Public Health Responsibility for Indigent Care

Some public health workers are concerned when their agencies serve as providers of last resort for medical care of the indigent, or administer Medicaid or other financing programs. Those concerned see these functions as detracting from essential public health activities such as disease surveillance and control through prevention. One county health officer told us that “when you put together preventive and curative, the latter gets the money, because no one has the guts to say I’m going to emphasize prevention. Sickness care takes precedence.”

Others see the public health role in the care of the indigent as essential—at least until other means are devised by society to take care of these needs. In many of our site visits, we were told of overwhelming unmet needs for medical care of the indigent. As noted in Chapter 4, almost three-quarters of state and local health agency expenditures are for personal health services. Many public health agencies have a long-standing focus on the provision of maternal and child health services to the indigent, emphasizing those services that have substantial long-term benefit through disease prevention and health promotion. (Miller and Moos, 1981; Public Health Foundation, 1986) This maternal and child health focus has been especially strong in a number of public health agencies in the South.

The tension caused by attempting to provide personal medical care services without at the same time depriving other public health functions of an appropriate share of scarce funds is aggravated by overall changes in the financing of medical care, which force more of the burden of care of the indigent back on to public agencies. (Desonia and King, 1985) Because the dollar flow for medical services is large, and because reimbursement through federally matched sources of funding, such as Medicaid, is available, care of the indigent looms large in the state budget-setting process as compared with other public health functions. Identification of public health with care of the indigent in the minds of decision makers and of the general public sometimes clouds the perception of the importance of public health to the entire population. For example, in one state the committee visited, the state health department pays for more than one-third of births each year. PHE3001 Public Health Problems and Solutions Essay.This, plus a strong family planning program, has contributed to an impressive reduction in the state’s infant mortality rate in recent years. Yet this record does not win the public support that it should: the well-to-do either don’t know about the department’s services to the poor or see them as unrelated to their own needs. The state’s legislature voted more funds for Medicaid, then cut the health department budget. By contrast, in a Canadian city visited during the study, universal entitlement to medical care lifts the burden of indigent care from the public health agency, leaving that agency free to focus its resources on other priorities in public health, such as effects of industrial pollutants on cancer incidence, improving the health outcomes of high-risk infants, smoking cessation, monitoring health status, and organizing the community to combat particular health problems.

Relationship of Public Health to Environmental Health

Many of the early accomplishments in the prevention of infectious disease were accomplished through public health management of water supply and sewage disposal. Even though a certain degree of tension existed from the earliest days of public health between environmental health activities relying heavily on sanitary engineering techniques and surveillance by sanitarians and the work of public health physicians and nurses providing preventive services to individuals, environmental health activities were integral parts of public health services until the 1960s and 1970s. Then major changes occurred in environmental health policy, planning, and organization at both state and federal levels of government. (Rabe, 1986) This movement combined a concern about such issues as protecting natural resources and energy conservation with the traditional environmental health activities designed to reduce the risk of disease and dysfunction. Many advocates of stronger public actions to prevent contamination of the environment saw existing public health agencies as too slow in responding to the need for new actions.

One effect of this increased public attention and the perception of unresponsiveness from public health agencies was a splitting off of many environmental health concerns from public health activities. The split was symbolized at the federal level by the creation of an independent new agency—the Environmental Protection Agency—to administer programs concerned with air and water, solid waste, pesticides, noise, and ionizing radiation. Most of these programs had once been a part of the Public Health Service. A similar organizational change took place in states. (Hanlon and Pickett, 1984; Rabe, 1986) The implications of these changes are considered later in this chapter, but a notable effect was to separate public health from the broad-based constituency interested in environmental protection. Those environmental protection functions still within the operational purview of public health, such as food protection and enforcement of standards for drinking water quality, were not as well supported and as well publicized as were programs for the control of pesticide use and for the reduction of human exposure to air pollution or ionizing radiation. Responsibility for identification, education, and modification of important environmental factors that increase the risk of illness and premature death was separated from other interrelated public health functions. As a result, many observers believe, the health implications of environmental hazards have not received the depth of analysis or the level of support they deserve. In some cases, uninformed analysis of environmental health risks may have exacerbated fears of those risks unnecessarily.PHE3001 Public Health Problems and Solutions Essay.

Relationship of Public Health to Mental Health

During most of its long history, the public function in mental health primarily was on care of the chronically ill mental patient, as illustrated by the large hospitals for the mentally ill. This activity in personal health services contrasted with the usual public health focus on prevention of disease and protection of the health of the public. Differing perspectives and operating modes were often reflected in organizational separation of mental health from public health at the state level. At the federal level, mental health responsibilities remained within the Public Health Service, although mental health groups have advocated the maintenance of a separate identity for mental health programs both at the state and federal levels in order to assure sufficient attention to these important health problems.

The trend in mental health services in the United States since World War II has been away from large custodial institutions and toward community-based services, stimulated by the National Mental Health Act of 1946 and by the federal Community Mental Health Centers legislation in the 1960s. This community approach and the mental hygiene movement, which had its origins in this country, were based on the belief that mental health problems were related to the community context, not only to the individual. (Turner, 1977) Thus, epidemiological concepts began to be applied to the identification of mental health problems in the population, and an interest in prevention of mental illness, promotion of mental health, and the early diagnosis of mental problems began to parallel more closely the traditional concerns of public health. Many health problems, such as those stemming from substance abuse, accidents, family violence, and teenage pregnancy, were recognized as having behavioral underpinnings.PHE3001 Public Health Problems and Solutions Essay.

Despite this expansion of the range of mental health services to include many public health issues, the relationship between public health and mental health remains underdeveloped. Organizational, historical, professional, and interest group barriers to more productive interaction persist even though mental health and public health have moved closer together conceptually.

