Public

Health Policy Forum

The Future of Public Health

Bailus Walker, Jr, PhD, MPH
During the past 3 decades a broad
and vigorous science base for health services has developed. Yet, the systems and
mechanisms for the delivery of the fruits
of this scientific knowledge to populations
that need them may have not reached their
full potential.
For all of the jubilant comparisons of
health status today with morbidity and
mortality trends in the early 1900s, most
Americans now agree that serious impairments of the health services system persist.
David Rogers,' professor of public
health at Cornell University, states the
case well: "In the last decade we have
seen the progressive weakening of local,
county and state public health agencies."
(p 530) This has developed despite the fact
that our entire complex of medical care
rests squarely on the achievement of the
public health service system and its cadre
of dedicated health professionals.
In any national rating of what measures have made the largest quantitative
difference in the health of the American
people, those provided by organized public health receive the highest commendations. But there is mounting evidence that
the keystone-state and local health

agencies-is eroding.
The symptoms of this erosion were
clearly identified several years ago in the
Institute of Medicine's The Future ofPublic Health.2 Recently, this evidence has
been brought into much starker relief at
the state and local levels-where health
services theory, concepts, and research
results must ultimately have relevance-by well-publicized crises in public
finances, including a $350 billion federal
deficit that is rising.
As we begin 1992, state and local governments across the United States are battling huge budget deficits, cutting services

once characterized as vital, laying off

health services personnel, reducing salaries of those that remain (prompting an
early exit of seasoned professionals), reducing workers' health benefits, and imposing fees on services that were earlier
provided free of charge, such as "911
health care."
Thousands of local jurisdictions are
so short of money that they can no longer
pay for basic public health services. This
situation leaves political leaders unsure
how to save these basic services if they
can be saved at all. Seeking new approaches to the delivery of services, a
number of local jurisdictions are now
studying proposals to create public authorities that would take responsibility for
managing public health services. Such
proposals are controversial because they
would result in an important shift in how
services are financed; they could affect tax
policy and public attitude toward state and
local govemments, and they could shape
the political power in the community. At
the same time demographic shifts,
changes in the job market, and the general
public's rising expectations of government, combined with general unhappiness
with tax-supported institutions, have
come together to produce an almost unprecedented challenge to organized public
health.
The concerns are evident in public
opinion polls showing a large number of
Americans no longer believe that the proBailus Walker, Jr, is with the University of
Oklahoma Health Sciences Center.
Requests for reprints should be sent to
Bailus Walker, Jr, College of Public Health,
University of Oklahoma Health Sciences Center, 801 Northeast 13th Street, Oklahoma City,
OK 73190.

American Journal of Public Health 21

Public Health Policy Forum

grams they are asked to pay for make any

real difference-except to make things
worse.3
These developments have injected
such new urgency into the debate over the
future of organized public health that the
arguments for improving state and local
public health services are no longer coming just from public health practitioners,
health advocates, and the other usual proponents of community-oriented health
and medical services. The business and
industrial community-recognizing the
value of comprehensive public health
services to economic growth and
development-calls for drastic improvements not just in schools and training programs but in water quality management,
maternal and child health programs, and
community nutrition services-to name
only three.
Evidence of this corporate attention
was clearest late last year when chairs and
chief executive officers of some of the nation's best known corporations-AT&T,
Prudential Insurance, Bell South, Honeywell, and Sky Chefs-appeared with us
before the House Budget Committee in
Washington. They called for near doubling of the Supplemental Food Program
for Women, Infant and Children (commonly known as WIC), and they talked
about how "profoundly worried" they
were about public health services for children and families.
Even the overwhelming majority of
Americans who have enjoyed easy access
to medical care-the middle-income and
the upper-middle-income people-use
many forums to express their concerns
about the soundness of the public health
service infrastructure. Private foundations and charitable organizations exhibit
their concerns through greater investment
of resources into new initiatives for capacity building.
The basis for these concerns appears
to be in a number of conflicting phenomena that are emerging from a slow and
inexorable movement beneath the surface
of demographic, social, economic, and
political currents.
The following listing provides a clue
of the immediacy of the challenge. Although the enumeration is significant, it is
not complete:
1. Many of today's disease

dys-

functions and premature deaths are preventable through the application of scientifically valid "promotion/prevention"
strategies. But as Sam Thier,4 former
president of the Institute of Medicine,
writes, "health promotion and disease
22 Amencan Journal of Public Health

prevention did not (in 1990) make much

headway in penetrating our technologically intensive society." (p 1)
2. After decades of decline, health
authorities have reported significant increases in measles, mumps, and whooping cough in the past 4 years-diseases
considered on the verge of eradication
only 5 years ago.
3. The number of tuberculosis
cases, an infectious disease also thought
to be on the decline, has forced community health officials to turn back the clock
and consider health service strategies, including reopening sanitariums, abandoned decades ago.
4. The problems of mental health
are so pervasive and the community mental health system is in such disarray that
jails, built to rehabilitate criniinals, have
become large, long-term holding tanks for
people with serious mental disorders and
others cast adrift by shrinking health and

