| Volume 4 Number 4 | Spring '99 |
|
Editor: |
Louis Rowitz, Ph.D |
Introduction -1-
Michael A. Stoto, PhD
What is the Role of Public Health in the Healthy Communities
Movement?-6-
Gretchen Kinder, MSW, MPH; Suzanne Cashman, ScD; Peter Lee, MPH
Healthy Communities-12-
Bailus Walker, Jr., PhD, MPH, FACE
Son of The Future of Public Health-23-
Bernard J. Turnock MD, MPH
A View from Here-25-
Robert M. Pestronk
Michael A. Stoto, PhD
Michael Stoto is now serving as Professor and Chair of the Department of
Epidemiology and Biostatistics, School of Public Health and Health Services
at The George Washington University
The Future of Public Health, issued by the Institute of Medicine (IOM) in 1988,
set forth a vision of public health and a specific role for the governmental
public health agency within that vision, including the mission and content of
public health, and an organizational framework. In the decade since the report
was released, there has been a significant strengthening of practice in governmental
public health agencies and other settings. Substantial social, demographic,
and technological changes in recent years, however, have made it necessary to
re-examine governmental public health agencies’ efforts to improve the
public’s health. Thus, in 1996, the IOM Committee on Public Health1, issued
a follow-up report Healthy Communities: New Partnerships for the Future of Public
Health (IOM, 1996). This report, based on discussion with a specially formed
Public Health Roundtable2 and with public health professionals and others in
a series of meetings and workshops around the United States, addresses two critical
public health issues that can greatly influence the opportunity for our public
to be healthy as the United States enters a new century—(1) the relationship
between public health agencies and managed care organizations, and (2) the role
of the public health agency in the community—and their implications for
the broader issues raised in The Future of Public Health. The full report from
which this summary is drawn is available on the Internet at www.nap.edu/catalog/5475.html.
The 1996 report reaffirmed the understanding of public health professionals and health scientists that the public’s health depends on the interaction of many factors; thus, the health of a community is a shared responsibility of many entities, organizations, and interests in the community, including health service delivery organizations, public health agencies, other public and private entities, and the people of a community. Within this context of shared responsibility, specific entities should identify, and be held accountable for, the actions they can take to contribute toward the community’s health. As a result of this understanding, the committee focuses its report on how governmental public health agencies, especially at the state and local level, can develop partnerships with managed care organizations for the delivery of personal and population-based health services and with public and private community organizations to deal with broader concerns to advance the health of the community. Developing these partnerships will be critical for advancing the health of the public and of communities in the future.
Because the issues raised in Healthy Communities remain critical, and because many in the public health community are not aware of this line of thinking, Dr. Louis Rowitz, director of the Illinois Public Health Leadership Institute, asked me to guest edit this edition. I have in turn asked public health practitioners and scholars to respond to the report in light of their own experience. As you will see, this has led to a rich discussion that we hope will help public health leaders as we approach the twenty-first century.
Public Health and Managed Care
There has been substantial growth in organized health care delivery systems (which include managed care organizations) in recent years, and these developments have important implications for the health of the public. Managed care organizations are systems that are under the management of a single entity that (a) insures members, (b) furnishes covered benefits through a defined network of participating providers, and (c) manages the health care practices of participating providers. Proponents of managed care have argued that its goals and tools are consistent with public health. Many public health professionals, on the other hand, have also expressed concerns about managed care organizations’ motives and ability to deliver on their promises. The committee’s view is that if the proper kinds of partnerships between managed care organizations and governmental public health departments are developed, managed care can indeed make an important contribution to improving the health of the public.
The proliferation of organized health care delivery systems, which continue to provide care for an increasing number of Americans, has made it possible in some locales for governmental public health agencies to assure the provision of personal health services which involve a one-to-one interaction between patient and provider entirely within the private sector. How many elements of public health services private organizations can or should subsume remains unclear, but the number could be considerable. Providing care for the uninsured, however, remains a challenge; governmental public health departments will be ill prepared and inadequately funded to do so if no other personal services are being provided.
In order to ensure that partnerships between governmental public health agencies and managed care organizations work effectively toward improving the health of the public, the committee reiterated The Future of Public Health recommendation that the function of local public health agencies should include an "assurance that high-quality services, including personal health services, needed for the protection of public health in the community are available and accessible to all persons. . . ." This assurance function can be carried out "by encouraging other entities (private or public sector), by requiring such actions through regulation, or by providing services directly." Public health agencies can only exercise this responsibility if they are adequately staffed, equipped, and funded for this complex and demanding task and have appropriate relationships with health service providers. These activities should not be undertaken at the expense of existing essential public health services. Particular concerns arise when health departments have a dual role: direct provision of personal health services to some people and regulating private entities providing similar services to others. To improve the efficiency of all health systems, health agencies and organized health delivery systems, in conjunction with other community stakeholders, must reach agreement on their proper roles and responsibilities, which will vary by locale. Successful models of the integration of public health and managed care and of joint approaches to policy development do exist and need to be studied and tested more broadly.
Most public health agencies do not currently have the full statutory and regulatory authority to ensure the accountability of the organized health delivery systems to the public. In the current regulatory structure, health care delivery systems are often regulated by insurance commissions that focus on fiscal integrity rather than on health. State Medicaid agencies, usually separate from public health departments, also typically focus on fiscal rather than medical accountability dimensions, except in states that have a quality initiative. Recognizing the clear need for financial oversight, governmental public health agencies should increase their ability to oversee health care providers, with the goal of becoming coequal partners with insurance regulators and state Medicaid agencies, to ensure that the public’s health is addressed in the regulation of public and private health care delivery systems. In many states, additional legislative authority will be needed before public health agencies can take on this role. This approach requires population-based health outcome and performance standards that can be monitored, and public health agencies should be a major contributor to the development and monitoring of these standards.
The functions described in this report cannot be undertaken without properly trained professionals available to all communities. Thus, public health professionals should be trained to work with health services organizations to ensure quality personal health services in a community, as an essential element in providing for the health of the public. In addition, public health agencies should actively participate with organizations such as state health professions boards, medical schools, and accrediting bodies in planning and policy development.
Public Health and the Community
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 (with legislators, boards of health, and non-health agencies) and with community partners to achieve public health 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 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, 1997). 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 and are
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 reasserted 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 their openness
and their communication with the public to maintain and increase their trustworthiness.
Revisiting The Future of Public Health
Through its analysis of the interactions between managed care organizations
and governmental public health agencies and the role of public health agencies
to enhance the health of the community, and through its discussions about the
many responses to The Future of Public Health, the committee found that the
constructs of the mission and substance for public health agencies envisioned
in that report have been extraordinarily useful in revitalizing the infrastructure
and rebuilding the system of public health at all levels of government in the
United States and continue to be viewed as the fundamental building blocks for
the future. However, although clear progress has been made, some of the recommendations
of that report have not yet been implemented. In light of this, the committee’s
analysis shows that the concepts in The Future of Public Health remain vital
and essential to current and future efforts to energize and focus the efforts
of public health. These concepts need to be advanced, applied, and taught to
all health professionals.
The committee also found that the concepts of assessment, policy development,
and assurance, while useful in the public health community itself, have been
difficult to translate into effective messages for key stakeholders, including
elected officials and community groups. These concepts need to be translated
into a vernacular that these groups can understand.
In conclusion, the committee found that the public health enterprise in the
United States, as embodied in governmental public health agencies, is necessarily
diverse in organization and function, but operates within the common framework
set out in The Future of Public Health. The committee’s discussions, however,
revealed continuing evidence of inadequate support for governmental public health
agencies in many communities. Now, as nearly a decade before, society must reinvest
in governmental public health agencies, with resources, commitments, and contributions
from government, private and non-profit sectors, and substantial legal authorities,
if the public’s health is to improve. The partnerships that are the focus
of this report—between governmental public health agencies and managed
care organizations, and between public health and the community—can provide
both political support and a vehicle for this reinvestment.
July 16, 1999
References
Institute of Medicine (IOM). 1988. The Future of Public Health. Washington: National Academy Press.