The need for a community-based strategy for prevention in mental health, drawing on fundamental public health concepts, was recognized by the Joint Commission on Mental Illness and Health in 1961 and the President’s Commission on Mental Health in 1978. (Joint Commission on Mental Illness and Health, 1961; President’s Commission on Mental Health, 1978) Referring to the progress made by public health in preventing disease and promoting health, the President’s Commission stated that “The mental health field has yet to use available knowledge in a comparable effort.” (President’s Commission on Mental Health, 1978) The strategy they recommended would be based on identification of high-risk groups in the population, identification of factors contributing to those risks, and development of cost-effective means of intervention to reduce risks, consistent with this society’s community and individual values. This strategy is consistent with the public health vision outlined by this committee in Chapter 2.

The Public Health Role in Encouraging Healthful Behaviors Through Education and Through Modifications in the Social Environment

Many of the modern opportunities for health improvement lie in achieving life-style and behavior changes. The evidence linking health problems to behavior is extensive. Well-known examples include links between lung cancer and smoking; AIDS and sexual behavior; motor vehicle trauma, teenage driving habits, and alcohol consumption; and family violence linked to family and job-related stress.

Educational efforts to tell persons about health risks or healthful behavior have been used to effect desired changes. Many of these efforts have been carried out by the private sector, often using the public media or private educational programs (e.g., advertising campaigns by voluntary health organizations). The role of state or local public health agencies has often been relatively minor. In the site visits, we often found that efforts to achieve healthful behavior did not seem to occupy a prominent place on the public health agenda.

In addition to intervention to change individual behavior, other strategies seek to control factors in the “social environment.” However, health programs to educate youth about the dangers of tobacco and alcohol, for example, are rarely matched by efforts to reduce consumption of these substances by increasing taxes or controlling advertising. Although public health professionals have traditionally recognized influences of the physical environment on health status, they have been less adept at recognizing health-related influences in the business, economic, and social environment and in fashioning and advocating strategies to control these factors.

Yet, in spite of the need for further definitive research, considerable evidence now demonstrates that the social environment can be a major cause of illness. (Institute of Medicine, National Academy of Sciences, 1982a; Berkman and Breslow, 1983) Job and family stress; promotion of hazardous products; encouragement of risk-taking behavior and violence through TV programs, movies, and other popular media; and peer pressure for substance abuse, premature sexual behavior (with associated health risks of sexually transmitted disease and teenage pregnancies), and school failure all are potential or actual etiologic factors in health problems, both physical and mental. Public health programs, to be effective, should move beyond programs targeted on the immediate problem, such as teen pregnancy, to health promotion and prevention by dealing with underlying factors in the social environment.

To deal with these factors, the scope of public health will need to encompass relationships with other social programs in education, social services, housing, and income maintenance.PHE3001 Public Health Problems and Solutions Essay.

Assessment and Surveillance

A foundation stone for public health activities is an assessment and surveillance capacity that identifies problems, provides data to assist in decisions about appropriate actions, and monitors progress. Epidemiology has long been considered the essential science of public health, and a strong assessment and surveillance system based on epidemiologic principles is a fundamental part of a technically competent public health activity.

Federal agencies, such as the Centers for Disease Control, the National Center for Health Statistics, and the National Institutes of Health, have provided national leadership, data, and technical assistance, all of which assist states and localities in carrying out their assessment responsibilities. However, many states and localities lack a fully developed capability for this essential function. While the collection of vital statistics has long been a state responsibility, other critical data are available only in the form of national sample surveys that cannot be directly desegregated to state and local areas without significantly compromising their accuracy. Table A.4 in Appendix A tells, for example, that half of the states collect morbidity data and even fewer conduct health interview surveys. On the other hand, the collection of data about communicable disease, health screening for some specific problems, and laboratory analysis are functions conducted by essentially all of the states.

The level of support provided for the function of assessment and surveillance reflects these difficulties and the competition for limited resources with other more publicly visible public health priorities. For example, in one state the committee visited, vital statistics had not been published at all during the 2 years preceding our visit. In another, a county health officer reported having to wait more than 2 years for aggregated data from the state after sending in local birth and death statistics.

Achieving and sustaining a comprehensive and integrated assessment and surveillance capacity is made more difficult by the fragmentation of the assessment function in many states where environmental health and mental health data are gathered by separate agencies. Meanwhile, the lack of direct federal encouragement and assistance to state efforts has limited the availability of good health data at the state and local levels.

Policy Development

Policy development is the means by which problem identification, technical knowledge of possible solutions, and societal values join to set a course of action. The site visits and other information available to the committee raise many issues about the soundness of current policy development in public health.

Much good work has been done at the national level in generating health data, in analyzing and applying those data to public health problems, and in the development of planning tools like The 1990 Objectives for the Nation and Model Standards. (U.S. Department of Health and Human Services, Public Health Service, 1980; American Public Health Association et al., 1985) However, in the site visits and other inquiries, we found that policy development in public health at all levels of government is often ad hoc, responding to the issue of the moment rather than benefiting from a careful assessment of existing knowledge, establishment of priorities based on data, and allocation of resources according to an objective assessment of the possibilities for greatest impact.

The resulting pattern of policy decisions, which has been described as a ”successive limited comparison” or as disjointed and “incremental” (Lindblom, 1959), is well established in the American public decision process, reflecting, perhaps, our national penchant for immediate problem-solving, belief in the desirability of limited government, and widespread distrust of government “social planning.” Policy development can follow the interests of charismatic decision-makers (sharp examples were offered in the site visits of the influence of particular legislators or county commissioners on a particular issue) without adequate consideration of options, unintended side effects, long-term results, or effective allocation of resources based on impact on health status. Although The 1990 Objectives for the Nation and Model Standards serve as very good frameworks for objective setting and systematic policy formulation, we saw little evidence of knowledge about or use of these planning tools in our discussions with state and local decision-makers. In fact, as the director of the Medicaid agency in one state observed, policy is too often decided on the basis of single cases. During the time we visited that state, the plight of an uninsured woman in need of a heart—lung transplant was monopolizing public dialogue, while severe stress-related problems among the state’s farmers and their families—alcoholism, family violence, accidents—received little notice even among public health professionals.PHE3001 Public Health Problems and Solutions Essay.

