National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Enduring Public Health Problems, concluded ...
Smoking and Substance Abuse
Thirty percent of American adults are addicted to cigarettes.
Cigarette smokers have a 70 percent higher death rate from all causes than non-smokers.
Smoking is the single greatest cause of premature death in this country.
It is estimated that smoking contributes to as many as 225,000 deaths from coronary heart disease, 100,000 deaths from cancers, and 20,000 deaths from chronic obstructive lung disease each year.
Additionally, 10 million Americans suffer from debilitating chronic diseases caused by smoking. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1983)
Also, smoking is the major identifiable cause of residential fire deaths and injuries in the country and is associated with higher injury and chemical illness risk in many occupations.
About 30 percent of all adults and about 20 percent of high schoolers in the United States regularly smoke cigarettes, but those proportions have decreased from 33 percent of adults and 27 percent of high school teenagers in 1979. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1986)
Annual per capita alcohol consumption in the United States has remained steady, at slightly under 3 gallons per person age 14 and over since 1978.
But alcoholism may be on the rise.
For example, 1982 data indicate that as many as 41 percent of teenagers engage in occasional binge drinking, an increase from 37 percent in 1975. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1986)
During the late 1970s and early 1980s, drug use remained relatively stable and even declined for some substances.
About 16 million Americans regularly smoke marijuana, 1 to 2 million regularly use cocaine, 1 million misuse barbiturates, and thousands are addicted to heroin. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1983)
Between 1977 and 1982, use of marijuana in young adults declined from about 19 percent to about 16 percent, and from 9 percent to 6 percent in teenagers.
But use of other drugs by adults, particularly cocaine, more than doubled, from under 1 percent to over 2 percent. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1983)
Alcohol and drug abuse are major factors in much illness, disability, and death in the United States.
Some problems are immediate, and some evolve over a period of time.
Ten percent of all deaths in the United States are related to alcohol use.
Cirrhosis of the liver, which is largely attributable to alcohol use, caused 10.7 deaths per 100,000 population in 1984.
Alcohol abuse is also frequently related to motor vehicle injuries and deaths.
In 1984, the death rate from alcohol-related motor vehicle accidents was 9.5 per 100,000, and from other alcohol-related accidents, 4.3 per 100,000.
Drug abuse has also been related to premature death, severe physical disability, psychological disability, homicides, suicides, and injuries.
In 1984, it was estimated that there were more than 3,500 drug-related deaths in 26 major metropolitan areas of the United States.
Drug use causes some 100,000 to 350,000 hospital admissions per year. (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services, 1986)
Intravenous drug use also is a major risk factor for contracting AIDS virus infection from contaminated needles and syringes.
The three habits of smoking, alcohol abuse, and drug abuse have consistently been related to poor pregnancy outcomes.
Despite some declining trends in substance abuse, the health effects of current and previous use will be felt for years to come.
There is some indication that public health measures directed toward controlling substance abuse, including health education of the public and of health professionals, have contributed to the reductions in substance abuse mentioned above.
In general, in the early 1980s more adults and teenagers reported awareness of the dangers of smoking, alcohol abuse, and drug abuse than had in the late 1970s.
But an ongoing effort will be required to reduce the long-term burden on the public health caused by substance abuse.
TO BE CONTINUED ...
ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Growing Challenges and Impending Crises
Some health problems are likely to be increased by factors that are already identifiable.
These ''time bombs" of public health include the following two examples.
Toxic Substances
The problem of hazardous waste generated by industry becomes bigger with each new discovery of environmental contamination from improper disposal of toxic materials.
Contamination exists in ground water, air, soil, and food and has serious implications for public health. (Walker, 1985)
Most toxic substances are present in more than one medium and may be readily transferred from air to soil to food and water.
For example, when residues from waste water treatment plants are incinerated, a portion of the pollutants is converted to air pollutants, which in turn contaminate water and soil.
Pollution of groundwater and other drinking water supplies is a serious threat to public health.
For example, for nearly 17 years, until voluntary closure in 1972, the Stringfellow acid pit near Riverside, California, accepted about 35 million gallons of industrial waste.
Thirteen years after the site stopped receiving toxic waste and 5 years after the pits were capped, a major groundwater basin was still being contaminated.
Various containment efforts were made to prevent these wastes from migrating.
These old technologies failed at this site as they have at other waste holding pits. (Embers, 1985)
Pesticides contaminate many common American foods (tomatoes, beef, potatoes, oranges, lettuce) and may be responsible for some cancers, according to Regulating Pesticides in Foods: The Delaney Paradox, a National Academy of Sciences report released in 1987.
That study focused on 28 of the 53 pesticides classified as carcinogenic or potentially carcinogenic.
More than 80 percent of those analyzed exceeded the Environmental Protection Agency threshold of acceptable cancer risk for an environmental toxicant — no more than one additional case of cancer for every 1 million persons exposed. (Board on Agriculture, National Academy of Sciences, 1987)
Although recent attention has been focused mainly on cancer, the range of adverse human health effects of exposure to chemicals and other toxic substances is broad.
Exposure to high levels of some substances for even short periods may produce acute, though often temporary, effects such as rash, burns, or poisoning.
Prolonged exposure to low doses can cause lung disease and neurobehavioral disorders.
There is growing evidence that environmental toxicants can cause reproductive problems, including miscarriages and birth defects.
An increased incidence of abortion and stillbirth among women exposed to high lead concentrations has long been recognized.
Studies of mercury and aluminum indicate that these metals, too, may affect pregnancy outcome.
The National Institute of Occupational Safety and Health reports that more than 4 million workers are directly exposed to those metals that can cause chronic kidney disease. (Walker, 1985; National Academy of Engineering, 1986)
Controlling toxic substances in the environment will continue to present new challenges for the legal and the public health systems of the nation.
With growing evidence of the human health effects of some toxic substances, the number of lawsuits and other efforts to obtain compensation by injured parties will rise.
Implementation of federal toxic substances control laws, such as the Toxic Substance Control Act (TSCA) and the Federal Insecticide, Fungicide and Rodenticide Act, has raised numerous questions concerning testing of thousands of chemicals in commercial use, including who should test them, when they should be tested, and for what effects they should be tested.