IOM. 1996. Healthy Communities: New Partnerships for the Future of Public Health. M. A. Stoto, C. A. Abel, and A. Dievler, eds. Washington: National Academy Press.
IOM. 1997. Improving Health in the Community: A Role for Performance Monitoring.
J. S. Durch, L. A. Bailey, and M. A. Stoto, eds. Washington: National Academy
Press.
Gretchen Kinder, MSW, MPH; Suzanne Cashman, ScD; Peter Lee, MPH
Gretchen Kinder is a Program Manager for the Mass Health Access Program in the Office of Community Programs at the University of Massachusetts Medical School. Suzanne Cashman is a member of the Faculty of the Department of Family Medicine and Community Health. Peter Lee is the Director of the Healthy Communities Massachusetts Network and on the staff of the Robert Wood Johnson Foundation’s Community Health Leaders Program.
Consequently, this approach calls for clinicians and health care organizations to be responsive to community needs while contributing to the community’s capacity to identify and resolve problems. While the difference in semantics between "community health" and "healthy communities" may be minor, the implications for how the health of a community is viewed are profound.
While public health has always been supportive of the principles and strategies of healthy communities, the profession’s leadership in this area has frequently been truncated by turf struggles with the medical culture. These struggles have born themselves out through categorical policies and funding that support disease-focused interventions or otherwise limit public health’s ability to engage in broad-based efforts to address interrelated health issues through creative leadership and planning. The Institute of Medicine’s 1988 report The Future of Public Health underscores the erosion of the public health infrastructure in great depth. In spite of these obstacles, there are several examples of public health entities that have utilized healthy communities processes to achieve improvements in health outcomes. In 1990 the Boston Commissioner of Health and Hospitals initiated the Healthy Boston neighborhood coalitions and health councils that focused on neighborhood community improvement efforts in response to a crisis in infant mortality rates. California was one of the first states to implement a statewide Healthy Cities training and capacity-building effort across the state. The South Carolina public health agency developed a statewide training program, based on the National Civic League’s Healthy Communities Action Project (NCL-HCAP) model in cooperation with the state hospital and municipal associations, the Governor’s office, and other key stakeholders. Other state and local public health authorities have implemented healthy communities initiatives through very limited, patched together funding, or through Preventive Health Block Grants. Public health agencies within the federal government are trying to support this approach to health improvement. The recently announced REACH effort of the Centers for Disease Control and Prevention emphasizes community planning as an integral component of chronic disease management in underserved communities. In spite of these examples and the history of public health as a catalyst in both community health improvement and healthy communities development, the profession is not popularly perceived as a leader in the healthy communities movement.
A recent study of the community health workforce and core competencies, completed as part of an initiative of the Coalition for Healthier Cities and Communities1, ranked public health professionals as 4th and 7th (out of 12) in terms of importance to the development of community health and healthy communities. In this study, the Workforce Training and Community Leadership Action Team of the Coalition asked a self-selected group of 23 public health and medical professionals, along with community members and activists, to define the ideal community health workforce and its core competencies. This project, conducted between September 1996 and May 1997, was part of a larger effort to understand how to foster health professions leadership in healthy communities organizing at the local level.
Through this research, individual participants were asked a series of iterative questions about the development of a community health workforce2. Respondents were first asked to generate a list of the health workers who contribute to the health of a community, and a list of the competencies they should have in order to be effective in their work. These lists were collapsed into a single list of health workers and competencies3. Participants were next asked to place each item on the collective list into one of each of the categories of health workers and competencies listed in Table One.
Table One: Health Worker and Competency Categories
Health Worker Categories Competency Categories
Clerical and administrative support Assessment and evaluation
Community activists Communication and teaching
Community and human service workers Community and individual empowerment
Health diagnosing and treating workers Community knowledge and participation
Health maintenance and treating workers Cultural proficiency
Health paraprofessionals and technicians Health planning and leadership
Health planners and administrators Legislative and community advocacy
Municipal and related workers Provision of medical and community health
Public health and prevention workers services
Religious workers Provision of non-medical and community health
Scientific technicians and researchers services
Teachers and education-related workers Professional and personal development
The last task given to participants was to prioritize these lists of categories in order of importance to the development of a competent community health workforce that is poised to take a leadership role in local healthy communities. The results of this exercise are listed in Table Two.
Health Planners and Administrators were defined as health commissioners and boards of health. Public Health and Prevention Workers were defined as public health educators, industrial hygienists, workplace health and safety specialists, environmental health specialists, sanitarians, nutritionists and dieticians.
Table Two: Priority Ranking of the Health Workforce and Core Competencies
Study Area Rank Category
Workforce High (1-4) Community and human service workers
Community activists
Medium (5-8) Health diagnosing and treating workers
Health planners and administrators
Health maintenance and treating workers
Health paraprofessionals and technicians
Public Health and prevention workers
Low (9-12) Teachers and education-related workers
Scientific technicians and researchers
Municipal and related workers
Clerical and administrative related workers
Religious workers
Competency High (1-3) Community knowledge and participation
Community and individual empowerment
Medium (4-6) Assessment and evaluation
Cultural proficiency
Communication and teaching
Low (7-9) Professional and personal development
Legislative and community advocacy
Provision of medical/non-medical and community health services
Health planning and leadership
This study shows the inter-relationship between public health and medical
professionals as contributors to community health improvement and healthy
communities development. As the lines between community health and healthy
communities continue to blur, the medical professions are taking on greater
roles as supporters of community building and health improvement. The idea
that professionals, particularly physicians, should be engaged in caring
for the community’s health while caring for the individual’s health
is articulated by the Pew Health Professions Commission recently published
report entitled, Recreating Health Professional Practice for a New Century.
In this updated edition, the first major recommendation for all health professions
is that professional training be changed "to meet the demands of a
new health care system." The authors’ critique is that most of
the nation’s educational programs remain oriented to prepare individuals
for yesterday’s health care system. Specific competencies the report
articulates for health care professionals include:
These competencies are heavily focused on building health professionals skills in community health improvement activities. This is an important niche for health diagnosing, maintenance and treating workers in the blurring lines between community health and healthy communities. They are important stakeholders in these efforts.
The uncertain role for medical professionals in community health improvement
has not limited their participation and leadership in healthy community
initiatives. Their assumption of leadership in the absence of substantive
experience has potentially detrimental implications for the healthy communities
movement. However interchangeable the terms community health and healthy
community may be, the competencies necessary for supporting these two distinct
concepts are distinct. Without active and visible participation in the movement
by public health professionals and others with competency in this area,
there is a potential that the spirit, intent and goals of the broad-based
healthy community efforts will be lost to more minor community health improvement
efforts. Public health is currently witnessing this through ossifying categorical
funding and policies, the shape and content of public health training programs,
and the conspicuous absence of healthy communities discussions in public
health forums.
There are action steps that can be taken to promote the integrity of the
principles, processes and outcomes of healthy communities. These include:
Advocate for the reduction of disease-specific funding and ensure that categorical
funding has adequate guidelines that will permit community-based collaboration
across funding streams, data collection, evaluation and staffing that are
truly community focused and facilitate collaboration.
Provide opportunities for on-the-job training and skills building for health professionals moving into community work using a competency framework that focuses on the elements of healthy communities. Experienced community building and community development experts should conduct training.
Bring community leaders into health care institutions to assist in the development of public health curricula and instruction; oversee community-campus linkages.
Develop, implement and expand internship programs and requirements for academic institutions which will "stretch the envelope" of understanding of community for future health care and public health leaders. In shorts, revise internships, practicum and field placement to be much more community centered.
Establish connections between local, state and federal public health networks and other key stakeholders to advocate for the development of healthy public policies and resources (e.g. training centers) that promote healthy communities, not simply community health improvement.
A final action step to consider taking is to be involved as an active participant in your local healthy community initiatives, or to catalyze these discussions within your community and professional circles. For assistance with getting involved in healthy communities, connect to the national website at www.healthycommunities.org.
