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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, continued ...
How the Public Health System Works — Aids as an Example
What are the problems public agencies are having in fulfilling their unique functions — of assessment, policy development, and assurance?
Is the statutory base adequate to cope with a new and compelling issue?
The intent of this section is to illustrate some of the problems by focusing on one, acquired immune deficiency syndrome (AIDS), and tracing through the system, largely by means of quotations obtained in our site visits.
Statutory Base
According to Gostin (Gostin, 1986), the statutory base of public health is poorly suited to dealing with AIDS.
The powers provided in statute are too restrictive, including outdated concepts of full isolation and quarantine that are inappropriate given the mode of transmission of AIDS.
Also there are no clear criteria to guide officials in exercising their powers.
Due process procedures are sketchy or absent.
This leaves too much room for unfettered administrative discretion about how to apply the law.
A modern public health law should remove the rigid distinctions between venereal and communicable disease and should enact strong, uniform confidentiality procedures.
Otherwise, public health is left with a stick too big to wield.
Site visit comments bear out this view.
For example:
"This state has strange confidentiality laws that make it difficult to target appropriate information to appropriate recipients."
"In the legislature there is inordinate emphasis on the physician's lack of information."
"They're not confronting the position the doctor faces in informing people and their contacts about the disease — for instance, the wife of an AIDS patient."
"They tried to make knowing donation of infected blood a crime, but it didn't go anywhere."
"Our law has made AIDS a reportable disease."
"We have little in the way of confidentiality."
"The new law makes knowing transmission of AIDS second-degree murder."
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, continued ...
How the Public Health System Works — Aids as an Example, continued ...
Assessment
Exercise of the assessment function is closely linked to the enabling structure put in place by statute.
Public health officials feel keenly the need to monitor the disease and mount effective programs to limit its spread.
Pursuing these functions raises many political sensitivities.
In addition, the speed with which the problem developed has public health struggling to keep up with changing dimensions and new technologies.
This makes long-range or even rather short-range planning a luxury agencies can't afford.
Some health agencies are accused of overemphasizing surveillance at the expense of preventive efforts such as education.
"The state has taken a commanding lead."
"They are secretive about sharing stats."
"I don't want names, but they'll only give out information on a countrywide basis."
"The hospitals are also tight lipped."
"The vital statistics give us the deaths."
"We're skeptical about the individuals themselves revealing the information."
"We need to track sero-positive individuals and maintain confidentiality."
"The gay rights groups are concerned about list collecting; they are resisting public health moves to get people in for counseling."
"On the other hand, there are scientific concerns about anonymous testing."
"These are new issues for disease control."
"The Department of Health Services has been so busy getting the new initiative implemented we can't really plan adequately."
"No one has yet been able to take a broader system view of the AIDS problem."
"No one is thinking about how to fit the pieces together."
"The research program at the university was good, but the main need now is for technology transfer."
"The results are not getting into the hands of community physicians fast enough."
"The department is trying to use the STD (sexually transmitted disease) model, emphasizing surveillance and epidemiology."
"I would argue that prevention should take precedence."
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, continued ...
How the Public Health System Works — Aids as an Example, continued ...
Assessment
Exercise of the assessment function is closely linked to the enabling structure put in place by statute.
Public health officials feel keenly the need to monitor the disease and mount effective programs to limit its spread.
Pursuing these functions raises many political sensitivities.
In addition, the speed with which the problem developed has public health struggling to keep up with changing dimensions and new technologies.
This makes long-range or even rather short-range planning a luxury agencies can't afford.
Some health agencies are accused of overemphasizing surveillance at the expense of preventive efforts such as education.
"The state has taken a commanding lead."
"They are secretive about sharing stats."
"I don't want names, but they'll only give out information on a countrywide basis."
"The hospitals are also tight lipped."
"The vital statistics give us the deaths."
"We're skeptical about the individuals themselves revealing the information."
"We need to track sero-positive individuals and maintain confidentiality."
"The gay rights groups are concerned about list collecting; they are resisting public health moves to get people in for counseling."
"On the other hand, there are scientific concerns about anonymous testing."
"These are new issues for disease control."
"The Department of Health Services has been so busy getting the new initiative implemented we can't really plan adequately."
"No one has yet been able to take a broader system view of the AIDS problem."
"No one is thinking about how to fit the pieces together."
"The research program at the university was good, but the main need now is for technology transfer."
"The results are not getting into the hands of community physicians fast enough."
"The department is trying to use the STD (sexually transmitted disease) model, emphasizing surveillance and epidemiology."