These and similar issues have slowed the rate at which the laws can be implemented. (Embers, 1985; Walker, 1985)
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Growing Challenges and Impending Crises
Some health problems are likely to be increased by factors that are already identifiable.
These ''time bombs" of public health include the following two examples.
Toxic Substances
The problem of hazardous waste generated by industry becomes bigger with each new discovery of environmental contamination from improper disposal of toxic materials.
Contamination exists in ground water, air, soil, and food and has serious implications for public health. (Walker, 1985)
Most toxic substances are present in more than one medium and may be readily transferred from air to soil to food and water.
For example, when residues from waste water treatment plants are incinerated, a portion of the pollutants is converted to air pollutants, which in turn contaminate water and soil.
Pollution of groundwater and other drinking water supplies is a serious threat to public health.
For example, for nearly 17 years, until voluntary closure in 1972, the Stringfellow acid pit near Riverside, California, accepted about 35 million gallons of industrial waste.
Thirteen years after the site stopped receiving toxic waste and 5 years after the pits were capped, a major groundwater basin was still being contaminated.
Various containment efforts were made to prevent these wastes from migrating.
These old technologies failed at this site as they have at other waste holding pits. (Embers, 1985)
Pesticides contaminate many common American foods (tomatoes, beef, potatoes, oranges, lettuce) and may be responsible for some cancers, according to Regulating Pesticides in Foods: The Delaney Paradox, a National Academy of Sciences report released in 1987.
That study focused on 28 of the 53 pesticides classified as carcinogenic or potentially carcinogenic.
More than 80 percent of those analyzed exceeded the Environmental Protection Agency threshold of acceptable cancer risk for an environmental toxicant — no more than one additional case of cancer for every 1 million persons exposed. (Board on Agriculture, National Academy of Sciences, 1987)
Although recent attention has been focused mainly on cancer, the range of adverse human health effects of exposure to chemicals and other toxic substances is broad.
Exposure to high levels of some substances for even short periods may produce acute, though often temporary, effects such as rash, burns, or poisoning.
Prolonged exposure to low doses can cause lung disease and neurobehavioral disorders.
There is growing evidence that environmental toxicants can cause reproductive problems, including miscarriages and birth defects.
An increased incidence of abortion and stillbirth among women exposed to high lead concentrations has long been recognized.
Studies of mercury and aluminum indicate that these metals, too, may affect pregnancy outcome.
The National Institute of Occupational Safety and Health reports that more than 4 million workers are directly exposed to those metals that can cause chronic kidney disease. (Walker, 1985; National Academy of Engineering, 1986)
Controlling toxic substances in the environment will continue to present new challenges for the legal and the public health systems of the nation.
With growing evidence of the human health effects of some toxic substances, the number of lawsuits and other efforts to obtain compensation by injured parties will rise.
Implementation of federal toxic substances control laws, such as the Toxic Substance Control Act (TSCA) and the Federal Insecticide, Fungicide and Rodenticide Act, has raised numerous questions concerning testing of thousands of chemicals in commercial use, including who should test them, when they should be tested, and for what effects they should be tested.
These and similar issues have slowed the rate at which the laws can be implemented. (Embers, 1985; Walker, 1985)
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Growing Challenges and Impending Crises, continued ...
Alzheimer's Disease or Dementia of the Alzheimer Type
As many as 2 million Americans are suffering from Alzheimer's disease, resulting in severe, disabling intellectual impairment.
The exact causes of Alzheimer's are unknown, but it is clearly associated with age. (Katzman, 1986)
Although a small percentage of those under age 60 are believed to have Alzheimer's, more than 20 percent of the population over age 80 is believed to have the disease.
The prevalence of cases of Alzheimer's increases 10- to 20-fold between age 60 and age 80 years. (Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services, 1984)
The number of Alzheimer's disease cases is expected to increase dramatically over the next several decades as the population ages.
The elderly are the most rapidly growing group within our population, and, within that group, the proportion of elderly age 85 and over is increasing the most rapidly.
In 1980, the elderly population in the United States (age 65 and over) numbered some 26 million, or about 11 percent of the population.
By the year 2025, as the baby boom of the mid-twentieth century reaches old age, the elderly population is expected to reach a peak of 58.5 million people, or a full 20 percent of the population. (Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services, 1984)
The association between Alzheimer's dementia and the aging of the population will increase greatly the demand for long-term care.
Currently, over half of the million and a half residents of nursing homes are estimated to have Alzheimer's disease. (Katzman, 1986)
Many others are cared for in sheltered housing or day care facilities.
When care is provided by family members or friends, the care givers themselves may suffer economic deprivation or declines in physical or mental health status.
Although considerable research is being done on the causes of Alzheimer's, it is likely that treatment of the disease will continue to require some form of long-term health care. (Katzman, 1986)
Alzheimer's represents a particular challenge to public health leadership to assure access to and quality of appropriate services.
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Growing Challenges and Impending Crises, continued ...
Alzheimer's Disease or Dementia of the Alzheimer Type
As many as 2 million Americans are suffering from Alzheimer's disease, resulting in severe, disabling intellectual impairment.
The exact causes of Alzheimer's are unknown, but it is clearly associated with age. (Katzman, 1986)
Although a small percentage of those under age 60 are believed to have Alzheimer's, more than 20 percent of the population over age 80 is believed to have the disease.
The prevalence of cases of Alzheimer's increases 10- to 20-fold between age 60 and age 80 years. (Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services, 1984)
The number of Alzheimer's disease cases is expected to increase dramatically over the next several decades as the population ages.
The elderly are the most rapidly growing group within our population, and, within that group, the proportion of elderly age 85 and over is increasing the most rapidly.
In 1980, the elderly population in the United States (age 65 and over) numbered some 26 million, or about 11 percent of the population.
By the year 2025, as the baby boom of the mid-twentieth century reaches old age, the elderly population is expected to reach a peak of 58.5 million people, or a full 20 percent of the population. (Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services, 1984)
The association between Alzheimer's dementia and the aging of the population will increase greatly the demand for long-term care.
Currently, over half of the million and a half residents of nursing homes are estimated to have Alzheimer's disease. (Katzman, 1986)
Many others are cared for in sheltered housing or day care facilities.
