMMUNITY 37 BOX 11. Public Trust and Confidence In Government Americans have had conflicting attitudes about government since the founding of this country. There is strong individualism in the United States that often leads to suspicion of government and the restraints that may be placed on the individual. However, the public does recognize the role that government can play in helping individuals and organizations achieve certain goals. In recent years, there has been a growing mistrust of government, government institutions, and politics in general. The public often has higher expectations of government agencies than of private-sector organizations and expects public officials to be scrupulously honest, to avoid conflicts of interest, to perform their jobs efficiently, and to be publicly accountable. The misdeeds of government officials are often printed on the front pages of newspapers. In addition, the number of large, technically oriented public agencies and private industries have increased, while at the same time public support for large-scale scientific and technological developments has decreased. However, there are some things that governmental agencies can do to build public trust and confidence. Trust is the belief that those with whom one interacts will take one's interests into account, even in situations in which one is not in a position to recognize, evaluate, or thwart a potentially negative course of action by those trusted. Confidence exists when the party trusted is believed to be able to empathize with one's interests, is competent to act on that empathy, and will go to considerable lengths to keep her or his word. Trustworthiness is a combination of trust and confidence. An erosion of public trust in governmental agencies will take hold when the following perceptions and beliefs become widespread. Benefits and Costs: · There is a perceived mismatch in the distribution of benefits and the costs associated with realizing the agency's mission. · The risk of hazard from program failure is perceived to be very high and very long lasting. Accuracy and Speed of Feedback: · High levels of technical, esoteric knowledge are required to conduct the agency's mission or to evaluate its success, risk, and hazards. · A long lag occurs in the time to the discover of success or failure, especially if the evidence of failure is likely to be ambiguous and equivocal. Capability of Others to Meet Expectations: · There is a perceived decline in the competence of agency members relative to the demands posed by the problems central to effective operations. · There is a perceived decline in operating reliability and in complete disclosure of information about difficulties and failures. Continued
38 BOX11. Continued HEALTHY COMMUNITIES Motivation of Others to Understand and Keep Bargains: · There is a perceived unwillingness to respect the views of the vulnerable parties. · There is a perceived inability to fulfill promises to maintain consistent levels of agency performance or promised public political support. There are several things that a governmental agency can do to establish and maintain public trust and confidence within its organization and external to its organization. Increasing institutional trustworthiness begins with its internal operations. An agency should commit itself and its contractors to maintain a high level of professional and managerial competence. It should establish and meet reasonable technical performance measures and schedule milestones that are dictated by a project's scientific requirements and pursue technical options and strategies that can be clearly demonstrated to broad segments of the public. It should reward honest self-assessment that permits the organization to solve problems that have been identified internally before they are discovered by outsiders. In addition, the agency should move the responsibility for promoting and protecting the internal efforts to sustain public trust and confidence throughout the organization. For an agency to build trust and confidence with the public, it should establish an advisory board at the state and local levels as well as at the national level that includes all interested parties in the work of the agency. The agency's top-level staff should be accessible to citizens and their representatives. Open communication with He community and agency constituents is crucial to developing institutional ~ustwor~iness. It is important to establish consistent and respectful efforts to reach out to state and community leaders and the general public for He purpose of informing, consulting, and collaborating win Hem about the technical and operational aspects of the agency's work arid activities. SOURCES: Based on a presentation by Todd LaPorte, professor of political sciences, University of California at Berkeley, at the June 27, 1996 meeting of the Public Heals Committee; LaPorte, 1994; Feingold, 1995; and LaPorte and Metlay, in press. Many problems such as violence, substance abuse, and teen pregnancy are fundamentally difficult because they have multiple, intertwined medical, social, and economic causes (Sommer, 1995; Yates, 1977~. Resolving these problems requires a comprehensive, collaborative response from different public agencies and private organizations, including but not limited to public health. For example, addressing the problem of lead poisoning prevention involves a coordinated strategy among governmental public health agencies, the medical community, environmental, occupational health, and housing agencies, business, labor, and the general public as well as the public education system. For other problems, the solutions seem more straightforward, yet the scientific evidence about the efficacy and cost-effectiveness of solutions has been elusive (Council on Linkages, 1995~. Policymakers need to know what types of