"I would argue that prevention should take precedence."
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, continued ...
How the Public Health System Works — Aids as an Example, continued ...
Policy Development
AIDS is extraordinarily controversial, and the political heat has been intense.
Pressure to do something fast, but not to infringe on the rights of high-risk groups, has health agencies struggling to balance basic knowledge development with the obligation to respond to immediate situations.
Among the many groups and individuals, public and private, engaged in fighting AIDS, health agencies have not taken a clear initiative in supplying leadership, and the public is unclear about what level of government it should look to for guidance or what it can appropriately and realistically expect any particular health agency to do.
Lack of public understanding about the real nature of the risk makes matters worse; on the other hand, as one person said: "If they knew they had practically no chance of getting it, then they really wouldn't give a damn."
"It was publicity that finally raised the consciousness of the eighth floor [health department leaders]."
"The legislature has been the leader."
"It convened the hearing and put funding in place."
"Such leadership should have come from the Department of Health Services, but it hasn't."
"The department has held no hearings."
"The state health director knows less than I do about what's happening in the state." (Legislative staff)
"The president and the governor should have taken the lead, but they seem not to want to discuss it."
"At the federal level, only CDC and NCI have been effective." (Activist)
"AIDS dictates the entire public health program in the state to an inappropriate degree."
"I spend one-third of my time on it."
"Don't ask me what we're doing about diabetes or high blood pressure."
"I simply don't know."
"There's not enough attention being paid."
"What gets done depends on the public mood."
"Much better education of the general public is needed so they will accept future expenditures."
"In the end, the lack of responsible public health organization for the nation will prove our greatest handicap."
"Governments, too, can suffer a wasting disease; the gradual erosion of the coordinated leadership of the Public Health Service has created a void."
"Surveillance of the nation's health is no longer the clear responsibility of any agency of government, nor is the surveillance of proposals for meeting crises."
"Isolated islands of excellence [CDC, NIH] do not alone constitute a national strategy to defend and promote the national health." (Keller and Kingsley, The Milbank Quarterly, 1986)
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, continued ...
How the Public Health System Works — Aids as an Example, continued ...
Policy Development
AIDS is extraordinarily controversial, and the political heat has been intense.
Pressure to do something fast, but not to infringe on the rights of high-risk groups, has health agencies struggling to balance basic knowledge development with the obligation to respond to immediate situations.
Among the many groups and individuals, public and private, engaged in fighting AIDS, health agencies have not taken a clear initiative in supplying leadership, and the public is unclear about what level of government it should look to for guidance or what it can appropriately and realistically expect any particular health agency to do.
Lack of public understanding about the real nature of the risk makes matters worse; on the other hand, as one person said: "If they knew they had practically no chance of getting it, then they really wouldn't give a damn."
"It was publicity that finally raised the consciousness of the eighth floor [health department leaders]."
"The legislature has been the leader."
"It convened the hearing and put funding in place."
"Such leadership should have come from the Department of Health Services, but it hasn't."
"The department has held no hearings."
"The state health director knows less than I do about what's happening in the state." (Legislative staff)
"The president and the governor should have taken the lead, but they seem not to want to discuss it."
"At the federal level, only CDC and NCI have been effective." (Activist)
"AIDS dictates the entire public health program in the state to an inappropriate degree."
"I spend one-third of my time on it."
"Don't ask me what we're doing about diabetes or high blood pressure."
"I simply don't know."
"There's not enough attention being paid."
"What gets done depends on the public mood."
"Much better education of the general public is needed so they will accept future expenditures."
"In the end, the lack of responsible public health organization for the nation will prove our greatest handicap."
"Governments, too, can suffer a wasting disease; the gradual erosion of the coordinated leadership of the Public Health Service has created a void."
"Surveillance of the nation's health is no longer the clear responsibility of any agency of government, nor is the surveillance of proposals for meeting crises."
"Isolated islands of excellence [CDC, NIH] do not alone constitute a national strategy to defend and promote the national health." (Keller and Kingsley, The Milbank Quarterly, 1986)
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, continued ...
How the Public Health System Works — Aids as an Example, continued ...
Assurance
Public health officials at the state and local level are very much aware of their responsibility to make sure that AIDS is combated effectively.
But they are hamstrung by the speed with which the problem has developed and the political heat it has generated, as well as by the difficulty of marshalling enough resources to do what they feel is needed.
At present, they lack the technology either to cure AIDS or to control its spread through the definitive and simple means of a vaccine.