When care is provided by family members or friends, the care givers themselves may suffer economic deprivation or declines in physical or mental health status.
Although considerable research is being done on the causes of Alzheimer's, it is likely that treatment of the disease will continue to require some form of long-term health care. (Katzman, 1986)
Alzheimer's represents a particular challenge to public health leadership to assure access to and quality of appropriate services.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Growing Challenges and Impending Crises, concluded ...
Revitalization of Public Health Capacities
To counter these and other threats to the health of the public will require a vital and effective public health system capable of the full range of responses necessary to make further progress against disease, disability, and premature death.
Controlling communicable disease, encouraging healthy lifestyles, reducing hazards in the environment, and targeting and assuring necessary personal health and long-term care services — all of the classic tools of public health — are necessary to maintain the benefits of past success and to respond to current and future challenges.
The successes of past public health efforts are many.
The virtual elimination of many infectious diseases, such as typhoid fever and paralytic polio; great reductions in many of the common childhood communicable diseases (Committee on Public-Private Sector Relations in Vaccine Innovation, Institute of Medicine, 1985); and initial progress in the control of common chronic diseases, such as heart disease, stroke, and some forms of cancer (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986), are ample evidence of the effectiveness of public health measures that join scientific knowledge and effective social action.
However, the success of past efforts can lead to complacency about the need for a vigorous public health enterprise at the national, state, and local levels.
To achieve public health objectives, public health will need to serve as leader and catalyst of private efforts as well as performing those health functions that only government can perform.
The committee believes firmly that the substantial improvements in health status that are the result of public health activities require vigorous, scientifically competent, politically astute, comprehensive, and sustained public health capacity.
It is, therefore, with great concern and some alarm that the committee has observed the current state of public health.
We have observed many symptoms of systemic problems, solutions to which will require a comprehensive strategy and a strong commitment on the part of the entire society.
We have observed disorganization, weak and unstable leadership, a lessening of professional and expert competence in leadership positions, hostility to public health concepts and approaches, outdated statutes, inadequate financial support for public health activities and public health education, gaps in the data gathering and analysis that are essential to the public health functions of assessment and surveillance, and lack of effective links between the public and private sectors for the accomplishment of public health objectives.
In our view, these problems reflect a lack of appreciation among the general public and policymakers for the crucial role that a strong public health capacity must play in maintaining and improving the health of the public.
Attention is focused on specific health problems such as AIDS, exposure to specific toxic agents, or substance abuse.
But these specific foci of interest lead to episodic actions, not to the sustained effort that is needed.
The necessary public health capacity to cope with the immediate, enduring, and impending threats to health cannot, in the committee's view, be turned on and off as particular health problems arise and receive attention.
This necessary capacity must be nurtured and supported by the society that reaps the benefits; it requires competent people, effective leadership, a scientifically sound knowledge base, the tools to monitor health problems and measure progress, a productive organizational structure, adequate financial resources, and a legal foundation that supports effective action, all motivated by a vision of the public's health that is understood and supported by that public.
By its very nature, public health requires support by members of the public — its beneficiaries.
While individual action to improve health is necessary, it is not enough, and, as the above examples illustrate, health status will fall short of the achievable if public health is not strong.
To provide a comprehensive and well-founded strategy to overcome the current disarray, the rest of this volume will examine and reaffirm the concepts of public health, develop a desirable framework for public health action, assess the current status of public health as an organized activity in the United States, and finally, recommend specific actions and directions that will provide a vigorous and effective public health enterprise sufficient to the challenges that lie ahead.
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Growing Challenges and Impending Crises, concluded ...
Revitalization of Public Health Capacities
To counter these and other threats to the health of the public will require a vital and effective public health system capable of the full range of responses necessary to make further progress against disease, disability, and premature death.
Controlling communicable disease, encouraging healthy lifestyles, reducing hazards in the environment, and targeting and assuring necessary personal health and long-term care services — all of the classic tools of public health — are necessary to maintain the benefits of past success and to respond to current and future challenges.
The successes of past public health efforts are many.
The virtual elimination of many infectious diseases, such as typhoid fever and paralytic polio; great reductions in many of the common childhood communicable diseases (Committee on Public-Private Sector Relations in Vaccine Innovation, Institute of Medicine, 1985); and initial progress in the control of common chronic diseases, such as heart disease, stroke, and some forms of cancer (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986), are ample evidence of the effectiveness of public health measures that join scientific knowledge and effective social action.
However, the success of past efforts can lead to complacency about the need for a vigorous public health enterprise at the national, state, and local levels.
To achieve public health objectives, public health will need to serve as leader and catalyst of private efforts as well as performing those health functions that only government can perform.
The committee believes firmly that the substantial improvements in health status that are the result of public health activities require vigorous, scientifically competent, politically astute, comprehensive, and sustained public health capacity.
It is, therefore, with great concern and some alarm that the committee has observed the current state of public health.
We have observed many symptoms of systemic problems, solutions to which will require a comprehensive strategy and a strong commitment on the part of the entire society.
We have observed disorganization, weak and unstable leadership, a lessening of professional and expert competence in leadership positions, hostility to public health concepts and approaches, outdated statutes, inadequate financial support for public health activities and public health education, gaps in the data gathering and analysis that are essential to the public health functions of assessment and surveillance, and lack of effective links between the public and private sectors for the accomplishment of public health objectives.
In our view, these problems reflect a lack of appreciation among the general public and policymakers for the crucial role that a strong public health capacity must play in maintaining and improving the health of the public.
Attention is focused on specific health problems such as AIDS, exposure to specific toxic agents, or substance abuse.
But these specific foci of interest lead to episodic actions, not to the sustained effort that is needed.
The necessary public health capacity to cope with the immediate, enduring, and impending threats to health cannot, in the committee's view, be turned on and off as particular health problems arise and receive attention.
This necessary capacity must be nurtured and supported by the society that reaps the benefits; it requires competent people, effective leadership, a scientifically sound knowledge base, the tools to monitor health problems and measure progress, a productive organizational structure, adequate financial resources, and a legal foundation that supports effective action, all motivated by a vision of the public's health that is understood and supported by that public.
By its very nature, public health requires support by members of the public — its beneficiaries.