PUBLIC HEALTH AND THE COMMUNITY 39 interventions are available, which ones have been shown to be effective, how much they cost, and whether they can be modified and adapted to local circumstances (Holtgrave et al., 1996~. Practitioners in governmental public health agencies need the confidence and funding to sustain new models of practice while maintaining models proven to be successful. The federal government has begun to document the effectiveness of public health interventions (DHHS, N.d.-b; Gordon et al., 1996), and this research has begun to be translated into practice. For example, evidence has accumulated that use of mammography can reduce the mortality due to breast cancer among women 50 years and older by 30%, and the Pap test has been shown to be an effective technology for reducing cervical cancer mortality QIenson et al., 1996~. In 1990, with passage of the Breast and Cervical Cancer Mortality Prevention Act, the Centers for Disease Control and Prevention (CDC) established a comprehensive public health program to increase access to breast and cervical cancer screening services for women who are medically underserved. This program has dramatically increased the number of older women screened for breast and cervical cancer (Henson et al., 1996~. Additional efforts are underway through CDC to improve the database on effective community-based interventions (CDC, 1996~. Even when promising solutions exist, public health agencies too often have difficulty generating support for interventions among elected officials and the general public. Programs to improve the public's health compete with medical care services for attention and resources. While medical care services treat urgent problems, many public health programs prevent problems from occurring or progressing. Thus the benefits of medical care are often more tangible and concrete, while the benefits of public health are more diffuse and less well appreciated. A key struggle for governmental public health leaders and those in the private and nonprofit sectors with an economic, ethical, or philosophical interest in the public's health is making the benefits of community-based, population-wide public health activities and initiatives more recognizable, and finding allies who will speak on behalf of these initiatives and the unique role for governmental public health agencies in carrying out these initiatives. A good example of this is the way that advocates at the state and local levels have been able to demonstrate how the general public is affected by the costs of smoking: paying the medical costs of lung cancer patients through higher insurance premiums or taxes for public programs, experiencing the effects of passive smoking, and the numerous allies in the communities who have embraced the tobacco-free movement. In contrast, public health policymakers have been somewhat less successful in generating support or alliances for HIV/AIDS prevention or STD control in part because of the incorrect perceptions that these are not widespread problems in the general population, that STDs do not have severe consequences, and because of the
40 HEALTHY COMMUNITIES public's reluctance to be open about sexuality (IOM, 1996). Public health agencies need to work with the community to identify common problems Hat both can work on together. Some have suggested that public health agencies be compared to police and fire departments in a public safety context (Box 12~. Others suggest that because the unique role of public health agencies relates directly to prevention and the community, it would be helpful to emphasize health protection, disease prevention, and health promotion (Baker et al., 1994~. Emphasizing the Public Health Functions Steering Committee's vision statement for governmental public health agencies-"Healthy People in Healthy Communities" might be a fruitful approach. BOX 12. A Metaphor for Public Health Public health agencies are a lot like fire departments. They teach and practice prevention at the same time that they maintain readiness to talce on emergencies. They are most appreciated when they respond to emergencies. They are most successful-and least noticed-when their prevention measures work the best. In another respect, the two are different. Everyone knows what a fire department does; few know what a public health department does. The very existence of health departments is testament to the fact that, when legislators, county commissioners, and other policymakers understand what those departments do, they support them. It is a rare person who, once familiar with the day-to-day activities of a public health department, would want to live in a community without a good one. SOURCE: Washington State Department of Health, 1994. CONCLUSIONS In its discussions with community group representatives and public health officials, the committee heard of many innovative and effective approaches to community partnerships and collaboration that are consistent with widespread themes regarding community development and "reinventing government." Broader application and further development of these new approaches to collaboration within government twin legislators, boards of heals, and nonhealth agencies) and with community partners to achieve public heals goals should be encouraged. Shared responsibility, however, requires careful management. The governmental public health agency in each community needs to be capable of identifying and working with all of the entities that influence a community's
PUBLIC HEALTH AND THE COMMUNITY 41 health, especially those that are not directly health related. This function must be undertaken by public health agencies that understand the interactions of the full range of factors that influence the community's health. To address this, a companion IOM report proposes a "community health improvement process" that draws on performance monitoring concepts, an understanding of community development, and the role of public health consistent with the Committee on Public Health's discussions (IOM, in press). Public health professionals who must work with a community to improve its own health need to be trained and their roles need to be upgraded or enhanced. The committee's discussions showed that many functions essential to the public's health, such as immunizations and health education, can be and are now being performed by either public or private entities, depending on the historical context, community resources, and political dynamics of a particular area. Some functions, however, such as environmental regulation and enforcement of public health laws, must remain the responsibility of governmental public health agencies. There also needs to be a resource in each community to ensure that the health impact of multiple interventions in the community are understood and addressed. This remains an ideal function for governmental public health agencies and should not be delegated. Thus, the committee reasserts the critical findings of The Future of Public Health that governmental public health agencies have a unique function in the community: "to see to it that vital elements are in place and that the [public health] mission is adequately addressed." These elements include assessment, policy development, and assurance. For a governmental agency to execute this responsibility effectively, there must be explicit legal authority as well as health goals and functions, that the public understands and demands. A fundamental building block for this new approach to governance is public trust. With trust in public institutions at risk or at low levels in many communities, governmental public health agencies must find ways to improve communication and openness with the public to maintain and increase their trustworthiness.