The fiscal implications of caring for AIDS patients are poorly understood because estimates of the potential number of cases are in dispute.
In some places where there are large numbers of AIDS patients, the private sector — especially voluntary groups such as gay rights organizations — have taken the lead in providing treatment and counseling, with the health department struggling to keep track of what is being done.
The nature of the problem makes the regulatory apparatus difficult to mobilize.
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, continued ...
How the Public Health System Works — Aids as an Example, continued ...
Assurance
Public health officials at the state and local level are very much aware of their responsibility to make sure that AIDS is combated effectively.
But they are hamstrung by the speed with which the problem has developed and the political heat it has generated, as well as by the difficulty of marshalling enough resources to do what they feel is needed.
At present, they lack the technology either to cure AIDS or to control its spread through the definitive and simple means of a vaccine.
The fiscal implications of caring for AIDS patients are poorly understood because estimates of the potential number of cases are in dispute.
In some places where there are large numbers of AIDS patients, the private sector — especially voluntary groups such as gay rights organizations — have taken the lead in providing treatment and counseling, with the health department struggling to keep track of what is being done.
The nature of the problem makes the regulatory apparatus difficult to mobilize.
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, concluded ...
How the Public Health System Works — Aids as an Example, concluded ...
The State of Public Health
This discussion of how the public health system is coping with the AIDS epidemic illustrates many of the problems encountered by these agencies when confronted by such a major new challenge.
Other examples would have revealed different sets of problems, such as how to sustain a continuing effort to maintain high rates of childhood immunizations where prior success breeds complacency, liability concerns raise the price and threaten the availability of vaccines, and limited resources are diverted to new challenges.
Both types of examples, the new crisis and the continuing effort, support a central theme of this report — the essentiality and proved effectiveness of public health measures for improving and protecting the health of the public and the imposing array of problems that undermine the public health capacity to respond.
AIDS illustrates both — a strain on the public health system and remarkable accomplishments by the public health community in a short time.
Response to a highly publicized crisis like AIDS cannot serve as the model for a sustained and effective public health effort addressed to the many health problems that, in the aggregate, dwarf the health impact of AIDS.
For example, the great increase in lung cancer took place more slowly and therefore lacked the dramatic impact of AIDS on the public consciousness, but it is a larger problem in terms of death and disability, and sustained public health effort can affect the magnitude of the disease burden.
The same is true for such major sources of health deficits as injuries, substance abuse, and environmental pollutants.
That public health accomplishes so much is a tribute to the effectiveness of its techniques and the dedication of its workforce.
Yet the problems and disarray that we have documented through our inquiries are a source of strong concern to the committee.
The next chapter contains our recommendations to help overcome these problems, strengthen the public health capability, correct the disarray, and refocus public health on its important mission.
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, continued ...
Impediments to the Essential Work of Public Health, concluded ...
How the Public Health System Works — Aids as an Example, concluded ...
The State of Public Health
This discussion of how the public health system is coping with the AIDS epidemic illustrates many of the problems encountered by these agencies when confronted by such a major new challenge.
Other examples would have revealed different sets of problems, such as how to sustain a continuing effort to maintain high rates of childhood immunizations where prior success breeds complacency, liability concerns raise the price and threaten the availability of vaccines, and limited resources are diverted to new challenges.
Both types of examples, the new crisis and the continuing effort, support a central theme of this report — the essentiality and proved effectiveness of public health measures for improving and protecting the health of the public and the imposing array of problems that undermine the public health capacity to respond.
AIDS illustrates both — a strain on the public health system and remarkable accomplishments by the public health community in a short time.
Response to a highly publicized crisis like AIDS cannot serve as the model for a sustained and effective public health effort addressed to the many health problems that, in the aggregate, dwarf the health impact of AIDS.
For example, the great increase in lung cancer took place more slowly and therefore lacked the dramatic impact of AIDS on the public consciousness, but it is a larger problem in terms of death and disability, and sustained public health effort can affect the magnitude of the disease burden.
The same is true for such major sources of health deficits as injuries, substance abuse, and environmental pollutants.
That public health accomplishes so much is a tribute to the effectiveness of its techniques and the dedication of its workforce.
Yet the problems and disarray that we have documented through our inquiries are a source of strong concern to the committee.
The next chapter contains our recommendations to help overcome these problems, strengthen the public health capability, correct the disarray, and refocus public health on its important mission.
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, concluded ...
