NCBI
The Future of the Public's Health in the 21st Century., continued ...
Financial Implications of a Changing Mission for Governmental Public Health Agencies in Providing Health Care Services
Essential public health service number 7 (see Box 3–1) charges state and local governmental public health agencies to “link people to needed personal health services and assure the provision of health care when otherwise unavailable” (Public Health Functions Steering Committee, 1994).
Thus, state and local governmental public health agencies are responsible for providing a safety net to guarantee that personal health care services are available to all members of the communities they serve.
As noted earlier, since 1988, state and local governments have turned increasingly to the private sector, particularly managed care organizations, to provide health care services for Medicaid beneficiaries and others, many of whom were once served directly by local public health departments.
In addition, an increasing number of employees (approximately 85 percent) (Kuttner, 1999) are covered by private health insurance, reducing their need for services from public health departments.
These changes seemed to provide great promise that local public health agencies would be able to shift their focus from the provision of personal health care services to previously neglected population-based public health functions (IOM, 1996).
In some states and communities, however, services to Medicaid patients had offered an important revenue stream that subsidized the population health programs of governmental public health agencies (Keane et al., 2001).
Thus, these agencies find themselves in a difficult relationship with managed care plans: on the one hand, encouraging their active partnership in the public health system, while, on the other, competing with them for revenues for some of these services (Lumpkin et al., 1998).
A study of state public health agencies found that 16 of 47 states had some kind of collaboration between their public health departments and managed care groups (DHHS, 1999).
In most cases, the managed care organizations were contracted to provide direct patient care (e.g., primary care and clinical preventive services).
Other studies of this collaboration reported similar findings.
Although there is great potential benefit from collaborations between public health agencies and managed care plans, current economic trends for managed care programs are not optimistic.
In 1997, 67 percent of managed care plans sponsored by safety-net providers lost money, and only 8 percent indicated that they broke even (Gray and Rowe, 2000).
In recent years, managed care organizations have been withdrawing from collaborative contracts with governmental public health agencies, once again leaving these agencies with the pressure of having to deliver personal health care services including primary care services to the uninsured or vulnerable populations rejected by the medical care system.
This instability in service delivery is also contributing to the disruption of individuals' continuity and availability of care (IOM, 2000a).
Of potential assistance to safety-net providers is the reemerging interest in federal support for “a doubling” of community health centers, operated either by traditional governmental public health agencies or by nongovernmental organizations.
Congress recently awarded DHHS with funding to add 1,200 new and expanded health center sites over a 5-year period.
At the end of 2002, DHHS will have invested $165 million in 260 new and expanded health centers capable of serving an additional 1.25 million people (HRSA, 2002).
As these centers redevelop, the lessons of the past must be kept in mind.
The allocation of federal and state resources to communities for these facilities and other health-related programs should be coordinated in a process that ensures the involvement and approval (or at least acknowledgment) of local public health agencies.
Moreover, coordination with state and local public health authorities and other community resources is essential (IOM, 1988).
The committee finds that, as in 1988, the continued lack of a nationwide strategy to ensure adequate financing of personal medical, preventive, and health promotion services will continue to place undue burdens on the public health system and to fragment the provision of personal health care services to those most in need of comprehensive integrated approaches.
Also, if the number of uninsured continues to increase, the diversion of resources urgently needed for population health efforts to the health care assurance component of the governmental public health system may be required.
The recent downturn in in-state revenues due to the national economic slump will exacerbate problems of sustaining the state share of Medicaid funding and lessen the likelihood of increased or, perhaps, even sustained state funding for the governmental public health infrastructure.
TO BE CONTINUED ...
ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
NCBI
The Future of the Public's Health in the 21st Century., continued ...
Improving the Operation and Management of the Governmental Public Health Infrastructure
Successfully implementing health policy based on multiple determinants of health and their impact on the health of communities and populations will depend on the effective performance of public health agencies at all levels of government.
The committee has discussed the need to strengthen specific aspects of the governmental public health infrastructure at the federal, state, and local levels — the competency of the workforce, the integration and enhancement of information and communication networks, and the improvement of the laboratory and organizational capacities to ensure that the essential public health functions are available to all Americans.
Another important priority is to improve the management and coordination of the work of public health agencies as they support this goal of protecting and improving the health of the population.
Public Health Performance Standards and the Accreditation of State and Local Health Departments
Performance measurement has become an essential tool for guiding quality improvement efforts and for holding organizations in the public and private sectors accountable for meeting specified responsibilities.
The National Public Health Performance Standards Program (NPHPSP), initiated in 1998, is an effort to use the ideas of performance measurement to promote the organization of state and local public health practice around delivery of the essential public health services (see Box 3–4).
In a national partnership, CDC, ASTHO, NACCHO, NALBOH, APHA, and PHF are working together to establish measurable performance standards for state and local public health systems, to develop tools to assess performance against these standards, and to create incentives for states and localities to use such tools.
Some of these measures could be used in a “report card” or as standards in a national program that accredits public health agencies.
The performance standards effort is seen as one way to help move the state and local components of the nation's public health system closer to the system envisioned in The Future of Public Health (IOM, 1988).
Separate sets of tools for governance have been developed and tested.
The instruments are available via CDC's NPHPSP website (www.phppo.cdc.gov/nphpsp), the ASTHO website for the state instrument (www.astho.org/phiip/performance.ht-ml) (ASTHO, 2001d), the NACCHO website for the local instrument (www.naccho.org/project48.cfm) (NACCHO, 2001f), and the NALBOH website for the governance instrument (www.nalboh.org/perfstds/perfstds.htm) (NALBOH, 2001).
Although the program is aimed at assessing the performance of the public health system as a whole, it recognizes that governmental public health agencies have key responsibilities for leading, coordinating, and supporting the efforts of various contributors.
The interest in measuring the performance of the public health system extends to the possibility of establishing a formal process of accreditation to certify that governmental public health agencies are meeting specified levels of performance.
Several states have developed or are developing state-specific performance requirements for local governmental public health agencies, but interest has also emerged in the development of nationally standardized, systematic performance evaluations for state and local public health agencies.
No agreement has been reached on the appropriate criteria or process for accreditation.
One of the key challenges is to create a system that is flexible enough to accommodate the wide variety of public health department structures and circumstances across states.
Given the resource constraints that state and local governmental public health agencies currently face, it is unclear how performance standards can be met or accreditation can be achieved when the resources to provide even the most basic services are often lacking.
Linking federal funding to accreditation based on public health performance standards has been proposed, but there may not be adequate incentives for states and localities that do not receive significant portions of their overall funding from federal agencies.
The promise of a long-term federal investment at the state and local levels linked to such a system could change the situation considerably.
To address these and other concerns, NACCHO has convened the Voluntary Accreditation Committee, which consists of eight local health officers who are charged with maintaining an ongoing discussion of the advantages and disadvantages of voluntary accreditation of local health departments.
They are currently researching lessons that might be learned from other voluntary accreditation efforts, such as those for hospitals, managed care organizations, and law enforcement agencies.
The Voluntary Accreditation Committee is also taking into account the work of states such as Florida, Illinois, Michigan, Missouri, Ohio, and Washington that are already active in the development of state-specific accreditation or performance standards for their local public health agencies.
Despite the controversies concerning accreditation, the committee believes that greater accountability is needed on the part of state and local public health agencies with regard to the performance of the core public health functions of assessment, assurance, and policy development and the essential public health services.
Furthermore, the committee believes that development of a uniform set of national standards leading to public health agency accreditation could provide such a mechanism, but only if adherence to such standards is linked to a commitment of sustained federal investment in the state and local public health infrastructure to assure that resources are available.
Moreover, such a mechanism could serve to increase levels of accountability among state and local elected officials in whose jurisdictions these agencies operate.
The breakthrough concepts of NPHPSP provide a way to conceptualize the system as the unit of accreditation and, from there, to evaluate the role of the agencies in facilitating the work of the system.
Accreditation is a useful tool for improving the quality of services provided to the public by setting standards and evaluating performance against those standards.
Accreditation mechanisms have helped to ensure the robustness of the health care delivery system (hospitals, clinics, programs) and medical and other educational programs.
Accreditation processes also provide information to the public about the quality of the services they receive (e.g., National Committee for Quality Assurance report cards on health plans) (IOM, 2001).
Governmental public health agencies currently have no such framework, and the communities they serve have little information on the quality of the services they receive.
An accreditation process could provide a structure for establishing quality assurance and improvements in governmental public health agencies.
Therefore, the committee recommends that the Secretary of DHHS appoint a national commission to consider if an accreditation system would be useful for improving and building state and local public health agency capacities.
If such a system is deemed useful, the commission should make recommendations on how it would be governed and develop mechanisms (e.g., incentives) to gain state and local government participation in the accreditation effort.
Membership on this commission should include representatives from CDC, ASTHO, NACCHO, and nongovernmental organizations.
This commission should focus on the development of a system that will further the efforts of NPHPSP.
The work of this commission should be closely linked to that of the commission whose creation the committee has recommended to examine issues related to the credentialing of public health workers, because it is conceivable that these mechanisms could be linked.
In both efforts, the relationship of the official public health agency to its role in the larger public health system will be key to accreditation.
TO BE CONTINUED ...
The Future of the Public's Health in the 21st Century., continued ...
Improving the Operation and Management of the Governmental Public Health Infrastructure
Successfully implementing health policy based on multiple determinants of health and their impact on the health of communities and populations will depend on the effective performance of public health agencies at all levels of government.
The committee has discussed the need to strengthen specific aspects of the governmental public health infrastructure at the federal, state, and local levels — the competency of the workforce, the integration and enhancement of information and communication networks, and the improvement of the laboratory and organizational capacities to ensure that the essential public health functions are available to all Americans.
Another important priority is to improve the management and coordination of the work of public health agencies as they support this goal of protecting and improving the health of the population.
Public Health Performance Standards and the Accreditation of State and Local Health Departments
Performance measurement has become an essential tool for guiding quality improvement efforts and for holding organizations in the public and private sectors accountable for meeting specified responsibilities.
The National Public Health Performance Standards Program (NPHPSP), initiated in 1998, is an effort to use the ideas of performance measurement to promote the organization of state and local public health practice around delivery of the essential public health services (see Box 3–4).
In a national partnership, CDC, ASTHO, NACCHO, NALBOH, APHA, and PHF are working together to establish measurable performance standards for state and local public health systems, to develop tools to assess performance against these standards, and to create incentives for states and localities to use such tools.
Some of these measures could be used in a “report card” or as standards in a national program that accredits public health agencies.
The performance standards effort is seen as one way to help move the state and local components of the nation's public health system closer to the system envisioned in The Future of Public Health (IOM, 1988).
Separate sets of tools for governance have been developed and tested.
The instruments are available via CDC's NPHPSP website (www.phppo.cdc.gov/nphpsp), the ASTHO website for the state instrument (www.astho.org/phiip/performance.ht-ml) (ASTHO, 2001d), the NACCHO website for the local instrument (www.naccho.org/project48.cfm) (NACCHO, 2001f), and the NALBOH website for the governance instrument (www.nalboh.org/perfstds/perfstds.htm) (NALBOH, 2001).
Although the program is aimed at assessing the performance of the public health system as a whole, it recognizes that governmental public health agencies have key responsibilities for leading, coordinating, and supporting the efforts of various contributors.
The interest in measuring the performance of the public health system extends to the possibility of establishing a formal process of accreditation to certify that governmental public health agencies are meeting specified levels of performance.
Several states have developed or are developing state-specific performance requirements for local governmental public health agencies, but interest has also emerged in the development of nationally standardized, systematic performance evaluations for state and local public health agencies.
No agreement has been reached on the appropriate criteria or process for accreditation.
One of the key challenges is to create a system that is flexible enough to accommodate the wide variety of public health department structures and circumstances across states.
Given the resource constraints that state and local governmental public health agencies currently face, it is unclear how performance standards can be met or accreditation can be achieved when the resources to provide even the most basic services are often lacking.
Linking federal funding to accreditation based on public health performance standards has been proposed, but there may not be adequate incentives for states and localities that do not receive significant portions of their overall funding from federal agencies.
The promise of a long-term federal investment at the state and local levels linked to such a system could change the situation considerably.
To address these and other concerns, NACCHO has convened the Voluntary Accreditation Committee, which consists of eight local health officers who are charged with maintaining an ongoing discussion of the advantages and disadvantages of voluntary accreditation of local health departments.
They are currently researching lessons that might be learned from other voluntary accreditation efforts, such as those for hospitals, managed care organizations, and law enforcement agencies.
The Voluntary Accreditation Committee is also taking into account the work of states such as Florida, Illinois, Michigan, Missouri, Ohio, and Washington that are already active in the development of state-specific accreditation or performance standards for their local public health agencies.
Despite the controversies concerning accreditation, the committee believes that greater accountability is needed on the part of state and local public health agencies with regard to the performance of the core public health functions of assessment, assurance, and policy development and the essential public health services.
Furthermore, the committee believes that development of a uniform set of national standards leading to public health agency accreditation could provide such a mechanism, but only if adherence to such standards is linked to a commitment of sustained federal investment in the state and local public health infrastructure to assure that resources are available.
Moreover, such a mechanism could serve to increase levels of accountability among state and local elected officials in whose jurisdictions these agencies operate.
The breakthrough concepts of NPHPSP provide a way to conceptualize the system as the unit of accreditation and, from there, to evaluate the role of the agencies in facilitating the work of the system.
Accreditation is a useful tool for improving the quality of services provided to the public by setting standards and evaluating performance against those standards.
Accreditation mechanisms have helped to ensure the robustness of the health care delivery system (hospitals, clinics, programs) and medical and other educational programs.
Accreditation processes also provide information to the public about the quality of the services they receive (e.g., National Committee for Quality Assurance report cards on health plans) (IOM, 2001).
Governmental public health agencies currently have no such framework, and the communities they serve have little information on the quality of the services they receive.
An accreditation process could provide a structure for establishing quality assurance and improvements in governmental public health agencies.
Therefore, the committee recommends that the Secretary of DHHS appoint a national commission to consider if an accreditation system would be useful for improving and building state and local public health agency capacities.
If such a system is deemed useful, the commission should make recommendations on how it would be governed and develop mechanisms (e.g., incentives) to gain state and local government participation in the accreditation effort.
Membership on this commission should include representatives from CDC, ASTHO, NACCHO, and nongovernmental organizations.
This commission should focus on the development of a system that will further the efforts of NPHPSP.
The work of this commission should be closely linked to that of the commission whose creation the committee has recommended to examine issues related to the credentialing of public health workers, because it is conceivable that these mechanisms could be linked.
In both efforts, the relationship of the official public health agency to its role in the larger public health system will be key to accreditation.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
NCBI
The Future of the Public's Health in the 21st Century., continued ...
Special Concerns About the Capacity to Meet Local Public Health Needs
In The Future of Public Health (1988), the IOM committee concluded that “no community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system” (IOM, 1988: 144).
The rationale behind this finding is clear: If a community is going to be able to meet its own health needs, it must have access to an identifiable public health infrastructure to provide the essential public health services.
Today, concerns remain about the availability of an adequate local public health infrastructure, particularly in terms of staffing and communications systems, to provide these services.
Despite the presence of some 3,000 local public health agencies throughout the country, these agencies are not equally distributed across states or across rural and urban areas.
For example, Bergen County, New Jersey, with a population of approximately 884,000 and an area of 234 square miles (Census Bureau, 2001a), is served by a strong county health department, 55 local boards of health, and 22 independent public health agencies that serve different and occasionally overlapping communities (T. Milne, NACCHO, personal communication, October 31, 2001).
By contrast, the state of Maine, with a population of about 1.3 million distributed over 30,862 square miles (Census Bureau, 2001b), has two local public health agencies (T. Milne, NACCHO, personal communication, October 31, 2001).
Challenges come from both an abundance of local public health agencies and their scarcity.
When multiple public health departments serve the same geographic area, they may experience difficulties coordinating activities and aligning priorities.
However, rural areas, with little or no local public health presence, may suffer from inadequate public health capacity or resources to address local needs and a paucity of educational and training support (Johnson and Morris, 2000).
Either we are all protected or we are all at risk.
Dr. Jeffrey Koplan, Formerly, Centers for Disease Control and Prevention
Data from NACCHO (2001e) also point to substantial differences in the workforce available to local public health agencies.
NACCHO's 1999– 2000 survey found that 50 percent of all local public health agencies responding had 17 or fewer full-time employees or contract staff, but for those serving metropolitan areas, 50 percent had at least 28 full-time employees or contract staff.
Some local public health agencies, however, currently have only one half-time employee as their entire public health agency staff.
Staffing levels have shown little change over the past decade.
A 1997 survey found that the median number of full-time employees was 16 (NACCHO, 1998), and in 1992–1993, NACCHO (2001e) reported that 42 percent of local public health agencies had less than 10 full-time staff members.
Given the many responsibilities and wide-ranging duties inherent in the assurance of population health, the committee is concerned that these low numbers do not bode well for the core capacity of some local public health agencies to provide the 10 essential public health services to their communities.
Simply increasing the size of the local public health agency workforce appears problematic, however.
The committee is concerned about reports by 68 percent of local public health agencies that budget restrictions prevent them from hiring needed staff, including public health nurses, environmental specialists, health educators, epidemiologists, and administrative personnel (NACCHO, 2001d).
In addition, local public health agencies in smaller, nonmetropolitan jurisdictions indicated that they could not hire the necessary staff because of a lack of qualified candidates in their areas and difficulty attracting other candidates to their locations.
Only 19 percent of the local public health agencies indicated that they needed new staff because of projected expansions of their programs and services (NACCHO, 2001d).
Many local public health departments also lack even the most basic tools necessary for rapid communication and access to information (GAO, 1999b).
For example, a 1999 survey of 1,200 local public health departments found that 19 percent did not have the capacity to send and receive e-mail via the Internet (Fraser, 1999).
The most common barriers cited by the departments without Internet access were prohibitive costs (64 percent), the need for hardware (64 percent), and the need for staff training (63 percent).
Additionally, only 48 percent of the health departments surveyed indicated that the director had continuous, high-speed Internet access at work, and only 44 percent indicated that the department had broadcast fax capabilities (Fraser, 1999).
In all cases, public health agencies in smaller and more remote jurisdictions had the least access to information and communications technologies, even though these agencies may actually have the greatest need for such technologies.
Given the evidence concerning the local public health workforce and communication capacity as well as related observations made throughout this chapter, the committee finds that too little has been done to support and strengthen the local public health infrastructure.
Over the past 14 years, governmental public health agencies have made great efforts in response to the recommendations concerning local public health agencies in The Future of Public Health (1988) (see Appendix C).
