ANSWER
They were carrying out the public health mission described in Chapter 2 necessitates systematically identifying health problems and developing solutions. This book has described the evolution of this problem-solving capability and its current status in the United States. With that description in mind, and drawing on a review of the literature, site visits, statements at the four open meetings, a review of other case studies (Miller & Moos, 1981; Institute of Medicine, National Academy of Sciences, 1982b), and the most recent evaluation of progress by the U.S. Public Health Service—The 1990 Health Objectives for the Nation (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services), Among these impediments are:
a lack of agreement on the scope of the public health mission;
insufficient capacity to carry out essential public health functions such as assessment, policy development, and service assurance;
Inequities in the distribution of services and the benefits of public health; limits on effective leadership, including poor interaction between the technical and political aspects of decisions, rapid turnover of leaders, and inadequate relationships with the medical profession; organizational fragmentation or submergence; problems in relationships among the various levels of government; inadequate development
These barriers must be overcome to ensure the committee believes it will be possible to develop and sustain the capacity to meet current and future public health challenges while maintaining current progress. There will be deaths and disabilities that could have been avoided with current knowledge and technologies. The health problems mentioned in Chapter 1 will continue to take an unnecessary toll, and the country will be unprepared to deal with future health threats.
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The challenges of responsiveness and continuity in public health are converging. Sustained success frequently leads to apathy. The visibility and excitement generated by new problems encourage ad hoc decisions that fragment programs and divert resources away from established and successful programs.
This chapter focuses on identifying the barriers that require the most attention, laying the groundwork for the following recommendations. The emphasis on obstacles rather than accomplishments may cast public health in an unfavorable light. Public health has a track record of success that should be celebrated. However, if public health is to maintain its track record of success, problems that threaten current and future capacities must be identified and addressed.
Visit: The Lack of Consensus on Public Health’s Mission and Content
In a democratic society, progress on public health issues requires sufficient agreement on the mission and content of public health to serve as the foundation for public action. There needs to be a clear consensus among public decision-makers, public health workers, private sector health organizations and personnel, and opinion leaders on translating a broad mission vision into specific activities. As discussed in Chapter 4, the governmental activities classified as “public health” differ significantly between jurisdictions. This diversity reflects a wide range of perspectives on the appropriate scope of public health activities among the many publics who must support public health through the political process and supportive activities in the private sector. As a result, it is challenging to build influential constituencies that go beyond a specific issue to support broad goals and the ongoing public health infrastructure.
We found many examples of constituencies formed around specific issues in our interviews (for example, toxic waste disposal, AIDS, Alzheimer’s disease, promotion of healthy lifestyles, and reduction of infant mortality rates). A democratic society favors organizing action around specific issues, a mid-nineteenth-century American tendency identified by de Tocqueville. (1899, De Toqueville) Although such a narrow focus frequently generates political support for action, it can also contribute to disjointed and fragmented decisions, a lack of concern for long-term issues, and a lack of support for a broader vision of the public health mission. It is easier to translate specific interests into sustained support for a broader public health capacity with a coherent and widely shared view of public health.
In addition to the diversity of activities described in Chapter 4, the committee identified several issues that divide public health.
Indigent Care is the responsibility of the public health system.
Some public health workers are concerned when their organizations serve as last-resort providers of indigent medical Care or administer Medicaid or other financing programs. According to those concerned, these functions detract from essential public health activities such as disease surveillance and control through prevention. One county health officer told us, “when you put together preventive and curative, the latter gets the money because no one has the guts to say I am going to emphasize prevention. “Illness care comes first.”
Others see the role of public health in the Care of the poor as critical—at least until society devises other ways to meet these needs. During many of our site visits, we were told of massive unmet needs for indigent medical Care. Personal health services account for nearly three-quarters of state and local health agency expenditures, as noted in Chapter 4. Many public health agencies have long focused on providing indigent women and children with maternal and child health services, emphasizing those services that have a significant long-term benefit through disease prevention and health promotion. Miller and Moos (1981) and the Public Health Foundation (1986) This emphasis on maternal and child health has been particularly strong in several public health agencies in the South.
