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The Future Pu~l~c of health Committee for the Study of the Future of Public Health Division of Health Care Services Institute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1988
NATIONAL ACADEMY PRESS · 2101 Constitution Ave., NW · Washinglon, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This project was supported by the W. K. Kellogg Foundation and two agencies of the U.S. Public Health Service (the Centers for Disease Control and the Health Resources and Services Administration, Contract No.U50/CCU 300989-01~. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.~. Committee for the Study of the Future of Public Health. The future of public health/Committee for the Study of the Future of Public Health, Division of Health Care Services, Institute of Medicine. p. cm. - (Publication IOM; 88-02) Includes bibliography and index. ISBN 0-309-03830-8 (paper); ISBN 0-309-03831-6 (cloth) 1. Public health Forecasting United States. I. Title. II. Series: IOM publication; 88-02. [DNLM: 1. Health Services-United States. 2. Public Health- history United States. 3. Public Health trends United States. 4. Quality of Health Care United States. W 84 AA1 I482f] RA445.I57 1988 362.1'097~dcl9 DNLM/DLC for Library of Congress 88-25538 CIP Copyrights 1988 by the National Academy of Sciences No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purpose of official use by the U.S. government. Printed in the United States of America Twelfth Printing, November 1997
Committee for the Study of the Future of Public Health RICHARD D. REMINGTON,* Chairman, Vice President for Academic Affairs and Dean of the Faculties, University of Iowa, Iowa City, Iowa DAVID AXELROD,* Commissioner of Health, State of New York Department of Health, Albany, New York EULA BINGHAM, Professor, Environmental Health, and Vice President for Graduate Studies and Research, University of Cincinnati, Cincinnati, Ohio JOSEPH BOYLE, Executive Vice President, American Society of Internal Medicine, Washington, D.C. LESTER BRESLOW,* Professor of Public Health, UCLA School of Public Health; Co-Director, Division of Cancer Control, UCLA Jonsson Comprehensive Cancer Control, University of California, Los Angeles, California TOBY CITRIN, J. A. Citrin Sons Company, Romulus, Michigan WILLIAM R. ELSEA, Commissioner of Health, Fulton County Health Department, Atlanta, Georgia JOHN R. EVANS,* Chairman and Chief Executive Officer, Allelix, Inc., Mississaugh, Ontario, Canada MELVIN M. GRUMBACH,* Edward B. Shaw Professor and Chairman, Department of Pediatrics, University of California, San Francisco, California ROBERT J. HAGGERTY,* President, William T. Grant Foundation, New York, New York ROBERT HARMON, Director, Missouri Department of Health, Jefferson City, Missouri RUTH KNEE, Consultant, Long-Term Mental Health Care, Fairfax, Virginia * Institute of Medicine member. . . . [11
IV THE FUTURE OF PUBLIC HEALTH LILLIAN MC CREIGHT, Assistant Commissioner for Professional Services, Health and Environment Control, Columbia, South Carolina BEVERLEE A. MYERS,*: Professor and Head, Division of Health Services, School of Public Health, University of California, Los Angeles, California BARBARA ROSENKRANTZ,* Professor and Chairman, Department of the History of Science, Harvard University, School of Public Health, Cambridge, Massachusetts ROBERT J. RUBIN, President, Health and Sciences Research Incorporated LOUISE B. RUSSELL,* Research Professor of Economics, Institute of Health Care Policy, Rutgers University, New Brunswick, N.J. HARVEY SLOANE, County Judge/Executive, Jefferson County Courthouse, Louisville, Kentucky HUGH TILSON, Division Director, Epidemiology, Information and Surveillance, The Wellcome Research Laboratories, Burroughs Wellcome Company, Research Triangle Park, North Carolina SARA M. TOWNSEND, Majority Whip, New Hampshire House of Representatives, Concord, New Hampshire BAILUS WALKER, JR., Professor of Environmental Science, Wadsworth Center for Laboratories and Research, State University of New York, Albany, New York J. JEROME WILDGEN,* Family Medical Associates, Kalispell, Montana STUDY STAFF KARL D. YORDY, Director, Division of Health Care Services CAMILLA M. STIVERS, Associate Study Director SUSAN E. SHERMAN, Research Associate H. DONALD TILLER, Administrative Secretary WALLACE K. WATERFALL, Editor, Institute of Medicine * Institute of Medicine member. t Deceased December 1986.
