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1 Introduction BACKGROUND In the mid-1970s, many in the medical community were confident that the war against infections diseases was nearly over. Infectious diseases were on the wane, powerful antibiotics were proven weapons in the armamentarium against bacterial infections, smallpox was on the verge of eradication, and new vaccines were being developed to combat a variety of diseases. These improvements to health were accomplished through advances in public health. The public was well aware of these advances and the amazing results produced by medical sci- ence but did not necessarily view them as a function of public health. Neverthe- less, the public's knowledge led patients to have greater expectations of their physicians and reinforced the concept of entitlement, that access to health care services of good quality is a social right of every citizen. Governments felt the pressure to make modern medicine more widely available and responded to the appeals of their citizens. Concerns over substance abuse, chronic diseases, tobacco use, teenage pregnancy, environmental pollut- ants, and geriatric disorders captured the attention of decision makers. Public health systems were expected to address these complex, challenging, and diverse problems facing the public, as well as to continue to perform their traditional roles in disease surveillance, responding to epidemics and preventing infectious diseases. Yet, the integration of these new roles was poorly defined, inade- quately supported, and not fully understood. Today, the public health system is at a crossroads as to how to define and sustain its role. The changing face of health care poses new challenges for the detection, treatment, and prevention of infectious diseases. Historically, local 24

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INTRODUCTION 25 public health departments, hospitals, and clinics have been the main source for infectious disease outbreak detection and treatment. The members of managed care organizations and the rate of privatization of public health laboratories con- tinue to increase in response to the needs of the communities they serve. Simul- taneously, many of the specific functions of public health laboratories and insti- tutions that provide epidemiological services may be being eroded. Along with that erosion, local public health systems may have a diminished capacity to de- tect and respond to emerging infectious diseases. Additionally, the public healthy system's capabilities may also be adversely affected by the growing number of the uninsured population that focused most of the burden for re- sources on the public safety net and public laboratories. The challenge for public health laboratories will be to implement cost-shifting or to obtain new sources of support. As expected, conflicts arise in public health and its priority setting as it moves away from its traditional focus on infectious disease control to address the evolving fields of chronic diseases and injury prevention. Each of these areas is consistent with the overall mission of public health. Unfortunately, they are all vying for the same available resources. For years, the public health system has been challenged to respond to a va- riety of new and reemerging disease threats, from Legionnaires' disease, to HIV infection, to Lyme disease, and, now, to the latest onslaught of reemerging in- feciions such as those caused by organisms that are resistant to antibiotics. The enduring problems of chronic illness and injury, the rising specter of environ- mental pollutants, and the transformation of the nation's health care system pro- vide strong incentives for public health to develop innovative systems for infec- tious disease surveillance and response. Privatization of health care and public health laboratories poses significant challenges to the traditional way in which disease surveillance has been con- ducted. Essentially, this has resulted in high-volume, low-cost analyses migrat- ing to the private sector, while low-volume and high-cost tests remain in the public sector. Changes in the health care system are posing significant concerns for the traditional way in which disease surveillance has been conducted. For example, Medicaid patients, whose health data were once easily available to public health officials, are now being increasingly served by the private insur- ance industry (most commonly, managed care), which may not have the same incentives to share data. A reevaluation and an alternative means to maintain those important elements that have been effective and that continue to be effec- tive for infectious disease surveillance are needed. The challenge will lie in how we in the public health care system can best work with the changing health care system to create a stronger and more appropriate surveillance system. The op- portunity will be to promote public health and its special role and importance in health care.