While individual action to improve health is necessary, it is not enough, and, as the above examples illustrate, health status will fall short of the achievable if public health is not strong.
To provide a comprehensive and well-founded strategy to overcome the current disarray, the rest of this volume will examine and reaffirm the concepts of public health, develop a desirable framework for public health action, assess the current status of public health as an organized activity in the United States, and finally, recommend specific actions and directions that will provide a vigorous and effective public health enterprise sufficient to the challenges that lie ahead.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, concluded ...
References
Annas, George J. 1986. "Your Money or Your Life: 'Dumping' Uninsured Patients from Hospital Emergency Wards." American Journal of Public Health 76(1):74–77.
Board on Agriculture, National Academy of Sciences. 1987. Regulating Pesticides in Foods: The Delaney Paradox. National Academy Press, Washington, D.C.
Committee on a National Strategy for AIDS, Institute of Medicine, and National Academy of Sciences. 1986. Confronting AIDS: Directions for Public Health, Health Care, and Research. National Academy Press, Washington, D.C.
Committee on Public-Private Sector Relations in Vaccine Innovation, Institute of Medicine, 1985. Vaccine Supply and Innovation, National Academy Press, Washington, D.C.
Committee on Trauma Research, Commission on Life Sciences, National Research Council, and Institute of Medicine. 1985. Injury in America: A Continuing Public Health Problem. National Academy Press, Washington, D.C.
Committee to Study the Prevention of Low Birthweight, Institute of Medicine. 1985. Preventing Low Birthweight. National Academy Press, Washington, D.C.
Desonia, Randolph A., and Kathleen M. King. 1985. State Programs of Assistance for the Medically Indigent. Intergovernmental Health Policy Project, Washington, D.C.
Embers, L. R. 1985. "Clean-up Mishaps Show Need to Alter Superfund Law." Chemical and Engineering News 63(21):11–21, May 27.
Hughes, Dana, Kay Johnson, Janet Simons, and Sara Rosenbaum. 1986. Maternal and Child Health Data Book: The Health of American's Children. Children's Defense Fund, Washington, D.C.
Katzman, Robert. 1986. "Alzheimer's Disease." New England Journal of Medicine 314(15):964–973.
Lenfant, Claude, and Edward Roccella. 1984. "Trends in Hypertension Control in the United States." Chest 86:459–462, September.
National Academy of Engineering. 1986. Hazards: Technology and Fairness. National Academy Press, Washington, D.C.
Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services. 1983. Public Health Service Implementation Plans for Obtaining Objectives for the Nation. Public Health Reports, supplement to the September–October 1983 Issue.
Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986. The 1990 Objectives for the Nation: A Midcourse Review. U.S. Department of Health and Human Services, Washington, D.C.
Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences Education, National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, Cheryl D. Hayes, editor. , ed. National Academy Press, Washington, D.C.
The Robert Wood Johnson Foundation. 1985. Announcing the Health Care for the Uninsured Program. Brochure. The Robert Wood Johnson Foundation.
The Robert Wood Johnson Foundation . 1987. Access to Health Care in the United States: Results of a 1986 Survey. Special Report Number 2. The Robert Wood Johnson Foundation.
Roccella, Edward J. 1985. "Meeting the 1990 Hypertension Objectives for the Nation: A Progress Report." Public Health Reports 100(6):652–56, November–December.
Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services. 1984. Alzheimer's Disease. U.S. Government Printing Office, Washington, D.C.
Walker, B. 1985. "The Present Role of the Local Health Department in Environmental Toxicology." Journal of Environmental Health 48(3):133–137, November–December.
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
1 The Disarray of Public Health: A Threat to the Health of the Public, concluded ...
References
Annas, George J. 1986. "Your Money or Your Life: 'Dumping' Uninsured Patients from Hospital Emergency Wards." American Journal of Public Health 76(1):74–77.
Board on Agriculture, National Academy of Sciences. 1987. Regulating Pesticides in Foods: The Delaney Paradox. National Academy Press, Washington, D.C.
Committee on a National Strategy for AIDS, Institute of Medicine, and National Academy of Sciences. 1986. Confronting AIDS: Directions for Public Health, Health Care, and Research. National Academy Press, Washington, D.C.
Committee on Public-Private Sector Relations in Vaccine Innovation, Institute of Medicine, 1985. Vaccine Supply and Innovation, National Academy Press, Washington, D.C.
Committee on Trauma Research, Commission on Life Sciences, National Research Council, and Institute of Medicine. 1985. Injury in America: A Continuing Public Health Problem. National Academy Press, Washington, D.C.
Committee to Study the Prevention of Low Birthweight, Institute of Medicine. 1985. Preventing Low Birthweight. National Academy Press, Washington, D.C.
Desonia, Randolph A., and Kathleen M. King. 1985. State Programs of Assistance for the Medically Indigent. Intergovernmental Health Policy Project, Washington, D.C.
Embers, L. R. 1985. "Clean-up Mishaps Show Need to Alter Superfund Law." Chemical and Engineering News 63(21):11–21, May 27.
Hughes, Dana, Kay Johnson, Janet Simons, and Sara Rosenbaum. 1986. Maternal and Child Health Data Book: The Health of American's Children. Children's Defense Fund, Washington, D.C.
Katzman, Robert. 1986. "Alzheimer's Disease." New England Journal of Medicine 314(15):964–973.
Lenfant, Claude, and Edward Roccella. 1984. "Trends in Hypertension Control in the United States." Chest 86:459–462, September.
National Academy of Engineering. 1986. Hazards: Technology and Fairness. National Academy Press, Washington, D.C.
Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, U.S. Department of Health and Human Services. 1983. Public Health Service Implementation Plans for Obtaining Objectives for the Nation. Public Health Reports, supplement to the September–October 1983 Issue.
Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986. The 1990 Objectives for the Nation: A Midcourse Review. U.S. Department of Health and Human Services, Washington, D.C.
Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences Education, National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, Cheryl D. Hayes, editor. , ed. National Academy Press, Washington, D.C.
The Robert Wood Johnson Foundation. 1985. Announcing the Health Care for the Uninsured Program. Brochure. The Robert Wood Johnson Foundation.
The Robert Wood Johnson Foundation . 1987. Access to Health Care in the United States: Results of a 1986 Survey. Special Report Number 2. The Robert Wood Johnson Foundation.