References
American Public Health Association, Association of State and Territorial Health Officials, National Association of County Health Officers, U.S. Conference of Local Health Officials, Department of Health and Human Services, Public Health Service. 1985. Model Standards: A Guide for Community Preventive Health Services. American Public Health Association, Washington, D.C.
Berkman, Lisa F., and Lester Breslow. 1983. Health and Ways of Living: The Alameda County Study. Oxford University Press: New York.
Committee on the Institutional Means for Assessment of Risks to Public Health, Commission on Life Sciences, National Research Council. 1983. Risk Assessment in the Federal Government: Managing the Process. National Academy Press, Washington, D.C.
Committee on a National Strategy for AIDS, Institute of Medicine, National Academy of Sciences. 1986. Confronting AIDS: Directions for Public Health, Health Care, and Research. National Academy Press, Washington, D.C. [PubMed]
Desonia, Randolph A., and Kathleen M. King. 1985. State Programs of Assistance for the Medically Indigent. Intergovernmental Health Policy Project, Washington, D.C.
De Toqueville, Alexis. 1899. Democracy in America. Colonial Press, New York.
Gilbert, Benjamin, Mary K. Moos, and C. Arden Miller. 1982. ''State Level Decision-Making for Public Health: The Status of Boards of Health." Journal of Public Health Policy (March): 51–61.
Gostin, Larry J. 1986. "The Future of Communicable Disease Control: Toward a New Concept in Public Health Law." The Milbank Quarterly 64 (Supplement 1): 79–96.
Hanlon, J., and G. Pickett. 1984. Public Health Administration and Practice. Times Mirror/Mosby.
Institute of Medicine, National Academy of Sciences. 1982. a. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences. National Academy Press, Washington, D.C.
Institute of Medicine, National Academy of Sciences. 1982. b. Health Services Integration: Lessons for the 1980s, vol. 2: Case Studies. National Academy Press, Washington, D.C.
Institute of Medicine, National Academy of Sciences. 1986. Improving the Quality of Care in Nursing Homes. National Academy Press, Washington, D.C.
Joint Commission on Mental Illness and Health. 1961. Action for Mental Health. Basic Books, New York.
Keller, Lewis H., and Lawrence A. Kingsley. 1986. "The Epidemic of AIDS: A Failure of Public Health Policy." The Milbank Quarterly 64 (Supplement 1): 56–78.
Lindblom, Charles E. 1959. "The Science of Muddling Through." Public Administration Review 19 (Spring): 79–88.
Lynn, Lawrence E. 1980. The State and Human Services. MIT Press, Boston, Mass.
Miller, C. Arden, and Mary K. Moos. 1981. Local Health Departments: Fifteen Case Studies. Public Health Association, Washington, D.C.
National Resources Defense Council v. Environmental Protection Agency. 824 F.2d 1211 (D.C. Cir., 1987).
Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986. The 1990 Health Objectives for the Nation: A Midcourse Review. U.S. Department of Health and Human Services, Washington, D.C.
Omenn, G. S. 1982. "What's Behind Those Block Grants in Health?"
306 (17):1057–60.
President's Commission on Mental Health. 1978. Report of the President's Commission on Mental Health, vol. 1. Government Printing Office, Washington, D.C.
Public Health Foundation. 1986. Public Health Agencies, 1984. Public Health Foundation, Washington, D.C.
Rabe, Barry G. 1986. Fragmentation and Integration in State Environmental Management. The Conservation Foundation, Washington, D.C.
Turner, John B., editor. , ed. 1977. Encyclopedia of Social Work, 17th ed. National Association of Social Workers, Washington, D.C.
U.S. Department of Health, Education, and Welfare. 1979. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. U.S. Department of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary for Health, and Surgeon General, Washington, D.C.
U.S. Department of Health and Human Services, Public Health Service. 1980. Promoting Health/Preventing Disease: The 1990 Objectives for the Nation. U.S. Department of Health and Human Services, Washington, D.C.
U.S. Public Health Service, Health Resources and Services Administration. 1987. Unpublished data supplied to Institute of Medicine Committee for the Study of the Future of Public Health.
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.
5 Public Health as a Problem-Solving Activity: Barriers to Effective Action, concluded ...
References
American Public Health Association, Association of State and Territorial Health Officials, National Association of County Health Officers, U.S. Conference of Local Health Officials, Department of Health and Human Services, Public Health Service. 1985. Model Standards: A Guide for Community Preventive Health Services. American Public Health Association, Washington, D.C.
Berkman, Lisa F., and Lester Breslow. 1983. Health and Ways of Living: The Alameda County Study. Oxford University Press: New York.