The tension caused by attempting to provide personal medical care services while depriving other public health functions of a fair share of scarce funds is exacerbated by overall changes in medical care financing, which shift more of the burden of indigent Care back onto public agencies. (1985, Desonia and King) Because the dollar flow for medical services is significant, and reimbursement through federally matched sources of funding, such as Medicaid, is available, indigent Care takes a prominent place in the state budget-setting process compared to other public health functions. In the minds of policymakers and the general public, the association of public health with Care for the poor sometimes obscures the importance of public health to the entire population. In one state visited by the committee, the state health department pays for more than one-third of births yearly. This, plus a strong family planning program, has significantly reduced the state’s infant mortality rate in recent years. However, this record does not win the public support it should: the well-to-do either need to learn about the department’s services to the poor or see them as unrelated to their needs. The state’s legislature voted for 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 the 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.
The Relationship Between Public and Environmental Health
Many early advances in infectious disease prevention were made possible by public health management of water supply and sewage disposal. Even though some tension between environmental health activities relied heavily on sanitary engineering techniques and surveillance by sanitarians and the work of public health physicians and nurses providing preventive services to individuals from the beginning of public health, environmental health activities were integral parts of public health services until the 1960s and 1970s. Then, significant changes occurred in environmental health policy, planning, and organization at the state and federal levels of government. (Rabe, 1986) This movement combined concerns about natural resource conservation and energy conservation with traditional environmental health activities aimed at reducing the risk of disease and dysfunction. Many supporters of more vital public actions to prevent environmental contamination saw existing public health agencies needing to be faster to respond to the need for new actions.
The separation of many environmental health concerns from public health activities resulted from increased public attention and the perception of unresponsiveness from public health agencies. At the federal level, the division was symbolized by establishing an independent news agency, the Environmental Protection Agency, to oversee programs dealing with air and water pollution, solid waste, pesticides, noise, and ionizing radiation. The majority of these programs were previously part of the Public Health Service. A similar organizational shift occurred in states. Hanlon and Pickett (1984), Rabe (1986). The consequences of these changes are discussed further in this chapter, but one notable effect was the separation of public health from the broad-based constituency interested in environmental protection. Environmental protection functions that remained within the operational purview of public health, such as food safety and the enforcement of drinking water quality standards, needed to be more well-supported and publicized as programs to control pesticide use and reduce human exposure to air pollution or ionizing radiation. Identifying, educating, and modifying significant environmental factors that increase the risk of illness and premature death were separated from other interconnected public health functions. As a result, many observers believe that the health consequences of environmental hazards have yet to receive the attention or support they deserve. Uninformed analysis of environmental health risks may have exaggerated fears of those risks in some cases.
The Connection Between Public Health and Mental Health
Throughout its long history, the public function in mental health has focused primarily on chronically ill mental patients, as evidenced by large hospitals for the mentally ill. This activity in personal health services contrasted with the usual public health focuses on disease prevention and public health protection. Differing perspectives and operating modes were frequently reflected in the state-level organizational separation of mental health and public health. Mental health responsibilities remained within the Public Health Service at the federal level, despite mental health groups advocating for the preservation of a separate identity for mental health programs at both the state and federal levels to ensure adequate attention to these critical health problems.
Since World War II, the trend in mental health services in the United States has been away from large custodial institutions and toward community-based services, fueled by the National Mental Health Act of 1946 and federal Community Mental Health Centers legislation in the 1960s. This community approach and the mental hygiene movement that began in this country were founded on the belief that mental health problems were related to the community context rather than just the individual. Turner (1977) As a result, epidemiological concepts began to be applied to the identification of mental health problems in the population, and an interest in mental illness prevention, mental health promotion, and early diagnosis of mental problems began to parallel more closely with traditional public health concerns. Many health issues, such as those caused by substance abuse, accidents, family violence, and teen pregnancy, have been identified as having behavioral underpinnings.