Roccella, Edward J. 1985. "Meeting the 1990 Hypertension Objectives for the Nation: A Progress Report." Public Health Reports 100(6):652–56, November–December.
Secretary's Task Force on Alzheimer's Disease, U.S. Department of Health and Human Services. 1984. Alzheimer's Disease. U.S. Government Printing Office, Washington, D.C.
Walker, B. 1985. "The Present Role of the Local Health Department in Environmental Toxicology." Journal of Environmental Health 48(3):133–137, November–December.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal
The discussion in Chapter 1 implicitly asked, "Why be concerned about public health?" and gave two broad answers.
The first answer focused on present threats to the health of the public.
Urgent new problems like AIDS and toxic wastes have been added to the public health agenda.
At the same time, a changing U.S. health system has brought more sharply into focus the unsolved dilemma of how to care for some 30 million uninsured and underinsured Americans, and has called into question old understandings about the respective roles of the private and public sectors.
These new concerns have heightened competition for scarce financial resources and public attention and support.
Americans assume that government is equipped to fulfill its obligation to protect the public from such threats.
But the nation's public health capacity has become seriously weakened, and public support — always fragile because of limited awareness — is increasingly being eroded by controversy.
The second answer pointed to past achievements as the basis for believing that public health still retains fundamental problem-solving capacity.
Historically, public health has made a difference in the quality of life for all Americans.
Governmental actions to assure the health of the people — such as water quality control, immunizations, and food inspection — have prevented much illness and many deaths.
These traditional and ongoing accomplishments have demonstrated the value of public health efforts, and exemplify the kind of success that is possible as a result of organized effort on the basis of technical knowledge.
If they demonstrate the best of which public health has been capable, they also underscore the urgency of rescuing this vital public capacity from its current decline.
Chapters 3 and 4 give a more detailed picture of the current status of U.S. public health.
They spell out its history, organization, current activities, and problems.
But first, the observation that something is wrong with public health implies some sense of what would be right: a vision against which to assess current realities and guide decisions about what changes should be made.
"Vision" as used here is not meant to suggest a form of impractical utopianism that results in a set of impossible dreams.
Instead, the aim is to fashion in the mind's eye — as the prerequisite to doing so in reality — an attainable ideal.
This chapter sets forth the committee's vision of public health.
It presents the value framework in which it has reflected about the present dilemma of public health and formed its recommendations.
The vision appears early in the report to encourage readers to weigh this ideal while they reflect on public health as described in the report and as they view it in their own communities.
The committee hopes readers will ask themselves not only whether or not they share the values or agree with the conclusions in this report, but also how closely the current reality of public health approximates their own ideal model and what they can do to move practice in directions they consider sound.
The committee's vision of public health includes the following conceptual elements:
A definition of "public health" that the committee believes is consistent with key American values.
This definition sets forth the committee's view of what the term "public health" should mean and what values are implied by that understanding.
The definition has three parts:
1. The mission of public health: a statement of ultimate goals or purposes.
This section addresses the question: What are the common goals of public health?
2. The substance of public health: a statement about subject matter.
This section addresses the question: What areas of concern does public health deal with?
3. The organizational framework of public health: a statement that distinguishes the concerns included in the term "public health" from the ways in which society organizes to deal with them.
This section addresses the question: How is "public health" different from "what public health agencies do?"
The governmental functions of public health.
Federal, state, and local agencies as institutions of government have unique authority, obligations, and duties.
This section discusses public health as a government responsibility.
It considers:
1. the duties that are essential to government's responsibility for public health;
2. the expression of these duties at the federal, state, and local levels; and
3.the relationship between government and the private sector.
The basic services of public health.
This section discusses the activities, tasks, programs, and benefits that are required to address the mission of public health.
In contrast to functions that are specific to the role of the public agency, responsibility for the provision of basic services is shared by public and private sectors.
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal
The discussion in Chapter 1 implicitly asked, "Why be concerned about public health?" and gave two broad answers.
The first answer focused on present threats to the health of the public.
Urgent new problems like AIDS and toxic wastes have been added to the public health agenda.
At the same time, a changing U.S. health system has brought more sharply into focus the unsolved dilemma of how to care for some 30 million uninsured and underinsured Americans, and has called into question old understandings about the respective roles of the private and public sectors.
These new concerns have heightened competition for scarce financial resources and public attention and support.
Americans assume that government is equipped to fulfill its obligation to protect the public from such threats.
But the nation's public health capacity has become seriously weakened, and public support — always fragile because of limited awareness — is increasingly being eroded by controversy.
The second answer pointed to past achievements as the basis for believing that public health still retains fundamental problem-solving capacity.
Historically, public health has made a difference in the quality of life for all Americans.
Governmental actions to assure the health of the people — such as water quality control, immunizations, and food inspection — have prevented much illness and many deaths.
These traditional and ongoing accomplishments have demonstrated the value of public health efforts, and exemplify the kind of success that is possible as a result of organized effort on the basis of technical knowledge.
If they demonstrate the best of which public health has been capable, they also underscore the urgency of rescuing this vital public capacity from its current decline.
Chapters 3 and 4 give a more detailed picture of the current status of U.S. public health.
They spell out its history, organization, current activities, and problems.
But first, the observation that something is wrong with public health implies some sense of what would be right: a vision against which to assess current realities and guide decisions about what changes should be made.
"Vision" as used here is not meant to suggest a form of impractical utopianism that results in a set of impossible dreams.
Instead, the aim is to fashion in the mind's eye — as the prerequisite to doing so in reality — an attainable ideal.
This chapter sets forth the committee's vision of public health.
It presents the value framework in which it has reflected about the present dilemma of public health and formed its recommendations.
The vision appears early in the report to encourage readers to weigh this ideal while they reflect on public health as described in the report and as they view it in their own communities.
The committee hopes readers will ask themselves not only whether or not they share the values or agree with the conclusions in this report, but also how closely the current reality of public health approximates their own ideal model and what they can do to move practice in directions they consider sound.
The committee's vision of public health includes the following conceptual elements:
A definition of "public health" that the committee believes is consistent with key American values.
This definition sets forth the committee's view of what the term "public health" should mean and what values are implied by that understanding.