Unfortunately, until recently, progress has been slow because of the lack of political and financial support that was needed long ago to fully realize the vision of the 1988 report.
Recent increases in infrastructure support in connection with bioterrorism preparedness are somewhat encouraging, but there is concern that such efforts may reinforce the complex problems created by prior categorical funding if excellent specific services (e.g., surveillance are informatics) are built on the foundation of a crumbling infrastructure.
For these reasons, the committee believes that every community, no matter how small or remote, should have identifiable and realistic access to the essential public health services, and that it is the responsibility of the states to ensure that such services are available.
However, for states to meet this obligation, the committee recommends that DHHS develop a comprehensive investment plan for a strong governmental national public health infrastructure with a timetable, clear performance measures, and regular progress reports to the public.
State and local governments should also provide adequate, consistent, and sustainable funding for the governmental public health infrastructure.
This investment is crucial to assure the preparedness of public health departments and the protection of communities, regardless of their size or location.
Some communities provided comments to the committee noting that a more precise description of an essential minimum level of local official agency capacity would aid their efforts to obtain public health services.
In an effort to be responsive to these requests, the committee struggled with the challenge to be more explicit with regard to the level of public health capacity that should be present in these small and remote communities.
Not surprisingly, some familiar problems were encountered.
For example, there are questions involving the proper definition of a “community” for this purpose and the appropriate response if a community has too small an economic base to sustain a formal public health agency with the necessary presence and capacity to provide public health protections.
The most robust approach to assessing need seems to be the use of a functional analysis based on the ability to provide the essential public health services, as recommended above.
The committee recognizes the potential value of a recommendation regarding the development of a formula to determine the “critical mass” of services and population (e.g., a ratio of one of each of the critical professions per 50,000 or 100,000 population), the geographic accessibility of services, and the workforce capacity necessary for the effective development of local public health agencies to serve small or remote communities.
Before such a recommendation can be made, however, solid, practice-oriented research must be conducted to provide the evidence on which to base a formula or other criteria.
The committee had hoped to be able to provide specific guidance to assist the nation in its efforts to rebuild and finance its public health infrastructure.
However, a comprehensive search of the published literature and extensive information gathering yielded very little firm, generalizable evidence on which to structure public health practice recommendations like those noted.
To remedy this situation, the committee recommends that CDC, in collaboration with the Council on Linkages between Academia and Public Health Practice and other public health system partners, develop a research agenda and estimate the funding needed to build the evidence base that will guide policy making for public health practice.
TO BE CONTINUED ...
The Future of the Public's Health in the 21st Century., continued ...
Special Concerns About the Capacity to Meet Local Public Health Needs
In The Future of Public Health (1988), the IOM committee concluded that “no community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system” (IOM, 1988: 144).
The rationale behind this finding is clear: If a community is going to be able to meet its own health needs, it must have access to an identifiable public health infrastructure to provide the essential public health services.
Today, concerns remain about the availability of an adequate local public health infrastructure, particularly in terms of staffing and communications systems, to provide these services.
Despite the presence of some 3,000 local public health agencies throughout the country, these agencies are not equally distributed across states or across rural and urban areas.
For example, Bergen County, New Jersey, with a population of approximately 884,000 and an area of 234 square miles (Census Bureau, 2001a), is served by a strong county health department, 55 local boards of health, and 22 independent public health agencies that serve different and occasionally overlapping communities (T. Milne, NACCHO, personal communication, October 31, 2001).
By contrast, the state of Maine, with a population of about 1.3 million distributed over 30,862 square miles (Census Bureau, 2001b), has two local public health agencies (T. Milne, NACCHO, personal communication, October 31, 2001).
Challenges come from both an abundance of local public health agencies and their scarcity.
When multiple public health departments serve the same geographic area, they may experience difficulties coordinating activities and aligning priorities.
However, rural areas, with little or no local public health presence, may suffer from inadequate public health capacity or resources to address local needs and a paucity of educational and training support (Johnson and Morris, 2000).
Either we are all protected or we are all at risk.
Dr. Jeffrey Koplan, Formerly, Centers for Disease Control and Prevention
Data from NACCHO (2001e) also point to substantial differences in the workforce available to local public health agencies.
NACCHO's 1999– 2000 survey found that 50 percent of all local public health agencies responding had 17 or fewer full-time employees or contract staff, but for those serving metropolitan areas, 50 percent had at least 28 full-time employees or contract staff.
Some local public health agencies, however, currently have only one half-time employee as their entire public health agency staff.
Staffing levels have shown little change over the past decade.
A 1997 survey found that the median number of full-time employees was 16 (NACCHO, 1998), and in 1992–1993, NACCHO (2001e) reported that 42 percent of local public health agencies had less than 10 full-time staff members.
Given the many responsibilities and wide-ranging duties inherent in the assurance of population health, the committee is concerned that these low numbers do not bode well for the core capacity of some local public health agencies to provide the 10 essential public health services to their communities.
Simply increasing the size of the local public health agency workforce appears problematic, however.
The committee is concerned about reports by 68 percent of local public health agencies that budget restrictions prevent them from hiring needed staff, including public health nurses, environmental specialists, health educators, epidemiologists, and administrative personnel (NACCHO, 2001d).
In addition, local public health agencies in smaller, nonmetropolitan jurisdictions indicated that they could not hire the necessary staff because of a lack of qualified candidates in their areas and difficulty attracting other candidates to their locations.
Only 19 percent of the local public health agencies indicated that they needed new staff because of projected expansions of their programs and services (NACCHO, 2001d).
Many local public health departments also lack even the most basic tools necessary for rapid communication and access to information (GAO, 1999b).
For example, a 1999 survey of 1,200 local public health departments found that 19 percent did not have the capacity to send and receive e-mail via the Internet (Fraser, 1999).
The most common barriers cited by the departments without Internet access were prohibitive costs (64 percent), the need for hardware (64 percent), and the need for staff training (63 percent).
Additionally, only 48 percent of the health departments surveyed indicated that the director had continuous, high-speed Internet access at work, and only 44 percent indicated that the department had broadcast fax capabilities (Fraser, 1999).
In all cases, public health agencies in smaller and more remote jurisdictions had the least access to information and communications technologies, even though these agencies may actually have the greatest need for such technologies.
Given the evidence concerning the local public health workforce and communication capacity as well as related observations made throughout this chapter, the committee finds that too little has been done to support and strengthen the local public health infrastructure.
Over the past 14 years, governmental public health agencies have made great efforts in response to the recommendations concerning local public health agencies in The Future of Public Health (1988) (see Appendix C).
Unfortunately, until recently, progress has been slow because of the lack of political and financial support that was needed long ago to fully realize the vision of the 1988 report.
Recent increases in infrastructure support in connection with bioterrorism preparedness are somewhat encouraging, but there is concern that such efforts may reinforce the complex problems created by prior categorical funding if excellent specific services (e.g., surveillance are informatics) are built on the foundation of a crumbling infrastructure.
For these reasons, the committee believes that every community, no matter how small or remote, should have identifiable and realistic access to the essential public health services, and that it is the responsibility of the states to ensure that such services are available.
However, for states to meet this obligation, the committee recommends that DHHS develop a comprehensive investment plan for a strong governmental national public health infrastructure with a timetable, clear performance measures, and regular progress reports to the public.
State and local governments should also provide adequate, consistent, and sustainable funding for the governmental public health infrastructure.
This investment is crucial to assure the preparedness of public health departments and the protection of communities, regardless of their size or location.
Some communities provided comments to the committee noting that a more precise description of an essential minimum level of local official agency capacity would aid their efforts to obtain public health services.
In an effort to be responsive to these requests, the committee struggled with the challenge to be more explicit with regard to the level of public health capacity that should be present in these small and remote communities.
Not surprisingly, some familiar problems were encountered.
For example, there are questions involving the proper definition of a “community” for this purpose and the appropriate response if a community has too small an economic base to sustain a formal public health agency with the necessary presence and capacity to provide public health protections.
The most robust approach to assessing need seems to be the use of a functional analysis based on the ability to provide the essential public health services, as recommended above.
The committee recognizes the potential value of a recommendation regarding the development of a formula to determine the “critical mass” of services and population (e.g., a ratio of one of each of the critical professions per 50,000 or 100,000 population), the geographic accessibility of services, and the workforce capacity necessary for the effective development of local public health agencies to serve small or remote communities.
Before such a recommendation can be made, however, solid, practice-oriented research must be conducted to provide the evidence on which to base a formula or other criteria.
The committee had hoped to be able to provide specific guidance to assist the nation in its efforts to rebuild and finance its public health infrastructure.
However, a comprehensive search of the published literature and extensive information gathering yielded very little firm, generalizable evidence on which to structure public health practice recommendations like those noted.
To remedy this situation, the committee recommends that CDC, in collaboration with the Council on Linkages between Academia and Public Health Practice and other public health system partners, develop a research agenda and estimate the funding needed to build the evidence base that will guide policy making for public health practice.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
NCBI
The Future of the Public's Health in the 21st Century, continued ...
Strengthening the Management Capacity of DHHS
From 1993 to 1997, DHHS, like all federal government departments, conducted a reinvention exercise to determine what work it should do and how it could do that work more effectively and responsively.
A recent monograph on DHHS and the impact of departmental reinvention efforts in the late 1990s identified two issues of particular significance: (1) the effect of the balance between centralization and decentralization on the management of departmental activities and (2) the relationship of the department with other agencies (Boufford and Lee, 2001).
Centralization versus Decentralization: Models for Managing DHHS
The committee's discussion of key federal functions — policy making, financing, infrastructure development, and the like — illustrate how the problems of fragmentation in federal public health activities affect the functioning of state and local public agencies.
Such problems are related to historical patterns and political interests that have shaped federal health structures, but they are not being addressed by the present management structure for health activities in DHHS.
The reinvention exercise led to a decision to have each of the PHS agencies report directly to the Secretary of DHHS rather than to the Assistant Secretary for Health.
Potential advantages were seen in bringing the agency heads closer to the Secretary and having more than a single voice for health at the decision-making table.
Boufford and Lee (2001) found that without a formal mechanism for joint priority setting and routine decision-making across the department, operations became even more decentralized, with staff identifying more with their own agencies or programs than with the department as a whole.
The leadership of operating divisions generally prefers to report directly to the Secretary, but division leaders would also welcome a clearly defined structure to formalize coordination, collaboration, and communication among departmental units.
Creating a formal mechanism for regular meetings of the heads of operating divisions, as well as meetings with the Secretary, would permit more substantive and forward-looking discussion of priorities and policies and would address the operational challenges of coordination and communication within the department.
Such a forum could also provide better oversight and interaction with cross-departmental groups created to address issues identified by the Secretary, such as the Data Council, the Children's Council, and the Environmental Health Policy Committee.
A defined charter, staff, and timetable for selected cross-cutting activities would strengthen collaboration across units and produce specific recommendations for action.
Recent decisions by DHHS leadership to recentralize public and legislative affairs functions do not address the fundamental issue of policy and program coordination.
There is also tension within DHHS about the role of the regional offices (Boufford and Lee, 2001).
Advocates for strong regional offices see them as effective vehicles for communicating DHHS priorities, learning about local needs and circumstances, and developing appropriate responses through the department or by other means.
The regional offices are also seen as aids in convening state leadership in health and human services in those regions and in convening local leaders to help them find ways to increase their access to federal programs or to collaborate with others in the public and private sectors to make DHHS programs effective.
Although others prefer that DHHS agencies work directly with state and local governments and grantees, such agency-by-agency linkages can add to the fragmentation of efforts to address population health.
If regional offices are to become an integral and valuable part of DHHS, they will require managerial attention and resources for significant staff development or redeployment to obtain the expertise needed in certain program areas (Boufford and Lee, 2001).
Interagency Collaboration
Interagency collaboration at the federal level can be difficult because of the specialized nature of agency structures.
Every agency has its traditional role and expectations for performance, its legislative champions, and its special-interest advocates.
According to Bardach (1998), barriers to collaboration across agency lines are the fact that collaboration tends to blur an agency's mission and the fact that the agency is politically accountable for pursuing that mission.
This historical reality has led to the increasing isolation of cabinet departments and the agencies within those departments from each other and has created real barriers to the programs within agencies that seek to collaborate.
This is understandable historically but is clearly dysfunctional in an increasingly complex world where no single agency can do its important work in isolation.
This lack of integration is especially evident in the area of health, where health-related programs are already fragmented within DHHS and are widely distributed across cabinet and subcabinet departments outside DHHS.
For example, when EPA became an independent agency, it assumed the regulatory functions of environmental protection, yet the key expertise in the human health effects of environmental hazards remains at DHHS in the National Center for Environmental Health at CDC, ATSDR, the National Institute of Environmental Health Sciences at NIH, and some parts of FDA.
Many agencies not traditionally associated with health issues make policy and manage programs with potential implications for health (see Chapter 2).
Greater policy coordination with the Departments of Education, Energy, Treasury, and Labor, to name a few, could enhance the potential to create the societal conditions needed for people to be as healthy as possible.
Another area for greater collaboration and coordination is with nongovernmental entities.
This can be particularly challenging in the area of health care delivery because of the government's role as regulator and payer.
The same holds true at the state level.
The need for effective coordinating structures is very important because most experienced government officials agree that major organizational restructuring is rarely worth the time and political trouble involved (even if it could be achieved), so although it may seem advisable to reunite DHHS and EPA or create a food safety agency independent from portions of FDA, the Department of Agriculture, and EPA, the obstacles are formidable.
Bardach (1998) found, however, that various administrative mechanisms could enhance the effectiveness of cross-agency collaboration.
These may include formal agreements at the executive level; assignment of personnel, budget, equipment, and space to a collaborative task; delegation and accountability for the relationships relating to the task; and the provision of administrative services to support the work.
The success of efforts such as the Presidential Task Force on Food Safety, the Task Force on Environmental Health Risks and Safety Risks to Children, and the multiagency task force on bioterrorism demonstrate the benefits of cross-agency collaboration.
The committee particularly noted that the lack of coordination between DHHS and other agencies with health-related responsibilities often creates major obstacles to the effective use of federal regulatory and standard-setting powers in health.
Inconsistencies between DHHS agencies and other science-based regulatory agencies — for example, between DHHS and EPA — lead to standards on the levels of particular chemicals or toxins hazardous to the health of humans that are different from the levels hazardous to the health of animals and vegetation (Boufford and Lee, 2001).
These issues are usually addressed on a case-by-case basis through work groups or crisis management activities.
During the Reagan administration, for example, cabinet councils chaired by a designated secretary were used to coordinate efforts across departments.
They worked when they were well staffed and participation at the deputy or assistant secretary level was consistent, with secretaries available as needed (Edward Brandt, personal communication, 2001).
A final challenge is the integration of federal standard setting and regulation with the equally varied jurisdictions of state and local health departments or other health-related agencies.
Again, creative and sustained mechanisms to develop collaborative relationships and to harmonize regulations within DHHS, across federal agencies, and among federal, state, and local governments are critical to effective action for protecting the population's health.
In June 2001, the Secretary of DHHS established the Advisory Committee on Regulatory Reform.
The committee is charged with conducting a department-wide initiative to reduce regulatory burdens in health care and to respond faster to the concerns of health care providers, state and local governments, and individual Americans who are affected by DHHS rules.
The Advisory Committee conducted six data-gathering meetings across the country.
The committee was expected to present a final report and recommendations in the fall of 2002 for changes in four areas: health care delivery, health systems operations, biomedical and health research, and the development of pharmaceuticals and other products.
A review of the report shows that much attention was directed to implementing changes in the health care delivery component of the public health system, with little attention paid to the regulatory inconsistencies, burdens, and inefficiencies in the governmental public health component of the system.
Given these organizational and management findings, the committee recommends that the Secretary of DHHS review the regulatory authorities of DHHS agencies with health-related responsibilities to reduce overlap and inconsistencies, ensure that the department's management structure is best suited to coordinate the efforts among agencies within DHHS with health-related responsibilities, and, to the extent possible, simplify relationships with state and local governmental public health agencies.
Similar efforts should be made to improve coordination with other federal cabinet agencies performing important public health services, such as the Department of Agriculture and the Environmental Protection Agency.
The committee also notes that the division of authority in the federal government hinders the development of a coherent international health policy.
With increasing cross-border flows of people, pharmaceuticals, and food, countries cannot adequately protect their populations through unilateral domestic or foreign policy action; they must collaborate with other countries and within the frameworks of international agreements.
This is especially true in matters of health and environment.
The World Health Organization (WHO) is a forum for standard setting on issues such as international travel health standards, the quality of pharmaceuticals, and food quality and safety.
A lack of funding for research on diseases that disproportionately affect the developing world (the “10/90” gap) (Davey, 2000), the weakness of the research infrastructure in these countries, and the need to address matters of intellectual property involved in making basic drugs available to nations without their own production capacities are only a few of the issues that can benefit from high levels of involvement from developed countries such as the United States, with its wealth and scientific expertise.
At present, the Department of State is the lead U.S. agency on international affairs and pays dues to international agencies like WHO.
Because of the importance of health and science to its work, it has recently appointed a deputy assistant secretary for health and science.
The funding for U.S. development assistance in health comes through congressional funding to the U.S. Agency for International Development, which funds much of its international health work by contract with DHHS, largely CDC.
DHHS has only limited authority from Congress to spend money on international health activities.
Coordination across all these agencies is critical to assuring a coordinated strategy for international health.
During the Clinton administration, a senior public health officer served on the National Security Council (NSC) as health liaison to the various agencies.
In a consultation conducted by IOM, among representatives from the major departments that address international health issues (and others involved in international health policy, from EPA to the Departments of Agriculture and Commerce), all agreed that there was a problem in coordination and clear leadership on international health that prevented effective long-term planning.
They agreed that NSC leadership could provide a focal point for such coordination, absent an executive decision to appoint a lead agency (IOM, 1999).
The NSC health liaison position was phased out during the early days of the Bush administration.
In America's Vital Interest in Global Health, IOM (1997a) called for better coordination of global health policy within the U.S. government through the use of a Task Force on Global Health.
That report also recommended legislative changes to expand international authorities and funding to DHHS “because of its unique scientific and technical expertise” to lead such an effort across the government and to serve as a focal point for links to nongovernmental organizations and academia.
This committee concurs with the need for an effective mechanism for coordination of international health policy making and urges the administration and Congress to consider steps to this end such as the appointment of a permanent NSC liaison for international health, the designation of a lead agency for international health or the formation of a formal cross-cabinet body, and the review of Public Health Service Act authorities for DHHS funding of international health initiatives.
TO BE CONTINUED ...
The Future of the Public's Health in the 21st Century, continued ...