Despite expanding mental health services to include many public health issues, the relationship between public health and mental health remains underdeveloped. Even though mental health and public health have moved closer together conceptually, organizational, historical, professional, and interest group barriers to more productive interaction remain.
The Joint Commission on Mental Illness and Health in 1961 and the President’s Commission on Mental Health in 1978 recognized the need for a community-based strategy for mental health prevention based on fundamental public health concepts. (1961 Joint Commission on Mental Illness and Health; 1978 President’s Commission on Mental Health) Regarding public health’s progress in disease prevention and promotion, the President’s Commission stated that “the mental health field has yet to use available knowledge in a comparable effort.” 1978 President’s Commission on Mental Health The strategy they proposed would be based on identifying high-risk groups in the population, identifying factors that contribute to those risks, and developing cost-effective risk-reduction interventions that are consistent with this society’s community and individual values. This strategy is consistent with this committee’s public health vision outlined in Chapter 2.
The Role of Public Health in Promoting Healthy Behaviors Through Education and Social Environment Modifications
Many of today’s health improvement opportunities revolve around lifestyle and behavioral changes. There is a large body of evidence linking health problems to behavior. Links between lung cancer and smoking; AIDS and sexual behavior; motor vehicle trauma, teen driving habits, and alcohol consumption; and family violence linked to family and job-related stress are all well-known examples.
Educational efforts to inform people about health risks or healthy behavior have been used to effect desired changes. Many of these initiatives have been carried out by the private sector, frequently through public media or private educational programs (e.g., advertising campaigns by voluntary health organizations). State or local public health agencies have frequently played a minor role. During our site visits, we frequently discovered that efforts to promote healthy behavior appeared to need to be higher on the public health agenda.
Other strategies, in addition to intervention to change individual behavior, 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 through taxation or advertising control. Although public health professionals have long recognized the physical environment’s influence on health status, they have needed to be more adept at recognizing health-related influences in the business, economic, and social environments and developing and advocating strategies to control these factors.
Despite the need for more definitive research, substantial evidence shows that the social environment can be a significant cause of illness—National Academy of Sciences Institute of (Medicine, 1982a; Berkman & Breslow, 1983). Job and family stress; hazardous product promotion; encouragement of risk-taking behavior and violence through TV shows, movies, and other popular media; and peer pressure for substance abuse, impulsive sexual behavior (with associated health risks of sexually transmitted disease and teenage pregnancies) and school failure are all potential or actual etiologic factors in physical and mental health problems. To be effective, public health programs should move beyond programs that address the immediate problem, such as teen pregnancy, and instead focus on health promotion and prevention by addressing underlying social factors.
To address these issues, the scope of public health must include relationships with other social programs such as education, social services, housing, and income maintenance.
Go to: Impediments to Public Health’s Essential Work
During its investigations, the committee discovered several issues impeding those charged with public health responsibilities from carrying out the essential functions of assessment, policy development and leadership, and ensuring access to public health benefits.
Evaluation and monitoring
An assessment and surveillance capacity that identifies problems provide data to aid decision-making about appropriate actions, and monitors progress is a cornerstone for public health activities. Epidemiology has long been regarded as the most crucial science in public health. A robust assessment and surveillance system based on epidemiologic principles are essential to a technically competent public health activity.
Federal agencies such as the Centers for Disease Control and Prevention, the National Center for Health Statistics, and the National Institutes of Health have provided national leadership, data, and technical assistance to states and municipalities in their assessment responsibilities. Many states and municipalities, however, need a fully developed capability for this critical function. While vital statistics have long been the responsibility of the states, other critical data are only available in the form of national sample surveys, which can only be directly desegregated to state and local areas without significantly compromising their accuracy. According to Appendix A’s Table A.4, half of the states collect morbidity data, and even fewer conduct health interview surveys. On the other hand, virtually all states collect data on communicable diseases, perform health screening for specific problems, and conduct laboratory analysis.