RETURN TO CONTENTS
Bailus Walker, Jr., PhD, MPH, FACE
Dr. Walker is Professor of Environmental and Occupational Medicine at Howard University Medical Center and Chairman for the Health Policy Council of the Government of the District of Columbia
The Institute of Medicine’s 1988 report on the Future of Public Health
represented the culmination of a revival of interest in governmental presence
in health — formally known as public health. With the remarkable advances
in the control of infectious diseases, a decline in interest began in the
traditional fields of public health paralleled by an upsurge of interest
in chronic diseases — which are multi-factorial in origin — and
medical care problems.
Historically, much of public health was associated with the prevention and control of communicable diseases. The decline in these diseases led to the erroneous assumption that public health problems were under control. This assumption became so ingrained that funds for state and local health departments were reduced or assigned to other programs. This situation, was clearly described by Shonick and Price,1 and is worth quoting at length:
Beginning about 1950, and greatly accelerating during the Kennedy and Johnson Administrations, the trend of federal legislation was toward channeling funds for health activities directly to private and quasi-governmental agencies, bypassing local (and state) health departments. The rationale has generally been that local health departments have not been sufficiently responsive to the changing demands of the times, particularly the need for accessible, primary ambulatory medical care in poverty areas. (p. 233)
From the standpoint of public health professionals at the state and local
levels, the 1988 IOM report was long overdue, and its full implementation
is vital, not only to public health leaders, but to every one in the nation.
Some of us who participated in the development of the Future of Public Health
say there is at least two ways of evaluating the 225-page document. One
is to say that it is a farsighted and forward looking proposal for the development
of a new national effort in public health. Another point of view is that
the report represents a terrible indictment of the status of public health
in the years before the report.
Both of these points of view may well be warranted. We in public health are naturally prone to point to our great achievements, but at times we hesitate to publicize what has been neglected or has failed to reach its maximum potential. By nature, the public health process — broadly defined — is a "messy affair;" participants scramble to cover up their mistakes (e.g. the Tuskegee Study) and protect their interests, and there is always intense conflict between advocates and regulators, between other government and private sector participants.
This conflict was brought home to us by the recent tobacco settlement. One of the chief goals of many of the state’s lawsuits against the tobacco was to reduce smoking. This goal is absent in most proposals emerging from the states. Straying from the tobacco settlement goals, a number of states are planning to use the money for public works projects, to purchase school computers and to reduce property taxes. Very little attention has been given to investing in public health.
Conflict is also evident in the increasing emphasis on reducing environmental health risks to children. Those who oppose this public health thrust suggest that environmental contamination does not play a prominent role in incidence of disease and dysfunction among children.2 Apparently, some analysts diagnose public health problems differently; anecdotes often outweigh solid evidence.
But most historians concede that there has never been a time when the public health system could rest smugly on its laurels. When the system has been in an up cycle, it has not lasted long enough for complacency to set in. And that is probably a good thing, because the system is now going through a challenging period.
So, it was entirely appropriate — indeed, commendable — for the Institute of Medicine (IOM) to convene the Committee of Public Health, the works of which are delineated in Healthy Communities: New Partnerships for the Future of Public Health.
While efforts, evidently, were made for contemporaneity in the references cited, many vintage writings are quoted or listed in the report, for the principles given in these pieces have not been frayed by time.
Although the report does not break new ground, it reinforces the vision that support of government is essential for a broad range of health-surveillance services and interventions that call for aggregate approaches. The report also etches in sharp relief the compelling reasons for seeking a stronger public health system. Clearly, if health is to be assured to each and every individual, public health leadership must be concerned with all of the various components.
This enterprise includes a multitude of resources — human and material — and a myriad of services derived from these resources. Lest we forget, the enterprise is composed of programs dealing with people and programs, concerned with facilities, programs related to services, research and educational activities. For example, to vaccinate underserved children, to control their parent’s blood pressure, to keep grandparents’ diabetes under control, the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services, supports a network of 746 community and migrant health centers, 128 health care programs for homeless people, and 22 primary care programs for residents in public housing.3
These and numerous other programs and services require the "productivity" of physicians, dentists, nurses, epidemiologists, and other professional and technical health man/woman power.
HEALTH WORK FORCE
One of the principal ideas identified by the Committee is the need to train health professionals to work with health organizations to ensure quality health services in the community.
Although many valuable contributions have been made by scientists and other professionals not specifically trained in the public health disciplines, a special need may exist to train more scientists and other professionals in those areas broadly defined as public health sciences.
But there are major policy issues related to the health work force. These issues can be compressed into four questions as posed by Uwe Reinhardt4 in a presentation at the 25th Anniversary observance of the IOM:
1. How should training of health professionals be financed?
2. What should be the content of the health education and training, especially in a world characterized by rapid technological changes and an increasingly diverse population?
3. Should the government or a quasi-governmental body of experts regulate the size composition, and geographic distribution of the health work force?
4. Given the highly personal interactions on which health care depends, how important is the racial and ethnic composition of the health work force?
These are exceedingly important questions — increasingly the subtext of health work force debates — which could not be adequately addressed within the space allotted this volume. Enmeshed in these questions are issues of work force analyses, projections and the shape of the supply and demand curve.
Measures of supply and demand have included employment opportunities, number of applicants to health sciences and medical schools, job satisfaction and anecdotes. But are these measures adequate in view of the numerous factors that influence the demand for health services? How do we factor into the demand equation divergence in types of health service personnel and a convergence of the settings in which services are provided? To what extent is both need and demand for health services affected by biomedical advances (e.g. molecular medicine)?
It might be argued that the development of the first device for home testing for hepatitis C liver virus achieves a net savings in the utilization of health services. The same applies to the recently FDA- (Food and Drug Administration) approved medicinal margarine that sharply lowers cholesterol. It is the first of a new generation of designer foods that act in many ways like medications.
The same also applies to developments in the diversity of application of pharmacokinetics and pharmacodynamic principles to the rational use of anticancer agents.
On another front, economic analysis suggest that increased purchasing power, whatever the amount, will allow populations to translate needs into demands, while other investigators state that this will allow groups to generate demand for health services in excess of actual need. In health, as in other areas, with every achievement the bar is raised and the expectations are intensified; the public demands that health services continue to improve. Indeed, all achievement is transitory and thus public health leadership can no longer take solace solely in the achievements of the past. Achievements bring to light new problems and new opportunities, and they can have broad implications for health work force requirements.
But, why is it that reports and scholarly papers which urge measures to increase the number of health services personnel, say virtually nothing about the need to organize services so that the work force is used more efficiently? The consistent programming at professional society meetings of presentations on the health work force, without addressing organizational issues, bespeaks continuing difficulties without total solutions.
There is another dimension to the work force issue: salaries and attraction to work at the state and local levels, where dollars and policies are translated into services. State and local governments have been particularly stingy with their budgets for public health workers. In high-cost-of-living areas for example, the salaries for highly qualified public health professionals have not kept pace with the cost of living. The problem of retaining health program managers and technical specialists once they are selected, bulks large in the consideration of effective public health leadership. It will not be solved by over-weening attention to such specific factors as morale, physical environment, hours, opportunity or power. All of these are subsumed in the health work force market. Consequently, compensation becomes a prime factor.
In the 21st century, it will behoove public health leaders to take a mature view of this matter and provide guidance to policymakers in developing compensation systems that will ensure the attraction and retention of the quality and number of health professionals essential for the success of the health services system. The American Public Health Association and others should have the foresight to promote adequate salaries for the public health work force.
Another way that work could be made more inviting would be to encourage the participation of state and local departments in research. The local community offers many opportunities for field studies of physical phenomena, of social and economic development and their effects on health. It is also an administrative laboratory where new methods may be developed and tested. There are many progressive public health leaders at the local level who welcome the chance to undertake research. Such activities are a welcome relief from the drudgery of inspection and enforcement that is basic to so many local environmental health programs. Research activities at the local level can be especially challenging in this period when the federal government is identifying new ways to deliver money to state and local governments to spend as they see fit.