Another problem is the fragmentation of policy development because of governmental structure. That structure is discussed in greater detail later in this chapter, but it deserves mention here because of its impact on policy formulation. Some of the fragmentation and diffusion of public health policy development is inherent in the U.S. system of government with its separation of powers between executive, legislative, and judicial branches and its federal system of national and state governments with further delegation by the states to local jurisdictions. In addition, health-related responsibilities are frequently divided among several agencies at the federal, state, and local levels (see Appendix A). The result is multiple decision-makers on a given issue, diffusion of responsibility and accountability, delays in decisions, and unresolved conflicts. We should also note, however, that a diversity of decision-makers may create opportunities for initiatives and innovations, for closer tailoring of policies to local circumstances, and for constituency groups to find an action point for a particular issue.

In a society that historically has preferred to minimize the role of the public sector, the committee finds that there is often a lack of a clear rationale for the public provision of services in the policy development process. It is not sufficient for the policy process to identify a need and a technical means to address the need. The policy determination also should include consideration of the appropriate public and private roles in which the public purpose is made clear, regardless of whether public or private means are chosen for conduct of the activity. The scope of public health often includes objectives that can be and are accomplished through stimulation of private actions rather than through direct public provision of services. In our interviews, several persons observed that public agencies often seem more comfortable with direct conduct of activities than with more indirect modes of action, such as stimulation of private activity to accomplish the public objective.

The relationship between the public and private sectors for the accomplishment of public health objectives becomes particularly apparent when regulation is the mode of public health activity chosen through the policy development process. Here again, a clear identification of the public purpose in the policy development process is necessary, along with the technical underpinning that can be provided by a solid assessment function. (Committee on the Institutional Means for Assessment of Risks to Public Health, Commission on Life Sciences, National Research Council, 1983) Sound analysis of health risk in the development of regulatory policies (e.g., water and air pollution controls, food safety, licensing of health providers) can lead to more rationality and credibility in the final regulatory decisions. It also can better concentrate public effort on activities that will lead to the greatest reduction of health problems for the effort and funds invested. The recommendations of the recent Institute of Medicine report on the regulation of nursing homes is an example of the link between a public assessment function and desired private actors. (Institute of Medicine, National Academy of Sciences, 1986) The importance of health risk analysis has also been recognized in the recent Federal Appeals Court decision holding that, in assessing the impact of proposed regulations, the Environmental Protection Agency must consider potential health risks rather than potential costs as the overriding factor. (National Resources Defense Council v. Environmental Protection Agency, 1987)

One by-product of a systematic policy development process is the identification of gaps or uncertainties in the knowledge base that should guide decisions.

Some problems with the policy development process can be accentuated through the domination of the process by very narrow special interests. For example: the board of health in one state consists entirely of representatives of the state medical society. Other special interests may dominate through the activities of key legislators, county commissioners, or appointments to public health leadership positions on the basis of narrow political interests. The final determinations in public health should always be political in the sense of being responsive to broad public values, but the committee is concerned that particular decisions—especially those with important technical content—may not have passed through a technically competent policy development process.PHE3001 Public Health Problems and Solutions Essay.

Another limitation on the development process is a constraint on the ability to respond to new challenges. This constraint may result from limited funding for public health activities or from the structure of budgetary decisions (e.g., 2-year budget cycles, limits on shifts among budget line items, Propositions 13 and 4 in California, Gramm—Rudman—Hollings at the federal level). Such structural boundaries on the decision process can hamper response to new challenges (e.g., AIDS, toxic waste disposal) by forcing substitution of the new activity for old functions. Added to the typical inertia of any organization and budget, these negative pressures put a special strain on the policy development process. In theory a good policy development process should be just as important for deciding on program reductions as it is for determining desirable program expansions. In practice, a ratchet effect is often observed in which it is much easier to consider program expansions on top of existing activities than it is to consider realignment of programs according to program priorities.

Assurance of Access to the Benefits of Public Health

Assurance of the availability of the benefits of public health to all citizens reflects a primary reason for the existence of public health activities. The committee identified many problems that impede the achievement of that assurance.PHE3001 Public Health Problems and Solutions Essay.

As described in Chapter 4 and Appendix A, the committee observed very wide variation of the content and intensity of public health activities across the country. Because benefit from well-conceived public health activities is clearly established, this variation means that there is considerable inequity in access to these benefits from jurisdiction to jurisdiction, as well as by social and income status. Decentralization of decisions and funds from the federal level accentuates this inequity, as does decentralization within states to local jurisdictions. For example, in one county visited, all the obstetricians—gynecologists in the county had unilaterally declared that they would no longer provide prenatal care to Medicaid or other poor patients. This was partly a protest against low reimbursement rates and partly an effort to pressure the state to do something about skyrocketing malpractice costs. Whatever the reason, the effect on poor women was devastating: they had literally nowhere to go for prenatal care since the health department did not provide such services. Women were presenting in labor at the local emergency room, having not seen a physician during their entire pregnancy.

Concern about equity implies that wide access to specified benefits is desirable. Within a nation of diverse needs, resources, and political structures, some diversity in the patterns and intensity of public health services is expected and appropriate. However, the committee was concerned about the degree of this diversity. A diverse response to local needs and circumstances needs to be balanced, in the committee’s view, with sufficient attention to equity of access to the benefits of public health programs. The degree of diversity of public health services in the country indicates that states and communities lack agreement on those services to which access should be assured.