The level of support provided for the function of assessment and surveillance reflects these challenges, as well as the competition for limited resources with other more visible public health priorities. In one state, for example, vital statistics still needed to be published in the two years preceding our visit. In another case, a county health officer reported that after sending in local birth and death statistics, he had to wait more than two years for aggregated data from the state.
The fragmentation of the assessment function in many states, where separate agencies gather environmental health and mental health data, makes achieving and maintaining a comprehensive and integrated assessment and surveillance capacity more difficult. Meanwhile, a lack of direct federal encouragement and support for state efforts has limited the availability of good health data at the state and local levels.
Policy Creation
Policy development is the process by which a problem’s identification, technical knowledge of potential solutions, and societal values come together to form a plan of action. The committee’s site visits and other information raise numerous concerns about the soundness of current public health policy development.
Much work has been done at the national level in generating health data, analyzing and applying that data to public health problems, and developing planning tools such as the 1990 National Objectives and Model Standards. (Public Health Service, U.S. Department of Health and Human Services, 1980; American Public Health Association et al., 1985) However, we discovered during our site visits and other inquiries that policy development in public health at all levels of government is frequently haphazard, responding to the issue of the moment rather than benefiting from a careful assessment of existing knowledge, the establishment of priorities based on data, and the allocation of resources based on an objective assessment of the possibilities for most significant impact.
The resulting policy decision pattern, 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, perhaps reflecting our national penchant for immediate problem-solving, belief in the desirability of limited government, and widespread distrust of government “social planning.” Policy development can be influenced by charismatic decision-makers (brilliant examples of the influence of specific legislators or county commissioners on a particular issue were provided during site visits) 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 provide excellent frameworks for goal setting and systematic policy formulation, we needed more evidence of knowledge of or use of these planning tools in our discussions with state and local officials. Indeed, one state’s Medicaid director observed that the policy is too often decided based on single cases. During our visit, the plight of an uninsured woman needing a heart-lung transplant dominated public discourse, while severe stress-related problems among the state’s farmers and their families—alcoholism, family violence, accidents—received little attention, even from public health professionals.
Another area for improvement is policy development fragmentation due to governmental structure. That structure is discussed in greater depth later in this chapter, but it is worth mentioning here because it influences policy formulation. Some of the fragmentation and diffusion of public health policy development is inherent in the United States system of government, with its separation of powers between the executive, legislative, and judicial branches, as well as its federal system of national and state governments, with further delegation to local jurisdictions by the states. Furthermore, multiple agencies frequently share health-related responsibilities at the federal, state, and local levels (see Appendix A). As a result, there are multiple decision-makers on a given issue, a spread of responsibility and accountability, decision delays, and unresolved conflicts. However, diverse decision-makers may create opportunities for initiatives and innovations, closer policy tailoring to local circumstances, and constituency groups to find a point of action for a specific issue.
In a society that historically preferred to downplay the role of the public sector, the committee frequently needs a clear rationale for the public provision of services in the policy development process. More is needed for the policy process to identify a need and a technical solution. The policy decision should also consider the appropriate public and private roles in which the public purpose is made clear, regardless of whether public or private means are used to carry out the activity. The scope of public health frequently includes goals that can and are achieved through the stimulation of private actions rather than the direct public provision of services. Several people said in our interviews that public agencies often seem more at ease with the direct conduct of activities than with more indirect modes of action, such as stimulating private activity to achieve a shared goal.
When regulation is the mode of public health activity chosen through the policy development process, the relationship between the public and private sectors for achieving public health objectives becomes evident. Again, a clear identification of the public purpose in the policy development process is required, as is the technical underpinning that a solid assessment function can provide. (National Research Council, Commission on Life Sciences, Committee on Institutional Means for Assessing Risks to Public Health, 1983) Sound health risk analysis in developing regulatory policies (for example, water and air pollution controls, food safety, and health provider licensing) can lead to more rationality and credibility in final regulatory decisions. It can also better focus public efforts on activities that will result in the most significant reduction of health problems for the amount of effort and money invested. The recent Institute of Medicine report on nursing home regulation is an example of a link between a public assessment function and desired private actors. (National Academy of Sciences, Institute of Medicine, 1986) The significance of health risk analysis was also recognized in a recent Federal Appeals Court decision holding that the Environmental Protection Agency must consider potential health risks as the overriding factor rather than potential costs in assessing the impact of proposed regulations. (Environmental Protection Agency v. National Resources Defense Council, 1987)
One byproduct of a systematic policy development process is the identification of knowledge gaps or uncertainties that should guide decisions.
