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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
OCR for page R2
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
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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
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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.
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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
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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
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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.
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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
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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.
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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
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. -
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
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The
Future
of
Public Health
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