Although Model Standards can be important tools for establishing a basic level of assurance, they leave wide leeway for states and localities to define their own version of extent of assurance of such public health benefits. (American Public Health Association et al., 1985) The objectives established by the Public Health Service, with considerable participation of other elements of the society, imply the desirability of universal access to the benefits of public health. (U.S. Department of Health and Human Services, Public Health Service, 1980) As indicated in Chapter 1, and as shown in the considerable progress toward achieving the objectives for 1990, even more equitable distribution of public health benefits is a realistic goal for many problems. (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986) The success in controlling some communicable diseases is so dramatic as to constitute a benefit that is universally available. The benefits of other public health interventions are more inequitably distributed. An effective assessment system that provides surveillance at the state and local level is necessary to identify inequities, especially for health problems such as injuries or chronic diseases for which the availability of services is more uneven and the role of public health less clearly established. Yet these problems loom large as causes of premature death and disability. Achieving desirable public health objectives such as smoking cessation, limiting the transmission of AIDS, prevention of low birthweight, and control of human exposure to toxic substances raises complex political and value issues in which the protection and improvement of the health of the public conflicts with other social values, such as individual freedoms or economic growth. The conflicts may erode support for effective public health actions, leaving gaps in access to benefits.

A special problem in assuring access to the benefits of public health activity is the diversity of funding sources for public health activities. Financial support for public health services varies greatly from state to state even after including federal block grant and project funds provided to the states (see Appendix A). PHE3001 Public Health Problems and Solutions Essay.In some states the amount of state and local funding is so minimal that basic services are heavily dependent on a flow of dollars from reimbursement by private and federal sources. Implicit in a concern about achieving assurance under present conditions of wide variation is a willingness of higher levels of government—federal and state—to reallocate tax revenues to areas of greatest need.

The Interaction of Technical Expertise and Political Accountability

In exploring the making of public health decisions in particular states and localities, we observed that technical expertise bearing on some public health problems may not be appropriately considered by the political policymakers, leading to decisions that are technically inadequate. For example, policymakers may not appreciate the problems raised by false positives in a testing program that is screening a low-risk population. The controversy over mandatory testing for AIDS sometimes reflects this lack of understanding. On the other hand, we observed that the technical experts may not understand or appreciate the appropriate and fundamental role for the political process in public policy-making, especially as it expresses society’s values as criteria for selecting among options that have been defined with appropriate technical competence.

Continuity of Leadership

In many public health jurisdictions, rapid turnover of leadership has been a problem. For example, the median tenure of state health officers in 1987 was about 2 years. (Gilbert et al., 1982) This rapid turnover probably reflects political-technical conflict, inadequate pay, the effects of reorganization, frustrations with the structure of decision-making, and low professional prestige. A rapid turnover of political appointees in federal, state, and local government is an established pattern in the American political system, reflecting the high value Americans place on making their government responsive to the democratic process. However, for an activity like public health, which is based on technical knowledge, rapid turnover of leadership in key positions can erode desirable technical competence. PHE3001 Public Health Problems and Solutions Essay.We have observed a trend in some jurisdictions to make key public health positions more subject to appointment on primarily political grounds than on the basis of professional expertise and standing, using “responsiveness” to new policy directions as a rationale. In one state the committee visited, political appointees occupy the top three levels of the health department hierarchy. When the governor changes, much of the leadership of the agency is wiped out. In this instance, career employees seem to be regarded as liabilities instead of assets, that is, the governor is widely reputed to see them as holdovers from the previous administration.

Another factor in the discontinuity of leadership has been the decline in the role played by the U.S. Public Health Service Commissioned Corps in providing experts on assignment to state and local public health agencies. For decades, the Commissioned Corps provided a personnel system with retirement benefits that allowed assignment of corps officers to state and local positions, constituting a national cadre of trained public health personnel. PHE3001 Public Health Problems and Solutions Essay.Although still used for this purpose, the corps membership has declined and has been less available for state and local assignment. (U.S. Public Health Service, Health Resources and Services Administration, 1987)

National Leadership for Public Health

The provision of appropriate national leadership for public health is closely related to the problems of governmental structure in our federal system as discussed earlier. The components of necessary national leadership include (1) identifying and speaking out on specific health problems, (2) allocating of funds to accomplish national public health objectives, (3) building constituencies to support implementation of appropriate actions, and (4) supporting development of the knowledge and data base by public health. The federal government has been active in all of these components over the years. The role of the Centers for Disease Control in strengthening the public health capacity of the nation is apparent and profound. The establishment of the Office of Disease Prevention and Health Promotion in the Public Health Service provided additional focus on public health issues. Publication of Healthy People (U.S. Department of Health, Education, and Welfare, 1979) in 1979 and the subsequent issuance of The 1990 Objectives for the Nation (U.S. Department of Health and Human Services, Public Health Service, 1980) and of Model Standards (American Public Health Association et al., 1985) represented a visible national leadership role in the establishment of public health objectives, working with state and local agencies and state and national nongovernmental health groups. The Environmental Protection Agency has played a major role in reducing environmental pollution. The National Institutes of Health led the campaign against hypertension. The National Institute of Mental Health led in the development of community mental health resources. The leadership role of the Surgeon General and the Public Health Service in reduction of smoking has been essential. Many other examples could be cited.

There have been complaints from state and local agencies since the 1960s that the federal government sometimes bypassed them in carrying out some federal health priorities. Examples include health planning, community health centers, regional medical programs, and professional standards review organizations. However, the current federal policy stance, going back over several administrations, has been to turn over more public health decision-making to the states. This has been accompanied, however, by a reduction in the flow of federal funds earmarked for public health activities, measured on an equivalent current services basis. For example, when the public health, mental health, and maternal and child health block grants were approved by Congress during the sweeping changes in 1981, decision-making was transferred to the states, but the federal funds included in the block grants were cut by 25 percent. (Omenn, 1982) Some national policy-makers argued for elimination of federal support for these functions. At the same time, federal revenue sharing was being eliminated, thus further reducing available federal funds that could be used for public health purposes. While some restoration of federal revenues was made by Congress in 1983, a net reduction from prior levels is still in place.

The AIDS epidemic has demonstrated the need for federal leadership in public health. Only the federal government can focus the attention and resources that such a health problem demands. In our site visits, many state and local officials welcomed national leadership on such issues, but at the same time complained about the fragmenting effect of some federal policies and programs and the lack of resources to carry out federal requirements.