Committee on the Institutional Means for Assessment of Risks to Public Health, Commission on Life Sciences, National Research Council. 1983. Risk Assessment in the Federal Government: Managing the Process. National Academy Press, Washington, D.C.
Committee on a National Strategy for AIDS, Institute of Medicine, National Academy of Sciences. 1986. Confronting AIDS: Directions for Public Health, Health Care, and Research. National Academy Press, Washington, D.C. [PubMed]
Desonia, Randolph A., and Kathleen M. King. 1985. State Programs of Assistance for the Medically Indigent. Intergovernmental Health Policy Project, Washington, D.C.
De Toqueville, Alexis. 1899. Democracy in America. Colonial Press, New York.
Gilbert, Benjamin, Mary K. Moos, and C. Arden Miller. 1982. ''State Level Decision-Making for Public Health: The Status of Boards of Health." Journal of Public Health Policy (March): 51–61.
Gostin, Larry J. 1986. "The Future of Communicable Disease Control: Toward a New Concept in Public Health Law." The Milbank Quarterly 64 (Supplement 1): 79–96.
Hanlon, J., and G. Pickett. 1984. Public Health Administration and Practice. Times Mirror/Mosby.
Institute of Medicine, National Academy of Sciences. 1982. a. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences. National Academy Press, Washington, D.C.
Institute of Medicine, National Academy of Sciences. 1982. b. Health Services Integration: Lessons for the 1980s, vol. 2: Case Studies. National Academy Press, Washington, D.C.
Institute of Medicine, National Academy of Sciences. 1986. Improving the Quality of Care in Nursing Homes. National Academy Press, Washington, D.C.
Joint Commission on Mental Illness and Health. 1961. Action for Mental Health. Basic Books, New York.
Keller, Lewis H., and Lawrence A. Kingsley. 1986. "The Epidemic of AIDS: A Failure of Public Health Policy." The Milbank Quarterly 64 (Supplement 1): 56–78.
Lindblom, Charles E. 1959. "The Science of Muddling Through." Public Administration Review 19 (Spring): 79–88.
Lynn, Lawrence E. 1980. The State and Human Services. MIT Press, Boston, Mass.
Miller, C. Arden, and Mary K. Moos. 1981. Local Health Departments: Fifteen Case Studies. Public Health Association, Washington, D.C.
National Resources Defense Council v. Environmental Protection Agency. 824 F.2d 1211 (D.C. Cir., 1987).
Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986. The 1990 Health Objectives for the Nation: A Midcourse Review. U.S. Department of Health and Human Services, Washington, D.C.
Omenn, G. S. 1982. "What's Behind Those Block Grants in Health?"
306 (17):1057–60.
President's Commission on Mental Health. 1978. Report of the President's Commission on Mental Health, vol. 1. Government Printing Office, Washington, D.C.
Public Health Foundation. 1986. Public Health Agencies, 1984. Public Health Foundation, Washington, D.C.
Rabe, Barry G. 1986. Fragmentation and Integration in State Environmental Management. The Conservation Foundation, Washington, D.C.
Turner, John B., editor. , ed. 1977. Encyclopedia of Social Work, 17th ed. National Association of Social Workers, Washington, D.C.
U.S. Department of Health, Education, and Welfare. 1979. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. U.S. Department of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary for Health, and Surgeon General, Washington, D.C.
U.S. Department of Health and Human Services, Public Health Service. 1980. Promoting Health/Preventing Disease: The 1990 Objectives for the Nation. U.S. Department of Health and Human Services, Washington, D.C.
U.S. Public Health Service, Health Resources and Services Administration. 1987. Unpublished data supplied to Institute of Medicine Committee for the Study of the Future of Public Health.
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.
6 Conclusions and Recommendations
Public health in the United States confronts a dilemma.
On the one hand, the advances against health problems for which public health was established in this country are largely taken for granted: safe water, substantial protection against formerly epidemic diseases, an infant death rate only one-tenth as high as in 1900.
It is difficult to maintain a sense of urgency about these matters, although continuing vigilance is necessary to preserve the gains that have been won.
For example, our country's progress in reducing infant mortality has actually slipped: throughout the 1970s, infant mortality declined at an average annual rate of 5 to 6 percent, while from 1981 to 1984, the rate of decline slowed to about 3 percent. (Hughes et al., 1986)
Infant mortality has actually increased recently in Detroit, Los Angeles, and elsewhere and remains distressingly high in poor communities.