Strengthening the Management Capacity of DHHS
From 1993 to 1997, DHHS, like all federal government departments, conducted a reinvention exercise to determine what work it should do and how it could do that work more effectively and responsively.
A recent monograph on DHHS and the impact of departmental reinvention efforts in the late 1990s identified two issues of particular significance: (1) the effect of the balance between centralization and decentralization on the management of departmental activities and (2) the relationship of the department with other agencies (Boufford and Lee, 2001).
Centralization versus Decentralization: Models for Managing DHHS
The committee's discussion of key federal functions — policy making, financing, infrastructure development, and the like — illustrate how the problems of fragmentation in federal public health activities affect the functioning of state and local public agencies.
Such problems are related to historical patterns and political interests that have shaped federal health structures, but they are not being addressed by the present management structure for health activities in DHHS.
The reinvention exercise led to a decision to have each of the PHS agencies report directly to the Secretary of DHHS rather than to the Assistant Secretary for Health.
Potential advantages were seen in bringing the agency heads closer to the Secretary and having more than a single voice for health at the decision-making table.
Boufford and Lee (2001) found that without a formal mechanism for joint priority setting and routine decision-making across the department, operations became even more decentralized, with staff identifying more with their own agencies or programs than with the department as a whole.
The leadership of operating divisions generally prefers to report directly to the Secretary, but division leaders would also welcome a clearly defined structure to formalize coordination, collaboration, and communication among departmental units.
Creating a formal mechanism for regular meetings of the heads of operating divisions, as well as meetings with the Secretary, would permit more substantive and forward-looking discussion of priorities and policies and would address the operational challenges of coordination and communication within the department.
Such a forum could also provide better oversight and interaction with cross-departmental groups created to address issues identified by the Secretary, such as the Data Council, the Children's Council, and the Environmental Health Policy Committee.
A defined charter, staff, and timetable for selected cross-cutting activities would strengthen collaboration across units and produce specific recommendations for action.
Recent decisions by DHHS leadership to recentralize public and legislative affairs functions do not address the fundamental issue of policy and program coordination.
There is also tension within DHHS about the role of the regional offices (Boufford and Lee, 2001).
Advocates for strong regional offices see them as effective vehicles for communicating DHHS priorities, learning about local needs and circumstances, and developing appropriate responses through the department or by other means.
The regional offices are also seen as aids in convening state leadership in health and human services in those regions and in convening local leaders to help them find ways to increase their access to federal programs or to collaborate with others in the public and private sectors to make DHHS programs effective.
Although others prefer that DHHS agencies work directly with state and local governments and grantees, such agency-by-agency linkages can add to the fragmentation of efforts to address population health.
If regional offices are to become an integral and valuable part of DHHS, they will require managerial attention and resources for significant staff development or redeployment to obtain the expertise needed in certain program areas (Boufford and Lee, 2001).
Interagency Collaboration
Interagency collaboration at the federal level can be difficult because of the specialized nature of agency structures.
Every agency has its traditional role and expectations for performance, its legislative champions, and its special-interest advocates.
According to Bardach (1998), barriers to collaboration across agency lines are the fact that collaboration tends to blur an agency's mission and the fact that the agency is politically accountable for pursuing that mission.
This historical reality has led to the increasing isolation of cabinet departments and the agencies within those departments from each other and has created real barriers to the programs within agencies that seek to collaborate.
This is understandable historically but is clearly dysfunctional in an increasingly complex world where no single agency can do its important work in isolation.
This lack of integration is especially evident in the area of health, where health-related programs are already fragmented within DHHS and are widely distributed across cabinet and subcabinet departments outside DHHS.
For example, when EPA became an independent agency, it assumed the regulatory functions of environmental protection, yet the key expertise in the human health effects of environmental hazards remains at DHHS in the National Center for Environmental Health at CDC, ATSDR, the National Institute of Environmental Health Sciences at NIH, and some parts of FDA.
Many agencies not traditionally associated with health issues make policy and manage programs with potential implications for health (see Chapter 2).
Greater policy coordination with the Departments of Education, Energy, Treasury, and Labor, to name a few, could enhance the potential to create the societal conditions needed for people to be as healthy as possible.
Another area for greater collaboration and coordination is with nongovernmental entities.
This can be particularly challenging in the area of health care delivery because of the government's role as regulator and payer.
The same holds true at the state level.
The need for effective coordinating structures is very important because most experienced government officials agree that major organizational restructuring is rarely worth the time and political trouble involved (even if it could be achieved), so although it may seem advisable to reunite DHHS and EPA or create a food safety agency independent from portions of FDA, the Department of Agriculture, and EPA, the obstacles are formidable.
Bardach (1998) found, however, that various administrative mechanisms could enhance the effectiveness of cross-agency collaboration.
These may include formal agreements at the executive level; assignment of personnel, budget, equipment, and space to a collaborative task; delegation and accountability for the relationships relating to the task; and the provision of administrative services to support the work.
The success of efforts such as the Presidential Task Force on Food Safety, the Task Force on Environmental Health Risks and Safety Risks to Children, and the multiagency task force on bioterrorism demonstrate the benefits of cross-agency collaboration.
The committee particularly noted that the lack of coordination between DHHS and other agencies with health-related responsibilities often creates major obstacles to the effective use of federal regulatory and standard-setting powers in health.
Inconsistencies between DHHS agencies and other science-based regulatory agencies — for example, between DHHS and EPA — lead to standards on the levels of particular chemicals or toxins hazardous to the health of humans that are different from the levels hazardous to the health of animals and vegetation (Boufford and Lee, 2001).
These issues are usually addressed on a case-by-case basis through work groups or crisis management activities.
During the Reagan administration, for example, cabinet councils chaired by a designated secretary were used to coordinate efforts across departments.
They worked when they were well staffed and participation at the deputy or assistant secretary level was consistent, with secretaries available as needed (Edward Brandt, personal communication, 2001).
A final challenge is the integration of federal standard setting and regulation with the equally varied jurisdictions of state and local health departments or other health-related agencies.
Again, creative and sustained mechanisms to develop collaborative relationships and to harmonize regulations within DHHS, across federal agencies, and among federal, state, and local governments are critical to effective action for protecting the population's health.
In June 2001, the Secretary of DHHS established the Advisory Committee on Regulatory Reform.
The committee is charged with conducting a department-wide initiative to reduce regulatory burdens in health care and to respond faster to the concerns of health care providers, state and local governments, and individual Americans who are affected by DHHS rules.
The Advisory Committee conducted six data-gathering meetings across the country.
The committee was expected to present a final report and recommendations in the fall of 2002 for changes in four areas: health care delivery, health systems operations, biomedical and health research, and the development of pharmaceuticals and other products.
A review of the report shows that much attention was directed to implementing changes in the health care delivery component of the public health system, with little attention paid to the regulatory inconsistencies, burdens, and inefficiencies in the governmental public health component of the system.
Given these organizational and management findings, the committee recommends that the Secretary of DHHS review the regulatory authorities of DHHS agencies with health-related responsibilities to reduce overlap and inconsistencies, ensure that the department's management structure is best suited to coordinate the efforts among agencies within DHHS with health-related responsibilities, and, to the extent possible, simplify relationships with state and local governmental public health agencies.
Similar efforts should be made to improve coordination with other federal cabinet agencies performing important public health services, such as the Department of Agriculture and the Environmental Protection Agency.
The committee also notes that the division of authority in the federal government hinders the development of a coherent international health policy.
With increasing cross-border flows of people, pharmaceuticals, and food, countries cannot adequately protect their populations through unilateral domestic or foreign policy action; they must collaborate with other countries and within the frameworks of international agreements.
This is especially true in matters of health and environment.
The World Health Organization (WHO) is a forum for standard setting on issues such as international travel health standards, the quality of pharmaceuticals, and food quality and safety.
A lack of funding for research on diseases that disproportionately affect the developing world (the “10/90” gap) (Davey, 2000), the weakness of the research infrastructure in these countries, and the need to address matters of intellectual property involved in making basic drugs available to nations without their own production capacities are only a few of the issues that can benefit from high levels of involvement from developed countries such as the United States, with its wealth and scientific expertise.
At present, the Department of State is the lead U.S. agency on international affairs and pays dues to international agencies like WHO.
Because of the importance of health and science to its work, it has recently appointed a deputy assistant secretary for health and science.
The funding for U.S. development assistance in health comes through congressional funding to the U.S. Agency for International Development, which funds much of its international health work by contract with DHHS, largely CDC.
DHHS has only limited authority from Congress to spend money on international health activities.
Coordination across all these agencies is critical to assuring a coordinated strategy for international health.
During the Clinton administration, a senior public health officer served on the National Security Council (NSC) as health liaison to the various agencies.
In a consultation conducted by IOM, among representatives from the major departments that address international health issues (and others involved in international health policy, from EPA to the Departments of Agriculture and Commerce), all agreed that there was a problem in coordination and clear leadership on international health that prevented effective long-term planning.
They agreed that NSC leadership could provide a focal point for such coordination, absent an executive decision to appoint a lead agency (IOM, 1999).
The NSC health liaison position was phased out during the early days of the Bush administration.
In America's Vital Interest in Global Health, IOM (1997a) called for better coordination of global health policy within the U.S. government through the use of a Task Force on Global Health.
That report also recommended legislative changes to expand international authorities and funding to DHHS “because of its unique scientific and technical expertise” to lead such an effort across the government and to serve as a focal point for links to nongovernmental organizations and academia.
This committee concurs with the need for an effective mechanism for coordination of international health policy making and urges the administration and Congress to consider steps to this end such as the appointment of a permanent NSC liaison for international health, the designation of a lead agency for international health or the formation of a formal cross-cabinet body, and the review of Public Health Service Act authorities for DHHS funding of international health initiatives.
TO BE CONTINUED ...
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
NCBI
The Future of the Public's Health in the 21st Century, concluded ...
CONCLUDING OBSERVATIONS
To most effectively protect and promote the health of the population, the nation's entire governmental public health infrastructure — its human resources, information systems, and organizational capacity — must be revitalized and strengthened.
Doing so will require federal, state, and local governmental collaboration to assess the needs in each community and to identify national and local strategies to meet those needs.
Furthermore, federal, state, and local governments will need to create innovative financing mechanisms that can add new resources (including those from the private sector) to those already committed by all levels of government to infrastructure development and capacity building and ensure that these investments are sustainable over time.
Most importantly, it is the responsibility of the federal government to ensure that these actions at the federal, state, and local levels contribute to the creation and maintenance of a comprehensive, intersectoral public health system that serves to protect and promote the health of Americans.
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Footnotes
1. The 10th Amendment enunciates the plenary power retained by the states: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”
2. According to 1990 Census Bureau data, about 56 percent of the American Indian and Alaska Native population lived in urban areas (IHS, 2001b). Census data for 2000 show a similar pattern, with 57 percent of individuals who identify themselves solely as Native American or Alaska Native living in metropolitan areas (Forquera, 2001).
3. For example, a South Dakota statute passed in the late 1800s and last amended in 1977 makes it a misdemeanor for a person infected with a “contagious disease” to “intentionally [expose] himself . . . in any public place or thoroughfare” (S.D. Codified Laws § 34–22–5). Similarly, an 1895 New Jersey statute forbids common carriers to “accept for transportation within this state any person affected with a communicable disease or any article of clothing, bedding, or other property so infected” without a license from the local board of health (N.J. Stat. Ann. § 26:4–11 9). This might have made some sense in a time when diseases such as influenza, diphtheria, and measles were significant sources of serious illness and death, but it serves little purpose today. Although it may be impolite for people with the flu to walk around in public, it is not a major health threat. Furthermore, efforts to isolate people who do not pose a significant health risk would often violate modern disability discrimination law (it was held that the threat of disease did not justify excessively stringent quarantine of a blind plaintiff's guide dog) (see Crowder v. Kitagawa, 81 F.3d 1480, 1481, 9th Circuit, 1996).
4. Turning Point, a program funded by the Robert Wood Johnson and W. K. Kellogg Foundations, works to strengthen the public health infrastructure at the state and local levels across the United States and spearheads the Turning Point National Collaborative on Public Health Statute Modernization.
5. The Model State Emergency Health Powers Act (MSEHPA) provides states with the powers needed “to detect and contain bioterrorism or a naturally occurring disease outbreak. Legislative bills based on MSEHPA have been introduced in 34 states” (Gostin et al., 2002).
6. Home-rule statutes (in constitutions or by statute) give localities (e.g., cities or counties) powers of self-government. In such cases, localities can exercise police powers independently from the state.
7. Federal agencies have developed numerous regulatory techniques and decision-making processes to identify and respond to health and safety risks (Gostin, 2000). Agencies can control entry into a field by requiring a license or permit to undertake specified activities; set health and safety standards, conduct inspections to ensure compliance, adjudicate violations, and impose penalties; abate nuisances that threaten the public; dispense grants, subsidies, or other incentives; and influence conduct through a wide variety of informal methods (Gostin, 2000). For example, the Department of Agriculture regulates the safety of meat, poultry, and eggs. EPA regulates air and water pollution, pesticides, and toxic wastes. The Department of Energy oversees radiation-related environmental management, environmental safety and health, and civilian radioactive waste management. The Department of Labor regulates occupational health and safety and self-insured employee benefit plans. The Department of Transportation sets and monitors standards for highway safety. The Bureau of Alcohol, Tobacco, and Firearms in the Department of the Treasury, the Consumer Product Safety Commission, the Federal Trade Commission, and the Occupational Safety and Health Administration also issue regulations that protect the public against health risks (Boufford and Lee, 2001).
8. The Council on Linkages between Academia and Public Health Practice is composed of leaders from national organizations representing the public health practice and academic communities. The council grew out of the Public Health Faculty/Agency Forum, which developed recommendations for improving the relevance of public health education to the demands of public health in the practice sector. The council and its partners have focused attention on the need for a public health practice research agenda.
9. Sandia is a multiprogram engineering and science laboratory operated by Sandia Corporation, a Lockheed Martin Company, for the Department of Energy's National Nuclear Security Administration.
10. CLIA, enacted by Congress in 1988, mandated a broad and wide-ranging change in the regulation of laboratories that perform testing for medical diagnoses. CLIA expanded federal regulatory authority to approximately 170,000 laboratories, most of which were previously unregulated laboratories in physicians' offices. In 1997, these laboratories performed an estimated 8 billion tests at a cost of approximately $30 billion. In June 1991, the Secretary of DHHS delegated responsibility for development and implementation of the scientific and technical aspects of the regulations to CDC. Within CDC, the Division of Laboratory Systems, Public Health Practice Program Office, carries out the responsibility of standards development and laboratory improvement, whereas CMS administers the program (CDC, 2001c).
11. Individual states reported a range from 1.4 to 89 staff per 1 million population.
12. CIDRAP was established in September 2001 with the mission of (1) supporting the development of and refining public policies relating to the prevention, control, and treatment of infectious diseases to ensure that they reflect the most current biomedical knowledge, and (2) promoting practices among both health care professionals and the public that aim to reduce illness and death from infectious diseases through provision of accurate, up-to-date information and education.
13. At the time that this report was drafted, legislation for a Department of Homeland Security was under debate. The legislation proposes a “single focal point” for managing and overseeing security functions across Congress, federal departments and agencies, state governments, and local governments. Such a department undoubtedly will have direct and indirect implications for governmental public health agencies. However, the evolving nature of this process led the committee not to include a discussion of this work in progress.
14. The Lewin Group is a health and human services consulting firm whose activities include advising public, private, and nonprofit sectors to improve policy, manage and evaluate programs, and maximize performance as well as other issues.
Bookshelf ID: NBK221231
National Center for Biotechnology Information,
U.S. National Library of Medicine
8600 Rockville Pike, Bethesda MD, 20894 USA
https://www.ncbi.nlm.nih.gov/books/NBK221231/
The Future of the Public's Health in the 21st Century, concluded ...
CONCLUDING OBSERVATIONS
To most effectively protect and promote the health of the population, the nation's entire governmental public health infrastructure — its human resources, information systems, and organizational capacity — must be revitalized and strengthened.
Doing so will require federal, state, and local governmental collaboration to assess the needs in each community and to identify national and local strategies to meet those needs.
Furthermore, federal, state, and local governments will need to create innovative financing mechanisms that can add new resources (including those from the private sector) to those already committed by all levels of government to infrastructure development and capacity building and ensure that these investments are sustainable over time.
Most importantly, it is the responsibility of the federal government to ensure that these actions at the federal, state, and local levels contribute to the creation and maintenance of a comprehensive, intersectoral public health system that serves to protect and promote the health of Americans.
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Footnotes
1. The 10th Amendment enunciates the plenary power retained by the states: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”
2. According to 1990 Census Bureau data, about 56 percent of the American Indian and Alaska Native population lived in urban areas (IHS, 2001b). Census data for 2000 show a similar pattern, with 57 percent of individuals who identify themselves solely as Native American or Alaska Native living in metropolitan areas (Forquera, 2001).
3. For example, a South Dakota statute passed in the late 1800s and last amended in 1977 makes it a misdemeanor for a person infected with a “contagious disease” to “intentionally [expose] himself . . . in any public place or thoroughfare” (S.D. Codified Laws § 34–22–5). Similarly, an 1895 New Jersey statute forbids common carriers to “accept for transportation within this state any person affected with a communicable disease or any article of clothing, bedding, or other property so infected” without a license from the local board of health (N.J. Stat. Ann. § 26:4–11 9). This might have made some sense in a time when diseases such as influenza, diphtheria, and measles were significant sources of serious illness and death, but it serves little purpose today. Although it may be impolite for people with the flu to walk around in public, it is not a major health threat. Furthermore, efforts to isolate people who do not pose a significant health risk would often violate modern disability discrimination law (it was held that the threat of disease did not justify excessively stringent quarantine of a blind plaintiff's guide dog) (see Crowder v. Kitagawa, 81 F.3d 1480, 1481, 9th Circuit, 1996).
4. Turning Point, a program funded by the Robert Wood Johnson and W. K. Kellogg Foundations, works to strengthen the public health infrastructure at the state and local levels across the United States and spearheads the Turning Point National Collaborative on Public Health Statute Modernization.
5. The Model State Emergency Health Powers Act (MSEHPA) provides states with the powers needed “to detect and contain bioterrorism or a naturally occurring disease outbreak. Legislative bills based on MSEHPA have been introduced in 34 states” (Gostin et al., 2002).
6. Home-rule statutes (in constitutions or by statute) give localities (e.g., cities or counties) powers of self-government. In such cases, localities can exercise police powers independently from the state.