Poor Relationships with the Medical Profession

A particular problem for public health leadership is the lack of supportive relationships with the medical care profession. There are numerous examples of practicing physicians being supportive of public health activities, but confrontation and suspicion too often characterize the relationship from both sides. The director of one state medical association perceived the state health department (led by a nonphysician) as failing to seek medical advice and as distrustful of private physicians. He cited the department’s effort to get a mandatory data reporting system through the legislature without consulting the association. On the other hand, health department personnel—including the director—told us that it was impossible for the department to do its job without the support of private physicians. As one official put it, “Without them, we’re dead in the water.” In contrast, we heard of one local health officer who, confronted with the problem of access to prenatal care, convened a meeting of local obstetricians to ask them each to agree to take one or two patients for whatever they would pay. The doctors all agreed, and the problem was resolved.

We found medical care leaders who were simply unaware of the activities carried out by public health; yet those same leaders are often crucial in the achievement of political support for public health activities and in the conduct of substantive public health activities in which the cooperation of the private medical community is highly desirable (e.g., the reporting of communicable diseases, the provision of prenatal care, the education of the public on healthful personal habits, and many other examples). Improving these relationships is an important challenge for public health leadership.

Community Organization for Public Health Action

In a free and diverse society, effective public health action for many problems requires organizing the interest groups, not just assessing a problem and determining a line of action based on top-down authority. There are many positive examples of public health officials taking leadership in organizing community support for actions toward public health objectives, but this dimension of leadership is not as firmly fixed in public health activities as may be desirable. This capability requires appropriate leadership skills and techniques, as well as an attitude that the community itself is a source of public health actions. These skills include the ability to communicate important agency values to public health workers and to enlist their commitment to those values, the ability to sense and deal with important changes in the community that are the context for public health programs, the ability to communicate with diverse audiences and to understand their perspectives and needs, and the ability to find common pathways for action. Appropriate training in these leadership skills needs to be a part of the educational preparation of public health leaders.

Organizational Separation of Environmental Health Programs, Mental Health Programs, and Indigent Care Programs

In a previous section, we discussed the problems that are created for a perceived coherence of public health activities when environmental health, mental health, and indigent care programs are administered by separate agencies. These separations also raise administrative, structural, and policy questions. In the case of environmental health, the committee was presented during its site visits with tangible indications of barriers to action caused by fragmentation of responsibility. In one county, officials were concerned about several toxic spills on highways, one of which had occurred near the county’s open reservoir. They had written more than a year prior to our visit to the state attorney general, who had jurisdiction in such cases, and as yet they had no answer. In another state, a rancher showed us the notebook of correspondence he had amassed over several years of attempts—as yet unsuccessful—to dispose legally of two barrels of toxic waste on his property.

Concern was also expressed that organizational fragmentation lessens desirable health-related technical input into the policy- and decision-making process—especially for environmental health activities and for the Medicaid program when it is administered by a social services agency. For mental health programs, the organizational separation may reflect a continued emphasis within mental health on the provision of services for the mentally ill rather than a “public health” orientation, including epidemiological surveillance and prevention.

Wherever organizational separation takes place, regardless of the validity of the reasons for that separation, separate program development is encouraged and desirable program coordination is impeded. Data systems are fragmented, impeding broad assessment and surveillance that make possible comparisons of program impacts on the health of the public and policy formulation based on comparable problem analysis and risk assessment. In the committee’s judgment, this separation contributes to the sense of disarray in public health that inhibits coherent governmental effort to improve and protect the health of the public. Such separation also divides constituencies that might otherwise help develop a broader vision of the public health mission.

Creation of Health and Human Services Superagencies

As described in Appendix A, almost half of the states have created umbrella health and human services “super” agencies. This combination of health and welfare accentuates the image in the minds of some policymakers that public health is predominately a welfare program. As a result, the relevance of public health to the broader society may be diminished. The emphasis of such health and welfare agencies on the coordination of services to particular individual clients, although a worthy objective, may give less attention to the broad population-based functions of public health that benefit the entire public.

Another problem with these umbrella health and human services agencies that was described to us is the appointment to managerial positions in these agencies of administrative generalists, with little or no health background or expertise. Desirable inputs from technically competent persons may therefore be subordinated in the policy and administrative process. Generalist managers may also be less attuned to a broad vision of public health, such as that set forth by this committee in Chapter 2.PHE3001 Public Health Problems and Solutions Essay.

It should be noted that at the federal level the Public Health Service has been part of such a “super” health and human services agency since before World War II (until 1977 also including education).

From the perspective of advancing a public health mission, the committee notes that both in the fragmentation model described above and the super-agency model, the role of public health leadership founded on a technically competent assessment function is lessened. Case studies have been made of these organizational changes (Lynn, 1980), but we note that there is no solid evidence of the impact of alternative organizational patterns on health status. Nevertheless, on the assumption that organizational structure can enhance or inhibit some aspects of program effectiveness, the committee believes the structural issues deserve attention.

We also believe that whatever the organizational structure, coordination with other human services programs will be necessary. For example, many issues of policy and program coordination will continue to exist at the interface between social programs and public health programs, especially for multiproblem families or vulnerable individuals, such as the disabled or the frail elderly. Likewise, such programs as housing, land-use planning, criminal justice, and education have important health implications. Public health will always have to reach across organizational boundaries for health-related inputs on policies and programs, just as other agencies will have to seek appropriate inputs from health agencies on their policies and programs. We question whether the ”super” agency health and welfare model has been a useful solution to those coordination needs.

Lack of a Clear Delineation of Responsibilities Between Levels of Government

The federal structure established in our Constitution deliberately introduces a degree of ambiguity and tension concerning the roles of the various levels of government. This ambiguity can clearly be seen in public health where we observe a “patchwork quilt” of relationships.