Outbreaks of measles, for which effective immunization is available, continue to occur.
The rate of syphilis is rising again. (U.S. Department of Commerce, Bureau of the Census, 1986)
But warnings about these events by public health officials are sometimes seen as self-serving.
On the other hand, despite general complacency that the public health job is done, public concern is mounting over new health problems: toxic substances in air, water, and food; cancer and heart disease; drug abuse and teenage pregnancy; AIDS.
Excitement about such new health threats often leads to laws, regulations, agencies, and appropriations that bypass the "old" public health.
Action is obviously necessary, but the traditional channels are widely regarded as unsuitable.
Thus the dilemma faced by public health is how to take on the new challenges while continuing its work to contain long-existing problems.
Public health leaders have not succeeded in making clear that both aspects of public health must be tackled vigorously.
All too often, political leaders push short-term "solutions" to various health crises without reference to the knowledge base that exists for sound programs.
The general public is confused.
The result is a hodgepodge of fractionated interests and programs, organizational turmoil among new agencies, and well-intended but unbalanced appropriations — without coherent direction by well-qualified professionals.
That disarray has stimulated this study and this volume.
The first chapter reflects the committee's sense as the study began that public health was in trouble, that few people knew and even fewer cared, and that those who did care were divided over the nature of the problem and what to do about it.
In conducting the study, committee members set aside temporarily their individual views — although not their shared concern — in order to take a fresh look at public health and to develop a common understanding of it.
The aim of the study has been to produce a report that examines the total range of public health activity, not simply an assortment of tax-supported programs.
The committee sought to identify a set of functions necessary for the protection and advancement of the public's health, to assess difficulties in carrying out these functions, and to recommend specific strategies for improvement.
Judgments about the specific programs that public agencies should undertake or what resources they should command always imply underlying assumptions about the agency's proper mission, scope of concern, and functions.
In Chapter 2, the committee sought to make its own assumptions explicit, so that the logic of the ensuing problem analysis, findings, and recommendations would be clear.
The committee's own deliberations proceeded along these lines, beginning with clarification of the mission and scope of public health.
The committee continued by distinguishing functions and responsibilities that only governmental agencies can undertake from those that should be shared with or left to the private sector.
Then, weighing its analysis of the existing dilemma of public health, as outlined in Chapters 3, 4, and 5, the committee asked with respect to each issue: Given our definition of public health and what we believe government's responsibilities ought to be, how should this challenge be addressed?
This final chapter, setting forth the committee's recommendations for the future of public health, traces the same path.
The committee is making three basic recommendations dealing with:
* the mission of public health,
* the governmental role in fulfilling the mission, and
* the responsibilities unique to each level of government.
The rest of the recommendations are instrumental in implementing the basic recommendations for the future of public health.
These instrumental recommendations fall into the following categories: statutory framework; structural and organizational steps; strategies to build the fundamental capacities of public health agencies — technical, political, managerial, programmatic, and fiscal; and education for public health.
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.
6 Conclusions and Recommendations
Public health in the United States confronts a dilemma.
On the one hand, the advances against health problems for which public health was established in this country are largely taken for granted: safe water, substantial protection against formerly epidemic diseases, an infant death rate only one-tenth as high as in 1900.
It is difficult to maintain a sense of urgency about these matters, although continuing vigilance is necessary to preserve the gains that have been won.
For example, our country's progress in reducing infant mortality has actually slipped: throughout the 1970s, infant mortality declined at an average annual rate of 5 to 6 percent, while from 1981 to 1984, the rate of decline slowed to about 3 percent. (Hughes et al., 1986)
Infant mortality has actually increased recently in Detroit, Los Angeles, and elsewhere and remains distressingly high in poor communities.
Outbreaks of measles, for which effective immunization is available, continue to occur.
The rate of syphilis is rising again. (U.S. Department of Commerce, Bureau of the Census, 1986)
But warnings about these events by public health officials are sometimes seen as self-serving.
On the other hand, despite general complacency that the public health job is done, public concern is mounting over new health problems: toxic substances in air, water, and food; cancer and heart disease; drug abuse and teenage pregnancy; AIDS.
Excitement about such new health threats often leads to laws, regulations, agencies, and appropriations that bypass the "old" public health.
Action is obviously necessary, but the traditional channels are widely regarded as unsuitable.
Thus the dilemma faced by public health is how to take on the new challenges while continuing its work to contain long-existing problems.
Public health leaders have not succeeded in making clear that both aspects of public health must be tackled vigorously.