The process’s dominance can exacerbate some issues with the policy development process by very narrow special interests. In one state, for example, the health board is entirely composed of representatives from the state medical society. Other special interests may dominate through the activities of critical legislators, county commissioners, or appointments to public health leadership positions based on narrow political interests. The committee is concerned that specific decisions, particularly those with significant technical content, may have yet to go through a technically competent policy development process.
Another constraint on the development process is the inability to respond to new challenges. This constraint may be caused by a lack of funding for public health activities or by the structure of budgetary decisions (e.g., 2-year budget cycles, limits on budget line item shifts, Propositions 13 and 4 in California, Gramm—Rudman—Hollings at the federal level). Such structural constraints on decision-making can stymie responses to new challenges (e.g., AIDS, toxic waste disposal) by requiring the substitution of new activities for old functions. Combined with the usual inertia of any organization and budget, these opposing pressures put an extraordinary strain on the policy development process. A good policy development process should be just as crucial for determining desirable program expansions as deciding on program reductions. In practice, a ratchet effect is frequently observed. It is far easier to consider program expansions on top of existing activities than to consider program realignment based on program priorities.
Assurance of Access to Public Health Benefits
A primary reason for the existence of public health activities is to ensure that public health benefits are available to all citizens. The committee identified numerous obstacles to achieving that assurance.
The committee observed a wide variation in the content and intensity of public health activities across the country, as described in Chapter 4 and Appendix A. Because the benefit of well-conceived public health activities is well established, this variation implies that there is significant inequity in access to these benefits across jurisdictions and by social and economic status. Decentralization of decisions and funds from the federal level and decentralization within states to local jurisdictions exacerbates this inequity. In one county, for example, all obstetricians—gynecologists had unilaterally declared that they would no longer provide prenatal Care to Medicaid or other low-income patients. This was partly a protest against low reimbursement rates and an attempt to pressure the state to address skyrocketing malpractice costs. Whatever the reason, the impact on poor women was devastating: they had nowhere to turn for prenatal Care because the health department did not provide it. Women arrived at the local emergency room in labor, having not seen a doctor during their pregnancy.
Concern for equity implies that broad access to certain benefits is preferable. Some variation in the patterns and intensity of public health services is expected and appropriate in a country with diverse needs, resources, and political structures. The committee, however, was concerned about the extent of this diversity. According to the committee, a diverse response to local needs and circumstances must be balanced with adequate attention to equity of access to the benefits of public health programs. The country’s public health services are diverse, indicating that states and communities cannot agree on which services should be guaranteed access.
Although Model Standards can help establish a basic level of assurance, they leave much room for states and municipalities to define their version of the extent of assurance of such public health benefits. American Public Health Association and others, 1985 The objectives established by the Public Health Service, with significant participation from other elements of society, imply the desirability of universal access to public health benefits. (Public Health Service, United States Department of Health and Human Services, 1980) As stated in Chapter 1 and demonstrated by the significant progress toward meeting the objectives for 1990, a more equitable distribution of public health benefits is a realistic goal for many problems. (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Public Health Service, 1986) Controlling some communicable diseases has been so successful that it has become a universal benefit. Other public health interventions have an unequal distribution of benefits. A practical assessment system that provides surveillance at the state and local levels is required to identify inequities, particularly for health problems such as injuries or chronic diseases, where service availability is uneven, and the role of public health needs to be clarified.