Questions about the appropriate division of responsibilities will probably persist as long as we have a federal structure of government. However, the committee is concerned that the lack of a clearer delineation of those roles impedes desirable cooperation and optimal use of the unique capacities peculiar to each level. Some patterns of relationship, such as the relationship of the Centers for Disease Control with states and localities in the control of communicable disease, seem to be relatively clear and productive. For other functions the relationships are less well established and are often sources of considerable tension. In the 1960s, the federal government deliberately bypassed official health agencies at the state and local levels in establishing certain federal health programs, such as neighborhood health centers and regional medical programs, to assure that federal objectives were met. Some environmental health problems raise complex questions of interstate or even international relationships in which a purely state or local focus of authority is insufficient for the problem. For example, in one of our site visits a county commissioner pointed out that pollution of beaches in his jurisdiction was caused by sewage effluent from a foreign country that borders on his district.

The relationship between the state and localities is extremely varied and is a product of particular provisions of state constitutions, political history, and inherent tensions between large urban areas and rural areas within a state. In most states, the statutes describing the authority of and relationships between state and local health agencies lack clarity and consistency. Often these statutes consist of successive overlays on prior law, rather than comprehensive codifications. Previous grants of authority to village, town, city, county, and state health officers and boards may have been made at different times using inconsistent language, resulting in a confusing patchwork of law which often mirrors an equally ambiguous set of relationships in practice. These ambiguities are often reflected in poor communication and in understandings between state and local officials.

This complex of problems deserves explicit attention if the future of public health is to be assisted by appropriate cooperation rather than impeded by dispute and confrontation.

Knowledge and its Application

Effective public health actions must be based on accurate knowledge of health problem causation, distribution, and the effectiveness of interventions. Actions often must be taken on the basis of incomplete knowledge, but these knowledge gaps can impede effectiveness of programs and ultimately public support for actions. For many public health problems the knowledge base, including knowledge about the effectiveness of specific interventions, is inadequate. Arguments in the policy formulation and regulatory decision processes often question knowledge that does exist, e.g., human health risks of toxic chemicals or effects of smoking on nonsmokers. Filling these knowledge gaps requires substantial resources, yet the need for additional knowledge is often perceived by decision-makers only when the decision needs to be made. Public health may then be accused of lacking competent expertise relevant to the immediate needs of decision makers.

Another problem with filling these knowledge gaps is the extraordinary breadth of substantive areas that are relevant to public health actions. Some knowledge arenas such as epidemiology are obvious, but public health is also a primary beneficiary of advances in biomedical knowledge that lead to definitive interventions, such as the development of new screening tests and vaccines. The research response to the AIDS problem illustrates this relevance. The same can be said for toxicological research that improves the ability of public health to perform informed risk assessments. The incredible ferment in research that is adding to our basic understanding of biological processes is, therefore, highly relevant to public health, as is reflected by the conduct of such research in a number of schools of public health.

Other knowledge bases are not quite so obvious but, nevertheless, important. For example, the recent report Confronting AIDS noted the importance of behavioral research, including fuller knowledge about sexual behavior, as an essential component of a successful public health strategy to limit the spread of this dread disease. (Committee on a National Strategy for AIDS, Institute of Medicine, National Academy of Sciences, 1986) Also relevant is evaluative research drawing on the social sciences in determining the effectiveness of public health interventions, both retrospectively and prospectively.

Because public health is an applied activity—usually carried out under firm fiscal constraints—it is often very difficult to nurture and sustain the necessary research activities in support of the public health effort. In our six site visits, we found only one state that made a substantial investment in research. It may be logical to aggregate much of the research effort to the federal level as has traditionally been done; however, this may leave undeveloped the function of applied research as a link between a generation of new basic knowledge and its application in the field. Private foundations have played a valuable role in the demonstration and education of new public health approaches. Just as developments in clinical practice have been enhanced by the conduct of clinical research, so it is essential that public health be enriched by appropriate basic and applied research in the full range of sciences relevant to public health.PHE3001 Public Health Problems and Solutions Essay.

The Need for Well-Trained Public Health Personnel

Many sections of this report have mentioned the need for well-trained public health professionals who can bring to bear on public health problems the appropriate technical expertise, management and political skills, and a firm grounding in the commitment to the public good and social justice that gives public health its coherence as a professional calling. The committee has identified a number of problems in meeting this need. Most public health workers, including some public health leaders, have not had formal educational preparation focused primarily on public health. (Institute of Medicine, Conference, March 1987) Those with adequate technical preparation may lack the training in management, political skills, and community diagnosis and organization that is appropriate for leadership roles in a complex, multifaceted social service activity. Public health leadership also requires an appreciation of the processes and values of government in the United States. The continuing evolution of public health constantly raises new challenges to public health personnel, requiring updating of knowledge and skills.

Many educational paths can lead to careers in public health, but the most direct is to obtain a degree from a school of public health. Schools of public health were established in major private universities early in the century. They now number 25—7 in private universities and 18 in public. During the early decades of their existence, they concentrated on training people with degrees in the health and related professions (physicians, nurses, engineers, dentists, and others) to become public health professionals. In recent years, however, as the mandate of public health has broadened and as public health problems and their solutions have become more complex, the schools have responded to this evolution by recruiting individuals from the behavioral sciences, from mathematics, from the biological sciences, and from other relevant fields and disciplines, as well as health professionals. (Institute of Medicine, Conference, March 1987)

Modern schools of public health serve important dual roles: that of a public health research institute and that of a public health educational facility. These roles reflect the great successes of public health in developing new knowledge and applying that knowledge in a social and political context to the benefit of the population. The complexity of modern issues in public health requires that the field continue to develop new technologies delivered in new ways. These technologies require both fundamental and applied research before they can be implemented as public health programs in an agency setting. Schools of public health have traditionally operated to serve this basic and applied research function, linking knowledge generation with practical problem-solving. PHE3001 Public Health Problems and Solutions Essay.Meeting the challenges to public health described in this report will require a strengthening of this linkage. The schools can build on their previous efforts to work cooperatively with agencies in evaluating public health programs and in assisting in their initial implementation.