Preface In recent years, there has been a growing sense that public health, as a profession, as a governmental activity, and as a commitment of society is neither clearly defined, adequately supported, nor fully understood. Con- cerns for chronic diseases, geriatric disorders, substance abuse, teen preg- nancy, and toxic substances in the environment seem to some critics of public health, both within and outside government, to be inadequately addressed by a public health apparatus originally conceived and constructed to meet a different set of concerns. To many observers, problems of delivery, financ- ing, coverage, and quality of personal health services seem inadequately addressed by health departments and other official agencies. Yet, many of these critics express the belief that the health problems now facing the public are complex, challenging, and diverse; that they cover a broad spectrum of infectious and chronic diseases; that they demand supe- rior personal and environmental health services; and that they involve preventive, therapeutic, and rehabilitative intervention. This very complex- ity, when added to the perceived potential vulnerability to new epidemics and environmental hazards of virtually the entire population, lead many observers to conclude that a governmental presence, perhaps an expanded presence, in health has never been more necessary. But what is the most appropriate nature of that governmental presence? How should government's role relate to that of the private sector? How should governmental responsibility for public health be apportioned among local, state, and federal levels? Should government be the health care provider of last resort or does it have a greater responsibility? Should public health consist only of a necessary residuum of activities not met by private v
Vl PREFACE providers? How should governmental activities directed toward the mainte- nance of an environment conductive to health be apportioned among various agencies? But above all, just what is public health? What does it include and what does it exclude? Based on an appropriate definition, what kinds of programs and agencies should be constructed to meet the needs and de- mands of the public, which is often resistant to an increasing role, or at least an increasing cost, of government? All these questions and more are considered in this report. Its recommen- dations and conclusions are based on an extensive contemporary assessment of public health as it is now practiced, as well as the opinions of hundreds of individual commentators. But ultimately, when data gathering has been completed, a synthesis and integration of findings must occur. It is this synthesis that has led to the results reported here. It is the hope of the committee, staff, reviewers, the Institute of Medicine, and the sponsors that this report will be helpful in focusing attention upon the public health and some means for its advancement. RICHARD D. REMINGTON, Chairman, Committee for the Study of the Future of Public Health
TO BEVERLEE A. MYERS Beveriee Myers was a member of this committee until her untimely death in December 1986. Her contribu- tions to the formulation and early implementation of the committee's work were extraordinary, even after her final illness was advanced. These contributions re- flected her characteristic insight, energy, and dedication to public health. Her remarkable ability to dissect and analyze complex issues, and the co up Zing of that anal- ysis with her broad experience in public health activ- ities, enabled ad of us to see our task more clearly. She was an exemplar of the best in public service. We share with many an appreciation of her accomplishments and a deep sense of loss. We dedicate this report to the memory of Beveriee Myers with affection and respect.
Acknowledgments The committee thanks the many persons who assisted in the conduct of this study. Without their contributions, the study could not have been accomplished. First, it thanks the practitioners of public health who shared their time and knowledge. Special thanks go to the several hundred people who welcomed the committee into their communities in the six states it visited. The persons with whom the committee spoke in California, Mississippi, New Jersey, South Dakota, Washington, and West Virginia were gracious, thoughtful, and informative beyond request. Many spent hours patiently explaining public health issues and operations within their communities; others spent considerable time assisting with arrangements for the visits. The insights and information they provided are an important foundation of this report. An- other several hundred people from dozens of states spoke at four public meetings. The committee thanks them for their words and thoughts. And the committee thanks the health officials of Toronto, Canada, who provided valuable information on the Canadian public health system. We also thank the many public health educators, public health practitioners, and others concerned with public health who participated in the conference on educa- tion and training for public health in Houston, Texas, in March 1987. The staffs of numerous national organizations, including the Public Health Foundation, the Association of State and Territorial Health Officials, the Association of Schools of Public Health, the American Public Health Asso- ciation, and others provided assistance, advice, and information crucial to the report. And the staff of the Health Sciences Center of the University of Texas at Houston School of Public Health assisted in sponsoring the confer IX
x ACKNOWLEDGMENTS ence on research, education, and training in public health. The staffs of the organizations sponsoring the report- the Kellogg Foundation, the Centers for Disease Control, and the Health Resources and Services Administra- tion were also unfailingly encouraging and generous with information and assistance. An additional person must also be thanked for finding and returning notes and drafts that were lost when baggage was stolen at the airport. The committee is grateful to him for his public spirit at a crucial stage in the preparation of the report. Without his assistance, completion of the report would have been considerably more difficult. The committee would also like to thank its staff. Karl Yordy, Study Director, Camilla Stivers, Associate Study Director, Susan Sherman, Re- search Associate, and H. Donald Tiller, Administrative Secretary, served with grace, insight, and exceptional diligence in carrying out the complex arrangements for this study and in pursuing the suggestions of the committee. Finally, the committee would like to state its great gratitude and admira- tion for the hundreds of people with whom it spoke who have dedicated their lives to protecting the public's health. Without the unflagging commitment of these people, the nation's public health system would not be as successful as it is. While the committee presents many suggestions for improving the public health system in the following report, it is confident that improve- ments can be made precisely because the individuals who work in the system are so capable. The committee wishes to thank these individuals for their tireless contributions to society.
Contents SUMMARY AND RECOMMENDATIONS 1. THE DISARRAY OF PUBLIC HEALTH A Threat to the Health of the Public..... 2. A VISION OF PUBLIC HEALTH IN AMERICA: An Attainable Ideal............................ . 3. A HISTORY OF THE PUBLIC HEALTH SYSTEM. 4. AN ASSESSMENT OF THE CURRENT PUBLIC HEALTH SYSTEM: A Shattered Vision............................... 5. Pug LTC HEALTH AS A PROBLEM-SOLVING ACTIVITY: Barriers to Effective Action.................. 6. CONCLUSIONS AND RECOMMENDATIONS SUPPLEMENTARY STATEMENTS. Xl .19 . . . . . .35 .56 ....73 . .107 . .138 160
. - X11 APPENDIXES A A Summary of the Public Health System in the United States ........................... B Biographies of Committee Members C Model Standards: PROGRAM AREAS.......... ~ ^~ _ ^~ ~^ ~ ~` BAN ~ · · · · · · ~ · · · · · · · · · · · · · · · · · · · ~ · · · - PROMOTING HEALT~PREVENTING DISEASE OBJECTIVES FOR THE NATION - 1990........................ D Site Visits: Site Selection and Methodology....... INDEX . . CONTENTS . . . .163 .203 .211 .212 .213 · - ....... 217
The Future of Public Health