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OCR for page 31
Public Health and the Community
As discussed above, a wide range of entities (governmental, private, and
nonprofit organizations) have an effect on and a stake in a community's health
(Patrick and Wickizer, 1995~. These entities include health care providers, public
health agencies, and community organizations explicitly concerned with health.
They also include other governmental agencies, community organizations, private
industry, and other entities that do not explicitly, or sometimes even consciously,
see themselves as having a health-related role; these include, employers, social
service and housing agencies, transportation and justice agencies, and faith
communities. Many of the relevant entities are based in and focus their attention
on the community in question (Box 9~. Others, such as state health departments,
federal agencies, managed care organizations, and national corporations that have
a broader scope than a single community, often play an essential role in
determining local health status (IOM, in press).
The discussions of the Committee on Public Health have led to the conclusion
that, as communities try to address their health issues in a comprehensive manner,
all of the stakeholders will need to sort out their roles and responsibilities and be
held accountable for them (IOM, in press). In most communities, there is only
limited experience with collaborative or coordinated efforts among these diverse
groups. To work together effectively, they will need a common language and an
understanding of the multidimensional nature of the determinants of heals. They
must also find a way to accommodate diversity in values and goals. Governmental
public health agencies have traditionally provided specific services to individuals
and to the community at large. Local health departments may need to
31
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32
HEALTHY COMMUNITIES
BOX 9. Public Health at the Local Level
The Committee on Public Health held a workshop on June 27, 1996, at the CDC in
Atlanta, Georgia. The first panel session focused on public health functions at the
community level. Parcel members included the chief executive officer of DeKalb
County, the director of the DeKalb County Health Department, the president of the
DeKalb County Local Board of Health, a liaison with the state department of health, and
members of community-based organizations. Highlights of the discussion are listed
below:
Many local health department provide the only source of primary arid preventive
care for uninsured populations in their communities. It is not clear that managed care
organizations will provide primary and preventive care to uninsured people. There
remains a substantial role for public health agencies to assure, and if necessary, to
provide those preventive services to uninsured people.
Core public health functions are important at the local level and have been
incorporated into the legal structure of a number of health departments. Panel members
felt that the core functions of public health as defined in The Future of Public Health are
important as a basis for organizing, understanding, and evaluating the local public health
mission.
In light of an increase in the public's general lack of trust in government, panel
members felt that it is important for public health agencies to develop more open
communication with the public to build their trust. Additionally, it is important for the
private sector to work on building institutional trustworthiness because there are many
partnerships between the public and private sectors in the area of public health, which
will most likely increase over time.
Panel members discussed how local public health agencies were dealing with
decreased funding for their activities. Many local public health agencies have to deal
with diminished funding, but many are responding to these changes in different ways.
For example, some local public health departments are collaborating with local
managed care plans to provide personal health services to the community.
In some local jurisdictions, the process for setting public health priorities is to preserve
only those services that are fee-producing. To preserve the non-income producing
programs (e.g., smoking prevention), panel members agreed that it is important to
establish participatory advisory groups to educate elected officials and community
leaders about different public health activities.
Panel members concluded that public health at the local level can be responsive to
the needs of the public arid effective in providing services to the community.
SOURCE: Panel discussion at the June 27, 1996 Public Health Committee meeting. l
transform themselves to become leaders in organizing a community's resources to
enhance its health (Baker et al., 1994, NACCHO Blueprint, 1994; APHA, n.d.~.
The Future of Public Health identifies the authorities of federal, state, and
local public health agencies in the United States, and makes recommendations
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PUBLIC HEALTH AND THE COMMUNITY
33
about governmental structures to carry out the responsibility of public health.
Among other conclusions, The Future of Public Health supports the American
Public Health Association's Model Standards Committee's concept that "every
community must be served by a governmental entity charged with . . .
responsibility . . . for providing and assuring public health and safety services."
The committee's discussions, however, have shown that many communities in the
United States currently lack the ability to provide essential public health services.
Some communities have nothing comparable to a local department of health, and
the variability in capacity and commitment in those that do is quite large. These
facts have led CDC Director David Satcher to comment that China has attempted
to ensure that every village has access to a village doctor (formerly know as
barefoot doctors) whose major role is to provide health education, screening, and
other public health interventions at the community level. It is important, Dr.
Satcher feels, that every community in the United States has access to a basic
public health unit that provides information and interventions needed to optimize
its health (D. Satcher, personal communications, 1996~.