Many schools of public health are located in research universities and therefore have specific responsibilities to the academic objectives of their institutions as well as to their fields of professional practice. This situation is by no means limited to public health, but characterizes graduate professional education in medicine, dentistry, engineering, law, and other fields. Each of these areas must accept the dual responsibility to develop knowledge and techniques of use to the profession and to produce well-trained professional practitioners.

Many observers feel that some schools of public health have in recent years become somewhat isolated from the field of public health practice. The result of this changing emphasis may be that some schools no longer place a sufficiently high value on the training of professionals for work in health agencies. The variation in public health practice noted earlier in this report and the limitations on employment opportunities in health agencies for well-trained professionals, restricting opportunities for graduates, have inhibited desirable responses by the educational institutions to the needs of practice. This situation is exacerbated by the fact that most public health workers have not had appropriate formal professional public health training. However, we lack sufficient knowledge about the public health workforce and its needs and opportunities.

Recognizing the importance of these and other issues relating to the education and training of public health personnel, the committee sponsored an invitational conference in Houston in March 1987 in cooperation with the University of Texas School of Public Health. The conference brought together public health educators, practitioners, and other concerned individuals to consider the future of education and training for public health. It helped identify issues, clarify consensus and areas of disagreement, and provide a broader input into the committee’s deliberations. The proceedings of that conference will be published separately from this report.

Distribution of Technical Expertise

Technical expertise in public health is not evenly distributed among jurisdictions. Some of the larger states have considerable internal expertise. Others lack such expertise. The consultation role of the Centers for Disease Control and the larger state public health agencies help fill this need, but important gaps remain. For example, in one of the states we visited, an assignee from the Centers for Disease Control was carrying out an important epidemiological study. When his short-term assignment was completed, however, the expertise necessary for essential assessment activities was no longer present on the staff. Public hearing participants reported that cut-backs in federal staffs, especially at the regional office level, have reduced the federal consultative capacity. This problem is further exacerbated by the lack of trained experts in such fields as epidemiology. Previous studies have shown persistent deficits in their availability. (Institute of Medicine, Conference, March 1987) In some jurisdictions, low salaries and unrewarding professional environments would inhibit the attraction of such expertise even if a sufficient aggregate supply existed.

Building Constituencies for Public Health

Our inquiries indicate that public health seems to suffer from a poor image or lack of attention even when its success in the solving of specific problems is highly publicized and commended. PHE3001 Public Health Problems and Solutions Essay.We were told by state and local elected officials that the general population often cannot identify the benefits they have received through public health activities. Public health, in this regard, suffers from its successes. Such achievements as a safe water supply, the disappearance of many childhood infectious diseases, reduction of the incidence of stroke, fewer childhood poisonings, reductions in lead poisoning, and control of food-borne infections are taken for granted until a problem occurs. Also, the identification of public health programs with means-tested welfare programs adds to the perception that public health concerns are not an integral part of the entire community.

Some of the public may have additional negative views of public health based on perceived interference with private freedoms and a moralistic tone of public health pronouncements. For example, smokers may resent efforts of public health authorities to limit smoking in public places. Other important interest groups, such as the tobacco industry, may oppose public health actions and question the competence of public health agencies because those actions may interfere with the economic interests of the group.

Although the broader medical community can and does identify with such public health issues as smoking, injury control, infectious disease control, and dietary change related to cardiovascular disease and cancer, many physicians look down on public health, as an organized activity, believing it to be second rate or meddlesome. The one-on-one orientation of most medical training, the limited exposure to such population-based concepts as epidemiology, and the lack of experience during the training process with interdisciplinary collaboration contribute to this lack of a natural alliance between the physicians and public health.

Finally, public health has both an enforcement (negative) and a facilitative (positive) aspect. This sends mixed signals about the image of public health to various population and interest groups.

We identify image as a problem not because we are concerned about the sensitivities of public health workers, but because we believe that these problems interfere with the capacity of public health agencies to mobilize the support of important constituencies, including the general public, for the public health mission. The image problem may also limit recruitment of talented persons into the field of public health practice. In a free society, public activities ultimately rest on public understanding and support, not on the technical judgment of experts. Expertise is made effective only when it is combined with sufficient public support, a connection acted upon effectively by the early leaders of public health.

Managerial Capacity

We have identified many aspects of the needed managerial capacity in the previous discussions, specifically under the label of leadership. Here, we reemphasize the complexity of the managerial tasks faced by the public health manager. We cannot think of a managerial responsibility that involves a wider range of skills, including not only the usual management and leadership skills for running a complex and interdisciplinary organization, but also the communication and constituency building skills of a public executive, and finally, but not least, access to up-to-date technical information, sometimes in emergency circumstances. The high visibility and intense public interest that arises when a public health emergency occurs adds to the stress of these positions. Finally, the nature of public health decisions often places the manager at the center of a conflict among competing societal values and political forces.PHE3001 Public Health Problems and Solutions Essay.

The early progress of public health in this country was advanced by the fortuitous presence of individuals who combined these many managerial characteristics. The present challenge is how to assure the ready availability of managers with these capabilities. This is unlikely to occur without special attention and a plan for the development and support of a cadre of talented persons with appropriate educational preparation and experience. Leadership development would be aided by adequate salary levels, particularly in the case of state and local health officers (the current low salaries for many of these positions are documented in Chapter 4 and Appendix A). Modernizing benefit programs so that personnel could accept “promotions” involving a change of political jurisdiction without losing accumulated pension funds would also help with the career development of a management cadre.