social services.
5. Long waits (7 hours in some
cases) and overcrowding in public hospital emergency rooms are so severe that
many patients who seek and need emergency care are leaving the hospital without
seeing a physician or other health care
professionals.
6. Almost lOyears after homelessness captured the nation's attention, empathy is turning to intolerance as communities impose harsher restrictions on
homeless people to reduce their visibility.
These changes in local policies are fueled
by a public that has grown increasingly
impatient with a problem that has worsened despite programs aimed at relieving
it.
7. In the summerof 1991, 25 workers died in a chicken processing plant that
had never been inspected for health and
safety compliance-evidence that much
remains to be done in the prevention of
job-related injuries and deaths.
8. Related to job-related injuries
and deaths is the current imiishing role
of labor, which over the years had developed a high degree of sophistication in occupational safety and health training of
workers, in monitoring and surveillance of
work places, and in policy formulation and
analysis. Today labor finds its ranks decreasing, its policy-influencing power
eroded, and its sense of mission in question.
The above milieus are reflected in
modern public health literature, in annual
reports of private foundations, in Morbidiay and Moitaly Weekly Reports, and in
the popular press. They are also evident in

the titles of numerous symposia, conferences, and presentations.

In this matrix of public health issues
and problems and their multifactorial determinants, lie new opportunities and
challenges for government, business and
industry, universities, and all parties involved in health services research, policy
development, analysis, and implementation.
The conversion of these opportunities and challenges into curricula, organizational structures, and the effective management of resources in public health
research and practice is difficult and sometimes baffling. That is reality.
Yet, at least three qualities of strategic thought seem essential to current and
future public health circumstances. FisSt,
we must strengthen our capacity to think
and act anew and to disenthrall ourselves
from past dogma as demographic shifts,
political and economic realities may require. Indeed, the sense of identity of public health, which was clear in its beginning
must be continuously redefined as
achievements occur (such as those in molecular epidemiology and in the social and
behavioral sciences) brings to light new
issues (or old issues with new dimensions)
and new opportunities.
All too frequently have we applied
old principles, sometimes successfully,
sometimes with pernicious or highly uncertain effect to situations that call for new
thinking and new strategies and approaches. For example, it is clear from the
1990 census, from the resurgence of measles and other diseases, from uncertainty
about the economy, and from the dire
problems of such programs as Medicaid
that we may need new ng about our
approaches to achieving maxmum immunization levels in at-risk populations.
Second, there must be a firm sense of
priorities, of what is really important in the
prevention of disease, dysfunction and
premature death, and the overall improvement in the quality of life. Perfectionism
and wholeness are not the aim. Judicious
isolation of the most important areas of
effort, with a fair sprinkling of even the
less significant and an ability to concentrate community resources upon them,
are reasonable objectives for the public
health community. Here we will need to
rationalize public health authority on a
more integrated basis. How can policymakers-governors, mayors, or county
executives--at the state and local levels
form a coherent view and establish priorities among interrelated public health issues when they are dispersed among
January 1992, Vol. 82, No. 1

Public Health Policy Forum

many agencies who often compete

fiercely for limited resources. Program
managers often pay lip service to "coordination" under these arrangements, and
we miss opportunities to deal comprehensively with pressing state and local health
problems. Further, we duplicate efforts to
meet specific concems and delay overall
community progress because differences
among agencies are not quickly resolved.
What is more, in this process we lose sight
ofhow tightly the mechanics of our human
ecological system are interrelated.
Third, there must be a kind of foresight and unforgiving sense of the connection between today's public health actions
(broadly defined) and the health conditions and health status not just in the next
two or three budget cycles, but in the next
decade and beyond. Many of the issues
and problems confronting public health
have less to do with health policy and
technical competencies per se than with
the economic basis of state and local
power that supports them.

The cost ofpublic health services will

continue to grow significantly and, consequently, the country needs to make the
effort, starting now, to look past daily economic problems to develop long-term
funding strategies that insulate public
health service from the ebbs and flows of
the economy. Barriers to innovative financing exist at all levels and come in
many forms-federal tax policies, regulatory restrictions, and state prohibitions
against certain financing and contractual
procedures. Overcoming these barriers
and creating incentives in their place is a
long and arduous process. It requires leadership at the federal level, changes in state
and local institutions, and probably the
hardest of all, changes in mindset about
the funding of public health services at the
state and local level.
These economic issues are not beyond the purview ofthe public health portfolio, because the key to a viable and
effective public health service system is
the active participation of public health
professionals-practitioners, researchers,

and academicians-in all aspects of the

public health enterprise, including priority
setting and assuring that monies are available to support community-oriented services and programs.
Across all these areas, there must be
a capacity for bold political and public
health leadership at the state and local levels and an ability and willingness to convince all sectors of the need to reestablish
the proud position and intellectually challenging role of organized public health in
the advancement of American society today and in the future. Cl

References
1. Rogers DE. A private sector view of public
health today. Am J Public Health.

1974;64:530-533.
2. Institute of Medicine. The Future ofPublic
Health. Washington, DC: National Academy Press; 1988.
3. Clymer A. Politicians take up the domestic
issues: Polls suggest why. The Week in Review. New Yori Tines. Sept 15, 1991: Section 4-3.
4. Thier S. President's Message, Institute of
Medicine Annual Report 1990. Washington,
DC: National Academy Press; 1991.

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