The definition has three parts:
1. The mission of public health: a statement of ultimate goals or purposes.
This section addresses the question: What are the common goals of public health?
2. The substance of public health: a statement about subject matter.
This section addresses the question: What areas of concern does public health deal with?
3. The organizational framework of public health: a statement that distinguishes the concerns included in the term "public health" from the ways in which society organizes to deal with them.
This section addresses the question: How is "public health" different from "what public health agencies do?"
The governmental functions of public health.
Federal, state, and local agencies as institutions of government have unique authority, obligations, and duties.
This section discusses public health as a government responsibility.
It considers:
1. the duties that are essential to government's responsibility for public health;
2. the expression of these duties at the federal, state, and local levels; and
3.the relationship between government and the private sector.
The basic services of public health.
This section discusses the activities, tasks, programs, and benefits that are required to address the mission of public health.
In contrast to functions that are specific to the role of the public agency, responsibility for the provision of basic services is shared by public and private sectors.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal, continued ...
A Definition of Public Health
"When I think of public health, I think of early intervention, prevention."
"Public health is immunization, school health, control of contagious disease."
"It's anything that affects the health of the community on a mass basis."
"Public health is the area of health outside the capability of the individual private practitioner."
"The core of public health is the capacity to identify problems, and having found them, measure them and attempt to intervene."*
The quotations above, gathered during the course of this study, illustrate that the effort to define public health is complex.
When asked, people tend to mix observations about what actual health departments do with assertions about what society as a whole ought to do.
Some emphasize a community focus, in contrast to individual patient care.
Others concentrate on ideas of government response to market failure.
Still others list the contents of practice, such as control of environmental hazards or care of the poor, or refer to professional skills, such as epidemiology or sanitary engineering.
As we will see in Chapter 3 and 4, this variety of definitions is exceeded — and perhaps also explained — by the complexity of the system in which, somewhere, "public health" is found.
The United States is notable among the countries of the world for complicated policy relationships among national, state, and local levels of government and for its interweaving of private and public sector activity.
Health affairs share in this complexity.
Given this intricate arrangement, the committee hopes that a clear definition will help those who work in, are served by, or study the system to sort out its elements, understand it, and work to make it perform more effectively.
From the beginning of its work, the committee believed that it was important not to limit understanding of "public health" to what health departments do.
Instead, it aimed to place government activities within a broader framework that can guide a wide range of institutional participants.
The intent is not to deemphasize the role of the public agency.
On the contrary, it is to point out the indispensability of its prerogatives and functions by calling attention to the context in which they are exercised.
This distinction between "public health" and "what health departments do" is reinforced by dividing the definition into three parts.
By separating the organizational expression of public health from understandings of its mission and subject matter, the committee intends to emphasize that the goals and concerns of public health can and should be addressed not only by health departments, but also by private organizations and practitioners, other public agencies, and the community at large.
The governing role of the official public health agency in assuring that the overall system works is, however, indispensable.
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal, continued ...
A Definition of Public Health
"When I think of public health, I think of early intervention, prevention."
"Public health is immunization, school health, control of contagious disease."
"It's anything that affects the health of the community on a mass basis."
"Public health is the area of health outside the capability of the individual private practitioner."
"The core of public health is the capacity to identify problems, and having found them, measure them and attempt to intervene."*
The quotations above, gathered during the course of this study, illustrate that the effort to define public health is complex.
When asked, people tend to mix observations about what actual health departments do with assertions about what society as a whole ought to do.
Some emphasize a community focus, in contrast to individual patient care.
Others concentrate on ideas of government response to market failure.
Still others list the contents of practice, such as control of environmental hazards or care of the poor, or refer to professional skills, such as epidemiology or sanitary engineering.
As we will see in Chapter 3 and 4, this variety of definitions is exceeded — and perhaps also explained — by the complexity of the system in which, somewhere, "public health" is found.
The United States is notable among the countries of the world for complicated policy relationships among national, state, and local levels of government and for its interweaving of private and public sector activity.
Health affairs share in this complexity.
Given this intricate arrangement, the committee hopes that a clear definition will help those who work in, are served by, or study the system to sort out its elements, understand it, and work to make it perform more effectively.
From the beginning of its work, the committee believed that it was important not to limit understanding of "public health" to what health departments do.
Instead, it aimed to place government activities within a broader framework that can guide a wide range of institutional participants.
The intent is not to deemphasize the role of the public agency.
On the contrary, it is to point out the indispensability of its prerogatives and functions by calling attention to the context in which they are exercised.
This distinction between "public health" and "what health departments do" is reinforced by dividing the definition into three parts.
By separating the organizational expression of public health from understandings of its mission and subject matter, the committee intends to emphasize that the goals and concerns of public health can and should be addressed not only by health departments, but also by private organizations and practitioners, other public agencies, and the community at large.
The governing role of the official public health agency in assuring that the overall system works is, however, indispensable.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal, continued ...
The Mission of Public Health
In eighteenth- and early nineteenth-century America, public health measures were taken in response to particular epidemic crises.
Thus the earliest definition of public health's mission was practical rather than formal: control of epidemic disease.
The first explicit statement came with the justly famous Shattuck Report of 1850, which declared "the conditions of perfect health, either public or personal" to be the goal of public health. (Rosenkrantz, 1972)
One of the earliest deliberate efforts to define public health's mission is still one of the most frequently cited.
According to C. E. A. Winslow (as quoted in Hanlon and Pickett, 1984):
Public health is the science and the art of (1) preventing disease, (2) prolonging life, and (3) organized community efforts for (a) the sanitation of the environment, (b) the control of communicable infections, (c) the education of the individual in personal hygiene, (d) the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and (e) the development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity.
More recently, Ellencweig and Yoshpe have conceived the goal of public health to be protection of the community against the hazards engendered by group life. (Ellencweig and Yoshpe, 1984)
Beauchamp sees the mission of public health as social justice and the protection of all human life. (Beauchamp, 1976)
The common themes that run through these interpretations are reflected in the words ''public" and "health."
What unites people around public health is the focus on society as a whole, the community, and the aim of optimal health status.
Clearly, public health is "public" because it involves "organized community effort."
It is not simply the outcome of isolated individual efforts.