All too often, political leaders push short-term "solutions" to various health crises without reference to the knowledge base that exists for sound programs.
The general public is confused.
The result is a hodgepodge of fractionated interests and programs, organizational turmoil among new agencies, and well-intended but unbalanced appropriations — without coherent direction by well-qualified professionals.
That disarray has stimulated this study and this volume.
The first chapter reflects the committee's sense as the study began that public health was in trouble, that few people knew and even fewer cared, and that those who did care were divided over the nature of the problem and what to do about it.
In conducting the study, committee members set aside temporarily their individual views — although not their shared concern — in order to take a fresh look at public health and to develop a common understanding of it.
The aim of the study has been to produce a report that examines the total range of public health activity, not simply an assortment of tax-supported programs.
The committee sought to identify a set of functions necessary for the protection and advancement of the public's health, to assess difficulties in carrying out these functions, and to recommend specific strategies for improvement.
Judgments about the specific programs that public agencies should undertake or what resources they should command always imply underlying assumptions about the agency's proper mission, scope of concern, and functions.
In Chapter 2, the committee sought to make its own assumptions explicit, so that the logic of the ensuing problem analysis, findings, and recommendations would be clear.
The committee's own deliberations proceeded along these lines, beginning with clarification of the mission and scope of public health.
The committee continued by distinguishing functions and responsibilities that only governmental agencies can undertake from those that should be shared with or left to the private sector.
Then, weighing its analysis of the existing dilemma of public health, as outlined in Chapters 3, 4, and 5, the committee asked with respect to each issue: Given our definition of public health and what we believe government's responsibilities ought to be, how should this challenge be addressed?
This final chapter, setting forth the committee's recommendations for the future of public health, traces the same path.
The committee is making three basic recommendations dealing with:
* the mission of public health,
* the governmental role in fulfilling the mission, and
* the responsibilities unique to each level of government.
The rest of the recommendations are instrumental in implementing the basic recommendations for the future of public health.
These instrumental recommendations fall into the following categories: statutory framework; structural and organizational steps; strategies to build the fundamental capacities of public health agencies — technical, political, managerial, programmatic, and fiscal; and education for public health.
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.
6 Conclusions and Recommendations, continued ...
The Public Health Mission, Governmental Role, and Levels of Responsibility
Mission
The committee defines the mission of public health as fulfilling society's interest in assuring conditions in which people can be healthy.
Public health is distinguished from health care by its focus on communitywide concerns — the public interest — rather than the health interests of particular individuals or groups.
Its aim is to generate organized community effort to address public concerns about health by applying scientific and technical knowledge.
These concerns include disease prevention and health promotion, encompassing physical, mental, and environmental health.
Many distinct and diverse professional disciplines are necessary in this effort, such as nursing, medicine, social work, environmental sciences, dentistry, nutrition, and health education.
These professions are unified within public health by dedication to its value system, by the public interest in health, and by its core science, epidemiology — the study of health problems in populations and the factors that affect them.
The mission of public health is more fundamental and more comprehensive than the specific activities of particular agencies.
Organized community effort to prevent disease and promote health involves private organizations and individuals, working on their own or in partnership with the public sector.
But the governmental public health agency has a unique function: to see to it that vital elements are in place and that the mission is adequately addressed.
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.
6 Conclusions and Recommendations, continued ...
The Public Health Mission, Governmental Role, and Levels of Responsibility
Mission
The committee defines the mission of public health as fulfilling society's interest in assuring conditions in which people can be healthy.
Public health is distinguished from health care by its focus on communitywide concerns — the public interest — rather than the health interests of particular individuals or groups.
Its aim is to generate organized community effort to address public concerns about health by applying scientific and technical knowledge.
These concerns include disease prevention and health promotion, encompassing physical, mental, and environmental health.
Many distinct and diverse professional disciplines are necessary in this effort, such as nursing, medicine, social work, environmental sciences, dentistry, nutrition, and health education.
These professions are unified within public health by dedication to its value system, by the public interest in health, and by its core science, epidemiology — the study of health problems in populations and the factors that affect them.
The mission of public health is more fundamental and more comprehensive than the specific activities of particular agencies.
Organized community effort to prevent disease and promote health involves private organizations and individuals, working on their own or in partnership with the public sector.
But the governmental public health agency has a unique function: to see to it that vital elements are in place and that the mission is adequately addressed.
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.
6 Conclusions and Recommendations, continued ...
The Public Health Mission, Governmental Role, and Levels of Responsibility, continued ...