Nonetheless, these issues are significant causes of premature death and disability. Achieving desirable public health goals such as smoking cessation, limiting AIDS transmission, preventing low birth weight, and controlling human exposure to toxic substances raises complex political and value issues in which public health protection and improvement conflict with other social values such as individual liberties or economic growth. Conflicts may erode support for practical public health actions, resulting in gaps in benefit access.
The diversity of funding sources for public health activities presents a unique challenge in ensuring access to the benefits of public health activity. Even when federal block grants and project funds are included, financial support for public health services varies significantly from state to state (see Appendix A). In some states, state and local funding needs to be increased so that essential services heavily rely on reimbursement from private and federal sources. Concern about achieving assurance in the current environment of wide variation implies a willingness on the part of higher levels of government—federal and state—to reallocate tax revenues to areas of greatest need.
Go to: Public Health Leadership
During its investigations, the committee discovered several issues that limit effective public health leadership. The committee’s vision for the future of public health necessitates leaders with a diverse set of skills, including technical competence in the substance of public health issues, managerial abilities, communication skills, knowledge of and skills in the public decision process, including its political dimensions, and the ability to mobilize constituencies for effective action. The committee recognizes that this is a demanding and multifaceted characterization of desirable leadership skills and that, as in most complex organizations, efforts to identify individuals with leadership potential and develop and nurture these capacities will be an ongoing challenge that will frequently fall short of the ideal. However, the committee believes that more emphasis should be placed on overcoming the specific issues that impede effective leadership. The following are specific issues that we discovered.
The Interplay of Technical Knowledge and Political Accountability
In investigating how public health decisions are made in specific states and municipalities, we discovered that technical expertise relevant to some public health issues might be overlooked by political policymakers, resulting in technically bad decisions. For example, policymakers may overlook the issues raised by false positives in a screening program for a low-risk population. The debate over mandatory AIDS testing sometimes reflects this misunderstanding. On the other hand, we found that technical experts may need help understanding or appreciating the appropriate and fundamental role of the political process in public policy-making, particularly when it expresses society’s values as criteria for selecting among options defined with appropriate technical competence.
Continuity in Leadership
Rapid turnover of leadership has been a problem in many public health jurisdictions. In 1987, for example, the median tenure of state health officers was about two years. Gilbert and colleagues (1982) This rapid turnover is most likely due to political-technical conflict, insufficient pay, the effects of reorganization, frustrations with the decision-making structure, and low professional prestige. A rapid turnover of political appointees in federal, state, and local government is a well-established pattern in the American political system, reflecting Americans’ high value in making their government responsive to the democratic process. On the other hand, rapid turnover of leadership in key positions can erode desirable technical competence in an activity like public health based on technical knowledge. In some jurisdictions, we have observed a trend to make critical public health positions more susceptible to an appointment based on political considerations rather than professional expertise and standing, citing “responsiveness” to new policy directions as justification. Political appointees occupy the top three levels of the health department hierarchy in one of the states visited by the committee. When the governor changes, much of the agency’s leadership is wiped out. Career employees appear to be regarded as liabilities rather than assets in this case, with the governor widely rumored to regard them as holdovers from the previous administration.
Another factor contributing to leadership discontinuity has been the decline in the role of the United States 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, allowing corps officers to be assigned to state and local positions, forming a national cadre of trained public health personnel. Although the corps is still used for this purpose, its membership has declined, making it less available for state and local assignments. (Health Resources and Services Administration, United States Public Health Service, 1987)
National Public Health Leadership
The provision of appropriate national leadership for public health is inextricably linked to the previously discussed governmental structure issues in our federal system. The components of necessary national leadership include (1) identifying and speaking out on specific health issues, (2) allocating funds to achieve national public health objectives, (3) building constituencies to support appropriate action implementation, and (4) supporting public health knowledge and database development. Over the years, the federal government has been involved in all of these components. The role of the Centers for Disease Control and Prevention in strengthening the nation’s public health capacity is clear and profound. The establishment of the Public Health Service’s Office of Disease Prevention and Health Promotion provided additional focus on public health issues. The publication of Healthy People (U.S. Department of Health, Education, and Welfare, 1979) in 1979, followed by The 1990 Objectives for the Nation (U.S. Department of Health and Human Services, Public Health Service, 1980) and 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, as well as state and national nongovernmental organizations. The Environmental Protection Agency has significantly contributed to reducing the environmental pollution. The National Institutes of Health spearheaded the anti-hypertension campaign. The National Institute of Mental Health was the pioneer in developing community mental health resources. The Surgeon General’s and the Public Health Service’s leadership roles in smoking reduction have been critical. Numerous other examples could be given.