7. Federal agencies have developed numerous regulatory techniques and decision-making processes to identify and respond to health and safety risks (Gostin, 2000). Agencies can control entry into a field by requiring a license or permit to undertake specified activities; set health and safety standards, conduct inspections to ensure compliance, adjudicate violations, and impose penalties; abate nuisances that threaten the public; dispense grants, subsidies, or other incentives; and influence conduct through a wide variety of informal methods (Gostin, 2000). For example, the Department of Agriculture regulates the safety of meat, poultry, and eggs. EPA regulates air and water pollution, pesticides, and toxic wastes. The Department of Energy oversees radiation-related environmental management, environmental safety and health, and civilian radioactive waste management. The Department of Labor regulates occupational health and safety and self-insured employee benefit plans. The Department of Transportation sets and monitors standards for highway safety. The Bureau of Alcohol, Tobacco, and Firearms in the Department of the Treasury, the Consumer Product Safety Commission, the Federal Trade Commission, and the Occupational Safety and Health Administration also issue regulations that protect the public against health risks (Boufford and Lee, 2001).
8. The Council on Linkages between Academia and Public Health Practice is composed of leaders from national organizations representing the public health practice and academic communities. The council grew out of the Public Health Faculty/Agency Forum, which developed recommendations for improving the relevance of public health education to the demands of public health in the practice sector. The council and its partners have focused attention on the need for a public health practice research agenda.
9. Sandia is a multiprogram engineering and science laboratory operated by Sandia Corporation, a Lockheed Martin Company, for the Department of Energy's National Nuclear Security Administration.
10. CLIA, enacted by Congress in 1988, mandated a broad and wide-ranging change in the regulation of laboratories that perform testing for medical diagnoses. CLIA expanded federal regulatory authority to approximately 170,000 laboratories, most of which were previously unregulated laboratories in physicians' offices. In 1997, these laboratories performed an estimated 8 billion tests at a cost of approximately $30 billion. In June 1991, the Secretary of DHHS delegated responsibility for development and implementation of the scientific and technical aspects of the regulations to CDC. Within CDC, the Division of Laboratory Systems, Public Health Practice Program Office, carries out the responsibility of standards development and laboratory improvement, whereas CMS administers the program (CDC, 2001c).
11. Individual states reported a range from 1.4 to 89 staff per 1 million population.
12. CIDRAP was established in September 2001 with the mission of (1) supporting the development of and refining public policies relating to the prevention, control, and treatment of infectious diseases to ensure that they reflect the most current biomedical knowledge, and (2) promoting practices among both health care professionals and the public that aim to reduce illness and death from infectious diseases through provision of accurate, up-to-date information and education.
13. At the time that this report was drafted, legislation for a Department of Homeland Security was under debate. The legislation proposes a “single focal point” for managing and overseeing security functions across Congress, federal departments and agencies, state governments, and local governments. Such a department undoubtedly will have direct and indirect implications for governmental public health agencies. However, the evolving nature of this process led the committee not to include a discussion of this work in progress.
14. The Lewin Group is a health and human services consulting firm whose activities include advising public, private, and nonprofit sectors to improve policy, manage and evaluate programs, and maximize performance as well as other issues.
Bookshelf ID: NBK221231
National Center for Biotechnology Information,
U.S. National Library of Medicine
8600 Rockville Pike, Bethesda MD, 20894 USA
https://www.ncbi.nlm.nih.gov/books/NBK221231/
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
NCBI
The Future of Public Health.
3A History of the Public Health System
In Chapter 1, the committee found that the current public health system must play a critical role in handling major threats to the public health, but that this system is currently in disarray.
Chapter 2 explained the committee's ideal for the public health system — how it should be arranged for handling current and future threats to health.
In this chapter the history of the existing public health system is briefly described.
This history is intended to provide some perspective on how protection of citizens from health threats came to be a public responsibility and on how the public health system came to be in its current state.
History
During the past 150 years, two factors have shaped the modern public health system: first, the growth of scientific knowledge about sources and means of controlling disease; second, the growth of public acceptance of disease control as both a possibility and a public responsibility.
In earlier centuries, when little was known about the causes of disease, society tended to regard illness with a degree of resignation, and few public actions were taken.
As understanding of sources of contagion and means of controlling disease became more refined, more effective interventions against health threats were developed.
Public organizations and agencies were formed to employ newly discovered interventions against health threats.
As scientific knowledge grew, public authorities expanded to take on new tasks, including sanitation, immunization, regulation, health education, and personal health care. (Chave, 1984; Fee, 1987)
The link between science, the development of interventions, and organization of public authorities to employ interventions was increased public understanding of and social commitment to enhancing health.
The growth of a public system for protecting health depended both on scientific discovery and social action.
Understanding of disease made public measures to alleviate pain and suffering possible, and social values about the worthiness of this goal made public measures feasible.
The history of the public health system is a history of bringing knowledge and values together in the public arena to shape an approach to health problems.
Before the Eighteenth Century
Throughout recorded history, epidemics such as the plague, cholera, and smallpox evoked sporadic public efforts to protect citizens in the face of a dread disease.
Although epidemic disease was often considered a sign of poor moral and spiritual condition, to be mediated through prayer and piety, some public effort was made to contain the epidemic spread of specific disease through isolation of the ill and quarantine of travelers.
In the late seventeenth century, several European cities appointed public authorities to adopt and enforce isolation and quarantine measures (and to report and record deaths from the plague). (Goudsblom, 1986)
The Eighteenth Century
By the eighteenth century, isolation of the ill and quarantine of the exposed became common measures for containing specified contagious diseases.
Several American port cities adopted rules for trade quarantine and isolation of the sick.
In 1701 Massachusetts passed laws for isolation of smallpox patients and for ship quarantine as needed.
(After 1721, inoculation with material from smallpox scabs was also accepted as an effective means of containing this disease once the threat of an epidemic was declared.)
By the end of the eighteenth century, several cities, including Boston, Philadelphia, New York, and Baltimore, had established permanent councils to enforce quarantine and isolation rules. (Hanlon and Pickett, 1984)
These eighteenth-century initiatives reflected new ideas about both the cause and meaning of disease.
Diseases were seen less as natural effects of the human condition and more as potentially controllable through public action.
Also in the eighteenth century, cities began to establish voluntary general hospitals for the physically ill and public institutions for the care of the mentally ill.
Finally, physically and mentally ill dependents were cared for by their neighbors in local communities.
This practice was made official in England with the adoption of the 1601 Poor Law and continued in the American colonies. (Grob, 1966; Starr, 1982)
By the eighteenth century, several communities had reached a size that demanded more formal arrangements for care of their ill than Poor Law practices.
The first American voluntary hospitals were established in Philadelphia in 1752 and in New York in 1771.
The first public mental hospital was established in Williamsburg, Virginia in 1773. (Turner, 1977)
The Nineteenth Century: The Great Sanitary Awakening
The nineteenth century marked a great advance in public health.
"The great sanitary awakening" (Winslow, 1923) — the identification of filth as both a cause of disease and a vehicle of transmission and the ensuing embrace of cleanliness — was a central component of nineteenth-century social reforms.
Sanitation changed the way society thought about health.
Illness came to be seen as an indicator of poor social and environmental conditions, as well as poor moral and spiritual conditions.
Cleanliness was embraced as a path both to physical and moral health.
Cleanliness, piety, and isolation were seen to be compatible and mutually reinforcing measures to help the public resist disease.
At the same time, mental institutions became oriented toward "moral treatment" and cure.
Sanitation also changed the way society thought about public responsibility for citizen's health.
Protecting health became a social responsibility.
Disease control continued to focus on epidemics, but the manner of controlling turned from quarantine and isolation of the individual to cleaning up and improving the common environment.
And disease control shifted from reacting to intermittent outbreaks to continuing measures for prevention.
With sanitation, public health became a societal goal and protecting health became a public activity.
The Sanitary Problem
With increasing urbanization of the population in the nineteenth century, filthy environmental conditions became common in working class areas, and the spread of disease became rampant.
In London, for example, smallpox, cholera, typhoid, and tuberculosis reached unprecedented levels.
It was estimated that as many as 1 person in 10 died of smallpox.
More than half the working class died before their fifth birthday.
Meanwhile, "In the summers of 1858 and 1859 the Thames stank so badly as to rise "to the height of an historic event … for months together the topic almost monopolized the public prints'." (Winslow, 1923)
London was not alone in this dilemma.
In New York, as late as 1865, "the filth and garbage accumulate in the streets to the depth sometimes of two or three feet."
In a 2-week survey of tenements in the sixteenth ward of New York, inspectors found more than 1,200 cases of smallpox and more than 2,000 cases of typhus. (Winslow, 1923)
In Massachusetts in 1850, deaths from tuberculosis were 300 per 100,000 population, and infant mortality was about 200 per 1,000 live births. (Hanlon and Pickett, 1984)
Earlier measures of isolation and quarantine during specific disease outbreaks were clearly inadequate in an urban society.
It was simply impossible to isolate crowded slum dwellers or quarantine citizens who could not afford to stop working. (Wohl, 1983)
It also became clear that diseases were not just imported from other shores, but were internally generated.
''The belief that epidemic disease posed only occasional threats to an otherwise healthy social order was shaken by the industrial transformation of the nineteenth century." (Fee, 1987)
Industrialization, with its overburdened workforce and crowded dwellings, produced both a population more susceptible to disease and conditions in which disease was more easily transmitted. (Wohl, 1983)
Urbanization, and the resulting concentration of filth, was considered in and of itself a cause of disease.
"In the absence of specific etiological concepts, the social and physical conditions which accompanied urbanization were considered equally responsible for the impairment of vital bodily functions and premature death." (Rosenkrantz, 1972)
At the same time, public responsibility for the health of the population became more acceptable and fiscally possible.
In earlier centuries, disease was more readily identified as only the plight of the impoverished and immoral.
The plague had been regarded as a disease of the poor; the wealthy could retreat to country estates and, in essence, quarantine themselves.
In the urbanized nineteenth century, it became obvious that the wealthy could not escape contact with the poor.
"Increasingly, it dawned upon the rich that they could not ignore the plight of the poor; the proximity of gold coast and slum was too close." (Goudsblom, 1986)
And the spread of contagious disease in these cities was not selective.
Almost all families lost children to diphtheria, smallpox, or other infectious diseases.
Because of the deplorable social and environmental conditions and the constant threat of disease spread, diseases came to be considered an indicator of a societal problem as well as a personal problem.
"Poverty and disease could no longer be treated simply as individual failings." (Fee, 1987)
This view included not only contagious disease, but mental illness as well.
Insanity came to be viewed at least in part as a societal failing, caused by physical, moral, and social tensions.
The Development of Public Activities in Health
Edwin Chadwick, a London lawyer and secretary of the Poor Law Commission in 1838, is one of the most recognized names in the sanitary reform movement.
Under Chadwick's authority, the commission conducted studies of the life and health of the London working class in 1838 and that of the entire country in 1842.
The report of these studies, General Report on the Sanitary Conditions of the Labouring Population of Great Britain, "was a damning and fully documented indictment of the appalling conditions in which masses of the working people were compelled to live, and die, in the industrial towns and rural areas of the Kingdom." (Chave, 1984)
Chadwick documented that the average age at death for the gentry was 36 years; for the tradesmen, 22 years; and for the laborers, only 16 years. (Hanlon and Pickett, 1984)
To remedy the situation, Chadwick proposed what came to be known as the "sanitary idea."
His remedy was based on the assumption that diseases are caused by foul air from the decomposition of waste.
To remove disease, therefore, it was necessary to build a drainage network to remove sewage and waste.
Further, Chadwick proposed that a national board of health, local boards in each district, and district medical officers be appointed to accomplish this goal. (Chave, 1984)
Chadwick's report was quite controversial, but eventually many of his suggestions were adopted in the Public Health Act of 1848.
The report, which influenced later developments in public health in England and the United States, documented the extent of disease and suffering in the population, promoted sanitation and engineering as means of controlling disease, and laid the foundation for public infrastructure for combating and preventing contagious disease.
In the United States, similar studies were taking place.
Inspired in part by Chadwick, local sanitary surveys were conducted in several cities.
The most famous of these was a survey conducted by Lemuel Shattuck, a Massachusetts bookseller and statistician.
His Report of the Massachusetts Sanitary Commission was published in 1850.
Shattuck collected vital statistics on the Massachusetts population, documenting differences in morbidity and mortality rates in different localities.
He attributed these differences to urbanization, specifically the foulness of the air created by decay of waste in areas of dense population, and to immoral life-style.
He showed that the poor living conditions in the city threatened the entire community.
"Even those persons who attempted to maintain clean and decent homes were foiled in their efforts to resist diseases if the behavior of others invited the visitation of epidemics." (Rosenkrantz, 1972)
Shattuck considered immorality an important influence on susceptibility to ill health — and in fact drunkenness and sloth did often lead to poor health in the slums — but he believed that these conditions were threatening to all.
Further, Shattuck determined that those most likely to be affected by disease were also those who, either through ignorance or lack of concern, failed to take personal responsibility for cleanliness and sanitation of their area. (Rosenkrantz, 1972)
Consequently, he argued that the city or the state had to take responsibility for the environment.
Shattuck's Report of the Massachusetts Sanitary Commission recommended, in its "Plan for a Sanitary Survey of the State," a comprehensive public health system for the state.
The report recommended, among other things, new census schedules; regular surveys of local health conditions; supervision of water supplies and waste disposal; special studies on specific diseases, including tuberculosis and alcoholism; education of health providers in preventive medicine; local sanitary associations for collecting and distributing information; and the establishment of a state board of health and local boards of health to enforce sanitary regulations. (Winslow, 1923; Rosenkrantz, 1972)
Shattuck's report was widely circulated after publication, but because of political upheaval at the time of release nothing was done.
The report "fell flat from the printer's hand."
In the years following the Civil War, however, the creation of special agencies became a more common method of handling societal problems.
Massachusetts set up a state board of health in 1869.
The creation of this board reflected more a trend of strengthened government than new knowledge about the causes and control of disease.
Nevertheless, the type of data collected by Shattuck was used to justify the board.
And the board relied on many of the recommendations of Shattuck's report for shaping a public health system. (Rosenkrantz, 1972; Hanlon and Pickett, 1984)
Although largely ignored at the time of its release, Shattuck's report has come to be considered one of the most farsighted and influential documents in the history of the American public health system.
Many of the principles and activities he proposed later came to be considered fundamental to public health.
And Shattuck established the fundamental usefulness of keeping records and vital statistics.
Similarly, in New York, John Griscom published The Sanitary Condition of the Labouring Population of New York in 1848.
This report eventually led to the establishment of the first public agency for health, the New York City Health Department, in 1866.
During this same period, boards of health were established in Louisiana, California, the District of Columbia, Virginia, Minnesota, Maryland, and Alabama. (Fee, 1987; Hanlon and Pickett, 1984)
By the end of the nineteenth century, 40 states and several local areas had established health departments.
Although the specific mechanisms of diseases were still poorly understood, collective action against contagious disease proved to be successful.
For example, cholera was known to be a waterborne disease, but the precise agent of infection was not known at this time.
The sanitary reform movement brought more water to cities in the mid-nineteenth century, through private contractors and eventually through reservoirs and municipal water supplies, but its usefulness did not depend primarily on its purity for consumption, but its availability for washing and fire protection. (Blake, 1956)
Nonetheless, sanitary efforts of the New York Board of Health in 1866, including inspections, immediate case reporting, complaint investigations, evacuations, and disinfection of possessions and living quarters, kept an outbreak of cholera to a small number of cases.
"The mildness of the epidemic was no more a stroke of good fortune, observers agreed, but the result of careful planning and hard work by the new health board." (Rosenberg, 1962)
Cities without a public system for monitoring and combatting the disease fared far worse in the 1866 epidemic.
During this period, states also established more public institutions for care of the mentally ill.
Dorothea Dix, a retired school teacher from Maine, is the most familiar name in the reform movement for care of the mentally ill.
In the early nineteenth century, under Poor Law practices, communities that could not place their poor mentally ill citizens in more appropriate institutions put them in municipal jails and almshouses.
Beginning in the middle of the century, Dix led a crusade to publicize the inhumane treatment mentally ill citizens were receiving in jails and campaigned for the establishment of more public institutions for care of the insane.
In the nineteenth century, mental illness was considered a combination of inherited characteristics, medical problems, and social, intellectual, moral, and economic failures.
It was believed, despite the prejudice that the poor and foreign-born were more likely to be mentally ill, that moral treatment in a humane social setting could cure mental illness.
Dix and others argued that in the long run institutional care was cheaper for the community.
The mentally ill could be treated and cured in an institution, making continuing public support unnecessary.
Some 32 public institutions were established due to Dix's efforts.
Although the practice of moral treatment proved to be less successful than hoped, the nineteenth-century social reform movement established the principle of state responsibility for the indigent mentally ill. (Grob, 1966; Foley and Sharfstein, 1983)
New ideas about causes of disease and about social responsibility stimulated the development of public health agencies and institutions.
As environmental and social causes of diseases were identified, social action appeared to be an effective way to control diseases.
When health was no longer simply an individual responsibility, it became necessary to form public boards, agencies, and institutions to protect the health of citizens.
Sanitary and social reform provided the basis for the formation of public health organizations.
Public health agencies and institutions started at the local and state levels in the United States.
Federal activities in health were limited to the Marine Hospital Service, a system of public hospitals for the care of merchant seamen.
Because merchant seamen had no local citizenship, the federal government took on the responsibility of providing their health care.
A national board of health, which was intended to take over the responsibilities of the Marine Hospital Service, was adopted in 1879, but, opposed by the Marine Hospital Service and many southern states, the board lasted only until 1883 (Anderson, 1985)
Meanwhile, several state boards of health, state health departments, and local health departments had been established by the latter part of the nineteenth century. (Hanlon and Pickett, 1984)
Late Nineteenth Century: Enter Bacteriology
Another major set of developments in public health took place at the close of the nineteenth century.
Rapid advances in scientific knowledge about causes and prevention of numerous diseases brought about tremendous changes in public health.
Many major contagious diseases were brought under control through science applied to public health.
Louis Pasteur, a French chemist, proved in 1877 that anthrax is caused by bacteria.
By 1884, he had developed artificial immunization against the disease.
During the following few years, discoveries of bacteriologic agents of disease were made in European and American laboratories for such contagious diseases as tuberculosis, diphtheria, typhoid, and yellow fever. (Winslow, 1923)
The identification of bacteria and the development of interventions such as immunization and water purification techniques provided a means of controlling the spread of disease and even of preventing disease.
The germ theory of disease provided a sound scientific basis for public health.
Public health measures continued to be focused predominantly on specific contagious diseases, but the means of controlling these diseases changed dramatically.