POLICY DEVELOPMENT IN PUBLIC HEALTH
The Future of Public Health defined policy development as "the process by
which society makes decisions about problems, chooses goals and the proper
means to reach them, handles conflicting views about what should be done, and
allocates resources." This definition suggests that partnerships between public
health agencies and community-based organizations are essential if policy
development is to be successful. The Future of Public Health, however, notes that
fragmentation is pervasive and persistent in public health. Fragmentation is "the
division of responsibility for health care among multiple, separate individuals and
agencies, each with a categorical purpose, and the whole lacking a coherent policy,
an integrated direction, and coordinated relationships" (Roemer et al., 1975~.
Many services of public health agencies are funded by the federal government
through a myriad of"categorical programs" aimed at specific underserved
populations and specific health problems (DHHS, n.d.-a). For example, prenatal
and infant care, immunizations, family planning services, and the prevention of
STDs and AIDS are funded through separate streams, some going directly to the
local level and others passing through the state or another fiscal intermediary.
Some have proposed general block grants, with few restrictions on how these
federal funds would be used as a solution to this fragmentation, but others are
concerned that unpopular but essential public health programs would not get
priority at the state or local level (Brown, 1996~. Another alternative are the
Performance Partnership Grants proposed by the Department of Health and
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34
HEALTHY COMMUNITIES
Human Services (DHHS, n.d.-b), which would have the local flexibility of block
grants and performance measures to ensure accountability. Although the
committee was not able to give this issue careful attention, these options deserve
further consideration.
One of the key considerations in public health is the extent to which public
health policymakers accept the essential political nature of public health and
develop ways to work with elected officials (Slivers, 1991~. Elected officials face
many different and sometimes contradictory expectations and demands from the
public (Stark, 1995), and therefore, public health agencies must compete for
limited attention. For improving the public's health to become a higher priority,
its importance must be made clear to elected officials. Recent research at the
county level indicates that when local health officials demonstrate various forms of
leadership on public health problems, it is possible to achieve improvements in the
health care system (Mirando et al., 1994) and develop support for the public health
department through the active advocacy of other community organizations.
COLLABORATION WITH THE COMMUNITY
The Future of Public Health acknowledged that public health policy is
formulated and implemented by a wide range of participants, including public
health professionals, other health professionals, public officials, and the
community (see Box 9~. Traditionally, public health was seen as the province of
the public health department; but increasingly, government agencies are
contracting with private community-based providers to carry out service programs
(Baker et al., 1994~. In substance abuse, HIV/AIDS, childhood disabilities, and
many other areas, there are a growing number of sophisticated organizations that
are directly providing personal preventive and care services
In recent years, community advisory boards, planning groups, and coalitions
have become common in public health. Currently, community participation
through an advisory group or coalition is mandated by a wide range of public
health programs addressing tobacco control (the COMMIT and ASSIST projects),
substance abuse (Office of Substance Abuse program's community partnership
grants), HIV/AIDS (Ryan White Care Act), maternal and child health (Healthy
Mothers/Healthy Babies, Healthy Start, Immunization, WIC, and Injury
Prevention), and women's health (Breast and Cervical Cancer Screening) (Sofaer,
1992~. Community-based organizations of this sort act as "advisors" and
"partners" to governmental public health agencies. This latter role involves a
long-term mutual commitment, a genuine desire of each partner to understand the
other, benefits to each partner that outweigh the costs of the partnership, and
meaningful collaboration in defining agendas and action strategies. Through this
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P UBLIC HEAL TH AND THE COMMUNITY
35
kind of genuine partnership trust can be established, and this ultimately gets
translated into a more powerful system to address community health problems and
to advocate for policy support.
Beginning in 1992, the W. K. Kellogg Foundation funded seven community-
based public health (CBPH) projects (in California, Georgia, Maryland,
Massachusetts, Michigan, North Carolina, and Washington) to link public health
agencies and their communities with academic leaders in public health. The
primary purpose of this four-year initiative was to implement the
recommendations of The Future of Public Health to reform professional education
by linking it more effectively with practitioners. Kellogg achieved this by
connecting both the academic and practice partners with communities that have
serious public health problems. Not only were the educational objectives realized,
but the initiative enhanced the capacity of all partners to improve the public's
health. For the partners, it provided access to new opportunities such as
leadership, education, and employment; skills in mobilizing resources; and, of
primary importance, an enhanced delivery of services. More specifically, it
proved a highly effective way of realizing the potential of public health's core
functions. One of the key lessons learned was that genuine partnership with and
by members of the community significantly enhances public health education,
research, and service including that which occurs in the practice agencies. The
Flint, Michigan project is profiled in Box 10.