In environmental health, this trend is a sign that environmental power-sharing is taking firmer hold than ever before. The Clinton Administration is seeking to spend $34 billion on environmental programs in fiscal year that begins October 1, a 5 percent increase over the amount Congress approved for the current fiscal year.
CORE FUNCTIONS
Healthy Communities speaks to the difficulty in translating to key stakeholders the concepts of assessment, policy development and assurance. Before we bemoan the lack of public understanding of the core functions of public health, let us ask ourselves why have we failed to educate stakeholders in a matter of such vital importance to the community. All around us, groups are educating stakeholders in such areas as the structure and content of DNA, genetic testing and environmental carcinogenesis.
In the Washington, D.C. area, we have conducted several sessions to "educate" non-scientists, consumer advocacy groups about DNA, toxicology and gene-environment interactions. When, may we ask, did the concept of core public health functions become so complicated that it could not be translated by modern public health leadership to local service club members, septic tank installers or publicly-assisted housing tenants?
Are the perceived difficulties in translating the core public health functions "into effective messages" an "etiological factor" in the lack of attention health promotion and disease prevention in the broader context of health care reform at both the federal and state levels. To be sure, policymakers are responding to issues such as prescription cost, loss of health benefits with layoffs, and unaffordable private coverage, and the "meaness" of managed care organizations. Seldom do the debates invoke the dependency of communities on essential community health services to ensure the health of the population.
There are, of course, exceptions. At least two states, Washington and Minnesota, have enacted legislation that not only makes improving the populations’ health an explicit goal of health care reform, but also supports achieving this goal through a broad range of reforms.
ASSURANCE OF SERVICES
Healthy Communities 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." Implied here is that public health must be comprehensive in concept and in practice. Compelling new evidence to supercede the older view of public health boundaries began accumulating in the late 1970's. Indeed, for many years, redefining public health has been a recurring theme in medical care — public health relations. Once again opposition is rising to restricting public health to what public health agencies currently do or what classic public health sought to undertake. This view has growing support among policymakers, as numerous organizations demonstrate that they are involved in promoting public health, and as public health planners recognize that many nonmedical activities contribute to healthy communities. As Miller 5 asserts, "From the viewpoint of comprehensive public health, the separation between government and nongovernmental activities and spending is arbitrary." Similarly, the division in government accounting between what is and what is not a public health measure is misleading. The monitoring by nonprofit watchdog organizations of foods for pesticide residue, and bottled water for bacteria are important public health functions. To their credit, proponents of the society-and-health approach (i.e., social factors that influence health) are calling for and even broader understanding of what contributes to the promotion of the public health — food stamps, standard housing, and employment.
At the same time the distinctions between domestic and international health problems are losing their usefulness and are often misleading. Thus, a new strategy for "healthy people in healthy communities," requires not only that communities merge the pursuit of health promotion and disease prevention services at home, but also that public health leadership recognize the global transboundary dimensions of the problems. Massive flows of goods and services and capital, cross international borders each day and cannot be ignored in assuring services necessary to achieve agreed upon public health goals.
Global health assessments which were addressed in 1997 by IOM’s Board of International Studies 6, underscores a theme — repeated with regularity — that in an interdependent world, international cooperation must be an integral part of public policy. Our common well-being will increasingly depend on factors such as health, environment and the economy, that have already been globalized. Lest cynics in state and local health services argue this has nothing to do with them, consider the following. The Constitution gave states numerous powers that underscored from the outset that they would have some role in foreign policy. The Constitution also gave federal courts jurisdiction over controversies between states and foreign countries precisely because communications, relations, and dealing between the two entities were expected.
Today it is difficult to think of a local health regulation in the United States that does not affect some foreign industrialist, traders, investors or tourists. Local governments have not only growing incentives to participate in global affairs, but also increasingly powerful means to do so. In fact, the explosive growth of municipal foreign policy in the past decade has been characterized as "impressive.7"
PUBLIC HEALTH AND MANAGED CARE
The Committee on Public Health joins everybody else, who has written on health service in this decade, in illuminating the contentious symbol of change which has come to characterize managed care. The IOM group was not nearly as harsh in its "assessment" as policymakers, editorial writers and others who have seized on the shortcoming of managed care to propose a broad spectrum of managed-care-reform policies.
The debate about managed care, and the way it is roiling the transformation of American health care, has gone through a number of phases, each reflecting the diverse nature of the controversy. Predictions are that the criticism will not subside any time soon because the industry represents a sea change from open-ended fee-for-service medicine.
On the relationship between managed care and community health service, one analyst has opined, that just as state health departments and Medicaid agencies used to engage in what was once called "the Cold War between the health zealots and the Medicaid infidels," community-based providers and managed care plans today often view each other with suspicion.8
An interesting phase of the debate, represented by a 1996 study commissioned by the Centers for Disease Control and Prevention,8 gave intellectual reinforcement to observant students of public health and advocates for a stronger emphasis on prevention and health promotion within managed care organizations.
The investigation examined eight health care organizations primarily in the Midwest and Northeast. With the exception of one organization among the study sites, prevention activities were ghettoized, clustered in parts of the organization often that are peripheral. The researchers described the prevention activities as programs "banging on the door, dying to get in, but rarely allowed in key meetings where an organization decides where to go with its future." The authors conclude, "In the short run, we found that capitation and managed care are probably going to hurt preventive efforts more than help them."9 Are these warning signs that public health partnerships will be insignificant until adequate emphasis is given to prevention by key entities in the relationship?
It is encouraging and noteworthy that segments of the health services community are responding to the challenges posed by the million years of life lost from preventable conditions. For example, academic medical centers are promoting — in subtle ways — preventive medicine and are adopting a population-oriented approach to medical care. There are also some efforts to link clinical practice and preventive medicine. This connection would be a significant step in bridging the continuing gap between the community orientation of public health and the individual orientation of clinical preventive medicine. It would also help fulfill the immense promise of "the proper kinds of partnerships between managed care organizations and governmental public health departments"10 by fostering direct and ongoing communications between managed care and community providers. The benefits of such communications to the public are unquantifiable.
ENVIRONMENTAL HEALTH
Healthy Communities list "protection against environmental hazards" as one of six health goals adopted by the Committee on Public Health. This writer agrees with this goal so thoroughly that it is difficult to comprehend why such vital area was not given more attention in the report. No doubt the group was unduly influenced by the present structure and organization of the federal and state governments, which have fractionated environmental programs among a number of agencies.
In Congress, interrelated environmental issues are dispersed among nearly 20 full committees and three or four dozen subcommittees. Does this dispersion enhance a legislators effort to form a coherent view of interrelated environmental issues? This could be a topic for serious debate. The Committee may have also overlooked an important consideration in defining the mission of public health. A substantial portion of the disease burden is environmentally provoked.
The Committee also may have overlooked present morbidity and mortality data which indicate that the major disease and health problems in the United States and other advanced nations of the world are caused or aggravated by environmental factors. For example, most cancers result from genetics and the environment. That is, genetic factors by themselves explain less than 10% of all cancer.
In fact, the progress of the past 20 years in environmental health has brought a number of environmentally-related diseases to a new level of understanding. Much of this success can be attributed to advances in molecular epidemiology, and toxicology. This work has underscored again and again that unless environmental factors in disease are considered a complete epidemiology cannot be achieved, even when there are identifiable genetic components.
Finally, the Committee may have given less than cursory attention to environmental health because the group did not include contributors who are at the forefront of the confederation of disciplines called the environmental health sciences. Thus, the deliberations of the Committee were apparently devoid of a fresh perspective on an important area of public health.