Laboratory research identified exact causes and specific strategies for preventing specific diseases.
For the first time, it was known that diseases had single, specific causes.
Science also revealed that both the environment and people could be the agents of disease.
During this period public agencies that had been developed to conduct and enforce sanitary measures refined their activities and expanded into laboratory science and epidemiology.
Public responsibility for health came to include both environmental sanitation and individual health.
The Development of State and Local Health Department Laboratories
To develop and apply the new scientific knowledge, in the 1890s state and local health departments in the United States began to establish laboratories.
The first were established in Massachusetts, as a cooperative venture between the State Board of Health and the Massachusetts Institute of Technology, and in New York City, as a part of the New York City Health Department.
These were quickly followed by a state hygienic laboratory in Ann Arbor, Michigan, and a municipal public health laboratory in Providence. (Winslow, 1923)
These laboratories concentrated on improving sanitation through detection and control of bacteria in water systems.
W. T. Sedgwick, consulting biologist for Massachusetts, was one of the most famous scientists in sanitation and bacteriologic research.
In 1891 he identified the presence of fecal bacteria in water as the cause of typhoid fever and developed the first sewage treatment techniques.
Sedgwick followed his research on typhoid with many similar investigations of epidemics.
"With the relish of a good storyteller, Sedgwick would unravel a plot in which the villain was a bacterial organism; the victim, the unwitting public; the hero, sanitary hygiene brought to life through the application of scientific methods." (Rosenkrantz, 1972)
In the 1890s, Sedgwick also conducted research on bacteria in milk and was one of the main spokesmen for restrictive rules on the handling and pasteurization of milk.
Laboratory research was also applied to diagnosis of disease in individuals.
Theobald Smith, director of the pathology laboratory in the federal Bureau of Animal Industry, earned an international reputation for his identification of the causes of several diseases in animals and the development of techniques to produce artificial immunity against them.
Later, as director of a state laboratory in Massachusetts, Smith developed vaccines, antitoxins, and diagnostic tests against such diseases as smallpox, meningitis, tuberculosis, and typhoid.
He established the principle of using biological products to produce immunity to a specific disease in the individual and argued that research on the process of disease in the individual as well as the cause of disease in the environment was necessary to develop effective interventions. (Rosenkrantz, 1972)
In New York, the city health department laboratory also promoted diagnosis of contagious diseases in individuals.
New York was one of the first health departments to begin producing antitoxins for physicians' use, and the department offered free laboratory analyses. (Starr, 1982)
Hermann Biggs, pathologist and later commissioner of the New York City Health Department, suggested the application of bacteriology to detecting and controlling cholera.
W. H. Park, another pathologist in the laboratory, introduced bacteriological diagnosis of diphtheria and production of diphtheria antitoxin. (Winslow, 1923)
The Successes of Bacteriology
Some of the comments of the time reveal the enthusiasm with which the public health workers embraced the new scientific foundation for their efforts.
Scientific measures were seen as replacing earlier social, sanitary, moral, and religious reform measures to combat disease.
Science was seen as a more effective means of achieving the same desirable social goals.
Sedgwick declared, "before 1880 we knew nothing; after 1890 we knew it all; it was a glorious ten years." (Fee, 1987)
Charles Chapin, superintendent of Health of Providence, Rhode Island, who published Sources and Modes of Infection in 1910, argued for strictly scientific measures of infectious disease control.
Chapin believed that time spent on cleaning cities was wasted, that instead health officers should concentrate on controlling specific routes of disease transmission.
"There was little more reason for health departments to assume responsibility for street cleaning and control of nuisances, … than 'that they should work for free transfers, cheaper commutation tickets, lower prices for coal, less shoddy in clothing or more rubber in rubbers….''' (Rosenkrantz, 1972)
Herbert Hill, director of the Division of Epidemiology of the Minnesota Board of Health, compared the new epidemiologist to a hunter seeking a sheep-killing wolf: "Instead of finding in the mountains and following inward from them, say, 500 different wolf trails, 499 of which must necessarily be wrong, the experienced hunter goes directly to the slaughtered sheep, finding there and following outward thence the only right trail … the one trail that is necessarily and inevitably the trail of the one actually guilty wolf." (Hill, as quoted by Fee, 1987)
The new methods of disease control were remarkably effective.
For example, prior to 1908 17 American cities had death rates from typhoid fever of 30 or more per 100,000 population; 18 had death rates between 15 and 30 per 100,000.
After water filtering systems were put in place, only 3 of the same cities had rates exceeding 15 per 100,000. (Winslow, 1923)
In another example, the number of deaths from yellow fever in Havana dropped from 305 to 6 in a single year after a team of American military scientists led by Walter Reed identified mosquitoes as carriers of the yellow fever virus. (Winslow, 1923)
As public health became a scientific enterprise, it also became the province of experts.
Prevention and control of disease were no longer tasks of common sense and social compassion, but of knowledge and expertise.
Health reforms were guided by engineers, chemists, biologists, and physicians.
And the health department gained stature as a source of scientific knowledge in health.
It became clear that not only public and individual restraint were needed to control infectious disease, but also state agency epidemiologists and their laboratories were needed to direct the way. (Rosenkrantz, 1974)
Early Twentieth Century: The Move Toward Personal Care
Further Development of State and Local Health Agencies
In the early twentieth century, the role of the state and local public health departments expanded greatly.
Although disease control was based on bacteriology, it became increasingly clear that individual persons were more often the source of disease transmission than things.
"The work of the laboratory led the Board to define the existence and character of an increasing number of the most dangerous diseases and to provide medical means for their control." (Rosenkrantz, 1972)
Identification and treatment of individual cases of disease were the next natural steps.
Massachusetts, Michigan, and New York City began producing and dispensing antitoxins in the 1890s.
Several states established disease registries.
In 1907, Massachusetts passed a law requiring reporting of individual cases of 16 different diseases.
Required reporting implied an obligation to treat.
For example, reporting of cancer was later added to the list, and a cancer treatment program began in 1927.
It also became clear that providing immunizations and treating infectious diseases did not solve all health problems.
Despite remarkable success in lowering death rates from typhoid, diphtheria, and other contagious diseases, considerable disability continued to exist in the population.
There were still numerous diseases, such as tuberculosis, for which infectious agents were not clearly identified.
Draft registration during World War I revealed that a substantial portion of the male population was either physically or mentally unfit for combat. (Fee, 1987)
It also became clear that diseases, even those for which treatment was available, still predominantly affected the urban poor.
Registration and analysis of disease showed that the highest rates of morbidity still occurred among children and the poor.
On the premise that a healthier society could be built through health care for individuals, health departments expanded into clinical care and health education.
In the early twentieth century, the New York and Baltimore health departments began offering home visits by public health nurses.
New York established a campaign for education on tuberculosis. (Winslow, 1923)
School health clinics were set up in Boston in 1894, New York in 1903, Rhode Island in 1906, and many other cities in subsequent years. (Bremner, 1971)
Numerous local health agencies set up clinics to deal with tuberculosis and infant mortality.
By 1915, there were more than 500 tuberculosis clinics and 538 baby clinics in America, predominantly run by city health departments.
These clinics concentrated on providing medical care and health education. (Starr, 1982)
As public agencies moved into clinical care and education, the orientation of public health shifted from disease prevention to promotion of overall health.
Epidemiology provided a scientific justification for health programs that had originated with social reforms.
Public health once again became a task of promoting a healthy society.
In the twentieth century, this goal was to be achieved through scientific analysis of disease, medical treatment of individuals, and education on healthy habits.
In 1923, C. E. A. Winslow defined public health as the science of not only preventing contagious disease, but also of "prolonging life, and promoting physical health and efficiency." (Winslow, as quoted in Hanlon and Pickett, 1984)
The Growth of Federal Activities in Health
Federal activities in public health also expanded during the late nineteenth century and the early twentieth century.
The National Hygienic Laboratory, established in 1887 in the Marine Hospital in Staten Island, New York, included divisions in chemistry, zoology, and pharmacology.
In 1906, Congress passed the Food and Drug Act, which initiated controls on the manufacture, labeling, and sale of food.
In 1912, the Marine Hospital Service was renamed the U.S. Public Health Service, and its director, the surgeon general, was granted more authority.
Although early Public Health Service activities were modest, by 1918 they included administering physical and mental examinations of aliens, demonstration projects in rural health, and control and prevention of venereal diseases. (Hanlon and Pickett, 1984)
In 1914, Congress enacted the Chamberlain-Kahn Act, which established the U.S. Interdepartmental Social Hygiene Board, a comprehensive venereal disease control program for the military, and provided funds for quarantine of infected civilians. (Brandt, 1985)
Federal activities also grew to include promoting programs for individual health and providing assistance to states for campaigns against specific health problems.
The Children's Bureau was formed in 1912, and the first White House Conference on child health was held in 1919. (Hanlon and Pickett, 1984)
The Sheppard-Towner Act of 1922 established the Federal Board of Maternity and Infant Hygiene, provided administrative funds to the Children's Bureau, and provided funds to states to establish programs in maternal and child health.
This act was the first to establish direct federal funding of personal health services.
In order to receive federal funds, states were required to develop a plan for providing nursing, home care, health education, and obstetric care to mothers in the state; to designate a state agency to administer the program; and to report on operations and expenditures of the program to the federal board.
The Sheppard-Towner Act was the impetus for the federal practice of setting guidelines for public health programs and providing funding to states to implement programs meeting the guidelines.
Although federally initiated, the programs were fully state-run. (Bremner, 1971)
As the federal bureaucracy in health grew and programs requiring federal-state partnerships for health programs were developed, the need for expertise and leaders in public health increased at both the federal and state level.
Mid-Twentieth Century: Further Expansion of the Governmental Role in Personal Health
From the 1930s through the 1970s, local, state, and federal responsibilities in health continued to increase.
The federal role in health also became more prominent.
A strong federal government and a strong government role in ensuring social welfare were publicly supported social values of this era.
From Roosevelt's New Deal in the 1930s through Johnson's Great Society of the 1960s, a federal role in services affecting the health and welfare of individual citizens became well established.
The federal government and state and local health agencies took on greater roles in providing and planning health services, in health promotion and health education, and in financing health services.
The agencies also continued and increased activities in environmental sanitation, epidemiology, and health statistics.
Federal Activities
Federal programs in disease control, research, and epidemiology expanded throughout the mid-twentieth century.
In 1930, the National Hygienic Laboratory relocated to the Washington, D.C., area and was renamed the National Institute of Health (NIH).
In 1937, the Institute greatly expanded its research functions to include the study and investigation of all diseases and related conditions and the National Cancer Institute was established as the first of the research institutes focused on particular diseases or health problems.
By the 1970s NIH grew to include an Institute for Neurological and Communicative Disorders and Stroke, an Institute for Child Health and Human Development, an Institute for Environmental Health Sciences, and an Institute of Mental Health, among others.
In 1938, Congress passed a second venereal disease control act, which provided federal funds to states for investigation and control of venereal diseases.
In 1939, the Federal Security Agency, housing the Public Health Service and national programs in education and welfare, was established.
The Public Health Service also continued to expand.
During World War II, the Center for Disease Control was established, and shortly thereafter, the National Center for Health Statistics. (Hanlon and Pickett, 1984)
Federal programs supporting individual health services and state programs also continued to grow, both in number of health problems and types of citizens addressed.
The Social Security Act was passed in 1935.
One title of the act established a federal grant-in-aid program to the states for establishing and maintaining public health services and for training public health personnel.
Another title increased the responsibilities of the Children's Bureau in maternal and child health and capabilities of state maternal and child health programs.
The National Mental Health Act, establishing the National Institute of Mental Health as a part of NIH, was passed in 1946.
This institute was also authorized to finance training programs for mental health professionals and to finance development of community mental health services in local areas, as well as to conduct and support research.
The Medicare and Medicaid programs, titles 18 and 19 of the Social Security Act, were passed in 1966.
These programs enabled federal payment for health services to the elderly and federal-state programs for payment for health services to the poor. (Hanlon and Pickett, 1984)
The Partnership in Health Act of 1966 established a "block grant" approach for a variety of programs, providing federal funding of state and county activities in general health, tuberculosis control, dental health, home health, and mental health, among others.
The block grant was used by the federal government as incentive to states and counties for further development of their health services. (Omenn, 1982)
The Comprehensive Health Planning Act, passed in 1967, established a nationwide system of health planning agencies and allowed development of community health centers across the country. (Hanlon and Pickett, 1984)
State and Local Activities
Expansion of state activities in health paralleled the growth in federal activities.
Many of the changes on the federal level stimulated or supported state programs.
States expanded their activities in health to accommodate Medicaid, health promotion and education, and health planning, as well as many other federally sponsored programs.
Medicare and Medicaid in particular had a tremendous impact at the state level.
To participate in Medicaid, states had to designate a single state agency to direct the program, setting up a dichotomy between public health services and Medicaid services.
Also, most states experienced a sudden growth in programs and program costs with the advent of Medicare and Medicaid.
For example, federal funding for the institutionalized mentally ill became available for the first time through Medicaid, allowing expansion of these services and their costs in many states. (Turner, 1977)
Some federal programs of the 1960s also inspired growth of health services in local health departments and in private health organizations.
Maternal and child health, family planning, immunization, venereal disease control, and tuberculosis control offered financial and technical assistance to local health departments to provide these services.
Other federal programs developed at this time allowed funds and technical assistance to be provided directly to private health care providers, bypassing state and local government authorities.
The Comprehensive Health Planning Act was an example of this trend.
It allowed federal funding of neighborhood or community health centers, which were governed by boards composed of a consumer majority and related directly to the federal government for policy and program direction and finances.
The National Health Service Corps Program, in which the federal government directly assigned physicians to provide medical care to citizens in underserved areas, is another example of unilateral federal action for health care.
The Late Twentieth Century: A Crisis in Care and Financing
By the 1970s, the financial impact of the expansion in public health activities of the 1930s through the 1960s, including new public roles in the financing of medical care, began to be apparent.
Per capita health expenditures increased from $198 in 1965 to $334 in 1970.
During the same period, the public sector share of this sum rose from 25 percent to 37 percent. (Anderson, 1985)
The social values of earlier decades came under criticism.
Containing health costs became a national objective.
The Health Maintenance Act of 1973, promoting health maintenance organizations as a less costly means of health care, and the National Health Planning and Resources Development Act of 1974, setting up a certification system for new health services, are examples of this effort. (Turner, 1977)
In the current decade, efforts toward cost containment continue.
Although health needs and health services have not diminished, political and social values of the time encourage fiscal constraint.
Current values also emphasize state responsibility for most health and welfare programs.
Block grants were implemented in 1981, consolidating the federal grants-in-aid to the states into four major groups and cutting back the amount of grant money (some of the cuts were restored in 1983).
Medicaid was altered to give greater leeway to the states in the design and implementation of the program, although the federal share of Medicaid financing was not changed.
Changes also have been made in Medicare payment policies to restrain the increase in costs, especially for hospital care. (Omenn, 1982)
At the same time, new health problems have continued to surface.
AIDS, a previously unknown contagious disease, is reaching epidemic proportions.
Greater numbers of hazardous by-products of industry are being produced and disposed of in the environment.
Many other issues are of growing concern — asbestos exposure, side effects from pertussis vaccines, Alzheimer's disease, alcoholism and drug abuse, and homelessness are just a few.
New health problems continue to be identified, conflicting with concerns about the growth of government and government spending in health.
Conclusion
Although science provided a foundation for public health, social values have shaped the system.
The task of the public health agency has been not only to define objectives for the health care system based on facts about illness and health, but also to find means to implement health goals within a social structure.
''The boundaries of public health [have changed] over time with the perception of new health and social problems and with political, economic, and ideological shifts within the government and the nation." (Fee, 1987)
The history of public health has been one of identifying health problems, developing knowledge and expertise to solve problems, and rallying political and social support around the solutions.
Despite the huge successes brought about by scientific discovery and social reforms, and despite a phenomenal growth of government activities in health, the solving of public health problems has not taken place without controversy.
Repeatedly, the role of the government in regulating individual behavior has been challenged.
For example, as early as 1853, Britain's Board of Health was disbanded because Chadwick, its director, "claimed a wide scope for state intervention in an age when laissez-faire was the doctrine of the day." (Chave, 1984)
The relationship between public health and private medical practice has also been much debated.
In 1920, the New York Medical Society vehemently opposed and succeeded in defeating a proposal for a system of public rural clinics throughout the state. (Starr, 1982)
Arguments about the scope of public health and the extent of public sector responsibility for health continue to this day.
The development of a scientific base for public health allowed some consistency in the public health system across the country.
All of the states in the United States are involved in some manner in sanitation, laboratory investigation, collecting vital statistics, regulation of the environment, epidemiology, administering vaccines, maternal and child health, mental health, and care of the poor.
How local systems conduct these programs differs greatly from area to area.
Changing values over both time and place have allowed great variety in the implementation of public health programs across the country.
The following chapter, which summarizes the current public health system in the United States and public health activities in six states visited by the committee, illustrates the variety of approaches to public health which have evolved throughout the current system.
References
• Anderson, O. W. 1985. Health Services in the United States: A Growth Enterprise Since 1875. Health Administration Press, Ann Arbor, Mich.
• Blake, Nelson M. 1956. Water for the Cities: A History of the Urban Water Supply Problem in the United States. Syracuse University Press, Syracuse, N.Y.
• Brandt, Allan M. 1985. No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880. Oxford University Press, New York.
• Bremner, Robert H., editor. , ed. 1971. Children and Youth in America: A Documentary History. Harvard University Press, Cambridge, Mass.
• Chave, S. P. W. 1984. "The Origins and Development of Public Health." In Oxford Textbook of Public Health, Vol. 1: History, Determinants, Scope, and Strategies, W. W. Holland, editor; , R. Detels, editor; , and G. Knox, editor. , eds. Oxford Medical Publications, Oxford University Press, New York.
• Fee, Elizabeth. 1987. Disease and Discovery: A History of the Johns Hopkins School of Hygiene and Public Health 1916–1939. Johns Hopkins University Press, Baltimore.
• Foley, Henry A., and Steven S. Sharfstein. 1983. Madness and Government: Who Cares for the Mentally Ill? American Psychiatric Press, Inc., Washington, D.C.
• Goudsblom, Johan. 1986. "Public Health and the Civilizing Process." The Milbank Quarterly64(2):161–88.
• Grob, Gerald N. 1966. The State and the Mentally Ill: A History of Worcester State Hospital in Massachusetts, 1830–1920. University of North Carolina Press, Chapel Hill, N.C.
• Hanlon, G., and J. Pickett. 1984. Public Health Administration and Practice. Times Mirror/Mosby.