Since the 1960s, state and local governments have complained that the federal government has sometimes bypassed them in carrying out some federal health priorities. Health planning, community health centers, regional medical programs, and professional standards review organizations are a few examples. However, for several administrations, the current federal policy has delegated more public health decision-making to the states. However, this has been accompanied by decreased federal funds earmarked for public health activities, as measured by equivalent current services. For example, when Congress approved the public health, mental health, and maternal and child health block grants during the sweeping changes in 1981, decision-making was transferred to the states, but federal funds included in the block grants were cut by 25%. (Omenn, 1982) Some national policymakers advocated for the abolition of federal funding for these functions. At the same time, federal revenue sharing was being phased out, reducing federal funds available for public health. While Congress restored some federal revenues in 1983, there is still a net reduction from prior levels.
The AIDS epidemic has highlighted the importance of federal leadership in public health. Only the federal government can direct the attention and resources required to address such a public health issue. During our site visits, many state and local officials welcomed national leadership on such issues. However, they also complained about the fragmenting effect of some federal policies and programs and a need for more resources to carry out federal requirements.
Relationships with the Medical Profession are strained.
The lack of supportive relationships with the medical care profession is a particular issue for public health leaders. There are numerous examples of practicing physicians who support public health activities, but confrontation and suspicion characterize the relationship on both sides far too often. One state medical association’s director perceived the state health department (led by a nonphysician) as ignoring medical advice and distrusting private physicians. He cited the department’s efforts to pass a mandatory data reporting system without consulting the association. On the other hand, health department personnel, including the director, told us that the department could not function without the assistance of private physicians. “Without them, we are dead in the water,” one official said. In contrast, we heard of one local health officer who, faced with the problem of prenatal care access, convened a meeting of local obstetricians and asked each of them to agree to take one or two patients for whatever they could pay. The doctors all agreed, and the problem was solved.
We discovered medical care leaders who were simply unaware of public health activities, yet, those same leaders are frequently critical in achieving political support for public health activities and in carrying out 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 a significant challenge for leaders in public health.
Community Public Health Action Organization
Effective public health action for many problems in a free and diverse society requires organizing interest groups, not simply assessing a problem and deciding on a course of action based on top-down authority. There are many positive examples of public health officials taking the lead in organizing community support for actions aimed at achieving public health goals. However, this dimension of leadership is not as firmly established in public health activities as it should be. This capability necessitates appropriate leadership skills and techniques and the belief that the community is a source of public health actions. These abilities include the ability to communicate essential agency values to public health workers and enlist their commitment to those values, the ability to detect and respond to significant changes in the community that serve as the context for public health programs, the ability to communicate with diverse audiences and understand their perspectives and needs, and the ability to find common pathways for action.
QUESTION
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Select a zip code near you to use as the target community in this discussion and later assignments. Select the zip code that includes the city government offices (city hall, city library), as well as retail stores, schools, and housing.
Review at least 1 community health needs assessment (CHNA) report as prepared by the closest nonprofit hospital serving the selected community.
Search online for [name of hospital] CHNA.
Select 1 issue of importance for the community as identified in the CHNA. Use this issue to describe levels of prevention in the assignment and to identify possible roles for local community and public health nurses.
Respond to the following in a minimum of 175 words:
Explain a current public health issue presented in Healthy People 2030 and how public health nurses can support the various levels of prevention for the issue.
Select a community of focus by zip code and identify a health issue of concern for that population.
Give examples of each level of prevention as applied to the selected health issue in your identified community.