In achieving the environmental goal of "healthy people in healthy communities," it is vital that public health leadership recognize the current surge of concern about urban sprawl and its relation to community health. A key dispute revolves around the question of the health, social and economic cost of peripheral sprawl. Families living in a region are affected by traffic congestion, the tax burden inherent in building new infrastructures and maintaining old ones. Governor Christine Todd Whitman of New Jersey, describes the situation this way: "....suburban sprawl is eating up open space, creating mind-boggling traffic jams, bestowing on us endless strip malls and housing developments, and consuming an ever share of our resources."11
While public health leaders have tended to view community development problems in terms of housing, water supply and waste water disposal, it may be that we are looking at symptoms of more basic sociological problems with related political attitudes. As Moe points out, "The provision of affordable housing, improved mobility, a clean environment, a transition from welfare to work, the livability and economic health of our communities — all are undermined by sprawl."12
In fact, there is scarcely a single national problem not exacerbated by sprawl or that would not be alleviated if sprawl were better contained. When the environmental health specialist attempts to grapple with health problems associated with sprawl, he/she frequently finds that the entire problem is seldom contained within a single jurisdiction. Yet, when inter-jurisdictional cooperation is discussed, one may find a relationship unlike that of independent nations. Indeed, the list of jurisdictional conflicts is almost endless. This is not surprising, since there are over 80,000 governmental units in the United States and many environmental and public health issues have no respect for political boundaries. Conflict occurs between the federal government and state government; between federal government and local governments; among neighboring states; between regions; and between state and local governments.
Clearly the solution does not rest simply in handling all problems at the state or federal level. Nor can these questions be resolved by professional public health workers alone. Today public health leaders must join with urban planners, social scientists, and other partners if they are to be effective. There are also questions involving public policy, and the political aspects must be taken into consideration. Programs to address sprawl and interrelated public health issues are often a product of a political tug-of-war among groups and of personal values of executive- and legislative-branch policymakers. Members of Congress, state legislators, business people, environmentalists, often express concern for fairness, compelling national interest and a multitude of other noble objectives. But often these expressed concerns are mere code words, used to advance pragmatic interest.
The rhetoric is particularly noteworthy in the context of inter-jurisdictional relations because it often masks individual or group efforts to get authority located where it will best serve a political, economic, or other objective. For example, state and local officials
seek to maximize their influence over, and benefits from, federal programs, while minimizing the political and economic cost to their jurisdiction and their constituents.
Not surprisingly, public health has had great difficulty accommodating itself to political dynamics. Historically public health was a "motherhood" issue. Because everyone gained when an infectious disease epidemic was brought under control, or the local water treatment plant was upgraded, few objected to such activities. Indeed, there was little to be gained by involving public health departments in political matters. As noted in Healthy Communities, the situation has changed drastically. Health has become an enterprise deeply involved in the political world and the political landscape is rapidly changing. The pace of change is faster than our current ability to assess the potential impact or implication of the transformation.
As a result, the health planning arena is littered with examples of programs that failed, not because of flaws in technical knowledge, but the lack of political resources necessary for multidimensional solutions to health problems. Describing how public health recommendations may be transformed into public policy through the political process is complicated. The relative amount of technical and political content will vary from issue to issue and from community to community. It will even vary from government to government. Likewise the methods employed to resolve partnership conflicts will vary. These variations are due to the large number of variables which determine political behavior. Unfortunately, the politics of public health has received vary little attention from students of political behavior.
But the realization is dawning that collective efforts to improve the health of the public require adequate consideration of "political resources." Political strategies and the political context.
A final thought is that as we approach the 21st century, the task of protecting public health is becoming increasingly complex. A broad spectrum of factors, operating both singly an din combination, are contributing to the emergence of pathogens, once thought to be on the verge of eradication. These and numerous other developments make it abundantly clear that prevention, rather than curative health services, offer the more promising approach to solution of most disease problems. Indeed, the more we learn about the health implication of environmental pollutants, of behavioral and occupational patterns, and of genetics, we are forced to conclude that efforts aimed at prevention must occupy a much larger place in health planning and in the delivery of health services than they have in the past.
Assuring that this idea is brought to full fruition is within the purview of public health and its partners and this, in essence, is the sum vector of the 66 pages entitled, Healthy Communities.
References
1. Shonick, W. and Price, W., 1977. Reorganization of Health Agencies by Local Government in American Urban Centers: What Do They Portend for Public Health? The Millbank Memorial Fund, Quarterly, 55:233-271.
2. Heubner, S. and Chilton, K., 1999. Environmental Alarmism: The Children Crusade. Issues in Science and Technology, 15:35-38.
3. HRSA, 1998. Assuring Access to Essential Health Care. U.S. Department of Health and Human Services.
4. Reinhardt, U. The Health Work Force in For the Public Good Highlights from the Institute of Medicine, 1970-1995. Washington, D.C., National Academy Press, p. 84.
5. Miller, S.M., 1995. Thinking Strategically About Society and Health. In Amick, B.C., Levine, S., Tarlov, A.R. and Walsh, D.C. (eds). Society and Health, New York, Oxford Press.
6. IOM, 1997. America’s Vital Interest in Global Health, Washington, D.C., National Academy Press.
7. Shuman, M.H., 1992. Dateline Main Street: Court v. Local Foreign Policies, Foreign Affairs, 86:158-177.
8. Lipson, D., 1997. Medicaid Managed Care and Community Providers: New Partnerships, Health Affairs, 16:91-107.
9. Voelker, R., 1996. Medical News and Perspectives: Will Altruism Endanger Prevention? JAMA, 19:275:1463-1464.
10. IOM, 1996. Healthy Communities: New Partnerships for the Future of Public Health, Washington, D.C., National Academy Press.
11. Whitman, C.T., 1998. Metropolitan Challenge, Brookings Review, 16:3.
12. Pope, C., 1999. Suburban Sprawl and Government Turf, Congressional Quarterly, 57:577-672.
Bernard J. Turnock MD, MPH
Bernard Turnock is Clinical Professor of Community Health Sciences at the University of Illinois at Chicago, School of Public Health. He has also served as Director of the Illinois Department of Public Health.
Sequels, whether they are movies, novels or blue ribbon reports, seldom live up to the originals. An interesting opportunity to test this hypothesis presents itself with the publication of a second report from the Institute of Medicine (IOM), Healthy Communities: New Partnerships for the Future of Public Health.1 This report revisits developments affecting the public health system since the appearance of The Future of Public Health in 1988. 2
The substance of the second report comes primarily from the committee's deliberations and several other IOM-sponsored projects in the field of public health (most notably, Improving Health in the Community, A Role for Performance Monitoring).3 The committee formulated conclusions after workshops and discussions in order to identify key forces shaping modern public health practice. The committee identified three such forces: (1) the rise of organized health care delivery systems, especially managed care; (2) the changing role and public expectations of government; and (3) the increasing involvement and mobilization of communities in matters pertaining to their own health.1 The committee basically concluded that, as a result of these forces, governmental public health agencies "are alive and well…making gains on some fronts and losing ground on others" and that there have been "an astounding array of activities carried out in response to The Future of Public Health."
Unquestionably, there has been a renewed interest in understanding and improving public health practice and the public health system since 1988. At the national level, we have seen the development and widespread use of APEXPH and various state adaptations (such as IPLAN in Illinois), the formulation of the essential public health services framework, a rebirth of interest in public health workforce development, examinations of the public health infrastructure leading to expanded objectives in the year 2010 national health objectives, just to name a few. Statewide public health improvement plans and broadly participatory community health improvement processes have become the norm rather than interesting exceptions. In finding that the public health enterprise was experiencing serious problems in the mid 1980's, the original IOM report has been generally considered to be the wake up call needed to increase and focus efforts to improve the results of our public health system.
But we should be careful that we don't overly attribute these developments to the 1988 report and, as public health professionals do every day, look to discern causes from effects. Although not widely criticized at the time, the process and evidence used to advance the bold claim of a system in disarray was neither extensive nor well documented. Still, the collective wisdom of the participants was up to the task of laying out the broad strokes of a framework that could be used to improve the public health system.