• Omenn, G. S. 1982. "What's Behind Those Block Grants in Health? New England Journal of Medicine306(17):1057–60.
• Rosenberg, Charles E. 1962. The Cholera Years. University of Chicago Press, Chicago, Ill.
• Rosenkrantz, Barbara G. 1972. Public Health and the State. Harvard University Press, Cambridge, Mass.
• Rosenkrantz, Barbara G. 1974. "Cart Before the Horse: Theory, Practice, and Professional Image in American Public Health." Journal of History of Medicine and Allied Sciences29:55–73. 1982.
• Starr, P. The Social Transformation of American Medicine. Basic Books, Inc., New York.
• Turner, John B., editor. , editor in chief. 1977. Encyclopedia of Social Work, seventeenth edition. National Association of Social Workers, Washington, D.C.
• Winslow, C. E. A. 1923. The Evolution and Significance of the Modern Public Health Campaign. Journal of Public Health Policy, South Burlington, Vt.
• Wohl, Anthony S. 1983. Endangered Lives: Public Health in Victorian Britain. Harvard University Press, Cambridge, Mass.
https://www.ncbi.nlm.nih.gov/books/NBK218224/
The Future of Public Health.
3A History of the Public Health System
In Chapter 1, the committee found that the current public health system must play a critical role in handling major threats to the public health, but that this system is currently in disarray.
Chapter 2 explained the committee's ideal for the public health system — how it should be arranged for handling current and future threats to health.
In this chapter the history of the existing public health system is briefly described.
This history is intended to provide some perspective on how protection of citizens from health threats came to be a public responsibility and on how the public health system came to be in its current state.
History
During the past 150 years, two factors have shaped the modern public health system: first, the growth of scientific knowledge about sources and means of controlling disease; second, the growth of public acceptance of disease control as both a possibility and a public responsibility.
In earlier centuries, when little was known about the causes of disease, society tended to regard illness with a degree of resignation, and few public actions were taken.
As understanding of sources of contagion and means of controlling disease became more refined, more effective interventions against health threats were developed.
Public organizations and agencies were formed to employ newly discovered interventions against health threats.
As scientific knowledge grew, public authorities expanded to take on new tasks, including sanitation, immunization, regulation, health education, and personal health care. (Chave, 1984; Fee, 1987)
The link between science, the development of interventions, and organization of public authorities to employ interventions was increased public understanding of and social commitment to enhancing health.
The growth of a public system for protecting health depended both on scientific discovery and social action.
Understanding of disease made public measures to alleviate pain and suffering possible, and social values about the worthiness of this goal made public measures feasible.
The history of the public health system is a history of bringing knowledge and values together in the public arena to shape an approach to health problems.
Before the Eighteenth Century
Throughout recorded history, epidemics such as the plague, cholera, and smallpox evoked sporadic public efforts to protect citizens in the face of a dread disease.
Although epidemic disease was often considered a sign of poor moral and spiritual condition, to be mediated through prayer and piety, some public effort was made to contain the epidemic spread of specific disease through isolation of the ill and quarantine of travelers.
In the late seventeenth century, several European cities appointed public authorities to adopt and enforce isolation and quarantine measures (and to report and record deaths from the plague). (Goudsblom, 1986)
The Eighteenth Century
By the eighteenth century, isolation of the ill and quarantine of the exposed became common measures for containing specified contagious diseases.
Several American port cities adopted rules for trade quarantine and isolation of the sick.
In 1701 Massachusetts passed laws for isolation of smallpox patients and for ship quarantine as needed.
(After 1721, inoculation with material from smallpox scabs was also accepted as an effective means of containing this disease once the threat of an epidemic was declared.)
By the end of the eighteenth century, several cities, including Boston, Philadelphia, New York, and Baltimore, had established permanent councils to enforce quarantine and isolation rules. (Hanlon and Pickett, 1984)
These eighteenth-century initiatives reflected new ideas about both the cause and meaning of disease.
Diseases were seen less as natural effects of the human condition and more as potentially controllable through public action.
Also in the eighteenth century, cities began to establish voluntary general hospitals for the physically ill and public institutions for the care of the mentally ill.
Finally, physically and mentally ill dependents were cared for by their neighbors in local communities.
This practice was made official in England with the adoption of the 1601 Poor Law and continued in the American colonies. (Grob, 1966; Starr, 1982)
By the eighteenth century, several communities had reached a size that demanded more formal arrangements for care of their ill than Poor Law practices.
The first American voluntary hospitals were established in Philadelphia in 1752 and in New York in 1771.
The first public mental hospital was established in Williamsburg, Virginia in 1773. (Turner, 1977)
The Nineteenth Century: The Great Sanitary Awakening
The nineteenth century marked a great advance in public health.
"The great sanitary awakening" (Winslow, 1923) — the identification of filth as both a cause of disease and a vehicle of transmission and the ensuing embrace of cleanliness — was a central component of nineteenth-century social reforms.
Sanitation changed the way society thought about health.
Illness came to be seen as an indicator of poor social and environmental conditions, as well as poor moral and spiritual conditions.
Cleanliness was embraced as a path both to physical and moral health.
Cleanliness, piety, and isolation were seen to be compatible and mutually reinforcing measures to help the public resist disease.
At the same time, mental institutions became oriented toward "moral treatment" and cure.
Sanitation also changed the way society thought about public responsibility for citizen's health.
Protecting health became a social responsibility.
Disease control continued to focus on epidemics, but the manner of controlling turned from quarantine and isolation of the individual to cleaning up and improving the common environment.
And disease control shifted from reacting to intermittent outbreaks to continuing measures for prevention.
With sanitation, public health became a societal goal and protecting health became a public activity.
The Sanitary Problem
With increasing urbanization of the population in the nineteenth century, filthy environmental conditions became common in working class areas, and the spread of disease became rampant.
In London, for example, smallpox, cholera, typhoid, and tuberculosis reached unprecedented levels.
It was estimated that as many as 1 person in 10 died of smallpox.
More than half the working class died before their fifth birthday.
Meanwhile, "In the summers of 1858 and 1859 the Thames stank so badly as to rise "to the height of an historic event … for months together the topic almost monopolized the public prints'." (Winslow, 1923)
London was not alone in this dilemma.
In New York, as late as 1865, "the filth and garbage accumulate in the streets to the depth sometimes of two or three feet."
In a 2-week survey of tenements in the sixteenth ward of New York, inspectors found more than 1,200 cases of smallpox and more than 2,000 cases of typhus. (Winslow, 1923)
In Massachusetts in 1850, deaths from tuberculosis were 300 per 100,000 population, and infant mortality was about 200 per 1,000 live births. (Hanlon and Pickett, 1984)
Earlier measures of isolation and quarantine during specific disease outbreaks were clearly inadequate in an urban society.
It was simply impossible to isolate crowded slum dwellers or quarantine citizens who could not afford to stop working. (Wohl, 1983)
It also became clear that diseases were not just imported from other shores, but were internally generated.
''The belief that epidemic disease posed only occasional threats to an otherwise healthy social order was shaken by the industrial transformation of the nineteenth century." (Fee, 1987)
Industrialization, with its overburdened workforce and crowded dwellings, produced both a population more susceptible to disease and conditions in which disease was more easily transmitted. (Wohl, 1983)
Urbanization, and the resulting concentration of filth, was considered in and of itself a cause of disease.
"In the absence of specific etiological concepts, the social and physical conditions which accompanied urbanization were considered equally responsible for the impairment of vital bodily functions and premature death." (Rosenkrantz, 1972)
At the same time, public responsibility for the health of the population became more acceptable and fiscally possible.
In earlier centuries, disease was more readily identified as only the plight of the impoverished and immoral.
The plague had been regarded as a disease of the poor; the wealthy could retreat to country estates and, in essence, quarantine themselves.
In the urbanized nineteenth century, it became obvious that the wealthy could not escape contact with the poor.
"Increasingly, it dawned upon the rich that they could not ignore the plight of the poor; the proximity of gold coast and slum was too close." (Goudsblom, 1986)
And the spread of contagious disease in these cities was not selective.
Almost all families lost children to diphtheria, smallpox, or other infectious diseases.
Because of the deplorable social and environmental conditions and the constant threat of disease spread, diseases came to be considered an indicator of a societal problem as well as a personal problem.
"Poverty and disease could no longer be treated simply as individual failings." (Fee, 1987)
This view included not only contagious disease, but mental illness as well.
Insanity came to be viewed at least in part as a societal failing, caused by physical, moral, and social tensions.
The Development of Public Activities in Health
Edwin Chadwick, a London lawyer and secretary of the Poor Law Commission in 1838, is one of the most recognized names in the sanitary reform movement.
Under Chadwick's authority, the commission conducted studies of the life and health of the London working class in 1838 and that of the entire country in 1842.
The report of these studies, General Report on the Sanitary Conditions of the Labouring Population of Great Britain, "was a damning and fully documented indictment of the appalling conditions in which masses of the working people were compelled to live, and die, in the industrial towns and rural areas of the Kingdom." (Chave, 1984)
Chadwick documented that the average age at death for the gentry was 36 years; for the tradesmen, 22 years; and for the laborers, only 16 years. (Hanlon and Pickett, 1984)
To remedy the situation, Chadwick proposed what came to be known as the "sanitary idea."
His remedy was based on the assumption that diseases are caused by foul air from the decomposition of waste.
To remove disease, therefore, it was necessary to build a drainage network to remove sewage and waste.
Further, Chadwick proposed that a national board of health, local boards in each district, and district medical officers be appointed to accomplish this goal. (Chave, 1984)
Chadwick's report was quite controversial, but eventually many of his suggestions were adopted in the Public Health Act of 1848.
The report, which influenced later developments in public health in England and the United States, documented the extent of disease and suffering in the population, promoted sanitation and engineering as means of controlling disease, and laid the foundation for public infrastructure for combating and preventing contagious disease.
In the United States, similar studies were taking place.
Inspired in part by Chadwick, local sanitary surveys were conducted in several cities.
The most famous of these was a survey conducted by Lemuel Shattuck, a Massachusetts bookseller and statistician.
His Report of the Massachusetts Sanitary Commission was published in 1850.
Shattuck collected vital statistics on the Massachusetts population, documenting differences in morbidity and mortality rates in different localities.
He attributed these differences to urbanization, specifically the foulness of the air created by decay of waste in areas of dense population, and to immoral life-style.
He showed that the poor living conditions in the city threatened the entire community.
"Even those persons who attempted to maintain clean and decent homes were foiled in their efforts to resist diseases if the behavior of others invited the visitation of epidemics." (Rosenkrantz, 1972)
Shattuck considered immorality an important influence on susceptibility to ill health — and in fact drunkenness and sloth did often lead to poor health in the slums — but he believed that these conditions were threatening to all.
Further, Shattuck determined that those most likely to be affected by disease were also those who, either through ignorance or lack of concern, failed to take personal responsibility for cleanliness and sanitation of their area. (Rosenkrantz, 1972)
Consequently, he argued that the city or the state had to take responsibility for the environment.
Shattuck's Report of the Massachusetts Sanitary Commission recommended, in its "Plan for a Sanitary Survey of the State," a comprehensive public health system for the state.
The report recommended, among other things, new census schedules; regular surveys of local health conditions; supervision of water supplies and waste disposal; special studies on specific diseases, including tuberculosis and alcoholism; education of health providers in preventive medicine; local sanitary associations for collecting and distributing information; and the establishment of a state board of health and local boards of health to enforce sanitary regulations. (Winslow, 1923; Rosenkrantz, 1972)
Shattuck's report was widely circulated after publication, but because of political upheaval at the time of release nothing was done.
The report "fell flat from the printer's hand."
In the years following the Civil War, however, the creation of special agencies became a more common method of handling societal problems.
Massachusetts set up a state board of health in 1869.
The creation of this board reflected more a trend of strengthened government than new knowledge about the causes and control of disease.
Nevertheless, the type of data collected by Shattuck was used to justify the board.
And the board relied on many of the recommendations of Shattuck's report for shaping a public health system. (Rosenkrantz, 1972; Hanlon and Pickett, 1984)
Although largely ignored at the time of its release, Shattuck's report has come to be considered one of the most farsighted and influential documents in the history of the American public health system.
Many of the principles and activities he proposed later came to be considered fundamental to public health.
And Shattuck established the fundamental usefulness of keeping records and vital statistics.
Similarly, in New York, John Griscom published The Sanitary Condition of the Labouring Population of New York in 1848.
This report eventually led to the establishment of the first public agency for health, the New York City Health Department, in 1866.
During this same period, boards of health were established in Louisiana, California, the District of Columbia, Virginia, Minnesota, Maryland, and Alabama. (Fee, 1987; Hanlon and Pickett, 1984)
By the end of the nineteenth century, 40 states and several local areas had established health departments.
Although the specific mechanisms of diseases were still poorly understood, collective action against contagious disease proved to be successful.
For example, cholera was known to be a waterborne disease, but the precise agent of infection was not known at this time.
The sanitary reform movement brought more water to cities in the mid-nineteenth century, through private contractors and eventually through reservoirs and municipal water supplies, but its usefulness did not depend primarily on its purity for consumption, but its availability for washing and fire protection. (Blake, 1956)
Nonetheless, sanitary efforts of the New York Board of Health in 1866, including inspections, immediate case reporting, complaint investigations, evacuations, and disinfection of possessions and living quarters, kept an outbreak of cholera to a small number of cases.
"The mildness of the epidemic was no more a stroke of good fortune, observers agreed, but the result of careful planning and hard work by the new health board." (Rosenberg, 1962)
Cities without a public system for monitoring and combatting the disease fared far worse in the 1866 epidemic.
During this period, states also established more public institutions for care of the mentally ill.
Dorothea Dix, a retired school teacher from Maine, is the most familiar name in the reform movement for care of the mentally ill.
In the early nineteenth century, under Poor Law practices, communities that could not place their poor mentally ill citizens in more appropriate institutions put them in municipal jails and almshouses.
Beginning in the middle of the century, Dix led a crusade to publicize the inhumane treatment mentally ill citizens were receiving in jails and campaigned for the establishment of more public institutions for care of the insane.
In the nineteenth century, mental illness was considered a combination of inherited characteristics, medical problems, and social, intellectual, moral, and economic failures.
It was believed, despite the prejudice that the poor and foreign-born were more likely to be mentally ill, that moral treatment in a humane social setting could cure mental illness.
Dix and others argued that in the long run institutional care was cheaper for the community.
The mentally ill could be treated and cured in an institution, making continuing public support unnecessary.
Some 32 public institutions were established due to Dix's efforts.
Although the practice of moral treatment proved to be less successful than hoped, the nineteenth-century social reform movement established the principle of state responsibility for the indigent mentally ill. (Grob, 1966; Foley and Sharfstein, 1983)
New ideas about causes of disease and about social responsibility stimulated the development of public health agencies and institutions.
As environmental and social causes of diseases were identified, social action appeared to be an effective way to control diseases.
When health was no longer simply an individual responsibility, it became necessary to form public boards, agencies, and institutions to protect the health of citizens.
Sanitary and social reform provided the basis for the formation of public health organizations.
Public health agencies and institutions started at the local and state levels in the United States.
Federal activities in health were limited to the Marine Hospital Service, a system of public hospitals for the care of merchant seamen.
Because merchant seamen had no local citizenship, the federal government took on the responsibility of providing their health care.
A national board of health, which was intended to take over the responsibilities of the Marine Hospital Service, was adopted in 1879, but, opposed by the Marine Hospital Service and many southern states, the board lasted only until 1883 (Anderson, 1985)
Meanwhile, several state boards of health, state health departments, and local health departments had been established by the latter part of the nineteenth century. (Hanlon and Pickett, 1984)
Late Nineteenth Century: Enter Bacteriology
Another major set of developments in public health took place at the close of the nineteenth century.
Rapid advances in scientific knowledge about causes and prevention of numerous diseases brought about tremendous changes in public health.
Many major contagious diseases were brought under control through science applied to public health.
Louis Pasteur, a French chemist, proved in 1877 that anthrax is caused by bacteria.
By 1884, he had developed artificial immunization against the disease.
During the following few years, discoveries of bacteriologic agents of disease were made in European and American laboratories for such contagious diseases as tuberculosis, diphtheria, typhoid, and yellow fever. (Winslow, 1923)
The identification of bacteria and the development of interventions such as immunization and water purification techniques provided a means of controlling the spread of disease and even of preventing disease.
The germ theory of disease provided a sound scientific basis for public health.
Public health measures continued to be focused predominantly on specific contagious diseases, but the means of controlling these diseases changed dramatically.
Laboratory research identified exact causes and specific strategies for preventing specific diseases.
For the first time, it was known that diseases had single, specific causes.
Science also revealed that both the environment and people could be the agents of disease.
During this period public agencies that had been developed to conduct and enforce sanitary measures refined their activities and expanded into laboratory science and epidemiology.
Public responsibility for health came to include both environmental sanitation and individual health.
The Development of State and Local Health Department Laboratories
To develop and apply the new scientific knowledge, in the 1890s state and local health departments in the United States began to establish laboratories.
The first were established in Massachusetts, as a cooperative venture between the State Board of Health and the Massachusetts Institute of Technology, and in New York City, as a part of the New York City Health Department.
These were quickly followed by a state hygienic laboratory in Ann Arbor, Michigan, and a municipal public health laboratory in Providence. (Winslow, 1923)
These laboratories concentrated on improving sanitation through detection and control of bacteria in water systems.
W. T. Sedgwick, consulting biologist for Massachusetts, was one of the most famous scientists in sanitation and bacteriologic research.
In 1891 he identified the presence of fecal bacteria in water as the cause of typhoid fever and developed the first sewage treatment techniques.
Sedgwick followed his research on typhoid with many similar investigations of epidemics.
"With the relish of a good storyteller, Sedgwick would unravel a plot in which the villain was a bacterial organism; the victim, the unwitting public; the hero, sanitary hygiene brought to life through the application of scientific methods." (Rosenkrantz, 1972)
In the 1890s, Sedgwick also conducted research on bacteria in milk and was one of the main spokesmen for restrictive rules on the handling and pasteurization of milk.
Laboratory research was also applied to diagnosis of disease in individuals.
Theobald Smith, director of the pathology laboratory in the federal Bureau of Animal Industry, earned an international reputation for his identification of the causes of several diseases in animals and the development of techniques to produce artificial immunity against them.
Later, as director of a state laboratory in Massachusetts, Smith developed vaccines, antitoxins, and diagnostic tests against such diseases as smallpox, meningitis, tuberculosis, and typhoid.