When grass-roots communities recognize that public health agencies are their
assurance that the health system operates to protect and improve their collective
health, they will advocate for the fiscal and regulatory tools to enable the agencies
to carry out that role. Rather than being seen as a component of government that
taxes them and does things to them, public health agencies can be recognized as
the visible expression of the community's desire to collectively address its
common health problems. Thus the strategy of forming deep, long-lasting
community partnerships is part of the same strategy that can ultimately provide
public health agencies with the tools to assure Hat the managed care system
operates to the benefit of the health of the public as awhole.
DIFFICULT PROBLEMS AND DIFFICULTY SOLVING PROBLEMS
In a democratic and pluralistic society, such as in the United States, public
policy-making in practice is not a rational or neutral process. Instead, it is a
dynamic and political process that involves a constant struggle of ideas and
interests (Stone, 1988~. Sometimes this process is disjointed and incremental;
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36
HEALTHY COMMUNITIES
BOX 10. Community-Based Public Health: GeneseeCounty,Michigan
The Flint and Vicinity Action Community and Economic Development Corporation
(FACED) is a member of a partnership in Genesee County, Michigan, comprising
community members, community-based neighborhood organizations, the University of
Michigan, arid the Genesee County Health Department. Along with organizational
counterparts in the City of Detroit, this Michigan consortium is one of seven state
partnerships funded by the W.K. Kellogg Foundation to improve the public's health
through the practice of community-based public health (CBPH).
FACED was begun by a group of ministers who were confronted regularly in their
congregations with a broad range of economic, social arid health dilemmas. CBPH
facilitated the formation of a nonprofit organization through which their ministry could
be expressed. CBPH subsequently contributed to the organization's financial, business,
administrative, and technical capacities. Among current activities, FACED now
transports community residents for health care appointments, coordinates the work of
seven "church health teams," orients local residents to services offered through
community agencies, trains and develops other organizations, and delivers tobacco use
prevention programming.
Over the four years of the CBPH partnership, wide gaps in culture, race, trust,
orientation, and history have been bridged among team members whose experience
working jointly now forms the foundation for work with an expanded network of
community residents and organizations. Experiences helping to pass local tobacco
control regulations, successful advocacy in the area of lead poisoning prevention and
abatement, and work along with other partners to begin fact-finding in association with a
potential case of environmental discrimination were also described.
The active arid supportive presence of the CBPH partnership enabled organizations
to: both preserve and lose their traditional identity dependent upon the special challenges
of the task; recognize and value the "voice" of community residents; and be adaptive in
the design and funding of programming and research.
SOURCE: Based on a presentation by Yvonne Lewis, program coordinator of the Flint
and Vicinity Action Community Economic Development, Inc., at the June 27, 1996,
meeting of the Public Health Committee.
other times it is more erratic and random (Lindblom, 1959; Kingdon, 1995). Public
health, like other areas of public policy such as education or criminal justice,
faces internal and external struggles in the development and implementation of
policy. These challenges include conflicting and competing values and goals,
struggles with defining and resolving problems, and obstacles to the
implementation of programs. Additionally, in recent years, a growing public
mistrust of government, government institutions, and politics has created other
challenges to society (Box 1 1~.
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PUBLIC HEALTH AND THE COMMUNITY
37
BOX 11. Public Trust and Confidence In Government
Americans have had conflicting attitudes about government since the founding of this
country. There is strong individualism in the United States that often leads to suspicion of
government and the restraints that may be placed on the individual. However, the public
does recognize the role that government can play in helping individuals and organizations
achieve certain goals. In recent years, there has been a growing mistrust of government,
government institutions, and politics in general. The public often has higher expectations of
government agencies than of private-sector organizations and expects public officials to be
scrupulously honest, to avoid conflicts of interest, to perform their jobs efficiently, and to be
publicly accountable. The misdeeds of government officials are often printed on the front
pages of newspapers. In addition, the number of large, technically oriented public agencies
and private industries have increased, while at the same time public support for large-scale
scientific and technological developments has decreased. However, there are some things
that governmental agencies can do to build public trust and confidence.
Trust is the belief that those with whom one interacts will take one's interests into
account, even in situations in which one is not in a position to recognize, evaluate, or thwart
a potentially negative course of action by those trusted. Confidence exists when the party
trusted is believed to be able to empathize with one's interests, is competent to act on that
empathy, and will go to considerable lengths to keep her or his word. Trustworthiness is a
combination of trust and confidence.