The updated report notes that the medical care industry, the American public, and communities seeking better results have begun to act in ways that will affect the health of quality of life for populations. It should come as no surprise that managed care on the one hand and community health improvement efforts on the other have evolved so rapidly. If public health were in such dire straits just a decade ago, why wouldn't other major stakeholders seize the opportunity to act on their own? With no collective mandate to curb excesses of capacity and costs within the medical care system, the impetus had to come from those paying the bills in terms of taxes, insurance premiums, reduced wages to support health insurance benefits, and out of pocket expenditures. The intermediaries men in these machinations have been third party payers, businesses, and governments---but since all the costs are eventually borne by individuals---this reflects the fact that we have passed the point of diminishing returns and demand more accountability and evidence of benefit. Similarly, many different community configurations have emerged to seek greater voice in the identification and prioritization of health-related problems and needs. Community health planning efforts and even the modern day community health improvement processes weren't spawned from any grand plan concocted at the national or federal levels in response to the clarion call of the first IOM report.
Churchill was fond of saying that he was confident that history would be kind to him. He correctly reasoned that if he had a hand in writing that history, his chances of being treated kindly would improve! Perhaps the IOM has also concluded that its role in improving the public health system will be viewed in a more positive light with their own interpretation of what transpired after their first report. Whether these attributions are accurate or not, it is unlikely that the impact of this second report will match that of the 1988 original. But it does provide us with an interesting opportunity to consider the many positive developments in public health over the past 10 years. Did they derive from the 1988 report or from the conditions described in that report?
References
1. Institute of Medicine. 1996. Healthy Communities: New Partnerships for
the Future of Public Health. A Report of the First Year of the Committee
on Public Health. MA Stoto, C Abel, A Dievler (eds). National Academy Press;
Washington DC.
2. Institute of Medicine. 1988. The Future of Public Health. Washington DC; National Academy Press.
3. Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington DC; National Academy Press.
Robert M. Pestronk, MPH
Health Officer
Genesee County, Michigan
In Theory
Governmental public health agencies in local communities (local health departments) are an important part of any community’s effort to improve the public’s health. They are a porous reservoir for a conceptual and operating framework whose intent is a healthy community. The reservoir is intentionally leaky so that it may saturate the surrounding area. The popularity and acceptability of the framework cycles in and out of fashion in the United States over time.
The framework has four elements. The first element is attention to the health of all residents in their political jurisdiction.1 This is different than the perspective of others operating in the health care system who may place their focus on "members" of a "plan", those who frequent an emergency room, those who are part of a professional’s practice, the poor, the uninsured, those with the ability to pay, the infirm, challenged, or disabled, the mother, or senior, or child, or those whose health status is historically disparate from other’s. It is all of these people and the rest of the residents of any jurisdiction whose health is of interest to a local health department.2 An understanding is implicit that poor health and disease respect few boundaries and that death, disease, and disability in one person or group often have direct and surprising effects on the health of seemingly unrelated people.
The second element is an attention to the broad determinants of health: clinical care is recognized as an important yet proportionately small contributor to the overall health of communities when contrasted with other determinants such as culture, personal decision- making, the physical environment, and genetics (Laframbois, 1973 and Lalonde, 1974).
The third element of the conceptual framework is prevention. Moving upstream
to discover, and act on, the determinants of disease are considered to be
a wise and productive investment of resources.
The fourth element is "community-based-ness". This includes a recognition that the resources, interests, history, culture, and fabric of each community are different; an understanding that strategic and tactical use of this recognition can make the difference between progress in efforts to improve the public’s health and stagnation; and, that the people of a community are the most important asset in a democratic society; their partnership and leadership are essential to long term, sustainable change. It is this fourth element which makes the work of the local health department most difficult in our current age of consolidation and integration. Ironically enough it is this element which is most desired and most useful to large health care systems as they try on the costume of an agent working for the public’s health.
In Practice
The structure and processes of local governmental public health agencies reflect the thousands of permutations possible on the factors that govern, comprise, and control them. They reflect each local community’s vision for itself formally crafted or implicitly understood by its elected or appointed boards and staff. They reflect the context imposed by federal and state constitutions, legal and regulatory framework, the financial resources appropriated through legislative action on three levels of government, and the rules established through both formal and informal decision-making within executive, legislative, and judicial branches of government. The structure and process of local health departments reflect the vision and skills of departmental staff and of the boards and staff of other organizations in their community. In these respects, local health departments are no different from any other organization.
These permutations express both the historic strength and weakness of local health departments. They do not exist isolated from a political jurisdiction. They are an integral part of it. They reflect the strengths and weaknesses, the foibles, failures, and foresightedness of the people of the community and those who work for, and with, them.
The activities and decisions of community members, and other organizations in any community, can both contribute to or hinder the local health department’s mission to improve the public’s health. Yet any local health department is unable to achieve its mission without the active and vocal support of community members and organizations. Community members and their organizations are not likely to be successful without the active and vocal support of a local health department or of some organizational presence comprised of one or more persons which functions as part of government at the local level.
The Elements of a Healthy Community and the Choice for a Local Health Department
If one designed an organization chart for the virtual organization that conducts all activities in the public, private, non-profit, and voluntary sectors of any political jurisdiction, it would be comprised of many "centers" or subsystems. Among the subsystems would be those for education, employment, and health, for example. Each of these subsystems in turn is comprised of organizational and human members who differ by community. A "community" is the collective result of the day to day decisions, habits, and behaviors of the individuals who live in the jurisdiction and work in its organizations.
A "healthy" community requires more than a health "system" or a "health care delivery system". A healthy community requires residents to learn and reflect about themselves and others, to have some understanding of their past and a vision for their future, and the interest and energy to work towards that future over and over again. It requires skilled persons to perform social, recreational, technical and professional tasks. In a market-based economy a healthy community requires residents to be employed at work withe wages and benefits to provide access to the goods and services considered important for a high quality of life or to be comfortable with what is actually necessary to assure the health of the larger community, their own well-being, and the planet. The creation of future can be much like the work of maintaining a beach in the face of constant erosion from water and wind. Some of what exists already must be maintained while new material is added for improvement.
It is the health subsystem that frequently commands the attention of those
working for local health departments even though other systems may be of
equal or greater importance to the health of a jurisdiction’s residents.
The health subsystem has been theorized to be formed of ten elements or
practices: (NACCHO, 1994)
1. Diagnosing the community’s health
2. Epidemic control
3. Providing a safe and healthy environment
4. Measuring performance, effectiveness, outcomes, and quality of health
services
5. Promoting healthy lifestyles
6. Fingerprinting disease through laboratory testing
7. Providing a safety net
8. Providing personal health care services
9. Discovery, research, and innovation
10. Mobilizing the community for action
The role for the local health department is to: assess whether these elements
are present (and determine the outcomes presently achieved from them); develop
local policies, incentives, and regulations which establish the jurisdiction’s
expectations for the health and future of those who live and work in the
jurisdiction; and from among those elements listed above, actually perform
those which are not done well by others or which it feels can be done "better"
in the public sector with the limited resources available to it. This last
task is sometimes referred to as the assurance role.
How important is this model of assessment, policy development, and assurance
most recently espoused in both Institute of Medicine’s 1988 and 1996
publications on the future of public health? It presents a useful "rational"
model regardless of the size of a health department. Even a department with
only a few staff people can help their community understand its assets,
what it lacks, where additional resources might already exist or might be
found, and how well services are being delivered by others. If one were
a department of a single staff person, the best use of a majority of one’s
time might be to help a governing board and community residents assess,
develop policy , and assure the quality of those elements that do exist
and work with others to identify the resources necessary for the remaining
elements. Even the resource weak can be resource-full. (Salmon, 1993)
Those in the world of practice recognize that the model is constantly challenged by the politics and pressures of governing boards, community residents, other organizations in the health care delivery system, and the categorical nature of many federal and state program funds as well as by the staff and rules which govern them. Services are much more immediate, compelling, and easy to understand than are thought, analysis, and planning. Service delivery provides credibility…to those who are receiving service, with others in the service delivery business, and with elected officials who are in the business of constituent service. Services are often a necessary backdrop or precondition upon which the rational model may be built.
Each local health department and its Board are faced with the continuous task of reshaping, reorganizing, and rebalancing itself along the continuum of assessment, policy development, and assurance. There is much more needed by way of funding and continuing education for local health departments to assure the viability and excellence of the rational model on a continuing basis in political jurisdictions. The renowned national institutes in the United States were not developed on a shoestring. Neither will this be the case for a rational model of assessment, policy development, and assurance.