The Governmental Role in Public Health
The committee believes that governments at all levels have an irreplaceable role to play in assuring conditions in which people can be healthy.
This means that federal, state, and local public health agencies have an obligation to assume certain vital functions directly.
In the committee's view, these responsibilities cannot properly be delegated to the private sector.
The committee finds that the core functions of public health agencies at all levels of government are assessment, policy development, and assurance.
Assessment
An understanding of the determinants of health and of the nature and extent of community need is a fundamental prerequisite to sound decision-making about health.
Accurate information serves the interests both of justice and the efficient use of available resources.
Assessment is therefore a core governmental obligation in public health.
The committee recommends that every public health agency regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems.
The extent to which information will be generated directly or collected from other sources will vary depending on the size of the agency and of the population served.
For example, the federal agency will have a nationwide purview, while smaller agencies may lack sufficient mass of expertise necessary for sophisticated research; thus interagency and intergovernmental cooperation is crucial.
Nevertheless, each public health agency at every level of government bears the responsibility for ensuring that the assessment function is fulfilled.
This basic function of public health cannot be delegated.
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.
6 Conclusions and Recommendations, continued ...
The Public Health Mission, Governmental Role, and Levels of Responsibility, continued ...
The Governmental Role in Public Health
The committee believes that governments at all levels have an irreplaceable role to play in assuring conditions in which people can be healthy.
This means that federal, state, and local public health agencies have an obligation to assume certain vital functions directly.
In the committee's view, these responsibilities cannot properly be delegated to the private sector.
The committee finds that the core functions of public health agencies at all levels of government are assessment, policy development, and assurance.
Assessment
An understanding of the determinants of health and of the nature and extent of community need is a fundamental prerequisite to sound decision-making about health.
Accurate information serves the interests both of justice and the efficient use of available resources.
Assessment is therefore a core governmental obligation in public health.
The committee recommends that every public health agency regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems.
The extent to which information will be generated directly or collected from other sources will vary depending on the size of the agency and of the population served.
For example, the federal agency will have a nationwide purview, while smaller agencies may lack sufficient mass of expertise necessary for sophisticated research; thus interagency and intergovernmental cooperation is crucial.
Nevertheless, each public health agency at every level of government bears the responsibility for ensuring that the assessment function is fulfilled.
This basic function of public health cannot be delegated.
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.
6 Conclusions and Recommendations, continued ...
The Public Health Mission, Governmental Role, and Levels of Responsibility, continued ...
The Governmental Role in Public Health, continued ...
Policy Development
Legitimate public decisions reflect a full examination of the public interest and sound analysis of problems and interventions.
Attention to the quality of decision-making about health is necessary so that the interests of all affected parties, especially the general public, are considered.
This attention is a basic responsibility of government in public health.
The committee recommends that every public health agency exercise its responsibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy.
Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process.
Specific strategies must be developed by each agency depending on its circumstances.
Later recommendations exemplify the kinds of steps that agencies may find appropriate.
The intent of this recommendation is to encourage agencies to view policy development as central to their roles and to develop strategic approaches to its achievement that anticipate possible problems.
Government should be equipped for this role by the technical knowledge and professional expertise of agency staff.
Used judiciously, the knowledge base of public health tempers the excesses of partisan politics and encourages just decisions.
Technical knowledge will have the best effect, however, when used in the context of a positive appreciation for the democratic political process, by professionals who are politically as well as technically astute.
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.
6 Conclusions and Recommendations, continued ...
The Public Health Mission, Governmental Role, and Levels of Responsibility, continued ...
The Governmental Role in Public Health, continued ...
Policy Development
Legitimate public decisions reflect a full examination of the public interest and sound analysis of problems and interventions.
Attention to the quality of decision-making about health is necessary so that the interests of all affected parties, especially the general public, are considered.
This attention is a basic responsibility of government in public health.
The committee recommends that every public health agency exercise its responsibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy.
Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process.
Specific strategies must be developed by each agency depending on its circumstances.
Later recommendations exemplify the kinds of steps that agencies may find appropriate.
The intent of this recommendation is to encourage agencies to view policy development as central to their roles and to develop strategic approaches to its achievement that anticipate possible problems.
Government should be equipped for this role by the technical knowledge and professional expertise of agency staff.
Used judiciously, the knowledge base of public health tempers the excesses of partisan politics and encourages just decisions.
Technical knowledge will have the best effect, however, when used in the context of a positive appreciation for the democratic political process, by professionals who are politically as well as technically astute.
TO BE CONTINUED ...