He established the principle of using biological products to produce immunity to a specific disease in the individual and argued that research on the process of disease in the individual as well as the cause of disease in the environment was necessary to develop effective interventions. (Rosenkrantz, 1972)
In New York, the city health department laboratory also promoted diagnosis of contagious diseases in individuals.
New York was one of the first health departments to begin producing antitoxins for physicians' use, and the department offered free laboratory analyses. (Starr, 1982)
Hermann Biggs, pathologist and later commissioner of the New York City Health Department, suggested the application of bacteriology to detecting and controlling cholera.
W. H. Park, another pathologist in the laboratory, introduced bacteriological diagnosis of diphtheria and production of diphtheria antitoxin. (Winslow, 1923)
The Successes of Bacteriology
Some of the comments of the time reveal the enthusiasm with which the public health workers embraced the new scientific foundation for their efforts.
Scientific measures were seen as replacing earlier social, sanitary, moral, and religious reform measures to combat disease.
Science was seen as a more effective means of achieving the same desirable social goals.
Sedgwick declared, "before 1880 we knew nothing; after 1890 we knew it all; it was a glorious ten years." (Fee, 1987)
Charles Chapin, superintendent of Health of Providence, Rhode Island, who published Sources and Modes of Infection in 1910, argued for strictly scientific measures of infectious disease control.
Chapin believed that time spent on cleaning cities was wasted, that instead health officers should concentrate on controlling specific routes of disease transmission.
"There was little more reason for health departments to assume responsibility for street cleaning and control of nuisances, … than 'that they should work for free transfers, cheaper commutation tickets, lower prices for coal, less shoddy in clothing or more rubber in rubbers….''' (Rosenkrantz, 1972)
Herbert Hill, director of the Division of Epidemiology of the Minnesota Board of Health, compared the new epidemiologist to a hunter seeking a sheep-killing wolf: "Instead of finding in the mountains and following inward from them, say, 500 different wolf trails, 499 of which must necessarily be wrong, the experienced hunter goes directly to the slaughtered sheep, finding there and following outward thence the only right trail … the one trail that is necessarily and inevitably the trail of the one actually guilty wolf." (Hill, as quoted by Fee, 1987)
The new methods of disease control were remarkably effective.
For example, prior to 1908 17 American cities had death rates from typhoid fever of 30 or more per 100,000 population; 18 had death rates between 15 and 30 per 100,000.
After water filtering systems were put in place, only 3 of the same cities had rates exceeding 15 per 100,000. (Winslow, 1923)
In another example, the number of deaths from yellow fever in Havana dropped from 305 to 6 in a single year after a team of American military scientists led by Walter Reed identified mosquitoes as carriers of the yellow fever virus. (Winslow, 1923)
As public health became a scientific enterprise, it also became the province of experts.
Prevention and control of disease were no longer tasks of common sense and social compassion, but of knowledge and expertise.
Health reforms were guided by engineers, chemists, biologists, and physicians.
And the health department gained stature as a source of scientific knowledge in health.
It became clear that not only public and individual restraint were needed to control infectious disease, but also state agency epidemiologists and their laboratories were needed to direct the way. (Rosenkrantz, 1974)
Early Twentieth Century: The Move Toward Personal Care
Further Development of State and Local Health Agencies
In the early twentieth century, the role of the state and local public health departments expanded greatly.
Although disease control was based on bacteriology, it became increasingly clear that individual persons were more often the source of disease transmission than things.
"The work of the laboratory led the Board to define the existence and character of an increasing number of the most dangerous diseases and to provide medical means for their control." (Rosenkrantz, 1972)
Identification and treatment of individual cases of disease were the next natural steps.
Massachusetts, Michigan, and New York City began producing and dispensing antitoxins in the 1890s.
Several states established disease registries.
In 1907, Massachusetts passed a law requiring reporting of individual cases of 16 different diseases.
Required reporting implied an obligation to treat.
For example, reporting of cancer was later added to the list, and a cancer treatment program began in 1927.
It also became clear that providing immunizations and treating infectious diseases did not solve all health problems.
Despite remarkable success in lowering death rates from typhoid, diphtheria, and other contagious diseases, considerable disability continued to exist in the population.
There were still numerous diseases, such as tuberculosis, for which infectious agents were not clearly identified.
Draft registration during World War I revealed that a substantial portion of the male population was either physically or mentally unfit for combat. (Fee, 1987)
It also became clear that diseases, even those for which treatment was available, still predominantly affected the urban poor.
Registration and analysis of disease showed that the highest rates of morbidity still occurred among children and the poor.
On the premise that a healthier society could be built through health care for individuals, health departments expanded into clinical care and health education.
In the early twentieth century, the New York and Baltimore health departments began offering home visits by public health nurses.
New York established a campaign for education on tuberculosis. (Winslow, 1923)
School health clinics were set up in Boston in 1894, New York in 1903, Rhode Island in 1906, and many other cities in subsequent years. (Bremner, 1971)
Numerous local health agencies set up clinics to deal with tuberculosis and infant mortality.
By 1915, there were more than 500 tuberculosis clinics and 538 baby clinics in America, predominantly run by city health departments.
These clinics concentrated on providing medical care and health education. (Starr, 1982)
As public agencies moved into clinical care and education, the orientation of public health shifted from disease prevention to promotion of overall health.
Epidemiology provided a scientific justification for health programs that had originated with social reforms.
Public health once again became a task of promoting a healthy society.
In the twentieth century, this goal was to be achieved through scientific analysis of disease, medical treatment of individuals, and education on healthy habits.
In 1923, C. E. A. Winslow defined public health as the science of not only preventing contagious disease, but also of "prolonging life, and promoting physical health and efficiency." (Winslow, as quoted in Hanlon and Pickett, 1984)
The Growth of Federal Activities in Health
Federal activities in public health also expanded during the late nineteenth century and the early twentieth century.
The National Hygienic Laboratory, established in 1887 in the Marine Hospital in Staten Island, New York, included divisions in chemistry, zoology, and pharmacology.
In 1906, Congress passed the Food and Drug Act, which initiated controls on the manufacture, labeling, and sale of food.
In 1912, the Marine Hospital Service was renamed the U.S. Public Health Service, and its director, the surgeon general, was granted more authority.
Although early Public Health Service activities were modest, by 1918 they included administering physical and mental examinations of aliens, demonstration projects in rural health, and control and prevention of venereal diseases. (Hanlon and Pickett, 1984)
In 1914, Congress enacted the Chamberlain-Kahn Act, which established the U.S. Interdepartmental Social Hygiene Board, a comprehensive venereal disease control program for the military, and provided funds for quarantine of infected civilians. (Brandt, 1985)
Federal activities also grew to include promoting programs for individual health and providing assistance to states for campaigns against specific health problems.
The Children's Bureau was formed in 1912, and the first White House Conference on child health was held in 1919. (Hanlon and Pickett, 1984)
The Sheppard-Towner Act of 1922 established the Federal Board of Maternity and Infant Hygiene, provided administrative funds to the Children's Bureau, and provided funds to states to establish programs in maternal and child health.
This act was the first to establish direct federal funding of personal health services.
In order to receive federal funds, states were required to develop a plan for providing nursing, home care, health education, and obstetric care to mothers in the state; to designate a state agency to administer the program; and to report on operations and expenditures of the program to the federal board.
The Sheppard-Towner Act was the impetus for the federal practice of setting guidelines for public health programs and providing funding to states to implement programs meeting the guidelines.
Although federally initiated, the programs were fully state-run. (Bremner, 1971)
As the federal bureaucracy in health grew and programs requiring federal-state partnerships for health programs were developed, the need for expertise and leaders in public health increased at both the federal and state level.
Mid-Twentieth Century: Further Expansion of the Governmental Role in Personal Health
From the 1930s through the 1970s, local, state, and federal responsibilities in health continued to increase.
The federal role in health also became more prominent.
A strong federal government and a strong government role in ensuring social welfare were publicly supported social values of this era.
From Roosevelt's New Deal in the 1930s through Johnson's Great Society of the 1960s, a federal role in services affecting the health and welfare of individual citizens became well established.
The federal government and state and local health agencies took on greater roles in providing and planning health services, in health promotion and health education, and in financing health services.
The agencies also continued and increased activities in environmental sanitation, epidemiology, and health statistics.
Federal Activities
Federal programs in disease control, research, and epidemiology expanded throughout the mid-twentieth century.
In 1930, the National Hygienic Laboratory relocated to the Washington, D.C., area and was renamed the National Institute of Health (NIH).
In 1937, the Institute greatly expanded its research functions to include the study and investigation of all diseases and related conditions and the National Cancer Institute was established as the first of the research institutes focused on particular diseases or health problems.
By the 1970s NIH grew to include an Institute for Neurological and Communicative Disorders and Stroke, an Institute for Child Health and Human Development, an Institute for Environmental Health Sciences, and an Institute of Mental Health, among others.
In 1938, Congress passed a second venereal disease control act, which provided federal funds to states for investigation and control of venereal diseases.
In 1939, the Federal Security Agency, housing the Public Health Service and national programs in education and welfare, was established.
The Public Health Service also continued to expand.
During World War II, the Center for Disease Control was established, and shortly thereafter, the National Center for Health Statistics. (Hanlon and Pickett, 1984)
Federal programs supporting individual health services and state programs also continued to grow, both in number of health problems and types of citizens addressed.
The Social Security Act was passed in 1935.
One title of the act established a federal grant-in-aid program to the states for establishing and maintaining public health services and for training public health personnel.
Another title increased the responsibilities of the Children's Bureau in maternal and child health and capabilities of state maternal and child health programs.
The National Mental Health Act, establishing the National Institute of Mental Health as a part of NIH, was passed in 1946.
This institute was also authorized to finance training programs for mental health professionals and to finance development of community mental health services in local areas, as well as to conduct and support research.
The Medicare and Medicaid programs, titles 18 and 19 of the Social Security Act, were passed in 1966.
These programs enabled federal payment for health services to the elderly and federal-state programs for payment for health services to the poor. (Hanlon and Pickett, 1984)
The Partnership in Health Act of 1966 established a "block grant" approach for a variety of programs, providing federal funding of state and county activities in general health, tuberculosis control, dental health, home health, and mental health, among others.
The block grant was used by the federal government as incentive to states and counties for further development of their health services. (Omenn, 1982)
The Comprehensive Health Planning Act, passed in 1967, established a nationwide system of health planning agencies and allowed development of community health centers across the country. (Hanlon and Pickett, 1984)
State and Local Activities
Expansion of state activities in health paralleled the growth in federal activities.
Many of the changes on the federal level stimulated or supported state programs.
States expanded their activities in health to accommodate Medicaid, health promotion and education, and health planning, as well as many other federally sponsored programs.
Medicare and Medicaid in particular had a tremendous impact at the state level.
To participate in Medicaid, states had to designate a single state agency to direct the program, setting up a dichotomy between public health services and Medicaid services.
Also, most states experienced a sudden growth in programs and program costs with the advent of Medicare and Medicaid.
For example, federal funding for the institutionalized mentally ill became available for the first time through Medicaid, allowing expansion of these services and their costs in many states. (Turner, 1977)
Some federal programs of the 1960s also inspired growth of health services in local health departments and in private health organizations.
Maternal and child health, family planning, immunization, venereal disease control, and tuberculosis control offered financial and technical assistance to local health departments to provide these services.
Other federal programs developed at this time allowed funds and technical assistance to be provided directly to private health care providers, bypassing state and local government authorities.
The Comprehensive Health Planning Act was an example of this trend.
It allowed federal funding of neighborhood or community health centers, which were governed by boards composed of a consumer majority and related directly to the federal government for policy and program direction and finances.
The National Health Service Corps Program, in which the federal government directly assigned physicians to provide medical care to citizens in underserved areas, is another example of unilateral federal action for health care.
The Late Twentieth Century: A Crisis in Care and Financing
By the 1970s, the financial impact of the expansion in public health activities of the 1930s through the 1960s, including new public roles in the financing of medical care, began to be apparent.
Per capita health expenditures increased from $198 in 1965 to $334 in 1970.
During the same period, the public sector share of this sum rose from 25 percent to 37 percent. (Anderson, 1985)
The social values of earlier decades came under criticism.
Containing health costs became a national objective.
The Health Maintenance Act of 1973, promoting health maintenance organizations as a less costly means of health care, and the National Health Planning and Resources Development Act of 1974, setting up a certification system for new health services, are examples of this effort. (Turner, 1977)
In the current decade, efforts toward cost containment continue.
Although health needs and health services have not diminished, political and social values of the time encourage fiscal constraint.
Current values also emphasize state responsibility for most health and welfare programs.
Block grants were implemented in 1981, consolidating the federal grants-in-aid to the states into four major groups and cutting back the amount of grant money (some of the cuts were restored in 1983).
Medicaid was altered to give greater leeway to the states in the design and implementation of the program, although the federal share of Medicaid financing was not changed.
Changes also have been made in Medicare payment policies to restrain the increase in costs, especially for hospital care. (Omenn, 1982)
At the same time, new health problems have continued to surface.
AIDS, a previously unknown contagious disease, is reaching epidemic proportions.
Greater numbers of hazardous by-products of industry are being produced and disposed of in the environment.
Many other issues are of growing concern — asbestos exposure, side effects from pertussis vaccines, Alzheimer's disease, alcoholism and drug abuse, and homelessness are just a few.
New health problems continue to be identified, conflicting with concerns about the growth of government and government spending in health.
Conclusion
Although science provided a foundation for public health, social values have shaped the system.
The task of the public health agency has been not only to define objectives for the health care system based on facts about illness and health, but also to find means to implement health goals within a social structure.
''The boundaries of public health [have changed] over time with the perception of new health and social problems and with political, economic, and ideological shifts within the government and the nation." (Fee, 1987)
The history of public health has been one of identifying health problems, developing knowledge and expertise to solve problems, and rallying political and social support around the solutions.
Despite the huge successes brought about by scientific discovery and social reforms, and despite a phenomenal growth of government activities in health, the solving of public health problems has not taken place without controversy.
Repeatedly, the role of the government in regulating individual behavior has been challenged.
For example, as early as 1853, Britain's Board of Health was disbanded because Chadwick, its director, "claimed a wide scope for state intervention in an age when laissez-faire was the doctrine of the day." (Chave, 1984)
The relationship between public health and private medical practice has also been much debated.
In 1920, the New York Medical Society vehemently opposed and succeeded in defeating a proposal for a system of public rural clinics throughout the state. (Starr, 1982)
Arguments about the scope of public health and the extent of public sector responsibility for health continue to this day.
The development of a scientific base for public health allowed some consistency in the public health system across the country.
All of the states in the United States are involved in some manner in sanitation, laboratory investigation, collecting vital statistics, regulation of the environment, epidemiology, administering vaccines, maternal and child health, mental health, and care of the poor.
How local systems conduct these programs differs greatly from area to area.
Changing values over both time and place have allowed great variety in the implementation of public health programs across the country.
The following chapter, which summarizes the current public health system in the United States and public health activities in six states visited by the committee, illustrates the variety of approaches to public health which have evolved throughout the current system.
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• Omenn, G. S. 1982. "What's Behind Those Block Grants in Health? New England Journal of Medicine306(17):1057–60.
• Rosenberg, Charles E. 1962. The Cholera Years. University of Chicago Press, Chicago, Ill.
• Rosenkrantz, Barbara G. 1972. Public Health and the State. Harvard University Press, Cambridge, Mass.
• Rosenkrantz, Barbara G. 1974. "Cart Before the Horse: Theory, Practice, and Professional Image in American Public Health." Journal of History of Medicine and Allied Sciences29:55–73. 1982.
• Starr, P. The Social Transformation of American Medicine. Basic Books, Inc., New York.
• Turner, John B., editor. , editor in chief. 1977. Encyclopedia of Social Work, seventeenth edition. National Association of Social Workers, Washington, D.C.
• Winslow, C. E. A. 1923. The Evolution and Significance of the Modern Public Health Campaign. Journal of Public Health Policy, South Burlington, Vt.
• Wohl, Anthony S. 1983. Endangered Lives: Public Health in Victorian Britain. Harvard University Press, Cambridge, Mass.
https://www.ncbi.nlm.nih.gov/books/NBK218224/
Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM
National Institute of Health National Library of Medicine
The Future of Public Health.
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
This study was undertaken to address a growing perception among the Institute of Medicine membership and others concerned with the health of the public that this nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray.
Public health is what we, as a society, do collectively to assure the conditions for people to be healthy.
This requires that continuing and emerging threats to the health of the public be successfully countered.
These threats include immediate crises, such as the AIDS epidemic; enduring problems, such as injuries and chronic illness; and growing challenges, such as the aging of our population and the toxic by-products of a modern economy, transmitted through air, water, soil, or food.
These and many other problems raise in common the need to protect the nation's health through effective, organized, and sustained efforts led by the public sector.
Unfortunately, the explorations of this committee, as documented in this report, confirm that our current capabilities for effective public health actions are inadequate.
In the committee's view, we have let down our public health guard as a nation, and the health of the public is unnecessarily threatened as a result.
As a society we seem to assume that we are fully capable of maintaining past progress (often dramatic improvements in the public's health and longevity), of addressing current problems, and of being prepared to respond to new crises or emergent health problems.
Instead, this committee has found a public health system that is incapable of meeting these responsibilities, of applying fully current scientific knowledge and organizational skills, and of generating new knowledge, methods, and programs.
The rest of this report sets out a conception of the vision that should guide the future of public health, analyzes the current situation and how it developed, and presents a plan of action that will, in the committee's judgment, provide a solid foundation for a strong public health capability throughout the nation.
The strengthening of that capability requires understanding and support by many actors in this society, not just those in public health agencies.
Therefore, the committee intends this report for a broad audience that includes elected public officials at all levels of government, voluntary health organizations, health care providers, educators of all of the health professions, and private citizens with interests in maintaining and improving health in their communities.
To help these broad audiences understand why we believe this topic is important to them and their communities, we begin by citing examples of specific threats that can be averted or lessened only through collective actions aimed at the community, in contrast with personal medical services initiated by patients or individual practitioners.
These examples will serve to illustrate ultimate targets of public health activity.
Improved organization, professional competence, and decisions about public interventions are valued not as ends in themselves, but as means to combat real dangers to the public's health.
TO BE CONTINUED ...
The Future of Public Health.
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
This study was undertaken to address a growing perception among the Institute of Medicine membership and others concerned with the health of the public that this nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray.
Public health is what we, as a society, do collectively to assure the conditions for people to be healthy.
This requires that continuing and emerging threats to the health of the public be successfully countered.
These threats include immediate crises, such as the AIDS epidemic; enduring problems, such as injuries and chronic illness; and growing challenges, such as the aging of our population and the toxic by-products of a modern economy, transmitted through air, water, soil, or food.