Its mission is to ensure that organized approaches are mobilized when they are needed.
For example, both smallpox vaccination of countless individuals and treatment of unvaccinated patients would not have rid us of smallpox without strategies aimed specifically at the communitywide (in this case, the worldwide) level, such as epidemiologic studies, consistent reporting of cases, and organized distribution of vaccine.
In a similar way, neither treatment of lung disease nor exhorting individuals to avoid smoking could have achieved the reduction of smoking in public places made possible by organized community effort to adopt laws and regulations restricting smoking.
Seat belt legislation is still another instance in which a communitywide approach has augmented individual effort.
Public health is also public in terms of its long-range goal, which is optimal health for the entire community.
This goal encompasses both the sum of the health status of individual community members and communitywide benefits such as clean air and water.
The "health" aspect of the public health mission is perhaps best understood by reference to the well-known World Health Organization (WHO) definition.
WHO has defined health as "a state of complete well-being, physical, social, and mental, and not merely the absence of disease or infirmity." (World Health Organization, as quoted by Hanlon and Pickett, 1984)
Our shared sense of what "complete well-being" might be, though none of us has ever experienced it, serves as a focus for commitment to extend community efforts beyond the narrow concerns of special interests and the boundaries of any one professional discipline.
The committee's own definition takes into consideration all of the dimensions outlined above.
The committee defines the mission of public health as: the fulfillment of society's interest in assuring the conditions in which people can be healthy.
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal, continued ...
The Mission of Public Health
In eighteenth- and early nineteenth-century America, public health measures were taken in response to particular epidemic crises.
Thus the earliest definition of public health's mission was practical rather than formal: control of epidemic disease.
The first explicit statement came with the justly famous Shattuck Report of 1850, which declared "the conditions of perfect health, either public or personal" to be the goal of public health. (Rosenkrantz, 1972)
One of the earliest deliberate efforts to define public health's mission is still one of the most frequently cited.
According to C. E. A. Winslow (as quoted in Hanlon and Pickett, 1984):
Public health is the science and the art of (1) preventing disease, (2) prolonging life, and (3) organized community efforts for (a) the sanitation of the environment, (b) the control of communicable infections, (c) the education of the individual in personal hygiene, (d) the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and (e) the development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity.
More recently, Ellencweig and Yoshpe have conceived the goal of public health to be protection of the community against the hazards engendered by group life. (Ellencweig and Yoshpe, 1984)
Beauchamp sees the mission of public health as social justice and the protection of all human life. (Beauchamp, 1976)
The common themes that run through these interpretations are reflected in the words ''public" and "health."
What unites people around public health is the focus on society as a whole, the community, and the aim of optimal health status.
Clearly, public health is "public" because it involves "organized community effort."
It is not simply the outcome of isolated individual efforts.
Its mission is to ensure that organized approaches are mobilized when they are needed.
For example, both smallpox vaccination of countless individuals and treatment of unvaccinated patients would not have rid us of smallpox without strategies aimed specifically at the communitywide (in this case, the worldwide) level, such as epidemiologic studies, consistent reporting of cases, and organized distribution of vaccine.
In a similar way, neither treatment of lung disease nor exhorting individuals to avoid smoking could have achieved the reduction of smoking in public places made possible by organized community effort to adopt laws and regulations restricting smoking.
Seat belt legislation is still another instance in which a communitywide approach has augmented individual effort.
Public health is also public in terms of its long-range goal, which is optimal health for the entire community.
This goal encompasses both the sum of the health status of individual community members and communitywide benefits such as clean air and water.
The "health" aspect of the public health mission is perhaps best understood by reference to the well-known World Health Organization (WHO) definition.
WHO has defined health as "a state of complete well-being, physical, social, and mental, and not merely the absence of disease or infirmity." (World Health Organization, as quoted by Hanlon and Pickett, 1984)
Our shared sense of what "complete well-being" might be, though none of us has ever experienced it, serves as a focus for commitment to extend community efforts beyond the narrow concerns of special interests and the boundaries of any one professional discipline.
The committee's own definition takes into consideration all of the dimensions outlined above.
The committee defines the mission of public health as: the fulfillment of society's interest in assuring the conditions in which people can be healthy.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal, continued ...
The Substance of Public Health
Within this mission fall a number of characteristic themes, which over the course of a long historical tradition have coalesced around the goal of the people's health.
Early public health focused on sanitary measures and the control of communicable disease.
With the discovery of bacteria and immunologic advances, disease prevention was added to the subject matter of public health. (Hanlon and Pickett, 1984)
In recent decades, health promotion has become an increasingly important theme, as the interrelationship among the physical, mental, and social dimensions of well-being has been clarified.
Over time, the substance of public health has expanded.
A 1985 editorial in the Journal of Public Health Policy pointed out that a commitment to multidimensional well-being implies the need to address factors that fall outside the normal understanding of "health," including decent housing, public education, adequate income, freedom from war, and so on. (Terris, 1986)
While encouraging a holistic approach, this tendency to widen the boundaries of public health has the effect of forcing practitioners to make difficult choices about where to focus their energies and raises the possibility that public health could be so broadly defined so as to lose distinctive meaning.
Even restricting public health's subject matter to disease prevention and control, health promotion, and environmental measures necessitates the involvement of a broad spectrum of professional disciplines.
In fact, it is frequently pointed out that public health is a coalition of professions united by their shared mission (described in the section above); their focus on disease prevention and health promotion; their prospective approach in contrast to the reactive focus of therapeutic medicine (Draper et al., as quoted in Hanlon and Pickett, 1984); and their common science, epidemiology:
Each [profession] brings to the public health task the distinctive skills of a primary professional discipline; but, in addition, each shares a distinctive and unique body of knowledge …
The mother science of public health is epidemiology, i.e., the systematic, objective study of the natural history of disease within populations and the factors that determine its spread. (as quoted by Terris, 1985)
Epidemiology is the "glue" that holds public health's many professions together.
It is by means of the application of scientific and technical knowledge, above all else, that public health practitioners strive to improve the lot of humankind, to understand the causes of disease, to identify populations at risk, and to develop new approaches to prevention. (Robbins, 1985)
Thus the committee defines the substance of public health as: organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of epidemiology.