An erosion of public trust in governmental agencies will take hold when the following
perceptions and beliefs become widespread.
Benefits and Costs:
· There is a perceived mismatch in the distribution of benefits and the costs associated
with realizing the agency's mission.
· The risk of hazard from program failure is perceived to be very high and very long
lasting.
Accuracy and Speed of Feedback:
· High levels of technical, esoteric knowledge are required to conduct the agency's
mission or to evaluate its success, risk, and hazards.
· A long lag occurs in the time to the discover of success or failure, especially if the
evidence of failure is likely to be ambiguous and equivocal.
Capability of Others to Meet Expectations:
· There is a perceived decline in the competence of agency members relative to the
demands posed by the problems central to effective operations.
· There is a perceived decline in operating reliability and in complete disclosure of
information about difficulties and failures.
Continued
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38
BOX11. Continued
HEALTHY COMMUNITIES
Motivation of Others to Understand and Keep Bargains:
· There is a perceived unwillingness to respect the views of the vulnerable parties.
· There is a perceived inability to fulfill promises to maintain consistent levels of
agency performance or promised public political support.
There are several things that a governmental agency can do to establish and maintain
public trust and confidence within its organization and external to its organization.
Increasing institutional trustworthiness begins with its internal operations. An agency
should commit itself and its contractors to maintain a high level of professional and
managerial competence. It should establish and meet reasonable technical performance
measures and schedule milestones that are dictated by a project's scientific requirements and
pursue technical options and strategies that can be clearly demonstrated to broad segments
of the public. It should reward honest self-assessment that permits the organization to solve
problems that have been identified internally before they are discovered by outsiders. In
addition, the agency should move the responsibility for promoting and protecting the
internal efforts to sustain public trust and confidence throughout the organization.
For an agency to build trust and confidence with the public, it should establish an
advisory board at the state and local levels as well as at the national level that includes all
interested parties in the work of the agency. The agency's top-level staff should be
accessible to citizens and their representatives. Open communication with He community
and agency constituents is crucial to developing institutional ~ustwor~iness. It is important
to establish consistent and respectful efforts to reach out to state and community leaders and
the general public for He purpose of informing, consulting, and collaborating win Hem
about the technical and operational aspects of the agency's work arid activities.
SOURCES: Based on a presentation by Todd LaPorte, professor of political sciences,
University of California at Berkeley, at the June 27, 1996 meeting of the Public Heals
Committee; LaPorte, 1994; Feingold, 1995; and LaPorte and Metlay, in press.
Many problems such as violence, substance abuse, and teen pregnancy are
fundamentally difficult because they have multiple, intertwined medical, social,
and economic causes (Sommer, 1995; Yates, 1977~. Resolving these problems
requires a comprehensive, collaborative response from different public agencies
and private organizations, including but not limited to public health. For example,
addressing the problem of lead poisoning prevention involves a coordinated
strategy among governmental public health agencies, the medical community,
environmental, occupational health, and housing agencies, business, labor, and the
general public as well as the public education system.
For other problems, the solutions seem more straightforward, yet the scientific
evidence about the efficacy and cost-effectiveness of solutions has been elusive
(Council on Linkages, 1995~. Policymakers need to know what types of
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PUBLIC HEALTH AND THE COMMUNITY
39
interventions are available, which ones have been shown to be effective, how
much they cost, and whether they can be modified and adapted to local
circumstances (Holtgrave et al., 1996~. Practitioners in governmental public health
agencies need the confidence and funding to sustain new models of practice while
maintaining models proven to be successful. The federal government has begun to
document the effectiveness of public health interventions (DHHS, N.d.-b; Gordon
et al., 1996), and this research has begun to be translated into practice. For
example, evidence has accumulated that use of mammography can reduce the
mortality due to breast cancer among women 50 years and older by 30%, and the
Pap test has been shown to be an effective technology for reducing cervical cancer
mortality QIenson et al., 1996~. In 1990, with passage of the Breast and Cervical
Cancer Mortality Prevention Act, the Centers for Disease Control and Prevention
(CDC) established a comprehensive public health program to increase access to
breast and cervical cancer screening services for women who are medically
underserved. This program has dramatically increased the number of older
women screened for breast and cervical cancer (Henson et al., 1996~. Additional
efforts are underway through CDC to improve the database on effective
community-based interventions (CDC, 1996~.