Three legs of a stool: A second chapter
In 1992, a diverse team in Genesee County, Michigan took the first steps down the path of community-based public health with funding from the W.K. Kellogg Foundation. This path helped us recognize the importance of partnership with local residents to achieve the public’s health. It helped us recognize that while the work of the health department alone was insufficient to improve the public’s health, regardless of the size of our budget, nonetheless the role of the health department was essential as a team member to achieve this goal. Some of our first few years of experience have been reported previously. (Israel et al, 1992; IOM, 1996; Pestronk, 1994,1995a, 1995b, 1996, 1997; Selig et al, 1993: Selig and Pestronk, 1995)
This type of partnership, and particularly its emphasis on the importance and activity of community-based organizations and "people", was not as fashionable when we began as it has now become. It is one part of the conceptual framework that cycles in and out of fashion over time. A dizzying array of reports, papers, and solicitations for proposals reach my desk monthly, as I am sure they do yours, seeking, recommending, or requiring partnerships to improve the public’s health.3 These collaborations have become fashionable in the public sector. Hospitals and managed care organizations, foundations and private corporations have recognized the importance of the consumer and voluntary associations in developing and managing health care delivery systems and in any effort to improve the public’s health.
Clearly, people of a community are necessary in any effort to improve the
public’s health.
Yet any effort to improve the public’s health will include four processes
simultaneously: creating awareness and action among the population at large;
behavior change among those affected with a particular disease (or those
for whom a particular outcome is sought or likely); change in practice among
health care professionals and practitioners; and, finally, a legal/regulatory
environment which states explicitly what outcomes are desired from the health
care delivery system, creates financial (or other) incentives for people,
organizations, and systems to produce healthier communities and people,
and a process to monitor whether desired outcomes and processes have been
achieved. The first two and the last processes require the participation
of people living in a community.
There has been a recent cycle of interest in linking community based organizations
with the people of a community, but an early call came from the Institute
of Medicine (IOM, 1988). The Institute’s Committee on Public Health
provided greater attention to this idea in 19964, even though it did not
set out to emphasize the relevance of "community" and "people"
in its report.5
There were originally nine partners in the Genesee County’s Community
Based Public Health Work, thinking of themselves as three legs of a stool.
One leg was the six community -based organizations, typically small non-profit
organizations focused on substance abuse, housing, school environment, youth,
economic development, or neighborhood organizing. A second leg was the academic
partners: the University of Michigan-Flint, specifically the Health Professions
Program; and, the University of Michigan School of Pubic Health in Ann Arbor.
The third leg was the Genesee County Health Department. Without one of the
legs, the partnership argued, the stool could not stand or support weight
well.
Sustainability of a Health Community Model
In the following section, I describe more recent events since Foundation funding ended, with particular focus on discovery, research, and innovation and mobilizing the community for action. The Foundation grant provided stimulus and exposure to new ideas and people. Yet even without the grant today, work continues in many of the original trunk areas in addition to new sprouts and branches whose roots and bud were from the original stock. I report here on the work of one of the original community based organizations and the University of Michigan School of Public Health. The work is an outgrowth of a process facilitated by the Genesee County Health Department. It reflects the conceptual and operating framework described earlier and an emphasis less focused on the traditional delivery of clinical services most often associated with local health departments. What is most exciting is the extent to which current efforts have developed a life and independence of their own and are contributing to the community’s efforts to improve the public’s health.
Flint and Vicinity Action Community Economic Development (FACED)6
Starting without a budget or staff in 1991, FACED now has a staff of 11 and a budget of $440,000. It also has a sense of some permanence to replace its earlier "ad hoc" year to year presence. "Good to be able to take a breather and have things in place before the beginning of the year," reports its current Director. In addition to knowing the sources of its funding for the upcoming year, several proposals are currently under consideration for additional funding.
According to its Deputy Director, "(Community based public heath has been)…a tremendous eye opening and growth-providing opportunity which is just at its beginning. One of its challenges is that we must constantly assess and reassess what we are doing in order to stay community based…. There are still areas that are not fully developed with respect to training youth for the future and the educational system."
The original work plan for FACED called for the development of three church
health teams. There are now twenty-eight teams with members from predominantly
African-American congregations. The teams work with their congregations
to share information and raise awareness in many areas chosen by the teams
and demanded by funders: the effects of tobacco use and tobacco cessation,
cardiovascular disease risk factors and prevention, diabetes risk factors
and prevention, childhood and adult immunization (explaining the consequences
of not being fully immunized and the reasons for staying up to date), breast
cancer, prostate cancer, maternal and infant health, and lead poisoning
prevention.
Workshops and conferences are organized regularly for individual churches
and for churches collectively. One unexpected benefit of these meetings
is that leadership and congregations from different denominations, who had
not previously worked closely with one another, are now starting to do so.
Staff estimates that these events have reached nearly 20,000 people. When
aggregated, categorical funding of work to reduce morbidity and mortality
in specific disease areas has helped create a broader foundation of workers
and organizations through which a range of others topic can be addressed.
Staff is now supported through an expanded base that includes contracts with State and County government, in-kind support through education and training from local colleges and universities, and contributions of an indirect nature.
Relationships with new organizations have been built. Ironically, Mott Community College, a local two year institution, was a very active early partner on the Genesee Team but became less active as a result of staff changes at the College. In the last few years, Mott, through the personal interest and efforts of its President, has created and supported a certificate training program for community health workers and community chore providers, and redesigned its nursing program. Getting in on the cutting edge of a burgeoning industry for older people in the United States and in the State of Michigan, these programs afford local residents the opportunity to train, go to work, and earn a living close to home, gaining a competitive edge over those who don’t have the certificate. Staff of the College are also helping FACED staff develop marketing materials and in-house marketing expertise so that through FACED’s own efforts, others in the community will become familiar with their work. Much as the early Health Department work "married" the resources of the Health Department to those of FACED, the College has creatively designed a similar marriage.
A partnership among FACED, the College, and the Genesee County Health Department has been formed to develop a business plan through which FACED may become more self sufficient by selling its expertise in the formation of church health teams to hospital systems in the Midwest and the rest of the United States. Grant funding is being sought for this plan.
FACED has also developed an unusual partnership with Lifesteps, a joint United Auto Workers/General Motors program through which Lifesteps workers provide partial health screenings for any person who attends a FACED-sponsored event where Lifesteps participates, regardless of whether the participants are UAW members or corporate employees. This strategic alliance has provided a way for those who might not have regular access to medical care or to health screenings to learn more about their health status and the steps that can be taken toward better health. They can also receive a referral to a source for medical care. Lifesteps staff train church health team members, repeating a consultative model originated (and still continuing) with Health Department public health nurses. Lifesteps staff is able to market their program to individuals who may be influential convincing UAW/GM members to participate in the Lifesteps program thereby assisting the Union and General Motors with their initiative to manage health care costs and achieve a healthier workforce.
Through a contract with the Health Department, FACED has hired four Maternal and Infant Health Advocates and a supervisor to visit homes and other places where pregnant mothers might live, shop, and socialize. Each worker has a caseload of approximately 40 people helping, for example to find beds, car seats, connect people with prenatal care. A bi-monthly support group has been formed for participants. Services have been donated by local beauty professionals, and during meetings pregnant women encourage and assist one another before, through, and following, delivery. Picnics have been organized for current participants, family members and alumni. A small group of fathers has begun to attend. Over 100 attended the last picnic.
Outreach work for FACED has further expanded as local efforts to find children eligible for the federal child health initiative program (CHIP) began. In a first phase, funds supported the work of health team members to distribute information brochures to over 100 churches. This was followed with training for team members on how to complete applications for insurance and how to talk with people about their health care coverage. A final round of work is about to begin in which the team members will be used as part of an intensive push Countywide to enroll residents. Team members will establish five church-based sites where staff will be located on a fixed schedule to provide information, assist with the completion of applications, and, generally, troubleshoot. The work of health team members will be coordinated with the work of other community members who are supervised by health department staff.