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26 PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS CHANGING LANDSCAPE OF PUBLIC HEALTH Adapted from a presentation by Margaret Hamburg, M.D. Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services The issue of emerging infectious disease in the changing landscape of pub- lic health requires a focused examination of the factors that have changed the nature and extent of human exposure and risk entailed by the agents that cause infectious diseases (IOM, 1992~. The changing demographics and environmental conditions both contribute to the emergence or resurgence of infectious diseases. Likewise, global travel, migration, trade and commerce, and changing socioeco- nomic conditions affect transmission of infectious diseases. Human behaviors, such as dietary habits, food preparation practices, poor personal hygiene, unsafe sexual behavior, and intravenous drug use, also contribute to disease transmis- sion. The overuse and misuse of certain pesticides has led to the resurgence of a range of important disease threats in the United States and, perhaps more sig- nificantly, worldwide. Recently, certain health care practices have also contributed to the problem of emerging infections. Among these practices are the increased use and inten- sity of certain health care services, including invasive medical procedures and immunosuppressive therapies, and the overuse and misuse of antibiotics, leading to a broad range of concerns about the development of antimicrobial resistance. Concomitant with these changing practices is the transformation of the health care delivery system and the emergence and deepening penetration of managed care. Delivery of Clinical Services The delivery of most clinical services has shifted largely from the inpatient to the outpatient setting, and physicians are increasingly providing empiric treatment rather than relying on laboratory tests for confirmatory diagnosis be- fore initiating treatment. Reliance on empiric treatment, however, decreases the completeness and accuracy of disease reporting and, when coupled with the availability of fewer routine laboratory tests, results in the loss of traditional means of disease reporting and approaches to disease management. These changes have compromised our ability to accurately monitor and respond to emerging disease threats. Another area of change in the health care arena is the evolving role of many public health departments in the delivery of clinical services. Providing health care services to underserved and indigent populations is viewed by many as an important role of public health departments, as part of the health care "safety net". Alternatively, some public health departments have focused their efforts on providing a more limited set of clinical services that are important for

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INTRODUCTION 27 overall disease control objectives, for example, providing directly observed therapy for patients with tuberculosis or antibiotic treatment for sexually transmitted diseases. Each of the paths described above is important to the changing identity of public health and the future stability of public health systems. In particular, many public health departments are dependent on clinical activities and the revenues from those activities. Revenues from clinical care services often cross- subsidize some of the other important public health functions, such as surveil- lance. Thus, discontinuing clinical services delivery in health departments can destabilize the financial infrastructure on which many public health systems depend for financial viability. Yet, continuing to provide clinical services in light of the changing and increasingly competitive health care environment and growth of managed care, can also be a destabilizing force for many public health departments. To be effective, health departments must look outside the context of clinical care delivery to a range of often unique services and functions that they can pro- vide to promote health and prevent disease. For example, communication about the importance of the public health infrastructure in addressing the potential threat of bioterrorism requires vigorous effort. Increased funding to build the fundamental capacity for infectious disease surveillance is an important first step in the detection of and response to a potential bioterrorist threat. The public health system is often fragmented and dependent on categorical funding streams at the federal, state, and local levels. One-time investments in public health activities, such as infectious disease surveillance, do not provide the consistent and sustained leadership and support needed to strengthen the public health system. Laboratory-Based Reporting The problems of a fragmented system of public health are echoed when one examines the plight of public health laboratories. For example, the structural mechanism of financing differs in each state laboratory. Each state laboratory resides within a unique health care and public health system, and each operates its own unique information system. Public health laboratories are struggling to find their position and role in the changing health care environment. Some of the important shifts in the landscape are related to competitive market forces that promote the growth of independent laboratories and the consolidation of hospital laboratories. Many managed care organizations are contracting with laboratories that offer the lowest prices. These laboratories often differ across states. Consequently, conflicts arise when guidelines for disease reporting vary across jurisdictions. Cost-saving programs have also decreased the volume of samples and the numbers of tests that are performed because of the greater use of empiric treatment of diseases. Health

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28 PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS care systems no longer send their specimens to the traditional laboratory that they may have previously used. With the breakup of local laboratory networks and with the performance of fewer routine laboratory tests by public health labo- ratories, there is a concomitant breakdown in some of the traditional systems of communications and collegial relationships that foster information exchange and . disease reporting. Improving Communication of Health Information Communicating the value and importance of the public health system is a perennial challenge in part because when the public health system functions well, it is invisible to the public and to public policy makers. The public health community must recognize that both policy makers and the public understand and respond to disease-specific issues. Theoretical issues in public health are not well understood by the lay public, but presenting clear, concise inflation about specific disease threats can help to communicate concepts of risk which are better understood by policy makers and the public. Communication of public health issues requires a strategy that reframes a number of important issues in terms that people understand. This is an important transition for public health, and the public health community must be positioned to maximize the opportu- nity to promo~te~public health and its special role and importance in health care.