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal, continued ...
The Substance of Public Health
Within this mission fall a number of characteristic themes, which over the course of a long historical tradition have coalesced around the goal of the people's health.
Early public health focused on sanitary measures and the control of communicable disease.
With the discovery of bacteria and immunologic advances, disease prevention was added to the subject matter of public health. (Hanlon and Pickett, 1984)
In recent decades, health promotion has become an increasingly important theme, as the interrelationship among the physical, mental, and social dimensions of well-being has been clarified.
Over time, the substance of public health has expanded.
A 1985 editorial in the Journal of Public Health Policy pointed out that a commitment to multidimensional well-being implies the need to address factors that fall outside the normal understanding of "health," including decent housing, public education, adequate income, freedom from war, and so on. (Terris, 1986)
While encouraging a holistic approach, this tendency to widen the boundaries of public health has the effect of forcing practitioners to make difficult choices about where to focus their energies and raises the possibility that public health could be so broadly defined so as to lose distinctive meaning.
Even restricting public health's subject matter to disease prevention and control, health promotion, and environmental measures necessitates the involvement of a broad spectrum of professional disciplines.
In fact, it is frequently pointed out that public health is a coalition of professions united by their shared mission (described in the section above); their focus on disease prevention and health promotion; their prospective approach in contrast to the reactive focus of therapeutic medicine (Draper et al., as quoted in Hanlon and Pickett, 1984); and their common science, epidemiology:
Each [profession] brings to the public health task the distinctive skills of a primary professional discipline; but, in addition, each shares a distinctive and unique body of knowledge …
The mother science of public health is epidemiology, i.e., the systematic, objective study of the natural history of disease within populations and the factors that determine its spread. (as quoted by Terris, 1985)
Epidemiology is the "glue" that holds public health's many professions together.
It is by means of the application of scientific and technical knowledge, above all else, that public health practitioners strive to improve the lot of humankind, to understand the causes of disease, to identify populations at risk, and to develop new approaches to prevention. (Robbins, 1985)
Thus the committee defines the substance of public health as: organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of epidemiology.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal, continued ...
The Organizational Framework of Public Health
Specific attention to the organizational framework for public health activities is important because many Americans support the goals of public health but are highly critical of a particular health department.
During the course of the study, when committee members and staff told people that its subject was "the future of public health," the most common first question they received was, "Do you mean what health departments do, or are you talking about public health in general?"
For many people the normal range of health department activities, whatever the level of government under study, does not adequately define "public health."
Clearly, the committee sees public health as more than what health departments do and perceives important roles for the private sector and for public-private partnerships in the future of public health, as subsequent discussion will amplify.
But the tone of some site visit conversations (see Chapters 3 and 4) suggests another consideration.
Numerous comments implied not only that the content of public health's future might vary depending on whether the reference point is health departments or a broader set of entities, but its likely quality — the prognosis — might also be different.
In other words, as site visits have illustrated, while the mission and substance of public health appear to have wide support around the country, the health department frequently does not.
There appears to be a gap between popular support for public health concerns and public confidence in the value and effectiveness of current health department activities.
People tend to be positive about public health values, but negative about the present public health agency.
No doubt some of this censure is due to the shadow that has been cast over public opinion about all public sector activity during the last decade.
The last two presidents of the United States have been elected on "less-government" platforms embellished with overtly antigovernment rhetoric.
Scorn for the capabilities and dedication of the public servant has become commonplace.
It is little wonder that in such a climate skepticism should be voiced about the effectiveness of health departments.
Although some of the criticism aimed at health departments may be deserved, the committee believes that the future of public health depends on redefining and restoring the role of health agencies at all levels of government to a position of respect.
Clearly, re-valuing the public sector responsibility for health will require strategies to respond to sound criticisms and improve the effectiveness of health departments.
But it also requires a change in the American dialogue about the necessity and worth of public sector activity — of governance.
In summary, the committee defines the organizational framework of public health to encompass both activities undertaken within the formal structure of government and the associated efforts of private and voluntary organizations and individuals.
TO BE CONTINUED ...
The Future of Public Health, continued ...
Institute of Medicine (US) Committee for the Study of the Future of Public Health.
Washington (DC): National Academies Press (US); 1988.
2A Vision of Public Health in America: An Attainable Ideal, continued ...
The Organizational Framework of Public Health
Specific attention to the organizational framework for public health activities is important because many Americans support the goals of public health but are highly critical of a particular health department.
During the course of the study, when committee members and staff told people that its subject was "the future of public health," the most common first question they received was, "Do you mean what health departments do, or are you talking about public health in general?"
For many people the normal range of health department activities, whatever the level of government under study, does not adequately define "public health."
Clearly, the committee sees public health as more than what health departments do and perceives important roles for the private sector and for public-private partnerships in the future of public health, as subsequent discussion will amplify.
But the tone of some site visit conversations (see Chapters 3 and 4) suggests another consideration.
Numerous comments implied not only that the content of public health's future might vary depending on whether the reference point is health departments or a broader set of entities, but its likely quality — the prognosis — might also be different.
In other words, as site visits have illustrated, while the mission and substance of public health appear to have wide support around the country, the health department frequently does not.
There appears to be a gap between popular support for public health concerns and public confidence in the value and effectiveness of current health department activities.
People tend to be positive about public health values, but negative about the present public health agency.
No doubt some of this censure is due to the shadow that has been cast over public opinion about all public sector activity during the last decade.
The last two presidents of the United States have been elected on "less-government" platforms embellished with overtly antigovernment rhetoric.
Scorn for the capabilities and dedication of the public servant has become commonplace.
It is little wonder that in such a climate skepticism should be voiced about the effectiveness of health departments.
Although some of the criticism aimed at health departments may be deserved, the committee believes that the future of public health depends on redefining and restoring the role of health agencies at all levels of government to a position of respect.
Clearly, re-valuing the public sector responsibility for health will require strategies to respond to sound criticisms and improve the effectiveness of health departments.
But it also requires a change in the American dialogue about the necessity and worth of public sector activity — of governance.
In summary, the committee defines the organizational framework of public health to encompass both activities undertaken within the formal structure of government and the associated efforts of private and voluntary organizations and individuals.
TO BE CONTINUED ...