There is additional and continuing liaison with Genesee County Health Department staff. Within the last two years, in a back-to-the-future scenario, community and school nurses have been added to the health department roster. FACED staff and workers, initially trained in part by local health department staff, are now in a reversal of roles, starting conversation about community based public health with health department nurses, sharing their perspective on work and what they know. Once again, staffs in both organizations are gaining an understanding of how each organization works and the value of partnership between FACED and the health department. Information, values, and philosophical base and processes which the Health Department initially helped FACED to understand are now being transferred back to health department staff.
In general, FACED leadership and staff have grown more comfortable and familiar with the resources and work of the health department. Several CBOs, including FACED, have commented that they have had a complete change in feeling about the health department, seeing it now as a collection of people, ideas, and information rather than as a monolithic organization which is impenetrable and of little practical use. Health department and FACED staff have become aware of the need to preserve relationships and coordinate their work. Especially important, health team members report that they feel empowered to think about and be involved with work in their own community.
There have been other changes, too. Through a relationship facilitated by the Genesee County Health Department and a local legislator, increased and continuing financial support from the State Public Health Agency now allows FACED the chance to build on work from the previous year. One year’s funding is viewed as an investment in the subsequent year rather than as simply the basis for one year’s work.
There has begun to be a metamorphosis in thought among some of the original CBOs and new partners who they have identified. This expanded group sits down periodically with one another to figure out how to present themselves and their ideas collectively to one another. This has resulted in more camaraderie among groups, less duplication and competition among each other, a greater understanding of the strengths of each other’s work, and greater comfort with a focused approach for each organization. Collectively, the group feels better
able to identify and speak about their needs to the health department, university, and others, saying, in effect, "here is our agenda and these are areas where we need you."
Finally, there has been a change in public perception of the organization and its leadership. FACED staff have been asked to assume responsibilities in other settings: e.g., an APHA Caucus on Public Health and a Safe Community; an African American Health Conference being organized by a State Senator; memberships on local boards and voluntary organizations, through presentations to state-wide and national conferences.
A similar metamorphosis and expansion are occurring at the University of Michigan.
University of Michigan School of Public Health (UMSPH)
Changes at the UMSPH can be described in four areas: research; teaching and learning; infrastructure to support further community-based works; and, influence on other units of the University.7
Research8
During the Kellogg years, UMSPH worked with its community and local public health partners to develop guidelines and principles for community-based research.9 The first research project based on these principles, one examining the work of village health workers in Detroit, was started in the last (partial) year of Foundation funding. This project was a stepping stone to what is now an expanded agenda of participatory research in Detroit and Genesee County.
The State’s first Urban Research Center (URC) in Detroit was funded by the Centers for Disease Control and Prevention (CDC) based in part on the guidelines and principles mentioned above. The URC now carries out a number of projects based on these principles.
The Michigan Center for Environment and Child Health (MCECH), funded by the Environmental Protection Agency and the National Institutes of Health, has its roots in the URC model. MCECH marries bench science using animal models on the effects of environmental threats with parallel intervention research examining changes in people’s health. The Center has a locally based management board comprised of community and academic representatives as well as an external advisory committee with similar represen-tation. Benefits accrue to science and the community as each learns about the other.
When funds for new Prevention Research Centers (PRC) became available through CDC, the community-based research model and the earlier initiatives in Detroit were adapted to create Michigan’s first center in Genesee County. The new PRC created a community board in Genesee County with representation from community members, the health department, the University, and a local Health Coalition. The Health Coalition’s Board, from whom their representatives are drawn, includes major businesses, health care delivery systems, health care providers, labor, government, and consumers. The local Genesee Community Board provides a model that can now be replicated in other communities in Michigan.
The PRC also formed a State of Michigan board comprised of leadership from statewide health advocacy organizations, the Michigan Department of Community Health, and UMSPH. Representatives from the State and Genesee County boards, along with the Dean and other UMSPH faculty, serve on the governing board for the PRC. The initial project for the PRC is being developed and steered by still a third governing board comprised of the principal investigator from the UMSPH and community residents. Through the PRC, eight Special Interest Projects (SIP) proposals were recently approved by the Genesee County Community Board to be submitted for funding to the CDC.
Through the URC, MCECH, PRC, and other UMSPH initiatives such as a recent NIH grant through which African American and Latino groups will participate in the development of genetics policies, the percentage of total research dollars supporting community-based work at UMSPH has been growing steadily as has the involvement of community residents in the design and management of academic research.
Teaching and Learning
A number of initiatives have expanded the community’s participation in collaborative teaching and learning with faculty and students. HRSA special project grants have been used for several purposes: to train students in community based processes as part of the standard UMSPH curriculum; to place students in community based organizations for summer internships; and, to support reflective work through which students share their field experience in class with one another and with faculty.
These placements have led to relationships with organizations representing all five communities of color in Michigan and have served as the basis for additional student learning/teaching projects within those communities.
One of the CDC SIP proposals, if granted, will support public health students and a preventive medicine occupational health resident in positions in community based organizations and a local health department.
A growing number of courses make use of community relationships: students are learning how to design health education materials and community nutrition programs in partnership with community residents. Epidemiology students will soon be placed in many local health departments to assess chronic disease levels, help design interventions, and develop proposals that can support community initiatives. A course discussing media and public health is now joining students and faculty with health advocates in local communities.
Infrastructure
Four structural changes have occurred at the UMSPH.
An Office of Community Based Public Health, initially supported with Foundation funds, houses a small yet permanent staff and regular cadre of graduate students. This office has assumed entrepreneurial responsibility for developing new opportunities that enable the school to further expand its community work. The Director of the Office has been appointed practice coordinator for UMSPH and participates in the Council of Practice Coordinators of the Association of Schools of Public Health. Recent experiences in local communities have enabled him to help facilitate an expansion of the Council’s definition of "practice". HRSA recently funded a conference in which coordinators from around the United States visited Michigan to explore with local community representatives how the expanded model could be developed in schools of public health nationwide.
Second, a community based public health committee has been created under the Dean’s direction. As one of very few school-wide committees, it is comprised of faculty from all departments, associate deans, community representatives, and students. The committee provides policy guidance for the School, and faculty receive credit towards merit and tenure decisions.
Third, there is now a permanent position to coordinate community/academic work. Two staff are charged with learning about the interests of community residents and groups and matching those with interests of faculty and students.
Finally, an annual community-service learning fair, to which are invited community organizations and health departments, now displays the work and interests of approximately forty organizations with whom students and faculty can meet and interact face to face to explore new areas for community work and job opportunities.
Impact on other units of the University
The work described above has created opportunities to share with other University Schools a style of community based research and teaching through which UMSPH faculty and community residents serve as consultants to newly developing projects. This work, in turn, has exposed UMSPH faculty, students, and staff and community residents to work in other parts of the University.
University of Michigan-Flint
The University of Michigan-Flint School of Health Professions and Studies was an original member of the Genesee Team. The relationships that have helped since the inception of the Kellogg grant have helped to broaden the appreciation of what it means to be community-based among faculty in the School thus changing the perception from providing services in a community setting to involving community members in academic program planning, development, and teaching. The School is now considering the development of a certificate program in community competence and is exploring additional ways in which the recipients of community services can be brought into the educational process for health education students at the undergraduate and graduate levels.
Conclusion
Local health departments can stimulate innovative and developmental work not only within their organization but also in other organizations as well. Partnerships, developed over time and based in mutual respect and trust, can develop a life of their own. Like a stone dropped into a pond, the work of local health departments can cause long-lasting and ever-expanding ripples of change over the surface of a community. The specific process used in Genesee County may not be appropriate or feasible in every local health jurisdiction and it may be unrealistic to expect that it should be so (Kreuter and Lezin, 1998). That there was success here has been helpful for us and, perhaps, a glimmer of hope that successful strategies to improve the public’s health can be, and are, being developed elsewhere and that local health departments have played a critical and essential role in achieving this goal.
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