The Lack of Fiscal Support

The wide array of challenges facing public health and the strongly ingrained American belief in limited government make it unlikely that adequate financial support for public health activities will ever be available. In the competition with other important public functions, it is probably naive to think that the “right” distribution of available public funds exists. However, we would note these special problems for public health as compared with other public functions:

• an explicit reduction of federal support for public health activities;
• the special financial problems faced by particular states as a result of declines in their economies;PHE3001 Public Health Problems and Solutions Essay.
• the appearance of new challenges to public health such as AIDS or the hazardous by-products of modern economies;
• the advance of our techniques both biological and epidemiological to identify risks to human health;
• the changing demographics of American society (e.g., an aging population);
• an interconnected world that shares health risks with increasing rapidity;
• the need to maintain and replace expensive public infrastructures for health, such as water and sewage systems;
• the rise in the costs of modern health care, which both add to the burden on public provision of health services and compete with funds for other public health functions;
• the need to provide sufficient core support for a public health delivery system; and
• the complex requirements and limited rewards for public health managers.

This list could be expanded, but these problems illustrate the challenge of achieving adequate fiscal support for public health activities.

Statutory Base

According to Gostin (Gostin, 1986), the statutory base of public health is poorly suited to dealing with AIDS. The powers provided in statute are too restrictive, including outdated concepts of full isolation and quarantine that are inappropriate given the mode of transmission of AIDS. Also there are no clear criteria to guide officials in exercising their powers. Due process procedures are sketchy or absent. This leaves too much room for unfettered administrative discretion about how to apply the law. A modern public health law should remove the rigid distinctions between venereal and communicable disease and should enact strong, uniform confidentiality procedures. Otherwise, public health is left with a stick too big to wield.

Site visit comments bear out this view. For example:

“This state has strange confidentiality laws that make it difficult to target appropriate information to appropriate recipients.”

“In the legislature there is inordinate emphasis on the physician’s lack of information. They’re not confronting the position the doctor faces in informing people and their contacts about the disease—for instance, the wife of an AIDS patient. They tried to make knowing donation of infected blood a crime, but it didn’t go anywhere.”

“Our law has made AIDS a reportable disease. We have little in the way of confidentiality. The new law makes knowing transmission of AIDS second-degree murder.”

Assessment

Exercise of the assessment function is closely linked to the enabling structure put in place by statute. Public health officials feel keenly the need to monitor the disease and mount effective programs to limit its spread. Pursuing these functions raises many political sensitivities. In addition, the speed with which the problem developed has public health struggling to keep up with changing dimensions and new technologies. This makes long-range or even rather short-range planning a luxury agencies can’t afford. Some health agencies are accused of overemphasizing surveillance at the expense of preventive efforts such as education.

“The state has taken a commanding lead. They are secretive about sharing stats. I don’t want names, but they’ll only give out information on a countrywide basis. The hospitals are also tight lipped. The vital statistics give us the deaths.”

“We’re skeptical about the individuals themselves revealing the information. We need to track sero-positive individuals and maintain confidentiality.”

“The gay rights groups are concerned about list collecting; they are resisting public health moves to get people in for counseling. On the other hand, there are scientific concerns about anonymous testing. These are new issues for disease control.”PHE3001 Public Health Problems and Solutions Essay.

“The Department of Health Services has been so busy getting the new initiative implemented we can’t really plan adequately. No one has yet been able to take a broader system view of the AIDS problem. No one is thinking about how to fit the pieces together.”

“The research program at the university was good, but the main need now is for technology transfer. The results are not getting into the hands of community physicians fast enough.”

“The department is trying to use the STD (sexually transmitted disease) model, emphasizing surveillance and epidemiology. I would argue that prevention should take precedence.”

Policy Development

AIDS is extraordinarily controversial, and the political heat has been intense. Pressure to do something fast, but not to infringe on the rights of high-risk groups, has health agencies struggling to balance basic knowledge development with the obligation to respond to immediate situations. Among the many groups and individuals, public and private, engaged in fighting AIDS, health agencies have not taken a clear initiative in supplying leadership, and the public is unclear about what level of government it should look to for guidance or what it can appropriately and realistically expect any particular health agency to do. Lack of public understanding about the real nature of the risk makes matters worse; on the other hand, as one person said: “If they knew they had practically no chance of getting it, then they really wouldn’t give a damn.”

“It was publicity that finally raised the consciousness of the eighth floor [health department leaders].”

“The legislature has been the leader. It convened the hearing and put funding in place. Such leadership should have come from the Department of Health Services, but it hasn’t. The department has held no hearings. The state health director knows less than I do about what’s happening in the state.” (Legislative staff)

“The president and the governor should have taken the lead, but they seem not to want to discuss it. At the federal level, only CDC and NCI have been effective.” (Activist)

“AIDS dictates the entire public health program in the state to an inappropriate degree. I spend one-third of my time on it. Don’t ask me what we’re doing about diabetes or high blood pressure. I simply don’t know.”

“There’s not enough attention being paid. What gets done depends on the public mood. Much better education of the general public is needed so they will accept future expenditures.”

“In the end, the lack of responsible public health organization for the nation will prove our greatest handicap. Governments, too, can suffer a wasting disease; the gradual erosion of the coordinated leadership of the Public Health Service has created a void. Surveillance of the nation’s health is no longer the clear responsibility of any agency of government, nor is the surveillance of proposals for meeting crises. Isolated islands of excellence [CDC, NIH] do not alone constitute a national strategy to defend and promote the national health.” (Keller and Kingsley, The Milbank Quarterly, 1986)

Assurance

Public health officials at the state and local level are very much aware of their responsibility to make sure that AIDS is combated effectively. But they are hamstrung by the speed with which the problem has developed and the political heat it has generated, as well as by the difficulty of marshalling enough resources to do what they feel is needed. At present, they lack the technology either to cure AIDS or to control its spread through the definitive and simple means of a vaccine. The fiscal implications of caring for AIDS patients are poorly understood because estimates of the potential number of cases are in dispute. In some places where there are large numbers of AIDS patients, the private sector—especially voluntary groups such as gay rights organizations—have taken the lead in providing treatment and counseling, with the health department struggling to keep track of what is being done. The nature of the problem makes the regulatory apparatus difficult to mobilize.