Even when promising solutions exist, public health agencies too often have
difficulty generating support for interventions among elected officials and the
general public. Programs to improve the public's health compete with medical
care services for attention and resources. While medical care services treat urgent
problems, many public health programs prevent problems from occurring or
progressing. Thus the benefits of medical care are often more tangible and
concrete, while the benefits of public health are more diffuse and less well
appreciated.
A key struggle for governmental public health leaders and those in the private
and nonprofit sectors with an economic, ethical, or philosophical interest in the
public's health is making the benefits of community-based, population-wide public
health activities and initiatives more recognizable, and finding allies who will
speak on behalf of these initiatives and the unique role for governmental public
health agencies in carrying out these initiatives. A good example of this is the way
that advocates at the state and local levels have been able to demonstrate how the
general public is affected by the costs of smoking: paying the medical costs of
lung cancer patients through higher insurance premiums or taxes for public
programs, experiencing the effects of passive smoking, and the numerous allies in
the communities who have embraced the tobacco-free movement. In contrast,
public health policymakers have been somewhat less successful in generating
support or alliances for HIV/AIDS prevention or STD control in part because of
the incorrect perceptions that these are not widespread problems in the general
population, that STDs do not have severe consequences, and because of the
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40
HEALTHY COMMUNITIES
public's reluctance to be open about sexuality (IOM, 1996). Public health
agencies need to work with the community to identify common problems Hat both
can work on together.
Some have suggested that public health agencies be compared to police and
fire departments in a public safety context (Box 12~. Others suggest that because
the unique role of public health agencies relates directly to prevention and the
community, it would be helpful to emphasize health protection, disease
prevention, and health promotion (Baker et al., 1994~. Emphasizing the Public
Health Functions Steering Committee's vision statement for governmental public
health agencies-"Healthy People in Healthy Communities" might be a fruitful
approach.
BOX 12. A Metaphor for Public Health
Public health agencies are a lot like fire departments. They teach and practice
prevention at the same time that they maintain readiness to talce on emergencies. They
are most appreciated when they respond to emergencies. They are most successful-and
least noticed-when their prevention measures work the best.
In another respect, the two are different. Everyone knows what a fire department
does; few know what a public health department does. The very existence of health
departments is testament to the fact that, when legislators, county commissioners, and
other policymakers understand what those departments do, they support them. It is a rare
person who, once familiar with the day-to-day activities of a public health department,
would want to live in a community without a good one.
SOURCE: Washington State Department of Health, 1994.
CONCLUSIONS
In its discussions with community group representatives and public health
officials, the committee heard of many innovative and effective approaches to
community partnerships and collaboration that are consistent with widespread
themes regarding community development and "reinventing government."
Broader application and further development of these new approaches to
collaboration within government twin legislators, boards of heals, and nonhealth
agencies) and with community partners to achieve public heals goals should be
encouraged.
Shared responsibility, however, requires careful management. The
governmental public health agency in each community needs to be capable of
identifying and working with all of the entities that influence a community's
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PUBLIC HEALTH AND THE COMMUNITY
41
health, especially those that are not directly health related. This function
must be undertaken by public health agencies that understand the
interactions of the full range of factors that influence the community's health.
To address this, a companion IOM report proposes a "community health
improvement process" that draws on performance monitoring concepts, an
understanding of community development, and the role of public health consistent
with the Committee on Public Health's discussions (IOM, in press). Public health
professionals who must work with a community to improve its own health
need to be trained and their roles need to be upgraded or enhanced.
The committee's discussions showed that many functions essential to the
public's health, such as immunizations and health education, can be and are
now being performed by either public or private entities, depending on the
historical context, community resources, and political dynamics of a
particular area. Some functions, however, such as environmental regulation
and enforcement of public health laws, must remain the responsibility of
governmental public health agencies. There also needs to be a resource in each
community to ensure that the health impact of multiple interventions in the
community are understood and addressed. This remains an ideal function for
governmental public health agencies and should not be delegated. Thus, the
committee reasserts the critical findings of The Future of Public Health that
governmental public health agencies have a unique function in the
community: "to see to it that vital elements are in place and that the [public
health] mission is adequately addressed." These elements include assessment,
policy development, and assurance. For a governmental agency to execute this
responsibility effectively, there must be explicit legal authority as well as health
goals and functions, that the public understands and demands. A fundamental
building block for this new approach to governance is public trust. With trust in
public institutions at risk or at low levels in many communities, governmental
public health agencies must find ways to improve communication and openness
with the public to maintain and increase their trustworthiness.
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Representative terms from entire chapter:
governmental public