These and many other problems raise in common the need to protect the nation's health through effective, organized, and sustained efforts led by the public sector.
Unfortunately, the explorations of this committee, as documented in this report, confirm that our current capabilities for effective public health actions are inadequate.
In the committee's view, we have let down our public health guard as a nation, and the health of the public is unnecessarily threatened as a result.
As a society we seem to assume that we are fully capable of maintaining past progress (often dramatic improvements in the public's health and longevity), of addressing current problems, and of being prepared to respond to new crises or emergent health problems.
Instead, this committee has found a public health system that is incapable of meeting these responsibilities, of applying fully current scientific knowledge and organizational skills, and of generating new knowledge, methods, and programs.
The rest of this report sets out a conception of the vision that should guide the future of public health, analyzes the current situation and how it developed, and presents a plan of action that will, in the committee's judgment, provide a solid foundation for a strong public health capability throughout the nation.
The strengthening of that capability requires understanding and support by many actors in this society, not just those in public health agencies.
Therefore, the committee intends this report for a broad audience that includes elected public officials at all levels of government, voluntary health organizations, health care providers, educators of all of the health professions, and private citizens with interests in maintaining and improving health in their communities.
To help these broad audiences understand why we believe this topic is important to them and their communities, we begin by citing examples of specific threats that can be averted or lessened only through collective actions aimed at the community, in contrast with personal medical services initiated by patients or individual practitioners.
These examples will serve to illustrate ultimate targets of public health activity.
Improved organization, professional competence, and decisions about public interventions are valued not as ends in themselves, but as means to combat real dangers to the public's 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.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Immediate Crises
The following are examples of problems that constitute immediate crises and can only be solved by collective action.
Both examples are major current concerns for most public health agencies throughout the nation.
AIDS (Acquired Immune Deficiency Syndrome)
The infectious disease of AIDS, caused by the human immunodeficiency virus (HIV), became an epidemic in little more than 5 years after its discovery.
The virus now infects more than a million people in the United States and millions more in other countries.
The cases of AIDS reported thus far are only the beginning of the expected toll because of the long period between infection and overt disease.
A sizable proportion of those now infected will progress to severe disease and death.
As noted by the Institute of Medicine and National Academy of Sciences in their 1986 report, the unchecked spread of HIV could convert the current epidemic into a catastrophe.
To slow the spread until a vaccine or definitive treatment is developed, the report recommended that the United States undertake a massive media, educational, and public health campaign.
This campaign would include effective education to inform the public of the danger and to describe changes in behavior that can minimize the risk of infection, voluntary testing to identify persons infected with the virus, and counseling of infected persons in order to contain the spread.
(Committee on a National Strategy for AIDS, Institute of Medicine, and National Academy of Sciences, 1986)
More than any other event of recent years, the AIDS epidemic has reminded us of the necessity of effective public health actions to protect individuals and society.
Access to Health Care for the Indigent
About 43 million Americans, or 18 percent of the population, do not have a physician, clinic, or hospital as a regular source of health care.
Some 38.8 million Americans, or 16 percent of the population, have difficulty obtaining health care when they need it.
Half these people have difficulty because they are unable to pay for care. (The Robert Wood Johnson Foundation, 1987)
Those who cannot afford health care — the medically indigent — include poor and near poor, employed and unemployed, uninsured and underinsured.
They include children, adults, and the elderly.
A survey in 1986 conducted by The Robert Wood Johnson Foundation estimated that some 22 million Americans did not have health insurance, public or private. (The Robert Wood Johnson Foundation, 1987)
About half of these people are employed but not insured; the other half are unemployed. (The Robert Wood Johnson Foundation, 1985)
Of those citizens with incomes below the federal poverty line, fewer than half receive Medicaid.
Those who do receive Medicaid may be covered only for selected services.
In many states, Medicaid covers basic hospital and ambulatory services, but not other basic needs such as dental services. (Desonia and King, 1985)
The proportion of persons below the poverty line who do not receive Medicaid increased from 47 percent in 1975 to about 54 percent in 1985. (The Robert Wood Johnson Foundation, 1985)
The proportion of persons with no regular source of health care has increased substantially, by 65 percent, in the past 5 years.
And the proportion of citizens who had health problems but refrained from making an ambulatory visit in the course of a year increased by 70 percent in the past 5 years. (The Robert Wood Johnson Foundation, 1987)
The 1986 survey documented the difficulties that poor Americans encounter in obtaining health care.
Despite their generally worse health status, the indigent are less likely to have a regular source of health care, are less likely to be insured, and are less likely to receive health care services than more affluent persons.
The better-off population made 37 percent more ambulatory visits to health care facilities than did poor persons of similar health status.
Yet it has been well documented that the indigent tend to have more illnesses and disabilities than more affluent citizens.
It has also been documented that the gap between rich and poor is widening.
Access to health care services in this country has become a crisis both for the population that has difficulty obtaining care and for providers of care, the latter often publicly owned or financed, and the growing reluctance of private health care institutions to provide free care is placing an increasing financial burden on public institutions.
The evidence shows that many Americans are going without needed health care.
Since 1984, more than half the states have passed legislation concerned with the health care needs of the medically indigent.
More than 20 states have appointed commissions to study means of providing care. (Desonia and King, 1985)
This issue promises to be a critical problem throughout the 1980s.
When the uninsured and poor do seek health care, the burden of providing this care falls disproportionately on a small number of institutions, often the public providers of health care.
Ten percent of the hospitals in the country provide more than 40 percent of all inpatient and ambulatory health care services to the uninsured. (The Robert Wood Johnson Foundation, 1985)
Studies in several cities indicate that an overwhelming proportion of the medically indigent are admitted or transferred to public hospitals and university hospitals when seeking care.
These hospitals, in turn, are in increasing financial jeopardy. (Annas, 1986)
The burden of ambulatory care for the uninsured and poor is also carried by community clinics and public health departments.
For a subset of these people, the problems are compounded by homelessness (IOM study, to be published).
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 ...
Immediate Crises
The following are examples of problems that constitute immediate crises and can only be solved by collective action.
Both examples are major current concerns for most public health agencies throughout the nation.
AIDS (Acquired Immune Deficiency Syndrome)
The infectious disease of AIDS, caused by the human immunodeficiency virus (HIV), became an epidemic in little more than 5 years after its discovery.
The virus now infects more than a million people in the United States and millions more in other countries.
The cases of AIDS reported thus far are only the beginning of the expected toll because of the long period between infection and overt disease.
A sizable proportion of those now infected will progress to severe disease and death.
As noted by the Institute of Medicine and National Academy of Sciences in their 1986 report, the unchecked spread of HIV could convert the current epidemic into a catastrophe.
To slow the spread until a vaccine or definitive treatment is developed, the report recommended that the United States undertake a massive media, educational, and public health campaign.
This campaign would include effective education to inform the public of the danger and to describe changes in behavior that can minimize the risk of infection, voluntary testing to identify persons infected with the virus, and counseling of infected persons in order to contain the spread.
(Committee on a National Strategy for AIDS, Institute of Medicine, and National Academy of Sciences, 1986)
More than any other event of recent years, the AIDS epidemic has reminded us of the necessity of effective public health actions to protect individuals and society.
Access to Health Care for the Indigent
About 43 million Americans, or 18 percent of the population, do not have a physician, clinic, or hospital as a regular source of health care.
Some 38.8 million Americans, or 16 percent of the population, have difficulty obtaining health care when they need it.
Half these people have difficulty because they are unable to pay for care. (The Robert Wood Johnson Foundation, 1987)
Those who cannot afford health care — the medically indigent — include poor and near poor, employed and unemployed, uninsured and underinsured.
They include children, adults, and the elderly.
A survey in 1986 conducted by The Robert Wood Johnson Foundation estimated that some 22 million Americans did not have health insurance, public or private. (The Robert Wood Johnson Foundation, 1987)
About half of these people are employed but not insured; the other half are unemployed. (The Robert Wood Johnson Foundation, 1985)
Of those citizens with incomes below the federal poverty line, fewer than half receive Medicaid.
Those who do receive Medicaid may be covered only for selected services.
In many states, Medicaid covers basic hospital and ambulatory services, but not other basic needs such as dental services. (Desonia and King, 1985)
The proportion of persons below the poverty line who do not receive Medicaid increased from 47 percent in 1975 to about 54 percent in 1985. (The Robert Wood Johnson Foundation, 1985)
The proportion of persons with no regular source of health care has increased substantially, by 65 percent, in the past 5 years.
And the proportion of citizens who had health problems but refrained from making an ambulatory visit in the course of a year increased by 70 percent in the past 5 years. (The Robert Wood Johnson Foundation, 1987)
The 1986 survey documented the difficulties that poor Americans encounter in obtaining health care.
Despite their generally worse health status, the indigent are less likely to have a regular source of health care, are less likely to be insured, and are less likely to receive health care services than more affluent persons.
The better-off population made 37 percent more ambulatory visits to health care facilities than did poor persons of similar health status.
Yet it has been well documented that the indigent tend to have more illnesses and disabilities than more affluent citizens.
It has also been documented that the gap between rich and poor is widening.
Access to health care services in this country has become a crisis both for the population that has difficulty obtaining care and for providers of care, the latter often publicly owned or financed, and the growing reluctance of private health care institutions to provide free care is placing an increasing financial burden on public institutions.
The evidence shows that many Americans are going without needed health care.
Since 1984, more than half the states have passed legislation concerned with the health care needs of the medically indigent.
More than 20 states have appointed commissions to study means of providing care. (Desonia and King, 1985)
This issue promises to be a critical problem throughout the 1980s.
When the uninsured and poor do seek health care, the burden of providing this care falls disproportionately on a small number of institutions, often the public providers of health care.
Ten percent of the hospitals in the country provide more than 40 percent of all inpatient and ambulatory health care services to the uninsured. (The Robert Wood Johnson Foundation, 1985)
Studies in several cities indicate that an overwhelming proportion of the medically indigent are admitted or transferred to public hospitals and university hospitals when seeking care.
These hospitals, in turn, are in increasing financial jeopardy. (Annas, 1986)
The burden of ambulatory care for the uninsured and poor is also carried by community clinics and public health departments.
For a subset of these people, the problems are compounded by homelessness (IOM study, to be published).
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 ...
Enduring Public Health Problems
Although such immediate crises as AIDS and care of the indigent tend to attract attention of the public and of policymakers, other public health problems with equally great significance for the health of the public and the well-being of our society require continuing attention.
Progress against an enduring problem may lead to complacency, and the very permanency of the problem may undermine continued vigilance and actions.
The four examples given here have all been targets of concerted action through public efforts, and some progress has been achieved.
Yet maintenance of that progress and continued advances require sustained effort.
Injuries
William Foege, former director of the federal Centers for Disease Control, has stated that injury is the principal public health problem in America today, affecting primarily the young, and will touch one of every three Americans each year.
Each year, more than 140,000 Americans die from injuries and another 70 million sustain nonfatal injuries.
Injury is the leading cause of death for children and young adults.
Motor vehicle accidents are the leading cause of severe injury and death, causing about 3.2 million injuries in 1982 and about one-third of the fatal deaths each year.
We have not done enough to reduce this toll.
Public action can reduce injuries by:
— education that persuades people to protect themselves from injury;
— legal requirements for desirable protective actions, such as auto seat belt use or the use of smoke detectors; and
— protection through product and environmental design, e.g., highway safety standards, automatic seat belts or air bags, sprinkler systems, childproof caps on medicines, and so on. (Committee on Trauma Research, Commission on Life Sciences, National Research Council, and Institute of Medicine, 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 ...
Enduring Public Health Problems
Although such immediate crises as AIDS and care of the indigent tend to attract attention of the public and of policymakers, other public health problems with equally great significance for the health of the public and the well-being of our society require continuing attention.
Progress against an enduring problem may lead to complacency, and the very permanency of the problem may undermine continued vigilance and actions.
The four examples given here have all been targets of concerted action through public efforts, and some progress has been achieved.
Yet maintenance of that progress and continued advances require sustained effort.
Injuries
William Foege, former director of the federal Centers for Disease Control, has stated that injury is the principal public health problem in America today, affecting primarily the young, and will touch one of every three Americans each year.
Each year, more than 140,000 Americans die from injuries and another 70 million sustain nonfatal injuries.
Injury is the leading cause of death for children and young adults.
Motor vehicle accidents are the leading cause of severe injury and death, causing about 3.2 million injuries in 1982 and about one-third of the fatal deaths each year.
We have not done enough to reduce this toll.
Public action can reduce injuries by:
— education that persuades people to protect themselves from injury;
— legal requirements for desirable protective actions, such as auto seat belt use or the use of smoke detectors; and
— protection through product and environmental design, e.g., highway safety standards, automatic seat belts or air bags, sprinkler systems, childproof caps on medicines, and so on. (Committee on Trauma Research, Commission on Life Sciences, National Research Council, and Institute of Medicine, 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 ...
Enduring Public Health Problems, continued ...
Teen Pregnancy
About half a million babies are born each year to teenage mothers in the United States.
Births to teenagers represented about 13 percent of all births in the nation in 1984.
Rates of teen pregnancy and delivery in the United States are significantly higher than those of comparable countries.
For example, 15-year-old girls in the United States are 5 times more likely to get pregnant than girls in any other developed country for which data are available. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987)
The number of births to teenage mothers in this country has serious public health implications.
Pregnant teenagers have higher rates of miscarriages, complications, stillbirths, and infant and maternal deaths than pregnant adults.
Low-income teenagers are more likely than adults to have premature births, increasing the likelihood of poor pregnancy outcomes. (Committee to Study the Prevention of Low Birthweight, Institute of Medicine, 1985)
Surviving children of teenage mothers are more likely to suffer injuries and more likely to be hospitalized by age 5 than children of adult mothers.
Adolescent pregnancies and births cause significant health problems both for teenage mothers and for their children.
In addition, teenage pregnancy is linked to school dropout, contributing to low future incomes, which are in turn associated with poorer health in future years. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987)
Many of the health problems associated with early pregnancy and childbearing can be significantly reduced with proper prenatal care and nutrition.
Yet adolescents are the least likely mothers to receive prenatal care. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987)
Only about half of all teen mothers begin prenatal care in their first trimester of pregnancy, and about 12 percent never receive any prenatal care. (Hughes et al., 1986)
Also, teenagers are far more likely to have poor eating habits.
Moreover, most teenage parents have difficulty in financing health care for themselves and for their children.
In many locations, teenage girls rely on public health agencies for health services.
Family planning services offered by many public health agencies as well as by private providers can prevent unwanted pregnancies but are underutilized.
When pregnancies do occur, efforts in health education and maternal and child health services are needed to improve pregnancy outcomes. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987)
Control of High Blood Pressure
Public health measures, once associated mainly with control of infectious disease, can also be effective against chronic diseases.
Epidemiological and statistical studies have established factors associated with high-risk from heart disease and stroke.
One of these risk factors is high blood pressure, which affects about 60 million Americans. (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)
In 1972, the Public Health Service mounted a national campaign to identify the population afflicted with high blood pressure and to lower the blood pressure levels. (Roccella, 1985)
The success of that campaign, which involved private agencies as well as national, state, and local public health agencies, is illustrated by the increased control of high blood pressure.
The progress in reducing high blood pressure has undoubtedly contributed to the considerable reduction in the incidence of stroke between 1972 and 1982.
Continued public health efforts will be required to maintain this progress because the incidence of uncontrolled hypertension is still very substantial.
Up to two-thirds of those with hypertension in 1976–1980 were not in control programs. (Lenfant and Roccella, 1984)
In 1986, high blood pressure control rates varied among communities from 25 to 60 percent. (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 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.
1 The Disarray of Public Health: A Threat to the Health of the Public, continued ...
Enduring Public Health Problems, continued ...
Teen Pregnancy
About half a million babies are born each year to teenage mothers in the United States.
Births to teenagers represented about 13 percent of all births in the nation in 1984.
Rates of teen pregnancy and delivery in the United States are significantly higher than those of comparable countries.
For example, 15-year-old girls in the United States are 5 times more likely to get pregnant than girls in any other developed country for which data are available. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987)
The number of births to teenage mothers in this country has serious public health implications.
Pregnant teenagers have higher rates of miscarriages, complications, stillbirths, and infant and maternal deaths than pregnant adults.
Low-income teenagers are more likely than adults to have premature births, increasing the likelihood of poor pregnancy outcomes. (Committee to Study the Prevention of Low Birthweight, Institute of Medicine, 1985)
Surviving children of teenage mothers are more likely to suffer injuries and more likely to be hospitalized by age 5 than children of adult mothers.
Adolescent pregnancies and births cause significant health problems both for teenage mothers and for their children.
In addition, teenage pregnancy is linked to school dropout, contributing to low future incomes, which are in turn associated with poorer health in future years. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987)
Many of the health problems associated with early pregnancy and childbearing can be significantly reduced with proper prenatal care and nutrition.
Yet adolescents are the least likely mothers to receive prenatal care. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987)
Only about half of all teen mothers begin prenatal care in their first trimester of pregnancy, and about 12 percent never receive any prenatal care. (Hughes et al., 1986)
Also, teenagers are far more likely to have poor eating habits.
Moreover, most teenage parents have difficulty in financing health care for themselves and for their children.
In many locations, teenage girls rely on public health agencies for health services.
Family planning services offered by many public health agencies as well as by private providers can prevent unwanted pregnancies but are underutilized.
When pregnancies do occur, efforts in health education and maternal and child health services are needed to improve pregnancy outcomes. (Panel on Adolescent Pregnancy and Childbearing, Committee on Child Development, Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council, 1987)
Control of High Blood Pressure
Public health measures, once associated mainly with control of infectious disease, can also be effective against chronic diseases.
Epidemiological and statistical studies have established factors associated with high-risk from heart disease and stroke.
One of these risk factors is high blood pressure, which affects about 60 million Americans. (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)
In 1972, the Public Health Service mounted a national campaign to identify the population afflicted with high blood pressure and to lower the blood pressure levels. (Roccella, 1985)
The success of that campaign, which involved private agencies as well as national, state, and local public health agencies, is illustrated by the increased control of high blood pressure.
The progress in reducing high blood pressure has undoubtedly contributed to the considerable reduction in the incidence of stroke between 1972 and 1982.
Continued public health efforts will be required to maintain this progress because the incidence of uncontrolled hypertension is still very substantial.
Up to two-thirds of those with hypertension in 1976–1980 were not in control programs. (Lenfant and Roccella, 1984)
In 1986, high blood pressure control rates varied among communities from 25 to 60 percent. (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986)
TO BE CONTINUED ...